Advanced Methods in Counseling and Psychotherapy clinical notes updated on january 14 2017

ADVANCED METHODS IN COUNSELING AND PSYCHOTHERAPY

- Clinical Notes on Individual, Couple and Family Therapy Demetrios Peratsakis, MS, PD, LPC, ACS --------------- . ---------------Updated: January 14, 2017

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“There's no coming to consciousness without pain.�

- Carl G Jung

Orientation to Practice Psychotherapy is the practice of healing psychological trauma and fostering personal growth and adjustment to change. It relies on great familiarity with a broad variety of clinical techniques as well as a sound understanding of the nature of human behavior. It is a very deliberate process that places enormous responsibility on the clinician for challenging, as well as supporting, individuals in their struggle to redefine themselves in a new way of being.

As substance abuse counselors working in New York City during the 1970s, many of us saw the need for advanced clinical training for the treatment of unresolved trauma and abuse. By 1980 a small group of us had begun supervision under the auspices of Dr. Robert Sherman, a long-time Fellow at the North American Society of Adlerian Psychology and Chair of Marriage and Family Therapy (MFT) Program at Queens College until his retirement in 1992.

This proved to be a very robust period of advanced clinical practice and exposure to such noted Adlerians as Kurt Adler, MD (1980), Bernard H. Shulman, MD (1980), Harold Mosak (1980-1981) and Larry Zuckerman (1982-1983) and many of the major founding theorists of family systems therapy including Maurizio Andolfi (1981), Carlos Sluski, MD (1983), Murray Bowen, MD (1984), James Framo (1985), Bunny Duhl (1986), Monica McGoldrick (1987), Carl Whitaker, MD (1988), Jay Haley (1989), Salvador Minuchin, MD (1990 and 1991), and Peggy Papp (1992).

Over the years, Robert Sherman sponsored my work as a field placement supervisor and as an adjunct instructor at the College (Diagnosis and Intervention in Couple and Family Therapy; 784.1 and Family Growth and Pathology; 784.5). In 1990 he arranged my participation in a two-day training intensive with Patricia and Salvador Minuchin, MD (Structural Family Therapy) and my enrollment in a 30-session (1990-1992), live supervision externship on Strategic Therapy and Clinical Supervision, with Dr. Richard Belson, Director of the Family Therapy Institute of Long Island, New York, and long-time collaborator of Jay Haley and Cloe Madanes.

Both Sherman and Belson were expert in advanced clinical methods and lectured broadly on ways in which to disengage power plays, redirect rage, and utilize revenge in the treatment of depression, betrayal and interpersonal trauma.

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These Notes Disclaimer: These Notes were last copyrighted in April 2016 and revised in November. Where not original, the source has been cited, where practicable, or the work sufficiently modified to reflect the addition of original thinking.

The Center for Disease Control (CDC) and the National Institute of Mental Health (NIMH) estimate that in any given year almost 25% of the adult public suffers from a serious, debilitating mental health condition, 26% of whom suffer from chronic depression.

Given the scope of the problem, it’s fairly important that one acquire a solid theoretical footing as well as experience in a broad array of clinical technique. This can be a challenge, for while there are several hundred forms of therapy there is no general consensus on the most basic precepts within our field, such as what constitutes personality, drives motivation, or purposes social interaction.

The beliefs expressed herein represent the more important principles and points of view that I have found to be helpful. Ultimately, of course, the best instruction comes from the work itself and the intimacy one is honored to develop with a stranger. This is, after all, is the reason that we are called to the field, for there is no greater privilege than to share in the abject suffering of another and to find solace and strength in their hope and striving for relief and redemption.

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Treatment Philosophy 101

Theoretical Premises While most practitioners have a preferred method of counseling, the underlying tenets of each on the nature of human behavior are relatively the same: 1. Believing is Seeing Action is a combination of behavior, emotion and will. It is not random but purposive, meaning it is consistent with and representative of the inner goals and beliefs of the individual. As such, actions are representative snap-shots or microcosms of the individual’s world-view, the context within which the individual defines themselves, their interaction with others, and their beingness in the world. 

In this regard, behaviors and emotions are not mere artifacts of the individual’s belief-system but communication that informs others, as well as the individual, of their intent.

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Behaviors and emotions create responses in others which, in turn, reaffirms the individual’s subjective experience of self in social interactions. This feed-back loop maintains a continuum to perception thereby preserving consistency in the manner in which one operates within the world.

In a fundamental way, one behaves in a manner that elicits responses in others that reaffirm one’s beliefs about their beingness and subjective experience of the world.

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While behavior and emotion is driven by belief, insight is not always a sufficient, nor a necessary, prerequisite for change. One may act differently and evidence change even if they do not understand the purpose of the action or its intent. Arguably, insight allows change to remain more anchored as well as to become generalized in its effect: o o

When one thinks differently, they behave differently When one behaves differently, they think differently

2. One Equals None 

Individuals do not exist in isolation; we are social beings that are born highly dependent within a family unit in which our needs are met, socialization occurs, identity is formed and intimacy developed and shared as a means of ensuring the safety and continuation of the species

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As such, problems are by-products of social relationships and do not exist outside the relationship context. Moreover, the solution to problems are also relational.

