Current Psychotherapies 10th Edition Wedding Test Bank

Test Bank

Resource Manual for Instructors To accompany Current Psychotherapies (10th Edition)

Created by Barbara Cubic, Ph.D.

Prepared by: Alexander Wait, Missouri State University & Anne Galbraith, University of Wisconsin-La Crosse

© 2014 Cengage Learning

Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States

© 2014 Cengage Learning, Inc.

Resource Manual for Instructors Current Psychotherapies (Tenth Edition) Dear Instructor: Current Psychotherapie s (10th Dedicated in memory of my father Edition) is a unique compilation of chapters on the most influential forms of psychotherapy His curiosity about life and quest for . The first knowledge continue to strengthen my eight editions commitment to the education of of Current Psychotherapie others and the field of psychology. s were edited

by Ray Corsini and Danny Wedding.

Sadly, Ray passed away prior to the creation of the most recent editions, but his influence clearly shows throughout. For instructors unfamiliar with Ray Corsini and his work, an interview of Ray by Danny Wedding is available at the following link: http://www.wadsworth.com/counseling_d/te mplates/student_resources/0534638546_cors ini/corsinivideos.html.

Ray David May (1930-2011)

Barbara Cubic

© 2014 Cengage Learning, Inc

© 2014 Cengage Learning, Inc. Many of the chapters in Current Psychotherapies are written by the creator of the theory, while other theories are described by influential clinicians in the field. Each chapter outlines the psychotherapy methods that accompany each of the various theories. This new edition also has a strong focus on the applicability of the various psychotherapies and the evidence for each approach and the theories behind them across cultural groups. This version of Current Psychotherapies includes a new chapter on psychoanalytic psychotherapies and, for the first time, a chapter on positive psychotherapy. The 10th edition of Current Psychotherapies also has significantly rewritten chapters on Adlerian psychotherapy and behavioral psychotherapy. Although this edition no longer includes the chapter on analytical psychotherapy (Jung’s approach) by Claire Douglas, the chapter remains available to instructors and their students on the companion website at www.cengagebrain.com.

This instructor’s manual is designed to serve as a resource for Current Psychotherapies (10th Edition) to facilitate the educational experience of students learning about psychotherapy.

An outline is provided for each chapter, which supplies an overview of the chapter’s content and highlights key terms. This outline is followed by multiple choice, fill-in-the-blank and essay test questions. Chapter-specific suggestions for a role play and discussion activities are also described. Instructors will also want to utilize Case Studies in Psychotherapies (ISBN: 9781285175232), which accompanies Current Psychotherapies as a resource to illustrate each therapy approach; therefore, the corresponding case for each chapter is

listed following the discussion activities for each form of psychotherapy.

To further aid instructors, Microsoft PowerPoint slides outlining the key points of each chapter are available.

These slides often add additional details to the materials presented in the chapters, expanding upon information on techniques, history of the therapy, or the theory. As with all of the resources provided through this manual, these slides can be used in their current form or modified by instructors to meet their specific classroom needs. The bookspecific website offers instructors this manual, test banks, and presentation slides available for download. Instructors can access the materials by visiting www.login.cengage.com. If you need assistance with accessing the materials, please contact your Cengage Learning sales representative.

In addition to the resources specifically designed for Current Psychotherapies instructors may want to utilize other resources to bring the psychotherapies to life for students. For example, instructors may want to review the American Psychological Association’s Theories in Action video clips. These clips illustrate various psychotherapies through portrayal of a realistic role-play with a client and an experienced therapist, followed by a brief discussion with the therapist about the therapeutic interaction portrayed. Showing these videos as students are reading Current Psychotherapies will bring the theories to life and provide the students with a richer understanding of each theory and how each therapy approach looks in practice.

Instructors might also want to look at examples of therapeutic approaches illustrated in two resources

© 2014 Cengage Learning, Inc.

© 2014 Cengage Learning, Inc. demonstrating how movies portray psychological issues and their interventions:

I hope the resources I have created or those referenced above are of benefit to you and your students.

Barbara Cubic

Wedding, D., Boyd, M. A., & Niemiec, R. M. (2009). Movies and Mental Illness: Using Films to Understand Psychopathology (3rd Edition). Hogrefe and Huber.

Niemiec, R. M., & Wedding, D. (2013). Positive Psychology at the Movies: Using Films to Build Character Strengths and Well-Being (2nd Edition). Hogrefe and Huber. © 2014 Cengage Learning, Inc

© 2014 Cengage Learning, Inc.

Resource Manual for Instructors Current Psychotherapies 10th Edition

Table of Contents Chapter 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Page

Introduction to 21st Century Psychotherapies Psychoanalytic Psychotherapies Adlerian Psychotherapy Client-Centered Therapy Rational Emotive Behavior Therapy Behavior Therapy Cognitive Therapy Existential Psychotherapy Gestalt Therapy Interpersonal Psychotherapy Family Therapy Contemplative Psychotherapies Positive Psychotherapy Integrative Psychotherapies Multicultural Theories of Psychotherapy Contemporary Challenges and Controversies

Introduction to 21st-Century Psychotherapies

1 10 35 54 72 88 107 127 142 160 181 201 217 238 257 278

© 2014 Cengage Learning, Inc.

Introduction to 21st-Century Psychotherapies

© 2014 Cengage Learning, Inc.

Chapter 1 Introduction to 21st-Century Psychotherapies Authors: Frank Dumont Key Points and Terms Evolution of the Science and Profession of Psychology Early attempts to address mental disorders include: ► Pre-Christian, temple-like asklepeia and other retreat centers, which used religiophilosophical lectures, to assuage if not remedy psychological disorders. ► Hellenist physicians understood that the brain was not only the seat of knowledge and learning but also the source of depression, delirium, and madness. ► Hippocrates insisted that his students address illnesses by natural means.

Psychotherapy in its present guise did not clearly emerge until the 18th century. Below are some key players: ► Scientific study of the unconscious attributed to renowned polymath Gottfried Wilhelm Leibniz: ▪ Investigated subliminal perceptions ▪ Coined the term “dynamic” ► Johann Friedrich Herbart: ▪ Attempted to apply mathematics to dynamics ▪ Suggested ideas struggle with one another to access consciousness ► Franz Anton Mesmer and his disciple the Marquis de Puysegur are influential in current understanding of: ▪ hypnotherapy ▪ rapport between therapist and patient ▪ influence of the unconscious ▪ importance of the qualities of the therapist ▪ spontaneous remission of disorders ▪ hypnotic somnambulism ▪ selective function of unconscious memory ▪ role of patient confidence ▪ common factors across effective treatments ► Arthur Schopenhauer ▪ Work strongly influenced Freud ► Gustav T. Fechner ▪ Made distinction between waking and sleeping states ▪ Attempted to measure the intensity of psychic stimulation ► Herman von Helmholtz ▪ Discovered the phenomenon of unconscious inference ► Emil Kraepelin ▪ Attention to classifying diseases ► Carl Gustav Carus Introduction to 21st-Century Psychotherapies

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© 2014 Cengage Learning, Inc. ▪

►

► ►

Developed one of the most sophisticated schemas the unconscious that exist, describing several levels to the unconscious ▪ Felt individuals were communicating at conscious and unconscious levels with each other in paravocal, nonverbal, organic, and affective modes in ways individuals were largely unaware of Carus Schopenhauer ▪ Principal argument was that we are driven by blind, irrational forces of which we are largely unaware Friedrich Nietzsche ▪ Viewed that humans lie to themselves more than they do to each other Moritz Benedikt ▪ Developed concept of seeking out and clinically purging “pathogenic secrets” The Impact of Biological Science on Psychotherapy

Every encounter with our environment causes a change within us and in our neural functioning.

One cannot unlearn knowledge unless neuronal decay and lesions undo memory.

Klaus Grawe has noted that “psychotherapy appears to achieve its effect through changes in gene expression at the neuronal level.” And research shows that therapy may be effective through triggering the expression of immediate-early genes (IEGs) through exposure to nurturant social events.

Much of the plasticity in our neuro-emotional systems is achieved through epigenetic changes.

In the current age of psychopharmacology, medicating patients for psychological purposes should require clear, preset clinical objectives.

Future developments in molecular genetic analysis, cognitive neuropsychology, and social cognitive neuroscience will continue to inform psychotherapy.

Clashing Standpoints • Gillath, Adams, and Kunkel (2012) provide a model for uniting disparate approaches to study of human nature.

• Resolution can be achieved through systemic integration of many variables that are at play at any moment.

• For example, Pope and Wedding (2012) discuss the danger inherent in neglecting to monitor patients who are taking psychotropic medication.

Evolutionary Biology and Behavioral Genetics • Anthropologists have discovered at least 400 universal behavioral traits.

• Steven Pinker (2002) has further documented the principle that all humans share a unique human nature.

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Introduction to 21st-Century Psychotherapies

© 2014 Cengage Learning, Inc. Cultural Factors and Psychotherapy Research shows it is clear that if patient and therapist are strongly wedded to different cultures, it matters if the authority figure is a member of a minority, non-dominant culture or dominant, majority culture. Some would argue that psychotherapies need to be indigenized.

The Challenges of Evidence Based Treatments Industrializing Psychotherapy ▪ Psychotherapy has gained recognition as a health discipline.

▪ Therapists will increasingly work in inter-professional medical teams.

▪ Integrated healthcare wave of the future.

▪ Therapists must demonstrate competence in treating patients in accordance with currently accepted standards of the larger mental-health services community.

Positive Psychology ▪ Revitalized by Martin Seligman and Mihaly Csikszentmihalyi.

▪ Built on solid historical foundations such as Alfred Adler’s view of self-actualization; Abraham Maslow’s concepts from Toward a Psychology of Being (1962); Carl Rogers view of therapy; and Milton Erickson’s work.

Treatment Efficacy, Therapist Aptitudes, and Diagnostic Coding ▪ Some disorders require a specific modality.

▪ Certain therapists are more capable of treating certain kinds of disorder than others.

▪ Therapists need to know the International Classification of Diseases (ICD-10-CM).

Empirically Based Treatments Division 12 of the American Psychological Association (APA) established a Task Force on Promotion and Dissemination of Psychological Procedures of empirically based treatments (EBTs) in 1995. However, EBTs are in much debate as patients present with a unique set of such variables and experience endless experiences and co-morbidity complicates the categorization of disordered patients for purposes of validating therapy for them.

Paul Meehl (1978) coined the term context-dependent stochastologicals to describe the complexity of random internal and external events (both past and present) that impact an individual.

Manualized psychotherapy is also debated, but most clinicians agree that therapy should proceed from the known (i.e. empirically validated) to the “unknown and untried” in a methodical, stepwise fashion. And, some therapies (e.g. interpersonal, behavioral and cognitive therapies) are more amenable to becoming manual-based.

However, in the end truly successful therapists adopt or develop a theory and methodology congruent with their own personality. As Michael Mahoney wrote, “The person of the therapist is at least eight times more influential than his or her theoretical orientation.”

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© 2014 Cengage Learning, Inc.

Chapter 1: Activities Role-play Ask one group of students to provide evidence that would support the environmentalist tradition and another group to provide evidence that would support the organicist tradition.

Encourage them to provide as much evidence as possible regarding whether a scientific based approach to psychological treatment is necessary.

Discussion Questions 1.

Seeking psychotherapy is often a difficult choice for individuals to make. Often, the process initially makes the individual feel worse rather than better. Ask students to discuss what characteristics would be related to a willingness to seek psychotherapy. Ask the students to discuss what characteristics would be related to refusal to seek psychotherapy.

2.

Ask the students to take the Therapeutic Readiness Scale developed by Fischer and Turner in 1970. Discuss how their responses can help them understand the barriers that might be present for psychotherapy.

Full citation for scale: Fischer, E., & Turner, J. (1970). Attitudes toward seeking professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35, 82-83.

3.

4

Psychotherapy is often misunderstood or devalued because it is often seen as an art rather than a science. Ask students to discuss their views of psychotherapy. Ask students to discuss whether the goal of psychotherapy should be use of an approach that is as empirically based as possible.

Introduction to 21st-Century Psychotherapies

© 2014 Cengage Learning, Inc.

Chapter 1: Potential Test Items Multiple Choice Test Bank 1.

In Chapter 1, Corsini illustrates a change in an inmate’s life after learning he had a high IQ. This story demonstrates that psychotherapy can be broadly defined as any: a. interaction between a therapist and a patient. b. technique which teaches a patient a new skill. c. self-concept-altering experience. d. interpretation provided to a patient.

REF: Negotiating Fault Lines in the EBT Terrain (p. 11-12) ANS: C

2.

Hellenist physicians believed the organ contributing to mental illness was the: a. heart. b. liver. c. brain. d. blood.

REF: Evolution of This Science and Profession (p. 2) ANS: C

3.

Gottfried Wilhelm Leibniz is credited with the: a. first scientific study of the unconscious. b. development of systematic psychotherapy. c. creation of the nature versus nurture debate. d. identification of defense mechanisms.

REF: Evolution of This Science and Profession (p. 2) ANS: A

4.

The psychotherapeutic term “dynamic” was first used by: a.

Sigmund Freud. b.

Gottfried Wilhelm Leibniz. c.

Hippocrates. d.

Franz Anton Mesmer.

REF: Evolution of This Science and Profession (p. 3) ANS: B

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© 2014 Cengage Learning, Inc. 5.

The idea that similar ideas attract and strengthen one another’s ability to be conscious is the result of the work of: a.

Alfred Adler. b.

Hippocrates. c.

Thomas Mann. d.

Johann Friedrich Herbart.

REF: Evolution of This Science and Profession (p. 3) ANS: D

6.

Franz Anton Mesmer is often viewed as the pioneer of: a. manualized therapy. b. free association. c. hypnotherapy. d. behavioral intervention.

REF: Evolution of This Science and Profession (p. 3) ANS: C

7.

Herman von Helmholtz described the unconscious reconstruction of what our past taught us about an object as: a. restructuring objects. b. psychic stimulation. c. cognitive discovery. d. unconscious inference.

REF: Psychotherapy-Related Science in the 19th Century (p. 4) ANS: D

8.

The organicist tradition refers to scientists who were: a. environmentalists. b. somatic focused. c. integrating music into therapy. d. lab-based.

REF: Psychotherapy-Related Science in the 19th Century (p. 4) ANS: D

9.

Emil Kraepelin’s work focused heavily on: a. multicultural variants of illness. b. classifications of diseases. c. surgical approaches to mental illness. d. use of hypnosis.

REF: Psychotherapy-Related Science in the 19th Century (p. 4) ANS: B

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Introduction to 21st-Century Psychotherapies

© 2014 Cengage Learning, Inc.

10.

The idea that nonlinear messages are systematically sent between the unconscious and the conscious in human interactions was developed by: a.

Hippocrates. b.

Carl Gustav Carus. c.

Franz Anton Mesmer. d.

Gottfried Wilhelm Leibniz.

REF: Psychotherapy-Related Science in the 19th Century (p. 5) ANS: B

11.

Arthur Schopenhauer’s principle argument was that: a. unconscious material could easily be made conscious. b. the unconscious did not exist at all. c. free will prevailed over determinism. d. we are driven by blind, irrational forces.

REF: Psychotherapy-Related Science in the 19th Century (p. 4) ANS: D

12.

Jungian therapy, based on the work of Moritz Benedikt, underscores the importance of: a. rewarding positive behavior. b. unconditional positive regard. c. purging pathogenic secrets. d. cognitive distortions.

REF: Psychotherapy-Related Science in the 19th Century (p. 5) ANS: C

13.

Neurosciences suggest elective psychotherapy leads to changes at the: a. cognitive level. b. behavioral level. c. neuronal level. d. interpersonal level.

REF: The Impact of the Biological Sciences on Psychotherapy (p. 6) ANS: C

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© 2014 Cengage Learning, Inc. 14.

The expression of certain genes that result from their activation by specific but common environmental events is referred to as: a. neuronal decay. b. somatiker. c. psychiker. d. epigenetics.

REF: The Impact of the Biological Sciences on Psychotherapy (p. 6) ANS: D

15.

Pope and Wedding would argue that in deciding to use psychotropic medications: a. preset clinical objectives need to be determined. b. immediate early genes are irrelevant. c. psychotherapy’s common factors are undermined. d. psychotherapy has occurred if patients suffering has been alleviated.

REF: The Impact of the Biological Sciences on Psychotherapy (p. 7) ANS: A

16.

Due to multicultural differences, segments of the population would likely benefit from: a. indigenized psychotherapies. b. exporting Euro-American psychotherapists. c. abandoning cultural philosophies. d. accepting a universal approach to psychotherapy.

REF: Cultural Factors and Psychotherapy (p. 10) ANS: A

17.

Positive psychology has considerable momentum and is most commonly linked with the work of: a.

Aaron Beck. b.

Sigmund Freud. c.

Martin Seligman. d.

Albert Ellis.

REF: Who Can Do Psychotherapy? (p. 14) ANS: D

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Introduction to 21st-Century Psychotherapies

© 2014 Cengage Learning, Inc. 18.

For the coding of mental illnesses for the purposes of reimbursement, as of October 2014, U.S. clinicians will need to use the: a.

DSM-5. b.

MMPI-2-RF. c.

ICD-10-CM. d.

PAI. REF: Conclusion (p. 16) ANS: C Essay Questions

1.

Raymond Corsini describes how a prisoner’s life changed when he was told that he had a high IQ. Why does Dr. Corsini consider this psychotherapy?

2.

Although Sigmund Freud is generally called the “father of psychotherapy,” describe the contributions of his key predecessors and contemporaries.

3.

Imagine that you are a beginning psychotherapist. Describe how you would utilize advances in neurosciences to inform your treatment approach.

4.

Many attempts have been made historically to categorize or classify mental illnesses.

Discuss the evolution of these attempts from beginning to current.

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© 2014 Cengage Learning, Inc.

Chapter 2 Psychoanalytic Psychotherapies Authors: Jeremy D. Safran and Alexander Kriss

Key Points and Terms

pcpt-cs

EGO unconscious

ID

SUPER-EGO

pre-conscious

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. Overview There is no single psychoanalytic theory of personality or treatment; a host of different theories and treatment models have developed over more than a century through the writings of theorists and practitioners from many different countries. Principles across psychoanalytic perspectives include the following: ► ► ► ► ► ►

Humans are motivated by unconscious motivations.

Therapy facilitates awareness of unconscious motivations to increase choices and exploration of ways in which we avoid painful experiences.

Humans are ambivalent about changing.

There is an emphasis on the therapeutic relationship as an arena for exploring the conscious and unconscious.

Therapeutic relationship is seen as an important vehicle of change.

Focus is on clients gaining insight into the link between their construction of past and present and self-defeating patterns.

Basic Concepts

Psychoanalysis (Psychodynamic Theory) ► ► ► ►

Freud’s legacy Few continue to practice psychoanalysis in its originally conceived form.

However, most forms of therapy stem from some element of psychoanalytic theory or technique.

Psychodynamic approaches retain central principles of psychoanalysis but not the metapsychology.

Primary Processes ► ► ► ►

Raw/primitive psychic functioning Begins at birth and operates unconsciously throughout life.

Past, present, and future are not distinguished.

Feelings and experiences are condensed, expressed metaphorically through dreams, fantasy, or acute psychosis.

Secondary Processes ► ► ►

Psychic functioning associated with consciousness.

Logical, sequential and orderly Foundation for rational, reflective thinking

Defense Mechanisms (described in the book) ►

Intellectualization: Individual talks about something threatening while keeping an emotional distance.

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© 2014 Cengage Learning, Inc. ► ► ►

Projection: Individual attributes a threatening feeling or motive they are experiencing to another person.

Reaction Formation: Individual denies a threatening feeling and proclaims the opposite.

Splitting: Individual attempts to avoid perception of the other as good from being contaminated by negative feelings, splits the representation of the other into two different images.

Other Examples of Defense Mechanisms Projection Displacement Obsessive-Compulsive Altruism Repression Avoidance Suppression Altruism

Regression Denial Sublimation ► ► ► ► ►

Concept of defense mechanisms introduced by Sigmund Freud but developed by Anna Freud.

Types of defenses employed have implications for mental and physical health.

Use of less mature defenses = more pathology.

Defensive styles have clinical implications regarding treatment.

Erik Erickson expanded Freud’s theory and examined effects of culture on psychological development.

Transference = Patient responds to therapist based on past experiences.

Countertransference = Therapist responds to patient based on past experiences.

One vs. Two Person Psychologies ► ►

The view of the therapist is no longer as an objective, neutral observer (i.e. blank screen).

Therapist and client are now viewed as co-participants engaging in a process of mutual influence at conscious and unconscious levels.

Comparing Psychoanalysis to Other Systems (see table on next page)

The popularity of psychoanalysis has been declining largely due to psychiatry’s shift towards a biological emphasis; development of evidence-based treatments (e.g. CBT); the negative public reaction to the arrogance, insularity, and elitism of psychoanalysis; and the lack of receptiveness to valid criticism and empirical research of psychoanalytic therapists.

History of Psychoanalysis The Life of Freud 1856 — Freud is born as the oldest of six surviving children.

1873 — Starts medical school and studies under Ernst Brucke.

1877 — Works with Josef Breuer, who had a patient called Anna O. 1885 — Studies under Jean Charcot in Paris, who was using hypnosis 1896 — Coins term “Psychoanalyse.” Freud starts his self-analysis.

1897 — Rejects his original seduction theory.

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. 1900 — Publishes The Interpretation of Dreams.

1902 — Forms Psychological Wednesday Society (Adler and Rank).

1904 — Publishes Psychopathology of Everyday Life.

1907 — Freud and Jung meet in Vienna.

1908 — Forms Vienna Psychoanalytical Society.

1909 — Forms International Psychoanalytical Society; Carl Jung serves as first president.

1923 — Develops structural model of id, ego, and superego.

1933 — Nazis burn his books in Berlin.

1938 — Leaves Vienna for London.

Sept. 26, 1939 — Dies in London.

Key Aspects

Ellis, Beck, Behavioral Theorists

Concur with Freud regarding the existence of an unconscious aspect to the psyche.

How unconscious material is defined and treated varies.

No emphasis on unconscious.

Analytical work heavily related to transference and countertransference.

Less credence given to transference.

Emphasis on creating empathic, congruent, non-judgmental relationship in the present.

No emphasis on transference; Note: Ellis acknowledges the concept; regards feelings as irrational beliefs.

Emphasizes past-present relationship.

Emphasis on the present relationship(s).

Dynamic, unconscious forces.

Anxiety related to existential fears.

Childhood Experiences

Transference

Unconscious

Freud

Comparing Psychoanalysis to Other Systems (continued) Major Comparisons Jung Adler Existential and Gestalt client-centered Theorists

Unconscious (Personal/ Collective); Incorporates mysticism and spirituality.

Societal pressure influence selfconcept.

Psychoanalytic Psychotherapies

Impact of past on present acknowledged; transference viewed as part of one’s real, current experience and is addressed directly.

Past only emphasized in relation to direct antecedents of current maladaptive behavior, thoughts and feelings.

Use of structured and active therapeutic techniques.

Covert and overt behavior.

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© 2014 Cengage Learning, Inc. All forms of therapy share the fundamental goal of establishing a working alliance to decrease patient/client distress.

History of Psychoanalysis (continued) Main clinical concepts ► ► ►

►

Free association: Encouraging patient to say “whatever comes to mind.”

Therapeutic listening: Focusing on all levels of communication evenly.

Therapeutic responding ▪ Interpretation: Therapist offers patient feedback on central themes.

• Manifest content – surface material • Latent content – deeper level ▪ Empathy: Conveying emotional understanding.

Therapeutic alliance: Partnership between therapist and patient.

Breur and Freud wrote Studies on Hysteria regarding the use of hypnosis with patients with hysteria. They argued hysteria resulted from emotions related to trauma that had not been discharged. In normal circumstances, such emotions would be abreacted (i.e., discharged in conscious psychological reactions). Therefore, the task of treatment was catharsis (i.e., release of emotion connected with a painful experience that had not been discharged).

Psychoanalysis was originated by Sigmund Freud (1856-1939).

The Evolution of Freud’s Ideas as Evidenced in Pivotal Writings In 1873, Freud started medical school and studied under Ernst Brucke. During his formative years, he was heavily influenced by neurology.

Studies on Hysteria (1895) [with Josef Breuer] ► Developed interests in hypnosis through work with Josef Breuer (who treated Anna O.) and Jean Charcot. ► Viewed task of treatment as catharsis of non-discharged affect connected to earlier trauma that the individual was defending their psyche against. ► Began forming ideas about the pleasure principle. ► Shifted to use of free association after abandoning hypnosis. ► Formulated thinking about resistance. ► Began developing his theory of childhood sexuality.

The Interpretation of Dreams (1900) ► Hypothesized about symbolic representation in dreams, “the royal road to the unconscious.”

▪ Manifest content — overt material ▪ Latent content — underlying meaning ▪ Day residue: Images from the day that make their way into dreams. ► Stages of Psychosexual Development 14

Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc.

Oral Phase ► From birth to 18 months ► Source of libidinal gratification is through feeding. ► Gratification of oral needs reduces tension and induces sleep. ► Coincides with Erikson’s trust and mistrust phase.

Anal Phase ► Between 18 months and 3 years ► Libidinal gratification is from retaining and passing feces. ► Toilet training must be done carefully or could lead to shame. ► Reaction formation may lead to obsessive compulsive meticulousness.

The Phallic Phase ► Libidinal gratification centers are in the genital region. ► Oedipus Complex: ▪ Unconscious sexual desire in a child (male) for opposite-sex parent.

▪ Later, Electra Complex described for females.

Latency Period ► Children can now be socialized. ► Continues until puberty.

Genital Phase ► Begins in puberty and continues throughout adulthood. ► Libidinal gratification occurs through sexuality with another object.

Comparing Freud’s Model with Other Developmental Models Age

Freud Psychosexual

Erikson Psychosocial

Piaget Cognitive

0-18 months 18 months-6 years

Oral

Trust vs. Mistrust

Sensorimotor

Anal (18 mos.-3 yrs) Phalic (3-6 yrs) Oedipal and Electra Complex

Autonomy vs. Shame (2-4 yrs) Initiative vs. Guilt (4-6 yrs)

Preoperational

6-12 years

Latency

Industry vs. Inferiority

Concrete Operations

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© 2014 Cengage Learning, Inc. 12+ years

Genital

Identity vs. Role Confusion (12-18 yrs) Intimacy vs. Isolation (18-25 yrs) Generativity vs. Stagnation (25-50 yrs) Integrity vs. Despair (50+ yrs)

Formal Operations

On Narcissism (1914) ► Focused on the psychology of psychoses, group formation and love.

The Ego and the Id (1923) ► Id: Instinctual pressures (e.g. aggression and sexual). ► Ego: Orients us toward the external world (mediates the internal and external). ► Superego: Individual’s moral voice.

Jung’s Basic Concepts Jung defined psyche as the inner realm of personality that balanced outside reality.

Spirit Soul

Idea

Jung’s Days with Freud ► Jung argued that delayed response times to emotionally-charged words reflect an unconscious functioning. ► Emotional complexes: Affectively charged ideas that are repressed because they are emotionally threatening.

Collective Unconscious ► Vast, hidden psychic resource shared by humans. ► Jung found basic motif across individuals in their dreams, fantasies, etc. ► Images from collective unconscious are shared by all, but modified by our own personal experiences.

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Road to the Unconscious Emphasis Interaction with Patient View of Complexes

View of the Unconscious

Jung Complexes Inclusive set of drives, i.e. search for meaning Face-to-face Broad, rich, complexes both negative and positive; focused on pre-Oedipal phase Collective

Freud Dreams Sexual and aggressive drives patient on couch Limited, negatively charged; focused on Oedipal phase Personal

Jung’s Model

SUPER-EGO pre-conscious

EGO

Material unimportant

to the psyche unconscious

repressed

ID

Current Scene in American Psychoanalytic Therapies Contemporary ego psychology has evolved into modern conflict theory and emphasizes the centrality in human experience and the action of ongoing conflict between unconscious wishes and defenses against them.

Object Relations Theory ► Melanie Klein, child therapist, pioneered play therapy. ► Development of internal representations of relationships. ► Influenced Bion’s concept of containment.

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© 2014 Cengage Learning, Inc. ►

Lacanian/post-Lacanian theory ▪ Jacques Lacan argued the ego is an illusion (no true self waiting to be discovered).

▪ Emptiness is the result of alienation from the self as our experience requires language to be communicated.

▪ Communication process results in a distortion of our experience.

Theorist Hartmann, Kris, Loewenstein, A. Freud

Focus Adaptive functions of the ego; transformation of instincts into metapsychological propositions

Winnicott, Bowlby, Mahler, Sullivan Sense of self and personal identity Horney and Fromm Kohut & Goldberg Kernberg Current Status

Social, political and cultural factors Self psychology Object relations Intersubjectivity

Determinism ► Psychological events are causally related to each other and to an individual’s past.

Dynamics ► There is an interplay of forces in the mind that act in unison or opposition. These elements ultimately express themselves through compromise.

Topography ► Individual psychic elements are layered in consciousness.

Genetics ► There is an enduring influence of the past on our present mental activity.

Theory of Personality Onset of Neurosis ► Childhood neurosis is common. ► Expressed through anxiety. ► In adulthood, neurosis occurs when the balance between drives and defenses is upset.

Post-Freudian Concepts Margaret Mahler hypothesized that the mother-infant relationship began in symbiosis (a state of oneness) and the primary task of early life was separation-individuation. Newer researchers have also emphasized the role of attachment. Fairburn was also a lead theorist in the development of object relations theory. Object refers to a person who has great significance to a child. Theory hypothesizes that emotional life is dependent on internalized object representations (i.e., unconscious mental images of our earliest, critical relationships). To sustain connection to earlier love objects, individuals often repeat patterns in later relationships.

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Melanie Klein ► Emphasized importance of primitive fantasies. ► Depressive position (loss) ► Paranoid position (persecution) Margaret Mahler ► Self emerges through separation and individuation.

D. W. Winnicott ► Developed concept of a transitional object.

Franz Alexander ► Problems result from trauma due to parental mismanagement and analyst needs to arrange a corrective emotional experience.

Heinz Kohut ► Self psychology ► Early dissonance in mother/child relationship creates narcissistic vulnerability. ► Therapy focuses on regulation of self-esteem.

Otto Kernberg ► Object relations and early relationships leave a residue of internalized relationship concepts.

Theory of Psychotherapy Psychoanalysis ► Patient achieves change through critical self-examination. ► Four 45-minute sessions a week for years. ► Patient expresses thoughts and feelings without fear of judgment. ► Analyst guides the process by encouraging in-depth awareness of interconnections.

Phases of Psychoanalysis 1. Opening a. Lasts 3-6 months. b. Patient reveals information at their pace. c. Structured, formalized interview discouraged. d. Analyst remains ultra-aware of patient’s actions and words and notes issues of significance. e. Analyst sketches out general outline of patient’s conflicts and resistances to identify themes.

2. Development of Transference a. Major portion of therapeutic work.

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© 2014 Cengage Learning, Inc. b. Overlaps with “working through” phase. c. Patient unconsciously reenacts childhood memories and fantasies and develops transference with the analyst. d. Transference seen as a process in which repetition in action replaces event recollection. e. By analyzing transference, therapist assists patient in understanding how the past affects their interactions in the present.

3. Working Through a. Multiple experiences of insight are needed to understand the nature of one’s conflicts. b. Analysis of the transference facilitates memory recall. c. Evidence builds to support which events really occurred versus which were fantasized. d. Patient develops an in-depth understanding of how childhood events impacted them psychologically.

4. Resolution of the Transference a. Termination phase of treatment. b. Analyst focuses on assisting the patient in resolving unconscious neurotic attachment to the analyst. c. Often, symptom intensification occurs due to an unconscious attempt to continue the therapeutic relationship. d. Ultimately, treatment focus is redirected to the future.

Psychoanalysis

Current Psychodynamic Approaches

Highly intensive.

3 or more sessions per week.

Patient lying down.

Therapist is outside of patient’s immediate visual awareness.

Training generally reserved for those with advanced training as a psychiatrist or psychologist.

Analyst has undergone personal analysis.

Less intensive.

1-2 sessions per week.

Patient sitting up.

Therapist faces patient.

Training generally offered to most mental health professionals.

Prior personal mental health treatment optional for the therapist.

Current Psychodynamic Approaches ► Therapeutic (supportive) relationship. ► Expressive work: Exploration of the patient’s problems (deepens over time).

• Patient is encouraged to say what comes to mind.

• Therapist pays “evenly hovering attention.” ► Multiple experiences of insight are needed to understand the nature of one’s conflicts. ► Goal is personal transformation. ► Patient learns how childhood events impacted them psychologically.

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. ► ►

►

►

Patient develops ways to cope more effectively in the present.

Not planned, comes when it comes.

• When patient decides to stop/goals are met.

Treatment focus is redirected to the future.

• How things will be after therapy ends.

Open-door policy.

• Patient can return at will.

Key Concepts ► Therapeutic alliance ► Transference ► Countertransference ► Resistance ► Intersubjectivity ► Enactment Process of Psychotherapy ► ►

► ►

Empathy Interpretation • Accuracy • Quality • Timing • Depth • Empathic quality Clarification, support and advice Termination

Mechanisms of Psychotherapy ► Making the unconscious conscious ► Emotional insight ► Creating meaning and historical reconstruction ► Limits of agency ► Containment ► Rupture and repair Appropriate Candidates for Psychoanalysis ► Motivated ► Openly disclosing ► Willing to self-scrutinize ► Able to accept parameters of psychoanalytic situation ► Individuals who are not in need of immediate crisis intervention ► Perhaps treatment of choice for personality disorders. ► Best suited for “problems in living” reflected in stress and distress. ► Applicable to family work (e.g. object relations family therapy). ► Play therapy with children is based on dynamic concepts.

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© 2014 Cengage Learning, Inc. ►

Can be paired with other forms of intervention (e.g. medications).

Evidence Supporting Psychoanalytic Concepts

► ► ►

►

►

RCTs support the efficacy of short-term dynamic psychotherapy (STDP) relative to control groups.

Meta-analyses have found substantial effect sizes for STDP as large/larger than those for short-term cognitive therapies (Shedler, 2010).

Abbass and colleagues (2006) evaluated 23 RCTs [1,431 clients receiving less than 40 STDP sessions].

• Overall effect size of 0.97 for general symptom improvement.

• Effect size increased to 1.51 at 9-mo f/u.

Leichsenring and Rabung (2008) demonstrated long-term psychoanalytic therapy (LTPT) effective for complex scenarios (e.g. Axis II disorders, chronic mental disorders, comorbidities).

• Reviewed 23 studies conducted between 1960 and 2008 (1,053 clients).

• Compared LTPT to a range of treatments (CBT, DBT, family therapy, STPD ).

• LTPT was more effective regarding overall outcome, target problems, and personality functioning.

Sandell and colleagues (2000s): • Evaluated outcome for 400 clients who received psychoanalysis [mean 51 mos; 3.5 x wk] /psychoanalytic therapy [mean 40 mos; 1.4 x wk] and found both effective.

• Three-year follow-up: Psychoanalysis led to better outcomes.

• More experienced psychoanalysts achieved better outcomes.

• Frequency and duration interacted to moderate outcome in a positive direction.

Psychoanalytic Approaches in a Multicultural World

Psychoanalytical approaches underscore the role unconscious biases and prejudices about race, culture, and class play in shaping our daily interactions. Internalized cultural attitudes play out unconsciously in the transference–countertransference matrix for both client and therapist.

Chapter 2: Activities Role play Imagine that a teenager is trying to decide whether to engage in smoking marijuana with his or her friends. Have three students role-play how the id, ego, and superego would converse to make a decision about what to do.

Discussion Questions 1.

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The average person in America knows who Freud was and several basic psychoanalytic concepts. Ask students which concepts they were aware of before reading this chapter.

Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. Ask them to discuss how they think psychoanalytic terms have influenced the public’s view of psychotherapy.

2.

Freud viewed dreams as the “royal road to the unconscious.” Ask willing students to report one of their dreams to the class and have other students give various possible interpretations of the dreams.

Use of Movies to Depict Concepts

Hollywood’s version of therapy is often a depiction of traditional psychoanalysis. The patient is seen lying on the couch with the therapist taking notes at their side without any direct eye to eye contact. Ask your students if this is their picture of therapy. Discuss whether movie portrayals of therapy have influenced their ideas about therapy and how. Movies and Mental Illness 3rd edition can provide movie depictions — especially Woody Allen films — on psychoanalysis to strengthen the discussion.

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© 2014 Cengage Learning, Inc. Case Illustration from Case Studies in Psychotherapies (7th Edition)

The Case of Simone by Jeremy Safran This case study illustrates many of the concepts from this chapter in more detail. It is also an excellent introduction to long-term psychotherapy — Dr. Safran worked with Simone for four years, typically seeing her three times each week.

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© 2014 Cengage Learning, Inc.

Chapter 2: Test Items Multiple Choice Test Bank 1.

A common assumption across psychoanalytic perspectives is that humans are motivated by: a. unconscious factors. b. learning principles. c. relationship stressors. d. biological predispositions.

REF: Overview (p. 20) ANS: A

2.

Psychoanalytic therapists view the therapeutic relationship as: a. the vehicle for change. b. irrelevant to the process. c. secondary to the theory. d. solely defined by the patient.

REF: Overview (p. 20) ANS: A

3.

During psychoanalysis, a patient discusses a fantasy. The psychoanalytical therapist would see this fantasy as linked to a(n): a. instinctually derived wish. b. behavioral pattern warranting change. c. cognitive distortion. d. irrational belief system.

REF: Overview (p. 21) ANS: A

4.

Psychoanalytic theory would assert that the behavior of a newborn is dominantly controlled by: a. collective unconscious. b. reaction formation. c. primary process. d. secondary process.

REF: Overview (p. 21) ANS: C

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© 2014 Cengage Learning, Inc. 5.

Secondary process refers to thinking that is: a. logical. b. verbal. c. primitive. d. visual.

REF: Overview (p. 21) ANS: A

6.

The process by which intrapsychic elements are barred from consciousness is termed: a. abreaction. b. determinism. c. conceptualization. d. defense.

REF: Overview (p. 21) ANS: D

7.

Every time Charles feels insecure in his relationship with Megan, he accuses Megan of being insecure. This is an example of: a. intellectualization. b. projection. c. reaction formation. d. splitting.

REF: Overview (p. 21) ANS: B

8.

Sally’s view of her therapist continuously shifts from “good” to “bad.” This is an example of: a. intellectualization. b. projection. c. reaction formation. d. splitting.

REF: Overview (p. 21-22) ANS: D

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. 9.

Bob talks rationally about the fact that his wife of 30 years has unexpectedly asked for a divorce and discusses the practical aspects of moving out, totally avoiding any show of emotion. This is an example of: a. intellectualization. b. projection. c. reaction formation. d. splitting.

REF: Overview (p. 21) ANS: A

10.

When someone denies a threatening feeling and is proclaiming to feel the opposite, they are displaying the defense mechanism of: a. intellectualization. b. projection. c. reaction formation. d. splitting.

REF: Overview (p. 21) ANS: C

11.

Joan becomes agitated with her psychoanalyst’s interpretations, perceiving the comments as judgmental, which reminds her of interactions with her father. This is known as: a. regression. b. transference. c. resistance. d. autoeroticism.

REF: Overview (p. 22) ANS: B

12.

The shift in psychoanalytic therapies from a one- vs. two-person psychology refers to the emphasis psychoanalytical therapy places on: a. couples counseling to address distress. b. the role of family in development of pathology. c. transference and counter-transference. d. mutual influence of therapist and patient in therapy.

REF: Overview (p. 22) ANS: D

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© 2014 Cengage Learning, Inc. 13.

Which of the following theorist was psychoanalytically trained prior to developing a distinct form of psychotherapy? a.

Albert Ellis b.

Martin Seligman c.

Albert Bandura d.

B. F. Skinner REF: Overview (p. 23) ANS: A

14.

Looking back at the historical development of psychoanalysis, it is ironic that a factor in the decline of the popularity of psychoanalysis is: a. psychiatry’s shift to a biological model. b. the public’s view that it is an elitist model. c. popularity of evidence-based approaches. d. non-responsiveness to valid criticisms.

REF: Overview (p. 23) ANS: B

15.

In Studies on Hysteria, Freud wrote about his early theoretical ideas derived from work with hypnosis and hysterics. This manuscript includes a summary of the work with Anna O., whose treatment was provided by: a.

Jean Charcot. b.

Josef Breuer. c.

Hermann Helmholtz. d.

Charles Darwin.

REF: History (p. 25) ANS: B

16.

Freud’s early view of hysteria described the symptoms as resulting from: a. hypnotic states for which the patient lacked awareness. b. behaviors learned early in childhood from role models. c. unexpressed emotions connected with painful experiences. d. an unresolvable sense of social inferiority.

REF: History (p. 25) ANS: C

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. 17.

In utilizing hypnosis, free association and other techniques, Freud’s therapeutic goal centered primarily on: a. eliminating memories of traumatic events. b. creation of a fixated state. c. making unconscious events conscious. d. converting conscious events into unconsciousness.

REF: History (p. 25) ANS: C

18.

Starting during infancy, there is a psychobiological push to repeat experiences that lead to tension reduction. This concept is known as: a. defense mechanisms. b. confident expectancy. c. embodiment actions. d. pleasure principle.

REF: History (p. 26) ANS: D

19.

The psychological theory created by Carl Jung is termed: a. analytical psychology. b. individual psychology. c. psychodynamic psychology. d. complex psychology.

REF: History (p. 28) ANS: A

20.

Jung described emotionally charged ideas that were repressed because they were too emotionally threatening as: a. shadows. b. complexes. c. libidos. d. egos.

REF: History (p. 27) ANS: B

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© 2014 Cengage Learning, Inc. 21.

Several variations on psychoanalytic theory have emerged. The theorist who emphasized the internal representations one makes of others was: a.

Anna Freud. b.

Melanie Klein. c.

Margaret Mahler. d.

D. W. Winnicott.

REF: History (p. 28) ANS: B

22.

Heinz Kohut, who studied the narcissistic personality, viewed its development as the result of the parental figures’ failed attempts to appropriately respond to a child’s early attention seeking. Therefore, he underscored the importance of a therapist: a. role modeling narcissism to offset patient’s behavior. b. discussing patient’s expression of sexual impulses. c. reviewing the patient’s formative years. d. establishing an empathic stance.

REF: History (p. 30) ANS: D

23.

Jacques Lacan would argue that the ego is a(n): a. biological entity. b. psychic discharge. c. illusion. d. catharsis.

REF: History (p. 31) ANS: C

24.

John Bowlby theorized that infants develop early representations of attachment figures and referred to these representations as: a. projective identification. b. transitional objects. c. internal working models. d. self psychology.

REF: Personality (p. 34) ANS: C

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. 25.

In contrast to therapy offered according to classic psychoanalytical theory, newer approaches focus less on childhood sexuality and more on: a. dream analysis. b. id impulses. c. determinism. d. attachment.

REF: Personality (p. 32-34) ANS: D

26.

In contrast to traditional psychoanalysis, current psychodynamic psychotherapy approaches are less: a. directive. b. empirically based. c. intensive. d. helpful.

REF: Psychotherapy (p. 35) ANS: C

27.

A therapist points out the similarities between her female patient’s current anger at a female boss and the childhood anger she felt towards her mother. The goal of psychoanalysis this illustrates is: a. narcissistic. b. strategic. c. transference. d. tactical.

REF: Psychotherapy (p. 36) ANS: C

28.

The central task of psychoanalytical therapy is to: a. resolve intrapsychic conflicts. b. establish empathy. c. break down defenses. d. strengthen the superego.

REF: Psychotherapy (p. 39) ANS: B

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© 2014 Cengage Learning, Inc. 29.

Psychoanalytical therapies rely heavily on therapists providing clients with ways to become aware of aspects of their intrapsychic experiences that have previously been unconscious. In other words, they rely on: a. interpretations. b. enactments. c. reconstructions. d. confrontations.

REF: Psychotherapy (p. 39) ANS: A

30.

In working with patients, therapists must learn to attend to their own emotional reactions and process disturbing emotions in a non-defensive, non-judgmental manner. This is referred to as: a. rupture. b. interpretations. c, enactments. d. containment.

REF: Psychotherapy (p. 43) ANS: D

31.

Just like how a mother will fail to attend to the needs of a child, no matter how well intended, a therapist will occasionally fail to attend to the needs of a patient. Negotiating this pattern within a relationship has been termed: a. transference and countertransference. b. rupture and repair. c. idealization and fixation. d. disappointment and despair.

REF: Psychotherapy (p. 43) ANS: B

32.

In contrast to short-term therapies, Leichsenring and Rabung (2008) found that, in the treatment of complex psychological disorders, long term psychoanalytical therapies were: a. less effective overall. b. more effective overall. c. less satisfying to patients. d. more satisfying to patients.

REF: Applications (p. 45) ANS: B

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Psychoanalytic Psychotherapies

© 2014 Cengage Learning, Inc. Fill in the Blanks 1.

Freud’s view of the individual psychic elements of the mind as layered in consciousness is known as _________.

ANS: Topography

2.

While the main emphasis of psychoanalysis is a focus on unconscious drives, the Jungian approach is focused on ______.

ANS: Cultural symbols

3.

Freud viewed the main task of therapy as _______, which he referred to as a release of emotion connected with painful experiences that had not been naturally discharged.

ANS: Catharsis

4.

According to Freud, ______ shifts from oral sources to anal sources to the genitals during early development and later is expressed through sexuality with another object.

ANS: Libidinal gratification

5.

Freud’s topographical model of the mind proposed ______, ______, and ______.

ANS: Conscious, preconscious, and unconscious

6.

When Freud revised his psychological model to a structural model, he proposed _____, _____, and _____.

ANS: Id, ego, and superego

7.

The ability to hold onto one’s own experience while simultaneously experiencing another as an independent center of subjectivity is termed ___________.

ANS: Intersubjectivity

8.

If a therapist finds himself/herself reacting to a patient in a manner similar to a previous person in their life, this is known as _________.

ANS: Countertransference

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© 2014 Cengage Learning, Inc. 9.

As part of the process of normal development, children defend against feelings that are threatening by projecting them onto an attachment figure. When patients attempt to project their distress onto the therapist, it is important for the therapist to engage in __________ (i.e., attend to their own painful emotions).

ANS: Containment

10.

The most rigorous evidence supporting psychoanalytical therapies comes from randomized clinical trials examining the efficacy of ________________________.

ANS: Short-term dynamic psychotherapy (STDP) Essay Questions

1.

Psychoanalysis is human nature viewed from the point of conflict. What does this mean?

Do you agree that human nature is best viewed from this perspective? Why or why not?

2.

Psychoanalytic theory hypothesizes that personality evolves from biology-experience interaction and that a healthy mood develops from “confident expectancy.” What happens psychologically if a child’s needs are not met or trauma occurs?

3.

Many of Freud’s ideas about childhood sexuality have been controversial, especially at the time they were first introduced. Discuss Freud’s ideas about childhood sexuality and how his concepts were related to the era in which they were hypothesized. Also discuss how these concepts would be related to normal development and the development of psychopathology.

4.

Psychoanalysis and psychoanalytic theory have fallen out of favor for many reasons.

Discuss some of the reasons. Then, discuss the research and advancements that proponents of psychoanalytical therapies could use to increase confidence in psychoanalytical approaches. Describe how newer models of dynamic psychotherapy differ from the original psychoanalytic situation that would have been offered through psychoanalysis.

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© 2014 Cengage Learning, Inc.

Chapter 3 Adlerian Therapy Authors: Michael P. Maniacci, Laurie Sackett-Maniacci, and Harold H. Mosak

Key Points and Terms Overview ► ► ► ►

Developed by Alfred Adler; also termed individual psychology.

Views person as a creative, responsible, “becoming” individual.

Psychopathology results from discouragement/sense of inferiority.

Energy needs to focus on social interests.

Holism ► ► ► ►

People should not be broken into parts.

Adlerians approach individuals holistically.

People need to be considered in their social contexts.

Field of study is the whole person in the person’s social network.

Teleology ► Adlerian psychology is concerned with purposes. ► Aristotle (1941) outlined four causes: ▪ Material: What is it made of?

▪ Efficient: What caused it to be?

▪ Formal: What shape does it take?

▪ Final: What purpose does it serve? (most emphasized by Adlerians) Creativity ► People viewed as actors, not merely as reactors.

