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Description : Check out this medical PowerPoint presentation titled "ADVANCED METHODS IN COUNSELING AND PSYCHOTHERAPY", by Demetrios Peratsakis, to learn about the Philosophy and Practice of Clinical Outpatient Therapy. Clinical outpatient therapy is a type of mental health treatment that takes place in an outpatient setting, such as a therapists office or clinic, rather than in a hospital or other inpatient facility. This type of therapy can be helpful for a wide range of mental health conditions, including depression, anxiety, bipolar disorder, and post-traumatic stress disorder. The philosophy of clinical outpatient therapy is centered on the idea that mental health conditions can be treated effectively through a combination of talk therapy and medication, if necessary. The therapist and the patient work together to identify the underlying causes of the patients symptoms and develop a treatment plan that addresses those causes.

Tags : Philosophy Clinical Outpatient Therapy, Practice of Clinical Outpatient Therapy, Clinical outpatient therapy, mental health treatment, depression, anxiety, bipolar disorder, post-traumatic stress disorder

Published on : Mar 14, 2023 | Views : 1154 | Downloads : 2

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ADVANCED METHODS IN COUNSELING AND PSYCHOTHERAPY The Philosophy and Practice of Clinical Outpatient Therapy Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, Certified Clinical Trauma Professional Western Tidewater Community Services Board
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DISCLAIMER The purpose of these materials is to help improve on one’s practice of therapy through a deeper understanding of methods. This material is intended to augment, not replace, the instruction and practice expectations of one’s home Community Services Board or Agency. As such, the ideas presented herein are simply those that assist us in our work and in our understanding of human motivation and pathology. ____________________ . ____________________
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“There's no coming to consciousness without pain.” - Carl G Jung The purpose of these materials is to help improve on one’s practice of therapy through a deeper understanding of methods. It is intended to augment, not replace, the practice expectations of one’s home Community Services Board or Agency.As such, the ideas presented herein are simply those that assist us in our work and understanding of human motivation and pathology. They are also a form of homage to Robert Sherman and Richard Belson, two remarkable clinicians that have greatly shaped our understanding of power and its role in psychological injury and the intergenerational transmission of trauma. Background: We were working as substance abuse counselors in the 1970’s when a small group of us began training with Dr. Robert Sherman in 1980 and continued until his retirement and relocation from New York City in 1992. Bob (Robert) was an AAMFT Clinical Supervisor, Author, co-founder of Adlerian Family Therapy, a long-time Fellow at the North American Society of Adlerian Psychology and Chair of the Department of Marriage and Family Therapy Programs at Queens College which he founded and where I served on faculty in 1986 and 1987. This remarkable, 12-year apprentorship included small-group instruction with noted Adlerians Kurt Adler (1980), Bernard H. Shulman (1980), Harold Mosak (1980-1981) and Steven Zuckerman (1982-1983), as well as a unique series of live-practice seminars with several theorists, including Maurizio Andolfi (1981), Adia Shumsky (1982), Carlos Sluski (1983), Murray Bowen (1984), James Framo (1985), Bunny Duhl (1986), Monica McGoldrick (1987), Carl Whitaker (1988), Jay Haley (1989), Salvador Minuchin (1990 and 1991) and Peggy Papp (1992). In March 1991, we completed a two-day intensive with Patricia and Salvador Minuchin. Over the course of his extremely distinguished career, Bob trained several thousand counselors and left an indelible mark on the field of therapy. I am proud and grateful to continue to regard him as a friend and mentor. In 1990, I joined Dr. Richard Belson, Director of the (Strategic) Family Therapy Institute of Long Island, in an innovative, two-year, live-supervision practicum that employed a solution-focused, team-therapy approach to treating chronic, highly intractable problems. At the time, Richard was collaborating with Jay Haley and Cloe Madanes at the Family Therapy Institute of Washington, D.C. (1980 to 1990), on faculty at the Adelphi School of Social Work, and serving on the editorial board of the Journal of Strategic and Systemic Therapies (1981 to 1993). He is most noted for his work on forgiveness, revenge, and various methods of undermining passive-aggressive acts and power-plays. To this day, I have yet to witness a more brilliant and creative tactician. Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, Certified Clinical Training Professional Executive Director, Western Tidewater Community Services Board 3
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The ideas presented herein presume a psychosocial, constructivist perspective on the origin and development of psychological symptoms. This differs greatly from the biomedical, which tends to view symptoms as the outward expression of some underlying brain disorder or biological condition, much like a fever denotes the existence of an infection. It is the recognition that even when its origins are rooted in a medical condition, symptoms may develop a psychological component. The essential difference is that cognitive-behavioral and family systems theories view symptoms as intentional manifestations, complex belief structures shared by the individual and their relationship system. These are social constructivist and social constructionism tenets as to how reality is perceived and shared (Vygotsky, 1978). In this regard problems are viewed as shared cognitive distortions, myths and legends that have acquired purpose and contain social meaning and power. At first, this notion may appear somewhat radical. You will find, however, that this vantage point can add inestimably to your insight on human behavior and to your ability to intervene on and reshape social interaction. 4 Important Message on these Notes
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Addiction Working with Addiction and Dependency from an Adlerian Perspective Western Tidewater Community Services Board June 11, 2020 5
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6 Home Remedy for Feelings of Worthlessness Addiction Overview
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8 Drugs Alcohol Suicide Diarrheal
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9 In 2018, 70M Americans had a mental and/or substance use disorder.
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10 1. Facing addiction in America 2016 analysis, based on results of SAMHSA 2013 national survey on drug use and health and OASAS drug-free America 2011 national survey. 2. Estimated economic cost in 2007, the last available estimate. Source: National Drug Intelligence Center. National Threat Assessment: the Economic Impact of Illicit Drug Use on American Society. May 2011. Department of Justice, Washington, DC. 3. Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, et al. Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse. Comparative Effectiveness Review No. 64. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. Available at: http://www.ncbi.nlm.nih.gov/books/NBK99199 4. Center for Behavioral Health Statistics and Quality. (2016). Results from the 2015 national survey on drug use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. State and federal governments spend in excess of $15 billion (and insurers contributing $5 billion more) on substance abuse services.
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Preoccupation with getting, using, and recovering from use Failed attempts to end or reduce use Needing more (tolerance) and cravings Declining health Declining performance Increased risk of job loss, loss of friends, family and shelter Increased risk of accidents, property damage and injury to others Increased risk of incarceration, legal and criminal issues 13 Signs of Addiction
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Drugs are fun! Genetics Mental disorders such as depression and anxiety Family history of addiction; learned patterns Deadens pain (trauma, meaninglessness) Performance enhancement; to make oneself more able, powerful and desirable Avoid responsibility (Escapism) Add Two: Act of defiance or revenge; way to control or punish others (prevail in a power-struggle) Perpetuates dependency under the guise of independence 14 Reasons for Addiction
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Counseling CBT; SFBT; Family Counseling FFT; MST Contingency management CRA/Community Reinforcement with Vouchers Contingency Management Interventions Twelve-step facilitation (TSF) Motivational Enhancement Therapy The Matrix Model (therapeutic alliance) 6. Drugs to help treat drug addiction (?!) Opioid (Methadone; Buprenorphine; Extended-release naltrexone; Lofexidine) Nicotine (replacement patch, inhaler, or gum; Bupropion; Varenicline Alcohol (Naltrexone; Disulfiram; Acamprosate) 15 Common Treatment Methods Good Stuff: Behavior Mod/Rewards Education Individual and Group Counseling Strong Therapeutic Community Family Involvement Relapse Prevention Focus
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16 Yet, We Continue to Fail
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17 Relapse Rates are Abysmal According to SAMHSA for data compiled between 1994-2004 Heroin 78.2 % Alcohol 68.4 % Cocaine 61.9 % Methamphetamine 52.2 % 40-60% of substance abusers relapse –National Institute on Drug Abuse
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18 - Journal Addiction
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19 Oxymoron: Motivation for Treatment 1. 2.
