Chapter 15 - Current Issues in Psychotherapy

My Lecture Notes.
Current Psychotherapies.

Chapter 15.

Current Issues in Psychotherapy.

Author: Danny Wedding.
Instructor: Jeff Garrett Ph.D.

Basic Concepts.
Human Resource Data.
U.S. Substance Abuse and Mental Health Services Administration.
193,000 Licensed Clinical Social Workers.
77,000 Psychologist.
41,000 Psychiatrists.
Regardless of professional discipline and training most therapists practice eclecticism.

Licensing vs. Certification.
Licensure – restricts the practice of a profession.
Certification – restricts the use of a professions name.

Most Frequent Causes for a Loss of License.
Dual Relationships.
Unprofessional Conduct.
Conviction of a Felony.
Failure to Comply with a Board Order.
Improper Billing Practices.
Incompetent Practice.

AHRQ (Agency for Healthcare Research and Quality).
Develops treatment guidelines.
Proponents suggest process standardizes the quality of care in mental health.
Critics suggest it leads to a "cookbook" approach negating the uniqueness of cases.
For more details go to www.guideline.gov .

Ethical Issues.
Dual Relationships.
When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a dual relationship.
Clear that relationships involving sexual or financial involvement violate ethical codes.
Other types of dual relationships can be more difficult to discern right course of action.
Adler and Dreikurs suggest therapy is educational and therefore providing therapy to friends and family is acceptable.
Lazarus and Zur (2002) challenge the rigidity of professional restrictions on non-sexual dual relationships.

Sexual attraction.
Intimacy of psychotherapy can lead to sexual arousal and fantasies.
4 out of 5 therapist report feeling sexual attraction to at least on client.
Most report guilt, anxiety and confusion when sexual feelings occur.
Only 10% of therapist feel their training prepared them for this type of situation.
Data regarding the sexual misconduct of therapists suggests incidence rates for sexual misconduct are fairly similar across professional disciplines.

"The guidelines are clear. ... There is no place for sex or other forms of personal intimacy in a professional helping relationship with a vulnerable person." Edelwich & Brodsky (1991).

Third-Party Payers.
Clinicians must be wary of illegal responses to insurance restrictions.
Legal options include only providing fee for service – (lower rates, offering pro-bono options).

Duty to Warn.
The legal case of Tarasoff v. the Regents of the University of California pertains to duty to warn. Tarasoff I - The legal case of Tarasoff I states that if the patient is at immediate risk of harming someone else, the provider has the duty to warn the intended victim.
Tarasoff v. the Regents of the University of California.
States that if a patient is at immediate risk of harming someone else the provider has a duty to warn the intended victim.

Duty to Protect.
Tarasoff II.
Hedlund v. Superior Ct. of Orange County.
States that if a patient is at immediate risk of harming someone else the provider has a duty to take steps to protect the intended victim.

Respondent Supervisor.
The legal doctrine of respondent superior allows supervisors to be held accountable for the actions of trainees.
Supervisors may be responsible for tragic outcomes if there is a failure to warn.

Reportable Circumstances.
Most laws have mandatory reporting laws on suspicion of child abuse including.
Physical abuse.
Sexual abuse.
Emotional abuse.
Neglect.

Privileged Communication.
Privilege – Special status extended to particular types of communication recognized by the law as unique, important and worthy of protection.
Extension of the 5th Amendment which gives Right of Privacy.
Right vested in the client.
Client can waive.

Prediction of Dangerousness.
Predicting violence is like predicting the weather – it’s easier in the short term.
No evidence that therapists predict danger any better than others. In fact, therapist may over predict danger.
Previous violence is best predictor of future violence - The most powerful predictor of future violence is a history of previous violence.

Other predictors.
Head injury.
Being abused as a child.
Witnessing a family member abuse others.
History of psychosis.

Informed Consent.
Therapist must inform clients of …
Nature of treatment.
Purpose of treatment.
Risks.
Benefits.
Alternative treatments.
Although it may not be ideal, informed consent can be obtained verbally.

Except in ….
Emergencies.
If consent is waived.
Incompetent patients.

HIPAA.

Effective April 4, 2003.
The Health Insurance Portability and Accountability Act (HIPAA) was developed to protect protected health information.
Under the Health Insurance Portability and Accountability Act (HIPAA) patient have a right to review and amend their own health records.
Provides safeguards regarding confidentiality of medical records and medical discussions.
Allows patients access to their medical records and an avenue for correcting errors in their records.

Risk Management Requires.
The most ethical way to manage risk in psychotherapy listed below is accurate and complete record keeping practices.
Strict adherence to ethical principles.
Careful identification of high risk clients.
Good record keeping standards.
Willingness to seek consultation as needed.
Taking patient complaints seriously.
Practice guidelines such as those developed by the Agency for Health Care Research and Quality will likely be used more frequently to determine appropriateness of care.

Cross Cultural Issues.

Ethnic Minorities.
Cultural differences need to be understood and taken into consideration.
African-American clients may benefit from action oriented and directive approaches.
Hispanic clients may benefit from reframing psychological problems in medical terms.
Filipino Americans may benefit from the therapist adopting a more authoritative style.
Caution needed to insure individual differences are still focused on regardless of culture.
Unfortunately some therapist practice in a biased, inadequate, or inappropriate fashion with this patient population.

Gay and Lesbian Clients.
American Psychiatric Association removed homosexuality from its official list of mental disorders in 1973.
Almost all therapist will treat gay and lesbian clients.
99% of therapists have seen at least one gay or lesbian client.
6% of current clients are gay and 7% are lesbian.
Unfortunately some therapist practice in a biased, inadequate, or inappropriate fashion with this patient population.

Psychopharmacology Issues.

Prescription Privileges for Non-medical Mental Health Professionals.
Controversial.
Consumer groups like NAMI have advocated for expansion of prescriptive authority. They argue that it will contain escalating health care cost and increase access to care especially for underserved populations and rural areas.
Opponents (see Hayes & Heiby, 1998) argue that it …
Will blur distinction between psychiatry and other disciplines.
Potentially endanger the public e.g., failure to recognize risks such as potential drug interactions.

Psychopharmacology Curriculums have been proposed.
In regards to prescription privileges limited practice prescribers would work independently with limited prescriptive authority.
Producing limited practice prescribers.
Work independently.
Consult with physicians when working with difficult cases and problems outside of their typical scope of practice.
Different from physician extenders who can only work under direct physician supervision.

Developments to date.
In the 1990s Department of Defense experiment trains psychologists to prescribe.
U.S. General Accounting Office (GAO, 1999) investigates project and determined graduates. were well trained but expressed concerns about the cost involved in training.
1999 Guam passes a bill to grant psychologist prescription privileges.
2002 New Mexico first state in the US to allow psychologists prescription privileges.
2004 Louisiana also allows psychologists prescription privileges.

The Future of Psychotherapy.

" … psychotherapy will become more directive, psycho-educational, present-centered, problem-focused, and briefer in the next decade … self help groups, social workers, and psychiatric nurses will proliferate … integrative, systemic and cognitive persuasions will thrive … specialization and peer review will become vital activities and pharmacotherapy will expand at the expense of psychotherapy." Norcross, et al. (1992).

Future Trends.

Practice guidelines and manual based treatments will be used more frequently.
Behavioral and cognitive-behavioral approaches will be favored because effectiveness can be measured.
Increased emphasis on empirically supported treatments.
Guidelines will be used to decide how and whom third party payers reimburse.
Technology will become a primary vehicle for health care.

Manderscheid & Henderson (2001).
HIPPA legislation will allow human rights to be fundamental in the health care system.
Consumers and family members will be more responsible for their health care.
Genetic treatments for biologically based disorders will become routine.

Twenty Things You need to Know About Current Issues in Psychotherapy.
1. Estimates suggest the professional discipline with the largest number of members providing clinical services is clinical social work.
2. Regardless of professional discipline and training most therapists practice eclecticism.
3. Data regarding the sexual misconduct of therapists suggests incidence rates for sexual misconduct are fairly similar across professional disciplines.
4. Restriction of the practice of a profession involves licensure.
5. The legal case of Tarasoff v. the Regents of the University of California pertains to duty to warn.
6. The legal doctrine of respondent superior allows supervisors to be held accountable for the actions of trainees.
7. Privileged communication can only be waived by the client.
8. In predicting violence, therapists may overpredict.
9. The most powerful predictor of future violence is a history of previous violence.
10. Although it may not be ideal, informed consent can be obtained verbally.
11. In regards to prescription privileges limited practice prescribers would work independently with limited prescriptive authority.
12. The Health Insurance Portability and Accountability Act (HIPAA) was developed to protect protected health information.
13. Under the Health Insurance Portability and Accountability Act (HIPAA) patient have a right to review and amend their own health records.
14. The most ethical way to manage risk in psychotherapy is accurate and complete record keeping practices.
15. Licensure restricts the practice of a profession where as certification restricts the use of a profession's name.
16. When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a dual relationship.
17. Four out of 5 therapists report feeling sexual attraction to at least 1 client.
18. The legal case of Tarasoff I states that if the patient is at immediate risk of harming someone else, the provider has the duty to warn the intended victim.
19. Evidence suggests that therapists are no better or more likely to over predict at predicting danger than individuals in the general population.
20. Practice guidelines such as those developed by the Agency for Health Care Research and Quality will likely be used more frequently to determine appropriateness of care.

Chapter 14 - Experiential Psychotherapy

My Lecture Notes.

Current Psychotherapies.

Chapter 14.

Experiential Psychotherapy.

Author:Alvin R. Mahrer.
Instructor: Jeff Garrett Ph.D.

History.
Experiential psychotherapy was developed by Alin R. Mahrer.
Alvin Mahrer is Professor Emeritus School of Psychology, Universty of Ottawa.
Author of 12 books and more than 200 other publications.

