Psychotherapy theory paper(Psychology Major Please)

For each theory discussed you will submit a paper with the following sections:

I. Brief 3 or more sentences summary of theory

II. Brief descriptions of major tenets of the theory (3 or more sentences per tenet)

III. Brief descriptions of common techniques of the theory (3 or more sentences per technique)

IV. Personal reflection/reaction to the theory (2 paragraphs)

V. Questions about the theory or its implementation (2 questions)

The first 3 sections will serve as a brief summary to which you may refer back in future courses, during practicum experiences, or when preparing for comps. The latter 2 sections are meant to help you process your reactions to each theory. Remember that you will have already summarized the theory in sections 1-3, so section 4 should focus on the thoughts and feelings that arose for you as you read the chapters associated with each theory.

Handbook for Social Justice in
Counseling Psychology: Leadership,

Vision, and

Action

Toward a Radical Feminist Multicultural
Therapy: Renewing a Commitment to Activism

Contributors: Susan L. Morrow, Donna M. Hawxhurst, Ana Y. Montes de Vegas, Tamara M.

Abousleman & Carrie L. Castañeda

Edited by: Rebecca L. Toporek, Lawrence H. Gerstein, Nadya A. Fouad, Gargi Roysircar &

Tania Israel

Book Title: Handbook for Social Justice in Counseling Psychology: Leadership, Vision, and

Action

Chapter Title: “Toward a Radical Feminist Multicultural Therapy: Renewing a Commitment to

Activism”

Pub. Date: 2006

Access Date: November 30, 2017

Publishing Company: SAGE Publications, Inc.

City: Thousand Oaks

Print ISBN: 9781412910071

Online ISBN: 9781412976220

DOI:

http://dx.doi.org/10.4135/9781412976220.n17

Print pages: 231-248

This PDF has been generated from SAGE Knowledge. Please note that the pagination of

the online version will vary from the pagination of the print book.

javascript:void(0);

http://dx.doi.org/10.4135/9781412976220.n17

Toward a Radical Feminist Multicultural Therapy: Renewing a Commitment
to Activism

Feminist counseling and psychotherapy, having emerged from the Women’s Liberation
Movement of the late 1960s and 1970s, would appear to be naturally situated in the social
justice arena in counseling psychology. However, many of the qualities that characterized
feminist therapy as it emerged from its grassroots origins (e.g., radical critique of mental
health systems and psychotherapy, consciousness raising, political analysis and activism, and
commitment to social transformation as integral to work with clients) have faded into the
background as feminist therapy has become more mainstreamed and feminist therapists have
focused increasingly on individual solutions to human problems (Marecek & Kravatz, 1998b;
Morrow & Hawxhurst, 1998). In addition, for a significant period in the herstory of feminist
therapy, multicultural perspectives were included unevenly and have been centralized only
recently in an integrative feminist multicultural therapeutic approach (Bowman & King, 2003;
Bowman et al., 2001; Brown, 1994; Comas-Díaz, 1994; Espín, 1994; Israel, 2003; Landrine,
1995). This chapter will review the evolution of feminist multicultural psychotherapy, identify
theoretical underpinnings for its ongoing development, and propose a social justice agenda
for feminist multicultural therapy in counseling psychology. In addition, we provide two
examples from our work as feminist multicultural counselors for social justice.

Herstory and Evolution of Feminist Multicultural Counseling

Feminist and multicultural counseling perspectives emerged from the social and political
unrest of the 1960s. As disenfranchised groups began pressing for social change, counselors
and other mental health professionals found themselves stranded without the tools to address
cultural differences and oppression (Atkinson & Hackett, 2004). Feminist and multicultural
scholars and practitioners began to criticize traditional therapies for their racist and sexist
underpinnings. Mainstream psychology, particularly through the diagnostic process,
pathologized women, people of color, and others for qualities and behaviors that were outside
of the White, male, heterosexual norm. In addition, “symptoms” arising from victimization (e.g.,
battered women’s syndrome; anger or fear responses to racism, sexism, heterosexism, etc.)
were often labeled as personality defects (e.g., borderline personality disorder, paranoia)
instead of being understood in the context of trauma theory as a reasonable consequence of
intolerable and oppressive circumstances.

Another criticism of traditional therapies was their exclusively intrapsychic focus (McLellan,
1999). McLellan also argued that traditional therapies assume that all people have equal
access to choice and power and that each individual is responsible for her or his own life
circumstances and unhappiness, failing to recognize the ways in which oppression limits
choice and power.

The impetus for multicultural counseling came from increasing attention to cross-cultural
counseling and cultural diversity emerging from ethnic and cultural movements of the 1960s
and 1970s. The 1973 American Psychological Association (APA) sponsored conference on
clinical psychology in Vail, Colorado, was an important turning point for the profession of
psychology when it was declared unethical to provide counseling services if the provider
lacked the appropriate cultural competence to do so (Korman, 1974). Multiculturalism in
psychology and counseling was not easily accepted in the field given the predominantly
intrapsychic focus and the view that human distress was primarily psychophysiologic in
nature. In response to this resistance, Smith and Vasquez (1985), in their introduction to a

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special issue of The Counseling Psychologist on cross-cultural counseling, wrote the
following:

We believe that the doctrine of color blindness in mental health and counseling
psychology has outlived its usefulness. Therapists are not color-blind. Culture is a
major factor in the life development of individuals, and ethnicity is a major form of
identity formation and group identification. (p. 532)

Over the years, the multicultural competency (MCC) literature has focused on five major
themes: “(a) asserting the importance of MCC; (b) characteristics, features, dimensions, and
parameters of MCC; (c) MCC training and supervision; (d) assessing MCC; and (e) specialized
applications of MCC” (Ridley & Kleiner, 2003, p. 5). Early training in multicultural counseling
stressed the importance of knowledge, awareness, and skills in working with diverse
populations; this trifold objective remains central in the training literature today. The
multicultural counseling literature has moved from a focus on merely appreciating and
celebrating diversity (as important a beginning as this was) to an insistence on examining the
underpinnings of privilege, power, and oppression, particularly as they relate to groups of
people who have been marginalized (Liu & Pope-Davis, 2003). The recent adoption by the
APA (2002) of Guidelines on Multicultural Education, Training, Research, Practice, and
Organizational Change for Psychologists was a stunning victory for the profession and
provided psychologists with aspirational goals to guide their work with ethnic minority
individuals.

Feminist therapy grew out of political activism in the United States in the 1970s and was
conceived of as a political act in and of itself (Mander & Rush, 1974). From its inception,
feminist therapy was a response to feminist critiques of traditional therapy practices that were
identified as harmful to women (Chesler, 1997). Its goals were twofold: to engage women in a
process of political analysis geared to raising their awareness of how interpersonal and
societal power dynamics affect their well-being, and to mobilize women to change the social
structures contributing to these harmful power dynamics (Ballou & Gabalac, 1985).

The first decade of feminist therapy was characterized by “a critical examination of mental-
health services to women, feminist consciousness-raising groups as an alternative to
psychotherapy, an activist and grassroots orientation to therapy for women, an emphasis on
groups as opposed to individual psychotherapy, and assertiveness training” (Morrow &
Hawxhurst, 1998, p. 38). In the second decade, feminist therapists worked to further define
feminist therapy by identifying and describing its goals, its processes, and the skills needed to
practice it (Enns, 1993). Books and articles about feminist therapy proliferated during this
time, as did critiques from within and outside the discipline (Morrow & Hawxhurst, 1998).

As feminist psychotherapy became increasingly mainstreamed and professionalized, radical
feminist writers such as Kitzinger and Perkins (1993) sounded the alarm that feminist therapy
—along with therapy in general—served a domesticating, depoliticizing function. Instead of
the “personal being political,” the political was being inexorably whittled away until it was once
again privatized, individualized, and personal. In a special issue of Women and Therapy
(1998) on “Feminist Therapy as a Political Act,” researchers and practitioners addressed this
problem in a number of ways. Hill and Ballou (1998) found that feminist therapists addressed
power issues in the client-counselor relationship and helped clients examine oppression and
the sociocultural causes of distress; in addition, some therapists actively worked for social
change by advocating for their clients and teaching clients to advocate for themselves.
However, Marecek and Kravatz (1998a, 1998b) found very little in their study of feminist

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therapists that distinguished the therapists as uniquely feminist. Most of the characteristics
espoused by participants in the study were characteristic of humanistic or New Age therapies
(McLellan, 1999).

In addition, prominent women of color in psychology and social work spoke out, bringing to
light some of the omissions that characterized the predominantly White feminist therapy
movement (Comas-Díaz, 1994; Espín, 1994). These authors provided an analysis of how
feminist therapy, as it existed then, was harmful to women of color and to other women who
were marginalized because it ignored important dimensions of their identities and life
circumstances (Brown, 1991, 1994). Women of color have historically—and justifiably—viewed
feminism as ethnocentric and class-bound and have challenged the centrality of gender
oppression espoused by many Euroamerican feminists (Bowman et al., 2001). Alternatively,
Espín (1994) recognized the potential value that feminist therapy could have for women of
color if it were to recognize ethnicity as a major component of oppression along with gender.
In describing her own journey of evolution as a feminist therapist, Brown (1994) referred to her
earlier practice as “monocultural” (p. 75) and articulated the importance of considering each
client’s unique constellation of identity dimensions and life circumstances rather than having
her or him choose one aspect of identity on which to focus in counseling. This process of self-
reflection has characterized multicultural and feminist endeavors with increasing honesty and
success over time.

A particular example of the ongoing integration of feminism and multiculturalism arose at a
working conference of the APA Division 17 Section for the Advancement of Women (SAW),
where conference organizers had been explicit in their planning for a feminist multicultural
agenda of a project that was intended to result in significant scholarly contributions in a
number of areas of feminist multicultural research and practice. Although organizers and
working group leaders embraced the terminology of “feminist multicultural” and working
groups were recruited for diversity across race/ethnicity, international status, sexual
orientation, gender, and professional/student status, issues emerged surrounding whose
voices were privileged. The SAW conference became a microcosm for working with issues of
privilege and voice. Feelings ran high, and the ensuing months led to conversations
(informally, through presentations and discussion hours at APA, and through writing and
publication), most particularly about the integration of racial/ethnic multiculturalism and White
feminism. Following the conference, Bowman et al. (2001) provided a particularly powerful
critique questioning the “real meaning of integrating feminism and multiculturalism” (p. 780).
These conversations continue to be an important venue through which feminist and
multicultural scholars and practitioners move toward greater integration. This does not
necessarily imply that the road is straightforward or easy. A core challenge to this integration
is to resolve a multicultural commitment to respect diversity of cultural values while
simultaneously holding a feminist value that women’s subservience to men is something to be
overcome. The complexity of working to empower women when their cultural or religious
beliefs dictate certain limits on their behavior is something that needs to be addressed
continually in order to continue the dialogue.

Gradually, feminist and multicultural counseling principles and practices have been integrated
into a form of therapy in which client and counselor analyze power dynamics on an
interpersonal and societal level and include in this analysis the ways that the various aspects
of the client’s identity and privilege (e.g., gender, race/ethnicity, sexual orientation, age,
socioeconomic status, religious affiliation, ability/disability status, etc.) affect these power
dynamics. Scholarship has continued to emerge in this integrated field and promises to guide
feminist multicultural practice (e.g., Asch & Fine, 1992; Bowman et al., 2001; Landrine, 1995;

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Palmer, 1996; Russell, 1996; Wangsgaard Thompson, 1992). Critical analyses of feminism by
scholars such as Bowman and King (2003) continue to challenge the assumptions of White
feminists, particularly around issues related to separatism and apparently contradictory
identities, while at the same time raising questions about the dilemma faced by women of
color when they are asked to “join with the struggle against racism and subordinate any
feelings of discrimination by sex for the greater good of saving the race” (p. 60). Integrative
work such as that by Israel (2003) identifies the importance and challenge of integrating
multiple identities such as race, ethnicity, gender, and sexual orientation. As feminist
multicultural counseling and psychotherapy move forward in the 21st century, several
contemporary influences have import for our commitments to social justice.

Concepts and Principles Related to Radical Feminist Multicultural Counseling for
Social Justice

Situated at the beginning of the 21st century, philosophical and political writings from critical
theories, liberation psychology, and recent writings in counseling for social justice and third-
wave feminist psychotherapy converge. The relevant concepts and principles from these
approaches provide strong underpinnings toward enhancing the possibilities of feminist
multicultural counseling and therapy for social justice.

Critical Theories

Critical race theory (CRT) is defined as a “radical legal movement that seeks to transform the
relationship among race, racism, and power” (Delgado & Stefancic, 2001, p. 144). The CRT
movement began in the 1970s and was largely influenced by critical legal studies and radical
feminism; however, it has been used in education and other fields (e.g., Delgado Bernal,
2002) and is applicable to feminist/ multicultural education, counseling, outreach, and
research. Critical race theory and its associated perspectives seek to better understand
divisiveness that surrounds issues of race and other forms of oppression and are strongly
driven by activism (Delgado & Stefancic, 2001). From this perspective, then, for many feminist
multicultural therapists, traditional forms of psychotherapy fall short in empowering clients,
especially those who are oppressed or marginalized. One reason for this shortfall is that
traditional therapies have been built on a European American worldview. Alternatively, critical
race gendered epistemologies emerge from numerous worldviews without regarding a White,
Euroamerican, male lens as the standard by which other perspectives are measured (Delgado
Bernal, 2002). Thus, CRT and other critical theories help to understand the complexities with
which clients are confronted.

“Critical race theorists have built on everyday experiences with perspective, viewpoint, and the
power of stories and persuasion to come to a better understanding of how Americans see
race” (Delgado & Stefancic, 2001, p. 38). This understanding is facilitated by the use of
counterstorytelling, the hallmark method of CRT. Counterstorytelling is writing that attempts to
critically analyze “accepted premises” held by the majority (Delgado & Stefancic, 2001, p.
144). Thus, storytelling becomes a tool to better engage and involve clients in therapeutic
work.

CRT’s emphasis on narrative analysis supports much of the work in which feminist and
multicultural psychotherapists engage their clients (McLellan, 1999). CRT is also a powerful
tool to train professionals who not only are empathic to a diverse clientele, but also strive to
more fully understand the complexities of clients’ lives that go beyond the immediate

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assumptions and who are genuinely attempting to meet clients’ individual needs. Client
experiences may not neatly fit the theories and textbook descriptions traditionally studied in
graduate training; thus, the process of telling and listening to stories can lead client and
counselor to an understanding of the complexities of their lives. CRT maintains that stories
“serve a powerful psychic function for minority communities” because stories are opportunities
to voice discrimination and also serve to uncover shared experiences of discrimination
(Delgado & Stefancic, 2001, p. 43).

The quest to more fully understand individuals from diverse communities has led critical race
theorists to focus on the specific experiences and needs of diverse communities. Some of the
offshoots of CRT include feminist critical theory (Fem Crit), Latina/o critical theory (LatCrit),
and critical theory drawn from queer theory (QueerCrit). Feminist critical theory (FemCrit) is an
important critical perspective that relates to feminist multicultural counseling. Specific to
FemCrit is the deconstruction of the concept “that there is a monolithic ‘women’s experience’
that can be described independently of other facets of experience like race, class, and sexual
orientation” (Harris, 1997, p. 11). Overall, CRT and its offshoots seek to address the braidings
of racism; sexism; heterosexism; and other forms of privilege, power, and oppression (Wing,
1997). These movements offer feminist multicultural counselors and therapists an opportunity
to move beyond previous, more simplistic understandings of oppression to embrace the
complexities that are necessary to understand in order to promote social justice.

Liberation/Critical Psychology

Like critical race theories, the basic premises of liberation psychology are to take a critical view
of and challenge the accepted assumptions in the field of psychology. Liberation psychology
had its genesis in liberation theology in Latin America, in which Biblical scriptures were
reinterpreted with a focus on the poor (“a preferential option for the poor”) and on social
justice. In the field of education, Paolo Freire (1970) insisted that this pedagogy “must be
forged with and not for the oppressed” (p. 48), emphasizing a core principle that the work of
those with privilege is not to liberate those who are oppressed but to join with them. This is
best illustrated in the words of an Aboriginal woman, who said, “If you are coming to help me,
you are wasting your time. But if you are coming because your liberation is bound with mine,
then let us work together” (Instituto Oscaro Romero, n.d.).

Asserting that traditional psychology serves to maintain the status quo in society, Prilleltensky
(1989) charged psychologists to become aware of their ideological constraints and to
deliberate on “what constitutes the ‘good society’ that is most likely to promote human
welfare” (p. 799). A core strategy for achieving this goal is conscientization, “the process
whereby people achieve an illuminating awareness both of the socieoeconomic and cultural
circumstances that shape their lives and their capacity to transform that reality” (Freire, 1970,
p. 51). Prilleltensky (1997) proposed an emancipatory communitarian approach “that
promotes the emancipation of vulnerable individuals and that fosters a balance among the
values of self-determination, caring and compassion, collaboration and democratic
participation, human diversity, and distributive justice” (p. 517).

Counseling for Social Justice

Counseling psychology’s growing commitment to a social justice agenda parallels the rise in
critical perspectives across a number of disciplines, including CRT and critical/liberation
psychology. A commitment to social justice implies that counselors and psychologists look
past the traditional narrow focus on counseling and psychotherapy and address societal

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concerns such as discrimination and oppression, privilege and power, equity and fair
distribution of resources, liberty, and equality (Vera & Speight, 2003). Social justice work has
long been on the agenda for feminist and multicultural therapists, despite the mainstreaming
and professionalization of feminist therapy described above. “A social justice-informed
psychologist seeks to transform the world, not just understand the world” (Vera & Speight,
2003, p. 261). Vera and Speight further suggested that such a transformation will require that
psychologists rethink their training models, question their overdependence on “individual
factors to explain human behavior” (p. 261), and expand the scope of their interventions
beyond individual counseling. In particular, counseling psychologists need to reclaim our
historical roots of prevention, person-environment interaction, and a focus on strengths;
attend to larger-scale interventions in institutions such as schools and social systems; work to
influence public policy; and engage in psychoeducation, community outreach, and advocacy.

Third-Wave Feminist Psychotherapy

The third wave of feminism in the United States is characterized by a generation of young
women—and men—who have been raised with expectations of greater gender equality and
freedom from oppression than women of the first and second waves experienced, along with
greater awareness of diversity (Bruns & Trimble, 2001). Many second-wave feminists have
expressed concerns that their efforts will have been in vain, that their “hard-won gains will be
lost and the women’s movements of the twentieth century eliminated from the history books or
relegated to the margins of history” (Kaschak, 2001, p. 1). Today’s young have learned about
feminism in the halls of academe in women’s and gender studies courses rather than through
the personal call to action initiated by incidents of overt discrimination—what second-wave
feminists called the “click.” Believing that their consciousnesses had already been raised and
that equal rights were a practical reality, third-wave feminists have been “shocked and
amazed when affirmative action was first overturned and abortion rights challenged” (Bruns &
Trimble, 2001, p. 27). Third-wave feminist psychologists and therapists have identified a
number of issues that have implications for feminist mult icultural counseling and
psychotherapy. Among them are the rejection of an economic model of power in which there
are “haves” and “have-nots” in favor of one that is relational (i.e., power is shared), the
incorporation of diverse narratives and experiences, and the need for mentoring from second-
wave feminists (Bruns & Trimble, 2001). Rubin and Nemeroff (2001) wrote of “embodied
contradictions of feminism’s third wave” (p. 92) in which young women are addressing the
many contradictions of their lives (e.g., viewing gender inequality as a thing of the past while
at the same time experiencing an antifeminist cultural backlash). In addition, as third-wave
feminists identify their own feminist agendas, they “aim to disrupt, confuse, and celebrate
current categories of gender, sexuality, and race” (p. 93). Bodies and body image are central
issues in which the third-wave feminist movement is grounded.

Critical race/gender theories, liberation psychology, counseling for social justice, and third-
wave feminism have in common an unapologetic analysis of power and oppression and a
commitment to advocacy and activism. Together, they enhance current multicultural and
feminist agendas and move the field closer to actualizing its social justice agenda.

Toward a Radical Feminist Multicultural Model of Counseling and Psychotherapy for
Social Justice: Implementing Feminist Multicultural Counseling

The practice of feminist multicultural therapy for social justice integrates historic and
contemporary feminist theory and therapy with increasingly complex understandings of

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multiculturalism, critical theories, and radical perspectives. It involves feminist multicultural
perspect ives on assessment and diagnosis; the personal as pol i t ical , including
consciousness-raising, conscientization, and demystification; an analysis of power in
psychotherapy—power dynamics between client and therapist as well as issues of privilege
and power in the life of the client; the importance of group work to empower clients; and
political action and activism.

Feminist Multicultural Perspectives on Assessment and Diagnosis

How can we work in academe or mental health systems that characterize the dominant
culture without participating in the conventional wisdom of mainstream counseling and
psychotherapy practice? Brown (1994) identified the “master’s tools” (Lorde, 1984) as

expressions of dominant attempts to control and define the process of healing so
that it does not threaten patriarchal hegemonies. These are the techniques used to
classify people, to impose social control… tools that a feminist therapist may find
herself required to learn about and use. (p. 179)

Diagnosis is one powerful example of such a process and system of techniques presented in
the context of science and medicine as reality. As feminist multicultural therapists working for
social justice, it is essential to call into question psychiatry’s sacred scripture (i.e., the
Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) (American Psychiatric
Association, 1994) and other “master’s tools” to which we continue to subscribe.

Sinacore-Guinn (1995) proposed an approach to assessment and diagnosis that is culture-
and gender-sensitive and that provides an alternative to traditional diagnostic models. She
also provided a useful training model designed to assist students in learning how to make
culture- and gender-sensitive diagnoses. Sinacore-Guinn proposed four broad categories that
can be used to understand a client’s presenting problem(s): (a) Cultural systems and
structures are considered broadly and include such variables as “community structure, family,
schools, interaction styles, concepts of illness, life stage development, coping patterns, and
immigration history” (p. 21); (b) Cultural values have five value orientations: time (focusing on
past, present, or future), activity (doing, being, or developing and growing), relational
orientation (individualistic, communal, or hierarchical), person-nature orientation (in harmony
with, control over, or subjugated to), and basic nature of people (innately good or evil); (c)
Gender socialization concerns what is considered gender-appropriate across cultures and
how gender variance is pathologized; (d) finally, trauma is a far-reaching and life-changing
event that must be considered within its social environmental and sociopolitical context.
Trauma must be considered both in its more acute forms (e.g., sexual abuse and assault) as
well as in its more insidious and chronic forms such as racism or homophobia.

A failure to explore the above-mentioned categories in depth with a client could easily lead to
an inappropriate diagnosis or a misdiagnosis by DSM-IV standards. Misunderstanding a
cultural value could result in misdiagnosis (e.g., a child whose culture is oriented toward
“being” rather than “doing” might meet many of the criteria for attention deficithyperactivity
disorder). In addition, counselors need to consider the possibilities of bicultural struggles or
conflicts that could lead to misdiagnosis, recognizing that, as cultural variables are more
diverse (e.g., multiple oppressions based on gender, race, class, sexual orientation, gender
expression), the struggle is more complex. It is troubling to speculate about the numbers of
clients who are diagnosed and pathologized using DSM criteria when the presenting
“symptoms” or problems could be explained and understood from the perspective of one’s

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cultural context, bicultural conflicts, and history and nature of trauma. From this broad
perspective, a client’s “symptoms” may actually be a culturally appropriate, nonpathological
management of cultural conflict. Only after an in-depth cultural analysis, which includes a
consideration of bicultural conflict and trauma, can a diagnosis be made. Even then, it is
important to call into critical question the existing systems of diagnosis and treatment,
examining ways that they perpetuate oppression and injustice.

The Personal as Political, Including Consciousness-Raising, Conscientization, and Demystification

Consciousness-raising or conscientization engages people in an analysis of their sociocultural
realities in such a way that they become better able to transform that reality. Part of this
process involves demystification. Mystification was defined by McLellan (1995) as “the
deliberate use [by the dominant group] of mystery, deceit, lies and half-truths for the purpose
of presenting a false reality” (p. 146) in order to ensure the continued dominance of that
group. Thus, consciousness-raising in the counseling setting engages clients in demystifying
their experiences (e.g., workplace discrimination) so that they understand the systemic forces
that affect them. Ideally, this process occurs in a group setting, whether the group is a
political discussion forum such as those of the civil rights and feminist movements of the
1960s and 1970s, a political action project (e.g., Freire), or feminist multicultural group
counseling.

Analysis of Power in Psychotherapy

Feminist multicultural therapists examine with the client power dynamics between client and
therapist as well as issues of privilege and power in the life of the client. Thus, differing
statuses related to privilege and power in the therapy dyad—those related to gender,
race/ethnicity, culture, class, sexual orientation, and so on, as well as those related to the
therapist-client hierarchy itself—are raised by the therapist in order to provide a context for
understanding how dynamics of oppression may operate in the therapy relationship. It is
important that this examination take into account not only the therapist’s relative power but the
client’s as well if, for example, the counselor is a person of color and the client is White.

In addition to examining power in the therapy relationship, feminist multicultural therapy
assists clients in analyzing power in their l ives at the personal, interpersonal, and
sociopolitical levels. Morrow and Hawxhurst (1998) defined empowerment as “a process of
changing the internal and external conditions of people’s lives, in the interests of social equity
and justice, through individual and collective analysis and action that has as its catalyst a
political analysis” (p. 41). They argued that empowerment involved both analysis and action,
similar to Freire’s (1970) notion of praxis, which combines reflection and action. Thus,
consciousness-raising is accompanied by action taken on one’s own behalf in the interest of
freedom.

The Importance of Group Work to Empower Clients

The centrality of group work for feminist therapists emerged, in part, from the consciousness-
raising movement of the early 1970s. Groups help to reduce the power discrepancy between
client and counselor, and group dynamics serve to better facilitate clients challenging the
power and mystique of the facilitator. A basic assumption of feminist group work is that
“women need to carve out their own space in what is essentially a hostile environment” (Butler
& Wintram, 1991, p. 16). The same can be said about members of any oppressed group.

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Thus, a core aspect of feminist group work is safety and trust, which needs to be established
early and revisited. The isolation of women, people of color, lesbian/gay/bisexual/transgender
(LGBT) people, as well as abuse survivors, people with eating problems, and the like, is
potentially alleviated in the group setting. One of the most powerful aspects of participating in
a group is finding out one is not alone. Groups also provide support and friendship and are a
door to creating community. Although this goal may seem at odds with counseling
approaches that discourage contact among members outside of group sessions, we believe
that providing the option for group members to meet outside of group helps to reduce
dependency on group leaders as well as empowering members by providing them the
opportunity to give and receive support as well as build a social network and community.
Groups themselves are microcosms of societal dynamics; thus, issues of privilege, power, and
oppression can be dealt with in an open environment in the group, with facilitators modeling
intercultural communication and respect. When people are able to successfully address their
experiences of isolation, alienation, and oppression within the group setting, they are
empowered to take steps on their own behalf and that of others in the world outside.

Political Action and Activism

Of all the components of feminist multicultural counseling, counselors and therapists—even
feminist therapists—struggle most with the idea of political action and activism. We propose
two foci for activism: activism on the part of the therapist and action/activism on the part of the
client. The two can converge in powerful ways.

Counselors and psychotherapists earn their living trying to heal the wounds inflicted by an
unjust society. Feminist multicultural therapists consider it unethical to do so without taking
steps to change social systems that oppress our clients. The Feminist Therapy Code of Ethics
(Feminist Therapy Institute, 2000) states that the feminist therapist seeks avenues to effect
social change and “recognizes the political is personal in a world where social change is a
constant.” Many feminist therapists have removed themselves from political action in the
feminist community in order to avoid overlapping relationships. Although feminist
psychologists have led the way over time in the move to protect clients from therapists’
abuses, there are situations in which these overlaps can be empowering if processed
carefully. When client and counselor work together to create sociopolitical change, some of
the mystique surrounding the therapist is reduced and the client sees herself or himself as
capable and competent.

Client action and activism occur on a number of levels. It may be necessary for many clients
to take their first steps as activists on behalf of themselves or their families before it is realistic
for them to engage in larger social, institutional, community, or political change. Although it is
not necessary for all clients to engage at a larger political level, it is important to understand
the exceptional potential for empowerment and transformation that accompanies participating
in social change, both for oppressed people and for their allies. When activist efforts converge
on the part of a client-counselor dyad in which one is a marginalized group member and the
other a dominant group member, the consequences can be astounding for both. For example,
when a heterosexual counselor and a lesbian or bisexual woman client work together for gay
rights, the counselor’s commitments become more apparent, and the client is viewed by
herself and her counselor as “the expert” in the activist work. Traditional therapeutic
boundaries are challenged in an appropriate manner, and power in the counseling
relationship moves toward a more egalitarian frame.

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Feminist Multicultural Counseling for Social Justice in Action

At the heart of feminist multicultural counseling for social justice is the premise that this work
is not restricted to the one-to-one psychotherapy hour. The examples below demonstrate the
integration of research, practice, and community-based social change (in Example 1) and of
counseling, prevention, education, and community action (in Example 2).

Finding Voice: The Music of Battered Women

The first author of this chapter, Sue Morrow, was privileged to consult with a faculty member
in music therapy, Elizabeth York, at a nearby university, on York’s qualitative investigation of
the efficacy of music therapy and creative arts interventions with women who were part of a
support group at the Community Abuse Prevention Services Agency (CAPSA). Dr. York took a
feminist research standpoint, which she defined as “women speaking their truth” (York, 2004,
p. 3). The researcher conducted participatory action research in which she and the regular
CAPSA support group facilitator engaged with client participants using “women’s music” over
a period of 9 months. The 40 women who participated contributed their original songs, stories,
and poems and took an active part in creating an ethnographic performance piece in order to
share their experiences of domestic violence with shelter workers and the public. Fifteen of
the original 40 women took part in a transformation from “therapy group” to “performance
group” (York, 2004, p. 11). The profound healing and empowerment experienced by these
women were accompanied by physical improvement in posture and coordination, “vocal
projection, emotional expression, and eye contact” (p. 12). In addition to seven public
performances as of this writing, the “Finding Voice” group has produced a book of poetry and
a CD of the performance.

Co-author Sue Morrow interviewed Beth York during the writing of this chapter to discuss the
feminist multicultural aspects of this project, and Beth’s responses were thought-provoking.
All of the women were White and English-speaking, ages 18–58, and all but one were
members of the Church of Jesus Christ of Latter-day Saints (LDS or Mormon Church). Their
socioeconomic statuses ranged from working to middle class. Beth described her process of
dealing with her own biases—based on being a non-LDS woman in a predominantly LDS
community—that led her to expect that these women would likely have accepted cultural
norms and messages to remain in their marriages and that these women would have a more
difficult time leaving battering relationships than non-LDS women. Beth dealt with the conflict
between her feminism and wanting to respect the religious values of her participants. She
shared with me her anger at the church for having inflicted these values on the women, but
she took care to examine and manage her feelings by journaling; debriefing with her
cofacilitator, who was LDS; and, as she put it, having a “crash course” in Mormonism. This
raises again the issue of the potential conflict between feminism and multiculturalism and
demonstrates how one woman managed this conflict in a social justice project.

University of Utah Women’s Resource Center

The University of Utah’s Women’s Resource Center (WRC) offers a feminist therapy field
practicum for graduate students in counseling psychology, professional counseling, and
social work to receive training in feminist multicultural counseling. Co-authors Donna
Hawxhurst, Ana Montes de Vegas, and Tamara Abousleman have worked together integrally
with this practicum as trainer and students. The staff and practicum counselors at the WRC

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represent a broad diversity of ages, ethnicities, cultures, socioeconomic origins, and sexual
orientations. The WRC has had a commitment over time to a multicultural agenda and has
formed strong relationships with the University’s Center for Ethnic Student Affairs (CESA) and
the Lesbian, Gay, Bisexual, Transgender (LGBT) Resource Center. Over time, its multicultural
perspective has moved from a focus on multiculturalism as race/ethnicity to one that is more
inclusive. A turning point was reached as the WRC staff (including support staff) and
practicum counselors moved into a shared commitment to a process that includes social
justice as a major part of its mission and a regular self-reflective process in which individuals
present their biases in a context of self-reflection, communication, feedback, and critical
honesty.

Feminist multicultural therapy training includes not only bias awareness, but also a critical
consideration of traditional therapy issues such as diagnosis and assessment. Sinacore-
Guinn’s (1995) model, described above, provides a framework for assessment and diagnosis
at WRC, with trainees learning to look critically at traditional assessment modalities. Training
staff and practicum counselors engage in this process by starting with themselves, looking at
cultural issues and cross-cultural dilemmas, examining their own cultural values, identifying
coping strategies, and looking at gender and trauma (including direct, indirect, and insidious)
in preparation for assessing clients. In conjunction with WRC, co-author Tamara Abousleman
has developed a feminist multicultural outcome assessment tool for use specifically in feminist
multicultural counseling environments.

Counselors are trained not just to provide individual counseling, but to conduct groups.
Groups at WRC are open to community members as well as students, faculty, and staff at the
university. In addition, a significant component of the training program involves outreach,
prevention, and social action programs designed to make changes in the university or the
larger community environment. The WRC partners with CESA, the LGBT Center, and the
International Student Center to create programs and groups that will meet the needs of
women who fall outside the groups traditionally served by campus women’s centers—
predominantly White, middle-class women who are either nontraditional students (women
returning to education) or already feminists. These partnerships have led to an International
Women’s Support Social hosted at WRC for international women students and wives of
international male students, a movie series for young lesbian and bisexual women, and a
focus group for women of color to explore issues related to campus climate.

One example of the integration of therapy training, outreach, prevention, and programming is
in the area of violence against women, where the WRC takes a multifaceted approach. In
addition to specific training in feminist therapy seminar in working with victims and survivors of
sexual abuse, sexual assault, and domestic violence, staff and practicum counselors
participate in Peers Educating to End Rape, most recently implementing a 40-hour on-
campus training for sexual assault crisis advocacy training with a particular focus on involving
campus services to students who might be at risk or unlikely to seek help. The training is
designed to develop competencies in dealing with victims of sexual assault and to raise the
consciousness of the university community about violence against women. This program is
especially important because it creates partnerships with men who become involved as allies
by working with young men on campus in prevention outreach, calling into question male
socialization to perpetuate violence. In addition, the WRC partners with community agencies
such as the Utah Coalition Against Sexual Assault and the YWCA’s Women in Jeopardy
Program for battered women in collaborative efforts to end violence against women and serve
the needs of female victims and survivors.

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In conclusion, feminist multicultural counseling for social justice offers a unique perspective to
the development of counseling psychology in which the complexities of an increasingly
diversified population and important social needs call for something more than “talking
therapy.” As counseling psychology revisits its roots in prevention and psychoeducation,
feminist therapists must reclaim their roots as activists and multicultural counselors must
move beyond knowledge, awareness, and skills to social action. Feminist multicultural
counseling for social justice offers the potential to bring the best of all three traditions into
alignment to contribute to meaningful and lasting change.

Susan L.MorrowDonna M.HawxhurstAna Y.Montes de VegasTamara M.AbouslemanCarrie
L.Castañeda
Authors’ Note: Correspondence concerning this chapter should be addressed to Susan L.
Morrow, University of Utah-Educational Psychology, 1705 E. Campus Center Dr. Rm. 327, Salt
Lake City, UT 84112–9255. Electronic mail may be sent via Internet to morrow@ed.utah.edu

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Collaboration in Culturally Responsive Therapy: Establishing A
Strong Therapeutic Alliance Across Cultural Lines

Anu Asnaani, M.A. and
Boston University, Boston, MA

Stefan G. Hofmann, Ph.D.
Boston University, Boston, MA

Abstract
Achieving effectiveness of therapeutic interventions across a diversity of patients continues to be a
foremost concern of clinicians and clinical researchers alike. Further, across theoretical
orientations and in all treatment modalities, therapy alliance remains a critical component to
determine such favorable outcome from therapy. Yet, there remains a scarcity of empirical data
testing specific features that most readily facilitate effective collaboration in a multi-cultural
therapy relationship. This article reviews the literature on terminology, empirical findings, and
features to enhance collaboration in multi-cultural therapy, suggesting guidelines for achieving
this goal in therapy with patients (and therapists) of various cultural/racial backgrounds. This is
followed by a multi-cultural case study presenting with several co-morbid Axis I disorders, to
exemplify the application of these guidelines over the course of therapy.

The role of culture in psychotherapy has been gaining significant attention in the past few
decades (Wohl, 1989; Seiden, 1999; Draguns, 1997), particularly as the populations seeking
psychological services grow increasingly diverse. Indeed, an often prominently stated aim of
training programs for mental health practitioners includes the need to ensure the cultural
competency of those delivering psychological treatments (Heppner, Leong, & Gerstein,
2008). Unfortunately, often this recognized need is insufficiently met because (1) of a lack
of a definitive structure and specific goals to achieve this cultural competency in therapists,
and (2) scant empirical data to support one training model over another (Laungani, 2005;
Whaley & Davis, 1997). This distinct gap between stated intent of incorporating cultural
differences into current evidence-based treatments, and actual clear guidelines for
accomplishing this goal must be more directly addressed.

Further, the importance of establishing a strong rapport with patients and developing a firm
therapist-patient alliance to target emotional symptoms remains an overarching goal of the
field of mental health (Taber, Leibert, & Agaskar, 2011). This article therefore aims to
review the empirical literature on effective enhancement of collaboration in the multicultural
therapy setting, to reveal the common and specific features across a range of treatment
modalities. This is followed by a case study of an actual patient to exemplify how these
features may be incorporated into treatment with a multicultural client, both in terms of
establishment/maintenance of a strong working alliance during treatment, and then in
healthy termination of the therapy relationship after a course of treatment.

Corresponding author for proofs and reprints: Stefan G. Hofmann, Ph.D., Department of Psychology, Boston University, 648 Beacon
St., 6th floor, Boston, MA 02215, shofmann@bu.edu.

Author Note
Dr. Hofmann is a paid consultant of Merck Pharmaceutical (Schering-Plough) for work unrelated to this study. This study was
partially supported by NIMH grants MH-078308 and MH-081116 awarded to Dr. Hofmann and MH-73937.

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Key Terms
Researchers have provided several relevant working definitions within cultural therapy that
are noted here. The first is culture itself, which in the currently discussed context broadly
refers to a system of beliefs, perspectives, and values a group of a particular race/ethnicity or
geographic region collectively share. Of course, cultural influence does not work in a
vacuum, and Hays (2008) coined an acronym that serves as a reminder to clinicians about
the multi-faceted nature of multi-cultural therapy (MCT) in terms of what they need to be
ADDRESSING: Age and generational influences, Developmental disabilities and
Disabilities obtained in later life), Religion and spiritual orientation, Ethnic and racial
identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and
Gender. Such a term captures the complexity of cultural identity and the number of factors
to consider when we discuss the impact of cross-cultural differences in therapy.

In addition, cultural identity of an individual is tied into other key processes not noted in
even this rather comprehensive acronym, such as discrimination and acculturative stress.
Briefly, cultural/racial discrimination can be described as a differential treatment of an
individual specifically due to certain negative beliefs about that person’s cultural/racial
group membership (Karlsen & Nazroo, 2002), and has been found to be linked to negative
psychological outcomes (Chou, Asnaani, & Hofmann, in press). Acculturative stress is more
specific to recently immigrated individuals who are undergoing the often difficult process of
acquiring and assimilating the cultural characteristics of the host country (Hwang & Ting,
2008), such that one’s own cultural identity is constantly being challenged and changed to
varying degrees. Finally, a major construct that certainly influences each individual’s
cultural beliefs is the idea of individualism versus collectivism, or independence versus
interdependence (Markus & Kitayama, 1991). This broader concept delineates key
differences between taking a collectivist/interdependent world view (i.e. that the greatest
priority lies in maintaining harmony within the cultural group, and thus individual gain is
deemphasized), from an individualist/independent value system (i.e. focus on individual
achievement and success is deserving of the greatest social admiration/reward). Indeed,
several empirical studies have found differences based on this construct in acceptability
towards, and extent of, certain psychological symptoms, including social anxiety (Heinrichs
et al., 2006), and depression, personality disorder features, and OCD (Caldwell-Harris &
Aycicegi, 2006). Again, these are important considerations that inform our understanding of
the cultural lens of patients engaging in something as personally revealing as psychological
therapy.

One other concept that is of particular importance in the current discussion is that of cross-
cultural competency, which provides an index of how skilled (1) a clinician feels about their
abilities to manage cultural issues raised in therapy, and (2) a patient perceives the clinician
to be in their ability to handle such topics in the therapeutic context (Lee, 2011). A survey of
689 APA-licensed psychologists found that while practitioners reported having discussions
about cross-cultural issues, they only did this with less than half of their cross-ethnic/racial
clients, although this was for a variety of verbalized reasons (Maxie & Arnold, 2006).
Further, the therapists most likely to discuss cultural differences with patients were those
who were older, female, of non-minority racial status, those who felt they were less
experienced with treating diverse clients, and those who felt training is an important feature
of effective therapy delivery. Indeed, a considerable amount of discussion has revolved
around the need to develop a cultural competency in the field of cross-cultural
psychotherapy (Sue, 1998; Kaweski, 2010; Taylor, Gambourg, Rivera, & Laureano, 2006).
Yet, an empirical study examining the impact of the competency ratings by 143 patients of
their therapists (N= 31) found no significant association between patients’ perceptions of
therapist cross-cultural competency and actual therapy outcome (Owen, Leach, Wampold, &

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Rodolfa, 2010). Such a finding indicates that the process is likely to be more complex than
simply providing superficial mention of cultural issues during therapy, or clinicians’ degree
of experience with diverse patients. Other experts in cross-cultural treatment have noted that
simply instructing clinicians to simply be sensitive to cultural differences or to familiarize
themselves with the culture-specific norms of clients is insufficient and not particularly
beneficial (Sue & Zane, 2009). Given this inconsistency in the literature on the impact of
cultural competency on outcome, there needs to be a more systematic empirical study of this
concept across a diversity of populations.

Empirical Data Identifying Specific Features
While differential rates in report and diagnosis of certain disorders across race-ethnic groups
in the United States have been noted in several large-scale epidemiological studies (Grant et
al., 2005a,b; Pole et al., 2008; Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010), the
empirical data in the efficacy and structure of culturally responsive therapy is still limited.
One meta-analysis examining a mix of 65 experimental and quasi-experimental studies
(which included 8, 620 participants) revealed a modest effect size (d = 0.46) in favor of
culturally-adapted treatments for clients of color as compared to traditional treatment
procedures (Smith, Rodriguez, & Bernal, 2011). Further, results indicated that when mental
health treatments were designed targeting one particular cultural group in mind, these
treatments outperformed other treatments serving patients from a variety of cultural
backgrounds. Such findings highlight two needs: (1) more rigorous, stricter treatment
designs to fully examine the relative benefit of culturally-specific treatments, and (2) more
systematic research into the specific components of culturally-sensitive therapy that predict
maximal benefit to clients. While both of these needs are recognized by proponents of
culturally-responsive psychotherapy, there have been a reasonable number of smaller
qualitative studies on specific aspects of multicultural therapy. Such studies provide rich
insight into the factors that clinicians are advised to consider when engaging in therapy with
clients of varying cultural backgrounds, and preliminary directions for most robust,
experimental study designs.

One study by Tsang, Bogo, & Lee (2011) analyzed the session transcript data of nine cases
from pre- to post-treatment. Complex coding procedures from a narrative research
perspective were supplemented by the information provided on various process and
symptom measures (which were both subjective and objective in nature). The analysis
revealed that therapists who actively and positively engaged in cross-cultural conversations
during therapy more effectively expressed an understanding of what the patient’s goals and
needs in therapy were, appeared more emotionally in-tune with clients, and demonstrated
appropriate management of cultural experiences raised by the client.

Another qualitative study investigated the impact of how practitioners from a dynamic or
relational treatment perspective addressed cultural issues with clients on the strength of the
treatment alliance (Lee, 2009). The therapists in this study consisted of 4 white clinicians,
and the content of their therapy sessions with 6 minority patients were analyzed using
Conversation Analysis and Structural Analysis of Social Behavior. The study results
revealed that therapists’ specific interactions during cross-cultural discussions were
associated with the Bond subscale of the Working Alliance Inventory-Short Revised (WAI-
SR; Hatcher & Gillaspy, 2006), which measures the interpersonal connection shared
between clinician and patient. There was no significant association between these moment-
by-moment interactions and the other two main subscales, i.e. extent of agreement on the
target of treatment (Goals subscale) or degree of agreement on what needs to be done
specifically to achieve these goals (Tasks subscale). Again, it appears that cultural
congruence between client and therapist plays a role in enhancing the moment-to-moment

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collaboration and alliance of the therapeutic relationship. Such a finding further points to the
need to incorporate cross-cultural features explicitly into treatment to facilitate the therapy
relationship, regardless of treatment modality.

Features of Effective Collaboration in Multicultural Therapy
Taken together, the empirical and observational findings discussed thus far reveal several
data-driven guidelines and hypotheses about how therapists’ cross-cultural competency may
be improved, and how the therapeutic bond may be most strengthened in a cross-cultural
therapy setting. In addition, there are several other cross-cultural models examining the
establishment of a strong working alliance, which are themselves grounded in existing
evidence-based research findings (e.g., Hays, 2009; Fontes, 2008; Sue & Zane, 2009). The
common features and themes as gleaned from these various sources are integrated to
produce the following guidelines for practitioners.

Guideline #1: Conduct a thorough culturally-informed but person-specific functional
assessment of presenting problem

Before modifying an existing treatment to be more culturally sensitive, therapists should
fully assess how much of the individual patient’s presenting problems may be interlinked to
his or her cultural identity/related constructs. That is, clinicians must be wary of premature
adoption of a modified treatment simply because an individual is from a particular cultural
group (Sue & Zane, 2009). All patients must still be regarded as unique individuals who lie
on a more dynamic spectrum of cultural identification, and cultural groups must be seen as
heterogeneous populations with some more or less likely dominant themes. Related to this,
before engaging in any adaptation of existing treatment techniques, there must be adequate
information gathered about how cultural beliefs are specifically shaping or maintaining
problematic emotional symptoms. A clinician should not make blanket assumptions about
how a specific cultural belief introduced by patients informs their experience of distress.
After a comprehensive functional assessment of the patient’s problems, the clinician can
consider the remaining guidelines.

Guideline #2: Engage in self-education about specific cultural norms and consult the
literature for culture-specific treatment techniques

As the meta-analytic findings by Smith and colleagues (2011) would indicate, patients might
most benefit from treatments that have been specifically modified for a certain population
rather than more generally culture-sensitive treatment techniques. As mentioned earlier, it is
imperative that as we embark on cross-cultural therapy that we stay as close to the empirical
data to guide us about effective treatments with different populations. Therapists should
therefore first refer to the literature about whether specific cultural adaptations of existing
treatments have already been tested and validated (e.g. Latinos: Borrego, 2010; Native
Americans: BigFoot & Schmidt, 2009; East Asians: Hwang, Wood, Lin & Cheung, 2006;
Southeast Asians: Otto & Hinton, 2006; African Americans: Kelly, 2006). Further, such a
review of the literature will enlighten the therapist on what beliefs are the norm of that
culture to reduce miscommunication in therapy, and will garner patient confidence in the
therapist’s abilities and knowledge.

Guideline #3: Ensure adequate and effective training of therapists in cross-cultural
competency

While the literature is mixed (e.g. Owen et al., 2010), there is some evidence that patients’
perceptions of how culturally competent the provider is can affect the working alliance
(Maxie & Arnold, 2006). Also, it is clear that cross-cultural therapy is a complex and multi-
layered process, and therefore ensuring cultural competency in mental health work is not

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simple for trainees to undergo. It is therefore obviously not enough to assume that garnering
cross-cultural competency is just a matter of educating oneself about cultural differences
between therapist and client (Sue & Zane, 2009). Rather, others have suggested that
therapists need to have a keen awareness of their own cultural and racial identity, and how
this may impact their relationship with clients (Plummer, 1997). For instance, multicultural
researchers have noted the importance of having practitioners discuss their feelings about
treating cross-cultural patients with their professional peers or supervisors (Barbarin, 1984),
and exploring attitudes toward psychological help-seeking in their own communities (Chung
& Lu, 1996). Such a reflection is indicative of an appreciation for the bidirectional influence
of culture in a therapy interaction, to facilitate a healthy dialogue about sensitive cross-
cultural topics that might arise during treatment.

Guideline #4: Explore the patient’s perspective on both seeking psychological treatment,
and the nature of the therapeutic relationship

There have been observed differences in perceptions of obtaining mental health treatment
among minority groups, and empirical evidence for the distinctly higher stigma associated
with obtaining psychological help in a number of minority cultures (Shea & Yeh, 2008;
Alvidrez & Azocar, 1999). Therefore, it may become necessary to first address the stigma
around receiving such treatment, particularly assessing for the impacts of this on the
individual’s sociocultural network. For instance, an individual identifying with
predominantly collectivist or interdependent cultural values may regard the need for therapy
as a sign of weakness and embarrassment to one’s family or community (Furukawa & Hunt,
2011), and this topic must be made explicit, particularly if treatment progress or adherence
becomes stalled. In addition, giving validation and respect for the client’s perspective on
mental health treatment will further enhance clinician-patient trust and bolster the
therapeutic bond.

A related matter is being aware of the preference for a preconceived ideal of an appropriate
relationship between the client and clinician. Specifically, most treatment perspectives in the
West emphasize a collaborative therapeutic relationship (Taber et al., 2011), but this might
be isolating or confusing to individuals from certain cultural backgrounds. In fact,
individuals identifying with cultures which are hierarchy-based (e.g., Eastern cultures) might
expect a more directive, authoritarian approach in the therapy relationship (Tsui, 1985), and
an over-emphasis on an equal therapist-patient relationship and socratic, open-ended
questioning might raise doubt in the patient about the therapist’s capabilities to treat the
problem at hand. On the other hand, certain treatment perspectives (e.g. CBT) involve a
considerable amount of direct questioning, which might be construed as disrespectful in
other cultures (such as Native Americans, and older European Americans; Hays, 2009).
Such considerations serve as a reminder of the importance of thorough initial assessment of
an individual’s cultural beliefs and influences, to prevent an early rupture in the therapeutic
alliance.

Guideline #5: Be aware of the importance of respect in the cross-cultural therapy setting
Clinicians engaging in multi-cultural therapy must set an overarching tone of respect in
order to meet the goals of therapy collaboratively with the client. This means allowing
individuals to fully express their individual stories and to explain how their cultural beliefs
have been uniquely part of this story (Coronado & Peake, 1992). Furthermore, establishing
trust in the therapy relationship is intricately interconnected to the level of respect shared
between the client and therapist. To that end, it is important that therapists validate the
client’s experiences, including encounters with cultural or racial discrimination, and possible
oppression in the majority culture. Patients want to feel believed and therefore clinicians are
advised to assume the reported incident occurred just as it was described by the patient, to

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provide support around such an experience, and then to later examine how much that
experience has influenced the current symptoms of interest (Kelly, 2006). Aligning oneself
with patients by demonstrating full support for the difficult race- or culture-related stressors
they may be facing will mitigate hesitation in discussing such sensitive issues with the
therapist (Vasquez, 2007).

Guideline #6: Identify and incorporate client’s culturally-related strengths and resources
into treatment

One general guideline across contemporary models of psychotherapy refers to an
exploration of individual strengths in order to enhance treatment success and adherence, and
this can be taken one step further in MCT. For instance, the identified culture itself can be a
major resource and provide an extensive support network for the client (Cross, 2003). Also,
culture itself influences a range of culture-specific skills (e.g. naturalistic medicinal
knowledge, cooking, fishing, farming, etc.), coping mechanisms (e.g. culture-specific
metaphors for understanding emotional symptoms; Hinton, Lewis-Fernandez, & Pollack,
2009), interpersonal organizations and community resources (culturally-oriented political or
social causes, places for worship, or financial resources), and artistic outlets for emotion
(through dance, art, and music; Hays, 2007).

Thus, it is important to bring these culture-influenced strengths of the individual to the
therapy discussion, particularly if these positive attributes may be incorporated into
treatment techniques and practice. Hays (2009) astutely notes, however, that certain cultures
(e.g. Asians & Native Americans) are culturally socialized to be modest about individual
strengths, and therefore these might not be easily verbalized if such individuals are directly
questioned about their own strengths. It is therefore suggested that individuals from this
more interdependent cultural set-up be asked to think what other significant individuals in
their lives might say the strengths of the patient are, in order to access this information and
incorporate it into the therapeutic relationship more readily.

Guideline #7: Identify and utilize technique-specific cultural modifications
Finally, as clinicians and clinical researchers, our foremost concern in mental health
treatment is ensuring adequate delivery of treatment techniques that will result in noticeable
improvement in our clients’ symptoms. Therefore, while it is reasonable to utilize treatment
techniques that have been seen to be efficacious, we must be ready to modify these
techniques in a culturally-sensitive fashion. Again, it is ideal to make cultural modifications
that have been validated in the population of interest, but in the absence of definitive
empirical evidence for all possible modifications, we must use our cross-cultural knowledge
to make reasonable changes to effective techniques. For instance, in the CBT framework, we
often ask clients to question the validity or reasonableness of a particular negative automatic
thought, but this might be regarded as uncaring on the part of the therapist, and places
negative judgment on the client’s belief system (Wood & Mallinckrodt, 1990). The therapist
might choose instead to take a more culturally responsive approach (Beck, 2005) and ask
clients to question the utility or helpfulness of the thought, encouraging them to weigh out
the pros and cons of holding on to this belief. Similarly, CBT often leads to an eventual
challenging of core (negative) beliefs that a patient holds about themselves or the world.
Therapists must be cautious of directing patients to challenge their core cultural beliefs, even
if a particular belief of the client seems incongruent or problematic within the therapist’s
own cultural value system.

With these guidelines in mind, the next section describes a case treated by one of the authors
(AA) and highlights the practical use of these techniques throughout the treatment episode.

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The influence of these culturally-responsive directives are demonstrated in the progressive
development of a strong working alliance in the following clinical case study.

Application of Alliance-Building Techniques: The Case of Karen1

Karen was a 37-year-old Jamaican-American female and a single mother of 3 teenage-age
children, who had recently lost her job due to a change in ownership at her medical
insurance firm. Karen presented to our cognitive-behavioral treatment (CBT) clinic with a
primary diagnosis of panic disorder with significant agoraphobia, and additional diagnoses
of obsessive-compulsive disorder and generalized anxiety disorder. She had also had a past
history of major depression and post-traumatic stress disorder from chronic and multiple
traumatic experiences. Karen had pursued significant prior treatment, but with little relief in
her ongoing anxiety symptoms.

She had decided to pursue treatment at our clinic because she had read about the efficacy of
CBT for treatment of various anxiety symptoms. She also hoped that the more structured
and short-term nature of this type of treatment might help her develop a more healthy
attachment to her provider, which had been difficult in the past. It therefore became apparent
from early on in treatment that one therapy goal would have to be to effectively develop a
strong working alliance while balancing reasonable boundaries to keep the purpose of the
therapeutic relationship clear. This goal was explicitly stated from the outset, and framed as
being in the best interest of both the patient’s progress and to maintain treatment fidelity and
effectiveness. However, it was recognized that much of Karen’s current support system lay
in the familiarity of relationships in her religious and ethnic community, therefore it might
take some time for her to feel comfortable with a more formalized and boundary-imposed
relationship with her therapist.

Guideline #1: Conduct a thorough culturally-informed but person-specific functional
assessment of presenting problem

The primary aim in the first several sessions was to fully explore the role of cultural beliefs
in the development and maintenance of Karen’s symptoms. Within the first session itself,
Karen expressed her strong religious belief and heavy involvement in church. Related to
this, it was clear that Karen received many negative messages from her children, mother,
and church friends about both her experience of panic-symptoms, and her decision to
receive “outside” (i.e. outside of the Caribbean American community) psychological help.
This did not deter Karen from seeking treatment, but through therapist exploration, Karen
admitted that this certainly fueled her own negative beliefs about being different from
everyone around her and made her feel discouraged about ever becoming better. She also
felt depressed about not being able to “kick these symptoms” on her own simply through
prayer and faith as others suggested, and felt like a failure about this perceived deficiency.

With these larger cultural themes in mind, the therapy content started focusing on specific
anxiety symptoms, and explored how culture infused her psychological symptoms in more
detail. For instance, Karen reported that her obsessive thoughts about being poisoned by
others (which would result in avoidance of eating or drinking items given to her by others at
their homes, or in other settings outside her own home) stemmed from a strong belief in
black magic, and that others were trying to harm her out of jealousy and control by the devil.

1Name and identifying information changed to protect patient’s privacy.

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Guideline #2: Engage in self-education about specific cultural norms and consult the
literature for culture-specific treatment techniques

The strong belief in black magic and having “an evil eye” cast upon someone was
recognized as a widely-accepted, culturally-congruent belief in individuals from the
Caribbean, and the therapist therefore did not question the validity of this belief.
Pathologizing such a common belief from that cultural system as disordered or undesirable
was regarded as culturally insensitive and potentially isolating for the patient. Instead, the
therapist focused more on increasing her motivation to target the avoidance and interference
associated with this thought.

Similarly, given the expressed importance of religion in Karen’s life view, the therapist
explicitly incorporated Karen’s spiritual strengths into the treatment very early on,
particularly to target the stigma she experienced from others surrounding her decision to
pursue psychological treatment. Specifically, the therapist proposed the idea that Karen’s
decision to seek formal help to address her anxiety symptoms was an example of her
following her own internal spiritual compass in order to maximize her strengths and abilities
to contribute to her community and family. Karen really started identifying with this
perspective shift, and became much more receptive to the more traditional treatment
techniques presented when they were framed with this religious lens.

Guideline #3: Ensure adequate and effective training of therapists in cross-cultural
competency

An interesting feature regarding these two interrelated themes (philosophical perspective
and stigma) was that Karen actually challenged the therapist to reflect at a very early stage
in treatment about her own beliefs regarding these issues, and how that might affect the
therapeutic relationship. Typically, therapists’ opinions on such topics are avoided; that is,
as clinicians we are instructed to re-direct patients’ questions about our own personal
beliefs. However, this was recognized as quite likely to be detrimental to the therapeutic
alliance, and would run the risk of having Karen disengage from treatment because of a
feeling of disconnection from the therapist. An excerpt from the session where the patient
directly questioned the therapist about her own beliefs is given below:

Karen:“There’s one more thing I need to ask you before we end today. Do you
think people who need therapy are weaker?”

Therapist:“I want to make sure I understand what you’re asking me, since this
seems pretty important to you. Do I think such individuals are weaker than who –
those who do not seek a therapist, or those who do not experience emotional
distress? And why is it important for you to know how I feel about it?”

Karen:“Those who do not go to a therapist – I don’t think anyone is completely free
from emotional distress. Do you think that I really should be able to deal with this
on my own, and that generally your work is to help people who are weak?”

Therapist:“First, I completely agree with you – I think each and every one of us
struggle with emotional distress, and therapy can be a great way for all of us to get
some support and skills to deal with our tough times better. That also means that I
actually think you’re not weak, but very strong to take the steps to come to therapy,
particularly because I know you don’t get a lot of support for that from those who
are close and important to you. Is that partly why you were asking, to see if I feel
the way they [her mother, children, and church community] do?”

Karen:“Kinda, yeah. It’s hard not to feel weak, because no one else in my life is in
therapy.”

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Therapist:“I can completely understand that feeling. You know, Karen, when I told
my family that I wanted to study Clinical Psychology, they were extremely
resistant to it. They didn’t feel “mental health” was a real thing, and weren’t even
quite willing to accept that anything except willpower or prayer to a higher power
could affect our emotional distress. Yet, I had to make a tough decision to stay true
to my course of study despite their protest, because I felt that while willpower and
spiritual pursuits can be extremely powerful, they are not always effective on their
own, in the absence of other resources. I think you and I are a lot alike in that way –
both determined to do our best and get the most out of our lives, even when our
families or communities might not agree. It’s hard to stay patient until they come
around and see the benefits like we do though, isn’t it?”

Karen:“I know! Sometimes I just want them to open their eyes and minds to see
that I was right about this being important and useful for me, and I even think some
of them need similar help, but they’re too stubborn to get it. You’re right, I am
determined, and I do feel good about sticking to my beliefs about making my
mental health a priority. I can feel God’s guidance in doing that. So even if they
disagree, I’m not going to give up on this. I need this jumpstart in my life.”

As exemplified in this excerpt, the therapist adequately revealed some personal beliefs and
experience with stigma observed around seeking psychological help in her own life. This
was presented after consultation with other clinicians, the literature, and reflection on her
personal beliefs towards psychological dysfunction. Even with only this partial disclosure on
the part of the therapist, Karen expressed feeling respected and more willing to continue
with treatment with this provider.

Guideline #4: Explore the patient’s perspective on both seeking psychological treatment,
and the nature of the therapeutic relationship

As mentioned previously, Karen reported having several past treatment episodes, with little
sustained improvement in her anxiety symptoms. She noted, however, that she had deeply
enjoyed several of these therapy experiences, specifically because of the strong therapeutic
relationship she shared with the providers during those experiences. That being said, in the
first session she verbalized a concern that her close relationship with her past therapists
eventually became a disadvantage, primarily because she found it difficult to terminate these
relationships or to continue with skills independently once therapy ended. This provided
insight into Karen’s own perceptions and concerns around an ideal therapist-client
relationship.

Boundary setting in the therapy relationship therefore became a shared goal throughout the
course of treatment. This had to be handled in a culturally-responsive way, because it was
important not to make Karen feel isolated in her experiences so she would feel comfortable
confiding in the therapist. Yet, Karen often pushed the boundaries of the professional
therapy relationship by wanting to call “just to chat”, asking the therapist details about her
family and upbringing, and wanting the therapist to come to her home community to meet
other members of her family and church. These were handled in a manner similar to how
matters of religiosity, politics, and related beliefs are typically dealt with in therapy, but the
cultural need to feel connected and incorporate the therapist into Karen’s own community
was acknowledged explicitly.

Guideline #5: Be aware of the importance of respect in the cross-cultural therapy setting
One recurrent problem area was Karen’s ongoing worry surrounding a “love-hate”
relationship with her mother. Specifically, she felt significant distress when interacting with
her mother, and yet she worried constantly about her mother dying, and felt that she would

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be unable to function with her mother gone. Most of her inner conflict in this relationship
stemmed from a strongly ingrained cultural pressure to maintain an active relationship with
her mother, but this relationship posed significant barriers to her own ability to be
productive and stress-free. The therapist would have been remiss in this case to suggest to
Karen that she disengage from this relationship with her mother (which would be
inconsistent with the interdependent family/community system). Instead, Karen was asked
to reflect thoroughly on this relationship (with various in-session exercises on the pros and
cons of her relationship with her mother), to help the patient become comfortable with
finding her own balance of meeting her familial responsibility and yet, protecting her own
mental health.

Similarly, while Karen expressed many traditional cognitions associated with her
agoraphobic concerns (e.g., inability to reach medical help promptly, or to escape when
experiencing panic symptoms), she also reported anxiety during exposure exercises around
the Center because of a prior experience of racial discrimination when in distress in a similar
predominantly White location. This experience was met with empathic validation and it was
discussed at length how much her own perceptions of being negatively regarded by others
due to her race tie into her fears around being helpless when experiencing panic outside
from her own geographic community. Once the patient felt supported and listened to around
this concern, the therapist worked on gradually exploring how Karen may more rationally
weigh out the probability that every individual around her will refuse to help her based on
her race/appearance, and she was receptive to this. In particular, the therapist encouraged her
to think of the instances in her life that others from the majority culture had actually been
caring and helpful towards her, in order to more rationally evaluate her fears about being
completely unsafe or alone.

Guideline #6: Identify and incorporate client’s culturally-related strengths and resources
into treatment

Again, Karen’s major positive characteristics were many, but several were directly linked to
her community and spiritual values. A recurrent theme throughout treatment was the
importance of belief in God and service to her church. Consequently, this particular
community/belief system was often referred to and integrated into the homework exercises
and therapy discussions. Aside from its previously-described use to increase her motivation
to address the anxiety symptoms that were interfering with her meeting her full potential, the
use of her community and church involvement were utilized. For instance, as she was
nearing the end of treatment, she independently volunteered to work with the clinic
administrators to disseminate information about available services, e.g. by going into local
churches in her neighborhood to share her positive experiences with therapy and anxiety
reduction. This exercise was extremely empowering for Karen, and met this need to
contribute meaningfully to her community. There was also a focus on strengthening
interpersonal relationships with her family members (e.g. going to get her nails done with
her young adolescent daughter), because of her highly expressed cultural value of staying
close-knit as an immigrant family. Thus, spending time with such individuals served both as
an exposure exercise (to reduce agoraphobic avoidance) and to meet this valued
interdependent cultural goal.

Guideline #7: Identify and utilize technique-specific cultural modifications
Treatment therefore progressed using empirically supported techniques with these cultural
guidelines integrated into the session content. Karen actually came for a relatively longer
treatment course than what is typical for CBT in this treatment setting (around 30 sessions),
primarily due to a other stressors (legal and significant medical conditions involving two of
her children) that suddenly happened about 15 sessions into the treatment. At this point in

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therapy, there had already been a considerable objective and subjective improvement in
Karen’s anxiety symptoms (particularly in her panic and agoraphobic symptoms). These
sudden crises forced the treatment to take a different focus for about 5 sessions, in order to
maintain the therapeutic alliance and to meet the immediate needs of the patient. Once these
external circumstances had reduced in urgency, treatment focus returned to managing with
her overall stress level and specific lingering anxiety symptoms.

There appeared to be a plateau reached in several of her symptoms (particularly her chronic
worry symptoms), and therefore it was decided that first-line CBT skills needed to be
supplemented with other related techniques. Of note, the technique of mindful meditation
was presented to Karen. However, to make this technique more palatable to this client,
mindfulness activities that emphasized resilience (with Karen’s history of experienced
racism and trauma as an explicit part of the extensive metaphor for mediatation) and
spiritual values-driven mindfulness practices were presented. Karen really enjoyed these
exercises, and reported a significant relief in the frequency and severity of her chronic worry
through consistent use of this skill.

Termination of therapy
Termination of therapy was collaboratively decided upon, on the basis of significant
reduction in anxiety symptoms, and at a point where the patient herself verbalized a need to
detach from her dependence on the therapeutic relationship to try the skills independently.
At the last session, Karen brought in a gift (a velvet rose) and a card with religious themes as
a gesture of gratitude for the therapist. At this particular treatment setting, gifts are usually
declined, but the therapist regarded Karen’s gift choice as a noted effort to stay within the
discussed boundaries and recognized the card as her desire to express herself from within
her own belief system. Given this, the token was accepted by the therapist, and Karen also
asked if she could occasionally call the therapist to update her on how things were, which
was discussed in terms of reasonable frequency of such updates. Three months after the
termination of treatment, Karen called the therapist to let her know she had found a job, and
was planning a trip to New York with her friends after over 20 years of feeling too anxious
to leave her hometown. The therapist responded to Karen with warm reinforcement for her
achievements, and reminded her of how far she had progressed since she had first started
treatment almost a year earlier, encouraging her to keep using the skills she had learned.

Concluding Thoughts
This case highlights some practical applications of empirically-driven guidelines for
enhancing collaboration when working with cross-cultural patients. Over the treatment
episode, one may observe how the therapist modified the entire process (from assessment, to
treatment interventions, and through to termination) to make it more culturally relevant to
Karen. There was an equal emphasis on delivering evidence-based treatment techniques and
on cultivating a strong therapeutic relationship to meet this goal. Tailoring the treatment
procedures to Karen’s individual needs (which were largely influenced by group-level
cultural, religious, and societal beliefs), and doing this explicitly, contributed to her
significant progress, as she expressed in the termination session. She reported feeling
respected, listened to, and entrusted in contributing to her own progress, which gave her
confidence to continue the skills on her own even after therapy had ended.

Certainly, the presented case study is not an exhaustive application of the described
guidelines. The discussion in this article assumes primarily a traditional therapy set-up, and
therefore the focus is on how to make more traditional modes of therapy more culturally
responsive. There are, however, several other features that have shown some indication of
aiding in treatment engagement in certain cultural groups in other countries, and should be

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considered if feasible. For instance, clinicians should consider delivering therapy in more
naturalistic, familiar settings (such as in the person’s residence, place of worship, or general
community area), in order to make the patient feel more comfortable and connected to the
therapy interventions introduced by the provider (Hickling, 1994). Also, this case highlights
the important role spirituality/religiousity can play in a patient’s willingness to seek or
adhere to treatment, particularly if religion is intricately tied into the person’s cultural
identity. Further, it is important to focus on both individual events in the patient’s life
(socioeconomic status, family structure, and potential trauma history), and the broader
cultural events that may intrinsically and more systematically impact a particular
population’s views toward help-seeking and the therapist as a person (e.g. Holocaust
experiences in Jewish patients, slavery/racism in African Americans, and English language
difficulties and resultant discrimination in Latinos). Part of the process with familiarizing
oneself with the customs and practices of a particular culture is being aware of, and
assessing the impact of, these significant historical/social themes (Comas-Diaz & Greene,
1994; Sue, 2009).

Finally, even clinicians who are aware of the nuances of these various cultural
considerations and who have engaged in extensive multi-cultural therapy must challenge
themselves to treat each case as unique. This overall attitude of curiosity and respect towards
clients, across treatment orientations, establishes a strong working alliance between the
therapist and patient. Our primary aim should be to use such resources/guidelines to
systematically provide the most comprehensive care, and to meet the needs of these
individuals who, regardless of culture, gender, or sexual orientation, are coming to
practitioners for help in their times of distress.

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Copyright © 2014 by the American Psychological Association. All rights reserved.
Except as permitted under the United States Copyright Act of 1976, no part of this
publication may be reproduced or distributed in any form or by any means, including,
but not limited to, the process of scanning and digitization, or stored in a database or
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Published by
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Library of Congress Cataloging-in-Publication Data
Psychotherapy theories and techniques : a reader / edited by Gary R. VandenBos,
Edward Meidenbauer, and Julia Frank-McNeil. — First edition.
pages cm
Includes bibliographical references.
ISBN 978-1-4338-1619-2 — ISBN 1-4338-1619-9 1. Psychotherapy. 2.
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http://www.apa.org/pubs/books

mailto:order@apa.org

Psychotherapy—Philosophy. 3. Psychotherapy—Methodology. I. VandenBos, Gary R.,
editor of compilation. II. Meidenbauer, Edward, editor of compilation. III. Frank-
McNeil, Julia, editor of compilation.
RC480.5.P785 2014
616.89’14—dc23
2013020747
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
First Edition
http://dx.doi.org/10.1037/14295-000
5

http://dx.doi.org/10.1037/14295-000

CONTENTS
Preface
How to Use This Book With PsycTHERAPY, APA’s Database of
Psychotherapy Demonstration Videos
Chapter 1. Acceptance and Commitment Therapy
Steven C. Hayes and Jason Lillis
Chapter 2. Acceptance and Commitment Therapy Process
Steven C. Hayes and Jason Lillis
Chapter 3. Behavior Therapy
Martin M. Antony and Lizabeth Roemer
Chapter 4. Behavior Therapy Process
Martin M. Antony and Lizabeth Roemer
Chapter 5. Brief Dynamic Therapy
Hanna Levenson
Chapter 6. Brief Dynamic Therapy Process
Hanna Levenson
Chapter 7. Cognitive Therapy
Keith S. Dobson
Chapter 8. Cognitive Therapy Process
Keith S. Dobson
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Chapter 9. Cognitive–Behavioral Therapy
Michelle G. Craske
Chapter 10. Cognitive–Behavioral Therapy Process
Michelle G. Craske
Chapter 11. Constructivist Therapy
Vittorio F. Guidano
Chapter 12. Constructivist Therapy Process
Greg J. Neimeyer
Chapter 13. Emotion-Focused Therapy
Leslie S. Greenberg
Chapter 14. Emotion-Focused Therapy Process
Leslie S. Greenberg
Chapter 15. Existential Therapy
Kirk J. Schneider and Orah T. Krug
Chapter 16. Existential Therapy Process
Kirk J. Schneider and Orah T. Krug
Chapter 17. Family Therapy
William J. Doherty and Susan H. McDaniel
Chapter 18. Family Therapy Process
William J. Doherty and Susan H. McDaniel
Chapter 19. Feminist Therapy
Laura S. Brown
Chapter 20. Feminist Therapy Process
Laura S. Brown
Chapter 21. Gestalt Therapy
Derek Truscott
Chapter 22. Gestalt Therapy Process
Uwe Strümpfel and Rhonda Goldman
Chapter 23. Multicultural Therapy
Lillian Comas-Díaz
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Chapter 24. Multicultural Therapy Process
Lillian Comas-Díaz
Chapter 25. Narrative Therapy
Stephen Madigan
Chapter 26. Narrative Therapy Process
Stephen Madigan
Chapter 27. Person-Centered Therapy
David J. Cain
Chapter 28. Person-Centered Therapy Process
David J. Cain
Chapter 29. Psychoanalytic Therapy
Jeremy D. Safran
Chapter 30. Psychoanalytic Therapy Process
Jeremy D. Safran
Chapter 31. Rational Emotive Behavior Therapy
Albert Ellis and Debbie Joffe Ellis
Chapter 32. Rational Emotive Behavior Therapy Process
Albert Ellis and Debbie Joffe Ellis
Chapter 33. Reality Therapy
Robert E. Wubbolding
Chapter 34. Reality Therapy Process
Robert E. Wubbolding
Chapter 35. Relational–Cultural Therapy
Judith V. Jordan
Chapter 36. Relational–Cultural Therapy Process
Judith V. Jordan
Chapter 37. Schema Therapy
Lawrence P. Riso and Carolina McBride
Chapter 38. Schema Therapy Process
Lawrence P. Riso, Rachel E. Maddux and Noelle Turini Santorelli
8

PREFACE
Whether you are a student in a clinical training program or a seasoned
practitioner, you may find it difficult to grasp the full range of
psychotherapy theories or to become even partially acquainted with the
plethora of associated techniques. My hope is that this book will be of
assistance. This is a reader—a compendium of excerpts of previously
published work. We chose to create this reader to provide access to some
of the best writing the American Psychological Association (APA) has
published on clinical theories and techniques in psychotherapy. The book
surveys the great variety of orientations practiced today and provides not a
complete explanation of each but rather a glimpse of these orientations at
their richest—neither distilled into pat definitions nor tidily packaged into
bullet points and takeaway phrases. Instead, short encounters with the best
writing on each approach, afford the reader a look at the way
psychotherapy is practiced today.
For every psychotherapeutic approach we have included an excerpt
on theory and an excerpt on the therapeutic process. At the end of the
excerpt on the therapy process we have included a list of techniques
associated with that approach to therapy. Some of these techniques appear
in the excerpts; others do not appear there. All are well-known
interventions used by practitioners of the orientation in question.
In addition, we have provided guidance on where to find video
examples of the techniques in our database of psychotherapy
9

demonstrations, PsycTHERAPY. Although PsycTHERAPY is a product
quite different from the individual videos in the APA Psychotherapy Video
Series, it was created for the same purpose: training and educating
psychotherapists. Just as the APA Psychotherapy Video Series has its
companion books—from The Anatomy of Psychotherapy: Viewer’s Guide
to the APA Psychotherapy Videotape Series to the more recent Exploring
Three Approaches to Psychotherapy—this book may be considered as a
companion to PsycTHERAPY.
Readers will find that viewing the video clips listed in the chapter
appendixes will augment the glimpse into psychotherapy practice provided
by the text excerpts. APA created its various psychotherapy video products
because there is no better way to demonstrate the timing, the look, the feel
of a technique than to capture it in video. In one way, the excerpts and the
video clips may be seen as serving the same purpose. That is, just as we
have captured a segment of our best writing on theory and technique in
this book, we have also captured segments of our videos that best
demonstrate some of the techniques for each of these theories. The
technique lists are a road map to finding these video clips.
Psychotherapy Theories and Techniques may be enjoyed on its own,
without the use of the videos, as an overview and introduction to the many
psychotherapies that exist today. The technique lists will be useful in that
they neatly identify the key techniques associated with each approach. Our
recommendation is to use the book in combination with PsycTHERAPY
by first reading the excerpts for each approach and then viewing all of the
associated video clips. This will give a vivid introduction to each
orientation—not a full one, not one meant to provide the background
necessary to take up practice of the approach—but certainly enough of an
introduction to get a good sense of what each of these orientations is about.
Observant readers will notice that many of the excerpts in this volume
come from chapters in the APA Theories of Psychotherapy book series. If
the writing intrigues you, I suggest going to the original books themselves
to read more, as they provide a succinct introduction to the history, theory,
and therapeutic process of the major approaches. Whatever further reading
10

this volume inspires, my hope is that Psychotherapy Theories and
Techniques: A Reader will provide a glimpse of the breadth, depth, and
richness of psychotherapy as it is practiced today.
Gary R. VandenBos, PhD
APA Publisher
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HOW TO USE THIS BOOK WITH
PSYCTHERAPY, APA’S DATABASE OF
PSYCHOTHERAPY DEMONSTRATION VIDEOS
Psychotherapy Theories and Techniques: A Reader contains 38
chapters, each made up of an excerpt from previously published work from
the American Psychological Association (APA). The chapters are paired
up: The first chapter in each pair is an excerpt on a psychotherapy theory,
and the second chapter is on psychotherapy technique. After the second
chapter in each pair, there is an appendix of techniques associated with the
approach discussed in that pair of chapters.
The appendices contain not only the list of techniques but also
information about where to find a video example of those techniques in
PsycTHERAPY, APA’s premier database of psychotherapy demonstration
videos. PsycTHERAPY contains hundreds of streaming videos of therapy
demonstrations, each approximately 45 minutes long. All of the videos in
PsycTHERAPY have been carefully tagged with metadata, making the
videos findable by therapist, approach, therapy topic, and index terms. In
addition, each video has been transcribed, and the transcripts may be
searched as well. None of the videos appear in the APA Psychotherapy
Video Series, but they were created in conjunction with that series.
The chapter appendices contain the following information for each
technique as well as where to find it in PsycTHERAPY:
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1. Technique name
2. Video title: the video in which the technique appears
3. Video identifying number: A 12-digit number uniquely identifying the
video in PsycTHERAPY
4. Time at which technique occurs: The beginning and end times for when
exactly the technique is demonstrated in the video
To locate a technique in PsycTHERAPY, use the following steps:
1. Open PsycTHERAPY in your browser (http://psyctherapy.apa.org).
2. Accept the disclaimer terms.
3. Enter the video identifying number in the Quick Search box in the
upper right (alternatively, enter the video title in this search box).
4. Click “Go.” This will bring you to the search result page, where the
video should appear.
5. Open the video page. Click on the “Clips” tab above the transcript
pane.
6. A clip with the name of the technique will be provided here.
Rather than searching for the video for each technique, it may be
easier to simply find the playlist associated with a given list of techniques.
For each list of techniques, there is a playlist in PsycTHERAPY that
collects all of the video clips of these techniques in one place. To locate a
playlist of all of the technique demonstrations in an appendix, use the
following steps:
1. Open PsycTHERAPY in your browser (http://psyctherapy.apa.org) and
accept the disclaimer terms.
2. Click on “Playlists” in the blue navigation bar at the top of the screen.
3. There will be a featured playlist for every one of the approaches in the
Psychotherapy Theories and Techniques book.
4. Click on the playlist you are looking for (e.g., “Behavioral Therapy
Techniques”).
5. Click “Play All Items” or click on an individual title in the playlist to
go directly to that technique clip.
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http://psyctherapy.apa.org