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21 “Treatment or Incarceration?” Justice Policy Institute. Jan. 2004. Jail = “forced” to quit
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What’s Clear is that Drugs are Very Addicting 23
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24 …why do so many addicts choose to relapse once they’ve stopped?! What’s Not so Clear Is…
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SA = MH 25 The Answer is Rather Simple
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26 Alcoholics and drug addicts suffer from a fundamental sense of inadequacy and worthlessness. They have learned, early on, a failing strategy for protecting themselves and their families. That tells us that- Treat the addicts and the addiction will disappear. Treating the addiction, won’t cure the addict.
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Understanding Addiction Why people choose to remain addicted 27
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Mixed messages OK/NOT OK Faulty genetics? Faulty brain? Faulty thinking? Faulty morals? No standardization Motivation; Self-medication Compound Interest: legal, criminal, finances, health Family problem/Patient-centered treatment “Dry” vs “Sober” Drugs increase impulsivity Street mix varies Cognitive impairment Current methods are failure prone! 28 Loads of Obstacles
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Growth Abstinence 29 Problem # 1: Goal of Treatment is Abstinence Abstinence Growth
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30 Problem # 2: Treatment Duration Active treatment should be long-term; ideally, a min. of 2-3 years/3-5 AA = Lifelong
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31 Problem # 3: Recovery Plans “It’ll be tough, but it’ll be worth it!” Failure Is Us!
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32 Hmmm… How does addiction begin?
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33 The Family of Origin Alcoholic and drug addiction families tend to have family relationships characterized by high codependency, including weak, blurred boundaries, lack of emotional separation (fusion), and intrusive demands for support, attention and protection that prevent family members from developing a strong and independent sense of self. Untreated, the sense of self, or Self-concept, remains undeveloped and immature, often resulting in defiant, irresponsible and highly dependent character elements.
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Sense of Worthlessness (Shame) Co-dependency Avoidance 34 The Roots of Addiction All involve issues of Power & Control - Diminished estimation of self and valuation by others - Self Concept vs Self Ideal Coping Strategies or preferred patterns of social interaction
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Evolves in childhood inadequate individuation/“differentiation of self” (formation of concept of Self) guilt- and shame-based parenting Results in poor self-esteem the continual need for safety and validation Promotes relationship-forming that provides protection and defense from risk, attack and the demands of responsibility (mutual enabling) pattern of intergenerational co-dependency 35 Co-dependency Co-dependency = an excessive reliance on a partner or others for approval and a sense of identity
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Me Family 36 Undifferentiation = The Root of Co-dependency Family Me Me Family-A Me Family-B Progressive differentiation (growth away from family ego mass) Individuation (You vs Me) Undifferentiated individuals remain fused (co-dependent) with their families You Me Co-dependent or Fused Families “Family Ego Mass” (Bowen) Low Differentiation Higher Differentiation You Coping Strategy Promotes - dependency high emotional reactivity conflict avoidance problems with intimacy
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37 Undifferentiated partners develop Over-functioning and Under-functioning roles. The roles are mutually dependent, complementary and reciprocal. The pattern defines acceptable ways to express intimacy and conflict relate to other family members share information within and outside the family make decisions and problem-solve demonstrate loyalty reaffirm methods for avoiding 1) anger and 2) rejection The pattern hardens around core functions, such as parenting, and sharpens during periods of stress. How Co-dependency Patterns Form
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Typically, one partner or caretaker in the dyad (often an addict) is overtly rigid and disengaged, while the other is extremely enmeshed. Structural Mapping: As disengagement and rigidity increase, co-dependency and enmeshment increase. As the co-dependent parent’s tolerance of the dominant parent’s control/abuse increases, the children are progressively misled into believing the dysfunction is their own fault. Guilt and Shame emerge. 38
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39 Family Dynamics that Emerge Boundaries are blurred and over-permeable Intrusive, invasive style between members Individuation and emotional independence discouraged Demand for loyalty and conformity to family norms and traditions; Parent(s) treat children as friends or confidents (favoritism; abdication of parental authority) Control through emotional manipulation (ostracism, criticism, humiliation, blaming) Guilt and Shame used to maintain status quo, preserve loyalty and punish beliefs or values that differ: You’ll never be good enough; perfectionism (shame) You can’t take care of yourself, you need me (shame) I’m in pain, don’t abandon or leave me (guilt) You must base your decisions on what makes me feel good (guilt) Your role is to protect and care for others (guilt) You are entitled to special treatment because you treat me special (guilt/vanity)
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40 Guilt and Shame fuel the child’s inner sense of inadequacy, promoting underlying feelings of helplessness and dependency into adulthood. (Worth-less-ness)
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41 Couple discord (Bowen) Power-struggles, bickering, domestic violence, infidelity Dysfunction in one of the partners (Bowen) Passive-aggressive symptoms: sexual inadequacy, depression, failure, vices Dysfunction in one or more of the children (Bowen) Family projection process/over-focus on children (transmission) Rigid Triangulation Emotional cut-off (Bowen) Active problem avoidance Difficulty launching children/leaving home (lack of individuation) Common Family Dysfunctional Patterns
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Adult Adult Collusion: Two members ally against a third, such as when a friend serves as a confidant with one of the partners during couple discord or siblings ally against another. The third member feels pressured or manipulated or gets isolated, feels ignored, excluded, or rejected as a result of being brought into the conflict Cross-generational Coalition: The third party is a child pulled into an inappropriate role (cross-generational coalition) such as mediator in the conflict between two parents. This could include parent-child-parent and parent-child-grandparent triangles. child IP Parent Addiction adds cohesion to family Mom Dad Collusion/Alliances and Cross-generational coalitions (Minuchin) Addiction Families
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Rigid Triangulation (Bowen) IP/PP Conflict in the dyad goes unresolved as attention is drawn away from important issues Addiction Co-dependency “Scape-goating” 2. Addiction adds cohesion and purpose to family roles and organization 3. Addiction perpetuates co-dependency in family relations (loyalty) Addiction serves as a protective “lightning-rod” for family anxiety and stress 4. Addiction perpetuates life-long power-struggle for adulthood (individuation) Addiction Families
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The Addict 44
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45 "All family life is organized around the most damaged person in it." ~ Sigmund Freud
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46 Individuals Develop Core Social Problems Individuals are prone toward feelings of shame, inadequacy and worthlessness Having low self-esteem; continual need for validation from others Guilt and Shame fuel depression and anxiety Difficulty with appropriate assertiveness; having weak and/or inflexible boundaries Self-concept continuously falls short of the Self-ideal Problems with Intimacy (difficulty with trust and closeness) Giving up the self in the process of helping others/pleasing others Hypervigilant to critique and the opinion of others Difficulty with trust, communicating and speaking true feelings, beliefs, and needs 3. Problems with Anger, Power and Control Need to control to protect self and mitigate failure Anger and blame fuel desire for revenge and inflates fall sense of vanity Problems Accepting criticism and failure Aggressive Avoidance Mitigates risk, failure and the likelihood of reaffirming one’s own sense of worthlessness. Problems contending with the responsibilities of Life’s demands
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47 Trauma Life Cycle Life Tasks The Demands of Life Maturation: Adaptation and Adjustment to Change Across the Life Span Trauma Normative and para-normative hardships including Loss; Betrayal; and natural or manmade Disasters and Tragedies Life Tasks Core domains of adulthood: Work; Love; Friendship (Alfred Adler) Life-Cycle Changes Normative and para-normative developmental changes that occur across the life-span (Monica McGoldrick) Most Assessment tools explore problems associated with these three domains.