Basic Concepts.
"The experiential conceptual system is a model that is useful, rather than a theory that is true." Alvin Mahrer.
No structured theory of personality.
The conceptual system utilized in experiential psychotherapy can generally be thought of as a model of usefulness.
No discussion of personality traits, needs, drives, psychodynamics, impulses, psychic defenses, cognitions or core schemas only potentials.
Experiential psychotherapy focuses on "potentials".
The experiential model of a person is relatively simple, made up of potentials for experiencing.
The experiential model views humans as made up of potentials for experiencing.
Each person has a unique set of potentials.

Operating Potentials for Experiencing.
In experiential psychotherapy, the concept of a constructed personal world refers to the fact. that the client engages in creating and organizing the meaning of the world.
Account for the way an individual behaves, reacts, perceives and constructs their world.
These potentials for experiencing are closer to the surface compared to other potentials which are deeper.

Deeper Potentials for Experiencing.
Far from the surface.
The foundation under operating potentials.
Their nature and content are individualized.
There are no universal deeper potentials for experiencing, no shared commonality.

Potentials.
There are relationships between and among potentials.
Potentials may interact effectively.
Potentials may also be at odds with one another.

Experiential Psychotherapy.
Focus is on ways that people build and construct their external world.
The external world presents itself to the person, and the person receives it, applies meaning to it.
The external world is available as a resource to chose from and utilize in a manner relevant to the person.
The person and the external world can work together to create and build what is important for the person.
The person can actively create the kind of external world it is important for the person to experience.
Humans build their own personal world to enable their own experiencing.
People are building and organizing the external world.
This organization represents externalizations of the person’s own deeper potentials.
Allows the person to experience what is important for the person to experience.
Existence consists of providing a safe degree of experiencing of potentials (not too little or too much) and maintaining the present state of integrative-good or disintegrative-bad relationships between potential for experiencing.

How Change Occurs.
In experiential therapy, the target of change is the client themselves.
When an individual is able to make a qualitative change in the relationships between potentials for experiencing, this is referred to as integration.
When an individual is able to make their deeper potentials become operating potentials for experiencing, this shift is called actualization.
An experiential psychotherapist is likely to focus on painful scenes of strong feeling.
Movement toward an optimal state requires radical, transformational shifts into becoming a qualitative new person.
Experientialists believe a person will remain essentially the same throughout life unless the person is ready, willing and able to undergo a qualitative, radical, transformational shift.
Undergoing this shift allows a person to become closer to the optimal person the person is capable of becoming.
Core of therapy is a four-step sequence followed in each session.
"Each session is a gateway into a whole new state, a radical transformational shift into being what the person can be." Alvin Mahrer.

Methods of Psychotherapy.
During an experiential session, the client sits eyes closed and discusses whatever is "out there."
During an experiential psychotherapy session, the therapist sits side-by-side with the client both faced forward.

Goals for Each Experiential Session.
For a person to become transformed through a radical shift leading to becoming what the person is capable of becoming.
For the qualitatively new person to be rid of previous painful scene-situations.

The Sequence of Steps in an Experiential Session.
Each session follows the same sequence.

Step 1 – Discover the Deeper Potential for Experiencing.
Get into a state of readiness for change.
Find a scene of strong feeling.
Fully live and be in the scene of strong feeling.
Discover the moment of peak feeling in this scene.
Discover the deeper potential for experiencing in the moment of peak feeling.
The Sequence of Steps in an Experiential SessionEach session follows the same sequence.

Step 2 – Welcome and Accept Deeper Potential for Experience.
Name and describe the deeper potential.
React positively and negatively to the deeper potential for experiencing.
Use other methods of welcoming and accepting the deeper potential.
The Sequence of Steps in an Experiential SessionEach session follows the same sequence.

Step 3 – Being the Deeper Potential for Experiencing Past Scenes.
Find recent, earlier, and remote life scenes.
Be the deeper potential for experiencing in past scenes.
The Sequence of Steps in an Experiential SessionEach session follows the same sequence.

Step 4 – Being the Qualitatively New Person in the New World.
Find unrealistic new post-session scenes.
Be the qualitatively new person in these unrealistic scenes.
Find realistic new post-session scenes.
Be the qualitatively new person in these realistic scenes.
Rehearse being the qualitatively whole new person in these scenes (modify as needed).
Be the qualitatively new person in the rehearsed scenes.

Termination.
In experiential psychotherapy, the number of sessions the patient has is determined by whether sessions are successfully proceeding through a four-step process.

Ten Things You Need to Know About Experiential Psychotherapy.
1. Experiential psychotherapy was developed by Alvin Mahrer.
2. The conceptual system utilized in experiential psychotherapy can generally be thought of as a model of usefulness.
3. The experiential model of a person is relatively simple, made up of potentials for experiencing.
4. The foundation for operating potentials for experiencing is deeper potentials for experiencing. 5. When an individual is able to make their deeper potentials become operating potentials for experiencing, this shift is called actualization.
6. Welcoming and accepting deeper potentials of experiencing occurs in the existential psychotherapy step two.
7. In the final step of experiential psychotherapy the client becomes a qualitatively new person.
8. During an experiential psychotherapy session, the therapist sits side-by-side with the client both faced forward.
9. Step 1 of an experiential session is to discover the deeper potential for experiencing.
10. Step 2 of an experiential session encourages the individual to welcome and accept deeper potential for experiencing.

(#6, #7, #9, and #10 are sample questions. You know all four steps. I will ask similar types of questions on the exam so that you can demonstrate your knowledge of the sequence of steps in an Experiential Session.)

Chapter 13 - Psychodrama

My Lecture Notes.
Current Psychotherapies.

Chapter 13.

Psychodrama.

Author: Adam Blatner.
Instructor: Jeff Garrett Ph.D.

Basic Concepts.
A form of psychotherapy in which clients enact the relevant events in their lives instead of discussing them.
In psychodrama clients enact various dimensions of real or imagined life experiences.
In contrast to role-playing, psychodrama typically involves more in-depth exploration of emotions.
In psychodrama, a patient will enact the events of their lives rather than talk about them.
Clients are encouraged to express themselves through dramatization, role playing, and dramatic self-presentation.
Verbal and nonverbal techniques are incorporated.

History.
Pioneered by J.L. Moreno, who got his ideas from watching children playing in the park in Vienna The inspiration for psychodrama originally came from the natural play of children.
In psychodrama, action sociometry techniques are often used and this is similar to the sand tray techniques, which are used in play therapy.
Psychodrama developed out of Moreno's ideas about social arrangements and how they enhance social interactions, which he termed sociometry.
Dramatic enactments have been used to express feelings/ideas and to heal throughout history.
Moreno integrated his interests in storytelling, dramatics, medicine and applied sociology.
Initial concepts for psychodrama resulted from Moreno’s vision of social arrangements which enhanced social interactions (sociometry).
Moreno organizes Theater of Spontaneity which played out daily news events.
In 1925 Moreno immigrated to US.
In 1931 Moreno coins the term "group psychotherapy" during an APA presentation.
In the 1930s Moreno’s ideas began to be tested clinically.
Moreno published several of his own journals (Sociometry, Sociatry, Group Psychotherapy, International Journal of Sociometry and Sociatry).
From the 1940s to the 1970s J.L. Moreno and Zerka Moreno traveled widely to disseminate the approach.
American Society of Group Psychotherapy and Psychodrama (ASGPP).
Founded in 1942 by J.L. Moreno.
The pioneer membership organization in group psychotherapy.
Organization focuses on ongoing developments in group psychotherapy and psychodrama.

Current Status.
Zerka Moreno continues to disseminate information about psychodrama.
American Society of Group Psychotherapy and Psychodrama (ASGPP) can be accessed at http://www.asgpp.org/ .
Journal of Group Psychotherapy, Psychodrama & Sociometry continues as main publication.
The approach continues to be refined although proponents of psychodrama believe the therapy does not receive the attention is should in textbooks on therapy.

Psychodrama’s Theory.
Can be applied to an individual (psychodrama) or a group (sociodrama).
Goals are to facilitate insight, personal growth, and integration on cognitive, affective, and behavioral levels.
Role dynamics are crucial to psychodrama.
Role refers to any function in a complex system.
Focus is on the practical application of social role theory.
An advantage of role theory over other theories is its framework for exploring interpersonal events.
Moreno's definition of "encounter" included an honest, direct dialogue and willingness to appreciate another's viewpoint.
Moreno believed that by becoming more aware of the roles we played we could play the roles more creatively.
Role Theory offers a common language which psychodrama made more user friendly.
Role dynamics offers a theoretical framework.
Moreno's definition of catharsis involves abreaction followed by integration.
Various roles or parts played.
Meta-role, the role beyond the roles, which defines how the roles are played.

Key Concepts.
Spontaneity.
Playfulness.
Self-expression.
Drama.
Dimension.
Sociometry.
Warming up.
Physical action.
The group.
Social.
Rapport.
Psychopathology.
Role dynamics attend to past, present, and future.
Psychological disturbance seen as resulting from conflicts but also from individuals not having mastered role components or skills.
Theory also recognizes that an individual might be healthy but disturbed because they are enmeshed in dysfunctional systems.
Also focuses on idea that some roles are overdeveloped and others are underdeveloped.

Psychopathology.
Psychological disturbance seen as resulting from conflicts but also from individuals not having mastered role components or skills.
Theory also recognizes that an individual might be healthy but disturbed because they are enmeshed in dysfunctional systems.
Also focuses on idea that some roles are overdeveloped and others are underdeveloped.
Other roles are invalidated or neglected by a family, a culture or society.

Psychotherapy.

The "heart" of psychodrama is role reversal.
If a protagonist is asked to step out of a scene and then the auxiliary replays how the protagonist was behaving the director is using the mirror technique.
Role reversal develops the capacity of empathy.
Moreno's definition of "encounter" included an honest, direct dialogue and willingness to appreciate another's viewpoint.
Restorative drama focuses on creating corrective emotional experiences.
Moreno called the human tendency to avoid engagement and rely on what has already been created a cultural conserve.