Adlerian Psychotherapy

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© 2014 Cengage Learning, Inc. ► ►

Parents affect children, but children affect parents also.

No two children ever grow up in the same family.

Phenomenology ► Important to understand an individual’s objective situation. ► Equally important to understand their subjective perspective. ► Many who appear to have (by external standards) a “gift” perceive it as a “curse.”

Determinism ► Hard determinism: “A leads to B.” ► Non-determinism states there are no causes; everything is a matter of free will. ► Adlerians advocate for soft determinism — stresses influences, not causes; probabilities, not certainties.

Social Field Theory ► Adlerians examine the social field in which behavior takes place. ► Adler described 3 main tasks of life: 1. Work 2. Community 3. Love ► Psychopathology designed to avoid or evade one or more of life’s tasks.

Motivation as Striving ► Individuals are motivated to move from minus situations to plus situations. ► Adler initially believed children felt inferior and strove to feel superior. ► He later reversed the order (i.e., realized children strive to achieve some goal first; only when frustrated do they feel inferior or inadequate).

Idiographic Orientation ► Adlerians emphasize the idiographic rather than the nomothetic nature of people. ► Specifics of a case are more important than the generalities.

Psychology of Use ► More important to know what “use” a person makes of what they have. ► Psychology of possession: Bill has quite a temper. ► Psychology of use: Bill’s temper is used to control others. ► Language of a psychology of use is active, directive, and complex.

Acting “As If” ► People form maps of their worlds and act “as if” those maps are accurate representations of reality. ► Life will not yield to our maps. ► Adlerians are interested in how we cling to our maps and use the term lifestyle in reference to this. ► Lifestyle has 4 main components: 1. Self-Concept: Who I am or am not.

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Adlerian Psychotherapy

© 2014 Cengage Learning, Inc. 2. Self-Ideal: Who I should be or should not be.

3. Worldview: Instructions about people, life, and the world.

4. Ethical Convictions: What is right or wrong, good or bad.

Self-Fulfilling Prophecy ► When people act “as if” their maps are real, true, or correct, they actively shape the feedback they receive. ► Feedback received is really partially a by-product of the feed-forward mechanisms they have sent out.

Optimism ► Adler believed people were neither fundamentally good nor fundamentally bad. ► They could be either, depending on many factors. ► Everybody can be better than he or she is at any given point.

Adler’s Central Strivings

Perfection

Competence

Superiority

Completion

Self Realization

Mastery

Self Actualization

Summary ► Life provides alternatives; individuals make choices. ► Concepts of value and meaning underscored. ► As all behavior is purposeful, symptoms are viewed in terms of their purpose. ► Living demands courage. ► Courage requires a willingness to take risks. ► Life has no intrinsic meaning; we give it meaning.

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© 2014 Cengage Learning, Inc. Comparing Adlerian Therapy to Other Systems Adlerian Psychotherapy Contrasted with Behavior Therapy “We (Adlerians) do not attempt primarily to change behavior patterns or remove symptoms. If a patient improves his behavior because he finds it profitable at the time, without changing his basic premises, then we do not consider that as a therapeutic success. We are trying to change goals, concepts, and notions.”

— Dreikers, 1963

Cognitive Behavioral

▪ ▪

Mindfulness

▪ ▪ ▪ ▪

Acceptance and Commitment Therapy

▪

Solution Focused Therapy

▪

▪ ▪

▪ ▪

Attachment Theory

▪ ▪ ▪ ▪ ▪

Positive Psychology

38

▪ ▪

Adlerian Psychotherapy Contrasted with Other Approaches Emphasizes a relationship between beliefs, emotions and behaviors.

Has analogous concepts (e.g., “should” statements in CBT similar to Adlerian unrealistic self-ideal beliefs).

Emphasizes what and how a person thinks.

Underscores the importance of the therapeutic relationship.

Shares perspective that what and how one thinks affects behavior and well-being.

Diverges in that Adlerians seek to identify and modify negative beliefs like CBT, while mindfulness helps clients accept their current thought patterns as “just thoughts” without modifying them.

ACT seeks to help a client articulate what he or she wants life to mean.

Therapist helps client create a life plan and move toward goals.

ACT therapists, like Adlerian therapists, collaborate with clients to define changes they want in regards to life tasks.

Lends themselves to a brief-therapy approach; both are goaloriented.

Works toward identifying client goals via a collaborative relationship.

Adlerians pose “The Question;” solution-focused therapists employ the “The Miracle Question.”

Both therapies embrace an optimistic view of people.

Adlerian theory incorporates role of attachment, attachment theory explores it in detail.

Via early experiences, children develop working models of self and others.

Attachment theory is more deterministic.

Attachment theory shares with Adlerian theory an emphasis on the importance of the social field.

Focus on an individual’s strengths is overlapping.

Despite this overlap, the positive psychology literature almost never mentions Adler’s ideas.

Adlerian Psychotherapy

© 2014 Cengage Learning, Inc.

Language How to Understand the Individual Substratum of the Theory Emphasis Characterization of the Individual View of Human Nature Role of Hereditary and Environment How Information about Child Development was integrated Focus Regarding Familial Interactions View of Others View of Women’s Perceptions of Self Source of Neurosis Neurosis is the Price we Pay for …

Adler Freud Common sense Esoteric Subjective Objective Interpersonal Intrapersonal Social Physiological Teleology Causality Holistic Reductionistic People can be good or People are bad bad Free to chose Deterministic Direct observation Postindictive Family constellation

Oedipal complex

Mitmenschen (fellows) Cultural messages Learning Lack of civilization

Enemies Penis envy Sexual Civilization

History of Adlerian Psychotherapy “Adler once proclaimed that he was more concerned that his theories survived than that people remembered to associate his theories with his name.”

Below are some examples of theorists Adler influenced: ► ► ►

Karen Horney Erich Fromm Harry Stack Sullivan

► ► ► ►

Carl Rogers Albert Ellis Aaron Beck Viktor Frankl

► ►

Abraham Maslow Rollo May

Influences on Adler ► Adler was born Feb.7, 1870, in Vienna and graduated in 1895 from Univ. of Vienna. ► In 1902, joined Freud’s Wednesday discussion groups. ► Introduced concept of aggression instinct in 1908 (not accepted by Freud until 1923). ► In 1911, resigned as President of the Vienna Psychoanalytic Society. ► In 1917, wrote Study of Organ Inferiority and Its Psychical Compensation. ► Adler created first community-outreach program. ► From 1926 to 1934, Adler lectured internationally. ► Died in Scotland on May 27, 1937.

Current Status of Adlerian Psychotherapy ► 1952 — Formation of American Society of Adlerian Psychology (now known as the North American Society of Adlerian Psychology).

Adlerian Psychotherapy

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© 2014 Cengage Learning, Inc. ► ► ►

Rudolf Dreikers brought family education centers to U.S. and offered group psychotherapy; similar programs continue today.

Journal of Individual Psychology Focus remains on reeducating individuals and reshaping society.

Theory of Personality Personality vs. Lifestyle ► Temperament refers to the inborn characteristics children have genetically. ► Temperament is quickly modified via learning and socialization. ► Personality is the collection of characteristics developed through socialization. ► Lifestyle is the use of personality, traits, temperament, psychological and biological processes to find place in social matrix of life. ► Development of lifestyle: ▪ Degree of activity ▪ Organ inferiority ▪ Birth order and sibling relationships ▪ Family values ▪ Family atmosphere ▪ Parenting style ► Reason refers to intelligence that includes the human element, the concern for others and their well-being. ► Safeguarding operations are those mechanisms people use to evade life tasks.

Family Constellation ► Family is primary social environment. ► Child competes for position within the family; psychological position is what is relevant. ► Important factors could include: ▪ Favored by others ▪ Birth order ▪ Gender ▪ Handicaps/organ inferiorities ▪ Alignment of family values and child ► No causal, 1-to-1 relationship between family position and traits assumed. ► Must be seen in the context of the entire family climate. ► Each child tries to gain worth within the family through their own perceptions of how to achieve it. ► Over time, child accepts conclusions “as if” they are truths. ► If child senses worth can be achieved through useful endeavors, they pursue the “useful side of life.” ► If not, child becomes discouraged and engages in destructive behavior to: ▪ Obtain attention.

▪ Seek power.

▪ Take revenge.

▪ Declare deficiency or defeat.

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Adlerian Psychotherapy

© 2014 Cengage Learning, Inc. Life Style Convictions Term Self-concept Self-ideal Weltbild Ethical

Convictions Who I am What I should be What the world is Personal “right or wrongs”

Inferiority Complex ► Discrepancy between self and ideal self, Weltbild, or ethical convictions. ► Ideas about masculine protest led to rift between Adler and Freud. ► Adler believed in equality of the sexes.

Adler’s Ideas About Coping ► Adlerians reject the conscious. Instead of framing coping in terms of defense mechanisms, they describe problem-solving devices used to protect self.

▪ Safeguards ▪ Excuses ▪ Projection ▪ Depreciation tendency ▪ Creating distance ▪ Identification The Psychotherapy Process Psychotherapy Change of lifestyle.

Counseling Change of behavior within the lifestyle.

Effective Therapy

Faith Love

Hope

Educational Enterprise ► Fostering social interest ► Decreasing feelings of inferiority ► Changing the person’s lifestyle ► Changing faulty motivations ► Encouraging a view of equality ► Helping patient become a contributing human being Adlerian Psychotherapy

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© 2014 Cengage Learning, Inc. Aims ► ► ► ►

Establishing a relationship Uncovering dynamics Interpretation leading to insight Reorientation

Analysis ► Lifestyle investigation ► Summary of family constellation ► Summary of early recollections ▪ Represents single events.

▪ “One day _______________ happened.”

▪ May be accurate or fantasy.

▪ Different than “reports,” which are grouped events.

▪ “My family used to always go on Sunday drives.” ► Reorientation ► Persuading the patient to attempt change ► Insight ► Understanding translated into constructive action ► Interpretation ► Emphasis is on purpose not cause, movement rather than description, use rather than possession. ► Past related to present through continuity of thoughts, behaviors, feelings.

Adlerian’s Concept of Basic Mistakes and Assets Classification Example Overgeneralization “Men are bad.”

False or impossible goals of security “I must make everyone like me.”

Misperceptions of life/life’s demands “I never get a break.”

Minimization/denial of one’s worth “I’m stupid.”

Faulty values “I must always take care of others regardless of the cost .”

View of Dreams ► Problem-solving activity ► Future orientation ► “Factory of emotions” “I woke smiling … so I knew my dreams were good, although I had forgotten them.”

— Adler (the day before his death) Adlerian Psychotherapy Verbal Techniques ► Advice given directly or through provision of alternatives.

▪ Encouragement ▪ Catharsis ▪ Abreaction 42

Adlerian Psychotherapy

© 2014 Cengage Learning, Inc. ▪

Confession

Adlerian Psychotherapy Action Techniques ► Role-playing ► Empty chair technique ► Midas technique ► Behind-the-back technique Other Adlerian Psychotherapy Concepts ► Therapist as model ► Change ► Acting “As If” ► Task setting ► Creating images ► Catching oneself ► Push-button techniques ► “Aha” experience Applications of Adlerian Psychotherapy “The whole body of social psychiatry would have been impossible without Adler’s pioneering zest.”

— Meerloo (eulogizing Adler) ► ► ► ►

Applications generally focus on prevention rather than psychopathology.

Clinical interventions expanded to psychotic patients rather than only neurotics.

Family education centers Addressing social problems

Evidence Adlerians reject causalism and use an idiographic (case method) approach. Therefore, research studies evaluating the theory or its clinical applications are rare. Adlerians are unlikely to support the emphasis on empirically-supported treatments. However, the Adlerian concept of lifestyle and the techniques used in Adlerian psychotherapy are in keeping with the focus on empirically-informed treatments.

Chapter 3: Activities Role-play Adlerians often use action techniques in therapy. Ask students to role-play implementing action techniques such as talking to an empty chair, the Midas technique and the behind-the back technique.

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© 2014 Cengage Learning, Inc. Discussion Questions 1.

The family constellation is a critical concept in Adlerian psychotherapy. Have students discuss how issues like birth order, gender, alignment with family values and being favored within a family later might impact an individual.

2.

Adler once said “It is easier to fight for one’s principles than to live up to them.” Ask students to discuss how a therapist who adhered to Adler’s principles might act outside of their clinical office.

Use of Movies to Depict Concepts

Movies and Mental Illness points out two films that illustrate social anxiety/avoidant personality disorders and how they result in a fear of rejection, which interferes with the formation of healthy interpersonal relationships: One Hour Photo (2002) and Finding Forrester (2000). In the first, Robin Williams plays a socially-isolated character who develops a pseudo family through photos. In the second, Sean Connery’s character is isolated in his apartment and can only be seen by others when cleaning his windows. Discussions of these films can lead to discussions about whether anxiety stems from a lack of courage to be imperfect. Additionally, the films can demonstrate how the development of courage to face ones inferiorities can alter one’s life.

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© 2014 Cengage Learning, Inc. Case Illustration from Case Studies in Psychotherapies (7th Edition)

The Case of Roger by Harold Mosak This case demonstrates an Adlerian therapy approach to the treatment of a gay man struggling, in part, with issues of sexual identity. As the therapy explores the client’s choices, the case illustrates Adlerian psychotherapy but also allows for discussions about ethical and professional issues associated with treating clients who may be dealing with sexual or gender identity concerns. In addition, the case illustrates the application of Adlerian techniques.

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© 2014 Cengage Learning, Inc.

Chapter 3: Potential Test Items Multiple Choice Test Bank 1.

Alfred Adler’s theory of personality emphasized the importance of: a. constructivist perspective. b. the collective unconscious. c. classical conditioning. d. character deficits.

REF: Overview (p. 55) ANS: A

2.

Adler viewed the primary influence on an individual as: a. genetic predispositions. b. intrapsychic conflicts. c. social context. d. behavioral reinforcers.

REF: Overview (p. 56) ANS: C

3.

In Adlerian psychology, the individual is viewed in a framework that is: a. reductionistic. b. holistic. c. behavioristic. d. oedipal.

REF: Overview (p. 56) ANS: B

4.

Adlerians emphasize which of the following causes: a. material. b. purpose. c. efficient. d. formal.

REF: Overview (p. 56) ANS: B

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Adlerian Psychotherapy

© 2014 Cengage Learning, Inc. 5.

Adlerians advocate for a model of behavior that relies on: a hard determinism. b. non-determinism. c. double determinism. d. soft determinism.

REF: Overview (p. 57) ANS: D

6.

Adler’s three original life tasks included: a. work, community, and love. b. work, power, and spiritual. c. sex, control, and courage. d. society, spiritual, and work.

REF: Overview (p. 57) ANS: A

7.

A plus situation is defined: a. through traits of courage. b. by each individual. c. by the environment. d. by societal expectations.

REF: Overview (p. 57-58) ANS: B

8.

To an Adlerian, a minus situation is: a. determined by heredity. b. personally chosen. c. environmentally established. d. universally the same for all humans.

REF: Overview (p. 58) ANS: B

9.

The assumption can be made that Adler would be proud when his ideas are described as: a. interchangeable with Freudian theory. b. including hope, faith and compassion. c. emphasizing sexual development. d. based on deterministic philosophy.

REF: Overview (p. 59) ANS: B

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© 2014 Cengage Learning, Inc. 10.

Adlerian theory and cognitive behavioral approaches both emphasize: a. inferiority complexes. b symbolism. c. birth order. d. belief systems.

REF: Overview (p. 60) ANS: D

11.

Solution-focused therapy’s use of the “Miracle Question” is congruent with Adler’s use of: a. unconscious motivation. b. irrational ideas. c. active behavior. d. the question.

REF: Overview (p. 61) ANS: D

12.

Congruent with the focus of Adlerian psychology, current Adlerians often focus on: a. treatment outcomes research. b private clinical practice. c. research on the origin of pathology. d. physical, mental and social well-being.

REF: History (p. 65) ANS: D

13.

Adlerians characterize one’s position in the family constellation in terms of the: a. physiological position. b. birth order ranking. c. parental view. d. pattern of influence.

REF: Personality (p. 66-67) ANS: C

14.

The use of one’s personality, traits, temperament, and psychological and biological processes to find a place in the social matrix of life refers to: a. lifestyle. b. conviction. c. self-concept. d. “right-wrong” code.

REF: Personality (p. 66) ANS: A

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© 2014 Cengage Learning, Inc. 15.

The individual with “psychopathology,” according to Adler, would be described most accurately as: a. incapable of social interest. b. suffering from biologically-based problems. c. void of inferiority feelings. d. discouraged rather than sick.

REF: Personality (p. 68) ANS: D

16.

A discrepancy between self-concept and self-ideal that results in discouragement and pathological symptoms represents: a. inferiority feelings. b. an ethical convictions dilemma. c. an inferiority complex. d. a sense of normality.

REF: Personality (p. 68) ANS: C

17.

For Adlerians, feelings of inferiority are deemed as: a. universal and normal. b. rare and abnormal. c. pervasive and abnormal. d. unusual yet normal.

REF: Overview (p. 68) ANS: A

18.

Which of the following is NOT one of the stages/processes of Adlerian psychotherapy? a.

Relationship building b.

Interpretation c.

Deconstructing d.

Reorientation REF: Psychotherapy (p. 72) ANS: C

19.

Adlerians’ description of a special diagnosis refers to: a. biologically based uncontrollable processes. b. the lifestyle assessment. c. the diagnostic interview. d. labels used for inferiority complexes.

REF: Psychotherapy (p. 73) ANS: B Adlerian Psychotherapy

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20.

As even psychologically healthy individuals continue to have some faulty convictions during reorientation, Adlerian psychotherapy focuses on: a. accepting that change is not achievable. b. instilling enough courage to obtain perfection. c. gaining insight regarding the source of errors. d. replacing large errors with smaller ones.

REF: Psychotherapy (p. 75) ANS: D

21.

A major goal of Adlerian psychotherapy can be viewed as a modification of: a. behavior. b. defenses. c. convictions. d. conflicts.

REF: Psychotherapy (p. 75) ANS: C

22.

An Adlerian therapist aims to be a(n): a. interpreter of transference. b. collaborative educator. c. authority figure. d. passive participant.

REF: Psychotherapy (p. 72) ANS: B

23.

Adlerians view recollections as projective techniques as individuals are seen as selectively recollecting past events congruent with: a. behavior patterns. b. lifestyle. c. social interest. d. neurotic symptoms.

REF: Psychotherapy (p. 74) ANS: B

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Adlerian Psychotherapy

© 2014 Cengage Learning, Inc. 24.

In the process of Adlerian psychotherapy, the therapist will often venture a guess. This method is congruent with the: a. willingness to be empathic. b. role of emphasizing the unconscious. c. courage to be imperfect. d. special diagnosis task.

REF: Psychotherapy (p. 75) ANS: C

25.

Adler considered a dream to be: a. early recollections emerging during sleep. b. an attempt to solve a future-oriented problem. c. lacking psychological importance. d. a restorative process for the mind.

REF: Psychotherapy (p. 77) ANS: B

26.

Spitting in the soup, as defined by an Adlerian, represents: a. demonstrating understanding regardless of its impact on behavior. b. an approach that lends itself to restructuring or beliefs by spoiling them. c. behavioral change regardless of its origin. d. a desire to discuss problems rather than solve them.

REF: Psychotherapy (p. 78) ANS: B

27.

The ability to portray courageous behavior is determined by whether: a. an individual possesses the trait of courage. b. the environment creates the setting for the behavior. c. omnipotent, perfection-driven behavior has been achieved. d. an individual has a willingness to take risks.

REF: Psychotherapy (p. 76) ANS: D

28.

Family sculpting refers to a technique where: a. an individual creates a perceived versus ideal sculpting of family. b. a therapist provides group therapy to patients. c. several theories form the basis of a treatment. d. concurrent individual and group therapy is offered.

REF: Psychotherapy (p. 78) ANS: A

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© 2014 Cengage Learning, Inc. 29.

In developing therapeutic relationships with couples, Adlerian therapists: a. adhere to the concept of the anonymous therapist. b. facilitate and interpret transference relationships. c. magnify social distance between partners. d. use a tactic called lifestyle matching.

REF: Applications (p. 79) ANS: D

30.

Multiple psychotherapy refers to a therapeutic format where: a. a therapist provides group therapy to patients. b. several theories form the basis of a treatment. c. concurrent individual and group therapy is offered. d. several therapists treat a single patient.

REF: Applications (p. 81) ANS: D Fill in the Blanks

1.

Adlerian therapy views psychopathology as resulting from a sense of _______.

ANS: Inferiority

2.

The term _______ refers to an approach where a therapist uses an interpretation to reframe a client’s symptoms in such a way they will give them up or, if they maintain the symptoms, the symptoms are now spoiled.

ANS: Spitting in the soup

3.

Adler believed that humans should be studied and treated _______.

ANS: Holistically

4.

Adler believed that life’s tasks centered around _______, _______, _______, _______, and _______.

ANS: Society, work, sex, universe, and ourselves

5.

Both Adler and Freud believed that women often perceive themselves as inferior to men.

Adler believed this resulted from _______, while Freud believed it resulted from _______.

ANS: Cultural messages; penis envy

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© 2014 Cengage Learning, Inc. 6.

Adler is credited with introducing the concept of _______ instincts into psychoanalytic theory.

ANS: Aggressive

7.

The fundamental question in Adlerian psychotherapy is “how does the individual use _______ and _______.”

ANS: Hereditary and environment

8.

When an Adlerian therapist examines Axis IV stressors (i.e., revealing what situations arose at the time of symptom development), this is referred to as the _______ factor.

ANS: Shock (exogenous)

9.

Adlerians view counseling as focusing on a change of behavior within lifestyle, whereas psychotherapy focuses on a change of _______.

ANS: Lifestyle

10.

The phase of Adlerian psychotherapy focused on persuading the patient to attempt change is termed _______.

ANS: Reorientation Essay Questions

1.

Despite Freud’s influence on Adler, there are numerous differences between Adlerian psychotherapy and psychoanalysis. Describe the differences.

2.

Adler believed that life presents us with challenges in the form of life tasks. What were the three life tasks Adler specifically named? What were the two other life tasks he alluded to in his writings?

3.

Adler developed his individual psychology during a turbulent time in history. Describe the impact the political and social issues of time may have had on his form of therapy.

4.

Adlerian psychotherapy focuses on lifestyle. Describe what Adler meant by this concept and Mosak’s four lifestyle convictions. Make sure and provide details about the impact of discrepancies between the convictions.

5.

Describe Adlerian psychotherapy. Begin by discussing the process and elaborating on “basic mistakes” and how they are uncovered in therapy. Then, describe some of the techniques which might be utilized.

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© 2014 Cengage Learning, Inc.

Chapter 4 Client-Centered Therapy Authors: Nathaniel J. Raskin, Carl R. Rogers and Marjorie C. Witty

Key Points and Terms Overview ► ►

► ► ►

►

►

►

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Client-centered therapy (also called the third force at the time of its inception) was developed by Carl Rogers, who was influenced by the work of Kurt Goldstein.

Carl Rogers: ▪ Considered among the most eminent psychologists of the 20th century.

▪ Most named by other psychotherapists as having influenced their practice.

Also termed person-centered, humanistic or phenomenological therapy.

Central hypothesis is that the provision of unconditional positive regard by a congruent therapist leads to therapeutic change.

The Person: ▪ Human is seen as sovereign, “a person.”

▪ Humans are viewed as having an actualizing tendency, seen as biological in nature not moral, to realize their unique potential.

▪ Theory places value on the patient’s self-determination and autonomy.

▪ The person is viewed as a creative, responsible, developing individual.

▪ View of the client is in opposition to a medical model that focuses on pathology and views the clinician as an expert who controls the treatment process.

Human Nature: ▪ Every organism possesses an inherent organismic valuing process.

▪ Rogers felt congruence (the state of wholeness and integration within the experience of the person) is the hallmark of psychological adjustment.

The Therapist: ▪ Therapist uses a “non-directive attitude” (i.e., follows the client’s lead).

▪ Therapist strives for “a way of being” (i.e., to be real).

The Relationship:

Client-Centered Therapy

© 2014 Cengage Learning, Inc. ▪

►

►

The quality of the therapeutic relationship is a major contributor to therapeutic outcome.

▪ By providing a therapeutic atmosphere that is real, caring, and nonjudgmental, the person can develop to their full potential.

▪ Client actively co-constructs the therapy.

▪ Individuals and groups are fully capable of articulating their own goals.

The therapist is nondirective and feels an egalitarian relationship is an ethical commitment (i.e., the moral compass that guides the process).

▪ Genuineness/congruence: Correspondence between the therapist’s thoughts and their behavior.

▪ Unconditional positive regard: Therapist’s attitude remains unaltered regardless of the patient’s choice.

▪ Empathic understanding: Profound interest and care for patient’s perceptions and feelings, a way of being.

The Client: ▪ Self-conce0070t • At therapy onset, self-regard/self-esteem often low.

• Improvements correlated with success in therapy.

• Goal is to be a fully functioning person.

▪ Locus-of-Evaluation • At therapy onset, focus on what others think.

• Progress associated with internal locus-of-evaluation.

▪ Experiencing • At therapy onset, rigid; success related to flexibility.

Comparing Client-centered Therapy with Other Approaches

Focusing-Oriented Therapy

▪ ▪ ▪

Emotion-Focused Therapy

▪ ▪ ▪ ▪

Prouty’s Pretherapy

▪

Positive Psychology

▪ ▪ ▪

Created by Eugene Gendlin Locates the experiencing process in the body Uses an acceptant listening to bodily sensing, termed felt-shift Stimulated by work of Laura North Rice “Evocation function of the therapist” Blends Client-centered therapy with Gendlin’s focus Garry Prouty recognized individuals with developmental delays and serious mental illnesses had deficits in relating Pre-therapy focuses on contact reflections in which the therapist mirrors the posture, gestures and facial impressions of the client to increase client’s ability to relate Accentuates the positive Focuses on the client’s strengths Committed to applying scientific methods to phenomena studied (similar to Humanistic approaches)

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© 2014 Cengage Learning, Inc. History of Client-Centered Therapy The work of Otto Rank was heavily influential in Roger’s theory development and ideas about clinical practice. The following elements of Rankian theory are most relevant: ► The client has personal creative powers. ► Self-acceptance and self-reliance are the goal. ► The client is the central figure in the therapy process. ► The therapist should not make the client dependent or attempt to alter the client directly. ► The goals of therapy are achieved through experience the present therapeutic relationship.

The History of Carl Rogers: ► Carl Rogers was born Jan. 8, 1902, in Oak Park, IL. ► Family emphasized strong work ethic, responsibility and the fundamentals of religion. ► Graduated in 1924 from Univ. of Wisconsin. ► Started at the Union Theological Seminary then transferred to Teacher’s College, Columbia University. ► Worked for 12 years at a child-guidance center. ► In 1939, Clinical Treatment of the Problem Child published. ► Offered professorship at Ohio State University. ► On Dec. 11, 1940, Rogers presented “Some Newer Concepts in Psychotherapy” at the Univ. of Minnesota (viewed by most as the birth of client-centered therapy). ► In 1942, Counseling and Psychotherapy published. ► During WWII, served as Director of Counseling Services for the US Organizations. ► Served as head of University of Chicago Counseling Center (12 years). ► In 1957, Rogers published classic paper on “necessary and sufficient conditions” for therapy. ► Died Feb. 4, 1987.

Current Status of Client-Centered Psychotherapy ► Special interest of Rogers was application of his theory to international relationships. ► Since 1982, Biennial International Forums on client-centered approach. ► Workshops annually at Warm Springs. ► The Association for the Development of the Person-Centered Approach (ADPCA) meets annually; information can be found at www.adpca.org. ► In 2000, the World Association for Person-Centered and Experiential Psychotherapy and Counseling (WAPCEPC) became an international forum for client-centered therapists; information can be found at www.pce-world.org.

Rogers’s Theory of Personality 19 Basic Propositions 1. Individual is center of a continually changing world of experience.

2. Organism reacts based on their reality.

3. Organism reacts as an organized whole.

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© 2014 Cengage Learning, Inc. 4. Organism has one basic tendency — actualization.

5. Behavior is goal-directed based on perception of reality.

6. Emotion accompanies and facilitates goal-directed behavior.

7. Best point to understand behavior is from the individual’s frame of reference.

8. Part of the perceptual field is differentiated as the self.

9. Self is formed through interaction.

10. Values come from experience and introjection from others.

11. Experiences are integrated, ignored or denied.

12. Behavior is generally consistent with self-concept.

13. Behaviors inconsistent with self-concept can occur, but are seen as “not owned.”

14. Psychological maladjustment comes from denied experiences.

15. Psychological adjustment occurs when experiences are assimilated.

16. Inconsistent experiences are threats.

17. Under the right conditions, inconsistent experiences can be examined or assimilated.

18. When the individual integrates in all of their experiences, they are more understanding of others.

19. As experiences are integrated, an internal locus-of-evaluation develops.

Rogers’s Theory of Personality Summarized ▪ Behavior is best understood through the individual’s reality (perception of experiences).

▪ Personal growth occurs through decreased defensiveness.

▪ Self-actualization is the organism’s one basic tendency.

▪ Experiences inconsistent with self-concept are threats leading to increased rigidity.

▪ Therapy allows the individual to accept and integrate all of their experiences.

Other Concepts ► Experience is the private world of the individual. ► Reality basically refers to the private perceptions of the individual.

▪ Social reality consists of perceptions that have a high degree of commonality among individuals. ► Deci and Ryan’s self-determination theory (SDT) focuses on intrinsic motivation and numerous studies have been conducted related to it. ► Self is the organized gestalt of “I” or “me.” ► Symbolization is the process by which an indicated becomes aware of experience. ► Psychopathology is defined by incongruence between an individual’s sensory and visceral experiences.

Psychotherapy Implied Therapeutic Conditions ► Client and therapist must be in psychological contact. ► Client must be experiencing distress. ► Client must be willing to receive conditions offered by therapist.

Paramount to the outcome is the therapist’s ability to meet the three core conditions.

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► ►

Brodley asserts that the client self-determines their own content and process.

Positive regard is demonstrated by allowing the patient to choose the type and format of therapy pursued.

Moment of Movement “It is not a thinking about something, it is an experience of something … an experiencing without barriers … experience which has been repeated many times in the past but which has never been completely experienced … The experience has the quality of being acceptable.”

— Rogers In 1959, Rogers described a moment of movement that became a series of events in therapy that lead to change. These moments of movements had four qualities: ► An experience of something. ► Without barriers. ► That has never been completely experienced before. ► Capable of being integrated into the self-concept.

Two possible theories of change regarding the therapeutic process: 1. The traditional view of an uncovering of hidden or denied feelings or experiences: a. Question is how these hidden experiences exist and how are they resolved. b. Listening to client’s narratives is thought to be the avenue for helping the client deal with these internal conflicts.

2. Zimring’s view that asserts a person becomes a person through interactions that occur within a cultural context: a. Individuals born within a Western culture have a “buried conflict” as part of a cultural legacy. b. Our phenomenological frame of references is always changing (i.e., “under construction”) resulting a dynamic concept of the self. c. Experience is seen as coming from the context in which we are in that moment. d. Implies two different types of inner conflicts: ▪ Objective — stressed in Western culture.

▪ Subjective — has little real-world value.

Applications of Client-centered Therapy ► ►

►

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Client-centered therapy is person focused not problem focused. Subsequently, each client is treated as unique.

Diagnoses, problems, and disorders are viewed as socially and politically derived concepts.

▪ Rogers termed the diagnostic process as “for the most part, a colossal waste of time.”

A common misconception about client-centered therapy is the view that the approach only uses the technique of reflection.

Client-Centered Therapy

© 2014 Cengage Learning, Inc. ►

Advocates of the approach indicate it is applicable to a myriad of problems in living across cultural groups. This assertion is made because the theory proposes the therapy outcome rests on the ability of the therapist to meet the core conditions of therapy.

Examples of Specific Applications ► Play therapy ► Client-centered group processes ► Classroom teaching ► Intensive groups ► Conflict resolution ► Individual level ► International level Other resources are also made available to clients; other participants (e.g. family members) can join in the therapy process when requested. ► Remember, the client directs the process.

Client-centered approaches oppose a “therapist-centric” position that assumes causality moves from a treatment to the disorder to the outcome.

Evidence ► Dodo Bird effect refers to the conclusion drawn from meta-analyses and large scale studies that all major psychotherapies yield comparable effect sizes. ► The Dodo Bird effect supports the concept that common factors (such as those espoused

by Rogers) account for changes seen in therapy. ► Bozarth asserts that effective psychotherapy is predicated on: ▪ Relationship between therapist and client.

▪ Inner and external resources of the client.

• Type of therapy, technique, training and experience of therapist largely irrelevant.

• Clients who receive psychotherapy improve more than those who do not.

• Little support that specific treatments are best for particular issues.

• Most consistent variables related to effectiveness are empathy, genuineness and unconditional positive regard. ► There are numerous studies that lend additional support for the core conditions of clientcentered therapy (esp. empathy and positive regard) and suggest these conditions account for most of the treatment progress.

▪ Repeatedly there is a positive association between core conditions and outcome.

▪ Example: Lambert (1992) conducted a meta-analytical review which estimated that treatment outcome variance is related as follows: • 30% therapeutic factors • 15% techniques • 15% placebo • 40% client variables ▪ Example: Elliot (2002) conducted a meta-analysis and concluded patients who received client-centered therapy show treatment changes that are: • Significant Client-Centered Therapy

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© 2014 Cengage Learning, Inc.

►

• Maintained at follow-ups (both greater and less than 12 months) • Substantially greater than those seen in untreated “controls” • Equivalent to other forms of therapy, including CBT ▪ Additionally, many studies produce positive results despite the fact that the therapists evaluated are not ideal at providing client-centered therapy (therapists evaluated often rarely used really active listening only) In regards to the empirically-supported treatments movement, client-centered therapists state that studying client-centered approaches is difficult and that many of the studies attempted to date have numerous methodological limitations.

▪ Double-bind procedures not feasible because therapists are aware of interventions being used.

▪ Difficulties identifying adequate control conditions ▪ Attrition in randomized trials Psychotherapy in a Multicultural World

Client-centered therapists react with skepticism to the idea of “culture specific” approaches and feel emphasis on cultural differences leads to simplistic stereotypes. Withingroup differences are believed to exceed between-group differences. Ability to form a therapeutic relationship depends upon a willingness to be open to and appreciative of all kinds of differences.

Chapter 4: Activities Role-play To illustrate a client-centered approach, have the class decide collectively what an appropriate role-play activity for Chapter 4 would be.

Discussion Questions 1.

Client-centered therapy focuses on genuineness, congruence, and empathy as the critical ingredients for a therapist. Ask students to discuss which of these would be most natural for them to offer to clients. Ask them to further discuss how they would build skill in each of these areas.

2.

Empathy is critical in client-centered therapy. Ask students to discuss their understanding of empathy and barriers that interfere with empathy. Then, ask students to discuss how to maintain empathy in therapy without over identifying with the client.

3.

Rogers’ approach would suggest that the only way to know whether therapy is effective is to use subjective research methods. Ask the class to discuss their view of using subjective ratings by clients and groups members. Encourage a discussion of both the benefits and limitations of such an approach.

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Client-Centered Therapy

© 2014 Cengage Learning, Inc. Use of Movies to Depict Concepts

Client-centered therapy emphasizes congruence, empathy, and unconditional regard — key elements depicted in Lantana (2001). Carl Rogers described these as both necessary and sufficient elements for change to take place. This film can lead to a discussion about the difference between these core elements occurring within a therapeutic relationship versus interactions with friends or family members where empathy, congruence, and unconditional positive regard occur.

Case Illustration from Case Studies in Psychotherapies (7th Edition)

Client-Centered Therapy with David: A Sojourn in Loneliness by Marjorie C. Witty This case shows a client-centered approach to the treatment of a man with schizophrenia.

It illustrates a therapist’s rejection of medical models, diagnostic labels, and artificial hierarchies between therapist and client. The case will allow students to discuss core principles of therapy.

The therapist’s acknowledgement of mistakes she made is also very interesting.

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Chapter 4: Potential Test Items Multiple Choice Test Bank 1.

In developing his theory and clinical practice regarding client-centered therapy, Carl Rogers was heavily influenced by the work of: a.

Albert Ellis. b.

Kurt Goldstein. c.

Sigmund Freud. d.

Aaron Beck.

REF: Overview (p. 96) ANS: B

2.

Which term refers to a state of wholeness and integration? a.

Empathy b.

Positive regard c.

Congruence d.

Experiencing REF: Overview (p. 97) ANS: C

3.

Client-centered therapists believe that empathy, unconditional positive regard, and congruence are: a. conveyed simply through listening and repeating the patient’s words. b. attitudes consonant with a therapist’s values and beliefs. c variables the client brings to the therapeutic relationship. d. attributes that can be faked while the therapist is in training.

REF: Overview (p. 98) ANS: B

4.

Success in client-centered therapy corresponds with a(n): a. rigid experiential mode. b. dependence on the therapist. c. devaluation of others. d. internal locus of control.

REF: Overview (p. 98) ANS: D

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Client-Centered Therapy

© 2014 Cengage Learning, Inc. 5.

Client-centered therapy focuses most heavily on the: a. present. b. future. c. past. d. irrational.

REF: Overview (p. 98) ANS: A

6.

A distinctive characteristic of client-centered therapy is the emphasis on the: a. human being as a person. b. evolutionary development of emotions. c. therapist’s maintenance of a directive stance. d. earliest recollections of the client.

REF: Overview (p. 96-98) ANS: A

7.

The client-centered therapist strives to use an approach that is best described as: a. medical. b. instrumental. c. directive. d. expressive.

REF: Overview (p. 96-98) ANS: D

8.

Gendlin’s experiential therapy locates the experiencing process in the: a. family. b. society. c. therapist. d. body.

REF: Overview (p. 102) ANS: D

9.

Prouty’s pre-therapy approach is most applicable to clients who are: a. personality disordered. b. seeking behavioral change. c. have limited insight. d. developmentally delayed.

REF: Overview (p. 104) ANS: D

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© 2014 Cengage Learning, Inc. 10.

Which of the following represents a similarity between Roger’s approach and Rankian theory? a.

Viewing the individual based on unconscious forces b.

Emphasis on transferential relationships c.

Allowing the client to be the central figure d.

Reliance on interpretation in therapy REF: History (p. 107-108) ANS: C

11.

The event most commonly identified with the birth of client-centered therapy is: a.

America’s involvement in World War II. b.

Maslow’s creation of the hierarchy of needs. c.

Roger’s presentation at the University of Minnesota. d.

Roger’s association with Elizabeth Davis.

REF: History (p. 109) ANS: C

12.

The University of Wisconsin study of hospitalized schizophrenics showed treatment outcome correlated highest with the: a. therapist’s perception of the therapeutic relationship. b. client’s perception of the therapeutic relationship. c. researcher’s objective ratings of therapeutic process. d. time spent with clients who received the least empathy.

REF: History (p. 109-110) ANS: B

13.

According to Rogers, the center of an individual’s world of experience is the: a. mother. b. father. c. family. d. individual.

REF: Personality (p. 111) ANS: D

14.

In Roger’s personality theory, behavior is defined as: a. the direct result of reinforcement and punishment. b. a goal directed attempt to satisfy an organism's needs. c. a biologically driven process of interacting. d. fulfillment of the drives of the id, ego, and superego.

REF: Personality (p. 112) ANS: B

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Rogers believed an organism has one basic tendency and striving, which is: a. a drive to seek and maintain pleasurable sensory experiences. b. to actualize, maintain and enhance the experiencing organism. c. fulfillment of basic needs for personal and species survival. d. an aggressive force the individual must balance with societal needs.

REF: Personality (p. 112) ANS: B

16.

For social purposes, reality is defined as: a. common perceptions across individuals. b. the private world of individual perceptions. c. uncommon perceptions across individuals. d. public knowledge of an individual’s perceptions.

REF: Personality (p. 114-115) ANS: A

17.

If given a choice, Rogers believed most individuals would chose to be: a. dependent. b. sick. c. aggressive. d. healthy.

REF: Personality (p. 115) ANS: D

18.

According to Rogers, psychological maladjustment occurs when an individual: a. denies significant sensory and visceral experiences. b. obtains insight regarding current and past experiences. c. relies on internal resources to define self-concept. d. accepts organic experiences into the self-structure.

REF: Personality (p. 116) ANS: A

19.

An infant’s ability to evaluate experience in terms of how it maintains or enhances them is known as: a. self-concept. b. self-preservation. c. direct organismic valuing. d. distorted symbolization.

REF: Personality (p. 116) ANS: C Client-Centered Therapy

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20.

The conceptual development of a concept of self is: a. a process completed by adulthood. b. unrelated to relationships with others. c. absolutely indefinable operationally. d. a fluid, changing process.

REF: Personality (p. 116) ANS: D

21.

The process by which an individual becomes aware of an experience is known as: a. symbolization. b. reality. c. actualization. d. experience.

REF: Personality (p. 116) ANS: A

22.

In ambiguous situations, individuals tend to symbolize experiences in a manner consistent with: a. social reality. b. parental attitudes. c. self-concept. d. a therapist.

REF: Personality (p. 116) ANS: C

23.

Fully functioning individuals capable of experiencing complete emotions rely on: a. external sources of evaluation. b. pleasure sustaining impulses. c. organismic valuing processes. d. biological instincts and drives.

REF: Personality (p. 117) ANS: C

24.

Understanding another individual by “living” in their internal frame of reference is: a. knowledge. b. empathy. c. congruence. d. reality.

REF: Psychotherapy (p. 117-118) ANS: B

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Which of the following is essential to therapy in addition to empathy, congruence and unconditional positive regard? a.

Education of the client regarding therapy process b.

Client’s experiencing of therapist-offered conditions c.

Periodic evaluative feedback to the client d.

Therapist’s maintenance of a mask of professionalism REF: Psychotherapy (p. 119) ANS: B

26.

In the first interview, a person-centered therapist will: a. gather historical information. b. go where the client goes. c. develop a treatment plan. d. complete a diagnostic formulation.

REF: Psychotherapy (p. 119) ANS: B

27.

When asked for advice, a person-centered therapist would most likely: a. facilitate the patient’s personal decision-making. b. provide an opinion based on empathic knowledge. c. focus on the transferential nature of the interaction. d. assign homework that would allow self-discovery.

REF: Psychotherapy (p. 119-120) ANS: A

28.

For a “moment of movement,” each statement is true EXCEPT which of the following? a.

The experience has the quality of being unacceptable. b.

It is an experience without barriers or inhibitions. c.

For the first time it is being experienced completely. d.

It is not a thought, but an experience at that instant.

REF: Psychotherapy (p. 120-121) ANS: A

29.

A successful person-centered therapy outcome would be defined by: a. objective assessments indicating progress. b. alleviation of symptoms representing a diagnostic label. c. a therapist’s perception that the client improved. d. the client’s evaluation that therapy was beneficial.

REF: Psychotherapy (p. 123) ANS: D Client-Centered Therapy

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30.

In person-centered therapy, termination is decided by: a. symptom reduction. b. the therapist. c. the client. d. behavior change.

REF: Psychotherapy (p. 119) ANS: C

31.

Zimring underscores the importance of how humans become persons within the context of their: a. own psyche. b. culture. c. family. d. psychic distress.

REF: Psychotherapy (p. 121) ANS: B

32.

If a child were raised by critical parents and unable to verbalize their own thoughts and feelings, Zimring’s paradigm would suggest degradation of the: a. subjective context. b. family context. c. objective context. d. everyday world.

REF: Psychotherapy (p. 121) ANS: A

33.

A client-centered therapist would likely view the diagnostic process as: a. crucial to treatment planning. b. a colossal waste of time. c. vital to establishing empathy. d. enhancing the client’s locus of control.

REF: Psychotherapy (p. 123) ANS: B

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The conclusion drawn from meta-analyses and large scale studies that all major psychotherapies yield comparable effect sizes is referred to as the: a.

Dodo Bird effect. b. common factors research. c.

Zimring’s paradigm. d. client-driven model.

REF: Applications (p. 130) ANS: A

35.

In Lambert’s meta-analytical review evaluating client-centered therapy, the outcome variable accounting for the most variance in treatment progress was: a. core conditions. b. therapeutic techniques. c. placebo factors. d. client variables.

REF: Applications (p. 130) ANS: D Fill in the Blanks

1.

Client-centered therapy was developed by ___________.

ANS: Carl Rogers

2.

Carl Rogers believed all humans had a _______ tendency, which he saw as a part of the _______ tendency of the world.

ANS: Actualizing; formative

3.

For Carl Rogers, _______, _______, and _______ were the three basic requirements to create a therapeutic environment.

ANS: Empathy, unconditional positive regard, and congruence (genuineness)

4.

When a therapist is able to maintain an unaltered attitude about a patient, regardless of the patient’s comments or choices, this is referred to as _______.

ANS: Unconditional positive regard

5.

In addition to the basic requirements of the therapeutic environment for the therapist, Rogers believed the client must focus on _______, _______ and _______.

ANS: Self-concept, locus-of-evaluation, and experiencing

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Client-centered therapy would argue that behavioral changes occur through _______ factors, whereas behavioral therapy sees behavior changing through _______ factors.

ANS: Internal; external

7.

The ongoing process in which individuals freely rely on the evidence of their own sense for making value judgments is referred to as the _______.

ANS: Organismic valuing process

8.

When a client is able to experience something without barriers, this is termed a __________.

ANS: Involvement of movement

9.

Carl Rogers would view neurosis as the result of incongruence between the _________ and the _________.

ANS: Real self; ideal self

10.

According to Bozarth's summarization of research on psychotherapy, the most consistent variables affecting therapy are _______, _______ and _______.

ANS: Empathy, unconditional positive regard, and congruence (genuineness) Essay Questions

1.

Rogers described self-actualization as an inherent human tendency, which is consistent with a formative tendency. What is a formative tendency? What is an actualizing tendency? How are these concepts used in Rogers’ theory of personality?

2.

Diagnostic formulation, psychological testing, interpretation, advice giving and probing for historical information are not a focus of person-centered therapy. How does a clientcentered therapist proceed in therapy?

3.

Do you agree or disagree with Rogers’ view that individuals, if given a choice, would chose to be healthy? Why or why not? Do you believe that an individual who seeks therapy has the capacity within themselves to move forward in therapy constructively without direction from the therapist? Why or why not?

4.

Rogers suggested that his approach could be useful in achieving conflict resolution at the international level. What difficulties might be encountered in applying his concepts internationally? What benefits might be present in utilizing a phenomenological view of conflict resolution between nations?

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What are Rogers’ basic assumptions regarding the implied therapeutic conditions needed for successful therapy in addition to those that are “therapist-offered?”

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Chapter 5 Rational Emotive Behavior Therapy Authors: Albert Ellis and Debbie Joffe Ellis Key Points and Terms

Overview ► ► ► ► ►

Practical and symptom-focused Philosophically-based, but techniques have empirical support Requires patient collaboration Patients change through identification of irrational thought processes.

Patient’s behavior and thought processes are evaluated and criticized when necessary.

Basic Propositions of REBT ► People have the potential to be rational, self-preserving, creative, functional and to use metathought or to be irrational, self-destructive, short-range hedonists, dysfunctional. ► Culture and family can perpetuate irrational thinking. ► Humans perceive, think, emote and behave simultaneously. ► All psychotherapies are not equally effective. ► A warm therapeutic relationship is not a necessary or sufficient condition for change. ► REBT uses techniques that work; focus is not symptom removal but cognitive change. ► Neurotic thinking is the result of unrealistic, illogical thinking. ► The causes of an individual’s problems are not the events that have happened but how the individual perceives them. ► REBT focuses on three insights.

▪ Insight 1: Adversity – belief about adversity – disturbed consequences ▪ Insight 2: People are upset now because they keep actively reinforcing irrational beliefs.

▪ Insight 3: Only hard work and practice will correct irrational beliefs. ► There is an element between stimulus and response; it is thought and emotional response.

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REBT provides clients with several powerful insights.

Comparing REBT to Other Therapies

REBT Compared with Psychoanalysis ► REBT does not focus on free association, complex history taking, dream analysis or sexual conflicts. ► Transference is seen in REBT as often resulting from irrational beliefs. ► REBT employs persuasive and directive techniques.

REBT Compared with Adler’s Theory ► Considerable similarities between approaches as Adler wrote about individuals developing fictional beliefs, which is a concept similar to Ellis’s irrational beliefs. ► Departs from Adler regarding emphasis on past memories, social interest. ► REBT is more future-oriented and behavioral.

