1 Essential psychotherapies: Theory and practice Summary by S.D. Schilperoord
Psychology of Abnormal Behaviour
Essential psychotherapies: Theory and practice
1. Contemporary issues in psychotherapy theory, practice, and research: A framework for comparative study
essential psychotherapies: fundamental to psychotherapeutic training, practice, and research
- foundational therapies (i.e. psychoanalytic, behaviour)
- recently developed (i.e. couple, integrative)
- role of therapists’ personalities
- ‘third wave’: dialectical behaviour therapy (e.g. increase emotional and cognitive regulation in borderline
personality disorder), mindfulness, acceptance and commitment therapy, meditation
- basis on different views of human nature and visions of reality
psychotherapy: application of techniques derived from established psychological principles by qualified
professionals to assist individuals to modify maladaptive or maladjustive psychological factors (i.e.
attitudes, behaviour)
- history of approach important in understanding implicit worldview of it
- understand context of emergence method
- psychoanalysis, humanism, behaviourism; systems-oriented, integrative/brief
The concept of personality
- theory of therapy (change)/personality not always have corresponding theory
- personality: structured, organise, integrated, degree of consistency and stability, development aspect/
emergence influences
- connection between personality theory and psychotherapy
Psychological health and pathology
- development and maintenance
- objective underlying features DSM disorders?
- undesirability; value structure
- assessment personality/pathology closely linked to underlying theory
The process of clinical assessment
- role of standard psychiatric diagnosis in assessment, unit level (individual, dyadic, systemic), psychological
level, cultural factors, use of tests or structured observations, assessment separate or integrated from/with
treatment, strengths/resources, other dimensions or factors
- practicality theory evident in problem stability and problem change
- purposeful action to understanding: previous steps, adaptive resources, context in which clinically relevant
concerns arise (→ define problem and select strategy)
- what maintains and what is helpful
- clinical interviews, direct observations, self-report instruments
- diagnosis/labelling or ‘fluid issues’
- intrapersonal-interpersonal dimension
The practice of therapy
- basic structure: frequency, duration, who included, structure
- goal setting: ‘universal’ treatment goals, selection of central goals, influence of cultural factors, intermediate/
mediate/ultimate goals?, discussion of goals, level of psychological experience at which goals are established
(over behavioural, affective-cognitive)
- process aspects of treatment: decision, ‘homework’, resistance to change, technical errors, medications,
termination, influence of recent findings
- influence of psychotherapy into the way people think and the beliefs they have
- sensitivity to modes of practice/cultural
- managed care organisations (MCOs) → supports certain kinds of practice
- medicalisation of mental health treatment
- medication vs therapy: placebo/suggestion, usually equally effective, reduce risk of relapse. combination
- influence biological understanding psychopathology and neuroscience: collaborations, willingness, courses
The therapeutic relationship and the stance of the therapist
- influence on outcome therapy
- techniques used to create treatment alliance
- activeness/directivity of therapist
- responsibility, self-disclosure, role change??, countertransference
- most essential attributes in approach?
- empirically supported treatments (EST): role/power of therapeutic techniques → focus on effect therapeutic
relationship
- reassurance, modelling of active coping
- suitability therapist for certain therapeutic orientation
- influence preferred ways of practising
- therapeutic techniques → therapist-patient relationship
assimilative integration: use of techniques in other frameworks than the one in which they were developed
,2 Essential psychotherapies: Theory and practice Summary by S.D. Schilperoord
Curative facts or mechanisms of change
- insight or understanding (historical-genetic/interactional)
- interpretations? learning of new interpersonal skills? shaped or taught?
- therapist’s personality or psychological health → change?
- techniques vs relational factors
- management of termination of therapy. common aspects used
specific factors
- systematic desensitisation, cognitive reframing
- treat particular disorder with technique → effect (medical model)
common factors: not specific to any approach
- client factors (i.e. motivation)
- therapist qualities (i.e. warmth)
- strategic processes (i.e. feedback)
- structural features of the treatment (i.e. provide rationale)
- contributions to therapeutic efficacy
- therapist factors
- patient/client factors
- relationship factors
- techniques
- interaction of factors above
- therapeutic effects largely due to general effects
Treatment applicability and ethical considerations
- target group, limitations approach to cultural backgrounds?, referral for another therapy, ethical issues?