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The goal for each individual in the collective is interdependence. Individuation, the ongoing process of differentiation, is a life-long struggle of defining one’s own self in relation to others.

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3. Change is Permanent 

Life is a series of progressive stages, called Family Life Cycle, with defined tasks and challenges.

These are the necessary functions of change and growth inherent in becoming human and in belonging to a community with others.

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Given that change is a continuous characteristic of life, it is how individuals adapt to change that determines whether they, or others, will incur problems

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Today’s solution becomes tomorrow’s problem. When adjusting to change becomes problematic, individuals often rely on inadequate remedies. Long-term reliance on inadequate solutions typically results in the creation of new problems or an exacerbation of the original need for change. Rigidity, lessens the potential for innovation and change.

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These will be labeled as symptoms and dysfunctions; they are, in fact, safeguarding mechanisms developed by individuals and families in response to chronic distress. They aid in the process of coping and adaptation, often a part of healing or revenge.

4. Conflict and Cooperation 

Foundation processes in human interaction that are critical to survival. While the benefits of cooperation are intuitive, those of conflict are less apparent; nonetheless, conflict is a necessary prerequisite to innovation. Conflict is change: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦

Conflict excites and encourages people to grow Conflict fosters an awareness that problems exist Reconciling conflicting views can lead to better solutions Managing conflict is quicker and more efficient than letting conflicts fester Challenging old assumptions can lead to changes in outdated practices and processes Conflict requires creativity to find the best outcomes Conflict raises awareness of what is important to individuals Managing conflicts appropriately helps build self-esteem and maturity Conflicts create opportunity

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Structures, which define most of our social interactions, help reduce conflict and increase cooperation, critical dynamics to innovation and growth. Social structures include roles and rules, legacies and myths, family subsystems, and patterns of interaction.

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Presenting Problems are, in essence, due to unresolved conflict or trauma. The most pervasive and insidious trauma is from betrayal. Trauma creates sadness, fear, and anger and can quickly lead to guilt and shame; when unresolved it leads to anxiety, depression and rage.

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The role of the therapist is active and dynamic, working in the here-and-now to create opportunities to practice new ways of being, and thereby to engender change. Most work should occur in session under the direct supervision of the therapist.

5. Power Controls 

Power, the ability to influence change, is at the core of every interaction

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A Problem is the result of a of a power-play, real or symbolic, between the individual and others, the individual and society, the individual and themselves

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The role of psychotherapy is to disengage and redirect the Power-play

GENERAL AFFIRMATIONS General Premise #1

OUR NEEDS ARE UNIVERSAL

“And mankind is naught but a single nation” --The Holy Quran a)

Our fears, our pain, our wants: knowing this, helps one join in an authentic and meaningful way

b) Forget the hype on type, emotions are the same. Different triggers, different degrees, same emotion. c)

A global assessment is easy; look to life-cycle as well as what is missing or not working well:

b)

What we all need --courtesy of Mark Tyrrell: 

feel safe and secure day to day

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give and receive attention

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have a sense of some control and influence over events in life

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feel stretched and stimulated by life to avoid boredom

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have fun sometimes and feel life is enjoyable

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feel intimate with at least one other human being

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feel connected to and part of a wider community

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be able to have privacy and time to privately reflect

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have a sense of status, a recognizable and appreciated role in life

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have a sense of competence and achievement

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a sense of meaning about life and what we do.

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General Premise #2

ALL PROBLEMS ARE RELATIONAL

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As social beings, problems are a product of social interaction, as is their cure. This includes those syndromes we historically have regarded as intrapsychic, such as depression and anxiety.

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Mutual causality: Change occurs in overlapping relationship systems that influence each other through continual feedback loops, the most common being roles, rules, triangles, intergenerational myths and legacies, and habituated structures and patterns such as symptoms and dysfunctional transactions.

 This premise, from Family Systems Therapy, adds immeasurable strength to one’s clinical insight

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Ask yourself: “Who else is involved (living or dead)?” Trace all that participate in the Presenting Problem and how.

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Ask yourself: “If this was not the problem, what (who) would be?”

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Relationships share three common features: Power, Intimacy and Conflict

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Cooperation and Conflict are fundamental forces in the drive for Belonging and Independence

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Power: the ability to influence outcome; it shapes Intimacy and Conflict

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Intimacy: belonging, acceptance, fusion, cooperation, pair-bonding, closeness, love

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Conflict: differentiation, individualism, independence, innovation

Problems arise due to o

Difficulties adapting to transition from one developmental stage to the next (Life Tasks; Family Life Cycle)

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Unresolved/Pervasive Conflict, typically due to problems adapting to change: leads to Powerplays and Betrayals

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Trauma due to Disasters, Illness and Betrayal (breaches in the intimacy and trust bonds)

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General Premise # 3 PURPOSIVENESS Behavior is purposive. Action is not random; it is goal-directed and consistent with one’s beliefs and world-view. This is not simply a matter of the outcome of a sequence of behaviors or actions, but of all sequences.  This premise, from Alfred Adler, adds immeasurable strength to one’s clinical insight o

"Toward what purpose was the behavior expressed?"

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"Toward what goal was the behavior aiming at?"

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"What is the 'use' or function of the behavior?”