1
ACCEPTANCE AND COMMITMENT THERAPY
STEVEN C. HAYES AND JASON LILLIS
The goal of acceptance and commitment therapy (ACT) is the
creation of psychological flexibility. The psychological flexibility model
underneath ACT emphasizes six specific processes that promote
psychopathology and needless human limitation, and six related processes
that promote psychological health and human flourishing.
PSYCHOLOGICAL FLEXIBILITY
Psychological flexibility is the process of contacting the present
moment fully as a conscious human being and persisting or changing
behavior in the service of chosen values. That skill is argued to be
composed of the following processes.
Cognitive Fusion Versus Defusion
If thinking is learned and regulated by arbitrary stimuli, it will always
be difficult, if not impossible, to fully eliminate thoughts we do not like.
There is no process called unlearning, and it is hard to eliminate all the
cues for certain thoughts. Indeed, trying to do so creates such cues
(Wenzlaff & Wegner, 2000). If a client with obsessive–compulsive
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disorder tries hard not to think of a disturbing image, for example, the
frequency of that image is almost certain to increase, as all of the various
distraction cues used become related to the very image being avoided and
begin to evoke it.
In relational frame theory (RFT), some contextual cues regulate the
emergence of relationships between events, but other cues regulate the
functions of related events. ACT tends to emphasize interventions that
change the functional context, not the relational context.
Suppose a person learns that another name for a favorite candy is
“jumjaw.” Even a single exposure to that training could establish a mutual
relation between these two events that may last a lifetime. But that is only
half the story. It is possible to undermine the automatic functions of
cognitive relations by altering the functional context. We do that in
ordinary ways when we, for example, imagine tasting a jumjaw versus
looking at one, but this insight from RFT can be used to clinical effect by
changing the literal context of thoughts. Suppose a person is struggling
with food urges that revolve around the thought “I want a jumjaw.” We
might diminish the behavioral impact of that thought by saying it aloud in
the voice of Donald Duck, or repeating the word jumjaw out loud until it
loses all meaning, or noting that “I am having the thought I want a
jumjaw” (this is called word repletion). These functional changes are
arguably easier and more reliable than the difficult work of changing the
occurrence of thoughts. ACT takes advantage of this insight and focuses
particularly on the alternation of functional contexts that determine the
behavioral impact of verbal/cognitive events.
Cognitive Fusion
Cognitive fusion (or what we will often just call fusion for short) is a
process in which verbal events have a strong behavioral impact beyond
other sources of regulation because they occur in a context of literal
meaning. In some external situations, fusion with thought is not harmful to
human functioning. A person trying to repair a broken bicycle needs to
understand cognitively what is broken and how to fix it; being
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continuously aware of the process of thinking, in order to increase the
psychological distance between the person and his or her thoughts, would
likely not add to the effectiveness of this process. Suppose it is clear on
inspection that a chain link is damaged. Thinking “I’m having the thought
that the chain link is damaged,” would be of little help. The chain is
damaged. Judgments about why it is damaged will likely help fix it.
That picture changes dramatically when the focus of what is being
addressed is not amenable to problem solving. A person who is suffering is
not like a bicycle with a broken chain. The emotions and thoughts being
struggled with are historical. Some are deeply conditioned, and those
aspects of history will not be changed. In such circumstances, ACT
practitioners are likely to try to change the functions of experiences rather
than their occurrence. Cognitive defusion is a classic method of that kind.
We will examine this in a somewhat extended example.
Imagine a person who feels insecure, guilt-ridden, and self-critical.
Decades earlier, her mother was very demanding and tried to motivate
more attention from her daughter by using criticism and blame. Hayes
(2009) shows a client in exactly that situation. We use another client as an
example here. We refer to her throughout by the name “Sarah.” The
transcript entries for Sarah in this volume are edited for clarity, space, and
confidentiality, but the actual word-for-word interactions can be seen on
the DVD.1
Sarah was seen by Steve Hayes in 2008. Sarah is in her early 60s and
is returning to therapy. She has chronic health problems due to lung
disease. She helps care for her elderly mother, and the relationship is very
conflicted. Her mother has always been extremely demanding and critical:
Sarah: Her standards for “if you love me”—well, she has criteria.
“If you love me, you’d ____.”
Therapist: Right, and then there is a list.
Sarah: And I can do nice things for her, and she notices them, but
it’s still not enough. You should never say no. You should
never say, “I’ve gotta go.” You should always be there to do
whatever she wants.
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This is not a new pattern. It turns out that even as a young child,
Sarah constantly heard, as she put it, “‘This should be this and this should
be that.’” Sarah observes, “It impressed me that my mother was full of
‘shoulds.’” The pressure to conform and to serve her mother’s needs went
all the way up to such judgmental and critical statements as, “and you call
yourself a Christian.”
The result of this history is that it is hard to set reasonable limits
without feeling bad about it:
Sarah: I feel bad if I’m not concerned about what my mother needs
for her happiness. And so this is kind of painful. I go over
here, “But I wanna be a good Christian, I wanna be, you know,
good to my mother and love her,” but then I’m not responsible
for making all of her moments happy. So it feels like a heavy
burden.
Therapist: Yeah. Even as you say it, you kind of winced.
Sarah: And even, you know, I got caller ID so I can see when it
was her. So that way if I didn’t think I could emotionally
handle it, I just wouldn’t. But even now every time her name
comes up on the caller ID, I have feelings. I feel overburdened.
Therapist: And sometimes when you don’t answer and she’s
called?
Sarah: You know what? I don’t do that so much because I still do
it to myself. Then I’m thinking, “Oh, what if this time it was
something really important?” I’ve had to deal with a lot of
guilt.
Fusion with judgment and self-criticism is extremely painful, but
worse than that, it pulls for ineffective actions. Let’s apply the same mode
of mind to this situation as one might apply to the broken bicycle. The
indication that something is broken is the emotional result of the history
we have been describing (e.g., “I feel a heavy burden” or “I feel a lot of
guilt”). The broken link in the chain is like the negative self-judgment that
leads to guilt and an inability to set reasonable limits. This pattern is
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historical—she was taught to do it. During the session, the client realized
how she too often “goes with the shoulds”—directed at herself and her
mother. In one of these moments, she declared, “That’s scary. The very
thing you have hated in someone else, then you start becoming that.”
The problem is that, as the person tries to fix the “broken bicycle” of
their own history, this very effort can amplify the thoughts and feelings
this history produces. It is easy to end up in the paradoxical and
unworkable situation of trying judgmentally to eliminate judgment (“I
shouldn’t say should!”). Difficult thoughts can become even more central.
Real behavior change can be put on hold while a war within is fought.
Sarah knows this:
Therapist: If you start arguing with them logically, difficult
thoughts and feelings can become even more central.
Sarah: I know! Isn’t that something?!
In an ACT model, the problem is not automatic thoughts. It’s that
there is no distance between the person and predictions, judgments, and
interpretations. Fusion itself is the problem. Fusion then restricts the ability
to be moved by contact with direct experience. This exchange shows the
process clearly:
Therapist: And when it’s happening, when these thoughts—these
“should” thoughts—get going, are they up here, right on you?
[Therapist holds his hand right in front of his face.] Or are they
sort of out there? [Therapist holds his hand a couple of feet
away from his face.]
Sarah: No, they’re right up there on me.
Therapist: They’re right up on you.
Sarah: Almost like I can’t breathe.
Therapist: Almost like you can’t . . . Oh, yeah.
Sarah: And when I’m talking to her on the phone like that she can
be telling me something interesting and I still don’t wanna talk
to her. I mean I don’t hate her, but her voice and her
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mannerisms annoy me.
The effects of fusion as seen in this case are typical. Fusion feeds a
problem-solving mode of mind, but treating our inner life that way turns
life from a process to be experienced into a problem to be solved.
Defusion
In ACT, therapy itself is viewed as a different context for
verbal/cognitive events; the goal is to establish a verbal community that
changes how the client interacts with or relates to thoughts, feelings, and
bodily sensations. The main goal is to undermine the excessive literal
quality of evaluations and judgments and to relate to them instead as
merely aspects of ongoing experience. That is the essence of defusion.
Exercises, metaphors, and other methods are used to help the client to be
able to see that a thought is more like a coffee cup than a lens; that is, it is
something one can look at, not merely look from. In that posture, thoughts
need not regulate actions other than mere noticing. They can, if they are
helpful, or not, if they are not. The issue is workability toward a goal, not
literal “truth.”
Let’s return to Sarah and show a method for how thoughts can be
looked at, not from.
Therapist: So let’s just see if we could sort of take some of that
burden off without having to take off the programming. Like,
let’s just look at how easy it is to get things programmed. If
you’ve got this judgmental critical streak going, sometimes
you probably even hear these words in your mother’s voice,
and I bet you they are so deeply in your head that . . .
Sarah: You’re right.
Therapist: Okay, so let’s just see how fast it happens. I’m gonna
give you three numbers to remember. If you remember them,
the people who are doing this filming, they’re giving me
money, and if you remember them a week from now I’ll give
you $10,000. Here are the numbers—1, 2, 3. Now if I come
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back and say, “What are the numbers?” what are you gonna
say?
Sarah: The numbers are 1, 2, 3.
Therapist: Oh! Good for you; $10,000. So if I say, “What are the
numbers?” you’ll say?
Sarah: 1, 2, 3.
Therapist: There’s no $10,000. I fibbed. [laughter] If I came back
next week, do you suppose you could remember those?
Sarah: I think so.
Therapist: Next month?
Sarah: Probably.
Therapist: It’s even possible, possible, next year?
Sarah: Yes.
Therapist: What if a very old man who is bald came up on your
deathbed and said, “Sarah, what are the numbers?” Is even that
possible?
Sarah: It’s possible.
Therapist: I’ve said it twice. Your mother said these judgmental
things to you a hundred times.
Sarah: Daily.
Therapist: They will never leave your head. There’s no place for
them to go. When you’re interacting with her, this voice shows
up. What are the numbers?
Sarah: 1, 2, 3.
Therapist: And if I get angry with my mother, then I’m . . .
Sarah: Bad. Oh, I see what you are saying! That’s why that guilt
and judgment just keep coming up!
The What Are the Numbers? exercise is a classic ACT cognitive
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defusion method. When the person sees how easy it is to program a human
mind, conditioned thoughts take on less literal meaning. Having “1, 2, 3”
come to mind (perhaps even for life!) means nothing about Sarah other
than that she has a history. This is experientially obvious after this
exercise. Yet Sarah is taking “I’m bad” literally, as if it means that there is
something wrong with her and that something needs to be changed. By
metaphorical extension, she now sees that it too could say nothing more
about her than that she has a history. In such a moment, the thought “I’m
bad” is being looked at, not looked from.
There are hundreds of specific ACT defusion methods such as the
What Are the Numbers? exercise. We have already mentioned word
repletion, adding “I am having the thought that ___” before difficult
thoughts, saying thoughts in unusual voices, or distilling difficult thoughts
down to a word and saying it out loud a number of times. The point is not
to ridicule thoughts but rather to be able to notice thought as an ongoing
process in the moment. Defusion methods can rapidly reduce the
believability and distress produced by thoughts. Some well-researched
defusion methods are as short as 30 seconds long (e.g., Masuda et al.,
2009).
A common objection to our arguments about defusion versus content
change in thinking is that if deliberate change or elimination is difficult,
unreliable, or risky, traditional cognitive restructuring should not work or
should even be harmful. In fact, there is little evidence that cognitive
restructuring is an effective component of traditional cognitive behavior
therapy (for a review of that evidence, see Longmore & Worrell, 2007).
But why isn’t it harmful? Some studies suggest that it is (Haeffel, 2010),
but we expect it is usually neutral because detecting and trying to change
thoughts can do both positive and negative things. It contains an
elementary distancing component that arguably has a defusion effect
(noticing your thoughts is a key facet of defusion, an argument similar to
that being made by mindfulness researchers in cognitive therapy; see
Segal, Teasdale, & Williams, 2004). In addition, thinking about how to
change thoughts can encourage greater cognitive flexibility just by
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generating multiple cognitive variants to consider. Indeed, ACT sometimes
uses this process by encouraging clients to formulate their self-narrative in
several different ways as a defusion method (Hayes, Strosahl, & Wilson,
1999). ACT theory suggests that negative effects from cognitive
restructuring would come from consequences such as greater entanglement
with difficult thoughts, increased cues for them, greater chance of thought
suppression, or amplification of a neurotic self-focus. These unintended
effects would vary with the skill of the clinician (skilled cognitive
therapists are trained to avoid most of them) and the propensity of
individuals to engage in them. Thus, some individuals would benefit, some
would be harmed, and on the whole it would be a wash.
REFERENCES
Haeffel, G. J. (2010). When self-help is no help: Traditional cognitive skills
training does not prevent depressive symptoms in people who ruminate.
Behaviour Research and Therapy, 48, 152–157.
doi:10.1016/j.brat.2009.09.016
Hayes, S. C. (2009). Acceptance and commitment therapy [DVD].
Washington, DC: American Psychological Association.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and
commitment therapy: An experiential approach to behavior change. New
York, NY: Guilford Press.
Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in
cognitive behavior therapy? Clinical Psychology Review, 27, 173–187.
doi:10.1016/j.cpr.2006.08.001
Masuda, A., Hayes, S. C., Twohig, M. P., Drossel, C., Lillis, J., & Washio, Y.
(2009). A parametric study of cognitive defusion and the believability and
discomfort of negative self-relevant thoughts. Behavior Modification, 33,
250–262. doi:10.1177/0145445508326259
Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2004). Mindfulness-based
cognitive therapy: Theoretical rationale and empirical status. In S. C.
Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and
acceptance: Expanding the cognitive-behavioral tradition (pp. 45–65).
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New York, NY: Guilford Press.
Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. Annual
Review of Psychology, 51, 59–91. doi:10.1146/annurev.psych.51.1.59
Excerpted from Acceptance and Commitment Therapy (2012), from Chapter 3, “Theory,” pp. 41–50.
Copyright 2012 by the American Psychological Association. Used with permission of the authors.
1The DVD, which can be purchased at http://www.apa.org/pubs/books/, is titled Acceptance and
Commitment Therapy and is copyrighted by the American Psychological Association. It is important to
note that the client’s name and other identifying information have been changed here to protect her
confidentiality. The reader who watches the DVD may notice some discrepancies.
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http://www.apa.org/pubs/books/

2
ACCEPTANCE AND COMMITMENT THERAPY
PROCESS
STEVEN C. HAYES AND JASON LILLIS
DEFUSION
Have you ever had the thought deep down that you’re a horrible
person or there is something really wrong with you? Perhaps you came by
that thought honestly; maybe somebody told you that, your dad screamed
it at you, or you derived it on the basis of painful and traumatic events in
your life. It is possible that this thought will be with you from time to time
for the rest of your life, at times powerfully so, and could be triggered by
just about anything that happens to you. Trying to get it out of your mind
means you have to focus on it. It means you have to treat it as important.
As you do so, you make it more central, you connect it to more events, and
you devote more life moments to it. As a result, you might actually make it
more frequent, amplifying its impact on your behavior. Treating thoughts
literally is called cognitive fusion, and it is a primary target of acceptance
and commitment therapy (ACT).
Imagine being in a place where you can have whatever thoughts you
have, more as you might watch the dialogue in a movie or a play. You can
have the thought, “There’s something wrong with me,” and, without
having to change or get rid of it, you can determine its impact on your life.
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As you experience that thought with perspective, awareness, and curiosity,
that is what you are doing. That is the goal of defusion work.
Fusion is so pervasive that the signs of it are often hard to notice.
There may be a loss of your sense of being present, like in a daydream; a
sense of being caught up in your thoughts, as though your mind were
working overtime; a sense of busyness, comparison, and evaluation.
Maybe you’re often looking to the future or thinking about the past, as
opposed to being connected to the now; there may be a sense of struggling
to clarify things. Conversely, defusion contains a sense of lightness,
flexibility, presence, consciousness, and playfulness. There is a sense that
you have the freedom to direct your behavior without the dominance of
certain thoughts. Defusion is simply seeing your thoughts as thoughts, so
that what you do is determined more by your choices and less by
automatic language processes.
In the subsections that follow, we discuss examples of cognitive
fusion processes and techniques designed to address these processes in an
attempt to change the context in which thoughts occur. There are hundreds
of defusion methods in the ACT literature—these are just a few examples.
Ubiquity
Thoughts are ubiquitous; they are always hanging around. Sometimes
they are big or small, loud or soft, good or bad, scary, happy, strange, and
so on. But they are there, and they often pull us out of the present moment.
It can be useful to simply call this process out and get it in the room. You
might consider naming your mind and the mind of your client, noting that
there are “four of us” in the room. Or you might refer to the mind as a
“word-generating machine” that is constantly churning out thoughts,
commenting on everything, judging, having opinions, causing a ruckus.
The natural tendency is to look at the world from our thoughts. Defusion
allows us to look at our thoughts rather than from them.
Watching your thoughts without involvement is inherently defusing.
Many mindfulness exercises fit the bill. The Thoughts on Clouds exercise
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is an example:
I’d like you to close your eyes and simply follow the sound of my
voice. Try to focus your attention on your breathing, and notice as
each breath enters and exits your nose or mouth. . . . And now I want
you to imagine sitting in a lush field. . . . Notice the trees and foliage,
see the blue sky, try to become aware of your surroundings and
really see yourself there. . . . And now I want you to lie down and
look up to the sky and notice that there are clouds moving at a steady
pace across the sky. . . . See if you can focus your attention on your
thoughts, and as you become aware of a thought, put it on a cloud
and watch it float across the sky. . . . Try to put each thought you
have on a cloud and watch it as it goes by. . . . If you notice that you
are no longer viewing the clouds from afar, but rather are caught up
in a thought, gently bring yourself back to the field, lying down,
gazing up at the clouds, and put each thought, one by one, on a
cloud.
When you debrief this exercise, it is a good idea to check in with the
client about his or her general experiences first. If the client was unable to
perform the exercise, some more basic mindfulness training might be
needed. Assuming the client was able to follow the exercise, you might
want to discuss the experience of watching thoughts versus being caught
up in thoughts. Typically clients are able to watch their thoughts for a
while but then get caught up in a sticky thought (something personal or
with emotional valence) or a process thought (e.g., “Am I doing this
right?”), or perhaps worries about the future or past. This distinction is key
because you are trying to teach the client to be able to notice the process of
thinking. Nobody is able to do this all the time, nor would that be
desirable; rather, it is important to be able to catch oneself entangled in
thought, so that fusion or defusion can be used on a basis of workability
rather than automaticity.
Literality
Swimming in a stream of thoughts, as we often do, we tend to
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experience our thoughts as being literally true. ACT calls this the context
of literality, and it can contribute greatly to suffering. We become like a
person so lost in a movie that the threats to the characters seem like
personal threats: each sudden sound eliciting a startle, each creak on the
stairs evoking an urge to flee. We are like that with our mental sounds and
creaks because we’ve forgotten that they are in large part echoes of
moments gone by.
If we treat thoughts as literal, then we must be invested in their
content. For example, if you have the thought “I am a horrible person,”
and you take that thought to be literally true, then it makes sense that you
would do anything to try and not have that thought or change that thought
in some way to make it possible for you to exist in the world and not be a
horrible person. However, if you can step back from the screen and notice
that there is a “you” and there is also a thought, maybe there is some room
there for you to just have that thought as it is, without struggle.
ACT uses a variety of techniques to undermine the literality of
thoughts. For example, clients might be asked to imagine that their
negative thoughts (e.g., “I’m a failure,” “I can’t do anything right”) are
like a radio station that can’t be shut off—it’s bad news radio, all bad news
all the time! They can also imagine a barrage of negative thoughts as pop-
up ads from hell. They can’t get a spam blocker for these! Another method
is to have clients say their thoughts in silly voices, or say them very slow
or very fast, or in the voice of themselves as children. Thoughts can be
distilled into a single word and said rapidly aloud for 20 to 30 seconds.
It is important not to use these methods to ridicule thoughts. You can
explain it to the client like this:
When you start seeing thoughts the way you would see things like a
billboard or a pop-up ad or radio voice, or when you change how
you interact with thoughts by speaking them slowly or singing them,
or having a puppet say it to you, it gives you just a little space to
look at them and use what is useful in them. It’s like stepping away
from the computer screen. Then maybe this thought is also just a
thought, and not necessarily anything that you have to do anything
about, and certainly not something that you have to turn over your
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life to.
Automaticity
Say whatever words come to mind when I give you these partial
phrases: “Only the good die . . . [young]” or “A picture is worth . . . [a
thousand words]” or “Blondes have more . . . [fun].” These words come as
a package in our history. If the words are painful (try this one: “I pretend
to be a good person but deep down I’m _____”), we might try to erase
them, but all we are doing is adding to them. Try it with any of these
statements and you will notice that another word appears and you are
initially pleased because it is not ____ [put in the forbidden word], until
you realize that “___ is not ___” is yet another relation. There is no
healthy eraser. This can be exactly like what is going on with clients. It can
help to see how this game is impossible to win:
Therapist: Tell me, as a child did you believe in Santa Claus?
Client: Sure. We put cookies out and everything, I’d write a wish
list.
Therapist: Do you still believe in Santa Claus?
Client: Of course not, but it’s fun for the kids.
Therapist: Yeah. And when you see a rainbow reaching the
ground, what’s over there?
Client: [chuckles] A pot of gold.
Therapist: Funny, everyone says that. Not a pile of gold, not a pot
of silver, but a pot of gold. Ever gone digging for it?
Client: [laughs] No.
Therapist: Back to Christmas for a moment. When you walk
through the toy store in mid-December, what do you see?
Client: Santa, all the Christmas stuff, elves, reindeer.
Therapist: And what does that make you think of?
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Client: Santa’s toy factory at the North Pole.
Therapist: Now you don’t believe in this stuff, right? But it still
comes up. And when you see a rainbow, what pops up in your
mind?
Client: A pot of gold.
Therapist: Where did these thoughts come from?
Client: I suppose we’re told this stuff when we are kids, by our
parents, other people.
Therapist: And this idea, you haven’t done well enough in your
life, that you’ve failed as a person. Where did that come from?
Client: I don’t know, same place, I guess, stuff I’ve heard, stuff
I’ve put together over the years.
Therapist: Yeah. And tell me, how would we get rid of the thought
of a pot of gold, or the elves?
Client: Don’t know, I guess we don’t.
Therapist: So what about this other stuff—I’ve failed. . . . I’m not
good enough, nothing I do is ever quite good enough, and all
the dozens of variations?
A classic ACT technique is the What Are the Numbers? exercise we
described in the case of Sarah in the chapter on the theory behind ACT. If
clients get a sense of the point, the exercise itself can be used as a form of
communication: Why should we take our own thoughts so seriously, when
they may be nothing more than conditioned events? How silly is it that we
are at the whim of their showing up at any time? The point is not to
convince clients that their thoughts are wrong, or useless, or silly, but to
offer a context in which they can notice that thoughts can be automatic.
Maybe your client needn’t give such importance to those thoughts or
engage in a struggle to change or get rid of them but, rather, can make
room for them and let them be, while choosing to live his or her life.
This was done later in the work with Sarah, when discussing her
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anger and frustration with her mother (it is also worth noting that she is
now spontaneously using more defused language as the result of the
previous defusion interventions):
Therapist: It’s something almost like “I’m bad for feeling that.”
Sarah: Yeah. That’s it. I think that’s the bottom line. I mean all the
other sentences come but the bottom-line sentence is “and that
means, I’m bad.”
Therapist: OK, [offering a tissue] so here comes “I’m bad.” What
are the numbers?
Sarah: 1, 2, 3.
Therapist: And if I get angry I’m . . . ?
Sarah: Bad.
Therapist: OK, here we go. We’ll just let that be there like that
[laying the tissue on her knee]. Is that your enemy? Does that
have to change before you can be there with yourself and
allow yourself to feel what you feel even when your mind says
you can’t? It’s just your conditioning. What are the numbers?
Excerpted from Acceptance and Commitment Therapy (2012), from Chapter 4, “The Therapy Process,” pp.
81–86. Copyright 2012 by the American Psychological Association. Used with permission of the authors.
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APPENDIX 2.1: ACCEPTANCE AND COMMITMENT THERAPY
TECHNIQUES
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3
BEHAVIOR THERAPY
MARTIN M. ANTONY AND LIZABETH ROEMER
Reviews of behavior therapy often focus more on the techniques than
on the theory underlying them. However, to conduct behavior therapy
skillfully, one must understand the conceptual basis and intention of the
specific techniques, beginning with the overarching goals of behavior
therapy.
GOALS OF BEHAVIOR THERAPIES
The overarching goal of behavior therapies is to help clients develop
flexible behavioral repertoires that are sensitive to environmental
contingencies and are maximally effective for the individual (e.g., Drossel,
Rummel, & Fisher, 2009). From a behavioral perspective, a wide range of
clinical problems are seen as evidence of habitual, stuck patterns of
responding that have developed over time because of associations and
contingencies in the environment (which can also include the internal
environment, e.g., physical sensations, thoughts, imagery) that maintained
these patterns in a given context. Therapy is therefore focused on
identifying the factors that are currently maintaining the difficulties in
question and on intervening to reduce problematic behaviors and responses
and increase more flexible, adaptive behaviors and responses. A central
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focus is on broadening behavioral repertoires and encouraging alternative,
adaptive repertoires that will enhance well-being and functioning, rather
than on symptom reduction (Drossel et al., 2009). That is, the intent is to
help clients engage in a range of behaviors that are likely to help them
function in their lives rather than solely to reduce their anxiety or
depressive symptoms.
An initial goal, therefore, is the careful assessment and analysis of
presenting problems to determine the contexts in which they occur, the
stimuli that trigger their occurrence, and the consequences that maintain
them. This functional analysis helps the client and the therapist to see the
ways in which problematic patterns of responding emerge in response to
specific cues and are maintained by specific consequences. It also helps to
determine whether problematic responses can be understood as resulting
from learned associations, reinforcing consequences, or skills deficits,
which will have implications for intervention. This analysis also helps to
determine how multiple problems interact so that treatment targets can be
chosen that will optimize positive outcomes by influencing more than one
presenting problem. Although people often think of cues and contingencies
as explaining only overt, simplistic behavior problems, such as phobias,
these same models can be used to understand more complex patterns of
responding, such as those that underlie relationship difficulties. For
instance, a client who presents for treatment because of relationship
concerns might first be asked to monitor when concerning interactions
with a partner occur. Functional analysis may reveal that the client has
developed a habit of responding to perceived instances of rejection (which
take the behavioral form of the client’s partner being focused on
something else or seeming distant) by feeling hurt and vulnerable. The
client may habitually respond to these feelings by expressing anger
through criticism or storming out of the room, behaviors that are
reinforced by the initial reduction in hurt and vulnerability that the client
experiences. However, these behaviors increase the partner’s tendency to
withdraw, thus perpetuating the problematic cycle of interaction. This
analysis provides several potential targets for intervention: the client’s
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learned emotional response to the partner’s behavior and the client’s
behavioral responses to feeling hurt and vulnerable. If the couple were in
treatment together, a functional analysis of the partner’s behavior would
also be conducted, providing additional targets for intervention.
In behavior therapy, the therapist and client collaboratively set
specific treatment goals and the therapist shares with the client the model
of how these goals will be met. Therapy is active in that the client engages
in exercises both within and between sessions designed to develop and
strengthen new learning and new patterns of responding and to weaken
old, habitual ways of responding. Given the emphasis on new learning,
practice is an essential part of treatment, requiring the client to actively
engage with the treatment. Actively engaging means that it is essential that
the client agree with the rationale for and goals of treatment. Therapists
need to be sensitive to indications that the conceptualization and plan
make sense to the client. As in all treatments, the therapist should be
attuned to and familiar with both general cultural views that may affect
how a client views health, clinical problems, and goals for treatment and
the specific perspective of a client and his or her family. These
perspectives should all shape the developing conceptualization and plan.
Behavior therapy is flexible and iterative. Therapists and clients are
continually evaluating the impact of interventions and the continued
relevance of stated goals. Alterations are made to treatment plans on the
basis of the effects of interventions, the feasibility of specific interventions
for a given individual, and changing external circumstances. The scientific
basis of behavior therapy makes continual hypothesis testing an explicit
characteristic of this approach to treatment. The findings from a functional
analysis are always treated as a working hypothesis, and ongoing
assessment and reflection are used to reevaluate and revise these models
and intervention plans in order to promote optimal functioning for the
individual.
Thus, the goals of behavior therapy are idiographic and are
determined and refined collaboratively in the therapeutic relationship. An
overarching goal of flexible, adaptive functioning is consistent across
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clients and presenting problems, but the specifics of what this will look
like for a given individual depend on the context and what is most
important to the client. Behavior therapists are careful not to assume that
they know what is optimal functioning for an individual, but instead aim to
help the individual examine his or her life to determine what will be
optimal for her or him.
KEY CONCEPTS IN BEHAVIOR THERAPIES
Behavior therapy is a broad category that encompasses a wide range
of intervention strategies, as well as variability in theoretical emphases.
Behavior therapists incorporate various behavioral approaches (e.g.,
cognitive, mindfulness based) to differing degrees. Also, because behavior
therapists emphasize the importance of scientific inquiry, theories that
underlie these approaches are constantly being refined on the basis of
scientific study and discovery. However, several shared theoretical
assumptions characterize therapy based in the behavioral tradition. In this
chapter, we provide an overview of these theoretical assumptions and also
discuss some of the points of disparity among behavior therapists.
Theory plays an important role in behavior therapies that is often
overlooked. The importance that behaviorists (and cognitive behaviorists)
place on empirical study has led to the development of numerous
manualized treatments that can be subjected to careful, controlled
evaluation to examine the efficacy of a specific approach. Although this
approach has many advantages, one disadvantage is that it can give the
impression that behavior therapy is a collection of techniques rather than a
coherent way of understanding human behavior and optimizing human
functioning. An emphasis on technique can leave clinicians who are
implementing interventions at a loss when aspects of a specific strategy do
not fit well with a given client. A clear understanding of the theory
underlying specific strategies helps therapists to flexibly implement
treatments, responding to individual clients’ needs while remaining
consistent with the underlying model of the treatment. For instance,
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strategies can be adjusted so that they are more culturally consistent for a
given client while still corresponding to the intervention’s initial intent.
For example, relaxation imagery that incorporates other people may be
more resonant for individuals who identify themselves in relation to others
than solitary images that are more commonly used, leading these
individuals to practice using imagery more regularly and benefit more
from treatment (La Roche, D’Angelo, Gualdron, & Leavell, 2006).
All Behavior Serves a Function
A central assumption of behavior therapists is that problematic
patterns of behavior happen for a reason. That is, even behaviors that seem
to be destructive or clearly harmful to an individual, such as substance
dependence, deliberate self-harm, or an abusive relationship, make sense
in the context of an individual’s learning history. In the context of
behavior therapy, the term behavior applies to a wide range of client
responses, including thoughts, physiological responses, emotional
responses, and covert behaviors as well as overt behaviors. Using a
behavioral conceptualization, even responses that seem irrational, such as
extreme anxiety in response to apparently nonthreatening cues or guilt and
shame in response to apparently benign interpersonal exchanges, happen
because of biological predispositions and prior learning experiences that
have shaped a client to have certain types of responses to particular
stimuli. In this way, puzzling behaviors can actually be explained and
understood because of previous learning experiences (which we describe
in more detail shortly).
Thus, a central goal in behavior therapies is to determine the potential
function of presenting problems. This determination serves several
purposes in therapy. First, as the therapist and client work together to
understand why the client is repeatedly having responses or engaging in
behaviors that she or he sees as problematic, these puzzling responses
begin to make more sense and seem less baffling. More important, the
client often experiences a reduction in self-blame and criticism as a result
37

of this increased understanding of why she or he is responding in this way.
For instance, clients with a long-standing history of anxiety often
experience relief when the fight-or-flight response, paths to learning fear,
and the natural but fear-maintaining response of avoidance are explained
to them. Although this understanding alone is often not enough to alter
responding, it does often help to reduce the criticism, judgment, and shame
that can exacerbate anxious responding and further interfere with
relationships and general functioning.
Although the validation that comes with a behavioral
conceptualization is likely an active ingredient in behavior therapies, a
more important goal is the identification of targets for intervention and
strategies that will promote new learning that is more adaptive and growth
enhancing. An understanding of principles of learning (described more
fully in the next section) is an important foundation in developing
intervention strategies that will most efficiently lead to robust new
learning.
BEHAVIOR IS LEARNED; NEW BEHAVIOR CAN BE LEARNED
THROUGH EARLY CUE DETECTION AND PRACTICE
Behavior therapies are based on an assumption that individuals have
learned to respond and act in the ways they habitually respond and act
through identifiable principles of learning. Behavior therapies evolved
from experimental research that detailed these learning principles. Modern
behavior therapies are similarly informed by newer developments in
experimental research that have identified complexities in principles of
learning (e.g., Bouton, Mineka, & Barlow, 2001; Craske et al., 2008). An
in-depth discussion of these principles and complexities is beyond the
scope of this book (see Bouton, Woods, Moody, Sunsay, & García-
Gutiérrez, 2006; Craske & Mystkowski, 2006; O’Donohue & Fisher,
2009), but we provide a summary so that therapists can use these
principles to guide implementation of behavior therapies.
38

Learning Through Association
Both humans and animals learn to associate stimuli that frequently
appear together. Classical conditioning refers to the process through which
a previously neutral stimulus becomes associated with a stimulus that
evokes certain responses (either aversive or appetitive). Through being
repeatedly paired with an unconditioned stimulus (US) that naturally
evokes a given response, the conditioned stimulus (CS) becomes a cue for
the US and elicits similar or related responses. This process is clearly
evolutionarily adaptive in that organisms learn that the presence of certain
stimuli indicates that a threat is likely to appear or that something desirable
is likely to appear, and respond accordingly. Once a stimulus has been
conditioned, it can lead to new learning by being paired with another
previously neutral stimulus, which will in turn come to be associated with
the CS and elicit similar or related responses.1 Through this process of
higher order conditioning, more stimuli come to be associated with
undesirable or desirable events. Also, through stimulus generalization,
stimuli that are similar to the CS also become learned cues, so that
eventually a broad range of stimuli are associated and evoke similar
responses. For instance, a learned fear of a bright red shirt might lead an
individual to respond with anxiety or fear to anything red in the
environment.
A client, Monique, can be used to illustrate these principles. Monique
presented for therapy reporting that she was anxious and uneasy in social
situations. A functional analysis, including monitoring of her symptoms
and exploration of specific incidents of anxiety during the previous week,
revealed that she responded with physiological arousal and anxious
thoughts when she interacted with people who looked or sounded critical.
She described her father as extremely critical when she was growing up
and stated that he would often turn his attention to other people or walk
away after he had criticized her for something. In this example, this
withdrawal of attention and affection from a parent was a US that would
have naturally elicited fear in a child. Its pairing with criticism from her
father led Monique to respond to her father’s criticism with anxiety
39

because she anticipated the removal of his attention and affection.
Gradually, these associations generalized, and she came to have similar
responses to any instances of perceived criticism, leading her to feel
anxious in a broad range of social situations.
People are particularly prone to learning threatening cues because it is
evolutionarily adaptive to identify markers for potential harm and danger
so that individuals can avoid this harm or danger. In addition, some
individuals are probably biologically predisposed to learn threat more
easily and robustly and are therefore more prone to anxiety (e.g., Lonsdorf
et al., 2009). Prior experiences with threat, or modeling of fear behavior by
significant role models, may also make it more likely that an individual
will easily learn to fear cues, and those responses will generalize (Mineka
& Zinbarg, 2006). Biology, prior experiences, and modeling likely play a
role in other kinds of learning, such as the reinforcing properties of alcohol
and drugs (e.g., Enoch, 2007).
Initial models of associative learning identified the conditions under
which learned associations (to CSs) could be extinguished such that an
organism no longer responded to the CS as though it were associated with
the US. Further study has indicated that the term extinction is a misnomer
because associations are not, in fact, unlearned. Instead, new, competing,
nonthreatening associations are learned. So, in the case of fear
conditioning, repeated exposure to the CS in the absence of the US will
lead to a new, nonthreatening association to the CS, such that fear is no
longer the predominant response. Extinction can therefore be thought of as
inhibitory learning (Craske et al., 2008) in that an association that inhibits
the previous association is learned. Rescorla and Wagner (1972) noted that
learning is an adjustment that occurs when there is a discrepancy between
the outcome that is expected and the outcome that occurs. So extinction
trials promote new learning in that the expected association does not occur,
so that the CS comes to be associated with “not US” instead of the US.
Bouton et al. (2006) reviewed the literature that suggests that
conditioned associations, as well as conditions that are likely to make
extinction or inhibitory learning more robust, are not unlearned. Animal
40

research has demonstrated that even after extensive extinction of fearful
associations, the continued presence of these associations is demonstrated
by (a) a renewal effect, in which a learned association to a CS returns
when the CS is presented in a different context from the extinction trials;
(b) spontaneous recovery, in which a learned association to a CS returns
after the passage of time; (c) reinstatement, in which a learned association
to a CS returns after the US is presented alone and the CS is presented
later; and (d) rapid reacquisition, in which an association to a previously
extinguished CS is learned much more rapidly in new conditioning trials.
All of these phenomena suggest that a learned fearful association is
maintained despite successful extinction. Bouton et al. interpreted these
findings as evidence that extinction learning is context specific, which
makes sense from an evolutionary standpoint—people learn cues for fear
easily, and generalize them, yet learning of inhibitory responses to feared
stimuli is more context specific. This serves an important survival function
in that individuals will not prematurely learn that a given stimulus is safe
simply because it was safe in a specific context. However, it makes it more
likely that learned fears will recur, making it important for therapists to
address relapse prevention in therapy, so that clients are prepared for these
recurrences and are able to continue to approach feared stimuli to promote
more robust extinction learned across multiple contexts. Researchers have
also suggested that the presence of retrieval cues during extinction trials
will help extinction (or inhibitory learning) generalize to novel contexts
(Craske et al., 2008).
Although associative learning is often described in terms of learned
associations to external stimuli, there is also extensive evidence that
organisms learn associations to internal stimuli as well (for an extensive
review of this literature in the context of panic disorder, see Bouton et al.,
2001). As a result, people’s own internal sensations can become threat
cues, leading them to respond with anxiety, which strengthens the cue,
potentially leading to a spiral of anxiety or panic. From a behavioral
perspective, thoughts can also become associated with a US. As such,
thoughts or memories of a traumatic event can elicit posttraumatic
41

responses, even in the absence of the event itself. Thoughts can also have
appetitive associations, so that a thought of a drink can lead to a powerful
conditioned response of craving for an individual addicted to alcohol.
Because these internal cues are beyond people’s instrumental control (they
cannot avoid thoughts of drinking or anxious sensations completely), these
associations are particularly likely to lead to clinical problems. As such,
learning new associations to these cues is often an important target of
treatment (as is learning not to respond to them behaviorally).
REFERENCES
Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory
perspective on the etiology of panic disorder. Psychological Review, 108,
4–32. doi:10.1037/0033-295X.108.1.4
Bouton, M. E., Woods, A. M., Moody, E. W., Sunsay, C., & García-Gutiérrez,
A. (2006). Counteracting the context-dependence of extinction: Relapse
and tests of some relapse prevention methods. In M. G. Craske, D.
Hermans, & D. Vansteenwegen (Eds.), Fear and learning: From basic
processes to clinical implications (pp. 175–196). Washington, DC:
American Psychological Association. doi:10.1037/11474-009
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury,
N., & Baker, A. (2008). Optimizing inhibitory learning during exposure
therapy. Behaviour Research and Therapy, 46, 5–27.
doi:10.1016/j.brat.2007.10.003
Craske, M. G., & Mystkowski, J. L. (2006). Exposure therapy and extinction:
Clinical studies. In M. G. Craske, D. Hermans, & D. Vansteenwegen
(Eds.), Fear and learning: From basic processes to clinical implications
(pp. 217–233). Washington, DC: American Psychological Association.
doi:10.1037/11474-011
Drossel, C., Rummel, C., & Fisher, J. E. (2009). Assessment and cognitive
behavior therapy: Functional analysis as key process. In W. T. O’Donohue
& J. E. Fisher (Eds.), General principles and empirically supported
techniques of cognitive behavior therapy (pp. 15–41). Hoboken, NJ:
Wiley.
42

Enoch, M. (2007). Genetics, stress, and risk for addiction. In M. Al’Absi (Ed.),
Stress and addiction: Psychological and biological mechanisms (pp. 127–
146). San Diego, CA: Elsevier. doi:10.1016/B978-012370632-4/50009-7
La Roche, M. J., D’Angelo, E., Gualdron, L., & Leavell, J. (2006). Culturally
sensitive guided imagery for allocentric Latinos: A pilot study.
Psychotherapy: Theory, Research, Practice, Training, 43, 555–560.
doi:10.1037/0033-3204.43.4.555
Lonsdorf, T. B., Weike, A. I., Nikamo, P., Schalling, M., Hamm, A. O., &
Öhman, A. (2009). Genetic gating of human fear learning and extinction:
Possible implications for gene-environment interaction in anxiety disorder.
Psychological Science, 20, 198–206. doi:10.1111/j.1467-
9280.2009.02280.x
Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective
on the etiology of anxiety disorders: It’s not what you thought it was.
American Psychologist, 61, 10–26. doi:10.1037/0003-066X.61.1.10
O’Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and
empirically supported techniques of cognitive behavior therapy. Hoboken,
NJ: Wiley.
Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is.
American Psychologist, 43, 151–160. doi:10.1037/0003-066X.43.3.151
Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning:
Variations in the effectiveness of reinforcement and nonreinforcement. In
A. H. Black & W. F. Prokasy (Eds.), Classical conditioning II: Current
research and theory (pp. 64–99). New York, NY: Appleton Century
Crofts.
Excerpted from Behavior Therapy (2011) from Chapter 3, “Theory,” pp. 15–24. Copyright 2011 by the
American Psychological Association. Used with permission of the authors.
1Initially, this learning process was thought to involve learning a response to a stimulus because that
stimulus had been associated with another stimulus that automatically elicited that response. However, an
extensive body of research has demonstrated that an association is learned between the previously neutral
stimulus and the US and that associations are also learned regarding the context in which these pairings
take place (Rescorla, 1988). In addition, conditioning can result in a different response to the CS than the
response to the US, one that is preparatory for the potential occurrence of the US and matched to the
properties of the CS (Rescorla, 1988). Although classical conditioning continues to often be described in
terms of learning responses, the term learned associations is a technically more accurate description of this
43

type of learning.
44

4
BEHAVIOR THERAPY PROCESS
MARTIN M. ANTONY AND LIZABETH ROEMER
EXPOSURE-BASED STRATEGIES
In the context of behavior therapy, the term exposure refers to the
repeated and systematic confrontation of feared stimuli (Moscovitch,
Antony, & Swinson, 2009). Many behavior therapists consider it to be an
essential component of behavioral treatment for most anxiety disorders, as
well as for certain related conditions. It has long been established in
research with animals and humans that repeated exposure leads to a
reduction in fear responding. Habituation is often cited in the literature as a
mechanism to explain how exposure works, although the pattern of change
seen in exposure is not consistent with what one might expect after
habituation (Moscovitch et al., 2009). For example, in habituation (as it is
typically defined) no new learning occurs, and there is a full reinstatement
of the response after a short break; neither of these is true in the case of
exposure (Tryon, 2005). Rather, models relying on the occurrence of new
inhibitory associative learning or extinction seem to explain the effects of
exposure much better than habituation models (for reviews, see
Moscovitch et al., 2009; Tryon, 2005).
The contemporary behavior therapy literature typically refers to three
types of exposure: in vivo exposure, imaginal exposure, and interoceptive
exposure. In vivo exposure involves exposure to external situations and
45

objects in real life (e.g., entering social situations to reduce anxiety around
other people, practicing driving to overcome a fear of driving), while
minimizing any forms of avoidance, such as distraction. It is a standard
component of evidence-based treatments for specific phobias, social
anxiety disorder, agoraphobia, obsessive–compulsive disorder (OCD),
posttraumatic stress disorder (PTSD), and other problems in which an
individual has an exaggerated fear of some external object or situation.
Typically, the difficulty of exposures is increased gradually across
sessions, although some forms of exposure therapy involve confronting the
most frightening stimuli right from the start (a process sometimes referred
to as flooding).
Imaginal exposure involves exposure in imagination to thoughts,
memories, imagery, impulses, and other cognitive stimuli and is most
often used in evidence-based treatments for OCD (e.g., exposure to
obsessional thoughts of stabbing a loved one) and PTSD (e.g., exposure to
a feared traumatic memory). Imaginal exposure may involve having the
client describe a feared stimulus aloud or in writing or having the client
listen to a verbal description of the feared stimulus, either in the form of an
audio recording or described out loud by the therapist. The therapist
encourages the client to imagine the stimulus vividly, with all of her or his
senses, to maximize the new associative learning that takes place (i.e., the
nonfearful associations to the range of conditioned stimuli present).
Interoceptive exposure involves purposely experiencing feared
physical sensations until they are no longer frightening. It is used most
often in the treatment of panic disorder. Examples of commonly used
interoceptive exposure exercises include breathing through a straw to
induce breathlessness, spinning in a chair to induce dizziness, and
hyperventilation to induce breathlessness and dizziness.
Exposure may involve other stimuli as well. For example, exposure to
visual stimuli in photos or on video is often used in the treatment of blood
and needle phobias (Antony & Watling, 2006) and fears of certain
animals, such as snakes, spiders, bugs, and rodents (Antony & McCabe,
2005). Exposure using computer-generated stimuli in virtual reality is also
46

increasingly being used for the treatment of certain phobias and other
anxiety disorders (Parsons & Rizzo, 2008).
Because behavioral models for disorders have begun to focus
particularly on the role of avoidance of emotions (e.g., Barlow, Allen, &
Choate, 2004; Mennin & Fresco, 2010) in maintaining difficulties, explicit
exposure to emotional responses (which has always been a part of
exposure-based treatment) has been proposed as an effective intervention.
Therapists might ask clients to imagine emotional situations or view
emotionally evocative film clips to reduce avoidance of their own
emotional responses.
GUIDELINES FOR EFFECTIVE EXPOSURE
A number of factors have been found to affect outcomes after
exposure-based treatments. First, exposure seems to work best when it is
predictable (i.e., the client knows what is going to happen and when it is
going to happen) and when it is under the client’s control (i.e., the client
controls the intensity and duration of the practice; see Antony & Swinson,
2000). Second, exposure works best when sessions are prolonged. Two-
hour exposures have been found to be more effective than 30-minute
exposures (Stern & Marks, 1973). However, contrary to previous
assumptions, it may not be necessary for fear to decrease in any particular
exposure session for a client to show improvement across sessions (Craske
& Mystkowski, 2006). Third, exposure seems to work best when practices
are not too spread out, particularly early in treatment (Foa, Jameson,
Turner, & Payne, 1980). A number of other variables can influence the
outcomes of exposure, including the extent to which the context of
exposure is varied and the extent to which safety behaviors (e.g.,
distraction) are used during exposure practices (for a review, see
Abramowitz, Deacon, & Whiteside, 2011; Antony & Swinson, 2000).
EXPOSURE HIERARCHIES
47

Before starting exposure therapy, the therapist and client typically
develop an exposure hierarchy, which is subsequently used to guide
exposure practices. The hierarchy usually includes 10 to 15 situations.
Each item is rated in terms of how much fear it would typically generate
and how likely the client would be to avoid the situation, using a Likert-
type scale (e.g., ranging from 0 to 100, where 0 = no fear or avoidance and
100 = maximum fear and avoidance). Ratings are used to determine the
order of items, such that the most difficult items are at the top of the list
and the less difficult items are at the bottom. Table 4.1, “Exposure
Hierarchy for Social Anxiety Disorder,” includes an example of an
exposure hierarchy for an individual with a diagnosis of social anxiety
disorder.
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TABLE 4.1.
Exposure Hierarchy for Social Anxiety Disorder
RESPONSE PREVENTION
Response prevention refers to the inhibition or blocking of a learned
behavioral response to a stimulus, with the goal of breaking the association
between the stimulus and the response (Nock, 2005). The process may be
facilitated by physically preventing the unwanted behavior (e.g., turning
off the main water source so a client with OCD cannot wash his or her
hands) or using reinforcement for not engaging in the unwanted behavior
(e.g., complimenting a client for his or her success at refraining from nail
biting).
Response prevention is most often discussed in the context of treating
OCD, in which it is also referred to as ritual prevention. Compulsive
rituals are believed to have the same functions as safety behaviors,
avoidance, and escape—namely, to prevent the occurrence of harm and to
reduce fear, anxiety, and distress. Compulsions are also thought to help
49

maintain fear of relevant obsessional thoughts, situations, and objects.
Therefore, along with exposure to feared stimuli, individuals with OCD
are typically encouraged to prevent their compulsive rituals.
In addition to the treatment of OCD, response prevention is used to
reduce the occurrence of safety behaviors in other anxiety-based disorders
and to reduce problematic impulsive behaviors (e.g., hair pulling in
trichotillomania).
REFERENCES
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure
therapy for anxiety: Principles and practice. New York, NY: Guilford
Press.
Antony, M. M., & McCabe, R. E. (2005). Overcoming animal and insect
phobias: How to conquer fear of dogs, snakes, rodents, bees, spiders, and
more. Oakland, CA: New Harbinger.
Antony, M. M., & Swinson, R. P. (2000). Phobic disorders and panic in
adults: A guide to assessment and treatment. Washington, DC: American
Psychological Association. doi:10.1037/10348-000
Antony, M. M., & Watling, M. A. (2006). Overcoming medical phobias: How
to conquer fear of blood, needles, doctors, and dentists. Oakland, CA:
New Harbinger.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified
treatment for emotional disorders. Behavior Therapy, 35, 205–230.
doi:10.1016/S0005-7894(04)80036-4
Craske, M. G., & Mystkowski, J. L. (2006). Exposure therapy and extinction:
Clinical studies. In M. G. Craske, D. Hermans, & D. Vansteenwegen
(Eds.), Fear and learning: From basic processes to clinical implications
(pp. 217–233). Washington, DC: American Psychological Association.
doi:10.1037/11474-011
Foa, E. B., Jameson, J. S., Turner, R. M., & Payne, L. L. (1980). Massed vs.
spaced exposure sessions in the treatment of agoraphobia. Behaviour
Research and Therapy, 18, 333–338. doi:10.1016/0005-7967(80)90092-3
50

Mennin, D. S., & Fresco, D. M. (2010). Emotion regulation as an integrative
framework for understanding and treating psychopathology. In A. M.
Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A
transdiagnostic approach to etiology and treatment (pp. 356–379). New
York, NY: Guilford Press.
Moscovitch, D. A., Antony, M. M., & Swinson, R. P. (2009). Exposure-based
treatments for anxiety disorders: Theory and process. In M. M. Antony &
M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp.
461–475). New York, NY: Oxford University Press.
Nock, M. K. (2005). Response prevention. In M. Hersen & J. Rosqvist (Eds.),
Encyclopedia of behavior modification and cognitive behavior therapy:
Vol. 1. Adult clinical applications (pp. 489–493). Thousand Oaks, CA:
Sage.
Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality
exposure therapy for anxiety and specific phobias: A meta-analysis.
Journal of Behavior Therapy and Experimental Psychiatry, 39, 250–261.
doi:10.1016/j.jbtep.2007.07.007
Stern, R., & Marks, I. (1973). Brief and prolonged flooding: A comparison in
agoraphobic patients. Archives of General Psychiatry, 28, 270–276.
Tryon, W. W. (2005). Possible mechanisms for why desensitization and
exposure therapy work. Clinical Psychology Review, 25, 67–95.
doi:10.1016/j.cpr.2004.08.005
Excerpted from Behavior Therapy (2011) from Chapter 4, “The Therapy Process,” pp. 59–63. Copyright
2011 by the American Psychological Association. Used with permission of the authors.
51