- efficacy (randomised clinical trials)/effectiveness (clinical setting)
- generic ethical matters (i.e. confidentiality, personal boundaries), ethical matters specific to multi person
clientele (i.e. balancing needs)
- sensitivity to cultural diversity
- multicultural competence → working alliance, therapist empathy, satisfaction
- importance of spirituality and religion
Research support and evidence-based practice
- nature and extent of research supporting efficacy/effectiveness, other arguments for effectiveness
- research → practice
- outcome research
- treatment > no treatment
- little difference in effectiveness of major therapies
- process research: what takes place, nature of techniques
- process-to-outcome research: variables to change/therapy outcome
- effects of client and therapist factors, interaction, and relation to outcomes
- evidence-based practice
- controlled + uncontrolled (efficacy/effectiveness)
- EST: tested by randomised clinical trials for a specific disorder + treatment manual; test vs meds
- unethical to practise other treatment + other concerns (i.e. applicability EST to comorbidity, common
factors neglected)
- evidence-based practice (EBP) vs EST; EBP; research + clinical expertise and patient values
- integrative view other APA divisions
- empirical research + clinical judgment and values
Case illustration
- background, relevant aspects (i.e. functioning), description of process and goal setting, highlight major
themes, etc.; summarises, open; subjective, omissions, bias/selection,
hermeneutic single-case efficacy design: positive/negative evidence
multiple case depth research: case study + experiential therapeutic principles
pragmatic case study method: systematic qualitative case studies on process and outcome, comparison
Integration and specialisation
- integration built on empirical foundations and conceptual and clinical concerns
- specialisation (may help integration also)
3. Relational psychoanalytic psychotherapy
Concepts of personality
- based on internalised identifications with caretakers
- self-system: developed out of anxiety experiences inconsistent with being
- self; organisation of experience within personality based on internalised experiences with others (Sullivan)
- good me, bad me (from anxious experiences), not me (from trauma)
- self as a social construct (true self, false self)
- two-person psychology (analytic third; psychoanalysis, culture)
- lack of connection or dissociation of experiences
- security, tenderness (intimacy), lust → malevolent transformation, aggression learned
,3 Essential psychotherapies: Theory and practice Summary by S.D. Schilperoord
- sexuality as a relational medium
- strong critique on Freudian sexual development theories; cultural advantages, lack of recognition
- homo/bi normal variations, aggression not inborn
- criticism: motivation reduced to single drive for relationships? security, safety, affectance
- theory of five motivational systems: physiological, attachment/affiliation, exploration/assertion, withdrawal/
antagonism, sensual/sexual
- internalised working models, infant research
- personality conflicts inevitable
- mind-body connection
Psychological health and pathology
- no neat correspondence with DSM, learned personality patterns, no expectation to uncover pathogen
- focus on strengths and gaps in resources; flexibility/rigidity; symptoms → communication
- schizophrenia: lost control of awareness/sense of consensually validated self
- impact of social and cultural contributions to problems in living (actuality)
- health: greater tolerance for anxiety-provoking experiences, assimilate new experiences/past
The process of clinical assessment
- assessment in interactions interpersonal/intrapsychic
- individual/dyadic/systemic
- precedents, context, secondary gains
The practice of therapy
- focused on experiences and meanings of people’s existence
• Basic structure of therapy: frequent, rarely at time limit, generally unstructured
• Goal setting
- increase awareness → broaden organisation experience → flexibility
- patient sets goals > symptom reduction
- enrichment of experience
- addressing (life/treatment) threatening behaviours first
- meaning/correlates of symptoms
- aim: self-actualisation (e.g. self-reflection, meaning in life)
• Process aspects of treatment: attempt to avoid ‘transference cures’/conform to therapist
• History taking and inquiry: curiosity, omissions?