Psychotherapy.
Roles of Group Members.
Protagonist – person(s) selected to "represent the theme" of group. The psychodrama participant who is the focus of the current psychological exploration is the protagonist.
Auxiliary – Group members who assume the roles of significant others in the drama. In psychodrama, the auxiliary refers to the individuals playing supporting roles. Using an auxiliary during psychodrama affects transference by directing it toward original sources.
Audience – Group members who witness the drama and represent the world at large.
The Stage – The physical space in which the drama is conducted.
Director – The psychodramatist who guides participants throughout the psychodrama.

Three Distinct Phases.
There are 3 distinct phases in a psychodrama, which include warm-up, action, and sharing.
1. Warm-up – Group theme is identified and protagonist is selected. Prior to a psychodrama the group participates in activities to increase involvement. This phase is known as warming up.
2. Action – Problem is dramatized and protagonist explores new methods of resolving problem.
3. Sharing – Group members are invited to express their connection with the protagonist’s work.

Multiple factors are used in psychodrama.
Engaging a creative attitude.
Warming-up.
Catharsis.
Insight.
Empathy.
Cognitive orientation.
Corrective experience.
Psychotherapy.
Multiple factors are used in psychodrama.
Transference.
Simulation.
Spirituality.
Role reversal.
Mirroring.
Doubling.
Concretizng.
Maximizing.

Application.
Methods are applicable to almost all types of problems.
Can be used as an adjunct to individual psychotherapy and group therapy.
Family sculpting can add to family therapy.
Supports a comprehensive recovery process for addiction.
Trauma and grief.
Cross cultural dynamics.
Day to day group interactions (business, schools, religious, self help).
Complex psychodramas should not be used with the following types of problems (acute psychosis, high anxiety, early withdrawal from alcohol or drugs, individuals with limited cognitive capacity).

Ten Things You Need to Know About Psychodrama
1. Psychodrama was pioneered by J.L. Moreno.
2. In psychodrama clients enact various dimensions of real or imagined life experiences.
3. In psychodrama, the auxiliary refers to the individuals playing supporting roles.
4. The psychodrama participant who is the focus of the current psychological exploration is the protagonist.
5. The "heart" of psychodrama is role reversal.
6. Prior to a psychodrama the group participates in activities to increase involvement. This phase is known as warming up.
7. In a psychodrama, protagonist is the individual selected to represent the theme of the group.
8. The three distinct phases of psychodrama are warm-up, action, and sharing.
9. J. L. Moreno is credited with coining the term group psychotherapy.
10. Psychodrama, a patient will enact the events of their lives rather than talk about them.

Chapter 12 - Family Therapy - Update 11/8/07

Current Psychotherapies

Chapter 12

Family Therapy

Authors:Irene & Hebert Goldenberg
Intructor: Jeff Garrett Ph.D.

Major Family Therapy Approaches
Object Relations. (Framo and Scharff).
Experiential. (Satir and Whitaker).
Transgenerational. (Bowen).
Structural. (Minuchin).
Strategic. (Haley).
Cognitive-Behavioral. (Beck and Ellis).
Social Constructionist. (deShazer and Anderson).
Narrative. (Michael White).

1. Object Relations. (Framo and Scharff).
Satisfying relationship with some “object” (e.g., parent) is a fundamental need.
Help client gain insight into early relationships (objects from past) and how it affects current relationships enabling individual development and fullfilling relationships.

2. Experiential. (Satir and Whitaker).
Troubled families need a “growth experience” derived from an intimate interpersonal experience (therapy).
By being real (authentic) and disclosing families learn to be more honest, more expressive, and better able to achieve personal and interpersonal growth.
For Satir, building self-esteem and learning to communicate openly are essential goals.
Whitaker – helping family members probe their own world of symbolic meanings frees them to activate innate growth processes.
Example of this approach is: Emotionally-Focused Couple Therapy

3. Transgenerational. (Bowen).
Thinking, feeling, and behaving are tied to the family system.
The individual’s problems arise and are maintain by relationship connections.
Problems are passed from one generation to the next
Fusion – most vulnerable
Differentiation of self – least vulnerable

4. Structural. (Minuchin).
Focused on how families are organized and what rules govern their transactions.
Pays attention to rules, roles, alignments, coalitions and boundaries.
Challenges rigid, repetitive transactions within a family, helping to “unfreeze” them and allow family reorganization.

5. Strategic. (Haley).
Assigns tasks to get family to change aspects of the system that maintain problematic behavior.
Paradoxical interventions are employed to force clients to abandon symptoms.
NOT interested in providing insight.

6. Cognitive-Behavioral. (Beck and Ellis).
Maladaptive behaviors can be extinguished as the contingencies of reinforcement are altered
Communication skills
Parent training skills
Cognitive restructuring

7. Social Constructionist. (deShazer and Anderson).
Each of our perceptions is not an exact duplication of the world, rather, a point of view seen through the limiting lens of our assumptions about people.
Jointly construct new options that change past accounts and allow new alternatives.

8. Narrative. (Michael White).
Our sense of reality is organized and maintained through stories.
Families present with negative, dead-end stories.
The goal is to explore alternative stories, make new assumptions, and open up new possibilities by re-authoring stories.

Variety of Concepts.

Cybernetic Epistemology.
lCybernetic Epistemology. A study of communication and control processes.
lCybernetic is a word that describes a regulatory system that operates by means of a feedback loop.
Example – Thermostat (dynamic equilibrium)
–Family homeostasis.
–Circular (not linear) causality.

Two Types of Systems.
1. Open systems.Allow new information in.Preferable to closed ones.Allow situations to be seen from different perspectives.
2. Closed Systems.Have varying degrees of inner circles.Those outside the system are viewed as having nothing to contribute (e.g., they wouldn’t understand the “way we do things”).

Concepts.
Family structure. Invisible set of functional demands that organize the ways in which family members interact.Operates through transactional patterns.

Transactional patterns. Repeated transactions establish patterns of how, when, and to who to relate. Boundaries.Rules defining in a system who participates, how and when.Determines the system’s sub-systems (i.e., each family structure). Continuum ranges from diffuse (enmeshment) to rigid (disengagement).

Sub-system. Individuals belong to different subsystems, with different levels of power and skills.

Dysfunction. A deviation from the healthy and normal.Dysfunction occurs when one of the following occurs. Rigid, diffuse or unclear boundaries coalitions formed against third party.Coalitions cross generational boundaries.Denied or concealed coalition.

Adaptation. Developmental changes within a family requiring alteration of boundaries.When adaptation does not occur it results in dysfunction.

Basic Family Therapy Concepts across All Schools of Thought.

Gender sensitive outlook. Stresses importance of not reinforcing stereotypical sexist or patriarchal attitudes.

Culturally sensitive therapy. Requires cultural competence.Therapist must remain aware of their own “cultural filters” and respect the “cultural filters” of the family being treated.

Differences between Family Therapy and Other Approaches.

Individual and family approaches have blended together considerably.
Main difference remains the degree of focus on the family unit.

History.

Background.
Early approaches focused on the individual (personality, internal, subjective).
Treatment therefore focused on neurotic conflicts and destructive interactions in the family of origin.
Individuals were treated separately from the families.
Family therapist hypothesized psychological problems were developed and maintained in the family context.
Personality was viewed as related to reciprocal interactions with others.
Psychological dysfunction explained in terms or circular, recursive interpersonal events.Most instrumental events.

Research on family dynamics and the etiology of schizophrenia.

Studies of small group dynamics.
Developments within social work.
Child guidance movement.
Marriage therapy practices.
Elements of group dynamics relevant to family therapy.
Kurt Lewin’s research speculating that a group is more than the sum of its parts.
Interdependence among group members seen as a stabilizing factor for maladaptive behaviors.
Distinction between the process (how ideas are communicated) and content (what is said) of group.
Discussions acting out familial conflicts with the group instead of discussing them.
Instructing group members to imagine that the group is their family of origin to allow. unresolved family issues to be known.

Impact of the child guidance movement.
Child guidance clinics were established on the premise that psychological problems began in childhood.
View focused on early intervention.
John Bowlby theorized children’s symptoms were often the result of family distress.
Began conjoint interviews.
Impact of the field of social work.
Social workers often make home visits.
Training centered around interviewing each individual family member to gain a comprehensive picture.
Many social workers became family therapist.

Current Status.

Eight major current approaches listed in the Basic Concepts section above.

Variety of Major Approaches.

Family Therapy Approaches do not subscribe to a theory of personality per se.

Virginia Satir.
Described family roles that serve to stabilize expected characteristic behavior patterns in a family.
Examples: If one child is the “bad child,” a sibling may take on the role of the “good child” to alleviate family stress.
Role reciprocity underscores why family dynamics are resistant to change.

Salvador Minuchin.
“Society acts as if all family violence is instrumental, and the response therefore is to increase control. But it is clear to us as family therapists that most cases of family violence are the products of generations of powerlessness. When we try to intervene by controlling the parents or with concern for the child alone, we can only produce a continuation of the pattern.”
Salvador Minuchin.
Founder of Structural Family Therapy (described in the Basic Concepts section). Author of the classic “Families and Family Therapy (1974).

Jay Haley.
Trained under the supervision of hypnotherapist Milton Erickson.
Developed a brief therapy model which focused on the context and possible function of the client’s symptoms.
Utilized directives to instruct clients to act in ways that were counterproductive to their maladaptive behavior.
Focus on clients actively doing something about their problems rather than understanding why they had problems.
Haley was instrumental in bridging gap between strategic and structural approaches to family therapy.
Explored concepts related to triangular and intergenerational relationships.
Client’s symptoms seen as the result of incongruence between manifest and covert levels of communication.
Symptoms gave client a sense of control in their interpersonal relationships.
Therapy should focus on client taking responsibility for their actions and to take a stand (i.e., therapeutic paradox).

Family Therapy.
Assumes an individual is understood best in the context of the family.
Families have a structure (how it is organized) and functions (how it meets member’s needs).
Healthy families have a clear, flexible power structure with the most competent members having the most power.
Dysfunctional families and often disengaged (isolated from one another) or enmeshed (overly involved with one another).
Families which are cohesive and adaptable best serve the functions of members.
Family systems attempt to achieve homeostasis (e.g., if mom and dad are in conflict a child may develop a problem to shift the focus).
Multigenerational transmission of both strengths and problems are common (i.e., grandmother, mother, daughter, all have been sexually abused).