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48 Socialization places continuous pressure on the need to adapt to change. Individuals that do not believe they are capable of successfully meeting the demands of life seek to avoid playing by the rules. Adler categorized these strategies as Neurosis, Sociopathology and Psychosis Strategies for Life’s Demands Tip #1: Self-esteem (Worth) = Self-ideal – Self-concept Tip #2: The more extreme the behavior, the lower the Self-esteem Tip #3: To increase Self-esteem, reduce isolation/increase Social Interest
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49 Failure and Shame Increase Avoidance Co-dependency “mutual enabling” Sociopathology “Yes, but so what?!” Neurosis “Yes, but…” Demetrios Peratsakis, LPC, ACS, CCTP; 2020 Avoidance helps mitigate responsibility for change and buffers feelings of failure and shame. But, avoidance negates accomplishment and the nourishment and confidence it provides! 1. 2. 3. The greater the overlap, the greater the tendency to avoid
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Child struggles with feelings of inadequacy and competency to contend with life’s demands Shaming results in low self-esteem and feelings of worthlessness Peers/Others may take on exaggerated importance (pseudo-independence) Defiance, violence and similar power-plays may take on exaggerated importance (pseudo-independence). Addiction is a power-play. 50 Guilt & Shame Overview
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Self-concept (I am worthless) and Self-ideal (I am very important) often at great extremes. Failure and rejection breed hurt and anger fueled by more guilt and shame. Rage becomes foundational, often expressed in passive-aggressive terms (depression, helplessness, addiction) Shame results in fear of intimacy or the risk of exposure of one’s inadequacy 51 Inadequacy ( “into-me-see” ) = hypersensitivity to betrayal, rejection and abandonment
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SHAME “There is no greater agony than bearing an untold story inside you.” -Maya Angelou, I Know Why the Caged Bird Sings Guilt and Shame are strong forms of self-deprecation (pity-pot) and provide a perfect justification for continuing to use. Guilt and Shame are purposive: they are forms of contrition without the necessity to change! (Adler) Yet….
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Achievement Sabotage/Risk Avoidance: undermining success in life tasks, such as work or academic performance, intimate relationships (Jones and Berglas;1978) Co-Dependency: Dependency on others to protect one’s exposure to potential incompetency and to avoid responsibility (Schoenleber & Berenbaum, 2012). Perfectionism, Arrogance, Exhibitionism and other Cognitive Distortions: negative view of other’s behaviors; selective focus on negative events; rigid rules and expectations; doubt as to own coping skills; etc. (Schoenleber & Berenbaum, 2012). Fantasy: active avoidance and denial of shame and feelings of guilt (Schoenleber & Berenbaum, 2012). Self-deprecation: one-down-position (Adler; Loader,1998) Anger/Aggression: countermeasures for contending with shame-based triggers (Schoenleber & Berenbaum, 2012); Power over others; Loader, 1998 Passive-aggressive Power-struggles, including depression, substance abuse, eating disorders, and withdrawal, isolation or failure (Adler) Fear of Intimacy: “Shame = Me Sham” Note: Due to the inherent difference in power and vulnerability, therapy is inherently shaming (Herman; 2011) 53 Shame Regulation Strategies
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54 Addiction, is an aggressive form of avoidance. -D. Peratsakis
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Treatment A Long Journey into Adulthood 55
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The Initial Consultation STEP 1: Global Assessment Standard instrument (ie DLA-20) or core realms of functioning: Relationship System (genogram not history) Unresolved Trauma Existing Power Struggles / Open Discord; Abuse Drug Use and Addiction (immediacy/risk) Overall social functioning with Love/Sexual Relations, Work, Friendships STEP 2: Rule Out* Exclude the possibility of a neurobiomedical condition STEP 3: Explore the PP or Symptom: “If the drinking/drug using was NOT the problem, what would be?”; Better yet, “Who would be?!” Track the Sequence of beliefs and interpersonal transactions surrounding the Presenting Problem (PP), Identified Patient (IP) or Symptom(s); Test the rigidity of the belief system, unbalance existing convictions and introduce new possibilities; Return to the Presenting Problem/Contracting, refocus on the goal of treatment and solidify agreement to work. 56
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57 Rule Out Underlying Medical Conditions Hormonal, neurochemical, structural injuries or irregularities of the body and brain Congenital Brain Damage (CBD): genetic (pre-birth) or birth trauma Acquired Brain Injury (ABI)/Neurological and Medical Illnesses: i.e.. stroke, tumors, aneurysms, thyroid disease, cancer, vitamin D deficiency, poisoning, exposure to toxic substances, infection, choking, complications due to alcoholism, substance misuse or medications. Traumatic Brain Injury (TBI): head/skull injury to brain (accidents, sports injuries, falls, violence) What to look for: Evidence of Progressive Decline in Cognitive Performance Selectivity of the Impairment Attitude toward Impairment by Caregivers “The Miracle Question” Things to Consider Formal Testing; Coordination with PCP or other primary healthcare providers “Can Do” vs “Can’t Do” ; “Can’t Do” vs “Wont Do” Institutional Behavior Chronic Duress/Severe Emotional Distress Symptom Purpose and Intent*
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1. Heal Trauma/Shame Lift depression and anxiety by working through Guilt, Anger and Shame (GASh) 2. Reconcile Power Issues a) Disengage and redirect existing power-plays, b) reconcile hurt and need for revenge, and c) work toward making amends and accepting responsibility. 3. Improve Self-worth Develop trust, intimacy and “social interest” through a) meaningful involvement; b) navigating the tasks of life, and c) accumulating achievement 58 SA Treatment Targets complimentary and mutually reinforcing goals
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Addiction psychotherapy requires treatment of the individual and their relationship system. It may include individual, couple and family therapy, so long as the milieus are not at cross-purposes. Adults seek a meaningful relationship for the exchange of trust, caring and sexual pleasure. If one exists, couple therapy provides an enormous benefit for reconciling many of the maturational issues of adulthood. If not, active search for a partner while developing greater achievement in work/school and fellowship is beneficial. Heal Trauma/Shame using Cognitive Restructuring Get to the pain; confront distraction from pain; dig at disparities between reporting and affect Tap into anger (to lift depression and anxiety); teach emotional regulation Work through family issues of guilt and shame Reconcile Power Issues Reconcile unresolved conflict, discord and cut-offs Redirect avoidance/passive aggressiveness and power-plays toward shared goals Address co-dependent functioning; individuation/differentiation of self 59 Overview of the Treatment Process
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Work to Build Self-worth Intimacy and work on co-dependency individuation of self; firming up self boundaries assertiveness training, values clarification and “I-statements” treating the dyads; changing the “see-saw” use therapeutic alliance and treatment community to build trust and mutual caring Accepting responsibility getting off the “pity pot” and making amends and restitution; forgiveness achievement in the Tasks of Life 3) Developing Social Interest integration into meaningful activity and psychosocial/socialization activities for decreasing isolation and improving ADLs creating a new personality and relationship building 4. Relapse Work and Recovery Extension of Goals under 4.3 above Find excitement and fuel passion in giving to others Take on leadership work/roles with others, mentor, teach and build 60
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Treat MH, SA will follow Age of onset/cognitive impairment “Wet” versus impaired; abstinence not a precondition of treatment Enabling is your need; Do NOT buy guilt trips, begging, promises or good intentions Addiction is co-dependency; get the other “addicts” into the room Recognize the need for safety through avoidance Recognize the need for control and revenge Relapse as a sign of increased vulnerability Improve worth and recovery is sustainable Medication to manage cravings and mood can be useful Expect collusion against the therapist; by the client and their membership Beware “Cold Turkey”; predict failure 61 Treatment Considerations