REBT Compared to Jungian Therapy ► There are lots of commonalities between the two approaches, especially regarding holistic view of individuals. ► REBT views the Jungian focus on dreams, fantasies, symbols or archetypes as a “waste of time.”

REBT Compared to Person-Centered Therapy ▪ There are lots of commonalities between the two approaches.

▪ Both emphasize importance of unconditional positive regard, which REBT labels as full acceptance or tolerance.

REBT Compared to Cognitive Therapy

Thoughts Labeled

CT Dysfunctional

REBT Irrational

Type of Reasoning Used

Inductive

Deductive

Beliefs Associated Psychopathology

with Cognitive specificity for each disorder

Core set of irrational beliefs

View of the Problem

Functional; pathology arises from multiple cognitive distortions

Philosophical; pathology arises from “shoulds,” “musts,” and “oughts”

Therapist’s Approach

More collaborative

More confrontational

Emphasis

Psychoeducation an early and critical component of treatment

Higher reliance on psychoeducation

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“Hot cognitions” critical, but obtained in a less aggressive manner

More aggressive focus on emotional-evocative methods; core set of irrational beliefs

REBT Compared to Behavior Therapy ► There are lots of commonalities between the two approaches. ► REBT has a strong focus on the cognitive aspects. ► More similar to cognitive therapy and multimodal therapy than BT. History of Rational Emotive Behavior Therapy ► ► ► ►

► ► ►

Developed by Albert Ellis, Ph,D. After two decades of practicing psychoanalysis, he became increasingly disillusioned by the limited progress patients were making.

Berne, Frank, Kelly, Low, Phillips Rotter, and Wolpe were all influential.

Other major influences were Asian and Stoic philosophers, Alfred Adler, Paul DuBois, persuasive forms of psychotherapy, Herzberg, Bernheim, Salter, Thorne, Alexander, French, Dollard, Miler, Stekel, Wolberg.

In 1957, Ellis wrote How to Live with a “Neurotic.”

In 1975, Ellis wrote A New Guide to Rational Living, which continues to be one of the most popular self-help books to date.

In 1977, Ellis wrote Handbook of Rational-Emotive Therapy.

Current Status of REBT ► In 2005, Society of Clinical Psychology members listed Carl Rogers, Albert Ellis and Sigmund Freud, in that order, as the most influential in the history of psychotherapy. ► Albert Ellis Institute established in 1959 teaches principles of healthy living. ► Journal of Rational-Emotive and Cognitive Behavior Therapy reports latest findings. ► Research supports several REBT premises: ▪ Thoughts and feelings are not two disparate processes.

▪ Beliefs are more important than events.

▪ Metathought occurs (often captured in images).

▪ Changing thoughts, behaviors, or emotions changes other modalities. ► The Albert Ellis Institute (www.rebt.org) and the Albert Ellis Foundation (www.albertellisfoundation.org) are two separate entities which disseminate the ideas of REBT to professionals and consumers.

Unfortunately, Albert Ellis had a strained relationship with the Albert Ellis Institute following his removal from the board by the Board of Trustees of the Albert Ellis Institute in 2005. In January 2006, the State Supreme Court in Manhattan ruled that the board incorrectly ousted Ellis at a meeting from which Ellis was excluded. The judge’s decision reinstated him to the board and the judge indicated that the institute’s position regarding Dr. Ellis was “disingenuous,” citing case law saying a “dismissal, accomplished without notice of any kind or the right of confrontation, is offensive and contrary to our fundamental process of democratic and legal procedure, fair play and the spirit of the law.”

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© 2014 Cengage Learning, Inc. Ellis’s Theory of Personality “Basic tenet of REBT is that emotional upsets, as distinguished from feelings of sorrow, regret, annoyance, and frustration, largely stem from irrational beliefs.”

— Ellis ►

Problematic beliefs center around words/concepts like … “should,” “ought,” “awful,” “must,” “I want,” and “I need.”

Ellis’s Theory of Personality “This is the basic personality theory of REBT. Humans largely create their own distress.”

— Ellis Albert Ellis Agrees with….

Freud that …

Horney and Fromm that …

Adler that …

Allport that …

Pavlov that …

Frank that …

Piaget that …

Anna Freud that …

Maslow and Rogers that …

The pleasure principle runs people’s lives.

Cultural and family influences impact people’s irrational thinking.

Fictitious goals order people’s lives.

Individuals think and act in a certain manner and have difficulty changing.

Cognitive conditioning occurs.

People are prone to the influence of suggestion.

Active learning is more effective than passive.

People refuse to acknowledge mistakes and resort to defenses.

Humans have great untapped resources.

Ways Individual’s Alleviate Pain ►

►

►

Distraction: ▪ Leads to less demands of others.

▪ Individual becomes less anxious.

▪ Palliative Satisfying demands ▪ If demands are catered to, the individual feels better but does not get better.

▪ Therapist can give love and approval, provide pleasurable sensations.

▪ Teach methods to have demands met; give reassurance.

▪ Ultimate impact is demandingness is reinforced.

Magic and mysticism ▪ Magical solutions are often offered to children and even to adolescents and adults.

▪ Generally, magical solutions only temporarily placate the individual.

Main Goals of REBT ► REBT’s goal is to achieve minimal demandingness and maximal tolerance.

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Although temporary, palliative techniques may be used in REBT; goal is for more permanent solutions.

Goal is minimization of musturbation, perfectionism, grandiosity, and low frustration tolerance.

REBT assists patients in seeing how giving up perfectionism improves their lives.

REBT teaches patients to differentiate between desires and “musts.”

Behavioral techniques are used in REBT to change habits as well as cognition.

REBT Psychotherapy

“REBT helps clients acquire a more realistic, tolerant philosophy of life … REBT practitioners often employ a rapid-fire, active-directive-persuasive-philosophical methodology.”

— Ellis Mechanisms of Psychotherapy ► No matter what feelings (which, by the way, do not distract the therapist) the patient discusses, the focus is on the patient’s irrational beliefs. ► REBT therapists do not hesitate to contradict the patient’s beliefs and are often one step ahead while showing acceptance. ► REBT therapists may do more talking than the patients. ► Strongest philosophical approach possible is used. ► Therapist doesn’t just tell the patient their beliefs are irrational, but attempts to encourage the patient to see this for themselves.

Applications of REBT ► ►

REBT is a broad based approach Easier to identify disorders that are not treated by the approach, which includes individuals who are psychotic, manic, autistic, brain-injured, mentally-deficient.

Major Areas of Impact of REBT ▪ Most effective with single symptom problems that also include anger management issues, religious clients, school-aged children and for preventative purposes.

▪ Field of education, especially regarding enhancing normative development.

▪ Research supporting CT also supports basic premises of REBT.

Chapter 5: Activities Role-play Provide the students with a copy of Albert Ellis’ RET Self-Help Form (obtainable from the Albert Ellis Institute). Ask them to role-play developing disputes for irrational beliefs and effective rational beliefs.

Discussion Questions

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Albert Ellis emphasizes the importance of unconditional positive regard but does not view it as sufficient to create change. His approach on the surface would appear to be one that is critical of the patient. Ask students to discuss how it is possible to accept patients but criticize their behaviors while maintaining unconditional positive regard.

2.

Albert Ellis makes it clear that he unequivocally believes that people’s belief systems cause their emotional distress. Ask students if they agree or disagree. Ask students to discuss some of the difficulties that would be encountered in trying to change thoughts.

3.

Unfortunately, Albert Ellis had a strained relationship with the Albert Ellis Institute following his removal from the board by the Board of Trustees of the Albert Ellis Institute in 2005. In January 2006, the State Supreme Court in Manhattan ruled that the board incorrectly ousted Ellis at a meeting from which Ellis was excluded. The judge’s decision reinstated him to the board and the judge indicated that the institute’s position regarding Dr. Ellis was “disingenuous,” citing case law saying a “dismissal, accomplished without notice of any kind or the right of confrontation, is offensive and contrary to our fundamental process of democratic and legal procedure, fair play and the spirit of the law.” Ask students to discuss their views about these matters and the impact these controversies might have on REBT in the future.

Use of Movies to Depict Concepts

Albert Ellis often discussed how the irrational belief that “life should be fair” was at the core of many emotional challenges individuals faced. There are several films that depict individuals who have had to face clearly unfair challenges dealing with medical illnesses and disabilities: ► Pride of the Yankees (1942), the life story of Lou Gehrig ► Tuesdays with Morrie (1999) ► A Brief History of Time (1992), an examination of the life and ideas of cosmologist Stephen Hawking ► Darius Goes West (2007), a film in which the protagonist suffers from Duchenne’s, a type of muscular dystrophy Rational Emotive Behavior Therapy

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Duet for One (1986), a film exploring the impact of multiple sclerosis in the life of a famous concert violinist

Encouraging students to watch these films can lead to significant discussions about life’s inherent unfairness and the importance of adapting to this fact.

Case Illustration from Case Studies in Psychotherapies (7th Edition)

A Twenty-Three Year Old Woman Guilty About Not Following Her Parent’s Rules

by Albert Ellis Albert Ellis was famous for his direct, forceful, confident style. In this case, he illustrates how he worked with a young woman whose thinking is clearly irrational. Albert Ellis also discusses his mistakes in therapy and critiques himself as a therapist. Instructors might want to encourage students to contrast Ellis’s style with Aaron Beck’s treatment of a depressed clinical psychologist in Chapter 7. Both Ellis and Beck are known for being superb clinicians. However, as these two cases demonstrate, their therapy styles are quite different: Ellis is much more confrontational and Beck is much more collaborative and Socratic. Discuss with students the pros and cons of each approach. Ask students to ponder which approach they might prefer if they were the client.

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Chapter 5: Potential Test Items Multiple Choice Test Bank 1.

REBT holds that: a. events determine our emotions. b. emotions are due to innate tendencies. c. beliefs mediate events and emotions. d. our beliefs about ourselves are rational.

REF: Overview (p. 151) ANS: C

2.

In the REBT chain (A B C D), A refers to: a. antagonistic thoughts. b. actualizing tendency. c. aggressive instincts. d. activating event.

REF: Overview (p. 151) ANS: D

3.

In the REBT chain (A B C D), B refers to: a. behavior. b. belief system. c. biopsychosocial model. d. biological predisposition.

REF: Overview (p. 151) ANS: B

4.

In the REBT chain (A B C D), C refers to: a. classical and operant conditioning. b. circular reasoning. c. emotional/behavioral consequences. d. countertransference.

REF: Overview (p. 151) ANS: C

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In the REBT chain (A B C D), D refers to: a. disputing irrational beliefs. b. defense mechanism. c. data from external sources. d. deterministic forces.

REF: Overview (p. 151) ANS: A

6.

Albert Ellis argues that humans tend to perceive, think, emote and behave: a. simultaneously. b. consistently. c. spontaneously. d. rationally.

REF: Overview (p. 151-152) ANS: A

7.

Ellis implies that highly cognitive, directive therapies requiring tasks and discipline are likely to be: a. effective in a shorter time period with less sessions required. b. low on empathy, congruence and unconditional positive regard. c. therapies that focus on insight and traumatic past experiences. d. long-term therapies that lead to insight, but limited behavior change.

REF: Overview (p. 152) ANS: A

8.

Which therapist characteristic would Ellis classify as desirable, but not necessary? a.

Acceptance b.

Warmth c.

Collaborative d.

Confrontative REF: Overview (p. 153) ANS: B

9.

The primary goal of REBT is: a. reduction or elimination of symptoms. b. alteration of basic values and beliefs. c. insight regarding childhood experiences. d. enhancing an individual’s social interest.

REF: Overview (p. 153) ANS: B

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REBT holds that neurotic problems directly stem from: a. impaired family relationships. b. childhood traumatic events. c. magical, non-validated thinking. d. physiological predispositions.

REF: Overview (p. 153) ANS: C

11.

Which of the following is NOT an insight stressed in REBT? a.

Only hard work and practice will correct irrational beliefs. b.

Self-defeating behavior is past-related but maintained by present beliefs. c.

Current distress results from self-continuation of irrational beliefs. d.

Emotional reactions are the result of past traumatic events.

REF: Overview (p. 154) ANS: D

12.

The individual to assert the importance of the S-O-R model of science over the S-R model was: a.

William James. b.

Wilhelm Wundt. c.

Ivan Pavlov. d.

James Cattell.

REF: Overview (p. 154) ANS: D

13.

If transference occurs, a REBT therapist is likely to: a. interpret it in the context of parent-child relations. b. ignore the transference issues entirely. c. relate it to the client’s irrational beliefs. d. criticize the client for immaturely relating.

REF: Overview (p. 155) ANS: C

14.

The psychotherapist who was the main precursor for REBT was: a.

Sigmund Freud. b.

Carl Rogers. c.

Carl Jung. d.

Alfred Adler.

REF: Overview (p. 155) ANS: D

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Albert Ellis was originally trained as a: a. behaviorist. b. psychoanalyst. c. humanist. d. family systems therapist.

REF: History (p. 157) ANS: B

16.

REBT research supports the tenet that: a. cognition always creates emotions and behaviors. b. cognitions, emotions and behaviors have a reciprocal relationship. c. behaviors always proceed cognitions and emotions. d. the cause of cognitions and behaviors are emotions.

REF: Personality (p. 160) ANS: B

17.

Ellis suggests humans have an innate nature to: a. want, need and condemn when needs aren’t met. b. have mental illness regardless of beliefs. c. develop rational beliefs. d. challenge their own irrational thoughts.

REF: Personality (p. 161) ANS: A

18.

If an individual’s needs aren’t met, they display a tendency to: a. seek healthy ways of need fulfillment. b. allow their needs to go unmet. c. childishly condemn themselves, others and the world. d. use internal resources to meet their needs.

REF: Personality (p. 161) ANS: C

19.

In REBT, caring too much about what others think is frequently associated with: a. psychological adjustment. b. emotional disturbance. c. high regard for others. d. conflicts with society.

REF: Personality (p. 161) ANS: B

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Which of the following statements represents an irrational belief? a.

Others should act the way I want them to. b.

Although this situation is difficult, I can handle it. c.

Being upset does not mean something is wrong with me. d.

My worth does not depend on solving this problem.

REF: Personality (p. 162) ANS: A

21.

Ellis contends that secondary problems can be created when: a. emotional consequences cycle into activating events. b. behavior changes occur while beliefs are unchanged. c. transferential relationships develop. d. traumatic events from childhood are left unexplored.

REF: Personality (p. 162) ANS: A

22.

Ellis states that many forms of psychotherapy overly stress: a. behavior change. b. irrational beliefs. c. traumatic events. d. unconditional positive regard.

REF: Personality (p. 163) ANS: C

23.

Through social conditioning, an individual’s proneness to create emotional distress is: a. minimized. b. redirected. c. eliminated. d. exaggerated.

REF: Personality (p. 163) ANS: D

24.

In REBT, the unconscious is viewed as: a. containing repressed memories secondary to id, ego, and superego conflicts. b. holding personal memories and nonpersonal archetypal material. c. virtually meaningless as most elements can be brought into conscious. d. representing thoughts that can never be brought into awareness.

REF: Personality (p. 165) ANS: C

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The most salient similarity between REBT and Adlerian psychotherapy is the emphasis on: a. birth order. b. childhood memories. c. confrontation. d. basic mistakes.

REF: Personality (p. 165) ANS: D

26.

Which of the following represents an area where there would be the most significant difference between REBT and Cognitive therapy (CT)? a.

Amount of focus on mediating beliefs. b.

Importance of homework compliance. c.

Lack of emphasis on past experience. d.

Therapist’s forcefulness in disputing beliefs.

REF: Personality (p. 165) ANS: D

27.

The solution for dealing with an individual’s demandingness most strongly supported by REBT is: a. decreasing demandingness. b. satisfying the demand. c. magic and mysticism. d. distraction.

REF: Psychotherapy (p. 166-167) ANS: A

28.

Which of the following methods would NOT be used frequently by a REBT therapist? a.

Cognitive restructuring b.

Role-playing c.

Dream analysis d.

Behavior therapy REF: Psychotherapy (p. 167-168) ANS: C

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On Albert Ellis’ REBT Self-Help Form, illustrated in the book, negative emotions are categorized as healthy versus unhealthy. An unhealthy emotion would be: a. disappointment. b. hurt. c. sadness. d. frustration.

REF: Applications (p. 182-183) ANS: B

30.

REBT would not be appropriate for individuals with: a. post-traumatic stress disorder. b. depression. c. adjustment issues. d. serious brain injury.

REF: Psychotherapy (p. 166) ANS: D

31.

To assist a client in dealing with cultural differences, REBT therapists would recommend: a. removing oneself from the unhealthy environment. b. adhering to one’s beliefs regardless of the personal cost. c. altering cultural beliefs that are held too rigidly. d. accepting the beliefs of the majority culture.

REF: Psychotherapy (p. 170) ANS: C

32.

REBT therapists deal with problems in treating clients by: a. exploring transference and countertransference issues. b. adhering to a rational philosophy of life and therapy. c. increasing congruence, empathy and unconditional positive regard. d. terminating REBT as problems imply it is ineffective.

REF: Psychotherapy (p. 168-169) ANS: B Fill in the Blanks

1.

REBT refers to the ABCD. ABCD stands for, _______, _______, _______, and _______.

ANS: Activating events, behavior, consequences, and dispute

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REBT states that people are distressed because they are reinforcing _______ thoughts.

ANS: Irrational

3.

In challenging individual thought processes, REBT would use _____ and _____.

ANS: Persuasion and directive

4.

REBT views the Jungian focus on the collective unconscious as a _______.

ANS: Waste of time

5.

In contrasting REBT and cognitive therapy, REBT uses _______ reasoning where CT uses _______ reasoning.

ANS: Deductive; inductive

6.

Research supporting REBT hypotheses suggests that _______ are more important than the events themselves ANS: Beliefs

7.

In therapy, REBT teaches patients to differentiate between those items they want or desire and _______.

ANS: Musts

8.

The letters REBT refer to the fact that the therapy approach focuses on _______, _______, and _______.

ANS: Rational thinking, emotion, and behavior

9.

Albert Ellis would label the belief “I must be liked by everyone” as _______.

ANS: Irrational

10.

When a situation is interpreted in a way that creates emotional distress, this distress can then lead to more emotional distress because it becomes a _______.

ANS: Activating event Essay Questions

1.

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What do the letters REBT stand for in Albert Ellis’ model of therapy? How does each of the REBT components interact?

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A therapist using REBT will often confront patients quite directly about their behaviors and thoughts. What do you see as the advantages and disadvantages of this type of approach? What kind of patients would be inappropriate for such an approach?

3.

Albert Ellis was originally a psychoanalyst. What similarities and differences do you see between his approach and those of Freud, Adler, Jung and Rogers?

4.

REBT and cognitive therapy have much in common. How are the two approaches different?

5.

A REBT therapist will often point out a patient’s irrational thinking. Who decides whether the patient’s thoughts are irrational? What criteria are used to determine that a belief is irrational? How does identifying a thought as irrational lead to change?

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Chapter 6 Behavior Therapy Author: Martin M. Anthony Key Points and Terms

Overview ►

Behavioral therapy (blends with CBT and REBT) integrates the behavioral techniques derived from principles of learning and cognitive restructuring techniques based on cognitive theories.

Features of Behavior Therapy ► Focuses on changing behavior ► Rooted in empiricism ► Assumes behaviors have a function ► Emphasizes maintaining factors rather than factors that may have initially triggered a problem ► Empirically supported ► Active ► Transparent ► Treatment driven by functional analysis of behavior (ABCs)

Most Different

Psychoanalytic Client-Centered

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Comparison of Behavior Therapy to Other Therapies Most Similar

REBT Multimodal Cognitive

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© 2014 Cengage Learning, Inc. Compared to Psychoanalytical Approaches Behavioral Therapy: ► Includes family members as needed ► Does not create symptom substitution as predicted ► More broadly applicable than most therapies. ► Empirical studies generally show it to be more effective. ► Treatment of choice for phobias, OCD, sexual dysfunction and many childhood disorders.

For example, in the Case of Little Hans ► Freud attributed Little Hans’ phobia of horses to castration anxiety. ► A behavior therapist would see it as a classically conditioned response.

“Third Wave” of Behavior Therapy ► Therapeutic approaches with overlapping conceptual and technical foundations.

▪ Dialectical behavioral therapy (DBT) • Focuses on balancing behavior change and acceptance.

• Mindfulness, which teaches individuals to observe and describe one experience or emotion at a time in a nonjudgmental, present-oriented manner.

▪ Acceptance and commitment therapy (ACT) • Combines behaviorism and relational frame theory.

• Goals are to teach patient: ► Acceptance to offset experiential avoidance ► Cognitive defusion: Separating the thinker from the thoughts ► Commitment to actions that lead to a valued life Ways Behavior Therapy Meets the Needs of Children and Adolescents ► Practical, here-and-now, experiential emphasis. ► Techniques can be adapted to meet the developmental level of the patient. ► Action oriented, which matches fact that children learn by doing. ► Incorporates rewards, which helps engage the patient.

The History of Behavior Therapy ►

► ► ► ► ► ►

Early examples of behavioral techniques being used include: ▪ Pliny the Elder used spiders at the bottom of a glass to treat alcoholism over 2,000 years ago (i.e., aversion therapy).

▪ Victor of Aveyron (Wild Boy of Aveyron) treated by Jean-Marc-Gaspard.

▪ Itard (1962) used strategies of modeling, shaping, and reinforcement.

Rise of behaviorism in 1900s as espoused by Watson Ivan Pavlov’s research E.L. Thorndike’s studies (first to describe operant learning) Joseph Wolpe’s systematic desensitization Eysenck’s description of BT as applied science Skinner’s operant conditioning paradigms Behavior Therapy

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Bandura’s social learning theories Mary Cover Jones’ use of a combination of modeling and exposure to treat a boy with rabbit phobia Mowrer and Mowrer’s use of classical conditioning principles to treat childhood bedwetting (bell and pad) Behavior Therapy’s View of Personality

► ► ► ► ►

Historically, behaviorists saw behavior as situation-specific/rejected trait theories.

But strict behavioral view is not strongly supported by research.

Strong evidence supports the notion of individual temperaments.

Now, most behavior therapists acknowledge temperament affects behavior.

Behaviorists also recognize behavior varies across situations.

Costa and McCrae’s (1992) Big Five Model ► Currently the most influential approach to describing core domains of personality. ► Broad factors assumed to be clusters of narrowly focused traits: 1. Openness 2. Conscientiousness 3. Extraversion 4. Agreeableness 5. Neuroticism Basic Principles of Learning ► Learning: A relatively permanent change in behavior, not due to fatigue, drugs, or maturation.

Classical Conditioning ► Pavlov’s Study: Food is presented to the dog and the dog salivates. No learning involved.

A neutral stimulus is presented to the dog (a tone). The dog does not salivate.

UCS UCR Unconditional stimulus ----> Unconditioned response (sight of food) (salivation) CS CR Conditioned stimulus -------> Conditioned response (tone) (salivation) ► ► ►

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The UCS and CS are repeatedly paired together until the UCR is elicited by the CS. ▪ In other words, the CS elicits the same behavior which is now termed the CR. If stimulus generalization occurs, the dog might respond to related stimuli with the same or similar response.

If stimulus discrimination occurs, the dog might not respond.

Behavior Therapy

© 2014 Cengage Learning, Inc. Extinction ► After learning has occurred, removing the UCS ultimately results in a decreased probability that the CR will be made because the dog learns that the bell no longer means food will follow.

Spontaneous Recovery ► After a time delay, if the stimulus is represented the CR will reoccur. This behavior will extinguish rapidly if the UCS does not follow quickly.

Operant or Instrumental Conditioning (B.F. Skinner) ► A response is emitted, perhaps randomly at first, and results in consequences. Hence, the probability of the response’s future occurrence is changed.

If you want the behavior to increase If you want the behavior to decrease

Add Stimulus Positive Reinforcement Punishment

Remove Stimulus Negative Reinforcement Extinction

Continuous Reinforcement ► Every response is followed by reinforcement, resulting in fast learning (acquisition) but also resulting in fast extinction.

Intermittent (or partial) Reinforcement ► Not every response is reinforced. ► Yields a stronger response ultimately.

▪ Fixed ratio schedule • Delivers reinforcement after a fixed number of responses and produces high response rate.

• Example: Commission work ▪ Fixed interval schedule • Reinforces the next response that occurs after a fixed period of time elapses.

• Example: Scheduled exam ▪ Variable interval schedules • Delivers reinforcement after unpredictable time periods.

• Example: Pop quizzes ▪ Variable ratio schedules • Yields the highest rates of response and greatest resistance to extinction.

• Example: Gambling

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Schedule Fixed ratio Fixed interval Variable interval Variable ratio

Behavioral Effect of the Reinforcement Schedules Effect Relatively fast rate of response Response rate drops to almost zero after reward; picks up rapidly before next reward Slow, steady response Constant high rate of response; hardest behavior to break

Secondary Reinforcement ► A symbol or a token gains reinforcement value due to its association with a real reinforcer (e.g., dollar bill).

Vicarious Learning (Modeling) ► Learning that occurs through observation. ► Vicarious learning is particularly relevant to children, but applies to all ages. ► By observing a model, one grasps entire behaviors as well as component parts. ► Vicarious learning may remain dormant until a situation warrants expression of the learned behavior.

Rule-Governed Behavior ► Contingencies learned indirectly through information heard or read. ► A person learns to look both ways before crossing the street because of comments made by their parents. ► A person develops a strong dislike of another individual based on gossip.

The Psychotherapy Process Therapeutic Process ► A strong therapeutic relationship is important in behavior therapy. ► Self-help approaches are more effective when therapist-administered. ► Ambivalence about treatment can be addressed with motivational interviewing.

▪ A client-centered approach designed to help clients explore and resolve sources of ambivalence about therapy.

Format and Structure of BT ► Quite diverse ► Behavioral interventions can be offered by therapists and many others (e.g., teachers, parents, physicians). ► Sessions vary in length based on interventions. ► Generally 10-20 sessions max Ethical Issues in BT ► Misconception that behavior therapy is coercive.

▪ Therapists must be aware of their potential influence on the client.

▪ Only make recommendations that are in the client’s best interests.

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Importance of shared goals.

BT often involves activities outside of the office.

▪ Confidentiality in public places must be maintained.

Sample of a Behavioral Plan ► Identify goals for change ► Operationalize the behavior/thoughts ► Separate traits from behaviors ► Distinguish overt from covert behaviors ► Obtain a baseline ► Complete a functional analysis ► Establish target behaviors to change: ▪ Behaviors to increase and to decrease ► Behaviors should be small, discrete, and chosen based on severity, immediacy, centrality and potential for success ► Develop a behavioral contract with goals and rewards ► Problem solve about possible obstacles ► Periodically reevaluate Applications of Behavior Therapy Some Areas Where Behavior Therapy Has Proven Efficacy ► Anxiety disorders ▪ Phobias, panic disorder, OCD, PTSD ► Depression ► Marital problems ► Behavioral medicine ► Childhood disorders ▪ Behavioral problems, hyperactivity, autism, enuresis ► Substance use ► Eating disorders ► Schizophrenia Efficacy and effectiveness of behavior therapy has been studied more intensively than in any other form of psychological treatment.

Examples of Behavior Therapy Treatment Techniques ► Behavioral activation ► Exposure based ▪ Invivo ▪ Imaginal ▪ Interoceptive ► Response prevention ► Operant-conditioning strategies ► Applied behavior analysis ► Reinforcement-based strategies Behavior Therapy

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Differential reinforcement Contingency management Behavior therapy treatment techniques Punishment-based strategies Aversive conditioning Physiological monitoring Role-playing Self-monitoring Behavioral observation Cognitive restructuring (see Chapter 7) Assertiveness training Social skills training Stimulus control techniques Relaxation techniques: ▪ Diaphragmatic breathing ▪ Breath-focusing exercises ▪ Mini-relaxations ▪ Mind focusing ▪ Coupling breathing and imagination ▪ Progressive muscle relaxation ▪ Repetitive motion ▪ Self-hypnosis ▪ Visualization

Evidence ► APA-Division 12 ESTs ▪ Behavioral treatments dominate the list of empirically-supported treatments.

▪ The case for behavioral and CBT treatments is more developed than the case for any other form of psychotherapy. ► ►

National Institute of Clinical Excellence (NICE) Taking an empirical approach in the therapy office ▪ Awareness of one’s biases about clients and their problems.

▪ Awareness of one’s biases about treatment.

▪ Collecting data throughout the course of therapy to test out assumptions about the variables that maintain a client’s problems.

▪ Collecting data over the course of treatment to evaluate outcomes.

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► ► ►

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Core principles/methods underlying BT assumed to be universal, applicable across cultures and species.

BT must find ways to encourage clients to use methods that may not fit with their cultural assumptions and beliefs.

Research on treating individuals across diverse groups with BT early in its development.

Behavior Therapy

© 2014 Cengage Learning, Inc.

Chapter 6: Activities Role-play Behavioral therapy relies heavily on relaxation techniques. Have students role-play guiding one another through breathing awareness, diaphragmatic breathing, autogenic training and progressive muscle relaxation.

Discussion Questions 1.

The concept of vicarious learning (i.e., modeling) has important implications for society. Have students discuss their view of the impact of children watching violence on television and at movies on later behavior.

2.

Managed care companies often require therapist to complete outpatient treatment reports periodically. The treatment reports request specific details about the symptoms that are targeted in treatment and which treatment techniques will be used.

These reports also often require quantitative information about the patient’s progress.

Provide the students with some examples of outpatient treatment reports and lead a discussion about how behavioral approaches may have influenced the development of these types of outpatient treatment reports.

3.

Behaviorists believe that behaviors which are reinforced continue to occur. Have students discuss ways that reinforcers and punishers are used to control people’s behavior in a classroom setting.

Use of Movies to Depict Concepts

Historically, opponents of behavioral therapy have indicated that the techniques might be used to manipulate individuals and impact their personal freedom. In Stanley Kubrick’s film A Clockwork Orange (1971), we see how behavioral techniques can be utilized to punish people in egregious ways. Additionally, the short story by Stephen King, Quitters, Inc., from the Night Shift collection, was included in the film Cat’s Eye (1985). This is the short story of how Behavior Therapy

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© 2014 Cengage Learning, Inc. consequences are used to alter behavior in ways that are inappropriate and unethical to the detriment of a client who wishes to quit smoking. Showing these examples can lead to lively class discussions about the ethics involved in using reinforcers and punishments to help others.

Case Illustration from Case Studies in Psychotherapies (7th Edition)

Covert Sensitization for Paraphilia by David Barlow This case illustrates application of covert sensitization, a behavioral technique, in the treatment of pedophilia. The case also highlights how cognitive aspects are integrated into treatment. Additionally, the case can spark conversations about how clinicians can separate their personal feelings about a matter, even one as unsettling as pedophilia, to provide a treatment that is in the best interest of a client.

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Chapter 6: Potential Test Items Multiple Choice Test Bank 1.

Behavioral theory is rooted in: a. empiricism. b. psychodynamics. c. humanism. d. eclecticism.

REF: Overview (p. 194) ANS: A

2.

A behavioral therapist focuses on the antecedents and consequences associated with a behavior. Which approach is the therapist utilizing? a.

Mindfulness b Cognitive defusion c.

Functional analysis d.

Vicarious learning REF: Applications (p. 208) ANS: C

3.

The social-cognitive theory suggests that: a. one must uncover hypothesized hidden motives for behavior. b. identification of defense mechanisms a person utilizes is crucial. c. cognitions can be measured through assessment of personality characteristics. d. individuals learn through watching the behavior of others.

REF: Personality (p. 199) ANS: D

4.

Behaviorists view abnormal behavior as: a. psychopathological. b. physiologically-based illnesses. c. governed by rules of learning. d. the result of unconscious conflict.

REF: Personality (p. 200) ANS: C

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Behavioral approaches considered part of the “Third Wave” include: a. rational emotive therapy. b. cognitive therapy. c. dialectical behavioral therapy. d. multimodal therapy.

REF: History (p. 199) ANS: C

6.

When individuals attempt to evade negative or distressing private experiences, ACT therapists would call this: a. cognitive defusion. b. deflection. c. minimization. d. experiential avoidance.

REF: Applications (p. 216) ANS: D

7.

The first figure linked with the rise of behaviorism in the United States in the early 1900s was: a.

J. Wolpe. b.

I. Pavlov. c.

H. J. Eysenck. d.

J. B. Watson.

REF: History (p. 196) ANS: D

8.

When the Society of Clinical Psychology of the American Psychological Association developed a list of the most efficacious, empirically based treatment approaches, which therapy approach dominated the list? a.

Psychoanalytic b.

Analytical c.

Behavioral d.

Family systems REF: Applications (p. 217) ANS: C

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Behavioral therapy often leads to improvements in areas of functioning that were not directly targeted in treatment. This is known as: a. desensitization. b. cognitive defusion. c. symptom substitution. d. generalization.

REF: Overview (p. 195) ANS: D

10.

The development of systematic desensitization is credited to: a.

J. Wolpe. b.

M. C. Jones. c.

A. A. Lazarus. d.

A. Bandura.

REF: History (p. 197) ANS: A

11.

One of the only early behavior theorists to use a trait theory of personality was: a.

Skinner. b.

Eysenck. c.

Wolpe. d.

Bandura.

REF: History (p. 198) ANS: B

12.

Which of the following represents one of the personality dimensions of the five-factor model? a.

Reactive b.

Recklessness c.

Extraversion d.

Passivity REF: Personality (p. 200) ANS: C

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According to behavioral theory, a person would be predicted to act consistently across situations: a. because personality traits are viewed as stable. b. if similar behavior leads to similar consequences. c. even if rewards were increased for different behavior. d. even if rewards were decreased for the same behavior.

REF: Personality (p. 200) ANS: B

14.

Classical conditioning is viewed as the pairing of conditioned stimuli with unconditioned stimuli and the process of learning: a. punishment follows the conditioned stimuli. b. reinforcement follows the unconditioned stimuli. c. correlational or contingent relationships are present. d. a relationship does not exist between stimuli.

REF: Personality (p. 200) ANS: C

15.

A positive reinforcer should affect behavior by: a. generally strengthening it. b. suppressing it in most situations. c. completely eliminating it. d. indirectly relating it to a CS. REF: Personality (p. 201) ANS: A

16.

Avoidance of an event that produces anxiety is: a. positively reinforcing. b. negatively reinforcing. c. stimulus control. d. punishing.

REF: Personality (p. 201) ANS: B

17.

The occurrence of a behavior in a situation other than where it was acquired is known as: a. discrimination. b. latent learning. c. generalization. d. shaping.

REF: Personality (p. 202) ANS: C

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18.

The acquisition of new knowledge and behavior by observing other people and events is called: a. vicarious learning. b. classical condition. c. stimulus control. d. operant conditioning.

REF: Personality (p. 202) ANS: A

19.

Which of the following is NOT a personality variable espoused by Costa and McCrae? a.

Agreeableness b.

Neuroticism c.

Conscientiousness d.

Expectancies REF: Personality (p. 200) ANS: D

20.

In the 1930s, Mowrer and Mowrer used behavioral principles to create a treatment approach for bed-wetting called the: a. bell and pad. b. punishment diaper. c. reward crib. d. classical sleep bell.

REF: History (p. 197) ANS: A

21.

In contrast to psychoanalysts, behavior therapists are: a. less genuine. b. less disclosing. c. past-oriented. d. more directive.

REF: Overview (p. 195) ANS: D

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© 2014 Cengage Learning, Inc. 22.

In behavioral therapy, the goals are ultimately set by the: a. diagnosis. b. family. c. client. d. therapist.

REF: Psychotherapy (p. 204) ANS: C

23.

In an initial assessment, which of the following factors would be LEAST important in establishing a treatment plan? a.

Coping skills the client maintains b.

Current reinforcement contingencies c.

Client’s perception of the problem d.

Early childhood experiences REF: Applications (p. 207-208) ANS: D

24.

A behavior therapist would NOT typically ask which of the following questions? a.

What? b.

When? c.

Why? d.

Where?

REF: Applications (p. 207-208) ANS: C

25.

Which of the following techniques would a behavioral therapist be LEAST likely to use? a.

Role-playing b.

Free association c.

Guided imagery d.

Self-monitoring REF: Applications (p. 207-216) ANS: B

26.

Which of the following assessment techniques would yield the best functional analysis for a behavioral therapist? a.

Direct behavioral observation b.

Minnesota Multiphasic Personality Inventory-2 c.

Beck Depression Inventory-II d.

Projective tests REF: Applications (p. 208) ANS: A

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27.

Exposure therapy primarily involves: a. immediately confronting a client with an intense anxiety situation. b. incrementally exposing a client to anxiety-producing stimuli. c. modeling for the client how to substitute assertive behavior for anxiety. d. using an unpleasant consequence such as shock when anxiety is experienced.

REF: Applications (p. 210-211) ANS: B

28.

Exposure therapy that involves purposely inducing physical sensations in the body is known as: a. imaginal exposure. b. interoceptive exposure. c. reorientation therapy. d. marginal conditioning.

REF: Applications (p. 210) ANS: B

29.

Behavioral therapists view assessment as a(n): a. unnecessary component to treatment. b. process completed during the first session. c. continuous process throughout therapy. d. reliable technique when projectives are used.

REF: Applications (p. 207-208) ANS: C

30.

A significant challenge to overcome when conducting behavioral observations is: a. reactivity. b. unconsciousness. c. prejudice. d. intellectualization.

REF: Applications (p. 208) ANS: A

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A research design that begins with a baseline period followed by an intervention followed by withdraw of the intervention with possible later reintroduction is known as: a. a manual based approach. b. actuarial judgment. c. reversal design. d. single case study.

REF: Applications (p. 218) ANS: C

32.

In a 2005 study, Hinton and colleagues found that Cambodian refugees with PTSD: a. would not trust a CBT approach because it felt controlling. b. could be successfully treated with CBT. c. had culturally specific beliefs that decreased prognosis. d. responded most effectively to reinforcement.

REF: Applications (p. 220) ANS: B

33.

Studies assessing the treatment efficacy of cognitive-behavioral therapy (CBT) across disorders suggest: a. manualized-based approaches are superior. b. relapse was common if CBT was used alone. c. psychoanalytical approaches were superior to CBT. d.

CBT has the most empirical support.

REF: Applications (p. 217-218) ANS: D

34.

Behaviorists recommend that treatment outcome be assessed through: a. multiple projective and objective techniques. b. subjective measures completed by the client. c. only therapist’s ratings of success. d. multiple, objective and subjective measures.

REF: Applications (p. 207) ANS: D Fill in the Blanks

1.

_______________ is a reinforcement based strategy in which the client’s environment is changed so that unwanted behaviors are no longer reinforced.

ANS: Contingency management

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A therapist attempts to assist a patient with anorexia nervosa by encouraging her to face her anxieties about eating directly. This approach is consistent with the ACT concept of addressing _______.

ANS: Experiential avoidance

3.

Dialectical behavioral therapy focuses on the balance between _________ and _______.

ANS: Behavior change and acceptance

4.

A _______ schedule of reinforcement yields the highest rate of response and the greatest resistance to extinction.

ANS: Variable ration

5.

_______ is usually associated with the development of the social cognitive theory.

ANS: Albert Bandura

6.

Some behaviorists reject theories of personality, but others recognize that the data regarding traits is convincing. An example of a model that many behaviorists might accept is Costa and McCrae’s _____________ model.

ANS: Five-factor

7.

In order to help a patient quit smoking, a therapist asks the patient to record what they were doing before smoking and how they feel afterwards. This is an example of using a _______ technique.

ANS: Self-monitoring

8.

In the treatment of anxiety disorders _______ techniques are often used, such as diaphragmatic breathing.

ANS: Relaxation

9.

To treat a patient with a phobia, a therapist helps the patient develop a hierarchy of anxiety producing situations and then helps the patient face those situations. This is termed _______.

ANS: Systematic desensitization

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© 2014 Cengage Learning, Inc. 10.

Another term for a punishment-based strategy such as giving a patient with alcoholism Antabuse so he vomits if he drinks is _______.

ANS: Aversive conditioning Essay Questions

1.

Behavioral therapy approaches can be described as occurring in waves. What was the focus of the first and second wave? How are the “third wave” approaches of dialectical behavior therapy and acceptance and commitment therapy similar and different from these earlier approaches?

2.

The main premise of behavioral therapy is that problematic behaviors, cognitions and emotions have been learned and can be unlearned under the right conditions. How does this basic premise contrast with psychoanalytic theories?

3.

Behavior therapists often use approaches that address covert behaviors (i.e., thoughts and images). How are these techniques (e.g., guided imagery) used? How would a behavioral therapist explain the theory behind why they are used in therapy?

4.

A therapist is asked to treat a patient with a phobia of bridges and tunnels. The therapist wants to use the treatment of choice for the case. Name and describe the technique(s) the therapist would use.

5.

Name the types of presenting problems that behavioral therapy would be most appropriate to treat. Why do you think these types of problems might respond best to behavioral interventions?

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Chapter 7 Cognitive Therapy Authors: Aaron T. Beck and Marjorie E Weishaar Key Points and Terms

Overview ► ► ► ► ► ►

Cognitive theory is based on the role information processing plays in survival.

The theory states cognition, behavior, affect, and motivation are intertwined and cooccur.

Therapeutic intervention focuses on the primacy of cognition.

Cognitive schema: A structure containing self-perceptions; thoughts about others and the world; our memories, goals, fantasies; and everything we’ve learned.

Cognitive shift: A systematic bias in information processing.

Cognitive vulnerabilities: Specific attitudes predisposing the interpretation of experiences.

Mode ► ► ► ►

►

Networks of cognitive, affective, motivational, and behavioral schemas.

Primal modes are universal and related to survival.

They include primal thinking, which is rigid, absolute, automatic and biased.

Dysfunctional modes are treated by deactivating them, altering their structure and content and developing more adaptive modes.

A cognitive therapist relies on collaborative empiricism and guided discovery. Focus is on patients testing beliefs and behaviors to develop positive mental health.

Cognitive and behavioral techniques are both employed.

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© 2014 Cengage Learning, Inc. Basic Characteristics of CBT ► Practical ► Symptom focused ► Empirically-derived techniques ► Requires patient collaboration ► Acknowledges underlying precursors of symptoms while remaining present-oriented ► Case conceptualization drives treatment.

Primary Roles of the CBT Therapist ► Conceptualizing the patient in cognitive terms ► Structuring the sessions ► Using collaborative empiricism and guided discovery to specify problems and set goals The Cognitive Model Behaviors

Situation

Automatic Thoughts

Underlying Beliefs

► ► ► ► ► ► ► ►

Emotions

Physiological Response

Automatic thoughts influence not only one’s emotional response, but also one’s behavioral, motivational and physiological responses.

The relationship is bi-directional (all systems act together as a mode); therefore, simultaneously biology, emotions, behavior (and motivation) influence thoughts.

Subsequently, biological treatments can change thoughts and CBT can change biological processes.

We all have cognitive vulnerabilities (i.e., core beliefs) that predispose us to interpret information in a certain way.

These vulnerabilities are developed early.

When these beliefs are rigid, negative, and ingrained, we are predisposed to pathology.

These core beliefs give rise to conditional assumptions (i.e., rules for living) as we mature.

In psychopathology, there are systematic biases toward selectively interpreting information in a certain manner that are disorder specific.

Strategies of Cognitive Therapy ► Collaborative empiricism ► Guided discovery ► Deactivation of dysfunctional modes ▪ Techniques that directly deactivate them

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Modifying their content and structure Constructing more adaptive modes to neutralize them Comparing CT to Other Therapies

CT Compared with Psychoanalysis ► Both assume behavior is influenced by beliefs of which we may be unaware. ► CT focuses on linkages among symptoms, conscious beliefs and current experiences; little concern with unconscious feelings or repressed emotions as in psychoanalysis. ► CT has minimal focus on childhood or developmental issues except in terms of assessment or when addressing core beliefs. ► CT is highly structured and generally short-term (12-16 weeks), whereas psychoanalysis is long-term and unstructured. ► In CT, the therapist actively collaborates with the patient.

REBT Compared to Cognitive Therapy CT Thoughts Labeled Dysfunctional

REBT Irrational

Type of Reasoning Used

Inductive

Deductive

Beliefs Associated with Psychopathology

Cognitive specificity for each disorder

core set of irrational beliefs

View of the Problem

Functional; pathology arises from multiple cognitive distortions

Philosophical; pathology arises from “shoulds,” “musts,” and “oughts”

Therapist’s Approach

More collaborative

More confrontational

Emphasis

Psychoeducation an early and critical component of treatment

Higher reliance on psychoeducation

Focus

“Hot cognitions” critical, but obtained in a less aggressive manner

More aggressive focus on emotional-evocative methods; core set of irrational beliefs

CT Compared to Behavior Therapy ▪ CT is very different from applied behavioral analysis.

▪ CT is the most commonly practiced form of cognitive behavior therapy (CBT), an overarching term to represent therapies that integrate cognitive and behavioral theories and techniques.

▪ CT sees the individual as more active rather than passive in change process.

▪ CT stresses expectations, interpretations and reactions.

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© 2014 Cengage Learning, Inc. Cognitive Therapy and Medication ► Studies generally show CT to be equivalent to psychotropic medications for depression, bulimia and some anxiety disorders. ► Generally, research suggests the combination of the two approaches is superior to either used in isolation. ► CT shows longer efficacy (less relapse) and increased likelihood of continuing gains when treatment is discontinued. ► CT and antidepressants (TCAs/1st generation SSRIs) show equal efficacy rates.

History of Cognitive Therapy ► ► ► ►

Developed by Aaron T. Beck, M.D. He was investigating the “anger turned inward” psychoanalytic concept regarding depression in 1960s and found evidence for negative cognitions.

Bandura, Ellis, Mahoney, and Meichenbaum’s ideas were all influential in the development of CT as they were developing their approaches simultaneously.

Other major influences were: ▪ Phenomenological approaches ▪ Structural theory and depth psychology ▪ Cognitive psychology

Current Status of CT ► Research has supported the CT cognitive specificity hypothesis and the cognitive triad. ► CT shown to reduce the rate of suicide re-attempts by 50% over an 18-month period.

Resources in CT ► Center for Cognitive Therapy (U/Penn) and Beck Institute are the major training sites (both in Philadelphia). ► Multiple other training sites in the United States and internationally. ► Cognitive Therapy and Research and Journal of Cognitive Psychotherapy ► Academy of Cognitive Therapy (for more information go to www.academyofct.org) ► National and international conferences for CT are held annually. ► CT has influenced the Association of Behavioral Therapy to the point that, in 2005, the organization changed its name to the Association for Behavioral and Cognitive Therapies (ABCT). ► CT is also now taught routinely in psychiatry residency programs in the United States.

Cognitive Therapy’s View of Personality ►

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Thinking is problematic or distorted when it is very: ▪ Extreme ▪ Broad ▪ Catastrophic ▪ Negative

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Unscientific Pollyanish Idealistic Demanding Judgmental Comfort seeking Obsessive Confusing

Cognitive Distortions ► Arbitrary inference: Drawing a conclusion without evidence or in the face of contradictory evidence.

▪ For example, a young woman with anorexia nervosa believes she is fat although she is dying from starvation. ► Selective abstraction: Dwelling on a single negative detail taken out of context.

▪ While on a date, you say one thing you wish you could have said differently and now see the entire evening as a disaster. ► Overgeneralization: A single negative event is viewed as a never-ending pattern of defeat.

▪ Following a job interview, an accountant does not receive the job. He/she begins thinking that they will never find a job position despite their qualifications. ► Magnification and/or minimization: The binocular trick. Things seem bigger or smaller than they truly are.

▪ An employee believes that a minor mistake will lead to being fired vs. an alcoholic who believes he/she doesn’t have a problem. ► Personalization: Assuming personal responsibility for something for which you are not responsible.

▪ Often seen in patients who are sexually abuse/assaulted. ► Dichotomous thinking: Things are seen as black and white, there is no gray or middle ground.

▪ Things are wonderful or awful, good or bad, perfect or a failure. ► Mind reading: Assuming someone is responding negatively to you without checking it out.

▪ If your husband is in a bad mood, you assume it is your fault and don’t ask what is wrong. ► Fortune teller error: Creating a negative self-fulfilling prophecy.

▪ You believe you will fail an important exam, so you do not study and fail. ► Emotional reasoning: You assume that your negative feelings result from the fact that things are negative.