Family Therapy and Psychosis.
Lidz studied families where a parent and child formed a relationship to the exclusion of the other parent which blurred boundaries.
· Hypothesized this type of relationship was a precursor to schizophrenia.· Lidz referred to 2 schizogenic families.

Lidz – Two schizogenic families

1. Marital schism. Family in a constant state of disequilibrium through repeated threats of parental separation.o Communication masks conflicts.o Parents disqualify each other and join with children excluding the partner.

2. Marital skew. a. Distorted parental relationship. b. Relationship is not under threat, due to one excessively powerful and dominant person.

Pseudo-mutuality and Pseudo-hostility
Wynne described family communication patterns which lead to perceptual and thought disorders as they denied reality of feelings.
Disjointed or fragmented communication leads to disrupted interactions.
Pressure is put on the child to maintain the façade to avoid meaningless of family relationships.
Pseudo-mutuality - A façade of togetherness. Absorbed with fitting together at the expense of developing separate identities.
Pseudo-hostility – quarreling that is merely a superfical tactic for avoiding deeper and more genuine feelings. A way of maintaining connection without becoming either deeply affectionate or deeply hostile to one another.

Double-bind relationship
Bateson described the Double-bind relationship.
· Communication which leads to mixed messages.· Repetitiveness leads to a unique learning experience in which the messages recipient cannot escape and cannot comment.· Leads the individual to lose their capacity to discriminate between the different levels of communication provoking psychosis.

Mystification.
Process that occurs when on or more family members fail to understand the meaning or the purpose of communication from another member.· The communication received is often deliberately vague.· The vague communication places the mystified persons in an inferior position.

Triangulation.
Occurs when a third person is brought into a dyadic relationship to de-intensify a disput between two people (generally parents).· Communication occurs through the third person.· The third person often hears negative comments about the individuals involved in the dispute.· When triangulation occurs, two people need to be communicating directly, but enmesh a third person so as to avoid any direct communication.

The Elephant in the Room.
The problem that no one wants (or dares) to talk about.· Problem is clearly visible to all involved.· Fear of retaliation or negative consequences and shame often keep individuals from discussing the problem.· Self blame is common.· Enablers continue to allow the problem to exist and not be discussed.

Lack of Differentiation.
· Autonomy is important for all individuals.
· Autonomy represents the degree of independence that an individual needs to function apart from others in a system.
· Fusion is the absence of differentiation.
· Lack of differentiation leads to enmeshment with others.

Scapegoating.
· Families often scapegoat on individual for all the family’s problems.
· The person scapegoated may have difficulties but is unduly blamed as they are often displaying the symptoms of an unhealthy family environment or have a bona fide illness.
· Lesser forms of scapegoating occur when every failure or conflict is pinned on an individual.
· Scapegoating rarely takes into consideration any other factors.
· e.g, Drinking is a conflict area where the couple can complain about each other endlessly with no demand for change … Through the years of Lars’ drinking has become the “cause” of all family problems. This fixing of causality on the behavior of one person blurs the nature of the other family transactions.” Salvador Minuchin.

Lack of Boundaries.
· All individuals need boundaries.
· The absence of boundaries produces unclear limits.
· Without boundaries abuse can easily occur.
· Families often have no boundaries in some areas and very rigid boundaries in other areas.
· Without boundaries humans are unable to emotionally relate to others or set reasonable limits on others.

Techniques.

Examples of Structural Family Therapy Techniques.
Goal is to restructure the family system to create clear and flexible boundaries.· Joining – therapist utilizes family’s language/styles of communication to form a nonjudgmental partnership.

· Focusing – Exploring specific areas.
· Enactment – Therapist has family enact an interaction to enable the family to try different ways of interacting.
· Intensification – Therapist increases emotional aspects of interactions transaction by a variety of means.
· Unbalancing – Conscious attempt to form coalition with one member against another or supporting one member at the expense of another to throw the family system off balance.

Examples of Milan Systemic Family Therapy Concepts and Techniques.

· Neutrality - Therapist is an observer and remains neutral.
· Hypothesizing – educated guess about symptoms in context.
· Circular questioning - designed to elicit differences. What is the symptom the client presents? What is it there for? What function does it serve? What is the context of the symptom i.e., what is happening when the symptom occurs? Why then? Why this symptom? Who can make it better? Who makes it worse? Who is affected by the symptom? How does the symptom affect the family and how does the family affect the symptom?
· Paradoxical Prescription – Symptoms of the client and family are positively connoted. Therapist prescribes the symptom (more of the same) to create a paradoxical effect.

Family Therapy Psychoeducation Approaches.
· Focus is on manageable tasks and strengths.
· Therapist empathizes with family and normalizes events when feasible.
· Educating families about illness.
· Communication training.
· Problem-solving.
· Formulating a detailed plan.
· Operant-conditioning strategies.
· Family education regarding diagnosis, symptoms, causes, treatment, and prognosis of illness as well as impact on family.

Application.
· Marital conflict.
· Parent-child conflict.
· Child abuse.
· Family problems with co-occurring mental disorders such as depression, anxiety, substance abuse.


Twenty Things You need to Know about Family Therapy


1. Nathan Ackerman wrote “The Psychodynamics of Family Life”. It is viewed by many as the first text defining the field of family therapy.

2. The individual identified with strategic family therapy is Jay Haley

3. The founder of structural family therapy is Salvador Minuchin

4. A family therapist will typically ask the entire family to attend the initial session.

5. A family therapist interacts in a manner that is active, empathic and balanced

6. Family therapists shift the locus of pathology from individuals to family systems

7. Viewing interactions as reciprocal suggests causality is circular

8. Family systems which allow new information in and individuals within the family to see things from different perspectives are called open systems.

9. The manner in which a family arranges, organizes, and maintains itself is known as its: Structure

10 A genogram is a family tree diagram of generational behavior patterns

11. When a third person is brought into a dyadic relationship to deal with a conflict, this is termed Triangulation

12. A family therapist asks each member of a family sequentially to pose the other family members in physical space as a representation of their view of the family. This technique is known as family sculpting

13. An example of Double-bind communication would be: A parent tells a child "I love spending time with you" while nonverbally appearing annoyed.

14. Designing interventions that are paradoxical in nature is known as therapeutic double-binds

15. Family therapists would often say that the identified patient in a family has been scape-goated by the family as the family blames them for the family's problem.

16. In family therapy the term "identified patient" conveys that a symptomatic family member expresses family dysfunction

17. Assuming a child's tantrum occurs because parents reinforced the behavior would be consistent with a Behavioral theoretical orientation

18. When parents are overly involved in the life of their and the boundaries within the family are diffuse. This family would be described as enmeshed

19. Rigid boundaries that permit limited emotional contact between members characterize families that are disengaged

20 In systems terms, family boundaries yield systems that exist along an open/closed continuum.

Multimodal Therapy - Chapter 11

My Lecture Notes.

Current Psychotherapies.
Multimodal Therapy.
Author: Arnold Lazarus.

Instructor: Jeff Garrett Ph.D.

Twenty Things You Need to Know About Multimodal Therapy
1. Multimodal therapy was developed by Arnold Lazarus.
2. The underlying principle of multimodal therapy is the necessity of individually tailored treatments.
3. A therapist's ability to use different treatment modalities without subscribing to their theoretical bases is called technical eclecticism.
4. The primary question a multimodal therapist asks is "Who or what is best for this particular individual?"
5. Deliberately tuning into a client's preferred modality initially is known as bridging.
6. Examining the firing order of a client's different modalities is termed tracking.
7. A structural profile in multimodal therapy is obtained by having patients complete likert scale ratings across BASIC I.D..
8. Lazarus describes thoughts outside of self awareness as nonconscious.
9. A structural profile in multimodal therapy is obtained by having patients complete likert scale ratings across BASIC I.D.
10. The principle of reciprocal determinism implies that thoughts mediate between stimuli and behavior.
11. Processes used to defend the individual against painful emotions would be termed by Lazarus as defensive reactions.
12. A multimodal therapist is best viewed as a trainer.
13. The nonjudgmental demeanor of a therapist is most readily linked with which BASIC I.D. area of affect.
14. Pre to post structural profiles are likely to change the most for depression.
15. In multimodal therapy, transference and countertransference issues are only addressed if problem arises.
16. Multimodal therapy is generally focused on being Psychoeducational and uses techniques which are eclectic.
17. Arnold Lazarus refers to the BASIC ID. These initials stand for Behaviors, affective responses, sensory reactions, images, cognitions, interpersonal relationships, and drugs and biology.
18. Lazarus is credited with coining the terms Behavior Therapy and Behavior Therapist.
19. Lazarus reports treatment relapse rates of less than 5%.
20. Multimodal therapy views all the modalities as crucial and believes they exist in a state of reciprocal transaction.

Basic Concepts.

Approach is largely psychoeducational and eclectic in nature.
Techniques used are theoretically consistent.
Based on social learning, general systems and group and communications theories.
Focuses on seven discrete but interactive modalities.
All modalities are crucial and exist in a state of reciprocal transaction/flux.
Successful treatment occurs when all modalities are addressed.
Multimodal Life History Inventory (Lazarus & Lazarus, 1991) administered to assess client in each modality.

BASIC I.D.

1. Behaviors.
2. Affective responses.
3. Sensory reactions.
4. Images.
5. Cognitions.
6. Interpersonal relationships.
7. Drugs and other biological interventions.

General Orientation is “Bespoke Therapy”.
Who or what is best for this particular individual?
· Bridging is the therapeutic procedure of tuning into the client’s preferred modality before branching towards other modalities.
· Tracking refers to a careful examination of the firing order of the different modalities.

Distinctive Features of Multimodal Therapy.
· Specific and comprehensive attention given to the entire BASIC ID.
· Use of second-order BASIC ID assessments.
· Use of modality profiles.
· Use of structural profiles.
· Deliberate bridging procedures.
· Tracking the modality firing order.