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Addicts carry enormous Rage. Since most of us have issues with Anger, this can be toxic. Often communicated passive-aggressively (depression, using, abject defiance or failure. Tap into the anger and examine more overt means of seeking revenge or retribution Work through guilt and shame; loyalty issues to family History of 1) childhood trauma (ACES) or 2) excessive “pampering” (indulgence and protection from the consequences of one’s own behavior). Either individual becomes depressed or aggressive when they don’t get their way. The addicted individual often appears arrogant and boastful. This is over-compensation for deep feelings of inadequacy and worthlessness. Perpetual “Adolescence” THINK FAMILY LIFE CYCLE ! Thrill-seeking (sketchy places and things; secrecy; defiance of morals, authority and the law) Behavior may be highly sexualized; relationships benchmarked with power and control issues Addiction is a means of proclaiming independence and empowerment Minimization of responsibility Self-medication for feelings of shame, guilt, sorrow and resentment Need for maturational tasks, adjustment to family power, responsibility, and individuation 62 Treatment Considerations
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Treatment Considerations Common Deficits Sample Interventions Family roles are rigid, although emotional boundaries are blurred High co-dependent with strict rules against leaving Members will collude against the therapist to avoid change Power issues, infantilization and erratic responsibility expectations (ie. families with problematic teenagers) Intimacy and trust are stunted or damaged because of chronic conflict and betrayal. Trauma prevalent among all members; domestic abuse common Maturational growth is stunted; over-identification with needs of family/self-sacrifice; failure to thrive as an individual. Relationships are reactive and highly charged. Thrill seeking; short-term/immediate need gratification; high impulsivity and no-follow-though. Control issues/pseudo-independence: “I choose to be addicted; you cannot control me!”. “Cold turkey” as sabotage/failure. A no lose proposition: “I win?”: I’m superman; “I lose?”: good reason to use. Align subs-systems; swap/manipulate roles; individuation values clarification, I-messaging and Self-concept work Autonomy and separation anxiety work; family council De-triangulate therapeutic alliance; co-therapy Resolve conflict/passive-aggressive power-struggles; re-align hierarchy; assist with “leaving home/empty nest” Rebuild trust by working through anger and need for revenge, redirecting power-plays and pushing for amends, forgiveness and redemption. Work on guilt and shame. Address major life tasks including work/school, mature friendships, and love with significant others (intimacy; sex); future focus, ie. marriage, parenthood Goal setting; work on social interest/meaningful activity with others; cultivate passions and hobbies Work on autonomy; empowerment and assertiveness training; leaving home/empty nest transition work “Spitting in the client’s soup”; predicting sabotage and restraining techniques 63
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There is no greater privilege, then to share in the suffering of another! TRAUMA
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65 Depression/Anxiety © 2014 Demetrios Peratsakis, LPC, ACS, Guilt Shame Anxiety: dread; perceived sense of vulnerability; preoccupation with safety; future oriented Depression: sorrow + hurt; result of a significant loss or becoming the victim of disaster or a betrayal by a trusted person or loved one; spectrum disorder; past oriented. Evolutionary advantage: reaffirms social bonds/protection. G-A-Sh : depression and anxiety are fueled by feelings of Guilt, Anger and Shame Trauma results in a mix of feelings and thoughts called depression and anxiety Working with Trauma
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66 66 Targeted Treatment Processes - Demetrios Peratsakis, LPC, ACS © 2015 Sadness Fear Anger Guilt Shame 1 2 3 Depression and Anxiety lift Work on Guilt and Shame Tap into Anger 1. The guilt and shame must be reconciled and their underlying (cognitive) distortions restructured The anger that accompanies the hurt must be validated and given voice. As the therapist taps into the anger, the depression will lift. The simple rule is: where there is depression, there is also anger. (When you see “Sad”, look for the “Mad”; to reduce the “Sad”, tap into the “Mad”) 3. Self-worth must be improved by increasing confidence and prestige through social involvement that is purposeful and meaningful. Empowerment begins as self-worth improves. Depression = hurt and sadness Anxiety = Fear
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Clinician awareness and acceptance of own shame Maintain a shame-free therapeutic alliance Give pain & shame “voice”: telling one’s story Explore, recognize, label and re-label shame Elicit unexpressed & avoided shame Exploring disconnections and self-distractions from pain Exploring the need for self-pity and blame Tap into underlying feelings of anger and rage Processing & treating shame Cognitive restructuring -see slides on sample treatment techniques Practicing vulnerability Developing social interest (meaningful attachment with others) 67 Strategy for Healing Shame
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While there are numerous strategies and interventions for repairing psychological injury, the following tactics should be a part of any approach and treatment plan. Medication can be a valuable tool for stabilizing the highs (anxiety) and lows (depression) in mood that accompany the emotional pain of trauma. Be mindful, however, that because medication (and drug use) can blunt the experience of pain, this may detract from the individuals willingness to seek counseling. When both are employed, medication should augment, but not serve as a substitute for, talk therapy. Ending the source of the Damage, then Repairing it. Failure to thrive, domestic violence and other sources of chronic demoralization must be addressed first. The simple rule is, 1) work to end the source of the injury, 2) while building up the self-esteem, and then 3) treat or repair the damage that’s been caused. Repair includes working through the underlying guilt, shame and anger (GASh). Since some of the worst damage results from betrayal, working to re-build trust in relationships and increasing social interest (care of others) is critical. (Re-) Building Self-worth: self-worth is tied to once estimation of self, their competencies and abilities, as well as to their evaluation by others. Empower the individual through constructive “can-do” skill developments, especially those that increase one’s sense of social competency and adulthood. Feeling able and “adult” has protective value, makes one feel less vulnerable and more confident. These can be any form of achievement, the more enduring the better. “Dooming the Client to Success” is important, so early endeavors should be small, geared for success and reviewed for the possibility of failure or sabotage. 68 Keys to Healing Trauma
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Revenge is important to the healing process. While immoral and illegal activities are counter-therapeutic and should be discouraged, many forms of retribution are beneficial to recovery. Validate the desire for revenge, give the underlying anger voice, and help the individual work through their own guilt and shame. A common admonition is that “It’s O.K. to hope the guy gets hit by a truck, so long as you’re not the one driving it”. Naturally, the best form of revenge is to heal and move forward with life. Forgiveness and Redemption: Forgiveness is transformational; for the perpetrator, as well as the victim. While retribution and apologies may be helpful, genuine forgiveness is only made possible by genuine remorse. Not all Depression is the Same. It’s helpful to think of depression as falling into one of three categories: Simple depression: the natural sadness and worry that accompanies disappointment and loss. Rarely will this result in the need for counseling. The individual and their relationship system will heal the pain on their own over time. Complex depression: An injury that results in a greater degree of pain that effects daily living, and is accompanied by a pervasive sense of guilt and shame. An important feature of complex depression is that the individual harbors unresolved resentment or rage. Untangling the hurt and voicing the anger are important to resolving it. Depressives: Individuals, often adult children of chronic childhood abuse, can develop a “depression-prone” or “depression-like” style of life that we call “depressive”. Depressives have learned from early on to control and manipulate others through their depression. It’s a highly effective strategy for getting one’s way without having to accept responsibility or blame. When you work with someone who you believe “wants to, but can not”, you feel compassion; but when you work with someone that you sense “can do, but will not”, you feel angry and resentful. Few syndromes pose a greater challenge to the therapist for these individuals can present as very demanding, passive aggressive, and manipulative. The key to success is to check your own anger and to remember that the person is in dire need of compassion and love, the very thing they fear and that their behavior is fashioned to guard against. 69
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Power Struggles
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Addicts and their relationships are characterized by power struggles, discord and conflict.Sabotage and defiance are excellent forms of revenge.Addiction, carries both while under the pretext of helplessness.