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“What is the outcome that occurs, when the behavior is expressed?”

 The primary goal of all human behavior is social belonging, while maintaining significance and a unique sense of self. We each hold beliefs about ourselves and how best to function with others  We interpret all action against these beliefs, interpreting the world and our place in it  Our own behavior shapes the thoughts and feelings of others who behave in a manner that reaffirms our beliefs about the world and social interaction (worldview re-affirmation)  We face the common challenge of maintaining self-esteem as we strive for social belonging  Our actions represent a constant striving from a perceived sense of minus (-), towards a perceived sense of the more positive (+)  As behaviors, Symptoms also have purpose, they are metaphoric patterns of communication  The responsibility of Free Will lays in the agony of free choice

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General Premise #4

ANXIETY & DEPRESSION

a) Anxiety and Depression are by-products of unresolved loss or trauma. They are fueled by anger, guilt and shame. b) We view behavior as having intent (action). So, too, are emotions; they are goal-directed and consistent with one’s beliefs; they are intentional, purposive, conscious and subjectively meaningful activity (Adler). c) Fear, Anger and Sadness are normative responses to conflict and hurt. Worry, Shame, Guilt, and Rage are recurring conditions (of thought and feeling) that, collectively, comprise Anxiety and Depression in their varied forms. As a set of behaviors, emotion, and interactive patterns, Anxiety and Depression are purposive; their central, underlying element is Power (Control). -Peratsakis d) Anxiety: the state of Being Afraid 

Fear, Dread and Panic: generalized hyper-vigilance against harm or threat

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Phobia, Obsession and Compulsion: targeted, repetitive actions that relieve stress as well as create it

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Is Anxiety simply another expression or form of depression, great sadness or sorrow?

e) Depression: Sorrow, Sadness, Sullenness, Worthlessness, Hopelessness or Despair. Possible reasons and intents 

Depression as a normative response to grief and hurt, a closing-in for healing and reevaluation . -common definition

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Depression as a means of protecting one’s self from fear or additional harm. –common definition

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Depression may be an act of punishment, revenge, or a win in a power-struggle .

Adler; Family Systems Therapy

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Depression may be a means of avoiding responsibility and placing others in one’s service. -Adler

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Depression may serve as a means of contrition for shame and wrong-doing (selfblame/shame; guilt). -Adler

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Depression as a socially acceptable alternative to expressing rage or the self-blame from “failing to do so”. –D. Peratsakis

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The Treatment Process Orientation to the Treatment Process 1. While many theories have been proposed regarding human nature and the treatment of problems that arise in the course of one’s lifetime, the main tasks of adulthood were first identified by Adler and expanded on by Dreikurs and Mosak (1987): Friendship, Occupation, Love, Self, and Spiritual. Maslow’s Hierarchy of Needs is also an excellent paradigm for examining the developmental transitions of life: Physiological, Safety, Belongingness, Love, Esteem, Selfactualization, and Self-transcendence. Existentialism and existential therapy posits four critical ‘angsts’ as drivers of our search for meaning which undoubtedly must be considered as part of our motivations, including death, freedom and its attendant responsibility, existential isolation, and finally meaninglessness.

These are important considerations although they are not fully systemic in nature. A broader, more intuitive perspective comes from life stage processes such as those highlighted in The Family Life Cycle model by McGoldrick and Carter. While not prescriptive, these are seen as ongoing social maturation issues placed against social and familial processes. They often overlap and require continual renegotiation of the status quo as an adaptation to natural change:  The Unattached Young Adult a. Accepting emotional and financial responsibility for self b. Differentiation of self in relation to family of origin c. Development of intimate peer relationships d. Establishment of self re work and financial independence  Couple/Partnership a. Commitment to new relationship b. Formation of marital or partner system c. Realignment of relationships with extended families and friends to include spouse  Families with Young Children a. Accepting new members into the system b. Adjusting marital/partner system to make space for child(ren) c. Joining in childrearing, financial, and household tasks d. Realignment of relationships with extended family to include parenting/grand-parenting roles  Families with Teens a. Increasing flexibility of family boundaries to include children's in-dependence and grandparent's frailties 10

b. Shifting of parent child relationships to permit adolescent to move in and out of system c. Refocus on midlife marital and career issues d. Beginning shift toward joint caring for older generation  Launching Children and Moving On a. Accepting a multitude of exits from and entries into the family system b. Renegotiation of marital system as a dyad b. Development of adult to adult relationships between grown children and their parents c. Realignment of relationships to include in-laws and grandchildren d. Dealing with disabilities and death of parents (grandparents)  Families in Later Life a. Accepting the shifting of generational roles b. Maintaining own and/or couple functioning and interests in face of physiological decline; exploration of new familial and social role options c. Support for a more central role of middle generation d. Making room in the system for the wisdom and experience of the elderly, supporting the older generation without over-functioning for them e. Dealing with loss of spouse, siblings, and other peers and preparation for own death. Life review and integration Similar processes of adaptation have been described for Divorced and Separated Families; Singlefamily Families; and Remarried, Reconstituted and Blended Families.

While the life cycle of a family describes the proper development of a family and its members it does not fully stress the underlying processes inherent in the social interactions. These are simple, yet exceedingly profound in their implications and include: Intimacy and Power and the drive for Meaningful Belonging or the process of improving oneself as an individual and as a member of the community.