APPENDIX 4.1: BEHAVIOR THERAPY TECHNIQUES
52

5
BRIEF DYNAMIC THERAPY
HANNA LEVENSON
The integrative view of time-limited dynamic psychotherapy (TLDP)
intertwines three substantive approaches that have complex, overlapping
historic and clinical perspectives, each one pertaining to a different focus
of the clinical work. The first leg of this theoretical stool is attachment
theory, which provides the motivational rationale for the therapy. From
attachment theory, one can answer the questions “Why do people behave
as they do?” “What is necessary for mental health, and how does mental
illness occur?” The second support comes from interpersonal–relational
theory, which forms the frame or platform for the therapy. “What is the
medium in which the therapy occurs?” The third leg emphasizes the
experiential–affective component, which is concerned with the process of
change. “What needs to shift for change to occur?” When I am working
clinically, I experienced these three perspectives as inseparable and
reinforcing one another—all contributing to support a stable base from
which to do therapy.1 In the next section each component will be
examined so that the reader can better understand my current perspectives
on the theory and practice of TLDP.
ATTACHMENT THEORY
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Attachment in Infancy
Attachment theory maintains that infants manifest an instinctive
behavioral repertoire (the attachment behavioral system) in the service of
maintaining physical closeness to caregivers. From an attachment
perspective, we are hardwired to gravitate toward “older and wiser” others
particularly during times of stress or threat. Moreover, we are genetically
programmed to solicit attention from our caregivers on whom we are
dependent because our very existence depends on this vital bond. Infants’
ability to elicit such attention is then maintained through a mutual
feedback loop in which caregivers (usually initially mothers) are socially
reinforced by their infants for engaging in attentional behaviors (e.g., the
infant’s steady gaze reinforces the mother’s cooing and staring back,
which then encourages the infant to fixate on her face and engage in
smiling behaviors that again results in more rapt attention from mother).
There is ample research to indicate that some of an infant’s ability to
imitate the social behavior of another (e.g., stick out one’s tongue after
seeing the mother stick out her tongue) and to respond to social cues from
a caregiver is not learned and is already available in the infant’s behavioral
repertoire just a few hours after birth (Meltzoff & Moore, 1977).
The literature on attachment theory and its application to
understanding human development is enormous and spans nearly 40 years
(Obegi & Berant, 2008). John Bowlby’s classic trilogy on attachment,
separation, and loss (1969, 1973, 1980) highlighted the importance of the
emotional quality of early childhood for understanding psychopathology.
Through observations, consultations, and the empirical/theoretical
literature that existed at the time, Bowlby concluded that
the young child’s hunger for his [sic] mother’s love and presence is
as great as his hunger for food, and that in consequence her absence
inevitably generates a powerful sense of loss and anger. . . . Thus we
reached the conclusion that loss of mother-figure, either by itself or
in combination with other variables yet to be clearly identified, is
capable of generating responses and processes that are of the greatest
interest to psychopathology. (1969, p. xiii)2
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Bowlby noticed that infants had a large repertoire of behaviors to
keep their mothers close and interactive. He believed the infant had
acquired this behavioral repertoire gradually over the course of evolution;
those infants who could connect had a better chance of passing on their
DNA to future generations. “Bowlby viewed the human infant’s reliance
on, and emotional bond with, its mother to be the result of a fundamental
instinctual behavioral system that, unlike Freud’s sexual libido concept,
was relational without being sexual” (Mikulincer & Shaver, 2007, p. 7,
emphasis added).
Attachment Patterns
While attachment originally pertained to an infant’s proximity
seeking, Bowlby later wrote of how the attachment needs and behaviors
continue throughout the life cycle, with adults turning to other adults,
especially in times of stress. As he stated in his treatise on healthy human
development, A Secure Base (1988), “All of us, from the cradle to the
grave, are happiest when life is organized as a series of excursions, long or
short, from the secure base provided by our attachment figure(s)” (p. 62,
emphasis added). We probably have no stronger example of this in modern
times than when so many people in the Twin Towers on 9/11, when faced
with a certain, horrific death, reached for their cell phones for the sole
purpose of making contact with loved ones.
The analysts called Bowlby a behaviorist (the ultimate condemnation,
no doubt) because of his interest in animal research and in observing the
actual behavior of children. But quite to the contrary, the behaviorists
would have nothing to do with his ideas. During this time, John Watson,
for example, was cautioning parents not to reward crying children with
attention. “Never hug and kiss them . . . never let them sit in your lap. If
you must, kiss them once on the forehead when they say goodnight”
(Watson, 1928, as quoted by Lewis, Amini, & Lannon, 2001, p. 71).
Ainsworth, an American colleague of Bowlby’s, developed an
experimental procedure to assess the attachment patterns of infants called
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the “Strange Situation” (Ainsworth, 1969). In this situation, infants came
with their mothers into a room with a one-way mirror. The infants would
spend some time in the room with their mothers, an experimenter, and a
variety of toys. At some point the mother would leave the child alone with
the experimenter who recorded the child’s behavior. When the mother
came back a short time later, the child’s behavior was again noted. Infants
who were classified as secure were able to use their mothers as a home
base as they explored their new surroundings. When their mothers left,
they were obviously distressed, but they were able to be soothed by her
return and resume constructive play. Children who were classified as
avoidant exhibited little visible distress when their mothers left and did not
greet her upon her return. They seemed more interested in the toys, but
their play was not particularly creative.3 These children were thought to
have deactivated their attachment system. The children labeled as anxious–
ambivalent looked distressed even when they entered the room with their
mothers. When their mothers left, they cried and were visibly angry. At
reunion, these children were not able to be comforted and remained
hyperaroused, unable to return to their play activities.
Internal Working Models
Bowlby’s formulations about the significance of internal working
models help therapists understand how patterns of attachment might be
maintained over time.4 He postulated that “an internal psychological
organization with a number of highly specific features, which include
representational models of the self and of attachment figure(s)” (1988, p.
29), develops over time and is built up through a series of experiences with
caregivers throughout one’s early life. Thus the child not only has an
internalized set of expectancies about how he or she will be treated by
others, but also an internalized model of how one sees, feels about, and
treats one’s self that is a reflection of how one has been treated by others.
Bowlby postulated that a securely attached child (i.e., a child who has
been responded to by caregivers in a contingent, helpful, and loving
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manner whether distressed or contented) comes to expect that there are no
aspects of the self that cannot be noticed, responded to, and dealt with.
However, children who are not securely attached (i.e., who have been
responded to sporadically, noncontingently, inadequately, or
inappropriately) learn that when they are under threat, they cannot count
on others to keep them safe.
Insecurely attached children get a quadruple whammy. First, they
have models of self and/or others that are negative; second, they also have
considerable difficulty self-correcting these harmful internalized models
because of difficulties cognitively and emotionally perceiving
disconfirmatory incoming information; third, since their working models
or templates are derived and perpetuated out of awareness, they continue
to be at their mercy. I am reminded of the saying that a fish has no idea of
water. So it is with working models. They have an enormous impact on
our lives, but we take them for granted as the way life is. Wachtel (2008)
points out a fourth way insecurely attached children are affected. The
stability of their internal working models persists in part because the
ongoing interactions with the very people who gave rise to these
experiences also persist (e.g., parents who were harsh toward their child as
an infant are harsh when the child is a toddler and harsh when the child is
an adolescent).
Adult Attachment
How does one understand the relevancy of attachment theory for
adults? As Bowlby stated, attachment is significant from “cradle to grave,”
but by the time people are adults, they normally do not need the proximity
to another human being to survive. Adults feel secure when their
attachment figures have confirmed “that (a) they are loved and lovable
people, and (b) they are competent or have mastery over their
environment” (Pietromonaco & Feldman Barrett, 2000, p. 167). Over the
years, this builds up a sense of felt security that individuals internalize and
carry with them throughout the life span (Stroufe & Waters, 1977).
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Shaver and Mikulincer (2008) delineate the three critical functions
necessary for a person to reach adult attachment figure status: (a) this
person is sought out at times of stress, or this person’s undesired leaving
creates distress and protest; (b) this person creates a “safe haven” because
he/she is a source of comfort, protection, or security; and (c) this person
provides a “secure base” from which the adult can explore the world, take
risks, and pursue self-development. Bowlby (1969/1982) acknowledged
that a variety of people, personages (like God), or even institutions could
be seen as attachment figures. In addition, the mental representations of
these central figures (or of oneself) also can be a source of felt security and
comfort. In a series of ingenious studies (see Shaver & Mikulincer, 2008),
it has been demonstrated that activation of mental representations of
attachment figures (e.g., asking people to visualize the faces of such
figures) promotes a positive feeling, reduces painful or hurt feelings, and
fosters empathy. (As a mini-experiment right now, the reader could take a
moment and imagine seeing the face of someone who has provided
comfort and security. Are you aware of having more positive feelings and
an increased sense of well-being?)
Mary Main, a student of Ainsworth’s, developed the Adult
Attachment Interview (AAI; Main, Kaplan, & Cassidy, 1985) to explore
the mental representations of adults’ attachment as children to their
parents. The AAI asks people to respond to specific questions about their
relationships with their parents when they were young. For example,
“Could you give me five adjectives or phrases to describe your
relationship with your mother during childhood?” Those interviewed are
then classified into one of three attachment styles—secure, dismissing, or
preoccupied—corresponding to the three categories found for infants in
the Strange Situation.
Secure adults describe their pasts (even those that were distressing) in
a clear and coherent manner; dismissing adults give few examples of their
relationships with parents and offer sparse, minimizing responses (e.g.,
“My relationship with my mother was fine”); and preoccupied adults’
responses show an inability to pull back from their anger and/or anxiety,
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apparently overwhelmed by their feelings. Thus, the securely attached
individuals demonstrate autobiographical competence (Holmes, 1993;
Siegel, 1999); they are able to tell a coherent story of how the past affected
them and why they are the way they are. Furthermore, they are able to
mentalize (Fonagy & Target, 2006); they can “interpret others’ minds,
which in turn fostered the ability to read and understand one’s own mental
states, especially those mental states that are based on emotions” (Jurist &
Meehan, 2008, p. 72). Such autobiographical competence and the ability to
mentalize have been hypothesized to be central to affect regulation and
mental health in general.5
Attachment-Based Therapy
Although there is no specific “attachment therapy” for adults, the
relevance of attachment theory for therapeutic formulation and
intervention is enormous. Bowlby (1988) outlined five therapeutic tasks—
all revolving around the therapist’s role of providing “conditions in which
his [sic] patient can explore his representational models of himself and his
attachment figures with a view to reappraising and restructuring them in
the light of the new understanding he acquires and the new experiences he
has in the therapeutic relationship” (p. 138, emphasis added). Specifically,
the therapist must: (a) provide a secure base, a “trusted companion,” so
that the painful aspects of one’s life can be examined; (b) assist
exploration of expectations and biases in forming connections with others;
(c) encourage consideration of how early parenting experiences are related
to current functioning; (d) help the patient see the past for what it is and
help him or her to imagine healthier alternative ways of acting and
thinking; and (e) help examine the therapeutic relationship as the patient’s
working models of self and other play out in the therapy. In fact, Bowlby
felt that examining the transference and countertransference in the here
and now of the sessions should be the main focus of therapy, with
explorations of the patient’s past delved into only as they are useful in
helping one understand current ways of feeling and coping with one’s
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interpersonal world. It is in this context that Bowlby specifically
mentioned the work of Strupp and Binder (1984) in his 1988 book, A
Secure Base, stating that TLDP contains many of the same ideas on
therapeutic process that he has outlined.
REFERENCES
Ainsworth, M. D. S. (1969). Object relations, dependency and attachment: A
theoretical review of the infant–mother relationship. Child Development,
40, 969–1025. doi:10.2307/1127008
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York, NY:
Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation anxiety and anger.
New York, NY: Basic Books.
Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss, sadness, and depression.
New York, NY: Basic Books.
Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment (2nd ed.). New
York, NY: Basic Books.
Bowlby, J. (1988). A secure base: Clinical applications of attachment theory.
London, England: Routledge.
Castonguay, L. G., & Beutler, L. E. (Eds.). (2005). Principles of therapeutic
change that work. New York, NY: Oxford University Press.
Fonagy, P., & Target, M. (2006). The mentalization-focused approach to self
pathology. Journal of Personality Disorders, 20, 544–576.
doi:10.1521/pedi.2006.20.6.544
Holmes, J. (1993). John Bowlby and attachment theory. London, England:
Routledge.
Jurist, E. L., & Meehan, K. B. (2008). Attachment, mentalization, and
reflective functioning. In J. H. Obegi & E. Berant (Eds.), Attachment
theory and research in clinical work with adults (pp. 71–93). New York,
NY: Guilford Press.
Karen, R. (1998). Becoming attached: First relationships and how they shape
our capacity to love. New York, NY: Oxford University Press.
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Lewis, T., Amini, F., & Lannon, R. (2001). A general theory of love. New
York, NY: Vintage Books.
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood,
and adulthood: A move to the level of representation. Monographs of the
Society for Research in Child Development, 50, 66–104.
doi:10.2307/3333827
Meltzoff, A. N., & Moore, M. K. (1977). Imitation of facial and manual
gestures by human neonates. Science, 198, 75–78.
doi:10.1126/science.198.4312.75
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure,
dynamics, and change. New York, NY: Guilford Press.
Neborsky, R. J. (2006). Brain, mind, and dyadic change processes. Journal of
Clinical Psychology, 62, 523–538. doi:10.1002/jclp.20246
Obegi, J. H., & Berant, E. (2008). Introduction. In J. H. Obegi & E. Berant
(Eds.), Attachment theory and research in clinical work with adults (pp. 1–
14). New York, NY: Guilford Press.
Pietromonaco, P. R., & Feldman Barrett, L. (2000). The internal working
models concept: What do we really know about the self in relation to
others? Review of General Psychology, 4, 155–175. doi:10.1037/1089-
2680.4.2.155
Shaver, P. R., & Mikulincer, M. (2008). An overview of adult attachment
theory. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research
in clinical work with adults (pp. 17–45). New York, NY: Guilford Press.
Siegel, D. J. (1999). The developing mind: Toward a neurobiology of
interpersonal experience. New York, NY: Guilford Press.
Siegel, D. J., & Hartzell, M. (2003). Parenting from the inside out: How a
deeper self-understanding can help you raise children who thrive. New
York, NY: Tarcher/Putnam.
Stroufe, L. A., & Waters, E. (1977). Attachment as an organizational
construct. Child Development, 48, 1184–1199. doi:10.2307/1128475
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to
time-limited dynamic psychotherapy. New York, NY: Basic Books.
Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy.
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New York, NY: Guilford Press.
Excerpted from Brief Dynamic Therapy (2010), from Chapter 3, “Theory,” pp. 29–36. Copyright 2010 by
the American Psychological Association. Used with permission of the author.
1Each of these three components has been identified as an empirically supported, therapeutic change
principle in the modern practice of psychotherapy (e.g., Castonguay & Beutler, 2005; Neborsky, 2006).
2When Bowlby heard Harry Harlow speak at an American Psychological Association Convention in 1958,
he immediately saw the relevancy of Harlow’s work with rhesus monkeys who preferred a “cloth mother,”
even though they were fed by a wire mesh “mother” (Karen, 1998).
3It should be noted that while the avoidant children did not appear distressed, measurements of their
physiology showed high degrees of activation. Thus, with children and adults classified as avoidant, there
is often marked internal distress with behavioral suppression.
4According to Mikulincer and Shaver (2007), the term working models was to connote two ideas: (a) the
models are heuristic—that is, they are pragmatically useful in predicting likely outcomes, and (b) the
models are provisional—that is, they are changeable as in a working title (p. 15).
5Siegel and Hartzell (2003) wrote a book for parents to help them understand that they could promote their
children’s mental health by “making sense” of their own lives in a way that is coherent—a way that tells a
story of how the past affected them and why they are the way they are in the present. Siegel (1999)
believes that such coherence leads to neural integration and facilitates raising securely attached children.
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6
BRIEF DYNAMIC THERAPY PROCESS
HANNA LEVENSON
MAINTAINING THE THERAPEUTIC RELATIONSHIP
In time-limited dynamic psychotherapy (TLDP), as with most clinical
approaches, managing the therapeutic relationship is a critical competency
(Binder, 2004). To strengthen the therapeutic alliance, the TLDP therapist
engages clients from a respectful and nonjudgmental stance, validates their
feelings and perceptions, and invites their collaboration in the process
(Strategy 1).
It is critical in this relationally based approach that the therapist
shows evidence of listening receptively to what the client is saying. This
receptivity may be communicated by body position, facial expression, and
head nodding (Strategy 2). Many of these are culturally determined. In a
brief therapy in general and in TLDP in particular, it is critical to assess,
use, and comment on the strengths of the client to foster change (Strategy
3). Often clients are the last to know about their own capacities. No one
has ever commented on them, elicited them, admired them; therefore,
clients are often blind to their own cognitive, emotional, and relational
resources. Highlighting their internal and external resources can often
build a strong positive alliance.
In Strategy 4 the therapist addresses “obstacles” (e.g., coming late)
and “opportunities” (e.g., willingness to be vulnerable) that might
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influence the therapeutic process. In psychoanalytically oriented therapies,
“overt or covert opposition to the therapist, the counseling process, or the
therapist’s agenda” (Bischoff & Tracey, 1995, p. 488) has been called
resistance. Resistance from the perspective of TLDP, on the other hand, is
viewed within the interpersonal sphere—as one of a number of
transactions between therapist and client (Levenson, 1995). The
assumption is that clients are doing what they believe is necessary to
maintain their personal integrity, ingrained perceptions of themselves, and
interpersonal connectedness. Resistance in this light reflects the clients’
attempts to do the best they can given how they construe the world. For
example, a client might miss a session following the session when she has
cried in the hour because she is so worried that the therapist will perceive
her as too needy.
Thus, when TLDP therapists feel as if they have hit a wall of
resistance from the client, they can stand back, appreciate the attachment-
based significance of the wall, and invite the client to look at possible
“good” reasons to have the wall. Such an approach often avoids power
plays with hostile clients and helps to promote empathy and collaboration.
ACCESSING AND PROCESSING EMOTION
No matter what else the therapist may do in the therapy, he or she is
trying to relate to clients in the here and now of the therapeutic
relationship from a deeply empathic place, helping to keep clients in an
emotionally receptive “working space” through what has been called
dyadic regulation (e.g., Tronick, 1989). Such transactions are
hypothesized to be beneficial in and of themselves in that they permit
emotional processing and the modulation of goal-directed behaviors and
adaptive strategies. However, as pointed out by Binder (2004) and others
(e.g., Henry, Strupp, Butler, Schacht, & Binder, 1993), helping clients stay
emotionally regulated (Strategy 5) is easier said than done when one is
interacting with powerful interpersonal dynamics that dysregulate the
therapist’s own emotional state. Thus, this strategy is more of a desired
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optimum therapeutic stance that will usually be manifested through several
other specific interventions.
For Strategy 6, the therapist actively encourages clients to experience
and express affect in the session. Activating the emotional fabric of the
person’s cyclical maladaptive pattern (CMP) is critical in changing it. As
Greenberg is fond of saying, “You must arrive at a place before you can
leave it.” From experiential theory, research, and practice, we know that
emotional arousal and expression are necessary precursors of change (e.g.,
Greenberg, 2002; Johnson, 2004). Similarly the therapist helps clients
become aware of emotions on the edge of awareness and helps them
deepen their emotional experience (Strategy 7). However, mere ventilation
of emotions is not enough, and the therapist must help clients label their
emotional experience and tune into its goal-directed significance (Strategy
8). In particular, the TLDP therapist is invested in focusing on the client’s
accessing, experiencing, and deepening any attachment-related feelings
specifically related to the person’s CMP (Strategy 9).
EMPATHIC EXPLORATION
Open-ended questions (Strategy 10) and inquiring into the personal
meanings of the clients’ words (Strategy 11) as well as asking for concrete
details (Strategy 12) all help the therapist understand the client’s world
from the inside out. It is not unusual when I am listening to the client talk
in a global fashion about a disturbing (or rewarding) interaction with
another person (“She just really ticked me off!”) to ask them to slow the
action down so that I can understand the details of the situation—both in
terms of external transactions and internal, visceral responses.1 Often
clients are quite surprised to see all the steps (e.g., attributions of self and
other) that have led them to their reaction that often feels as if it “just
happens.”
FOCUSED INQUIRY
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Throughout the therapy, the TLDP therapist attempts to maintain a
circumscribed line of inquiry and stays on the focus unless there are
dramatic indications to the contrary (Strategy 13). Such a focusing,
however, should not be done in a dogmatic or controlling manner. Binder
(2004) defines problem formulation and focusing to be one of the five
competencies in conducting good interpersonal–psychodynamic therapy.
Maintaining a focus is the most commonly mentioned feature defining
brief dynamic therapy. The TLDP therapist uses the emotional–
interpersonal goals derived from the formulation to keep the therapy on
track. Such focusing is critical in a brief therapy that demands making the
best use of time.
RELATIONSHIP FOCUS
The TLDP therapist encourages clients to talk about their
relationships with others (including with the therapist). Focusing on
relevant thoughts, feelings, and beliefs associated with such transactions is
of paramount importance (Strategy 14). Much of the therapeutic work will
focus on the clients’ relationships outside of the sessions (unless a negative
process emanating from within the sessions needs to be addressed
directly). Similarly, the therapist helps clients explore their perceptions of
how the therapist might be acting, feeling, or thinking about them
(Strategy 15). In this way, the therapeutic relationship is examined as a
here-and-now microcosm of what might happen with others.
In a reciprocal fashion, it can often be helpful for therapists to self-
disclose their countertransference in response to clients’ specific behaviors
(Strategy 16). Of course the therapist is always self-disclosing
inadvertently through gestures, voice quality, facial expression, etc. Self-
disclosure is “not an option; it is an inevitability” (Aron, 1991, p. 40). But
here I am talking about the therapist’s self-involving disclosures—
statements in the present tense that describe the therapist’s reactions to
some aspect of the client’s CMP (McCarthy & Betz, 1978). In this way the
therapist can open up other possibilities in the clients’ perceptions of
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others and help clients appreciate their impact on others. In TLDP
therapists need to become comfortable with comprehending their own
internal processes and then deciding when, where, and how to share these
with clients. TLDP advocates limited self-disclosure specifically designed
to give clients more information about the dynamics involved in relating to
others. Such disclosures can be narrowly seen as a manifestation of the
therapist’s clinical honesty (Wilkinson & Gabbard, 1993, p. 282).
In particular, the therapist focuses on his or her reactions to the client
that are particularly relevant for the client’s CMP. It should be noted that
the therapist’s sharing such reactions is not only helpful for bringing into
awareness negative aspects when there are reenactments, but also for
recognizing when there are positive shifts in the quality of the interaction.
For example, after Mrs. Follette (the guarded client described earlier)
allowed herself to be more open in session, the therapist shared that he felt
closer to her. The reader is referred to Levenson (1995) for a discussion of
this type of interactive self-disclosure as distinguished from other types of
disclosures.
Related to self-disclosing strategies is metacommunication (Strategy
17). From an interpersonalist position (Kiesler, 1996), metacommunication
involves discussing and processing what occurs in the here-and-now
client–therapist relationship that involves both therapist and client. For
example, “It seems, Mr. Johnson, as you get quieter and quieter, I become
more and more reassuring. I am not sure what is happening here, but can
we take a look at what this feels like for both of us?” Muran’s (2001)
expansion of the definition of metacommunication to include
intrapersonal aspects (i.e., communication with parts of the self) is also
useful. From an attachment point of view, metacommunication can be
pivotal in providing corrective emotional experiences, shifts in self-
awareness, and richer narratives of the self in relation to self and others.
While much of the therapy will be devoted to examining the clients’
issues in their relationships outside the therapy (especially for those with
more flexible working models), the therapist’s observations about
manifestations of the CMP (not necessarily full-blown reenactments) in
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the sessions provides an in vivo understanding of the client’s behaviors
and stimulus value. By ascertaining how an interpersonal pattern has
emerged in the therapeutic relationship, the client has, perhaps for the first
time, the opportunity to examine the nature of such behaviors in a
relatively safe environment.
I want to make a comment here about the use of transference
interpretations, since they have been a standard intervention strategy for
psychodynamic therapists in both short- and long-term therapies (although
intersubjective, two-person approaches like TLDP shy away from using
them). When therapists are “analyzing the transference,” they are linking
emotionally charged interactions with past significant others (usually
parents) with what is happening in present transactions between therapist
and client, rather than making observations about the ongoing therapeutic
process. For example, if I would have explained to Mr. Johnson that “you
want me to nurture and take care of you in ways you didn’t get from your
parents,” this would be an example of a transference interpretation.
Kasper, Hill, and Kivlighan (2008) differentiate between immediacy
(her term for metacommunication) and transference interpretations in a
similar manner:
Immediacy seeks to promote the here-and-now awareness of
problematic interpersonal patterns and to create a corrective
emotional experience by establishing new interpersonal patterns. By
contrast, transference interpretations seek to promote the client’s
awareness of the existence and insight into the origin of displaced
interactional patterns by providing an explanation or reason for the
behaviors. (p. 282, emphasis added)
I very much like quoting Strupp’s admonition that the supply of
transference interpretations far exceeds the demand. A few go a long way.
In part I have placed a major focus in TLDP on experiential learning and
empathic attunement, because of the deleterious effect repeated
transference interpretations can have on psychotherapeutic process and
outcome. Clients often experience such interventions as blaming and/or
belittling (Henry, Schacht, Strupp, Butler, & Binder, 1993; Piper, Azim,
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Joyce, & McCallum, 1991). There is convincing empirical evidence that
questions the heretofore prominent role transference interpretations have
played in psychodynamic interventions (Henry, Schacht, et al., 1993;
Høglend, Johannsson, Marble, Bøgwald, & Amlo, 2007; Piper et al.,
1991).
EXPLORATION OF MALADAPTIVE CYCLICAL PATTERNS
In Strategy 18, the therapist helps clients explore their introjects (how
they feel about and treat themselves) and how these relate to their
interpersonal patterns (CMPs). Inquiring about how one feels about
oneself during certain interpersonal behaviors (especially those that are
attachment-related) links one’s sense of self with transactions with others.
As I say to Ann in the clinical case to follow, “How do you feel about
yourself when you cry yourself to sleep, making sure that your boyfriend
does not hear you?”
The therapist then helps clients put all of the aforementioned
emotional–interpersonal information of self and others into describing a
cyclical pattern (Strategy 19). For example:
So when you feel so alone and depressed, and expect no one will be
there for you, you make sure that you present yourself as “together,”
“cool,” and not “needy.” Is that right? The problem is that others get
the message that you don’t want their attention, and so they leave
you alone. Yes? You see people aren’t there for you, and you then
tell yourself that no one would want to be with someone so needy,
and this makes you feel more depressed, and the whole cycle begins
again. Do I have that right?
It is very important at this stage that the therapist be as specific as
possible and slowly review each component of the pattern, checking it out
with clients at each linking, soliciting their elaboration and emotional
confirmation.
Once the pattern has been recognized, the therapist refers to the CMP
throughout the therapy and, at each link, helps the client access,
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experience, and deepen the attachment-related feelings (Strategy 20). The
therapist focuses on previously warded-off, unacknowledged, disowned, or
disavowed attachment-related feelings and/or primary emotions
specifically relevant to the CMP. The therapist confronts blocks in
experiencing by using experiential techniques such as arousal, heightening,
and empathic conjecture (Johnson, 2004). In this way, the client comes to
understand the deeper, attachment-based needs that drive the maladaptive
cycle and begins to appreciate how this working model has colored his or
her worldview.
When appropriate, the therapist then links the need for disowning
these primary emotions to the clients’ early experiences (Strategy 21). The
clients come to understand how they perceived these basic core emotions
as undesirable by caregivers; therefore, these emotions were suppressed
and finally disowned so that early attachments would not be threatened.
The therapist can help depathologize the client’s current behavior and
symptoms by explaining how they were a way to survive emotionally as a
child, but now they serve no useful purpose and may even be alienating.
Over time, the therapist helps the client incorporate more core
feelings (Fosha, 2000) and more adaptive thoughts and behaviors into a
new coherent narrative that opens up an expanded sense of self and a
wider repertoire of actions, leading to greater intrapersonal and
interpersonal health (Strategy 22). Going back to our example of Mr.
Johnson, by the end of therapy, he was able to talk about how he had to
squelch his angry feelings as a child to avoid being beaten by his alcoholic
father—a very different narrative than when he entered therapy and
shamefully saw himself as weak. In his last session, Mr. Johnson said he
now felt entitled to be angry—“honest anger.”
PROMOTING CHANGE DIRECTLY
One of the most important TLDP treatment strategies is providing
opportunities for clients to have new experiences in session that are
designed to help undermine their CMPs (Strategy 23). Therapists should
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seize opportunities to expand or deepen experiences that disconfirm
clients’ intrapersonal and interpersonal schemata. The therapist makes
clear and repeated efforts to promote such experiential learning (e.g.,
facilitating new behaviors that the client sees as “risky”). With sufficient
quality and/or quantity of these experiences, clients can foster healthier
internalized working models of relationships. In this way TLDP promotes
change by altering the basic infrastructure of the client’s transactional
world, which then reverberates to influence the concept of self.
Going back to our case of Mr. Johnson, at one point in the sixth
session, he was complaining that he could not think and participate in the
therapy because he had not eaten breakfast. When I asked him what he
wanted to do, he was confused by my question. Of course he would finish
the session! Upon further inquiry, I learned that he thought I would be
angry if he left the session early to get something to eat, and he would
want to avoid my anger at all costs. When I simply stated back to him that
it seemed he was choosing to remain in the session and be uncomfortable
hoping not to displease me, he said he would go get some food if I thought
it were a good idea. I expressed my curiosity about his leaving the decision
up to me by stating in a puzzled tone, “If I thought it was a good idea?”
A short while later, Mr. Johnson said he felt better and would finish
the session. However, in the next session a similar dynamic (but with
different content) arose, and that time, Mr. Johnson announced that he
wanted to leave the session early to attend to his personal needs (i.e., take
a stool softener so he would not be constipated later that evening when his
children came to visit). Rather than interpreting what I thought was going
on at an unconscious level, I simply told Mr. Johnson I would look
forward to seeing him at our usual time next week. Mr. Johnson’s stating
his own needs over what he imagined were my wishes (that he should stay
in the session no matter what) had been a big risk for him because, as I
learned later, he thought I was going to throw him out of therapy if he
were not “compliant.” Being aware that he was directly verbalizing his
own needs (for once in his life), taking a chance that I would disapprove
and might even retaliate, and then finding out that his assertiveness did not
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jeopardize our relationship was a major new intrapersonal and
interpersonal experience for Mr. Johnson.
However, I do not want to give the impression that in TLDP the
therapist tries to create that one new experience that totally realigns the
client’s affective and cognitive world. Rather, new experiences should be
encountered throughout the therapy—sometimes as almost imperceptible
nuances embedded in the relationship context. In our long-term follow-up
study of clients who have received TLDP (Bein, Levenson, & Overstreet,
1994), many clients described that one of the biggest benefits they got
from therapy was having the opportunity to be more in touch with their
emotions as they related in new and healthier ways to their therapists.
Unlike many long-term psychodynamic models, in TLDP the
therapist may give directives to help clients foster their growth outside of
the session (Strategy 24). Giving homework, for example, is very
compatible with the TLDP approach. However, before making any such
assignments, the TLDP therapist must carefully weigh the implications of
such directives to make sure they are not a subtle reenactment of the
client’s dysfunctional pattern. For example, asking Mr. Johnson to take
assertiveness training classes may sound like a good idea on the surface.
But if it is something he does because he feels he must do whatever I say
in order to stay in my good graces, the homework assignment just serves to
feed his attachment fears and compliant security operations—ultimately
making sure he has yet another dysfunctional interpersonal interaction.
TIME-LIMITED ASPECTS
Strategy 25 involves the therapist’s introducing and discussing the
time-limited or brief nature of the therapy. The brief therapist does not do
this just at the end of the treatment. At the beginning of the work and
periodically throughout, the TLDP therapist comments on the limits on the
time and/or scope of the work. TLDP, however, is not one of those models
(like that of Mann, 1973) that emphasizes the finiteness of time in order to
precipitate change. Rather, it is thought of as the backdrop against which
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dysfunctional patterns take center stage. As termination approaches, one
can expect to see the client’s anxiety about loss handled in ways
characteristic for that particular person given his or her CMP. Painful
emotions associated with previous losses can be evoked. However, the
TLDP therapist does not stray from the overarching goals of the treatment.
Given the TLDP systems framework, when one person (the client)
changes, other people’s responses are affected, usually reinforcing the
client’s positive changes. As previously mentioned, I think of the
therapeutic work continuing after the sessions have ended. For example,
with Mr. Johnson, where there used to be a vicious dysfunctional cycle,
now there was more of a victorious cycle filled with energy and joy. As a
consequence of his feeling more powerful in the world, he began
socializing more. He experienced himself as more alive and involved in
life; his self-pity and depressive thinking were dramatically decreased.
Now that he was a happier person, his adult children enjoyed being around
him more, which only served to quiet his fears of abandonment and
reinforce his sense of security. A year after he ended treatment, during a
follow-up interview (done by another therapist), I learned that Mr. Johnson
had moved into a house owned by two other people. After living there a
short time, he had been instrumental in setting up a rule that if any tension
occurred among the housemates, they would sit down at the dining room
table and talk about it after dinner. For a man who had been so conflict-
avoidant, this was a clearly a sign of further growth. The therapy continued
in Mr. Johnson’s life, although the sessions had ended a year ago.
How does the therapist make a good decision about knowing when a
client is “ready” to end?2 As one of the originators of single-session
therapy, Michael Hoyt (Hoyt, Rosenbaum, & Talmon, 1992), has said to
me, “Clients are not ‘done’; they are not baked like a cake!” In brief
therapy, we are clearly not looking for therapeutic perfectionism. All of
the loose ends are not tied together. However, since brief therapy often
ends while the client usually is in the midst of changing, I have six sets of
questions to help guide beginning brief therapists in making termination
decisions as the therapy is proceeding:3
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Has the client evidenced interactional changes with significant others
in his or her life? Are these transactions more rewarding?
Does the client evidence more emotional fluidity within himself or
herself? Does the client report a fuller experience of self?
Has the client had a new experience (or a series of new experiences)
of himself or herself and the therapist within the therapy?
Has there been a change in the level on which the therapist and client
are relating (usually from parent–child to adult–adult)?
Has the therapist’s countertransferential reaction to the client shifted
(usually from negative to positive)?
Does the client manifest some understanding about his or her
dynamics and the role he or she needed to play to maintain them?
If the answer to most of these questions is no, then I do not consider
that the client has had an adequate course of TLDP. The therapist should
consider why this has been the case and weigh the possible benefits of
using another therapeutic model, another course of TLDP, a different
therapist, nonpsychological interventions, and so forth.
REFERENCES
Aron, L. (1991). The patient’s experience of the analyst’s subjectivity.
Psychoanalytic Dialogues, 1, 29–51. doi:10.1080/10481889109538884
Bein, E., Levenson, H., & Overstreet, D. (1994, June). Outcome and follow-up
data from the VAST project. In H. Levenson (Chair), Outcome and follow-
up data in brief dynamic therapy. Symposium conducted at the annual
international meeting of the Society for Psychotherapy Research, York,
England.
Binder, J. L. (2004). Key competencies in brief dynamic psychotherapy:
Clinical practice beyond the manual. New York, NY: Guilford Press.
Bischoff, M. M., & Tracey, T. J. G. (1995). Client resistance as predicted by
therapist behavior: A study of sequential dependence. Journal of
Counseling Psychology, 42, 487–495. doi:10.1037/0022-0167.42.4.487
Fosha, D. (2000). The transforming power of affect: A model for accelerated
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change. New York, NY: Basic Books.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work
through their feelings. Washington, DC: American Psychological
Association. doi:10.1037/10447-000
Henry, W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., & Binder, J. L.
(1993). Effects of training in time-limited dynamic psychotherapy:
Mediators of therapists’ responses to training. Journal of Consulting and
Clinical Psychology, 61, 441–447. doi:10.1037/0022-006X.61.3.441
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L.
(1993). Effects of training in time-limited dynamic psychotherapy:
Changes in therapist behavior. Journal of Consulting and Clinical
Psychology, 61, 434–440. doi:10.1037/0022-006X.61.3.434
Høglend, P., Johansson, P., Marble, A., Bøgwald, K., & Amlo, S. (2007).
Moderators of the effects of transference interpretations on brief dynamic
psychotherapy. Psychotherapy Research, 17, 160–171.
doi:10.1080/10503300701194206
Hoyt, M. F. (1985). Therapist resistances to short-term dynamic
psychotherapy. Journal of the American Academy of Psychoanalysis, 13,
93–112.
Hoyt, M. F., Rosenbaum, R., & Talmon, M. (1992). Planned single-session
psychotherapy. In S. H. Budman, M. F. Hoyt, & S. Friedman (Eds.), The
first session in brief therapy (pp. 59–86). New York, NY: Guilford Press.
Johnson, S. M. (2004). The practice of emotionally focused couple therapy:
Creating connection (2nd ed.). New York, NY: Brunner-Routledge.
Kasper, L. B., Hill, C. E., & Kivlighan, D. M., Jr. (2008). Therapist immediacy
in brief psychotherapy: Case study I. Psychotherapy Theory, Research,
Practice, Training, 45, 281–297. doi:10.1037/a0013305
Kiesler, D. J. (1996). Contemporary interpersonal theory and research:
Personality, psychopathology, and psychotherapy. New York, NY: Wiley.
Levenson, H. (1995). Time-limited dynamic psychotherapy: A guide to clinical
practice. New York, NY: Basic Books.
Levenson, H., & Burg, J. (2000). Training psychologists in the era of managed
care. In A. J. Kent & M. Hersen (Eds.), A psychologist’s proactive guide
to managed mental health care (pp. 113–140). Hillsdale, NJ: Erlbaum.
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Mann, J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard
University Press.
McCarthy, P. R., & Betz, N. E. (1978). Differential effects of self-disclosing
versus self-involving counselor statements. Journal of Counseling
Psychology, 25, 251–256. doi:10.1037/0022-0167.25.4.251
Muran, J. C. (2001). A final note: Meditations on “both/and.” In J. C. Muran
(Ed.), Self-relations in the psychotherapy process (pp. 347–372).
Washington, DC: American Psychological Association.
doi:10.1037/10391-014
Piper, W. E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (1991).
Transference interpretations, therapeutic alliance, and outcome in short-
term individual psychotherapy. Archives of General Psychiatry, 48, 946–
953. doi:10.1001/archpsyc.1991.01810340078010
Tronick, E. Z. (1989). Emotions and emotional communication in infants.
American Psychologist, 44, 112–119. doi:10.1037/0003-066X.44.2.112
Wilkinson, S. M., & Gabbard, G. O. (1993). Therapeutic self-disclosure with
borderline patients. Journal of Psychotherapy Practice and Research, 2,
282–295.
Excerpted from Brief Dynamic Therapy (2010), from Chapter 4, “The Therapy Process,” pp. 81–94.
Copyright 2010 by the American Psychological Association. Used with permission of the author.
1It is quite ironic that often my feedback to trainees learning to work briefly is to “slow down” the process.
2I have found that having an explicit ending date (rather than a fixed number of sessions or a brief therapy
defined by a limited focus) works best for training. With a fixed date, therapists-in-training are forced to
confront their “resistances” to working briefly (Hoyt, 1985)—for example, fears of being seen as
withholding, the need to be needed, and overconcern for “successful” termination. Also when I do group
supervision with a specific termination date, all the trainees are roughly on the same page—beginning and
ending together. Without such a structure, I have found that beginning brief therapists often find “good
reasons” for extending the length of the therapy.
3Unfortunately, in today’s managed care environment, the decision of when to end therapy is often not
made collaboratively between therapist and client. Instead it may be a decision made by an administrative
person or limited by one’s insurance coverage to a specified number of sessions for specific diagnoses. See
Levenson and Burg (2000) for a discussion of the effect of these economic influences on professional
training and patient care.
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APPENDIX 6.1: BRIEF DYNAMIC THERAPY TECHNIQUES
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7
COGNITIVE THERAPY
KEITH S. DOBSON
It has been argued that cognitive therapy is based on a realist model
of human functioning (Held, 1995). According to this model, events occur
in the real world, irrespective of whether someone perceives their
occurrence and whether they are perceived accurately. From this
epistemological underpinning, it can be argued that human adjustment is
reflected by optimal accuracy in perception of the world, and by
implication, human maladjustment is reflected by lack of accurate
correspondence between perception and actual events—or by
misperception of the world. Consistent with this perspective, human
adjustment can also be defined as the extent to which the individual
accurately appraises his or her environment and is therefore able to cope
with the demands of that environment.
The realist viewpoint can be contrasted with a constructivist
perspective, which holds that the existence of an objective, external reality
is wrong or, at the least, a weak and untestable premise. In the first
instance, a radical constructivist perspective would be that the external
world does not exist; that all that can and does exist is what we perceive
and experience. In this sense, any one person’s reality is uniquely situated
in space and time, so that it is neither the same reality that that person
“knew” yesterday nor the same reality that he or she will experience in the
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future. A somewhat weaker version of the constructivist perspective is that
it is irrelevant whether an external reality exists because humans are
fallible in their perception. As such, we will never know what “reality” is
in any event, since our perceptions and experiences are always limited by
the possible range of human experience, by our history and development
experiences, and by our current state, which might either enhance or limit
our possible set of experiences.
From a constructivist perspective, human adjustment is not defined by
the correspondence between perception and the real world, but rather by
the coherence or integrity of experience. Also from this perspective,
language does not reflect our experience of the world, but it literally
defines the world and how it can be perceived: “In a constructivist view,
human beings are denied any direct access to an immediate reality beyond
language, defined broadly as the entire repertory of symbolic utterances
and actions afforded to us by our culture” (Neimeyer, 1995, p. 15, italics in
original).
Realist and constructivist perspectives have often been contrasted,
especially with regard to the epistemological underpinnings of each
perspective and their attendant research methodologies (Mahoney, 1991).
In particular, whereas a realist perspective is consistent with logical
positivism and quantitative science, constructivism eschews a universal
perspective on science and instead supports the use of qualitative methods
in research, situated within the experience of individuals, who are in turn
considered to be situated within a unique historical, cultural, and personal
context (Guidano, 1984).
Cognitive therapy has been primarily associated with a realist
perspective and epistemology. Evidence in support of this claim can be
found in many writings. For example, cognitive therapists have discussed
the individual as a “personal scientist” (Arnkoff, 1980; Mahoney, 1977)
who seeks knowledge of the world and who can accurately perceive that
reality or can have distorted perceptions. Some of the better-known
techniques of cognitive therapy teach patients to recognize biases and
distortions in perception and to have more realistic perceptions, so that the
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patient can solve problems in a “realistic” manner. In those instances in
which it might not be clear whether the patient’s perceptions are accurate
or if there is simply not enough information, cognitive therapists may work
with patients to gather “evidence” and discuss the implications of this new
information. Cognitive therapists are comfortable with scales and
measurement tools that have been developed through group and
quantitative research; they also rely on diagnosis and research evidence,
and they incorporate ideas related to evidence-based treatment (Dobson &
Dobson, 2009) into case conceptualization and planning.
Other features of cognitive therapy are actually more consistent with
constructivism. For example, cognitive therapists recognize that
individuals have unique cultural, historical, and personal backgrounds,
which shape the meanings that they assign to their experience: “The
cognitive perspective posits . . . the dual existence of an objective reality
and a personal, subjective, phenomenological reality” (Alford & Beck,
1997, p. 23). Put otherwise, the cognitive model posits that an individual’s
perceptions and appraisals are based in part on the objective nature of the
event or experience, as might be experienced by anyone in that situation,
and in part on the unique ways of knowing, language, and developmental
experiences of the individual.
NATURE OF COGNITION
Within the overall cognitive model of human experience, distinctions
are made among different types of cognition or thought. Various
typologies or conceptualizations of cognition have arisen, but two are of
particular relevance here: the information processing model and the
cognitive model of cognition.
The information processing model of cognition is consistent with the
idea that objective reality occurs and can be attended to, perceived, known,
and stored in memory. A series of aspects of this cognitive system,
including cognitive structures, content, processes, and products, have been
distinguished (Ingram & Kendall, 1986; Kendall & Ingram, 1987). Each of
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these aspects is discussed next.
Cognitive structures represent the organization of long-term
memories, which are held within the mind. These structures are composed
of specific memories, situated at a specific place and time (sometimes
referred to as episodic or autobiographical memory), as well as organized,
linguistically based collections of memories (sometimes referred to as
semantic memory). Semantic memory is the symbolic representation of the
formal knowledge that is collected through experience and tends to be
shared among people within a certain culture and during a historical
period. By definition, however, autobiographical memory is unique and
based on personal experience.
Both autobiographical and semantic memories are themselves
structured. For example, they comprise different aspects of memory,
including sensory aspects of knowledge and experience, but they also
comprise linguistic, emotional, and even potentially bodily or behavioral
aspects of knowledge. These memories are also hierarchically organized.
For example, the autobiographical memory of “mother” will comprise a
number of different events or interactions, not only with “my mother” but
“mothers” in general, and even “not mother” (i.e., experiences that
differentiate mother and mothering from different other types of
experiences, such as “father” and “fathering”). Semantic memories can be
formally hierarchical, for example, in the way that “living organisms” is a
superordinate construct that encompasses animals, which in turn
encompasses mammals, which in turn encompasses dogs (among other
animals), which in turn encompasses specific breeds or types of dogs.
Cognitive structures not only represent a repository for the storage of
memories but also guide the processing of new information. New
information is more easily processed if there is an existing template or
structure into which it can be placed. It appears that existing cognitive
structures can actually bias attention to and processing of new information
so that new information fits within them. Thus, once cognitive structures
are established, they tend to be self-confirming or self-maintaining.
Cognitive content can be defined as the actual material that is held
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within cognitive structures or is the object of new information processing.
Cognitive content is as variable as the range of human experience and
includes words, images, memories, sensory experiences, fantasies, and
emotions. There is a tendency in the cognitive literature to assume that
cognitive content must be subject to verbal mediation—it must be named,
or at least be nameable. However, this assumption is somewhat
controversial, as some cognitive theorists would argue that even emotional
memories are part of the content that humans can experience.
Cognitive processes include the various mechanisms through which
information flows through the information processing system. They
include the various sensory and attentional processes through which new
experiences enter the system. They are known not to be literal copies of
the external world but are potentially biased by the emotional state of the
person who is attending to the environment and to preexisting structures.
Once information comes into attention, various processes can either
amplify the information (e.g., rehearsal of information) or reduce its
salience (e.g., selective forgetting). Furthermore, if information is
transferred into long-term memory, either it can be assimilated into
existing memory structures or, if the experience is unique or bizarre,
accommodation of the memory structures might be required to enable the
memory to be retained.
Several cognitive processes are associated with memory for cognitive
structures. Certain biases or heuristics might either enhance or diminish
the opportunity to recall certain information. Some memories may depend
on the actual state of the person, so that they are best recalled when the
person tries to remember in a state that is similar to when the information
was first put into memory. Some memories appear to be lost or repressed
but are later accessible. It even appears that memories can be changed or
manipulated to some extent.
The final aspect of the information processing model is cognitive
products. These products are the specific cognitions that result from the
dynamic interplay among cognitive structures, content, and processes.
They can take the form of specific ideas or reactions to events, memories
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of events, or thoughts about or reflections on different experiences. Some
cognitive products may occur very quickly or “automatically” if they
involve well-used cognitive structures and processes, whereas others may
only result from reflection and consideration. Cognitive products also exist
in different forms, such as verbal utterances, images, or even emotional
memories.
In contrast to the information processing model of cognition, as
reflected in the constructs of structure, process, content, and product, the
cognitive model of cognition was formulated specifically in the context of
cognitive therapy. This model makes use of some of the same principles
and processes as the information processing model, but the terminology is
more specific, and the model is more attuned to the needs of a clinically
useful way to consider these constructs. This model has been presented in
graphical form in various sources (Alford & Beck, 1997; Dobson &
Dobson, 2009).
According to the cognitive model, individuals possess cognitive
structures, which are a composite of both formal (semantic) and personal
(autobiographical or episodic) knowledge and experience. Various terms
have been used to refer to these structures, but the most common are
beliefs and schemas. Within the cognitive model, schemas are seen as both
reactive, in that they respond to and incorporate new information, and
proactive, in that they influence which types of situations a person might
be willing to enter, the information that is attended to in different
situations or contexts, and even the range of experiences an individual is
able to have.
Because the schema construct is broad, there have been efforts to
identify the possible content of schemas in various disorders. For example,
in an early article about depression, A. T. Beck, Rush, Shaw, and Emery
(1979) discussed the cognitive triad, which consists of beliefs about the
self, the world, and the future. They went on to specify typical or
characteristic beliefs that a depressed person has in each of these three
domains. Specifically, they suggested that depressed persons view
themselves as “losers,” that they are “helpless” in the world, and that the
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future is “hopeless.” Over time, this model has been presented in various
ways. In one recent model, core beliefs and schemas interact dynamically
with critical incidents or triggers to activate assumptions or behavior rules,
as well as automatic thoughts, which then lead to the symptoms of
depression.
Key schemas have been similarly identified in other disorders, such
as the idea that the world is “dangerous” in anxiety disorders (A. T. Beck
& Emery, 1985) or that other people are “hostile” for people with anger
problems (A. T. Beck, 1999). Models either have been or are being
developed for a wide range of disorders and clinical problems (Tarrier,
2006).
It has been argued that schemas may also follow common patterns
that cut across disorders. A. T. Beck, Epstein, Harrison, and Emery (1983)
identified the two schema themes of sociotropy and autonomy to reflect
this idea and developed the Sociotropy–Autonomy Scale (SAS) to measure
these constructs. From this perspective, sociotropy reflects an interpersonal
dependency and the personal belief that one needs interpersonal relations
and support to function. Sociotropic persons are vulnerable to anxiety if
their interpersonal relationships are threatened or to depression if these
relationships are actually disrupted or broken. In contrast, autonomous
persons tend to define themselves in terms of their individual
achievements, accomplishments, and degree of independence or
autonomy. Autonomous persons become anxious if their autonomy is
threatened and depressed if they suffer a blow to their sense of
achievement or accomplishment. These constructs are not specific to a
particular disorder but cut across different emotional response patterns.
Considerable research has been done to validate the SAS and to
demonstrate its predictive validity. In general, the internal reliability and
factor structure of the SAS have been substantiated (Bieling, Beck, &
Brown, 2000, 2004; Ross & Clark, 1993). Research has also demonstrated
that the dimension of Sociotropy interacts with interpersonal difficulties to
predict depression, although the evidence in support of the construct of
Autonomy has been somewhat more elusive to obtain (Bieling & Alden,
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2001; Coyne & Whiffen, 1995; Raghavan, Le, & Berenbaum, 2002;
Robins, Bagby, Rector, Lynch, & Kennedy, 1997).
A schema model has been developed in the context of personality
disorders (Young, 1990; Young, Klosko, & Weishaar, 2003). This model
lists 18 different negative or dysfunctional early maladaptive schemas
(EMSs). These constructs are divided into five broad domains:
abandonment/instability, mistrust/abuse, emotional deprivation,
defectiveness/shame, and social isolation/alienation. The specific EMSs
are fairly closely related to different personality disorders in some
instances, as for example in the area of “dependence/incompetence,”
which is similar to the idea of dependent personality disorder, as defined in
the Diagnostic and Statistical Manual of Mental Disorders (4th ed.;
American Psychiatric Association, 2000). In other instances, however,
EMSs reflect broad and stable dimensions of functioning that potentially
cut across disorders. For example, “failure” is likely a personal schema
seen in a number of different disorders.
Young and colleagues (Young, 1990; Young et al., 2003) have
developed different scales to assess these schema dimensions. The Schema
Questionnaire and its short form have been subjected to several
psychometric studies, and despite the fairly complex nature of the scale,
results have been generally positive (Lee, Taylor, & Dunn, 1999; Schmidt,
Joiner, Young, & Telch, 1995). The short form of the Schema
Questionnaire also has good internal reliability and factor structure
(Welburn, Coristine, Dagg, Pontefract, & Jordan, 2002). The predictive
value of these scales has yet to be fully evaluated, however.
Hypothetically, schemas develop naturally and spontaneously in
everyone as major mechanisms that are used in making sense of the world
and our lived experiences. Furthermore, every person has schemas in many
different areas, some of which may be positive and some of which might
be negative, depending on developmental experiences. One of the more
difficult assumptions related to the schema model, however, is that
schemas lie relatively dormant until primed or activated by a relevant
situation or trigger. So, for example, a person who has a strong
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interpersonal dependency schema will function well and appear to be
functionally independent, unless his or her interpersonal relationships are
threatened, at which time negative thoughts, emotions, and behaviors
might all be demonstrated. The assumption of “silent schemas” has been
expressed as a diathesis–stress process, in that schemas represent a
diathesis or vulnerability toward distress or dysfunctional behavior, but
only when activated by a relevant stressor (Coyne & Whiffen, 1995;
Robins & Block, 1989).
Once a schema is activated by a trigger or situation, the cognitive
model holds that the information that the individual is experiencing is
appraised. Appraisals can be benign or potentially positive, depending on
the nature of the event and the corresponding schemas. Most of the focus
in cognitive therapy, however, is on more insidious and negative
appraisals. A. T. Beck et al. (1979) argued that in psychopathology,
negative appraisals tend to be relatively reflexive and “automatic,” as they
reflect overlearned reactions to various types of situations. Although these
appraisals or “automatic thoughts” are often made without conscious effort
or deliberation, they can be brought to awareness and evaluated with
appropriate training and skills.
The concept of automatic thoughts actually encompasses different
aspects of the information processing model of cognition. The actual
thoughts are the product of information processing, which includes
attention to the trigger or stimulus situation, thoughts about the situation
(e.g., rumination, distorted appraisals), appraisals of the meaning of the
situation as mediated by the schemas, and the production of a cognitive
product, which is the thought itself. Cognitive theorists have elucidated a
variety of possible ways in which situations can be misperceived or
distorted to yield negative outcomes (A. T. Beck et al., 1979; J. S. Beck,
1995). Patients use these cognitive distortions selectively, in ways that
help to maintain the integrity and stability of schemas, even sometimes at
the risk of emotional health.
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8
COGNITIVE THERAPY PROCESS
KEITH S. DOBSON
Once automatic thoughts are being consistently reported in treatment,
appropriate interventions can be selected. Three broad classes of
interventions for negative automatic thoughts can be distinguished by the
manner in which the patient might answer the following three questions:
1. What evidence supports or does not support the automatic thought?
2. What are the viable alternative thoughts in this situation?
3. What meaning is attached to the automatic thought?
The interventions associated with each of these three questions are
discussed next.
EVIDENCE-BASED INTERVENTIONS FOR AUTOMATIC
THOUGHTS
In general, the first set of interventions that a cognitive therapist will
consider relates to the match or mismatch between the automatic thought
and the situation or trigger. Patients with various diagnoses
characteristically distort or misperceive events or their own experiences in
a manner that is consistent with their core beliefs and current problems.
For example, patients with anxiety tend to overstate the danger of
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situations they face or might underestimate their ability to cope. Angry
people often overstate the intention of another person with little supporting
evidence. Therefore, identifying distorted or exaggerated thoughts is a
regular feature of cognitive therapy for various disorders.
The general belief in cognitive therapy is that patients perceive the
world and themselves in a manner consistent with their core beliefs and
schemas. Schemas not only affect how we view events that have already
occurred but also lead us to look for information in new situations that is
consistent with our core beliefs and to engage in different behaviors that
tend to reinforce our beliefs. Also as noted previously, the cognitive model
presumes that real events occur and may be perceived accurately or be
distorted. The degree of discrepancy between the actual event and the
perception of it is a direct reflection of the degree of psychopathology
experienced by the patient.
If the therapist comes to understand that the patient is engaging in
cognitive distortions, either through reviewing thought records or other
analyses of the negative thoughts that the patient brings to therapy, he or
she may discuss the process of cognitive distortions with the patient. The
therapist would educate the patient about the proactive nature of core
beliefs and note that distortion is a normal process for anyone with a
particular set of core beliefs. For example, a woman with social anxiety
disorder likely has the perception that other people are critical, which leads
her to reduce her social engagement, to perceive criticism from other
people when it may not be intended, and generally to perpetuate her belief
about the critical nature of others. Providing a rationale of this type to
patients can allow them to understand why they might distort social
interactions. An understanding of this process can also help patients in
searching for distortive processes in the future.
A cognitive therapist who chooses to intervene in cognitive
distortions might provide the patient with a list of cognitive distortions and
a definition of each distortion. The patient might then be encouraged to
examine his or her automatic thoughts and to explore with the therapist
whether any of these thoughts are distorted. Some patients enjoy this
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investigative process, which can allow them to distance themselves from
the momentary experience of the situation and to look at the “facts of the
matter” more dispassionately. Some patients enjoy the process of labeling
their own cognitive distortions because it gives them a shorthand way to
think about their negative thought processes.
If the patient demonstrates a clear and repeated type of cognitive
distortion, the cognitive therapist might discuss it at length with the
patient. For example, many patients with anxiety disorders engage in
fortune-telling and make negative predictions about what will happen if
they confront their feared object or situation. The therapist can discuss the
cognitive, emotional, and behavioral consequences of negative fortune-
telling, and once the patient concurs, the therapist and patient can design a
behavioral experiment to test the predictions that are being made by the
patient. In the case of depression, a characteristic cognitive distortion is
that of making negative attributions for failure (in particular, blaming
oneself for negative outcomes). If the therapist observes this attributional
pattern, he or she can spend time with the patient in observing the facts of
the situation to determine whether negative attributions are warranted.
A number of specific interventions have been developed for the
evidence-based approach to negative automatic thoughts. In some cases,
the intervention consists of asking the patient for more details about the
trigger or situation that precipitated the negative thoughts. The therapist
then listens for distortions in the patient’s perceptions and through a series
of questions contrasts the facts of the matter with the perceptions. If
skillfully done, this type of Socratic questioning will identify for the
patient where he or she has exaggerated or misperceived the situation and
will allow the patient to modify the automatic thoughts to be more
consistent with the facts. In instances where insufficient evidence exists to
fully judge the accuracy of the thought, homework may be developed to
collect more information.
Negative fortune-telling is a common distortion. Often, based on the
negative prediction, a patient may fail to engage in a particular social task
or other behavior; indeed, avoidance patterns almost always have some
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degree of negative fortune-telling associated with them. For example, a
patient who expects his partner to get angry with him in certain situations
may purposely avoid getting into those situations. When this type of
negative automatic thought emerges, the patient can undertake a
homework assignment in which he or she makes a prediction (ideally, a
specific and time-limited prediction that can be evaluated against the
evidence), then goes out and collects information to evaluate the accuracy
of the prediction. Such assignments are ideal in the context of cognitive
therapy because they may identify exaggerated negative predictions by the
patient and allow the patient to modify such predictions in the future. In
instances where the outcome is partially negative, graduated thinking and
degrees of success or failure can be discussed. And even in instances
where the outcomes are as negative as the patient had predicted, the patient
can still congratulate himself or herself for having explored the situation
that has been previously avoided. In addition, knowing the actual
outcomes will allow the therapist and patient to discuss more effective
problem-solving strategies for use in the future.
As noted above, another fairly common type of cognitive distortion is
negative attribution. Negative attributions occur regularly in patients with
depression: They often blame themselves for perceived failure. Negative
attributions also emerge in anger-related problems when the patient makes
negative attributions toward other people in the social environment (e.g.,
“He did it to me, and on purpose”). Attributional biases are relatively easy
to evaluate using evidence-based strategies. In the context of depression,
overly negative attributions for failure can often be identified. Sometimes
just drawing such biases to the attention of patients with depression can
allow them to examine other causes for different outcomes and to blame
themselves less for failure. As they make positive changes during
treatment, depressed patients can use positive attributional biases to give
themselves credit for the advances that they have made. Indeed, a general
strategy in cognitive therapy is to encourage internal attributions for
positive changes made over the course of therapy.
Labeling is yet another type of cognitive distortion that lends itself to
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an evidence-based intervention. People engage in labeling as a shorthand
way to describe themselves or others. Labels are often extreme and, almost
by definition, categorical. When the cognitive therapist hears a patient
engaging in labeling, he or she can undertake a series of interventions.
First, the therapist may inquire about the actual behaviors or attributes of a
person that the patient uses as cues to make the label. Often a particular
feature or behavior is being noted and other aspects of a person’s behavior
are ignored. Developing a broader perception of a person may undermine
the labeling process. Second, the process of asking about the actual
behaviors allows for a more complete description of the person, including
not only the associated negative attributes but also his or her positive
attributes or characteristics. Third, when the behaviors rather than the label
are described, it often becomes clear that the person does not always do
whatever the patient has noticed in applying the label. The awareness of
variability allows for discussion about the extent to which that person
engages in various activities and for a more graduated and evidence-based
perception of the person.
Evidence-based strategies have recently been used with regard to
delusions. Whereas in the past it was thought that formal delusional
experiences could not be evaluated (since by definition they are out of
contact with reality), more recent clinical experience and trials have shown
that delusions can be subjected to evidence-based intervention (Beck,
Rector, Stolar, & Grant, 2009). This type of intervention follows a series
of steps: The particular delusional belief is identified, its consequences are
named, predictions based on the delusional belief are made, and then
evidence-based strategies are used to test the predictions. Recent clinical
work suggests that evidence-based approaches can undermine the
confidence that patients have in their deluded beliefs and, if the experiment
is effective, can undermine a delusional idea (Kingdon & Turkington,
2005).
The following dialogue exemplifies how a cognitive therapist might
work with a patient using evidence-based techniques:
Therapist: As you speak, I get the impression that you might
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sometimes not just react to the situation you are in, but also to
your own way of thinking about things.
Patient: I’m not sure what you mean.
Therapist: Well, earlier you told me that you started to cry when
you heard that your friend may have cancer.
Patient: Yes, of course.
Therapist: So what idea did you have, do you think, that made you
so sad?
Patient: I imagined her husband and their children trying to get by
without her. She has always been the strength in the family,
and I just can’t imagine them doing very well.
Therapist: So, in your mind, it is like you already have your friend
dead and buried. But what did she actually tell you? Did she
say she had cancer?
Patient: Well, no, not exactly. She told me she had a lump in her
breast, and that she was going to see her doctor right away. I
know that breast cancer is pretty serious.
Therapist: Do women have this problem without having cancer?
Patient: I suppose so.
Therapist: And if it was breast cancer, what is the survival rate?
Patient: I don’t actually know.
Therapist: So, I think that I understand your compassion and
concern about your friend and her family, but is it possible that
you have maybe overreacted to what you actually know?
Patient: Well, when you put it this way, I guess so. But I was
really upset, so naturally I just thought of the worst possibility.
In all of the evidence-based strategies listed above, it is insufficient
for the therapist to have the evidence to undermine a given negative
automatic thought. It is imperative for the patient to recognize the evidence
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that is needed to undermine the thought. An effective question that can be
asked of the patient in designing experiments or evaluating evidence is,
“What information or evidence would it take for you to change your
mind?” Having elaborated the patient’s requirement for evidence to
modify the automatic thought, the therapist and patient can then work to
that end. For the therapist to simply contradict the patient’s automatic
thoughts or to tell him or her the “truth” about a matter is rarely of much
use because the patient’s perspective is the critical ingredient in changing
the emotional and behavioral outcomes of the initial perception.
ALTERNATIVE-BASED INTERVENTIONS
The second class of interventions in working with negative thoughts
is the examination of alternatives. In some cases, having reviewed the
evidence related to a negative automatic thought, it becomes apparent that
the original thought is not justified. The patient can be asked for a more
accurate rendition of the situation. A simple strategy to urge this type of
alternative thinking is to inquire whether the patient can think about the
event in another way. The tactic of encouraging alternative perspectives
may illustrate for the patient how locked in and rigid certain types of
thinking are. This exercise allows patients to look at the situation from
another person’s perspective or from their own perspective as if they were
not as distressed.
A more formal strategy to encourage alternative responses to negative
automatic thoughts is the rational role play in which the therapist asks the
patient to state out loud his or her automatic thoughts. The therapist then
verbalizes each statement and encourages the patient to respond, similar in
form to a debate or a role play among alternative thoughts. If the patient
struggles with this exercise, the therapist may role-play the alternative
responses to the original negative thoughts to provide possible ways to
“talk back” to these thoughts. The therapist should assess the believability
of these alternatives so that the patient can either accept or reject them. If
the therapist does take the step of responding to the negative automatic
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thoughts, it is necessary to reverse this role play so that the patient has the
opportunity to respond in an alternative manner to his or her original
negative thoughts. This type of role play exercise can be repeated across
sessions until the patient is fluent with the process of responding to
negative thoughts. The rational role play technique can incorporate
elements of an evidence-based response, but the alternatives must be
credible to the patient, even if no evidence exists to support or refute the
alternative thoughts.
Another strategy to examine reasonable alternatives to negative
automatic thoughts involves homework in which the patient identifies
possible alternative thoughts, even in the absence of particular evidence
and even if the alternatives do not seem credible. The homework
assignment is not to find out whether the original thought was true but
rather to poll friends and colleagues about alternative ways to view the
situation. The strategy of polling encourages the patient to learn about
perspectives that may be viable alternatives to the original negative
thought. If the therapist is aware of a particular resource or system to
capture such alternatives, this kind of perspective taking might be
extended by using various media or other information sources. For
example, in Feeling Good (Burns, 1980), different types of alternative
perspectives are provided for difficult thoughts in several chapters. In
addition, movies or books might aid in this type of perspective taking.
Another strategy for generating alternatives to negative thoughts is to
treat the process as a problem-solving exercise. In problem-solving therapy
(D’Zurilla & Nezu, 2007), the technique for overcoming problems
involves generating as many ways to solve a problem as possible. During
problem solving, the patient is encouraged to withhold any judgments
about the “correct” or optimal response until the largest possible number
of alternatives has been generated. In like fashion, cognitive therapists can
encourage the patient to generate many alternative thoughts to the
particular situation, and the therapist and patient can together review the
viability of the alternative perspectives. This exercise also can be useful in
assessing the patient’s ability to think about situations in different ways. If
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necessary, the therapist can prompt or encourage different ways of
thinking about situations. In general, however, a cognitive therapist will
tend not to provide alternative perspectives unless the patient is willing to
entertain the suggestions as reasonable alternatives. Again, the purpose of
looking at alternative thoughts is not to generate ideas that the therapist
can believe but rather to develop alternatives that are credible to the
patient.
The use of humor is another strategy to encourage alternative
perspectives to a negative thought. Jokes and humor often require a sudden
shift in perspective. For example, many jokes are set up so that the listener
expects a certain kind of dialogue or communication; a twist in perspective
or radical shift in what is being communicated creates humor. If the
therapeutic relationship is sound and if patients have shown any
predilection toward humor, subtle jokes about the patients’ original
negative thoughts can encourage them to look at alternatives. If humor is
used as a cognitive therapy technique, being clear that the humor is
directed toward the thoughts rather than the patients is critical. Belief by
patients that the therapist is making fun of them or is not taking their
problems seriously can lead to a therapeutic rupture. Humor should be
used judiciously and typically later in the process of therapy, once the
patient is feeling better than when he or she first came to therapy and when
the therapist is confident in the therapeutic relationship.
Another technique to encourage alternative thoughts is to ask the
patient how useful or adaptive the original negative thought was. The
intent is not to look at the accuracy or the viability of the negative thought
but rather at its value or utility in the patient’s life. In some cases, a
negative thought might be accurate, but holding on to it is not helpful with
respect to the patient’s ongoing relationships or longer term personal goals
(e.g., “Yes, he hurt your pride. How helpful is it, though, to harbor
resentment toward men in general? Doesn’t this reaction get in the way of
making new relationships?”). In such cases, patients can be asked about
the value of retaining this thought to encourage them to hold on to it less
tightly so that alternative thoughts can be entertained.
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The question about the value of holding on to a particular thought
may lead to a broader discussion about the meaning that the thought has
for the patient. A patient may say that he cannot let go of a particular
thought even though he knows that it is problematic because to do so
would have a particular meaning for him. For example, a patient might
hang on to hurt feelings that were precipitated by a relationship rejection
long after the other person has started new relationships. On inquiry, it
may turn out that he has this reaction because giving up hurt feelings
would signal to him that the relationship is over and that he is alone. The
discussion can then lead to a deeper discussion about the meanings
associated with particular negative thoughts, as is described below.
Emotional reasoning is a type of negative thought that lends itself to
an examination of alternatives. Emotional reasoning occurs when people
use their emotional response to a situation to justify the automatic thought
that led to the response. For example, after an altercation the patient may
say “I felt horrible, so she must have really insulted me badly.” If the
therapist hears this type of distortion, the logical error of affirming an
antecedent based on a consequence can be discussed. The therapist can
also use this opportunity to generate alternative thoughts or reactions to the
situation as thought experiments. For example, the therapist can ask
questions such as “How might somebody else have responded to this
situation?” or “How might you have responded to this situation, if you
weren’t feeling the way that you are at present?” The therapist can help the
patient recognize that thoughts do not establish facts; thoughts are just
thoughts and can be evaluated in their own right.
Which of the above methods is most effective in generating credible
alternatives to the original negative thought? Unfortunately, discovering
which of these interventions will be effective with a particular patient, or
at what time over the course of therapy it will be effective, is often a
matter of trial and error. Fortunately, cognitive therapists have generated
many interventions, so if one attempt does not work, an alternative
strategy may be effective. Sometimes it is useful to step back from the
actual interventions and discuss with the patient the general idea of
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looking at the evidence and the alternatives to negative thoughts. Such a
discussion has an educational aspect and provides a framework for the
patient to think about his or her negative thoughts. The discussion also
signals the therapist’s desire to help the patient develop more adaptive
ways to respond to difficult situations and to give the patient the freedom
to approach difficult people and situations in more productive ways.
Cognitive restructuring techniques such as those described above
often can be done through simple therapeutic dialogue—the thrust and
parry of verbal exchange in psychotherapy. However, it is also possible to
formalize these strategies through written experiments. A number of
techniques have been developed in this regard. For example, a relatively
easy strategy for looking at alternative thoughts is through the use of a
flash card. If the patient has a repetitive negative thought or behavioral
pattern to which a more adaptive and viable alternative can be generated,
the original negative thought can be written on the top part of the flash
card and the more viable alternative on the bottom. The card can be posted
in a visible location for the patient, such as on the refrigerator at home or
on a bulletin board at work, so that when the original negative thought
occurs, the alternative is readily available. A similar technique is called
TIC-TOC. In TIC-TOC, if a patient has a recurring negative thought that
can be counteracted by a viable and reasonable alternative, the patient can
be encouraged to think about the image of a pendulum clock, so that when
the first TIC (task-interfering cognition) occurs, it can be replaced with a
TOC (task-oriented cognition).
Perhaps the best-known formal technique for modifying automatic
thoughts is the use of an expanded dysfunctional thought record (DTR).
Figure 8.1 presents an example of a complete DTR. Columns have been
added for the identification of cognitive distortions in the figure, the
correction of negative thoughts (which can be achieved through evidence
review, the generation of reasonable alternatives, or a combination), and
the emotional and behavioral outcomes of the alternative thoughts. This
type of DTR allows the patient and therapist to work through various
difficult situations and negative thoughts, to explore them fully, and to
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formally write down the method for changing these thoughts. In many
cases of cognitive therapy, several sessions will be spent working through
DTRs to ensure that the patient has the techniques well in hand. In addition
to having these forms preprinted, free-form diary formats, handwritten
sheets, or computerized thought records may be used. Regardless of the
type of form, the key is to have the methods readily available for use by
patients. The cognitive therapist should use the format that will work in the
patient’s life.
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Figure 8.1. Completed dysfunctional thought record.
REFERENCES
Beck, A. T., Rector, N. A., Stolar, N., & Grant, P. (2009). Schizophrenia:
Cognitive theory, research, and therapy. New York, NY: Guilford Press.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York, NY:
Morrow.
D’Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive
approach to clinical intervention (3rd ed.). New York, NY: Springer.
Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of schizophrenia.
New York, NY: Guilford Press.
Excerpted from Cognitive Therapy (2012), from Chapter 4, “The Therapy Process,” pp. 64–76. Copyright
2012 by the American Psychological Association. Used with permission of the author.
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APPENDIX 8.1: COGNITIVE THERAPY TECHNIQUES
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9
COGNITIVE–BEHAVIORAL THERAPY
MICHELLE G. CRASKE
The principles and theories that underlie cognitive–behavioral therapy
(CBT) derive from several different sources that have become interweaved
with each other as CBT has developed from its initial behavioral routes to
the contemporary cognitive–behavioral integration. The more behaviorally
oriented clinician will draw mainly from learning theory in
conceptualizing a presenting problem and formulating a treatment plan,
whereas the more cognitively oriented clinician will favor the theory and
principles of cognitive appraisal. The cognitive–behavioral clinician can
comfortably draw from both learning theories (including social learning
theory) and cognitive appraisal theory to conceptualize a problem and
formulate a treatment plan.
GOALS
Broadly speaking, the goal of CBT is to achieve symptom reduction
and improvement in quality of life through the replacement of maladaptive
emotional, behavioral, and cognitive response chains with more adaptive
responses. Underlying this goal is the notion that problem behaviors,
cognitions, and emotions have been acquired at least in part through
experience and learning and therefore are open to modification through
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new experience and learning.1 The target of CBT is to teach new ways of
responding and to develop new learning experiences that together promote
more adaptive patterns of behavioral, affective, and cognitive responding.
Also, these changes are attempted within relatively brief periods of time;
in other words, CBT aims to be not only problem-focused but also time
limited.
Another goal of CBT is for long-term positive effects that are self-
maintaining. Thus, learning experiences are repeated, and new ways of
responding are practiced over a sufficient number of occasions and
contexts that they become the major determinants and preferred methods
of responding in the long term, independent of the therapy context. In this
way, CBT aims to tool clients with their own repertoire of skills for
dealing with problematic situations and thereby become less and less
dependent on, and eventually autonomous from, the therapist.
These two overarching goals are achieved within the framework of a
set of guiding principles of behavioral theory and science and cognitive
theory (and more recently, cognitive science) for conceptualizing
presenting problems and formulating intervention strategies. These
principles drive another goal, which is to use an individually based
functional analysis of the causal relations among cognitions, behaviors,
emotions, and environmental and cultural contexts for tailoring
intervention strategies specifically to the needs of a given problem. Thus,
rather than assuming that one standard treatment fits all, CBT is based on
careful observation and understanding of each individual’s presenting
problem. Functional analysis refers to an analysis of not only the
instrumental antecedents and consequences, but also which stimuli are
producing which conditional responses (CRs), which cognitions are
contributing to behaviors and emotions, and within which environmental
and cultural contexts these occur. The therapist and client then make an
informed choice about which methods for behavioral and cognitive change
to use from a variety of different intervention strategies.
Another goal is to have a flexible approach to implementation, which
is facilitated by ongoing evaluation and modification of intervention
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Administrator
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strategies as appropriate. Linked with this is the aim of engaging the client
in the process of experimentation and ongoing evaluation of the
effectiveness of the chosen interventions. Evaluation not only permits
revision to the intervention strategies where necessary but provides an
assessment of overall progress. Overall progress is measured by agreed-
upon markers between the client and the therapist, and when the evidence
indicates lack of progress, consideration is given to alternative treatment
methods. Clearly, this entails therapist–client collaboration in formulating
and implementing a treatment plan and a highly active orientation on the
part of the client.
LEARNING THEORY: CLASSICAL CONDITIONING
Classical (or respondent) conditioning depends on innately evocative
stimuli (unconditioned stimulus [US]) producing an unconditional,
reflexive response (UR), such as when physical injury reflexively produces
a pain grimace. When a neutral stimulus is paired with the US, the neutral
stimulus becomes a conditional stimulus (CS) with powers to elicit a CR
that resembles the original UR (Pavlov, 1927). For example, in the case of
persons undergoing chemotherapy (US) that causes them to vomit (UR),
the nurse may become a CS by association with administration of the
chemotherapy. Consequently, sight of the nurse may produce conditional
nausea in the patient even before the chemotherapy is administered the
next time. Furthermore, through a process of generalization, the CR may
begin to emerge in reaction to stimuli similar to the original CS. Following
from the preceding example, generalization may result in conditional
nausea in response to seeing the medical clinic or administrative staff. In
addition, Pavlov (1927) demonstrated that if the CS is presented enough
times without the US, the CR lessens or extinguishes. Continuing the
example, once the chemotherapy course has completed, repeated visits to
the clinic for checkups would result in an eventual diminution of the
conditional nausea response.
The principles of aversive classical conditioning are applied mostly to
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anxiety disorders. Early theorizing of fears and phobias relied on
contiguous classical conditioning models in which a neutral stimulus
develops conditional fear-provoking properties simply by virtue of close
temporal pairing with an aversive stimulus. Examples would include
ridicule and rejection by a peer group leading to conditional fear (i.e.,
phobia) of social situations or barking by a ferocious dog leading to
phobias of dogs. These early theories were criticized for being too
simplistic (e.g., Rachman, 1978), especially as not everyone who
undergoes an aversive experience develops a phobia. That is, not everyone
who is ridiculed by a peer group develops social phobia, and not everyone
who is barked at by a ferocious dog develops a phobia of dogs. Recent
revisions to classical conditioning models of fear and anxiety (see Mineka
& Zinbarg, 2006, for a review) correct the earlier pitfalls.
The newer models continue to emphasize the role of aversive
experiences in the formation of conditional anxiety responses, but instead
of being limited to direct experience with negative events, they extend to
conditioning through vicarious observation of negative events or even
informational transmission about negative events (see Mineka & Zinbarg,
2006, for citations of supportive research). For example, observing
someone else be physically injured and/or be terrified in a car accident
may be sufficient for the development of a conditional fear of motor
vehicles, as would being told about the dangers of driving and the high
likelihood of fatal car accidents. Vicarious and informational transmission
of conditioning represents the incorporation of cognitive processes into
classical conditioning models. The newer conditioning models also
recognize that a myriad of constitutional, contextual, and postevent factors
moderate the likelihood of developing a conditional phobia after an
aversive event. Constitutional factors (or individual difference variables)
include temperament. For example, individuals who tend to be more
nervous in general are believed to be more likely to develop a conditional
phobia after a negative experience than less “neurotic” individuals who
undergo the same negative experience. Another constitutional factor is
personal history of experience with the stimulus that is subsequently paired
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with an aversive event, as prior positive experience may buffer against the
development of a conditional phobia. For example, the effects of observing
one parent react fearfully to heights may be buffered by having previously
observed other family members react without fear to heights. Recognition
of individual difference factors addresses the earlier criticism that not
everyone who undergoes an aversive experience develops a phobia; rather,
certain individuals are prone to developing conditional phobic responses
following an aversive experience as a function of their temperament and
life experience.
Contextual factors at the time of the aversive experience include
intensity and controllability: More intense and less controllable negative
events are more likely to generate conditional fear than less intense and/or
more controllable negative events. According to these premises,
individuals trapped for a lengthy period of time inside an elevator stuck
between floors would be more likely to develop a conditional fear of
elevators than the person who can escape from a stuck elevator relatively
quickly. Similarly, soldiers at the front line of combat would be more
likely to develop conditional fear than those further away. Another
contextual factor pertains to principles of preparedness, or the innate
propensity to rapidly acquire conditional fear of stimuli that posed threat to
our early ancestors (Seligman, 1971). Examples of such stimuli are
heights, closed-in spaces from which it is difficult to escape, reptiles, and
signals of rejection from one’s group. Thus, as a species, humans are more
likely to develop long-lasting conditional fears following negative
experiences in prepared situations (e.g., being laughed at by peers)
compared to other, “nonprepared” situations (e.g., being shocked by an
electric outlet). Preparedness is believed to account for the nonrandomness
of phobias, or the fact that some objects or situations are much more likely
to become feared than other objects.
Following conditioning, a variety of postevent processes may
influence the persistence of conditional fear, including additional aversive
experiences, expectancies for aversive outcomes (Davey, 2006), and
avoidant responding. For example, the child who is teased by a peer group,
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then ruminates about being teased, expects further teasing, and avoids the
peer group is more likely to develop social anxiety than the child who
undergoes the same teasing but returns to the peer group the next day. In
sum, recent models of classical conditioning recognize that the
development of an excessive and chronic conditional fear is not explained
by a specific aversive event in isolation but by an interaction among
predisposing features, the aversive event, and reactions to the event.
The classical conditioning model is also applicable to disorders
related to substance use, in which the principles of appetitive conditioning
apply as well as aversive conditioning. Appetitive conditioning refers to
conditioning with a US that produces an innately positive response,
whereas aversive conditioning refers to conditioning with a US that
produces an innately negative response. In the case of substance use
disorders, euphoria serves as an innately positive UR to the drug. Over
time, environmental stimuli present during the euphoric state become
conditional. These environmental stimuli may be the locations in which
the drugs are usually consumed or the people with whom drug taking
normally occurs. Consequently, the environmental stimuli elicit
conditional urges or cravings to take more of the drug. Known as the
conditioned appetitive motivational model of craving (Stewart, de Wit, &
Eikelboom, 1984), this model explains the difficulties experienced when
recovering drug users return to the environments in which they originally
developed their drug dependence. That is, just seeing a group of friends
with whom drugs used to be taken may be enough to produce cravings for
the drugs, even though the drugs themselves are not present.
Siegel (1978) proposed the conditional compensatory response
model, a classical conditioning model of drug tolerance. In this model,
environmental stimuli associated with drug intake become associated with
the drug’s effect on the body and elicit a CR that is opposite to the effect
of the drug, driven by an automatic drive for body homeostasis. As this CR
increases in magnitude with continued drug use, the drug’s effects
decrease and tolerance increases. Finally, aversive classical conditioning
has been evoked as an additional mechanism by which stimuli associated
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with the unpleasant periods of drug withdrawal elicit withdrawal-like
symptoms. For example, if withdrawal is typically experienced upon
waking from sleep, then waking may elicit conditioned withdrawal
symptoms that in turn could drive continued drug use to minimize
withdrawal effects.
PRINCIPLES OF TREATMENT
The treatment model that derives from classical conditioning states
that behaviors and emotions can be changed by disrupting the associations
that have formed between a cue (CS) and either an aversive or a pleasant
outcome (US). In learning theory, this is referred to as extinction.
Conditioning involves pairings of the CS with the US; extinction involves
repeated presentations of the CS without the US. The corresponding
treatment is referred to as exposure therapy; in this therapy, the client
repeatedly faces the object of fear (in the case of anxiety disorders) or the
drug-related cue (in the case of substance use disorders) in the absence of
an aversive or a pleasant outcome. As an example, individuals with social
anxiety would be encouraged to repeatedly enter social situations without
being ridiculed or rejected, or individuals with posttraumatic stress
disorder would be encouraged to repeatedly enter places where they were
previously traumatized without being retraumatized. As another example,
individuals who drink alcohol excessively would be exposed to substance
cues (e.g., sight or smell of alcohol) and prevented from consuming the
alcohol so that the CS is repeatedly presented in the absence of
reinforcement that comes from the consumption of the drug. This is called
cue exposure.
Several mechanisms are believed to underlie extinction and thereby
exposure therapy. One such mechanism is habituation (or decreased
response strength simply as a function of repeated exposure). Another
mechanism, inhibitory learning, is considered to be even more central to
extinction (Myers & Davis, 2007). Inhibitory learning means that the
original association between a CS and aversive event is not erased
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throughout extinction, but rather a new inhibitory association (or
expectancy) is developed. For example, as a result of exposure therapy for
fear of dogs, an original “excitatory” association between a dog and
ferocious barking would be complemented by a new “inhibitory”
association between a dog and the absence of ferocious barking.
Consequently, as a result of exposure therapy, two sets of associations
exist in memory. Once exposure therapy is over, the level of fear that is
expressed when a dog is encountered in daily life will depend on which set
of associations is evoked. Interestingly, basic research by Bouton and
colleagues (reviewed in Bouton, Woods, Moody, Sunsay, & Garcia-
Gutierrez, 2006) indicates that context is important in determining which
set of associations is evoked. If the previously feared stimulus is
encountered in a context that is similar to the extinction/exposure therapy
context, then the inhibitory association will be more likely to be activated,
resulting in minimal fear. However, if the previously feared stimulus is
encountered in a context distinctly different from the extinction/exposure
therapy context, then the original excitatory association is more likely to
be activated, resulting in more fear. Following the example of dog phobia,
assume that the exposure treatment was conducted in a dog training center.
Then, once treatment is over, a dog is encountered on a neighborhood
sidewalk, a context that is distinctly different from the dog training center.
On the sidewalk, the original excitatory fear association is more likely to
be activated than the new inhibitory association that was developed
throughout exposure treatment, resulting in the expression of fear.
Thus, a change in context is presumed to at least partially account for
the return of fear that sometimes occurs following exposure therapy for
anxiety disorders (Craske et al., 2008) and relapse following treatment for
substance use disorders (e.g., Collins & Brandon, 2002). In addition to
context, other factors can also reactivate the original excitatory
association. One such factor is being exposed to a new negative
experience. Thus, persons who are successfully treated for their fear of
dogs may have their fear return if they are subsequently involved in a car
accident (in learning theory this is called reinstatement) or if they are
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barked at by another ferocious dog (termed reacquisition).
Innovative strategies are now being tested for enhancing new
inhibitory associations throughout exposure therapy (see Craske et al.,
2008, for a review). In addition, attention is being given to ways of
enhancing the retrievability of new inhibitory associations once exposure
therapy is completed, and thereby decreasing relapse, such as conducting
exposure therapy in multiple contexts. Another is to provide retrieval cues
that remind clients, when they are outside of the therapy context, of the
new learning that took place in the therapy context or at least recommend
to clients that they actively try to remember what they learned when in the
therapy context (see Craske et al., 2008).
Another key concept associated with extinction of CRs is safety
signals, or conditional inhibitors that predict the absence of the aversive
stimulus. When the conditional inhibitor is present, the CS is not paired
with the US; when the conditional inhibitor is not present, the CS is paired
with the US. In the experimental literature, safety signals alleviate distress
to the CS in the short term, but when no longer present, fear to the CS
returns (Lovibond, Davis, & O’Flaherty, 2000). Common safety signals
for anxiety disorder clients are the presence of another person, therapists,
medications, food, or drink. Thus, clients with panic disorder and
agoraphobia may feel relatively comfortable walking around a shopping
mall with a bottle of medication in their pocket (even if the medication is
never taken) but report being anxious in the shopping mall when without
the bottle of medication. Conditional inhibitors have been shown to
interfere with extinction learning in human experimental studies (e.g.,
Lovibond et al., 2000).
REFERENCES
Bouton, M. E., Woods, A. M., Moody, E. W., Sunsay, C., & Garcia-Gutierrez,
A. (2006). Counteracting the context-dependence of extinction: Relapse
and tests of some relapse prevention methods. In M. G. Craske, D.
Hermans, & D. Vansteenwegen (Eds.), Fear and learning: From basic
processes to clinical implications (pp. 175–196). Washington, DC:
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American Psychological Association.
Collins, B. N., & Brandon, T. H. (2002). Effects of extinction context and
retrieval cues on alcohol cue reactivity among nonalcoholic drinkers.
Journal of Consulting and Clinical Psychology, 70, 390–397.
doi:10.1037/0022-006X.70.2.390
Craske, M. G., Kircanksi, K., Zelikowsky, M., Mystkowski, J., Chowdhury,
N., & Baker, A. (2008). Optimizing inhibitory learning during exposure
therapy. Behaviour Research and Therapy, 46, 5–27.
doi:10.1016/j.brat.2007.10.003
Davey, G. C. L. (2006). Cognitive mechanisms in fear acquisition and
maintenance. In M. G. Craske, D. Hermans, & D. Vansteenwegen (Eds.),
Fear and learning: From basic processes to clinical implications (pp. 99–
116). Washington, DC: American Psychological Association.
Lovibond, P. F., Davis, N. R., & O’Flaherty, A. S. (2000). Protection from
extinction in human fear conditioning. Behaviour Research and Therapy,
38, 967–983. doi:10.1016/S0005-7967(99)00121-7
Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective
on the etiology of anxiety disorder: It’s not what you thought it was.
American Psychologist, 61, 10–26. doi:10.1037/0003-066X.61.1.10
Myers, K. M., & Davis, M. (2007). Mechanisms of fear extinction. Molecular
Psychiatry, 12, 120–150. doi:10.1038/sj.mp.4001939
Pavlov, I. P. (1927). Conditioned reflexes (G. V. Anrep, Trans). London,
England: Oxford University Press.
Rachman, S. (1978). Fear and courage. San Francisco, CA: Freeman.
Seligman, M. E. P. (1971). Phobias and preparedness. Behavior Therapy, 2,
307–320. doi:10.1016/S0005-7894(71)80064-3
Siegel, S. (1978). Tolerance to the hyperthermic effect of morphine in the rat is
a learned response. Journal of Comparative and Physiological
Psychology, 92, 1137–1149. doi:10.1037/h0077525
Stewart, J., de Wit, H., & Eikelboom, R. (1984). Role of unconditioned and
conditioned drug effects in the self-administration of opiates and
stimulants. Psychological Review, 91(2), 251–268. doi:10.1037/0033-
295x.91.2.251
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Excerpted from Cognitive–Behavioral Therapy (2010), from Chapter 3, “Theory,” pp. 19–26. Copyright
2010 by the American Psychological Association. Used with permission of the author.
1Genetic endowments and temperament are viewed as additional contributing factors to problem
behaviors, cognitions, and emotions.
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10
COGNITIVE–BEHAVIORAL THERAPY
PROCESS
MICHELLE G. CRASKE
SKILL- AND REINFORCEMENT-BASED STRATEGIES
Self-Monitoring
In cognitive–behavioral therapy (CBT), self-monitoring is a tool for
evaluating the functional relations among thoughts, behaviors, and
emotions, and their antecedents and consequences, as they occur (vs.
retrospective report). Self-monitoring is particularly valuable for recording
subjective experience, such as appraisals (e.g., “My friends must think I
am a fool.”) and levels of subjective distress. Moreover, self-monitoring is
useful for behaviors or physiological events that are difficult to record
otherwise because they occur infrequently (e.g., occasional panic attacks)
or under conditions that are difficult to replicate in the presence of the
therapist (e.g., compulsive rituals that are dependent on the home
environment; Craske & Tsao, 1999). Overall, self-monitoring is used
widely across a large array of disorders and behavioral problems.
Self-monitoring begins with a rationale that emphasizes the
importance of a personal scientist model of learning to observe one’s own
reactions. Then, clients are trained to use objective terms and anchors
rather than affective-laden terms. For example, clients with panic disorder
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are trained to record the intensity of their symptoms on 0- to 10-point
scales in place of using a general description of how “bad” the panic attack
felt. The objectivity of recording is presumed to enhance its effectiveness.
Then, clients are taught what, when, where, and how to record. Various
types of recording exist, but the most common are event recording, or
whether an event occurs during a period of recording (e.g., did a panic
attack occur today), and frequency recording, or recording every event
during the period of recording (e.g., every panic attack during the day).
Diaries are the most common form of recording, although counters or
palm tops can be used. Data are then transformed into graphs, to
demonstrate change over time (such as frequency of panic attacks per
week, or average number of calories consumed per day). Feedback from
the therapist about self-monitoring positively influences compliance with
self-monitoring. In addition, therapists can use the self-monitoring data to
emphasize progress or to identify previously undetailed functional
relations among cognitions, behaviors, and emotions that are worthy of
targeting in treatment.
The underlying mechanisms of self-monitoring are not entirely clear,
although increased awareness of the problem behavior and/or its
antecedents and consequences may facilitate motivation to change (Heidt
& Marx, 2003). Additionally, recording the frequency of behaviors over
the course of therapy may provide reinforcement as positive behavioral
changes are noted. Also, self-monitoring may provide a cue or reminder
for engaging in newly acquired cognitive and behavioral skills.
Rarely is there an outright contraindication to self-monitoring,
although the method of monitoring is often modified to suit particular
needs and offset potential pitfalls. For example, the person with obsessive–
compulsive or perfectionistic tendencies may benefit from limit setting or
tightly abbreviated forms of self-monitoring. Occasionally, negative affect
can be worsened as it is monitored. For example, monitoring negative
affect may activate negative self-evaluation; something that may be then
addressed by cognitive restructuring of the negative self-evaluation. Self-
monitoring in general will be more difficult for the person who lacks
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motivation and in turn serves to “confirm” a sense of failure in those
persons who already judge themselves to be failures and cannot even
succeed at self-monitoring (Heidt & Marx, 2003). In the latter case,
problem solving and behavioral activation may be helpful approaches for
increasing engagement in self-monitoring.
Relaxation
Relaxation has been a mainstay of behavioral treatments and
encompasses an array of strategies, including autogenic training (Schultz
& Luthe, 1959), progressive muscle relaxation training (Jacobson, 1938),
breathing retraining (e.g., Kraft & Hoogduin, 1984), and various forms of
meditation and yoga. Progressive muscle relaxation is a commonly used
methodology, although in its condensed form of 8 to 15 sessions as
standardized by Bernstein and Borkovec (1973) relative to the lengthy
training (30–50 sessions) originally developed by Jacobson (1938).
Progressive muscle relaxation training involves tensing and relaxing major
muscle groups in progression, followed by deepening relaxation through
slow breathing and/or imagery. The data show that muscle relaxation is
anxiety reducing overall (e.g., Lang, Melamed, & Hart, 1970). Relaxation
has been used for sleep disturbance, headache, hypertension, asthma,
alcohol usage, hyperactivity, and various forms of anxiety, as well as other
disorders.
The procedure involves progressive tensing (for 10 s) and relaxing
(for 15–20 s) the following muscle groups: dominant hand and forearm,
dominant bicep, nondominant hand and forearm, nondominant bicep,
forehead, upper cheeks and nose, lower cheeks and jaws, neck and throat,
chest/shoulders and upper back, abdominal region, dominant thigh,
dominant calf, dominant foot, nondominant thigh, nondominant calf,
nondominant foot.
After a rationale is provided, the client’s current emotional state is
measured for purpose of comparison with the state that is achieved after
relaxation. This can be done using a simple 0 to 100 visual analogue scale
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or a more sophisticated behavioral relaxation scale (Poppen, 1998). The
latter scale also provides a precise definition of the targeted state of each
body area to be achieved during relaxation. Next, the therapist provides a
verbal description and then models the relaxed and tensed postures for
each muscle area. The client then imitates the therapist while the latter
provides feedback. The entire set of tensing and relaxing exercises are
completed with therapist guidance. The client then practices the procedure
daily between therapy sessions. Over sessions, the number of muscle
groups can be reduced (from 16 to 8 to 4 muscle groups). Furthermore,
cue-controlled relaxation is sometimes used, in which the state of
relaxation between each tensing is paired with the word “relax”; that word
then becomes a conditional cue that eventually elicits conditional relaxed
sensations in isolation of the entire set of tensing and releasing exercises.
One mechanism underlying relaxation training is enhanced
discrimination between feelings of relaxation and tension, achieved
through paying attention to the sensations associated with each state during
the training. The assumption is that clients then are better able to detect
tension in their daily lives (Ferguson, 2003). Second, the training is
presumed to build a skill for how to evoke the relaxation response as a
means of self-control when experiencing tension in daily life. The
physiological intent is for relaxation to activate more parasympathetic
activity and thereby slow sympathetic autonomic processes such as heart
rate and sweating. However, as with other relaxation techniques, such as
breathing retraining, the mechanism may pertain more to a sense of control
or other cognitive variables than to actual physiological change (e.g.,
Garssen, de Ruiter, & van Dyck, 1992).
When relaxation is paired with a biofeedback signal, as is used in the
treatment of headache or chronic pain, another mechanism is brought to
bear, that being shaping through reinforcement. That is, changes in
physiological responding are achieved by continuous raising of the
criterion (such as larger reductions in muscle tension) and reinforcement
for each successful attainment of the criterion in the form of the
biofeedback signal. Again, however, others suggest that perceptions of
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control may be equally if not more accountable for the effectiveness of
biofeedback, since use of bogus biofeedback signals is as effective as
veridical feedback (e.g., Rains, 2008). As an example, Mary had suffered
from chronic tension headaches for many years. She was first taught
progressive muscle relaxation training, including cue-controlled relaxation,
which she practiced twice daily in relaxing environments for three weeks.
Then, while continuing to use progressive muscle relaxation as a daily
exercise, she simultaneously used the cue-controlled element of relaxation
within the context of six weekly biofeedback sessions as she learned to
progressively lower her muscle tension. As a result of this training, Mary’s
self-monitoring of headache activity indicated that it had decreased by
approximately one half since the two weeks before treatment initiated.
The skill of relaxation is most often employed for states of heightened
autonomic arousal that interfere with quality of life or therapy progress, or
as a coping skill to actively face challenging situations. Relaxation has
been shown to be particularly helpful in the treatment of phobias and
anxiety disorders, preparing for surgery and other medical procedures, and
coping with chronic pain. It is also incorporated into treatments that focus
on emotion regulation, as in dialectical behavior therapy for borderline
personality disorder (Linehan, 1994). Occasionally, negative reactions can
be produced by relaxation, such as relaxation-induced anxiety (Heide &
Borkovec, 1983). The latter involves intrusive thoughts, fears of losing
control, and the experience of unusual and therefore anxiety-producing
bodily sensations (such as depersonalization). However, rather than being
a contraindication to continued relaxation, discussion of the processes and
continued exposure to relaxation and its associated states can be an
effective tool for managing relaxation-induced anxiety.
Behavioral Rehearsal of Social Skills and Assertiveness
In behavioral rehearsal of social skills and assertiveness, a set of skills
is taught through instruction, modeling, and role play and feedback, as
therapist and client play out different roles. Social skills include nonverbal
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(e.g., facial expressions, body movements, affective displays) as well as
verbal components (e.g., refusing requests from others that seem
unreasonable, and making requests; Dow, 1994).
An initial step is evaluation of skills in social and assertive situations,
usually complementing the client’s self-report by observational
methodology, such as through role plays with the therapist or direct
observation of client behaviors in the natural environment. A rationale
then is provided that emphasizes how learning social and assertive skills
will help clients to achieve personal control and respect for self and others,
which in turn will contribute to the attainment of their own life goals. A
hierarchy of behaviors is then devised for the purposes of role playing and
behavioral rehearsal. For example, assertive requests for behavior change
in others include a statement of the negative impact of the current
behavior, provision of a specific and reasonable alternative behavior, and a
statement of the likely positive impact of the new behavior on both parties.
Then, the therapist directly models the specific skill or presents the
skill through another model, such as through the use of video. Modeling
can involve a mastery approach, in which the model performs the desired
behavior with confidence and competency. Alternatively, modeling can
involve a coping approach, in which the model initially displays some
trepidation and error followed by increasing skill. The latter approach may
be particularly helpful for clients who are hesitant or fearful (e.g., Naugle
& Maher, 2003). The client then rehearses the behavior.1 Typically, clients
are asked to evaluate their own performance first before the therapist
reinforces their efforts, provides verbal feedback regarding execution of
the skill, and shapes behavioral approximations. Videotaping sometimes
can be helpful in this regard. Following mastery in-session, homework is
assigned to practice the new behaviors in real-life situations between
treatment sessions. Consideration also is given to realistic performance
expectations and the value of self-reinforcement for continued rehearsal
and practice.
A subset of social skills training is communication training for
couples in distress. The assumption is that either couples lack the
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communication skills for negotiating conflict, and/or for reasons of
stimulus control of behaviors, effective communication skills are not being
used in the context of interpersonal tension. Couples communication
training involves speaker/listener skills to understand and validate the
partner’s perspective. The therapist defines each skill. Listening skills
include parroting (i.e., repeat), paraphrasing (i.e., rephrase), reflection (i.e.,
discern emotional meaning of speaker’s message), and validation (i.e.,
convey that speaker’s message is understandable). Speaking skills include
learning to make succinct statements, to clarify and express accurate
feeling statements, and to level (i.e., to express the core underlying
feelings associated with a problem; e.g., Gottman et al., 1976). Then, the
therapist provides reinforcement and corrective feedback to the couple as
each practice using these skills to communicate in the therapy setting.
Homework is to practice the same skills in their daily life between
sessions.
In terms of mechanisms, behavioral rehearsal itself relies on
principles of reinforcement and shaping. The new behavior is reinforced
by the therapist. Once achieved, skills of communication and assertiveness
may function as reciprocal inhibitors of conditional fear in social situations
and/or contribute to extinction of conditional responses (CRs) by
devaluing the expectancy of the unconditioned stimulus (i.e., increased
assertiveness lessens fear of negative reactions from others). Additionally,
the same skills may function to overcome deficits in behavioral repertoires
(e.g., McFall & Marston, 1970). The new or modified behaviors are
expected to result in an increase in positive reinforcers and decrease in
punishers from the social environment, thereby improving overall mood
and life satisfaction and functioning. Finally, implementation of these
newly acquired skills may raise self-efficacy and decrease negative beliefs
about oneself and the world.
Behavioral rehearsal of social skills and assertiveness is particularly
helpful when there are clear deficits in these skills (e.g., pervasive
developmental disorders, psychosis, or extreme social anxiety or avoidant
personality disorder), or their rate of expression is limited overall or
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limited in certain contexts (due to anxiety or depression, for example).
Assertiveness training should be implemented in a culturally responsive
manner. This involves consideration of cultural values pertaining to
independence and autonomy. CBT in general and assertiveness training in
particular is permeated with European/North American norms that place
high value on independence and autonomy (see Hays & Iwamasa, 2006).
Assertiveness may conflict with values of collectivism and the importance
of family in Asian, Arabic, Latino, African American, and other cultures.
Culturally sensitive modifications to assertiveness include prefacing
assertive communication with traditional forms of deference and respect
(e.g., Organista, 2006), or by replacing assertiveness with other CBT
strategies, such as problem solving.
Problem-Solving Training
Problem solving is a skill that has been implemented for a wide array
of difficulties, including anxiety, depression, couples conflict, and stress
management. In general, clients are taught a set of skills for approaching
problems of everyday living. Steps involved in problem solving include
problem definition and formulation, generation of alternatives, decision
making, and verification.
D’Zurilla and Nezu (1999) identified two main targets of treatment:
the orientation toward problem solving and the style of problem solving.
The goals of problem-solving training are to increase positive and decrease
negative problem-solving orientation and to foster a rational problem-
solving style that minimizes maladaptive styles of being impulsive or
careless or avoiding problems. Thus, training begins with steps of
problem-solving orientation to develop positive self-efficacy beliefs, such
as by reverse-advocacy role play that encourages clients to recognize their
overly negative beliefs through contrast and by visualization of
successfully resolving a problem and being reinforced as a result. The
orientation phase also includes recognition that problems are a normal part
of human existence and ways of identifying problems as they occur, such
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as by using negative emotions as a cue for recognizing that a problem
exists and to observe what is occurring in the environment that is causing
the emotions.
For the style of problem solving phase, clients are first trained in
problem definition. This involves gathering information about the
problem, objectively and concisely defining the problem, separating facts
from assumptions, identifying the features that make the situation
problematic, and setting realistic goals (Nezu, Nezu, & Lombardo, 2003).
Next, alternatives are developed by generating as many solutions as
possible, deferring judgment until a full list is generated, and then
developing a list of action plans for the enactment of each solution. In the
decision-making phase, a cost benefit analysis is conducted of each
solution to identify the ones that are most likely to be successful and to be
implemented. Effective solutions, or solutions that are likely to be
successful and lead to the most positive and least negative consequences,
are then selected. The final step is implementing the action plan associated
with the most effective solution, and evaluating the success of its
implementation along with troubleshooting and modification where
necessary.
Problem solving is essentially a skill-building intervention. The
mechanisms underlying problem solving include reinforcement from skills
acquisition and from the success with which the problem solving resolves
pending problems. In addition, by facing problematic situations rather than
avoiding them, a type of exposure is being conducted that may lead to
extinction of CRs. Furthermore, changes in cognitive appraisals and
assumptions are involved in the problem orientation phase of the
procedure. Also, successful implementation of problem solving may raise
self-efficacy and provide evidence that disconfirms negative beliefs about
the self and the world.
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D’Zurilla, T. J., & Nezu, A. M. (1999). Problem-solving therapy: A social
competence approach to clinical intervention (2nd ed.). New York, NY:
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Heidt, J. M., & Marx, B. P. (2003). Self-monitoring as a treatment vehicle. In
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1There are some occasions when modeling and overt rehearsal are not appropriate, such as when
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addressing skills associated with sexual intimacy; in these cases, covert or imaginal rehearsal is used
instead.
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APPENDIX 10.1: COGNITIVE–BEHAVIORAL THERAPY
TECHNIQUES
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11
CONSTRUCTIVIST THERAPY
VITTORIO F. GUIDANO
Contemporary cognitive psychology is still dominated by rationalist
and objectivist perspectives, which have traditionally avoided or devalued
the phenomenological realm and the complex nature of lived human
experience. When reality is assumed to be an objective external order that
exists independently from people’s observations of it—an assumption
common to objectivism, realism, and traditional rationalism—it is
inevitable that people will overlook their own characteristics and processes
as observers. The only possible themes of investigation in an objectivist
world are to refine or perfect one’s perceptions of that world and to modify
one’s mental representations in ways that reflect improved “contact” or
compliance with objective reality.
A constructivist approach entails significant changes in these initial
assumptions and in the possible themes of investigation. From such a non-
objectivist perspective, an essential task becomes understanding how
people’s characteristics as observers are involved in the process of
observing, as well as how people otherwise participate in cocreating the
dynamic personal realities to which they individually respond. This shift
leads necessarily to a radical change in traditional formulations of human
experience, human knowing, and professional helping.
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BASIC FEATURES OF HUMAN EXPERIENCE
A proper framework for investigating such a problem, it seems,
should rest on two basic points. One is the assumption of an evolutionary
epistemological perspective—that is, a perspective that is based in the
continuing study of evolving knowledge and knowing systems. Given that,
as human beings, we cannot escape our particular way of being—which is
fleshbound and animal—such a stance requires a central acknowledgment
of the embodiment of human experience. The second basic point in this
framework is that the ordering of our world is inseparable from our
experiencing of it. We do, in fact, “experience it,” or, more accurately, we
“experience.” The “it” is an objectification, however, and hence, implies a
distancing between the experiencer and the living moment.
What is important to emphasize here is that there is no outside,
impartial viewpoint capable of analyzing individual knowledge
independent of the individual exhibiting this knowledge; there is no
“God’s eye point of view” (Putnam, 1981). Hence, knowledge should be
considered from an ontological and epistemological perspective in which
knowing, consciousness, and all other aspects of human experience are
seen from the point of view of the experiencing subject. How an individual
experiences is affected by the self-knowledge that he or she has been able
to conjure. On the basis of these premises, I outline here some of the basic
features inherent to the nature and the structure of human experience, with
the aim of deriving from them a consistent methodology and strategy of
intervention for cognitive therapy (cf. Guidano, 1991, 1995).
Experiencing and Explaining
Given that we can perceive the reality in which we live only from
within our perceiving order, we always find ourselves, as human beings, in
the immediacy of our ongoing praxis of living, which is the absolute
primary ontological condition. The praxis of living is one of those
dimensions that is difficult (perhaps impossible) to put into words. It is the
“living of living,” if you will, or the “practice of practicing,” which is a
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life-span project for all of us. Maturana (1986) pointed out the following:
In these circumstances, whatever we say about how anything
happens takes place in the praxis of our living as a comment, as a
reflection, as reformulation; in short, as an explanation of the praxis
of our living, and as such it does not replace or constitute the praxis
of living that it purports to explain. (pp. 3–4)
Human experience, therefore, appears as the emerging product of a
process of mutual regulation continuously alternating between
experiencing and explaining—that is, a process in which ongoing patterns
of activity (immediate experience) become subject to linguistic distinctions
and are reordered in terms of symbolic propositions distributed across
conceptual networks. The level of symbolic reordering (explanation)
makes possible new categories of experience, such as true–false, real–
unreal, right–wrong, and subjective–objective, to name a few. This
interdependence between subjective and objective, emotioning and
cognizing, experiencing and explaining, and so forth, is constitutive of any
human knowing process, just as is feeling ourselves to be alive.
In humans, as in all mammals (and especially all primates), affective-
emotional activity corresponds to and depends on immediate and
irrefutable apprehensions of the world. Hence, from a purely ontological
point of view, feelings can never be “mistaken.” It is through feelings that
we experience our way of being in the world. In other words, we always
are as we feel (Olafson, 1988). At the level of immediate experiencing, it
is not possible to distinguish between perception and illusion (Maturana,
1986). For example, the perturbing feeling of having seen a ghost is, for
the subject who is feeling it, a momentarily real and inescapable
experience. Only by shifting to the level of “languaging” can the
individual explain the felt experience in a variety of alternative manners,
such as its having been a trick of light or an illusion, thereby making the
experience consistent with his or her current appraisal of the world. In
other words, errors can be noticed only a posteriori (after the experience)
and depend on the point of view that we, as observers, take in reordering
our experiencing. All rational-cognitive reordering involves expanding the
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coherence of symbolic rules to make the flow of immediate experience
more consistent with the continuity of one’s current appraisal of the world.
Rather than representing an already given reality according to a logic
of external correspondence, knowledge is the continuous construction and
reconstruction of a world by the ordering individual in an attempt to make
ongoing experiences consistent (Arciero, 1989; Arciero & Mahoney, 1989;
Maturana, 1988; Varela, 1987; Winograd & Flores, 1986).
Self and the Emotional Realm of Intersubjectivity
The evolutionary development of humans and their environments has
always been fundamentally intersubjective. This is a relatively recent
realization in global thinking. In fact, the phenomenon of “globalization”
has sometimes been likened to the shrinking of the planet, bringing all of
its inhabitants into more extensive contact. Most pertinent for this
discussion is the fact that we humans are undeniably social beings. We
need others (who, in turn, need us), and we participate in communities of
identity and otherness that are crucial to our mutual well-being and
development. We live in a complex interpersonal reality primarily
structured and made consistent by language. Among other things, this fact
implies that any knowledge of oneself and the world is always dependent
on and relative to knowledge of others. The increasing complexity of the
interpersonal dimension has afforded humans a range of skills in
intersubjective learning (e.g., imitation and modeling) paralleled by an
increase in the capacity for self-individuation (Kummer, 1979;
Passingham, 1982). In fact the ability to discriminate among individual
others appears to be hardwired in primate organization, as evidenced by
the central role of the face in the primate emotional system (Ekman, 1993;
Reynolds, 1981). Hence, facial recognition has emerged as a neocortical
process whose evolutionary progression closely parallels the emergence of
a more complex interpersonal realm (e.g., closer mother–infant
relationship and competition and social bonds) that requires incremental
capacities for attunement with others’ behaviors and intentions in order to
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viably adapt.
Facial recognition should therefore be regarded as a self-referent
ordering of intersubjective experience that facilitates the possibility of self-
individuation. On the one hand, the ability to discriminate between
individual others allows one to anticipate their perceptions of one’s action,
thus improving interactional synchrony and reciprocity. On the other hand,
simulating how others will interpret one’s actions entails the capacity to
view oneself from the perceived perspective of others. This enhances the
possibilities for self-bordering (i.e., setting one’s own psychological
boundaries) and self-individuation.
The human dimension of intersubjectivity is a prerequisite for
individuation and self-recognition (Gallup & Suarez, 1986), bringing about
the differentiation of a sense of self—both as subject and as object.
Language, in fact, affords the ability to make distinctions and references
regarding the flow of immediate experience, making it possible to at least
symbolically distinguish the self that is experiencing from the self that is
appraising those experiences.
The experience of “being a self” is something intertwined with and
arising from the endless flowing of one’s praxis of living so that, as
Gadamer (1976) explained, “the self that we are does not possess itself:
one could say that it happens” (p. 55). In other words, the experiencing–
explaining interdependence that underlies self-understanding is matched
by an endless process of circularity between the immediate experience of
oneself (the acting and experiencing I) and the sense of self that
continually emerges as a result of abstractly self-referencing the ongoing
experience (the observing and appraising me; James, 1890/1989; Mead,
1934; Smith, 1978, 1985). The self as subject (I) and the self as object
(me) therefore represent the irreducible dimensions of a selfhood dynamic
whose directionality depends on the continuous flow of our praxis of
living. Indeed, the acting and experiencing I is always one step ahead of
the current evaluation of the situation, and the appraising me becomes a
continuous process of reordering one’s conscious self-image.
Consider an emotional realm inherent to an intersubjective reality in
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which adaptation always transforms itself into a social relationship (e.g.,
the mother–infant bond). In a space–time dimension apprehensible in
terms of proximity and distance from a safe base of emotional attachment,
psychobiological attunement of and to caregivers allows the newborn
human to order its sensory inflow into feelings that become recognizable
only within an approach–avoidance continuum. In such a space–time
dimension, attachment comes to exert a primary role in differentiating a
range of decodable emotional tonalities (a) by regulating the rhythmic
oscillation between arousal-inducing (exploration and play) and arousal-
reducing (security and clinging) psychophysiological patterns and (b) by
exerting a secondary role of modulating fear and anger by alternating
between these same patterns (Fox & Davidson, 1984; Reynolds, 1981;
Schore, 1994; Suomi, 1984). Alternatively, within an intersubjective
reality, attachment exerts an organizational role in the development of a
sense of self both as subject and as object.
Whereas the newborn’s attunement to a synchronous source of
regularities organizes his or her sensory inflow into a stream of recurrent
psychophysiological rhythms, the emotional aspects of attachment
transform feeling tonalities into specific emotional modules. Through
regularities drawn from caregivers’ behaviors and affective messages, the
infant can begin to construct basic feelings that are inseparable from early
perceptions, actions, and memories. The emergence of subjective
experience is matched by the perception that one is an entity differentiated
from other objects and people in the surrounding world. In other words,
the initially ambivalent experience of being a self emerges with varying
constraints of definition as a result of intersubjective experiences,
especially those associated with intense emotional activity.
Psychophysiological rhythms and emotional schemata become basic
ingredients of infantile consciousness, a consciousness that is truly and
fundamentally affective in nature and quality (Buck, 1984; Emde, 1984;
Izard, 1980; Schore, 1994). The self-feeling immediately and tacitly
perceived as an inner kinesthetic sense of I is therefore primarily organized
around prototypical emotional schemata differentiated out of emotional
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reciprocity with caregivers.
The I comes to see himself or herself as a me (i.e., like other
surrounding people) only through the consciousness that caregivers have
of his or her behavior. Anticipating others’ perceptions of one’s actions
facilitates the recognition of ongoing patterns of emotional schemata out of
the stream of recurrent inner states, structuring them into specific
emotional experiences connected to related intentions and goal-oriented
behaviors. Evidence suggests that infants’ perceptions of themselves,
although dependent on their caregivers’ behavior, are not confined to those
situations in which their parents attempt to meet their basic needs. Indeed,
it appears that parental imitation of infant behavior is very common from
the earliest periods (Bretherton & Waters, 1985; Harter, 1983), and it is
therefore very likely that such imitations are essential cues that allow the
infant to recognize or internalize as his or her own those characteristics
and attitudes that caregivers perceive as belonging to the infant as a
person. In other words, self-consciousness emerges from a self-
recognizability made possible only by the empathic ability to take the
attitude of others onto oneself, subsequently elaborating a conscious self-
image that consists of emotionally etching the profile of the me out of the
experienced I.
Selfhood Dynamics and Life-Span Development
Individual life-span development should be regarded as a
hortogenetic progression, meaning that it is an open-ended, spiraling
process in which the continuous reordering of selfhood dynamics results in
the emergence of more structured and integrated patterns of internal
complexity. Self-regulating abilities reflect a dynamic equilibrium known
as “order through fluctuations” (Brent, 1978; Dell & Goolishian, 1981;
Prigogine, 1976). That is, continuous—both progressive and regressive—
shifts of the point of equilibrium in I–me dynamics provide a scaffolding
that enables one to maintain a coherent continuity of experiencing while
allowing the assimilation of the perturbations that emerge from that
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experiencing. I now take a look at two essential variables involved in this
lifelong process: the role of awareness in regulating and modulating
challenging perturbations and the role of emotional activity in triggering
them.
In strictly ontological terms, being aware of oneself means reaching
an explanation for the ongoing experience of being a unique, irreducible,
and often unpredictable I. Hence, awareness is a reflexive process for self-
referencing immediate experience (I) in order to amplify consistent aspects
of the perceived me while inhibiting discrepant aspects. Because the acting
and experiencing I is always one step ahead of the current appraisal of the
me, each person is in a position where it is possible to experience much
more than the minimum required at that moment to maintain his or her
own self-image consistency in that particular situation. As a consequence,
the ability to manipulate immediate experiencing while self-referencing
and reordering becomes essential. This ability is necessary to direct
conscious attention in ways that contrast with the selected appraisal of the
current situation. In this sense, one can say that no self-awareness can be
viable without a necessary level of self-deception. Thus, it follows that
excessive self-deception lowers the accuracy of decoding immediate
experiencing (possibly to critical levels of uncontrollability), whereas
limited self-deception, by failing to reject extraneous information,
complicates the self-referencing process exponentially such that levels of
complexity in selfhood dynamics are difficult to manage. Hence, any
individual, although having critical emotional tonalities in immediate
experiencing, is also endowed with specific self-deceiving abilities
designed to manipulate their decoding so that it is consistent with the
quality of awareness they have reached thus far. Through such procedures,
individuals can appraise critical feelings and make them intelligible
without questioning the total validity of the currently existing self-image.
Alternatively, attachment to significant others, although it shifts
toward a more abstract level with maturation, maintains its fundamental
interdependence with selfhood dynamics throughout the life span. This
shift, it seems, explains the crucial role of affectivity in triggering
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significant perturbations. Although attachment is central to the stable
differentiation of a sense of self, new patterns of attachment emerge (e.g.,
intimate love relationships) throughout maturational stages during
adulthood, attachments that function to confirm, support, and further
expand the pattern of self-coherence that has thus far been structured. It
follows naturally that the influence of early attachments is subsequently
manifested in later styles of attachment, which continue to differentiate
along the entire developmental pathway (Bretherton, 1985). Indeed, the
continuity of attachment throughout the life span is understandable if one
considers that the perception of certain affective relationships as being
unique to the self begins early in life and that subsequent adult bonds of
love seem to grow out of these very first attachments (Hazan & Shaver,
1987; Marris, 1982; Shaver, Hazan, & Bradshaw, 1988; Weiss, 1982). Just
as unique primary bonds seem to be necessary prerequisites for
“perceiving a world” and “recognizing one’s being in it,” so in adulthood
—though at a different level of abstraction—is building a unique
relationship with a significant other an important way for one to perceive a
consistent sense of uniqueness in his or her “being in the world.” Hence, if
working models of attachment figures are interdependent with ongoing
patterns of self-perception, it is clear that any perceived modification of
these models is matched by intense perturbations in immediate
experiencing; these disruptions can trigger the emergence of I–me
discrepancies, which in turn can challenge the current appraisal of the self.
In fact, the importance of a balanced interplay of the individual’s network
of unique relationships throughout the life span is currently supported by
evidence from various sources. First, life-events research has shown that
the most disrupting emotions a person can experience in life are those
triggered in the course of establishing, maintaining, and dissolving such
relationships (Bowlby, 1977; Brown, 1982; Hafner, 1986; Henderson,
Byme, & Duncan-Jones, 1981). Second, recent epidemiological evidence
has shown how the “social network index” should be regarded as a
significant predictor of health on the basis of findings suggesting that
social and affective isolation is a major risk factor for morbidity and
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mortality (House, Landis, & Umberson, 1988).
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12
CONSTRUCTIVIST THERAPY PROCESS
GREG J. NEIMEYER
Presenting problems represent windows onto the client’s system of
constructions. Clients’ “effort after meaning”—as Bartlett (1932) so aptly
phrased it—assures that they have struggled to understand the nature of
their experience prior to therapy, and their presence in therapy speaks to
the difficulty they have encountered along the way. When participating in
a constructivist form of therapy, neither client nor therapist can enjoy the
familiar moorings that anchor more realist or rationalist forms of therapy
(see Mahoney & Lyddon, 1988; G. J. Neimeyer & Neimeyer, 1993; Parry
& Doan, 1994). Gone is the certainty of a single “best,” “right,” or
“functional” form of thinking, feeling, or behaving. Gone, too, is the
directive, disputational comportment associated with that certainty,
replaced by a more tentative, patient struggle aimed at developing a
constructive process of exploration from within the individual (see Clark,
1989, 1993) that may lead to a more viable and developmentally
progressive understanding of the world (Lyddon & Alford, 1993; R. A.
Neimeyer, 1995).
There are many ways to encourage this kind of exploration and
experimentation. For most constructivists, the nature of the therapeutic
relationship itself is a figural feature in this process (Guidano, 1991;
Lyddon & Alford, 1993; Mahoney, 1991). This relationship supports and
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contextualizes various forms of direct and indirect intervention. As Kelly
(1969c) has noted,
the relationships between therapist and client and the techniques they
employ may be as varied as the whole human repertory of
relationships and techniques. . . . It is the orchestration of techniques
and the utilization of relationships in the on-going process of living
and profiting from experience that makes psychotherapy a
contribution to human life. (p. 223)
Constructivist approaches have contributed significantly in both of
these regards, placing inflection on the nature of interpersonal and
therapeutic bonds on the one hand, and sponsoring a wide variety of novel
methods of intervention on the other. Mirror time, streaming, fixed-role
therapy, controlled elaboration, tightening and loosening techniques,
interpersonal transaction groups, bipolar sculptures, personal epilogues,
repertory grid techniques, systemic bowties, time and place binding,
laddering, and various forms of journaling have all emerged from
constructivist traditions—and these are just a few techniques (see
Mahoney, 1991; G. J. Neimeyer, 1993; R. A. Neimeyer & Neimeyer,
1987).
Still, constructivists are wary of an exclusive dedication to technique,
preferring instead to emphasize the critical role of the therapeutic
relationship in enabling and initiating human change. “I am not against
technique,” noted Mahoney (1991, p. 253), in a sentiment shared by many
constructivists, “I am against technolatry.”
This caveat contextualizes the discussion of methods that follows. All
methods, all techniques, and all forms of intervention necessarily evolve