▪ If you feel bad, then that means the world or situation is bad. You don’t consider that your feelings are a misrepresentation of the facts. ► Should statements: Use words like “should,” “must,” and “ought” rather than “it would be preferred” to guilt self. ► Labeling and mislabeling: Name calling such as “He’s a jerk,” rather than just criticizing the behavior.

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Process of Psychotherapy in Cognitive Therapy Structure of a CBT Session ► Mood check ► Setting the agenda ► Bridging from last session ► Today’s agenda items ► Homework assignment ► Summarizing throughout and at end of the session ► Feedback from patient General Principles of CT ► Goal is to correct dysfunctional thinking and help patients modify erroneous assumptions ► Patient is taught to be a scientist who generates and tests hypotheses ► Relationship between patient and therapist is collaborative Fundamental Concepts ► Collaborative empiricism ▪ Goal is to demystify therapy. ► Socratic dialogue ▪ Form of questioning used to help patients come to their own conclusions about their thoughts and behaviors. ► Guided discovery ▪ Therapist collaborates with patient to develop behavioral experiments to test hypotheses.

Process of Therapy 1. Initial sessions ▪ Essential to build rapport.

▪ Focus is problem definition, goal setting and symptom relief.

▪ Therapist provides psychoeducation in initial sessions.

▪ Behavioral interventions may more prominent.

2. Middle sessions ▪ Emphasis shifts from symptoms/behaviors to patterns of thinking.

3. Termination ▪ Expectation that therapy is time limited.

Examples of Behavioral Interventions in CT ► Weekly activity monitoring with ratings of mastery and pleasure ► Activity scheduling ► Graded task assignments ► Conducting behavioral experiments (e.g., being assertive to assess what happens) ► Exposure type techniques ► Role-plays

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More Details About a Specific Behavioral Technique: Weekly Activity Monitoring ► Patient records activities and rates them for pleasure and mastery. ► Can be used in several different ways. ► The activity monitoring form allows the therapist and the patient to: ▪ Assess how patients are spending their time.

▪ Measure the sense of accomplishment and/or pleasure received from various activities.

▪ Determine which activities are occurring too much or too little.

▪ Evaluate automatic thoughts or emotional shifts.

▪ Fill in specific times with planned activities, such as pleasant activities for depressed patients or activities that must be done for procrastinating patients.

▪ Compare predicted ratings of accomplishment and pleasure with actual ratings.

Examples of Cognitive Interventions in CT ► Elicit automatic thoughts through dysfunctional thought records. ► Identify whether the thoughts represent distortions in information processing. ► Use Socratic questions to evaluate the thought process. ► Generate alternatives in terms of how to think or how to behave differently.

More Details About a Specific Cognitive Technique: Dysfunctional Thought Records ► Eliciting automatic thoughts ▪ Basic question: What thought just went through your mind?

• Ask when an emotional shift is noted in session.

• Create an emotional shift by having the patient describe or visualize a recent situation in which they felt intense emotions and then answer the question.

• If patient can’t answer the question, try asking: ► Do you think you were thinking _____________? ► If someone else was in the situation, what do you think they might have been thinking? ► Were you thinking ______________? (insert something paradoxical) ▪ Use Socratic questions to have patient examine and refute their dysfunctional thoughts.

• What evidence do you have to support the belief?

• What evidence do you have to refute it?

• What would your spouse, best friend, sibling (or anyone whom you admire greatly) say in this situation?

• What would you say to your spouse, best friend, or sibling if they were thinking the same thing you are?

• How could you look at this situation so you would feel less depressed?

Is this view as reasonable as your first choice?

▪ Use the downward arrow technique to obtain less accessible beliefs.

• If that were true, what would it mean to you (about you)?

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And, then what?

Principles for Setting Effective Homework ► Make sure rationale is clear. ► When feasible, have patient chose the task. ► Personalize task to therapy goals. ► Begin where patient is, not where patient thinks he/she should be. ► Be specific and concrete: where, when, with whom etc. ► Formalize the task (e.g., write on paper). ► Plan ahead for potential obstacles and “trouble shoot.” ► Practice the task in session. ► Review homework at the beginning of each session.

Other Cognitive Therapy Techniques ► De-catastrophizing: “What if that happened? Then what?” ► Reattribution: Alternative explanations systematically examined. ► Redefining: Help patient define the problem differently.

▪ “Nobody ever talks to me” becomes “I need to try to initiate conversations so other people become interested in me.” ► Decentering: Used with social anxiety to shift the focus. Patient is taught to see that thoughts are just thoughts and not “them” or “reality.”

Applications ►

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Meta-analyses and other recent methodologically-rigorous studies that have studied the efficacy of CT have found large effect sizes for: ▪ Unipolar depression ▪ Generalized anxiety disorder ▪ Panic disorder ▪ Social phobia ▪ Childhood depressive and anxiety disorders Moderate effect sizes for: ▪ Marital problems ▪ Anger ▪ Childhood somatic disorders ▪ Chronic pain Small effect sizes for: ▪ Schizophrenia ▪ Bulimia nervosa CT yields lower relapse rates than antidepressant medications and reduces the risk of symptom relapse.

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Cognitive therapy focuses on understanding a patient’s beliefs within a cultural context.

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Chapter 7: Activities Role-play Create a patient scenario. For example, ask students to imagine they are talking to another student who is considering quitting school. Have students offer examples of Socratic questions to help the student decide whether to continue school. Have other class members evaluate whether the questions offered are Socratic or not.

Discussion Questions 1.

Choose three cognitive distortions to discuss in detail. Remind students that all humans engage in cognitive distortions and that distorting information is only problematic when it occurs frequently and rigidly. Ask them to give examples of times when they may have engaged in each cognitive distortion discussed.

2.

Ask students to imagine they are in class and have just found out that there will be a pop quiz on cognitive therapy. Encourage them to discuss what might be some of the automatic thoughts they would experience. Then ask the class to consider what automatic thoughts a student with depression might have.

3.

Provide students with a Weekly Activity Monitoring Form to complete between classes.

Have students discuss how frequently they completed the form and what obstacles interfered with completing the form on a regular basis. Ask students to consider how difficult this task might be for depressed patients and to discuss ways they could increase the likelihood that a depressed patient does the assignment.

Use of Movies to Depict Concepts

Movies and Mental Illness points out that, while cognitive behavioral therapy is the most empirically-supported method and a frequently used approach, it is rarely depicted in films. Ask students to discuss why it may not have Hollywood appeal.

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© 2014 Cengage Learning, Inc. Case Illustration from Case Studies in Psychotherapies (7th Edition)

An Interview with a Depressed and Suicidal Patient by Aaron T. Beck Aaron Beck, developer of cognitive therapy, is an authority on suicide and depression. In this case study, Beck demonstrates how cognitive therapy is used to assist a depressed professional woman and illustrates the Socratic manner used in cognitive therapy.

The case also demonstrates the differences between cognitive therapy and REBT.

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Chapter 7: Potential Test Items Multiple Choice Test Bank 1.

The theory behind cognitive therapy asserts that: a. unconscious conflicts from childhood lead to pathology. b. all psychopathology results from cognitive distortions. c. thoughts precede and determine emotions and behavior. d. altering thoughts influences feelings, motivations and behaviors.

REF: Overview (p. 231) ANS: D

2.

Structures that contain an individual’s core beliefs and assumptions are labeled: a. automatic thoughts. b. cognitive distortions. c. cognitive schemas. d. voluntary thoughts.

REF: Overview (p. 232) ANS: C

3.

When an individual is predisposed under stress to misinterpret information in a biased fashion, cognitive theory would state that the individual is exhibiting a: a. cognitive vulnerability. b. primal mode. c. cognitive profile. d. sociotropic personality.

REF: Overview (p. 232) ANS: A

4.

Cognitive theory asserts individuals with personality disorders are largely operating from: a. selfless motivations. b. meta thought. c. primal modes. d. deliberate thinking.

REF: Overview (p. 232) ANS: D

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Primal modes refer to modes that are: a. developed before age 5-6. b. universal and related to survival. c. necessary for human relating. d. triggered by misperceptions.

REF: Overview (p. 232) ANS: B

6.

Collaborative empiricism assumes the patient can play the role of a: a. practical scientist. b. therapist for their family. c. verbal debater. d. computer analyst.

REF: Overview (p. 232) ANS: A

7.

Guided discovery refers to the process by which a therapist: a. serves as a guide to clarify problem behaviors and thoughts. b. assists a patient to resolve unconscious conflicts. c. confronts and persuades patients to change thoughts. d. guides an exploration of a patient’s dreams and fantasies.

REF: Overview (p. 233) ANS: A

8.

Which of the following would create the most significant change in a dysfunctional mode for a patient? a.

Altering automatic thoughts b.

Providing reassurance and empathy c.

Teaching distraction and relaxation techniques d.

Modifying core beliefs REF: Overview (p. 233) ANS: D

9.

Cognitive and psychodynamic therapies are similar in that both theorize that: a. meanings behind behavior are readily accessible to conscious interpretation. b. behavior can be influenced by beliefs one is not immediately aware. c. a patient’s self-report is a screen for more deeply concealed ideas. d. therapy should be highly structured, directive and short-term.

REF: Overview (p. 233) ANS: B

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In contrast to rational emotive behavior therapy (REBT), cognitive therapists hypothesize that: a. problems in cognitive processing are philosophical. b. similar irrational beliefs underlie all psychopathology. c. beliefs are categorized as rational or irrational . d. each mental disorder has its specific cognitive content.

REF: Overview (p. 234) ANS: D

11.

A cognitive therapist will label a non-adaptive thought as: a. irrational. b. unconscious. c. dysfunctional. d. pathological.

REF: Overview (p. 234) ANS: C

12.

Bandura would argue that the most effective way to change a thought is to teach a patient to: a. argue with their thoughts. b. change a behavior. c. adopt the beliefs of the therapist. d. explore childhood experiences.

REF: Overview (p. 235) ANS: B

13.

In contrast to Albert Ellis, who confronted patients about their beliefs, Aaron Beck’s approach was: a. more collaborative. b. non-directive. c. less empirically based. d. focused on irrational beliefs.

REF: History (p. 236) ANS: A

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Which of the following was NOT a primary influence on the theory behind cognitive therapy? a.

Phenomenological psychology b.

Structural theory c.

Computer technology d.

Cognitive psychology REF: History (p. 235) ANS: C

15.

Research on depression in the 1960s, which served as the foundation of cognitive therapy, was conducted by: a.

Albert Bandura. b.

Aaron Beck. c.

Albert Ellis. d.

Donald Meichenbaum.

REF: History (p. 235) ANS: B

16.

The cognitive model of depression postulates three specific concepts that are: a. depression, anxiety and neuroticism. b. congruence, empathy, and unconditional positive regard. c. cognitive triad, schemas, and cognitive errors. d. irrationality, rationality and masturbation.

REF: History (p. 236) ANS: C

17.

Studies comparing the efficacy of cognitive therapy versus medication for depression have found cognitive therapy: a. is not as effective as medication. b. is superior or equal to medication. c. has lower long term effects. d. does not reduce suicidal ideation.

REF: Applications (p. 250) ANS: B

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The multi-site study conducted by the National Institute of Mental Health on treatment of depression showed: a. interpersonal and cognitive therapy were as effective as medication for moderately depressed patients. b. cognitive therapy was the treatment of choice for severely depressed patients. c. cognitive therapy was more effective than placebo for severely depressed patients. d. patients receiving medications had the lowest relapse rate at one year followup.

REF: Applications (p. 250) ANS: A

19.

Beck’s research suggests suicide risk is associated with: a. hopelessness. b. personalization. c. infantile sexuality. d. irrationality.

REF: History (p. 238) ANS: A

20.

Beck’s two personality dimensions, or modes of behavior, he hypothesized were related to depression are: a. introversion and extraversion. b. sociotropy and autonomy. c. neuroticism and psychoticism. d. stability and instability.

REF: Personality (p. 239) ANS: B

21.

A cognitive distortion refers to: a. lying to protect one’s self-image. b. distortion of past memories. c. a systematic error in reasoning. d. drug induced shifts in beliefs.

REF: Personality (p. 240) ANS: C

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Drawing a specific conclusion without supporting evidence, or even in the face of contradictory evidence, is defined as: a. dichotomous thinking. b. magnification. c. personalization. d. arbitrary inference.

REF: Personality (p. 240) ANS: D

23.

Attributing external events to oneself without evidence supporting a causal connection is termed: a. personalization. b. selective abstraction. c. overgeneralization. d. arbitrary inference.

REF: Personality (p. 240) ANS: A

24.

Kate has anorexia nervosa and when she gains one pound she believes she is fat. If she loses one pound, she can perceive herself as thin. Kate’s thought process reflects: a. arbitrary inference. b dichotomous thinking. c. magnification. d. personalization.

REF: Personality (p. 240) ANS: B

25.

Shannon has a history of chronic depression. According to cognitive theory, which statement likely represents her thought process upon discovering she has failed an exam? a.

I can study harder next time and improve my grade. b.

Yesterday was an unlucky day for me to take an exam. c.

It was a poorly written examination by a poor teacher. d.

I’m a failure, always have been and always will be.

REF: Personality (p. 240-241) ANS: D

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Which of the following disorders is associated with an inflated view of self and future? a.

Anxiety disorder b.

Obsession c.

Hypomania d.

Compulsion REF: Personality (p. 241) ANS: C

27.

Which disorder is associated with catastrophic interpretations of bodily/mental experiences? a.

Panic disorder b.

Paranoia c.

Depression d.

Anorexia nervosa REF: Personality (p. 241) ANS: A

28.

In paranoia, an individual has an inflated sense of: a. worthlessness. b. grandiosity. c. injustice. d. responsibility.

REF: Personality (p. 241) ANS: C

29.

In cognitive therapy, a patient learns to eliminate negative or dysfunctional thoughts by learning beliefs that are: a. irrational. b. absolute. c. positive. d. realistic.

REF: Psychotherapy (p. 244) ANS: D

30.

The cognitions that are most accessible and least stable are: a. core beliefs. b. voluntary thoughts. c. assumptions. d. automatic thoughts.

REF: Psychotherapy (p. 245) ANS: B

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Which of the following is a primary goal in the initial cognitive therapy interview? a.

Transference development b.

Symptom relief c.

Non-directiveness d.

Dream analysis REF: Psychotherapy (p. 245-248) ANS: B

32.

Cognitive therapy is not appropriate as an exclusive treatment for: a. unipolar depression. b. panic disorder. c. obsessive-compulsive disorder. d. bipolar disorder.

REF: Applications (p. 250) ANS: D

33.

Asking a patient to ponder “what if” scenarios about feared consequences is known as: a. redefining. b. reattribution. c. decatastrophizing. d. decentering.

REF: Applications (p. 252) ANS: C

34.

Assisting a patient in initiating a task at a non-threatening level and then gradually increasing the task difficulty is referred to as: a. hypothesis testing. b. diversion. c. roleplaying. d. graded task assignment.

REF: Applications (p. 253-254) ANS: D

35.

For which of the following disorders has CT shown the largest treatment effect size? a.

Bulimia nervosa b.

Chronic pain c.

Panic disorder d.

Schizophrenia REF: Applications (p. 255) ANS: C

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© 2014 Cengage Learning, Inc. Fill in the Blanks 1.

According to cognitive theory, thoughts _________________ shifts in emotions.

ANS: Co-occur with or influence

2.

Cognitive therapists encourage patients to use _________________ reasoning, whereas REBT therapists rely on __________________ reasoning.

ANS: Inductive; deductive

3.

A cognitive therapist treating a patient with suicidal ideation would focus on _________________ because it is a strong predictor of eventual suicide.

ANS: Hopelessness

4.

Cognitive theory states that an individual’s fundamental beliefs and assumptions are contained in structures termed __________________.

ANS: Cognitive schemas

5.

A patient with anorexia nervosa believes that she is thin when she exercises, but fat if she eats. This would be an example of the ___________________ cognitive distortion.

ANS: All or nothing thinking

6.

The belief hierarchy proposed in cognitive theory goes from ___________________ (the most stable, least accessible cognitions) to _______________________ (the least stable but most accessible cognitions).

ANS: Core beliefs or assumptions; voluntary thoughts

7.

Cognitive theory recognizes all humans make mistakes in processing information and hypothesizes that it is ___________________biases in processing that leads to psychopathology.

ANS: Systematic

8.

The preferred method of dialoguing with a patient in cognitive therapy is through the use of ______________________ questions.

ANS: Socratic

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Early in treatment, a cognitive therapist may rely more on _______________ techniques; later in treatment, the focus shifts towards ______________ techniques.

ANS: Behavioral; cognitive

10.

Through _________________ cognitive therapy patients create homework assignments for themselves called “behavioral experiments” with input from their therapist.

ANS: Guided discovery Essay Questions

1.

Cognitive therapy is often described incorrectly; many therapists who are not trained in cognitive therapy believe the cognitive model states that thoughts cause feelings.

Describe the cognitive model accurately.

2.

To a novice therapist, the distinctions between cognitive therapy, behavioral therapy, REBT and multimodal therapy are often difficult to decipher. Describe how these approaches differ.

3.

Describe the goal of Socratic questioning. Write out some examples of Socratic questions and some examples of non-Socratic questions.

4.

Empirical studies have repeatedly shown that cognitive therapy and antidepressant medications are both highly effective in the treatment of depression. Furthermore, the combination of the two approaches is often preferable. Describe the benefits to using both in combination. Would there be any potential for one approach to undermine the other? If so, how? If not, why not?

5.

Cognitive therapy is one of the most empirically-validated therapies available. State why you think cognitive therapy lends itself well to being researched. Contrast researching cognitive therapy to the difficulties inherent in researching psychoanalytic approaches.

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Chapter 8 Existential Psychotherapy Authors: Irvin D. Yalom and Ruthellen Josselson Key Points and Terms

Overview ► ► ►

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Existential psychotherapy is not a specific technique or “school of therapy.”

More philosophical in nature and focuses on issues central to human existence.

Focus is on “ultimate concerns:” ▪ Death ▪ Freedom ▪ Isolation ▪ Meaning Primary task of therapy is to facilitate genuineness.

Primary role of the therapist is to be a “fellow traveler” with the patient.

Emphasis is on living authentically and responsibly and also addresses questions of meaning, creativity and love.

Freedom: Refers to idea that we all live in a universe without inherent design and are the authors of our lives and thus responsible for our choices.

Responsibility: Linked to freedom.

Isolation: Refers to an unbridgeable gulf between ourselves and others; believed to be the primary source of anxiety according to Eric Fromm.

▪ Interpersonal isolation: Isolated from others.

▪ Intrapersonal isolation: Isolated from parts of ourselves.

▪ Existential isolation: Aloneness in the universe.

Meaning: Refers to developing a purpose for our lives by plunging into an enlarging, fulfilling self-transcending endeavor.

Death: Refers to our awareness of our mortality.

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© 2014 Cengage Learning, Inc. History of Existentialism “Where have I come from? Why am I here? Where am I going? What do I value?” ► ► ► ► ► ► ► ►

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Existential thinking has occurred throughout history and has been reflected across literature, art, music, and religion.

Greek philosopher Epicurus discussed death anxiety.

Coalesced into a formal system of thought in the 19th century.

Term existentialism is most associated with Jean Paul Sartre and Gabriel Marcel.

Exemplified in the writings of Kierkegaard (profound analysis of anxiety and despair) and Nietzsche (who developed insights into guilt and resentment).

Major advances in existential psychology resulted as a reaction to the mechanistic premises of behaviorism and deterministic views of psychoanalysis.

20th century proponents of an existential view include Binswanger, Boss, Heidegger, Husserl.

In 1958, existential psychotherapy introduced to the U.S. with publication of Existence: A New Dimension in Psychiatry and Psychology by Rollo May, Ernest Angel, and Henri Ellenberger.

Other seminal works by May include Man’s Search for Himself, Freedom and Destiny, and The Cry for Myth.

Eric Fromm’s works Escape from Freedom and Art of Loving explored existentialism.

Victor Frankl’s Man’s Search for Freedom described logotherapy, a psychotherapy focused on will, freedom, meaning and responsibility.

Yalom published the first comprehensive textbook in existential psychiatry, entitled Existential Psychotherapy, in 1980.

Unifying themes for existentialists are freedom, reflection and responsibility.

Current Status ► Existential psychotherapy has presuppositions underlying all types of therapy as it is a way of thinking about human beings. ► Contemporary existentialists apply the concepts across settings, groups, diverse populations, and diverse aspects of human suffering. ► The popularity of The Gift of Therapy (written by Yalom) in 2002 shows that therapists are highly interested in dealing with existential issues personally and with their patients. ► Existential psychotherapy is an integrative approach.

Comparison of Existential Therapy to Other Therapies Most Different

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Most Similar

Psychoanalytic

Humanistic

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© 2014 Cengage Learning, Inc. Existential Theory of Personality ► ►

Existential psychotherapy does not offer a theory of individual differences and its theory of personality focuses on living authentically.

Existential psychotherapy is a dynamic psychotherapy.

Awareness of ►

Anxiety

Defense Mechanism

May described anxiety as the clash between being and non-being.

Issues Related to Human Existence ► Freedom: Requires that an individual confront the limits of his own destiny (i.e., their talents and limits); willing represents moving from wishing to deciding to action.

▪ Wishing is closely aligned to feeling.

▪ Impulsivity avoids wishing by failing to discriminate between wishes.

▪ Compulsivity avoids wishing by acting on unconscious inner demands rather than conscious desires. ► Isolation: Can be interpersonal (divide between oneself and others) and intrapersonal (fact we are isolated from parts of ourselves). ► Meaninglessness: Meaning creates hierarchal order of our values and tells us how to live, but not why we live. ► Death: Distress is due to failure to deal with the inevitability of death; confronting the inevitability of death can yield passion.

▪ Specialness: At an unconscious level we want/need to believe that the laws of existence don’t apply to us.

▪ Ultimate rescuer: To deal with concept of death, individuals often develop a belief in a personal omnipotent savior.

Comparing Existential Psychotherapy to Other Systems Approach Key Difference(s) Psychodynamic ▪ Existentialists reject predetermined explanatory systems concerning human ordeal.

▪ Conflict viewed as grounded in the human predicament, not suppressed instincts.

▪ Existentialists are not drawn to concepts (e.g. Jung’s archetype, collective unconscious).

Gestalt ▪ Less emphasis on technical contrivance in an existential model.

▪ Gestalt approaches exemplify more optimism.

Cognitive and ▪ Existentialists view these systems as oversimplifying human Behavioral experience.

▪ CBT has a more circumscribed plan for change. ► ► ►

Sees human strife as related to our existential predicament.

Conflict is between the individual and the “givens” of existence.

“Our problems reside in our very arrival on the planet.”

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While clients present with “every day” concerns, there are “ontological underpinnings.”

▪ Fear of flying might represent ultimate concerns regarding death.

▪ Difficulty adjusting after a divorce might relate to loneliness concerns.

The existential approach is an attitude.

▪ Therapist is a “fellow traveler.”

▪ The relationship (i.e., the encounter) heals as the therapist is willing to be a companion as the client confronts existence and all it entails.

If clients are living in inauthentic modes of being, the goal of psychotherapy is to relinquish these modes.

▪ Clients entering therapy in an existential crisis may be easier to work with (as they may be more willing to face existential issues) than those who come in because of specific symptoms.

▪ Therapy is a “boundary” situation to allow the client to move toward authenticity.

Therapeutic processes include: ▪ Focus on the here-and-now ▪ Therapeutic listening and empathy (requires genuineness and transparency) ▪ Therapeutic guiding (i.e., encouraging personalization of one’s dialogue) • Eliciting examples of the client’s troubles • Exploring the patient’s dreams • Facilitating the client to take ownership over their thoughts Bottom line: There are no ultimate answers for ultimate concerns.

▪ Ultimate concerns are confronted but not conquered.

▪ Psychotherapy helps the client relinquish false expectations about ultimate concerns to allow them to live fully in the moment.

More Details about Existential Psychotherapy ► Ultimate concerns have implications for therapy process. ► Psychodynamic treatment model is followed. ► Ultimate concerns create boundary situations that are experiences that force individuals to confront an existential situation. ► Dealing with death anxiety can be transforming; examples of dealing with it might be diagnosis of a terminal illness, death of a family member or friend, major life transitions, milestones. ► Psychotherapy can address existential isolation.

Existential Group Psychotherapy ► Patients learn how their behavior is viewed by others, how it makes others feel, how it creates opinions others have of them and how it influences their opinions of self.

Applications of Existential Therapy (ET) ► ►

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The clinical setting determines the applicability of the existential approach.

Existential psychotherapy is applicable to a diverse population.

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Most appropriate for patients confronting a boundary situation, but applicable in many other circumstances because dealing with ultimate concerns may be underlying symptoms such as anxiety, depression, anger, etc.

Evidence ► Systematic, corroborative evidence for ET is relatively limited. ► Difficult to create controlled experimental designs to test the approach. ► Much of the research supporting ET uses qualitative/phenomenological methods (which has gained greater professional legitimacy recently by the APA Presidential Task Force on Evidenced-Based Practice). ► ET is supported by the research behind “common factors,” which underscores the importance of the relationship in the therapeutic process. ► Qualitative research has validated the importance of presence, self-reflection, and consideration of alternatives in therapy. ► Studies have shown transcendence (i.e., moving beyond limitations) as essential to change.

Treatment ► ET has been shown to be beneficial for: ▪ Individual therapy ▪ Group therapy ▪ Families and couples ▪ Diverse diagnostic and ethnic populations ▪ Group mediation Psychotherapy in a Multicultural World ► ►

►

Existential psychotherapy considers the situation of the whole person located in society and culture.

All humans share in the dilemmas of existence, but existential therapists recognize that some difficulties occur when an individual has adopted wholesale formulas for managing these concerns that were provided by their cultural, often religious, systems.

Existential therapists attempt to understand how belief systems provide a sense of meaning to a patient, stay authentic with regard to their own beliefs and increase the patient’s engagement with purpose and meaning in life.

Chapter 8: Activities Role-play Ask a willing student to imagine that they have just been diagnosed with a terminal illness and will likely die in six months. Ask another willing student to imagine they are a therapist who is going to be with the patient while he/she determines how to spend the remainder of their life. Have the students role-play how they would dialogue about this difficult subject.

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Discussion Questions 1.

Ask students to discuss the ultimate concern of death by having them write the eulogy they would like to have read at their funeral. Encourage a discussion of the thoughts and feelings this exercise created.

2.

Irv Yalom has indicated that to deal with death anxiety, individuals often create an ultimate rescuer (i.e., a personal, omnipotent savoir). Most religions would assert that an ultimate rescuer truly exists and that meaning for humans is related to how a human serves that ultimate rescuer. Ask the students to discuss these opposing views.

3.

Systematic, corroborative evidence for existential therapy is difficult to create from controlled experimental designs. More recently, qualitative and phenomenological research methods have gained greater professional legitimacy by the APA Presidential Task Force on Evidenced-Based Practice. Ask students to discuss their ideas about how to develop empirical data for existentialism and whether they feel qualitative methods alone would suffice.

Use of Movies to Depict Concepts

Existential psychotherapists help people deal with making meaning out of their lives and facing challenging situations such as death. Films that lend themselves to class discussions easily about the challenges of dealing with death include The Bucket List (2008) starring Jack Nicholson and Morgan Freeman; Beaches (1988) starring Bette Midler and Barbara Hershey; and Steel Magnolias (2000) starring an all-star cast including Julia Roberts and Sally field.

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© 2014 Cengage Learning, Inc. Case Illustration from Case Studies in Psychotherapies (7th Edition)

If Rape were Legal by Irv Yalom This case shows existential therapy offered in the context of group psychotherapy by Irv Yalom, an expert in existential and group therapy. This case illustrates dream analysis as well as how a therapist copes with denial in the context of therapy. The case also gives a class the opportunity to discuss challenging questions like how to deal with death and dying and allocation of resources (like psychotherapy) on individuals facing death.

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Chapter 8: Potential Test Items Multiple Choice Test Bank 1.

Existential psychotherapy is a: a. philosophical approach to existence. b. set of rules for therapy. c. technical therapy approach. d. religious psychotherapy.

REF: Overview (p. 265) ANS: A

2.

The therapeutic stance of the existential therapist is as a(n): a. role model b. fellow traveler c. analytical transcriber d. reflective mirror REF: Overview (p. 269) ANS: B

3.

According to existentialists, when an individual recognizes their uniqueness and is remaining true to the self they are being: a. authentic. b. self-centered. c. neurotic. d. rational.

REF: Overview (p. 266) ANS: A

4.

The primary task of existential therapy is to facilitate: a. insight. b. behavior change. c. genuineness. d. cultural consciousness.

REF: Overview (p. 269) ANS: C

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Existentialists consider anxiety that is proportionate to the situation confronted as: a. neurotic anxiety. b. normal anxiety. c. repression. d. libidinal drives.

REF: Overview (p. 267) ANS: B

6.

In contrast to psychoanalytical approaches, existential approaches: a. accept predetermined explanatory systems concerning human ordeal. b. view conflict as grounded in human predicament, not suppressed instincts. c. incorporate concepts such as Jung’s archetype and collective unconscious. d. concur with behaviorists that consequences of behavior are paramount.

REF: Personality (p. 273) ANS: B

7.

Existential approaches are most similar to which of the following approaches? a.

Behavioral b.

Gestalt c.

Cognitive d.

Psychoanalytic REF: Overview (p. 269) ANS: B

8.

The existentialist who first emphasized death anxiety was: a.

Husserl. b.

Kierkegaard. c.

Nietzsche. d.

Epicurus.

REF: History (p. 270-271) ANS: D

9.

In 1958, existential psychotherapy was introduced to the U.S. with publication of Existence: A New Dimension in Psychiatry and Psychology by: a.

Irvin Yalom. b.

Kirk Schneider. c.

Ernest Angel. d.

Rollo May. REF: History (p. 271) ANS: D

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The first comprehensive textbook on existential psychotherapy was written by: a.

Rollo May. b.

Irvin Yalom. c.

Ernest Angel. d.

Viktor Frankl.

REF: History (p. 271) ANS: A

11.

Existential psychologists would advocate viewing the person: a. in anti-intellectual terms. b. both subjectively and objectively. c. entirely objectively. d. completely subjectively.

REF: Overview (p. 266) ANS: B

12.

Proponents of existential psychotherapy have not advocated specific training institutes because its: a. presuppositions can underlie any form of therapy. b. theory was never embraced by psychology. c. leaders have never valued formal education. d. premises cannot be taught, only experienced.

REF: Overview (p. 265) ANS: A

13.

In contrast to gestalt therapists, existential psychotherapists apply techniques: a. only during the assessment phase. b. when patients request they do so. c. spontaneously as indicated. d. in a technically contrived manner.

REF: History (p. 272) ANS: C

14.

In general, existential psychotherapy can be considered an approach that is: a. directive. b. cognitive-focused. c. integrative. d. emotional-focused.

REF: Overview (p. 265) ANS: C

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The individual who described logotherapy was: a.

Frankl. b.

Heidegger. c.

Husserl. d.

Nietzsche.

REF: History (p. 271) ANS: A

16.

Existentialism is most largely influenced by the field of: a. astronomy. b. engineering. c. computer science. d. liberal arts.

REF: History (p. 271) ANS: D

17.

In existential terms, the conflicts individuals experience are regarding: a. cultural and interpersonal environment. b. interactions with parental figures. c. the givens of existence. d. innate instinctual forces.

REF: History (p. 271) ANS: C

18.

Which of the following is NOT one of Yalom’s identified ultimate concerns? a.

Death b.

Meaninglessness c.

Freedom d.

Integrity REF: Overview (p. 266-269) ANS: D

19.

The existential concept of freedom refers to the fact that we: a. are born with a sense of purpose. b. can never truly obtain independence. c. displace our responsibilities onto others. d. are the authors of our own world.

REF: Overview (p. 266-267) ANS: D

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A concept ultimately associated with freedom is: a. accepting dependence. b. assuming responsibility. c. denying personal needs. d. relinquishing wishes.

REF: Overview (p. 266-267) ANS: B

21.

The presuppositions of existential psychotherapy apply best to: a. psychodynamic approaches. b. cognitive behavioral techniques. c. contemplative practices. d. all forms of therapy.

REF: Overview (p. 265) ANS: D

22.

Which of the following approaches to human distress would be incompatible with an existential approach? a.

Behavioral b.

Cognitive c.

Psychopharmacological d.

None, all are potentially compatible REF: Overview (p. 265) ANS: D

23.

The Gift of Therapy (2002) was written by: a.

Rollo May. b.

Victor Frankl. c.

Irv Yalom. d.

Friedrich Nietzsche.

REF: History (p. 272) ANS: C

24.

Existentialists hypothesize that anxiety is the result of: a. biologically-based instincts. b. awareness of ultimate concerns. c. competing cognitive distortions. d. id related libidinal drives.

REF: Personality (p. 273) ANS: B

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To cope with ultimate concerns regarding death, individuals will often use the defense mechanism of: a. accepting vulnerability. b. avoiding a sense of uniqueness. c. creating an ultimate rescuer. d. focusing on the uniqueness of others.

REF: Personality (p. 277) ANS: C

26.

From the existential perspective, “deep” conflict means the: a. most fundamental concern at that moment. b. difficulties experienced during individuation. c. earliest to occur in an individual’s life. d. inaccessible memories from childhood.

REF: Psychotherapy (p. 278) ANS: A

27.

Rollo May defines destiny in terms of our awareness of: a. private thoughts. b. limitations. c. sexuality. d. aloneness.

REF: Overview (p. 266) ANS: B

28.

An experience that forces an individual to confront an existential issue is known as a: a. boundary situation. b. moment of insight. c. therapeutic confrontation. d. personal revelation.

REF: Psychotherapy (p. 288) ANS: A

29.

Limitations created by forces of nature fall in which category of destiny? a.

Cosmic b.

Genetic c.

Cultural d.

Circumstantial REF: Overview (p. 268) ANS: A

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Existential psychotherapy (ET) primarily focuses on: a. childhood experiences. b. irrational thoughts. c. the here-and-now. d. maladaptive behaviors.

REF: Psychotherapy (p. 278) ANS: C Fill in the Blanks

1.

Existential psychotherapy is not a specific technique or set of techniques. It is more _______ in nature.

ANS: Philosophical

2.

Existentialists believe that one does not possess a(n) ___________ but rather embodies a(n) _______.

ANS: Personality; experience

3.

Normal anxiety is seen as proportionate to the situation involved. When the anxiety exceeds the situation present, it is considered _______.

ANS: Neurotic

4.

______________ is a form of psychotherapy described by Victor Frankly that focuses on will, freedom, meaning and responsibility.

ANS: Logotherapy

5.

When an individual can move past a situation in order to move toward their future, it is said that the person has _______ the immediate situation.

ANS: Transcended

6.

Existentialists believe that _______ originates out of the awareness that one’s being can end.

ANS: Anxiety

7.

Yalom indicated that there are four ultimate concerns, which include _______, _______, _______, and _______.

ANS: Death, freedom, isolation, and meaningless

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The fact that we are isolated from parts of ourselves is termed _______.

ANS: Intrapersonal isolation

9.

_______ refers to a human’s belief in a personal omnipotent servant, which will guard and protect them.

ANS: Ultimate rescuer

10.

Ultimate concerns create experiences, which force us to confront an existential situation called _______ situations.

ANS: Boundary Essay Questions

1.

Existential psychotherapy developed out of a concern with finding a more reliable and basic way of understanding human beings without skewing the view through theoretical frameworks. Discuss how existential psychotherapy differs from other psychotherapies.

2.

If the existential approach is an attitude, what is the role of the therapist? Why would a therapist need to participate in training?

3.

In the preamble read at Alcoholics Anonymous meetings, it states that the program works for those who are ready to live in a rigorously honest manner. How might existential approaches help an individual confront alcoholism?

4.

Describe the similarities and differences between a client-centered therapy approach and existential psychotherapy.

5.

Discuss the “ultimate concerns” of death, freedom, isolation, and meaningless and how these issues might arise in therapy and be treated.

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Chapter 9 Gestalt Therapy Authors: Gary Yontef and Lynne Jacobs Key Points and Terms

Overview ► ► ► ► ► ►

Gestalt psychotherapy is focused on process (what is happening) rather than on content (what is being discussed).

Developed by Fritz and Laura Perls.

Gestalt comes from the German word for “whole.”

Therapy focuses on the person’s experience in the here-and-now.

Holism and field theory are interrelated in gestalt theory.

Organismic self-regulation requires knowing and owning.

Phenomenological Method ► Direct perception is considered more reliable than explanations or interpretations. ► Clients are taught to be attentive to all parts of themselves including posture, breathing and methods of movement. ► Unresolved conflicts are worked out in the therapy session as if they are happening in that moment.

Gestalt Therapy ► Therapist and client dialogue about their perspectives. ► Differences of perspective are the focus of experimentation and further dialogue. ► Goal is for the client to have increased awareness of what they do, how they do it and how they can change or accept themselves.

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Behavioral

Most Similar

Psychoanalytic

Humanistic

Gestalt Therapy Compared to Other Systems “Distinction between gestalt therapy, behavior modification and psychoanalysis is clear. In behavior modification, the patient’s behavior is directly changed by the therapist’s manipulation of environmental stimuli. In psychoanalytic theory, behavior is caused by unconscious motivation, which becomes manifest in the transference relationship … In Gestalt therapy the patient learns to fully use his internal and external senses so he can be self-responsible and self-supportive. Gestalt therapy helps the patient regain the key to this state, the awareness of the process of awareness. Behavior modification conditions [by] using stimulus control, psychoanalysis cures by talking about and discovering the cause of mental illness [the problem], and gestalt therapy brings self-realization through here-and-now experiments in directed awareness.”

— Yontef, 1969 Gestalt

Person-Centered

REBT

Focuses on awareness and personal disclosure

Trusts patient’s selfreport

Confronts patient’s irrational thinking

Comparison of Gestalt Therapy to Other Therapies ► Over recent decades, gestalt therapy has had parallel developments with psychoanalysis with emphasis on the whole person, process thinking, subjectivity and affect, impact of life events on personality, viewing people as motivated towards growth and more integration of impact of interpersonal relations. ► Similarities of gestalt therapy with CBT and REBT include attention to cognition, encouraging present orientation, seeing role of focusing on the future on anxiety, creation of guilt by moralistic and unreasonable thinking. ► Major difference is that gestalt therapists do not assume to know the truth about what is irrational.

History of Gestalt Therapy ► ►

Main influences were psychoanalysis; humanistic, holistic, phenomenological approaches; and existential writings.

Frederick “Fritz” Salomon Perls ▪ Trained as a psychiatrist.

▪ Worked with Kurt Goldstein, a principal figure of the holistic school of psychology who studied the effects of brain injuries on WWI veterans.

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Laura Perls ▪ Trained as a psychologist.

▪ Worked with the gestalt psychologist Max Wertheimer.

The Perls ▪ Because of Nazism, the Perls fled Western Europe in 1933 to South Africa, where they practiced until 1945.

▪ In 1947, Ego, Hunger and Aggression: A Revision of Psychoanalysis is published in London under F. S. Perls’s name and included text reevaluating the psychoanalytic view on aggression.

▪ At the end of the war, the Perls emigrated to New York City.

▪ Collaboration began with artists and intellectuals versed in philosophy, psychology, medicine, and education resulting in elaboration of gestalt theory, therapy and therapists.

▪ In 1951, the Julian Press publishes Gestalt Therapy: Excitement and Growth in the Human Personality by F. S. Perls, Ralph Hefferline, and Paul Goodman/ ▪

►

►

Current Status of Gestalt Therapy ► Gestalt therapy institutes exist internationally. ► Virtually every major city in the United States has at least one gestalt institute. ► Association for the Advancement of Gestalt Therapy formed to govern adherence to gestalt principles. ► Four major journals in English (numerous others in other languages): ▪ International Gestalt Journal ▪ British Gestalt Journal ▪ Gestalt Review ▪ Australian Gestalt Journal Gestalt Therapy’s Theory of Personality The Field Theory Perspective ► Field theory underlies the gestalt phenomenological perspective. ► Field theory describes the whole field of which an event is part of rather than classifying it or seeking a cause-effect sequence. ► A person constitutes a field. ► No action is at a distance (i.e., what has effect must touch that which is affected in time and space). ► The phenomenological field is defined by the observer; therefore, one must know the observer’s frame of reference. ► Field approaches are descriptive rather than speculative, interpretive, or classificatory.

Organismic Self-Regulation “There is only one thing that should control: the situation … If you understand the situation you are in and let the situation you are in control actions, then you learn to cope with life.”

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Human regulation is either: ▪ Organismic • Acknowledgment of what is • Choosing and learning happen holistically • A natural integration of mind and body • Requires that the habitual become fully aware as needed ▪ Shouldistic • What one thinks should or should not be • Cognition reigns

Gestalt (Figure-Ground) Formation “Insight is a patterning of the perceptual field in such a way that the significant realities are apparent; it is the formation of a gestalt in which the relevant factors fall into place with respect to the whole.”

— Heidbreder (1933) Consciousness and Unconsciousness ► View is radically different from the Freudian view. ► Concepts of awareness and unawareness replace the unconscious. ► Gestalt theory recognizes that background and forefront change fluidly. ► Patient’s conflicts are regulated to background and are brought to forefront through therapy.

Health ► ► ►

Health is an awareness of shifting need states.

Being whole is identification with one’s ongoing, moment by moment experience.

Requires being in contact with what is actually occurring.

Other Gestalt Concepts ► People are inclined towards growth and self-regulation. ► Conditions can impede growth. ► People define themselves in relation to others. ► Disturbances at the boundaries ▪ In optimal functioning when something is taken in there is contact and awareness.

▪ Experiences that are blocked create isolation. ► Creative adjustment ▪ Creative balance between changing the environment and adjusting to current conditions. ► Maturity ▪ Good gestalt describes a perceptual field organized with clarity and good form.

▪ Results from creative adjustment. ► Disrupted personality functioning Gestalt Therapy

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►

►

►

►

►

▪ Mental illness is the inability to form clear figures in the moment.

Polarities ▪ Health represents ability to shift between figure and ground (polarities such as life/death; strength/weakness).

▪ Maladjustment occurs when polarities become rigid and are seen in dichotomies.

Resistance ▪ Gestalt therapists see resistance as process of opposing the formation of a threatening figure.

Anxiety ▪ Gestalt therapists are concerned with the process of anxiety, not content of anxiety.

▪ Anxiety results from futurizing and unsupported breathing.

Impasse ▪ Terror that occurs when a person’s supports are not available and new supports have not yet been mobilized.

Development ▪ Humans are born with capacity for self-regulation.

▪ Recent gestalt theories of development have been based on embodiment and relatedness.

Gestalt Psychotherapy

Main Gestalt Therapy Principles ► Awareness ► Direct experience ► Contact ► Relationship ► Experimentation ► Phenomenological focusing Four Dialogue Characteristics 1. Inclusion ▪ Putting oneself as fully as possible into the experience of the other without judging, analyzing or interpreting while simultaneously retaining a sense of one’s separate, autonomous presence.

▪ Represents phenomenological trust in immediate experience.

▪ Provides a safe environment and strengthens the patient's self-awareness.

2. Presence ▪ The gestalt therapist expresses their observations, preferences, feelings, personal experience and thoughts to the patient.

▪ Therapist is modeling phenomenological reporting.

▪ Enhances patient’s trust and use of immediate experience to raise awareness.

3. Commitment to dialogue ▪ Contact refers to something that happens in an interaction.

▪ Therapist allows contact to happen rather than making contact happen.

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© 2014 Cengage Learning, Inc. 4. Dialogue is lived ▪ Dialogue is something done.

▪ “Lived” emphasizes the excitement/immediacy of the process.

▪ Mode of dialogue can vary; examples might include dance, song, art, words, movement.

Techniques of Patient Focusing ► Patient-focusing techniques are elaborations of: ▪ “What are you aware of (experiencing) now?” and “Try this experiment and see what you become aware of (experience) or learn.”

Main Tools of Gestalt Therapy ► Awareness ▪ Being in touch with one’s existence, with what is.

▪ Gestalt therapy focuses on creation of an awareness continuum where what is of primary concern and interest to the organism, the relationship, the group or society becomes gestalt and into the foreground.

▪ Primary concerns are fully faced, worked through, sorted out, changed, or eliminated.

▪ As one becomes aware of and faces concerns, they can become the background — which leaves the foreground free for the next primary gestalt. ► “Stay with it” ▪ Therapist encourages client to follow a report of awareness with the instruction to “stay with it” or “feel it out.” ► Enactment ▪ Therapist asks the patient to act out feelings or thoughts to increase awareness. ► Exaggeration ▪ A special form of enactment where the therapist asks the patient to exaggerate some feeling, thought, or movement to feel it more intensely. ► Guided fantasy ▪ Therapist encourages visualizing rather than enacting. ► Loosening and integrating techniques ▪ Therapist asks the patient to imagine the opposite of whatever is believed to be true.

▪ Integrating techniques bring together processes the patient keeps apart.

▪ Examples might include asking a patient to put words to crying; identifying where in their body one feels an emotion; or asking a patient to express positive and negative feelings about the same person. ► Body techniques ▪ Therapist provides ideas about how the patient can increase awareness of body functioning.

▪ Examples would be teaching the patient breathing exercises or to hold the body in a certain posture while feeling a certain emotion. ► Therapist Disclosures

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Therapist uses “I” statements judiciously to enhance therapeutic contact and the patient’s awareness.

Requires wisdom to know when to self-disclose.

Therapists may share what they are experiencing in their senses or emotionally.

Applications of Gestalt Therapy

► ► ► ►

►

► ► ► ►

Approach can be used with any patient population.

Therapist must have a comfort with and knowledge of the patient population being treated; the therapist must be able to relate to the patient to dialogue.

An individualized approach is used with each patient.

Gestalt therapy has traditionally been considered most effective with neurotic disorders (i.e., anxious, perfection-driven, phobic and depressed clients) as the approach enhances staying in the moment and enjoyment in life.

Treating psychotic, disorganized, personality-disordered or severely disturbed clients calls for “caution, sensitivity and patience.”

▪ Approach should not be used with this population unless a “long-term commitment” to the patient is possible.

Gestalt therapy can be used for crisis intervention, impoverished individuals, groups (both clinical and growth focused), couples.

Approach has been successfully used for treatment of psychosomatic disorders including migraine, ulcerative colitis and spastic neck and back.

Application of gestalt therapy in schools has been promising.

Gestalt therapists do not rely heavily on formal diagnostic evaluations and research methodology.

Evidence ► Gestalt therapists believe any treatment dyad and treatment process has so much complexity it cannot possibly be adequately measured. ► All interactions are seen as experiments involving calculated risk-taking. ► Gestalt therapy does not lend itself well to randomized control trials (RCTs). ► Research in neurology and infant development supports gestalt concepts of here-andnow and the inseparability of emotion and thought. ► Greenberg’s process-experiential therapy (designed to empirically test combining experiential techniques and therapeutic factors) supports gestalt therapy. ► Research on therapeutic factors is supportive of gestalt therapy.

▪ Additionally effectiveness of combining experiential techniques and a good therapeutic relationship has been robustly demonstrated. ► Meta-analysis has supported: ▪ Gestalt therapy as being equally effective as CBT. ▪ The experiential confrontation process (i.e., directing attention to the patient’s experience and behaviors directly activated in the session) as a strong predictor for positive therapeutic outcome.

▪ Directive experiential approach shown to be more effective than clientcentered approaches and cognitive-behavioral therapy.

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Support for specific techniques includes: ▪ Two-chair technique leads to greater depth of experience than empathic reflection alone.

▪ Empty-chair dialogue leads to reduction in general distress and a reduction in a sense of unfinished business.

Psychotherapy in a Multicultural World

► ►

► ►

Founders of gestalt therapy were all cultural/political outsiders.

Gestalt therapy fits with multicultural awareness and competence because: ▪ “Process-oriented” theory ▪ Multicultural interaction requires therapist recognizes implications of own social/cultural/political situation.

Multicultural theories often refer to field theory because of empirical support for phenomenological, experiential explorations with clients.

Dialogical attitude, a humble attitude that includes a willingness to be affected and changed by the client, allows the therapist to learn from the patient about the patient’s culture.

Chapter 9: Activities Role-play In gestalt therapy, patients are often asked to put feelings or thoughts into actions.