Comparing Multimodal Therapy to Other Systems.

The Multimodal therapist is not concerned with theoretical orientation, but rather asks: What works, for whom, and under what particular circumstances?
Multimodal therapy shares more in common with other approaches than differences.
All approaches advocate respect of the client.
Conflict resolution necessary for success.
Multimodal therapy integrates eclectic approaches in a theoretically thoughtful manner.
Approach draws significantly on cognitive and behavioral approaches because of their coping emphasis.

The Multimodal Position.
“The aim of MMT is to come up with the best methods for each client rather than force all clients to fit the same therapy. … Three depressed clients might be given very different treatments. … The only goal is helping clients make desired changes as rapidly as possible.” Zilbergeld.

History.

Hippocrates discussed human personality as mulitilayered.
Galen and Dubois also had multimodal views of humans.
MMT overlaps with the theory of functionalism offered by William James.
Arnold Lazarus earned his Ph.D. in clinical psychology from the University of Witwatersrand, Johannesburg, South Africa.
Worked 6 years in private practice and then emigrated to the U.S..
Taught at Standford University, Temple University Medical School, Yale University, and Rutgers University.
In 1958 Lazarus introduced the terms behavior therapy and behavioral therapist.
In 1965 Lazarus writes a paper on multimodal approach to alcoholism.
Over time Lazarus becomes a stronger proponent of a broad based approach and advocated against “narrow-band behavior therapy”.
At Rutgers Lazarus is a Distinguished Professor of Psychology (since 1972) and teaches in the Graduate School of Applied and Professional Psychology.

Current Status.

Formal training in MMT is offered at Rutgers and there are several MMT Institutes in the U.S. and one in London.
MMT approach is being studied internationally.
Numerous publications are available on the topic.

Multimodal Therapy View of Personality.

Humans are the product of genetic endowment, their environment and social learning.
Humans respond to their perceptions rather than to reality.
Perceptions are based on what is attended to.
New experiences create change.
Each individual reacts to the demands of the environment based on their individualized personal response pattern.
Psychopathology occurs when there is inflexible response patterns or response patterns that become conditioned in a maladaptive order.
At the physiological level the concept of thresholds is critical.
Individuals favor certain modalities over others.
An individual’s preferred modalities can be mapped into structural profiles on a 35-item. Structural Profile Inventory (SPI).
Multimodal Life History Inventory developed in Lazarus & Lazarus (1991) is a 15 page inventory administered to assess clients in each modality as the questionnaire assess antecedents, current problems and maintaining factors.

Multimodal Psychotherapy.
Addresses issues by intentionally introducing functional associations.
Modeling and vicarious learning are used to alter the firing order of modalities.

Examples of Treatment Techniques across BASIC ID.

Behaviors.
· Extinction.
· Counter-conditioning.
· Positive reinforcement.
· Negative reinforcement.
· Punishment.

Affective responses.
· Abreaction.
· Owning and accepting feelings.

Sensory reactions.
· Tension release.
· Sensory pleasuring.

Images.
· Creating coping images.

Cognitions.
· Cognitive restructuring.
· Awareness.

Interpersonal relationships.
· Modeling.
· Dispersing unhealthy collusions.
· Paradoxical maneuvers.
· Nonjudgmental acceptance.

Drugs and other biological interventions.
· Medications.
· ECT.

Application of MMT.

Treatment and prevention.
Classroom.
Childcare agencies.
Parent training.
Institutional settings.
Community disasters.

Chapter 10 Gestalt Therapy - Updated 3/21/06

Current Psychotherapies.

Chapter 10.

Gestalt Therapy.

Gary Yontef and Lynne Jacobs.
Instructor: Jeff Garrett Ph.D.

Founders of Gestalt Therapy.
Fritz Perls and Laura Perls.

Three founders of Gestalt Psychology.
Max Wertheimer.
Kurt Koffka.
Wolfgang Kohler.

"Gestalt" is a German word that means "whole" (shape or form).
"Gestalt" - A physical, biological, psychological, or symbolic configuration or pattern of elements so unified as a whole that its properties cannot be derived from a simple summation of its parts.

Tension between Gestalt Psychology and Gestalt Therapy
"Perls’s Gestalt therapy should not be considered a clinical application or the development of Gestalt psychology." (p.254 History and Systems of Psychology. David Hothersall).

Field Theory
Kurt Lewin (1890-1947) adopted a Gestalt approach in developing an innovative field theory which addressed ….
Child development.
Industrial management.
Social Psychology.

Comparison of Gestalt Therapy to Other Therapies.

Most Different = Behavioral Therapies

Most Similar = Humanistic Theories


Comparison to Other Therapies.
Although similar in some ways to rational emotive behavior therapy (REBT) and cognitive therapy (CT), a gestalt therapist does not imply that they know the rational way to think.

In contrast to psychoanalysis, gestalt therapy emphasized the potential of the here and now.

History.
Frederick "Fritz" Salomon Perls.
Trained as a psychiatrist.
Worked with Kurt Goldstein, a principal figure of the holistic school of psychology, who studied the effects of brain injuries on WWI veterans.
Trained in psychoanalysis with Karen Horney and Wilhelm Reich.

Laura Perls.
Trained as a psychologist.
Worked with Gestalt psychologist Max Wethheimer.

The Perls.
Because of Nazism the Perls fled Western Europe in 1933 to South Africa, where they practiced until 1945.
In 1947 Ego, Hunger and Aggression: A Revision of Psychoanalysis was published in London under F.S. Perls’ name and included text reevaluating the psychoanalytical view on aggression
At the end of the war, the Perls emigrated to New York City.
Collaboration began with artists and intellectuals versed in philosophy, psychology, medicine, and education resulting in elaboration of Gestalt Theory, Gestalt Therapy and Gestalt Therapist.
In 1951 Julian Press published Gestalt Therapy: Excitement and Growth in the Human Personality by F.S. Perls, Ralph Hefferline, and Paul Goodman.

Current Status.
Gestalt Therapy Institutes internationally.
Virtually every major city in the U.S. has at least one Gestalt Institute.
Association for the Advancement of Gestalt Therapy formed to govern adherence to gestalt principles.
International Gestalt Therapy Association newly formed.
Four Major Journals.
International Gestalt Journal.
British Gestalt Journal.
Gestalt Review.
Australian Gestalt Journal.

Some Basic Principles of Gestalt Therapy Theory.

Focused on process (what is happening) rather than on content (what is being discussed).
"Gestalt" comes from the German word for "whole".
Focused on the person’s experience in the here and now.
Holism and field theory are interrelated in gestalt theory.
Organismic self-regulation requires knowing and owning.

Holism.
All of nature is seen as a unified whole. The whole is different from the sum of its parts.
We can only be understood to the extent that we consider all the dimensions of human functioning.
No superior value is place on any one aspect of the individual. Gestalt therapy attends to clients’ thoughts, feelings, behaviors, body, relationships, and dreams.

Field Theory.
Field - A set of mutually interdependent elements.
The organism must be seen in its environment (context), as part of the constantly changing field.
Everything is relational, in flux, interrelated, and in process.
Gestalt therapists pay attention to what is occurring at the boundary between the person and the environment.
The purpose of a boundary is to separate and connect us to others
Lewin thought of an individual as a complex energy field, a dynamic system of needs and tensions that directs perceptions and actions. Behavior (B) is a function (f) of a person (P) interacting with an environment (E).
B = f(P,E)

Basic Concepts (Continued).

Phenomenological.
The phenomenological perspective asserts that all reality is subjectively interpreted.
Objective reality, as defined by a gestalt therapist, is non-existent.

Gestalt (Figure-Ground) Formation
"Insight is a patterning of the perceptual field in such a way that the significant realities are apparent; it is the formation of a gestalt in which the relevant factors fall into place with the respect to the whole" Heidbreder, 1933

Gestalt Theory recognizes that background and forefront change fluidly
Patient’s conflicts are regulated to background and are brought to forefront through therapy

Describes how the individual organizes the environment from moment to moment.
The undifferentiated field is called the background (or ground), and the emerging focus of attention is called the figure.
The figure-formation process tracks how some aspect of the environmental field emerges from the background and becomes the focal point of the individual’s attention.
The dominant needs of an individual at a given moment influence this process.

Holism
The idea that individuals are growth oriented, self-regulating and only understandable within the context of their environment

Gestalt Therapy is best considered as a form of existential therapy
The focus is on the …
what and how of behavior (not why).
here-and-now.
integrating fragmented parts of the
personality.
unfinished business from the past.

Boundaries.
Disturbances at the Boundaries.
Experiences that are blocked creates isolation.

Creative Adjustment.
Creative balance between changing the environment and adjusting to current conditions
According to Gestalt therapy psychological adjustment requires an awareness of our need states Achieving a balance between individual needs and the environment reflects creative adjustment.

Maturity.
Good gestalt describes a perceptual field organized with clarity and good form.
Results from creative adjustment.

Disrupted Personality Functioning.
Mental illness is the inability to form clear figures in the moment.
Polarities
Maladjustment occurs when polarities become rigid and are seen in dichotomies.
Positive mental health is seen as the ability for an individual to shift between figure and ground, in other words to be able to deal with competing concepts like life and death which are considered polarities.

Resistance
Gestalt Therapists see resistance as the process of opposing the formation of a threatening figure.
A gestalt therapist would view resistance as an attempt to maintain psychological integrity

The impasse is the point in therapy at which clients:
avoid experiencing threatening feelings.
experience a sense of "being stuck."
imagine something terrible will happen.
When a client remains stuck in nonfunctional ways of thinking and behaving a gestalt therapist would say the client is experiencing impasse.

People are inclined to towards growth and self regulation.
Conditions can impede growth.
People define themselves in relation to others.

The essential nature of the individual’s relationship with the environment is interdependence, not independence.
Individuals have the capacity to self-regulate in their environment.
Individuals can reown the parts of themselves they have disowned.

View of human nature is rooted in
- existential philosophy.
- phenomenology.
- field theory.