from and reside within the context of a given relationship in a given time
and place (Efran & Clarfield, 1993). In this sense, techniques can be
regarded as coconstructed meaning rituals—vehicles for punctuating,
initiating, or reorganizing experience—and, as such, they hold no power
apart from the social and cultural contexts that inform them. Human
change follows less from the application of a given technique per se than
from the meaning that follows from its use in the therapeutic process. In a
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direct sense, therefore, a technique does not “do” anything for a person;
rather, the person does something with the technique.
CONSTRUCTING A LIFELINE
For constructivists, psychotherapeutic technique occurs in relational
contexts. For that reason, in most constructivist therapies a premium is
placed on forging an intimate therapeutic bond between client and
therapist. This bond enables them to participate jointly in conjuring a
variety of alternative worlds to be explored and elaborated. These twin
processes—exploration and elaboration—serve as the linchpins of the
psychotherapeutic process, and both follow from the development of a
strong working relationship.
Forging a Bond
Like Bowlby’s (1988) “secure base,” constructivists regard the
therapeutic relationship as a kind of home base, or emotional tether, for the
client to use in his or her personal exploration (Guidano, 1991). Although
the ways in which this type of attachment may be formed can be quite
varied, they converge in providing a kind of secure, permissive
acceptance. Adopting what Kelly (1955) has referred to as a “credulous
approach,” the therapist takes the client’s perspective seriously and
respects it, even though she or he may not choose to be bound by it. Part of
this credulous approach implies acceptance of the client, although
acceptance takes on special meaning in this context: It is understood as a
willingness to use the client’s personal knowledge system, to see the
problem and the world through his or her eyes, though not necessarily to
be encapsulated by it. To this is added an attitude of inquiry—a curiosity
or fascination with the client’s perspective and its implications. From this
the therapist develops a form of collaborative empiricism, establishing a
working relationship that conveys a willingness to conjoin the client in an
exploratory process that may seek to test or transcend the limitations of the
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client’s personal worldview.
This kind of therapeutic relationship is qualitatively distinct from
other forms of therapeutic alliances. As Kelly (1969b) observed,
instead of assuming, on the one hand, that the therapist is obliged to
bring the client’s thinking into line, or, on the other, that the client
will mysteriously bring his own thinking into line once he has been
given the proper setting, we can take the stand that client and
therapist are conjoining in an exploratory venture. The therapist
assumes neither the position of judge nor that of the sympathetic
bystander. He is sincere about this; he is willing to learn along with
his client. He is the client’s fellow researcher who seeks first to
understand, and then to examine, and finally to assist the client in
subjecting alternatives to experimental test and revision. (p. 82)
The constructivist therapist’s attitude, therefore, is more inquisitive
than disputational, more approving than disapproving, and more
exploratory than demonstrative.
Beyond this, specific permission is sometimes given to remove the
limits on what can be said and done in the therapy room. The therapist
might emphasize, for example, that “this therapy room is a special kind of
place for you. Here you can say things, express feelings and thoughts, and
act out things that you might never even consider, much less do, in the
outside world.” This kind of explicit permissiveness again underscores the
security of the therapeutic arena, and it begins to conjure the image of a
hypothetical, “as if” world (Vaihinger, 1924) in which the client may
fashion and test new meanings and behaviors.
Conjuring a World
Even as the nascent therapeutic world is conjured into existence, its
function is already being partially fulfilled. Because it is a hypothetical
place, a make-believe world, the client can feel free to experiment with
changes without necessarily jeopardizing or assaulting existing meaning
structures. New perspectives can be tried on without shedding present
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constructions, thereby circumventing much of the threat and anxiety
associated with significant personal change.
A recent development in cosmetology provides a metaphorical
marker for the power of this pretend world and illustrates its utility in
facilitating personal change. Developed a few years ago, this technological
advance enables cosmetologists to project the image of their clients’ faces
into a limitless assortment of different hairstyles. These projections
transport people into whole new identities in swift succession, enabling
them to peer out from within their make-believe worlds under the guise of
a cast of different characters. From the copious curls of Dolly Parton to the
shorn scalp of Sinead O’Connor, from the flowing tresses of Crystal Gayle
to the boyish coiffure of Lady Di, these computer-generated images permit
a sort of smorgasbord sampling of identities, a playful means of engaging
and disengaging a parade of alter egos without risking the more terminal,
steely feel of actual scissors to scalp.
As a kind of metaphor for constructivist psychotherapy, this
procedure pairs the exploratory, experiential features of significant change
with important identity safeguards that protect extant personal meaning.
After all, the comic value of Bill Clinton adopting the dreadlocks of Bob
Marley or the electrified look of Don King would be matched only by the
sheer terror that would, for Clinton, accompany that actual transformation.
Radical reconstruction of current meanings, particularly those central to
the self, is customarily and understandably resisted.
For most constructivists, the self constitutes an organized meaning
unit, and events that signal profound changes in that system are
threatening. Variously referred to as “personal construct systems” (Kelly,
1955), “personal meaning organizations” (Guidano, 1991), “cognitive
structures” (Liotti, 1987), and “core ordering processes” (Mahoney, 1991),
these interconnected networks of meaning are taken to constitute the
individual. By jeopardizing the integrity of this worldview, change—
particularly significant, core role change (Kelly, 1955)—produces massive
threat and anxiety. In response, the individual understandably develops a
self-protective approach that is commonly recast as “resistance” within the
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therapeutic context. “A cognitive structure that attributes meaning and
causal relationships to an important class of emotional experiences,” noted
Liotti (1987, p. 95), “will be quite resistant to change if the individual does
not develop alternative meaning structures.” This self-protective theory of
resistance is common to many diverse constructivist approaches (Guidano,
1991; Kelly, 1955; Liotti, 1987; Mahoney, 1991), and the development of
a secure, “pretend world” in therapy is one means of cultivating these
alternative meaning structures.
Central to this pretend world is the language of hypothesis. “There is
something in stating a new outlook in the form of a hypothesis,” noted
Kelly (1969a, p. 156), “that leaves the person himself intact and whole.”
The use of this language, the development and exploration of alternative
meanings, can occur alongside of rather than instead of existing meanings.
It is the security associated with the preservation of existing meanings that
often enables the exploration of new ones. Kelly (1969a) has characterized
threat as
the experience that occurs at the moment when we stand on the brink
of profound change in ourselves and can see just enough of what lies
ahead to know that so much of what we are now will be left behind
forever, once we take that next step. (p. 156)
It is precisely at this point that the language of hypothesis can be most
helpful, preserving the integrity of the client’s current understandings, but
momentarily suspending them as well, while alternative possibilities are
explored. Having bracketed present perspectives, the person is free to
envision alternative possibilities, to experience fresh perspectives from
behind an assortment of masks. And these masks, Kelly (1969a) observed
wryly, “have a way of sticking to our faces when worn too long” (p. 158).
For the constructivist psychotherapist, therefore, alternative
perspectives are encouraged. Forged and tested within an as-if world, these
various viewpoints are designed to dislodge the client from a strict
allegiance to any single belief or conviction. “The psychologist is at his
best,” observed Kelly (1969a), “when he speaks the language of
hypothesis rather than imposes psychological certainties on his clients” (p.
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154).
That being said, techniques for encouraging this hypothetical
exploration and personal revision must enable the client’s active
participation in the process of meaning making. In this regard,
constructivist psychotherapy is an engaging, interactive vehicle for the
negotiation of new meanings. Meaning is made through action, through
participation, and through concrete and representational manipulations of
the world. These manipulations yield novel experience, that is, perceived
invalidations of present systems of knowing that require active efforts of
meaning making to render them sensible within a coherent meaning
structure (see Mahoney, 1991). This kind of “continuous self-reordering,”
noted Guidano (1991), “is inherently characterized, moment by moment,
by a series of possible ‘I’/‘Me’ discrepancies, that is, perceived gaps
between immediate experience and self-consciousness that challenge
ongoing patterns of self-control” (p. 69). One important means of fostering
this kind of exploratory self-reordering is through various forms of
interpersonal enactments.
Conducting the Exploration
Mahoney (1991) has noted “the importance of active exploratory
behavior on the part of the changing individual,” emphasizing that “there
can be no real learning without novelty—that is, without a challenge to or
elaboration of what has become familiar” (p. 19). Enactments, various
forms of interpersonal role plays, constitute one important vehicle for
introducing this novelty. Enactments can vary from very brief,
unstructured, casual scenarios all the way to the formalized and enduring
role plays that constitute fixed-role therapies. Regardless of their brevity or
length, their spontaneity or formality, all enactment procedures share a
common set of goals. Foremost among these is to provide for elaboration
of the clients’ personal worldview while protecting their core role
structures from premature invalidation, to buffer them from assault until
they are better able to consider abandoning them.
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Casual enactments are brief, informal role plays designed to give the
client an opportunity to experiment by trying on a part to see what it is
like. Rarely more than a few minutes duration each, these enactments are
aimed at discovery rather than demonstration, at exploration rather than
rehearsal. An enactment is “designed, like a good experiment, to give the
experimenter and his colleagues a chance to observe its outcomes” (Kelly,
1955, p. 1166).
Casual enactments have several salient features. Although brief, they
can nonetheless present potent opportunities for discovery, even when they
involve little or no actual conversation. Moreover, they foster a fleet-
footed fluidity by enabling the client to move quickly among multiple
perspectives.
Unverbalized casual enactments can be as potent as their more verbal
counterparts. Clients often profit immensely from a brief enactment that
casts them in a role that they are wholly unable or unwilling to enact or
express in any overt way. “Just sitting there and feeling that he is cast in a
certain part, or that he is perceived as being in a certain part,” noted Kelly
(1955), “is, in itself, a form of adventure which he is not likely to pass off
lightly” (p. 1147).
One of my recent experiences with the potency of Kelly’s (1955)
insight came in an early session with “David,” a client in his late 20s who
was referred to me with alcoholism and alcohol-related difficulties. David
had experienced several run-ins with the law at the time, having lost his
driver’s license and been placed on probation for a weapons violation in
the process. He had returned home to live with his parents because his life
had been so “out of control,” and he was contemplating a return to his
private apartment. He spoke openly about how concerned his parents were
about him and how they feared that returning to his apartment would again
give him the license to drink that he could not exercise in their home. He
was frustrated and angry that they did not trust him, and he felt a growing
impasse that he could not resolve: either stay with them and sacrifice his
adult freedoms, or return to his apartment and disappoint and provoke his
parents, potentially jeopardizing their support of him.
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I immediately cast David in his mother’s role, pointed to a nearby
empty chair, and said “Tell David what concerns you have. Tell him about
your fears and worries for him.” David, portraying his mother, talked
fluidly for several minutes, detailing a set of concerns undoubtedly
familiar to him. I then asked him to sit in the other chair and respond, as
David, to his mom’s concerns. He sat frozen. “I can’t. I can’t say
anything!” he said. “I mean, she’s right, I’ve always started drinking when
I got by myself and that started the cycle down. I mean, what can I tell
her?” As he spoke, he flushed with emotion and turned to talk about how
he was unwilling to provide her with the kind of false assurances that he
had in the past. He spoke, too, of how justified her concerns were and how
unjustified his own anger and frustration with her was, saying that “This
has nothing to do with Mom in a sense, I mean, I’ve got to find some way
of handling this thing myself.” From here we turned to talking about
possible safeguards, ways that he could reduce the ever-present temptation
to start drinking and provide some tentative assurances to himself, as well
as to his mother, en route.
In this and other uses of casual enactment, the client can be asked to
shift perspectives. This provides one means of developing a contextual
shift as discussed by Efran and Clarfield (1993). I have used a wide variety
of such enactments productively in my practice, and Kelly (1955) has
detailed a number of possibilities in this regard. In one form of enactment,
for example, the client is asked to report to the therapist as if he or she
were the client’s best (real or imagined) friend. Simple prompts like “What
concerns do you have about him or her?” or “What do you see going on
from your perspective?” can initiate the enactment and help breathe life
into the interaction. Another approach is to have the client portray the part
of the therapist while the therapist enacts the part of another therapist who
is being consulted about the client. This offers the additional advantage of
indicating something about the client’s constructions of the therapist and
of the nature of the therapeutic enterprise. Yet another enactment that can
have powerful effects is to ask the client to enact an admired or respected
person, parent or otherwise, who has served as a source of inspiration or in
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the role of wise council for the client. In this variation, I typically ask
clients to stand up, close their eyes, and imagine adopting the voice,
movement, and mannerisms of that person. When they open their eyes
they are to introduce the client and talk about specific aspects of the pride
and concerns that they have regarding them. As with most casual
enactments, roles can then be reversed to enable the client to shift
perspectives within the same context or scenario.
In addition to brief, casual enactments, more elaborate enactment
procedures can also be formulated within the therapeutic arena. Among the
most elaborate of these is Kelly’s (1955) fixed-role therapy. Like other
enactments, the purpose of fixed-role therapy is primarily exploratory, to
help dislodge the client from his or her adherence to an extant perspective
by encouraging the adoption of an alternative one. Unlike the enactments
described above, however, fixed-role therapy involves systematically
developing a new, alternative identity, rather than simply co-opting an
already available perspective.
REFERENCES
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University Press.
Bowlby, J. (1988). A secure base. New York, NY: Basic Books.
Clark, K. M. (1989). Creation of meaning: An emotional processing task in
psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 26,
139–148. doi:10.1037/h0085412
Clark, K. M. (1993). Creation of meaning making in incest survivors. Journal
of Cognitive Psychotherapy, 7, 195–203.
Efran, J. S., & Clarfield, L. E. (1993). Context: The fulcrum of constructivist
psychotherapy. Journal of Cognitive Psychotherapy: An International
Quarterly, 7, 173–182.
Guidano, V. E. (1991). The self in process: Toward a post-rationalist cognitive
therapy. New York, NY: Guilford Press.
Kelly, G. A. (1955). The psychology of personal constructs (2 vols.). New
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York, NY: Norton.
Kelly, G. A. (1969a). The language of hypothesis: Man’s psychological
instrument. In B. Maher (Ed.), Clinical psychology and personality: The
selected papers of George Kelly (pp. 147–163). New York, NY: Wiley.
Kelly, G. A. (1969b). Man’s construction of his alternatives. In B. Maher
(Ed.), Clinical psychology and personality: The selected papers of George
Kelly (pp. 66–93). New York, NY: Wiley.
Kelly, G. A. (1969c). Psychotherapy and the nature of man. In B. Maher (Ed.),
Clinical psychology and personality: The selected papers of George Kelly
(pp. 207–223). New York, NY: Wiley.
Liotti, G. (1987). The resistance to change of cognitive structures: A counter-
proposal to psychoanalytic metapsychology. Journal of Cognitive
Psychotherapy: An International Quarterly, 1, 87–104.
Lyddon, W. J., & Alford, D. J. (1993). Constructivist assessment: A
developmental epistemic perspective. In G. J. Neimeyer (Ed.), Casebook
of constructivist assessment (pp. 31–57). Newbury Park, CA: Sage.
Mahoney, M. J. (1991). Human change processes: The scientific foundations
of psychotherapy. New York, NY: Basic Books.
Mahoney, M. J., & Lyddon, W. J. (1988). Recent developments in cognitive
approaches to counseling and psychotherapy. The Counseling
Psychologist, 16, 190–234. doi:10.1177/0011000088162001
Neimeyer, G. J. (1993). The challenge of change: Reflections on constructivist
psychotherapy. Journal of Cognitive Psychotherapy, 7, 183–194.
Neimeyer, G. J., & Neimeyer, R. A. (1993). Defining the boundaries of
constructivist assessment. In G. J. Neimeyer (Ed.), Casebook of
constructivist assessment (pp. 1–30). Newbury Park, CA: Sage.
Neimeyer, R. A. (1995). An invitation to constructivist psychotherapies. In R.
A. Neimeyer & M. J. Mahoney (Eds.), Constructivism in psychotherapy
(pp. 1–8). Washington, DC: American Psychological Association.
Neimeyer, R. A., & Neimeyer, G. J. (Eds.). (1987). Personal construct therapy
casebook. New York, NY: Springer.
Parry, A., & Doan, R. E. (1994). Story re-visions: Narrative therapy in a
postmodern world. New York, NY: Guilford Press.
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Vaihinger, H. (1924). The philosophy of “as if.” Berlin, Germany: Reuther &
Reichard.
Excerpted from Robert A. Neimeyer and Michael J. Mahoney (Eds.), Constructivism in Psychotherapy
(2000), from Chapter 6, “The Challenge of Change,” pp. 112–119. Copyright 2000 by the American
Psychological Association. Used with permission of the author.
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APPENDIX 12.1: CONSTRUCTIVIST THERAPY TECHNIQUES
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13
EMOTION-FOCUSED THERAPY
LESLIE S. GREENBERG
In emotion-focused therapy (EFT), emotion is viewed as
fundamentally adaptive and as providing our basic mode of information
processing, rapidly and automatically appraising situations for their
relevance to our well-being and producing action tendencies to meet our
needs. With the aid of emotions, people react automatically to their
apprehension of patterns of sounds, sights, and smells and to other
nonverbal signs of people’s intentions in a way that has served us well as a
species for centuries and as individuals for years. Fear-induced flight
produces safety, disgust expels a noxious intrusion, and in sadness one
calls out for the lost other. People respond emotionally, in an automatic
fashion, to patterns of cues in their environment that signal novelty,
comfort, loss, or humiliation.
Client emotions thus act as a kind of therapeutic compass, guiding the
client and therapist as to what is important to the client and what needs are
being met (or not met). A key principle of EFT is that emotions provide
access to needs, wishes, or goals and the action tendencies associated with
them. Thus, every feeling has a need, and every emotion scheme activation
provides a direction for action, one that will promote need satisfaction.
When a client acknowledges feeling sad, this statement conveys that their
tacit processing has evaluated that they have lost something important to
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them, are in need of comfort, and probably want to cry out for the
connection. By contrast, in couples therapy the expression of underlying
adaptive emotions to the partner is seen as crucial in changing the partner’s
view of the self and emotion and its expression thereby changes negative
interactions (Greenberg & Goldman, 2008).
Emotion is a brain phenomenon that is vastly different from thought.
It has its own neurochemical and physiological basis and is a unique
language in which the brain speaks. The limbic system, a part of the brain
possessed by all mammals, is responsible for basic emotional responses. It
governs many of the body’s physiological processes and thereby
influences physical health, the immune system, and most major body
organs. Le Doux (1996) identified two different paths for producing
emotion: the shorter and faster amygdala pathway, which sends automatic
emergency signals to brain and body and produces gut responses, and the
longer and slower neocortex pathway, which produces emotion mediated
by thought. Clearly it was adaptive to respond quickly in some situations,
but at other times better functioning resulted from the integration of
cognition into an emotional response (by reflecting on emotion).
The developing cortex added to the emotion brain’s adaptive wisdom
a new form of emotional response. This new emotional response system
used not only inherited emotional responses, like fear of the dark, but also
learned signs of what had evoked emotion in a person’s own life
experience, like fear of one’s father’s impatient voice. Those emotional
memories and organizations of lived emotional experience were formed
into emotion schemes (Greenberg & Paivio, 1997; Greenberg, Rice, &
Elliott, 1993; Oatley, 1992). Through these internal organizations or neural
programs, people react automatically from their emotion systems, not only
to inherited cues, such as looming shadows or comforting touch, but also
to cues that they had learned were dangerous or life enhancing. These
reactions are rapid and automatic.
EMOTION SCHEMES
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Emotion schemes are at the base of the adult emotional response
system. They are internal emotion memory structures that synthesize
affective, motivational, cognitive, and behavioral elements into internal
organizations that are activated rapidly, out of awareness, by relevant cues.
Schemes are elicited by cues that match the input features of the scheme
and produce experience and action as their output. Important life
experiences, significant by virtue of having activated emotional responses,
become coded into emotion schematic memory. The emotion scheme
represents both the situation as construed and its emotional effect on the
individual, and this is done in a predominantly wordless or imagistic script
in the form of narrative. Thus, emotional memories of cuddling in one’s
mother’s arms or being physically abused are coded as procedural
memories of what happened and how this felt. The scheme represents an
unfolding of an experience from the initial cue (e.g., a touch) to a sequence
of moments of experience, with a beginning, middle, and end. The innate
capacity for emotional response and experience thus evolves into core
emotion schematic autobiographical memories with an internal narrative
structure (Angus & Greenberg, 2011).
Emotion schematic learning makes emotions a flexible, adaptive
processing system but also opens them to the possibility of becoming
maladaptive. People not only flee from predators and get angry at
violations of their territorial boundaries, but they also fear their boss’s
criticism and get angry at self-esteem violations. The important issue is
that the emotionally motivated, basic mode of processing that is set in
motion by scheme activation occurs out of awareness and influences
conscious processing. Only after this basic mode of processing has been
activated does the person begin to process more consciously for sources of
danger and ultimately symbolizes in words the appraised danger and
generates ways of coping with it. Thus, the activation of a fear scheme sets
a basic mode of processing for threat in motion, and this conscious
processing works in the service of the affective goal activated by the
scheme (safety in the case of fear). Emotion schematic processes can
include linguistic components but often consist largely or entirely of
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preverbal elements (including bodily sensations, visual images, and even
smells); emotion schemes are also oriented toward action to satisfy needs,
goals, and concerns.
The development of schemes is best understood as the development
of neural networks that represent the basic story of a lived experience. A
network is shown in Figure 13.1. Here, a scheme of fear of failing, formed
from the experience of having failed a mother’s expectation, contains
components of a visual image of the mother’s face, a variety of nonverbal
physiological and sensory aspects of those experiences, as well as the
action tendency to withdraw and possibly, but not necessarily, a belief
stated in language that the self is going to fail an expectation. The whole
representation is an unfolding sequence as shown by the arrows leading
from one node to the next. The most obvious therapeutic implication is
that optimal emotional processing involves activating the whole scheme
and focusing on all of the narrative schematic elements. Particular
difficulties occur when the person excludes all the elements from
awareness, or neglects one or more types of elements, so that his or her
experiencing is not processed fully or coherently.
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Figure 13.1. Emotion scheme.
Enduring change occurs through the synthesis of two or more existing
schemes and the formation of higher level schemes (Piaget & Inhelder,
1973). In development, when opposing schemes are coactivated,
compatible elements from the coactivated schemes synthesize to form new
higher level schemes. For example, in a 1-year-old child, schemes of
standing and falling can be dynamically synthesized into a higher level
scheme for walking, by a process of dialectical synthesis (Greenberg &
Pascual-Leone, 1995; Pascual-Leone, 1991); similarly, schemes of
different emotional states can be synthesized to form new integrations.
Thus, a schematic emotional memory of fear and withdrawal from prior
abuse can be synthesized with current empowering anger against violation,
which motivates approach rather than withdrawal, to form a new sense of
confidence or assertion.
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EMOTION GENERATION
The flow diagram in Figure 13.2 depicts the process of emotion
generation; it can be used to think linearly about what is in reality a
complex nonlinear and dynamic process. (A more representative form of a
more complex dynamic process can be found in Greenberg & Pascual-
Leone, 2001.) In this diagram, attention to a stimulus preconsciously
activates an emotion scheme (or more accurately, a number of schemes) by
the cues matching the releasers of a scheme. For example, a frown or a
raised voice activates a fear scheme. In addition, certain automatic
cognitive processing takes place along a separate and ultimately slower
path that helps generate conscious appraisals in language. Each scheme
includes its basic components of affect, action tendency, need, and
cognition structured in a wordless narrative; the person experiences the
other as a threat, the body tenses and prepares for escape, and negative
beliefs about self become primed. With attention the activated scheme or
schemes in turn may be symbolized in language giving rise to conscious
emotion, the concern or desire, an action tendency and thought, and these
combine, in the case of fear activation, to influence behavioral avoidance.
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Figure 13.2. The dialectical construction of the self.
Note that in this model it is not cognitive appraisal in language that
produces emotion; rather, it is a type of automatic pattern matching that
releases the scheme that produces emotion. In this view, meaning appraisal
occurs at two levels. The first level is the rapid evaluation of patterns
matching internal features of the emotion scheme where the evaluation is
one of fit—for example, a frowning face rather than a more conscious
cognitive appraisal of explicit meaning (this person is angry at me and I
am in danger). The latter is generated by more automatic and deliberate
cognitive processes. The cognitive level of meaning in language is
influenced by and interacts with the experiential output of the emotion
scheme. However, emotion scheme activation provides our basic mode of
processing information and sets specific emotion-based scripts (e.g.,
seeking, safety, closeness, boundary protection) into motion, plus certain
anticipatory expectations that guide ways of thinking. Emotion schemes
themselves are not directly available to awareness but can only be
accessed indirectly through the experiences they produce. EFT works to
activate schemes, articulate their output in language, and then explore and
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reflect on this experience to create new meaning (Greenberg, 2002;
Greenberg & Safran, 1987).
Emotion schemes thus provide implicit higher order organizations of
experience based on biologically given emotional responses influenced by
the person’s history of lived emotional experience. The emotion schematic
memory system is the central catalyst of self-organization. It is the
generator of not only healthy states such as confidence, calm, and security
but also of disordered self-organizations, such as anxious insecurity,
shame-based worthlessness, or lonely abandonment. Emotion schemes and
their activation are the final targets of intervention.
TYPES OF EMOTION
Not all emotion serves the same function. It is theoretically and
clinically crucial to distinguish between different types of emotional
experience and expression in order to guide intervention. Four types of
emotional experience are outlined in this section.
The normal function of emotion is to rapidly process complex
situational information, to provide feedback to the person about his or her
reaction, and to prepare the person to take effective action. Such
uncomplicated responses are referred to as primary adaptive emotion
responses because the emotion is a direct reaction consistent with the
immediate situation, and it helps the person take appropriate action. For
example, if someone is threatening to harm your children, anger is an
adaptive emotional response because it helps you take assertive (or if
necessary, aggressive) action to end the threat. Fear is the adaptive
emotional response to danger and prepares us to take action to avoid or
reduce the danger, by freezing and monitoring, or, if necessary, by fleeing.
Shame, on the other hand, signals that we have been exposed as having
acted inappropriately and are at risk of being judged or rejected by others;
it therefore motivates us to correct or hide in order to protect our social
standing and relationships. Rapid, automatic responding of this kind
helped our ancestors survive. Such responses are to be accessed and
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promoted. Not all emotions, however, are functional or fit the situation.
The three types described in the following paragraphs generally are
dysfunctional.
Maladaptive primary emotions are also direct reactions to situations,
but they no longer help the person cope constructively with the situations
that elicit them; rather, they interfere with effective functioning. These
emotion responses generally involve overlearned responses, based on
previous, often traumatic, experiences. For example, a fragile client may
have learned when she was growing up that closeness was generally
followed by physical or sexual abuse. Therefore, she will automatically
respond to caring or closeness with anger and rejection as a potential
violation.
Secondary reactive emotions follow some more primary response
(i.e., they come second). Often people have emotional reactions to their
initial primary adaptive emotion, so that it is replaced with a secondary
emotion. This “reaction to the reaction” obscures or transforms the original
emotion and leads to actions that are, again, not entirely appropriate to the
current situation. For example, a man who encounters rejection and begins
to feel sad or afraid may become either angry at the rejection (externally
focused) or angry with himself for being afraid (self-focused), even when
the anger is not functional or adaptive. Many secondary emotions obscure
or defend against a painful primary emotion; others are emotional
reactions to primary emotions. If the man feels ashamed of his fear, he
experiences secondary shame. People can feel afraid of, or guilty about,
their anger, ashamed of their sadness, or sad about their anxiety.
Secondary emotions can also be responses to interceding thoughts—in
other words, an emotion that is secondary to a thought (e.g., feeling
anxious because of an expectation of rejection). Some emotions can be
secondary to thought, but it is important to notice that this is symptomatic
emotion and that the thought itself stems from a more primary mode of
processing set in motion by a maladaptive emotion scheme, probably the
fear of rejection. Although thought can produce emotion, not all emotion is
produced by thought.
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Instrumental emotions are emotions expressed to influence or control
others. For example, crocodile tears may be expressed to elicit support,
anger to dominate, and shame often is expressed deliberately to indicate
that one is socially appropriate. A person may respond deliberately or out
of habit, automatically or without full awareness. In either case, the display
of emotion is independent of the person’s original emotional response to
the situation, although the expression may induce some form of internal
emotional experience. These emotions are referred to as manipulative or
racket feelings.
REFERENCES
Angus, L., & Greenberg, L. S. (2011). Working with narrative in emotion-
focused therapy: Changing stories, healing lives. Washington, DC:
American Psychological Association.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work
through their feelings. doi:10.1037/10447-000
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-focused couples therapy:
The dynamics of emotion, love, and power. doi:10.1037/11750-000
Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in
psychotherapy. New York, NY: Guilford Press.
Greenberg, L. S., & Pascual-Leone, J. (1995). A dialectical constructivist
approach to experiential change. In R. A. Neimeyer & M. J. Mahoney
(Eds.), Constructivism in psychotherapy (pp. 169–191).
doi:10.1037/10170-008
Greenberg, L., & Pascual-Leone, J. (2001). A dialectical constructivist view of
the creation of personal meaning. Journal of Constructivist Psychology,
14, 165–186. doi:10.1080/10720530151143539
Greenberg, L., Rice, L., & Elliott, R. (1993). Facilitating emotional change.
New York, NY: Guilford Press.
Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy: Affect,
cognition, and the process of change. New York, NY: Guilford Press.
Le Doux, J. (1996). The emotional brain: The mysterious underpinnings of
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emotional life. New York, NY: Simon and Schuster.
Oatley, K. (1992). Best laid schemes. New York, NY: Cambridge University
Press.
Pascual-Leone, J. (1991). Emotions, development, and psychotherapy: A
dialectical constructivist perspective. In J. Safran & L. Greenberg (Eds.),
Emotion, psychotherapy, and change (pp. 302–335). New York, NY:
Guilford Press.
Piaget, J., & Inhelder, B. (1973). Memory and intelligence. London, England:
Routledge and Kegan Paul.
Excerpted from Emotion-Focused Therapy (2011), from Chapter 3, “Theory,” pp. 36–44. Copyright 2011
by the American Psychological Association. Used with permission of the author.
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14
EMOTION-FOCUSED THERAPY PROCESS
LESLIE S. GREENBERG
The two major tasks are helping people (a) with too little emotion
access more emotion and (b) with too much emotion to contain their
emotions. There are many possible ways of helping clients access feelings,
including encouraging attention to bodily sensations that cue emotions,
helping clients recall previous emotion episodes or situations that bring up
particular feelings, and using vivid emotion cues, such as poignant words
or images in communicating with clients. In addition, therapists can
suggest that clients act as if they feel a certain way, or exaggerate and
repeat phrases or gestures (e.g., speaking in a loud, angry voice; shaking
one’s fist). It also is important to help clients monitor their level of arousal
in order to maintain the safety that allows emotion to arise. This latter
strategy is very important because most people cut off access to their
feelings if they sense that they are losing control.
Therapists often ask me what they should do to access emotion in
constricted clients or to help regulate dysregulated clients. These questions
are better posed as follows: In what kind of relationship will a therapist be
able to help the client access or regulate emotion? The relationship always
plays a key role in both accessing and influencing the type of emotion
experienced and how it is processed. The assumption in emotion-focused
therapy (EFT) is that the therapist is a potential agent in accessing emotion
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through affect attunement, in regulating emotion through interpersonal
soothing, and in providing new emotional experiences through the
relationship.
Types of empathy that help clients access and symbolize their
emotions range from purely understanding empathic responses, through
validating and evocative responses, to exploratory and conjectural
responses as well as empathic refocusing (Elliott, Watson, Goldman, &
Greenberg, 2004; Greenberg & Elliott, 1997). Empathic exploration is the
fundamental mode of intervention in EFT and is a response that is focused
on the leading edge of the client’s experience—that which is most alive or
poignant or implicit—to help it unfold. When a therapist’s response is
structured in such a way that it ends with a focus on what seems most alive
in a client’s statement, the client’s attention is in turn focused on this
aspect of his or her experience and more likely to differentiate this leading
edge of his or her experience. By sensitively attending, moment by
moment, to what is most poignant in clients’ spoken and nonspoken
(nonverbal) narrative, a therapist’s verbal empathic exploration can help
capture clients’ experiences even more richly than the clients’ descriptions.
This helps clients symbolize previously implicit experience consciously in
awareness.
Clients usually begin therapy by telling the story of their problem.
EFT therapists start with empathy and encourage clients to focus inward
and deepen their experience. If this does not deepen client experience, they
move to focusing, guiding attention to the bodily felt sense. This often is
followed later by more stimulating interventions such as chair dialogues
and imagery work in which affect is heightened to bring it vividly into
focal awareness.
The therapist encourages clients to bring their attention to their
experiencing as it is bodily felt and to ask themselves, “What’s
problematic for me?” The therapist then helps the client verbalize the
feeling, focus on the experiential effect this has, sense a problem as a
whole, and let what is important come up from that bodily sensing. This is
the focusing process and represents the basic style of engagement with
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internal experience that is being encouraged.
EFT therapists also help clients who feel overwhelmed or emotionally
flooded develop adaptive strategies for containing emotion by using a
range of possibilities, including observing and symbolizing the
overwhelming feelings (e.g., meditatively creating a safe distance by
adopting an observer’s stance and describing one’s fear as a black ball
located in one’s stomach). Offering support and understanding and
encouraging clients to seek others’ support and understanding are also
helpful in regulating emotions, as is encouraging clients to organize their
distressing emotions (e.g., by making a list of problems). Helping clients
to engage in self-soothing is a crucial strategy. Here the therapist
encourages relaxation, self-comfort, and self-care (e.g., “Try telling this
other part of you, ‘It’s OK to feel sad’”). Helping clients in distress distract
themselves (e.g., by counting backwards or going in imagination to a safe
place) is another useful intervention for promoting regulation. If clients
become overwhelmed in the session, the therapist can regulate their
distress by suggesting that they breathe, put their feet on the ground, feel
themselves in their chair, look at the therapist, and describe what they see.
Paradoxically, one of the most effective ways of helping clients
contain emotion may actually be helping them to become aware of it,
express it, and decide what to do about it as soon as it arises. This is
because suppressing an emotion and doing nothing about it tend to
generate more unwanted emotional intrusions, making it more
overwhelming or frightening. One of the dilemmas for clients and
therapists alike is knowing when to facilitate awareness and experience of
emotion and when to regulate it. A helpful practical guideline, especially
for people who experience overwhelming destructive emotions, is to be
aware of how intense the feeling is and to use this as a guide to coping.
Emotional approach and awareness should be used when the emotions are
below some manageable level of arousal, say 70%, but distraction and
regulation should be applied when they exceed this level and the emotions
become unmanageable.
In addition to these general strategies for working with emotion, the
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different types of emotion described in Chapter 3 must be worked with in
different ways. Primary adaptive emotions must be accessed and more
fully allowed to provide information and action tendency. To help clients
sort out if what they are feeling is a primary adaptive emotion, therapists
respond empathically and act as surrogate information processors, offering
symbols to describe feelings that clients can check against their
experiences for fit. Therapists can help to assess whether an emotion is
primary by asking, “Is this what your core feeling is at rock bottom?” or
prompting them (“Check inside; see if this is your most basic feeling”).
Maladaptive emotions are best handled by helping the client to approach,
allow, tolerate, symbolize, regulate, and explore these emotions. After they
have been accessed and accepted rather than avoided, they become
amenable to change by accessing different underlying emotions (e.g.,
undoing maladaptive shame with anger, self-compassion, or pride) and by
reflecting on them to make sense of them. Therapists help clients access
these emotions by means of empathic exploration of, and empathic
conjectures into, the client’s deeper experience. To access maladaptive
emotions, therapists might ask, “What is your most vulnerable feeling, one
you have had from early on, ever since you can remember?” or “Does this
feeling feel like a response to things that have happened in the past, or
does it feel mainly like a response to what’s happening now?” Other
questions that are helpful are “Does this feel like a familiar stuck feeling?”
and “Will this feeling help you deal with the situation?”
Secondary reactive emotions are best responded to with empathic
exploration in order to discover the underlying primary emotions from
which they are derived (e.g., primary fear under reactive anger). To get
beneath the secondary emotions, therapists also might ask, “When you feel
that, do you feel anything in addition to what you’re most aware of
feeling?” or “Take a minute and see if it feels like there is something else
underneath that feeling.” Instrumental emotions are best explored for their
interpersonal function or intended impact on others. After conveying an
understanding that the person feels sad or angry, the therapist might say, “I
wonder if maybe you are trying make a point or tell this person something
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with this feeling?” People may recognize the intention in their emotional
experience, be it their desire for self-protection or comfort or their attempt
to dominate the other.
PRINCIPLES OF EMOTIONAL CHANGE
From the EFT perspective, change occurs by helping people make
sense of their emotions through awareness, expression, regulation,
reflection, transformation, and corrective experience of emotion in the
context of an empathically attuned relationship that facilitates these
processes. These empirically supported principles of emotional change
(Greenberg, 2002) are discussed below in relation to working with
emotion in therapy and not with reference to managing emotion in life. For
example, in therapy it often is helpful to promote awareness, arousal, and
expression of traumatic fear or unexpressed resentment to a significant
other, whereas in life one might want to promote coping behaviors and
regulation of affect.
Awareness
Increasing awareness of emotion is the most fundamental overall goal
of treatment. When people know what they feel, they reconnect to their
needs and are motivated to meet them. Increased emotional awareness is
therapeutic in a variety of ways. Becoming aware of and symbolizing core
emotional experience in words provide access both to the adaptive
information and the action tendency in the emotion. It is important to note
that emotional awareness is not thinking about feeling; it involves feeling
the feeling in awareness. What is disowned or split off cannot change.
When that which is disclaimed is felt, it changes. Only when emotion is
felt does its articulation in language become an important component of its
awareness. The goal is acceptance of emotion. Self-acceptance and self-
awareness are interconnected. To truly know something about oneself, one
must accept it.
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Three important stages of emotion awareness of problematic
emotions can be delineated. The first stage of change is awareness of
emotion after the event, when a person is reflecting on what was felt in the
past, which can serve as a basis for learning how to respond better in the
future. This also may include awareness of the trigger of the emotional
response. Much of insight-oriented therapy stops at step one, in which
people understand why they acted in a particular way they regretted, but
this does not help them to stop behaving that way or being triggered again
by similar situations. The second stage is reduction in the length of time it
takes an emotion to determine one’s feelings. The third stage is
recognizing the emergence of the emotion as it is arising and being able to
head it off before it arises (e.g., one recognizes the impulse to anger or
disappointment and can transform it before it emerges fully). Here one can
see the impulse before the action. Finally, in the last stage of change the
emotion is not triggered in the first instance.
Expression
Expressing emotion in therapy does not involve venting secondary
emotion but rather overcoming avoidance to experience and being able to
express previously constricted primary emotions (Greenberg & Safran,
1987). Expressive coping also may help one attend to and clarify central
concerns and may serve to promote pursuit of goals. There can be no
universal rule about the effectiveness of emotional expression, and the
distinction between the role of expression in therapy, to reexperience and
rework past problematic experience, versus expression in life must be
maintained. The role of arousal and expression and the degree to which
they could be useful in therapy (and in life) depend on what emotion is
expressed, about what issue, how it is expressed, by whom, to whom,
when and under what conditions, and in what way the emotional
expression is followed by other experiences of affect and meaning. In daily
life, expression of problematic emotions is often not helpful. In therapy,
arousal and expression are necessary but not always sufficient for
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therapeutic progress.
Because of the strong human tendency to avoid experiencing and
expressing painful emotions, clients must be encouraged to overcome
avoidance and approach painful emotion in sessions by attending to their
bodily experience, often in small steps. This may involve changing explicit
beliefs (e.g., “Anger is dangerous” or “Men don’t cry”) governing their
avoidance or helping them face their fear of dissolution (Greenberg &
Bolger, 2001). Then clients must allow and tolerate being in live contact
with their emotions. These two steps, approaching emotion and tolerating
often uncomfortable emotion, are consistent with notions of exposure.
Extensive research supports the effectiveness of exposure to previously
avoided feelings for a sufficient length of time in reducing its negative
effect (Foa & Jaycox, 1999). From the emotion-focused perspective,
however, the emotional processing steps of approach, arousal, and
tolerance of emotional experience are necessary but not sufficient for
change of primary maladaptive emotions. Optimum emotional processing
involves both the integration of cognition and affect (Greenberg, 2002;
Greenberg & Pascual-Leone, 1995; Greenberg & Safran, 1987) and the
transformation of affect, not only its tolerance (Greenberg, 2002). After
contact with primary maladaptive emotional experience such as core
shame or basic insecurity is achieved and the emotion is expressed, clients
must also cognitively orient to that experience as information; symbolize it
in awareness and explore, reflect on, and make sense of it; and finally
transform it.
Regulation
The third principle of emotional processing involves the regulation of
emotion. For some individuals, psychological disorders and situations
emotions are under- or dysregulated (Linehan, 1993). An important issue
in any treatment is what emotions are to be regulated; how they are to be
regulated then becomes a central aspect of treatment. Emotions that
require down-regulation generally are either secondary emotions, such as
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despair and hopelessness, or anxiety about anxiety or primary maladaptive
emotions, such as the shame of being worthless, the anxiety of basic
insecurity, and panic.
The first step in helping emotion regulation is the provision of a safe,
calming, validating, and empathic environment. This helps soothe
automatically generated underregulated distress (Bohart & Greenberg,
1997) and helps strengthen the self. This is followed by the teaching of
emotion regulation and distress tolerance skills (Linehan, 1993) involving
such things as identifying triggers, avoiding triggers, identifying and
labeling emotions, allowing and tolerating emotions, establishing a
working distance, increasing positive emotions, self-soothing, breathing,
and seeking distraction. Forms of meditative practice and self-acceptance
often are most helpful in achieving a working distance from overwhelming
core emotions. The ability to regulate breathing and to observe one’s
emotions and let them come and go are important processes to help
regulate emotional distress.
Another important aspect of regulation is developing clients’ abilities
to self-soothe and develop self-compassion. Emotion can be down-
regulated by soothing at a variety of different levels of processing.
Physiological soothing involves activation of the parasympathetic nervous
system to regulate heart rate, breathing, and other sympathetic functions
that speed up under stress. Promoting clients’ abilities to receive and be
compassionate to their emerging painful emotional experience is an
important step toward tolerating emotion and self-soothing. Being able to
soothe the self develops initially by internalization of the soothing
functions of the protective other (Sroufe, 1996; Stern, 1985). Over time
this is internalized and helps clients develop implicit self-soothing, the
ability to regulate feelings automatically without deliberate effort.
Reflection
In addition to recognizing emotions and symbolizing them in words,
promoting further reflection on emotional experience helps people make
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narrative sense of their experience and promotes its assimilation into their
ongoing self-narratives. What we make of our emotional experience makes
us who we are. Reflection helps to create new meaning and develop new
narratives to understand experience (Goldman, Greenberg, & Pos, 2005;
Greenberg & Angus, 2004; Greenberg & Pascual-Leone, 1997;
Pennebaker, 1995). Pennebaker (1995) showed the positive effects of
writing about emotional experience on autonomic nervous system activity,
immune functioning, and physical and emotional health and concluded that
through language, individuals are able to organize, structure, and
ultimately assimilate both their emotional experiences and the events that
may have provoked the emotions.
Exploration of emotional experience and reflection on what is
discovered to form coherent narratives are other important processes in
change. Reflection promotes understanding of the way in which the self is
psychologically constructed and constituted. Narrative provides a
cognitive organizing process, a type of temporal gestalt where the meaning
of individual life events and actions is determined by a particular plot or
theme. The story renders the experiences and memories of the client into a
meaningful coherent story, orders our experience, and provides a sense of
identity. Human beings long to experience their own sense of personal
meaning and need to create meaning to overcome an existential vacuum.
Transformation
Probably the most important way of dealing with maladaptive
emotion in therapy involves not mere exposure to the maladaptive
emotion, nor its regulation, but its transformation by other emotions. This
applies most specifically to transforming primary maladaptive emotions,
such as fear and shame and the sadness of lonely abandonment, with other
adaptive emotions (Greenberg, 2002). I suggest that maladaptive
emotional states are best transformed by undoing them by activating other
more adaptive emotional states. In EFT, an important goal is to arrive at
maladaptive emotion, not for its good information and motivation but to
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make it accessible to transformation. In time, the coactivation of the more
adaptive emotion, along with or in response to the maladaptive emotion,
helps transform the maladaptive emotion. The paradox of the path to
emotional change is that it needs to start not with trying to change emotion
but with fully accepting the painful emotion. Emotions must be fully felt
and their message heard before they are open to change by other emotions.
A major premise guiding intervention in EFT is that if you do not accept
yourself as you are, you cannot make yourself available for transformation.
One cannot leave a place until one has arrived at it; for emotion, one has to
feel it to heal it. Even those aspects of oneself one truly wants to change
must first be accepted, even embraced. Self-transformation thus is always
preceded by self-acceptance.
The process of changing emotion with emotion goes beyond ideas of
catharsis, completion and letting go, exposure, extinction, or habituation,
in that the maladaptive feeling is not purged, nor does it simply attenuate
by the person feeling it; rather, another feeling is used to transform or undo
it. Although dysregulated secondary emotions such as the fear and anxiety
in phobias, obsessive compulsiveness, and panic and fear-laden intrusive
images may be overcome by mere exposure, in many situations primary
maladaptive emotions (e.g., the shame of feeling worthless, the anxiety of
basic insecurity, and the sadness of abandonment) are best transformed by
contact with other emotions. For example, change in primary maladaptive
emotions such as core shame or fear of abandonment is brought about by
the coactivation of an incompatible, more adaptive experience such as
empowering anger and pride or compassion for the self to the same
situations. The new emotion undoes the old response rather than
attenuating it (Fredrickson, 2001). This involves more than simply feeling
or facing the feeling, which leads to its diminishment; rather, the
withdrawal of tendencies primary maladaptive fear or shame (for example)
is transformed into staying in contact by activating the approach
tendencies in anger or comfort-seeking sadness.
In therapy, maladaptive fear of abandonment or annihilation from
past childhood maltreatment, once aroused in the present, can be
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transformed into security by the activation of more empowering,
boundary-establishing emotions of adaptive anger or disgust at the
maltreatment that were felt in the past but not expressed, or by evoking the
previously inaccessible softer soothing feelings of sadness and need for
comfort or compassion toward the self. Similarly, maladaptive anger can
be undone by adaptive sadness. Maladaptive shame, which was
internalized from the contempt of others, can be transformed by accessing
both anger at violation at the abuse one suffered, by self-compassion, and
by accessing pride and self-worth; anger at being unfairly treated or
thwarted is an antidote to hopelessness and helplessness. The tendency to
shrink into the ground in shame or collapse in helplessness can be
transformed by the thrusting forward tendency in presently accessed anger
at violation. Withdrawal emotions from one side of the brain are replaced
with approach emotions from another part of the brain or vice versa
(Davidson, 2000a, 2000b). After the alternate emotion has been accessed,
it transforms or undoes the original state and a new state is forged. Often a
period of regulation or calming of the maladaptive emotion in need of
change, and making sense of it, is needed before the activation of an
opposing transforming emotion.
How does the therapist help the client access new emotions to change
emotions? A number of ways have been outlined (Greenberg, 2002).
Therapists can help the client access new subdominant emotions occurring
in the present by a variety of means, including shifting attention to
emotions that are currently being expressed but are only “on the
periphery” of a client’s awareness—or, when no other emotion is present,
focusing on what is needed, and thereby mobilizing a new emotion
(Greenberg, 2002). The newly accessed, alternate feelings are resources in
the personality that help change the maladaptive state. These new feelings
either were felt in the original situation but not expressed or are felt now as
an adaptive response to the old situation. Bringing out implicit adaptive
anger at a perpetrator can help change maladaptive fear in a trauma victim.
When the tendency to run away in fear is combined with the tendency of
angry individuals to thrust forward, this leads to a new relational position
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of holding the abuser accountable for wrongdoing while seeing oneself as
having deserved protection, rather than feeling guilty and unsafe. It also is
essential both to symbolize, explore, and differentiate the primary
maladaptive emotion (in this case fear), and regulate it by breathing and
calming, before cultivating access to the new more adaptive emotion (in
this case anger).
Other methods of accessing new emotion involve using enactment
and imagery to evoke new emotions, remembering a time an emotion was
felt, changing how the client views things, or expressing an emotion for
the client (Greenberg, 2002). Once accessed, these new emotional
resources begin to undo the psycho-affective motor program previously
determining the person’s mode of processing. New emotional states enable
people to challenge the validity of perceptions of self and other connected
to maladaptive emotion, weakening its hold on them. Accessing adaptive
needs acts automatically as disconfirmation of maladaptive feelings and
beliefs.
In my view, enduring emotional change of maladaptive emotional
responses thus occurs by generating a new emotional response, not
through a process of insight or understanding but by generating new
responses to old situations and incorporating these into memory. EFT
works on the basic principle that people must first arrive at a place before
they can leave it. Maladaptive emotion schematic memories of past
childhood losses and traumas are activated in the therapy session in order
to change these by memory reconstruction. Introducing new present
experience into currently activated memories of past events has been
shown to lead to memory transformation by the assimilation of new
material into past memories (Nadel & Bohbot, 2001). By being activated
in the present, the old memories are restructured by the new experience of
both being in the context of a safe relationship and by the coactivation of
more adaptive emotional responses and new adult resources and
understanding to cope with the old situation. The memories are
reconsolidated in a new way by incorporating these new elements. The
past can in fact be changed—at least the memories of it can be!
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Corrective Emotional Experience
New lived experiences with another person (often the therapist) are
especially important in providing an interpersonal corrective emotional
experience. Experiences that provide interpersonal soothing, disconfirm
pathogenic beliefs, or offer new success experience can correct previously
established interpersonal patterns. An experience in which a client faces
shame in a therapeutic context and experiences acceptance, rather than the
expected contempt or denigration, has the power to change the feeling of
shame. Having one’s anger accepted by the therapist rather than rejected
leads to new ways of being. Now the client can express vulnerability or
anger with the therapist without being punished and can assert without
being censured. The undeniable reality of this new emotional experience
allows clients to experience that they are no longer powerless children
facing powerful adults. Corrective emotional experiences in EFT occur
predominantly in the therapeutic relationship, although success experience
in the world is also encouraged.
The goal in EFT is for clients, with the help of more favorable
circumstances in therapy, to experience mastery in reexperiencing
emotions they could not handle in the past. The client then undergoes a
corrective emotional experience that repairs the damaging influence of
previous relational experiences. Corrective interpersonal emotional
experiences also occur generally throughout the therapeutic process,
whenever the patient experiences the therapist as attuning to and validating
the client’s inner world. Overall, the genuine relationship between the
patient and the therapist, as well as its constancy, is a corrective emotional
experience.
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development. New York, NY; Cambridge University Press.
doi:10.1017/CBO9780511527661
Stern, D. (1985). The interpersonal world of the infant. New York, NY: Basic
Books.
Excerpted from Emotion-Focused Therapy (2011), from Chapter 4, “The Therapy Process,” pp. 70–82.
Copyright 2011 by the American Psychological Association. Used with permission of the author.
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APPENDIX 14.1: EMOTION-FOCUSED THERAPY TECHNIQUES
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15
EXISTENTIAL THERAPY
KIRK J. SCHNEIDER AND ORAH T. KRUG
GOALS OF THE APPROACH
Freedom Within Limits
The aim of existential–humanistic (E–H) therapy is to “set clients
free” (May, 1981, p. 19). Freedom is understood as the capacity for choice
within the natural and self-imposed limits of living (Schneider, 2008). The
natural limits of living refer to the inherent limitations of birth, heredity,
age, and so forth, and the realities of living—often referred to as “the
givens of existence”—such as death, separateness, and uncertainty. Self-
imposed limits are the boundaries established by humans, such as culture,
language, and lifestyle.
The freedom to do or to act is probably the clearest freedom we
possess. The freedom to be or to adopt attitudes toward situations is a less
clear but even more fundamental freedom (May, 1981). Freedom to do is
generally associated with external, physical decisions, whereas freedom to
be is associated with internal, cognitive, and emotional stances. Within
these freedoms we have a great capacity to create meaning in our lives—to
conceptualize, imagine, invent, communicate, and physically and
psychologically enlarge our worlds (Yalom, 1980). We also have the
capacity to separate from others; to transcend our past; and to become
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distinct, unique, and heroic (Becker, 1973). Conversely, we can choose to
restrain ourselves, to become passive, and to give ourselves over to others
(May, 1981; Rank, 1936). We can choose to be a part of others or apart
from others, a part of our possibilities or apart from our possibilities
(Bugental & Kleiner, 1993).
Acknowledge Freedom’s Limitations
Notwithstanding the vast possibilities, there are great limitations on
all these freedoms. We can only do and be so much. Whatever we choose
implies a relinquishment of something else (Bugental, 1987, p. 230). If we
devote ourselves to scholarship, we relinquish a degree of athleticism. If
we engage in wealth accumulation, we lessen our opportunities for
spiritual pursuits. Moreover, every freedom has its price. If one stands out
in a crowd, one becomes a larger target for criticism; if one acquires
responsibility, one courts guilt; if one isolates oneself, one loses
community; if one merges and fuses with others, one loses individuality,
and so on (Becker, 1973; May, 1981). Finally, every freedom has its
counterpart in destiny. May (1981) defines four kinds of destiny, or
“givens” beyond our control: cosmic, genetic, cultural, and circumstantial.
Cosmic destiny embraces the limitations of nature (e.g., earthquakes,
climatic shifts); genetic destiny entails physiological dispositions (e.g., life
span, temperament); cultural destiny addresses preconceived social
patterns (e.g., language, birthrights); and circumstantial destiny pertains to
sudden situational developments (e.g., oil spills, job layoffs). In short, our
vast potentialities are matched by crushing vulnerabilities. We are
semiaware, semicapable, in a world of dazzling incomprehensibility.
How, then, shall we deal with these clashing realities according to
existential theorists, and what happens when we do not? Let us consider
the latter first. The failure to acknowledge our freedom, according to
existential theorists, results in the dysfunctional identification with limits,
or repressed living (May, 1981). This dysfunctional identification forfeits
the capacity to enliven, embolden, and enlarge one’s perspective. The
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reticent wallflower, the pedantic bureaucrat, the paranoid reactionary, and
the robotic conformist are illustrations of this polarity. The failure to
acknowledge our limits, on the other hand, results in the sacrifice of our
ability to discipline, discern, and prioritize life’s chances (May, 1981). The
aimless dabbler, the impulsive con man, the unbowed hedonist, and the
power-hungry elitist exemplify this polarity.
Integrate Freedom and Limitation
The great question, of course, is how to help clients become
emancipated from their polarized conditions and “experience their
possibilities” as they engage their destinies (May, 1981, p. 20). Put another
way, how do we help clients to integrate freedom and limits? This
question strikes at the heart of another existential problem—that of
identity. Whereas reprogramming clients’ behaviors or helping them to
understand the genesis of their polarized conditions leads to partially
rejuvenated identities, for existential theorists, experiential encounters
with these conditions are the great underappreciated complements to the
aforementioned change processes (Schneider, 2007, 2008). The E–H
practitioner believes that if life-limiting patterns are experienced in the
present, then clients will be more willing and able to choose life-affirming
patterns in the future. Put another way, the path to greater freedom is
paradoxically found through an encounter with the ways in which we are
bound (Krug, 2009).
The experiential modality for existential theorists embraces four basic
dimensions: the immediate, the kinesthetic, the affective, and the profound
or cosmic (Schneider, 2008). The road to a fuller, more vital identity, in
other words, is to help clients experience their polarized conditions, to
assist them to “embody” those conditions and their underlying fears and
anxieties, and to help them attune, at the deepest levels, to the implications
of what has been discovered. In so doing, E–H therapists help clients to
respond to, as opposed to react against, panic-filled material. This work
typically results in clients experiencing their polarized conditions as
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restrictive or self-limiting. Consequently, it not only allows clients to
understand their part in the construction of their restrictive patterns, it also
helps them accept the givens of existence that may have been avoided,
denied, or repressed. However, for the E–H practitioner, responsibility
assumption is not sufficient. It is simply preparatory for substantive
change evidenced when clients choose more life-affirming patterns for
themselves and with others. The net result, according to existential
theorists, is an expanded sense of self, specifically an enhanced capacity
for intimacy, meaning, and spiritual connection in one’s life (Bugental,
1978; May, 1981).
An Illustration of This Process
The classic case of Mercedes, by Rollo May (1972), further illustrates
this standpoint. Mercedes lived much of her life in subordination to others.
Her stepfather was a pimp and her mother a prostitute. Mercedes herself
was coerced into prostitution to enable the family to subsist. Yet,
Mercedes bristled at her subservient position. She harbored tremendous
resentment toward her “clientele” and even more toward her “caretakers.”
She was frequently depressed, impaired in her love life, and unable to
carry her pregnancies with her husband to full term. May utilized many
approaches to help Mercedes confront and integrate her rage, which in his
view portended her freedom. These efforts, however, invariably failed to
spark her, until one day when he encountered her experientially. Instead of
encouraging her to acknowledge her resentment, he acknowledged it for
her. He vented his fury on her stepfather; he unleashed his indignation
toward her mother; and he embodied the bitterness she had harbored. In
turn, Mercedes was finally able to affirm and express these qualities—
directly and bodily—in herself. The upshot, according to May, is that
Mercedes integrated her freedom: She quit prostitution, revived her
marriage, and carried her pregnancy to term.
Varied Interpretations of Experiential Encounter
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The experiential mode is diversely interpreted by existential theorists.
For example, Yalom (1980) appears to stress the immediate and affective
elements of his interpersonal therapeutic contacts, but he refers little to
kinesthetic components. Bugental (1987) stresses kinesthetic elements of
his encounters—illuminating what is “implicitly present but unregarded”
(Bugental, 1999, p. 25)—but places lesser emphasis on interpersonal
implications of those elements (Krug, 2009). Tillich (1952) and Friedman
(1995) accent the interpersonal dimension of therapeutic experiencing but
convey little about the kinesthetic aspect.
There are also differences among existential theorists regarding
verbal and nonverbal channels of communication. May (1983), Yalom
(1980), and Friedman (1995), for example, rely relatively heavily on
verbal interventions, whereas Bugental (1987), Gendlin (1996), and Laing
(1967) draw upon comparatively nonverbal forms of mediation.
Finally, there are differences among existential theorists with regard
to philosophical implications of therapeutic experiencing. Although most
existential theorists agree that clients need to confront the underlying
givens (or ultimate concerns) of human existence during the course of a
typical therapy, the nature and specificity of these givens varies. Whereas
Yalom (1980), for example, focuses on the need for clients to
experientially confront death, freedom, isolation, or meaninglessness,
Bugental provides a more elaborate schema: the need for clients to
confront embodiment–change, finitude–contingency, action–responsibility,
choice–relinquishment, separation–apartness, or relation–being a part of
(Bugental & Kleiner, 1993). And whereas May (1981) unites these
positions with his notion of freedom and destiny (or limitation), as
previously suggested, there is only a vague explication of this synthesis in
his work.
A Central Concern: The Present Moment
Despite these differences, each theorist shares a central concern—
namely, how is this client in this moment coping with his or her awareness
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of being alive? The E–H theorists address this concern by focusing more
on the implicit—moment to moment—processes in therapy than on
explicit content. E–H theorists take an ahistorical approach; that is, the
past is integral only insofar as it is alive, within the person, in the present
moment. Moreover, E–H therapists seek to understand a person as a
human being in the world, related to his or her physical, personal, and
social worlds. It is assumed that a person is not simply a collection of
drives and behavior patterns within an encapsulated self. It is further
assumed that each person is more than the sum of his or her parts and that
each person constructs a particular world from unique perceptions of the
world. Finally, the E–H therapist assumes, as May (1983) suggests, that
“the person and his world are a unitary, structural whole . . . two poles, self
and world, are always dialectically related” (p. 122).
Consequently, the E–H theorist takes a step back from examining a
person’s drives and specific behavior patterns; with a wider scope, she or
he understands these in the context of a person’s relation to existence
(May, 1958a, 1958b; Merleau-Ponty, 1962). These relations, which
manifest as structures, are not abstract but actual, and though they may be
obscured from conscious awareness, they are nevertheless evident (though
perhaps implied) in the present moment. They express themselves through
words spoken, and not through bodily gestures, vocal tones, dreams, and
behavior patterns.
The Cultivation of Presence
The existential therapist aims to know the person who comes for
therapy at this “structural” level. As May (1958a) states, “The grasping of
the being of the other person occurs on a quite different level from our
knowledge of specific things about him” (p. 38). In order to “grasp the
being” of the client, and consequently help the client “grasp her being,” the
therapist must bring a full and genuine presence to the therapeutic
encounter. The Latin root for presence is prae (before) + esse (to be); thus,
presence means “to be before.” Consequently, presence in a therapeutic
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setting can be understood as the capacity “to be before” or to be with one’s
being and/or “to be before” or to be with another human being.
Presence involves aspects of awareness, acceptance, availability, and
expressiveness in both therapist and client. Presence implies that the
encounter is real. For Martin Buber (1937/1970), it means that the person
who is before one has ceased being an “it” and has become a “thou”; it
means that we are all humans who include each other in each other’s
recognition. Indeed, as Gabriel Marcel (1951) suggests, intersubjective
presence begins with “we are” as opposed to “I think.” If one can be truly
present with another, then a genuine encounter has occurred.
Even with this emphasis on presence, E–H theorists recognize the
influence of the past in their present-centered encounters. They
acknowledge, for example, the power of developmental deficits to impact
therapeutic processes (Schneider, 2008; Yalom, 1980). However, the bases
of those deficits and the contexts within which they are addressed differ
significantly from those advanced by more conventional standpoints. For
example, whereas psychoanalytically oriented theorists tend to view
ruptures in early interpersonal relationships as the bases for developmental
deficits, E–H-oriented theorists take a wider view. This view
acknowledges those early ruptures but goes beyond them to embrace the
fuller experience of rupture or estrangement before being itself (May,
1981; Schneider, 2008; Yalom, 1980). Put another way, whereas
psychoanalytic theorists tend to focus on isolable family or physiological
factors in the etiology of suffering, E–H theorists tend to home in on
dimensions that are purported to underlie such factors, such as the
experience of life’s vastness, the terror of dissolving before, or, on the
other hand, exploding into life’s vastness and the struggle with the enigma
of death (Becker, 1973; Schneider, 1993, 1999a, 1999b, 2008; Yalom,
1980).
Given this background, it may now be clearer why E–H theorists
focus on here-and-now experiences of the past (as manifested in body
posture, vocal tone, etc.) over discussions about the past. Whereas
discussions can help clients to assimilate a specifiable event, such as an
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abuse memory, experiential awareness can help clients to assimilate the
life stance, such as the sense of dissolution that both echoes and transcends
the event.
For E–H theorists, accordingly, the deepest roots of trauma cannot
simply be talked about or explained away; they must be rediscovered, felt,
and lived through (Bugental, 1987; Krug, 2009; Schneider, 2008).
Four Core Aims
To sum, E–H theorists share four core aims: (a) to help clients to
become more present to themselves and others; (b) to help them
experience the ways in which they both mobilize and block themselves
from fuller presence; (c) to help them take responsibility for the
construction of their current lives; and (d) to help them choose or actualize
ways of being in their outside lives based on facing, not avoiding, the
existential givens such as finiteness, ambiguity, and anxiety.
KEY CONCEPTS
Sense of Self
E–H psychology assumes that one does not experience a personality;
one lives an experience. Moreover, E–H psychology assumes that lived
experience is the basis on which one forms or creates a sense of self (May,
1975). E–H theorists’ understanding of identity formation, or the “I am”
experience, has been significantly influenced by May’s perspective on
human experience. His perspective focuses on awareness as an essence of
being that has two dimensions. The first dimension is the fact of
awareness: Every person is aware that she or he exists and consequently
copes in various ways with this awareness. This is understood as the
“existential predicament” and has been a major focus of existential
philosophy and psychology (see Camus, 1955; Marcel, 1956; May, 1975,
1981; Sartre, 1956).
The second dimension focuses on how a person is aware and refers to
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the foundational structure of human experience—namely, how anxiety,
which stems from awareness of existence, drives a person to create
meaning through an ongoing dialectical process between the subjective
and objective poles of reality. May (1975) asserts that this dialectical
process of meaning making, which he calls “passion for form,” is the
essence of genuine creativity. May acknowledges that his principle of
human experience is similar to the ideas of several great philosophers, one
of whom is Alfred N. Whitehead.
Whitehead’s philosophy is part of a philosophical tradition going
back to Heraclitus that focuses on process. Reality is not an assortment of
material things, which is the Aristotelian notion, but one of process. Nature
is a process not a thing. A river is not a thing but a continuing flow.
Therefore, human beings, being a part of nature, are understood as a matter
of process, of activity, of change (Rescher, 2000).
In Whitehead’s ontology every organism or “occasion of experience”
is “a dipolar unity . . . that enfolds . . . the past . . . into the present . . . and
orients the organism toward the future in a ‘creative advance’” (de
Quincey, 2002, p. 174). A significant aspect of the structure of experience
is that the past is always flowing into the present moment. Another
significant aspect is the ongoing shaping of experience into a pattern from
the “welter of material” from the past and from the external world.
Whitehead argues that a person is never simply aware of bare existence or
thought. Awareness is a person’s subjective reaction to his or her
environment derived from a shaping of a welter of emotions, thoughts,
hopes, fears, and valuations into a consistent pattern of feelings. According
to Whitehead, this shaping results in a sense of unity or “I am.” May
(1975) specifically correlates his conceptualization of “passion for form”
and its relationship to the formation of a sense of self or identity to
Whitehead’s “process of shaping” and the resulting “sense of unity”:
What I am calling passion for form is, if I understand Whitehead
aright, a central aspect of what he is describing as the experience of
identity. I am able to shape feelings, sensibilities, enjoyments, and
hopes into a pattern that makes me aware of myself as a man or
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woman. But I cannot shape them into a pattern as a purely subjective
act. I can do it only as I am related to the immediate objective world
in which I live. (p. 135)
Whitehead’s process perspective provides May, and existential
psychotherapy, with a sound philosophical position from which to explain
how a sense of identity is created. Identity is created not as a purely
subjective act but only as a dialectical process with the objective world. By
understanding the “I am” experience as an ongoing dialectical process
between subjective and objective poles, E–H theorists and practitioners
have a more complex understanding of how a sense of self or identity is
created and maintained. This understanding can be like a road map for
therapists, helping them to see more clearly in the living moment the ways
in which their clients are forming their worlds. The road map also
elucidates the significant role the therapist plays in helping a client
reconstitute his or her world. Finally, the road map confirms in a concrete
way a basic assumption of existential therapy, which is that human beings
have the potential to grow and recreate themselves through ongoing
creative practices.
REFERENCES
Becker, E. (1973). Denial of death. New York, NY: Free Press.
Buber, M. (1970). I and thou (W. Kaufmann, Trans.). New York, NY:
Scribner’s. (Original work published 1937)
Bugental, J. F. T. (1978). Psychotherapy and process: The fundamentals of an
existential–humanistic approach. New York, NY: McGraw-Hill.
Bugental, J. F. T. (1987). The art of the psychotherapist. New York, NY:
Norton.
Bugental, J. F. T. (1999). Psychotherapy isn’t what you think. Phoenix, AZ:
Zeig, Tucker, & Theisen.
Bugental, J. F. T., & Kleiner, R. (1993). Existential psychotherapies. In G.
Stricker & J. R. Gold (Eds.), Comprehensive handbook of psychotherapy
integration (pp. 101–112). New York, NY: Plenum Press.
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Camus, A. (1955). The myth of Sisyphus and other essays (J. O’Brien, Trans.).
New York, NY: Knopf.
de Quincey, C. (2002). Radical nature: Rediscovering the soul of matter.
Montpelier, VT: Invisible Cities Press.
Friedman, M. (1995). The case of Dawn. In K. J. Schneider & R. May (Eds.),
The psychology of existence: An integrative, clinical perspective (pp. 308–
315). New York, NY: McGraw-Hill.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy. New York, NY:
Guilford Press.
Krug, O. T. (2009). James Bugental and Irvin Yalom: Two masters of
existential therapy cultivate presence in the therapeutic encounter. Journal
of Humanistic Psychology, 49(3), 329–354.
doi:10.1177/0022167809334001
Laing, R. D. (1967). The politics of experience. New York, NY: Ballantine.
Marcel, G. (1951). Mystery of being—Faith and reality. Chicago, IL: Gateway
Edition.
Marcel, G. (1956). The philosophy of existentialism. New York, NY:
Philosophical Library.
May, R. (1958a). Contributions of existential psychotherapy. In R. May, E.
Angel, & H. Ellenberger (Eds.), Existence (pp. 37–91). New York, NY:
Basic Books.
May, R. (1958b). The origins and significance of the existential movement in
psychology. In R. May, E. Angel, & H. Ellenberger (Eds.), Existence (pp.
3–36). New York, NY: Basic Books.
May, R. (1972). Power and innocence. New York, NY: Norton.
May, R. (1975). The courage to create. New York, NY: Norton.
May, R. (1981). Freedom and destiny. New York, NY: Norton.
May, R. (1983). The discovery of being. New York, NY: Norton.
Merleau-Ponty, M. (1962). The phenomenology of perception (C. Smith,
Trans.). London, England: Routledge & Kegan Paul.
Rank, O. (1936). Will therapy (J. Taft, Trans.). New York, NY: Knopf.
Rescher, N. (2000). Process philosophy: A survey of basic ideas. Pittsburgh,
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PA: University of Pittsburgh Press.
Sartre, J. P. (1956). Being and nothingness (H. Barnes, Trans.). New York,
NY: Philosophical Library.
Schneider, K. J. (1993). Horror and the holy: Wisdom-teachings of the
monster tale. Chicago, IL: Open Court.
Schneider, K. J. (1999a). Clients deserve relationships, not merely
“treatments.” American Psychologist, 54, 206–207. doi:10.1037/0003-
066X.54.3.206
Schneider, K. J. (1999b). The paradoxical self: Toward an understanding of
our contradictory nature (2nd ed.). Amherst, NY: Humanity Books.
Schneider, K. J. (2007). The experiential liberation strategy of the existential–
integrative model of therapy. Journal of Contemporary Psychotherapy, 37,
33–39. doi:10.1007/s10879-006-9032-y
Schneider, K. J. (2008). Existential–integrative psychotherapy: Guideposts to
the core of practice. New York, NY: Routledge.
Tillich, P. (1952). The courage to be. New Haven, CT: Yale University Press.
Yalom, I. (1980). Existential psychotherapy. New York, NY: Basic Books.
Yalom, I. (1998). The Yalom reader. New York, NY: Basic Books.
Excerpted from Existential–Humanistic Therapy (2010), from Chapter 3, “Theory,” pp. 13–22. Copyright
2010 by the American Psychological Association. Used with permission of the author.
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16
EXISTENTIAL THERAPY PROCESS
KIRK J. SCHNEIDER AND ORAH T. KRUG
THE CULTIVATION AND ACTIVATION OF INTRAPERSONAL
PRESENCE
Bugental (1987) is representative of the intrapersonal tradition in
existential–humanistic (E–H) therapy, although this characterization is far
from discrete, and much about his approach can be considered
interpersonal as well. Within the former tradition, however, Bugental
outlines four basic practice strategies, or that which he terms “octaves” for
activating clients’ presence. These are listening, guiding, instructing, and
requiring.
The first octave, listening, draws clients out and encourages them to
keep talking so as to obtain their story without “contamination” by the
therapist. Examples of listening include “getting the details” of clients’
experiences and “listening to emotional catharsis, learning [clients’ views
of their] own life or . . . projected objectives” (Bugental, 1987, p. 71). The
second octave, guiding, gives direction and support to clients’ speech,
keeps it on track, and brings out other aspects. Examples of guiding
include exploration of clients’ “understanding of a situation, relation, or
problem; developing readiness to learn new aspects or get feedback”
(Bugental, 1987, p. 71).
The third octave is instructing. Instructing transmits “information or
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directions having rational and/or objective support”; examples include
“assignments, advising, coaching, describing a scenario of changed
living,” or reframing (Bugental, 1987, p. 71). Finally, the fourth octave is
requiring, which brings a “therapist’s personal and emotional resources to
bear” to cause clients to change in some way; examples of requiring
include “subjective feedback, praising, punishing [e.g., admonishing],
rewarding,” and “strong selling of [a] therapist’s views” (Bugental, 1987,
p. 71).
Listening and guiding comprise the lion’s share of E–H activation of
presence. Whereas instructing and requiring can certainly be useful from
the E–H point of view, they are implemented in highly selective
circumstances. For example, instructing may be very helpful to clients at
early stages of therapy—those who have fragile emotional constitutions,
such as victims of chronic abuse, or clients from authority-dependent
cultures. Requiring, similarly, may be useful in these situations but also in
the case of therapeutic impasses or entrenched client patterns, as we shall
see. For the majority of E–H practice situations, however, listening and
guiding are pivotal to the deepening, expanding, and consolidating of
substantive client transformation.
May (1981) illustrates the value of listening with his notion of the
pause. He writes,
It is in the pause that people learn to listen to silence. We can hear
the infinite number of sounds that we normally never hear at all—the
unending hum and buzz of insects in a quiet summer field, a breeze
blowing lightly through the golden hay . . . And suddenly we realize
that this is something—the world of “silence” is populated by a
myriad of creatures and a myriad of sounds. (May, 1981, p. 165)
The client, similarly, is almost invariably enlivened in the pause. As
Bugental (1987, p. 70) suggests, it is in the therapist’s silence at given
junctures that abiding change can take root.
The provision of a working “space,” a therapeutic pause, not only
helps the therapist to understand but, most importantly, assists the client to
vivify (or intensively elucidate) herself or himself. Vivification of a
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client’s world is one of the cardinal tasks of E–H therapy. To the extent
that clients can “see” close up the worlds in which they’ve lived, the
obstacles they’ve created, and the strengths or resources they possess to
overcome those obstacles, they can proceed to a foundational healing.
Listening elucidates one of the most crucial realizations of vivification—
the contours of a client’s battle.
The client’s battle—and virtually every client has one—becomes
evident at the earliest stages of therapy. For some this battle takes the form
of an interpersonal conflict, for others an intrapsychic split. To cite just a
few examples, it may encompass the compulsion for and rejection of binge
eating, a conflict with one’s boss, or a struggle between squelched
vocational potential and evolving aspirations. Regardless of the content of
clients’ battles, however, their form can be understood in terms of two
basic valences—the part of themselves that endeavors to emerge and the
part of themselves that endeavors to resist, oppose, or block themselves
from emerging (Schneider, 1998). One can understand from this
description of resistance and defenses that existential therapy is, as Yalom
(1980) suggests, a kind of dynamic therapy that models its understanding
of “forces in conflict” on Freud’s dynamic model of mental functioning.
Whereas therapeutic listening acquaints and sometimes immerses
clients in their battle, therapeutic guiding intensifies that contact.
Therapeutic guiding can be further illustrated by encouragements to clients
to personalize their dialogue—for instance, to give concrete examples of
their difficulties, to speak in the first person, and to “own” or take
responsibility for their remarks about others. Guiding is also illustrated by
invitations to expand or embellish on given topics, such as in the
suggestion “Can you say more?” or “How does it feel to make that
statement?” or “What really matters about what you’re saying?” Finally,
guiding is exemplified by the notation of content/process discrepancies,
such as “you smile as you vent your anger at him” or “notice how shallow
your breathing is right now” (Bugental, 1987; Schneider, 2008).
Schneider (1998, 2008) has formulated a mode of guiding called
guided or embodied meditation. This approach has proven pivotal for
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many clients, particularly those who battle over-intellectualization.1
Embodied meditation begins with a simple grounding exercise, such as
breathing awareness or progressive relaxation (usually assisted by the
closing of the eyes). From there, it proceeds to an invitation to the client to
become aware of his or her body. The therapist may then ask what, if any,
tension areas are evident in the client’s body. If the client identifies such
an area, which often occurs, the therapist asks the client to describe, as
richly and fully as possible, where the tension area is and what it feels like.
Following this and assuming the client is able to proceed with the
immersion, he or she is invited to place his or her hand on the affected
area. (This somatic element can often be, although not necessarily,
experientially critical.) Next, the client is encouraged to experientially
associate to this contact. Prompts such as “What, if any, feelings,
sensations, or images emerge as you make contact with this area?” can be
of notable therapeutic value. Dr. Schneider reports having seen clients
open emotional floodgates through this work, but he has also seen clients
who feel overpowered by it. It is of utmost importance for the therapist to
be acutely attuned while practicing this and other awareness-intensive
modes.
Guidance is also illustrated by a variety of experimental formats that
can be offered in E–H therapy. These experiments, including role-play,
rehearsal, visualization, and experiential enactment (e.g., pillow-hitting,
kinesthetic exercises), serve to liven emergent material and vivify or
deepen the understanding of that material (Mahrer, 1996; Schneider, 2008;
Serlin, 1996). The phrase “Truth exists only as it is produced in action”
(Kierkegaard cited in May, 1958, p. 12) has much cachet in this context.
When clients can enact (as appropriate) their anxieties, engage their
aspirations, and simulate their encounters, they bring their battles into the
room—in “living color”—for close and personal inspection.
While experimentation within the therapeutic setting is invaluable,
experimentation outside the setting can be of equivalent or even superior
benefit. After all, it is the life outside of therapy that counts most for
clients, and it is in the service of this life that therapy proceeds.
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Experimentation outside of therapy, then, has two basic aims: (1) it
reinforces intratherapy work, and (2) it implements that work in the most
relevant setting possible—the lived experience. Accordingly, E–H
therapists encourage clients to practice being aware and present in their
outside lives. They may gently challenge clients to reflect on or write
about problematic events, or they may propose an activity or therapeutic
commitment (e.g., Alcoholics Anonymous or assigned readings). They
may also challenge clients to do without a given activity or pattern. For
example, Yalom (1980) challenged his promiscuous client Bruce to try
living without a sexual partner for an extended period. This was a highly
demanding exercise for Bruce, whose sexual compulsions were formidable
and afforded no pause. Yet, after the exercise, Bruce reported rich
therapeutic realizations, like the degree to which he felt empty in his life
and the blind and compulsive measures he took to fill that emptiness.
Emptiness, Yalom reported, subsequently became the next productive
focus.
Prompts to clients to “slow down” or “stay with” charged or
disturbing experience can also facilitate intensified self-awareness. We
have known many a supervisee (and even seasoned colleague) who has
had difficulties with this facilitation. They are superb at helping clients to
reconnect with the parts of themselves they have shunted away, and they
inspire deep somatic immersion in expressiveness, but they are left with
one gaping question: “What do I do after the client is immersed?” The
exasperation in this puzzlement is understandable. E–H work can seem
tormenting. It can instigate profound moments of unalloyed pain. The last
thing a therapist wishes to do in such a situation is to enable increased
suffering or to hover in continued despair. And yet, given the client’s
desire and capacity for change, these are precisely the allowances that E–H
therapists must provide, precisely the groundworks they must pursue. They
must develop trust and a sense that the work will unfold (Welwood, 2001).
Hence, what do we advise our supervisees and colleagues? We suggest
that it is in their interest to trust—in particular, to trust that gentle prompts
to “stay with” or “allow” intensive material will almost invariably lead to
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changes in that material. While these changes may not feel immediately
welcome or gratifying—indeed, they may even feel regressive for a time—
they do represent evolution, the “more” that every person is capable of
experiencing.
REFERENCES
Bugental, J. F. T. (1987). The art of the psychotherapist. New York, NY:
Norton.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy. New York, NY:
Guilford Press.
Leijssen, M. (2006). Validation of the body in psychotherapy. Journal of
Humanistic Psychology, 46, 126–146. doi:10.1177/0022167805283782
Mahrer, A. R. (1996). The complete guide to experiential psychotherapy. New
York, NY: Wiley.
May, R. (1958).The origins and significance of the existential movement in
psychology. In R. May, E. Angel, & H. Ellenberger (Eds.), Existence (pp.
3–36). New York, NY: Basic Books.
May, R. (1981). Freedom and destiny. New York, NY: Norton.
Schneider, K. J. (1998). Existential processes. In L. S. Greenberg, J. C.
Watson, & G. Lietaer (Eds.), Handbook of experiential psychotherapy (pp.
103–120). New York, NY: Guilford Press.
Schneider, K. J. (2008). Existential–integrative psychotherapy: Guideposts to
the core of practice. New York, NY: Routledge.
Serlin, I. A. (1996). Kinesthetic imagining. Journal of Humanistic Psychology,
36(2), 25–33. doi:10.1177/00221678960362005
Welwood, J. (2001). The unfolding of experience: Psychotherapy and beyond.
In K. J. Schneider, J. F. T. Bugental, & J. F. Pierson (Eds.), The handbook
of humanistic psychology: Leading edges in theory, practice, and research
(pp. 333–341). Thousand Oaks, CA: Sage.
Yalom, I. (1980). Existential psychotherapy. New York, NY: Basic Books.
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Excerpted from Existential–Humanistic Therapy (2010), from Chapter 4, “The Therapy Process,” pp. 39–
44. Copyright 2010 by the American Psychological Association. Used with permission of the author.
1Although several variations of embodied mediation have been shown to be highly effective with certain
populations (e.g., see Gendlin, 1996; Leijssen, 2006), in the wrong hands they also can be debilitating. As
with all approaches discussed in this volume, care must be taken to ensure that facilitation is preceded by
appropriate training, skill development, and sensitivity to clients’ needs.
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APPENDIX 16.1: EXISTENTIAL THERAPY TECHNIQUES
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17
FAMILY THERAPY
WILLIAM J. DOHERTY AND SUSAN H. MCDANIEL
Every theory has a set of driving questions it attempts to answer, and
as theories develop over time, they usually extend their reach as new
questions arise. Here are the original questions addressed by family
therapy theories.
1. How do individuals develop symptoms within families? This was
the primary question in the development of family therapy, with the initial
focus on schizophrenia and then on a wide range of psychosocial
problems, including depression, anxiety disorders, psychosomatic illness,
childhood conduct disorders, and substance abuse disorders. When a
“new” problem was identified, such as bulimia and borderline personality
disorder, family therapy theorists set about understanding the problem in
terms of its family context. Sometimes the emphasis is on how family
dynamics lead to the onset of a particular problem (e.g., oppositional
defiant disorder stemming from undermining between the parents), and
sometimes the emphasis is on how the family comes to organize itself
around the disorder and thereby perpetuate the problem (as in the case of
anxiety disorders or alcoholism, in which the disorder might have
preceded the formation of the family but family dynamics keep it going).
All family therapy theories place a major emphasis on here-and-now
family process, and some also emphasize longer term family of origin
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processes.
2. How do families maintain levels of interpersonal connection that
allow for both emotional bonding and individual autonomy? Different
theorists address this question in different ways. Bowen (1978) viewed the
family as tending toward interpersonal enmeshment or overinvolvement;
optimal functioning involves the fostering of differentiation of self and
consequent ability to maintain emotional connections without loss of
autonomy. Minuchin (1974) viewed the family as tending toward extremes
of enmeshment or disengagement, with the former promoting family
cohesion at the expense of the individual and the latter promoting the
opposite. Minuchin also emphasized the importance of differentiated
subsystems in the family; for example, a clear but flexible boundary
separating the parental subsystem from the children’s subsystem promotes
separation within the context of interpersonal support. We discuss the term
boundary more fully later in this chapter.
3. How does family conflict become unmanageable? For obvious
reasons, family conflict is a major preoccupation of family therapy
theories. A core approach to understanding family conflict relies on
systems dynamics first identified by Bateson in the 1930s: the circular
processes whereby negative interactions escalate symmetrically to
destructive levels (Watzlawick, Beavin, & Jackson, 1967). For example, a
father’s coerciveness elicits rebellious responses by his son, which lead to
further coerciveness from the father and heightened resistance from the
son—and so the escalation continues. A second standard approach is to
examine the role of third parties (triangular patterns) in maintaining
irresolvable conflicts. A covert alliance between mother and son might
underlie the sustained, overt conflict between father and son (Haley,
1976). A third approach to the question of unmanageable family conflict
focuses on overall family systems properties such as overconnectedness or
enmeshment, which would make serious conflict flow from attempts of
family members to assert and protect their autonomy (Minuchin, 1974).
4. How can families change dysfunctional patterns? Here the primary
focus has been on how therapists can assist families to change. Family
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therapists generally view the unit of systems change as one consisting of a
therapist and a family (Haley, 1976). The therapist uses the therapeutic
relationship to elicit new family patterns, which the family internalizes at
home.
Dozens of other important questions about families are addressed by
theory in family therapy. However, we think that most of them can be
subsumed under the four we have delineated here.
CLASSIC CONCEPTS
Relatively few concepts are employed in all family therapy theories.
Nevertheless, a number of concepts are in common parlance because of
their status as classic, first-generation family therapy ideas. Although there
are formal assessment tools for these and other family therapy concepts
(Jordan, 2003), the complexity of family dynamics is such that few
assessment tools can capture the subtleties of a particular family. Here we
stress how family therapists see the family dynamics emerging in the
clinical interview from history and direct observation of families in the
therapy room.
1. Cohesion and individuation. Implicit or explicit in every theory of
family functioning that has arisen from family therapy is the idea that
optimal family functioning involves a precarious balance between group
solidarity, often termed cohesion, and individual autonomy, often called
differentiation (Olson, Russell, & Sprenkle, 1983). Families with too much
connectedness raise children who are oversocialized and will have
difficulty leaving home emotionally, and families with too much
separateness raise children who are undersocialized and will have
difficulty trusting others (Minuchin, 1974). In both cases, it is considered
likely that some family members will show signs of psychosocial
pathology.
Determining a family’s levels of cohesion and individuation cannot
be done without an understanding of the family’s cultural context
(McGoldrick, Giordano, & Garcia-Preto, 2005) and life cycle stage (Carter
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& McGoldrick, 2005). Some families are more intensely involved with one
another as a reflection of their ethnicity, and families with young children
are likely to be more engaged with one another than are families with
young adult offspring. What family therapists look for are struggles over
connection and autonomy (e.g., parent–adolescent conflict over rules), lack
of nurturance and support for a dependent family member (e.g., an ill
member who is not being cared for adequately), and the inability of a
family member to make decisions and play independent roles in his or her
cultural context (as when a young adult is not able to make friends and
secure employment). In the therapy room, enmeshment can be seen in
family members speaking for one another and reading one another’s
minds. Disengagement can be seen in family members’ not responding to
emotional cues and failing to connect with the process of healing and
change.
2. Adaptability. Derived from the systems theory principle that
successful organisms are continually adapting to their environment, the
concept of family adaptability or flexibility is a cornerstone of family
therapy theory (von Bertalanffy, 1976). It means the ability of a family to
shift its beliefs and interactional styles in the face of developmental
changes and environmental challenges that can create relational problems
and psychosocial pathology in family members. In articulating their
circumplex model of family assessment, Olson et al. (1983) maintained
that adaptability (flexibility) and cohesion (connectedness vs.
separateness) are the two primary concepts in all systems theories of the
family.
Family therapists see adaptability in how the family has coped with
challenges in the past and how it rises to the challenge presented in therapy
now. In adjusting to a divorce, some families form workable new patterns
of shared parenting in different households, but others become paralyzed
around coparental conflict and resistance of children to change. In dealing
with a serious illness in an elderly parent, some families take on and share
new caregiver roles; in other families, one child steps up while the others
continue to relate to the parent as if nothing has changed.
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3. Boundaries. This concept, which is most widely used in structural
family therapy (Minuchin, 1974), has roots in systems theory. Every living
organism has boundaries separating it from its environment, and complex
organisms have internal boundaries demarcating subsystems such as cells
and organs (von Bertalanffy, 1976). Minuchin defined boundaries as
family rules determining who will participate in the family and its
subsystems and how they will participate. Boundaries must be clear if
family members are to know how to relate to one another and to the world.
As described previously, family boundaries can be enmeshed—not enough
protection of autonomy—or disengaged to the exclusion of appropriate
contact between members of different subsystems. Pauline Boss’s (2001)
research demonstrates the consequences of this “boundary ambiguity,”
when family members are unclear as to who is in and out of the family and
its subsystems. Clear boundaries also protect the integrity of subsystems
within the family, such as the marital couple or the sibling group. They
also allow for a balance of cohesion and individuation.
Family therapists see boundary violations in situations such as a
father sharing confidences with his daughter about his relationship with the
mother, or an adolescent boy becoming a quasi-spouse to his mother after
the death of the father. Therapists see boundary ambiguity in situations
when it’s not clear whether a new stepparent is a “real” parent with
authority or just the spouse of the real parent. In general, boundaries are
one of the most useful concepts in family therapy.
4. Triangles. Triadic interactional configurations are at the heart of
how family therapists think about problematic family interactions. Bowen
(1978) defined a triangle as a “three-person emotional configuration” and
saw triangles as the basic building block of any emotional system,
including the family. Bowen proposed that two-person systems become
unstable in the face of high anxiety, leading them to involve a third party
—often the most vulnerable family member—to form a more stable
triangle. For example, destabilizing marital conflict might become
deflected into disagreement over parenting, with the child’s problems
keeping the focus away from the original marital problem. This triangle
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endures during calmer periods, with emotional forces continually shifting
back and forth among the threesome. In subsequent periods of high stress,
according to Bowen, each family member tries for the outside position,
leaving the conflict to be contained between the other two.
Family therapists see Bowen-type triangles in situations where a
father might take the outside position during family conflict, leaving the
arguments to occur between mother and child. In one case, the 12-year-old
boy would curse his mother (but never his father) when he got angry at
her, while the father stayed “neutral” and disengaged. Family therapists
often focus on family secrets as a way to understand emotional triangles in
a family—who is in the know on a family secret and who is cut out, and
then who takes the heat when the secret is revealed.
5. Coalitions. This is a variation, out of structural and strategic family
therapy, on the triangle concept that emphasizes negative alliances, termed
coalitions, between two or more family members against another family
member. Some coalitions involve the basic three parties in a triad, whereas
other coalitions can involve larger groups, as when several adult children
align with father in blaming mother for a parental divorce. The term
coalition was used extensively by Minuchin (1974) in his discussion of
three kinds of “rigid family triads.” The first rigid triad, called
triangulation, is the pattern in which a parent demands that the child take
sides in a parental dispute. The second concept, detouring, is the pattern
whereby parents maintain harmony by reinforcing a child’s deviant
behavior; focusing on the child’s problems allows them to avoid dealing
with their own conflict. Finally, intergenerational coalitions are deemed by
Minuchin (1974), Haley (1976), and many other theorists to be a central
dysfunctional pattern in families. These occur most commonly when one
parent and a child take sides against another parent. This pattern can
continue throughout life.
Family therapists see coalitions when a divorced mother tells her
children that their (good enough) father cannot be trusted, when a father
tells his adult daughter that her mother was never “affectionate” enough
for him, and when an out-of-town daughter works with a frail parent to
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prevent a nursing home placement by allying behind the back of the in-
town daughter who is responsible for the mother’s care.
6. Intergenerational transmission. A key principle of family therapy
is that family interaction patterns tend to repeat across generations and
may create problems for subsequent generations. Although no family
therapy theory would dispute this assumption, several theories strongly
emphasize it. These include Bowen’s theory (Bowen, 1978; Kerr &
Bowen, 1988) and Boszormenyi-Nagy’s theory of the family as an ethical
group (Boszormenyi-Nagy & Spark, 1973). Boszormenyi-Nagy, for
example, described how “destructive entitlement” is passed on through
generations when a child who feels deprived of attentive, responsible
parenting grows up with a sense of being owed by the world and becomes
an inattentive, nonresponsible parent to the next generation. Bowen
described how patterns of “cutoffs” between family members can take
hold over many generations as family members deal with their anxiety and
conflict by amputating family relationships.
Family therapists often see intergenerational patterns of cutoffs
between fathers and children, based in part on the fragility of male–female
couple relationships. This challenge is especially common among low-
income families facing employment and other environmental challenges
(Edin & Kefalas, 2007). Despite feeling hurt by the underinvolvement of
their fathers, children grow up to expect and repeat the pattern.
7. Family belief systems. Family therapists have always been
concerned with how family members understand their problems. But it
was not until the 1970s and 1980s that theories developed a more explicit
emphasis on family beliefs systems. Kantor and Lehr (1975) and
Constantine (1986) presented a theory of family paradigms, which are a
family’s fundamental worldview—its core beliefs and values about how
the family should function. For example, how does the family view the
larger world—as a safe place for the family to interact with via open
boundaries or a dangerous place to be walled off as much as possible? The
Milan model of family therapy developed an emphasis on particular family
beliefs about the disturbed family member’s symptom (Boscolo, Cecchin,
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Hoffman, & Penn, 1987). For example, adherents to the Milan model
might hypothesize that family beliefs related to a child’s obesity (family
members agree he’s just like his dad) may be tied into family dynamics
that maintain the weight problem.
Nowadays, many therapists encounter differences between Western
beliefs in mental health and those of non-Western immigrant families who
view mental health problems as threatening and stigmatized in their
communities. The advantage of seeing these beliefs as not just those of
individuals but also of their families and communities is that the therapist
is less apt to make the mistake of thinking that an individual family
member can readily take on a new perspective. Forming a consensus with
a family that its member’s condition involves both emotional and physical
components requires a respect for the power of family belief systems.
8. Self processes. This concept divides the family therapy field into
two groups: those with an explicit theory of the self in addition to family
process and those who remain exclusively at the level of family process.
The major approaches to understanding the self in the family are object
relations family therapy and Bowen’s family therapy. James Framo (1981)
was a pioneer in applying psychoanalytically derived object relations
theory to family therapy. Object relations theory emphasizes how the self
develops in relation to significant others, especially parents (see also
Scharff & Scharff, 1987). Problematic parent–child relations lead to
internal splits in the child (e.g., good–bad, pride–shame) that are projected
onto love objects as an adult. Thus, adult family members tend to see each
other through lenses distorted by undeveloped parts of the self, which
leads to efforts to turn each other into ideal parents who can complete the
self. Idealization ends in disillusionment when the individual projects the
disowned part of the self onto the family member. For example, a husband
who is cut off from his own feelings of weakness and inadequacy projects
them onto his wife and then tries to “fix” himself by “fixing” her.
In Bowen’s theory, self-differentiation is the psychological
prerequisite for healthy family functioning. Only a differentiated self can
handle constructively the emotional intensity of family relations, without
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resorting to reactive or disengaged behavior. This differentiation process
involves the progressive ability to separate thinking from emotional
process and to maintain one’s capacity to make free choices in social
situations involving strong affect.
Family therapists are always working with multiple “selves” in the
family and therefore have working models of the role of the self. But
family therapists see the self in interpersonal terms, never as an “I”
separate from a “we.” The internal splits of the self are highly visible in
the therapy room and thus can be worked with directly, as when successful
parents of a struggling young adult child project their fears of failure onto
the offspring—and do so right in the therapy hour where the therapist can
help them own their fears. When the parents bounce back and forth
between overprotection and desire to cut their child off from the family,
the family therapist can work on their differentiation of self—how to be in
supportive relationship with their child without fusion or disengagement.
Richard Schwartz (1997) developed a model of internal family systems
therapy where the therapist uses systemic principles to work with multiple
“parts” of the individual patient’s self that frequently mirror interpersonal
conflicts.
9. Family life cycle challenges. All family interaction patterns occur
in the context of where the family is in its life course, from a family in
formation to a family in old age, rearing children versus launching
children, divorcing and recombining in stepfamilies, and so forth. In the
early decades of family therapy, family life cycle stage was an implicit
rather than explicit emphasis. The work of Betty Carter and Monica
McGoldrick (2005) brought work of family development scholars (Duvall,
1977; Hill, 1970) into the family therapy field. For example, it is not
surprising that many families present for therapy when children are
adolescents and the family is dealing with the challenge of managing to
stay connected with parental leadership during a time when the adolescent
requires more autonomy. Similarly, combining two families with children
in a stepfamily poses challenges that tax the ability of families to change
while maintaining continuity with the past.
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The original family life cycle models focused on the stages of the
nuclear family, but the same ideas can be applied to the complexities of
extended families. It is not uncommon in today’s world of longevity for
therapists to work with four-generational families where one of the
generations is attending to the needs of three others! One family, for
example, had a stressful nursing home placement of the great grandmother
at the same time as a heart problem in her son in the next generation and a
difficult pregnancy and health complication in the third generation, with a
new baby in the fourth generation requiring extra attention because of an
ill mother. Understanding the life cycle stages clashing here can be
essential for the family therapist. Otherwise, the problems are seen as
piecemeal and treated accordingly.
REFERENCES
Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic
family therapy. New York, NY: Basic Books.
Boss, P. (2001). Family stress management: A contextual approach (2nd ed.).
Newbury Park, CA: Sage.
Boszormenyi-Nagy, I., & Spark, G. M. (1973). Invisible loyalties. New York,
NY: Harper & Row.
Bowen, M. (1978). Family therapy in clinical practice. New York, NY:
Aronson.
Carter, B., & McGoldrick, M. (Eds.). (2005). The expanded family life cycle:
Individual, family and social perspectives (3rd ed.). Needham Heights,
MA: Allyn & Bacon.
Constantine, L. (1986). Family paradigms. New York, NY: Guilford Press.
Duvall, E. M. (1977). Marriage and family development (5th ed.).
Philadelphia, PA: Lippincott.
Edin, K., & Kefalas, M. (2007). Promises I can keep: Why poor women put
motherhood before marriage. Berkeley: University of California Press.
Framo, J. L. (1981). The integration of marital therapy with sessions with
family of origin. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of
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family therapy (pp. 133–158). New York, NY: Brunner/Mazel.
Haley, J. (1976). Problem-solving therapy. San Francisco, CA: Jossey-Bass.
Hill, R. (1970). Family development in three generations: A longitudinal study
of changing family patterns of planning and achievement. Cambridge,
MA: Schenkman.
Jordan, K. (Ed.). (2003). Handbook of couple and family assessment.
Hauppauge, NY: Nova Science.
Kantor, D., & Lehr, W. (1975). Inside the family: Toward a theory of family
process. San Francisco, CA: Jossey-Bass.
Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on
Bowen theory. New York, NY: Norton.
McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity
and family therapy (3rd ed.). New York, NY: Guilford Press.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard
University Press.
Olson, D. H., Russell, C. S., & Sprenkle, D. H. (1983). Circumplex model of
marital and family systems: VI. Theoretical update. Family Process, 22,
69–83. doi:10.1111/j.1545-5300.1983.00069.x
Scharff, D. E., & Scharff, J. S. (1987). Object relations family therapy. New
York, NY: Basic Books.
Schwartz, R. C. (1997). Internal family systems therapy. New York, NY:
Guilford Press.
von Bertalanffy, L. (1976). General system theory (2nd ed.). New York, NY:
Braziller.
Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1967). Pragmatics of human
communication. New York, NY: Norton.
Excerpted from Family Therapy (2010), from Chapter 3, “Theory,” pp. 30–38. Copyright 2010 by the
American Psychological Association. Used with permission of the authors.
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18
FAMILY THERAPY PROCESS
WILLIAM J. DOHERTY AND SUSAN H. MCDANIEL
In family therapy, the relationship between family members, not the
relationship between the therapist and the patient or family, is primary. In
psychoanalysis or psychodynamic psychotherapy, the transference of the
patient’s introject of a parental figure onto the therapist becomes the grist
for interpretation and exploration. In family therapy, it is the actual
relationships that are the focus of treatment. Behavior therapists may talk
with patients about how significant others reward progress or unwittingly
reinforce symptoms. In family therapy, those positive and negative
reinforcements are available for view in the therapy room directly.
Because of this, the intimacy in the room is typically between family
members rather than with the therapist.
Part of the challenge for the family therapist is developing what Ivan
Boszormenyi-Nagy and Geraldine Spark (1973) termed multilateral
partiality, or alliances with all members of the family. This term refers to
the need for the family therapist to form strong relationships of trust and
fairness with each member of the family, without taking sides and
inadvertently forming a coalition with one member of the family against
another (a professional version of an intergenerational coalition). This can
be difficult when, for example, an adolescent is appealing and a parent
appears to be too harsh. However, forming a warm bond with the
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adolescent while remaining cool with the parent only inflames the
problem. Instead, the therapist is charged with finding something in each
family member to connect with, recognizing that this kind of neutrality (or,
better said, multipartial alliance) is part of the healing aspects of most
family therapy. With multiple patients, there are inevitably multiple
agendas. In the case of Jorge and Maria, the therapist worked to
understand both party’s positions—Jorge’s worrying and Maria’s
advocacy for the relationship. By describing both positions respectfully,
the therapist joined successfully with both members of the couple without
siding with one against the other.
THE ROLE OF THE THERAPIST
The family therapist is in charge of the structure of treatment
(Whitaker & Bumberry, 1988). This means that the therapist will organize
the timing of the sessions, where and how they will occur, and who should
come. He or she may suggest homework assignments to diagnose the
problem and test the family’s willingness to change.
The family therapist is also in charge of the communication in
therapy. With more than one person, and sometimes many people, in the
room, the therapist has many relationships to develop and manage. He or
she becomes a kind of traffic cop—teaching family members to
communicate without blame, listen respectfully to each other,
acknowledge they heard what was said, and learn to deal with conflict,
difference, and emotional intensity. The therapist wants to hear the
individual and family stories, to understand their belief systems, and, like
an applied anthropologist, to help the family find the solutions to their pain
and their problems from within their culture and value systems.
The therapist may also be something of a teacher, educating or
showing patients how their behavior affects each other. A common
example of this is when a depressed patient is demanding and difficult
when he feels badly so that his spouse distances from him, which only
leads the patient to feel more depressed and be more difficult. Uncovering
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all these cycles, or cycles related to violence or child misbehavior or
psychosomatic illness, can be foci of family therapy, helping the family to
recognize the effect of each individual’s behavior on the other.
THE ROLE OF THE PATIENT AND FAMILY
While the therapist is in charge of the treatment, the family is in
charge of the initiative for change (Whitaker & Bumberry, 1988). It is
critical that the therapist not become more invested and motivated in
change than the family. Otherwise, a pursuer–distancer dynamic occurs
with the therapist as pursuer, often resulting in the family backing away
from change (Fogarty, 1976). The skill of the therapist is in increasing the
patient’s and family’s motivation for change.
Sandra and Molly came to therapy because of some mild partner
violence (Sandra had slapped Molly on the arm once); both said they
wanted to stop this destructive way of relating before it got worse. When
the therapist tried to schedule an intake session, neither member of the
couple could agree on when to come in. Finally, both said that Wednesday
at 8 p.m. would work, though the therapist had stated that she saw patients
only until 7 p.m. The therapist was tempted to bend the commitment to
herself and her own family out of concern for this couple’s problem.
However, recognizing a potentially unhelpful pattern at the beginning of
therapy, she said she would work hard to schedule them, but it had to be
sometime during her regular office hours before 7 p.m. Whitaker and
Bumberry (1988) called this the “battle for structure” and insisted the
therapist must win this battle for treatment to succeed.
The therapist also asked Sandra and Molly each to take notes anytime
either of them began to feel angry and bring the notes into therapy, thereby
working to increase their motivation for change. Whitaker and Bumberry
(1988) called this the “battle for initiative” and insisted that the family
must win this battle for treatment to succeed.
BRIEF AND LONG-TERM STRATEGIES AND TECHNIQUES
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The techniques and strategies of family therapy operationalize
systems thinking and can be used in single-session therapy or long-term
work. Goal setting, in the beginning, allows the family and the therapist to
stay focused and measure the progress and outcome of therapy. The use of
tools such as the genogram, time lines, and sculpting organizes complex
family information so that it is useful to the family and the therapist.
Techniques such as positive connotation and listing family strengths help
to broaden the assessment of the presenting problem. Circular questions,
enactment, and externalizing the problem are techniques that put the
presenting complaint in context.
Goal Setting
Family therapy is an active therapy. Early in treatment, the therapist
works to define the presenting problem, the people involved with the
problem, the interpersonal patterns of behavior related to the problem, and
the criteria by which each family member would know if the therapy is
successful. Goal setting becomes a group activity, with the therapist
working to help the family negotiate common achievable goals in their
own words. This is not so easy. (If it were, the family would likely not
need therapy!) Sometimes, goal setting can take several sessions, because
family members do not agree on the definition of the problem or the
desired outcome. Also, many times initial goals are framed in
unachievable terms.
Sonia, for example, stated that her goal for couples therapy was to
have her husband, Reynolds, never express anger with her. Therapy then
focused on psychoeducational principles that normalize anger, so an
appropriate goal focused instead on how Sonia wishes Reynolds to express
his anger to her.
Enactment
In many psychotherapies, patients talk about other relationships and
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problems. In family therapy, these relationships and problems are brought
into the room. After setting a goal about dealing with anger, the therapist
asked Reynolds to show how he acts when he’s angry with Sonia.
“Assume that you had a bad day at work. Then think of something that
Sonia does that is sometimes irritating. Turn to her and show me what
happens when you’re angry.”
The in-session enactment allows the therapist and the patients to
witness the problem firsthand. The patients can then reflect on the
experience, and the therapist can coach them on alternative ways of
communicating. “Try telling Sonia when you come in the door, ‘Honey, I
had a stressful day at work. Let me tell you about it.’ Monitor your own
internal experience to make sure that you don’t take out your difficult day
on the person you love the most.” After the couple tried out this new way
of communicating, the therapist advised, “When expressing your feelings
about an irritating habit, be sure to start with, ‘When you leave your
workout clothes on the floor, it makes me angry. I feel like you want me to
do all the cleaning up in the house, even though we both have outside
jobs.’”
Circular Questions
Family therapists use interview techniques that reveal the nature of
relationships in the family (Selvini Palazzoli, Boscolo, Cecchin, & Prata,
1980). One of those techniques, called circular questions, sometimes
brings to light long-standing misunderstandings.
Therapist: Sonia, when Reynolds leaves his clothes on the floor,
what is he trying to communicate to you?
Sonia: He wants me to become a better housewife. He’s hoping I’ll
do his chores as part of that. But I’m not!
Reynolds: [looking shocked] This is not a test of your skills! I’ve
always been sloppy in the bedroom. I need to change that now
that I have a roommate.
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Externalizing the Problem
A family therapy technique introduced by Michael White (White &
Epston, 1990) moves the problem outside of one individual or one
relationship. Externalizing the problem reduces blaming behavior that can
prevent the problem from being resolved.
Bill and Stella came for therapy because Stella was having recurrent
spells of blanking out. At first her physician thought she might have
epilepsy, but long-term monitoring in the hospital revealed that these
spells were psychogenic in origin. The neurologist thought their timing
was related to marital stress and referred the couple for therapy. In the
second session, after setting goals that included reducing the blanking out
spells and improving their marriage, the therapist asked Stella and Bill to
consider these spells as something external to both of them.
“What do the spells look like?” the therapist asked. “What color are
they? Do they have a name? Are they like an animal, a plant, a person?”
Stella and Bill had surprisingly little disagreement about the nature of
the spells. Stella said they were red, “hot like a fire.” Bill agreed, adding
they were “like a red porcupine, all sharp and bristly.” These descriptions
gave the therapist valuable information about the possible relationship of
these spells to anger in the relationship. When the therapist asked about a
name for this porcupine, Stella said, “Porky.”
To some extent this exercise served to desensitize both members of
the couple to talking about the spells, which had theretofore been
mysterious and somewhat scary. The therapist then set about to find out
when Porky was likely to come on the scene and to slowly help the couple
learn to identify their anger and express it appropriately. Two sessions
after externalizing this symptom, Stella revealed that Bill was sometimes
emotionally abusive to her. Her Catholic faith, she felt, did not permit her
to express anger back. She now noticed that Porky tended to appear in
reaction to Bill’s emotional tirades. Over time, Bill was placed on
antidepressants as an aid to learning self-regulation skills. As his verbal
abuse eased, Stella’s blanking out spells stopped altogether. Both Stella
and Bill continued to work on communication and anger management.
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Family Sculpting
Another technique that serves as both assessment and intervention is
that of family sculpting (Satir, 1988). Most commonly, the therapist asks
one family member to place other family members in a physical pose, as if
in a sculpture, to represent the way that sculptor views the family
functioning. The therapist may ask for three sculpts: one from an important
time in the past, one in the present, and one that shows how the family
member would like to see the family functioning in the future. This
exercise is often more revealing than verbal description. Each family
member may get a chance, so that differing perspectives (e.g., from a
married couple) may be illuminated and discussed.
For example, when asked to sculpt how the couple’s relationship is at
present, Stella set herself in one corner working and Bill in another. Bill’s
sculpt was similar, except he was playing racquetball while Stella was at
home reading. When asked how she wanted it to be, Stella sat herself and
Bill side by side, very still, each staring lovingly at their interlocking
hands. For his part, Bill walked the couple around a garden pointing out
interesting plants and flowers. This exercise revealed the couple’s differing
temperaments and goals for the relationship much more vividly than had
their earlier verbal descriptions.
REFERENCES
Boszormenyi-Nagy, I., & Spark, G. M. (1973). Invisible loyalties. New York,
NY: Harper & Row.
Fogarty, T. (1976). Marital crisis. In P. Guerin (Ed.), Family therapy: Theory
and practice (pp. 325–334). New York, NY: Gardner Press.
Satir, V. (1988). The new peoplemaking. Palo Alto, CA: Science and Behavior
Books.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980).
Hypothesizing—circularity—neutrality: Three guidelines for the
conductor of the session. Family Process, 19, 7–19.
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Whitaker, C., & Bumberry, W. (1988). Dancing with the family: A symbolic–
experiential approach. New York, NY: Brunner/Mazel.
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New
York, NY: Norton.
Excerpted from Family Therapy (2010), from Chapter 4, “The Therapy Process,” pp. 54–60. Copyright
2010 by the American Psychological Association. Used with permission of the authors.
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APPENDIX 18.1: FAMILY THERAPY TECHNIQUES
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19
FEMINIST THERAPY
LAURA S. BROWN
Feminist therapy has as its superordinate goal the empowerment of
clients and the creation of feminist consciousness. Much of what is written
in this field has to do with developing methodologies for achieving that
goal in a diverse set of circumstances. The therapy relationship is
construed as a setting in which, because of the norms and boundaries
established by the therapist and her or his adherence to certain principles,
people can experience the social environment of an egalitarian
relationship. Consequently, development of egalitarian and empowering
strategies that are tailored to the particular individual seeking assistance is
central to feminist therapy practice. Such empowerment is seen as having
the important function of subverting patriarchal influences in the lives and
psyches of all of those involved in the therapy process, including the
therapist. Because both parties, therapist and client alike, are immersed in
patriarchal cultures, the process of uncovering disempowerment and
developing strategies toward empowerment is ongoing, with each feminist
therapist discovering the deep and subtle ways in which patriarchal
assumptions of hierarchy and privilege inform her or his work and the
experience of the people who come into the office.
A feminist therapist continuously asks, “What are the power
dynamics in this situation? Where am I taking patriarchal assumptions for
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granted as true?” The answer to these questions might be something as
deceptively simple as including a commentary about gender and social
class in an assessment report about learning disabilities to unpack the
effects of those variables on the problems being evaluated. Or it might be
something as complex and subtle as unpacking the minutiae of power
dynamics in the arrangement of office furniture to enhance feelings of
equality among those participating in therapy or questioning whether the
word client is itself inherently disempowering (Brown, 2006).
Feminist therapy as a model does not have specific treatment goals as
do many other psychotherapies. Instead, the outcomes of treatment, which
represent empowerment for the individual client, are determined
collaboratively and assessed via client satisfaction and self-report.
Feminist therapists ask clients about their goals and propose ways of
meeting those goals; therapist and client discuss, negotiate, and renegotiate
these agreements, formally and informally, throughout the course of
psychotherapy. When clients do not know their goals, the goal of therapy
becomes uncovering the client’s wishes; feminist therapists do not use the
absence of client knowledge of needs and desires as a cue to impose their
own sense of what the goals of therapy ought to be.
This client-focused model of determining the defining characteristics
of good outcomes and the effectiveness of therapy places feminist therapy
in close relationship with other paradigms such as person-centered,
narrative, and multicultural, which place power to define outcome in
clients’ hands as one piece of a larger strategy of client empowerment
within the therapy relationship itself. This stance challenges the social
construction of outcome as something measured by therapists or
predetermined by the treatment approach. It makes clients the authorities.
Rather than measuring outcome with an instrument whose scales are
determined by an expert’s decision as to what is an important change in
therapy, feminist therapists ask their clients to say what has changed for
them and how those changes matter to them, a qualitative,
phenomenological, and client driven, rather than quantitative and expert
driven, methodology for assessing outcome.
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Because feminist therapy conceptualizes human experience as taking
place in four realms of power—somatic, intrapersonal/intrapsychic,
intrapersonal/social–contextual, and spiritual/existential, all in constant
exchange and interaction (see Table 19.1)—disempowerment and
empowerment are seen as potentially occurring in any and all of these
axes. Feminist therapy consequently defines power, not simply in the usual
sense of control of other humans and/or resources, but in a manner
identifying the locations, behavioral and intrapsychic, where patriarchal
cultures lead people to experience powerlessness and power. Bias,
stereotype, and oppression all constitute social forces that create
disempowerment; they can be enacted in the large context of society or
culture, the smaller context of family and community, and,
intrapsychically, internalized and felt as a part of self. Disempowerment
and the consequences of powerlessness are construed as central sources of
emotional distress and behavioral dysfunction. Feminist therapy asks, in
general and in specific, what might constitute a move toward power for a
given person in the domains where powerlessness has been experienced.
The feminist therapist is tasked with the cocreation, with her or his client,
of strategies that will invite and support empowerment for each person.
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TABLE 19.1
The Biopsychosocial/Spiritual–Existential Axes of Personal Power
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TABLE 19.1
The Biopsychosocial/Spiritual–Existential Axes of Personal Power
(Continued)
POWER AND ITS MANY FACES
Power in the Somatic/Biological Realm
Power can be categorized into the four axes of the
biopsychosocial/spiritual-existential model. Thus, in the biological realm,
power means being in contact with one’s body. Power in the bodily realm
means that the body is experienced as a safe place and accepted as it is
rather than forced to be larger or smaller than it would be if adequately
nourished. If its size or shape creates a lack of safety for a person, change
of size or shape happens in the service of safety, which is a form of power,
or other paths to safety that do not require modification of the body are
considered. Power in the body means connection with bodily desires for
food, comfort, sexual pleasure, and rest. It also entails access to means of
meeting those needs that do not lead to intentional harm to one’s own body
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or that of others and that do not routinely violate a person’s values. Note
that power in the body does not require the ability to see, hear, walk, or
talk; nor is a powerful body necessarily free of pain or illness, nor strong
or physically fit. Rather, empowerment at the biological level has to do
with the psychosocial/spiritual relationship of self to embodiment and with
the creation of a stance of compassion, acceptance, and advocacy, as
needed, for one’s embodied experiences.
Power in the Intrapersonal/Intrapsychic Realm
In the psychosocial realm, power means that one knows what one
thinks and has the ability to critically examine one’s own thoughts and
those of others. A person can change her or his mind when new data
appear that would warrant such a change; in other words, one is flexible
without being suggestible. Power entails the capacity to trust in the
information available from one’s own intuition and inner knowing, and the
ability to find sources of information that will expand the range of one’s
world and capacities. Powerful people know what they feel as they are
feeling it and can use their feelings as a useful source of information about
what is happening in the here and now. Power in the realm of affect means
an absence of numbness, with current feelings reflecting current, not past
or possible future, experiences. Psychosocial power includes the ability to
experience powerful and intense emotions, to contain affect as needed to
function effectively in one’s psychosocial world, and to channel emotions
into effective interpersonal strategies. Power on this axis includes, as well,
the capacity to self-soothe in ways that are not harmful to self or others
physically, psychosocially, or spiritually.
Interpersonal/Social–Contextual Power
Powerful people are more interpersonally effective than not, able to
have their desired impacts on others more of the time than not. They
realize that they do not control others or the physical world and are able to
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accept the limits of power and control with grace. Powerful people forgive
themselves their humanity and are able to forgive the humanity of others,
but they do not forget to protect themselves from people who are unsafe
emotionally or physically to them. Powerful people are well defined and
differentiated, yet flexible when this will increase the likelihood of a
desired outcome. Powerful people have access to their capacities for
creativity and fantasy as sources of delight and have a sense of reality that
assists them to function in their chosen pursuits.
In the interpersonal realm of psychosocial power, powerful people are
capable of forming relationships that work more of the time than not with
other individuals, groups, and larger systems. Powerful people can create
and sustain intimacy, can be close without loss of self or engulfment of
other, and are able to be differentiated without being distant or detached.
They are able to decide to end relationships when those become
dangerous, toxic, or excessively problematic for them, and they are also
able to remain and work out conflict with others when that is a possibility.
They enter roles in life—parent, partner, worker—most often from a place
of choice, intention, and desire, not accidentally, although they welcome
serendipity and the opportunity to encounter the new.
Power in the Spiritual Realm
In the realm of spiritual and existential experience, powerful people
have systems of meaning making that assist them in responding to the
existential challenges of life and that have the potential to give them a
sense of comfort and well-being. They have a sense of their heritage and
culture and can integrate it into their identity in ways that allow them to
better understand themselves. They are aware of the social context and can
engage with it rather than being controlled by it or unaware of its impact.
Powerful people have a raison d’être and are able to integrate that into
important aspects of their daily lives.
PATRIARCHY AND DISEMPOWERMENT: CAUSES OF DISTRESS
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Feminist therapy asserts that patriarchal systems surrounding most
human life intentionally and unintentionally disempower almost all people
on one or more of these variables, such that this paradigm of the powerful
person is entirely aspirational. At the same time, the theory behind
feminist therapy argues that much powerlessness can be transformed, even
within the material constraints of patriarchal realities, and that one
disempowerment strategy of patriarchies has been the creation of a trance
of powerlessness that is both cultural and personal, in which various
messages are conveyed that most people cannot empower themselves. The
wide-scale disempowering messages conveyed by patriarchies about the
inevitability of hierarchies, the impossibility of effecting real social
change, and the immutability of gendered and other socially constructed
roles and relationships all contribute to this societal trance. Feminist
therapy subverts and interrupts the trance of powerlessness by inviting its
participants to notice where and how greater power is actually available to
them. Feminist analysis exposes how power, both intrapersonal and
interpersonal, is not truly constrained by sex, phenotype, social class,
body, or any of the usual rationales given by the larger context as to why
someone cannot do or be a particular thing. By instituting and sustaining
challenges to cultural messages suggesting that to give up and go along is
the only available option, feminist therapy and its practitioners undermine
what is dangerous in patriarchy and create hope, which is a necessary
ingredient of the change process.
Within this broad aspirational construct of what constitutes inter- and
intrapersonal power, feminist therapists invite clients to discover strategies
for becoming more powerful, using the tools of psychotherapy and the
relationship of therapist and client as the womb in which such power can
grow. It is more usual than not for most people entering therapy to have
their power be invisible and unavailable to them and the notion that they
might have power at all frankly risible. When the feminist therapist first
asks in a therapy session, “What is the powerful thing you could do now?”
many people’s response is a variation on, “There is no powerful thing.”
Offering the model of power described previously to clients and framing
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power as being a continuous variable, rather than a matter of having or not
having, breaks the trance of powerlessness, as people begin to understand
that they have already been powerful innumerable times and in a wide
range of ways.
Gary, a working-class Euro American man in his early thirties, had
been diagnosed at a young age with Asperger syndrome (AS), placed in
special education classes, and teased and bullied by peers because of his
socially odd behaviors. His parents, who had each attended community
college for training in the skilled trades, were compliant with the medical
and psychological authorities who told them that their son would never be
capable of normal relationships and thus responded to his complaints about
mistreatment by peers by implying that it was all due to his AS. When he
sought psychotherapy for the persistent posttraumatic responses to the peer
violence of his childhood, he expressed surprise when Bill, his feminist
therapist, asked him about what powerful thing he could do. He responded
that he was and always had been powerless. But Gary came to his third
session with a printout of several online thesaurus entries about the word
power, telling Bill, “I think that if I study these, I will find a powerful
thing to do.” The therapist reflected to Gary that he had just done a
powerful thing—he had used his considerable skills and talents as an
online researcher to begin to unpack and subvert what he had been told
about power.
Frequently, prior to the feminist therapist offering this frame for
power, when that power has been apprehended by the individual, it has
more often felt negative and dangerous than self-affirming. For people
who have been abused by power, power may have become confused with
abusiveness, including abusiveness toward self. Many people who enter
therapy perceive their strategies for responding to disempowerment—
strategies in which creativity, talent, and desperation have combined to
now-problematic outcomes—as what is wrong with them, evidence of
their powerlessness and failure. “I failed to protect myself,” says the
woman who was horrifically abused by her parents from her earliest
memory, not seeing her dissociation as the way in which she protected
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herself when no other models of self-protection were available. “I’m not
smart enough for graduate school,” says the man who dropped out of high
school at age 16 to help support his struggling family and who acquired his
subsequent education in settings that failed to offer him the study skills
available to the children of the middle class with whom he must now
compete in his master’s program. Often, people have experienced extreme
violations of body, mind, thought, feeling, spirit, culture, or some
combination of all of these, and have protected themselves by developing
strategies of passivity; dissociation from body, affect, or memory; or self-
inflicted violence (Brown & Bryan, 2007; Rivera, 2002). For the feminist
therapist, all of these strategies and struggles to maintain the capacity to be
alive are evidence of a person’s previous struggles to achieve power in the
face of patriarchy. The pain a person feels is seen, not as psychopathology,
but as evidence of an already present and active capacity in the struggling
person to move toward the model of powerful individual. The first step of
empowerment involves reframing pain as the sign of the desire to become
that powerful person.
REFERENCES
Brown, L. S. (2006). Still subversive after all these years: The relevance of
feminist therapy in the age of evidence-based practice. Psychology of
Women Quarterly, 30, 15–24. doi:10.1111/j.1471-6402.2006.00258.x
Brown, L. S. (2006, May). Feminist therapy with difficult and challenging
clients. Invited workshop presented for the Chinese Guidance and
Counseling Association, Taipei, Taiwan.
Brown, L. S. (2006, August). Swimming as a feminist. Invited presentation at
the meeting of the American Psychological Association, New Orleans,
LA.
Brown, L. S. (2010). Feminist therapy. Washington, DC: American
Psychological Association.
Brown, L. S., & Bryan, T. C. (2007). Feminist therapy with people who self-
inflict violence. Journal of Clinical Psychology, 63, 1121–1133.
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doi:10.1002/jclp.20419
Rivera, M. (2002). The Chrysalis Program: A feminist treatment community
for individuals diagnosed as personality disordered. In M. Ballou & L. S.
Brown (Eds.), Rethinking mental health and disorder: Feminist
perspectives (pp. 231–261). New York, NY: Guilford Press.
Excerpted from Feminist Therapy (2010), from Chapter 3, “Theory,” pp. 29–37. Copyright 2010 by the
American Psychological Association. Used with permission of the author.
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20
FEMINIST THERAPY PROCESS
LAURA S. BROWN
Feminist therapy’s vision of humans as
biopsychosocial/spiritual/existential entities extends into the development
of feminist strategies for transformation via psychotherapy. Feminist
therapists will engage with a very wide and diverse range of change
strategies with clients. So long as the superordinate goals of
empowerment, egalitarianism, and analysis of power, gender, and social
location can be integrated, feminist therapy offers a protean integrative
model of practice that has allowed it to be utilized with very different
individuals in settings ranging from refugee camps on the Thailand–Burma
border (Norsworthy, 2007) to a prison in Washington State (Cole, Sarlund-
Heinrich, & Brown, 2007) to mainstream dominant culture men receiving
psychotherapy in a private practice office (Brooks, 1998).
Feminist therapy, and the induction into the egalitarian model, begins
with the process of consent, which I have previously referred to as
“empowered consent” (Brown, 1994). My clients are offered a five-page,
single-spaced document to take home and review in which the basic
frameworks of feminist practice are outlined, with an emphasis on the
relational nature of therapy, the rights of clients, and the responsibilities of
the therapist (a copy of this document is available at
http://www.drlaurabrown.com). This document, and those written by other
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Home