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Power, at the core of every social interaction, is influence and control within the relationship system. It determines style of communication (how love/caring, anger, other emotions are expressed/understood) style of decision-making and problem-solving level of trust for meeting or not meeting needs rules for interdependence and attachment; independence, distance and closeness between members rules around positions and roles (these are relatively enduring and acquire “moral character” and “status” in the family's power hierarchy, often replicated outside the family at work and with others). Conflict is always about power; it occurs around issues of money, work, sex, children, chores, and “in-laws” The Power (& Control) Dimension 73
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Drive; natural force of Life Expression of one’s Will, interests & wants Ability to Influence Outcome Power Natural product of interaction; collision of Wills Routinely mediated and reconciled Tension ensues offset by Triangulation Conflict 2 “Wills” Become 1 “Won’t” Stale-mate/Power Balances Power may be passive-aggressive or issues may be “avoided”. Chronic tension may lead to illness, dysfunction or misbehavior Members may hurt one another Power-Play Action to break the Stalemate Negative Triangulation: scape-goat others/issues; collusions Misbehaviors Betrayal, Failure, Violence, Revenge, etc. Misbehavior Power….where there’s a “Will” -there’s a “Won’t!” -Demetrios Peratsakis, LPC, ACS Unresolved Conflict Sequence 74
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Neutralizing or Breaking an Impasse Often Results in Trauma Unresolved, conflict builds Anxiety Common Problem-solving Remedies Collaboration/Alliance (win/win) Compromise (I bend/you bend) Accommodation (I lose/you win) Competition (I win/you lose) Avoidance (no win/no lose) Triangulation (win/win/lose) Conflict Anxiety builds until resolved Chronic Tension Results in* Open Discord Stable, unsatisfying Unstable (unsatisfying) Impairment in a Child Attention Seeking Power Seeking Revenge Seeking Displays of Inadequacy Impairment in a Partner Failure Depression Illness Emotional Cut-off, Escape or Expulsion * Bowen (1-4); Adler (2. a,b,c,d) Power Struggle Tension solidifies into long-term discord Power Play Anger and hurt result in dire attempts to break the impasse Demetrios Peratsakis, LPC, ACS, CCTP © 2014 The ABC’s of Conflict, Power-struggles & Power-plays Unresolved, conflict becomes an impasse or power-struggle that may be broken by abuse or a violent power-play 75 Examples: Treachery/Betrayal theft, disloyalty, sabotage, incest, abandonment, infidelity Revenge punishment, suicide, crime, depression, addiction, eating disorders, failure or acts of inadequacy Violence warfare, bullying, threats, rage, domestic violence, abuse Rigid Detouring to an Identified Patient/IP (“Scapegoating”) Escape or Expulsion (cut-off) A B C
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76
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Anger and Aggression are natural, protective reactions to fear and (the risk) injury and considered one of the four primary emotional pairs that develop within six months of birth (Anger/Disgust, Fear/Surprise, Sadness, and Joy) According to Adler (1913), there are two (unconstructive) methods by which we protect or safeguard our self-esteem: depression; and aggression Anger is a way to control others or to get one’s way It may be overt (bullying/violence, persuasion) or covert (passive aggressive) It can provide a faulty sense of power To retain the anger, the harm or emotional pain must continually be reactivated (rumination), often in the form of self-pity or blame On the Use & Mis-Use of Anger 77
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2. Anger can temporarily empower, mobilize, and counter-act feelings of inadequacy, especially a) sorrow, b) guilt and c) shame It can counter-act feelings of depression and anxiety This is why we often feel sad, when we are, in fact, angry. In some families anger is so toxic that it is more acceptable to become ill, depressed or “insane” Guilt and shame result in feelings of worthlessness and hopelessness (aka powerlessness) Individuals prone to feelings of worthlessness often develop a great sense of ‘nobility’, stemming from beliefs associated with the desire to change, make amends or seek revenge. The ensuing struggle justifies one’s good intentions despite the unwillingness to change or relinquish its control of others. Anger may establish distance or stave off intimacy. Anger may express as domestic abuse and betrayal or else as a passive-aggressive syndrome, such as depression, sexual inadequacy, addiction, compulsions, and eating disorders. On the Use & Mis-Use of Anger 78
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The Mis-Use of Power Retaliation and Abuse in the Relationship System (see section on Domestic Violence)
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Relationship of Power to Intimacy Intimacy Requires an Equal Sharing of Power
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81
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Power and Intimacy Mutuality of influence allows each partner to feel important and supported in the relationship -affirming identity and worth. Partners can then open themselves to being changed by the other, to accept influence. They also feel safe enough to reveal their innermost thoughts, express concerns, even admit weakness, uncertainty, or mistakes in a partner’s presence. Mutual vulnerability becomes a high-water mark of bringing one’s whole self into a relationship (Carmen Knudson-Martin; Family Process) 82
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Intimacy: a Psychotherapist’s Definition An agreement (Trust) to risk hurt and pain (Vulnerability) in order to experience acceptance (Love) and belonging in a meaningful way (Worth). Belonging in a Meaningful Way = Self-Worth = Mental Health Intimacy increases belonging in a meaningful way Trauma reduces our capacity for love; it makes us self-protecting, reducing our willingness to risk pain. Psychological Injury is damage to our sense of self-worth 83
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Inequality of power reduces one partner’s ability to openly share, succeed in conflict and feel fairly valued 1. The potential for personal growth is reduced 2. Stress is increased Intimacy Requires an Equal Sharing of Power 84
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Disengaging and Redirecting Power-Plays in the Therapeutic Alliance Taking a “One-down” Position and Reaffirming the Working Alliance
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Not talking, selective disclosure, not answering Not following advice or suggestions Coming late or leaving early Non-payment/non-compliance with required releases/paperwork Stalking, Threatening, or Intimidating Provocative or threatening clothing Change seating or other office arrangements Provocative or threatening language Dominating the conversation Inappropriate touching, hugging, etc Inappropriate gifts or offering incentives Belligerence and Rage Acting seductively, coy or unduly vulnerable Not improving or regressing Sets appointments then Cancels/No Shows Member sets appointment, other refuses to attend Member sets appointment then sabotages another’s participation Both attend, one sees a problem, the other does not Both attend, one begins to no-show Both attend, both agree one member is the problem Carpet-bombing PP keeps changing/new crisis every session Power-Plays in the Therapeutic Alliance 86 1-13, Ofer Zur, P.D.; 14- 22, D. Peratsakis
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Understanding the nature of power and its integral relation to our social interactions is the key to mediating power-plays and remedying conflict. Power, is influence and control within the relationship system. It is the ability to influence outcome, the manifest expression of our will. In this regard, it is never random but purposive and consistent with our self-concept and worldview. It colors our beliefs, opinions, interests and desires and can best be understood through our behavior and the intended goal of our action. Understand the Nature of the Power Play 87
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88 Examine the Intent of the Power Struggle Does the client need to control others in order to feel more worthwhile or superior? Is the client angry or upset with the therapist? Is the client second-guessing the utility or effectiveness of treatment? Has the therapist in a manner that is suspect or that has damaged the trust? Does the therapist misuse their power and belittle, shame, or induce guilt in the client, especially by moralizing, lecturing or assuming a haughty or “parental” attitude? Is the client frightened, contending with mistrust from prior emotional trauma and psychological injury? Is the client worried or freighted about the potential consequences of change?
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Disengaging and Redirecting the Power Play Stop the process and ask directly about the issue. “I think I may have stepped on your toes a bit, are we going to be okay?……..” Take a 1-down: “I’m not sure where we are; how should we proceed?”; “I’m a bit lost, where should we go from here?” Point to the ambivalence: “I’m getting some mixed messages; should we move forward or not; is this worth trying to change?” Seek permission to power-play: “My role is to push you in ways that will be uncomfortable. That may be more than you bargained for but otherwise we may waste a lot of time and not get as much done”. “Would you rather I annoy you or waste your time?” 89
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Recovery 90
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91 “…everyone who is deeply unhappy…(was) deprived in their younger years of being able to develop the feeling of community, the courage, the optimism, and the self-confidence that comes directly from the sense of belonging. This sense of belonging…can only be won by being involved, by cooperating, and experiencing, and by being useful to others. Out of this emerges a lasting, genuine feeling of worthiness.” -Individual Psychology; Alfred Adler, 1926 Social Interest, the Key to Recovery
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92 Social Interest = Responsibility to Others Developing one’s social interest, one’s skill in belongingness, is the path toward remedial growth, redemption, and recovery.
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93 Social Interest We are socially beings with an extremely heightened sense of consciousness. The purpose of our consciousness is to keep society together; to predict, assess and effectively navigate complex social relationships. - Social Intelligence Theory, Anthropology This has enormous evolutionary advantage as it’s by-product, human culture, provides innovation, a continuous font of adaptability to change. Adler proposed that man has a fundamental desire to feel belonging to others; that this “social interest” was the primary motive in man. - Adlerian Psychology; Rudolf Dreikurs, 1949 According to Adler, social interest is “a feeling of community, an orientation to live cooperatively with others, and a lifestyle that values the common good above one's own interests and desires” (Guzick, Dorman, Groff, Altermatt, & Forsyth, 2004; p. 362). Developing one’s social interest, one’s skill in belongingness, is the path toward remedial growth, redemption, and recovery.