Ask students to form groups in sets of three. Have one person act out a feeling (i.e., sadness, anger, happiness, shame). Have the other two people observe the enactment and share their observations.

Discussion Questions 1.

Use gestalt images to spark a conversation about figure/ground. A good example would be the gestalt image of a vase versus two faces looking at one another. This type of image will allow students to discuss how perspective is important in viewing pictures and then can lead to a discussion of events in life and how they can be figure or ground.

2.

Have students engage in a prototypical gestalt therapy experiment. Ask them, “What are you aware of, or experiencing, right here and now?” Then have students discuss how it feels to increase awareness.

3.

Gestalt therapy is often used in substance abuse treatment programs. Ask students to discuss why this approach might be helpful with this patient population. What might be some of the barriers that may be encountered?

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Gestalt therapists have been using unique techniques for years to help people determine a sense of wholeness and interconnection. Substance abuse treatments often use gestalt principles.

The film 28 Days (2000), starring Sandra Bullock, depicts the challenges of overcoming alcoholism and the importance of rehabilitation programs. The film can lead to class discussions about the utility of gestalt techniques in addressing addictions.

Case Illustration from Case Studies in Psychotherapies (Seventh Edition)

First or Nowhere?

by Sally Denham-Vaughan This case is reprinted from International Gestalt Journal and demonstrates a therapy session followed by four critiques. The therapist, Sally Denham-Vaughan, then responds to the four critiques of her work. The case shows the many ways in which a therapist can conduct a therapy session. Core gestalt principles are illustrated such as field theory, presence, contact, awareness, boundaries, retroflection, and the conceptual limits imposed by diagnostic labels.

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Chapter 9: Potential Test Items Multiple Choice Test Bank 1.

Which of the following individuals and his collaborators founded gestalt therapy? a.

Gary Yontef b.

Fritz Perls c.

Albert Einstein d.

Martin Buber REF: Overview (p. 299) ANS: B

2.

The idea that individuals are growth-oriented, self-regulating and only understandable within the context of their environment is known as: a. organismic self-regulation. b. contact. c. static awareness. d. holism.

REF: Overview (p. 300) ANS: D

3.

A set of mutually interdependent elements is referred to as a: a. field. b. gestalt. c. whole. d. context.

REF: Overview (p. 300) ANS: A

4.

Five years later, a patient remains negatively affected by the murder of a friend. A gestalt therapist would say the patient’s current field is being affected by the: a. actual murder itself. b. guilt the patient can’t resolve. c. memory of the event. d. repression of the event.

REF: Overview (p. 300) ANS: C

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The paradoxical theory of change states individuals: a. who force themselves to act differently will create automatic changes. b. will stay the same when attempting to become who they are not. c. cannot change others but can change how they react to others. d. who believe in change are creating a delusion to relieve their anxiety.

REF: Overview (p. 300) ANS: B

6.

The gestalt term describing an individual’s ability to focus on the here-and-now is: a. contact b. organismic self-regulation c. conscious awareness d. experimentation REF: Overview (p. 300-301) ANS: A

7.

In contrast to psychoanalysis, gestalt therapy emphasized the: a. rule of abstinence. b. importance of therapist neutrality. c. transference neurosis. d. potential of the here-and-now.

REF: Overview (p. 300) ANS: D

8.

In contrast to the past, parallel changes in gestalt therapy and psychoanalysis have occurred with both approaches now emphasizing: a. instinctual urges. b. id, ego, and superego. c. self in relation to others. d. deterministic principles.

REF: History (p. 306) ANS: C

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Although similar in some ways to rational emotive behavior therapy (REBT) and cognitive therapy (CT), a gestalt therapist: a. believes thoughts about the future are not relevant. b. would not use changes in behavior to change thoughts. c. disregards the idea of moralistic thoughts in relation to guilt. d. does not imply that they know the rational way to think.

REF: Overview (p. 304) ANS: D

10.

Wilhelm Reich described how individuals often engage in repetitive experiences, behaviors and body postures that keep them fixed in roles. He referred to this concept as: a. lack of self-awareness. b. character armor. c. holistic determination. d. locked development.

REF: History (p. 305) ANS: B

11.

The word gestalt is analogous with: a. perceptual whole. b. creative indifference. c. in the moment. d. conscious awareness.

REF: Overview (p. 300) ANS: B

12.

The phenomenological perspective asserts that all reality is: a. objectively defined. b. subjectively interpreted. c. descriptive behaviors. d. causal of problems.

REF: Overview (p. 302) ANS: B

13.

Which of the following would be inconsistent with the dialogic relationship? a.

Conveyance of empathic understanding b.

Therapist display of authenticity c.

Mutual patient-therapist self-disclosure d.

Therapist control of the outcome REF: History (p. 306) ANS: D Gestalt Therapy

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14.

Objective reality, as defined by a gestalt therapist, is: a. non-existent. b. patient-therapist congruence. c. events on which observers agree. d. events on which observers disagree.

REF: Overview (p. 302) ANS: A

15.

The purpose of a boundary is to: a. separate us from others. b. connect us to others. c. separate and connect us to others. d. divide biological and psychological needs.

REF: Personality (p. 311) ANS: C

16.

According to Gestalt therapy, psychological adjustment requires: a. unconditional positive regard by others. b. an awareness of our need states. c. congruence between objective and subjective reality. d. equality between actual and ideal self-concepts.

REF: Overview (p. 301-302) ANS: B

17.

A parent and a child become so enmeshed that the child can no longer experience a sense of separate identity. This is known as: a. contact. b. isolation. c. confluence. d. assimilation.

REF: Personality (p. 309) ANS: C

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While receiving constructive criticism, Sally is able to accept the opinions of her mother that are helpful and discard those that are not beneficial. Sally is demonstrating: a. introjection. b. assimilation. c. projection. d. retroflection.

REF: Personality (p. 309) ANS: B

19.

After receiving a pay raise, Danny wants to celebrate with others. Instead, he buys champagne and celebrates alone because he has no close friends. This reflects the boundary disturbance of: a. introjection. b. assimilation. c. projection. d. retroflection.

REF: Personality (p. 311) ANS: D

20.

Achieving a balance between individual needs and the environment reflects: a. creative adjustment. b. introjection. c. holism. d. polarity.

REF: Personality (p. 311-312) ANS: A

21.

A gestalt therapist interprets a patient’s neuroticism as continued use of a strategy that was adaptive previously, but is no longer helpful. This means the therapist is seeing the neuroticism as: a. projection. b. good gestalt. c. introjection. d. creative adjustment.

REF: Personality (p. 312-314) ANS: D

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A gestalt therapist would view resistance as: a. intentional thwarting of the therapy process. b. an attempt to maintain psychological integrity. c. reflective of an underlying id-superego conflict. d. created by the patient in response to transference.

REF: Personality (p. 314) ANS: B

23.

In treating anxiety a gestalt therapist is most likely to: a. teach the patient to breathe more fully. b. explore past events which lead to the anxiety. c. make a referral to a psychiatrist for medication. d. discuss his/her own feelings of anxiety with the patient.

REF: Personality (p. 315-316) ANS: A

24.

When a patient remains stuck in nonfunctional ways of thinking and behaving, a gestalt therapist would say the patient is experiencing: a. bad gestalt. b. too much support. c. an impasse. d. organismic self-regulation.

REF: Psychotherapy (p. 316) ANS: C

25.

The primary goal of gestalt therapy is: a. elimination of psychopathology. b. increased awareness. c. insight regarding conflicts. d. behavior change.

REF: Overview (p. 299) ANS: B

26.

The primary emphasis of gestalt therapy is on the: a. past. b. present. c. future. d. unknown.

REF: Overview (p. 303) ANS: B

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If a psychoanalytic therapist observed a gestalt therapist in action, he/she might be concerned about the therapist’s: a. emphasis on the past. b. attempts to force behavior change. c. maintenance of a passive stance. d. degree of self disclosure.

REF: Overview (p. 303) ANS: D

28.

Gestalt therapy’s empty-chair technique, in which a patient is encouraged to express feelings to others or themselves in a symbolic manner, would be an example of: a. enactment. b. focusing. c. guided imagery. d. body awareness.

REF: Psychotherapy (p. 322) ANS: A

29.

Greenberg’s research comparing person-centered, directive experiential and cognitivebehavioral therapies suggested: a. person-centered therapy was most effective. b. directive experiential therapy was most effective. c. cognitive-behavioral therapy was most effective. d. there were no reliable differences between approaches.

REF: Overview (p. 302) ANS: B

30.

Circular causality refers to interactions that are: a. based on irrational beliefs. b. self-enhancing. c. linear but temporally unrelated. d. reciprocating.

REF: Applications (p. 327) ANS: D Fill in the Blanks

1.

Gestalt psychotherapy is focused on _______ rather than on _______.

ANS: Process; content

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The word gestalt comes from a German word meaning _______.

ANS: Whole

3.

Gestalt therapy was developed by _______ and _______.

ANS: Fritz and Laura Perls

4.

_______ theory underlies the gestalt immunological perspective.

ANS: Field

5.

Utilizing field theory, a person constitutes a _______.

ANS: Field

6.

Field approaches are not speculative, interpretative, or classificatory. They are _______.

ANS:

7.

Descriptive

Gestalt therapists believe that it is important for human regulation to be _______ in order for the individual to become fully aware in a healthy manner.

ANS: Organismic

8.

In gestalt therapy, the concept of unconscious is replaced by the concepts of _______ and _______.

ANS: Awareness and unawareness

9.

Positive mental health is seen as the ability for an individual to shift between figure and ground; in other words, to be able to deal with competing concepts like life and death, which are considered _______.

ANS: Polarities

10.

In most types of therapy, the therapist may not reveal considerable amounts of information about themselves. In gestalt therapy, therapist disclosure is considered _______ if done _______.

ANS: Appropriate; judiciously

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© 2014 Cengage Learning, Inc. Essay Questions 1.

Gestalt therapy started out as a revision of psychoanalysis and then evolved. Discuss how gestalt therapy and psychoanalysis are similar and how they are different. Compare the gestalt therapy view of insight with Freud’s view.

2.

Describe field theory. How is it related to understanding humans?

3.

Gestalt theory states that people function according to an overarching principle called creative adjustment. What does this term mean?

4.

At first glance, the concept of resistance would appear incompatible with gestalt theory.

How is resistance viewed in gestalt therapy?

5.

In gestalt psychotherapy the therapist is focused on the “what” and “how” and “here-andnow.” What does this mean?

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Chapter 10 Interpersonal Psychotherapy Author: Myrna M. Weissman and Helen Verdeli Key Points and Terms

Overview ► IPT developed by Gerald Klerman and Myrna Weissman is time-limited, symptom-focused therapy. ► First used with unipolar, non-psychotic depression in adults. ► Theory is that depression occurs in an interpersonal context. ► Triggers of depressive episodes involve disruptions of significant attachments and social roles.

▪ Grief, interpersonal disputes, role transitions, and interpersonal deficits ▪ Recognizes genetics, personality, and early childhood factors and clarifies relationship between onset of depressive symptoms and interpersonal difficulties. ► Focuses on interpersonal problems and building interpersonal skills. ► Shown efficacious with major depression, bipolar disorder, post-partum depression, bulimia, binge-eating disorder, and PTSD. ► Used with adolescents and adults and in hospital clinics — inpatient and outpatient, school-based clinics, primary care, prisons. ► Individual, group, conjoint, and telephone therapy shown to be effective. ► Focuses on prevention, acute treatment, and maintenance. ► Applicability in western countries, sub-Saharan Africa, Asia, and Latin America. ► Depression conceptualized as having three components: symptom formation, social functioning, and personality factors. ► Adapted to address chronic mood disturbances in borderline personality disorder by extending treatment duration while preserving fundamental strategies and techniques. ► IPT differs from a modular approach, which characterizes cognitive behavior or dialectical behavior therapy where cognitive or mindfulness strategies can be conducted before but also after behavioral ones.

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Patient prescribed “sick role” at treatment onset and educated about depression as a treatable medical problem to demystify symptoms, excuse patient from blame for their illness, separate the disorder from personality, and permit experimentation with change.

▪ Developing a sense of mastery in one interpersonal context can transfer over.

▪ Some disorders are seen as triggers and others are seen as consequences.

Treatment ► Conducted in 3 distinct phases: initial, middle, and termination. ► One or (at most) two areas of interpersonal conflict to focus on should be identified. ► Treatment length is generally 12-16 consecutive weekly sessions to present a clear expectation of rapid relief and generate mobilization and optimism. ► Manual-based and incorporates regular symptom assessment.

Comparison of Interpersonal Therapy to Other Therapies ►

►

IPT shares much in common with other approaches including: ▪ Clarification of mood states and linking them to interpersonal events ▪ Communication analysis and decision making ▪ Interpersonal skill building ▪ Utilizing homework to gain a sense of mastery of current social roles ▪ Combating social isolation ▪ Improving group belonging ▪ Finding meaning in “here-and-now” IPT asserts depression is biological, but symptoms are triggered by stress — particularly the loss of or threat to an important interpersonal attachment.

▪ This idea is consistent with many developmental and attachment theories.

Compared to …

Psychodynamic CBT

REBT Humanistic

IPT focuses on the here-and-now.

IPT intervenes at the conscious level.

IPT does not attempt to uncover distorted thoughts.

IPT emphasizes changing maladaptive communication patterns.

IPT does not attempt to uncover irrational thoughts.

IPT asserts that a “safe” therapeutic environment is necessary but not sufficient for change.

The History of Interpersonal Therapy

►

►

In the early 20th century, Adolf Meyer viewed mental illness as the result of an individual’s maladaptive attempt to adjust to the changing environment.

▪ Meyer created the “life chart” to track relationships between life history, illness (physical and psychiatric), and stressful events.

Sullivan asserted that one can only understand and address mental illness by making sense of the person’s interpersonal matrix.

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►

►

Bowlby noted a universal human need for affectional bonds (attachments) to develop and maintain mental representations of self and others and separation or threat of separation of these bonds causes emotional distress.

Ainsworth identified three major attachment styles: secure attachment, ambivalentinsecure attachment, and avoidant-insecure attachment.

▪ A forth attachment style known as disorganized-insecure attachment was added later.

▪ Anxious/ambivalent, avoidant and disorganized styles are insecure attachment patterns and are considered to be secondary behavioral strategies in response to an insensitive or unavailable caregiver.

IPT was also heavily influenced by the research on correlations between life events and depression (i.e., relative risk of developing depression after the most stressful category of events to be a striking 6:1).

Beginnings of IPT ► IPT developed as a therapy arm for an 8-month clinical trial designed for subjects who had shown symptom reduction while on anti-depressant medication during their acute phase of depression. ► Key components of the new therapy were its time-specific nature, focus on current problems, use of a manual to standardize the procedure, and standardized assessments. ► IPT’s most important and distinctive features: conducting an interpersonal inventory of important people currently in the patient’s life; giving the patient the sick role; linking symptoms to interpersonal situations; and selecting problem areas associated with the onset of the current depressive episode.

Current Status ► Evidence for the efficacy of IPT is strongest for mood disorders. ► Group therapy in particular supported by RCTs and an abbreviated form of IPT called interpersonal counseling (IPC) has also been developed and tested. ► A new adaption, IPT-EST (Evaluation, Support, and Triage) provides a three-session intervention based on the diagnosis, identification of interpersonal problems, and management of depression. ► Few professional training programs teach IPT as part of a program in evidence-based psychotherapy. ► Three supervised IPT cases following didactic training usually suffice to learn to perform IPT competently. ► www.interpersonalpsychotherapy.org (International Society for Interpersonal Psychotherapy) Interpersonal Therapy’s Theory of Personality ►

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A theory of personality is not directly relevant to IPT as pathology is considered to have three component processes (symptom function, social and interpersonal relations, a personality and character problems).

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► ►

► ►

► ►

► ► ►

IPT does not make definitive Axis II diagnostic assessment during the acute phase of the depression.

IPT can help improve attachment styles.

▪ For example, IPT and Bartholomew’s 4-category model (i.e. secure anxiety, dismissing, preoccupied, fearful) merge well where adult attachment is conceptualized as combinations of the internal working models of the self and others.

Anxiety refers to whether the individual has the inner resources for security and selfsoothing vis-à-vis an important relationship.

An internal working model of others yields the dimension of avoidance, whether security is maintained through proximity or alternatively, self-reliance and emotional distance.

Secure individuals are relatively more protected against psychological distress.

Insecurely attached individuals tend to have lower self-esteem, poorer affect regulation strategies, marked problems with emotional support, and a higher number of depressive symptoms.

Fearful attachment pattern is correlated with depression.

Although IPT in its original form explicitly addressed only Axis I disorders, Markowitz and colleagues have a strong rationale for treating BPD with IPT as BPD is a “mood-inflected chronic illness.”

IPT provides the patient success experiences.

IPT allows patients to conceptualize BPD as a chronic, yet treatable illness, aims at solving patients’ problems in the relationships outside of the office.

The patient is given tools to deal with mood dysregulation triggers that result in correction of interpersonal dysfunction.

Interpersonal Psychotherapy

►

IPT for acute depression is 16 sessions for adults, 12 for adolescents, divided into three phases: the initial phase, middle phase, and termination phase.

Initial Phase: ► Therapists administer depression rating scales or symptoms checklists and evaluates patients’ idiosyncratic symptoms of depression over 3-4 sessions. ► Therapists confirm diagnosis of depression and give syndrome name, give hope, assign “sick role,” and help patients to rationalize and manage the impact of depression on their life. ► Emphasis is on: ▪ Psychoeducation about depression and instill hope ▪ Managing patients consequences from depression/creating time to heal ▪ Understanding how depression affects and is affected by the patients’ important social ties and roles ▪ Identifying 1-2 interpersonal problem areas

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© 2014 Cengage Learning, Inc. Middle Phase: ► Majority of work is assisting patients in clarifying how they are affected by and affect their interpersonal environment to build antidepressant relational skills. ► Problem areas addressed: ▪ Grief ▪ Interpersonal disputes • Renegotiation • Impasse • Dissolution ▪ Role transitions ▪ Interpersonal Deficits.

Termination Phase: ► Deadline for termination set to keep patient active. ► Emphasis is on: ▪ Evaluating depressive symptoms to determine if patient is full/partial responder ▪ Addressing patient’s sadness’ and/or anxiety about ending treatment ▪ Increasing patients’ competence and independence in continuing gains ▪ Reviewing what skills were useful ▪ Reducing guilt if IPT has not been successful ▪ Deciding whether to set up maintenance IPT (monthly therapy sessions for a year) ► ► ►

Commenting on how the affect is communicated (verbally and non-verbally) is the “bread and butter” of IPT. IPT therapists are active, directive, but not prescriptive.

▪ Forms are not used and there is no exploration of the unconscious.

IPT techniques: Linking mood to an interpersonal event, conducting communication analysis, generating options, role-playing, and assigning homework (less prescriptive than CBT).

Applications of Interpersonal Therapy

►

►

IPT was developed to treat unipolar, non-psychotic depression and has been shown to be efficacious with this population both as a monotherapy and in combination with medication.

It has also been adapted to other depressed patients with good results.

Key considerations ► A moderator: ▪ Suggests for whom or under what conditions a treatment works ▪ Is a pretreatment or baseline characteristic ▪ Is independent of received treatment ▪ Has an interactive effective with treatment on therapeutic outcome ▪ Helps identify the most appropriate treatment for the patient

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►

► ►

►

► ►

Efficacy testing typically tests the treatment within a relatively homogenous group, under optimal clinical circumstances, and with the therapy performed by highly trained experts.

Effectiveness studies, which by contrast include a broad range of participants conducted in real life setting by community clinicians.

IPT-A is for depressed adolescents.

▪ IPT-A is 12 sessions, integrates telephone contact, and engages in a collaborative relationship with the parents and school.

IPSRT is designed for bipolar disorder and treats the depressive phase much like unipolar depression: focusing on interpersonal disputes and role transitions associated with depressive episodes.

▪ IPT does not treat the manic aspect directly, but in IPSRT a behavioral component and social rhythm therapy are integrated in aimed at helping patients avoid the disruptions to their daily routine that can trigger manic episodes.

IPT for bulimia nervosa (IPT-BN) focuses on the interpersonal problems that may trigger binge episodes.

For dysthymia, IPT makes less sense for a disorder.

▪ IPT for dysthymia (IPT-D) iatrogenic role transition: makes treatment itself a role transition.

Treatment Outcome Research for IPT ► Evidence for baseline depressive severity as a moderator of treatment outcome is equivocal. ► Benefits of IPT (particularly in combination with medication) compared to other psychotherapeutic interventions such as CBT may only emerge in relation to more depressed individuals. ► Somatic Anxiety appears to reduce response to IPT. ► Patients with low baseline social dysfunction respond significantly better to IPT. ► Patients with high attachment avoidance do better in CPT than IPT. ► Efficacy of IPT-A has been validated through a number of RCTs. ► IPT has shown efficacy as a treatment for geriatric depression across a number of studies. ► IPT lends itself to the issues most frequently encountered in pregnancy and childbirth: major role transition, disputes, and grief. ► IPT has shown efficacy in treating depression in primary care patients with HIV, cancer, and coronary disease. ► IPSRT has shown efficacy in increasing length of time between manic episodes. ► In clinical trials comparing IPT-BN to CBT, patients took longer to attain symptom reduction, but showed significant and lasting involvement. ► IPT has shown efficacy in trials for binge eating disorder, PTSD, social phobia and panic disorder. ► IPT for borderline personality disorder remains under testing. ► In initial trials, IPT has failed to demonstrate efficacy for substance abuse.

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► ►

►

Group IPT (IPT-G) can help validate the sick role (i.e., shows others suffer) and allows practicing of interpersonal skills and diminished focus on each individual’s particular interpersonal difficulty.

Interpersonal counseling (IPC) is a form of IPT with fewer, shorter sessions and has been used with medical patients with co-morbid depression with some success.

Conjoint (couples) IPT has been used to treat couples in which one or both spouses are depressed.

▪ Conjoint IPT has led to reports of greater improvement in marital satisfaction.

Telephone IPT has been tested successfully in a number of small pilot studies.

Interpersonal Psychotherapy in a Multicultural World

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IPT has been practiced internationally. The example used in the chapter describes how it was adapted for use in Southwest Uganda.

To allow IPT to be feasible, acceptable, ecologically valid, effective, and sustainable, researchers/clinicians must: ▪ Understand the mental health issues and needs of the community • In Uganda, there are high levels of grief (due to AIDS or other epidemics), interpersonal disputes (property boundaries, political fights, wives protesting an HIV-positive husband’s demands for sex) and a number of role transitions (becoming sick or married, a husband’s decision to marry a second wife).

• Syndromes with high prevalence in Uganda included some DSM criteria for depression, but also included not responding when greeted and not appreciating assistance when it was provided. ► “y’okwetchawa” (self-loathing) ► “okwekubagiza” (self-pity) ▪ Validate assessment scales on the new population ▪ Intervene with the community ▪ Adapt the therapy as needed • Adaptations made for local Uganda context: ► Ugandan cultural context strategies adapted to local cultural norms. ► Indirect forms of communication had to be employed. ► Focus on identification of aspects of life that were under their control.

▪ Provide the mental health services, in part or total, through educated local lay people • World Vision sponsoring the Uganda project using the World Health Organization’s task shifting model (i.e. the delegation of tasks to less specialized local health workers) ▪ Develop collaborations ▪ Commitment from international experts to gradually let local experts take over

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Results of the Clinical Trials in Southwest Uganda ► An RCT found modified IPT-G for depression to be significantly more effective than the control condition and the treatment was very well received by the local community. ► IPT for adolescents living in Internally Displaced Persons (IDP) camps in Northern Uganda included two additional treatment conditions: Creative Play (CP) and wait list.

▪ Significant improvement of depression in the IPT group compared to other two conditions. ► Over 2,500 people in southwest Uganda have been treated, including adolescents in eight IDP camps in northern Uganda. ► Plans to use IPT in many East and West African countries with depressed and traumatized populations (e.g., distressed primary care patients in Goa, India; depressed Hispanic immigrants in the US). ► Cultural issues that emerged from therapy with Hispanic patients: ▪ Centrality of the family (familismo) ▪ Conflicts between the migration and acculturation ▪ Gender issues (machismo) ▪ Need for culturally acceptable confrontational approaches

Chapter 10: Activities Role-play Although most patients might appreciate the focus of interpersonal psychotherapy (IPT) on interpersonal issues, IPT strongly asserts that depression is a biological illness that can be triggered by stress — most notably interpersonal stressors. Describing the biological and interpersonal factors related to depression might seem complicated or contradictory to a patient. Ask students to role-play how they would explain the theory behind IPT and the rationale for the treatment approach to a patient.

Discussion Questions 1.

Interpersonal therapy for depressed adolescents (IPT-A) differs from the model used for adults. Have the students discuss how the use of 12 sessions, integration of telephone contacts, and engagement in a collaborative relationship with the parents and school might enhance the model with adolescents. Ask the students to consider any negative consequences to these alterations to the model.

2.

According to the International Society for Interpersonal Psychotherapy, few professional training programs teach IPT as part of a program in evidence-based psychotherapy. Yet, they assert that three supervised IPT cases following didactic training usually suffices to learn to perform IPT competently. Ask the student to discuss any concerns they might have about clinicians independently providing IPT having only seen three cases under supervision.

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3.

World Vision sponsored the Uganda project using the World Health Organization’s task shifting model (i.e., the delegation of tasks to less specialized local health workers). Ask the students to discuss the pros and cons of the task shifting model.

Use of Movies to Depict Concepts

Interpersonal issues are generally the content of all movies at some level. However, there are currently no movies that specifically depict the interpersonal therapy approach. Ask students to consider how they would create a movie that would highlight the specific benefits of interpersonal therapy. Additionally, instructors could take current popular films, like Silver Linings Playbook (2013), and discuss how interpersonal therapy approaches might be beneficial.

Case Illustration from Case Studies in Psychotherapies (Seventh Edition)

A Case Study for the New IPT Therapist

by Marie Crowe and Sue Luty This case study depicts IPT in the treatment of a depressed woman having an affair. The patient is a part of a randomized clinical trial, and subsequently the treatment she is receiving is specific, detailed, and manualized. The treatment focuses on interpersonal disputes, and the therapist (a) seeks information; (b) explores parallels in various relationships; (c) explores 168

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© 2014 Cengage Learning, Inc. relationship patterns; and (d) explores the client’s communication patterns. In addition, the therapist signals what is likely to be significant; provides supports; explores affect; explores options; helps with problem-solving; draws analogies; and challenges the client when necessary.

The therapist also attempts to identify, describe, and classify the most salient themes that emerge during the course of therapy. This case can help students discuss their comfort level with approaches that are detailed, exacting, and specific.

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Chapter 10: Potential Test Items Multiple Choice Test Bank 1.

The developers of interpersonal therapy were: a.

Myrna Weissman and Helen Verdeli. b.

John Bowlby and Mary Ainsworth. c.

Gerald Klerman and Myrna Weissman. d.

Gerald Klerman and Adolf Meyer.

REF: Overview (p. 339) ANS: C

2.

Interpersonal therapy developed as part of a: a. research study evaluating the effects of depression on cardiac patients. b. political movement to demystify psychotherapy. c. a therapy arm for a clinical trial evaluating anti-depressant efficacy. d. feministic movement to infuse interpersonal issues in therapy.

REF: Overview (p. 342) ANS: C

3.

In adapting interpersonal therapy to a client from a Hispanic background a therapist should be aware of: a. centrality of the family. b. impact of machismo. c. migration versus acculturation conflicts. d. all of the above.

REF: Applications (p. 367) ANS: D

4.

In contrast to the homework given in a cognitive therapy session, an interpersonal therapist will: a. utilize more forms to maintain standardization. b. establish the homework for the patient. c. be less prescriptive overall across therapy. d. not utilize homework given the patient’s sick role.

REF: Overview (p. 343) ANS: C

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In describing depression to a patient an interpersonal therapist would explain that: a. psychosocial triggers cause depression but medications can help. b. depression is biological but symptoms can be triggered by stress. c. unconscious factors related to childhood will be the treatment focus. d. dysfunctional thoughts and maladaptive core beliefs create depression.

REF: Overview (p. 343) ANS: B

6.

Interpersonal therapists prescribe a “sick role” to patients. This means that: a. depressed patients are not expected to engage in homework. b. family members must take over their responsibilities while they are in treatment. c. prescription medications must be a core part of the treatment. d. depression is biological and it is not their fault they are ill.

REF: Overview (p. 340) ANS: D

7.

The goal of prescribing a “sick role” to a patient in interpersonal therapy is to: a. allow them to be passive to get the help they need. b. insure that insurance benefits will cover treatment. c. demystify the symptoms and engage the patient. d. secure a leave of absence from responsibilities.

REF: Overview (p. 341) ANS: C

8.

Interpersonal therapy has NOT been shown to be efficacious for which of the following conditions? a.

Substance abuse b.

Bulimia nervosa c.

PTSD d.

Unipolar depression REF: Applications (p. 363) ANS: A

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In contrast to dialectical behavior therapy for a patient with borderline personality disorder, in interpersonal therapy: a. implementation of treatment techniques follows a preconceived order. b. self-injurious or self-destructive behaviors would not be addressed. c. therapy continues for years because of the chronic nature of the condition. d. the patient is prescribed the “sick role” and allowed to be passive.

REF: Overview (p. 339) ANS: A

10.

If a patient was in a depressive phase of their bipolar disorder, an interpersonal therapist would: a. treat the depressive phase in a similar manner to unipolar depression. b. not prescribe the patient a “sick role” as in unipolar depression. c. not treat the patient because interpersonal therapy is not appropriate. d. treat the patient with a non-standardized interpersonal approach to therapy.

REF: Applications (p. 362) ANS: A

11.

The typical length of interpersonal therapy for depression for an adult would be: a.

8 sessions. b.

16 sessions. c.

24 sessions. d.

48 sessions.

REF: Overview (p. 342) ANS: B

12.

In which phase of interpersonal therapy would the clinician focus on helping the patient identify ways that depression has affected their interpersonal relationships as well as how their interpersonal relationships have impacted their depression? a.

Initial b.

Middle c.

Family d.

Termination REF: Overview (p. 343) ANS: A

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In the early 20th century, Adolf Meyer recommended the use of a life chart with patients.

A life chart: a. estimated how long a patient would live depending on their level of depression. b. recorded the physical health problems a person developed over the course of their depressive illness. c. tracked the relationships between life history, physical and psychological illnesses, and stressful events. d. diagramed an individual’s family history of depression so they could see the biological nature of the illness.

REF: History (p. 344) ANS: C

14.

In response to an insensitive or unavailable caregiver, an individual might develop which type of attachment style according to Mary Ainsworth’s theory? a.

Affectionate b.

Ambivalent c.

Secure d.

Bi-directional REF: History (p. 344) ANS: B

15.

Which of the following statements is true about affectional bonds, as described by John Bowlby? a.

Humans have a universal need for affectional bonds. b.

Affectional bonds are destructive and should not be fostered. c.

Affectional bonds only develop in congruence with pathology. d.

Higher functioning individuals have no need for affectional bonds.

REF: History (p. 344) ANS: A

16.

In the Uganda culture, it is highly likely that a depressed individual would: a. seek help readily from individuals from a different culture. b. feel stigmatized by interpersonal therapy’s focus on relationship disputes. c. not appreciate assistance for depression when it was provided. d. respond when greeted to cover up that they were experiencing depression.

REF: Applications (p. 365-366) ANS: C

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Interpersonal therapy-evaluation, support, triage (IPT-EST) is designed to: a. provide long-term, ongoing services to severely depressed patients. b. offer a 3-session intervention based on rapid diagnosis and treatment. c. augment IPT’s focus on interpersonal issues with thought monitoring. d. specifically target the special needs of geriatric patients with depression.

REF: History (p. 346-347) ANS: B

18.

According to the International Society for Interpersonal Psychotherapy, following didactic training an individual needs to complete how many supervised IPT cases before they are likely to perform IPT competently? a.

1 b.

3 c.

10 d.

25 REF: History (p. 347) ANS: B

19.

Which statement accurately describes the theory of personality that drives interpersonal therapy? a.

Psychoanalytic theory forms the foundation for interpersonal therapy. b.

Interpersonal therapy is guided by multiple personality theories. c.

Cognitive theory forms the foundation for interpersonal therapy. d.

A theory of personality is not directly relevant to interpersonal therapy.

REF: Overview (p. 340) ANS: D

20.

Using Bartholomew’s four category model of adult attachment, which of the following styles would leave an individual more protected against psychological distress? a.

Secure anxiety b.

Dismissing c.

Preoccupied d.

Fearful REF: Personality (p. 348-349) ANS: A

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Using Bartholomew’s four category model of adult attachment, which of the following styles is most consistently correlated with depression? a.

Secure anxiety b.

Dismissing c.

Preoccupied d.

Fearful REF: Personality (p. 348-349) ANS: D

22.

If a patient is deemed a partial responder during the termination phases of interpersonal therapy, the therapist will: a. instill guilt to motivate the patient to be more compliant. b. review which skills taught were useful and encourage their use. c. encourage the patient to accept that their symptoms are chronic. d. terminate treatment regardless because IPT only allows for 16 sessions.

REF: Psychotherapy (p. 357-358) ANS: B

23.

The rationale that Markowitz and others have used for adapting interpersonal psychotherapy to borderline personality disorder (BPD) is that: a.

BPD is a mood-inflected chronic illness. b. the self-destructive nature of BPD is relationship driven. c. using IPT avoids labeling the patient with an Axis II disorder. d. early family relationship conflicts cause BPD. REF: Applications (p. 363) ANS: A

24.

In contrast to interpersonal therapy for adults, interpersonal therapy for adolescents: a. lasts longer (20 or more sessions). b. uses telephone contacts more frequently. c. does not focus on interpersonal conflicts. d. avoids defining a “sick role” in depression.

REF: Applications (p. 362) ANS: B

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An interpersonal therapist and patient should collaboratively identify how many problem areas to address over the course of treatment? a.

1-2 (to stay focused) b.

4-5 (to learn to generalize skills) c.

16 (one per session) d.

Varies depending on patient’s presenting issues REF: Personality (p. 349) ANS: A

26.

Interpersonal psychotherapy originated as a treatment for: a. schizophrenia. b. unipolar depression. c. social anxiety. d. borderline personality disorder.

REF: Applications (p. 360) ANS: B

27.

Which of the following statements accurately characterizes the research on the role of moderators comparing outcomes in interpersonal psychotherapy and cognitive therapy for depression? a.

Somatic anxiety appears to increase responsiveness to interpersonal therapy. b.

Patients with high baseline social dysfunction respond significantly better to interpersonal therapy. c.

High attachment avoidance leads to a better outcome in interpersonal therapy. d.

Evidence for baseline depressive severity as a moderator of treatment outcome is equivocal.

REF: Applications (p. 360) ANS: D

28.

Research studies that evaluate the effects of a treatment within a relatively homogenous group, under optimal clinical circumstances, and with the therapy performed by highly trained experts are called: a. efficacy studies. b. effectiveness studies. c. expert-led research. d. none of the above.

REF: Applications (p. 361-362) ANS: A

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Patients with high attachment avoidance and depression: a. tend to fare better in cognitive therapy. b. tend to fare better in interpersonal therapy. c. show similar outcomes in cognitive and interpersonal therapy. d. have poor responses in all forms of therapy.

REF: History (p. 345) ANS: A

30.

The data on baseline depressive severity as a moderator of treatment suggests: a. depression severity has not been accurately measured in treatment. b. treatment benefits emerge best in relation to less depressed individuals. c. depressive severity does not moderate treatment outcomes. d. the research is equivocal on baseline levels of depression as moderators.

REF: Applications (p. 360) ANS: D

31.

Conjoint interpersonal psychotherapy for depression has demonstrated that: a. treating a couple when both spouses are depressed is not beneficial. b. conjoint interpersonal therapy leads to greater marital satisfaction. c. less gains are made in treatment by both spouses if treated together. d. conflicts in therapy arise as both patients want to assume a “sick role.”

REF: Applications (p. 364) ANS: B

32.

Okwekubagiza, a term from Uganda, refers to: a. self-pity. b. self-esteem. c. self-loathing. d. selflessness.

REF: Applications (p. 365) ANS: A

33.

In the randomized clinical trial evaluating modified interpersonal group psychotherapy (IPT-G) for depression in Southwest Uganda: a. the treatment was not well-received by the community. b.

IPT-G was more effective than the control condition. c. valid assessment measures to use could not be identified. d. direct forms of communication had to offset some cultural norms.

REF: Applications (p. 366) ANS: B

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In a study using interpersonal psychotherapy (IPT) for treating depression in adolescents living in internally displaced persons (IDP) camps in Northern Uganda: a.

IPT performed poorer than creative play but better than a wait list. b.

IDP adolescents were too anxious to discuss interpersonal conflicts. c.

IPT performed better than both the Creative Play and wait list control. d.

Grief was so dominant that IPT could not be used effectively.

REF: Applications (p. 366) ANS: C

35.

The World Health Organizations task shifting model refers to: a. the importance of collaboratively engaging patients into treatment. b. task sharing among interdisciplinary teams to create better outcomes. c. delegating tasks to less specialized local health workers. d. shifting resources from a national to an international level.

REF: Personality (p. 348-349) ANS: C Fill in the Blanks

1.

Interpersonal therapy asserts depression is _______________, but symptoms are triggered by ____________.

ANS: Biological; stress

2.

According to interpersonal therapy, triggers of depressive episodes involve disruptions of significant attachments and social roles generally related to _______________, __________________, and __________________.

ANS: Grief, interpersonal disputes, and role transitions

3.

A(n) _____________________ is a research investigation that includes a broad range of participants conducted in a real-life setting by community clinicians.

ANS: Effectiveness study

4.

Commenting on how _________ is communicated (verbally and non-verbally) is the “bread and butter” of interpersonal therapy.

ANS: Affect

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In interpersonal therapy, depression is conceptualized as having three components: _______________, ___________________, and _______________.

ANS: Symptom formation, social functioning, and personality factors

6.

The creators of interpersonal therapy state that it is difficult to view dysthymia as a disorder and therefore identify _____________ as a role transition itself.

ANS: Treatment

7.

Key components of interpersonal therapy are its ____________ nature, focus on _____________ problems, use of a _________ to standardize the procedure, and _____________ assessment.

ANS: Time-specific; current; manual; standardized

8.

One of interpersonal therapy’s most important and distinctive features is conducting a(n) __________________ of important people currently in the patient’s life.

ANS: Interpersonal inventory

9.

Ainsworth originally identified three major attachment styles which she labeled ______________, ______________, and ____________. A forth attachment style known as ____________________ was added later.

ANS: Secure attachment, ambivalent-insecure attachment, and avoidant-insecure attachment; disorganized-insecure attachment

10.

In Bartholomew’s four-category model, ___________ refers to whether the individual has the inner resources for security and self-soothing vis-à-vis an important relationship.

ANS: Anxiety Essay Questions

1.

In interpersonal therapy, a depressed patient is prescribed a “sick role.” Explain what that means and how this “sick role” is used therapeutically.

2.

Interpersonal therapy merges well with theories of attachment that focus on how an individual conceptualizes internal working models of the self and others. Describe either Mary Ainsworth’s theory of attachment styles or Bartholomew’s four-category model of attachment and describe how they relate to interpersonal therapy.

3.

Although interpersonal therapy (IPT) in its original form explicitly addressed only Axis I disorders, Markowitz and colleagues have a strong rationale for treating borderline

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© 2014 Cengage Learning, Inc. personality disorder (BPD) with IPT. Describe their rational for why IPT might be a helpful intervention for BPD. 4.

In the middle phase of interpersonal therapy, the majority of the focus is on assisting patients in clarifying how they are affected by and affect their interpersonal environment to build antidepressant relational skills. Describe the problem areas to be addressed.

5.

In Uganda, there are high levels of grief (due to AIDS or other epidemics), interpersonal disputes (property boundaries, political fights, wives protesting an HIV-positive husband’s demands for sex) and a number of role transitions (becoming sick, becoming married, a husband’s decision to marry a second wife). Proponents of interpersonal therapy (IPT) have indicated that IPT has been shown to be beneficial in treating depression in Uganda. Describe how IPT was adapted to meet the needs of individuals from Uganda.

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Chapter 11 Family Therapy Authors: Irene Goldenberg, Herbert Goldenberg and Eric Goldenberg Pelavin Key Points and Terms

Overview ► ► ► ►

Family therapy is both a theory and a treatment method.

The identified patient is the family member considered to have a problem or be a problem for the family.

The identified patient’s problems are seen as a reflection of problematic interactions within the family.

Recently, the context for family therapists has broadened to add in the surrounding cultural community.

Major Family Therapy Approaches ► Structural ► Strategic ► Cognitive-behavioral ► Social constructionist ► Experiential ► Object relations ► Multigenerational ► Narrative

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© 2014 Cengage Learning, Inc. Focus of Family Therapy Approaches Present-oriented Strategic Structural Social constructivist Cognitive behavioral Experiential

Past-oriented Object relations Multigenerational Narrative

Basic Family Therapy Concepts ► Family structure is different from family processes. ► Organization and wholeness ► 1st Order Cybernetic Epistemology: Family described in terms of circular causality, feedback loops, boundaries, subsystems.

▪ 2nd Order Cybernetics also acknowledges the impact of the observer (i.e. family therapist). ► Focus on family homeostasis. ► Family receives both positive and negative feedback. ► Two types of systems: ▪ Open systems • Allow new information in • Preferable to closed ones • Allow situations to be seen from different perspectives ▪ Closed systems • Have varying degrees of inner circles • Those outside the system completely are viewed as having nothing to contribute (e.g., “they wouldn’t understand the way we do things”).

Structural Family Therapy: Key Concepts ►

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Family structure: Invisible set of functional demands that organize the ways in which family members interact.

▪ Operates through transactional patterns Transactional patterns: Repeated transactions establish patterns of how, when and to whom to relate.

Boundaries: Rules defining in a system who participates, how and when.

▪ Determines the system’s sub-systems (i.e., each family structure).

▪ Continuum ranges from diffuse (“enmeshment”) to rigid (“dis-engagement”).

Sub-system: Individuals belong to different subsystems, with different levels of power and skills.

Dysfunction: A deviation from the healthy or normal.

▪ Dysfunction occurs when one of the following occurs: • Rigid, diffuse or unclear boundaries coalitions formed against third party • Coalitions cross generational boundaries • Denied or concealed coalition

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Adaptation: Developmental changes within a family requiring alteration of boundaries.

▪ When adaptation does not occur, it results in dysfunction.

Basic Family Therapy Concepts Across all Schools of Thought ► Gender sensitive outlook ▪ Stresses importance of not reinforcing stereotypical sexist or patriarchal attitudes. ► Culturally sensitive therapy ▪ Requires cultural competence.

▪ Therapist must remain aware of their own “cultural filters” and respect the “cultural filters” of the family being treated.

Differences in Family Therapy and Other Approaches ► ►

Individual and family approaches have blended together considerably.

Main difference remains the degree of focus on the family unit in family therapy.

History of Family Therapy

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Early approaches focused on individual therapy and the patient-therapist relationship in treating psychological disorders.

Although theorists believed families influenced personality, suggested most important factors governing human behavior were internal and subjective.

Treatment therefore focused on neurotic conflicts and destructive interactions in the family of origin.

Patients were treated separately from their families.

Family therapists hypothesized psychological problems were developed and maintained in the family context.

Personality was viewed as related to reciprocal interactions with others.

Psychological dysfunction explained in terms of circular, recursive interpersonal events.

Most instrumental events ► Research on family dynamics and the etiology of schizophrenia ► Studies of small group dynamics ► Developments within social work ► Child guidance movement ► Marriage therapy practices ► Elements of group dynamics relevant to family therapy ► Kurt Lewin’s research speculating that a group is more than the sum of its parts ▪ Interdependence among group members seen as a stabilizing factor for maladaptive behaviors.

▪ Distinction between the process (how ideas are communicated) and content (what is said) of group.

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© 2014 Cengage Learning, Inc. Discussions acting out familial conflicts with the group instead of discussing them.

▪ Instructing group members to imagine that the group is their family of origin to allow unresolved family issues to be known.

Impact of the child guidance movement ▪ Child guidance clinics were established on the premise that psychological problems began in childhood.

▪ View focused on early intervention.

▪ John Bowlby theorized children’s symptoms were often the result of family distress.

▪ Began conjoint interviews.

Impact of the field of social work ▪ Social workers often visited clients in their homes.

▪ Training centered on interviewing each individual family member to gain a comprehensive picture.

▪ Many social workers became family therapists.

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Current Status of Family Therapy ► Current trend is toward eclecticism and an integrative approach. ► Eight major current approaches listed in Overview (see 1st page of this section).

Variety of Major Approaches (Family therapy approaches do not subscribe to a theory of personality per se) General Concepts ► Family is a system governed by a set of organized, established rules. ► Redundancy principle: Family has a restricted range of options for interactions. ► Families create narratives about themselves that link with an individual family member’s current actions and attitudes.

Virginia Satir ► Described family roles that serve to stabilize expected characteristic behavior patterns in a family.

▪ Examples: If one child is the “bad child,” a sibling may take on the role of the “good child” to alleviate family stress. ► Role reciprocity underscores why family dynamics are resistant to change.

Salvador Minuchin “Society acts as if all family violence is instrumental, and the response therefore is to increase control. But it is clear to us as family therapists that most cases of family violence are the products of generations of powerlessness. When we try to intervene by controlling the parents or with concern for the child alone, we can only produce a continuation of the pattern.”

— Salvador Minuchin ► Founder of structural family therapy (described in Overview section). ► Author of the classic Families and Family Therapy (1974).

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Concepts developed by Minuchin are used to train family therapists today.

Jay Haley ► Trained under the supervision of hypnotist Milton Erickson. ► Developed a brief therapy model that focused on the context and possible function of the patient’s symptoms. ► Utilized directives to instruct patients to act in ways that were counterproductive to their maladaptive behavior. ► Focus was on patients actively doing something about their problems rather than understanding why they had problems. ► Haley was instrumental in bridging the gap between strategic and structural approaches to family therapy. ► Explored concepts related to triangular and intergenerational relationships. ► Patient’s symptoms seen as the result of incongruence between manifest and covert levels of communication. ► Symptoms gave patient a sense of control in their interpersonal relationships. ► Therapy should focus on patient taking responsibility for their actions and to take a stand (i.e., therapeutic paradox).

Family Therapy ► ► ► ► ► ► ►

Assumes an individual is understood best in the context of the family.

Families have a structure (how it is organized) and functions (how it meets member’s needs).

Healthy families have a clear, flexible power structure with the most competent members having the most power.

Dysfunctional families are often disengaged (isolated from one another) or enmeshed (overly involved with one another).

Families that are cohesive and adaptable best serve the functions of members.

Family systems attempt to achieve homeostasis (e.g., if Mom and Dad are in conflict, a child may develop a problem to shift the focus).

Multigenerational transmission of both strengths and problems are common (i.e., grandmother, mother, daughter all have been sexually abused).

Family Therapy and Psychosis ► Lidz studied families where a parent and child formed a relationship to the exclusion of the other parent, which blurred boundaries.

▪ Hypothesized this type of relationship was a precursor to schizophrenia.

▪ He referred to 2 schizogenic family.

▪ Marital schism: • Family in a constant state of disequilibrium through repeated threats of parental separation.

• Communication masks conflicts.

• Parents disqualify each other and join with children, excluding the partner.

▪ Marital skew: Family Therapy

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Distorted parental relationship.

Relationship is not under threat, due to one excessively powerful and dominant parent.

Wynne described family communication patterns that lead to perceptual and thought disorders as they denied reality of feelings.

▪ Pseudo-hostility and pseudo-mutuality • Disjointed or fragmented communication leads to disrupted interactions.

• Pressure is put on the child to maintain the facade to avoid meaningless of family relationships.

Bateson described the double-bind relationship.

▪ Communication that leads to mixed messages.

▪ Repetitiveness leads to a unique learning experience in which the messages recipient cannot escape and cannot comment.

▪ Leads the individual to lose their capacity to discriminate between the different levels of communication provoking psychosis.

Mystification: Process that occurs when one or more family members fail to understand the meaning and or purpose of communication from another member, especially a parent.

▪ The communication received is often deliberately vague.

▪ The vague communication places the mystified person in an inferior position.

Triangulation: Occurs when a third person is brought into a dyadic relationship to deintensify a dispute between two people (generally the parents).

▪ Communication occurs through a third person.

▪ The third person often hears negative comments about the individuals involved in the dispute.