feminist therapists for their clients, serves as an initial invitation for
discussions about the nature of feminist therapy practice. The client’s
ownership of the therapy and her or his right to determine its goals and
directions provide a powerful catalyst and jumping-off point for the
development of an egalitarian relationship at all steps of therapy.
Although in practice no aspect of psychotherapy is purely somatic,
interpersonal, contextual, or spiritual, each exchange will have a particular
focus and core on one of these axes. The following section discusses
strategies for feminist empowerment models on the somatic axis of power.
SOMATIC INTERVENTIONS
Feminist therapy values somatic interventions as one integrated
component of treatment. A feminist therapist will consider ways in which
a client is disempowered on the biological axis and notice how apparent
disempowerment may actually represent resistance strategies employed in
the service of survival or safety. Feminist therapists practice empowerment
at this juncture by framing each of these ways of being as what was
available to the person as a way of being in the body that best allowed her
or him to function and that was congruent with her or his identity. This is a
first step toward inviting that person to consider, then explore, ways of
being differently and in a more empowered manner in her or his body.
Alicia, a Euro American heterosexual woman in her mid-30s, had
been bullied by her peers while a child because she walked with a limp,
the after-effects of a childhood accident in which she fell off a playground
structure. Her family had no health insurance coverage and was unable to
pay for physical therapy after her bones knitted. Alicia had done two
things with these experiences. First, the accident had taken on enormous
negative salience, representing “the day my life changed for the worse
forever.” Second, she had developed shame about how her body moved.
The ultimate result of these two important experiences was that she had
become physically very immobile. She came into therapy to deal with
depressed mood and a loss of motivation for working on her master’s
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thesis. In the course of exploring how her class background and her being
the first in her family to go to college were factors in her fears of
inadequacy as a professional and her feelings of disloyalty to her family,
her therapist suggested the notion of using exercise as a means of
improving mood.
Both therapist and client were surprised at the vehemence of Alicia’s
response. “I don’t do that, I don’t have a body,” she told Katarina, the
therapist. Katarina invited Alicia to consider how not having a body was a
part of her identity. Together they explored the importance to Alicia of this
identity marker, which emerged as having two functions that were
temporarily empowering to her. Dissociation from her body reduced
intrusive memories of the fall and distanced Alicia from her grief over the
loss of the active body she had been in before that day. It also allowed her
to be as invisible to others as possible, so that her limp would be
minimally visible. Each of these was an important safety strategy for
Alicia. She told Katarina that for the present she would rather take
medication for her mood, as she was not yet ready to stop using these
strategies, “and I’m not sure if I ever will be.”
Katarina’s response was to validate Alicia as the person in charge of
her therapy process; they continued to explore other strategies for Alicia to
accomplish her goals. Six months later Alicia told Katarina that she was
ready to approach the topic of her accident, now seeing it linked to her
difficulties with her thesis. “Being frozen is something I know how to do;
being frozen was the best I could do. I didn’t want my family to see me as
a stuck-up, overeducated person, or my professors to see me as the
working-class kid that I am, and I didn’t want to see me as disabled, or the
other kids to see my limp. So I freeze. Maybe it’s time to be visible and
thaw. Or not. But let’s talk about it.”
Feminist therapists will integrate a variety of strategies aimed at
increasing power on the biological/somatic axis into their work with
clients. They may invite clients to consider learning about strengthening or
increasing flexibility of body; to develop greater stamina; to discover how
to feed themselves in a loving way; to consider tai chi or yoga; to use
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bodywork treatments such as massage, Feldenkrais, or Hellerwork; and to
explore the usefulness of formal medications. No one of these approaches
to engaging with the body will be privileged by a feminist therapist;
whichever pathway toward somatic empowerment is a fit for the client is
the one that the client and therapist will explore.
Feminist psychopharmacology (Jensvold, Halbreich, & Hamilton,
1996) has studied how sex differences in hormones and responses to drugs,
though often little known by those prescribing them, need to be taken into
account if prescribing is to happen in a nonoppressive and empowering
manner. Many modern psychotropic medications, although effective
somatic interventions for some people, also carry risks of side effects that
dull sexuality, increase risk of weight gain and diabetes, and have
unknown consequences for children who are in utero when pregnant
women use them. Feminist psychopharmacology supports clients in
exercising judgment and autonomy regarding these and other somatic
interventions, rather than defaulting to the prescription of a pill.
Kristina was severely depressed after the birth of her first child. She
was nursing and unwilling to take medication that might pass through
breast milk to her son. She was generally uncomfortable with Western
medicine and wanted to do without pills if possible for everything in her
life. She was also so depressed that she could barely relate to her baby and
was frightened that he would be emotionally harmed by her tears and
lethargy. Paralyzed with indecision by her depression and terrified of
making the wrong choice, she told Jeneen, her therapist, that she was
tempted to just take a pill and be done with it. “But then I’ll hate myself.”
Jeneen asked Kris if she would like her to be “more pushy” about what to
do, and when Kris assented, Jeneen suggested a stepwise process for
making a decision about whether and how to take medication. Kris did a
consultation with a physician expert in nutritional foundations for mood,
with the understanding that this would work more slowly than medication.
If, after a period of time, she was not feeling able to parent well, the next
step would be to try an antidepressant medication that her physician had
carefully researched as to its safety for nursing mothers and their babies.
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Kris and Jeneen also worked out a “panic button” strategy by which either
one could raise the alarm about the safety of parent and child and speed up
the process. With the pressure to make a decision off, Kris improved
slightly with the nutritional intervention, sufficiently for her to become
more active again in the decision-making process. She eventually decided
to take the offered antidepressant from a position of more power than she
had initially been able to muster.
PSYCHOSOCIAL INTERVENTIONS
Because it is a technically integrative approach to psychotherapy,
feminist therapy does not prescribe particular psychosocial interventions.
The emphasis, as noted throughout this volume, is on tailoring
interventions to meet clients at their strengths, skills, and capacities, all
with the goal of increasing the client’s movement toward personal power
on the four axes and evoking feminist consciousness in the process. In a
given day, across sessions, a feminist therapist may utilize tools and
strategies from psychodynamic psychotherapies, cognitive therapies,
mindfulness-based paradigms, humanistic psychotherapies, expressive and
movement therapies, and others. Feminist therapists will offer options to
clients when these are available within their own repertoire of skills.
REFERENCES
Brooks, G. (1998). A new psychotherapy for traditional men. San Francisco,
CA: Jossey-Bass.
Brown, L. S. (1994). Subversive dialogues: Theory in feminist therapy. New
York, NY: Basic Books.
Cole, K. L., Sarlund-Heinrich, P., & Brown, L. S. (2007). Developing and
assessing effectiveness of a time-limited therapy group for incarcerated
women survivors of childhood sexual abuse. Journal of Trauma and
Dissociation, 8, 97–121. doi:10.1300/J229v08n02_07
Jensvold, M. F., Halbreich, U., & Hamilton, J. A. (Eds.). (1996).
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Psychopharmacology and women: Sex, gender, and hormones. Arlington,
VA: American Psychiatric Association.
Norsworthy, K. (2007, August). Multicultural feminist collaboration and
healing from gender-based violence in Burma. In E. N. Williams (Chair),
International perspectives on feminist multicultural psychotherapy—
Content and connection. Symposium presented at the meeting of the
American Psychological Association, San Francisco, CA.
Excerpted from Feminist Therapy (2010), from Chapter 4, “The Therapy Process,” pp. 78–81. Copyright
2010 by the American Psychological Association. Used with permission of the author.
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APPENDIX 20.1: FEMINIST THERAPY TECHNIQUES
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21
GESTALT THERAPY
DEREK TRUSCOTT
Frederick Perls (1893–1970)—known to all as “Fritz”—was the
charismatic and controversial founder of gestalt therapy. Gestalt therapy—
like person-centered therapy—flourished during the North American
human potential movement of the 1960s and will probably always be
associated with that historical period and the flamboyant Fritz. It endures
as a therapeutic system, however, because of its unique incorporation of
the “whole person” into therapy.
Fritz was born and raised in Berlin. After serving as a medical
corpsman in World War I, he earned his doctor of medicine degree,
specializing in psychiatry. He then moved to Vienna to undertake training
in psychoanalysis, and he studied there with Karen Horney and Wilhelm
Reich. Reich (1897–1957) was a student of Freud who was influential in
introducing such central ideas to what would become gestalt therapy as
organismic self-regulation and character armor, although he went on to
have a controversial career. Fritz later worked with Kurt Goldstein, a
principal figure of the holistic school of psychology who is best known for
coining the term self-actualization (Goldstein, 1939).
While working with Goldstein, Fritz met and later married Laura
Perls (née Lore Posner; 1905–1990). Laura studied psychology at
Frankfurt University and received a doctorate in science. Among her
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teachers were psychologists Kurt Goldstein and Max Wertheimer (one of
the founders of Gestalt psychology) and existential philosophers Paul
Tillich and Martin Buber. Fritz and Laura later fled Western Europe, just
ahead of the Nazis, to South Africa, where they established a
psychoanalytic institute.
Fritz and Laura cowrote Ego, Hunger and Aggression: A Revision of
Freud’s Theory and Method (Perls, 1947)—although Laura was not given
authorship credit—during this period of upheaval, and the book presaged
many gestalt therapy concepts. In it they reevaluated the psychoanalytic
conceptualization of aggression and suggested that Sigmund Freud had
underestimated the importance of basic bodily functions like eating and
digestion. They also discussed holistic and existential perspectives and
described therapeutic exercises designed to promote physical awareness
rather than cognitive insight.
In response to the rise of apartheid in South Africa, Fritz and Laura
immigrated to the United States and established the New York Institute for
Gestalt Therapy in 1952. Several years of collaboration with members of
this group resulted in a comprehensive formulation of the theory and
practice for their approach. Paul Goodman (1911–1972) is generally
credited with writing Gestalt Therapy: Excitement and Growth in the
Human Personality (Perls, Hefferline, & Goodman, 1951), the seminal
book on the theory and practice of gestalt therapy. Best known for his
1960 book Growing Up Absurd: Problems of Youth in Organized Society,
Goodman was the prototypical starving artist, discouraged and
marginalized, rarely making ends meet to support his wife and two
children. During a period in his life when he was particularly distraught, he
met Fritz and Laura and became a founding member of the New York
Institute.
Half of Gestalt Therapy consisted of reports of the results of exercises
in awareness that Ralph Hefferline (1910–1974) administered with his
students at the institute. The other half was a statement of their new
approach. Although a rather dense read and not initially well received,
Gestalt Therapy remains a cornerstone of the gestalt approach.
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Fritz spent the rest of his life training, giving workshops, and
establishing gestalt training centers. After establishing the New York
Institute, he established the Cleveland Institute of Gestalt Therapy in 1954;
then the Esalen Institute in Big Sur, California, in 1962; and, finally, one
on Vancouver Island, British Columbia, Canada, shortly before his death
in 1970. Most of his writings from the latter part of his life were
transcribed from his workshops. Laura remained in New York, where she
continued to lead long-term training groups for gestalt therapists until the
mid-1980s.
Gestalt therapy drew influences from a number of sources. First is
psychoanalysis, from which the rationalist concern with the inner life was
drawn and adapted. As it is for the psychodynamic therapist, for the gestalt
therapist the fundamental material with which to work is subjective
phenomena—what is going on inside the client. Rejected were the
construct-laden theory that Freud and his followers developed and their
reductionistic worldview. Gestalt therapy adopted instead the humanistic
emphasis on holism and growth.
Existentialism also informs gestalt therapy. The existentialist view
that Western societies have exalted intellectual reason over subjective
experience is turned into the imperative used by Fritz to “lose your mind
and come to your senses” (Perls, 1969, p. 69). Another influence from
existentialism is the gestalt therapist’s encouragement of individuals to
make choices about how they will live on the basis of their own
experience, rather than living according to established habits or
unquestioningly accepting the norms of society. They also turned away
from Freud’s rationalist search for the reason why a person behaves a
certain way and toward the existential how a person lives. Gestalt therapy
is concerned with what is—the present, subjective experience. To gestalt
therapists, “why” the client is the way he or she is is of no consequence to
helping choose healthy behavior. What “caused” clients to become the
way they are is assumed to be irrelevant.
Finally, Gestalt psychology gave to gestalt therapy more than its
name. Although gestalt therapy is not directly an application or extension
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of Gestalt psychology, the latter’s focus on interaction and process and
many of its important experimental observations and conclusions inform
gestalt therapy. In particular, gestalt therapy incorporates the Gestalt
psychology concept of homeostasis. Needs are understood as disturbing of
an individual’s homeostasis. A healthy person, when aware of a need, acts
to satisfy the need and thus returns to balance. Distress arises when a
person is unable to act to regain homeostasis. For example, where displays
of grieving are frowned on, emotions might be channeled into a
psychosomatic illness. In this way, awareness is directed away from the
grief and transferred onto concern about the illness—a concern the society
will allow the person to take action to deal with.
Gestalt therapy also draws from Gestalt psychology language to
describe this process of needs arising as figure/ground (gestalt) formation.
The figure is whatever is the focus of attention for an individual within the
entire field. The field encompasses other people, the environment, and the
individual as a whole (i.e., mind, body, and emotions). The ground is
everything else in the field except the figure. Whatever need is most
disturbing of an individual’s homeostasis becomes figural for that person.
With the need is satisfied, it merges back into the ground to make way for
the next figure to emerge and so on.
GESTALT RATIONALE
A human being is a unified whole that cannot be reduced to a simple
summation of physical, biological, psychological, or conceptual properties.
We are different from the mere sum of our parts. We all have a heart,
kidneys, lungs, and a brain and also emotions, sexuality, memories, hopes,
and dreams. Gestalt therapy strives to enlist our innate homeostatic
tendency toward becoming a whole that is as healthy as we are able to be.
Distress is understood as withdrawal from awareness of our experience of
body, self, and environment. This withdrawal arises out of the lessons we
learned in childhood when we were dependent on others for our survival.
We learned to deny certain aspects of our experience because they were
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literally life threatening. Often, clients who seek help through
psychotherapy are in a state in which thoughts and feelings associated with
distinct memories and fantasies about the past linger in the background of
their experience. This state is associated with an inauthentic existence that
results in preoccupations (e.g., worrying), compulsive behavior, wariness,
and self-defeating behavior.
Because contact and withdrawal change from moment to moment as a
need is met or an interest is pursued and other needs and interests are
allowed to arise, healthy functioning results from contact with our
experience in the present. Answers to questions of how and why
development may have been arrested in a client’s childhood are not
germane to current health. Instead, growth takes place as we let go of
distractions that prevent personal growth from taking place. When these
distractions are gone, a focused experience remains. With this uncluttered
awareness, concentration is deepened, leading us into wholehearted
functioning. In a world gone mad with complexity, the simplicity of
immediate experience allows us to shed debilitating habits of mind that
distract us from contact with our true selves. Life happens in the present—
not in the past or the future—and when we are dwelling on the past or
fantasizing about the future, we are not truly living. Our past informs our
present; it does not determine it. Our future can inspire us; it need not
dominate us. Through contact with our present experience, we are able to
take responsibility for our actions and find the excitement, energy, and
courage to live life fully and with intention.
GESTALT GOALS
In gestalt therapy, the singular goal is awareness: awareness of the
contact between our physical bodies, our environment, and our selves.
Ideally, this awareness progresses to deeper levels as therapy proceeds and
becomes a state that clients can experience more often in their life. This
deepened awareness allows greater capacity for self-regulation and more
opportunity for self-determination. Awareness allows clients to better
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accept responsibility for their actions and reactions and to freely choose
how to live their lives. Awareness also facilitates personal growth. Rather
than attempting to help clients solve their problems, the gestalt therapist
strives to show clients that awareness is a means for them to find their own
solutions. Symptoms that prompt someone to seek therapy are understood
as processes resulting from personal growth that has been thwarted. With
awareness of how unacknowledged feelings are active in our experience,
growth is released and symptoms resolve.
GESTALT CHANGE PROCESSES
From a gestalt perspective, change is paradoxical. This is because the
more one tries to be who one is not, the more one stays the same (Beisser,
1970). If, instead, clients are encouraged to focus on the here and now of
their experience, they will find that any point of contact becomes a portent
of exciting new possibilities (Polster & Polster, 1973). Change then occurs
spontaneously and without effort through awareness of what and how we
are thinking, feeling, and doing—through awareness of the field of our
present moment. The ensuing process leads to changes in the entire field
that is the client’s existence. It is this experience that is essential for
change—not thinking or talking about the experience. Most of us tend to
talk about ourselves, our past, our problems, our dreams, our ideas. The
more aware we are of the full extent of our experience, the more able we
are to integrate and accept all aspects of our self. In addition, the more
thorough the exploration, the more intense the reorganization, allowing us
to accept responsibility for our actions and reactions and thereby make
choices that are based on a more authentic appreciation of environmental
demands and of our true needs and desires.
GESTALT CHANGE TASKS
Historically, Fritz discouraged preestablished techniques and
encouraged therapists instead to design “games” or “experiments” that are
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individually tailored to each client (Levitsky & Perls, 1970). Yet, the use
of classic gestalt techniques has persisted, perhaps because they are just so
intriguing and in part because it is actually very difficult to propose unique
change tasks for each client in each unique circumstance. Gestalt change
tasks are called games to emphasize the interpersonal nature of the task
and to highlight the “as if” quality of the undertaking. If the client
experiences reluctance, this too is honored as an opportunity for learning.
In fact, how we resist contact in the here and now can be a rich resource
from which the therapist draws to propose original, individualized tasks.
The aim of gestalt exercises is to help clients learn about themselves
from immediate experience—not from the therapist’s conceptualizations.
The exercises aim to heighten an individual’s awareness of deadened
feelings and sensations, reawakening knowledge of personal agency in
shaping what is taken for granted as a fixed reality. Thus, the client is
given a high degree of control over how and what is learned from
psychotherapy.
Such experiments, properly undertaken, are part of the collaborative
give-and-take between client and therapist in a psychotherapy session. The
use of the present moment for therapeutic leverage is isomorphic of living
in the here and now. When designing an experiment, the therapist pays
particular attention to the client’s nonverbal language and proposes a task
designed to intensify the client’s current experience in order to expand
awareness of the here and now. Ideally, each individualized experiment
grows out of the therapist’s responsive interaction with the client. Because
the experience can be very emotional and unsettling, it is best if clients are
prepared for experiments (Greenwald, 1976) and a strong therapeutic
relationship is established beforehand. The following paragraphs describe
some of the games proposed by gestalt therapists.
Internal dialogue exercises are probably the most famous of the
gestalt experiments. They are intended to address internal conflicts caused
by uncritical acceptance of others’ opinions and promote an integration of
all aspects of self. The client plays each role and engages in a dialogue by
moving back and forth between two chairs. From each chair, the client
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speaks directly to the imagined person–entity in the empty chair. The most
common conflict is the top dog–underdog. The top dog is the inner
dictator who tells us what we should do. The underdog plays the victim–
rebel and schemes to thwart and avoid doing as the top dog demands.
Making the rounds is a group-based task that involves asking the
client to speak to or do something with the other members of a group.
Group members take turns giving the client feedback about what they have
observed. This allows the client to take interpersonal risks, present newly
owned aspects of the self, and confirm or disconfirm assumptions in
relation to others.
Reversal exercises invite the client to behave in a manner opposite of
his or her usual presentation, such as having a shy person behave in an
extroverted way. This is helpful for denial of latent aspects of the self. The
client is thrust into experiencing what at first feels strange and alien but
eventually whole and authentic.
Rehearsal exercises have the client say aloud the inner thinking we
all rehearse in preparation for behaving in expected ways. Our internal
rehearsals tend to result in inhibitions of spontaneity and genuineness. By
saying them aloud, the client can take ownership of his or her intentions to
please others and consciously choose to meet those expectations or not.
Exaggeration exercises are used when the client appears to be
unaware of some aspect of his or her experience. The client is invited to
amplify a subtle behavior—such as a vocal tone or a gesture—to heighten
awareness. Exaggeration exercises can also be used with verbal statements
in which some important experience is glossed over. This allows the client
to experience something that he or she had been avoiding, thereby
facilitating integration.
Dream analysis in gestalt therapy considers all parts of a dream to be
parts of the dreamer. Dreams are seen as very useful because they are the
most spontaneous and uninhibited expression a person can make. To work
with a dream, the client retells the dream as though experiencing it here
and now. The therapist then uses what is revealed by the dream to raise the
client’s awareness of self. This may mean the client acts out the dream’s
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different elements—be they people or objects. Alternatively, dream
analysis might involve finishing the dream in a different manner, or the
therapist might ask the client to do an internal dialogue exercise with the
dream to determine what it has to tell the person.
Using the language of responsibility involves encouraging clients to
say what they mean and mean what they say. In other words, clients use
language that injects real feeling into their words. The language of
responsibility has three important aspects: (a) directness—talking directly
to the therapist or another group member rather than alluding to matters by
being indirect (e.g., “Smoking is harmful to the environment” may be
replaced by “I cannot breathe properly, and you are killing me by smoking
when I am with you!”); (b) checking things out—encouraging the client to
ask directly, “How do you feel about that?” instead of guessing what
another person thinks or feels; and (c) first person, active speech—
allowing the speaker to own what is being said and imbue it with personal
meaning and emotion (e.g., “It is not good for people to live alone”
contrasts with “I do not like to live alone”).
REFERENCES
Beisser, A. (1970). Paradoxical theory of change. In J. Fagan & I. Shepherd
(Eds.), Gestalt therapy now (pp. 77–80). New York, NY: Harper & Row.
Goldstein, K. (1939). The organism: A holistic approach derived from
pathological data in man. New York, NY: American Books.
Goodman, P. (1960). Growing up absurd: Problems of youth in the organized
society. New York, NY: Vintage.
Greenwald, J. A. (1976). The ground rules in gestalt therapy. In C. Hatcher &
P. Himelstein (Eds.), The handbook of gestalt therapy (pp. 267–280). New
York, NY: Jason Aronson.
Levitsky, A., & Perls, F. (1970). Rules and games of gestalt therapy. In J.
Fagan & I. L. Shepherd (Eds.), Gestalt therapy now (pp. 140–149). Palo
Alto, CA: Science and Behavior Books.
Perls, F., Hefferline, R., & Goodman, P. (1951). Gestalt therapy: Excitement
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and growth in the human personality. New York, NY: Julian Press.
Perls, F. S. (1947). Ego, hunger and aggression: A revision of Freud’s theory
and method. Durban, South Africa: Knox.
Perls, F. S. (1969). Gestalt therapy verbatim. Lafayette, CA: Real People
Press.
Polster, E., & Polster, M. (1973). Gestalt therapy integrated. New York, NY:
Brunner/Mazel.
Excerpted from Becoming an Effective Psychotherapist: Adopting a Theory of Psychotherapy That’s Right
for You and Your Client (2010), from Chapter 6, “Gestalt,” pp. 83–90. Copyright 2010 by the American
Psychological Association. Used with permission of the author.
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22
GESTALT THERAPY PROCESS
UWE STRÜMPFEL AND RHONDA GOLDMAN
Isadore From (1984) warned decisively against reductionist methods
wherein Gestalt therapy is represented as the sum of its various techniques.
However, although this is a holistic approach, distinct methods and
interventions can be identified (From, 1984). The therapist discourages the
client from making on-the-spot interpretations, as well as thinking and
rationalizing that prevent awareness of emotions and sensory experience.
An emphasis away from plans for the future, talking about the past, or
thinking in abstractions is encouraged. Awareness can also be achieved by
experimenting with the expression of impulses and feelings (Naranjo,
1993). As Gestalt therapy evolved, a number of micro- and
macrotechniques have been developed. Microtechniques describe what the
therapist does on a moment-to-moment basis, whereas macrotechniques
are experiments such as two-chair and empty-chair interventions. We
describe some of the most salient types of microtechniques below.
In repetition responses, the therapist suggests that the client repeat a
gesture, verbal expression, or particular aspect of body language. For
example, a client with depression who has no access to his or her feelings
might shrug his or her shoulders often. The therapist may ask the client to
repeat this gesture several times, while at the same time asking the client
about his or her feelings. This may help the client to share with the
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therapist his or her feelings of profound resignation.
Exaggeration and elaboration techniques are based on the same
principles of awareness. Clients are asked to repeat and intensify a
particular behavior to bring unconscious emotional processes into
awareness. Automated aspects of functioning that are not processed in
awareness can be brought to the client’s attention in this way. If a client
tends to grin, the therapist may ask the client to concentrate on his or her
facial expression and exaggerate it.
Identification involves the client concentrating on a sensory
experience, such as a headache, a feeling of tension, sickness in the
stomach, or an element within a dream. This is one of the earliest
techniques of Gestalt therapy and can be introduced by the therapist in a
number of ways, such as “What do your tears say?” or “Can you give your
loneliness a voice?” Identification may be regarded as a projective
technique in which primary emotions or reactions like disgust and
contempt are discovered and symbolized.
Representing or dramatizing is a technique in which clients are asked,
for example, to assume the roles of influential people in their lives in
staging a family scene. This technique is often practiced in groups in
which different roles may be adopted by different people, but it is also
effective in individual therapy. This technique is partially informed by
psychodrama practices, and the possibilities for dramatization are limitless.
The enactment of inner conflict helps activate emotional processes and
provides a tangible, living stage for the client. Habitual patterns of conflict
that have been rigidly repeated over a lifetime become conscious, enabling
the client to break the chain of repeated dysfunctional behavior.
Dramatizations are also practiced within the context of both the empty-
chair and the two-chair method. For a more full description of Gestalt
therapy techniques, see Greenberg, Rice, and Elliott (1993).
The following case example illustrates the macrointervention of the
empty-chair and two-chair dialogues; the microinterventions are embedded
within the dialogues. The following dialogues are excerpts from a case
with a 27-year-old woman with depression. She has two young children,
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and her husband is a compulsive gambler. She initially feels both
responsible and abandoned when he goes out to gamble, leaving her alone
with the children and draining the family of financial assets. Her father
was also a compulsive gambler, and her mother had always “put up with
it,” silently suffering with her pain. On two occasions prior to therapy, the
client had left her husband, and her family had basically responded with
the message that a good wife “stands by her man.” The following dialogue
illustrates a sample of an empty-chair dialogue used by the therapist (T) in
which the client (C) is working with unfinished business with her mother
and in which she eventually forgives her mother (microinterventions are
identified throughout in brackets).
C: (toward mother) You expected so much from me; you made me
believe that you knew what was right for me, that I should
always take care of the children, my younger brothers.
T: Tell her what you missed out on. [identification]
C: (crying) I wanted to be myself. I wanted you to accept me as an
individual.
T: Tell your mom what you wanted to hear. [expression of need]
C: (crying) I wanted to hear you say you loved me.
T: Tell her what it was like for you.
C: (crying) It was lonely and confusing, knowing that I did as you
said, and I always tried to please you but you never expressed
your love. [identification]
T: You feel a lot of sadness with her love not coming to you.
C: I also believe that at the time, it was hard for her. I know what
she was going through with my father ‘cause of what I went
through, um . . . just being stuck in her own confusion because
of his gambling.
T: Okay, come over here, and be your mom and tell her how it was
for you that you were not able to love her. [dramatization]
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C: I was uh very occupied by your father’s gambling.
Later in dialogue, as her mother again:
C: (crying) I was wanting something I wasn’t getting from your
father. I wanted to make him see that his family was
important. I just felt despair.
T: You felt desperate to try to turn things around.
C: (crying) and um . . . I’m sorry that I didn’t allow you to do other
things, to have other relationships with your friends or anyone,
I needed your help at home . . . as much as you needed your
own time with your friends.
In this dialogue, the therapist is encouraging the client to fully express
her sadness and acknowledge her unmet need for approval and love from
her mother. This allows her to achieve a new understanding of her
mother’s struggles and how those may have contributed to her inability to
be more giving with her daughter. The therapist is encouraging the client’s
construction of new meaning particularly in relationship to her mother.
What follows is a two-chair work dialogue in which the same client is
working with a self-evaluative split. In this excerpt, a shift (softening of
the critic or harsh topdog) begins to take shape. (Microinterventions are
identified throughout in brackets.)
C: I feel I don’t count, that I don’t know anything, that I am stupid.
T: OK, come back over here (to critic chair). Make her feel stupid.
[dramatizing]
C: You don’t count, you’re stupid, you are worthless.
T: Again, make her not count. [exaggeration]
C: You’re stupid. It doesn’t matter what you say, there’s no
meaning to what you say; you just don’t know anything.
T: OK, come back to this chair. How do you feel when she puts
you down and ridicules you? [encouraging emotional
expression]
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C: Oh (sigh), I just feel like she is right and that is just the way it
is.
T: Do you notice when you say this that your shoulders kind of
hunch and you slump in your chair. Hunch over like that some
more. What is it like to feel so hopeless? [repetition]
C: I just feel so alone (client begins to cry).
T: Yeah, it hurts, give the loneliness a voice. What do you want to
say to her? [identification and encouraging emotional
expression]
C: It hurts when you talk to me like this (sobbing).
T: Yeah, it hurts when she talks to you like this. What do you want
from her? [encouraging emotional expression]
C: I want you to accept me unconditionally. I want you to listen to
me.
Later in the dialogue,
T: Now change back over here (to critic chair). She says she wants
to feel she counts and she wants to be heard, accepted. What
do you say?
C: Okay, um, yes that is fair. [beginning of softening of critic]
T: So, what are you saying, that you understand her need?
C: (crying) Um, yeah, I’m sorry. You don’t deserve to be treated
like that. [elaboration of softening]
In this dialogue, the therapist helps the client move beyond her
feelings of hopelessness to access her primary feelings of sadness and
loneliness and accompanying need for approval. Identification and
validation of these emotions help to strengthen the self, which allows her
to stand up to her critical self. Later in the dialogue, when the client moves
into the other chair, her critical self softens and becomes more accepting.
As the dialogue ends, the client is beginning to access underlying needs for
nurturance.
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By the end of a 16-week therapy, the client was no longer depressed
and did not feel guilty or responsible when her husband gambled. She
showed significant improvement in her self-esteem and interpersonal
relationships.
DREAMWORK
A survey conducted in Florida on the use of dreamwork by
psychotherapists (Keller et al., 1995) showed that the Gestalt method is
used more often than the Freudian approach. Prominent Gestalt therapists,
such as Polster and Polster (1973), give work with dreams a central place
in Gestalt therapy. A number of techniques are used to give dreamwork
immediacy. The client is asked to start by telling the dream as if it is
occurring in the present, which helps the dreamer relate more directly to
the dream’s content. The client may also be asked to act out the dream, to
identify with a figure or a mood, and to narrate his or her dream
experiences from a subjective perspective.
The following dialogue excerpt, extracted from a dream seminar by
Fritz Perls (P), exemplifies this type of dreamwork. The participant, Nora
(N), is a member of the seminar and is familiar with Gestalt interventions
such as identification and dramatization.
N: In my dream I was in an incomplete house and the stairs have
no rails. I climb up the stairs and get very high, but they go
nowhere. I know that in reality it would be awful to climb that
high on these stairs. In the dream it’s bad enough, but it’s not
that awful, and I always wonder how I could endure it.
P: Okay. Be this incomplete house, and repeat the dream again.
(Although familiar with Gestalt methods, Nora shows
difficulty getting into the method of identification.)
Later in the dialogue,
N: I am the house and I’m incomplete. And I have only the
skeleton, the parts and hardly the floors. But the stairs are
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there. And I don’t have the rails to protect me. And yet I do
climb and—
P: No, no. You’re the house. You don’t climb.
N: Yet I’m climbed on. And I end somewhere on the top, and it—
and it leads nowhere and—
P: Say this to Nora. You’re the house and talk to Nora.
N: You’re climbing on me and you’re getting nowhere. And you
might fall. Usually you fall.
P: . . . Now say the same thing to some people here, as the house.
“If you try to climb on me . . . ”
N: If you try to climb on me, you’ll fall.
P: Can you tell me more what you’re doing to them if they’re
trying to live in you and so on . . . . (Nora sighs) Are you a
comfortable house to live in?
N: No, I am open and unprotected and there are winds blowing
inside. (voice sinks to whisper) And if you climb on me you’ll
fall. And if you’ll judge me . . . I’ll fall.
P: You begin to experience something? What do you feel?
N: I want to fight.
P: Say this to the house.
N: I want to fight you. I don’t care about you. I do. I don’t want to.
(crying) . . . I don’t want to cry and I don’t want you—I don’t
even want you to see me cry. (cries) . . . I’m afraid of you . . . I
don’t want you to pity me.
P: Say this again.
N: I don’t want you to pity me. I’m strong enough without you,
too. I don’t need you and—I, I wish I don’t need you.
Emotions that arise in the course of the telling of the dream are an
important source of information that provide insight for the dreamer.
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Dreams are understood as clients’ projections, representing the functioning
of the self and the dreamer’s existential situation in life. In this example,
the client describes an incomplete house and becomes sad and later angry
while she identifies with this element. The reworking of dreams offers an
opportunity for the client to reintegrate neglected aspects of the self. Perls
(1969) commented on Nora’s dream:
Nora’s projection is the incomplete house. She does not experience
herself at the beginning as an incomplete house. It’s projected as if
she is living in this house. But she herself is the incomplete
house. . . . If you’re capable of projecting yourself totally into every
little bit of the dream—and really become that thing—then you
begin to reassimilate, to reown what you have disowned, given
away. The more you disown, the more impoverished you get. Here is
an opportunity to take back. The projection often appears as
something unpleasant. . . . But if you realize, “This is my dream. I’m
responsible for the dream. I painted this picture. Every part is me,”
then things begin to function and to come together, instead of being
incomplete and fragmented. (p. 98)
Later in the session, Perls helps the client contact her self-support
functions. Through the method of identification, Nora starts to realize that
she, as the house, has the potential for solid foundations and surroundings.
P: Can you tell this to the group. That you have solid foundations?
N: You can walk and it’s safe, and you could live with it if you
don’t mind being a little bit uncomfortable. I’m dependable.
P: So what do you need to be complete?
N: I don’t know. I . . . I don’t think I need, I . . . I just feel I . . . I
want more.
P: Aha. How can we make the house a bit warmer?
N: Well, cover it, close—put windows in it; put walls, curtains,
nice colors—nice warm colors.
Working with the client’s experience is characteristic of Gestalt
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therapy. Experiencing is indivisible from emotional processes. On both a
micro and macro level, Gestalt therapy has a range of interventions aimed
at confronting spontaneously arising emotions in the contact process and
thereby supporting clients in deepening their experience.
REFERENCES
From, I. (1984). Reflections on Gestalt therapy after thirty-two years of
practice: A requiem for Gestalt. Gestalt Journal, 7, 4–12.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional
change: The moment-by-moment process. New York, NY: Guilford Press.
Keller, J. W., Brown, G., Maier, K., Steinfurth, K., Hall, S., & Piotrowski, C.
(1995). Use of dreams in therapy: A survey of clinicians in private
practice. Psychological Reports, 76, 1288–1290.
doi:10.2466/pr0.1995.76.3c.1288
Naranjo, C. (1993). Gestalt therapy: The attitude and practice of an
atheoretical experimentalism. Nevada City, CA: Gateways/IDHHB.
Perls, F. S. (1969). Gestalt therapy verbatim. Moab, UT: Real People Press.
Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of
theory and practice. New York, NY: Brunner/Mazel.
Excerpted from David J. Cain and Julius Seeman (Eds.), Humanistic Psychotherapies: Handbook of
Research and Practice (2002) from Chapter 6, “Contacting Gestalt Therapy,” pp. 205–211. Copyright
2002 by the American Psychological Association. Used with permission of the authors.
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APPENDIX 22.1: GESTALT THERAPY TECHNIQUES
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23
MULTICULTURAL THERAPY
LILLIAN COMAS-DÍAZ
Exploration of clients’ ethnocultural heritage elicits ancestry, history,
genetics, biology, and sociopolitical legacy. More specifically, clinicians
obtain contextual information on clients’ maternal and paternal cultures of
origin, religions, social class, gender and family roles, languages, and
other variables. As you examine your clients’ multiple contexts, make sure
to consider the larger historical and sociopolitical factors that inform their
lives. In addition to eliciting collective narratives, you can assess
generational experiences such as disconnection; dislocation; and trauma,
including sociopolitical trauma, such as a group history of slavery,
colonization, the Holocaust, and others. Moreover, you can inquire about
history of collective formative events. These may include natural disasters,
political violence, terrorism, and social cataclysms, such as the Great
Depression, that tend to lead to an enduring and distinguishing
membership affiliation (Elder, 1979). Such affiliation engenders feelings
of shared participation in social experiences that create firm bonds,
distinguishing persons who have endured these events from those who
have not. For example, a bonding experience for many baby boomers is
the Vietnam War. Likewise, clinicians can explore experiences with
collective oppression and trauma. For instance, whereas many women feel
connected by experiences of sexism, many people of color feel bonded by
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experiences of racism, and many women of color are “branded” by sexist
racism. Moreover, having lived through collective bonding events tends to
shape responses to subsequent events. These bonding experiences can lead
to sympathetic trauma or feeling secondhand (vicarious) trauma if one
witnesses a trauma inflicted upon a person of one’s cultural group. To
illustrate, many African Americans experienced traumatic responses to the
televised incident in which White policemen were beating African
American Rodney King (Shorter-Gooden, 1996). Their sympathetic
trauma was akin to a realization that “it could happen to me.” This type of
indirect trauma goes beyond psychological identification and empathy for
the pain of others and relates to the fact that one’s membership in an ethnic
group predisposes one to potentially become a victim of a hate crime.
It is important to explore the presence of historical and contemporary
cultural trauma. Cultural trauma refers to the victimization that individuals
and groups may experience because of their culture, including their
ethnicity, race, gender, sexual orientation, class, religion, or political
ideology, and their interaction with other diversity characteristics. These
events can have long-standing effects on individuals and groups. For
example, individuals with a history of colonization may experience
postcolonization stress disorder (PCSD). PCSD results from a historical
and generational accumulation of oppression, the struggle with racism,
cultural imperialism, and the imposition of mainstream culture as
dominant and superior (Comas-Díaz, 2000; Duran & Duran, 1995). As a
form of posttraumatic stress disorder, however, PCSD is an entity unto
itself. Contemporary exposure to racism, xenophobia, homophobia, hate
crimes, and other forms of oppression causes cultural trauma. Moreover,
many individuals experience cultural trauma individually, collectively,
vicariously, intergenerationally, or all of these ways. The following
vignette illustrates the usefulness of exploring clients’ ethnocultural
heritage.
An upper-middle-class married woman, Laura, sought treatment for
anxiety after Sister Mary, her spiritual adviser, suggested psychotherapy to
her. Laura’s symptoms included sweaty palms, heart palpitations,
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nervousness, and dizziness during social interactions with her husband’s
colleagues. As an attorney, Laura did not experience dysfunctional
symptoms in her professional role. Her husband, John, was a White
philanthropist who could trace his ancestral origins back to the Mayflower.
Laura’s clinician, Dr. Cross, was a psychologist with cross-cultural
experience (he spent a year in Sicily as an American field student) and a
White American man of British ancestry. After completing a clinical
assessment, Dr. Cross decided to conduct a multicultural assessment to
further explore the source of Laura’s anxiety. In exploring Laura’s
ethnocultural heritage, he found out that her mother, Clara, was a Mexican
sculptor who grew up in a working-class neighborhood in Arizona, where
Clara suffered severe ethnic and gender discrimination. Laura’s father,
Don, a lawyer who is a White American and whose ancestry is British, met
Clara at an art exhibition. In discussing her maternal ethnocultural
heritage, Laura realized that she felt like an impostor and harbored fears of
being “found out” as half Mexican. Consequently, she was able to identify
the dread of being rejected by her husband’s social and business circle as
the source of her anxiety. Laura was a tall, blonde, fair-skinned woman
who many believed “did not look stereotypically Mexican.” Even though
Laura did not report being the victim of direct ethnic prejudice, her
mother’s stories about being called a “wetback” (a pejorative term used to
designate Mexicans without a legal residence status) were vivid in her
mind and in her nightmares. It appeared that Laura was experiencing an
intergenerational trauma (Danieli, 1998) arising from her mother’s
exposure to racism and xenophobia in Arizona. The succession of
traumatic events and oppression that members of a cultural group endure,
historical trauma has intergenerational effects (Evans-Campbell, 2008).
Unfortunately, the intergenerational trauma continues to affect subsequent
generations because when the cultural trauma is not resolved, it becomes
internalized.
SOCIOPOLITICAL TIMELINES
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To explore the effects of history and cultural trauma on clients,
clinicians can chart a sociopolitical timeline. This process helps
individuals to connect their history to the present and to envision a future.
You can complement the examination of the effects of sociopolitical
and historical factors through the exploration of your client’s sociopolitical
timeline. A timeline helps to identify your client’s personal, family, and
historical events.
Laura’s sociopolitical timeline is as follows:
April 25, 1846: Mexican–American War begins
January 1848: Peace agreement and Treaty of Guadalupe Hidalgo
1950: Clara, Laura’s mother, is born
1955: Clara immigrated to the United States
1964: Civil Rights Act
1960s: Chicano movement
1970s: Women’s movement
1975: Laura’s parents are married
1980: Laura is born
2008: Barack Obama, the first person of color (mixed race, White and
Black African) to become president of the United States, is elected
April 28, 2010: Arizona anti-immigration law (see Arizona State
Senate, 2010)
BIOCULTURAL AND ECOLOGICAL CONTEXTS
The meaning of pain and suffering has cross-cultural variations.
Consequently, when you delineate your client’s ethnocultural heritage, you
can explore biocultural variables—the physical factors grounded in a
cultural context. When you adopt a physical health mode during the first
stage of the assessment, you can examine your client’s health and illness
belief systems. For instance, a belief in mind–body–spirit unity is relevant
to an understanding of culture-bound syndromes as coping skills,
particularly anger management. To illustrate, mal de pelea among Latinos
and hwa-byung among Koreans are syndromes related to anger
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management within a culturally specific context (American Psychiatric
Association, 2000).
When you promote health as a holistic construct, you help to cement
a multicultural therapeutic alliance. Assessing biological functioning is
congruent with culturally diverse clients who are familiar with the U.S.
medical or public health model. Moreover, you can explore your clients’
biocultural genetic predispositions to illnesses. As an illustration, one in
four Ashkenazi Jews carries a genetic predisposition to develop Tay–Sachs
disease, Canavan disease, Niemann–Pick disease, Gaucher disease,
familial dysautonomia, Bloom syndrome, Fanconi anemia, cystic fibrosis,
and mucolipidosis IV (see Jewish Virtual Library, 2011). Likewise, lower
rates of Alzheimer’s dementia are present in African Americans, Japanese
(with autopsy confirmation), and Cree Indians than in White populations
(Sakauye, 1996). As a clinical implication of these findings, if a Japanese
American presents with Alzheimer’s-related symptoms, clinicians may
want to explore the existence of other types of disorders, such as multi-
infarct dementia.
Exploring a client’s biocultural background can provide useful
information. For example, Laura reported that her maternal uncle had died
of diabetes-related complications. After learning about Laura’s maternal
Mexican ancestry, Dr. Cross inquired about Laura’s propensity to develop
diabetes. A physical exam revealed that Laura had a prediabetic condition.
Similarly, clinicians can gather information following a wellness
perspective. Many sociocentric individuals view wellness as a balance
among the physical, emotional, relational, cognitive, ecological, and
spiritual dimensions. Therefore, you can examine clients’ lifestyle through
questions about nutrition (special foods), physical activity, ability or
disability status, use of alternative medicine, intake of vitamins and herbs,
relaxation practices, spiritual practices, use or abuse of substances, and
others. In addition, you can explore clients’ ecological contexts, such as
living in the northern latitude and being susceptible to seasonal affective
disorder, as well as being exposed to higher than normal lithium soil
quantities in the U.S. Southwest. Along these lines, you can examine your
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clients’ environmental circumstances. For example, Caspi, Taylor, Moffitt,
and Plomin (2000) found that lower income neighborhoods are associated
with children’s development of behavioral problems. Living in high-
density areas forces inner-city individuals to endorse specific survival
adaptations—behaviors that become dysfunctional when living in low-
crime areas. Although one’s clients may not reside in a lower income
neighborhood, they may be vicariously affected by having significant
others who do.
MULTIGENERATIONAL GENOGRAMS
You can diagram clients’ ethnocultural heritage with the use of
multigenerational genograms (McGoldrick, Gerson, & Petry, 2008;
McGoldrick, Gerson, & Shellenberger, 1999). Similar to family trees,
genograms present family relationships, issues, and concerns in a
multigenerational format. A multigenerational genogram recognizes the
centrality of a collective identity, highlighting the connections with
intergenerational and historical linkages. It is important to earn a client’s
trust and credibility before attempting to do a genogram.
When you diagram a genogram, you can use symbols to organize and
understand a client’s family history and dynamics from a nuclear to an
extended genealogical perspective (McGoldrick et al., 1999, 2008). A
multigenerational genogram goes back at least three generations and helps
you to map a client’s patterns and dynamics in a collective context
(McGoldrick et al., 1999). See GenoPro (1998–2013) for basic genogram
symbols; see also McGoldrick et al. (1999, 2008).
CULTURAL GENOGRAMS
Genograms are particularly useful when you compare your own
genealogy with your client’s. As a clinical tool, a genogram helps one
examine clinician–client similarities and differences. As part of your
clinical training or personal therapy, you may have already completed your
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own genogram. However, when working with multicultural clients, you
should diagram your own cultural genogram. Note that clinicians should
make sure that they have earned enough cultural credibility before
introducing this multicultural tool.
Cultural genograms place individuals within their collective contexts,
including but not limited to genealogical, biological, developmental,
historical, political, economic, sociological, ethnic, and racial influences
(Hardy & Laszloffy, 1995). In short, cultural genograms emphasize the
role of context in the lives of individuals. Hardy and Laszloffy advanced
the concept of the cultural genogram as an extended genealogical tool to
map contextual relationships among heritage, affiliation, history, collective
trauma, ecology, place, community, racial socialization, experiences with
oppression, ingroup dynamics, outgroup dynamics, relationship with
dominant society, relationship with members of other racial ethnic groups,
politics, identity, immigration, translocation, adaptation, acculturation,
transculturation, ethnic/racial identity development, and many other
contextual factors. In particular, cultural genograms examine the
management of cultural differences and similarities. Because of the
emphasis on ethnocultural heritage, it is important to go at least five
generations back when completing a cultural genogram. In addition to
charting the regular information obtained through a genogram, cultural
genograms (Comas-Díaz, 2011; Hardy & Laszloffy, 1995) chart culture-
specific information such as
activities of daily life;
birth, marriage, death, and developmental milestone rituals;
meaning of cultural similarities and differences;
meaning of leisure;
ethnocultural heritage;
cultural translocation;
cultural adaptation, acculturation, and transculturation;
dual consciousness, biculturalism, and multiculturalism;
communication style;
cultural–racial/ethnic identity development;
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soul wounds;
historical and contemporary trauma;
racial socialization;
gender racial socialization;
experience with oppression and privilege;
internalized oppression and privilege;
orientation to time;
sense of agency;
ingroup/outgroup member dynamics;
relations with dominant society members;
spirituality and faith;
geopolitics, ecological influences; and
psychopolitical influences.
Clinicians should not expect to complete a cultural genogram in a
single session. Allow yourself enough time to let clients’ cultural
genealogical stories emerge. Both an assessment and a treatment
instrument, a cultural genogram promotes clients’ self-healing because it
allows them to reconnect with their cultural heritage. Use your clinical
judgment when conducting a cultural genogram with your multicultural
clients. Information on cultural genograms is in Hardy and Laszloffy
(1995).
Clinicians should complete their own cultural genogram. Figure 23.1
shows an example.
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Figure 23.1. Example of a cultural genogram. Please note that “Red slaves” are
people who were kidnapped from Goajira (Venezuela) and forced into slavery (see
Regional Office for Culture in Latin America and the Caribbean, n.d.). The
genogram information here follows the genogram formulation by McGoldrick and
colleagues
(continues)
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Figure 23.1. (Continued) (1999, 2008; standard genogram symbols can be viewed
at http://courses.wcupa.edu/ttreadwe/courses/02courses/standardsymbols.htm). The
essential differences between a genogram and a cultural genogram are that the
latter goes back at least five generations, emphasizes ethnoracial identity,
acknowledges the sociopolitical and historical contexts, and recognizes
sociocentric cultural values. Here, some genogram symbols were modified to
reflect racial–ethnic identification and collectivistic cultural values, and
“universal” symbols were added to simplify the diagram.
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual
of mental disorders (4th ed., text rev.). Washington, DC: Author.
Arizona State Senate. (2010). Fact sheet for S.B. 1070. Retrieved from
http://www.azleg.gov/legtext/49leg/2r/summary/s.1070pshs .htm
Caspi, A., Taylor, A., Moffitt, T. E., & Plomin, R. (2000). Neighborhood
280