Gestalt Therapy’s Theory of Personality
Organismic Self-regulation.
"There is only one thing that should control: the situation … If you understand the situation you are in and let the situation you are in control actions, then you learn to cope with life." Fritz Perls
Human regulation is either organismic or shouldistic.
Organismic.
Acknowledgement of what is.
Choosing and learning happen holistically
A natural integration of mind and body
Shouldistic
What one things should or should not be
Cognition reigns
Gestalt Therapy’s Theory of Personality

Consciousness and Unconsciousness
View is radically different from Freudian view
In gestalt therapy, the concept of unconscious is replaced by the concepts of awareness and unawareness
Concepts of awareness and unawareness replace the unconscious

Gestalt Therapy
Goal is for the client to have increased awareness of what they do, how they do it and how they can change or accept themselves

The Figure-Formation Process
The figure-formation process tracks how some aspect of the environmental field emerges from the background and becomes the focal point of the individual’s attention.
The dominant needs of an individual at a given moment influence this process.

The Now
Initial goal is for clients to gain awareness of what they are experiencing and doing now
Promotes direct experiencing rather than the abstractness of talking about situations
Therapist directs clients to "bring the fantasy here"
Rather than talk about a childhood trauma the client is encouraged to become the hurt child
Ask "what" and "how" instead of "why"
Our "power is in the present"
Nothing exists except the "now"
The past is gone and the future has not yet arrived
For many people, the power of the present is lost
They may focus on their past mistakes or engage in endless resolutions and plans for the future

Unfinished Business
Feelings about the past are unexpressed
These feelings are associated with distinct memories and fantasies
Feelings not fully experienced linger in the background and interfere with effective contact
Pay attention on the bodily experience because if feelings are unexpressed they tend to result in physical symptom
Result:
Preoccupation, compulsive behavior, wariness oppressive energy and self-defeating behavior
Solution: get in touch with the stuck point (impasse).

Contact and Resistances to Contact
CONTACT – The gestalt term describing an individual's ability to focus on the here and now
Interacting with nature and with other people without losing one’s individuality
Contact (connect) and Withdrawal (separate)
RESISTANCE TO CONTACT – the defenses we develop to prevent us from experiencing the present fully

Five major channels of resistance:
1. Introjection: uncritically accept others’ belief and standards without thinking whether they are congruent with who we are
2. Projection: the reverse of introjection; we disown certain aspect of ourselves by assigning them to the environment
3. Retroflection: turning back to ourselves what we would like to do to someone else
Directing aggression inward that we are fearful to directing toward others.
4. Deflection: The process of distraction, or fleeting awareness that makes it difficult to maintain sustained contact. A way of avoiding contact and awareness by being vague or indirect.
e.g., overuse of humor
5. Confluence: less differentiation between the self and the environment.
e.g., a need to be accepted---to stay safe by going alone with other and not expressing one’s true feeling and opinions.
e.g., A parent and a child become so enmeshed that the child can no longer experience a sense of separate identity.

Clients are encouraged to become increasingly aware of their dominant style of blocking contact

Energy and blocks to energy
Pay attention to where energy is located, how it is used, and how it can be blocked
Blocked energy (resistance):
Tension some part of the body; numbing feelings, looking away from people when speaking, speaking with a restricted voice
Recognize how their resistance is being expressed in their body
Exaggerate their tension and tightness in order to discover themselves

Gestalt psychotherapy is focused on process rather than on content

Main Gestalt Therapy Principles
Awareness
Direct experience
Contact
Relationship
Experimentation
Phenomenological focusing

Four Dialogue Characteristics

1. Inclusion
Putting oneself as fully as possible into the experience of the other without judging, analyzing or interpreting while simultaneously retaining a sense of one’s separate, autonomous presence
Represents phenomenological trust in immediate experience
Provides a safe environment and strengthens the client’s self-awareness

2. Presence
The Gestalt Therapist expresses their observations, preferences, feelings, personal experience and thoughts to the client
Therapist is modeling phenomenological reporting
Enhances client’s trust and use of immediate experience to raise awareness

3. Commitment to dialogue
Contact refers to something that happens in an interaction
Therapist allows contact to happen rather than making contact happen

4. Dialogue is lived
Dialogue is something done
"Lived" emphasizes the excitement/immediacy of the process
Mode of dialogue can vary. Examples might include dance, song, art, words, movement

Techniques

Techniques of Client Focusing elaborations of …
"What are you aware of (experiencing) now? And "Try this experiment and see what you become aware of (experience) or learn."
The Gestalt therapist pays attention to the client's nonverbal language.

Main Tools of Gestalt Therapy

Awareness
Being in touch with one’s existence, with what is
Gestalt Therapy focuses on creation of an awareness continuum where what is of primary concern and interest to the organism, the relationship, the group or society becomes the gestalt and into the foreground
Primary concerns are fully faced, worked through, sorted out, changed, or eliminated
As one becomes aware of and faces concerns they can become the background which leaves the foreground free for the next primary gestalt

Stay with it
Therapist encourages client to follow a report of awareness with the instruction: "Stay with it" or "Feel it out"

Enactment
Therapist asks the client to act out feelings or thoughts to increase awareness
Gestalt therapy's empty chair technique, in which a patient is encouraged to express feelings to others or themselves in a symbolic manner enactment

Exaggeration
A special form of enactment where the therapist asks the client to exaggerate some feeling, thought, or movement to feel it more intensely
Main Tools of Gestalt Therapy

Loosening and Integrating
Therapist asks the client to imagine the opposite of whatever is believed to be true
Integrating techniques bring together processes – the client keeps alert
Examples might include asking a client to put words to crying; identifying where in the body one feels an emotion; Or asking a client to express positive and negative feelings about the same person

Guided Fantasy
Therapist encourages visualizing rather than enacting

Body Techniques
Therapist provides ideas about how the client can increase awareness of their body functioning
Examples would be teaching the client breathing exercises or to hold the body in a certain posture while feeling a certain emotion

Therapist Disclosures
Therapist uses "I" statements judiciously to enhance therapeutic contact and the client’s awareness
Requires wisdom to know when to self disclose
Therapists may share what they are experiencing in their senses or emotions
In most types of therapy, the therapist may not reveal considerable amounts of information about themselves. In gestalt therapy, therapist disclosure is considered appropriate if done judiciously

Reversal technique
A Gestalt technique that is most useful when a person attempts to deny an aspect of his or her personality (such as tenderness)

The Gestalt approach to dreams
Ask the client to become all parts of his or her own dream. The client interprets and discovers the meaning of the dream for himself or herself.

Therapeutic Goals
The basic goal of Gestalt therapy is attaining awareness, and with it greater choice.
Awareness includes knowing the environment, knowing oneself, accepting oneself, and being able to make contact.
Stay with their awareness, unfinished business will emerge.

Dialogue b/w client and therapist is stressed.
The therapist has no agenda, no desire to get anywhere)
The therapist understands that the essential nature of the individuals relationship with the environment is interdependent, not independent.
Therapy is a spontaneous; here and now experience

Therapist’s function and Role
Increase clients’ awareness
Pay attention to the present moment
Pay attention to clients’ body language, nonverbal language, and inconsistence b/w verbal and nonverbal message (e.g., anger and smile)
"I" message
Therapist’s function and Role
Pay attention to language patterns.
Language can both describe and conceal

Examples of the aspects of language that Gestalt therapist might focus on.
1. "It" talk – "it" instead of "I" (depersonalizing language) e.g., "It is difficult to make friends" instead of "I have difficulty making friends"
2. "You" talk – "you" instead of "I" (global and impersonal)
3. Questions - keep the questioner hidden, safe, and unknown.
4. Language that denies power – qualifiers and disclaimers such as "perhaps", "sort of", "I guess", "possibly", "I suppose"
5. "I can’t " talk – instead of "I won’t"
6. Listening to metaphors
- It’s hard for me to spill my guts
- I don’t have a leg to stand on
- I feel like a have a hole in my soul
- I feel ripped to shreds
- I feel like I’ve been put through a
meat grinder
6. Listening to metaphors
Seek to translate the meaning of these metaphors into manifest content so that it can be dealt with in therapy.
e.g., "What is your experience of being ground meat?" "Who is doing the grinding"
7. Listening to language that uncovers the story (fleshing out the flash).
Clients often use language that is elusive yet significant clues to a story that illustrate their life struggles. Clients slide over pregnant phrases but alert therapist can help flesh out their story line.

Client’s Experience in Therapy
General orientation is dialogue
Therapist à no interpretation that explain why they are acting in certain ways.
Client à making their own interpretation
Three-stage (Polster, 1987)
Discovery (increasing awareness)
Accommodation (recognizing that they have a choice)
Assimilation (influencing their environment)

Relationship Between Therapist and Client

Person-to-person
The quality of therapist-client relationship
Therapists knowing themselves
Therapists share their experience to clients in the here-and-now

Therapist's Use of self in therapy
Therapeutic techniques and procedures
The experiential work
Use experiential work in therapy to work through the stuck points and get new insights

Preparing client for experiential work
Get permission from clients
Be sensitive to the cultural difference (e.g., Asian cultural value: emotional control). Know when to leave the client alone.

Respect resistance
Therapeutic techniques and procedures
Increase awareness about the incongruence between mind and body (verbal and nonverbal expression)

Therapeutic techniques and procedures

1. The internal dialogue exercise – Pay close attention to splits in personality function.
Top dog - is righteous, authoritarian, moralistic, demanding, bossy. The critical parent that badgers w/ "shoulds" &"oughts"
Underdog – manipulates by playing the role of a victim: defensive, apologetic, helpless, weak, and feigning powerlessness.
The top dog demands thus-and-so while the underdog defiantly plays the role of disobedient child.
As a result of this struggle for control, the individual becomes fragmented into controller and controlled.
The conflict between top dog and underdog is rooted in the mechanism of introjection which involves incorporating aspects of others, usually parents, into one’s ego system.
It is essential that clients become aware of toxic introjects that poison the system and prevent personality integration.