2. People are extremely resourceful, resilient and self-correcting, typically requiring no professional help for the myriad of challenges and problems that arise in life. While counseling may provide immeasurable support, it is poorly understood as a process and medium for change. 

What constitutes normalcy, dysfunction and cure? To what extent are their definitions dependent upon custom, consensus or norms? When is treatment complete?

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Why do problems or symptoms take particular forms? Why do they strike certain individuals within a family or group and not others? Why do they express at certain times and not a month or a year earlier or later? Are symptoms intergenerational?

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Does the format, including frequency and length of sessions, duration of treatment, and variation in the schedule of meeting times, impact treatment outcome and, if so, how?

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Given the variety of theoretical formats is any more beneficial for certain conditions or syndromes? Since each can be effective, what common elements are essential? How has medication management and cultural trends affected overall interest in care?

3. Despite its commonplaceness counseling is prone to failure adding to the challenges that confront the clinician. To maximize the opportunity for success the therapist must be exceedingly well trained 

They must possess a good working contextual framework for understanding human behavior (theory)

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They must be knowledgeable in clinical syndromes, how they develop and the role that symptoms play within the individual’s sense of self and their relationship systems

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They must understand that although our prejudice is to view the individual as the loci of problems, that as social beings whose problems are by-products of our relationship systems, we must continually identify and call attention to the relational components that create and maintain them.

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They must be knowledgeable in matters related to mood and emotion, including anger, sadness, guilt, fear and hurt me and their corresponding manifestations such as violence, depression, shame, anxiety and revenge

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They must have mastery over simple as well as advanced psychotherapeutic techniques and understand the interplay between assessment, intervention, and change

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They must have insight into their own problems, values, and beliefs and how this benefits and detracts from the therapeutic milieu

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They must have insight into the stigmas and morays surrounding complex social conditions such as addiction, homosexuality, single-parenthood and extra-marital affairs

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They must understand how common misconceptions about cognitive ability or intelligence, even among treating professionals, can effect treatment and service options

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They must understand the major disability categories, including intellectual and developmental disabilities, mental health and substance use disorders for children as well as adults

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4. Having responsibility for the process, the therapist must understand their role in creating and controlling the opportunity for change. The Therapist 

is active and personable in session, seeing the primary task as one to educate the client(s) about the benefits and dangers of change, while providing them the opportunity to do so

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is responsible for the outcome of the treatment, including if it fails and insight and change do not occur

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controls therapy by their own behavior, by what they accept and do not accept

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gives directives, prescribes rituals and orders tasks within session and for homework

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manipulates mood; escalating and diffusing distress, joy, sadness and rage

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manipulates space and time and interrupts behavior cycles, sequences and other patterns

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challenges, blocks, re-directs and reframes communications

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sits within arm’s reach of the client, moves people, and re-partners members in collusions, alliances and triangles

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ascribes overt meaning to covert intent

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believes what is done or not done, not what is said

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regards behavior and emotion as purposive and moves to match behavior with belief, belief with behavior, and both with intent

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never rescues, allowing the client(s) to act due to duress

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never asks for permission, never accepts “secrets”, never parents (gets parents to parent)

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understands that how therapy ends is more important than how it begins

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understands that if one is not actively discouraging, one is passively encouraging

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understands that every referral is a forced referral

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understands reluctance (“nothing venture, nothing lost”) and that the therapeutic process is a dynamic struggle for change and sameness

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understands that clients have a right (at times an obligation) to leave, to not change, or to die

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understands that treatment structure is arbitrary and that one can and should redefine the duration, length, place and frequency of therapy

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crafts the session as an arena to practice new ways of thinking and behaving

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accepts that the treatment process is isomorphic and transforming and is willing to be subject to change and growth as well

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never (ever) works harder than the client(s)

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never (ever) moves ahead until the directive or work assignment is done; and

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never (ever) interrupts the opportunity for change

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Assessment and Problem Determination Contracting 

Therapy begins with “contracting”, a highly sophisticated process whereby agreement is drawn on ◦ what is the chief complaint (presenting problem or symptom) ◦ what is the desired goal (s) or outcome of treatment ◦ how is success to be understood or measured, in behavioral terms, and ◦ who is to participate and under what terms

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While labels and diagnoses may be useful as short-hand descriptors, they represent the beliefs of others and can readily cloud one’s initial impressions as to the current level of functioning and motivation for change. They are also individual and dissuade concentration on the relational component of the problem.

General Assessment Elements As social beings, we do not exist outside the context of others. While each of us may view ourselves as independent and separate, our personality and sense of self was forged by family, then friends and the society at-large. There is, therefore, a relational component to each of our actions, beliefs and behaviors that reaffirms our way of being in the world and shapes our adaptation to the continuous myriad of changes that constitute existence (Tasks of Adulthood; Family Life Cycle). Our success in continually changing while retaining important elements of our sameness is what defines the success of our adaptation and consequently whether problems will surface that warrant remedy. 

Presenting Problem and its History: Problems and symptoms are manifestations of an inherent dysfunction or rigid pattern of interacting and serve as a metaphor for the change that is needed. They are purposive as stop-gap measures that preserve a level of safety between the imperative to change and the desire to remain the same.