http://courses.wcupa.edu/ttreadwe/courses/02courses/standardsymbols.htm

http://www.azleg.gov/legtext/49leg/2r/summary/s.1070pshs .htm

deprivation affects children’s mental health: Environmental risks identified
in a genetic design. Psychological Science, 11, 338–342.
doi:10.1111/1467-9280.00267
Comas-Díaz, L. (2000). An ethnopolitical approach to working with people of
color. American Psychologist, 55, 1319–1325. doi:10.1037/0003-
066X.55.11.1319
Comas-Díaz, L. (2011). Multicultural approaches to psychotherapy. In J. C.
Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of
psychotherapy: Continuity and change (2nd ed., pp. 243–267).
Washington, DC: American Psychological Association.
doi:10.1037/12353-008
Danieli, Y. (Ed.). (1998). International handbook of multigenerational
legacies of trauma. New York, NY: Plenum Press.
Duran, E., & Duran, B. (1995). Native American postcolonial psychology.
Albany: State University of New York Press.
Elder, G. (1979). Historical change in life patterns and personality. In P. Baltes
& O. G. Brim (Eds.), Life-span development behavior (Vol. 2, pp. 117–
159). New York, NY: Academic Press.
Evans-Campbell, T. (2008). Historical trauma in American Indian/Native
Alaska communities: A multilevel framework for exploring impacts on
individuals, families, and communities. Journal of Interpersonal Violence,
23, 316–338. doi:10.1177/0886260507312290
GenoPro. (1998–2013). Rules to build genograms. Retrieved from
http://www.genopro.com/genogram/rules/
Hardy, K. V., & Laszloffy, T. (1995). The cultural genogram: Key to training
culturally competent family clinicians. Journal of Marital and Family
Therapy, 21, 227–237.
Jewish Virtual Library. (2011). Ashkenazi Jewish genetic diseases. Retrieved
from http://www.jewishvirtuallibrary.org/jsource/Health/genetics.html
McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and
intervention (3rd ed.). New York, NY: Norton.
McGoldrick, M., Gerson, R., & Shellenberger, S. (1999). Genograms:
Assessment and intervention. New York, NY: Norton.
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Regional Office for Culture in Latin America and the Caribbean. (n.d.).
Introduction: Breaking the silence, the case of Aruba. Retrieved from
http://www.lacult.org/sitios_memoria/Aruba.php?lanen
Sakauye, K. (1996). Ethnocultural aspects. In J. Sadavoy, L. W. Lazarus, L. F.
Jarvik, & G. T. Grossberg (Eds.), Comprehensive review of geriatric
psychiatry (2nd ed., pp. 197–221). Washington, DC: American Psychiatric
Press.
Shorter-Gooden, K. (1996). The Simpson trial: Lessons for mental health
practitioners. Cultural Diversity and Mental Health, 2, 65–68.
doi:10.1037/1099-9809.2.1.65
Excerpted from Multicultural Care: A Clinician’s Guide to Cultural Competence (2012), from Chapter 3,
“Multicultural Assessment: Understanding Lives in Context,” pp. 67–74. Copyright 2012 by the American
Psychological Association. Used with permission of the author.
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http://www.lacult.org/sitios_memoria/Aruba.php?lanen

24
MULTICULTURAL THERAPY PROCESS
LILLIAN COMAS-DÍAZ
Historically, multicultural individuals have resorted to diverse sources
of healing. Just to name a few, these sources include empowerment
approaches, such as ethnic psychotherapies, folk healing, and spiritual
practices. For instance, network family therapy emerged from a Native
American context to use individuals’ relational network in support of the
healing process (Attneave, 1990). As a result, mainstream counselors
borrowed and incorporated network therapy into substance abuse treatment
(Galanter, 1993).
Multicultural care promotes the incorporation of diverse healing
modalities into mainstream treatment. This means that multicultural caring
clinicians aim to empower their clients by complementing their treatment
orientation with varied approaches. In fact, several multicultural experts
recommend the use of a plurality of interventions in clinical practice (Sue
& Sue, 2008).
In this chapter, I present multicultural treatment as an empowering
approach. First, I present a cultural adaptation of mainstream clinical
practice. Then, I discuss empowerment as an example of a culture-centered
clinical treatment. A clinical case illustrates the empowering focus of
multicultural treatment. I conclude with a discussion of the ethics of being
a multicultural caring clinician.
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CULTURAL ADAPTATION OF MAINSTREAM MENTAL HEALTH
PRACTICE
Seeking mental health services can be a paradox for multicultural
individuals. Although people of color have a significant need,
unfortunately, the history of service delivery to these populations is
fraught with obstacles and missed opportunities. To illustrate, most people
of color have to overcome a history of medical research abuses and
subsequent mistrust toward the health care delivery. Regrettably, this
medical legacy affects those clients of color whose primary care
practitioners refer them to mental health treatment. Moreover, numerous
multicultural individuals perceive clinical practice as being monocultural,
ethnocentric, and insensitive to their cultural and spiritual experiences
(Hall, 2001; Sue, Bingham, Porché-Burke, & Vasquez, 1999). As such,
clinical practice tends to reflect dominant cultural values and to ignore
multicultural worldviews. Consequently, many culturally diverse
individuals fear that dominant mental health practice is a stigmatizing and
acculturative institution (Ramirez, 1991). In contrast, when multicultural
clients encounter clinicians who respect, hear, understand, and care for
them, they tend to remain in treatment. Certainly, cultural competence is
the key to engage multicultural clients to treatment. For instance, research
found clinicians’ cultural competence, compassion, and sharing their
clients’ worldview were more important factors than ethnic matching
between client and clinician (Knipscheer & Kleber, 2004). Consequently,
clinicians’ lack of cultural competence is one reason many multicultural
individuals resort to alternative sources of healing.
Although some clinicians have questioned the applicability of
dominant clinical practice to multicultural clients (Bernal, Bonilla, &
Bellido, 1995; Sue et al., 1999), others have suggested a cultural
adaptation to mainstream clinical practice (Altman, 1995; Bernal &
Scharrón-del-Río, 2001; Foster, Moskowitz, & Javier, 1996; Kakar, 1985).
The cultural adaptation of mainstream psychotherapy consists of both the
development of generic cross-cultural skills and the acquisition of culture-
specific skills. Because every encounter is multicultural in nature, when
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you enhance your generic cross-cultural skills, you improve your cultural
competence with all clients.
Nonetheless, when you develop culture-specific skills, you enhance
your ability to work with particular cultural populations. According to
multicultural experts, the development of culture-specific skills includes
(a) involvement of culturally diverse people in the development of
interventions; (b) inclusion of collectivistic cultural values (such as
familism, social cohesion, contextualism); (c) attention to spirituality,
religion, and faith; (d) recognition of the relevance of acculturation; and
(e) acknowledgment of the effects of oppression on mental health (Muñoz
& Mendelson, 2005).
According to Bernal et al. (1995), a cultural adaptation of mainstream
psychotherapies needs to include the dimensions of language, persons,
metaphors, content, concepts, goals, method, and context. Specifically, the
language used in treatment needs to be culturally congruent to the client’s
worldview; the persons must be engaged in a good therapeutic
relationship; metaphors must include symbols and concepts shared by
members of the cultural group; the content of the clinician’s cultural
knowledge must be sufficient (i.e., does your client feel understood by
you?); the concepts of the treatment must be congruent with the client’s
culture; the goals of therapy must be culturally congruent; the methods and
instruments of therapy must be culturally adapted and validated; and the
context must include the clients’ ecology, including historical and
sociopolitical circumstances.
An example of the incorporation of cultural factors in treatment is
ethnic family therapy. As a field, family therapy has a legacy of
incorporating ethnicity and culture into its theory and practice (Ho, 1987;
McGoldrick, Giordano, & Garcia-Preto, 2005). Ethnic family therapy
emerged out of this tradition to address the cultural context of families and
to use ethnic values in treatment. Boyd-Franklin’s (2003) multisystemic
approach presented in her book Black Families in Therapy is a classic
example of this perspective. As an illustration of a multicultural care
treatment, ethnic family therapy requires clinicians to develop cultural
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competence. Family clinicians commit to cultural competence by
becoming multiculturally aware, avoiding ethnocentric attitudes and
behaviors, aiming to achieve an insider/outsider status, and engaging in
selective disclosure (Ariel, 1999).
Psychoanalysis has a long-standing tradition of examining the
relationship between culture and psyche. This tradition gave birth to
psychoanalytic anthropology (Devereux, 1953). Early on, psychoanalysts
exhibited an interest in the relationship between oppression and
psychological functioning (Kardiner & Ovesey, 1951). Along these lines,
proponents of the cultural school of psychoanalysis believed that human
development is rooted in environmental factors that vary across cultural
contexts and historical periods (Seeley, 2000). Adherents of the cultural
school of psychoanalysis, such as Eric Fromm, Karen Horney, and Harry
Stack Sullivan, argued that culture shapes behavior because individuals are
contextualized and embedded in social interactions (Comas-Díaz, 2011).
Some psychoanalysts are responding to the call to culturally adapt their
practice through the incorporation of clients’ social, communal, and
spiritual orientations into psychoanalysis (Foster et al., 1996). As a vivid
example, Altman (1995) reported using a modified object relations
framework, in which he examines his clients’ progress by their ability to
use relationships to grow, rather than by the insight that they gain.
Similarly, Indian psychoanalyst Kakar (1985) culturally adapted his
clinical practice by educating, empathizing, and actively expressing
warmth toward his East Indian patients.
And yet, other multicultural clinicians recommended the cultural
adaptation of evidence-based practice (EBP) based on commonalities
regarding mind–body connection, the role of thoughts in health and illness,
and the importance of education in healing (Muñoz & Mendelson, 2005).
Lamentably, EBP approaches tend to underemphasize the role of historical
and sociopolitical contexts in the delivery of clinical care to people of
color and, thus, lack a contextual–ecological viewpoint to examine social
and environmental problems (Rogers, 2004). To address these concerns, an
American Psychological Association (APA) Presidential Task Force
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reconceptualized EBP as the “integration of the best available research
with clinical expertise in the context of client characteristics, culture, and
preferences” (APA Presidential Task Force on Evidence-Based Practice,
2006, p. 273). Although evidence-based treatments tend to lack cultural
and ecological validity (Hall, 2001; Rosselló & Bernal, 1999), research on
culture-sensitive EBPs has shown benefits for some culturally diverse
populations. For example, researchers found positive gains in the areas of
depression (Kohn, Oden, Muñoz, Robinson, & Leavitt, 2002; Organista,
Muñoz, & González, 1994), anxiety (Sanderson, Rue, & Wetzler, 1998),
obsessive disorder (Hatch, Friedman, & Paradis, 1996); attention-
deficit/hyperactivity disorder, depression, conduct disorder, substance use,
trauma-related disorders, and other clinical problems (Horrell, 2008)
among clients of color. (The interested reader can consult Morales &
Norcross, 2010, for a report on the conference “Culturally Informed
Evidence Based Practices.” The conference proceedings are available at
http://psychology.ucdavis.edu/aacdr/ciebp08.html.)
Notwithstanding the above-mentioned gains, people of color drop out
of mental health treatment more often than their White counterparts
(Miranda et al., 2005; Organista et al., 1994). Unfortunately, a
decontextualized manualized clinical approach (Carter, 2006; Wampold,
2007) tends to restrict access to treatment of choice (Norcross, Koocher, &
Garofalo, 2006; Rupert & Baird, 2004). To bridge this gap, experts
recommend that clinicians incorporate culture-centered strategies into their
clinical approaches (Bernal & Scharrón-del-Río, 2001). Indeed,
empowerment is a central component of culture-centered clinical
interventions.
EMPOWERMENT: A CULTURE-CENTERED CLINICAL
INTERVENTION
APA Multicultural Guideline 5 (APA, 2003) recommends that
clinicians recognize that there are situations in which adapting culture-
centered interventions to their practice will increase their clinical
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http://psychology.ucdavis.edu/aacdr/ciebp08.html

effectiveness. In other words, this guideline asks clinicians to focus on
clients’ cultural contexts and to include a broad range of interventions into
their practice. You can comply with this recommendation when you
complement your practice with empowering, pluralistic, and holistic
approaches. Given the central relationship between health and oppression
in the lives of many people of color, numerous clinicians have recognized
the need for empowerment approaches in multicultural care (Muñoz, 1996;
Sue & Sue, 2008).
To facilitate empowerment, you can acknowledge your clients’
experiences with racism, sexism, classism, homophobia, heterosexism,
ethnocentrism, ableism, ageism, and other forms of discrimination. For
instance, you can open a clinical space to discuss the effects of the
oppression on your clients’ lives. In such a space, you can become a
witness and an interpreter of your clients’ maladies. Dr. Cassidy witnessed
John’s experiences with oppression regarding race and sexual orientation.
During their initial session, Dr. Cassidy facilitated the emergence of a
working alliance when he examined John’s ADDRESSING areas. John’s
responses to the ADDRESSING tool revealed a conflict with being a gay
Black man raised working class with a minister father in a Southern
Baptist community. Although John reported no previous personal or
family psychiatric history, he agreed to see a psychologist for anger
management. John’s responses to the explanatory model of distress
revealed that the behavior of his White coworkers triggered his anger. He
acknowledged being the victim of a combined racist and homophobic
discrimination at work. John stated that a White coworker spotted him
walking out of a gay bar several days before the harassment at work began.
In addition, John described several incidents where he experienced racial
microaggressions (“You’re an affirmative action baby”). Perhaps John’s
combined lower social status as an African American gay man made him
more of a discrimination target. As a result, John discussed with Dr.
Cassidy his plan to file a discrimination complaint at work.
After analyzing the symbolic meaning of John’s intended complaint,
how would you handle this plan? In other words, should you advocate for,
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against, or remain neutral on John’s plan to file an Equal Employment
Opportunity complaint? Although multicultural caring clinicians do not
need to be politically active, they recognize that clinical practice is
grounded in a political context and, thus, can be a political action. In other
words, your clinical orientation can be an instrument of the status quo, or,
conversely, it can be an empowering activity. You can conduct a cultural
self-assessment to explore your political ideology.
Cultural Self-Assessment: Political Ideology
What is your political ideology—conservative, liberal, centrist,
radical, libertarian, apolitical, or none? Do you belong to a political party?
How do you feel about clients endorsing political views different from
your own? How do you feel about clients endorsing your personal political
views? How do you feel about the political issues affecting minority
groups? For example, how do you feel about state abortion laws, same-sex
marriage, anti-immigration laws, and the Americans With Disabilities Act
(1990)? What criteria do you use when you examine political issues in
your clinical practice?
Empowerment as a Multicultural Clinical Tool
Regardless of your political orientation, remember that mainstream
clinical practice’s neglect of sociopolitical contexts can be detrimental to
many multicultural clients. In other words, numerous people of color’s
realities differ from the experience of most majority group members
because of their history of collective oppression and trauma (Vasquez,
1998). Moreover, people of color tend to internalize their oppression.
Regardless of your political orientation, you can use empowerment
approaches to help your clients differentiate functional adaptive responses
from dysfunctional ones.
Multicultural caring clinicians use empowering approaches to foster
clients’ examination of their oppression to promote liberation
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(Pinderhughes, 1994). Therapeutic empowerment helps clients to increase
their self-efficacy, mastery, agency, and control (Dass-Brailsford, 2007).
For example, research findings suggested that African American
adolescents empowered by cultural pride and racial socialization endorsed
fewer depressive behaviors as opposed to those who reported experiences
of discrimination (Davis & Stevenson, 2006). Empowerment promotes
self-healing by allowing the doctor who resides in each patient a chance to
go to work. When you subscribe to an empowerment multicultural model,
you recognize your clients’ contextual reality, accept their experience as
valuable knowledge, affirm their cultural strengths, and acknowledge their
perspectives on healing. In summary, a multicultural empowerment helps
clients to
increase their access to resources;
develop options to exercise choice;
affirm cultural strengths;
strengthen support systems;
promote cultural identity development;
foster self-healing;
develop critical consciousness;
overcome internalized oppression;
improve individual and collective self-esteem; and
engage in transformative actions.
The clinical emphasis on empowerment in the United States has
political roots. Civil rights movements (e.g., Black power, Chicano/Brown
power; gay, lesbian, and bisexual rights) have led to the empowerment of
minorities. These movements raised consciousness and attempted to
redress the social and political inequities affecting marginalized minority
groups. Minority empowerment movements examined the dynamics of
power and privilege between dominant group members and individuals
from disenfranchised groups. As a result, multiculturalism emerged to
promote a critical dialogue on oppression and power and to explore
models for healing and liberation.
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Critical Consciousness Dialogue
Looking beyond the shores of the United States, multiculturalists
found an example of such critical dialogue in Freire’s (1970) education for
the oppressed. A Brazilian educator, Freire identified his model as
conscientizacion, or critical consciousness—a process of personal and
social liberation through critical thinking. Adherents of critical
consciousness teach their clients to critically perceive their circumstances,
analyze the causes of their oppression, and discover new ways of action
(Freire, 1970). Clinicians using critical consciousness promote clients’
agency and ask them to engage in transformative actions. Succinctly put,
conscientizacion encourages clients to examine meaning, beliefs, and
existential choices to critically analyze their situation, affirm ethnocultural
strengths, and promote personal and collective transformation.
Because oppression robs its victims of their capacity for critical
thinking, the development of conscientizacion involves asking questions to
help clients to make a connection between their concerns and the
distribution of power. Asking critical questions, such as What? Why?
How? For whom? Against whom? By whom? In favor of whom? In favor
of what? To what end? (Freire & Macedo, 2000, p. 7) can raise
consciousness and initiate critical reflection and dialogue about
individuals’ life circumstances. This process facilitates clients’
examination of their own issues against the backdrop of sociopolitical
realities.
Marcia, the African American client, missed the first part of a lecture
because she misplaced her admission ticket. You may remember that the
White female clerk denied her entrance to the conference until she found
Marcia’s name on a second list. Marcia expressed anger at the incident and
interpreted the clerk’s behavior as racist. My question about alternative
explanations seemed to direct her anger toward me (“It’s easy for you to
ask about alternative explanations. You’re not Black.”). In addition, you
may remember that as a result, we engaged in a discussion about our racial
differences (“You’re right, I’m not Black. How do you feel about working
with a non-Black clinician? Can we talk about your experiences with
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racism?”). This discussion resulted in a power differential analysis
between us.
Let us see what happened when I asked Marcia the following critical
consciousness questions:
Lillian: Can we examine the incident from a different perspective?
Marcia: Fine with me.
Lillian: Why do you think the clerk refused to let you in?
Marcia: You tell me . . . .
Lillian: Honestly, I really want to know what you think.
Marcia: I told you she’s a racist hypocrite.
Lillian: Who benefits from her behavior?
Marcia: What kind of question is that?
Lillian: Please, can you think about it? Who benefits?
Marcia: Not me!
Lillian: What happened afterward?
Marcia: I already told you, she gave the presenter his badge.
Lillian: Can you tell me more?
Marcia: Had a late night? [Laughs] Your memory isn’t so good
today.
Lillian: Come on.
Marcia: OK. The presenter was standing next to me when he asked
the clerk to let him in the room. Where’re you going with this?
Lillian: Please bear with me. I’m trying to help. What was the
woman’s purpose in letting you wait?
Marcia: I will not answer that question. [Moves backwards into
her chair.]
Lillian: OK. It’s natural to be angry.
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Marcia: You may be trying to help, but . . .
Lillian: But . . . ?
Marcia: Why don’t you help me with my snowballing anger?
Lillian: Snowballing?
Marcia: Yeah. My snowballing anger gets everything in its way.
Lillian: How does it get to you?
Marcia: [Takes several deep breaths, straightens her skirt, and
moves forward in the chair.] I’m tired of fighting racism.
I remembered the power analysis I had conducted previously, in
which I compared Marcia’s areas of privilege and oppression with mine.
As a result, the topic of dark skin emerged as both a connection and a
disconnection between us. Although I am not White, my skin color is
lighter than Marcia’s.
Lillian: I wonder if there is a connection between your snowballing
anger and what happened?
Marcia: I don’t know, maybe . . .
Lillian: What was the presenter’s skin color?
Marcia: Were you there?
Lillian: I don’t understand your question. [Not addressing
Marcia’s ironic tone in her question] No, I wasn’t there.
Marcia: So why are you asking about his color?
Lillian: Well, a hunch.
Marcia: He was Indian, you know, from India, and his skin was
quite dark.
Lillian: What do you make out of that?
Marcia moved slowly toward the box of tissues in front of her. She
took one tissue. She then grabbed a second one while still holding the box
in her left hand. Finally, Marcia took a third tissue. She released the box
293

and bunched the three tissues together. Only then did Marcia’s tears began
to flow.
RACISM-RELATED DISTRESS
As I indicated previously, the single most common problem
underlying psychotherapy with African American women is racism-related
distress (Landrine & Klonoff, 1996). Marcia’s encounter with the White
female clerk was colored by her societal role as a Black woman, the social
distance between Blacks and Whites in Washington, DC, and her exposure
to personal and collective racial discrimination. Her angry reaction at the
clerk’s behavior uncovered a racial–gender injury, a response consistent
with evidence showing that racism is a pathogen with biological
consequences for its victims (Krieger, 1999). To illustrate, research has
documented that African Americans show greater increases in blood
pressure when exposed to a stressful task than do Whites (Anderson, Lane,
Muranaka, Williams, & Houseworth, 1988; Treiber et al., 1993). This
racial difference can be understood in the context of African Americans’
cumulative exposure to racial discrimination (Sue, Capodilupo, & Holder,
2008). Certainly, racial discrimination has been related to health problems
among ethnic minorities (Araújo & Borrell, 2006; Williams, Neighbors, &
Jackson, 2008; Williams, Yu, Jackson, & Anderson, 1997). Moreover,
African Americans’ history of slavery and exposure to microaggressions
can result in oversensitivity toward perceived acts of disrespect, as they
may be subliminally associated with historical trauma.
Lillian: Can you tell me what is like for you to be a Black woman?
Marcia: It ain’t easy . . . too much stress.
Lillian: How can I help?
Marcia: You can’t get it. You have light skin.
Lillian: Yes, my skin is lighter than yours. I don’t experience what
you do as a Black woman.
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Marcia: No, you don’t. [Says this in a loud voice as she averted
her eyes.]
Lillian: How can I help? [Asks this in a soft voice.]
Marcia: [Speaks after a long pause.] Can you help me to separate
my legitimate anger from overreactions?
The power differential analysis that I conducted in a previous session
offered a safe place for the discussion of racial differences. Marcia
identified colorism (preference for light skin over dark skin) as a main
difference between us. I attempted to remain “present” and did not shy
from exploring our differences as women of color. Furthermore, by
answering critical consciousness questions, Marcia confronted the
possibility that she may have overreacted to the White clerk’s behavior.
Marcia associated her cumulative exposure to racial microaggressions with
an exacerbation of her irritable bowel syndrome. It seemed that her
exposure to racial stress and her “snowballing” anger culminated in
physical and psychological symptoms.
Constant exposure to racism increases behavioral exhaustion,
psychological distress, and physiological disturbances (Clark, Anderson,
Clark, & Williams, 1999). For example, Marcia revealed a history of
overreactions to neutral interpersonal situations. She reported a series of
conflicts in relationships with her adult offspring, relatives, friends, and
neighbors. Marcia’s reactions seemed consistent with ethnocultural
allodynia, a psychological reaction to cumulative pain. In medicine,
allodynia refers to exaggerated pain sensitivity in response to neutral or
relatively innocuous stimuli, resulting from previous exposure to painful
stimuli. I and my partner, Frederick Jacobsen, borrowed the term allodynia
and coined the concept of ethnocultural allodynia as an increased
sensitivity to ethnocultural dynamics associated with exposure to
emotionally painful social, racial, and ethnoracial stimuli (Comas-Díaz &
Jacobsen, 2001).
Ethnocultural allodynia entails a disturbance in individuals’ ability to
judge perceived ethnocultural and racial insults and, subsequently, discern
defiant and maladaptive responses from adaptive ones. Ethnocultural
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allodynia describes a pain caused by previous racial and ethnic and
cultural injuries as an extreme reaction to neutral or ambiguous stimuli.
Therefore, people of color can develop ethnocultural allodynia as a
reaction to an increased sensitivity to ethnocultural and racial dynamics
associated with past exposure to microaggressions. Marcia’s ethnocultural
allodynia was a maladaptive response involving an injury to her sense of
self that compromised her coping.
Completing Marcia’s cultural genogram offered a fuller picture of the
context of her historical and contemporary trauma. To aid in this process,
Marcia brought a photo album during the completion of her cultural
genogram. The essential differences between a regular genogram and a
cultural genogram are that the latter goes back at least five generations,
emphasizes ethnoracial identity, acknowledges the sociopolitical and
historical contexts, and recognizes sociocentric cultural values.
Figure 23.1 shows Marcia’s cultural genogram. I included the
information suggested by Hardy and Laszloffy (1995) and used the form
suggested by McGoldrick and colleagues (McGoldrick, Gerson, & Petry,
2008; McGoldrick, Gerson, & Shellenberger, 1999). I modified some
genogram symbols to reflect racial and ethnic identification and
collectivistic cultural values. Moreover, I added more universal symbols to
simplify the genogram.
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APPENDIX 24.1: MULTICULTURAL THERAPY TECHNIQUES
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25
NARRATIVE THERAPY
STEPHEN MADIGAN
There is no power relation without the correlative constitution of a
field of knowledge, nor any knowledge that does not presuppose and
constitute at the same time power relations.
—Michel Foucault (Discipline and
Punish: The Birth of the Prison)
A MULTISTORIED VERSION OF LIFE
By taking up a poststructural theoretical view, Epston and White
proposed that the complexity of life, and how lives are lived, is mediated
through the expression of the stories we tell. Stories are shaped by the
surrounding dominant cultural context; some stories emerge as the long-
standing reputations we live through, and other (often more preferred)
stories of who we are (and might possibly become) can sometimes be
restrained and pushed back to the margins of our remembered experience
(Madigan, 1992, 2007). But whatever the stories are that we tell (and don’t
tell), they are performed, live through us, and have abilities to both restrain
and liberate our lives (Epston, 2009; Parker, 2008; Turner, 1986; White,
1995, 2002).
White and Epston organized their therapy practice around the idea of
a multistoried version of life (of what a story/problem-story can mean).
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This therapeutic concept afforded them the flexibility to view persons and
problems not as fixed, fossilized, or under any one unitary description,
theory, or label (White, 2002; White & Epston, 1990). Multistoried
considerations regarding who a person might be in relation to the problem
allowed them to reconsider and resist an isolated or categorized story of a
person.1
Epston and White’s narrative therapy afforded the person and/or
problem definition a flexibility for multiple interpretations of what he or
she might be—allowing both client and therapist the possibility to re-vise,
re-collect, and re-member (McCarthy, personal communication, 1998;
Myerhoff, 1986; White, 1979) a story from various and competing
perspectives (Madigan, 1996; Madigan & Epston, 1995; White, 2005). It is
among these relational re-authoring conversations that change was
believed to take place in narrative therapy (Zimmerman & Dickerson,
1996).
Epston and White also believed that a multistoried version of life
might include a newly revised re-telling about a person’s and/or group’s
past, present, and future (Denborough, 2008). For example, in 1974,
millions of Americans were deemed healthy (literally) overnight when the
diagnostic category homosexuality was erased from the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders. At that time, the American Psychiatric Association made
headlines by announcing that it had decided homosexuality was no longer
a mental illness. The decision was brought forward as gay activists
demonstrated in front of the American Psychiatric Association convention.
The 1974 vote showed 5,854 association members supporting and 3,810
opposing the disorder’s removal from the manual.
From a narrative therapy perspective, the practice of voting on
whether homosexuality constitutes mental illness is not only
therapeutically absurd but, needless to say, also highly unscientific and
politically motivated (J. Tilsen, personal communication, 2006). Narrative
therapists regard the vote on the status of gay identity as a clear example of
how illogical it is for professionals in positions of power to be allowed to
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make arbitrary decisions regarding the mental health identity of others
(Caplan, 1995; Nylund, Tilsen, & Grieves, 2007). Nevertheless, with the
stroke of a powerfully political pen, these identified homosexual persons,
once viewed as sick and/or morally evil by professional members of
psychiatry, religion, the law, and so on, were moved (at least by the
American Psychiatric Association) from one side of the healthy/unhealthy
binary to the other (however, they remained unholy and unlawful in the
eyes of many religious institutions and legal jurisdictions).
The politics of such a move is quite telling about how psychological
decisions regarding healthy/unhealthy identities are willfully created in the
fields of mental health. The politics of psychiatry’s power-over position
also demonstrates the capricious and half-baked intellectual scenery of
psychological decision making.
As witnesses to this process of documentation within psychological
history, we might now turn our sights toward how other categories of
pathology are invented. For example, we might question what institutional
processes are involved in turning so-called healthy persons into supposed
unhealthy and not “normal” members of society (Nylund & Corsiglia,
1993, 1994, 1996). The answer to this question regarding the legitimacy of
a person’s identity may depend on who is telling this story, from what set
of ethical beliefs they are telling the story from, and with what authority
they are telling it. The conclusion is often our realization that not all stories
told are equal. However, the power to advise or label someone (and
through this process decide who is normal and who is not normal) is often
a source of unquestioned authority and privilege by both professionals and
those who seek our help.
From the outset, narrative therapy has explored the issue of
storytelling rights with people and the influence this may have in
constructing a life support system for problems (M. White, personal
communication, 1990). Take, for example, the story that a sole parent and
immigrant mother recently told me about how, during a 15-minute
physical checkup with her new general practitioner, she was informed that
she was a “depressed” person. Despite the medical doctor’s psychological
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diagnosis proving to be shocking news for the woman, she did adhere to
the culturally sanctioned medical/psychological expertise by purchasing
the selective serotonin reuptake inhibitor medication prescribed. It was
through the mediated politics of this (somewhat common) power-related
medical interchange that she then began to question her own version of
herself (as healthy and well functioning). When I asked her how she
currently viewed herself, she responded that she had begun the process of
performing herself as a depressed person.
By reproducing the professional’s opinion of her as a depressed
person (as a more relevant and complete story of who she was), the woman
began to question her reputation as a community leader within her cultural
group, as a strong survivor within her family, as a loving parent to her
children, and as a skilled worker to her employer. Unfortunately, these
community-supported stories of herself were not accounted for by the
doctor during their 15-minute problem-focused depression interview.
Without an exploration by the family doctor into the intersectionality2
of the woman’s personhood—living outside the boundaries and
confinements of the disembodied category of depression—the relationship
between depression and the person was left vastly underexplored. Naming
the woman’s experience depression and having the professional expert’s
story individually inscribed onto her body did absolutely nothing to
account for a relational and contextual exploration of other relevant issues
such as gender, race, sexuality, class, and so forth. To a narrative therapist,
a noncontextualized therapeutic interview of this kind would be viewed as
unethical.
RE-AUTHORING CONVERSATIONS
Psychologist Jerome Bruner3 (1990) suggested that within our
selection of stories expressed, there are always feelings and lived
experience left out of the dominant story told. Narrative therapy is
organized through the text analogy, with the central idea that it is the
stories people tell and hold about their lives that determine the meaning
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they give to their lives. Therefore, it is what we select out as meaningful
from the stories we tell that is given expression. For example, a grade of
80% on a driving test could be expressed through a story of appreciating
what was remembered in order to achieve an 80% passing grade or,
alternatively, what it was that accounted for all that was forgotten that did
not afford a perfect grade—two descriptions and two very different
experiences in the telling of these descriptions.
Epston and White relied heavily on the text analogy (Bruner, 1990) as
a way to explore re-authoring conversations4 with the people who came to
see them in therapy. Re-authoring conversations were a crucial part of both
the philosophical underpinnings of narrative therapy theory as well as the
practice work itself. White and Epston found that persons tended to seek
out therapy when the narratives they were telling (or were somehow
involved in) did not quite represent their lived experience and when there
were vital aspects of their experience that contradicted dominant narratives
about them (D. Epston, personal communication, 1991). They found that
by externalizing problems, the process assisted persons in separating from
saturated tellings of these problem stories. Persons then began to identify
previously neglected aspects of their lived experience (that contradicted
the dominant story told).
Epston and White also found that re-authoring conversations invited
people to do what they routinely do, that is, to link events of their lives in
sequences through time—according to a theme or a specific plot (Bruner,
1990). It was in this activity of telling/performing their story that people
were assisted by the therapist to identify the more neglected events of their
lives, named in narrative therapy as unique outcomes5 (Goffman, 1961).
People were then encouraged to capture these unique outcomes into
alternative story lines named unique accounts. For example, when Tom
first entered into therapy with me, he initially relayed a version of himself
as a “failed” person. It was only after a bit of narrative inquiry that he
began a fascinating re-telling of himself that included stories about his life
lived as a proud father, fair-minded employer, talented gardener, etc.—
stories once restrained through a totalized telling of himself as a resident-
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psychiatric-ward-chronic-problem person.
White and Epston (1990) felt that unique outcomes provided a
starting point for re-authoring conversations that lived outside the
restraints of the problem-saturated story being told. Unique outcomes
made available a point of entry into the alternative story lines of people’s
lives that, at the outset of these therapeutic conversations, became visible
only as withered traces that were full of gaps and not clearly named. As
these conversations proceeded, therapists built a scaffold around the
emerging subordinate story (M. White, personal communication, 1991).
As unique outcomes were identified, the narrative therapy
conversation plotted them into an alternative story line about the person’s
lived experience. Unique outcomes were explained by way of unique
accounts as the narrative therapist worked to generate questions to
produce, locate, and resurrect alternative (and preferred) stories that filled
in—and made more sense of—the client’s stories of unique outcomes
(White, 1988/1989).
Questions were introduced by Epston and White to investigate what
these new developments in the story might mean about the person and his
or her relationships (stories that lived outside the dominant-problem story
being told by the person, family members, or professional). It was then
important to the therapeutic conversation for these subordinate stories to
be given a thicker description (Geertz, 1983) and plotted into an alternative
story about the person’s life.
More questions might be crafted to inspire what White and Epston
(1990) called unique redescription questions6 designed to investigate what
the new developments might reflect about the person and his or her
relationships. Questions also involved the investigation of plot lines to
discover unique outcomes, unique accounts, unique possibilities, and
unique circulations of the story, as well as experience of experiences,
preferences, and historical locations to support the evolving story.
The numerous ways that Epston and White designed narrative
therapy’s re-authoring conversations acted to re-invigorate people’s efforts
to understand (a) what it was that was happening in their lives, (b) what it
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was that had happened, (c) how it had happened, and (d) what it all could
possibly mean. In this way, therapeutic conversations encouraged a
dramatic reengagement with life and with history and provided options for
people to more fully inhabit their lives and their relationships.
Epston and White established that there were some parallels between
the skills of re-authoring conversations and the skills required to produce
texts of literary merit.7 Among other things, texts of literary merit
encourage (in the reader) a dramatic reengagement with many of their own
experiences of life. It is within this dramatic reengagement that the gaps in
the story line are filled, and the person lives the story by taking it over as
his or her own.
Operating alongside the skills that construct texts of literary merit,
White and Epston made it possible for people to address and to fill in the
gaps of these alternative landscapes of their experience (Epston, 1998).
Their narrative therapy questions were not oriented to the already known
in ways that precipitated the sort of thoughtlessness that is the outcome of
boredom and an acute familiarity with the subject,8 and nor were these
narrative questions oriented to precipitate the sort of thoughtlessness that is
the outcome of fatigue and of failure to identify the unfamiliar.9
As re-authoring conversations evolved, they provided conditions
under which it became possible for people to step into the near future of
the landscapes of action of their lives (Epston & Roth, 1995). Questions
were introduced that encouraged people to (a) generate new proposals for
action, (b) account for the circumstances likely to be favorable to these
proposals for action, and (c) predict the outcome of these proposals.
Epston and White found that people were likely to respond to
questions by generating identity conclusions that were informed by the
well-known structuralist categories of identity—these being categories of
needs, motives, attributes, traits, strengths, deficits, resources, properties,
characteristics, drives, and so on. These structuralist identity conclusions
invariably provided a poor basis for knowledge of how to proceed in life.
As these conversations further evolved, there were opportunities for people
to generate identity conclusions that were informed by nonstructuralist
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categories of identity—intentions and purposes, values and beliefs, hopes,
dreams and visions, commitments to ways of living, and so on (M. White,
personal communication, 1992).
It was in the context of the development of these nonstructuralist
identity conclusions that people found the opportunity to progressively
distance themselves from their problemed lives, and it was from this
distance that they became knowledgeful about matters of how to proceed
(D. Epston, personal communication, 2009). It was also from this distance
that people found the opportunity to have significant dramatic
engagements with their own lives and to take further steps in the
occupancy and habitation of their life.10
REFERENCES
Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University
Press.
Caplan, P. J. (1995). They say you’re crazy: How the world’s most powerful
psychiatrists decide who’s normal. Reading, MA: Addison-Wesley.
Denborough, D. (2008). Collective narrative practice: Responding to
individuals, groups, and communities who have experienced trauma.
Adelaide, Australia: Dulwich Centre.
Epston, D. (1998). Catching up with David Epston: A collection of narrative
practice-based papers published between 1991 and 1996. Adelaide,
Australia: Dulwich Centre.
Epston, D. (2009). Down under and up over: Travels with narrative therapy
(B. Bowen, Ed.). Warrington, England: AFT.
Epston, D., & Roth, S. (1995). In S. Friedman (Ed.), The reflecting team in
action: Collaborative practice in family therapy (pp. 39–46). New York,
NY: Guilford Press.
Geertz, C. (1983). Local knowledge: Further essays in interpretive
anthropology. New York, NY: Basic Books.
Goffman, E. (1961). Asylums: Essays in the social situation of mental patients
and other inmates. New York, NY: Doubleday.
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Madigan, S. (1992). The application of Michel Foucault’s philosophy in the
problem externalizing discourse of Michael White [Additional
commentary by Deborah Anne Luepnitz, rejoinder by S. Madigan].
Journal of Family Therapy, 14, 265–279. doi:10.1046/j..1992.00458.x
Madigan, S. (1996). The politics of identity: Considering community discourse
in the externalizing of internalized problem conversations. Journal of
Systemic Therapies, 15, 47–62.
Madigan, S. (2007). Anticipating hope within written and naming domains of
despair. In C. Flaskas, I. McCarthy, & J. Sheehan (Eds.), Hope and
despair in narrative and family therapy: Adversity, forgiveness and
reconciliation (pp. 100–112). Hove, England: Routledge.
Madigan, S. (2011). Narrative therapy. Washington, DC: American
Psychological Association.
Madigan S., & Epston, D. (1995). From “spy-chiatric gaze” to communities of
concern: From professional monologue to dialogue. In S. Friedman (Ed.),
The reflecting team in action: Collaborative practice in family therapy
(257–276). New York, NY: Guilford Press.
Myerhoff, B. (1986). “Life not death in Venice”: Its second life. In V. W.
Turner & E. M. Bruner (Eds.), The anthropology of experience (pp. 261–
286). Chicago: University of Illinois Press.
Nylund, D., & Corsiglia, V. (1993). Internalized other questioning with men
who are violent. Dulwich Centre Newsletter, 1993(2), 29–34.
Nylund, D., & Corsiglia, V. (1994). Attention to the deficits in attention deficit
disorder: Deconstructing the diagnosis and bringing forth children’s
special abilities. Journal of Collaborative Therapies, 2(2), 7–16.
Nylund, D., & Corsiglia, V. (1996). From deficits to special abilities: Working
narratively with children labeled “ADHD.” In M. F. Hoyt (Ed.),
Constructive therapies 2 (pp. 163–183). New York, NY: Guilford Press.
Nylund, D., Tilsen, J., & Grieves, L. (2007). The gender binary: Theory and
lived experience. International Journal of Narrative Therapy and
Community Work, 3, 46–53.
Parker, I. (2008). Constructions, reconstructions and deconstructions of mental
health. In A. Morgan (Ed.), Being human: Reflections on mental distress
in society (pp. 40–53). Ross-on-Wye, England: PCCS Books.
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Turner, V. (1986). The anthropology of performance. New York, NY: PAJ
Books.
White, M. (1979). Structural and strategic approaches to psychodynamic
families. Family Process, 18, 303–314. doi:10.1111/j.1545-
5300.1979.00303.x
White, M. (1988/1989, Summer). The externalizing of the problem and the re-
authoring of lives and relationships [Special issue]. Dulwich Centre
Newsletter.
White, M. (1995). Psychotic experience and discourse. In M. White (Ed.), Re-
authoring lives: Interviews and essays (pp. 45–51). Adelaide, Australia:
Dulwich Centre.
White, M. (2002). Addressing personal failure. International Journal of
Narrative Therapy and Community Work, 3, 33–76.
White, M. (2005). Children, trauma and subordinate storyline development.
International Journal of Narrative Therapy and Community Work, 3/4,
10–22.
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New
York, NY: Norton.
Zimmerman, J. L., & Dickerson, V. C. (1996). If problems talked: Narrative
therapy in action. New York, NY: Guilford Press.
Excerpted from Narrative Therapy (2011), from Chapter 3, “Theory,” pp. 29–38. Copyright 2011 by the
American Psychological Association. Used with permission of the author.
1Common solitary story lines of people who come to therapy include over-involved mother, under-
involved man, despondent immigrant worker, anorexic girl, depressed sole parent, oppositional youth—
and any universally agreed-on description acting to harden the categories of what can be storied and/or
given relevance.
2Intersectionality is a sociological theory seeking to examine how various socially and culturally
constructed categories of discrimination interact on multiple and often simultaneous levels, contributing to
systematic social inequality. Intersectionality holds that the classical models of oppression within society,
such as those based on race/ethnicity, gender, religion, nationality, sexual orientation, class, or disability,
do not act independently of one another; instead, these forms of oppression interrelate, creating a system of
oppression that reflects the “intersection” of multiple forms of discrimination.
3Bruner suggested that there are two primary modes of thought: the narrative mode and the paradigmatic
mode. In narrative thinking, the mind engages in sequential, action-oriented, detail-driven thought. In
paradigmatic thinking, the mind transcends particularities to achieve systematic, categorical cognition. In
the former case, thinking takes the form of stories and “gripping drama.”
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4The text analogy proposes that meaning is derived from storying our experience. And it is the stories that
persons tell that determine meaning about their lives.
5Unique outcomes are also referred to as exceptions. Unique accounts of these unique outcomes are also
referred to as, for example, alternative stories or subordinate storylines.
6See Chapter 4 of Madigan (2011) on unique redescription questions.
7White and Epston’s book Narrative Means to Therapeutic Ends was originally published in 1990 as
Literary Means to Therapeutic Ends.
8A narrative therapist is interested in having completely new and novel conversations in therapy with the
person. This involves a new re-telling of the story of the person/problem and not a parroting of what has
been told many times before by the person or by experts commenting on the person/problem relationship.
9As in the development of any skills, competence in the expression of these scaffolding questions is
acquired through practice, more practice, and then more practice.
10Some material in this section has been reprinted from Workshop Notes, by M. White, September 21,
2005, and retrieved from http://www.dulwichcentre.com.au/michael-white-workshop-notes . Copyright
2005 by the Dulwich Centre. Reprinted with permission.
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michael-white-workshop-notes