▪ When triangulation occurs, two people need to be communicating directly, but enmesh a third person to avoid any direct communication.

The Elephant in the Room: The problem that no one wants/dares to talk about.

▪ Problem is clearly visible to all involved.

▪ Fear of retaliation or negative consequences and shame often keep individuals from discussing the problem.

▪ Self-blame is common.

▪ Enablers continue to allow the problem to exist and not be discussed.

Lack of Differentiation: ▪ Autonomy is important for all individuals.

▪ Autonomy represents the degree of independence that an individual needs to function apart from others in a system.

▪ Fusion is the absence of differentiation.

▪ Lack of differentiation leads to enmeshment with others.

Scapegoating ▪ Families often scapegoat one individual for all of the family’s problems.

▪ The person scapegoated may have difficulties but is unduly blamed as they are often displaying the symptoms of an unhealthy family environment or have a bona fide illness.

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Lesser forms of scapegoating occur when every failure or conflict is pinned to an individual.

Scapegoating rarely takes into consideration any other factors.

“Drinking is a conflict area where the couple can complain about each other endlessly with no demand for change … Through the years, Lars’ drinking has become the ‘cause’ of all family problems. This fixing of causality on the behavior of one person blurs the nature of the other family transactions.”

— Salvador Minuchin ►

Lack of Boundaries ▪ All individuals need boundaries.

▪ The absence of boundaries produces unclear limits in terms of what others may or may not say or do to a person.

▪ Without boundaries, abuse can easily occur.

▪ Families often have no boundaries in some areas and rigid boundaries in others.

▪ Without boundaries, humans are unable to emotionally relate to others or set reasonable limits on others.

Examples of Structural Family Therapy Techniques ► Goal is to restructure the family system to create clear and flexible boundaries.

▪ Joining: Therapist utilizes family’s language/styles of communication to form non-judgmental partnerships.

▪ Focusing: Exploring specific areas.

▪ Enactment: Therapist has family enact an interaction to enable the family to try different ways of interacting.

▪ Intensification: Therapist increases emotional aspects of interactions transaction by a variety of means.

▪ Unbalancing: Conscious attempt to form coalition with one member against another or supporting one member at the expense of another to throw the family system off balance.

Examples of Milan Systemic Family Therapy Concepts and Techniques ► Neutrality ► Therapist is an observer and remains neutral.

▪ Hypothesizing: Therapist makes educated guess about the patient’s symptoms and context in which they occur.

• Circular questioning designed to elicit differences. ► What is the symptom that the patient presents? What is it there for? What function might it serve? What is the context of the symptom (i.e., what is happening when the symptom occurs)?

Why now? Why this symptom? Who can make it better? Who makes it worse? Who is affected by the symptom and in what way? How does the symptom affect the family and how does the family (and others) react?

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Paradoxical prescription: Symptoms of the patient and family are positively connoted • Positive connotation: Therapist prescribes the symptom “more of the same” to create a “paradoxical effect.”

Family Therapy Psychoeducational Approaches ► Focus is on manageable tasks and strengths. ► Therapist empathizes with family and normalizes events when feasible. ► Educating families about illness ► Communication training ► Problem-solving approaches ► Highlighting advantages/ disadvantages of options ► Formulating a detailed plan to implement the solution ► Operant-conditioning strategies ► Education focuses on the concept that “__________ is an illness, but family plays a very important part in keeping the patient well.” ► Family educated on diagnosis, symptoms, causes, treatment and prognosis of the illness. ► Impact on the family is discussed.

Applications of Family Therapy ►

Research has shown that family therapy is particularly indicated in: ▪ Common child psychiatric disorders ▪ Child abuse ▪ Eating disorders, especially anorexia nervosa ▪ Depression ▪ Schizophrenia ▪ Marital and family distress

Evidence ► ► ► ► ► ►

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Research supporting clinical methods lagged behind their use.

Process research: Focusing on what actually occurs during a therapy session that leads to a desired outcome.

Emotionally focused couple therapy: A manual-based approach integrating research with attachment theories.

Functional family therapy: Combines systems and behavioral theories and has empirical support.

Outcome research: Focusing on what specific therapeutic approaches work best with which specific problems.

Efficacy studies: Does a particular treatment work under ideal conditions?

▪ Note: RCTs to date suggest clients receiving family therapy fare better than untreated controls.

Effectiveness studies: Does a treatment work under real-life situations?

Evidence strongest for: ▪ Family-based interventions for adolescent, high risk, acting out behaviors

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Parent management training Psychoeducation programs for marital discord Programs aimed at reducing relapse and re-hospitalization for patients with schizophrenia Psychotherapy in a Multicultural World

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Family therapists stay aware of: ▪ Movements taking place in society and in specific cultural environments ▪ Own personal strengths and — most importantly — weaknesses, biases, and prejudices ▪ When consultation is appropriate or when referral is necessary ▪ Client’s internal/external frame of reference Family therapy allows for differentiation between idiosyncratic behaviors and culturally determined thinking or action because other family members are present.

Multicultural family genograms offer a global perspective on issues of ethnicity, economics, religion and political factors influencing family dynamics.

Multicultural expertise recognized as necessary to understand boundary lines, communication rules, displays of emotions, gender expectations, rituals, immigrant and refugee status, and the way these variables affect therapy.

The theory of social construction in family therapy has also provided an additional philosophical foundation for multicultural counseling.

Narrative model of Michael White takes a stand against the imposition of dominant culture imperatives.

Chapter 11: Activities Role-play Create a family scenario (e.g., family with two parents and a male and female child seek treatment for the daughter’s refusal to eat). Have willing students participate in an enactment.

Discussion Questions 1.

Have students discuss the four schools of family therapy identified in the chapter. Ask them to speculate about which approach they feel would be most useful for their family if they were to seek treatment.

2.

Family therapists state that insight is unimportant and view it as an intellectual game that prevents real change from taking place. Ask students to discuss whether they agree with this stance.

3.

A technique used in family therapy is the therapeutic double-bind. Ask students to consider whether directing families to continue to manifest their presenting symptoms poses any ethical concerns. Ask the student to discuss how they feel family members might respond to such an intervention.

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Use of Movies to Depict Concepts

Numerous films depict how families deal with tragedies and triumph. Because families share common experiences while individuals within have their own unique experiences, an outside facilitator can often see dynamics playing out family members themselves do not recognize. Simultaneously, families are often able to work out conflicts through indirect means.

For example, Henry and Jane Fonda in On Golden Pond (1982) demonstrate how a father and daughter work out long standing issues. In a more recent film, The Fighter (2012), starring Mark Wahlberg and Christian Bale, there is a depiction of how a family heals and brothers reunite through a commitment to boxing. Instructors might want to show a variety of films depicting how families resolve conflicts and then open a discussion to students about the pros/cons of involving a therapist.

Case Illustration from Case Studies in Psychotherapies (Seventh Edition)

The Daughter Who Said No by Peggy Papp This case study provides a step-by-step description of the treatment of a 23-year-old patient with anorexia nervosa and her family. The family presented with a high degree of enmeshment, covert alliances between the generations, subverted conflict, and power struggles fought with guilt and martyrdom. The parents appeared to be in rigidly symmetrical positions, constantly in conflict and diverted this conflict through their daughter. The therapeutic dilemma centers around what will happen to the client and the various members of her family if she gives up her anorexia and becomes a full-blown woman. The consultation group is used to debate this dilemma, and the sibling subsystem is enlisted to free the client from her involvement in the parent’s issues. Twenty sessions were held over the period of one year with a one-, two- and three year follow-up.

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Chapter 11: Potential Test Items Multiple Choice Test Bank 1.

In family therapy, the term “identified patient” conveys that: a. one member of the family typically creates the unit’s discord. b. family meetings are used to convince individual members to seek help. c. a symptomatic family member expresses family dysfunction. d. family therapy should focus on identifying the problems of each individual.

REF: Overview (p. 373) ANS: C

2.

Family therapists shift the locus of pathology from individuals to: a. parents. b. sociocultural norms. c. biological predispositions. d. family systems.

REF: Overview (p. 373) ANS: D

3.

The manner in which a family arranges, organizes, and maintains itself is known as its: a. evolution. b. structure. c. process. d. wholeness.

REF: Overview (p. 373) ANS: B

4.

Viewing interactions as reciprocal suggests causality is: a. circular. b. undetermined. c. linear. d. determined.

REF: Overview (p. 373) ANS: A

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During an argument, a father nonverbally communicates to his son to “cool off” prior to further interactions. This is an example of: a. negative feedback. b. linear causality. c. positive feedback. d. miscommunication.

REF: Overview (p. 375) ANS: A

6.

A couple escalates an argument regardless of the consequences. This is an example of: a. linear causality. b. negative feedback. c. homeostasis. d. positive feedback.

REF: Overview (p. 375) ANS: D

7.

Second order cybernetics focuses primarily on: a. the role of circular causality in a family system. b. feedback loops. c. boundaries within a family subsystem. d. the impact of the family therapist on the family system.

REF: Overview (p. 376-377) ANS: D

8.

Sandy’s parents are overly involved in her life and the boundaries within her family are diffuse. This family would be described as: a. enmeshed. b. restrictive. c. disengaged. d. isolative.

REF: Overview (p. 377) ANS: A

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Rigid boundaries that permit limited emotional contact between members characterize families that are: a. open. b. disengaged. c. relational. d. enmeshed.

REF: Overview (p. 377) ANS: B

10.

In systems terms, family boundaries yield systems that: a. are defined as either open or closed. b. represent flexibility or insularity. c. exist along an open/closed continuum. d. refer to visible lines separating subsystems.

REF: Overview (p. 377) ANS: C

11.

Family therapists are encouraged to take a gender-sensitive outlook. This means the therapist should: a. assess but not attempt to modify a family’s views of gender roles. b. theoretically separate the influence of gender from culture and social class. c. compensate for disparate opportunities offered to males and females in a family. d. be careful not to reinforce sexist or patriarchal attitudes.

REF: Overview (p. 378) ANS: D

12.

The primary conceptual difference between family systems approaches and Adlerian psychotherapy is the Adlerian’s: a. emphasis on the social context of behavior. b. therapeutic focus on the individual. c. holistic view of the individual. d. focus on present circumstances and future goals.

REF: History (p. 379-380) ANS: B

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Assuming a child’s tantrum occurs because parents reinforced the behavior would be consistent with which theoretical orientation listed below? a.

Psychoanalytic b.

Behavioral c.

Person-centered d.

Family systems REF: Overview (p. 379) ANS: B

14.

A parent tells a child “I love spending time with you” while appearing annoyed. This is an example of: a. redundancy principle. b. pseudomutuality. c. pseudohostility. d. double-bind communication.

REF: History (p. 380) ANS: D

15.

An alcoholic husband maintains an authoritative manner with his wife and children while the wife acts as if nothing is wrong. This scenario illustrates: a. pseudohostility. b. scapegoating. c. marital schism. d. marital skew.

REF: History (p. 381) ANS: D

16.

The Psychodynamics of Family Life, viewed by many as the first text defining the field of family therapy, was written by: a.

Nathan Ackerman. b.

Virginia Satir. c.

Jay Haley. d.

Salvador Minuchin.

REF: History (p. 381) ANS: A

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The family therapy approach most likely to focus on the multigenerational transmission of problems and each family member’s ability to differentiate is: a. object relations. b. experiential. c. structural. d. transgenerational.

REF: History (p. 383) ANS: D

18.

A therapist employing paradoxical interventions most likely adheres to which of the following family therapy viewpoints? a.

Strategic b.

Structural c.

Experiential d.

Behavioral REF: History (p. 383-384) ANS: A

19.

Rather than providing an objective view regarding a conflict, a family therapist asks questions of each family member to obtain their perspective. This approach would be described as: a. reframing. b. cognitive restructuring. c. circular questioning. d. the miracle question.

REF: History (p. 381) ANS: C

20.

A family is encouraged to tell the “family story” with hope that a new family story can be developed to facilitate change. Which of the following therapy approaches is being used? a.

Strategic b.

Social constructionist c.

Structural d.

Cognitive-behavioral REF: History (p. 385) ANS: B

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The redundancy principle refers to a family’s: a. desire to scapegoat a family member. b. restricted range of interactional patterns. c. maladaptive response to family crises. d. need to enact family of origin issues.

REF: Personality (p. 386) ANS: B

22.

A dysfunctional family’s portrayal of false closeness that forces togetherness despite individual needs is referred to as: a. pseudo-hostility. b. double bind. c. pseudo-mutuality. d. mystification.

REF: Personality (p. 386-388) ANS: C

23.

Which of the following family paradigms is likely to lead to the LEAST dysfunction? a.

Consensus-sensitive b.

Environmentally-sensitive c.

Interpersonal-distance-sensitive d.

Neutrally-sensitive REF: Personality (p. 386) ANS: B

24.

A family argues constantly to avoid intimacy. This illustrates: a. scapegoating. b. mystification. c. pseudo-hostility. d. double bind.

REF: Personality (p. 387) ANS: C

25.

A mother tells her child “I know you’re not hungry,” despite the child’s sense that he/she is hungry. This is an example of: a. triadic communication. b. pseudo-mutuality. c. mystification. d. redundancy principle.

REF: Personality (p. 387) ANS: C

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26.

To deal with their own sense of loneliness in a marriage, a couple becomes overly involved in the problems of their son. This model of interaction is: a. monadic. b. dyadic. c. biadic. d. triadic.

REF: Personality (p. 388) ANS: D

27.

Blaming marital discord on a wife’s rigid, controlling demeanor would presume a model of interaction that was: a. biadic. b. dyadic. c. triadic. d. monadic.

REF: Personality (p. 388) ANS: D

28.

To deal with their daughter’s refusal to eat, previously controlling parents attempt to interact supportively and empower their daughter to make her own decisions. This scenario represents a change that is: a. second-order. b. first-order. c. third-order. d. multiple-order.

REF: Psychotherapy (p. 389-390) ANS: A

29.

A family therapist will typically ask which of the following family members to attend the initial session? a.

Only the identified patient b.

The entire family c.

Only the parents d.

The identified patient and the parents REF: Psychotherapy (p. 390) ANS: B

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A genogram is a: a. compilation of each family member’s values and ideals. b. family tree diagram of generational behavior patterns. c. reenactment of previous negative communication patterns. d. physical acting out of family conflicts.

REF: Psychotherapy (p. 393) ANS: B

31.

Designing interventions that are paradoxical in nature is known as: a. reframing. b. circular questioning. c. family sculpting. d. therapeutic double-binds.

REF: Psychotherapy (p. 394) ANS: D

32.

A family therapist asks each member of a family sequentially to pose the other family members in physical space as a representation of their view of the family. This technique is known as: a. reframing. b. family sculpting. c. enactment. d. circular questioning.

REF: Psychotherapy (p. 395) ANS: B

33.

A family therapist employing a solution-focused approach asks the miracle question. The therapist wants to know what would happen if a miracle occurred and: a. the family won a large sum of money. b. one member of the family could be changed. c. the problem that lead to therapy was solved. d. family members never saw each other again.

REF: Psychotherapy (p. 395) ANS: C

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A family therapist interacts in a manner that is: a. active, empathic and balanced. b. nondirective and insight-oriented. c. passive and nonjudgmental. d. separately-oriented toward family members.

REF: Psychotherapy (p. 395-397) ANS: A

35.

Effectiveness studies of family therapy focus primarily on: a. whether a treatment works under ideal conditions. b. the cost-benefit analysis of individual versus family therapy. c. the risks of using solution-focused therapy in high risk situations. d. whether a treatment works in real clinical situations.

REF: Applications (p. 400-401) ANS: D Fill in the Blanks

1.

Family systems that allow new information in and individuals within the family to see things from different perspectives are called _______ systems.

ANS: Open

2.

When family boundaries are overly diffuse, they are described as representing _______.

ANS: Enmeshment

3.

The founder of structural family therapy is _______.

ANS: Salvador Minuchin

4.

The individual identified with strategic family therapy is _______.

ANS: Jay Haley

5.

When problems are passed down from a grandmother to a mother and to a daughter, this is termed _______ transmission.

ANS: Multigenerational

6.

When the parents within a family offer repeated threats of separation and utilize the child in order to disqualify one another, this is referred to as _______.

ANS: Marital schism Family Therapy

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7.

Communication that leads to mixed messages results in a(n) _______ relationship.

ANS: Double bind

8.

When a third person is brought into a dyadic relationship to deal with a conflict, this is termed _______.

ANS: Triangulation

9.

Family therapists would often say that the identified patient in a family has been _______ by the family, as the family blames them for the family’s problem.

ANS: Scapegoated

10.

When a family therapist makes a conscious attempt to form coalitions with one member against another within a family, this technique is called _______.

ANS: Unbalancing Essay Questions

1.

In family therapy, the “client” is the whole family. Describe how family therapy would proceed without relieving individual family members of their responsibility for their own behavior.

2.

Discuss the concept of triangulation and the problems associated with it.

3.

Describe the differences between structural family therapy and strategic family therapy.

4.

Adlerian psychotherapy focuses on the family constellation. How is this similar or different from family therapy?

5.

Describe the differences between first-order and second-order changes within a family.

Give an example of a first-order change versus a second-order change.

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Chapter 12 Contemplative Psychotherapies Author: Roger Walsh Key Points and Terms

Overview ► ►

►

►

Examples of contemplative practices are contemplation, yoga and meditation.

Contemplative practices are found in most cultures.

▪ Most researched are: • Transcendental meditation (TM), a mantra practice • Buddhist mindfulness, or vipassana ▪ Contemplative practices: • Are simple effective, inexpensive and often pleasurable • Offer profound insight and self-understanding, reduce stress • May ameliorate psychological and psychosomatic disorders • Enhance well-being, foster latent capacities and accelerate personal development Terms meditation and contemplation are used synonymously in this chapter.

▪ Meditation: Self-regulation practices focused on training attention and awareness to bring mental process under greater voluntary control.

▪ Yoga: Similar aims to meditation but more inclusive (e.g., ethics, lifestyle, body postures, diet, breath control, study and intellectual analysis).

Bad News – Good News ▪ Central Assumptions • Mind’s ordinary state is uncontrolled, underdeveloped, and dysfunctional.

• Dysfunction goes unrecognized because: ► Humans share it. ► Self-masking distorts awareness to conceal it.

• Psychological suffering is largely a function of this mental dysfunction.

• We can train the mind.

• Training the mind enhances well-being.

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Mental training allows awareness of our remarkable real nature.

Contemplative disciplines offer techniques for training of the mind.

These claims can be tested for oneself.

Understanding Contemplative Therapies from a Developmental Perspective ► Prepersonal/preconventional: No coherent sense of self. ► Personal/conventional: Enculturation, inauthentic, unfulfilling life, “shared hypnosis.” ► Transpersonal/postconventional: Upper limits of health and normality.

Comparing Contemplative Psychotherapies to Other Approaches Contemplative perspectives believe that upsychoanalysis: ▪ Tragically underestimates human nature and potential ▪ Overlooks individual strengths ▪ Is accurate that conflict is a given for “normal” people, but it can be transcended ▪ Has a tendency towards grandiosity ▪ Is accurate about the importance of deep introspection but does not have a recognition of the deepness of the unconscious Contemplative perspectives are in agreement with Jungian approaches about: ▪ The multilayered nature of the unconscious ▪ Importance of archetypal forces ▪ The mind’s innate drive towards growth ▪ Beneficial effects of transpersonal experiences Contemplative perspectives are in agreement with cognitive and rational emotive approaches about: ▪ The appreciation of the enormous power of thoughts and beliefs (although contemplative therapies focus on a deeper level of beliefs) ▪ Humans are prone to erroneous thought processes which they accept as truths Contemplative perspectives and Existential approaches: ▪ Center on “ultimate concerns” ▪ Agree on the lack of authenticity in our lives ▪ Offer overlapping but distinct solutions (both focus on need for courage in facing life’s realities, but contemplative approaches cultivate mental qualities and maturation to transpersonal stages to do so) History of Contemplative Psychotherapies ► ► ►

Shamanism is the most enduring of all current psychotherapies.

Meditative and yoga practices are at least 3,000 years old.

Many contemplative approaches (e.g., Buddhism, Taoism, Confucianism, Christian Contemplatives) arose out of the Axial Age.

Current Status of Contemplative Psychotherapies ► In recent years, there has been a resurgence of interest in contemplative practices.

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►

TM and mindfulness have been the most researched aspects.

Contemplative technical eclecticism (e.g., Jon Kabat-Zinn’s ideas) generally combining mindfulness and other psychotherapies have considerable support.

Attempts at theoretical integrations that synthesize contemplative perspectives with psychological perspectives are also developing.

▪ Transpersonal: First explicitly integrative school of Western psychology.

▪ Integral psychology: Traces psychological development, pathologies and treatment from infancy to adulthood using Western resources and then from personal to transpersonal using contemplative resources.

▪ Integral therapies: Multimodal therapy approach that integrates educational, psychotherapeutic, contemplative and somatic approaches.

Prior to integrating contemplative practices into therapy approaches, therapists need personal training in these practices and should receive that training from expert guides.

Contemplative Psychotherapies’ Theory

►

There are multiple theories, but recurrent themes include: ▪ Consciousness • Broad spectrum of states of consciousness.

• Our perceptual sensitivity and clarity, concentration, sense of identity, and emotional and cognitive processes vary with states of consciousness in predictable ways.

• Higher states possess our typical capacities and heightened ones.

• Meditation reveals these unrecognized thoughts, images and fantasies.

• Awakening from our day-to-day “dream” state can lead to liberation and enlightenment.

▪ Identity • Self is different from our usual assumptions as the self being a continuous, consistent and stable entity.

• Meditation allows us to pass arbitrary self-boundaries and identify with others and humankind in general (self-transcendence).

▪ Motivation • Motives are organized from survival to self-transcendence.

• Metamotives (e.g. self-actualization, self-transcendence and selfless services) are an essential part of our nature.

• Metamotive blindness (i.e., denial of these needs): ► Leads to living inauthentically ► May result in metapathologies ► Results in the belief that lesser motives (e.g., sex, money) lead to happiness putting humans on a “hedonic treadmill” ▪ Development • Western psychology focuses on prepersonal/preconventional and personal/conventional.

• Contemplatives focus on transpersonal/postconventional.

▪ Higher capacities • At postconventional levels: Contemplative Psychotherapies

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© 2014 Cengage Learning, Inc. Metamotives evolve ► Cognitive development proceeds to vision logic or network logic — seeing interconnections between group ideas simultaneously.

Unhealthy factors vary across contemplative practices. ► For example, Buddhism’s Three Poisons ▪ Delusion: Unrecognized mental dullness ▪ Addiction: Cravings • Suffering is gap between what we crave and what we have.

▪ Aversion: Compulsive need to avoid distress. ►

•

Types of Meditation ► Concentration meditations: Holding attention on a stimulus. ► Awareness meditations: Allowing attention to move from one object or another.

Psychological Health ► Relinquishment of delusion, addiction and aversion ► Development of specific healthy mental qualities ► Maturation to postconventional/transpersonal levels Contemplative Psychotherapies: The Approach ►

Central tenet: Mind can be trained to relinquish unhealthy attributes and allow healthy ones to flourish.

Seven Qualities/Seven Treatments (treatments in parentheses) ► Ethics (Say only what is true and helpful) ▪ Karma: Psychological residue left by past behavior.

▪ Struggle to reverse old habits.

▪ Sought from within. ► Emotional transformation (Using wise attention to cultivate beneficial emotions) ▪ Reducing problematic emotions.

▪ Cultivating positive emotions.

▪ Developing equanimity (maintaining calmness in face of provocative stimuli). ► Redirecting motivation (Exploring the experiences of craving) ▪ Analogous to Maslow’s hierarchy of needs. ► Training attention (Do one thing at a time) ▪ Primary tool is meditation. ► Refining awareness (Awareness meditation, mindful eating) ► Wisdom (Reflecting on our mortality) ▪ Knowledge is something we have; wisdom is something we become.

▪ Wisdom refers to a deep understanding of and a way of responding to existential issues. ► Altruism and service (Transforming pain into compassion) ▪ A means to and an expression of psychological well-being.

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Process of psychotherapy is a repetitive practice of contemplative techniques that goes through six stages: 1. Recognizing mental dysfunction 2. Recognizing habitual patterns 3. Cognitive insights 4. Development of exceptional qualities 5. Emergence of transpersonal experiences 6. Stabilization of transpersonal development Challenges include: ▪ Emotional lability during early stages.

▪ Existential crises as one advances.

▪ Underlying psychopathology may emerge.

Reattribution and reframing may be particularly helpful during these challenges.

Mechanisms Suggested by Contemplative Traditions ► Calming the mind ► Enhanced awareness ► Disidentification (observing) ► Rebalancing mental elements Mindfulness Factors

Arousing Factors Effort Investigation Rapture

Calming Factors Concentration Calm Equanimity

Applications of Contemplative Psychotherapies ► ► ► ► ► ►

Psychological disorders Somatic disorders Enhanced well-being (both for patients and health professionals) Enhanced therapist qualities Transpersonal growth Developing specific skills ▪ Cultivation of love: Focusing on love of one individual and conditioning it to others.

▪ Lucid dreaming: The ability to know one is dreaming while still sleeping.

Evidence ► Classic approach for evaluating contemplative therapies is personal experience. ► Meditation is one of the most extensively researched psychotherapies. ► Research has demonstrated developmental, physiological (e.g., EEG studies), biochemical and neural effects. ► Research consistently supports that contemplative practices yield exceptional abilities. ► May be most beneficial for those who are internally-focused, open-minded, willing to self-evaluate, self-controlled, good concentrators, low on emotional lability, less psychologically disturbed.

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Unclear how durable the effects are if practice stops.

Research limitations are created as most studies are means-oriented (focusing on what is measurable).

Psychotherapy in a Multicultural World

► ►

Therapy methods are limited by maturity of the therapist, so multicultural issues must take this into consideration.

Approach that does so is diversity dynamics that states: ▪ Diversity occurs in all systems, including therapeutic relationships.

▪ Diversity creates “diversity tension,” which leads to problems and benefits.

▪ Adults differ on their levels of psychological development.

▪ An individual’s developmental level influences what they observe and understand and influences attitudes and responses to diversity.

▪ Diversity situations contain creative potentials, opportunities for learning.

▪ Diversity training needs to foster psychological maturity.

Chapter 12: Activities Role-play Although most people agree on the importance of reflecting on tough topics like mortality, actually engaging in self-reflection about the topic is often difficult. Ask three willing students to role-play, asking each other one of the following questions and trying to provide a genuine answer. Then, ask the students to discuss their comfort level with this exercise.

▪ Knowing we will all die, what is truly important in life?

▪ If you were to die tomorrow, what would you regret not having done?

▪ What relationships remain unhealed in your life, and how could you begin healing them?

Discussion Questions 1.

Contemplative practices are one of the earliest forms of psychotherapy and one of the most researched. Have students discuss why they believe contemplative practices have endured for centuries.

2.

During a class, have an individual trained in contemplative practices take students through a contemplative technique such as the raisin exercise or a meditation practice.

Ask students to discuss their response to the activity.

3.

Motives such as sex, power, and wealth are considered to result from metamotive blindness. Ask the students if they agree and to discuss why they believe these motives are more prominent in society than metamotives like self-actualization and selftranscendence.

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© 2014 Cengage Learning, Inc. Use of Movies to Depict Concepts

Eastern cultures have encouraged the use of contemplative practices in order for individuals to maintain well-being. Over the last three decades, these types of approaches have increasingly become embedded into Western forms of psychotherapy. Several films depict how an individual can grow personally and spiritually by using contemplative practices. Additionally, these films demonstrate how contemplative practices can enhance the lives of individuals dealing with serious psychological issues. Elements of these films can be used in classroom discussions to help students discuss whether the goal of psychotherapy is to eliminate symptoms or to create transcendence.

Case Illustration from Case Studies in Psychotherapies (7th Edition)

Using Mindfulness Effectively in Clinical Practice: Two Case Studies

by Tory A. Eisenlohr-Moul, Jessica R. Peters, and Ruth A. Baer Mindfulness, acceptance and commitment therapy and dialectical behavior therapy have been described as the “third wave” of cognitive-behavioral therapy. Each of these approaches includes contemplative practice. The two case studies demonstrate the application of mindfulness in the treatment of a female with generalized anxiety disorder (GAD) and a female with borderline personality disorder (BPD). Instructors can ask students to discuss why psychotherapy is increasingly incorporating contemplative practices and how to make these types of interventions palatable to patients.

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Chapter 12: Potential Test Items Multiple Choice Test Bank 1.

Therapies aimed at transforming one’s state of awareness, facilitating well-being, and developing healthy lifestyles through practices such as meditation and yoga are known as: a. pathological. b. contemplative. c. existential. d. client-centered.

REF: Overview (p. 412) ANS: B

2.

In contrast to most Western psychotherapies, contemplative psychotherapies focus more on: a. biological issues and less on spiritual issues. b. behavioral changes and less on existential issues. c. developing exceptional capacities such as heightened calmness. d. cognitive issues and less on pathology.

REF: Overview (p. 413) ANS: C

3.

Which of the following contemplative practices focuses heavily on the use of a mantra? a.

Yoga b.

Transcendental meditation c.

Mindfulness d.

Cognitive restructuring REF: Overview (p. 412) ANS: B

4.

Self-regulation practices focused on training attention and awareness to bring mental process under greater voluntary control is known as: a. cognitive restructuring. b. yoga. c. meditation. d. free association.

REF: Overview (p. 412) ANS: C

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A practice with similar aims to meditation but that includes aspects such as body posturing and changing diet is known as: a. cognitive restructuring. b. yoga. c. meditation. d. free association.

REF: Overview (p. 412) ANS: B

6.

Which of the following is a true statement about the bad news – good news of contemplative practices? a.

The mind’s ordinary state is overdeveloped. b.

Psychological suffering is largely a function of physical dysfunction. c.

Controlling the mind is not within our capacity. d.

Training the mind enhances well-being.

REF: Overview (p. 412-413) ANS: D

7.

Contemplative practices primarily offer opportunities for: a. the body to recover from physical trauma. b. an individual to engage in cognitive restructuring. c. training the mind to enhance well-being. d. rectifying rifts that have formed within families.

REF: Overview (p. 412-413) ANS: C

8.

Contemplative therapists would say that the primary reason dysfunction goes unnoticed is because: a. humans share it. b. religion distorts our sense of reality. c. stigmatization of mental illness. d. humans are somatic not introspective.

REF: Overview (p. 412) ANS: A

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During early development, an individual has no coherent sense of self. Which of the following stages of development does this reflect? a.

Prepersonal b.

Personal c.

Conventional d.

Postconventional REF: Overview (p. 413) ANS: A

10.

The stage of development that reflects enculturation and an inauthentic, unfulfilling life is known as: a. preconventional. b. transpersonal. c. postconventional. d. personal.

REF: Overview (p. 413) ANS: D

11.

Contemplative practices are primarily focused on the stage of development referred to as: a. preconventional. b. transpersonal. c. postconventional. d. personal.

REF: Overview (p. 413-414) ANS: B

12.

Contemplative perspectives agree with psychoanalytic theory that: a. conflict is a given for normal people and cannot be transcended. b. human nature and potential are limited because of psychological conflicts. c. oedipal conflicts are crucial in the course of development. d. deep introspection is important in understanding the unconscious.

REF: Overview (p. 414-415) ANS: D

13.

Contemplative therapies are most congruent with the ideas espoused by: a. psychoanalytical theory. b.

Jungian theory. c. cognitive behavioral theory. d. rational emotive behavioral theory.

REF: Overview (p. 415) ANS: B

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14.

Contemplative perspectives are in most agreement with cognitive and rational emotive behavioral approaches about: a. the enormous power of thoughts and beliefs. b. humans being generally aware of their thought processes. c. the importance of integrating behavioral techniques into therapy. d. the multilayered nature of the unconscious.

REF: Overview (p. 416-417) ANS: A

15.

In addition to the goals of existential approaches contemplative perspectives: a. center on ultimate concerns. b. believe that there is a lack of authenticity in our lives. c. focus on the need for courage in facing life’s realities. d. cultivate mental qualities and maturation to transpersonal stages.

REF: Overview (p. 417) ANS: D

16.

Higher order states involve: a. only themes regarding social interest. b. rational thought process and not emotions. c. skills directly related to survival of the species. d. capacities of usual conditions plus additional ones.

REF: Personality (p. 427) ANS: D

17.

The primary aim of therapies such as Buddhism is: a. maya. b. insight. c. behavior change. d. enlightenment.

REF: History (p. 419) ANS: D

18.

The most enduring of all current psychotherapies is: a.

Buddhism. b. psychoanalysis. c.

Shamanism. d.

Jungian.

REF: History (p. 419) ANS: C Contemplative Psychotherapies

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19.

Meditation practices can be subdivided into the two main categories of: a. concentration and awareness. b. active and passive. c. cognitive and emotional. d. psychophysiological and meditational.

REF: Personality (p. 427) ANS: A

20.

Contemplative technical eclecticism that focuses on combining mindfulness and other psychotherapies is most associated with: a.

Carl Rogers. b.

Carl Jung. c.

Jon Kabat-Zinn. d.

John Norcross.

REF: History (p. 420) ANS: C

21.

The term for the point when meditation allows an individual to pass arbitrary selfboundaries and identify with others and humankind in general is: a. metamotive. b. self-transcendence. c. self-actualization. d. mantra.

REF: History (p. 421) ANS: B

22.

Which of the following statements about motives is true? a.

Motives are organized from survival to self-transcendence. b.

Metamotives are not an inherent part of human nature. c.

Metamotive blindness is rare. d.

Authentic living is characterized by motives such as sex, money, power.

REF: Personality (p. 425) ANS: A

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The denial of needs such as self-actualization and self-transcendence leads to: a. less psychopathology but mental dullness. b. living in an authentic manner. c. a focus on hedonistic needs. d. enhanced self-esteem but decreased selflessness.

REF: Personality (p. 426) ANS: C

24.

At postconventional levels, an individual’s metamotives evolve and their cognitive development: a. remains constant but spiritual enlightenment advances. b. is unaffected as they are in a meditational trance. c. yields advanced mathematical and verbal skills they were unaware of. d. allows them to see interconnections between group ideas simultaneously.

REF: Personality (p. 426) ANS: D

25.

A main goal of contemplative practices regarding emotional transformation is: a. focusing on survival needs. b. developing equanimity. c. reversing bad habits. d. encouraging cathartic venting of emotions.

REF: Psychotherapy (p. 430) ANS: B

26.

Which of the following statements is FALSE about meditation? a.

It may lead to lower mortality rates. b.

It benefits severely disturbed patients most. c.

It may increase a therapist’s empathy. d.

It is related to improved self-esteem and a sense of control.

REF: Personality (p. 426) ANS: B

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During a group therapy session, patients are asked to hold a raisin, look at it carefully, smell it, and slowly eat it while paying close attention to its texture and taste. This is an example of: a. inappropriate use of contemplation. b. a mindfulness technique. c. exposure with response prevention. d. gestalt therapy exercise.

REF: Applications (p. 448) ANS: B

28.

Research has shown that when an individual stops contemplative practices: a. the effects are maintained for life. b. the effects are maintained for at least 1-3 years. c. it is unclear how durable the effects are. d. a rebound effect occurs in which symptoms get substantially worse.

REF: Applications (p. 449-452) ANS: C

29.

The first stage in the process of contemplative psychotherapy would be the repetitive practice of contemplative techniques to aid in the: a. recognition of mental dysfunction. b. recognition of habitual patterns. c. advancement of cognitive insights. d. development of exceptional qualities.

REF: Psychotherapy (p. 433-434) ANS: A

30.

In the cultivation of love, an individual is taught to: a. love all individuals equally by focusing on their positive attributes. b. focus on their love of one individual and condition it to others. c. develop a stronger sense of self-worth. d. recognize the existence of a higher power and to love this entity.

REF: Applications (p. 444-445) ANS: B Fill in the Blanks

1.

The most researched contemplative practices are __________ and ____________.

ANS: Transcendental meditation and Buddhist mindfulness or vipassana (mindfulness also acceptable)

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© 2014 Cengage Learning, Inc. 2.

_______ focuses on self-regulation practices but also incorporates ideas like lifestyle, body postures, diet, and breath control.

ANS: Yoga

3.

In the developmental phase called _______ or __________, there is no coherent sense of self.

ANS: Prepersonal or preconventional

4.

Contemplative approaches are mainly invested in the stage of development known as ________ or ________, which focus on the upper limits of health and normality.

ANS: Transpersonal or postconventional

5.

________ is the term for psychological residue left by past behavior.

ANS: Karma

6.

Buddhism’s three poisons are ________, _______, and __________.

ANS: Delusion, addiction, and aversion

7.

Suffering is the gap between what we ________and what we ________.

ANS: Crave; have

8.

A technique called “exploring the experiences of craving” is a contemplative practice aimed at ______________, one of the seven qualities.

ANS: Redirecting motivation

9.

Maintaining calmness in the face of provocative stimuli is known as __________.

ANS: Equanimity

10.

The ability to know one is dreaming while still sleeping is termed ___________.

ANS: Lucid dreaming Essay Questions

1.

Contemplative psychology contends that we are only half grown and half awake! Explain how contemplative therapists would use a developmental perspective to support this statement.

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Contemplative practices predate any other form of psychotherapy discussed in Current Psychotherapies. Contrast the theory behind contemplative psychotherapy with the theories of Sigmund Freud, Carl Jung, existentialists and Aaron Beck.

3.

From a contemplative perspective, a human’s normal state of being is equated to being “asleep.” If one is highly distressed, one is described as being in a “nightmare;” if one is highly enlightened, one is described as having experienced an “awakening.” Explain this metaphor about the state of human beings from a contemplative perspective.

4.

Effective contemplative disciplines use seven central kinds of practices to cultivate seven corresponding human qualities. Describe these practices and qualities and the manner in which they are linked.

5.

Describe alcohol addiction from a contemplative perspective. How would contemplative practices be utilized in treatment for substance abuse and why?

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Chapter 13 Positive Psychotherapy Authors: Tayyab Rashid and Martin Seligman Key Points and Terms

Overview Flourishing ► Traditional psychotherapies focus on the negatives. ► Positive psychotherapy (PPT) is built on the principles of positive psychology. ► Flourishing is a state characterized by positive emotions, a strong sense of personal meaning, good work, and positive relationships.

Positive Psychotherapy (PPT) ► Name does not suggest that other psychotherapies are negative. ► PPT is not intended to replace traditional therapeutic approaches. ► PPT is an approach that seeks to balance the attention given to negative and positive life events in psychotherapy. ► PPT focuses on the reorientation to a build-what’s-strong model that supplements the traditional fix-what’s-wrong approach.

Comparing Positive Psychotherapy to Other Therapies Psychoanalytic View ► Arthur Schopenhauer and Sigmund Freud felt that the best humans could ever achieve was minimizing their own misery. ► Freud posited that negatives were an indispensable element of human existence. ► Assumed defenses built to repress conflicts and manage the unbearable anxiety they cause.

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© 2014 Cengage Learning, Inc. Psychotherapy Has Hit a Dead End: The 65% Barrier ► In the treatment of depression, CBT and pharmacotherapy both hit a ceiling at 65% response rate.

▪ Placebo may account for 45-55% of this effect.

▪ The more valid and realistic the placebo, the greater the placebo response. ► Why a 65% barrier?

▪ Behavioral change is difficult.

▪ People lack motivation, have co-morbid issues, or live in unhealthy environments that are not amenable to change.

▪ Easier to continue to behave in maladaptive ways.

Other Challenges Facing Psychotherapy ► About 40% of clients terminate therapy prematurely. ► Clients only make superficial changes as a result of therapy. ► Traditional psychotherapy takes a palliative approach.

▪ i.e., has stopped looking for a cure ► Psychotherapy largely a science of victimology.

How PPT Challenges Traditions ► Focuses on learning to function well in face of psychological distress. ► Trying to break the 65% barrier. ► Builds on research. ► Presence of character strengths shown to make a significant incremental contribution toward recovery from depression. ► Gratitude leads to lower levels of stress and depression.

History of Positive Psychotherapy Maslow’s Hierarchy of Needs

Self-Actualization Self Esteem Love and Belonging Safety Physiological

Early Beginnings of PPT ► Jahoda’s Current Concepts of Positive Mental Health (1958) argued well-being should be appreciated in its own right. ► Frankl (1963) noted that the primary human drive was not pleasure, but the pursuit of meaning.

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© 2014 Cengage Learning, Inc. Limited Attention to Positives ► Psychological Abstracts (since 1887) articles have a 14:1 negative to positive ratio. ► Handbook of Psychotherapy and Change by Bergin and Garfield does not include wellbeing or happiness in the subject index (Lambert, 2013). ► Diagnostic Statistical Manual(s) created by the American Psychiatric Association have catalogued hundreds of psychiatric symptoms for disorders, but not a single and coherent classification of strengths until 2004.

Examples of Therapies Incorporating Positives ► Fordyce (1983) focused on increasing happiness for college students through 14 strategies. ► Well-being therapy (WBT) integrates CBT and well-being and is effective in treating affective and anxiety disorders. ► Frisch’s quality-of-life therapy (QOLT) integrates CT with positive psychology and has been shown effective with depressed clients.

Positive Interventions are Making Progress ► Journal of Clinical Psychology (2009) focused exclusively on positive interventions for clinical disorders. ► Positive psychology interventions are being explored in clinical settings. ► Interventions focusing on one or two positive attributes have been conducted. ► As APA President Marty Seligman urged: ▪ “Psychology to supplement this historical goal with a new goal: Exploring what makes life worth living and building the enabling conditions of a life worth living.”

Current Status of PPT ► ►

► ► ►

►

► ►

More than a 1000 articles related to positive psychology published in peer-reviewed journals between 2000 and 2010.

Peer-reviewed journals include the Journal of Positive Psychology, Journal of Happiness Studies, International Journal of Well-being and Applied Psychology: Health and Wellbeing.

Positive psychology is taught internationally.

Programs on positive psychology developed in the United States.

Online positive psychology resources are available: ▪ www.authentichappiness.com ▪ www.ppc.com ▪ www.viacharacter.org ▪ www.positivepsychologynews.com Grants for Positive Psychology Center to explore longitudinal indicators of positive health, positive neuroscience, the mechanisms of self-regulation, and retention among college students.

International Positive Psychology Association founded in 2007.

International level scientific gatherings on positive psychology.

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Positive psychology exercises under the Comprehensive Soldier Fitness Program are now being taught within the US Army.

Considerable popular press attention towards positive psychology.

Theory of Personality for Positive Psychology

Positive Psychology Asserts ► Notion that childhood determines adult personality is false. ► Genes have a tremendous influence on adult personality. ► Heritability does not determine how unchangeable a trait will be. ► Happiness is a personality trait that can be changed.

Formula for Happiness ► H=S+C+V ▪ H: Enduring level of happiness ▪ S: Personal set range ▪ C: Circumstances ▪ V: Factors under personal volitional control Psychotherapy Can Be a Venue for Strength-Building ► Fixing weaknesses yields remediation, whereas nurturing strengths produces growth and more well-being. ► Repairing or fixing weakness does not necessarily make clients stronger or happier. ► Using strengths increases clients’ self-efficacy and confidence in ways focusing on weakness cannot. ► Strengths offer ways to facilitate being good, kind, humorous, industrious, curious, creative, and grateful. ► Strengths essentially come from being good, not feeling good. ► Within PPT, there are six main virtues identified with a total of 24 character strengths identified under all six of the virtues.

Table Values in Action Classification Listed below are six virtues. Subsumed in each virtue are character strengths.

Wisdom and knowledge: Strengths that involve acquiring and using knowledge. a.

Creativity: Thinking of novel and productive ways to do things. b.

Curiosity/openness to experience: Taking an interest in all of ongoing experience. c.

Judgment/open-mindedness/critical thinking: Thinking things through and examining them from all sides. d.

Love of learning: Mastering new skills, topics, and bodies of knowledge. e.

Perspective: Being able to provide wise counsel to others.

Courage: Emotional strengths that involve exercise of will to accomplish goals in the face of opposition, either external or internal. a.

Bravery: Not shrinking from threat, challenge, or pain.

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Persistence: Finishing what one starts, maintaining a course of action in spite of obstacles. c.

Integrity: Speaking the truth and presenting oneself in a genuine way. d.

Vitality/zest: Approaching life with excitement and energy; not doing things halfway or halfheartedly; living life as an adventure; feeling alive and activated.

Humanity: Interpersonal strengths that involve tending and befriending others. a.

Love: Valuing close relations with others — in particular, those in which sharing and caring are reciprocated; being close to people. b.

Kindness: Doing favors and good deeds for others; helping them; taking care of them. c.

Social intelligence: Being aware of the motives and feelings of self and others; knowing what to do to fit into different social situations; knowing what makes other people tick.

Justice: Strengths that underlie healthy community life. a.

Citizenship: Working well as member of a group or team; being loyal to the group; doing one’s share. b.

Fairness: Treating all people the same according to notions of fairness and justice; not letting personal feelings bias decisions; giving everyone a fair chance. c.

Leadership: Encouraging a group of which one is a member to get things done and, at the same time, maintain good relations within the group; organizing group activities and seeing that they happen.

Temperance: Strengths that protect against excess. a.

Forgiveness and mercy: Forgiving those who have done wrong; accepting the shortcomings of others; giving people a second chance; not being vengeful. b.

Humility/modesty: Letting one’s accomplishments speak for themselves; not seeking the spotlight; not regarding oneself as more special than one is. c.

Prudence: Being careful about one’s choices; not taking undue risks; not saying or doing things that might later be regretted. d.

Self-regulation (self-control): Regulating what one feels and does; being disciplined; controlling one’s appetites and emotions.

Transcendence: Strengths that forge connections to the larger universe and provide meaning. a.

Appreciation of beauty and excellence: Noticing and appreciating beauty, excellence, and/or skilled performance in all domains of life, from nature to arts to mathematics to science. b.

Gratitude: Being aware of and thankful for good things; taking time to express thanks. c.

Hope/optimism: Expecting the best in the future and working to achieve it; believing that a good future is something that can be brought about. d.

Humor/playfulness: Liking to laugh and tease; bringing smiles to other people, seeing the light side; making (not necessarily telling) jokes. e.

Spirituality: Knowing where one fits within the larger scheme; having coherent beliefs about the higher purpose and meaning of life that shape conduct and provide comfort.

Adapted from Peterson & Seligman, 2004 Positive Psychotherapy

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Chris Peterson’s Model for Evaluating Disorders ► Peterson (2006) argues that if psychology as usual uses a lens of abnormality to view normality, “then why not use the lens of normality or even super normality to view abnormality?” ► For each psychological condition (that is not clearly linked with biological factors) Peterson would ask the following questions: ▪ What psychological state or trait reflects absence of character strength?

▪ What state or trait signifies its opposite?

▪ What state or trait displays its exaggeration? ► A disorder may result from the absence of a given character strength, but it can also result from its presence in extreme forms.

PPT is Based on 3 Primary Assumptions ► Psychopathology results when inherent capacities for growth, fulfillment, and happiness are thwarted by sociocultural factors. ► Positive emotions/strengths are authentic and real. ► Effective therapeutic relationships can be built on exploration and analysis of positive personal characteristics and experiences.

Seligman’s Conceptualization of Happiness and Well-being ► PPT is primarily based on Seligman’s deconstruction of “happiness” into three scientifically measurable and manageable components: 1. Positive emotion (the pleasant life): a. Dimension of human experience endorsed by hedonic theories of happiness. b. Consists of experiencing positive emotions about the present, past, and future and learning new skills to amplify the intensity and duration of these emotions. c. Positive emotions build resilience by “undoing” the effects of negative emotions. d. Depressed clients seeking psychotherapy experience a lower than 0.5:1 ratio of positive to negative emotion. e. Fredrickson (2009) found that experiencing three positive emotions for every negative emotion may be a threshold for flourishing.

2. Engagement (the engaged life): a. Relates to the pursuit of engagement, involvement, and absorption in work, intimate relations, and leisure. b. Stems from Csikszentmihalyi’s (1990) work on flow, a psychological state brought about by intense concentration. c. Flow typically results in temporal distortion (a lost sense of time). d. Seligman (2002) proposes a way to enhance engagement is to identify clients’ salient character strengths and then help clients find opportunities to use them more. e. In PPT, clients learn about undertaking intentional activities that use their signature strengths to create engagement.