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94
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95 Techniques for Improving Self-worth and Restructuring Cognitive Distortions
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96 Sample Techniques for Enriching Worth Worth is the estimation of our own value. While intricately tied to the opinion of others, it is also a valuation we make when comparing ourselves to others, to our own past conduct or accomplishments and to some ideal or idealized imagining. Mostly, we can never match up to the ideal which results in some degree of a) guilt feelings (I am not moral enough), b) shame (I am not good enough) and c) striving (If I can do better…). When we believe the estimation of our moral compass or competency by others is unjust or unfair (real or imagined) we harbor resentment at the perceived injustice. This is why Guilt and Shame is most often accompanied with Anger; and, while the anger may appear to be targeted toward oneself, it is, in truth, resentment at the injustice place upon one by others or another. There is truth to the old therapist saying that “a dead mother can be the most demanding…”). There are many self-esteem, self-protection and self-regard techniques and exercises including worksheets and journals, many of which are available free on-line or purchased as workbooks. Below are some simple, as well as more sophisticated techniques or schools of technique that should become a routine part of the therapist’s tool-box Work through Guilt, Anger and Shame. This is a very sophisticated area of work. Increase Differentiation of Self (delineation of one’s Self-boundaries). These reduces overall reactivity: a) demarcate feeling from thought; b) one’s own feelings and thoughts from another’s; c) the origin of one’s beliefs; d) the relationship between thought and belief (interpretation). Increase one’s sense of belonging. When anxious, depressed or under duress one isolates and restricts their sphere of contact (isolating will also result in depression and anxiety). Reconnect to others, meaningful goals and activities. Behavior Rehearsal (real and imagined practice) reduces anxiety and stimulates competencies Reframing: every situation, including a problem, has some positive aspect, either in process or in outcome. Turn meaning and personal context from a felt minus (-) into a felt plus (+). To be effective, it must be true. To be more impactful, it must be more than the mere “oh, look at the upside”, it must cut to the root of the despair: ie. “…while it’s true that you stayed for fear of leaving, that may have been the price you had to pay to ensure that you were making the right decision for your kids. That’s a remarkable sacrifice that only a loving mother could do”.
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97 Explore fears and dreads: “What’s the worst that could happen? What would you do? And then what?”. “If we did battle with this _____, what would we need to do in order to win?” Top Ten List/ "Boasting": Tell me what you are good at? To others: “What is he/she good at?” Example prompts: I like myself because… I’m an expert at…; I feel good about…; My friends would tell you I have a great…; My favorite place is… People say I am a good…People compliment me about…I’m loved by… I’ve been told I have pretty… I consider myself a good… What I enjoy most is… The person I admire the most is… I have a natural talent for… Goals for my future are… I know I will reach my goals because I am… I feel good when I… I’ve been successful at… I laugh when I think about… The traits I admire myself for are… I feel peaceful when… Self-Esteem Journal: many, many online worksheets and journals; ie. http://www.self-esteem-experts.com/self-esteem-worksheets.html or http://spiritwire.com/selfesteemtips.html Mild Hypnotic Suggestion: “When did you first realize that you could....? Simple Paradox: exaggerate the symptom or complaint in order to obtain recoil Reduce “Buts” and “Shoulds”: Move to acceptance of behavior truth; change “But” to “And” “Doom” Client to Success: direct task in a manner that more energy must be expended to fail than to succeed. Action must be in defined, behavioral terms within the client’s control: restrict frequency, duration, location, participants, et al; then predict the difficulty of the task and that many often fail at it the first few times. Examine Success: what worked? How do we do more of what worked and then apply that to other things? Log all that is going well enough to Not want to change
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98 Gift to Self: have client reward self for some success Increase social competency: art, dance, wine, film, literature Increase sense of physical safety and health: vitamins, yoga, karate, balancing a check-book Pet therapy: new puppy, kitten or fish; volunteer at kennel Ordeals: Attach burdensome rituals to negative thought and behaviors. This is a very sophisticated area of work Act “As If”/Chrissie and Christina Chairs: more sophisticated than “behavior rehearsal”, “acting as if” involves taking on a whole personna, becoming the person who is competent to do the thing desired, a “New Identity” (ie. “that was the old way, the old you (“Chrissy”); tell me how Christina, the new you, will do it?”) An excellent way of using this is to create a new personna based on the client’s name; ie. “so, Chrissie, if you were capable of finally doing this and being more like that very capable woman you describe, let’s call her “Christina” (I think there was a noblewoman or Queen by that name), could you tell me how “Christina” would do it?” Now a “super-ego” version of Chrissie has been created and one can say things like “that’s the old way(“Chrissie”), tell me how “Christina” would do it?” “Spitting in the Client’s Soup”: Make the covert intent, overt: exposing the hidden agenda or motive (covert intent) can neutralize its utility and power. This is especially helpful when it undermines the nobility often associated with “good intentions”, that which disguises true intent. To do so, point to the real motive of the client's behavior; for example: “It seems like you are trying to make me feel angry, so that I can push you away and then you can tell yourself that nobody wants you?” “You seem to be punishing her with your depression (incompetence); that’s a clever way to get even. You must be really pissed at her!” Turning to wife in session: “I wonder if he brought you so that I can take care of you while he leaves and escapes the marriage!” 21. Therapist takes a One-down position: this “forces” the client in the “one-up position”
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99 Paradoxical Interventions: This rather sophisticated body of work involves prescribing the very symptoms, rules, roles or behaviors that are reportedly problematic. Highly effective, it relies on the client’s inherent rebelliousness or defiance. Of course, the public hearing that you asked someone to “cut themselves with a bigger knife if they are serious about suicide” may not play well in the news. Guided Imagery: the use of imagination to heal trauma and to create incremental recuperation. Guided Imagery involves a relaxation exercise coupled with a suggestion or task. The greater the relaxation, the more profound the experience possible. Example; after some relaxation work “imagine that you are holding a baby, and the baby is you……” “you have become very, very small, entered your body and gone up to look through your eyes. What do you see?” “you anger (guilt, shame) is a black, spiky ball that is very cold (client’s description)….let’s focus on its coldness and make it just a bit warmer, a little bit warmer now, and a bit warmer, still…” “picture yourself having done “it”/something well it; now watch yourself in the process, like a movie, running it backwards and forwards and seeing how you did it in a new way, a way that now works” “pretend you are sleeping and when you awoke a miracle had occurred and everything was going well in your life…” “time travel to a time in the past/future, when everything was/is as it should be……” “fantasize the “evil” part of you…”; “fantasize the “good” part of you…” “picture that you have met someone that likes you; they confide what they admire about you… 24. Empty Chair: for rehearsal and expression of anger and unfinished business. The more detailed the description the more “real” the protagonist becomes. The chair has now become a “concrete reminder” of the person and can be put away and pulled out as often as desired, but should never be used for anything else as it is now representative of the person or symptom or entity depicted. Example: exorcizing the Ghost; place the “ghost” (person, rule, behavior, illness, symptom) in the chair and confront them as the source of the trauma, loss or betrayal Example: Co-therapy/exorcizing One’s Past; make the client the therapist and have them treat their past self
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100 Mindfullness: meditation is a powerful technique for a) relaxing the body, b) stilling the mind and c) exercising one’s connectivity to their senses Matching Intent: we are often aware that what we say and what we do are not in sync and that our behavior is a truer indication of our intent. Owning one’s intent, despite how that may feel to self or seem or others, is an important step toward empowerment. One then is free to choose to change. Born Again/In-Utero Re-growth: recreate one’s birth and life history Improve Problem-solving Skills: CBT and many models of therapy have good worksheets for improving decision-making and problem-solving capabilities which help make an individual feel less inept. An important part of this is learning to “Broaden Narrow Problems and Narrow Broad Problems”. “Fessing Up and Owning”: our own misbehavior and harm to others, no matter how “justified”, results in diminished self-worth. These must be remedied or reconciled in order for redemption to occur: emotional cut-offs; cross-generational coalitions, collusions and other subversive alliances; discord with a parent, partner, child or loved one; exiting power-struggles; Betrayals 30. “Acts of Contrition” are necessary to make amends and seek forgiveness. Examples include get on knees and beg for forgiveness go to church/temple/place of worship and seek confession talk about one’s own shame; describe one’s own weakness write a letter, poem or newspaper ad of apology contact relatives, children, peers or co-workers and “confess to the sin” allow the victim to give them a “token” punch in the arm, step on the toe or spit at the shoes arrange and participate in a voluntary (controlled) public “shaming” or reading of transgressions destroy or damage a favored possession; give away a cherished belonging hold a “confessional” sacrifice a favored activity or need (“Lent”) enter “indentured servitude” for a period of time