The empty chair – is one way of getting the client to externalize introjects.
Use two empty chairs. Ask the client to sit in one chair and be fully the top dog and then shift to the other chair and become the underdog.
As introjects surface the client can experience the conflict more fully. The conflict can be resolved by the clients acceptance and integration of both sides.
This technique helps clients get in touch with a feeling or a side of themselves that they may be denying.
Rather than talking about the conflicted feeling, they intensify the feeling and experience it fully. Further, by helping the clients realize that the feeling is a very real part of themselves, the intervention discourages them from disassociating the feeling.
The goal of this exercise is to promote a higher level of integration between the polarities and conflicts that exist in everyone.
The aim is not to ride oneself of certain traits but to learn to accept and live with the polarities.

2. Making the rounds
The purpose is to confront, to risk, to disclose the self, to experiment with new behavior, and to grow and change.
Is most useful when a person attempts to deny an aspect of his or her personality (such as tenderness)
Therapeutic techniques and procedures

Example – A group member does not participate. Experiment - Go around to each person and say "What makes it hard for me trust you is……" OR "I’d like to make contact with you but I’m afraid of being rejected [or accepted]"

3. Rehearsal exercise
Reverse the typical style (e.g., a pessimist is directed to act like an optimist, a critical negative client is directed to act positive)
Plunge into the very thing that is fraught with anxiety and make contact with those parts of themselves that have been denied.
Goal – e.g., accept positive and negative side.
May get stuck when rehearsing silently or internally
Share the rehearsals out load with a therapist

4. Exaggeration exercise
Helps client become aware of the subtle signals and cues they are sending through body language.
Exaggerate a gesture or movement repeatedly, which usually intensified the feelings attached to the behavior and makes the inner meaning clearer.

4. Exaggeration exercise
Movements, postures, and gestures may communicate significant meanings, yet the cues may be incomplete. So the client is asked to exaggerate the movement or gesture repeatedly, which usually intensifies the feeling attached to the behaviors and makes the meaning clearer.
e.g., trembling (shaking hands, legs), slouched posture, clenched fists, tight frowning, crossed arms, etc. Then the therapist asks the client to put words to the movements.

5. Staying with the feeling
Clients may want to avoid unpleasant feelings.
At key moments when the client attempt to flee from the feeling the therapist may ask the client to stay with the feeling they wish to avoid.
Go deeper into the feelings they wish to avoid
Facing, confronting, and experiencing feelings not only takes courage but is also a mark of a willingness to endure the pain necessary for unblocking and making way for newer levels of growth.

6. The Gestalt approach to dream work
Not interpret or analyze dreams
Bring dream back to life as though they were happening now
The dream is acted out in the present to become different parts of the dream
Projection: every person or object in the dream represents a projected aspect of the dreamer.
Royal road to integration
Dreams serve as an excellent way to discover personality
No remember-à refuse to face what it is at that time

From a multicultural perspective
Must work with clients from their cultural perspectives

Limitations
Focus on "affect"
Asian cultural value: emotional control
Prohibiting to directly express the negative feelings to their parents.

A contribution of this therapeutic approach is that
it enables intense experiencing to occur quickly.
it can be a relatively brief therapy.
it stresses doing and experiencing, as opposed to talking about problems.

Summary and Evaluation

Gestalt therapy encourages clients to
experience feelings intensely.
stay in the here-and-now.
work through the impasse.
pay attention to their own nonverbal messages.

According to Gestalt theory, people use avoidance in order to:
keep themselves from facing unfinished business.
keep from feeling uncomfortable emotions.
keep from having to change.

In Gestalt therapy, the relationship between client and counselor is seen as
A joint venture
An existential encounter
An I/Thou interaction

Limitations of Gestalt Therapy
Clients who have been culturally conditioned to be emotionally reserved might not see value in experiential techniques.
Clients may be "put off" by a focus on catharsis.
Clients may believe that to show one's vulnerability is to be weak.
Ineffective therapists may manipulate the clients with powerful experiential work.

Some people may need psycho-education.

Application
Anxiety
Depression
Perfection driven
Phobic
Crisis intervention
Groups
Couples

Psychosomatic disorders including migraine, spastic neck and back pain
Does not rely heavily on formal diagnostic evaluations and research methodology
Gestalt Therapists do not believe that a statistical approach can tell the individual client or therapist what works for him or her
All interactions are seen as experiments involving calculated risk taking
Caution when attempting to treat psychotic, disorganized, personality disorders, or severe mental illness. Should not be used with these disorders unless a long-term commitment is possible

Chapter 9 Existential Therapy

My Lecture Notes.

Current Psychotherapies.

Chapter 9

Existential Psychotherapy

Rollo May and Irvin Yalom
Instructor: Jeff Garrett Ph.D.

Introduction:
Existential psychotherapy is not a specific technique or set of techniques. It is more philosophical in nature.
Existential psychotherapy is a philosophy about human nature.
Proponents of existential psychotherapy have not advocated specific training institutes because its presuppositions can underlie any form of therapy.
In existential terms, the conflicts individuals experience are regarding the givens of existence.
From the existential perspective "deep" conflict means the most fundamental concern at that moment.

Key Figures
Viktor Frankl.
Rollo May.
Irvin Yalom.

Viktor Frankl:
Viktor Frankl's approach to existential theory is known as logotherapy.

Rollo May:
Rollo May has been instrumental in translating some concepts drawn from existential philosophy and applying them to psychotherapy.

Irvin Yalom:
According to Yalom, the concerns that make up the core of existential psychodynamics are
death.
freedom.
isolation.
meaninglessness.

Basic Concepts:
Existential psychotherapy is more philosophical in nature.
Existential psychotherapy is not a specific technique.
Focuses on issues central to human existence.

Existential therapy is basically an experiential approach to therapy.
It is based on a personal relationship between client and therapist.
It stresses personal freedom in deciding one's fate.
It places primary value on self-awareness.

View of Human Nature:
The basic dimensions of the human condition are …
The capacity for self-awareness.
The tension between freedom & responsibility.
The creation of an identity & establishing meaningful relationships.
The search for meaning, purpose, and values of life.

Accepting anxiety as a condition of living:
The awareness of death and nonbeing.
The Capacity for Self-Awareness.
We can reflect and make choices because we are capable of self-awareness.
Expanding our awareness in realizing that:
We are finite - time is limited.
We have the potential, the choice, to act or not to act.
Meaning is not automatic - we must seek it.
We are subject to loneliness, meaninglessness, emptiness, guilt, and isolation.

Freedom and Responsibility:
The central issue in therapy is freedom and responsibility.
A concept ultimately associated with freedom is assuming responsibility.
The existential concept of freedom refers to the fact that we are the authors of our own world
The bridge between wishing and action is decision.
We are free to choose among alternatives.
We are responsible for our lives, for our action, and for our failure to take action.

Blaming others for their problems---
Recognize how they allowed others to decide for them and the price they pay.
Encourage them to consider the alternative options.

We Cannot Escape
Freedom and Responsibility:
Existential therapy is rooted in the premise that humans cannot escape from freedom and responsibility.

Freedom and Responsibility involves the notion that …
our freedom requires us to accept responsibility for directing our own life.
we are free to choose who we will be.
they go hand in hand.

Question
What are the possible reasons that people tend to blame others for their problems?

The Concept of "Bad Faith" :
The concept of "bad faith" refers to leading an inauthentic existence.
An Example of Bad Faith.
A example statement that illustrates "bad faith" is - naturally I'm this way, because I grew up in an alcoholic family.
The creation of Identity and Establishing Meaningful Relationships

Striving for Identity:
Identity is "the courage to be".
We must trust ourselves to search within and find our own answers.
Our great fear is that we will discover that there is no core, no self.

Struggling with our identity:
Challenging clients---in what ways that they have lost touch with they identity and letting others to design their life.

Relationship to others:

Aloneness.
We are alone---So, we must give a sense of meaning to life, decide how we will live, have a relationship with ourselves, and learn to listen to ourselves.

Relatedness.
We need to create a close relationship with others.
Challenging clients----What they get from they relationship? How they avoid close relationship?
Relatedness can be Therapeutic.
Existentialists contend that the experience of relatedness to other human beings can be therapeutic.
The search for meaning, purpose, and values of life.

Question.
What is the meaning or purpose of your life?
What do you want from life?
Where is the source of meaning for you in life?

The Search for Meaning:
Meaninglessness in life leads to emptiness and hollowness (existential vacuum).
Existentialists believe that the major solution to meaninglessness is engagement.
Finding meaning in life is a by-product of engagement, which is a commitment to creating, loving, working, and building.

Accepting Anxiety as a Condition of Living.
Anxiety – A Condition of Living.
Existential therapists define anxiety as a threat to our existence.
Anxiety arises from one’s strivings to survive.
If anxiety is proportionate to the situation confronted, existentialists would consider it normal anxiety.
In contrast to normal anxiety, neurotic anxiety is repressed anxiety.
Existential anxiety is normal.
An outcome of being confronted with the four given of existence: death, freedom, existential isolation, and meaninglessness.
Anxiety can be a stimulus for growth as we become aware of and accept our freedom.

Two Types of Anxiety.
1. Normal Anxiety.
2. Neurotic Anxiety.

Question:
What is the positive motivation of being anxious?

Normal Anxiety.
Normal Anxiety – appropriate response to an event being faced. (motivation).
e.g., Existential Anxiety is a constructive form of normal anxiety we experience as we become increasingly aware of our freedom and responsibility.
According to May, freedom and anxiety are two sides of the same coin.
Existential anxiety is seen as a function of our acceptance of our aloneness.
From the existential viewpoint, the aim of therapy is NOT to eliminate anxiety so clients can live comfortably.

Neurotic Anxiety.
Neurotic Anxiety – out of proportion to the situation.
Out of awareeness.
Tends to immobilize the person.

The Awareness of Death and Nonbeing.
Death.
According to the existential viewpoint, death gives significance to living.

Question:
If you only have 30 days left, what’s your feelings? What will you do?