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© 2014 Cengage Learning, Inc. 3. Meaning (the meaningful life): a. Meaning refers to using signature strengths to belong to and serve something bigger than oneself. b. Frankl (1963) emphasized happiness cannot be attained by desiring happiness; It must “ensue” as the unintended consequence of working for a goal greater than oneself. c. PPT asserts a lack of meaning is not just a symptom but a cause of psychological disorders. d. Theory of happiness recently revised and two new elements added 1. Positive relationships 2. Accomplishment The Full Life ► The full life entails happiness and life satisfaction. ► Is much more than the sum of its components — pleasure, engagement, and meaning. ► These components are neither exclusive nor exhaustive.

The PPT Psychotherapy Process ► ► ► ► ► ► ► ►

PPT helps clients explore their strengths.

Therapist first focuses on building a congenial relationship by mindfully listening.

The positive introduction is discussed in detail and often runs as a dynamic narrative throughout the course of therapy.

Therapists encourage clients to describe strengths.

Clients are then provided a handout that briefly describes the 24 core character strengths, without their labels.

Next, clients are asked to complete an online Values in Action–Inventory of Strengths (VIA-IS; Peterson & Seligman, 2004) to identify their signature strengths.

Top five strengths identified on the Values in Action–Inventory of Strengths are generally considered client’s strengths.

PPT follows an approach known as dynamic strength-assessment to be more comprehensive.

Dynamic Strength-Assessment ► Uses the values in action classification model. ► Clients identify (but don’t rank) five strengths best illustrating their personality. ► Identical collateral data is collected from a friend or family member. ► Clients then complete an online self-report measure of strengths. ► Clients are provided a worksheet to compute their strengths and create a composite score. ► Clients then share memories, experiences, real-life stories, anecdotes, accomplishments, and skills that illustrate development and use of these strengths. ► Strengths are discussed as: ▪ Tonic: Displayed in nearly all situations.

▪ Phasic: Displayed only in some situations or with certain groups. ► Clients also identify under- or overuse of strengths.

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© 2014 Cengage Learning, Inc. Overview of the 14-Session Model of PPT Session Topic and Homework 1

Orientation to PPT; positive introduction

2

Character strengths; dynamic strengths; assessment; blessing journal

3

Signature strengths; signature strength action plan

4

Good vs. bad memories; writing memories

5

Forgiveness; forgiveness letter

6

Gratitude; gratitude letter and visit

7

Mid-therapy; feedback session

8

Satisficing vs. maximizing; satisficing

9

Hope, optimism, and posttraumatic growth; one door closes, one door opens

10

Positive communication; active constructive

11

Signature strengths of others; family strengths tree

12

Savoring; planned savoring activity

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Altruism; gift of time

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The full life

Positive Themes in Other Therapy Models ► Most therapists can incorporate strengths in therapy without significantly changing their therapeutic framework. ► Clients can be helped to devise personalized strength-based pathways to solve life’s problems. ► These pathways often are hidden from clients because of symptomatic distress.

Examples of PPT Strategies ► Positive reappraisal to help clients unpack bitter memories and place them in perspective.

▪ Clients create psychological space between themselves and the negative memory.

▪ Clients devise an inventory of negative and positive aspects of the bitter memory.

▪ Clients recognize cues that activate the recall of a bitter memory, then engage in an adaptive and alternative activity.

▪ Encourage clients to consider option of forgiveness.

▪ PPT does not deny negative emotions or encourage rose-colored glasses.

▪ PPT aims to validate negative experiences.

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Simultaneously encouraging clients to explore their effects.

Seek out potential positives from their difficult and traumatic experience.

Example of a PPT Exercise ► Savoring teaches clients to slow down and enjoy experiences they would normally hurry through. ► To insure someone is eating while fully present and non-judgmentally aware, the focus is on teaching client awareness of taste and texture of food, thoughts experienced while eating, physical sensations in the body and tension in the body.

Mechanisms of Change in PPT ► Broadens and builds therapeutic resources. ► Increases behavioral, cognitive, and affective flexibility. ► Allows clients to develop their signature strengths. ► Teaches clients to deal with problems head on. ► Provides reeducation of attention.

Applications of PPT Who Might Not Benefit from PPT ► Some clients may feel that character has no place in therapeutic discourse because they may feel it will invoke judgment by the therapist and therefore may not be receptive to PPT. ► A client with deeply entrenched self-perception of being victim may not benefit from PPT initially. ► Identification of character strengths may exaggerate the inflated self-view of someone with narcissistic characteristics. ► Clients who have experienced trauma may not benefit from a PPT approach initially until other issues are addressed. ► Clients expecting a linear progression of improvement may find PPT challenging.

Who Could Benefit from PPT ► Pilot studies have reported promising findings, yet should be viewed cautiously until replicated on a large scale. ► More needs to be known about the efficacy of PPT with specific clinical condition, its generalizability, or the role of possible mediating variables ► PPT can help clients with a wide range of psychological disorders. ► Clients with depression appear to benefit most from PPT exercises. ► Clients with co-occurring disorders (e.g., depression and anxiety, depression and adjustment issues) can benefit from PPT exercises. ► Group PPT has also been shown to be effective with a range of psychological disorders, including depression, addiction, borderline personality disorder and schizophrenia. ► PPT exercises can also be adopted for other treatment modalities. ► PPT sequence can be altered as needed. ► Core PPT exercises have been used with nonclinical samples in life and executive coaching, education, and organizations.

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RCTs completed online using PPT exercises have shown promising results.

PPT offers tremendous potential for expanding the horizons of psychotherapy.

Evidence for PPT

►

► ►

► ► ► ►

Seligman, Steen, Park, & Peterson (2005) and Seligman, Rashid, & Parks (2006) ▪ Both studies demonstrated that PPT exercises, delivered singularly or as comprehensive treatment package, are effective in undoing symptoms of depression as well as in amplifying well-being.

Three studies have demonstrated the validity and reliability of the Positive Psychotherapy Inventory (PPTI).

Rashid & Uliaszek (2012) integrated PPT with DBT for BPD in 12-session group.

▪ Compared to treatment as usual, participants in the intervention group (skills and strengths) improved more on measures of well-being, emotional regulation, and overall symptom reduction.

PPT exercises shown effective with adolescents seeking treatment for drug addiction and behavioral challenges by Kingdom, Akhtar & Boniwell (2010).

RCT by Rashid & Anjum (2008) with 6th graders found PPT exercises were effective in increasing well-being and improving social skills as reported by teachers and parents.

Preference for one PPT exercise links to adherence to match exercises according to Schueller (2011).

The findings about the effectiveness of PPT are encouraging but more research is needed to evaluate PPT’s effectiveness with a variety of psychological disorders, including comparisons with traditional symptom-targeted treatments.

PPT in a Multicultural World

► ► ►

Happiness, in Western culture, has been synonymous with pursuit of pleasure (hedonism).

PPT’s approach, largely based on the notion of pursuit of good life (eudemonia), is more conducive to multicultural clients because it includes a broader notion of happiness.

PPT’s positive introduction; focus on stories, anecdotes, and resilience; and focus on meaning, relationship, engagement, and accomplishment appeals to the diverse.

▪ These can all be examined and discussed within a cultural context.

▪ Balancing negative with positive can make psychotherapy more empowering for diverse clients.

International Findings on PPT ► Strengths may manifest differently across cultures. ► Melanie Bay (2012), working in France, compared group PPT, CBT and medication.

▪ Clients in PPT experienced greater therapeutic benefits regarding depressive symptoms, optimism, life satisfaction and emotional intelligence. ► In Iran, Moeenizadeh & Salagame (2010) found clients in well-being therapy fared better than CBT.

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Chapter 13: Activities Therapy approaches tied to positive psychology lend themselves well to class activities as the strategies used are aimed at well-being. Additionally, therapies tied to positive psychotherapy use step-by-step instructions for assessing well-being, include ways to tailor interventions, and focus on outcome measurement.

Role-play Ask six students to participate in a role-play. Give each student a virtue to embody. Then provide the students with a scenario where they can act out that virtue by taking a topic that is highly debated (e.g., gun control, same-sex marriage, international politics). Have the remainder of the students guess which virtue the student is representing.

Case Illustration from Case Studies in Psychotherapies (7th Edition)

Strength-Based Assessment in Clinical Practice

by Tayyab Rashid and Robert F. Ostermann This case study demonstrates the importance of assessment in the facilitation of psychotherapy by demonstrating how the assessment of character strengths and virtues can be used to supplement more traditional measures of personality. Additionally, discussing the case may get students personally interested in learning more about their own profile of character strengths.

For students interested in understanding their signature strengths, the Values in Action Inventory of Strengths is online and there is no charge for taking the VIA-IS. The inventory has been translated into 17 languages and taken by more than 2 million people. The VIA-IS can be taken at viame.org.

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Chapter 13: Potential Test Items Multiple Choice Test Bank 1.

The primary difference between positive psychology approaches and other therapy approaches is that positive psychology focuses on: a. restructuring negative thoughts. b. evidence-based approaches to treatment. c. building character strengths. d. changing maladaptive behaviors.

REF: Overview (p. 462) ANS: C

2.

A state characterized by positive emotions, a strong sense of personal meaning, good work, and positive relationships is referred to as: a. judgment. b. understanding. c. insight. d. flourishing.

REF: Overview (p. 462) ANS: D

3.

Which of the following theorists felt that negatives were an indispensable element of human existence and assumed defenses were built to repress these conflicts and manage the unbearable anxiety they caused? a.

Albert Ellis b.

Sigmund Freud c.

Marty Seligman d.

Aaron Beck REF: Overview (p. 463) ANS: B

4.

In the treatment of many psychological disorders, including depression, evidence-based therapies and pharmacotherapy both hit a ceiling at about: a.

95 percent. b.

65 percent. c.

45 percent. d.

25 percent.

REF: Overview (p. 463-464) ANS: B

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Positive psychology emerged because: a. clients make substantial changes as a result of therapy. b. traditional psychotherapy has found a cure for many disorders. c. about 10% of clients terminate therapy prematurely. d. psychotherapy has become largely a science of victimology.

REF: Overview (p. 464) ANS: D

6.

Proponents of positive psychology have pointed out the limited attention the literature pays to positive human characteristics. For example, since 1887, Psychological Abstracts articles have a negative to positive ratio of: a.

2:1. b.

4:1. c.

8:1. d.

14:1.

REF: History (p. 466) ANS: D

7.

Since its inception, the Diagnostic Statistical Manual(s) created by the American Psychiatric Association has catalogued hundreds of psychiatric symptoms for disorders, but it only began including a single and coherent classification of strengths in: a.

1980. b.

1998. c.

2004. d.

2012.

REF: History (p. 466) ANS: C

8.

According to positive psychology, the formula for happiness is, H (enduring level of happiness): a. = S (personal set range) + C (circumstances) + V (factors under personal volitional control). b. = S (support system ) + S (personal set range) + C (circumstances). c. = C (circumstances) + V (factors under personal volitional control). d. = S (support system ) + S (personal set range) + C (circumstances) + V (factors under personal volitional control).

REF: Personality (p. 469) ANS: A

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Which of the following is NOT considered a virtue in positive psychology? a.

Wisdom b.

Transcendence c.

Attractiveness d.

Courage REF: Personality (p. 470-471) ANS: C

10.

Which of the following virtues describes an individual’s strengths that protect against excesses? a.

Transcendence b.

Wisdom c.

Temperance d.

Justice REF: Personality (p. 471) ANS: C

11.

Which of the following virtues describes an individual’s strengths that forge connections to the larger universe and provide meaning? a.

Transcendence b.

Wisdom c.

Temperance d.

Justice REF: Personality (p. 471) ANS: A

12.

Which of the following virtues describes an individual’s strengths that underlie healthy community life? a.

Transcendence b.

Wisdom c.

Temperance d.

Justice REF: Personality (p. 471) ANS: D

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Being aware of one’s blessings and taking time to express thanks (i.e., gratitude) is considered a character strength under which of the virtues? a.

Wisdom b.

Temperance c.

Transcendence d.

Courage REF: Personality (p. 471) ANS: C

14.

Fredrickson (2009) found that an individual must experience how many positive emotions for every single negative emotion to reach the threshold for flourishing? a.

1 b.

3 c.

5 d.

10 REF: Psychotherapy (p. 477) ANS: B

15.

Chris Peterson would argue that many psychological disorders could be understood as: a. unresolved unconscious conflicts. b. repetitive engagement in maladaptive behaviors. c. an absence or excess of character strengths. d. an individual’s unwillingness to develop strengths.

REF: Personality (p. 472) ANS: C

16.

When an individual uses their signature strengths to belong to and serve something bigger than oneself, Martin Seligman would say this is related to the: a. pleasant life. b. meaningful life. c. engaged life. d. community life.

REF: Psychotherapy (p. 478) ANS: B

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A full life is the: a. sum of pleasure, engagement, and meaning. b. more than the sum of pleasure, engagement, and meaning. c. acquisition of all 24 character strengths. d. continuous displaying of the six virtues.

REF: Psychotherapy (p. 479) ANS: B

18.

Csikszentmihalyi coined the term flow to refer to: a. the interrelationship of therapist-client working on character strengths. b. a psychological state brought about by intense concentration. c. one’s ability to savor an experience by focusing on the five senses. d. beliefs in a stream that naturally occur unconsciously.

REF: Psychotherapy (p. 477) ANS: B

19.

The Values in Action–Inventory of Strengths is administered online to clients in positive psychotherapy to identify: a. signature strengths. b. interpersonal support systems. c. actions reflecting strengths. d. character building experiences.

REF: Psychotherapy (p. 479) ANS: A

20.

A dynamic strength assessment uses the: a. antecedents-behavior-consequences analysis. b.

Ericksonian stages of development. c. moral development schematic. d. values in action classification model.

REF: Psychotherapy (p. 481-482) ANS: D

21.

In positive psychotherapy, a client is encouraged to complete an online self-report measure of character strengths. This is part of a: a. savoring exercise. b. dynamic strength-assessment. c. phasic character strength inventory. d. virtue reorganization attempt.

REF: Psychotherapy (p. 482) ANS: B

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22.

In positive psychotherapy, when a character strength is described as tonic it means the strength is displayed: a. in a limited number of circumstances. b. only with certain individuals. c. in almost all situations. d. under periods of significant distress.

REF: Psychotherapy (p. 482) ANS: C

23.

In the traditional format, positive psychotherapy is offered in which of the following number of sessions? a.

6 b.

8 c.

14 d.

20 REF: Psychotherapy (p. 480-481) ANS: C

24.

In helping a client deal with difficult childhood experiences, which of the following would NOT be a positive psychotherapy technique a therapist would employ? a. encouraging the client to consider forgiveness. b. using free association tasks and hypnosis. c. devising an inventory of negative and positive aspects of memories. d. engaging in an adaptive and alternative activity.

REF: Psychotherapy (p. 483-484) ANS: B

25.

In treating patients with narcissistic personality disorder with positive psychotherapy, therapists must be mindful of the fact that: a. the client may try to usurp the therapist’s authority and shift the focus. b. issues related to low self-esteem will be the client’s preferred focus. c. focusing on virtues may make the client more anxious. d. identification of character strengths may exaggerate the client’s inflated self-view.

REF: Psychotherapy (p. 487) ANS: D

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Which of the following types of clients might NOT find positive psychotherapy effective? a.

Those expecting a linear progression in symptom reduction b.

Individuals with adjustment disorders with depressed mood c.

Clients presenting with borderline personality disorder d.

Clients who are children or adolescents REF: Applications (p. 487) ANS: A

27.

Studies evaluating positive psychotherapy have found that the positive psychotherapy exercises: a. can be altered in sequence as needed. b. cannot be adopted for other treatment modalities. c. should be delivered in the sequence recommended. d. are not able to be adapted effectively to on-line activities.

REF: Applications (p. 487-489) ANS: A

28.

To date, positive psychotherapy tends to show the most benefit for clients presenting with: a. anxiety disorders. b. psychotic disorders. c. depressive disorders. d. personality disorders.

REF: Applications (p. 488) ANS: C

29.

In a study integrating positive psychotherapy with dialectical behavioral therapy (Rashid & Uliaszek, 2012) to treat borderline personality disorder, the intervention group: a. showed comparable improvement to treatment as usual. b. lead to a reduction in adherence to the DBT techniques. c. showed more improvement than treatment as usual. d. resulted in no changes, suggesting both approaches should be used separately.

REF: Applications (p. 489) ANS: C

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Attempts to apply positive psychotherapy with children and adolescents have found: a. the concepts are too challenging for individuals under the age of 25. b. treatment increases well-being and decreases behavioral problems. c. positive psychotherapy is effective but less so than family therapy. d. the exercises are only helpful if delivered directly by the parent(s).

REF: Applications (p. 489) ANS: B

31.

In a 2011 study by Schueller, preference for one positive psychotherapy exercise linked with: a. less interest in other match exercises . b. more interest in medications. c. worsened treatment outcomes. d. adherence for the match exercise.

REF: Applications (p. 490) ANS: D

32.

Positive psychotherapy would assert it has vast appeal across cultural groups because, in contrast to Western culture’s definition of happiness, positive psychotherapy equates happiness with: a. pursuit of pleasure. b. pursuit of a good life. c. a narrower view of life. d. thrill-seeking.

REF: Applications (p. 490) ANS: B

33.

When positive psychotherapy is conducted internationally, therapists must be mindful of the fact that character strengths: a. are universal concepts that manifest similarly across cultures . b. become less relevant in certain cultures. c. may manifest differently across cultural groups. d. are Western concepts and rejected by Eastern therapists.

REF: Applications (p. 490) ANS: C

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Melanie Bay conducted a study in 2012 evaluating the impact of group positive psychotherapy, cognitive behavioral therapy and medication on depressive symptoms in French patients. Bay found that: a.

French clients responded more to positive psychotherapy than American clients. b.

French clients responded less to positive psychotherapy than American clients. c. clients fared equally with positive psychotherapy and cognitive behavioral therapy. d. clients receiving positive psychotherapy experienced greater therapeutic benefits.

REF: Applications (p. 490) ANS: D

35.

In a 2010 study, Moeenizadeh and Salagame found Iranian clients in well-being therapy (i.e., a treatment similar to positive psychotherapy) fared: a. better than those receiving CBT. b. worse than those receiving CBT. c. better than those receiving medications. d. worse than those receiving medications.

REF: Applications (p. 490) ANS: A Fill in the Blanks

1.

In contrast to traditional psychotherapy, which has focused on client’s troubles, positive psychology focuses on a client’s six _____________.

ANS: Virtues

2.

________________ is a state characterized by positive emotions, a strong sense of personal meaning, good work, and positive relationships.

ANS: Flourishing

3.

Martin Seligman states that the treatment of psychological disorders has hit a _____% barrier, with placebo accounting for _____ to ____% of this response rate.

ANS: 65; 45 to 55

4.

Michael Frisch’s _____________________integrates cognitive therapy with Positive Psychology ideas and has been shown to be effective with depressed clients.

ANS: Quality of life therapy (QOLT)

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Positive psychotherapists believe happiness is one of those personality traits that can be _____________.

ANS: Changed

6.

Research suggests that roughly ____ to ____% of happiness is accounted for by genetics.

ANS: 40 to 50

7.

_________ is the psychological state brought about by intense concentration.

ANS: Flow

8.

Strengths are discussed as ______ (kindness is displayed in nearly all situations) or __________ (kindness is displayed variably across situations).

ANS: Tonic; phasic

9.

Clients with symptoms of ___________ appear to benefit most from PPT exercises.

ANS: Depression

10.

Schueller (2011) found that individual’s preference for one positive psychology exercise was linked to increased adherence for the ________________.

ANS: Match exercise Essay Questions

1.

Chris Peterson argues that if psychology as usual uses a lens of abnormality to view normality, “then why not use the lens of normality or even super normality to view abnormality?” Explain what this means. How is it applicable to mental disorders? Choose three disorders and describe them according to Chris Peterson’s model.

2.

Positive psychotherapy is based on three primary assumptions. What are they? How do they guide the therapy process?

3.

Positive psychotherapy is largely based on Seligman’s (2002) conceptualization of happiness and well-being. Describe Seligman’s model of happiness.

4.

Describe the 14-session positive psychotherapy approach. What techniques are utilized?

How is progress assessed?

5.

What are the six virtues described in positive psychology? What evidence supports the classification scheme used? Provide a character strength example of each virtue.

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Chapter 14 Integrative Psychotherapies Authors: John C. Norcross and Larry E. Beutler Key Points and Terms

Overview What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?

— Gordon Paul (1967) ► ►

►

There is a decline in ideological struggles and an increased acknowledgment of the inadequacies of any one theoretical system and the potential value of others.

Escalating popularity of integrative psychotherapies (other terms for the same concept include eclecticism, integration, rapprochement, differential therapeutics, prescriptive matching).

All about tailoring therapy to the unique needs of the client.

Four integrative pathways (not mutually exclusive) ► Technical eclecticism: ▪ Guided primarily by research and experience.

▪ Focuses on predicting for whom interventions will work.

▪ Foundation is actuarial.

▪ Uses procedures drawn from different therapeutic systems without subscribing to the theories. ► Theoretical integration: ▪ Two or more therapies are integrated to create the best result.

▪ A conceptual framework is created that synthesizes the best elements of two or more therapies.

▪ Seeks an emergent theory that is more than the sum of its parts. ► Common factors ▪ Focuses on core ingredients different therapies share in common.

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►

►

Goal of creating more parsimonious and efficacious treatments.

Therapeutic alliance, catharsis, acquisition and practice of new behaviors and client’s positive expectancies are most frequently proposed.

Assimilative integration ▪ Firm grounding in one system of psychotherapy.

▪ Willingness to selectively incorporate (assimilate) practices and views from other systems.

All of the above are different from syncretism.

▪ Uncritical and unsystematic combinations that are an arbitrary blend of methods without a rationale or empirical verification.

Norcross and Beutler ► Systematic eclectic or systematic treatment selection — intentionally blend several of the four paths toward integration. ► Drawing on effective methods across theoretical schools (eclecticism) by matching those methods to particular cases on the basis of empirically-supported principles (treatment selection) and by adhering to an explicit and orderly (systematic) model. ► Committed to defining broader changing principles. ► Theory is uniformly valid and no mechanism of therapeutic action is applicable to all individuals. ► Treatment selection is derived directly from outcome research. ► Embraces the potential contributions of multiple systems of psychotherapy. ► Treatment selection is predicated on multiple diagnostic and non-diagnostic client dimensions. ► Offers treatment methods and relationship stances.

Comparing Integrative Approaches to Pure-Form Therapies ► Pure-form therapies are part and parcel of integrative approaches as integration could not occur without the constituent elements provided by single-school therapies ► Single school therapies manifest several weaknesses: ▪ More rational than empirical.

▪ Tend to favor the strong personal opinions, if not pathological conflicts, of their originators.

▪ Recommend their treatment to virtually every patient and problem encountered.

▪ Largely consist of descriptions of psychopathology and personality rather than of mechanisms that promote change.

History of Integrative Psychotherapy ► ► ► ► ► ►

Integration has existed as long as philosophy and psychotherapy have existed.

In the 1930s, formal ideas on synthesizing psychotherapies began.

Frederick Thorne: Modern era “grandfather of eclecticism in psychotherapy.”

Arnold Lazarus is the most prominent and articulate advocate for eclecticism.

Goldstein & Stein (1976) in Prescriptive Psychotherapy outlined treatments for different people based on their problems and living situations.

Efforts advancing common factors are congruent with integrative psychotherapies.

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►

► ►

In Persuasion and Healing, Jerome Frank (1973) argued change is from a(n): ▪ Emotionally charged, confiding relationship ▪ Healing setting ▪ Rationale or conceptual scheme ▪ Therapeutic ritual In 1980, Sol Garfield introduced eclectic psychotherapy predicated on common factors and Marvin Goldfried published an influential article calling for the delineation of therapeutic change principles.

1970s-1980s: Several attempts at theoretical integration were introduced.

James Prochaska and Carlo DiClemente created a transtheoretical (across theories) approach delineating stages of change that is the most extensively researched integrative therapy.

Current Status ► ¼ to ½ of clinicians disavow an affiliation with a particular school of therapy, preferring term eclectic or integrative. ► In the past decade, eclecticism was the most common orientation in the U.S., but cognitive therapy is rapidly challenging eclecticism as the modal theory. ► Integration receives less endorsement outside of the U.S. and Western Europe. ► Two interdisciplinary societies: ▪ Society for the Exploration of Psychotherapy Integration (SEPI) ▪ Society of Psychotherapy Research (SPR) ► Training programs are challenged to create coordinated training curriculums.

▪ 80-90% of training directors (both graduate and internship) state training in a variety of models is needed.

• A third believe students should be trained in one therapeutic system proficiently first.

• Half believe students should be trained to be at least minimally competent in a variety of systems.

• Remainder believe training should be in a specific integrative system from the outset.

Integrative Psychotherapy View of Personality ► ► ► ► ► ►

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Central focus is on the process of change.

Integrative conceptualization makes no overt specific assumptions about how personality and psychopathology occur.

Integrative theories of personality are predictably broad and inclusive.

Implicitly embodied in the life-span approaches of developmental psychology.

Asserts that one does not need to know how a problem developed to resolve it, just needs to know what to do.

Acknowledges that understanding personality characteristics does help clinicians improve treatment efficacy.

▪ For example, patient’s coping style — what one does when confronted with new experiences or stress.

Integrative Psychotherapies

© 2014 Cengage Learning, Inc. Integrative Psychotherapy ► ►

Strongly values continuous, clinical assessment.

Relatively traditional approach with one exception: ▪ Collection from the onset of information on multiple patient dimensions that will guide treatment selection.

▪ One mechanism for doing this is through computerized approaches that make highly individualized predictions about the effects of different therapists and therapies.

Five Patient Characteristics Used in Integrative Psychotherapy ► ►

►

►

►

Diagnosis Coping Style ▪ Externalizing: Impulsive, stimulation-seeking, extroverted • Symptom-focused and skill-building techniques are more effective.

▪ Internalizing: Self-critical, inhibited, introverted • Insight and awareness-enhancing therapies are more effective.

Resistance Level ▪ Resistance: Being easily provoked by external demands • High: Respond to non-directive, self-directed, or paradoxical techniques.

• Low: Respond to directive and structural techniques.

Patient Preferences ▪ Being responsive to patient preferences is one of the most potent means to enhance the therapeutic alliance.

Stages of Change

Psychoanalytical and Insight-Oriented Therapies Most Useful

Undeveloped parts No intention to change Unaware or under aware of a problem Therapist’s best stance to be nuturing

Elements from collective Aware that a problem exists unconscious Thinking about thinking about changing Therapist’s role is Socratic teacher

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Combines intent and behavioral criteria Intend to make significant changes in near future Existential, Cognitive and Interpersonal Therapies Continue to be Useful, but Behavioral Therapies Most Useful Precontemplation Modifies behavior, experiences and environment Therapist’s role is an experienced coach Contemplation Preventing relapse Consolidating gains Therapist is a consultant A Comprehensive Treatment Plan Involves ► Therapeutic relationship ► Treatment setting (where) ► Treatment format (who participates) ► Treatment intensity (duration, length, frequency) ► Pharmacotherapy is integrated easily into integrative approaches. ► Strategies and techniques — focus on change principles, not specific techniques. ► Relapse prevention (remember relapse is the rule rather than the exception) ► Change processes include: ▪ Consciousness raising ▪ Self-reevaluation ▪ Emotional arousal ▪ Social liberation ▪ Self-liberation ▪ Counterconditioning ▪ Environmental control ▪ Contingency management ▪ Helping relationships Applications of Integrative Psychotherapy ► ►

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Because of its flexibility, integrative approaches are applicable to practically all clinical disorders and treatment goals.

Particularly indicated for: ▪ Complex patients and presentations

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Disorders that haven’t responded favorably to conventional, pure-form psychotherapies Disorders that have scant controlled treatment outcome research When pure-form therapies have failed

Evidence ► Complete body of research on psychotherapy informs treatment decisions and key principles of integrative psychotherapy. ► Outcome research on integrative therapies has found strongest support for: ▪ Acceptance and commitment therapy ▪ Cognitive analytic therapy ▪ Dialectical behavior therapy ▪ Emotionally-focused couple therapy ▪ Eye movement desensitization and reprocessing ▪ Mindfulness-based cognitive therapy ▪ Systematic treatment selection ▪ Transtheoretical psychotherapy ▪ Dozen more self-identified integrative therapies have some empirical support ► Guiding principles on which a clinician of any theoretical orientation can map a therapeutic approach also support integration. ► Programmatic research on stages of change: ▪ Amount of client progress is a function of their pretreatment stage of change.

▪ Particular processes are more effective during particular stages of change.

▪ Meta-analysis of 47 cross-sectional studies (d = .70 and .80).

▪ Research on transtheoretical model indicates that tailoring treatments to the client’s stage of change significantly improves outcomes across disorders. ► Research on coping styles ▪ 80% of 20+ studies demonstrated differential effects of the type of treatment as a function of patient coping style. ► Research confirms high patient resistance consistently associated with poorer treatment outcomes.

▪ Matching therapist degree of direction to client level of resistance improves therapy efficiency and outcome. ► Empirical evidence supports benefits of beginning with the relational preferences and treatment goals of the client. ► Patient expectancy- a powerful factor.

▪ 32 studies found a positive relationship.

▪ 19 studies found mixed results.

▪ Only 15 studies found no relationship ► Diagnosis is the one patient characteristic with the least amount of evidence of differential treatment effects. ► Integrative psychotherapies are committed to the synthesis of practically all effective, ethical change methods.

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© 2014 Cengage Learning, Inc. Psychotherapy in a Multicultural World ► ► ► ►

Integrative therapies do not rely on a particular founder or theory of personality.

Sole principle is that people and cultures differ and should be treated as such.

Virtually every feminist, multicultural, and cultural-responsive theory describes itself as eclectic or integrative.

Integrative psychotherapies have been applied cross-culturally and internationally with equal success.

Empirical Evidence ► Meta-analysis of 76 studies (Griner & Smith, 2006) showed: ▪ Adapting therapy to the client’s culture exerts a medium, positive effect (d =.45).

▪ Therapy targeted to a specific cultural group is more effective than that provided to clients from a variety of cultural backgrounds.

▪ Therapy conducted in clients’ native language (if other than English) is twice as effective than when it is conducted in English. ► Paniagua, 2005 ▪ Use of translators in sessions is associated with weak alliances, more misdiagnoses (usually more severe than necessary), and higher dropout rates.

Effective Practices ► Acquaint beginning clients with the respective roles of patient and therapist (i.e., pretherapy orientation) for historically marginalized populations. ► Augment an individualistic position with a collectivistic orientation to clinical work.

Chapter 14: Activities Role-play Ask five students to participate in a role-play by each taking the part of one of the five stages of change. Have the students choose a presenting problem they would like to discuss.

Then ask each student to describe some of the things they might say or do during the stage of change they are representing and ask the other students in the class to guess which stage of change the student is discussing.

Discussion Questions 1.

Advocates of learning a single form of therapy in depth and conceptualizing and treating patients from one model have accused integrative approaches of creating therapists who are jacks of all trades and masters of none. Ask students to discuss the pros and cons of in-depth training of one form of therapy versus a breadth-based training of multiple forms of therapy.

2.

The authors of the chapter on integrative psychotherapy state that one criticism of pure forms of therapy is that they tend to favor the strong personal opinions, if not pathological conflicts, of their originator(s). Ask students if they agree with this

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© 2014 Cengage Learning, Inc. statement. If so, ask the students to discuss the pros and cons of a theory reflecting the opinions and/or psychological issues of its originator(s).

3.

Over half of all therapists in the U.S. indicate that they provide services from a framework of technical eclecticism. Ask students to discuss their opinions about this escalating popularity of integrative psychotherapies.

Use of Movies to Depict Concepts

Movies rarely show psychotherapy offered in a pure form. Integrative psychotherapy draws from all other therapies, combining them in a conceptualized and systematic way. While there are no movies that specifically illustrate the approach, almost all depictions of a sustained therapy approach in movies ultimately are integrative.

Case Illustration from Case Studies in Psychotherapies (Seventh Edition)

Integrative Psychotherapy with Mr. F. H.

by Larry Beutler This case illustrates a therapist doing what works with a client (i.e., using an integrative approach). Throughout the case, students will see an illustration of how systematic treatment Integrative Psychotherapies

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© 2014 Cengage Learning, Inc. selection (STS) occurs. The client being treated is addicted to heroin and cocaine and is experiencing significant marital and financial problems. The therapist uses behavioral approaches and incorporates psychological testing to guide treatment. Homework assignments are given to the client and the patient is also benefitting from medication. The case also shows the integration of diagnosis with assessment of stages of change, coping style, resistance level, and the patient’s personal preferences.

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Chapter 14: Potential Test Items Multiple Choice Test Bank 1.

Integrative psychotherapy is based on: a. eclecticism. b. ideological superiority. c. syncretism. d. pharmacotherapy.

REF: Overview (p. 499) ANS: A

2.

A client-centered therapist is most likely to use an integrative approach based on: a. technical eclecticism. b. theoretical integration. c. common factors. d. assimilative integration.

REF: Overview (p. 500-501) ANS: C

3.

A clinician integrates two or more therapies into a conceptual framework that synthesizes the best elements of the therapies. This approach is consistent with: a. technical eclecticism. b. theoretical integration. c. common factors. d. assimilative integration.

REF: Overview (p. 500) ANS: B

4.

Based on research and clinical experience a therapist chooses a collection of techniques from several theoretical models. This approach shows adherence to: a. technical eclecticism. b. theoretical integration. c. common factors. d. assimilative integration.

REF: Overview (p. 500) ANS: A

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Generally, a clinician conceptualizes cases from a cognitive theoretical framework and uses cognitive and behavioral techniques. However, in a therapy session, an empty chair technique was used. This decision is consistent with: a. technical eclecticism. b. theoretical integration. c. common factors. d. assimilative integration.

REF: Overview (p. 501) ANS: D

6.

A therapist using an arbitrary blend of methods without a rationale or empirical verification of those methods is engaging in: a. deception. b. technical eclecticism. c. syncretism. d. assimilative integration.

REF: Overview (p. 501) ANS: C

7.

Intentionally blending concepts of technical eclecticism, theoretical integration, common factors and assimilative integration yields an approach known as: a. syncretism. b. systematic eclectic. c. biased treatment selection. d. new wave.

REF: Overview (p. 501) ANS: B

8.

One criticism an integrative therapist might make of someone who adhered solely to one theoretical model is that: a. their theory is more empirical driven than based on rationality. b. the theory tends to be overly influenced by the theory’s originator. c. they recommend different approaches for every problem encountered. d. focus is too much on mechanisms that promote change.

REF: Overview (p. 500-502) ANS: B

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The grandfather of eclecticism in psychotherapy in the modern era is: a.

Frederick Thorne. b.

Carl Rogers. c.

John Norcross. d.

Arnold Lazarus.

REF: History (p. 504) ANS: A

10.

In Persuasion and Healing, Jerome Frank (1973) argued which of the following factors was important to the process of change? a.

An authoritative therapist b.

A distressed patient willing to accept advice c.

Therapeutic debating with the patient d.

A therapeutic ritual REF: History (p. 504) ANS: D

11.

James Prochaska and Carlo DiClemente created an approach delineating stages of change that is: a. transtheoretical in nature. b. most applicable to lifestyle changes. c. most applicable to mental disorders. d. biased towards the use of behavioral approaches.

REF: History (p. 505) ANS: A

12.

The most extensively researched integrative therapy is: a. technical eclecticism. b. new wave. c. stages of change. d. systematic eclectic.

REF: History (p. 505) ANS: C

13.

The concept of integration psychotherapy has received the most endorsement in the: a.

U.S. and Western Europe. b.

Middle East. c.

Third World countries. d.

Asian region.

REF: History (p. 505-506) ANS: A

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More training directors (of both graduate and internship training programs) believe trainees are best served by a model that: a. provides proficiency in one therapeutic system. b. creates trainees that are minimally competent in a variety of systems. c. starts as integrative from the onset and remains so. d. is all inclusive regardless of whether an approach has empirical validation.

REF: History (p. 506) ANS: B

15.

The personality theory that best fits with integrative psychotherapy is: a. psychoanalytic. b. cognitive. c. broad and inclusive. d. client-centered.

REF: Personality (p. 508) ANS: C

16.

Integrative psychotherapy uses psychological assessment in a traditional manner with the exception that: a. projective techniques are never used due to their lack of empirical validation in the literature. b. therapists collect information on multiple patient dimensions that guide treatment selection. c. psychological assessment measures are used at intake and not at other points of therapy. d. assessment techniques are only utilized if the patient preferences include it as part of treatment.

REF: Psychotherapy (p. 509-511) ANS: B

17.

An individual with an externalizing coping style is: a. impulsive, stimulation seeking, extroverted. b. self-critical, inhibited, introverted. c. less likely to have psychopathology. d. more pathological than one with an internalizing style.

REF: Psychotherapy (p. 512) ANS: A

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Insight and awareness-enhancing therapies are more effective for individuals who have a coping style that is: a. passive. b. internalizing. c. externalizing. d. aggressive.

REF: Psychotherapy (p. 512) ANS: B

19.

Symptom-focused and skill-building techniques are more effective for individuals who have a coping style that is: a. passive. b. internalizing. c. externalizing. d. aggressive.

REF: Psychotherapy (p. 512) ANS: C

20.

Individuals with a high level of resistance tend to respond best to techniques that are: a. non-directive, self-directed, or paradoxical. b. focused on advice and suggestion. c. delivered in an authoritarian manner. d. directive and structural.

REF: Psychotherapy (p. 512) ANS: A

21.

Directive and structural techniques are most likely to be effective with individuals who have: a. internalizing coping styles. b. aggressive coping styles. c. high levels of resistance. d. low levels of resistance.

REF: Psychotherapy (p. 512) ANS: D

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Psychoanalytical and insight-oriented therapies tend to be most useful with clients who are in which of the following stages of change? a.

Precontemplation b.

Preparation c.

Action d.

Maintenance REF: Psychotherapy (p. 510-511) ANS: A

23.

Behavioral therapies tend to be most useful with clients who are in which of the following stages of change? a.

Precontemplation b.

Contemplation c.

Preparation d.

Action REF: Psychotherapy (p. 510-511) ANS: D

24.

An individual who is in the contemplation stage of change is: a. unaware that they have a problem. b. aware of a problem and considering change. c. intending to make changes in the near future. d. working on modifying their behavior.

REF: Psychotherapy (p. 510) ANS: B

25.

An individual who is in the preparation stage of change is: a. unaware that they have a problem. b. aware of a problem and considering change. c. intending to make changes in the near future. d. working on modifying their behavior.

REF: Psychotherapy (p. 511) ANS: C

26.

An individual who is in the action stage of change is: a. unaware that they have a problem b. aware of a problem and considering change c. intending to make changes in the near future d. working on modifying their behavior REF: Psychotherapy (p. 511-514) ANS: D

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27.

An individual who is in the contemplation stage of change responds best to a therapist who is serving the role of a: a. nurturer. b.

Socratic teacher. c. experienced coach. d. consultant.

REF: Psychotherapy (p. 512) ANS: B

28.

A client is recording the number of cigarettes smoked daily and the therapist is teaching the client relaxation and distraction skills to use in the future instead of smoking. The client is likely in which of the following stages of change? a.

Precontemplation b.

Preparation c.

Action d.

Maintenance REF: Psychotherapy (p. 511) ANS: B

29.

Insight-oriented techniques tend to be least useful during the stage of change known as: a. precontemplation. b. preparation. c. action. d. maintenance.

REF: Psychotherapy (p. 511) ANS: C

30.

An individual with alcohol dependence gets a DUI and is forced to attend counseling, although they don’t intend to stop drinking. The therapist will likely accomplish more by using an approach that is: a. insight-oriented. b. existential. c. behavioral. d. interpersonal.

REF: Psychotherapy (p. 511) ANS: A

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Outcome research on integrative therapies has found strongest support for: a. acceptance and commitment therapy. b. psychoanalytical therapy. c. cognitive behavioral therapy. d. multimodal therapy.

REF: Applications (p. 519) ANS: A

32.

The aspect of integrative therapy making it most applicable to many disorders is: a. reliance on behavioral techniques. b. emphasis on insight. c. flexibility/inclusion. d. integration of family.

REF: Summary (p. 528) ANS: C

33.

An example of a disorder that might respond best to integrated treatment is: a. schizophrenia. b. panic disorder. c. tobacco dependence. d. adjustment disorder.

REF: Applications (p. 518) ANS: A

34.

Programmatic research on stages of change has found that: a. pretreatment stage of change is not related to amount of client progress. b. therapy should be postponed for clients in precontemplation. c. stage of change is correlated with short-term but not long-term progress. d. tailoring treatments to stage of change significantly improves outcomes.

REF: Applications (p. 520) ANS: D

35.

The one patient characteristic with the least amount of evidence of differential treatment effects is: a. coping style. b. diagnosis. c. patient preferences. d. resistance level.

REF: Applications (p. 521) ANS: B

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© 2014 Cengage Learning, Inc. Fill in the Blanks 1.

Technical eclecticism focuses on predicting for whom interventions will work by using a foundation that is ___________.

ANS: Actuarial

2.

Gordon Paul’s famous questions ask: “______ treatment, by ________, is most effective for _______ individual with _________ specific problem, and under ________ set of circumstances?”

ANS: What; whom; this; that; which

3.

________________ is used by clinicians who have a firm grounding in one system of psychotherapy but a willingness to selectively incorporate practices and views from other systems.

ANS: Assimilative integration

4.

A patient’s ________ is defined by what one does when confronted with new experiences or sources of stress.

ANS: Coping style

5.

Through advocacy for integration and his development of multimodal therapy, ________________ is the most prominent and articulate advocate for eclecticism.

ANS: Arnold Lazarus

6.

Integrative psychotherapists underscore the importance of relapse prevention because the research suggests relapse is _________________________.

ANS: The rule rather than the exception

7.

Over the past decade, __________was the most common orientation in the U.S. but __________ is rapidly challenging eclecticism as the modal theory.

ANS: Eclecticism; cognitive therapy

8.

Matching therapist ____________ to client level of resistance improves therapy efficiency and outcome.

ANS: Degree of direction

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____________ is a change process focusing on policy interventions.

ANS: Social liberation

10.

If a patient puts money in a jar every time she exercises, she is using ________________________.

ANS: Contingency management Essay Questions

1.

There are four main pathways to developing an integrative approach that are not mutually exclusive. Describe each pathway. How are the pathways different? Provide examples of each pathway and how one or more of the pathways could be integrated.

2.

Some purists have accused therapists using eclectic approaches as simply guessing about what works for whom and randomly choosing techniques to treat a patient. Explain how an integrative psychotherapist would respond to this accusation.

3.

What is systematic eclectic or systematic treatment selection? What type of patient might benefit most from this approach?

4.

A patient is advised by his doctor to quit smoking; his family also wants him to quit. The patient is not sure he is ready. Hypothesize about the stage of change this patient is starting from and describe how he would likely progress through the stages of change if he were to successfully quit smoking. What types of interventions would his therapist use at each stage of change to assist him?

5.

What are five patient characteristics assessed in integrative psychotherapy that predict treatment outcome? Describe a patient with the highest probability of a successful treatment outcome.

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Chapter 15 Multicultural Psychotherapies Author: Lillian Comas-Diaz Key Points and Terms

Overview ► ► ► ► ► ►

►

Culture is defined as an individual’s total environment.

Worldview refers to people’s systemized ideas and beliefs about the universe.

Multicultural refers to the interaction between people across a culture.

Racial micro aggressions refer to assaults individuals receive on a regular basis solely because of their race, color, and or ethnicity.

Cultural trauma refers to a legacy of adversity, pain, and suffering among many minority group members.

Harry Triandis (1995) classified worldviews according to how individuals define themselves and relate to others across an individualist-collective spectrum.

▪ Collectivistic: Identity is associated with relationships to others.

▪ Denominated: View themselves independently from others.

Research has identified a human tendency to categorize individuals into in-group and outgroup members, leading to unconscious negative racial feelings and beliefs.

Dominant Models of Psychotherapy ► Believed to support mainstream cultural values ► Neglect multicultural worldviews ► Promote ethnocentrism (the belief that one’s worldview is inherently superior and desirable to others) Multicultural Psychotherapies ► Promote cultural sensitivity (i.e., awareness, respect, and appreciation for cultural diversity). ► Believe definitions of health, illness, healing, normality, and abnormality are culturally embedded.

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►

Consider power differentials based on: ▪ Race ▪ Gender ▪ Social class ▪ Sexual orientation ▪ Age ▪ Religion ▪ National origin ▪ Ability/disability ▪ Language ▪ Place of residence ▪ Ideology ▪ Membership in other marginalized groups Promote empowerment and social justice and affirm strengths.

Multicultural Psychotherapists ► Work towards cultural competence (i.e., the set of knowledge, behaviors, attitudes, skills, and policies needed to work effectively in multicultural situations). ► To become culturally competent, an individual: ▪ Becomes aware of their worldview ▪ Examines their attitude towards cultural differences ▪ Learns about different worldviews ▪ Develops multicultural skills ▪ Learns about one’s position in relation to societal power and privilege ► Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Clients exhorted practitioners to: ▪ Recognize cultural diversity.

▪ Understand central role culture, ethnicity, and race play in culturally diverse individuals.

▪ Appreciate the significant impact of socioeconomic and political factors on mental health.

▪ Help clients understand their cultural identification. ► Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change (Commitment to Cultural Awareness and Knowledge of Self and Others, Education, Research, Practice, Organizational Change and Policy Development) emphasize the importance of recognizing that: ▪ We are cultural beings.

▪ Value cultural sensitivity and awareness.

▪ Use multicultural constructs in education.

▪ Conduct culture-centered and ethical psychological research with culturallydiverse individuals.

▪ Use culturally appropriate skills.

▪ Implement organizational change process ► Developing cultural competence is a lifelong process.

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Cross and colleagues (1989) identified a cultural spectrum:

Destructiveness

► ► ► ► ►

Incapability

Blindness

Pre-competence

Competence

Destructiveness: Attitudes, policies, and practices are destructive to cultures and individuals.

Incapacity: Racial superiority of the dominant group.

Cultural blindness: Belief that culture makes no difference.

Cultural pre-competence: Do not know exactly how to proceed.

Cultural competence: Possessing a set of knowledge, behaviors, attitudes, skills, and policies needed to work effectively in multicultural situations.

Cultural Competence Guidelines for Organizations ► Therapists should: ▪ Evaluate that institution’s mission statement includes diversity.

▪ Assess policies with regards to diversity.

▪ Evaluate how people of color perceive specific policies.

▪ Acknowledge within group diversity.

▪ Be aware that diversity requires examination.

▪ Recognize that multicultural sensitivity may mean advocating. ► Multicultural psychotherapists who emphasize empowerment subscribe to the following assumptions: ▪ Reality is constructed into a context.

▪ Experience is valuable knowledge.

▪ Learning/healing results from sharing multiple perspectives.

▪ Learning/healing is anchored in meaningful and relevant contexts.

Other Systems ►

► ► ► ► ►

Research has found that, although evidence-based practices appear effective for a number of culturally diverse populations, in contrast to European Americans, African Americans: ▪ Tend to drop out of cognitive behavior therapy (CBT) at a higher rate.

▪ Found treatment less positive after receiving services, even when they expressed positive expectations initially.

Culture affects psychotherapeutic process more than it affects treatment outcome.

Personal and collective history is an important element in people of color’s lives.

Transcultural psychiatry and psychology advocated for the use of community and indigenous resources.

Minority empowerment movements furthered the development of multicultural psychotherapies.

Paulo Freire (1973) identified dominant models of education as instruments of oppression.

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Conscientization: Critical consciousness as a process of person and social liberation.

• Involves questions of what, why, how, for whom, against whom, by whom, in favor of whom, in favor of what, and to what end.

• Helps oppressed individuals to author their own reality

Types of Therapy/Counseling ► Re-evaluation counseling (RC) is an empowering co-counseling approach where two or more individuals take turns listening to each other without interruption.

▪ “Counselor” encourages the “client” to discharge emotions (catharsis).

▪ Next, “client” becomes the “counselor” and listens to the client. ► Feminist therapists embrace diversity as a foundation for practice.

▪ Attempts to empower all people and promote equality at individual, interpersonal, institutional, national, and international levels.