Exploring the history of the Presenting Problem is therefore critical to understanding the problematic sequence and pattern of behaviors that maintain it.

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Power o Influence and control within the relationship system o Determines style of communication and decision-making (how love, caring, anger, and so on is expressed and understood) o Defines level of trust for meeting and not meeting personal and group needs o Establishes rules for interdependence and independence, for closeness and distance between members, for who participates and joins 15

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Level of Functioning: Family, Group and Membership Dynamics (Who does what and why?) o One’s past (family of origin) creates one’s present and defines (myths) one’s perspective on relationships mode (pattern) of interaction ◦ Boundaries: who participates and how ◦ Roles: expectations of behavior within a given setting ◦ Rules: pattern of interactions or behavior ◦ Power: degree of influence o Change is a necessary condition of life. How its inherent developmental and lifecycle tasks are negotiated determines adjustment and whether dysfunction will arise.

Adjustments to both Family Life Cycle Changes as well as the Tasks of Adulthood are indicators of underlying satisfaction as well as anxieties o Conflict determines relational patterns: Alliances, Collusion, Triangulations, Cut-offs and Ghosts ◦ Dysfunctional patterns of behavior: - Boundary problems: excessive enmeshment or disengagement - Alignment problems: alliances (tag-team) or collusions (secret pacts) - Triangulations/Triangles: shift or rotate anxiety; participation may or may not be voluntary - Cut-offs and ghosts retain conflict and stress - Power problems: confusion or misuse of influence/control (hierarchy) o Role Assignments ◦ Roles or positions are assigned/assumed from the family of Origin, then added to in time

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They consist of patterns of behavior that is expected to be maintained; they acquire “moral character” and are relatively enduring

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Role behavior is reciprocal and interactive

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Roles and positions have “status”, thereby determining placement on the power-hierarchy (power), leading to alliances, collusions and triangulations

Motivation for Change: Flexibility and Resiliency Factors as well as an understanding of who wants the change and why and who prefers to retain the current manner of being. Desires for change as well as fear of change are important to evaluate.

Perspective on Symptom Development Different schools of thought have viewed that which individuals regard as unwanted, painful or in need of change differently. Invariably referred to as “symptoms”, “syndromes”, “dysfunctions”, or “problems”, these conditions have been viewed as responses to stress as well as the causes of distress.

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They are viewed as originating from within the individual and effecting the external social sphere as well as originating within the social relationship unit and the individual incurring or accepting ownership of the condition. Ironically, they have been viewed as adaptive as well as maladaptive mechanisms to change.

1. Behavior (and emotion) is purposive (Adler) 

The individual continually reaffirms their worldview and the manner in which they must interact with others

2. Problems are a product of social relationships (Adler) 

Individuals develop relationships with individuals that reaffirm their own affirmations

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There is a relational component to every normative and para-normative event

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Individuals and families undergo developmental change (stages)

3. Social interaction develops structure whose pattern of behavior and rules determine the effectiveness of functioning or the development of symptoms (Minuchin). Similarly, faulty adaption to change will concretize over time into dysfunctional structures (Haley).

Structural and Strategic Family Systems Therapies approach the same problem from opposing perspectives: Structural: Attempts to change the structure in order to change the system, in order to change the symptom.

Strategic: Attempts to change the symptom, in order to change the system, in order to change the structure.

4. Despite being unwanted, symptoms play an important role in the safety and well-being of the individual and their family or social system: ◦

◦ ◦ ◦ ◦ ◦ ◦

“When anxiety increases and remains chronic for a certain period, the organism develops tension, within itself or in the relationship system;the tension may result in physiological symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen) Symptoms are a defense against anxiety (Freud) Structural: change the system, in order to change the symptom (Minuchin) Strategic: change the symptom, in order to change the system (Haley/Madanes) Problems are faulty interactions among people during adaptation to life-cycle changes Symptoms are safe-guarding mechanisms (Adler) Treatment is sought not for change, but due to the failure to adequately adapt to change.

Symptom = “Adaptive response” (Haley) = “Solution” that is now the “Problem”.

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5. The presenting problem is both a representation of the problem and an index of progress 6. Timing: symptoms typically manifest during periods of duress (crisis or impasse) ◦

Normative (universal issue, even if not experienced): marriage, parenthood, families with adolescents, ‘empty nest’, partner/child death, aging

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Para-normative (common but not universal issue): divorce, re-marriage, trauma, war, severe illness

7. Removal of a symptom or problem can threaten the individual and the system: ◦ ◦ ◦ ◦

a worsening of the existing symptom or problem (rebound); the creation of a new symptom, symptom-bearer or problem (deflection); the development of physical or psychiatric illness (conversion); or the abandonment of treatment (escape)

8. Treatment failure or failure to change will be used to justify ◦ the severity of the symptom and the struggle ◦ the inadequacy of the member to change ◦ the inadequacy of the therapist to accomplish change Beware! For those with chronic, life-long symptom profiles, there can be great nobility in suffering and vindication in the ‘slaying’ of therapists!

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The Goal of the Therapy Process

Overall Goals of Treatment and of the Therapist While clients seek treatment for relief from the distress of their situation or symptom(s), the job of the therapist is to create a remedial process by which adjustment to change can occur.