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Push Button Technique: 3 memories and 2 buttons Confusion Technique/Oration before the Oracle Coin Toss (Wishing Well): “What were you hoping for..?” Red, White and Blue Poker Chips: sobriety from symptoms Early Recollections/Dreams Genogram: Family Messages/”How I View…” Concrete Reminders: Lucky Coins, Power Stones, Hash Tags and Band-Aids Pretending to have the Symptom (use of a timer) Cliff Hangers: “ I see a lot of significance in something you said today. Let’s discuss it next time” “The Question” - “How would your life be different if you no longer had this problem?” (“Suppose I gave you a pill….”; “Imagine I have a magic wand…”; “If you looked into a crystal ball…”) Reflecting As If (RAI; Richard Watts) The therapist uses reflective questions such as: If you were acting as if you were the person you would like to be, how would you be acting differently? If a good friend would see you several months from now and you were more like the person you desire to be or your situation had significantly improved, what would this person see you doing differently? 101
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Create a new symptom (ie. “I am also concerned about ________; when did you first start noticing it?”) Move to a more manageable symptom (one that is behavioral and can be scaled; ie. chores vs attitude) Add, remove or reverse the order of the steps (having the symptom come first) Remove or add a new person to the loop Inflate/deflate the intensity of the symptom or pattern Change the frequency or rate of the pattern or symptom Change the duration of the symptom or pattern Change the time (hour/time of day/week/month/year) of the symptom or pattern Change the location (in the world or body) of the symptom/pattern Change some quality of the symptom or pattern Perform the symptom without the pattern; short-circuiting Perform the pattern without the symptom Change the sequence of the elements in the pattern Interrupt or otherwise prevent the pattern from occurring Add (at least) one new element to the pattern Break up any previously whole elements into smaller elements Link the symptoms or pattern to another pattern or goal Reframe or re-label the meaning of the symptom Point to disparities and create cognitive dissonance Note: 1-4, Minuchin/Fishman; 5-6, 22, 23, Adler; 7-21, O’Hanlon. Pattern or element may represent a concrete behavior, emotion, or family member 102 42. Manipulating the Character of the Symptom The therapist and client track the pattern or sequence of behaviors and interactions surrounding the problem or symptom. The therapist then explains that over time problems become similar to ‘bad habits’ and that many find it helpful to change a part of it, thereby making it easier to “kick the habit”:
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Cognitive Restructuring Techniques 103
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Change occurs when the meaning, power or purpose of a belief is modified The most common method for countering negative, self-limiting and counter-productive thoughts is to use Critical Reasoning or a process known as Cognitive Restructuring (Doyle, 1998; Hope, 2010) to “unbalance” and redefine the belief structure. There are four generally recognized steps: Identify problematic images or mental activity that occur as a response to some trigger, like an action or event. These "automatic thoughts" (ATs) convey negative assumptions and predictions about the self, others, the world and ways to belong and function socially; Isolate the distorted, irrational, or mistaken assumption that underlies the automatic thought; Use a Socratic dialogue (through interviewing, role-play or imagery) to introduce doubt, pose new possibilities, and undermine or attack its underlying logic (“unbalancing”). Examples include, Examine the Pros and Cons; assess the negative consequences and scale or assess its cost Weaken a strongly held belief by pitting it against an equally strong opposite belief Point to disparities and logical inconsistencies, especially between beliefs or values Inflate, exaggerate or dramatize the belief to make it extreme, trivial or silly Create or reframe a narrative or story that puts the situation in a more favorable context (reframing) Examine the family rule or “voice” behind the assumption and attend to the loyalty issues Use of the “Miracle Question”, Time Travel or Time-outs to imagine and explore freedom from AT Develop, reframe or re-narrate a rational rebuttal to the automatic thought 104 a) Unbalancing Beliefs
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Thought Stopping: short-circuiting negative ideation; Self-Talk: positive self-affirmation “Spitting in the Soup”: undermine the narrative by interpreting the motive or making its covert intent, overt, then frustrate its inherent sense of “nobility” or personal gain What if this wasn’t so? Explore a scenario in which the idea was no longer true or applicable. Explore “worse-case” scenarios; “What’s the worst thing that would happen if…?” Empty Chair: externalize the belief as an opponent or “demon”, then encourage rebellion against it Use imagery, visualization, role-play, sculpting, drawing or other projective techniques to gain perspective, elongate the narrative or directly manipulate some part of it Use free association, analysis of dreams, early recollections, or fantasy exercises to undermine the power of the belief or myth or to foster imagery-based exposure Mindfulness meditation, relaxed breathing, yoga or progressive relaxation to reduce fragmentation and anxiety, still panic, integrate body and mind and improve focus Activity Scheduling to intentionally experience activities typically avoided Graded Exposure or desensitization to feared or toxic experience, increasing comfort Successive Approximation or breaking large steps into smaller ones Journaling or thought record of moods and/or thoughts, especially noting the time, the extent of the mood or thought, and what led to it Skills Training (i.e.. assertiveness, communication, social skills) designed to remedy skills deficits through modeling, coaching and direct instruction, and role-play training Flagging the Minefield ((Sklare, 2005) or anticipating and preparing for relapse and pitfalls 105
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It is important to continually test the rigidity of the beliefs surrounding the Presenting Problem and the Identified Patient. Introducing new possibilities, reframing and resequencing existing interactional patterns or re-organizing roles, rules and organizational structures or patterns increases flexibility and expands the client’s perspective and ability to interpret -and then respond, in a different way. History of Presenting Problem (PP): major nodal events surrounding the problem onset, including trauma, betrayals, losses, anniversary dates and major transitional events such as retirement, divorce, graduations or beginning school, leaving home, et al. The difficulties adapting to change, hardships or periods of heightened stress often foster the creation of problematic or symptomatic behavior patterns. The symptom onset often clues you in on the possible purpose the symptom or problem serves. Pattern of Interaction This refers to the sequence of behavior surrounding the Presenting Problem or problem occurrence (who does what, when and where). This repetitive, interactional loop maintains the presenting problem and highlights who participates in maintaining it. Manipulating its components, introduces new possibilities and fosters a revised perspective on the problem, its etiology and purpose. Unbalancing the Symptom 106 Change occurs when the meaning, power or purpose of the P.P. is modified
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107 Behaviors, feelings and thoughts surrounding the presenting problem (PP) or symptom harden over time becoming interactional patterns that acquire history with well-defined roles and rules and expectations. In essence, a pattern or “structure” around which communication and membership is organized, boundaries defined, and power expressed and reconciled. In particular, the emerging pattern fulfills the mutual purposes of its participants, providing a vehicle for communication and attachment and the open expression of love, anger, trust, and responsibility. Underlying this, we often find a prolonged and deeply embedded power-struggle, fueled by concomitant feelings of hopelessness, resentment and rage. It is often passive-aggressive. How Psychological Symptoms Form
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108 Shared Distortion Shared values and opinions, represented by the overlapping shaded areas, mirror a part of each member’s belief structures thereby reaffirming (concretizing) their ‘truth’ and purpose. Shared Cognitive Distortions Symptoms are convictions maintained by sequences of thoughts and behaviors, by the individual as well as their relationship system. Interrupting these will necessarily alter the symptom and directly challenge its rigidity and inevitability.