▪ Women of color feminist therapists address the interactions between racism, sexism, classism, heterosexism, ethnocentrism, ableism, and other forms of oppression. ► Ethnic family therapists (e.g., Boyd Franklin’s (2003) Black Families in Therapy) attempt to: ▪ Know their own culture ▪ Avoid ethnocentric attitudes and behaviors ▪ Achieve an insider status ▪ Use intermediaries ▪ Have selective disclosure ▪ Often use cultural genograms ► Several professional and academic organizations have supported the development of multicultural psychotherapies.

▪ Publications on the topic include Cultural Diversity and Ethnic Minority Psychology, Journal of Multicultural Counseling and Development, Psychology of Women Quarterly, and Women and Therapy.

Current Status ►

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Multicultural psychotherapists practice following three models or a combination thereof: ▪ Cultural adaptation of dominant psychotherapy ▪ Ethnic psychotherapies • Integrates cultural variables in treatment through the examination of worldviews, cultural transitions, relationships and context.

• Based on a philosophical spiritual foundation that promotes connective, ancestral and sacred affiliations in healing.

• Some include approaches based on Eastern philosophical traditions.

• Frequently use narratives as a collectivistic way of relating. ► Testimonio chronicles traumatic experiences in Latin America. ► Cuento therapy, has been empirically proven to be an effective treatment for Puerto Rican children.

Multicultural Psychotherapies

© 2014 Cengage Learning, Inc. Dichos (sayings) are a form of flash psychotherapy that consist of Spanish proverbs or idiomatic expressions capturing folk wisdom.

▪ Holistic approaches • Folk healing is form of indigenous psychotherapy.

• Fosters empowerment, encourages liberation, and promotes spiritual development.

Bernal, Bonilla and Bellido recommend inclusion of eight cultural dimensions.

▪ Language (fits clients worldview) ▪ Persons (therapeutic relationship) ▪ Metaphors (shared concepts of a cultural group) ▪ Content (therapist’s cultural knowledge) ▪ Concepts (treatment concepts culturally consonant with client’s context) ▪ Goals (objectives congruent with client’s adaptive cultural values) ▪ Method (cultural adaptation and validation of methods and instruments) ▪ Context (client’s environment, including history and sociopolitical circumstances) Empirical studies on the cultural validity of empirically-supported treatments are scarce.

Ricardo Munoz suggested culturally adapting cognitive behavioral treatments through: ▪ Involvement of culturally diverse people in the development of interventions ▪ Inclusion of collectivisitic values ▪ Attention to religion/spirituality ▪ Relevance of acculturation ▪ Acknowledgement of the effects of oppression Pamela Hays (2001) framework: ▪ Age ▪ Developmental ▪ Disabilities (acquired) ▪ Religion ▪ Ethnicity ▪ Socioeconomic status ▪ Sexual orientation ▪ Indigenous heritage ▪ National origin ▪ Gender Culturally sensitive psychotherapy (CSP) targets specific ethnocultural groups, so a group may benefit from a specific intervention more than from interventions designed for others.

APA Multicultural Guidelines number 5 encourages psychologists to strive to learn about non-Western healing traditions and to acknowledge and enlist the assistance of recognized helpers and traditional healers in treatment.

Carolyn Attneave’s network therapy, a community-based approach, recreates the social context clan’s network to activate and mobilize a person’s family, kin and relationships Psychology of liberation: ▪ Developed by Ignacio Martin-Baro.

▪ Collaborative approach focused on assisting oppressed clients in developing critical analysis and engaging in transformative actions. ►

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Resonates with African-American psychology as it is based on Black liberation theology and Africanist traditions.

Theory of Personality

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Multicultural clinicians adhere to diverse theories of personality.

A unique contribution of multicultural psychotherapy is the formulation of cultural identity development theories.

▪ View the self as an internal representation of culture.

▪ Ethnic and racial identity stage affects beliefs, emotions, behaviors, attitudes, expectations, and interpersonal style.

Diverse models of identity development propose members of groups move through stages:

Value dominant group/devalue own group

Value own group/ devalue dominant group

Integrate appreciation for multiple groups

Ethnic Minority Groups (Atkinson, Morten & Sue, 1998) ► Conformity → Dissonance → Resistance/immersion → Introspection → Synergistic ▪ Conformity: Internalize racism; choose dominant groups’ values, lifestyles, role models.

▪ Dissonance: Question and suspect dominant group’s values.

▪ Resistance/immersion: Endorse minority-held values, reject dominant culture’s values.

▪ Introspection: Establish their own racial ethnic identity.

▪ Synergistic: Experience self-fulfillment without categorically accepting minority values.

White American Groups (Helms, 1990) ► Contact → Disintegration → Reintegration → Pseudoindependence → Autonomy ▪ Contact: Individuals are aware of minorities, do not perceive themselves as racial beings.

▪ Disintegration: Acknowledge prejudice and discrimination.

▪ Reintegration: Engage in blaming the victim and in reverse discrimination.

▪ Pseudoindependence: Become interested in understanding cultural differences.

▪ Autonomy: Accept, respect, and appreciate both minority and majority group members.

Gay and Lesbian Groups (Cass, 2002) ► Confusion → Comparison → Tolerance → Acceptance → Pride → Synthesis ▪ Confusion: Questions their sexual orientation.

▪ Comparison: Accepts possibility that they may be a sexual minority.

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Tolerance: Recognition that one is gay or lesbian.

Acceptance: Increases contact with other gays and lesbians.

Pride: Prefer to be gay or lesbian.

Synthesis: People find peace with their own sexual orientation.

Feministic Identity (Downing and Rush, 1985) ► Passive/acceptance → Revelations → Embeddedness/emanation → Synthesis → Active commitment Theory of Psychotherapy ► ► ► ► ►

Multicultural psychotherapists do not subscribe to a unifying theory of psychotherapy.

Focus is on “How can a therapist understand the life of a culturally different client?”

Therapeutic alliance requires cultural congruence between clients’ and therapists’ worldviews.

To begin moving towards cultural self-awareness, therapist identifies the dominant culture’s values in which they communicate and practice.

Bennet’s (2004) multicultural sensitivity development model: ▪ Denial → Defense → Minimization → Acceptance → Adaption → Integration

Ethonocentric and Ethnorelative Stages ► The ethnocentric stages: ▪ Denial: Deny existence of cultural differences, avoid culturally diverse people.

▪ Defense: Recognize other cultures but denigrate them.

▪ Minimization: View own culture as universal. ► The ethnorelative stages: ▪ Acceptance: Recognize and value cultural differences.

▪ Adaptation: Develop multicultural skills.

▪ Integration: Sense of self expands to include diverse worldviews. ► The ideal therapist role varies from culture to culture. ►

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Atkinson, Thompson and Grant (1993) asserted that low acculturated clients expect therapists to behave as advisor, advocate, and or facilitator of indigenous support systems.

More acculturated clients may expect their clinician to act as a consultant, change agent, counselor and or psychotherapist.

Besides acculturation, clients’ expectations are shaped by interpersonal needs, developmental stages, ethnic identity, spirituality, and numerous other factors.

Cultural Empathy ► Empathy is an interpersonal concept referring to a clinician’s capacity to attend to the emotional experience of clients. ► Somatic aspect of empathy refers to non-verbal communication and body language. ► Cognitive aspect of empathy occurs by becoming an empathic witness. ► Affective component, involves emotional connectedness, the development of affective empathy is critical in multicultural psychotherapy.

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Cultural empathy is a learned ability to obtain an understanding of the experience of culturally diverse individuals informed by cultural knowledge and interpretation.

Cultural empathy is the ability to place self in the other’s culture and is developed by engaging in self-reflection.

Every therapeutic encounter promulgates the projection conscious and/or unconscious messages about the client’s and the therapist’s cultures.

Clients of color expect psychotherapists to demonstrate cultural credibility (i.e., client’s perception of the psychotherapist as a trustworthy and effective helper).

Most dominant psychotherapists ignore transferential cultural issues while multicultural psychotherapists examine it through a dialogue on cultural differences and similarities.

Comas-Diaz and Jacobsen (1991) ► Intra-ethnic transference may transform the therapist into one of several roles: ▪ Omniscient/omnipotent therapist ▪ Traitor ▪ Auto-racist ▪ Ambivalent ► Inter-ethnic transferential reactions may lead the patient to: ▪ Overcompliance and friendliness ▪ Denial ▪ Mistrust, suspiciousness and hostility ▪ Ambivalence ► In inter-ethnic dyads, countertransferential reactions by the therapist may include: ▪ Denial of cultural differences ▪ Clinical anthropologist’s syndrome (excessive curiosity about clients’ ethnocultural backgrounds at the expense of their psychological needs) ▪ Guilt (about societal and political realities) ▪ Pity ▪ Aggression ▪ Ambivalence ► In intra-ethnic dyads some of the countertransferential manifestations include: ▪ Us and them mentality (shared victimization) ▪ Cultural myopia (inability to see clearly due to ethnocultural factors that obscure therapy ▪ Distancing ▪ Survivor’s guilt ▪ Overidentification ▪ Ambivalence ▪ Anger Mechanisms of Psychotherapy ►

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Multicultural psychotherapists may use contemplative practices; promote spiritual development; foster creativity through use of art, folklore, ethnic practices, and other creative cultural forms; and lead the patient to cultural consciousness (i.e., the affirmation, redemption, and celebration of one’s ethnicity and culture).

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Ethnopsychopharmacology ► Ethnopharmacology is the field that specializes in the relationship between ethnicity and responses to medications. ► Ethnocentrism has resulted in culturally diverse clients’ mistrust of psychopharmacology. ► Racial and ethnic groups may respond or use medications differently.

▪ African Americans with affective disorders are often misdiagnosed, and thus mistreated with antipsychotic medications.

▪ Common for Latinos to share medications with family members and significant others (due to familism), self-medicate and combine medications with herbal remedies.

▪ Diets of some people of color contain foods that are incompatible with certain kinds of psychotropic medications.

Applications ►

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Multicultural psychotherapies apply to everyone and are particularly helpful when individuals present to treatment with identity issues, relationship problems, cultural adaptation, ethnic and racial stressors, and conflicts of diverse nature.

A multicultural assessment is a process-oriented tool that leads to culturally appropriate treatment and might include: ▪ Explanatory model of distress • A culture-centered assessment based on an anthropological method that elicits a clients’ perspectives of their illness, experience and healing.

▪ Cultural formulation and analysis • A process oriented approach that places diagnosis in a cultural context examining: ► Individual’s cultural identity ► Cultural explanations for individual illnesses ► Cultural factors related to the psychosocial environment and levels of functioning ► Cultural elements of the therapist-client relationship ► Overall cultural assessment of diagnosis and treatment ▪ Cultural genogram • Diagram of a genealogical tree highlighting dynamics from a nuclear to an extended family perspective. ► www.genopro.com/genogram_rules/default.htm • Cultural genogram places individuals within their communal contexts. ► Uses three or more generations of ancestors. ► Clients invited to use imagination to summon up family information (e.g., photos). ► Share the symbols used in family genograms. ► Important factors might include individual and family culture(s), meaning of race and ethnicity, sexual orientation, family, social class, marriage, gender roles, relations, migration, refugee experience, acculturation, stress, spirituality and faith, history and Multicultural Psychotherapies

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politics, trauma (including sexual and gender trauma) and meaning of differences.

▪ Ethnocultural assessment • Explores diverse stages in cultural identity development ► Heritage stage ▪ Explores ethnocultural ancestry, history, genetics, and sociopolitical contexts and cultural trauma. ► Family saga stage ▪ Entails examining the family, clan and group story. ► Niche stage ▪ Attends to the post-transition analysis with special emphasis on client’s intellectual and emotional interpretation of family saga. ► Self-adjustment stage ▪ Cultural resilience assessed during this stage. ► Relationships stage ▪ Final stage of the ethnocultural assessment.

▪ Explores clients’ significant affiliations, including exploration of the therapist-client relationship.

Multicultural assessments can be complemented with a power differential analysis (i.e., an analysis of the client’s cultural group’s social status compared to the therapist).

Evidence

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More research is needed on multicultural psychotherapies.

Inconclusive results and low validity for ethnic matching (Karlsson, 2005).

▪ Empirical findings suggest that clients working with psychotherapists of similar ethnic backgrounds and languages tend to remain in treatment longer.

▪ Ethnic and linguistic match does not necessarily translate into mutual cultural identification; nor is it necessarily desirable for some clients.

Multicultural therapists advocate for research funding that is applicable to the lives of culturally diverse individuals and communities.

Chapter 15: Activities Role-play In practical terms, cultural empathy is the ability to place one’s self in the culture of another individual and is developed through self-reflection. Ask the students to try placing themselves in the “culture shoes” of someone of a culture different than their own and discuss some of the challenges and benefits that individual may have experienced because of their culture.

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© 2014 Cengage Learning, Inc. Discussion Questions 1.

Ask the class to discuss the concept of cultural competence and identify activities that an individual might need to participate in to develop cultural competence.

2.

According to Paulo Freire, in 1973, dominant models of education were “instruments of oppression.” Ask the class to discuss whether they believe this statement applies to today’s educational system and to defend their answer.

3.

Ask students to discuss the various identity development models described in the multicultural chapter.

Use of Movies to Depict Concepts

Each individual is impacted by the culture they experience. To try to understand individuals from a different culture requires openness to recognizing that one’s own worldview is not an all-encompassing view of the world out there. Many movies depict the challenges individuals face across various cultures and the challenges individuals face trying to understand each other. Movies and Mental Illness can provide several examples of films that depict cultural issues that would make for lively class discussions.

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© 2014 Cengage Learning, Inc. Case Illustration from Case Studies in Psychotherapies (Seventh Edition)

The Case of Alma by Comas-Diaz This case study demonstrates the importance of using a culturally-adapted approach in therapy. The client is a Latina female who presents with the complaint “I’m dead inside.”

Although, on initial read one might assume the issue is existential in nature, the case demonstrates how this client’s concerns are heavily influenced by a complex cultural matrix.

Throughout the case, Dr. Comas-Diaz illustrates several culturally-specific techniques and methods.

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Chapter 15: Potential Test Items Multiple Choice Test Bank 1.

An individual’s total environment is referred to as: a. worldview. b. culture. c. multicultural. d. cultural trauma.

REF: Overview (p. 535) ANS: B

2.

When minority group members are left with a legacy of adversity, pain and suffering, this is termed: a. collectivistic events. b. cultural trauma. c. racial microaggressions. d. ethnocentrisms.

REF: Overview (p. 538) ANS: B

3.

In Harry Triandis’s classification of worldviews, the term for an identity associated with relationships to others is: a. collectivistic. b. deterministic. c. denominated. d. integrated.

REF: Overview (p. 534) ANS: A

4.

The belief that one’s worldview is inherently superior and desirable to others is labeled: a. worldview. b. ethnocentrism. c. mainstream. d. incapability.

REF: Overview (p. 533) ANS: B

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According to Harry Triandis’ classification of worldviews, a denominated individual views themselves as: a. associated with relationships. b. fragmented by cultural trauma. c. independent from others. d. nominated for cultural superiority.

REF: Overview (p. 534) ANS: C

6.

Developing a set of knowledge, behaviors, attitudes, skills, and polices to work effectively within multicultural situations references is called: a. behavioral identification. b. multicultural education. c. empowerment promotion. d. cultural competence.

REF: Overview (p. 534) ANS: D

7.

In the cultural spectrum described by Cross and colleagues, the belief that culture makes no difference refers to: a. cultural competence. b. cultural incapacity. c. cultural destructiveness. d. cultural blindness.

REF: Overview (p. 536) ANS: D

8.

In the cultural spectrum described by Cross and colleagues, a sense of racial superiority refers to: a. cultural competence. b. cultural incapacity. c. cultural destructiveness. d. cultural blindness.

REF: Overview (p. 536) ANS: B

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In the cultural spectrum described by Cross and colleagues, cultural pre-competence refers to a situation where a therapist: a. understands most cultural values and effectively interacts with diverse clients. b. respects cultural differences but doesn’t know how to proceed with clients. c. believes their racial group is superior to others but is able to disguise this bias. d. feels racially superior and openly discloses this with clients to proceed in therapy.

REF: Overview (p. 536) ANS: B

10.

Research on evidence based practices suggests that, in contrast to their European American counterparts, African Americans: a. participate in cognitive behavior therapy longer. b. had negative expectations of therapy frequently. c. found treatment less positive despite positive expectations. d. do not respond to cognitive behavioral therapy.

REF: Overview (p. 540) ANS: C

11.

Paulo Freire identified dominant models of education as instruments of: a. oppression. b. cultural awareness. c. freedom. d. independence.

REF: Overview (p. 538) ANS: A

12.

A form of counseling in which two or more individuals take turns listening to each other without interruption refers to: a. cognitive behavioral therapy. b. dialectical behavior therapy. c. re-evaluation counseling. d. reattribution counseling.

REF: History (p. 541-542) ANS: C

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In Pamela Hays’ ADDRESSING framework, the “R” stands for: a. race. b. religion. c. region. d. rational.

REF: History (p. 545) ANS: B

14.

In Pamela Hays’ ADDRESSING framework, the “I” stands for: a. indignation. b. interracial attitudes. c. interdependence. d. indigenous heritage.

REF: History (p. 545) ANS: D

15.

In Pamela Hays’ ADDRESSING framework, the “N” stands for: a. negotiating. b. natural selection. c. national origin. d. negligence.

REF: History (p. 545) ANS: C

16.

The American Psychological Association’s multicultural guideline number 5 encourages psychologists to: a. strive to learn about non-western healing traditions. b. evaluate their institution’s mission statements. c. incorporate cultural diverse populations into research. d. teach about treatments for ethnically diverse populations.

REF: History (p. 545) ANS: A

17.

In assisting a patient network, therapy aims to recreate an individual’s: a. genealogical history. b. cultural context. c. history of oppression. d. cultural blindness.

REF: History (p. 545) ANS: B

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A narrative that chronicles traumatic experiences for Latin Americans is known as: a. collectivism. b. individualism. c. testimonio. d. cuento.

REF: History (p. 546) ANS: C

19.

Network therapy refers to an approach to treatment that relies on a(n): a. community based process. b. network of multiple providers. c. internet based communication. d. patient building a social network.

REF: History (p. 545-546) ANS: A

20.

According to Atkinson, Morten and Sue, the identity development of ethnic minority groups follows which of the following patterns? a.

Conformity to introspection to dissonance b.

Dissonance to synergistic to conformity c.

Conformity to resistance to synergistic d.

Resistance to conformity to dissonance REF: Personality (p. 546-547) ANS: C

21.

According to the model of ethnic minority group identity development described by Atkinson, Morten and Sue, in the resistance stage an individual would: a. choose the dominant group’s values, lifestyles, and role models. b. question and suspect the dominant group’s values. c. endorse minority-held values and reject dominant culture’s values. d. experience self-fulfillment without categorically accepting minority values.

REF: Personality (p. 547) ANS: C

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According to Janet Helms, the identity development of White American groups follows which of the following patterns: a. pseudoindependence to disintegration to autonomy. b. contact to reintegration to autonomy. c. reintegration to disintegration to pseudoindependence. d. autonomy to pseudoindependence to reintegration.

REF: Personality (p. 547) ANS: B

23.

In the model of White American identity development described by Janet Helms, in the disintegration phase an individual: a. is not aware of minorities. b. acknowledges prejudice and discrimination. c. engages in reverse discrimination. d. appreciates both minority and majority group members.

REF: Personality (p. 547) ANS: B

24.

According to Cass, the identity development of gay and lesbian individuals follows which of the following patterns: a. comparison to confusion to tolerance. b. pride to comparison to acceptance. c. confusion to tolerance to synthesis. d. comparison to synthesis to tolerance.

REF: Personality (p. 547-548) ANS: C

25.

In the model of gay and lesbian identity development described by Cass, in the phase of tolerance an individual: a. questions their sexual orientation. b. recognizes that they are gay or lesbian. c. increases contact with other gays and lesbians. d. accepts possibility that they may be a sexual minority.

REF: Personality (p. 547-548) ANS: B

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According to feministic models of identity development, for females to achieve a positive identity which of the following patterns would occur? a.

Embeddedness to passive acceptance to active commitment b.

Revelations to passive acceptance to active commitment c.

Revelations to embeddedness to synthesis d.

Synthesis to revelations to passive acceptance REF: Personality (p. 548) ANS: C

27.

In Bennet’s (2004) multicultural sensitivity development model, multicultural awareness is divided into the two stages of: a. embeddedness and denial. b. ethnocentric and synthesis. c. integration and adaption. d. ethnocentric and ethnorelative.

REF: Psychotherapy (p. 549) ANS: D

28.

In Bennet’s (2004) multicultural sensitivity development model, during which of the following stages does a therapist view their own culture as universal? a.

Denial b.

Minimization c.

Acceptance d.

Integration REF: Psychotherapy (p. 549) ANS: B

29.

During an ethnocultural assessment, in which of the following stages would a therapist attend to the client’s intellectual and emotional interpretation of the family saga? a.

Heritage b.

Family saga c.

Niche d.

Relationships REF: Applications (p. 559) ANS: C

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Ethnopharmacology is the field that specializes in: a. the relationship between ethnicity and responses to medications. b. decreasing substance use in ethnic minority groups. c. increasing the number of minorities practicing medicine. d. recording how the field of medicine has discriminated against minorities.

REF: Psychotherapy (p. 554-555) ANS: A Fill in the Blanks

1.

________________ refers to people’s systemized ideas and beliefs about the universe.

ANS: Worldview

2.

___________________ refer to assaults individuals receive on a regular basis solely because of their race, color, and or ethnicity.

ANS: Racial microagressions

3.

The belief that one’s worldview is inherently superior and desirable to others is known as ____________.

ANS: Ethnocentrism

4.

_____________ is a learned ability to obtain an understanding of the experience of culturally diverse individuals informed by cultural knowledge and interpretation.

ANS: Cultural empathy

5.

Critical consciousness as a process of person and social liberation is known as ____________________.

ANS: Conscientization

6.

A healing narrative approach to treatment known as __________ therapy has been empirically prove to be an effective treatment for Puerto Rican children.

ANS: Cuento

7.

A diagram of a genealogical tree highlighting dynamics from a nuclear to an extended family perspective that places individuals within their communal contexts using three or more generations of ancestors is known as a __________________.

ANS: Cultural genogram

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A therapist displaying excessive curiosity about a client’s ethnocultural background at the expense of their psychological needs is experiencing ____________________ syndrome.

REF: Clinical anthropologist’s

9.

According to Comas-Diaz and Jacobsen (1991), during intra-ethnic transference the therapist is often transformed into one of four roles which include __________, _____________, ____________, _____________.

ANS: Omniscient/omnipotent therapist, traitor, auto-racist, and ambivalent

10.

In the final stage of the ethnocultural assessment, the _____________ stage, the therapist explores significant affiliations with the patient, including exploration of the therapistclient relationship.

ANS: Relationships Essay Questions

1.

Multicultural psychotherapies developed because dominant models of psychotherapy appeared to overly support mainstream cultural values and neglect multicultural worldviews. Describe the evidence to support the need for multicultural therapies and the process that a therapist might go through to move towards cultural competence. Include a description of ethnocentrism and how it might impact cultural competence.

2.

Multicultural clinicians adhere to diverse theories of personality. However, a unique contribution of multicultural psychotherapy is the formulation of cultural identity development theories. Describe what cultural identify development theory is. Then, contrast the theory of identity development for ethnic minorities and the theory of identity development for White American groups.

3.

Describe Bennet’s (2004) multicultural sensitivity development model.

4.

Comas-Diaz and Jacobsen (1991) have described a number of transferential and countertransferential issues that can occur due to cultural issues. Describe the issues that might occur in both intra-ethnic and inter-ethnic therapist-patient relationships.

5.

Describe the process of a multicultural assessment and some of the techniques that might be used to perform one.

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Chapter 16 Contemporary Challenges and Controversies Authors: Ken S. Pope and Danny Wedding Key Points and Terms Mental Health Workforce Technical Eclecticism ► Refers to combining concepts and techniques from various psychotherapy approaches. ► Whatever their professional identification, the majority of individuals who practice psychotherapy indicate their orientation is technical eclecticism.

SAMHSA (2012) ► 34,000 deaths in the United States annually from suicide. ► Decreased health-care expenditures devoted to mental health. ► Rapid increase in per capita spending on psychotropics. ► Shortages of mental-health providers in almost every state. ► Idaho has most dramatic shortage of mental-health professionals — 31.6%. ► West Virginia has highest percentage of its residents living in counties with a marked shortage of prescribing professionals — 85%.

Changing Workforce ► According to the American Psychiatric Association (2012) ▪ Number of U.S. medical students choosing psychiatry as a specialty has been declining for the past six years.

▪ About half of currently practicing psychiatrists are over the age of 55. ► Number of non-physician mental-health providers continues to grow.

Human Resource Data ► Most mental health professionals practice technical eclecticism. ► For every 100,000 U.S. citizens there are: ▪ 3 psychiatric nurses ▪ 14 psychiatrists (providing primarily medication management) ▪ 16 marriage and family counselors ▪ 31 psychologists ▪ 82 social workers ▪ 54 counselors Licensing vs. Certification ► Licensure: Restricts the practice of a profession. ► Certification: Restricts the use of a profession’s name. ► In 2013, all 50 states required psychiatrists, psychologists, social workers, psychiatric nurse practitioners and marriage and family counselors to be licensed.

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© 2014 Cengage Learning, Inc. Is Psychotherapy Needed? ► Many question the value of psychotherapy. ► Alan Kazdin argued in Time (2011) that 70% of people with mental health needs don’t receive needed treatment because psychotherapy doesn’t address pressing health needs. ► Research suggests individuals seek mental health services from physicians.

Integrated Care Term

Source, context, connotation

Integrated care

Tightly integrated, on-site teamwork with unified care plan. Often connotes close organizational integration as well, perhaps involving social and other services Related to the concepts of the Patient Centered Medical Home, a single-site, regular source of care for individuals seeking a broad range of biomedical and behavioral health care services and patient-centered care: “Care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (IOM, 2001). ► ► ►

Growing national trend of collaborative and integrated care (i.e., co-location of mentalhealth and medical care).

Requires interprofessional training.

Model facilitates respect between different professions and supports the “curbside consults” and “hallway hand-offs.”

Physicians, Medications and Psychotherapy ► Patient’s preferences for psychotropic medications. ► Primarily in the use of antidepressants to treat depression. ► Follow-up care is limited. ► Many seek care from primary care providers. ► In two states (NM, LA) and Guam, psychologists have prescription privileges. ► Growing trend towards collaborative care and integrative care.

DSM-5 and ICD-10 ICD-10 Produced by a global health agency with a constitutional public health mission Global, multidisciplinary and multilingual

DSM-5 Single national professional association U.S. psychiatrists

193 WHO member countries

Assembly of the American Psychiatric Association Distributed as broadly as possible at a Generates a very substantial portion of the very low cost, with substantial discounts to American Psychiatric Association’s revenue low-income countries, and available free on the Internet

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EST has been difficult and controversial to put into practice as psychotherapy is a fluid, mutual, interactive process.

Effectiveness of treatments must be established for specific purposes.

▪ Kazdin notes there are over 550 interventions for children and adolescents but only a small percentage of these have been researched.

APA 2005 Presidential Task Force on Evidence-Based Practice ▪ The integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.

Important to recognize that: ▪ Other areas of medicine have same dilemmas in defining clear guidelines.

▪ Guidelines should not be overly opinion-based/reliant on expert consensus.

▪ Crucial to avoid politicization of guidelines.

Guidelines for treating behavioral disorders can be found at AHRQ Guideline Clearinghouse (www.guidelines.gov).

▪ Proponents suggest process standardizes the quality of care in mental health.

▪ Contrasts AHRQ expert consensus reports against “cookbooks” negating the uniqueness of cases.

Phones, Computers and the Internet

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Digital age offers opportunities and challenges.

▪ Many of these challenges relate to restricting possible access to confidential information (some problems could occur that would never have been foreseen and are completely unintentional breaches).

Weblogs, instant messaging, video chats and social networks are changing doctor-patient relationships.

Professional and trainees need to be aware of risks involved in others having accessing to too much personal information about them (e.g., Google searches, Facebook pages).

More details for telephone and internet therapy are at Ethics Codes & Practice Guidelines for Assessment, Therapy, Counseling and Forensic at http://kpope.com/ethcodes/index.php.

Therapist Sexual Involvement with Patients, Non-Sexual Physical Touch and Sexual Feelings

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No circumstances or rationale justifies sexual involvement with a patient!!!!!

Effects of Therapist-Patient Sexual Involvement Cluster into 10 General Areas ► Ambivalence ► Guilt ► Emptiness and isolation ► Sexual confusion ► Impaired ability to trust ► Confused roles and boundaries

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Emotional lability Suppressed rage Increased suicidal risk Cognitive dysfunction

Sexual Attraction ► Intimacy of psychotherapy can lead to sexual arousal and fantasies. ► 4.4% of therapists reported engaging in sex with at least one patient (no statistical difference among social workers, psychiatrists or psychologists). ► Males (therapists, supervisors, professors) more likely to cross sexual boundaries.

▪ 6.8% do in contrast to 1.6% of female therapists. ► 88-95% of sexual contact between male therapist and female patient. ► 4 out of 5 therapists report feeling sexual attraction to at least one client. ► Most report guilt, anxiety and confusion when sexual feelings occur. ► 10% of therapist feel their training prepared them for this type of situation.

Pope & Bouhoustsos (1986) Scenario Description Role Trading Therapist becomes patient.

Sex Therapy Therapist presents sex as part of the treatment.

As If …

Therapist treats positive transference as not the result of therapy.

Svengali Therapist exploits patient dependence.

Drugs Therapist uses drugs for seduction.

Rape Therapist uses force.

True Love Therapist rationalizes behavior.

It Just Got Therapist fails to attend to therapeutic intimacy appropriately. out of Hand Time Out Therapist fails to separate sessions from therapeutic relationship.

Hold Me Therapist exploits patient’s desire for physical contact for comfort. ► ►

Non-sexual touch may be comforting, but must be used judiciously and can easily be misperceived.

Best to avoid touch unless an extraordinary situation warrants it.

Non-Sexual Multiple Relationships and Boundary Issues

Dual Relationships ► The 2nd most often reported ethical dilemma is sorting out dual relationships. ► Right course of action regarding dual relationships can be difficult to discern.

▪ Always the therapist’s responsibility to maintain the boundary no matter how challenging the patient is ► Most problematic dual relationships are ones in which there are: ▪ Incompatibility of expectations ▪ Diverging obligations ▪ Increased power and prestige between therapist-patient Contemporary Challenges and Controversies

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Patrusksa Clarkson wrote about the “mythical, single relationship,” stating it was impossible to avoid all situations where a dual relationship might occur.

Factors Related to Behaviors and Beliefs About Dual Relationships Include: ► Therapist’s gender, profession, age, experience, marital status, region of residence and theoretical orientation ► Client’s gender ► Practice setting (e.g., solo, group, outpatient, inpatient) ► Practice locale (size of community) ►

► ►

In 1991, Pope and Vetter recommended changes to the APA Code of Ethics that: ▪ Defined dual relationships more carefully (delineating when indicated) ▪ Realistically addressed situations (especially in small practice communities) ▪ Distinguished between dual relationships and accidental or incidental contact Sound judgment about nonsexual boundaries always depends on context Available guidelines for the topic are: ▪ Younggren (2002) Ethical decision-making and dual relationships; Gotlieb (1993) Avoiding exploitive dual relationships: A decision making model; Sonne (2006) Nonsexual multiple relationships: A practical decision-making model for clinicians and other resources at http://kspope.com/dual/index.php ▪ Faulkner and Faulkner (1997) Managing multiple relations in rural communities: Neutrality and boundary violations ▪ Lamb & Catanzaro (1998) Sexual and Nonsexual Boundary Violations Involving Psychologists, Clients, Supervisees, and Students: Implications for Professional Practice ▪ Campbell & Gordon (2003) Acknowledging the Inevitable: Understanding Multiple Relationships in Rural Practice ▪ Burian & Slimp (2000) Social dual-role relationships during internship: A decision-making model Accessibility and People with Disabilities

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1/5 of U.S. citizens have disabilities.

Percentage is higher among females (Native American and African American females with the highest).

1/3 of females with work disabilities and 40% of those with severe disabilities live in poverty.

Training in the area is questionable.

▪ Without training in disabilities therapist tend to focus on extraneous issues.

▪ Of 618 APPIC internship sites only 81 listed a disabilities rotation.

Resources at: ▪ Accessibility and Disability Information and Resources in Psychology Training and Practice at http://kpope.com ▪ Pope & Vasquez (2005) How to Survive and Thrive as a Therapist: Information, Ideas and Resources for Psychologists (Chapter 4)

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© 2014 Cengage Learning, Inc. Detainee Interrogations APA, the Law and Individual Ethical Responsibility ► Laws or regulations can conflict with client needs or a therapist’s values. ► Nuremberg Ethic states individual ethical responsibility exists beyond the dictates of law.

▪ In 2002, APA adopted code stating that when encountering an irreconcilable conflict between “ethical responsibilities and state’s authority, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority.”

▪ U.S. military supported this shift.

▪ APA reversed decision in 2010.

Detainee Interrogations ► Profession has grappled with whether detainee interrogations compromise professional ethical values or whether the special skills, training, and values of healthcare professionals help to ensure that interrogations are safe, effective, and ethical. ► Such questions confronted the profession with a striking urgency in the aftermath of 9/11. ► Statement of the APA on Psychology and Interrogations to US Senate Select Committee on Intelligence: ▪ Conducting an interrogation is inherently a psychological endeavor …

Psychology is central to this process … Psychologists have expertise in human behavior, motivations and relationships … Psychologists have valuable contributions to make toward … Protecting our nation’s security through interrogation processes. (APA, 2007) ► APA’s assurances regarding psychologist’s role in safe, legal, ethical, and effective interrogations were controversial within the field. ► Some felt psychologists’ involvement was detrimental. ► Pentagon adopted a new policy in 2006 that focused solely on psychologists, rather than psychiatrists, in strategies for interrogating detainees. ► APA assured “psychologists knew not to participate in activities that harmed detainees” (i.e., psychologists would keep interrogations safe and ethical). ► APA policy attracted sharp criticism.

▪ Editor of British Medical Journal described it as shocking.

▪ Bioethicist Steven Miles indicated APA was unique in providing policy cover for abusive.

▪ Amnesty International sent an open letter to APA describing necessary steps to acknowledge and confront “the terrible stain on … American psychology.” ► American Psychological Association has not yet reached a final or complete resolution regarding psychology’s participation in detainee interrogations. ► Some suggest the effects of psychologists’ involvement were detrimental regarding interrogations as psychologists may have designed tactics, trained interrogators, developed more aggressive interrogation methods when needed and had direct roles in breaking detainees down. ► In 2008, APA membership approved a petition that prohibited psychologists from working in the same setting where persons are held outside of, or in violation of, either

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© 2014 Cengage Learning, Inc. International Law or the U.S. Constitution, unless they are working directly for the detainee or for an independent third party, working to protect human rights.

▪ This petition would not become a part of the APA Ethics Code nor be enforceable.

In Contrast to the American Psychological Association American Psychiatric Association ► Board of Trustees and the Assembly of District Branches ▪ clear prohibition that no psychiatrist should participate directly in the interrogation of person including: • Being present in the interrogation room • Asking or suggesting questions • Advising authorities on the use of specific techniques or interrogations with particular detainees American Medical Association ► Participation in detainee interrogations prohibited including a ban on medically monitoring an interrogation.

American Civil Liberties Union (ACLU) ► Unredacted Report Confirms Psychologists Supported Illegal Interrogations in Iraq and Afghanistan ► ►

►

APA Ethics Office: Documents demonstrate that the APA’s policy of engagement served the intended purpose.

ACLU: Indicated documents warrant the opposite conclusions (i.e., involvement of psychologists lead to harm).

For more information about the debate over detainee interrogations refer to http://kspope.com/interrogation/index.php Cultures

Language Barriers ► 18.7% of U.S. residents speak a language other than English at home. ► 8.4% of U.S. residents have limited English proficiency. ► Between 1990 and 2000, 47% increase in number of Americans speaking a language other than English at home and 53% increase in number with limited English proficiency. ► These statistics are particularly relevant for Californians and Miami residents. ► Even when a therapist and patient speak a language (there are many varying dialects). ► When language barriers can be crossed, there are other complexities such as cultural and group differences (e.g., gender, sexual orientation, ethnic identity).

Cultural Issues ► Culture plays a significant role in the development of psychological disorders.

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© 2014 Cengage Learning, Inc. ► ► ► ► ► ► ► ► ► ►

Rates of depression and substance abuse are low in Mexican Americans born in Mexico.

After 13 years in the U.S., rates of depression for immigrant Mexican American females rise precipitously.

Chinese American immigrant females have a lifetime prevalence rate of major depression approximately half of White women.

Patients with schizophrenia recover sooner and function better in poor countries.

People of Mexican descent born in the U.S. have twice the risk of depression and anxiety and four times the risk of drug abuse.

Black and Hispanic patients are more than three times as likely to be diagnosed with schizophrenia.

White women in the U.S. are three times as likely to commit suicide as Black and Hispanic women.

Effects of psychiatric drugs vary widely across different ethnic groups.

The culture of biomedicine also affects over-diagnosis, misdiagnosis and treatment.

Crucial that therapists realize their culture also affects treatment.

Chapter 16: Activities Role-play Ask students to ponder their views about expanding prescription privileges to mental health professionals who are not psychiatrists. Have students who believe that psychiatrists should be the only discipline who can prescribe debate those who believe there is benefit to having psychologists and other mental health professionals gain prescription privileges.

Discussion Questions 1.

The ethical codes of mental health professions discuss the importance of avoiding dual relationships. However, Adlerian psychotherapists would suggest that therapy is educational; therefore, providing therapy to friends and family is acceptable. Ask students to discuss the benefits and risks of providing therapy to friends and family.

2.

At the time of this publication, psychologists have legally earned prescription privileges in the states of New Mexico and Louisiana and the territory of Guam. Hawaii also considered adopting prescription privileges for psychologists, but the bill was vetoed by the governor. Have students discuss their view of psychologists and other disciplines earning prescription privileges. What will be the pros and cons? How do they believe expanding prescription privileges will impact quality of care?

3.

Integrated care refers to the provision of mental health services within the primary care setting. Within integrated care, the medical team members and mental health clinicians openly share information and sessions are brief because a population-based method is used. Advocates arguing for this approach point out that most patients with depression, substance abuse and many other mental illnesses seek and receive their treatment from primary care providers. Proponents against this approach are concerned about the risks to

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© 2014 Cengage Learning, Inc. confidentiality and that therapies are not offered in their pure forms. Ask students to discuss the pros and cons of this trend.

Use of Movies to Depict Concepts

Movies frequently portray therapists facing ethical dilemmas and these depictions can lead to rich class discussions. For example: ► Ethical codes for therapists indicate there are no circumstances justifying sexual involvement with a patient. However, surveys suggest 4.4% of therapists report engaging in sex with at least one patient with most (88-95%) violations occurring between a male therapist and female patient. The film Mr. Jones (1993), starring Richard Gere and directed by Alan Greisman and Debra Greenfield, depicts a psychiatrist who engages in a romantic relationship with a male patient with bipolar disorder. Issues raised by this film can lead to a discussion about the risks to patients when boundaries are crossed as well as how this film debunks the myth that sexual violations towards patients are perpetrated by males. ► In Prince of Tides (1991), Barbra Streisand, who also directs the movie, portrays a psychiatrist who becomes sexually involved with a patient’s brother played by Nick Nolte. Discussing this film can allow students to have a lively discussion about whether the psychiatrist has acted unethically and crossed a boundary. ► Establishing and maintaining appropriate boundaries in a therapeutic relationship is the ethical duty of a therapist. To illustrate some of the challenges of navigating boundaries, instructors might want to direct students to Final (2001), a drama starring Denis Leary, who wakes in a psychiatric hospital after an accident. This film is directed by Campbell Scott.

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Chapter 16: Potential Test Items Multiple Choice Test Bank 1.

Estimates suggest the professional discipline with the largest number of members providing clinical services is: a. psychiatry. b. clinical psychology. c. clinical social work. d. psychiatric nursing.

REF: The Mental-Health Workforce (p. 571) ANS: C

2.

Regardless of professional discipline and training most therapists practice which of the following form of therapy? a.

Psychoanalytic b.

Behavioral c.

Supportive d.

Eclecticism REF: The Mental-Health Workforce (p. 570) ANS: D

3.

Restriction of the practice of a profession involves: a. certification. b. licensure. c. accreditation. d. privileges.

REF: The Mental-Health Workforce (p. 571) ANS: B

4.

Which of the following statements would accurately reflect the likely opinions of most psychologists regarding sexual attraction to clients? a.

Most therapists have not been sexually attracted to clients. b.

Relatively few therapists feel guilt about their sexual attraction to clients. c.

More male therapists feel sexual attraction to clients than female therapists. d.

Therapists feel their training has prepared them to deal with sexual feelings.

REF: Therapists’ Sexual Involvement With Patients, Nonsexual Physical Touch, and Sexual Feelings (p. 584) ANS: C

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When rationalizations allow a therapist to discount the professional nature of a therapistpatient relationship and become sexually involved with a client, Pope and Bouhoutsos would label this scenario as: a.

Role Trading. b.

True Love. c.

Hold Me. d.

Sex Therapy.

REF: Therapists’ Sexual Involvement With Patients, Nonsexual Physical Touch, and Sexual Feelings (p. 584) ANS: B

6.

“As if...” scenarios that lead to sexual involvement with clients are ones in which the therapist: a. becomes the patient, allowing their needs to become therapy’s focus. b. presents sexual intimacy as a treatment for sexual or other problems. c. reacts like positive transference is not the result of therapy. d. creates and exploits a patient's exaggerated dependence.

REF: Therapists’ Sexual Involvement With Patients, Nonsexual Physical Touch, and Sexual Feelings (p. 584) ANS: C

7.

Data regarding the sexual misconduct of therapists suggests: a. female therapists report higher levels of sexual involvement with clients. b. incidence rates for sexual misconduct are fairly similar across disciplines. c. therapists who have sexual relations with clients rarely repeat the offense. d. sexual misconduct is rare and patient reports are typically unfounded.

REF: Therapists’ Sexual Involvement With Patients, Nonsexual Physical Touch, and Sexual Feelings (p. 584) ANS: B

8.

The second most reported ethical dilemma described by therapists is: a. sexual misconduct. b. fraudulent billing. c. dual relationships. d. breach of confidentiality.

REF: Nonsexual Multiple Relationships and Boundary Issues (p. 587) ANS: C

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When a therapist rationalizes having had sex with a patient by indicating that they had fallen in love, Pope and Bouhoustsos would label this scenario as: a.

True Love. b.

Hold Me. c.

It Just Got Out of Hand. d.

Role Trading.

REF: Therapists’ Sexual Involvement With Patients, Nonsexual Physical Touch, and Sexual Feelings (p. 584) ANS: A

10.

Research shows that most incidences of sexual contact occur between a male therapist and a female patient. What percentage falls in this category? a.

58-64% b.

70-75% c.

88-95% d.

Over 99% REF: Therapists’ Sexual Involvement With Patients, Nonsexual Physical Touch, and Sexual Feelings (p. 584) ANS: C

11.

Information about the use of antidepressants to treat depression suggests that: a. most patients seek medications from mental health providers. b. medications are rarely a patient’s preference. c. follow-up in the first month is limited after medications are started. d. psychotherapy is the modal treatment, but medications are on the rise.

REF: Physicians, Medications, and Psychotherapy (p. 573) ANS: C

12.

Data suggests individuals seeking treatment for depression are increasingly more likely to: a. seek psychotherapy over medications. b. request family counseling over individual therapy. c. receive services in primary care over mental health settings. d. obtain services in mental health settings over primary care.

REF: Physicians, Medications, and Psychotherapy (p. 573) ANS: C

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© 2014 Cengage Learning, Inc. 13.

Integrated care refers to a model of care that: a. co-locates mental and medical health care. b. is specifically adapted for minority patients. c. integrates religion into psychotherapy. d. requires higher financial investments from patients.

REF: Physicians, Medications, and Psychotherapy (p. 573) ANS: A

14.

Which of the following states allows psychologists to prescribe psychotropic medications? a.

Virginia b.

New Mexico c.

Florida d.

Alaska REF: Physicians, Medications, and Psychotherapy (p. 574) ANS: B

15.

By 2012, approximately how many psychologists had completed Level 3 Clinical Pharmacotherapy training? a.

15 b.

150 c.

1,700 d.

15,000 REF: Physicians, Medications, and Psychotherapy (p. 574) ANS: C

16.

Which of the following professional organizations argued that its profession possessed unique skills that would be helpful in the interrogation of detainees? a.

American Psychiatric Association b.

American Psychological Association c.

American Medical Association d.

American Civil Liberties Union REF: Detainee Interrogations (p. 595-596) ANS: B

17.

Which of the following demographic groups has the highest rate of disabilities? a.

Black females b.

Hispanic females c.

Native American males d.

Black males REF: Cultures (p. 597) ANS: A

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18.

Individuals from Black and Hispanic cultures are three times more likely to be diagnosed with which of the following disorders in contrast to Whites? a.

Antisocial personality disorder b.

Attention deficit disorder c.

Schizophrenia d.

Depression REF: Cultures (p. 598) ANS: C

19.

Research suggests that, after 13 years in the U.S., rates of depression for female immigrant Mexican Americans: a. remains the same as Mexican females. b. rises precipitously. c. drops precipitously. d. leads to a suicide rate 5 times higher than in White women.

REF: Cultures (p. 598) ANS: B

20.

The female ethnic group at highest risk for suicide in the U.S. is: a.

Black. b.

Hispanic. c.

Chinese. d.

White.

REF: Cultures (p. 598) ANS: D

21.

Which of the following statements is true? a.

Patients with schizophrenia have a poorer prognosis and a lower level of functioning in poor countries. b.

U.S. born Mexican-Americans have a lower risk of drug abuse than those born in Mexico. c.

Black women in the U.S. are three times as likely to commit suicide as White and Hispanic women. d.

The effects of psychiatric drugs vary widely across different ethnic groups.

REF: Cultures (p. 598) ANS: D

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© 2014 Cengage Learning, Inc. Fill in the Blanks 1.

Within the current mental health work force, _________ represent the largest number of clinicians.

ANS: Clinical social workers

2.

More than 50% of all psychiatrists practice ______ psychiatry.

ANS: Biological

3.

___________ restricts the practice of a profession, whereas ___________ restricts the use of a profession’s name.

ANS: Licensure; certification

4.

When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a _______ relationship.

ANS: Dual

5.

_______ out of five therapists report feeling sexual attraction to at least one client.

ANS: Four

6.

_______% of therapists feel that their training prepared them for a situation where they felt sexual attraction towards a client.

ANS: 10

7.

Pope and Bouhoutsos describe 10 common scenarios clinicians use in order to justify sexual activity with patients. The scenario where the therapist exploits the patient’s dependence is called _______.

ANS: Svengali

8.

If a therapist rationalizes engaging in sexual behavior with a patient by stating that both have extremely strong romantic feelings towards one another, this is a scenario labeled _______ by Pope and Bouhoutsos.

ANS: True Love

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© 2014 Cengage Learning, Inc. 9.

Between 1990 and 2000, the number of Americans speaking a language other than English at home ________ and the number of Americans with limited English proficiency ________.

ANS: Increased; increased

10.

Approximately ________ of U.S. citizens who have disabilities, ______of females with work disabilities and ______ of those with severe disabilities live in poverty.

ANS: 20%; 33%; 40% Essay Questions

1.

Describe what the most frequent causes for a loss of license are and how a therapist might avoid them.

2.

Four out of five therapists report feeling sexual attraction to at least one client, as the intimacy of psychotherapy can lead to sexual arousal and fantasies. Name and describe the ten scenarios discussed by Pope and Bouhoustsos (1986) regarding how therapists become sexually involved with a client.

3.

In recent years, there have been several trends in mental health care regarding who provides mental health services, the types of services provided and the amount of services offered. Describe these changes and the forces in the field that may be driving the changes.

4.

Rural areas often have limited health care resources. Imagine that you are going to provide services to clients in a rural area either by phone or Internet. Discuss the steps you would take to provide clinical services appropriately and describe why these steps are necessary.

5.

The importance of cultural competence is more real today than ever before. Describe how culture and acculturation may impact the development, diagnosis and treatment of depression, schizophrenia and substance abuse across different ethnic groups.

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