26
NARRATIVE THERAPY PROCESS
STEPHEN MADIGAN
UNIQUE OUTCOME QUESTIONS
Unique outcome questions invite people to notice actions and
intentions that contradict the dominant problem story. These can predate
the session, occur within the session itself, or happen in the future.
Given over-responsibility’s encouragement of worry, have there been
any times when you have been able to rebel against it and satisfy
some of your other desires? Did this bring you despair or pleasure?
Why?
Have there been times when you have thought—even for a moment—
that you might step out of worry’s prison? What did this landscape
free of worry look like?
I was wondering if you had to give worry the slip in order to come to
the session here today?
What do you think it may have been that helped support the hope in
yourself that helped you sidestep worry?
Can you imagine a time in the future that you might defy worry and
give yourself a bit of a break?
UNIQUE ACCOUNT QUESTIONS
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Conversations develop more fully following the identification of
unique outcomes and begin to demonstrate how they can become features
in a preferred alternative story. Unique account questions invite people to
make sense of exceptions/alternatives to the dominant story of the problem
being told (e.g., “I always worry”). These exceptions may not be registered
as significant or interesting or different; however, once uttered and
uncovered, they are held alongside the problem story as part of an
emerging and coherent alternative narrative.
Unique account questions/answers use a grammar of agency and
locate any unique outcome in its historical frame, and any unique outcome
is linked in some coherent way to a history of struggle/protest/resistance to
oppression by the problem or an altered relationship with the problem.
How were you able to get yourself to school and thereby defy worries
that want to keep you to themselves at home alone?
Given everything that worry has got going for it, how did you object
to its pushing you around?
How might you stand up to worry’s pressure to get you worried
again, to refuse its requirements of you?
Was it easier to be worry free for those moments when you were
simply watching that movie unencumbered?
Could your coming here today be considered a form of radical
disobedience to worry?
UNIQUE RE-DESCRIPTION QUESTIONS
Unique re-description questions invite people to develop meaning
from the unique accounts they have identified as they re-describe
themselves, others, and their relationships.
What does this tell you about yourself that you otherwise would not
have known?
By affording yourself some enjoyment, do you think in any way that
you are becoming a more enjoyable person?
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Of all the people in your life who might confirm this newly
developing picture of yourself as worrying less, who might have
noticed this first?
Who would support this new development in your life as a worry-free
person?
Who would you most want to notice?
UNIQUE POSSIBILITY QUESTIONS
Unique possibility questions are viewed as next-step questions. These
questions invite people to speculate about the personal and relational
futures that derive from their unique accounts and unique re-descriptions
of themselves in relation to the problem.
Where do you think you will go next now that you have embarked on
having a little fun and taking a couple of little risks in your life?
Is this a direction you see yourself taking in the days/weeks/years to
come?
Do you think it is likely that this might revive your flagging
relationship, restore your friendships, or renew your vitality? (This
conversation can lead back to unique re-description questions.)
UNIQUE CIRCULATION QUESTIONS
Circulation of the beginning preferred story involves the inclusion of
others. Circulating the new story is very important because it fastens down
and continues the development of the alternative story (Tomm, 1989).
Is there anyone you would like to tell about this new direction you are
taking?
Who would you guess would be most pleased to learn about these
latest developments in your life?
Who do you think would be most excited to learn of these new
developments?
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Would you be willing to put them in the picture?
Experience of Experience Questions
Experience of experience questions invite people to be an audience to
their own story by seeing themselves, in their unique accounts, through the
eyes of others.
What do you think I am appreciating about you as I hear how you
have been leaving worry behind and have recently taken up with a bit
of fun and risk?
What do you think this indicates to Hilda (her or his best woman
friend) about the significance of the steps you have taken in your new
direction?
Questions That Historicize Unique Outcomes
These questions represent any important type of experience of
experience questions. Historical accounts of unique outcome allow for a
new set of questions to be asked about the historical context. These
questions serve to (a) develop the blossoming alternative story, (b)
establish the new story as having a memorable history, and (c) increase the
likelihood of the story being carried forward into the future. The responses
to these produce histories of the alternative present (M. White, personal
communication, 1993).
Of all the people who have known you over the years, who would be
least surprised that you have been able to take this step?
Of the people who knew you growing up, who would have been most
likely to predict that you would find a way to get yourself free of
worry?
What would “X” have seen you doing that would have encouraged
him or her to predict that you would be able to take this step?
What qualities would “X” have credited you with that would have led
him or her to not be surprised that you have been able to____?1
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PREFERENCE QUESTIONS
Preference questions are asked all throughout the interview. It is
important to intersperse many of the previous questions with preference
questions to allow persons to evaluate their responses. This should
influence the therapist’s further questions and check against the therapist’s
preferences overtaking the client’s preferences.
Is this your preference for the best way for you to live or not? Why?
Do you see it as a good or a bad thing for you? Why?
Do you consider this to your advantage and to the disadvantage of the
problem or to the problem’s advantage and to your disadvantage?
Why?
CONSULTING YOUR CONSULTANTS QUESTIONS
Consulting your consultants questions serve to shift the status of a
person from client to consultant. The insider knowledge the person has in
relationship to his or her experience with the problem—because of lived
experience—is viewed by the therapist as unique and special knowledge.
The insider knowledge is documented and can be made available to others
struggling with similar issues (Madigan & Epston, 1995).
Given your expertise in the life-devouring ways of anorexia, what
have you learned about its practices that you might want to warn
others about?
As a veteran of anti-anorexia and all that the experience has taught
you, what counterpractices of fun and risk would you recommend to
other people struggling with anorexia?
The structure of the narrative interview is built through questions that
encourage people to fill in the gaps of the alternative story (untold through
a repeating of the problem-saturated story). The discursive structure assists
people to account for their lived experience, exercise imagination, and
circulate the remembered stories as meaning-making resources.
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The therapeutic process of narrative therapy engages the person’s
fascination and curiosity. As a result, the alternative story lines of people’s
lives are thickened (Turner, 1986) and more deeply rooted in history (i.e.,
the gaps are filled, and these story lines can be clearly named).
COUNTERVIEWING QUESTIONS
Personally, I only ask questions in therapy, or at least I ask questions
99% of the time.2 This is the way I was taught by David Epston and
Michael White and the way that has always felt the most comfortable.
For the experienced narrative therapist, questions are not viewed as a
transparent medium of otherwise unproblematic communication. It is
considered a common practice for narrative therapists to be deeply
committed to the ongoing investigation and location of therapeutic
questions within community discourse as a way of figuring out the history
and location of where our questions come from (Madigan, 1991a, 1993,
2007). The process of discovering the influences that shape therapeutic
questions and discussing why we use them with the people we talk with in
therapy is viewed as a practice of therapist accountability3 (Madigan,
1991b, 1992). Questioning therapists about their therapeutic questions is
also used as a framework for narrative supervision (Madigan, 1991a).
Experiencing a close-up re-reading of therapy allows the idea of
counterviewing questions (Madigan, 2004, 2007) to emerge. A narrative
therapy organized around counterviewing questions speaks to narrative
therapy’s deconstructive therapeutic act. Narrative questions are designed
to both respectfully and critically raise suspicions about prevailing
problem stories while undermining the modernist, humanist, and
individualizing psychological project.4
Narrative therapy counterviewing also creates therapeutic conditions
to do the following:
explore and contradict client/problem experience and internalized
problem discourse through lines of questions designed to unhinge the
finalized talk of repetitive problem dialogues and create more
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relational and contextual dialogues,
situate acts of resistance and unique accounts that could not be readily
accounted for within the story being told,
render curious how people could account for these differences,
appreciate and acknowledge these as acts of cultural resistance, and
rebuild communities of concern.
Narrative therapy’s method of close-up deconstructive
counterviewing engages the relational world of therapeutic interviewing in
the following ways:
Counterviewing is an intensely critical mode of reading professional
systems of meaning and unraveling the ways these systems work to
dominate and name.
Counterviewing views all written professional texts (files) about the
client as ways to lure the therapist into taking certain ideas about the
person for granted and into privileging certain ways of knowing and
being over others.
Counterviewing is an unraveling of professional and cultural works
through a kind of antimethod that resists a prescription—it looks for
how a problem is produced and reproduced rather than wanting to pin
it down and say this is really what it is.
Counterviewing looks for ways in which our understanding and room
for movement is limited by the lines of persuasion operating in
discourse.
Counterviewing also leads us to explore the ways in which our own
therapeutic understandings of problems are located in discourse.
Counterviewing allows us to reflect on how we make and remake our
lives through moral-political projects embedded in a sense of justice
rather than in a given psychiatric diagnosis.
REFERENCES
Madigan, S. (1991a). Discursive restraints in therapist practice: Situating
therapist questions in the presence of the family—A new model for
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supervision (Cheryl White, Ed.). International Journal of Narrative
Therapy and Community Work, 3, 13–21.
Madigan, S. (1991b). A public place for schizophrenia: An interview with C.
Christian Beels. International Journal of Narrative Therapy and
Community Work, 2, 9–11.
Madigan, S. (1992). The application of Michel Foucault’s philosophy in the
problem externalizing discourse of Michael White [Additional
commentary by Deborah Anne Luepnitz, rejoinder by S. Madigan].
Journal of Family Therapy, 14, 265–279. doi:10.1046/j..1992.00458.x
Madigan, S. (1993). Questions about questions: Situating the therapist’s
curiosity in front of the family. In S. G. Gilligan & R. Price (Eds.),
Therapeutic conversations (pp. 219–236). New York, NY: Norton.
Madigan, S. (2004). Re-writing Tom: Undermining descriptions of chronicity
through therapeutic letter writing campaigns. In J. Carlson (Ed.), My finest
hour: Family therapy with the experts (pp. 65–74). Boston, MA: Allyn and
Bacon.
Madigan, S. (2007). Watchers of the watched—Self-surveillance in everyday
life. In C. Brown & T. Augusta-Scott (Eds.), Postmodernism and narrative
therapy (pp. 67–78). New York, NY: Sage.
Madigan S., & Epston, D. (1995). From “spy-chiatric gaze” to communities of
concern: From professional monologue to dialogue. In S. Friedman (Ed.),
The reflecting team in action: Collaborative practice in family therapy
(257–276). New York, NY: Guilford Press.
McLean, C., White, C., & Hall, R. (Eds.). (1994). Accountability: New
directions for working in partnership [Special issue]. Dulwich Centre
Newsletter, 1994(2–3).
Tomm, K. (1989). Externalizing problems and internalizing personal agency.
Journal of Strategic and Systemic Therapies, 8, 16–22.
Turner, V. (1986). The anthropology of performance. New York, NY: PAJ
Books.
Excerpted from Narrative Therapy (2011), from Chapter 4, “The Therapy Process,” pp. 88–95. Copyright
2011 by the American Psychological Association. Used with permission of the author.
1Once the therapist begins to get a grasp on the format and the conceptual frame for developing temporal
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questions (past, present, or future), unique account questions, unique re-description questions, etc., they
become a easier to develop and will eventually seem “ordinary” to the interviewer and the context.
2I created the idea of counterviewing questions as a means to explore and explain the deconstructive
method involved in narrative therapy interviewing.
3For further reading on accountability practices, see McLean, White, and Hall (1994) and Tamasese and
Waldegrave (1994), Dulwich Centre Newsletter, Nos. 1 and 2.
4For a clear example of counterviewing, see the American Psychological Association six-part DVD live
session set of Stephen Madigan’s narrative therapy work, Narrative Therapy Over Time (2010).
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APPENDIX 26.1: NARRATIVE THERAPY TECHNIQUES
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27
PERSON-CENTERED THERAPY
DAVID J. CAIN
Carl Rogers published the most complete statement of his approach in
1959 and never modified it in any significant way. However, Rogers never
considered his theory to be a finished product and anticipated that it would
be developed further over time. The most essential concepts of his
approach will be identified in this section, followed by variations of
person-centered therapy and substantive contemporary developments.
THERAPEUTIC GOALS
The goals of the person-centered therapist are primarily process goals.
Therefore, the quality of engagement, moment to moment, between
therapist and client is central. The fundamental goal of person-centered
therapists is the creation of an optimal therapeutic relationship for their
clients. As Rogers has eloquently stated: “Individuals have within
themselves vast resources for self-understanding, and for altering their
self-concepts, basic attitudes, and self-directed behavior; these resources
can be tapped if a definable climate of facilitative psychological attitudes
can be provided” (1980, p. 115). The “definable climate” includes (a) the
therapist’s congruence, genuineness, authenticity, or transparency; (b)
unconditional positive regard or nonpossessive warmth, acceptance,
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nonjudgmental caring, liking, prizing, affirmation; and (c) a genuine desire
to understand the client’s experience and accurate empathic
communication of that experience. Toward the end of his life, Rogers also
identified therapist presence as a powerful and facilitative aspect of the
person-centered therapist’s manner of being. Rogers (1957) assumed that
if the client experienced these therapist qualities or conditions, personal
growth would take place.
While Rogers and other person-centered therapists were concerned
with clients’ achievement of their goals, the emphasis of the therapist is on
creating conditions for growth rather than alleviation of symptoms alone.
In other words, the emphasis is on the development of the whole person
rather than on a specific complaint. For some person-centered therapists,
the only goal is to provide the core conditions, while other person-centered
therapists believe that the identification of and focus on specific client-
generated goals is desirable because it gives the therapy direction and
cohesion and assures that the therapist and client are working toward the
client’s ends.
KEY CONCEPTS
Actualizing Tendency
Rogers defined the actualizing tendency as “the inherent tendency of
the organism to develop all its capacities in ways which serve to maintain
or enhance the organism” (1959, p. 196). This definition suggests that
people naturally move toward differentiation, expansion in growth,
wholeness, integration, autonomy and self-regulation, and effectiveness in
functioning. The actualizing tendency is viewed as a biologically based
master motive that subsumes other motives such as a reduction in needs,
tensions, and drives as well as an inclination to learn and be creative. It is
the bedrock on which person-centered psychotherapy is based. A core
belief in an actualizing tendency is the basis for the client-centered
therapist’s trust and optimism in clients’ resourcefulness and capacity to
move forward and find solutions to their problems. Art Combs, speaking
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of the person’s fundamental drive toward fulfillment or health, stated,
“Clients can, will and must move toward health, if the way seems open to
them to do so” (1999, p. 8, italics in original). Tageson believes that the
“living organism . . . will always do the best it can to actualize its
potentials . . . and it will do so as a unit along all dimensions of its
functioning” (1982, p. 35, italics in original). While Rogers viewed the
actualizing tendency as primarily constructive and prosocial, he and others
(e.g., Bohart, 2007) acknowledged that persons may develop behaviors
that are neither moral nor enhancing though they represent persons’
attempt to adapt as best they can (e.g., lying or stealing to get something
one wants). Although life experiences may weaken the actualizing
tendency, it is always assumed to exist as a potential on which clients can
draw.
Self, Ideal Self, and Self-Actualization
The self (self-concept, self-structure) as defined by Rogers (1959) is
the “organized, consistent conceptual gestalt composed of perceptions of
characteristics of the ‘I’ or ‘me’ . . . together with the values attached to
these perceptions” (p. 200). The self is a fluid and changing gestalt that is
available to awareness and that is definable at a given time. Though
relatively consistent over time, it is also malleable as new experiences alter
the ways persons view themselves. The terms self and self-concept
represent persons’ views of who they are, while the term self-structure
represents an external view of the self. The ideal self represents the view
of self the person would like to be. Often there is a discrepancy between
the self one sees one self to be and the person one hopes or strives to be.
As the self-structure is developed, the “general tendency toward
actualization expresses itself also in the actualization of that portion of the
experience of the organism which is symbolized in the self” (Rogers,
1959, p. 196). Thus, when aspects of experience defined as the self are
actualized (e.g., “I am athletic”), the process is one of self-actualization.
The actualization of the self may be in harmony with the actualizing
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tendency to maintain and enhance the organism, or it may be at odds with
the actualizing tendency, resulting in the development of aspects of the self
that may be valued by the person but have adverse consequences. For
example, the person may develop his or her capacity to be deceptive, thus
gaining desired ends from others while such deception compromises the
integrity of the person and therefore does not maintain or enhance the total
organism/person.
Congruence and Incongruence
Congruence describes a state in which the person’s self-concept and
experiences, including thoughts, feelings, and behavior, are in harmony.
That is, the person is integrated, whole, or genuine. Rogers believed that
congruence represents an optimal state of functioning and a primary
quality of mental health. Incongruence represents a state of discord
between the self-concept and experience. Rogers (1959) described this
state as one of “tension and internal confusion” (p. 203) because people
cannot reconcile the discrepancy between their thoughts, feelings, or
actions and the way they perceive themselves. For example, a person who
views himself or herself as having high integrity will likely experience
distress when realizing that he or she frequently engages in dishonest
behavior. When a person is in a state of incongruence but is unaware of it,
the person becomes vulnerable to experiencing anxiety, threat, and
disorganization or confusion about the sense of self. At such moments the
person may feel a wave of uncertainty or insecurity about who he or she is
and experience being out of sorts, troubled by some vague concern, or “off
center.”
Psychological Adjustment and Maladjustment
In Rogers’s theory, optimal psychological adjustment “exists when
the concept of the self is such that all experiences are or may be
assimilated on a symbolic level into the gestalt of the self-structure.
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Optimal psychological adjustment is thus synonymous with complete
congruence of self and experience, or complete openness to experience”
(1959, p. 206). Rogers believed that if persons were nondefensively
receptive to all experiences, they would likely make good decisions,
achieve high levels of adjustment, and function well. In short, a person
who is psychologically adjusted is congruent and integrated and functions
well because he or she has taken in and assessed all experiences and
information that may be relevant to living effectively.
On the other hand, “psychological maladjustment exists when the
organism denies to awareness, or distorts in awareness, significant
experiences, which consequently are not accurately symbolized and
organized into the gestalt of the self-structure, thus creating an
incongruence between self and experience” (Rogers, 1959, p. 204). Thus,
maladaptation is essentially a state of incongruence between one’s self and
one’s experience. The person is likely to experience threat when “an
experience is perceived . . . as incongruent with the structure of the self”
(p. 204). Consequently, the person cannot integrate some experiences or
corresponding actions with the self because they don’t fit. For example, a
man confidently entering a talent show (seeing himself as talented) may
get feedback from credible judges that he has little or no talent. The person
is thrown into a state of threat and disillusionment because he cannot
reconcile the disheartening feedback with a view of himself as talented. He
may be inclined to deny or distort such threatening information in an
attempt to maintain the integrity of the self as perceived. Thus, after a
period of time, the man who received feedback that he was not talented
may revise the view of self by denying that the judges were fair or
competent in perceiving the person’s “real” talent. By doing so, he remains
maladjusted because his decisions are based on incomplete or distorted
information.
Experience and Openness to Experience
By experience, Rogers referred to
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all that is going on within the envelope of the organism at any given
moment which is potentially available to awareness. It includes
events of which the individual is unaware, as well as all the
phenomena which are in consciousness. . . . It includes the influence
of memory and past experience, as these are active in the moment, in
restricting or broadening the meaning given to various stimuli. It
also includes all that is present in immediate awareness or
consciousness. (1959, p. 197)
Experience includes the person’s awareness of his or her behavior.
Synonyms include the experiential field and phenomenal field, and this
concept encompasses thoughts, feelings, sensations, and images.
When the person is open to experience, he or she readily takes in
information arising from within or from the external environment without
defensiveness. Openness to experience is critical to optimal functioning
because it enables the person to receive and process any and all
experiences and draw from those experiences to make effective decisions
in daily life. Conversely, defensiveness reduces the person’s receptivity to
experience, capacity to process, make sense of, and act on experience that
may be threatening to the self. Simply put, sometimes what one may
benefit from knowing is not necessarily what one may be willing or able to
know and examine. A woman who makes excuses for her boyfriend’s
failure to make time for her or show much interest in her may be failing to
access information critical to her dealing effectively with him. Failing to
do so renders her vulnerable to self-blame, insecurity, anxiety, or
depression.
Positive Regard and Unconditional Positive Regard
People experience positive regard when they perceive that some
aspect of their self-experience (e.g., feelings, beliefs) or behavior makes a
positive difference to or is valued by someone else. In this state the person
is likely to feel warmth, liking, respect, and acceptance from others.
Rogers (1959) views the need for positive regard as a basic need that is
essential to one’s well-being. We experience unconditional positive regard
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when we perceive that any experience or behavior is accepted without
conditions by another person. Thus, a person may act in ways of which he
or she is not proud but still find that he or she is accepted by another.
Rogers (1959) states, “This means to value the person, irrespective of the
differential values which one may place on his specific behaviors” (p.
208). When clients experience unconditional positive regard from their
therapists, they are likely to feel accepted and prized, which in turn enables
them to develop more tolerant and accepting feelings toward themselves.
While unconditional positive regard is theoretically possible, some have
argued that it is an unachievable ideal. However, when clients feel
predominantly accepted and consistently valued for who they are by their
therapists or significant others, they are likely to develop positive and
accepting views of themselves. This desire to be seen accurately and be
accepted seems to be a powerful and universal need in people. Therapists
display unconditional positive regard toward their clients when they are
accepting toward experiences or behaviors of which clients may
sometimes be proud and, at other times, ashamed. Consequently, clients
learn to accept themselves as flawed but worthy persons.
Clients experience positive self-regard when they are accepting of
their behavior independently of whether the behavior is accepted or prized
by others. Unconditional self-regard is experienced when an “individual
perceives himself in such a way that no self-experience can be
discriminated as more or less worthy of positive regard than any other”
(Rogers, 1959, p. 209). That is, the person continues to value himself or
herself regardless of his or her experiences or behavior. Again, while
unconditional self-regard is theoretically possible, it is more likely that
persons generally accept themselves while being aware they sometimes
fail to live up to their own standards.
Conditions of Worth
Conditions of worth exist in the person “when a self-experience . . . is
either avoided or sought solely because the individual discriminates it as
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being less or more worthy of self-regard” (Rogers, 1959, p. 209). Simply
put, this means that an individual may engage in or avoid a behavior based
on whether it brings him or her acceptance or regard from another person.
The approval of another may take on such importance that the person
disregards whether or not the behavior enhances his or her self, growth, or
well-being. Children are especially vulnerable to the conditions of worth
communicated by their parents and significant others and therefore may
value an experience or behavior “positively or negatively solely because of
these conditions of worth which he has taken over from others, not
because the experience enhances or fails to enhance his organism” (p.
209). Consequently, an experience “may be perceived as organismically
satisfying, when in fact this is not true” (p. 210). For example, a young boy
may be proud that he does not cry when he is hurt because he has learned
from his parents that crying is weak while stifling one’s tears means he is a
“big boy.” If his parents did not disapprove of crying, the boy would likely
cry when distressed and experience this behavior as natural and
acceptable.
As primarily social beings, people are constantly concerned about
how others see them and whether others like or approve of them.
Consequently, most people engage in frequent “image management” to
achieve others’ approval and whatever benefits accompany such approval.
The dilemma of image management and approval seeking is that, even
though people may avoid rejection by important others, they become
alienated from themselves and fearful of being the natural, spontaneous
selves they are. Internally, they know they are not being true to themselves
and sometimes feel like frauds. However, this need to be liked and
accepted can be so powerful as to compromise one’s values, integrity, and
self. It does indeed take courage to be and reveal one’s true self since the
risks of disapproval and rejection may be real. Conversely, living
authentically and being true to one’s self brings the satisfaction that comes
from standing somewhere for something. It enables one to live with
integrity even though it may create discord with others. As Rogers has
said, “it’s risky to live.”
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Locus of Evaluation
Locus of evaluation refers to the source of the person’s values. If the
source is internal, the person is “the center of the valuing process, the
evidence being supplied by his own senses. When the locus of evaluation
resides in others, their judgment as to the value of an . . . experience
becomes the criterion of value for the individual” (Rogers, 1959, p. 209).
Rogers viewed functioning from an internal locus of evaluation as a sign
of autonomy or self-governance and mental health. When the locus of
evaluation is external, the person relies on the views of others, especially
persons of authority or other authoritative sources (e.g., Bible, parents) to
guide their lives. People often prefer to allow others to guide or influence
their choices in hope that it will lead to a sound and safe decision while
removing full responsibility from themselves for their decisions (e.g., “I
followed the advice of my therapist”). Conversely, making choices based
on one’s own beliefs, values, and senses may be experienced as more risky
but may also result in a feeling of pride, confidence, and self-reliance.
Organismic Valuing Process
This process suggests that persons have a built-in, trustworthy,
evaluative mechanism that enables them to experience “satisfaction in
those . . . behaviors which maintain and enhance the organism and the
self” (Rogers, 1959, p. 209). As an ongoing process, experiences are
viewed freshly and valued in terms of how well they serve the person’s
sense of well-being and potential growth. Person-centered therapists’
belief in the organismic valuing process enables them to trust that clients
will act in their best interests when guided by this bodily felt source of
wisdom. Consequently, person-centered therapists facilitate the client’s
attending to all experiences, external and internal, to guide them. For
persons to benefit from the guidance and wisdom of their organismic
valuing processes, they must pay attention to their inner voices, feelings,
and intuitions and discriminate which of these is likely to enhance their
choices for healthy living. Clients, of course, may choose to ignore the
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inherent wisdom of their organismic valuing processes and make life
decisions based on other factors that they perceive to serve them at a given
time. For example, a wife’s allegiance to her abusing spouse may be
harmful to her well-being and growth but chosen nevertheless because the
spouse provides for her basic needs (e.g., food and dwelling) and even
some of her emotional needs (e.g., periodic love and affection).
Internal and External Frame of Reference
The client’s internal frame of reference refers to “all of the realm of
experience which is available to the awareness of the individual at a given
moment” (Rogers, 1959, p. 209). It is the subjective experience of the
person and can only be known fully by the person. This frame of reference
includes thoughts, feelings, perceptions, sensations, meanings, memories,
and fantasies. Therapist empathy enables the therapist to grasp the client’s
inner world through inference, though the accuracy of the therapist’s
understanding is confirmed or disconfirmed by the client. To view another
person from an external frame of reference means to “perceive solely from
one’s own subjective internal frame of reference without empathizing with
the observed person” (1959, p. 211). For example, a man who spends long
hours at work each day may perceive himself as dedicated to his family
(internal frame of reference), while his wife may view him as neglecting
his family (external frame of reference).
REFERENCES
Bohart, A. C. (2007). The actualizing person. In M. Cooper, M. O’Hara, P. F.
Schmid, & G. Wyatt (Eds.), The handbook of person-centered
psychotherapy and counselling (pp. 47–63). New York, NY: Palgrave
Macmillan.
Combs, A. W. (1999). Being and becoming: A field approach to psychology.
New York, NY: Springer.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic
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personality change. Journal of Consulting Psychology, 21, 95–103.
doi:10.1037/h0045357
Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal
relationships as developed in the client-centered framework. In S. Koch
(Ed.), Psychology: A study of science, Vol. 3. Formulations of the person
and the social context (pp. 184–256). New York, NY: McGraw-Hill.
Rogers, C. R. (1977). Carl Rogers on personal power. New York, NY:
Delacorte.
Rogers, C. R. (1980). A way of being. Boston, MA: Houghton Mifflin.
Tageson, C. W. (1982). Humanistic psychology: A synthesis. Homewood, IL:
Dorsey Press.
Excerpted from Person-Centered Psychotherapies (2010), from Chapter 3, “Theory,” pp. 17–26.
Copyright 2010 by the American Psychological Association. Used with permission of the author.
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28
PERSON-CENTERED THERAPY PROCESS
DAVID J. CAIN
THE VARIETIES OF EMPATHY
In this section I will identify some of the various forms empathy
might take. Silent listening often has a comforting effect on clients,
allowing them to say what’s on their mind in their own pace and manner.
Cindy was a client who wanted me to listen without responding while she
told me the entire story of her marriage and divorce. And so I did, for
several weeks, carefully recording everything she said. Later, we returned
to her story and processed the experience in detail. In an evaluation of my
therapy with her, she described me as a “fantastic listener.” Intent and
patient listening is a form of attending to or ministering to another. This is
an involved form of listening, not a passive one, that is often therapeutic in
and of itself. The primary limitations of silent empathy are that therapists
do not give their clients a response to interact with, nor do clients know if
they have truly been understood.
Empathic understanding responses are the staple of the person-
centered therapist in that they attempt to grasp and accurately
communicate the client’s basic message. This is the fundamental or basic
form of empathy upon which more complex forms of empathy are built.
These deceptively simple responses often lead clients to explore further
what is currently present for them. They help set in motion and sustain
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clients’ attention to relevant aspects of their experience.
C: I am just dragging today.
T: Just no energy for anything.
C: No, I just feel like staying home and avoiding everything I have
to do.
Clarification is a form of empathy in which the therapist articulates
clearly what the client is attempting to say, struggling to find words for, or
expresses in a vague way. It brings into focus what the client means. Using
a musical metaphor, it is as if the client hits a note off key and the therapist
hits the right note. The client experiences a “ring of truth” and clarity.
C: I’m really out of sorts.
T: You seem angry.
C: I guess I am. Nothing is going right today!
Affective empathy focuses on the client’s emotion or bodily felt sense
of a problem. It goes beyond the content of the client’s messages and
articulates the feeling that is expressed or implied.
C: I just can’t believe my mother is dead.
T: You’re feeling sad and lost that she’s no longer with you.
C: Terribly.
Explorative empathy uses a probing and tentative style as the therapist
attempts to assist the client to locate, explore, unfold, examine, and reflect
on unclear or hidden aspects of experience. The exploration might take the
form or broadening or deepening the clients’ understandings of their
realities.
C: I can’t quite put my finger on it, but I feel anxious about my
upcoming wedding to Jim.
T: So there’s some vague sense of doubt or fear about marrying
Jim?
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C: Yes. Like I’m not sure that he and I have the same hopes for our
life together.
Evocative empathic responses are designed to heighten, make more
vivid, amplify, and bring to life clients’ experiences. The therapist uses
rich, penetrating, connotative language, feeling words and imagery, and a
dramatic expressive manner that heightens the client’s experience.
Accurately capturing the full feeling tone is especially important as the
therapist strives to grasp the full impact of the client’s experience.
C: (recalling being mugged)
T: You were scared to death he was going to shoot you. The hairs
on your neck stood up as you felt the cold gun barrel on your
neck and heard a threatening voice saying “Give me your
wallet or you will never see another day.”
C: That still sends shivers down my spine.
Inferential empathy endeavors to infer the meaning of something the
client has hinted at or has stated at a more superficial level; it articulates
the tacit or implicit in what is said. In this form of empathy, the therapist
often articulates what is unspoken but at the edge of awareness, relying on
his or her intuition and therapeutic judgment to do so. The veracity of the
understanding is confirmed by the client’s sense of its rightness.
C: (a professional tennis player) I played the worst game of my
life in the final of my last tournament.
T: I know that leaves you profoundly disappointed in yourself, and
I sense that you have tapped into your worst fears that you
cannot perform under pressure.
C: Ugh. That’s it! I just couldn’t overcome my fear that I was
going to screw up. Then I tightened up and lost all confidence.
And did play poorly.
Affirmative empathic responses validate the client’s experience or
sense of self, whether positive or negative. To be optimally effective, such
responses require credible evidence from the therapist’s and client’s
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knowledge of the client.
C: I am so proud of how my children are doing. I think I’m a good
mother.
T: You are a good mother.
C: I think I’ve been neglectful of my husband.
T: From what you’ve said, I can see that you have been neglectful
lately.
Empathic challenges are responses by therapists that address clients’
perceptions and assumptions. While still acknowledging and remaining
within the client’s frame of reference, empathic challenges gently offer an
alternative understanding or perspective—a different way of viewing the
client’s world, offering an opportunity for the client and therapist to work
toward the best understanding possible.
C: I don’t want to go to work today.
T: I think you do want to go to work but just not have to deal with
your boss.
C: I guess that’s true. I do like my work, just not working for my
boss.
Conjectural or hypothetic empathy expresses the therapist’s attempt
to get at that which is out of or at the fuzzy edge of the client’s awareness.
The therapist provides an interpretation of the client’s reality but does not
attempt to provide new information. The therapist’s response is grounded
in the client’s disclosures even though the information may not be in the
foreground of the client’s consciousness. Such responses often reflect
something the therapist grasps that has not yet been articulated by the
client but which is easily recognizable if accurate. Adlerian therapists have
identified a mechanism called the recognition reflex that suggests that
people naturally recognize a personal truth when it is clearly presented.
The therapist might offer a hypothesis by saying something like “I have an
idea of what might be going on. Would you like to hear my
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understanding?” The client almost inevitably is curious to hear what the
therapist sees and readily accepts the invitation. The therapist then frames
the response in a tentative manner by saying “Could it be that . . . ?” or “Is
it possible that . . . ?” and then offers his or her understanding. By framing
the conjecture or hypothesis in this manner, it is easily rejected if
inaccurate. When it is accurate, the client resonates with it and confirms it.
C: I just don’t know what to make of Kate’s irritability toward me
lately.
T: I have a thought about what may be going on. Would you like to
hear my conjecture?
C: Yes.
T: Could it be that you have some fears that she doesn’t accept you
as you are?
C: Yes. That’s it. I guess I didn’t want to admit that.
Observational empathy is a response to nonverbal modes of
communication such as facial expression, vocal tone, and body language.
Observational empathy often takes the form of process observations
regarding the client’s manner of expression. Such responses often heighten
clients’ self-awareness and help them recognize that what they experience
and communicate often goes beyond their words.
C: I can’t believe how mean my mother can be.
T: I notice that your hand is all balled up in a fist as you talk about
your mother.
C: I guess I am very angry at her.
Self-disclosure may serve to show that therapists grasp their clients’
realities by sharing their own experiences. Such responses are often
desirable when clients experience something that they doubt anyone else
can possibly understand and often concern something powerful, like the
feeling of the loss of a cherished pet.
C: When my dog died, I felt like a large piece of me died with him.
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T: I think I do have some sense of how devastating that still is for
you. When my dog died, I felt a terrible sense of sadness and
loss. Like one of my best friends was gone.
C: Exactly.
First person empathy is a style in which the therapist speaks in the
first person as if he or she were the client. Such responses have the effect
of being more personal and impactful since clients hear their own voices
spoken.
C: I am so depressed I can barely get out of bed.
T: I feel almost completely immobilized.
C: I just have no energy or desire to do anything.
A variation of first-person empathy is similar to the psychodrama
method of “doubling” in which the therapist tries to inhabit the person of
the client. It has its roots in an acting approach in which the actor
seemingly becomes the person he or she is playing. In this approach to
empathy, the therapist sits next to the client, with minimal eye contact in
order to focus completely on the immediate, lived experiences of the
client. In such moments, the therapist essentially is the client and speaks
the client’s voice. The therapist also allows himself or herself some
“creative license” to express something outside of or on the edge of the
client’s awareness or to express something in a more dramatic way that the
client has understated. Clients often report the powerful impact of hearing
themselves speak; they say they get a more poignant sense of themselves.
One of my clients expressed her appreciation for having the opportunity to
have a “clone” of herself. She felt her true self was brought to life, and this
enabled her to see and hear herself in a fresh way. In this style the therapist
continuously checks with the client to verify the accuracy of his or her
articulated understanding of the client.
C: I can’t believe my husband cheated on me.
T: I feel crushed and betrayed.
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C: That bastard! How could he do that?
T: I hate him for violating my trust.
C: I guess I do. I’m furious.
There are many other ways to communicate understanding to our
clients, limited only by the therapist’s imagination, creativity, and use of
self. Sometimes empathy emerges from the therapist’s intuitive sense of
how to respond and takes unusual forms. For example, a therapist hears a
client’s feeling of being overwhelmed and comments, “Stop the world. I
want to get off.” Improvisational forms of empathy are often spontaneous
and novel expressions of understanding. On many occasions I have sung a
verse from a song to a client that captures the essence of the experience. A
client of mine was talking about the difficulty of living with her boyfriend
and I sang, “I don’t know how to love him.” Empathy might take simple
forms such as offering a client a cup of tea when the therapist notices how
stressed the client feels. Sometimes the form of empathy might be
surprising and penetrating. For example, respected client-centered
therapist John Shlien told of a client who was struggling with painful
issues regarding his mother, to which Shlien responded, “Mama! Mama!”
The client resonated strongly to Shlien’s response. In sum, therapists and
clients may find a wide variety of empathic responses to be effective.
EMPATHY AND EMOTION
Working empathically with clients’ emotions is at the heart of
effective therapy. Most of the problems clients experience are emotional in
nature (e.g., depression, anxiety) or have a strong emotional component
(e.g., conflicted relationships, low self-esteem). The “body knows” more
than can be articulated, and finding the potential wisdom contained in
clients’ feelings often leads them forward. Our emotions have a number of
important functions. They (a) reflect the body’s interpretation of a
situation or experience; (b) alert us to what’s wrong or right, good or bad
for us and orient us toward what’s needed for our well-being; (c) represent
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impulses to act and serve to energize and prioritize action; (d) contain
personal wisdom essential to effective functioning and growth; (e) reveal a
meaning system that informs us of the importance of events in our lives;
(f) often serve as precognitive means of adaptation enabling us to respond
quickly to events; (g) help identify core beliefs or schemas; (h) help us
clarify our motivation; (i) often serve as “wake-up calls” to attend to how
one’s life is not working; and (j) are critical to sound decision making.
Rather than view emotion primarily as something that interferes with
functioning, person-centered/humanistic therapists have embraced the
importance of understanding the adaptive nature of emotion in effective
decision making and functioning. Neuroscientist Antonio Damasio, author
of Descartes’ Error, provides evidence that “certain aspects of the process
of emotion and feeling are indispensable for rationality [and] . . . take us to
the appropriate place in a decision-making space, where we may put the
instruments of logic to good use” (1994, p. xiii). One cannot know oneself
or function well in the world without paying attention to one’s feelings.
Conversely, an impairment in persons’ ability to access emotional
information disconnects them from one of their most adaptive meaning
production systems and impairs their ability to make sense of the world.
A sizable and growing body of research shows that working with
client emotion, and that depth of experiencing in particular, is consistently
related to good client outcome (e.g., Greenberg, Korman, & Paivio, 2002).
However, most clients do not tend to process their feelings uninvited,
while some prefer to avoid them. Since clients often express emotions
without attending to them, it is especially important for the therapist to
point to what is felt, or on the edge of awareness, and invite the client to
attend to it with curiosity and discover its personal meaning and
implications. Further, as Sachse and Elliott (2002) have reported, the
quality of the therapist’s empathic response to the client may deepen,
maintain, or diminish client’s experiential processing and self-exploration.
In short, when therapists deepen their responses, clients deepen theirs, but
when therapists flatten their responses to emotion, so do clients. Finally, it
is important to underscore that both emotional expression and reflection on
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the experienced emotion are critical for client change. The mere
expression of emotion, while possibly cathartic, typically does not lead to
functional learning unless the client cognitively processes the implied
meaning of the emotion and its implications for more effective living.
ROLE OF THE CLIENT
When Rogers articulated his “necessary and sufficient conditions”
hypothesis, he specified only two conditions for the client: that the client
and therapist are in psychological contact and that the client be “in a state
of incongruence, being vulnerable or anxious” (1957, p. 96). Rogers
believed that if clients experienced anxiety, or incongruence between their
experiences and self-concepts, they would be sufficiently motivated to
alleviate distress. This belief is also grounded in Rogers’s assumption of
an inherent master motivation, the actualizing tendency, which serves to
maintain and enhance the organism. Rogers’s concept of an organismic
valuing process, a trustworthy evaluative mechanism that enables persons
to experience satisfaction in behaviors that serve the person’s growth, was
seen as a source of wisdom in the client. The concept of “psychological
contact” meant to Rogers that at least a minimal relationship between
therapist and client existed, one in which therapist and client make a
perceived difference in the field of the other. He stated his belief that
“significant personality change does not occur except in a relationship”
(1957, p. 96). Rogers’s faith was that if certain specifiable therapist
qualities were experienced by the client, then the actualizing tendency
would propel the client toward growth and psychological health.
As in any therapy, the client’s responsibility is to identify and discuss
meaningful concerns and problems. As clients do so and experience their
therapists’ nonjudgmental empathy, they tend to elucidate their issues
further, explore and reflect on them, and assess how new learnings and
insights might be applied to their daily lives. Since person-centered
therapy is fundamentally nondirective, it is the client’s responsibility to
determine the direction of therapy and how to participate. Since person-
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centered therapy is basically a relational therapy, clients are likely to
benefit to the degree that they engage effectively with their therapists.
Clients’ willingness to express their feelings and process them is also a
critical client task. In addition, it is the client’s responsibility to make the
choice to change and the effort to incorporate change in their daily lives.
Clients of person-centered therapists sometimes need to adjust to the
reality that their therapist will not guide, suggest, direct, or otherwise
attempt to influence their decisions. Although this may create discomfort
and uncertainty, clients of person-centered therapists often benefit
ultimately by learning how to make choices and direct their lives. By
doing so, they eventually become their own locus of evaluation and the
authors of their lives. Most clients who find the person-centered therapist’s
nondirectiveness to be uncomfortable usually come to understand its
purpose and adapt to it reasonably well. Person-centered therapy’s
effectiveness is, to a large degree, dependent on the client’s inclination
toward and capacity for self-reflection, something that can be cultivated to
varying degrees in most clients.
REFERENCES
Damasio, A. R. (1994). Descartes’ error: Emotion, reason, and the human
brain. New York, NY: Putnam.
Greenberg, L. S., Korman, L. M., & Paivio, S. C. (2002). Emotion in
humanistic psychotherapy. In D. J. Cain & J. Seeman (Eds.), Humanistic
psychotherapies: Handbook of research and practice (pp. 499–530).
Washington, DC: American Psychological Association.
doi:10.1037/10439-016
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic
personality change. Journal of Consulting Psychology, 21, 95–103.
doi:10.1037/h0045357
Sachse, R., & Elliott, R. (2002). Process–outcome research on humanistic
therapy variables. In D. J. Cain & J. Seeman (Eds.), Humanistic
psychotherapies: Handbook of research and practice (pp. 83–115).
Washington, DC: American Psychological Association.
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doi:10.1037/10439-003
Excerpted from Person-Centered Psychotherapies (2010), from Chapter 4, “The Therapy Process,” pp.
94–103. Copyright 2010 by the American Psychological Association. Used with permission of the author.
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APPENDIX 28.1: PERSON-CENTERED THERAPY TECHNIQUES
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29
PSYCHOANALYTIC THERAPY
JEREMY D. SAFRAN
To begin thinking about the goals of psychotherapy, it is essential to
make some assumptions about what psychological health looks like. And
these assumptions are inevitably influenced by values and beliefs about the
nature of what constitutes the “good life.” Different forms of
psychotherapy and different psychoanalytic traditions hold different
assumptions about the nature of the good life and by implication the goals
of psychoanalysis. Freud’s oft-quoted remark that “psychoanalysis
transforms neurotic misery into ordinary unhappiness” is seen by some as
reflecting a pessimistic perspective on life. But it can also be seen as
embodying a certain form of wisdom. Freud believed that life by its very
nature involves various forms of suffering: illness, loss of loved ones and
friends, disappointments, and ultimately death. It is essential, however, to
distinguish what might be termed existential suffering from self-imposed
neurotic suffering. From Freud’s perspective, one of the goals of
psychoanalysis is to help people learn to grapple with life’s inevitabilities
with a certain degree of equanimity and dignity.
As I discuss in greater detail later in this chapter, many contemporary
psychoanalysts have emphasized the goal of living life with vitality.
Dimen (2010), paraphrasing the author Andrew Solomon, said that “good
treatment restores vitality, not happiness” (p. 264). In addition, for many
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contemporary psychoanalysts there is also an emphasis on challenging
potentially oppressive normative emphases on singular and conventional
definitions of “mental health” and on replacing them with a respect for and
appreciation of the infinite number of different ways of being in this world
and a celebration of this diversity (e.g., Corbett, 2009; Dimen, 2010;
Harris, 2008). In the words of the influential British psychoanalyst, Donald
Winnicott (1958): “We are poor indeed if we are only sane” (p. 150).
As Cushman and Gilford (2000) argued, in many respects
psychoanalysis goes against the grain of many values that are
characteristic of our culture and that are reflected in such developments as
the managed care system and the evidence-based treatment movement.
According to them, the advent of the managed care system, the evidence-
based treatment system, and the dominance of the health care system by
the cognitive–behavioral tradition reflect such values as clarity, activity,
speed, concreteness, practicality, realism, efficiency, systematization,
consistency, independence, and self-responsibility.
Psychoanalysis, in contrast, tends to value such dimensions as
complexity, depth, nuance, and patience. This emphasis on patience,
acceptance, and allowing things to unfold in their own way can be traced
back to some aspects of Freud’s early thinking and is an important thread
that is expressed in different ways in different psychoanalytic traditions.
Freud cautioned analysts that the “furor sanandi” (an excessive zeal to
cure) could interfere with the therapist’s ability to assume the kind of
attitude of patience and acceptance that is necessary to be truly helpful.
Wilfred Bion (1970) is famous for speaking about the importance of
approaching every session “without memory or desire” in order to allow
the “emotional truth” of what is taking place to emerge (p. 57).
The downside of this type of perspective is that it can lend itself to the
type of never-ending analysis that is caricatured in Woody Allen movies
and that clients have valid reasons to be concerned about. In fact, some
very prominent analysts have argued that this attitude can too often
degenerate into a failure to grapple with the question of what is genuinely
helpful to clients and is one of the factors that has led to the declining
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popularity of psychoanalysis (Renik, 2006). On the other hand, there is a
certain wisdom embodied in this emphasis that can serve as a valuable
corrective to the contemporary Western tendency to overestimate our
capacity for individual efficacy and mastery and that fails to recognize the
limitation of our ability to “have it all.”
COMPLEXITY, AMBIGUITY, AND CURIOSITY
Psychoanalysis tends toward the view that at a fundamental level,
human beings are complex creatures whose experience and actions are
shaped by multiple and often conflicting conscious and unconscious
determinants, as well as by social and cultural forces. Related to this is an
emphasis on the importance of tolerance of ambiguity. Psychoanalytic
thinking assumes that given the complexity of human experience, there is a
fundamental ambiguity to the therapeutic process. This sense of ambiguity
forecloses the possibility of pat understandings of what is going on with
one’s client or in the therapeutic process. This can lead to a fair amount of
anxiety for novice therapists who want to feel that they can understand
what is going on in a definitive fashion and have clear guidelines for
practice. The positive side of this fundamental ambiguity is a genuine
curiosity in watching the process emerge and allowing one’s
understanding to unfold and evolve over time (McWilliams, 2004). This
can be associated with a genuine respect for the complexity of human
nature and a feeling of humility in the face of the ultimate unknowability
of things.
THE ETHIC OF HONESTY
Freud believed in the importance of shedding one’s illusions and
coming to accept the inevitabilities of life. He believed that self-deception
is ubiquitous, and he valued the process of self-reflection and truth seeking
(in the sense of searching for one’s real motives). In a sense, one could say
that psychoanalysis is associated with an ethic of honesty (e.g.,
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McWilliams, 2004; Thompson, 2004). Clients are encouraged to strive to
be truthful with themselves about their own motives, and this type of
honesty is expected of therapists as well.
Once we accept the idea of unconscious motivation, we begin to
recognize that we are all at some level strangers to ourselves. We begin to
see that we therapists are just as susceptible to self-deception as our clients
are. It is not unusual for trainees in supervision to find out that they were
intervening in a certain way because of feelings that they were completely
unaware of (e.g., competitiveness, insecurity, irritation, a desire for
control) and that our rational or theoretical understanding of why we are
acting as we are as therapists is often only part of the story or an after-the-
fact justification.
Conducting psychotherapy from a psychoanalytic perspective thus
inevitably involves an ongoing process of self-discovery and personal
growth for therapists. It is difficult to work with clients, especially
challenging ones, without being willing to explore one’s own contribution
to what is going on in the therapeutic relationship in an ongoing fashion
and a willingness to reflect on why we are doing what we are doing in a
given session. Many contemporary psychoanalysts believe that in many
successful treatments, both the client and the therapist change. Practicing
psychoanalysis is thus not for the faint of heart.
A SEARCH FOR MEANING, VITALITY, AND AUTHENTICITY
Freud’s emphasis was on becoming aware of our irrational,
instinctually based wishes and then renouncing or taming them through
our rational faculties. One important shift in the goals of psychoanalytic
thinking, especially in North America, involves an emphasis on the
importance of creating meaning and revitalizing the self. This shift may in
part be a result of changing cultural and historical conditions. This shift in
cultural sensibility corresponds to an important shift in the cultural
landscape from Freud’s time to ours. Psychoanalysis was born during an
era when individualism was in the process of becoming more pronounced.
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In the Victorian culture of Freud’s time, the self was viewed as dangerous
and an emphasis was placed on self-mastery and self-control (Cushman,
1995). Over the last century, the culture of individualism has continued to
evolve, and the individual has become increasingly isolated from the
community. This is a double-edged sword. On the one hand, the more
individuated person of contemporary culture is freer of the potentially
suffocating influence of community. On the other hand, he or she is cut off
from the sense of meaning and well-being that potentially flows from
being integrated with a wider community.
The disintegration of the unifying web of beliefs and values that
traditionally held people together and that give life its meaning has
resulted in the emergence of what Philip Cushman (1995) referred to as the
empty self. This empty self experiences the lack of tradition, community,
and shared meaning as an internal hollowness; a lack of personal
conviction and worth; and a chronic, undifferentiated emotional hunger. In
contemporary Western culture, psychological conflicts are thus more
likely to involve a search for meaning and a hunger for intimate and
meaningful relationships than a conflict between sexual instincts and
cultural norms (Mitchell, 1993; Safran, 2003).
This search for meaning is linked to a process of individuation—a
process of both discovering and deciding what one really believes in,
rather than simply accepting consensual social values. Philosophers and
historians tell us that the concept of authenticity is a relatively novel
invention that emerged in 18th-century Europe (Guignon, 2004; Taylor,
1992). Its emergence was associated with the rise of the culture of
Romanticism. The Romantic movement can be understood as a backlash
against the Enlightenment. It was an attempt to recover a sense of oneness
and wholeness lost with the rise of modernity. The Romantic movement
holds that truth is discovered not through scientific investigation or by
logic but through immersion in one’s deepest feelings. There is a distrust
of society in the Romantic movement and an implicit belief in the
existence of an inner “true self” that is in harmony with nature.
Conventional social rituals are seen as artificial and empty, and as
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potentially stifling authenticity. Consistent with this sensibility, there is an
important thread in contemporary psychoanalytic thinking that views the
therapist’s authentic responsiveness to the client as an important element
in the change process. The therapist’s ability to act spontaneously or to
improvise in response to the demands of the moment is viewed as a
potential antidote to the devitalizing effects of social ritual and conformity
in people’s lives (e.g., Ringstrom, 2007; Stern et al., 1998). Irwin Hoffman
has persuasively argued that it is important not to emphasize the value of
spontaneity at the expense of ritual, and vice versa. He argues instead for
the value of thinking in terms of the dialectical interplay between ritual
and spontaneity in the therapeutic process. A detailed discussion of
Hoffman’s perspective is beyond the scope of this book, but the interested
reader is referred to Hoffman (1998).
REFLECTION-IN-ACTION VERSUS TECHNICAL RATIONALITY
At a time when there is a growing emphasis in the psychotherapy
field on the importance of developing evidence-based practices that can be
delivered in a standardized fashion, there is an important trend in
contemporary psychoanalytic thinking that emphasizes the unique nature
of every therapeutic encounter and the impossibility of developing
“standardized” interventions or principles of intervention. The idea that
professional knowledge consists of “instrumental problem solving made
rigorous by the application of scientific theory and technique” is referred
to as technical rationality by Schön (1983, p. 21). Interestingly, Schön
(1983) and others conducting research on differences in the problem-
solving styles of experts versus novices (e.g., Dreyfus & Dreyfus, 1986)
have found that skilled practitioners across a wide range of disciplines
(musicians, architects, engineers, managers, psychotherapists) do not
problem-solve in a manner consistent with this model of technical
rationality. Instead, they engage in a process of what Schön termed
reflection-in-action. This involves an ongoing appraisal of the evolving
situation in a rapid, holistic, and (at least partially) tacit fashion. It involves
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a reflective conversation with the relevant situation that allows for
modification of one’s understanding and actions in response to ongoing
feedback.
It has become increasingly common for contemporary psychoanalytic
thinkers to argue that this notion of reflection-in-action provides a better
framework for conceptualizing the therapeutic activities of a skilled
therapist than does the model of technical rationality (Aron, 1999;
Hoffman, 2009; Safran & Muran, 2000). The therapist can no longer look
toward a unitary and universal set of principles to guide his actions.
Instead, he is confronted with a multiplicity of theoretical perspectives that
he can use to help him reflect on how best to act in this particular moment
with this particular client. Any guidelines derived from theory must
ultimately be integrated with the therapist’s own irreducible subjectivity
(Renik, 1993) and with the unique subjectivity of the client to find a way
of being that is facilitative in a given moment.
KEY CONCEPTS
In this section, I outline some of the central concepts of
psychoanalytic thinking. Most, if not all, of these concepts have evolved
over time. In addition, whereas some of these concepts originated in the
early days of psychoanalytic thinking, others emerged at later stages in the
evolution of psychoanalytic theory.
The Unconscious
The concept of the unconscious is central to psychoanalytic theory.
Over time psychoanalytic conceptualizations have evolved, and these days
different models of the unconscious are emphasized by different
psychoanalytic schools. Freud’s original model of the unconscious was
that certain memories and associated affects are split off from
consciousness because they are too threatening to the individual.
As Freud’s thinking about the unconscious evolved, he began to
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distinguish between two different principles of psychic functioning that are
always taking place at the same time: secondary process and primary
process. Secondary process is associated with consciousness and is the
foundation for rational, reflective thinking. It is logical, sequential and
orderly. Primary process, which operates at an unconscious level, is more
primitive in nature than secondary process. In primary process, there is no
distinction between past, present, and future. Different feelings and
experiences can be condensed together into one image or symbol, feelings
can be expressed metaphorically, and the identities of different people can
be merged. The “language” of primary process does not operate in
accordance with the rational, sequential rules of secondary process or
consciousness. Primary process can be seen operating in dreams and
fantasy.
Over time Freud came to think of the unconscious not only in terms
of traumatic memories that had been split off but also in terms of
instinctual impulses and associated wishes that are not allowed into
awareness because we have learned that they are unacceptable through
cultural conditioning. These instincts and associated wishes are often
related to the areas of sexuality and aggression. For example, a woman has
sexual feelings toward her sister’s husband but disavows them or pushes
them out of awareness because she experiences them as too threatening. A
man has angry feelings toward his boss but pushes them out of awareness
because they are too threatening. Freud referred to the process through
which unacceptable wishes are kept out of awareness as repression.
This perspective ultimately became formalized and elaborated further
by Freud with his distinction between the id, the ego, and the superego. It
is important to point out, however, that although this conceptualization had
an important influence on the development of subsequent psychoanalytic
theory, many contemporary psychoanalysts no longer find it to be
particularly useful. Charles Brenner, one of the major architects of
mainstream American ego psychology in the 1950s, explicitly rejected the
usefulness of this model of the mind as early as the mid-1990s (Brenner,
1994) in favor of a model that simply sees intrapsychic conflict as
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ubiquitous.
Many contemporary interpersonal and relational psychoanalysts find
it more useful to think of the mind as consisting of multiple self-states that
may to varying degrees be in conflict with one another and that emerge in
different relational contexts (e.g., Bromberg, 1998, 2006; Davies, 1996;
Harris, 2008; Mitchell, 1993; Pizer, 1998). In this perspective, there is no
central executive control in the form of the ego. Consciousness is a
function of a coalition of different self-states. It is thus an emergent
product of a self-organizing system that is influenced in an ongoing
fashion by current interpersonal context. From a developmental
perspective, experience taking place in the context of interpersonal
transactions that are intensely anxiety provoking or traumatic can be kept
out of awareness. But there is no hypothetical psychic agency keeping it
out of awareness. Instead, there is a failure to attend to the experience and
construct a narrative about it (Stern, 1997, 2010). It is thus this failure of
attention and construction that leads to the splitting off or dissociation of
aspects of experience. And just as the interpersonal context leads to the
dissociation of experience in the first place, we need others to help us
attend to and construct a narrative about it. As Donnel Stern (2010) put it
in his most recent book, the therapist thus serves as an essential “partner in
thought” for the client.
Whether the unconscious is conceptualized in traditional Freudian
terms, or in terms of aspects of experience that are not symbolized (or self-
states that are dissociated), the concept of the unconscious is central to
psychoanalytic thinking. For most psychoanalysts, one of Freud’s most
important insights is that “we are not masters of our own house.” We are
all motivated by forces outside of our awareness.
Fantasy
Psychoanalytic theory holds that people’s fantasies play an important
role in their psychic functioning and the way in which they relate to
external experience, especially their relationships with other people. These
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fantasies vary in the extent to which they are part of conscious awareness
—ranging from daydreams and fleeting fantasies on the edge of awareness
to deeply unconscious fantasies that are defended against. In Freud’s early
thinking, these fantasies were linked to instinctually derived wishes and
served the function of a type of imaginary wish fulfillment. In this view of
fantasies, they are typically linked to sexuality or aggression. Over time
Freud and other analysts developed a more elaborate view of the nature of
fantasy that sees fantasies as serving a number of psychic functions,
including the need for the regulation of self-esteem, the need for a feeling
of safety, the need for regulating affect, and the need to master trauma.
Because fantasies are viewed as motivating our behavior and shaping our
experience, yet for the most part operate outside of focal awareness,
exploring and interpreting clients’ fantasies is viewed as an important part
of the psychoanalytic process.
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Routledge.
Brenner, C. (1994). The mind as conflict and compromise formation. Journal
of Clinical Psychoanalysis, 3, 473–488.
Bromberg, P. M. (1998). Standing in the spaces: Essays on clinical process,
trauma and dissociation. Hillsdale, NJ: Analytic Press.
Bromberg, P. M. (2006). Awakening the dreamer: Clinical journeys. Hillsdale,
NJ: Analytic Press.
Corbett, K. (2009). Boyhoods: Rethinking masculinities. New Haven, CT:
Yale University Press.
Cushman, P. (1995). Constructing the self, constructing America: A cultural
history of psychotherapy. Reading, MA: Addison-Wesley.
Cushman, P., & Gilford, P. (2000). Will managed care change our way of
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Davies, J. M. (1996). Linking the “pre-analytic” with the postclassical:
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Dimen, M. (2010). Reflections on cure, or “I/thou/it.” Psychoanalytic
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Dreyfus, H. E., & Dreyfus, S. E. (1986). Mind over machine: The power of
human intuition and expertise in the era of the computer. New York, NY:
Free Press.
Guignon, C. (2004). On being authentic. London, England: Routledge.
Harris, A. (2008). Gender as soft assembly. Hillsdale, NJ: Analytic Press.
Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process: A
dialectical-constructivist view. Hillsdale, NJ: Analytic Press.
Hoffman, I. Z. (2009). Doublethinking our way to “scientific” legitimacy: The
desiccation of human experience. Journal of the American Psychoanalytic
Association, 57, 1043–1069. doi:10.1177/0003065109343925
McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s
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Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York, NY:
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Pizer, S. A. (1998). Building bridges: The negotiation paradox in
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Renik, O. (1993). Analytic interaction: Conceptualizing technique in light of
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Ringstrom, P. A. (2007). Scenes that write themselves: Improvisational
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56. Copyright 2012 by the American Psychological Association. Used with permission of the author.
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PSYCHOANALYTIC THERAPY PROCESS
JEREMY D. SAFRAN
INTERPRETATION OF TRANSFERENCE AND
COUNTERTRANSFERENCE
One of the most important forms of interpretation is referred to as a
transference interpretation. This is an interpretation that focuses on the
here and now of the therapeutic relationship between the client and the
therapist. The reason that transference interpretations are considered to be
particularly important is that they have the advantage of drawing the
client’s attention to something that is happening in the moment. A
transference interpretation thus has an immediate and experiential quality
to it. By drawing the client’s attention to the way in which their
perceptions and actions are shaping their experience of things in the here
and now, therapists provides them with an opportunity to actually observe
themselves in the process of shaping their experience of the situation. They
thus begin to experience themselves as agents in the construction of
reality. Transference interpretations can focus exclusively on the
therapeutic relationship or explore similarities between what is taking
place in the therapeutic relationship and other relationships in the client’s
life (both present and past). For example, Doris, a divorced woman in her
mid-30s, consistently complains about romantic partners being
emotionally unavailable and has just been speaking about her supervisor as
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not being sufficiently supportive. For the last few sessions (including this
one), I have had the sense that Doris is feeling frustrated with me, so I say,
“I wonder if there is any similarity between your experience with your
supervisor and the way in which you are experiencing our relationship in
this moment?” Interpretations that do not involve a focus on the here and
now of the therapeutic relationship can run the risk of leading to an
intellectualized understanding. It is one thing to conceptually or
intellectually understand one’s own role in a self-defeating pattern and
another to have an experientially grounded, emotionally immediate
understanding.
For many contemporary psychoanalytic therapists, transference
interpretations have become inseparable from the process of the
exploration of the transference/countertransference matrix. Consistent with
an emphasis on a two-person psychology, transference is not
conceptualized as a distorted perception arising in a vacuum but as one
element in an ongoing transference/countertransference enactment. In
practice, then, transference interpretations often involve an ongoing
collaborative exploration of who is contributing what to the relationship.
In my own writing, I have used the term metacommunication to designate
this process of collaborative exploration (e.g., Safran & Muran, 2000).
Metacommunication consists of an attempt to step outside of the relational
cycle that is currently being enacted by treating it as the focus of
collaborative exploration, a process of communicating or commenting on
the relational transaction or implicit communication that is taking place. It
is an attempt to bring ongoing awareness to bear on the interaction as it
unfolds. There are many different forms of metacommunication. A
therapist can offer a tentative observation about what is taking place
between him or her and the client (e.g., “It seems to me that we’re both
being cautious with each other right now . . . does that fit with your
experience?”). A therapist can convey a subjective impression of
something the client is doing (e.g., “My impression is that you’re pulling
away from me right now”). Or the therapist can disclose some aspect of his
or her own experience as a point of departure for exploring something that
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might be taking place in the therapeutic relationship (e.g., “I’m aware of
feeling powerless to say anything that you might feel is useful right now”).
Any disclosure of this type must be considered the very first step in an
ongoing process of exploring the transference/countertransference cycle.
The therapist does not begin by assuming that his or her feelings are in any
way caused or evoked by the client, but rather that they may offer clues as
to something that is unconsciously being enacted in the relationship.
It is also important to bear in mind that clients can experience
straightforward traditional interpretations of the transference as a criticism
or as a form of one-upmanship, especially in situations in which the
therapeutic alliance is strained. In other words, they can be experienced by
clients as the therapist’s attempt to take himself or herself out of the
equation by insinuating something to the effect of “The tension we’re
having in our relationship right now is your fault and I’ve got nothing to
do with it.” This is particularly likely to occur in situations in which the
therapist is caught in an enactment and is unconsciously using the
interpretation to deny any responsibility for what is going on or is
defensively blaming the client for a mutually constructed pattern in the
therapeutic relationship.
NONTRANSFERENCE INTERPRETATIONS
Although I have been emphasizing the value of transference
interpretations because of their emotional immediacy, it is important not to
minimize the potential value of interpretations that don’t make reference to
the therapeutic relationship. In some situations, making a well-timed, well-
worded interpretation about an event taking place in the person’s
relationships outside of the therapy situation can be particularly useful.
This is especially true if the client is confused about what is taking place in
the situation and is receptive to considering the possibility that a specific
unconscious conflict is playing a role. For the interpretation to be helpful,
however, the context has to be such that the client really does experience
the interpretation as a new and emotionally meaningful way of looking at
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the situation, rather than just as an intellectualized and arid attempt to
understand what is going on. It is difficult to specify exactly what type of
context facilitates this sense of newness other than to say that the client
needs to be experiencing a genuine sense of confusion and a search for
understanding, and the interpretation must be phrased in such a way that it
facilitates further exploration rather than shutting down. For example,
Peter, a successful professional in his 40s, began treatment after his wife
discovered that he was having an affair with a female coworker and
threatened to leave him. He immediately ended the affair and sought
therapy in the hope of understanding what had led him to have an affair in
the first place. This was the only time he had ever had an affair, and he
experienced it as completely out of character for himself and a form of
compulsion or addiction that he had no control over. After spending
several sessions getting to know him, I began to get a sense of a man with
considerable disowned anger who was feeling devalued by and
emotionally isolated from his wife. I began to interpret his affair as an
attempt on his part to reaffirm his sense of potency and lovability and as an
expression of disowned anger at his wife. He experienced this
interpretation, combined with the process of beginning to develop greater
ownership of his needs for validation and for emotional intimacy and of
his anger, as extremely helpful.
Another reason that extratransference interpretations can be valuable
is that clients are coming to treatment to deal with problems in their
everyday lives, not with problems in their relationships with their
therapists. To the extent that the therapist focuses exclusively on
transference interpretations, the client may have difficulty finding
relevance to his or her everyday life. Of course in practice, this potential
problem is often reduced by making transference interpretations that
involve establishing a link between what is taking place in the therapeutic
relationship and what is taking place in the client’s everyday relationships.
Although this type of interpretation can be extremely helpful, as
previously indicated the potential danger is that the client will experience
this linking of the two relationships as an attempt to blame him or her for
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what is going on in the therapeutic relationship by saying, in essence,
“You’re doing the same thing with me that you do with everyone else in
your life.” The therapist thereby refuses to accept responsibility for his or
her own contribution to what is taking place in the therapeutic relationship.
This can be especially likely to happen if the alliance is tenuous or there is
a therapeutic impasse. In such situations, it can be useful to carefully
explore what is taking place in the therapeutic relationship on its own
terms, with a genuine openness to understanding how each partner is
contributing to what is taking place, rather than to rush to establish links
with relationships in the client’s everyday life.
GENETIC TRANSFERENCE INTERPRETATIONS AND
HISTORICAL RECONSTRUCTION
A third major type of interpretation is referred to as a genetic
transference interpretation. A genetic transference interpretation involves
conveying a hypothesis about the role that one’s developmental
experiences have played in shaping one’s current conflicts. For example,
the therapist may interpret the client’s tendency to be overprotective of
other people, thereby denying his or her own needs, as stemming from the
client’s history of protecting a depressed and fragile mother.
Because psychoanalysis originated with the exploration of the client’s
past, there has been a tendency at different points in psychoanalytic
thinking to overestimate the importance of making genetic transference
interpretations. The problem with an excessive emphasis on interpretations
of this type is that it can lead to an intellectualized understanding of the
potential influence of the past on the present without resulting in a real
change. Notwithstanding this potential problem, a good genetic
transference interpretation can play a valuable role in helping the client to
begin to replace a sense of confusion and perplexity with some sense of
meaning and understanding. It can also help to reduce the client’s tendency
to excessive self-blame by helping him or her to see that current problems
are a meaningful and understandable result of an attempt to cope with a
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difficult or traumatic childhood situation. For example, Howard, a male
client in his mid-20s, experienced a lack of direction in his life, a chronic
low-level depression, and a sense of inadequacy. His father was an
extremely successful business executive whom my client described as
charismatic and always the center of attention. When Howard was 8 years
old, his father and mother divorced. Although Howard maintained a
relationship with his father, he felt he was never able to obtain his
approval. Over time, it emerged that whenever Howard would tell his
father about something he had accomplished or was excited about, he had
the impression that his father belittled him. In one session, I suggested to
Howard that perhaps his father felt the need to “put him down” because of
his own need to be the center of attention and an associated feeling of
being threatened by any success his son might have. Howard found this
interpretation extremely helpful, and it opened the door for exploring
important associated feelings.
Of course, too much emphasis on tracing the historical roots of one’s
current self-defeating patterns can lead to a type of preoccupation with the
past and a tendency to blame others rather than to develop a sense of
agency that can promote change. This is, however, by no means inevitable,
and to the extent that it does take place it can and should be explored in the
same way that any defense is explored.
THE USE OF DREAMS
Dream interpretation was once considered central to psychoanalytic
practice. Freud referred to dreams as the “royal road to the unconscious,”
and some of his most important early breakthroughs in psychoanalytic
theory and practice emerged out of the interpretation of his own dreams
and the dreams of clients. Freud considered dreams to be a form of wish
fulfillment and had a well-worked-out methodology for working with
dreams. Since Freud’s time, a variety of different psychoanalytic models
have been developed for conceptualizing the meaning of dreams and for
working with them. One particularly useful approach to dream
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interpretation was developed by Fairbairn, who conceptualized all figures
in a dream to represent different aspects of the self. For example, I once
had a female client who was terrified to sleep at home alone when her
husband was away. At such times it was common for her to have dreams
in which she was being chased by an axe murderer. When I suggested that
she experiment or play around with the possibility of seeing herself in the
role of the axe murderer, she was able to contact some of the aggressive
feelings associated with being in the role and ultimately to contact
disowned feelings of anger toward her husband for abandoning her during
his frequent business trips.
Although a variety of different psychoanalytic approaches to the
interpretation of dreams have developed over time, I think it is fair to say
that dream interpretation no longer plays the central role in North
American psychoanalytic theory and practice that it once did. To some
extent the exploration of transference/countertransference enactments has
become more central. Nevertheless, most psychoanalysts and
psychoanalytic therapists including myself do find it particularly useful to
work with dreams under certain circumstances. One situation in which
dreams can be particularly useful is when clients have difficulty contacting
and expressing their inner life during treatment. In this type of situation,
suggesting to clients that they begin to pay attention to and write down
their dreams is a way of providing material for the treatment that emerges
spontaneously while the client is asleep and is not subject to the same type
of defensive processes that otherwise can drastically constrain the range of
experiences. Of course, the client’s recording of the dream and subsequent
recounting of it in the session involves a process of reconstruction, but the
fashion in which it is reconstructed can be of interest in and of itself.
Another situation in which working with dreams can be particularly
interesting is one in which the client reports a particular vivid dream or
one with striking or startling imagery and associated affect.
REFERENCE
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Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A
relational treatment guide. New York, NY: Guilford Press.
Excerpted from Psychoanalysis and Psychoanalytic Therapies (2012), from Chapter 4, “The Therapy
Process,” pp. 85–91. Copyright 2012 by the American Psychological Association. Used with permission of
the author.
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APPENDIX 30.1: PSYCHOANALYTIC THERAPY TECHNIQUES
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RATIONAL EMOTIVE BEHAVIOR THERAPY
ALBERT ELLIS AND DEBBIE JOFFE ELLIS
THE ABC (OR ABCDE) THEORY
The ABC (or ABCDE) theory of rational emotive behavior therapy
(REBT) clarifies the connection between an activating event and its
consequences by identifying the beliefs involved, and it provides the
means for replacing irrational beliefs with rational ones through
disputation and the emergence of effective new philosophies. It simplifies
the process of illuminating how we self-disturb and shows the way to un-
self-disturb. Clients benefit when their therapists teach them the procedure
by doing it with them, and individuals benefit from doing it on their own,
particularly through writing, in the early days of their learning the REBT
technique.
A stands for activating events or adversities. We identify clearly what
happened.
C stands for consequences. They may be both emotional and
behavioral.
Although the Bs precede the Cs, when doing the procedure, it is
helpful to identify the Cs first and to notice which of the emotional ones
are “unhealthy” negative emotions, such as anxiety, depression, rage,
shame, guilt, jealousy, and hurt. REBT does not seek to change “healthy”
negative emotions, such as annoyance and frustration, regret, and
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disappointment, because these are often appropriate responses to difficult
circumstances and do not debilitate a person as the unhealthy ones can
frequently do.
B stands for beliefs or belief system. People’s belief systems include
functional or rational beliefs (RBs) and dysfunctional or irrational beliefs
(IBs) and includes them strongly (emotionally) and behaviorally (activity-
wise). Their RBs, as noted earlier, tend to be preferences and wishes (e.g.,
“I want to perform well and be approved of by significant others”), and
IBs tend to include absolutistic musts, shoulds, and demands (e.g., “I
should/must/ought to/have to perform well and be approved by significant
others”). It is important to remember that when people want to change
their IBs (which lead to self-defeating consequences) to RBs (which lead
to self-helping consequences), they had better work on their believing-
emoting-behaving, and not merely on their believing. This means, more
specifically, that they had better vigorously and forcefully (that is,
emotively) change their dysfunctional Bs and, at the same time, forcefully
and persistently feel and act against them. Why? Because, as already
noted, their believing invariably includes their emoting and their behaving
and is integrally related to these.
D stands for disputing. After distinguishing rational from irrational
beliefs, one keeps one’s preferences and forms effective and healthy new
philosophies. People achieve this by changing their demands through
arguing with and vigorously disputing them. There are three main forms of
disputing and rational questioning:
1. Realistic disputing. In this form of disputing, the IBs are challenged by
investigating the truth or factual reality behind them. Typical questions
that are asked include: Why must I perform well? Where is the
evidence that I must be approved by significant others? Where is it
written? Is it really awful, terrible, and as bad as it could be? Can I
really not stand it?
2. Logical disputing. In this form of disputing, the logic underlying the
IBs is investigated. Typical questions include: Are my beliefs logical?
Do they follow from my preferences? Does it follow that if I perform
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badly and lose approval of others then that makes me an inadequate
person?
3. Pragmatic disputing. In this form of disputing, one investigates the
pragmatic outcome of holding the IBs. Typical questions include: Will
holding this belief help me or hurt me? What results will I get if I
believe that I absolutely must perform well and always be approved of
by significant others? Do I want these results?
When people persistently dispute their IBs, and retain their RBs, the
outcome is E, which stands for effective new philosophies. These are
healthy, functional, and realistic positions from which to perceive oneself,
others, and one’s world. Examples of effective new philosophies are the
following: “No matter how badly I acted, I am not a bad person—just a
person who acted badly that time” and “Although some circumstances in
my life are difficult and unfortunate at present, that does not mean that the
world is all bad or that my whole life is rotten. Nor will these
circumstances last forever.” At this point, people can create additional and
appropriate coping statements.
To enjoy and maintain healthy preferences and to continue to
surrender dysfunctional demands, ongoing application of REBT
techniques is required. This takes us to the next key concept of REBT.
WORK AND PRACTICE
Work and practice lead to the most lasting of changes and not only to
feeling better but also to getting better. In the following pages are several
thinking, feeling, and action REBT techniques, which are also described in
many other REBT writings. REBT recommends trying the ones that seem
most appropriate for the person and the disturbances he or she wishes to be
free of. It recommends giving each technique a solid trial. If one doesn’t
work, it recommends using another, and another, and still another! Even
when one works, it pushes for trying some of the others as well. REBT
recommends using each method many times. Assess and reassess progress
(or lack of it). Keep on doing, doing, doing the methods earnestly,
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forcefully, and vigorously.
THE MULTIMODAL NATURE OF REBT
REBT is multimodal—it has created intellectual, affective, and action
techniques and has adapted some methods from other therapies, which
have been comfortably integrated with the REBT ones.
REBT was pioneering in that it integrated emotive and behavior with
thinking methods. Cognitive, emotive, and behavioral methods have been
used for centuries to help people with disturbances by philosophers,
religious and spiritual leaders, and therapists. Many of these techniques
were adopted and adapted by therapists such as Pierre Janet (1898), Paul
Dubois (1907), and Alfred Adler (1929). When, in the 1950s, these
methods were falling into disuse, George Kelly (1955) and I (AE)
independently revived them, and in the 1960s and 1970s, Aaron Beck
(1976), Donald Meichenbaum (1977), William Glasser (1965), David
Barlow (1988), and others repeated this revival in using many kinds of
cognitive behavior therapy.
Following are some of the main REBT cognitive, emotive, and
behavioral techniques.
Cognitive Techniques
ABC (or ABCDE) Method for Emotional and Behavioral Disturbance
This method was described earlier in this chapter.
Possible Secondary Symptoms
Possible secondary symptoms include anxiety about anxiety,
depression about depression, and so forth. Acknowledge any self-
castigation and accept it as failing to be helpful in changing the primary
disturbance, but be aware that does not make you a failure. Then go back
to using the ABC approach to remedy the secondary symptoms.
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Assessing the Cost–Benefit Ratio
This relates to one’s unconditional acceptance of self, others, and life
on an ongoing basis—of one’s behaviors and of one’s activities in life.
Make lists of the plusses and minuses in each case and assess where
changes may be beneficial.
Distraction Methods
These include activities such as meditation, yoga, other relaxation
techniques, and exercising, which are often palliative and may only work
for a while. Although not elegant solutions, they can be helpful in allowing
you to step back, refresh, and possibly assess the issues of disturbance
more objectively and helpfully.
Modeling
Albert Bandura (1997) and other psychologists have used modeling to
help children and adults to acquire learning skills, and REBT and cognitive
behavioral therapists have often taught their clients how to use it
successfully (J. S. Beck, 1995; Ellis, 2001a, 2001b, 2003a, 2003b, 2005).
Some ways of using this technique are as follows:
Find people you know who exhibit the attitudes, emotional well-
being, and behaviors you aspire to develop and ask them how they do
so. Use their relevant thoughts, feelings, and actions to model yours.
Investigate people you do not know—perhaps famous ones, whether
living or dead—and use them as models. Some of our clients felt
inspired by hearing the famous story of Epictetus, a Roman slave who
warned his master not to tighten the ball and chain on his leg because
he might break Epictetus’ leg. The master ignored him, tightened the
chain, and actually broke the leg. Whereupon, without feeling hurt
and angry, Epictetus calmly said, “See, I was right. You broke my
leg.” His master was so impressed with Epictetus’ self-acceptance
and lack of anger that he freed him to become the leading Stoic
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philosopher of Rome. I incorporated aspects of his philosophy into
REBT theory and particularly like his wise statement, written in the
first century ad in The Enchiridion: “Men are not disturbed by things,
but by the views which they take of them” (Ellis, 1962, p. 54). Some
of our clients used Epictetus as a model of accepting and unangry
demeanor and helped themselves by choosing to act this way more of
the time. The actor Christopher Reeve was rendered paralyzed in a
horse-riding accident. We read newspaper articles that described how
he used his remaining years of life to campaign for stem cell research
and other causes; he made an impact and was productive despite his
severe disabilities (Christopher and Dana Reeve Foundation, 2010).
Many consider him a model of acceptance of adversity and of
constructive action despite limitations. Many other models of
advantageous behaviors and attitudes can be found.
Biblio–Audio–Video Therapies
Books and recorded sources of information on REBT, on some of the
other cognitive behavioral therapies, and on various life-enhancing
philosophies—current and past—may be helpful for repetitively pursuing
the rational practices that are appropriate and reinforcing.
Talking About REBT With Others
Helping others by using REBT principles with them reinforces its
principles. Talking people out of their rigid irrationalities helps people talk
themselves out of their own irrationalities. This is particularly applicable
in a group therapy setting.
Problem Solving
REBT encourages practical problem solving. This includes looking at
the adversity one faces and figuring out action plans worth trying.
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Philosophic Discussion
REBT may also include considerable philosophic discussion with
clients and students.
Emotive–Evocative Techniques
Rational Emotive Imagery
This can be done in a brief period of time each day and is an effective
exercise for quickly changing unhealthy negative emotions to healthy
ones. It involves cognizing, as using imagery does. In addition to doing it
with clients, and teaching them to do it on their own, we regularly use it
with volunteers from audiences at workshops, and I (AE) particularly have
been using it in my famous Friday Night Workshops for more than 40
years. Both volunteers and audience observers have consistently reported
back, as have clients, that it helped them get in touch with, and change,
strong dysfunctional feelings. The approach was created by Maxie
Maultsby Jr. in 1971 after he studied with me in 1968. A number of
therapists have advocated it (Lazarus, 1997).
Rational emotive imagery helps people vividly experience one of the
fundamental concepts of REBT: That when people are faced with
adversity, negative emotions are almost always healthy and appropriate
when they consist of feelings of sorrow, disappointment, frustration,
annoyance, and displeasure. It would actually be aberrant for a person to
feel happy or neutral when these events occurred. Having certain negative
emotions is fundamental in helping people to deal with unpleasant reality
and motivate themselves to try to change it. The problem is that practically
the whole human race can easily transmute the healthy negative feelings of
disappointment and regret into disturbed feelings such as anxiety,
depression, rage, and self-pity. These are legitimate emotions in the sense
that all emotions are legitimate; however, they usually sabotage rather than
help people. Therefore, it is preferable that in using rational emotive
imagery, one thinks of something that he or she sees as very unpleasant
and strongly feels the kinds of unhealthy, negative feelings that one would
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frequently experience in reaction to it. The person gets in touch with these
feelings, feels them strongly, and then works on changing them to healthy
negative feelings by changing their thinking about the same unfortunate
situation. When individuals have changed their feelings to healthy (rather
than unhealthy) negative ones, they are then to keep practicing, preferably
at least once a day, for the next 30 days, until they have trained themselves
to experience, automatically or unconsciously, the healthy negative feeling
whenever they imagine this adversity or when it actually happens. They
usually can manage to bring on their healthy negative feelings within 2 or
3 minutes and within a few weeks are usually able to automatically bring
them on. Many people have achieved excellent results in changing
dysfunctional anxiety, guilt, depression, and anger throughout our years of
practice.
Shame-Attacking Exercises
This popular emotive–evocative, as well as behavioral, exercise is
famous in REBT. It recognizes that shame is suffered by many who
wrongly and demandingly tell themselves that they should never act in
foolish ways or appear foolish, wrong, or stupid to others. When they
demand that they “should not” or “must not” have erred, then they feel
ashamed, embarrassed, humiliated, or depressed (or any combination of
the above). Shame is created from judging one’s act and oneself—and
from the false interpretation that one’s deed represents oneself and that
when a deed is rotten and worthless, so is the person. This is false. The
shame-attacking exercise does not discourage people from assessing the
success or failure of what they do, but does encourage the removal of self-
damning. It consists of doing something one considers shameful and
would normally avoid doing—something one would severely put oneself
down for doing. An example is wearing “inappropriate” clothing to a
formal occasion, and while doing this “shameful” act, one works on one’s
thoughts and emotions so that one doesn’t feel embarrassed—one is
intentionally doing a foolish thing while focusing on not putting oneself
down while doing it. One of the many suggestions I (AE) have shared over
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the years is to yell out the stops in the subway or on a bus while remaining
on the vehicle as it moves on from each of these stops. People may stare—
an excellent opportunity to practice unconditional self-acceptance and
cessation of self-damning!
Strongly Using Coping Statements
Since the early years of REBT, I have recommended that clients and
members of the public identify and dispute strongly their irrational beliefs
and devise instead rational coping statements. By the 1970s, cognitive
behavioral therapists such as Aaron Beck (1976), Donald Meichenbaum
(1977), Maxie Maultsby Jr. (1971), and David Burns (1980) were also
encouraging their clients to do so. We have already described how
successful disputing leads to healthy coping statements. What makes this
emotive is the vigor and strength we use while repeating them over and
over to ourselves, so that with time, we genuinely are convinced of the
truth and benefit of them. So one forcefully repeats them, choosing
relevant coping statements. Some general ones that many find helpful:
I can stand what I don’t like. I just don’t like it.
Even if I fail at something, I am never, never, never a failure.
Nothing is awful, just inconvenient.
Role Playing
In therapy, workshops, and group therapy, role playing can be helpful
for evoking disturbing emotions to dispute the contributing beliefs to feel
undisturbed. Among friends, relatives, or group therapy members with
whom one role-plays, situations considered difficult are enacted. If the
situation, for example, is a risky job interview, the role player gives the
fearful person a hard time in the interview, and the person wanting to
overcome the fear does his or her best to succeed at it. When others are
present and observing the role play, they are then invited to critique the
interview. Then the role play is tried again. If the person feels anxious
during this next role play, he or she and the “interviewer” (as well as any
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others present) look for the “shoulds, oughts, and musts” that are creating
the anxiety and insecurity. These demands are then vigorously disputed.
The goal is to help the person achieve healthful concern but not unhealthy
anxiety. Also helpful is reverse role playing in which another voices the
anxiety-creating beliefs and the person who wants to get rid of them
persists in disputing and talking the other out of them.
Make Strong Disputing Tapes
In this exercise, a person tape-records some of his or her IBs, such as,
“I must always succeed and be approved of by others.” The individual then
disputes the IBs on the same tape, realistically, logically, and
pragmatically, making the disputing as forceful and emotive as possible.
The disputing tape can then be listened to with critical friends, who give
constructive feedback and note how forceful it is. It is repeated until it
feels solidly convincing.
Use of Humor
People are encouraged to keep things in healthy perspective by not
taking themselves, others, and the actions of oneself and by others too
seriously. I (AE) have written hundreds of rational humorous songs, which
are helpful in this regard.
Behavioral Techniques
Reading the previous two sections on cognitive and emotive
techniques, you may have noticed that there is some overlap of cognitive,
emotive, and behavioral—and in the following techniques, which are
largely behavioral, you will see overlap again. We remind you of a
pioneering REBT theme from 1955 that continues to the present—and will
continue: Human thinking, feeling, and behaving are integrated and
include important aspects of each other.
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REFERENCES
Adler, A. (1929). The science of living. New York, NY: Greenberg.
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Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of
anxiety and panic. New York, NY: Guilford Press.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York,
NY: International Universities Press.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY:
Guilford Press.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York, NY:
Morrow.
Christopher and Dana Reeve Foundation. (2010). Christopher Reeve:
Biography. Retrieved from
http://www.christopherreeve.org/site/c.ddJFKRNoFiG/b.4431483/
Dubois, P. (1907). The psychic treatment of nervous disorders. New York,
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Excerpted from Rational Emotive Behavior Therapy (2011), from Chapter 3, “Theory,” pp. 23–32.
Copyright 2011 by the American Psychological Association. Used with permission of the authors.
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32
RATIONAL EMOTIVE BEHAVIOR THERAPY
PROCESS
ALBERT ELLIS AND DEBBIE JOFFE ELLIS
BRIEF AND LONG-TERM STRATEGIES AND TECHNIQUES
Brief Therapy
When I (AE) originated rational emotive behavior therapy (REBT), it
was designed as a therapy that could be effective and brief for many
clients. After my experience working as a psychoanalyst from 1947 to
1953, during which I found that most forms of psychoanalysis were too
drawn-out, long-winded, and inefficient, I (with my “gene for efficiency”)
started using REBT, both briefly and in more prolonged treatment. Clients
who are severely disturbed, for biological as well as environmental
reasons, usually benefit more from longer term and more intensive
treatment, but many individuals who self-disturb or self-neuroticize can be
significantly helped in five to 12 sessions, and in some cases even fewer
sessions.
When clients understand the REBT principles of how they disturb
themselves, of how they can undisturb themselves and of how they can
choose to maintain healthy thinking, feeling, and behaving, they are well
on the way to stability and greater fulfillment. They have learned that they
can maintain their gains by continuing to practice REBT principles—and
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they make the effort to do so. Effective therapy with lasting results is a
lifelong process, initiated with a therapist and maintained by self-therapy
and ongoing effort (and follow-up and refresher sessions when
appropriate).
Thus, in effective REBT brief therapy, the client soon grasps that
their emotional disturbances are largely created as a result of
irrational thinking and the tendency to escalate preferences into
absolutistic shoulds, oughts, and musts;
by actively and vigorously disputing their absolutistic demands—
while maintaining their preferences—with thinking, feeling, and
acting methods, the demands can be changed to healthy preferences;
dysfunctional thinking, feeling, and actions can easily return and
ongoing effort will be required to prevent that from happening;
if a relapse occurs, they can unconditionally accept themselves with
the relapse, recognizing that it is a human tendency to fall back at
times and that all humans are fallible—then they can return to the
methods that worked for them before; and
they had better willingly do “homework” for the rest of their lives.
One of my (AE) famous lines is: “Life has inevitable suffering as well
as pleasure. By realistically thinking, feeling, and acting to enjoy what you
can, and unangrily and unwhiningly accepting painful aspects that cannot
be changed, you open yourself to much joy.” When remembering this,
clients can experience healthy perspective.
Some of our clients, usually those who are highly motivated and
particularly bright, effected healthy transformations in their lives after only
one or two sessions. Many were already quite self-aware and had read a
great deal of useful literature, and the REBT seemed to succinctly
formulate in easy-to-do form some of what they had already been
contemplating. A good number of people familiar with Buddhism, and
some of them who practiced it, took quickly and easily to the ABCs of
REBT. Some of the similarities between Buddhist and REBT principles
were described earlier in this book.
And talk about brief therapy: In a study by the authors, published in
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the Journal of Rational-Emotive and Cognitive Behavior Therapy (Ellis &
Joffe, 2002) and titled “A Study of Volunteer Clients Who Experienced
Live Sessions of Rational Emotive Behavior Therapy in Front of a Public
Audience,” 97 of the 100 respondents found their session helpful.
Volunteers agreed to a 30-minute demonstration—quite a brief time
indeed. It is hoped that they carried out their homework and that they
continue to remember REBT principles and to act on them.
Long-Term Therapy
This section focuses on REBT group therapy because it is an
excellent example of the application of REBT therapy that continues on a
long-term basis. As already mentioned, clients with greater endogenous
disturbances and poor learning skills can benefit more from long-term
individual REBT therapy—and from long-term group therapy.
Additionally, less disadvantaged clients who have significantly benefited
from individual therapy may wisely elect to replace it with long-term
REBT group therapy. Some clients choose to do both.
Let’s now look at aspects of REBT group therapy. Some clients go
directly into group therapy without having had individual sessions; others
join group therapy on the recommendation of their therapist while still
attending individual sessions or after a period of individual sessions has
concluded. Several methods of psychotherapy use group therapy for
expediency reasons—because it is more practical and cheaper for the
clients and not because it fits in with the theory that ostensibly underlies
these methods.
REBT basically uses an elegant and educational rather than a medical
or psychodynamic model. Consequently, like most teaching, it is almost
inevitable that it be done in group as well as individual sessions. It is
usually used in small group sessions, with from eight to 12 clients on a
once-a-week basis, but it is done at times with much larger groups, such as
a class of 20 or 30 students or a public workshop at which more than 100
people may be present. Its group aspects are also adaptable to audiovisual
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presentations because it can be taught and practiced with the use of CDs,
DVDs, webcasts, live radio and TV presentations, bibliotherapy,
programmed instruction, and other forms of mass media presentations. As
much or more than any other contemporary form of psychotherapy,
therefore, it is truly group oriented, and frequently the REBT practitioner
uses group processes as the method of choice rather than because special
circumstances practically force him or her to do so.
In small-scale group therapy of eight to 12 clients, the participants are
interested in getting to the roots of their emotional disturbances,
understanding the difficulties of the other members of the group, and
helping themselves and their fellow group members to (a) rid themselves
of their current symptoms and function better in their intrapersonal and
interpersonal affairs and (b) minimize their basic disturbability, so that for
the rest of their lives, they will tend to feel appropriate rather than
inappropriate emotions and to reduce (and preferably remove) the
tendency to upset themselves needlessly. In REBT groups, the therapeutic
goal is partly symptom removal, but, more important, it is for each of the
members to achieve a profound philosophic change and (more
specifically) to accept (although not necessarily like) reality; to give up all
kinds of magical thinking; to stop awfulizing, catastrophizing, and
demonizing about life’s misfortunes and frustrations; to take full
responsibility for their own emotional difficulties; and to stop all forms of
self-rating and fully and unconditionally accept oneself and others as being
fallible and human.
The main goals of REBT group therapy are the same as those of
REBT individual therapy: namely, teaching clients that they are
responsible for their own emotional upsets or disturbances; that they can
change their dysfunctional or debilitating emotions and behavior by
changing their irrational beliefs and self-defeating philosophies; and that if
they acquire radically new and profoundly held rational belief systems,
many may healthfully cope with almost any unfortunate activating events
that may arise in their lives and keep themselves, at worst, deeply
sorrowful and regretful but not anxious, depressed, or enraged about these
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activators. Some of the important group-oriented goals and methods that
are used in REBT include the following.
Because REBT teaches individuals how to accept the existence of
suffering and grim circumstances in life, and how to change what they can
through effort instead of by whining and demandingness, all group
members are encouraged to reveal and discourage the presenting
individual’s perfectionism, rigidity, and demands. Leaders educate
members to make suggestions and constructively criticize any self-
defeating or unhelpful thoughts, behaviors, and emotions that come up,
and to learn from them. However, they are taught not to criticize, damn, or
feel hopeless about oneself, others, or life itself. Group leaders do their
best to model the REBT attitudes and behaviors. All members are also
taught to dispute—logically, realistically, pragmatically, and empirically—
the disturbance-creating thinking of the other members.
The therapist usually is appropriately active, probing, challenging,
confronting, and directive. He or she persistently models rational thinking
and appropriate emoting. He or she is not only a trained therapist but also
teaches the scientific, or logicoempirical, method to the group members, so
that they can apply it effectively to their personal and emotional lives.
Both the therapist and the group consistently give activity-oriented
therapy session and homework assignments to group members. Some of
these assignments (e.g., speaking up in group itself) may be carried out
and monitored during the regular sessions. Other assignments (e.g.,
making social contacts) are to be carried on outside the group but regularly
reported and discussed during group sessions. We have observed that such
assignments are more effectively given and followed up when given by a
group than by an individual therapist.
REBT includes a number of behavioral methods (as already explained
earlier), including assertion training, in vivo risk taking, role playing, and
behavior rehearsal, which can partly be done in individual sessions but are
more effective in group. Thus, if a member is usually afraid to tell people
what he thinks of their behavior, he may be induced to do so with other
group members.
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The group deliberately encourages observing emotions and behaviors
rather than obtaining information through the client’s secondhand reports.
Angry or anxious individuals, who might feel at home with an individual
therapist and hide their feelings in therapy, can often reveal much in group,
where they interact with several of their peers.
In REBT, some clients fill out written homework report forms and
give them to the therapist to go over. In group sessions, a few homework
forms are often read and corrected so that all the members of the group,
and not merely the individual handing in the form, may be helped to see
specifically what unhealthy negative emotional consequence was
experienced (at point C); what activating events occurred to spark it (at
point A); what rational and irrational beliefs the individual told himself or
herself (at point B) to create the dysfunctional consequences; and what
kind of effective disputing could be done (at point D) to minimize or
eradicate the irrational beliefs that led to the self-defeating consequences.
By hearing about other group members’ main problems and how they dealt
with them on the homework report, clients are helped to use these reports
more efficiently themselves.
Individuals receive valuable feedback from the group as to how they
malfunction and what they are probably foolishly telling themselves to
create their disturbances. They also learn to view others and to give
feedback. More important, they gain practice in talking themselves out of
their irrational beliefs and therefore in consciously and unconsciously
talking themselves out of their own self-defeating irrational beliefs.
One main purpose of REBT group sessions is to offer members a
wider range of possible solutions to their problems than they might
normally receive in individual sessions. Out of 10 people present at a
given session, one may finally zero in on a presenter’s central problem
(after several others have failed), and another may offer an elegant solution
to it (after various ineffectual, inelegant, symptom-focused solutions have
hitherto been offered). Whereas a single would-be helper may give up on a
difficult issue (or person), some group members may persist and finally
prove to be quite helpful.
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Revealing intimate problems to a group of people may itself be
therapeutic for the client. In regular REBT small-group therapy, he or she
discloses many ordinarily usually hidden events and feelings to a dozen or
so peers. In REBT public workshops, individuals may reveal themselves to
a hundred or more people. Especially if they are usually shy and inhibited,
this kind of disclosure may be a most useful risk-taking experience, which
the therapist will often emphasize by showing the inhibited person that he
or she has opened up and actually received little, if any, criticism or an
attack that he or she predicted. Further, even if one is disapproved or
laughed at, he or she can still accept oneself and find this censure
unfortunate rather than awful.
Group members are of all ages, usually ranging from about 20 to 70,
and including all kinds of diagnostic categories. Groups usually have a
fairly equal number of males and females or may intentionally include one
gender only. After a member joins a group, he or she may have
concomitant individual therapy sessions regularly or irregularly. Most
group members choose to have them irregularly and therefore mainly learn
the principles and practices of REBT in the course of the group process.
Clients who are distinctly shy or who have problems relating to others are
particularly encouraged to join a group because working out their
difficulties with their peers may be better for them than only working with
an individual therapist (who has a particular role with them and therefore
is not representative of the people they associate with in real life).
All groups are open-ended. That is, once a member joins, he or she
can attend group for a minimum of 6 weeks and then (after giving 2
weeks’ notice) drop out at any time. Those who drop out are usually soon
replaced by new members. When a member joins, he or she comes into a
group that is filled mostly with long-term members who have been in
attendance for a period of several months to some years and who help
teach “some of the ropes” of REBT, during regular sessions, after sessions,
and in private contacts that they may have during the week. New members
are also prepared for the group process by (a) having had one or more
individual REBT sessions, (b) reading various books on REBT, and (c)
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attending workshops and lectures.
REBT group therapy has some disadvantages and limitations,
especially when compared with more individualized REBT processes. In
small-group procedures, for example, group members can easily, out of
overzealousness and ignorance, mislead other members and at times even
present them with harmful directives and views. They can give poor or
inelegant solutions, for example, continuing to show a disturbed person the
“practical” methods he or she can use to make oneself more successful in
life, rather than what deeper philosophic changes he or she can make in
disturbance-creating outlooks.
Some difficult, and even some well-intentioned, group members can
waste time in irrelevancies. Some may try to dominate, neglect doing
homework assignments, lead the problem presenter “down the garden
path,” or sidetrack and defuse some of the therapist’s main points. Some
may hold back because they inordinately look for the approval of other
group members; others bring out their own and others’ minor instead of
major difficulties and otherwise get off on various nontherapeutic limbs.
Group members can also bombard a presenter with so many and such
powerful suggestions that he or she feels overwhelmed. They can give
poor homework assignments or keep presenting so many new problems
that old assignments are not sufficiently checked up on. They can allow a
member, if the therapist does not actively intervene, to get away with
minimal participation and hence make minimal change in his or her
disordered behavior. They can become overly frustrated and hostile and
can irrationally condemn a participant for his or her symptoms or
continuing resistance to working at giving up those symptoms. The well-
trained REBT group therapist is vigilant about attending to any of these
occurrences and brings the group back on track.
REBT group therapy, consequently, is hardly a panacea for all ills,
nor is it suitable for all individuals who feel emotionally disturbed and
come for help. Some clients are not ready for it and would better continue
with individual REBT before entering a group. Others, such as some
compulsive talkers or hypomanic individuals, may benefit considerably
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from group work but can be too disruptive and require too much
monitoring and training. Hence, it may be best to exclude them and have
them work out their problems in other modes of treatment. We believe,
however, that many disturbed clients can benefit as much, and probably
more, from group therapy than from individual treatment alone.
To conclude this section on brief and long-term strategies and
techniques, we remind readers about REBT’s goals of helping people not
merely to feel better but to get better for the long term. Hence, both short-
and long-term clients are encouraged and taught how to maintain and
enhance their REBT gains after they leave therapy and are urged not to
hesitate to return for booster individual sessions or to rejoin their therapy
group if they backslide, relapse, or think they are progressing too slowly.
REFERENCE
Ellis, A., & Joffe, D. (2002). A study of volunteer clients who experienced live
sessions of rational emotive behavior therapy in front of a public audience.
Journal of Rational-Emotive and Cognitive-Behavior Therapy, 20, 151–
158. doi:10.1023/A:1019828718532
Excerpted from Rational Emotive Behavior Therapy (2011), from Chapter 4, “The Therapy Process,” pp.
47–54. Copyright 2011 by the American Psychological Association. Used with permission of the authors.
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APPENDIX 32.1: RATIONAL EMOTIVE BEHAVIOR THERAPY
TECHNIQUES
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33
REALITY THERAPY
ROBERT E. WUBBOLDING
Choice theory provides a comprehensive explanation of human
behavior. Its purview ranges from effective behaviors often described as
mentally healthy, in-control, and self-actualizing to minimally and
severely ineffective or out-of-control behaviors, such as those described in
the DSM–IV–TR. Contrary to current criticism (Sue & Sue, 1999) that
counseling and psychotherapy theories founded in a Euro-American
context are culture bound, choice theory addresses behaviors of individuals
and groups representing cultures from every continent. The delivery
system reality therapy, summarized in the acronym WDEP, applies to
individuals and groups from virtually every ethnicity (Mickel, 2005;
Wubbolding, 1989, 1991, 2000b; Wubbolding et al., 2004). In speaking of
reality therapy as used in Korea, Kim and Hwang (2006) state,
Since 1986 reality therapy and choice theory have been introduced to
the counseling and business fields in Korea followed with much
research. . . . It is embraced by professionals, including counselors,
educators, psychologists, psychiatrists, social workers and others, as
well as parents. (p. 25)
Citing several research studies in the Malaysian language, Jusoh,
Mahmud, and Ishak (2008) state, “These works are testimony that reality
therapy, when applied in suitable modules, can be beneficial for clients of
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various backgrounds” (p. 5).
Because of the emphasis on human behavior as chosen and due to
major expansions in control theory, Glasser renamed the foundational
principles and the developments of control theory choice theory. It remains
an internal control system in that behavior is not thrust on human beings
from the external environment or culture nor determined by past
experiences or parental persuasion. Though these influences can leave
their imprint, they do not nullify free choice.
Choice theory is based on the principle that human motivation is a
“here and now” phenomenon. As a psychological explanation, choice
theory posits five human needs from which springs choice (Glasser, 1998,
2005, 2008). These needs are seen as genetic and therefore universal. They
are not culture bound, not limited to any racial or ethnic group. Rather,
they are motivators that drive the behavior of all human beings.
SURVIVAL OR SELF-PRESERVATION
The psychological needs described below are housed in the cerebral
cortex, sometimes referred to as the “new brain” because of its more recent
development in the history of humankind. It sometimes receives a help-me
signal from the autonomic nervous system that houses the “old brain,” the
place of the survival or self-preservation need. It causes the system to
resist disease, to feel hunger and thirst, to seek physical homeostasis, and
to pursue sexual gratification. Characteristic of all biological sensate
creatures, the need for self-preservation drives the organism to maintain
life. And yet, human living is more complicated than mere self-
preservation. The satisfaction of survival often occurs not in isolation but
as a motivation interdependent with the satisfaction of other needs.
Twenty-first century survival requires at least some human interaction,
successful endeavors, and effective choices. Enjoying life also provides
need satisfaction and is often an additional benefit. Glasser (1998) states,
“It is these additional lifelong needs beyond survival that make our lives so
complicated, so different from those of animals” (p. 33).
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BELONGING, LOVE, AFFILIATION
Human beings possess an innate need for human closeness and for
interdependence. While the genetic origin of this need remains
hypothetical, belonging and other needs provide a basis and a pathway for
effective therapy. Two examples illustrating the efficacy of satisfying the
need for belonging in a constructive manner can be found in stories of
forced confinement and captivity.
Nien Cheng’s Interrogations
Cheng (1986) tells the story of her 6-year solitary confinement during
the Maoist regime in China and how she coped with her almost
overwhelming loneliness and isolation and the accompanying passivity
and depression. Within the rigid restrictions imposed upon her, she gained
a sense of belonging by shouting her answers during her interrogations.
She satisfied her need for belonging as best she could, believing that other
prisoners in the same building could hear her voice. Thus, her shouting
was her way of gaining a sense of belonging with them as well as
communicating a source of courage to them. She also tells of an increased
sense of power accompanying this deep feeling of belonging.
Fred and Porter’s Bond
Hirsch (2004) presents a story of heroic courage and human bonding.
Fred Cherry and Porter Halyburton, fighter pilots and prisoners of war in
Vietnam, suffered unspeakable psychological and physical tortures during
their nearly seven years’ internment. Major Fred Cherry, an African
American Air Force pilot, was raised in a segregated world. Shot down
and wounded, he suffered additional torture at the hands of his captors,
adding to his pain and suffering. U.S. Navy Lieutenant Junior Grade Porter
Halyburton, a White man raised in the South in the 1940s and ’50s,
became Fred’s cellmate. Their legendary closeness saved both of them.
Porter nursed Fred, who received extremely primitive treatment for his
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injuries, including several operations and poor postoperative treatment. He
helped Fred by bathing and exercising him, while Fred supported him
psychologically for 7 months. Fred taught Porter the lessons of heroism,
loyalty, and a bias-free worldview. Because of their synergistic union, they
both survived and carried with them during the rest of their imprisonment
the desire to survive, not only to rejoin their families, but to see each other
again and resume their friendship. Another prisoner, Giles Norrington, a
Navy pilot shot down in 1968, recalled,
By the time I arrived, Porter and Fred had already achieved
legendary status. . . . The respect, mutual support, and affection that
had developed between them were the stuff of sagas. Their stories,
as individuals and as a team, were a great source of inspiration.
(Hirsch, 2004, pp. 9–10)
As Hirsch noted,
Many of the POWs had to cross racial, cultural, or social boundaries
to exist in such close confines. But Halyburton and Cherry did more
than coexist—they rescued each other. Each man credits the other
with saving his life. One needed to be saved physically; the other,
emotionally. In doing so, they forged a brotherhood that no enemy
could shatter. (p. 10)
In November 2004 Fred and Porter appeared on C-SPAN. They once
again stated that they would do the same again for each other.
Parenthetically, Fred stated that he has never once dreamed about
Vietnam, illustrating a principle crucial to reality therapy: Human
relationships alleviate pain and can even lessen posttraumatic stress.
These anecdotes illustrate the life-sustaining nature of the human
effort to satisfy the need for belonging. On the operational level, reality
therapists see belonging as the most prominent need. Regardless of the
presenting issue, the effective use of reality therapy includes a therapeutic
alliance as a foundation for assisting clients to improve their interpersonal
relationships. Wubbolding (2005) states, “Enhanced acquaintanceships,
friendships and intimacies provide the royal road to mental health and
quality living” (p. 44).
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INNER CONTROL, POWER, ACHIEVEMENT, SELF-ESTEEM,
RECOGNITION
Originally referred to as power, the third human motivator or source
of behavior covers a variety of concepts. Satisfying the need for power
does not equate with dominating or controlling other human beings.
Fulfilling this need is not a zero-sum game. There need not be winners and
losers in the quest for power. Rather, individuals choose activities aimed at
helping them gain a sense of inner control, the perception that they are in
charge of their lives, that they have achieved or accomplished something.
For instance, upon being released from the hospital after a successful
surgical procedure, the patient experiences a sense of inner control, a
feeling of being in charge of her own life.
Even competitors often feel an intense sense of accomplishment not
merely because they have triumphed over others but because they have
demonstrated to themselves and others their highest level of achievement.
At the 2008 Olympics in Beijing, Carol Huynh won the first Canadian
gold medal in wrestling. Hawthorn (2008) described how the Huynh
family arrived in Canada after fleeing from Vietnam in 1978. Carol’s
parents watched her from the stands, weeping and cheering. Neither they
nor Carol herself described this accomplishment as defeating an opponent.
Rather, they spoke of the discipline required as well as the support she
received from her coach, her family, and the people from Hazelton, British
Columbia, and from her current home in Calgary, Alberta. Her coach,
Debbie Brauer, stated, “Kinship is very strong. It’s a community that,
despite its problems, really does pull together. It’s not what you do for a
living, or what color your skin is, but who you are that matters”
(Hawthorn, 2008, p. 7).
On the other hand, the urge to triumph in competition also satisfies
the power need. The desire to win an election, to defeat the opponent, to
triumph over the other team creates the feeling of power and achievement.
Some people choose to satisfy their need for power by conquering and
exploiting others emotionally, intellectually, and even physically.
Fulfilling this need with little concern for the needs of others explains
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antisocial and even Axis II behaviors, often providing a substitute for a
person’s inability to satisfy belonging in an appropriate manner.
Human beings desire the self-perception of being capable of
achieving, of accomplishing something, of pride, status, and importance.
For the most part, they seek these inner satisfactions in a positive,
effective, or mentally healthy manner. But they sometimes attempt to
fulfill these needs in ways that are self-destructive or harmful to others. In
discussing choice theory applied to juvenile delinquents and their need for
recognition, Myers and Jackson (2002) state,
The juveniles have been lectured by the best. What they have not
gotten is praise for doing a good job. They have not received
approval from those they love and respect. They have not been
rewarded for a job well done. And, the touch they have received may
have been the back of someone’s hand. Let juveniles know when
they do well. (p. 199)
Many people attempt need satisfaction, especially fulfilling their need
for status or importance, by the abuse of drugs, which consequently creates
the illusion of need satisfaction. They gain the momentary perception of
being in charge of their own lives, but they have deluded themselves.
When the illusion fades, the feeling of power or achievement disintegrates,
often resulting in a deepening sense of powerlessness.
FREEDOM, INDEPENDENCE, AUTONOMY
The fourth human motivator urges people to search for options, to
select among possibilities, and to make specific choices. Depending on
culture and experience, human beings seek independence or autonomy in
varying degrees and in diverse ways, either life enhancing or damaging to
self or others. Uncovering satisfactory options constitutes a primary goal
in the practice of reality therapy. As with other needs, the external world
imposes natural or environmental limits on human choice. Still, the
practitioner of reality therapy avoids falling into the trap of agreeing with
the oft-stated refrain, “I have no choice.” As Glasser (1998) states, “There
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is always a choice.”
Viktor Frankl (1984) based his logotherapy on the principle that no
matter how dire the circumstances, the human person has a choice. During
his 3 years of imprisonment at Auschwitz, he believed he had a choice, not
regarding actions but how he would perceive the diabolical world of the
concentration camp. Carl Rogers frequently described a hypothetical
prisoner in solitary confinement tapping on the wall in Morse code, “Is
anybody out there?” After years of engaging in the only choice available,
he hears a response: “Yes, I am on the other side of the wall.” The prisoner
must have experienced an intense feeling of liberation and even
exhilaration.
People express and fulfill the need for freedom in a variety of ways.
Some people have a high need for freedom and seem to tolerate little
restriction or structure. Others feel free when they are required to conform
to a predictable routine. When asking participants in training sessions
“What do you like about your job?” many respond that they know what to
expect on their jobs. Others state, “No two days are alike.” Clearly, some
individuals enjoy a maximum amount of variety, while others find need
satisfaction in a more organized work environment.
FUN, ENJOYMENT
Aristotle defined a human as a creature that is risible—that is, it can
laugh. Choice theory embraces the principle that people have an innate
need or motivation that directs but does not compel their behavior toward
fun or at least enjoyment. From the cradle to the grave, human beings find
ways to be comfortable and to enjoy their surroundings. Moreover, Glasser
(1998) connects the need for fun with learning:
We are the only land-based creatures who play all our lives and
because we learn all our lives, the day we stop playing is the day we
stop learning. People who fall in love are learning a lot about each
other and they find themselves laughing almost continually. One of
the first times infants laugh is when someone plays peek-a-boo with
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them. I believe they laugh because that game teaches them
something very useful. They learn, I am I and you are you. (p. 41)
Wubbolding (2000b) states, “The developmental task of
differentiating oneself from others involves the deep inner need for fun”
(p. 16). Other developmental tasks are facilitated by enjoyment.
Adolescents and adults, young and old, seek personal adjustment by
redirecting their thoughts and actions from life’s problems to pleasant
endeavors. A major task for a therapist implementing choice theory is
helping clients make positive and often delectable choices leading to a
sense of inner joy.
When counseling couples and families, the effective reality therapist
assists them in planning to have fun together, suggests Wubbolding
(2000a, 2000b). He also states, “If they have achieved a high degree of
intimacy, they have spent time together learning. A therapist, using reality
therapy, helps clients have fun together, do enjoyable activities as a [unit],
laugh at themselves and at the foibles of others. The comedian Victor
Borge has said that the shortest distance between two people is a laugh”
(Wubbolding, 2000b, p. 16).
At first glance the role of fun in mental health might seem shallow
and superficial. In discussing the role of enjoyment in a client’s life, it
might appear that the therapist is facilitating an avoidance of deeper issues.
The opposite, however, is true: A discussion of positive mental health
provides an alternative to major and minor disorders. For example,
diagnostic criteria for dysthymic disorders include low energy or fatigue
and feelings of hopelessness. In terms of choice theory needs, these
individuals do not effectively satisfy their need for fun.
Questioning clients about their need for fun is a useful starting point
in the process of therapy with many clients. With oppositional adolescents,
the reality therapist frequently asks them to “describe the last time you did
something that was fun without getting in trouble or did something that
would not have gotten you in trouble if your parents, teachers or police
observed you doing it.” This approach coincides with the Eriksonian
axiom, “There is not a one-to-one correlation between the problem and the
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solution.” To discuss fun with clients exemplifies reality therapy as a
mental health system, not merely a system for remediating mental
disorders. Sometimes the solution seems to have little to do with the
problem.
IS THERE A HUMAN NEED FOR SPIRITUALITY, FAITH,
MEANING, OR PURPOSE?
Staub and Pearlman (2002) describe a need for spirituality—that is,
transcendence of the self. They state that in later life this need becomes
more significant, “but the groundwork for its satisfaction is laid all through
life. We can fulfill it through spiritual experiences or connection to God or
other spiritual entities. . . . We can fulfill it by creating higher, more
universal meaning in our lives” (p. 1).
In reviewing the literature on human needs, Litwack (2007) states,
If one studies the history of mankind, it is difficult to dismiss the
power of spirituality. Whether called a formal religion, humanism or
a belief in nature, throughout history mankind seems to have had the
need to believe in something other (higher, different) than oneself.
(p. 30)
Frankl’s logotherapy (1984) shares the emphasis on human decision
and choice as a theoretical cornerstone. He also emphasizes meaning and
purpose as a foundational principle for therapy and even for daily living.
Frankl attributes his own sense of purpose, meaning, and faith as reasons
for his surviving Auschwitz. He further associates the need for purpose
and meaning with prisoners’ survival more than their athletic and physical
strength.
The use of reality therapy has been applied to spirituality in helping
clients deepen their faith in the divine, to live a spiritually oriented life,
and to focus on issues outside and larger than themselves (Carleton, 1994;
Linnenberg, 1997; Tabata, 1999; Wubbolding, 1992). Many clients
perceive that their problems and issues have a spiritual and moral
dimension (Mickel & Liddie-Hamilton, 1996). In discussing family
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therapy, Mickel and Hall (2006) describe love as expressed in family life
as holistic and spiritual. They assert that love is beyond the physical and
mental world in that it lasts forever.
Choice theory as articulated by William Glasser places faith and
spirituality as behaviors chosen to satisfy needs. On the other hand, he
allows for faith as a need but not one of his formulations. He emphasizes
that anyone instructing others about choice theory is free to add needs to
the basic five, but it should be emphasized that the additional needs are
beyond the original theory (Glasser, 2008).
REFERENCES
Carleton, R. (1994). Reality therapy in the Christian context [Audio cassette].
Montgomery, AL: Private Publication.
Cheng, N. (1986). Life and death in Shanghai. New York, NY: Grafton Books.
Frankl, V. (1984). Man’s search for meaning. New York, NY: Washington
Square Press.
Glasser, W. (1998). Choice theory. New York, NY: HarperCollins.
Glasser, W. (2005). Defining mental health as a public health issue.
Chatsworth, CA: William Glasser Institute.
Glasser, W. (2008, July 16). Back to the basics. Keynote address to annual
international conference of the William Glasser Institute, Colorado
Springs, CO.
Hawthorn, T. (2008, August 18). A golden day for a village that reached out to
a family. Globe and Mail, pp. 1, 7.
Hirsch, J. (2004). Two souls indivisible. New York, NY: Houghton Mifflin.
Jusoh, A. J., Mahmud, Z., & Ishak, N. M. (2008). The patterns of reality
therapy usage among Malaysian counselors. International Journal of
Reality Therapy, 28(1), 5–14.
Kim, R.-I., & Hwang, M. (2006). A meta-analysis of reality therapy and
choice theory group programs for self-esteem and locus of control in
Korea. International Journal of Choice Theory, 1(1), 25–30.
Linnenberg, D. (1997). Religion, spirituality and the counseling process.
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International Journal of Reality Therapy, 17(1), 55–59.
Litwack, L. (2007). Basic needs—a retrospective. International Journal of
Reality Therapy, 16(2), 28–30.
Mickel, E. (2005). Africa centered reality therapy and choice theory. Trenton,
NJ: Africa World Press.
Mickel, E., & Hall, C. (2006). Family therapy in transition: Love is a healing
behavior. International Journal of Reality Therapy, 15(2), 32–35.
Mickel, L., & Liddie-Hamilton, B. (1996). Family therapy in transition: Social
constructivism and control theory. Journal of Reality Therapy, 16(1), 95–
100.
Myers, L., & Jackson, D. (2002). Reality therapy and choice theory. Lanham,
MD: American Correctional Association.
Staub, E., & Pearlman, L. (2002). Understanding basic psychological needs.
Retrieved from http://www.heal-reconcile-rwanda.org/lec_needs.htm
Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and
practice (3rd ed.). New York, NY: Wiley.
Tabata, M. (1999). The usefulness of reality therapy for biblical counseling.
Japanese Journal of Reality Therapy, 5(1), 30–34.
Wubbolding, R. (1989). Radio station WDEP and other metaphors used in
teaching reality therapy. Journal of Reality Therapy, 8(2), 74–79.
Wubbolding, R. (1991). Understanding reality therapy. New York, NY:
HarperCollins.
Wubbolding, R. (1992). You steer [CD]. Cincinnati, OH: Center for Reality
Therapy.
Wubbolding, R. (2000a). Reality therapy. In A. Horne (Ed.), Family
counseling and therapy (3rd ed., pp. 420–453). Itasca, IL: Peacock.
Wubbolding, R. (2000b). Reality therapy for the 21st century. Philadelphia,
PA: Brunner Routledge.
Wubbolding, R. (2005). The power of belonging. International Journal of
Reality Therapy, 24(2), 43–44.
Wubbolding, R. E., Brickell, J., Imhof, L., Kim, R. I., Lojk, L., & Al-Rashidi,
B. (2004). Reality therapy: A global perspective. International Journal for
the Advancement of Counselling, 26(3), 219–228.
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http://www.heal-reconcile-rwanda.org/lec_needs.htm