• Silence and free association
- therapist in the background
- safe atmosphere; moderate arousal desired
- corrective emotional experience
• Analysis of defence and resistance
- anxiety in reactivation of dissociations
- empathic-centred/other-centred listening
- resistance to the awareness of transference
• Analysis of transference:
- shed light on subjective reality
- patterns of interaction and selective attention that reduced anxiety in the past
- ‘wearing the attribute’
• Mutual enactment
- unconsciously based interaction
- actualisation of the transference: living out experience → discussion, alter
• Interpretation: collaborative, based on antecedents, self-awareness
• Analysis of dreams: connection of dream to patient’s life, transference
• Encouraging experiences in the moment (or imagine)
• Technical errors
- basic boundaries
- imposition preferred theory, rush interpretation, insisting on transference/failure to address
- explanation without insight, criticising
- problems with involvement (too (in)active)
- wording/expression
• Termination: goals achieved/no longer needs help with them (become own therapist)
The therapeutic relationship and stance of the therapist: mutual but asymmetrical
• Countertransference (L2s5)
- conscious countertransferential feelings/awareness (very informative)
- projective identification: feelings projected/felt unto/by therapist → reduce anxiety
- ‘containers’ of difficult feelings until they can experience and regulate them consciously
- empathy
- affective neutrality impossible → awareness of countertransference preferable
• Self-disclosure: potentially valuable
(Ch.7)
transference: the tendency of the client to read things into the therapist’s behaviour based on the client’s past
experience
,4 Essential psychotherapies: Theory and practice Summary by S.D. Schilperoord
countertransference: the tendency of the therapist to read things into the client’s behaviour based on the
therapist’s past experience and unresolved problems
Curative factors or mechanisms of change
- new experiences and development of new meanings of experience
- analysis of transference or other relationships
- strengthen health parts personality
- (emotional) insight(s) about therapeutic relationship, impact of past on functioning, other matters →
awareness, tolerance of uncertainty/anxiety
- mourning lost possibilities
- expansion of awareness, openness to new experiences, new meanings and new self-organisation in safe
situation (‘regression’, ‘agape’)
Treatment applicability and ethical considerations
- widely applicable; preferably self-reflective, verbal, willing to examine own contributions to problems
- adjustments when not ideal candidate
- clarity for patients seeking symptom reduction
- ethical consideration of applicability per
7. Person-centred psychotherapy and related experiential approaches
empathy, respect, congruence, acceptance; experiencing
The concept of personality
• Personality as process
- functioning and change
- capacity for continual growth, adaptation, learning, modifying
- present in the moment; openness → effective functioning and decision-making
- actualising tendency: the inherent tendency of individuals to develop by forming more differentiated and
integrated personal life structures
- → potential for resilience
- field theory (individual ↔ environment)
- concept of self as a ‘map’ developed to help navigate the world
- self-actualisation: the tendency of the organism to enhance its own self-development
- tentative self-concept → productive learning → positive development
- rigid self-concept → defensive/maladaptive development
- agency/ableness: a sense that one can confront challenge (instead of autonomy)
- growth potential within reality → respect cultural diversity
- facilitating communication more important that judging who is correct → open sharing, acceptance,
respect → mutual understanding
- congruence (genuineness?): all aspects of self, thoughts, experiences, feelings, are listened to
• Experiencing and feelings
- emphasis on being open to internal experience
- experiencing: the immediate, nonverbal sensing of patterns and relationships in the world and within the
self (e.g. intuitive knowing)
- meanings acquired through experiencing (‘felt sense’: therapeutic change at this level)
- feelings ≢ emotions; trust one’s feelings → listen to them as a source of information
- trust feeling → check against ongoing experience
- use of all faculties in fully functioning people (rationale, sense)
• Emotion theory (PE-EFT)
- emotion as functionally adaptive; quick and efficient provision of information about impact of environment
→ respond to meet needs/goals
- alert to what is important/meaningful, wholeness
- emotion schemes: higher-order organisation of experience
- perceptual-situational: awareness of external situation (episodic memories)
- bodily-expressive: bodily reaction and felt sense (e.g. helplessness when ridiculed)
- motivational-behavioural: actions and behavioural responses that accompany different emotional states