To accomplish this, the therapist must A) continually create opportunities for the practice of new ways of behaving, interacting, feeling and thinking, while 2) continually challenging and redirecting the power and meaning of the situation or symptom(s). A) Interventions and Tactics The clinical session consists of giving directives (interventions) and permitting the client to accomplish the work prescribed. In this regard, therapy is nothing more than a long series of creating deliberate opportunities for change: 

Directives are very deliberate (often manipulative) tasks assigned to provide practice in new ways of thinking and behaving

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Task performance provides reassessment and, in turn, redirection

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Resistant to a task should be expected, but not tolerated

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Ordering a task or directive: ◦

Pretend that you are a Director (therapist) on a movie set: introduce the scene (task) and direct the actor’s behavior (directive) while filming the scene (allowing work to be done);

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Simple introductions, include: “Let’s try something…”; Some people find this helpful…” ; “Let’s do an experiment”; “I’m going to have you do something that may be uncomfortable… ”

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Once a task has been assigned the therapist's job is to continually redirect straying or delay back to task, while working on their own anxiety, impatience and need to rescue. If the task cannot be completed, the therapist should explore a) what would happen had the task been accomplished and b) what was going on for the person while struggling with the task

Contracting for clinical work is the first and foremost opportunity to engage in discovering the potency of symptoms and the possible consequences to their change. Since change is difficult and bares its own consequent outcomes, the role of the therapist is to set the tone as educational and as an opportunity to explore the importance of the desire for change. The fight for clarity can only occur when the individual can effectively argue for the need of the change, the concerns and 19

downturns, as well as the benefits, and the extent of work that would be needed to effect the desired change. Rarely, can this be deduced from the onset; rather, by experimentation and by gaining insight into the purpose of the symptom and the dysfunctional interactional patterns that reaffirm it can one begin to properly assess both the scope of the needed change and the level of interest in accomplishing it. Contracting is an exceedingly complex and sophisticated process, requiring significant groundwork and preparation. Contrary to the common belief that therapy begins once the problem for seeking counseling is clarified, it is the very act of clarification, that is the true onset of therapy: ◦

Why has the client come in seeking treatment now? Why not a month ago or two?

What has changed to create the urgency to now?

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What is it about the symptom that is so objectionable? How is it that it does not occur all the time or in all circumstances or with all people? Confront perceptions of reality.

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Exploring who is affected by the symptom helps identify the purpose of the symptom and who helps maintain it; consequently, it identifies those that should participate in treatment, in person or by representation.

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The symptom must have a relational component; identify who maintains the symptom’s occurrence to plan on a reliable treatment strategy.

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Some symptoms are more toxic than others. Symptoms in children, for example, are typically more acceptable than illness in the ‘marital relationship’. In some families, physical illness or depression are acceptable expressions, whereas a display of anger is not.

◦

Consider who has the power to return the member(s) to treatment.

◦

Goals for therapy must have concrete, behavioral components that are measurable and that can be clearly delineated for evaluating progress and risk. How would one know the symptom is being alleviated or has been resolved? How does one measure progress toward attaining the desired relief? What is reasonable with regard to how long it may take to achieve the goal, how achievable it is and the amount of work that may be involved? Every goal has a work measure attached to it; mere symptom relief, while an acceptable goal, will not resolve the purpose of the symptom and the change that must be reconciled. Understanding the amount of work that must be employed to alleviate pain is an important ingredient in deterring the importance of attaining that goal.

20

B) Challenging the Symptom and the World View. In essence, “If this was not the problem what, or who, would it be?”: 1. Symptoms are unsuccessful attempts to balance or alleviate stress and occur as a result of adjustment to change by the individual, family or group. As such, symptoms are homeostatic mechanisms that become (presenting) problems due to their failure to resolve the problem or change they initially sought to remedy. Presenting Problems are ‘metaphoric communications’ for dysfunction. As such, the particular nature, form or venue of the dysfunction has meaning and is purposive. Recognizing what the Presenting Problem “accomplishes”, what it fosters or prevents, alters or magnifies, provides great insight into its cause and remedy.

2. The History of the Presenting Problem, or those sets of facts surrounding its origin and occurrence, should, likewise, be examined for clues as to the purpose of the dysfunctional symptom or interaction profile. By tracing the history surrounding displays of the dysfunction, one determines the interactional pattern that maintains and sustains it. In this regard, the history of the Presenting Problem denotes its dysfunctional interactional pattern; that which maintains the Presenting Problem. If, then, the Presenting Problem is a metaphoric communication for the dysfunction, the pattern of behaviors and interaction with others that re-affirms the dysfunction holds purpose and meaning as well. Meaning refers to the manner in which one views themselves in relation to others and the manner in which they operate in the world, their roles, their self-concept or personal identity. a. As behaviors and goals have purpose, so do the patterns of behaviors and interactions that support them. Dysfunctional interaction patterns have purpose. b. The Presenting Problem and its History, each purposive, indicate the Life Tasks that must be (re-)negotiated and reconciled. In this manner, Presenting Problems and their patterns can be said to indicate those elements of social relations that must be redefined or restructured. Change the symptom and you change the system; change the system, and you change the symptom. c. Life Tasks are those necessary milestones that must be negotiated in order to further one’s maturity as a social being and expand one’s interrelatedness with others.