Excerpted from Reality Therapy (2011), from Chapter 3, “Choice Theory,” pp. 31–39. Copyright 2011 by
the American Psychological Association. Used with permission of the author.
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34
REALITY THERAPY PROCESS
ROBERT E. WUBBOLDING
Many of the skills for establishing a constructive atmosphere in the
therapeutic relationship are common to other theories and are
characteristic of healthy human relationships. Consequently, they serve as
an appropriate foundation for reality therapy interventions based on choice
theory. Most typical of reality therapy is a systematic series of
interventions summarized by the acronym WDEP (Wubbolding, 1989,
1991, 2000, 2008). Each letter represents a cluster of possible ways to help
clients become increasingly aware of the various elements of their internal
control systems, examine a broader spectrum of opportunities, and thereby
make more effective choices. These four letters focus the theory on clinical
practice and provide its delivery system, making it usable for the therapist
and for the client. In speaking of the WDEP system, Glasser stated, “It is
an eminently usable tool that can be learned by readers, used in agencies
and schools, and taught in classrooms. I hope that this system will become
a household phrase and used by therapists, counselors, teachers and
parents” (Wubbolding, 1991, p. xii).
EXPLORING WANTS
The key question under the W of the WDEP system is
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WHAT DO YOU WANT?
The user of reality therapy is aware of the theoretical concept of the
quality world. Its contents are everything highly valued: core beliefs,
ideas, and treasured possessions and relationships. The question “What do
you want?” summarizes quality world interventions made by the therapist.
In exploring the quality world, the therapist assists clients to formulate,
clarify, and prioritize the pictures in their mental picture albums—that is,
their wants. This process serves as the foundation for other interventions
based on the WDEP system and requires much attention in the therapeutic
process. Its importance is illustrated in the well-known caution to “be
careful what you wish for.” An employee desiring early retirement might
be well advised to avoid nurturing “medical retirement” as a quality world
picture. This desire might result not in the satisfaction of the freedom
need; it might result in a threat to the survival need.
Levels of Wants
Because of the primary importance of wants, the quality world is
often referred to as the “world of wants.” Though the quality world is rich
in content, the common denominator of the various ingredients of the
quality world—and therefore the focus of therapy—consists in the wants
of the client. Everything in the quality world appears desirable. However,
these wants are not constant or standardized. They exist at various levels
of desirability and are changeable.
Nonnegotiable demand. Some wants, such as the desire for oxygen,
nourishment, or the freedom from torture, are so intensely desired that
clients cannot function without them. Some clients rigidly cling to wants
that, in fact, damage relationships. However, with skillful counseling and
negotiation, clients can move toward more fluid wants and better
relationships. For example, an unyielding parent insists that an adolescent
conform to the same rules that were in force during childhood.
Pursued goal. Clients expressing the positive symptom “I want to
improve” formulate goals that are backed up by behaviors. Going to
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school, developing a positive relationship, finding a job, and joining a 12-
step program are examples. A more intense want could replace a pursued
goal, as when a young person enlists in military service and leaves behind
a relationship.
Wish. Some effort is made to achieve the wish, but its satisfaction
requires little exertion. Taking a chance on the lottery entails less than
overwhelming effort. Sometimes a wish focuses on something impossible
to achieve. A resident of northern Minnesota might wish for Caribbean-
like weather in January, or a resident of Jamaica might wish for snow to
practice tobogganing for the Winter Olympics.
Weak whim. Fulfilling this want is slightly desirable but of little
importance. A man selects a tie to wear for work but cares little about the
exact color or design. In counseling couples, one person expresses the
pursued goal of a happier relationship, while the other says that it would be
nice but it is of little value.
Double bind. Sabotaging a want with ineffective behaviors sends the
signal “I want it but I don’t want it.” A person genuinely wants to lose
weight but undermines the effort by consistently overeating. Habitual
bickering in a relationship damages the achievement of a genuine want
expressed by couples, “We want our marriage to improve.”
Reluctant passive acceptance. Clients on their own or through therapy
learn to accept the inevitable. Many people gain an acceptance of a
disease, handicap, situation, or event that is not desired. A person feels
pain at rejection by a lover. Someone contracts a fatal illness or is injured
in an accident. Another person experiences a loss of physical prowess or
even faces death. Though the unavoidable may be undesirable, human
beings learn to accept it.
Nondesired active acceptance. People often formulate clearly defined
wants knowing that a side effect or consequence of its fulfillment will be
an undesirable result. The pain of childbirth is hardly desirable, yet women
accept it as an unavoidable corollary of the joy of giving birth. A battered
woman living in a shelter desires to visit her father, knowing that there is a
high likelihood of being abused. These side effects are not quality world
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pictures, but they unavoidably accompany the highly desired want.
Fantasy dream. Even though there is overwhelming evidence that the
attainment of the dream is impossible, a person might fantasize about
having a family like the Cosby TV family or the Brady Bunch. These
wants are out of reach, unattainable, but they remain expressed as
“Wouldn’t it be nice?”
Though it is not necessary to categorize precisely every want during
the process of therapy, it is useful to help clients determine the degree of
intensity of a want. Helpful questions include, “How intensely do you
want it?” “Is your want a nonnegotiable desire or a weak whim?” “Is it
something you intend to pursue relentlessly, or is it something ‘it would be
nice to have’?” From the perspective of choice theory, the quality worlds
of some clients lack priorities among wants. For many people recovering
from addictions and members of codependent families, all wants appear to
be equally important and urgent. A major part of the reality therapy
process with such individuals entails helping them realize that some wants
are of greater consequence than others.
Level of Commitment
Asking clients questions focusing on how hard they want to work at
achieving their goals or how much energy they wish to exert to satisfy
their wants and needs helps them move from Stage I “I want to improve”
to Stage II “Positive symptoms.” When clients decide that behavioral
change is to their advantage, they are ready to make more effective
choices, and therapy can proceed more rapidly when therapists help them
raise their level of commitment. Wubbolding (2000) has identified five
levels of commitment.
1. “I don’t want to be here. Leave me alone. Get off my back.”
Clients coerced to attend therapy sessions by family or court often display
resistance, reluctance, and even hostility toward change and toward the
therapist. This level, in fact, represents no commitment. Yet it is
commonly heard by private practitioners, probation officers, child care
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workers, and practitioners in university counseling centers when clients
have experienced an intervention and are sent to receive help.
2. “I want the outcome, but I don’t want to make the effort.” Some
clients seek better relationships with family members, a job promotion,
weight reduction, freedom from oversight by law enforcement, or a myriad
of other wants. Failing to exert effort places their behavior at this second
level of commitment. Though slightly higher than the first level, it
contains resistance to action planning. The reality therapist helps clients
evaluate this level of commitment and its lack of efficacy in effecting want
and need fulfillment.
3. “I’ll try.” “I might.” “I could.” “Maybe.” “Probably.” The
middle level of commitment shows some willingness to take more
effective control of one’s own behavior. However, change is not
immutably linked to an “I’ll try” commitment. “Trying” allows room for
excuses and failure. The reality therapist can point to an airline customer’s
question, “When does your flight leave for Los Angeles?” If the ticket
agent responds, “We will try to depart at 9:15 a.m.,” the customer would
ask for a higher level of commitment. Still, the middle level of
commitment represents more resolve than Levels 1 or 2.
4. “I will do my best.” Though containing an escape hatch to failure
expressed as “I did my best, but I didn’t follow through,” doing one’s best
points toward action planning. It represents a step beyond mere wanting
and trying and a willingness to choose positive symptoms.
5. “I will do whatever it takes.” Efficacious choices and follow-
through behaviors characterize the highest level of commitment. Clients
consistently follow through on plans and even accept the responsibility for
less than desired outcomes. For instance, an employee chooses behaviors
designed to ensure a promotion. However, the employer does not bestow
the honor desired by the worker. The employee makes no excuses, places
no blame, and looks to the future.
The levels of commitment are best seen as developmental. Even
though Level 3 is not as efficacious as Level 5, it can represent a client’s
improvement in that he or she has moved from resistance and apathy to a
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higher level of motivation for change.
Exploring the Perceptual System
Contained in the perceptual system are two components. Three
perceptual filters constitute the first component, whereby human beings
acknowledge the world, see relationships, and place a value on incoming
information. The second component is the perceived world, a storehouse
of perceptions of self and the external world.
When discussing the three perceptual filters, the therapist seeks
information and clarification for ascertaining how clients see the world
around them. To what degree do they see the world without putting a value
on their perceptions? What do they believe is high value for them? Do they
see a relationship between how their own behavior impacts the world
around them and the incoming information received from it? For example,
does a client perceive any connection between treating coworkers rudely
and the perception that they don’t like him? Does a specific client believe
that her use of drugs has a relationship to her loss of family, loss of job, or
loss of status? How much does a client value effective, altruistic, or legal
behaviors purposely chosen to satisfy needs? Or does the client see value
only in behaviors that are an attempt to satisfy needs regardless of whether
they are unsuccessful, harmful to others, or even outside the law?
Connected with this exploration is the discussion of locus of control.
First formulated by the social learning theorist Rotter (1954), the notions
of internal place of control versus a sense of external control coincide with
the principles of internal control psychology, more specifically choice
theory. In speaking of Rotter’s work, Mearns (2008) states,
People with a strong internal locus of control believe that the
responsibility for whether or not they get reinforced lies within
themselves. Internals believe that success or failure is due to their
own efforts. In contrast, externals believe that the reinforcers in life
are controlled by luck, chance or powerful others. Therefore, they
see little impact of their own efforts on the amount of reinforcement
they receive. (p. 4)
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The single difference between Rotter’s principle and choice theory is
that in choice theory the payoff for behavior is not seen as reinforcing but
rather as satisfying the internal motivation, or general needs and specific
wants.
Reality therapists help clients ascertain their perceived degree of
internal versus external control. People depressing themselves believe that
they are at the mercy of external circumstances, that they are powerless
because of events beyond their control. Others adopt the self-talk, “I can’t
because they won’t let me.” Consequently, one of the goals of reality
therapy is to help clients change their perception of victimization by
changing their actions. The principle of internal control entails application
beyond psychology and therapy. Burnett (1995) states that society is “tired
of people claiming to be a victim every time someone confronts them for
an antisocial behavior” (p. i). He provides the example of Bart Simpson: “I
didn’t do it.” “Nobody saw me do it.” And finally, “You can’t prove
anything.”
Embracing the principle of internal control rather than external
control does not imply that every limitation, problem, defeat, or pathology
is within a person’s ability to control. Many assaults from the external
world are unavoidable and are direct attacks against one or more human
need: self-preservation, belonging, power or inner control, freedom, and
fun. When threatened, it is often difficult and sometimes impossible to
generate a need-satisfying behavior. The driver of a car skidding out of
control on an icy street is likely to feel out of control and unable to choose
a relaxed, calm, and self-confidencing behavior. Choice theory does not
teach that changing perceptions from external to internal is easy; nor is the
perception of internal control easily accessible. Therefore, a principle of
internal control congruent with choice theory is Human beings (clients)
have more control than they often perceive.
REFERENCES
Burnett, D. (1995). Raising responsible kids. Laguna Niguel, CA: FunAgain
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Press.
Mearns, J. (2008). The social learning theory of Julian B. Rotter. Retrieved
from http://psych.fullerton.edu/jmearns/rotter.htm
Rotter, J. B. (1954). Social learning and clinical psychology. New York, NY:
Prentice Hall.
Wubbolding, R. (1989). Radio station WDEP and other metaphors used in
teaching reality therapy. Journal of Reality Therapy, 8(2), 74–79.
Wubbolding, R. (1991). Understanding reality therapy. New York, NY:
HarperCollins.
Wubbolding, R. (2000). Reality therapy for the 21st century. Philadelphia, PA:
Brunner Routledge.
Wubbolding, R. (2008). Reality therapy. In J. Frew & M. Spiegler (Eds.),
Contemporary psychotherapies for a diverse world (pp. 360–396). Boston,
MA: Houghton Mifflin.
Excerpted from Reality Therapy (2011), from Chapter 4, “The Therapy Process,” pp. 76–82. Copyright
2011 by the American Psychological Association. Used with permission of the author.
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http://psych.fullerton.edu/jmearns/rotter.htm

APPENDIX 34.1: REALITY THERAPY TECHNIQUES
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35
RELATIONAL–CULTURAL THERAPY
JUDITH V. JORDAN
Relational–cultural theory (RCT) arose from an effort to better
understand the importance of growth-fostering relationships in people’s
lives. It seeks to lessen the suffering caused by chronic disconnection and
isolation, whether at an individual or societal level, to increase the capacity
for relational resilience, and to foster social justice. Walker (2002) notes
that the connections and disconnections that characterize relationships
occur in a context that has been “raced, engendered, sexualized and
stratified along dimensions of class, physical ability, religion or whatever
constructions carry ontological significance in the culture” (p. 2). The
effects of privilege, marginalization, and cultural forces are seen by RCT
as central to psychological development. Relational–cultural theorists have
“depicted culture as more than the scenic backdrop for the unfolding of
development; rather, culture is viewed as an active agent in relational
processes that shape human possibility” (Walker, 2005, p. 48). The insight
that relational development is always completely suffused with social and
cultural identities has been central to the development and practice of
RCT.
While the RCT model was originally developed to better represent
women’s experiences, it has become clear that men’s psychological
growth has also been distorted by the lenses used to study it. Men’s desires
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and needs for connection have been denied and made invisible. The
dominant culture has insistently demanded that men achieve the goals of
independence, autonomy, and individualistic competitive achievement.
The denial of vulnerability, the need for a strong and separate self, and the
reliance on power over others as the path to safety have exacted enormous
costs for men (Pollack, 1998). Bill Pollack (1998) has written about what
he calls the normative trauma of male socialization, and Ron Levant has
outlined what he calls normative alexithymia in men schooled in a
“strong,” stiff-upper-lip, tough, hard, nonfeminine masculinity (Levant,
1992). Today, RCT hopes to better represent both women’s and men’s
psychological experience as it seeks transformation of chronic
disconnection into connection and empowerment for individuals of both
genders and for society as a whole.
CORE CONCEPTS
The core concepts of RCT (Jordan, 2000) include the following:
1. People grow through and toward relationship throughout the life span.
2. Movement toward mutuality rather than separation characterizes mature
functioning.
3. Relationship differentiation and elaboration characterize growth.
4. Mutual empathy and mutual empowerment are at the core of growth-
fostering relationships.
5. Authenticity is necessary for real engagement and full participation in
growth-fostering relationship.
6. In growth-fostering relationships, all people contribute and grow or
benefit. Development is not a one-way street.
7. One of the goals of development from a relational perspective is the
development of increased relational competence and capacities over
the life span.
MUTUAL EMPATHY AND GROWTH-FOSTERING
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RELATIONSHIPS
In sum, rather than moving toward greater separateness and
independence, the goal is to increase our capacity for relational resilience,
mutual empathy, and mutual empowerment. Mutual empathy is the core
process that allows for growth in relationship. In a dyad, it involves the
responsiveness of two people, but it can occur between more people as
well. In this movement of empathy, with each person affected by and
seeing her impact on the other, the individual sees the possibility for
change and for connection. Thus, aspects of one’s experience that have
been split off and seen as unacceptable or threatening begin to come back
into relationship. When protective strategies of disconnection are
operating, people remain stuck in old patterns of disconnection. Under
these conditions there is not much room for growth. In mutual empathy,
people begin to see that they can bring more and more of themselves into
relationship. In this process, they become more present, more open to
change and learning.
The need for connection in which growth is a priority is the core
motivation in people’s lives. In growth-fostering relationships, people are
able to bring themselves most fully and authentically into connection. Jean
Baker Miller suggested that these relationships have five outcomes (“the
five good things”): a sense of zest; a better understanding of self, other,
and the relationship (clarity); a sense of worth; an enhanced capacity to act
or be productive; and an increased desire for more connection (Miller &
Stiver, 1997).
DISCONNECTION
RCT sees disconnections as normative in relationships; they occur
when one person misunderstands, invalidates, excludes, humiliates, or
injures the other person in some way. Acute disconnections occur
frequently in all relationships. If they can be addressed and reworked, they
are not problematic; in fact, they become places of enormous growth.
When an injured person, particularly one who has less power, can
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represent her or his experience of disconnection or pain to the more
powerful person and be responded to, with interest or concern, the less
powerful, hurt person has a sense of “mattering,” of having an effect on
the other. This strengthens connection as well as a sense of relational
competence. Thus, places of empathic failure can become places of
increasing trust and strength in relationships.
If, however, the less powerful person is not allowed or encouraged to
voice her or his hurt or anger, that person will learn to suppress that aspect
of her or his experience. She or he learns to move into hiding and
inauthenticity to stay in relationship. Often with shame or withdrawal, the
person moves out of genuine, growth-producing relationship. Furthermore,
the person twists herself or himself to fit in, to be acceptable to this
powerful other person. The person feels profoundly disempowered and
unseen. The relationship itself is diminished by these exchanges, and if
they occur repeatedly, a condition of chronic disconnection develops. In
this situation the less powerful, injured person feels she or he is to blame
for the disconnection and feels immobilized and increasingly isolated. The
injured person brings less and less of her or his real experience into the
relationship and often loses touch with her or his own feelings and inner
experience. While this dynamic creates isolation and disempowerment at
the personal level, it also preserves the politics of dominance. In this way
the personal is political, the political is personal, and the rewriting of a
psychological paradigm becomes an act of social justice.
RELATIONAL IMAGES
Relational images (RI) are the inner constructions and expectations
we each create out of our experience in relationships (Miller & Stiver,
1997). They develop early in life and are carried from one relationship to
another, sometimes subject to modification (growth) and sometimes
limiting our expectations in ways that anchor us in the relational past. Our
expectations of relationships are held in these relational images. Chronic
disconnections lead to negative relational images. When relational images
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are flexible, they can be modified and do not generate inappropriate
generalizations. However, when they are rigidified and overly generalized,
they keep us from participating fully in the actual relationship at hand. In
this way they operate similarly to what many psychodynamic models refer
to as transference in therapy, bringing expectations from the past to bear
on the present in a way that distorts current reality.
While Freud believed that therapist neutrality and objectivity were
necessary for transference to develop (Freud, 1912/1958), RCT sees
“transference” phenomena emerging in all relationships. In this context,
“Replication becomes problematic when it keeps people ‘stuck in the past’
and not free to engage in new relationships in the present” (Miller &
Stiver, 1997, p. 138). RCT further suggests that “neutrality” and distance
on the part of the therapist can interfere with moving into a new and
different relational experience in therapy. Instead, the therapist can
actively participate in helping to reshape relational images: “Memories of
one’s past relationships, with their history of connections and
disconnections, shape the content and complexities of the relational images
people bring into therapy. These images inform the expectations people
have about relationships in general, but in therapy they become the focus
of exploration” (Miller & Stiver, 1997, p. 139).
In therapy, the therapist and client also search for exceptions to the
dominant relational image known as discrepant relational images. If a core
relational image is “Whenever I make my needs known, I will be
abandoned,” a discrepant relational image might be “My Aunt Cathy was
really there for me whenever I needed her.” The negative relational image
“When I get angry at people they retaliate by rejecting me” could be
contradicted by the discrepant relational image “My brother used to stick
with me and validate my anger.” If negative relational images contribute to
a sense of hopelessness and isolation, these discrepant relational images
challenge their “pathological certainty”; they are places of hope and
relational possibility upon which therapists can help expand.
Often, profound reworking of these negative relational images occurs
around empathic failures in the therapy relationship itself. If one assumes
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that negative relational images and a sense of woundedness and self-blame
arose in situations where the individual was unable to represent the pain of
her experience to the other, more powerful person, being able to represent
the pain of being misunderstood or not seen by the therapist to the
therapist and having that representation acknowledged and addressed can
open previously closed doors. The repair of these disconnections is at the
heart of therapy. In these repairs, the individual’s sense of insignificance,
relational incompetence, and isolation shifts. Relational expectations and
neurological circuits are modified as the therapist responds to the client in
ways that disconfirm the entrenched and limiting relational images.
Negative relational images begin to change, relational expectations are
altered, and the effects of shame and self-blame give way to self-empathy
and hope. These transformations, while sometimes incremental, are
profound, and they bring the client into current reality with the ability to
develop current relationships. We have referred to this condition as
relational mindfulness (Surrey, 2005; Surrey & Eldridge, 2007) or
relational awareness (Jordan, 1995).
Jean Baker Miller developed the notion of “condemned isolation”
(Miller, 1989) to capture the fixedness and pain of the relational images
that keep us locked out of relationship and therefore out of hope. In
condemned isolation we feel immobilized, unworthy, and alone, and we
feel that we have created this reality. The individual feels that she or he is
to blame for her or his powerlessness and hopelessness and there is
something intrinsically “wrong” with her or him. Under such conditions,
she or he will not risk the vulnerability necessary to make connections.
The threat of further isolation is simply too great. Miller and Stiver (1997)
coined the term central relational paradox to capture what happens in this
situation. Though we deeply desire and need connections, we are terrified
of what will happen if we move into the vulnerability necessary to make
deep connection, so we keep large aspects of ourselves out of connection.
We develop strategies of disconnection, trying to protect ourselves by
disconnecting, keeping parts of ourselves split off. We develop these
strategies to avoid isolation, but paradoxically they contribute to our sense
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of isolation and being unseen. In her research with adolescent girls,
Gilligan formulated an almost identical paradox (Gilligan, 1990). She
documents the ways in which girls in early adolescence seem to lose
certain outspoken and insightful parts of themselves as they attempt to fit
into the kinds of relationships the culture prescribes for them. The extreme
of this dissociation from one’s own inner experience occurs in sexual and
physical abuse (Herman, 1992). We thus see how these strategies and their
consequences can result from social forces, as well as from individual
experiences.
CONTROLLING IMAGES AND SHAME
Controlling images also create patterns of isolation and
disempowerment. African American sociologist Patricia Hill Collins
(2000) has explored the ways society creates controlling images to shame
and disempower certain groups. They define who we are, what is
acceptable, and what we can do. Collins notes that controlling images—
like stereotypes of “mammies, matriarchs, welfare mothers”—are actually
lies that hold people in their “place” and induce the notion that change
cannot happen. These defining images feel real and immutable. It is hard
for people to stay with their own truth when they are immersed in a sea of
distorting and controlling images. Often, these societal controlling images
become part of an individual’s relational images: “From a relational–
cultural perspective, strategies of disconnection give rise to internalized
oppression, a complex of relational images grounded in the distortions and
disinformation required to normalize the inequalities of a power-over
culture” (Walker, 2005, p. 54).
Strategies of disconnection frequently arise around shame and a sense
of unworthiness. Shame is a contributing factor to much immobilization
and a major source of chronic disconnection: “In shame, one feels
disconnected, that one’s being is at fault, that one is unworthy of empathic
response, or that one is unlovable. Often in shame people move out of
connection, lose their sense of efficacy and lose their ability to
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authentically represent their experience” (Jordan, 2000, p. 1008). Shame
arises naturally when people feel that their “being” is unworthy, that if
people knew them more fully, they would reject or scorn them. Shame is
named by Tomkins (1987) as one of the original affects, present from birth
and reflected in gaze aversion. But shame is also imposed upon people to
control and disempower them.
Shaming is a powerful way to silence and isolate individuals, but it
also plays a large role in silencing and disempowering marginalized
groups whose members are strategically, if often invisibly, shamed in
order to reinforce their isolation and thus their subordination: “Isolation is
the glue that holds oppression in place” (Laing, 1998). A dominant group’s
authority can be maintained by the widespread power tactic of silencing
those who present differing views of reality. Microaggressions, in which
seemingly small acts of violence or disrespect go unnamed and
unchallenged, are a part of the invisibility of these power tactics (Jenkins,
1993). In particular, when the dominant group inevitably and strategically
discourages open conflict and expression of difference by the nondominant
groups, differences are framed as signs of deficiency. The marginalized
groups often internalize the dominant group’s standards, and internalized
oppression (Lipsky, 1984) functions to perpetuate the shame and
disempowerment.
Often, moving from group shame to a sense of worth is based on the
effects of creating cohesive group pride (gay pride, Black pride, girl
power). Creating or joining a community buffers individuals from the
disempowerment of marginalization. In these collective, empowering
movements out of shame, people reclaim their dignity and their right to be
respected by others. In The Skin We’re In, Janie Ward (2000) has written
about the importance to Black adolescent girls of actively creating healthy
resistance (liberation resistance) to the dominant White norms that threaten
to silence and isolate them. She points to the importance of thinking
critically about the dominant realities, naming them, and opposing them
with alternative versions of reality. This creates a sense of positive identity
and undermines the notion of THE reality or THE truth, which often is
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only a panoply of “controlling images” (Collins, 2000; Robinson & Ward,
1991; Ward, 2000).
It is essential that clinicians recognize the multiple sources of shame
that bring people into therapy. Helen Block Lewis coded transcripts of
hundreds of psychotherapy sessions and found that shame was by far the
most common emotion patients expressed (Lewis, 1987). RCT’s focus on
helping individuals build and rebuild their capacity for growth-fostering
relationships calls for taking into account any and all forces affecting that
capacity, including, especially, oppressive social systems. Racial identity
models (Helms & Cook, 1999) allow us to understand how deeply
racial/ethnic identity issues are woven into our social fabric and how
profoundly they affect relational possibilities. Controlling images and
shame have a profound impact on development: “How one is regarded by
the culture influences one’s ability to negotiate developmental tasks”
(Walker, 2005, p. 50). Therapists and clients can work together to
understand and address the effect of controlling images, shame, and
oppression: “Given the foundational premise [of RCT] that healthy
development occurs through action-in-relationship, it follows that
developmental potential is enhanced when an individual can function free
of the inhibiting objectifications that limit the range of growth and
possibility” (Walker, 2005, p. 50). The dynamics of shame and oppression
can also pertain to dyadic relationships, particularly abuse situations where
the perpetrator often shames and isolates the target.
The central relational paradox suggests that when a person has been
humiliated, hurt, or violated in early relationships, the yearning for
connection actually increases. But at the same time the person develops an
exaggerated sense that the vulnerability necessary to enter authentic
relationship is not safe. Thus there is an enhanced desire for connection
and an increased fear of seeking connection. In therapy it becomes very
important for the therapist to honor this central relational paradox. The
therapist must be respectful of the strategies of disconnection and must
deeply understand why these strategies of disconnection were developed
and how they helped keep the person alive at crucial times in unresponsive
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or violating relationships. The therapist must “feel with” the client in the
sense of really “getting it,” developing a contextual empathy that helps her
or him see the conditions that created this need for self-protection through
disconnection. At the same time, the therapist must hold the overarching,
even if tentatively embraced, desire for more real connection. In moving
from chronic disconnection to connection, supported by the therapist, the
client will begin to relinquish strategies of disconnection and in so doing
will have to experience a certain sense of vulnerability and risk. As the
client begins to relinquish the strategies of disconnection, the therapist will
need to expect sudden disconnects following increased closeness or
authenticity, as the client leaps to old patterns of safety. In part, the work
of therapy involves differentiating current relational possibilities from old
relational images. It involves introducing uncertainty into the client’s
overly generalized and fixed negative relational images (e.g., shifting
“When I show my tenderness, I get beaten up” to “When I was vulnerable
as a child my stepfather beat me, but my current boyfriend is there for
me”) and helping the client experience new relationships for her- or
himself.
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Routledge.
Freud, S. (1958). Recommendations to physicians practicing psychoanalysis.
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works of Sigmund Freud (Vol. 12, pp. 111–120). London, England:
Hogarth Press. (Original work published 1912)
Gilligan, C. (1990). Joining the resistance: Psychology, politics, girls and
women. Michigan Quarterly Review, 29, 501–536.
Helms, J. E., & Cook, D. (1999). Using race and culture in counseling and
psychotherapy: Therapy and process. Boston, MA: Allyn & Bacon.
Herman, J. (1992). Trauma and recovery. New York, NY: Basic Books.
Jenkins, Y. M. (1993). Diversity and social esteem. In J. L. Chin, V. De La
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Cancela, & Y. M. Jenkins (Eds.), Diversity in psychotherapy: The politics
of race, ethnicity, and gender. (pp. 45–64). Westport, CT: Praeger.
Jordan, J. V. (1995). Boundaries: A relational perspective. Psychotherapy
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Jordan, J. V. (2000). The role of mutual empathy in relational/cultural therapy.
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4679(200008)56:8<1005::AID-JCLP2>3.0.CO;2-L
Laing, K. (1998). Katalyst leadership workshop presented at In Pursuit of
Parity: Teachers as Liberators, Boston, MA.
Levant, R. F. (1992). Toward the reconstruction of masculinity. Journal of
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Lewis, H. B. (Ed.). (1987). The role of shame in symptom formation. Hillsdale,
NJ: Erlbaum.
Lipsky, S. (1984). Unpublished and untitled manuscript.
Miller, J. B. (1989). Connections, disconnections and violations. Work in
Progress, No. 33. Wellesley, MA: Stone Center Working Paper Series.
Miller, J. B., & Stiver, I. (1997). The healing connection: How women form
relationships in therapy and in life. Boston, MA: Beacon Press.
Pollack, W. (1998). Real boys: Rescuing our sons from the myths of boyhood.
New York, NY: Random House.
Robinson, T., & Ward, J. V. (1991). A belief in self far greater than anyone’s
disbelief: Cultivating resistance among African American female
adolescents. In C. Gilligan, A. G. Rogers, & D. Tolman (Eds.), Women,
girls and psychotherapy: Reframing resistance (pp. 87–103). New York,
NY: Harrington Park Press.
Surrey, J. (2005). Relational psychotherapy, relational mindfulness. In C. K.
Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and
psychotherapy (pp. 91–110). New York, NY: Guilford Press.
Surrey, J., & Eldridge, N. (2007). Relational–cultural mindfulness.
Presentation at the Jean Baker Miller Training Institute Workshop,
Wellesley College, Wellesley, MA.
Tomkins, S. S. (1987). Shame. In D. Nathanson (Ed.), The many faces of
shame (pp. 133–161). New York, NY: Guilford Press.
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Walker, M. (2002). Power and effectiveness: Envisioning an alternate
paradigm. Work in Progress, No. 94. Wellesley, MA: Stone Center
Working Paper Series.
Walker, M. (2005). Critical thinking: Challenging developmental myths,
stigmas, and stereotypes. In D. Comstock (Ed.), Diversity and
development: Critical contexts that shape our lives and relationships (pp.
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Excerpted from Relational–Cultural Therapy (2010), from Chapter 3, “Theory,” pp. 23–32. Copyright
2010 by the American Psychological Association. Used with permission of the author.
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36
RELATIONAL–CULTURAL THERAPY
PROCESS
JUDITH V. JORDAN
Relational–cultural theory (RCT) appreciates that therapy unfolds in a
complex and often unpredictable way. Initially the therapy relationship
must become “safe enough” to allow the exposure and exploration of
vulnerability. With the client, the therapist explores what might get in the
way of asking for support and affirms the wisdom of the client’s existing
strategies of disconnection. Therapists should not try to dismantle these
strategies of disconnection but rather take a respectful approach to them,
appreciating their necessity. This period of therapy can be difficult and can
last a long time if there has been significant neglect or violation in early
relationships. When, over time, the therapy relationship does not replicate
the pain of earlier relationships, relational discrepancies are experienced
and noticed, and change becomes possible. The client’s new understanding
of her or his own and others’ contribution to the relationship becomes
more nuanced and differentiated.
One day Lisa, a client with posttraumatic stress disorder (PTSD), saw
frustration in my face and asked, “Do you just want to throw me out or
maybe kill me?” Because we had experienced other crises like this, she
could hear me when I answered that I was indeed feeling frustrated, but in
no way did I want to throw her out or kill her, that if anything my
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frustration made me get a little too intense about trying to understand
better. She could see that I was not her rageful father who had repeatedly
assaulted her when he was angry. Her relational images were beginning to
shift and a more differentiated experience of affect was coming into being.
As the client comes to expect more authentic connection, she or he
begins to take small risks in the area of dealing with the inevitable
conflicts that occur in relationships. Rather than moving into avoidance or
inauthenticity, the client may begin to try out stating a difference or
disagreement. Clients develop more relational confidence and resilience.
Relational confidence involves seeing that one has the capacity to move
another person, effect a change in a relationship, or affect the well-being of
all participants in the relationship. The negative relational images that have
limited the client to an expectation that she does not “matter,” that she
cannot have an impact, and that she is relationally incompetent begin to
alter when she sees her own relational competence emerge. Seeing,
feeling, and knowing the experience of impact on the therapist moves the
client back into relationship.
Relational awareness or mindfulness involves bringing a kind of
attunement and consciousness to relationships themselves in addition to
each participant in the relationship. Questions like “What does the
relationship need?” “How strong is the relationship?” and “What will
support the relationship?” begin to be important. Getting through things
together is part of the work. And staying in the uncertainty of the process
is more easily said than done. One useful therapy mantra is “listening with
curiosity rather than reaching for certainty.”
I remember when Lisa, who was extremely critical of me even after
we had established a good record of working through disconnections,
walked into my office one day and said, “This has been a pretty tough
relationship for both of us, hasn’t it? I remember when you called my
sister by the wrong name and I decided that was it, we were done. I said
you were losing your marbles or maybe you just didn’t care. And you
sputtered an apology that I tried to believe. And then remember when I
told you later that you weren’t the smartest therapist I’d ever had but you
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weren’t the dumbest? And I thought I was giving you a present with that?
Yeah, we’ve been through a lot and we’re still here talking to each
other. . . . Amazing. I guess we both deserve some credit for that!” This
acknowledgment was, in itself, a therapeutic milestone.
Together, over time, the therapist and client create a relationship in
which the client can include more of herself, her experience, and her
feelings, especially those parts of her experience she has had to keep out of
relationship. The therapist is empathic with how terrifying it is for the
client to express yearnings for connection and relinquish strategies to stay
out of connection. In therapy with an emotionally present therapist who is
committed to responsively reworking relational failures, isolation lessens
and the brain changes. In what RCT refers to as the corrective relational
experiences where relational images are reworked, it is highly likely that
neuronal shifts occur as well.
It is also useful if the therapist can grasp how therapy actually
“threatens” a client’s strategies of disconnection. It is essential that the
therapist appreciate how dangerous it feels to the client to give up these
strategies of disconnection; without them, she or he may feel powerless
and out of control. The therapist works on being empathic with the central
relational paradox, whereby the client at once yearns to move into
authentic, safe relationship and fears relinquishing the strategies of
disconnection to do so. This push–pull can sometimes result in impasses.
When such an impasse occurs, the therapist needs to refocus on following
the client’s lead and help titrate the movement toward connection
appropriately, in such a way that the client is not triggered into terror.
RCT psychotherapy outcomes include greater freedom to express
yearnings for connection without feeling helpless. Strategies of staying out
of connection decrease. The client experiences greater confidence in her or
his capacity to bear her or his feelings, knowing that she or he need not be
alone. Complex feelings and cognitions replace “all or nothing”
functioning. Pathological certainty shifts. The client develops an enlarged
sense of relational resources in her or his life. Feeling connected and
empowered, the client begins to experience more of the “five good things”:
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zest, clarity, worth, productivity, and desire for more connection. Thus as
the client’s relational skill shifts, her or his energy can move into
productive and creative work.
Because RCT therapy enhances the client’s desire for connection, it is
an approach that is intrinsically about building networks and community.
With an appreciation of the sociopolitical forces that create chronic
disconnection and disempowerment, the individual often feels empowered
to begin to challenge limiting social conditions. Thus RCT therapy does
not simply aim to help people “adjust” to disempowering social
circumstances. Such an approach would support the notion that the
problem is “in the individual,” a model of thinking intrinsically embedded
in separation psychology. Rather, by naming destructive social practices,
empathizing with the impossibility of making change alone, reinforcing
the importance of finding allies, and examining ways to resist shaming
practices at both a collective and a personal level, RCT therapy supports
skills that create both personal well-being and social justice. In her work
with African American adolescent girls, Janie Ward (2000) provides a
beautiful model for building this resistance to isolating and disempowering
cultural forces. As isolation and shame are lessened, energy becomes
available for building more enlivening connections and constructive
community.
In sum, compared to many therapeutic approaches, RCT therapy does
not offer a vast array of specific techniques. Its major contribution to the
therapist’s toolbox is its insistence on the use of mutual empathy and
radical respect for the client and its emphasis on understanding and
reworking chronic disconnections and dysfunctional relational images. The
therapy relationship itself creates healing and change.
THE ELEMENTS OF THERAPY
Working With Connections and Disconnections
A disconnection occurs in an interaction when one person does not
feel heard, understood, or responded to by another person, and there is a
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loss of empathic responsiveness. Disconnections occur all the time in
relationships. Most of them are minor, and they can often become places to
work on building stronger connection. If the hurt or “injured” person can
represent her or his feelings to the other person and be responded to
empathically, disconnection leads to stronger connection. Working toward
reconnection requires a commitment to better understanding and the effort
of repair. If therapists get invested in maintaining images of themselves as
totally empathic, caring healers, or people who have moved beyond the
human condition of uncertainty, suffering, and stumbling in their own
journeys, they will undoubtedly abandon clients at their moments of
greatest honesty and vulnerability. When a client takes the risk of voicing
a criticism or doubt about the therapist, the therapist who needs to be right
or “in control” may well resort to a distancing or demeaning understanding
of this honesty, such as “She’s confusing me with her father,” “He’s
resisting my interpretation,” or “She’s expressing her hostility toward me.”
It is always easier for therapists to bring their empathy to bear on the
client’s experience when the client’s hurt is from others. When therapists
themselves are the source of the injury, they must make a special effort to
avoid defensiveness and thus blame or abandon the client.
RCT therapy suggests that when therapists learn that their
misattunements are part of a disconnection, they need to try hard to stay
present and take in whatever the complaint or injury is. This can entail
being nondefensive and responding in a manner that affirms the client’s
experience—that is, offering a response that presumably was not there
when the client was hurt or injured by others as a child. Thus, the therapist
might apologize for failures in memory or lapses in attention or suggest
that indeed she or he didn’t “get” something and try to go back over it to
see how to do better this time. When an empathic failure occurs, the most
important question is What happens next? Is the client offered a relational
milieu that says that understanding the client and the client’s healing is
more important than the therapist’s pride or ego? Is the therapist dedicated
to really understanding and being with the client’s experience? If the
therapist sends the message that she or he can receive and work on
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feedback about her or his own limitations and fallibility, then chronic
disconnection need not ensue. Unlike in past relationships, clients do not
have to go into shame or protective inauthenticity but can stay with their
own experience as the therapist stays with them. This relational repair
brings about healing and rekindles hope.
VIGNETTE
The Struggle to Stay Connected
Diana, a 20-year-old woman, was one of my most challenging clients
and also one of my most valued teachers. She had been in treatment with
several therapists before she arrived at my office. Although some of her
therapists “gave up on her,” she had fired others for being too “shrinky and
cold.” At that time I was practicing in a psychiatric teaching hospital
where Diana was hospitalized. She began treatment with some hope and
also caution. It didn’t take her long to find me disappointing. She found
me far too conventional and “stiff.” She also was quick to notice the ways
that I didn’t “get” her. In response to my empathic failures, Diana would
call her former therapists to report on the latest “dumb” thing I had said.
Many of these therapists happened to be esteemed former supervisors of
mine. Diana was an accurate recorder of my mistakes so when I would
encounter one of these people in the cafeteria or elsewhere, they would let
me know that she had called and then ask, with some surprise, if I had
really said such and such (with a roll of the eyes to indicate how ridiculous
it would have been if I had). Of course I had.
I was filled with a sense of shame, exposure, and some irritation that
Diana was exposing my failings to so many people. My images of myself
as a kind, empathic therapist were being substantially challenged. I had to
struggle with my own tendency to disconnect. I was defensive and had
little understanding of her pattern of doing this. At first I traveled the
traditional route of seeing her actions as being about her veiled hostility
toward me. I tried to get her to talk about this. Mostly, I think, I was trying
to find a way to get her to stop exposing my incompetence. But over time I
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came to appreciate that Diana had developed an intelligent and effective
way to stay in treatment with me. For her as a trauma survivor, therapy
behind closed doors, where she was invited to share her vulnerability with
a powerful other person, was in no way a safe situation. In fact it was
triggering. She had been sexually abused, behind closed doors, by a
supposedly trustworthy powerful person (her stepfather). The therapy
situation did not offer her safety. Each time I made a mistake or failed her
empathically, she experienced an “amygdala hijack.” In other words, what
might have been perceived as a small error by others signaled to her that
she was unsafe and that potentially she would be violated. Thus, that small
error caused a big reaction.
In response to this reaction, Diana did something brilliant. She
brought the therapy out from behind the closed doors and said, “Listen to
this. Look at this. Look at what my therapist is saying and doing. Witness
this relationship.” In this way she could feel safe enough to stay in the
work. While I struggled with this dynamic and was blind to its meaning for
way too long, I finally did understand that she was indeed doing what she
had to do to overcome the terror that the situation created for her. When I
finally could appreciate this with her and demonstrated that I could get
beyond my own uncertainty, shame, and sense of exposure to stay with her
needs and help her be safe, she began to feel safe enough to trust that we
would work on the misunderstandings and failures together; she no longer
had to go into high alert when an empathic failure occurred. But she also
knew that if she needed to bring in witnesses, she had that option.
Together Diana and I built enough trust to take the next step of
talking together about the hurts, disappointments, and disconnections she
experienced in therapy with me. She contributed a great deal to
establishing a relationship that was safe enough for both of us that we
could facilitate her healing.
The therapist’s ability to work with disconnections—those occurring
in the therapy and outside it—is crucial to the movement of the therapy.
Very importantly, the therapist does not want to abandon people to their
repetitive expectations of nonresponsiveness from others or push them
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toward connection when connections have not been experienced as safe.
Both the desire to connect and the strategies of disconnection that have
developed to protect an individual’s vulnerability in a nonempathic milieu
must be honored. The therapist must attend carefully to the disconnections
in therapy and be ready to renegotiate them to effectively expand the
possibility for future change. Sometimes that means pointing out a
particular pattern of disconnection; sometimes that means quietly allowing
retreat from vulnerability, without a word. For in those moments of
extreme vulnerability, there is the possibility that any comment could be
perceived as shaming. When the therapist hurts the client—whether
through thoughtlessness, misunderstanding, or defensiveness—the hurt
must be addressed: with acknowledgment and sometimes even an apology,
conveying a clear sense that it is not okay for the therapist to hurt the
client, but also pointing out that such misunderstandings may be inevitable
at times. Often the therapist needs to show the pain she or he feels at
having created pain for the client. Contrary to the commonly expressed
fear that showing this will lead to a constriction of feeling or will invite the
client to “take care of the therapist,” this open acknowledgment often leads
to a sense that the therapist cares and is strong enough to show her or his
vulnerability.
People who suffer with chronic disconnection and hold negative
relational images often misattribute blame to themselves for their isolation.
They feel in some way defective, that they have caused the isolation, they
are bad or boring or not deserving of love. So it is especially important that
therapists take appropriate responsibility for their contributions to
disconnections.
Once in therapy I was a bit preoccupied with a project I was working
on. A client I had been seeing for some time was talking about how
important writing in her journal was. But as I listened, I couldn’t really
follow her and I was feeling a bit lost. I commented, “Things seem to be
getting unclear in here today.” She quickly responded: “With you or with
me?” In that moment she helped me see that my own drifting attention was
leaving her feeling alone and in that isolation she was beginning to slip
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away. I acknowledged that I thought I was a bit preoccupied and that she
had probably been feeling like I had left her alone and that perhaps a
journal was a more reliable place to communicate. It was not necessary to
say what exactly preoccupied me; this is part of the difference between
experiential validation and full disclosure.
When a disconnection occurs, whatever the relationship has been or is
moving toward shifts. There is uncertainty. Accompanying uncertainty is
often anxiety and fear. It is a moment of possibility and risk. This moment
can be an opportunity to forge stronger connection or to close down
around pain and fear. When there is nonresponsiveness, a holding of
images of what should be, or clinging to some illusion of certainty,
therapist and client move out of the open space of relatedness into
guarding their separateness or self-images. When the situation is indeed
unsafe, this represents appropriate protectiveness. If people cannot take the
small risks to test out how safe the relationship would be for open curiosity
and learning, they cannot move toward each other. Questions to ask
include: Can we do something about this difficulty in our relationship? Is
there sufficient mutuality and safety to undertake the necessary
vulnerability to work through the difficulty together? Through asking and
answering questions like these, therapist and client together build a new
template for negotiating hard places in relationship.
WORKING WITH EMPATHY
Empathy is a crucial element in rebuilding relational images and
creating connection. Empathy is a complex cognitive affective skill; it is
the ability to put oneself in the others’ shoes, to “feel with” the other, to
understand the other’s experience. It is crucial to the felt experience of
connectedness and is therefore crucial to healing in therapy. It demands
clarity of the source of the affect (where does the affect first arise?), and it
creates increasing clarity about the meaning of the client’s experience. It
also lessens the experiential distance between client and therapist.
Empathy is not just a means to better understand the client; in mutually
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empathic exchanges, the isolation of the client is altered. The client feels
less alone, more joined with the therapist. It is likely that in these moments
of empathy and resonance, there is active brain resonance between
therapist and client (Schore, 1994), which can alter the landscape and
functioning of the brain. Thus, those areas of the brain that register
isolation and exclusion fire less and those areas that indicate empathic
responsiveness begin to activate. The orbitofrontal cortex is quite plastic
and subject to relational reworking throughout most of life. Empathic
responsiveness in therapy can help develop new neuronal pathways and
shift old patterns of firing.
Mutual empathy is based on the notion that in order for empathy to
“make a difference,” to create healing and lessen isolation, the client must
be able to see, know, and feel the therapist’s empathic response. Chronic
disconnection leads to demoralization and a loss of hope for empathic
responsiveness from the other person; indeed, from all others. Only by
bringing oneself more fully into empathic relationship can one learn new
responses and begin to discard the old, fixed, overly generalized
expectations of relational failure.
Mutual empathy, based in respect, allows both people to see the
impact they have on one another. The therapist’s responsiveness to the
client’s feelings gives the client a firsthand experience of being “felt”
(really understood) by the other, of having impact. When the client notices
the therapist tearing up as she herself is tearfully recounting her mother’s
painful death, she knows her pain is received and felt, that her suffering
matters. The client feels less isolated and hopeless. Whereas in prior
relationships, the client may have felt closed down and not responded to,
she or he now sees how she or he emotionally affects the other person.
There is a deepening sense of trust in these exchanges—in oneself, in the
other, and in the relationship—and an expanding belief in the possibility
that relationships and individuals can make a difference in the surrounding
world. The client’s cognitive capacities also come alive, with more clarity
and creativity. Finding growth-fostering relationships does not lead to
withdrawal from the world in a cocoon of warm and gratifying connection.
441

Rather, it leads to an increased investment in the world and in others’ well-
being.
The separate self model overemphasizes the “taking in” of supplies
and the building of a separate sense of well-being. RCT contends that
one’s own growth need not be pitted against another’s; participating in
growth-fostering relationships enables mutual growth. Empathy for oneself
and others is enlarged. Overly personalized and distorted understandings
of past relationships begin to shift.
REFERENCES
Schore, A. (1994). Affect regulation and the origin of the self: The
neurobiology of emotional development. Hillsdale, NJ: Erlbaum.
Ward, J. V. (2000). The skin we’re in: Teaching our children to be emotionally
strong, socially smart, spiritually connected. New York, NY: Free Press.
Excerpted from Relational–Cultural Therapy (2010), from Chapter 4, “The Therapy Process,” pp. 38–51.
Copyright 2010 by the American Psychological Association. Used with permission of the author.
442

APPENDIX 36.1: RELATIONAL–CULTURAL THERAPY
TECHNIQUES
443

444

445

37
SCHEMA THERAPY
LAWRENCE P. RISO AND CAROLINA MCBRIDE
More than 30 years ago, Aaron T. Beck (1967, 1976) emphasized the
operation of cognitive schemas as the most fundamental factor in his
theories of emotional disorders. Schemas, accordingly, played a principal
role in the development and maintenance of psychological disorders as
well as in the recurrence and relapse of episodes.
Despite the central place of cognitive schemas in the earliest writings
of cognitive therapy, the cognitive techniques and therapeutic approaches
that later emerged tended to address cognition at the level of automatic
negative thoughts, intermediate beliefs, and attributional style. In a similar
way, the psychotherapy protocols that developed tended to be short term.
Relatively less attention was paid to schema-level processes.
In most accounts of clinical cognitive theory, cognition can be
divided into different levels of generality (Clark & Beck, 1999). Automatic
thoughts (ATs) are at the most specific or superficial level. Automatic
thoughts are moment-to-moment cognitions that occur without effort, or
spontaneously, in response to specific situations. They are readily
accessible and represent conscious cognitions. Examples of ATs include
“I’m going to fail this test,” “She thinks I’m really boring,” or “Now I’ll
never get a job.” ATs are often negatively distorted, representing, for
instance, catastrophizing, personalization, or minimization. They are
446

significant in that they are tightly linked to both the individual’s mood and
his or her behavioral responses to situations.
Beliefs at an intermediate level (termed intermediate beliefs or
conditional assumptions) are in the form of “if . . . then” rules. Examples
of intermediate beliefs include “If I do whatever people want, then they
will like me” and “If I trust others, I’ll get hurt.”
At the highest level of generality are cognitive schemas. Negative
automatic thoughts and intermediate beliefs are heavily influenced by
underlying cognitive schemas, particularly when these schemas are
activated. In cognitive psychology, the notion of cognitive schemas has
played an important role in the understanding of learning and memory. For
clinical contexts, A. T. Beck (1967) described a cognitive schema as “a
cognitive structure for screening, coding, and evaluating the stimuli that
impinge on the organism” (p. 283).
A number of authors have returned recently to Beck’s original notions
of the need to conceptualize patients in terms of their cognitive schemas
(see, for instance, Young, 1995, and Safran, Vallis, Segal, & Shaw, 1986).
Jeffrey Young (1995; Young, Klosko, & Weishaar, 2003) has been one of
the more influential proponents of a schema-focused clinical approach.
Noting limitations of traditional cognitive therapy, Young (1995)
suggested that a focus on schemas was often necessary because some
patients have poor access to moment-to-moment changes in affect, making
a primary focus on ATs unproductive. Other patients are readily able to
recognize the irrationality of their thoughts in therapy but then report that
they still “feel” bad. Still others are unable to establish a productive and
collaborative working alliance that is required for more symptom-focused
work. Finally, Young noted that patients seen in the community are often
much more complex and chronic than are those enrolled in clinical trials
with 3-month cognitive therapy protocols. As a consequence, the need to
focus on underlying schemas has begun to influence the practice of
cognitive therapy. In this volume, we have compiled work by a number of
authors who tailor the schema-focused approach to the understanding and
treatment of specific clinical problems.
447

The increased interest in cognitive schemas parallels the search for
underlying dimensions of vulnerability to psychopathology. The search for
these underlying processes includes factors such as temperament,
personality, and personality disorders. Schema-focused approaches also
represent a return to an interest in developmental antecedents of
psychopathology.
The concept of schemas has a rich ancestry in psychology deriving
from cognitive psychology, cognitive development, self-psychology, and
attachment theory. Within the cognitive therapy literature, the term
cognitive schema has had multiple meanings (James, Southam, &
Blackburn, 2004; Segal, 1988; Young et al., 2003). These definitions vary
in the extent to which schemas are accessible or inaccessible cognitive
structures. Nearly all definitions, however, maintain that cognitive
schemas represent highly generalized superordinate-level cognition, that
schemas are resistant to change, and that they exert a powerful influence
over cognition and affect. As in psychoanalytic theory, the notion of
cognitive schemas suggests the power of unconscious processes in
influencing thought, affect, and behavior. However, unlike the
psychodynamic unconscious, schemas exert their influence through
unconscious information processing, rather than through unconscious
motivation and instinctual drives.
Early attempts to study cognitive schemas used paper-and-pencil
measures such as the Dysfunctional Attitudes Scale (Weissman & Beck,
1978). Numerous studies found that currently ill individuals consistently
scored higher on self-report inventories purportedly measuring
dysfunctional schemas than did control participants who were never
depressed (see Segal, 1988, for review). However, subsequent research
demonstrated that these elevated scores normalized with symptomatic
recovery (Blackburn, Jones, & Lewin, 1986; Giles & Rush, 1983; Haaga,
Dyck, & Ernst, 1991; Hollon, Kendall, & Lumry, 1986; Silverman,
Silverman, & Eardley, 1984). The explanation for these findings, from a
schema-theory perspective, was that following recovery, cognitive
schemas became dormant and thus difficult to detect.
448

Therefore, the next generation of research examined cognitive
schemas using information-processing tasks. It was assumed that
information tasks would be less prone to reporting biases and more able to
detect latent schemas, particularly when these tasks were accompanied by
an effort to prime or activate the schema. In one such task, individuals
made judgments of whether a number of positive and negative personal
adjectives were self-descriptive, followed by an incidental recall test.
Results indicated that not only were individuals with depression biased
toward recall of negative self-referent information (Derry & Kuiper, 1981;
Dobson & Shaw, 1987) but also, and perhaps more importantly, these
formerly depressed individuals were biased in their recall after undergoing
a sad mood induction (Hedlund & Rude, 1995; Teasdale & Dent, 1987). In
other work, individuals who had recovered from depression made more
tracking errors during dichotic listening tasks than did control participants,
who were never depressed, after they underwent a sad mood induction
(Ingram, Bernet, & McLaughlin, 1994). Finally, Miranda and colleagues
(Miranda, Gross, Persons, & Hahn, 1998; Miranda, Persons, & Byers,
1990) assessed dysfunctional attitudes in formerly depressed versus never
depressed individuals. Although the groups exhibited similar levels of
dysfunctional attitudes before any mood induction, following the mood
induction procedure only the formerly depressed group showed increases
in their reporting of dysfunctional attitudes. These and other studies
substantiated the notion that schemas are latent during nonsymptomatic
periods and become accessible and impact cognitive processing when they
are activated.
The importance of schemas in the development and maintenance of
psychopathology, as well as the role of schemas in treatment resistance,
has much in common with the Diagnostic and Statistical Manual of
Mental Disorders (4th ed.; DSM–IV; American Psychiatric Association,
1994) Axis II personality disorders. Like personality disorders, schemas
represent purportedly stable generalized themes that develop early in life
and are important considerations for understanding and treating a wide
range of psychopathological conditions. Unlike personality disorders,
449

however, schemas are dimensional rather than categorical, are more
cognitive–affective than behavioral, and were derived from the traditions
of personality psychology and cognitive phenomenology, rather than the
traditions of operationalized psychiatric nomenclature and descriptive
psychopathology.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.). Washington, DC: Author.
Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical
aspects. New York, NY: Harper & Row.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York,
NY: International Universities Press.
Blackburn, I. M., Jones, S., & Lewin, R. J. (1986). Cognitive style in
depression. British Journal of Clinical Psychology, 25, 241–251.
Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory
and therapy of depression. New York, NY: Wiley.
Derry, P. A., & Kuiper, N. A. (1981). Schematic processing and self-reference
in clinical depression. Journal of Abnormal Psychology, 90, 286–297.
doi:10.1037/0021-843X.90.4.286
Dobson, K. S., & Shaw, B. F. (1987). Specificity and stability of self-referent
encoding in clinical depression. Journal of Abnormal Psychology, 96, 34–
40. doi:10.1037/0021-843X.96.1.34
Giles, D. E., & Rush, A. J. (1983). Cognitions, schemas, and depressive
symptomatology. In M. Rosenbaum, C. M. Franks, & Y. Jaffe (Eds.),
Perspectives on behavior therapy (pp. 184–199). New York, NY:
Springer.
Haaga, D. A., Dyck, M. J., & Ernst, D. (1991). Empirical status of cognitive
theory of depression. Psychological Bulletin, 110, 215–236.
doi:10.1037/0033-2909.110.2.215
Hedlund, S., & Rude, S. S. (1995). Evidence of latent depressive schemas in
formerly depressed individuals. Journal of Abnormal Psychology, 104,
450

517–525. doi:10.1037/0021-843X.104.3.517
Hollon, S. D., Kendall, P. C., & Lumry, A. (1986). Specificity of
depressotypic cognitions in clinical depression. Journal of Abnormal
Psychology, 95, 52–59. doi:10.1037/0021-843X.95.1.52
Ingram, R. E., Bernet, C. Z., & McLaughlin, S. C. (1994). Attentional
allocation processes in individuals at risk for depression. Cognitive
Therapy and Research, 18, 317–332.
James, I. A., Southam, L., & Blackburn, I. M. (2004). Schemas revisited.
Clinical Psychology & Psychotherapy, 11, 369–377. doi:10.1002/cpp.423
Miranda, J., Gross, J. J., Persons, J. B., & Hahn, J. (1998). Mood matters:
Negative mood induction activates dysfunctional attitudes in women
vulnerable to depression. Cognitive Therapy and Research, 22, 363–376.
doi:10.1023/A:1018709212986
Miranda, J., Persons, J. B., & Byers, C. N. (1990). Endorsement of
dysfunctional beliefs depends on current mood state. Journal of Abnormal
Psychology, 99, 237–241. doi:10.1037/0021-843X.99.3.237
Safran, J. D., Vallis, T. M., Segal, Z. V., & Shaw, B. F. (1986). Assessment of
core cognitive processes in cognitive therapy. Cognitive Therapy and
Research, 10, 509–526. doi:10.1007/BF01177815
Segal, Z. V. (1988). Appraisal of the self-schema construct in cognitive
models of depression. Psychological Bulletin, 103, 147–162.
doi:10.1037/0033-2909.103.2.147
Silverman, J. S., Silverman, J. A., & Eardley, D. A. (1984). Do maladaptive
attitudes cause depression? Archives of General Psychiatry, 41, 28–30.
Teasdale, J. D., & Dent, J. (1987). Cognitive vulnerability to depression: An
investigation of two hypotheses. British Journal of Clinical Psychology,
26, 113–126.
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the
Dysfunctional Attitude Scale: A preliminary investigation. Paper presented
at the meeting of the American Educational Research Association,
Toronto, Ontario, Canada.
Young, J. E. (1995). Cognitive therapy for personality disorders: A schema-
focused approach. Sarasota, FL: Professional Resource Exchange.
451

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A
practitioner’s guide. New York, NY: Guilford Press.
Excerpted from Lawrence P. Riso, Pieter L. du Toit, Dan J. Stein, and Jeffrey E. Young (Eds.), Cognitive
Schemas and Core Beliefs in Psychological Problems: A Scientist–Practitioner Guide (2007), from
Chapter 1, “Introduction: A Return to a Focus on Cognitive Schemas,” pp. 3–6. Copyright 2007 by the
American Psychological Association. Used with permission of the authors.
452

38
SCHEMA THERAPY PROCESS
LAWRENCE P. RISO, RACHEL E. MADDUX AND NOELLE TURINI
SANTORELLI
Years of unrelenting depression can render chronic patients hopeless
about their future and their prospects for improving during therapy.
Therefore, along with a focus on schemas, early symptom reduction is
extremely important. The lack of any tangible sign of improvement in the
first few weeks of therapy can reinforce the patient’s hopelessness and
defectiveness schemas. Thus, early on, behavioral activation strategies
such as activity scheduling and assertiveness training along with targeted
sleep interventions should be considered.
Once a schema has been identified, the therapist can assist the patient
in examining the validity and usefulness of the schema, as well as arriving
at alternative or more realistic beliefs. The Core Belief Worksheet (CBW;
Beck, 1995) is a useful format for weighing the evidence for and against a
schema and its related core belief. The CBW helps patients to articulate
the core belief (or schema), rate the extent to which they agree with it, and
systematically evaluate the data that support or refute it. The level of
confidence in the belief is rerated after the data are examined, and the
process is often continued over many sessions. The CBW helps patients
discover how they exaggerate the “truthfulness” of the belief and establish
some distance from inaccurate and destructive ideas. Over time, the CBW
453

will help patients develop more accurate and functional alternative beliefs.
Another useful technique in addressing negative schemas is guided
imagery. We have found the descriptions of guided imagery provided by
Beck (1995); Edwards (1990); and Layden, Newman, Freeman, and Morse
(1993) to be particularly helpful. Imagery exercises can be emotionally
evocative and powerful vehicles for corrective experiences, although they
must be handled with the utmost sensitivity. Patients who believe they are
defective and unlovable because of the sexual abuse they once experienced
may need to reprocess the trauma via imagery, actively and rationally
responding to the faulty conclusions they had drawn about themselves. Of
course, great care and caution needs to be exercised in such a situation to
ensure that the patient understands the nature of and rationale for the
procedure, and that he or she agrees to it in a collaborative discussion. In
addition, care must be taken to ensure sufficient time is allotted in the
session for the debriefing that follows. The imagery and reprocessing may
be repeated over many sessions, until the patient is better equipped to
rationally respond to the negative beliefs and connotations that the sexual
abuse once engendered.
Guided imagery may be used in other ways. For example, patients
can deliberately manipulate their images to “rewrite” a distressing
outcome. One patient’s image involved being helplessly berated by his
intensely critical father when he was 9 years old (described later in the
case illustration). By walking into the image as an adult, he could explain
to the boy (i.e., himself at age 9) that his father was an extremely volatile
person in the midst of an outburst, possibly related to his alcoholism. His
criticisms and rantings at that moment, or any other for that matter, could
hardly be construed as an accurate appraisal of anyone’s character or
abilities.
Role playing is another useful method of undermining problematic
core beliefs and schemas. Therapist and patient can take turns playing the
role of the schema, versus that of the healthy alternative viewpoint. This
point–counterpoint technique (Young, 1995) allows for the brainstorming
of many rational responses to the schema, under conditions of high affect
454

and high sensory involvement. In a similar way, therapist and patient can
role play important interpersonal situations in the patient’s life that
typically evoke schematic reactions (e.g., arguments with a parent; being
criticized by a colleague). Such an exercise affords patients the chance to
practice more adaptive cognitive and behavioral responses while validating
the emotions that have been evoked by the high-risk situation. Through
repetitions and constructive corrections, the patient learns to counteract
even well-established schemas and their concomitant emotions and
behaviors, thus providing vital new interpersonal skills.
Patients with chronic depression often have schemas of helplessness,
weakness, and inadequacy that lead to passivity during treatment. Thus,
therapists must guard against a tendency to become overly directive and
dominant during sessions, which will only breed more passivity.
According to the interpersonal theory of Donald Kiesler (1983, 1996),
dominance and submission are reciprocal tendencies. That is, patients who
are submissive in session present an interpersonal pull for therapists to
become more dominant (see also McCullough, 2000). However, this is an
interpersonal trap in therapy, because becoming more directive brings on
the reciprocal tendency for patients to be even more passive and
submissive. Consider this example:
Patient: There’s really nowhere to turn. You know, nobody who
really cares. I just don’t know how to climb out of this. I’m
totally at a loss.
Therapist: I’m sure your wife still cares. You really need to talk to
her.
Patient: You think so?
Therapist: Yes. You need to be really honest and straightforward.
This is no time to mince words.
Patient: So the direct approach, huh? I guess you’re right. But
what should I say? I’d probably screw it up.
In this example, the therapist is getting deeper and deeper into telling
the patient how to solve problems and is setting the stage for more and
455

more passivity from the patient.
Other patients exhibit hostility toward therapists, which pulls for
more hostility from the therapist. This dynamic occurs because friendliness
and hostility are corresponding interpersonal tendencies (friendliness pulls
for friendliness and hostility pulls for hostility). Remaining cognizant of
the reciprocal and corresponding dynamics will help therapists recognize
and respond to these challenging interpersonal pulls. At times, the therapist
can even strategically vary his or her interpersonal stance. For instance, a
therapist can actually take a passive stance (e.g., “I feel a little stumped
myself”) to pull for a more active and problem-solving approach from
patients (e.g., “Well, I guess one thing I can do is talk to my wife”).
RETAINING THE BASIC PRINCIPLES OF COGNITIVE THERAPY
A focus on schemas in the treatment of chronic depression differs
from traditional cognitive therapy by placing a greater emphasis on early
childhood experiences, making greater use of emotive techniques such as
guided imagery, using the therapeutic relationship as a vehicle of change,
and conducting a lengthier course of therapy because of the resistance to
change of underlying schemas. Despite the somewhat different emphasis,
it is essential to maintain the basic elements of traditional cognitive
therapy including keeping the therapy active and directive, using cognitive
therapy techniques, emphasizing self-help homework, and conducting
structured sessions (Young, 1995). Most of all, it is essential to develop a
list of clear therapeutic goals. Vague and global ideas are in need of
specifics to decrease the chronic patient’s confusion, hopelessness, and
feelings of being overwhelmed with problems.
REFERENCES
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY:
Guilford Press.
Edwards, D. J. A. (1990). Cognitive therapy and the restructuring of early
456

memories through guided imagery. Journal of Cognitive Psychotherapy, 4,
33–50.
Kiesler, D. J. (1983). The 1982 Interpersonal Circle: A taxonomy for
complementarity in human transactions. Psychological Review, 90, 185–
214. doi:10.1037/0033-295X.90.3.185
Kiesler, D. J. (1996). Contemporary interpersonal theory and research:
Personality, psychopathology, and psychotherapy. New York, NY: Wiley.
Layden, M. A., Newman, C. F., Freeman, A., & Morse, S. B. (1993).
Cognitive therapy of borderline personality disorder. Needham Heights,
MA: Allyn & Bacon.
McCullough, J. P. (2000). Treatment for chronic depression: Cognitive
behavioral analysis system of psychotherapy. New York, NY: Guilford
Press.
Young, J. E. (1995). Cognitive therapy for personality disorders: A schema-
focused approach. Sarasota, FL: Professional Resource Exchange.
Excerpted from Lawrence P. Riso, Pieter L. du Toit, Dan J. Stein, and Jeffrey E. Young (Eds.), Cognitive
Schemas and Core Beliefs in Psychological Problems: A Scientist–Practitioner Guide (2007), from
Chapter 3, “Early Maladaptive Schemas in Chronic Depression,” pp. 47–50. Copyright 2007 by the
American Psychological Association. Used with permission of the authors.
457

APPENDIX 38.1: SCHEMA THERAPY TECHNIQUES
458

目录
Preface 9
How to Use This Book With PsycTHERAPY, APA’s
Database of Psychotherapy Demonstration Videos 12
Chapter 1. Acceptance and Commitment Therapy 15
Chapter 2. Acceptance and Commitment Therapy
Process 25
Chapter 3. Behavior Therapy 33
Chapter 4. Behavior Therapy Process 45
Chapter 5. Brief Dynamic Therapy 54
Chapter 6. Brief Dynamic Therapy Process 64
Chapter 7. Cognitive Therapy 82
Chapter 8. Cognitive Therapy Process 94
Chapter 9. Cognitive–Behavioral Therapy 111
Chapter 10. Cognitive–Behavioral Therapy Process 122
Chapter 11. Constructivist Therapy 135
Chapter 12. Constructivist Therapy Process 148
Chapter 13. Emotion-Focused Therapy 163
Chapter 14. Emotion-Focused Therapy Process 174
Chapter 15. Existential Therapy 192
Chapter 16. Existential Therapy Process 204
Chapter 17. Family Therapy 213
Chapter 18. Family Therapy Process 224
Chapter 19. Feminist Therapy 233
Chapter 20. Feminist Therapy Process 244
Chapter 21. Gestalt Therapy 251
Chapter 22. Gestalt Therapy Process 261
Chapter 23. Multicultural Therapy 271
Chapter 24. Multicultural Therapy Process 283
459

Chapter 25. Narrative Therapy 306
Chapter 26. Narrative Therapy Process 317
Chapter 27. Person-Centered Therapy 328
Chapter 28. Person-Centered Therapy Process 339
Chapter 29. Psychoanalytic Therapy 353
Chapter 30. Psychoanalytic Therapy Process 365
Chapter 31. Rational Emotive Behavior Therapy 375
Chapter 32. Rational Emotive Behavior Therapy Process 387
Chapter 33. Reality Therapy 399
Chapter 34. Reality Therapy Process 411
Chapter 35. Relational–Cultural Therapy 420
Chapter 36. Relational–Cultural Therapy Process 432
Chapter 37. Schema Therapy 446
Chapter 38. Schema Therapy Process 453
460

Preface
How to Use This Book With PsycTHERAPY, APA’s Database of Psychotherapy Demonstration Videos
Chapter 1. Acceptance and Commitment Therapy
Chapter 2. Acceptance and Commitment Therapy Process
Chapter 3. Behavior Therapy
Chapter 4. Behavior Therapy Process
Chapter 5. Brief Dynamic Therapy
Chapter 6. Brief Dynamic Therapy Process
Chapter 7. Cognitive Therapy
Chapter 8. Cognitive Therapy Process
Chapter 9. Cognitive–Behavioral Therapy
Chapter 10. Cognitive–Behavioral Therapy Process
Chapter 11. Constructivist Therapy
Chapter 12. Constructivist Therapy Process
Chapter 13. Emotion-Focused Therapy
Chapter 14. Emotion-Focused Therapy Process
Chapter 15. Existential Therapy
Chapter 16. Existential Therapy Process
Chapter 17. Family Therapy
Chapter 18. Family Therapy Process
Chapter 19. Feminist Therapy
Chapter 20. Feminist Therapy Process
Chapter 21. Gestalt Therapy
Chapter 22. Gestalt Therapy Process
Chapter 23. Multicultural Therapy
Chapter 24. Multicultural Therapy Process
Chapter 25. Narrative Therapy
Chapter 26. Narrative Therapy Process
Chapter 27. Person-Centered Therapy
Chapter 28. Person-Centered Therapy Process
Chapter 29. Psychoanalytic Therapy
Chapter 30. Psychoanalytic Therapy Process
Chapter 31. Rational Emotive Behavior Therapy
Chapter 32. Rational Emotive Behavior Therapy Process
Chapter 33. Reality Therapy
Chapter 34. Reality Therapy Process
Chapter 35. Relational–Cultural Therapy
Chapter 36. Relational–Cultural Therapy Process
Chapter 37. Schema Therapy
Chapter 38. Schema Therapy Process

Running head:

COGNITIVE-BEHAVIORAL THEORY

Cognitive-Behavioral Theory

Summary of Theory

Cognitive-behavioral therapy is a form of psychotherapy that aims to develop new patterns of behavioral, affective, and cognitive responding by modifying or replacing maladaptive behaviors, emotions, and thoughts. Unlike other traditional psychotherapies, which focus on past experiences to explore the causality of the presenting problems, CBT emphasizes the solutions by conceptualizing the presenting problems.

Tenets of Theory

The central tenet of cognitive-behavioral therapy is based on the learning theory: the classical conditioning model. The classical conditioning model provides us the explanation of the formulation of clients’ problems. It promotes the idea that unconditioned stimulus (US) leads to unconditional response, when a neutral stimulus is paired with the US, it becomes a conditional stimulus to produce a conditional response. Also, the more intense and less controllable over the aversive experiences during the negative events are more likely to develop the classical conditioning response. In addition, the person’s temperament and life experience may contribute to the generation of conditional responses. In conclusion, the classical conditioning model can help us to understand the clients’ learning experiences related to their mental problems in order to formulate effective interventions.

Techniques

There are many techniques in cognitive-behavioral therapy, including self-monitoring, relaxation, behavioral rehearsal of social skills and assertiveness, problem-solving training, etc. Self-monitoring encourages clients to record themselves in order to objectively observe their behaviors. In this way, clients can obtain an awareness of their behaviors, at the same time, their motivation can be reinforced by receiving the positive feedback from the therapist. Relaxation involves helping clients to experience the difference between feelings of relaxation and tension; thereby they are able to develop relaxation response in their daily life when intense emotions detected. In the process of behavioral rehearsal of social skills and assertiveness, psychoeducation, skill training, and behavioral rehearsal are used to help clients develop a specific alternative skill or behavior to remedy their deficits in a specific area. Problem solving also involves teaching clients a set of skills for coping with their daily life problems. In the process of problem-solving, initially clients are encouraged to identify their problems and negative beliefs, then they can generate the most realistic solution by going through the cost-benefit analysis. The successful and effective solutions can serve as a reinforcement to generate a new pattern of lifestyle.

Personal reflection

Cognitive-behavioral therapy is based on the concept that people’s cognitions are the central factor that affects how they experience the events. Therefore, we might have different interpretations regard to the same event. For example, if I was doing a presentation in the class and one of the students kept yawning during my presentation. I might think “Why is this guy does not interest in my presentation? Am I doing it so bad? Why people do not have any respect?” In this scenario, I would be so angry. However, I might interpret differently, such as “this person is having a long day and he is so tired.” With those thoughts, I would more likely to just concentrate on my presentation without being emotional. This is why CBT is effective in the treatment of social anxiety disorders. Because people with social anxiety disorders are more likely to think negatively when they expose to a social or performance situation. Therefore, people can develop new patterns of behavior by having a better understanding of their cognitive processes.

It is no doubt that CBT is the most widely used psychotherapy in the counseling field. With the problem focused and goal-oriented approach, CBT is effective to deal with a wide range of mental problems. However, it can cause a problem when the client gets lost and struck in his or her dysfunctional thoughts. For example, by using CBT in the treatment of a victimized client, it would be helpful for the client to change his or her view about themselves from a victim to a survivor. However, a traumatized client is more like to have difficulties in identifying their cognitions because of self-protection. Therefore, I would prefer to focus more on the development of past experience instead of trying to change their cognitions.

Questions

How can we address the client’s emotion in the cognitive-behavioral therapy since it places central focus on the cognition and behavior?

CBT is effective with reducing symptoms even without focusing on therapeutic relationship and underlying causes, how can we balance it from the humanistic perspective?

References

In VandenBos, G. R., In Meidenbauer, E., & In Frank-McNeil, J. (2014). In Cognitive-Behavioral Therapy (pp. 111-133). Psychotherapy theories and techniques: A reader.

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