Awareness of Death:
Death provides the motivation for us to live our lives fully and take advantage of each opportunity to do something meaningful.

More Basic Concepts.

The Basic "I-Am" Experience.
The "I-Am" experience is about being i.e., the realization of one's being.
The term ontological means science of being (or the nature of being).
Existentialists consider the "I am" experience as a precondition for a solution in life and feel that this is an ontological experience.
"I am now living and I could take my life".
"The idea of suicide has saved my life many times." Nietzsche.
Existential psychotherapy seeks a deeper and more discerning type of therapy.
The "I am" experience is no a solution in itself it is a precondition for a solution.

An ontological experience;
Ontis = "to be" and Logical = "the science of".
Nonbeing is illustrated in the experience of fear of death, destructive hostility, severe anxiety and critical illness.

Existential Model of Anxiety.
Anxiety is more basic than fear.
Anxiety arises from our personal need to survive, to preserve our being, and to assert our being. Normal anxiety is proportionate to the situation. It does not require repression and can be used for creativity.
Neurotic anxiety exceeds or minimizes the situation, is repressed and destructive.
(Normal anxiety is seen as proportionate to the situation involved. When the anxiety exceeds the situation present, it is considered neurotic).

Existential Model of Anxiety (see the power point slide in class).

Awareness of Ultimate Concern ---> Anxiety ---> Defenses

Existential Model of Guilt:
Normal guilt is proportionate to the situation, sensitizes us to the ethical aspects of behavior and can be used for creativity.
Neurotic guilt is about fantasized transgressions, leads to "Forgetting being" and is destructive.

The Three Forms of Being-in-the-World.
Unwelt – world around, biological world.
Mitwelt – with world, world of one’s fellow human beings.
Eignewelt – own world; relationship to one’s self.

Significance of Time.
Human experiences like joy, depression and anxiety occur in the dimension of time rather than space.
Love cannot be measured by the number of years one has known a loved one.

Two Types of Guilt.
1. Neurotic Guilt.
Guilt that arises out of fantasized transgressions is called neurotic guilt.
2. Normal Guilt.
A characteristic of normal guilt is that it sensitizes us to ethical behavior.

Human Capacity to Transcend the Immediate Situation:
Transcend means "to climb over and beyond".
Existing involves a continual emerging.
A transcending of one’s past and present must occur in order to reach the future.
When an individual can move past a situation in order to move towards their future, it is said that the person has transcended the immediate situation.

Comparing Existential Psychotherapy to Other Systems.
Contrasts of Existential Theory to Humanistic Approaches.
Humanistic therapies overlap with existential psychotherapy.
Both emphasize growth and fulfillment of self.
Goals are for self mastery, self-examination and creativity (A primary goal of existential therapy is to help the patient accept personal responsibility).

Comparing Existential Psychotherapy to Other Systems.
(see power point slid in class).

Other Key Contrasts.
Existentialists reject concept of the person as propelled by drives and instincts.
Existentialists feel Jungians quickly avoid the patient’s immediate crises by being too focused on theory.
Rollo May's major criticism of client-centered therapists was that they overidentified with the patient.
Client-Centered Therapists do not confront the client directly and firmly.

History.
Existential thinking has occurred throughout history.
Exemplified by Augustine, Pascal, Kierkegaard, Nietzsche.
Fundamental questions leading to the development of existential psychotherapy included:
Where was the actual immediate person to whom these things were happening?
Are we seeing clients as they really are, or are we simply seeing a projection of our theories about them?
In 1958 existential psychotherapy introduced to the US with publication of Existence: A New Dimension in Psychiatry and Psychology by Rollo May, Ernest Angel, and Henri Ellenberger
In 1981 Yalom published the first comprehensive textbook in existential psychiatry entitled Existential Psychotherapy.

Other Important Writings.
Rollo May’s The Meaning of Anxiety (1977); Man’s Search for Himself (1953); Existential Psychology (1961).
James Bugental’s The Search for Existential Identity (1976).
Victor Frankl’s Man’s Search for Meaning (1963).

Six Ontological Principles
1. Humans are centered in self and derive meaning from that center.
2. Humans are responsible for mobilizing the courage to protect, affirm, and enhance the self.
3. People need other people with whom they can empathize and learn.
4. People are vigilant about potential dangers to self.
5. Humans can be aware of themselves thinking and feeling at one moment and my be aware of. themselves as the person who thinks and feels in the next moment.
6. Anxiety originates out of awareness that one’s being can end.

Existential Psychotherapy.
A form of dynamic psychotherapy.
Holds a different view of inner conflict.
Conflict is between the individual and the "givens" of existence termed ultimate concerns.
1. Death.
2. Freedom.
3. Isolation.
4. Meaninglessness.
_____________________________

Death:
The most obvious ultimate concern.
"A terrible truth".
Conflict between awareness of death and desire to live.
To cope we erect defenses against death awareness.
Psychopathology in part is due to failure to deal with the inevitability of death.

Freedom
Refers to the fact that humans are the authors of their own world.
We are responsible for our own choices.
Conflict is between groundlessness and desire for ground/structure.
Implications for therapy.
Responsibility.
Willing.
Impulsivity.
Compulsivity.
Decision.
Existential Psychotherapy.

Isolation. - The fact that we are isolated from parts of ourselves is termed intrapersonal isolation Intrapersonal isolation = Fact we are isolated from parts of ourselves.
A form of isolation that refers to the fact that each of us enters and departs the world alone is existential.
Existential isolation differs from Interpersonal isolation = Divide between self and others.
Intrapersonal isolation = Fact we are isolated from parts of ourselves.

Meaninglessness.
Meaning creates hierarchal order of our values.
From a schema regarding the meaning of life an individual generates a hierarchy of values.
Tells us how to live not why to live.
Conflict stems from "How does a being who requires meaning find meaning in a universe that has no meaning?"

Existential Frame of Reference.
Specialness.
Despite rationality we often believe the laws of biology are no applicable to us.

Ultimate Rescuer.
Belief in a personal omnipotent servant to guard and protect us.
(To cope with ultimate concerns regarding death individuals will often use the defense mechanism of creating an ultimate rescuer).


Ultimate concerns have implications for therapy process (Existentialists hypothesize that anxiety is the result of awareness of ultimate concerns).
Psychodynamic treatment is followed.
Ultimate concerns boundary situations which are experiences which force individuals to confront an existential situation. (Ultimate concerns create experiences, which force us to confront an existential situation called boundary situations).
An experience which forces an individual to confront an existential issue is known as a boundary situation.
Examples might be diagnosis of a terminal illness or death of a family member or friend.

Psychotherapy can address existential isolation.
Jung suggested 30% of patients seek treatment because of personal meaninglessness.

Therapeutic Goals:
To expand self-awareness.
To increase potential choices.
To help client accept the responsibility for their choice.
To help the client experience authentic existence.

Expanding Awareness:
Expanding awareness is a basic goal of existential therapy.
Fully Human.
The existential emphasis is based on the philosophical concerns of what it means to be fully human.

Therapist’s Function and Role:
Understand the client’s subjective world.
Encourage clients to accept personal responsibility.
When clients blame others, therapist is likely to ask them how they contributed to their situation.

A Prime Factor in Determining the Outcomes of Therapy.
The existential approach puts emphasis on the therapist as a person and the quality of the client/therapist relationship as one of the prime factors in determining the outcomes of therapy.

Client’s Experience in Therapy.
They are challenged to take responsibility.
Major themes in therapy sessions are anxiety, freedom and responsibility, isolation, death, and the search for meaning.
Assist client in facing life with courage, hope, and a willingness to find meaning in life.
Philosophically, the existentialist would agree that the final decisions and choices rest with the client.
people redefine themselves by their choices.
a person can go beyond early conditioning.
making choices can create anxiety.

Relationship Between Therapist and Client.
Therapy is a journey taken by therapist and client.
The person-to-person relationship is key.
The relationship demands that therapists be in contact with their own world.
The core of the therapeutic relationship.
Respect and faith in the clients’ potential to cope and discover alternative ways of being.
Therapists share their reactions to clients with genuine concern and empathy as one way of deepening the therapeutic relationship.

I/Thou Relationships in Therapy:
(Martin Buber).
Martin Buber stressed the importance of presence, which allows for the creation of I/Thou relationships in therapy.

Therapeutic techniques and procedures:
It is not technique-oriented.
The interventions are based on philosophical views about the nature of human existence.
Free for draw techniques from other orientations.
The use of therapist self is the core of therapy.

Techniques are not emphasized:
Existential therapy is not considered as a system of highly developed techniques.
Subjective understanding of clients is primary.
In the existential approach subjective understanding of clients is primary and techniques are secondary.
The term unfolding refers to the therapist's attempt to uncover with the patient what was there all along.

Questions:
Which populations is existential therapy particularly useful?
Which issues is existential therapy particularly useful?

Existential Group Psychotherapy.
Clients learn how their behavior is viewed by others, makes others feel, creates opinions others have of them and influences their opinions of self.

Applications of Existential Psychotherapy.
The clinical setting determines the applicability of the existential approach.
Most applicable when clients are dealing with a phase of life issue or a boundary situation.
A comprehensive existential approach is most feasible in long term therapy.

Existential therapy is especially appropriate for clients who are struggling with developmental crises.
Identity in adolescents.
Coping with disappoints in family and career.
Grief counseling.
Coping with physical limitations as one ages.

From a multicultural perspective:
Contributions.
Applicable to diverse clients to search for meaning for life.
Be able to examine the behavior is influenced by social and cultural factors.
Help clients to weigh the alternatives and consequences.
Change external environment and recognize how they contribute.

From a multicultural perspective.
Limitations.
Excessively individualistic.
Ignore social factors that cause human problems.
Even if clients change internally, they see little hope the external realities of racism or discrimination will change.
For many cultures, it is not possible to talk about self and self-determination apart from the context of the social network.
Many clients expect a structured and problem-oriented approach instead of discussion of philosophical questions.

Major Criticisms
Vague and global approach.
Lofty and elusive concepts.
It lacks a systematic statement of the principles and practices of psychotherapy.