(e.g. crying)
- symbolic-conceptual: verbal and visual representations of experience, labels (e.g. rage)
- role of affect regulation: processes such as awareness and reflection as key to therapeutic process, focus
on inner experience, awareness and represent experience in words, accept and tolerate emotional
experience, ways of expression in relation to goals/need
• Dialectical constructivism: the self as a constantly evolving but organised multiplicity of selves; experiencing
potentials from emotion schemes in environment interaction
• Theory of development
- active, curious, exploring child
- growing → more inclusive framework of understanding self and world (unlike psychoanalysis), Piaget
- orientation towards exploring and confront challenge (not avoiding pain and frustration, only when
overwhelmed)
Psychological health and pathology
- failure to be open to information from which we can learn (blocks to learning; e.g. stuck in misperceptions)
, 5 Essential psychotherapies: Theory and practice Summary by S.D. Schilperoord
- incongruence between aspects of the self-concept and experience + response/resolve attempt (tentative →
integration/creativity; rigid → x)
- imposed conditions of worth → rigid self-concepts/conform → rigid ‘shoulds’ for decision making → ignore or
misinterpret own experience → dysfunctional behaviour (p.233)
- failure to use emotional information in adaptation → persistence dysfunctional reactions, unable to meet
demands situation
- primary adaptive emotion: a direct emotional response that is consistent with the situation and enables the
person to take appropriate action in response to it; automatic, survival
- maladaptive emotions: overlearned from difficulty/trauma
- secondary emotions: occur in response to adaptive emotions (hide vulnerability)
- instrumental emotions: emotional reactions used to manipulate or control others (incongruent)
- fail to attend to and symbolise own internal reactions
- reactions from rigid ‘emotion schemes’
- full functioning: fluid and flexible, evolving
The process of clinical assessment
- diagnostic labels for communication purposes
- process diagnoses: assessment of the presence of dysfunctional emotion schemes (block)
- markers → emotional processing problem → type of intervention to facilitate exploration (e.g. memory →
trigger?)
- e.g. → problematic reaction point (PRP): puzzled by reaction to person/event (e.g. unreasonable)
The practice of therapy
- traditional: nondirective, companion, client’s frame of reference
- controversy: self-disclosure, suggestion of techniques, attempt to systematically facilitate experiencing
(e.g. empty chair)
- philosophy → eclectic practicing
• Philosophy
- client → growth, healing; therapist = expert guide
- provide optimal (supportive) conditions for growth
- painful experiences emerge as part of self-healing process in time when necessary
- respectful towards self-direction/regulation
• Basic structure of person-centred and experiential therapies: flexible in duration, frequency, setting, number of
sessions, format
• Goal setting
- provide conditions that enable client to e.g. explore, reorganise, etc.
- help arrive at own answer, client knows situation best
- not what, but how?
- traditional: only goals for therapist
- focusing-oriented/process-experiential: suggestion of process goals
• Techniques and strategies
• Person-centred
- facilitative therapeutic relationship = technique
- reflection: left unsaid but within client’s awareness (≢ interpretation)
- expressing empathy spontaneously and in reflection (possible self-disclosure)
- infrequent suggestion of techniques (how)
• Focusing-oriented
- facilitate referring inwardly to experience/feelings, articulate; immediate felt experience
- ‘experiential’ responding: empathic responding focused on felt aspects, metaphors
- sharing of own immediate experience in therapy relationship (modelling)
- focusing: client is asked to focus inwardly, clear space, focus on one problem → felt shift
- techniques from other therapies (e.g. relaxation)
• Process-experiential/emotion-focused
- integrative
- problems from cognitive-affective information
- facilitate cognitive-affective to enhance deeper exploration
- identify problem, select intervention, systematic guidance
- therapeutic markers
- conflict split (want/should) → Gestalt two-chair exercise
- unfinished business → Gestalt empty-chair exercise → personal resolution
• Process of therapy
- focus on what the client brings up, flow
- resistance as a sign therapist needs to be more empathic/congruent
- termination of therapy rarely a problem
- use of personal self-disclosure in case of doubt (e.g. I worry/wonder that..)
- errors: failure to be empathic, imposing agenda, failure to be in touch with unfolding moment-by-moment
process
The therapeutic relationship and the stance of the therapist
- most important factor; primary conditions (see also slide 19)
- unconditional positive regard/warmth: distinction person/behaviour → intrinsic worth