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Create a new symptom (i.e.. “I am also concerned about ________; when did you first notice her doing that?”) Switch to a more manageable symptom (one that is behavioral and can be scaled; i.e.. chores vs attitude) I.P. another family member (create a new symptom-bearer or sub-group; i.e.. “the kids”, “the boys”) I.P. a relationship (“the relationship makes her depressed”) Push for recoil through paradoxical intention (caution!) “Spitting in the Soup” –make the covert intent, overt, then frustrate its inherent sense of “nobility” Increase symptom intensity by describing worse-case scenario or what could happen if things went unchecked Add, remove or reverse the order of the steps (having the symptom come first) Remove or add a new member to the loop Inflate/deflate the intensity of the symptom or pattern Change the frequency or rate of the symptom or pattern Change the duration of the symptom or pattern Change the time (hour/time of day/week/month/year) of the symptom or pattern Change the location (in the world or body) of the symptom/pattern Perform the symptom without the pattern; short-circuiting Change some quality of the symptom or pattern Perform the pattern without the symptom Change the sequence of the elements in the pattern Interrupt or prevent the pattern from occurring Add (at least) one new element to the pattern Break up any previously whole elements into smaller elements; cut sequences into smaller steps Link the symptoms or pattern to another pattern or goal Reframe or re-label the meaning of the symptom Point to disparities and create cognitive dissonance Disengage the power-play that fuels the symptom and tap the underlying anger Surface Guilt and Shame and mobilize the underlying anger and desire for revenge Note: 1-4, Minuchin/Fishman; 5-6, 22, 23, Adler; 8-21, O’Hanlon; 7, 25, 26, Peratsakis Pattern or element may represent a concrete behavior, emotion, or family member Introducing New Possibilities 109
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Social structures, includes rules, roles, sub-systems, alliances and collusions exist through shared convictions and belief systems. These organize function and interaction and contribute to long-standing beliefs about the system, its membership and guidelines for interacting; modifying these, change perspective and, in turn, interpretation, opinion and prediction. Restructuring intwilleraction, modifies reality. Below are some common tactics. Disengage and redirect existing power-plays; implement “truce” and reconcile unresolved conflict and cut-offs. Approach the conflict through sequential interpretations (same problem highlighted through different points of view) and track the sequence of interactive behavior (“…and then what happens?”) until the loop comes to a close. Re-enact problem scenarios or use role-play and sculpting to illuminate family or relationship structures and roles, then rescript their narratives and practice revisions Separate people who are sitting together Block interruptions or inappropriate requests for confirmation, to control or to censor Discourage use of one member as a repository for another’s memories, feelings or thoughts Approve descriptions of competence. Encourage members to reward competence in session Tell one member to help another to change If one controls, confront another for encouraging their dominance Direct individuals to speak to each other 110 c) Unbalancing Structure & Organization Change occurs when the meaning, power or purpose of transactions are modified
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Use of ‘empty chair’ to represent absent members, hidden rules, secrets or taboos; manipulate and use space, to connect and disconnect, to show closeness or distance; use props and furniture (concrete reminders) to illustrate relational components Unbalance alliances, coalitions and collusions; fashion new ones, or temporarily join a subsystem, to adjust the balance of power and improve communication patterns Establish, strengthen, or weaken boundaries; empower the executive sub-system I-Messages; increase differentiation of self, personal space and independence of members Block inappropriate roles or role behavior; model appropriate behavior. Prescribe role reversals; revise roles, strengthen existing natural roles, or assign new ones Temporarily shift power and authority structure: Queen for a Day; King of the Castle Provide more structure in a chaotic organization; reduce rigidity in an inflexible structure Take a “one-down” position to force the client or family into the “one-up” Create celebrations, honorifics or exorcisms to modify, up or down, the power surrounding a member; introduce new customs, rituals, practices or ordeals Hold an exorcism or funerary rite for the old belief, family myth or legend; create a ritual or assignment to be practiced that mirrors the new belief. Create a new point in time (“then” versus” from here forward”) or establish a “truce” for moving forward 111
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Use of a Genogram, Socio-map or Family Floor Plan to examine truisms and taboos Establish a Family Council so that grievances and supports can be materialized Spread out a symptomatic role among all family members to expose the family secret or remove or rotate the symptomatic member from the scapegoat position Introduce other clients or families to session and foster interfamilial organization Time-travel or regrow the client or family from scratch and have them “act as if” they are the person or persons they wish to be Use Behavior Rehearsal; “Acting As If”; Guided Imagery; and Fantasy techniques to work on self-empowerment and explore fears and dreads to success and failure Work through issues of Guilt, Anger and Shame (GASh); focus on desires and acts of revenge and move toward acts of forgiveness and redemption Connect with each member and affirm their value; create Caring Days, Identify and validate strengths; encourage recognition by the family of each other through celebrations, boasting, awards and acts of praise. Promote “New Talk” Refer clients to additional educational materials and resources, experts and trainers Assign tasks and functions based on abilities. “What is she good at?” Help members with assertiveness and improve mediation and negotiation skills. Curtail acts of aggression, back-biting, complaining, rivalry, subterfuge and revenge 112
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Identify choices and make joint decisions. “Doom” clients to success by setting small, common workable goals and anticipating obstacles, sabotage and possible failure Identify and emphasize positive changes and movement; examine what worked Reframe negative meanings and negatively charged events Recall incidents that worked successfully in the past or solutions from TV, Movies or others Increase self-esteem, personal worth and mutual respect and valuation; connect in a meaningful way. Improve self-image through boasting and self-esteem worksheets Challenge underlying “nobility” of self-defeating behaviors (“Spitting in Client’s Soup”) Use paradox (with caution) to prescribe existing roles, rules, and patterns of interaction Add or detract family members from session Bring other families into session and pair subsystems, foster interfamily competitions or use members in similar roles as co-therapists Place the symptom on vacation or write a prescription to schedule it at given times Have the clients experience each other in a different, fun, way or varied venue Explore what each member is willing to do to alleviate the current problem, change the rule, alter the belief, or help create, through a change in their own behavior, a new interactional paradigm 113
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Use of the Therapeutic Alliance to foster change. Few components of the therapy process are as potentially transformational as the relationship that, clients have with the therapist. By continuously demonstrating acceptance and positive regard, active listening, and support and encouragement, the therapist provides a safe milieu for the experimentation and trial of new ways of thinking and behaving. Moreover, a seasoned therapist may use their own way of being, their own style of interacting with the client to both frustrate and promote behavior change. Even by simply responding in a manner that is different then what is expected -or routinely experienced with others, the therapist has created the opportunity for change. Finding a balance between support and confrontation, at times even provocation, is an important attribute of the experienced therapist. So, too, is the ability to disengage and redirect the power-struggles that arise between the therapist and client and that are common to the therapeutic relationship. In this regard, the greatest agent of change is often the clinician, themselves. 114
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References Adler, A., The Individual Psychology of Alfred Adler, H. L. Ansbacher and R. R. Ansbacher (Eds.) (Harper Torchbooks, NY 1956 Adler, A., The Practice and Theory of Individual Psychology, translated by P. Radin (Routledge & Kegan Paul, London 1925; revised edition 1929, & reprints Ansbacher, Rowena R. (Editor), Ansbacher, Heinz Ludwig (Editor); Superiority and Social Interest: A Collection of Later Writings by Alfred Adler Cognitive Restructuring: Gladding, Samuel. Counseling: A Comprehensive Review. 6th. Columbus: Pearson Education Inc., 2009. Conte, Christian. Advanced Techniques for Counseling and Psychotherapy, Springer Publishng Company, New York Dinkmeyer, D., Pew, W. and Dinkmeyer, D. Jr. 1979. Adlerian Counseling and Psychotherapy, Monterey, CA: Brooks/Cole. Dreikurs, R., Gould, S. and Corsini, R. 1974. Family Council, Chicago: Henry Regnery. Erford, Bradley T., 2015, 2010. Forty Techniques Every Therapist Should Know, 2nd edition, Merrill Counseling Series, Pearson Hope D.A.; Burns J.A.; Hyes S.A.; Herbert J.D.; Warner M.D. (2010). "Automatic thoughts and cognitive restructuring in cognitive behavioral group therapy for social anxiety disorder". Cognitive Therapy Research. 34: 1–12. Sherman, R., Oresky, P., Rountree, Y. 1991. Solving Problems in Couples and Family Therapy, Brunner/Mazel. New York Sherman, R., Fredman, N., 1986. Handbook of Structured Techniques in Marriage & Family Therapy, Brunner/Mazel, NY Sherman, R., Dinkmeyer, D.,1987. Adlerian Family Therapy, Brunner/Mazel, New York 115
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-for additional materials contact dperatsakis@wtcsb.org