3. Symptoms are expressions of how one sees the world and their place in it. In this regard they are “metaphors” about one’s relationship to others, how to belong socially and how to control and exert power over circumstances with others. Freud considered them as a defense against anxiety, Adler as safe-guarding mechanisms and Haley referred to them as adaptive responses. They are both a consequence of the failure to respond to change, and a means of adjusting to and reconciling change. Given this one can see how a poor solution to necessary change has, in fact, become the problem itself or its camouflage. The solution has become the problem.

21

4. As social beings, there will always be a relational component to the symptom. It is, therefore, important to investigate and understand who else is involved and how. Individual, personal problems are always social and always bound in issues of power. Revenge, the desire to belong (acceptance) and placing others in one’s service (control), for example, are common underpinnings of social interactions.

Locating and understanding the source(s) of power within a relationship and the symptoms that express their dysfunctional interactions is an important goal of therapy. By reframing the inherent power component one obtains great insight into the purpose and target of the symptom.

For example: a. Depression: “I’m helpless so you will serve me!” b. Madness: “You can’t control me!” c. Rage: “Don’t get close to me!”; “I will control you!” d. Suicide: “You will suffer!” e. Procrastination/Laziness: “I will defeat you!” f.

Self-loathing: “Let me shame me before you do!”

g. Criminal acts: “I’m better than you!”; “Now you know what it feels like to be hurt!”

5. Perhaps the most fundamental goal of symptom management, however, is the alleviation or amelioration of the symptom. However, since the symptom serves a purpose, there is a direct consequence, sometimes more terrible, to its change. Understand its purpose, to anticipate the consequences of change.

6. To accomplish this, the therapist must continually challenge and redirect the power of the symptom and begin to re-define its meaning. Relabeling depression as anger or suicidality as revenge can have powerful consequences, materially altering the individual’s experience of the event and their perspective of themselves and others. In addition, it can deftly modify the interaction between players and the power plays that develop in response.

7. Psychotherapy is no substitute for medication management or medical intervention; it should be employed only for the treatment of psychological and relational problems. It is important to note, however, that physical, biochemical and medical ailments or problems can have a psychological component as well as a relational concern. Understanding the appropriateness of clinical intervention is a critical precursor to any agreement to contract for symptom management through the counseling process.

22

8. Since treatment is sought not for change, but due to the failure to adequately adapt to change, premature removal of the symptom can threaten the individual and the system. Moreover, given that the symptom helps preserve safety for the individual or system, premature attempts to remove or block the symptom would likely result in undesirable consequences, including a. a worsening of the existing symptom or problem (rebound); b. the creation of a new symptom, symptom-bearer or problem (deflection); c. the development of physical or psychiatric illness (conversion); or d. the abandonment of treatment (escape).

The resulting failure will be used as a justification as to the severity of the symptom, as the inadequacy of the member to change, or the inadequacy of the therapist to accomplish change.

For those with chronic and life-time symptom profiles, there can be great nobility in long-term suffering and vindication in the ‘slaying’ of therapists.

9. Change, in thought or deed, must be practiced in a safe environment. Few assignments are safe to practice outside of the treatment session, unless the potential areas for failure and risk are adequately identified and their likelihood predicted. a. Track the power component; b. Separate people who are sitting together; c. Block interruptions or inappropriate requests for confirmation, to control or to censor; d. Discourage use of one member as a repository for another’s memories, feelings or thoughts; e. Approve descriptions of competence. Encourage members to reward competence in session; f.

Be generous with positive statements

g. Support age-appropriate independence; h. Tell one to help another to change; i.

Examine personal and family myths;

j.

Examine personal and family roles and tasks;

k. Encourage the use of humor and candor around human foibles; 23

l.

Turn members into co-therapists;

m. Avoid individual (non-relational) interpretations; n. If one controls, confront another for encouraging their dominance; o. Approach relational conflicts through sequential interpretations (same problem is highlighted through different points of view); p. Manipulate and use space, to connect and disconnect, to show closeness or distance; q. Use props and furniture (concrete reminders) to illustrate relational components; r.

Give anecdotes and personal experience. Normalize symptoms as social problems;

s. Bring situations to immediacy/enact them/restrict discussion of past events; t.

Emphasis differences/emphasis similarities;

u. Direct individuals to speak to each other; v. Accommodate to the individual or family’s style, tempo, language and affective range; w. Broaden narrow problems, narrow broad problems; x. Analyze sources of support and stress; y. Track the sequence of interactive behavior (“…and then what happens?”) until the loop comes to a close.

10. As the sequence of behavior maintains the dysfunctional interaction, its interruption will, necessarily, alter the symptom, presenting a direct challenge to its rigidity and inevitability. Ways to interrupt the sequence include reversing the order of the steps (having the symptom come first), removing a step or adding a new one, removing a member of the loop or adding a new one, and practicing the sequence at times and places that are not customary (controlling the symptomatic pattern). Behavior rehearsal or demonstrating the sequence in session is a subtle yet profound means of identifying the steps of the sequence while creating an opportunity to experience and exercising control over the symptom.

Always Challenge and Redirect the Power & Meaning of a Symptom: a) Create a new symptom. b) Move to a more manageable symptom 24

c) I.P. another family member. (create a new symptom-bearer) d) I.P. a relationship e) Reframe or re-label the meaning of the symptom. f) Change the intensity of the symptom/pattern. (Inflate/Deflate) g) Change the frequency or rate of the symptom/pattern h) Change the duration of the symptom/pattern i)

Change the time (hour/time of day/week/month/year) of the symptom or pattern.

j)

Change the location (in the world or body) of the symptom/pattern

k) Change some quality of the symptom or pattern. l)

Perform the symptom without the pattern; short-circuiting.

m) Perform the pattern without the symptom. n) Change the sequence of the elements in the pattern o) Interrupt or otherwise prevent the pattern from occurring. p) Add (at least) one new element to the pattern. q) Break up any previously whole element into smaller elements r) Link the symptoms or pattern to another pattern or goal s) Point to disparities Note: of

Minuchin

and

Fishman;

E

–

1.

A-D courtesy O’Hanlon, 1982.

courtesy of

Adler;

F-S

2.

Pattern or element may represent a concrete behavior, emotion, or individual family member.

courtesy of

25

Mosak’s Rules of Therapy 1.

2.

3.

4.

5.

6.

7.

8.

You will survive!

Your patient will probably survive, too!

Know your patient No tactic is a panacea Keep moving, stay in motion You must know your theory Never play the patient’s game Develop your own style

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ADLERIAN ACTION GLOSSARY I first met Harold Mosak at the North American Society of Adlerian Psychology in New York City, as part of a lecture series set up between 1980 and 1983 by Robert Sherman. The meetings also included such notables as Kurt Adler, son of Alfred Adler, Bernard H. Shulman and Lawrence Zuckerman.

Mosak’s lessons were particularly instructive in helping to gain insight into the Adlerian perspective on human nature, much of which can be illustrated through Action Phrases used interpret the hidden meaning behind common expressions.

Harry A. Olson compiled the majority of those listed below, most attributable to Harold Mosak and Leo Gold and often highlighted in Sherman’s own lectures.

Intoduction “Adlerians consider all behavior as movement through life, that is, purposive activity in the service of the fictional life goal. One's behavior is also the answer one makes to the questions and tasks posed by life, based on one's biases, one's accurate and mistaken notions. Since all life is an active process, then it follows that in order to understand behavior most fully, it must be examined in action terms. In other words, we must understand not what a person is, but what he is doing. The best way to communicate this concept is to make it a point to use verbs, ie. action language, when discussing or describing behavior as opposed to noun or adjectival terms or variants of the verb, to be.” -- Harry A. Olsen Understanding what an individual may be actually meant, despite what they said, can provide great insight as to their intent: 

"I AM MOODY": I can do anything I want, and use feelings to discourage others from dealing with me. I will keep you guessing.



"I AM STUBBORN": I plant my feet and dare the world to move me. (Mosak)



"I AM AN INDIVIDUAL": No one can make (should make) me do what I don't want to do.



"I AM SENSITIVE": ("I hurt") Mark of power. Has built-in accusation, "I cry and it's your fault!"

"Get off my back"-typical of pleasers when they get criticised or don't get continual affirmation.



"l AM TIMID": I force attention upon myself. (Mosak) (If at a party, everyone is dancing but you, whom do you think they will notice?)



"l AM SHY" : I force attention upon myself. (Mosak)



"I WORRY": (a) I control others by trying to make them feel guilty for causing me pain. (b) I stop action and thus avoid resolving the problem.



"I FEEL GUILTY": I will continue to misbehave, all the while trying to convince the world that I am good, with good intentions, but I have this area of my life that I can't control. (McKelvie) 27



"I CAN'T" : I won't. (Sherman)



"I'LL TRY": But I don’t expect to succeed. I won't. (Mosak; Sherman)



“I WISH I COULD”: I don’t want to and don’t want you mad at me for saying ‘No’ (Peratsakis)



"YES, BUT" : I won't.



"I ARGUE": - (Harangue, Not debate) I feel superior by putting others down. I must compete.



"WHO AMI?": I am struggling to conform the world to my personal desires (to ask "who am I?" as an attempt to find identity is mistaken. He has an identity: Lifestyle).



"I HAVE A TEMPER": (a) I need to intimidate to get my way. (b) When 1am right and you are wrong, righteous indignation. (Gold)



"I CAN'T FORGIVE": I am striving to be holier than God. God forgives. (Moral superiority) (Gold) Excuse to remain distant.



"I LIKE CAUSES": I am looking for perfection. At least world could be better.



"I'M AMBIVALENT" or "IN CONFLICT OVER": I am unwilling to take action to solve my problems. (One step forward, one step backward-won't move off center.) (A. Adler)



"I'M CONFUSED" : "Don't pin me down" (Mosak)



"IT'S A HABIT": "You won't get me to change that! (Mosak)



"I'M A REBEL": "I can't afford to submit to life. I must be in control of me. (Mosak)



"I CAN'TKEEP FRIENDS": 1wish to dominate others. (Mosak)



"I HAVE TROUBLE WITH MATH": I question my ability to stand on my own to solve problems or be independent. (People good in math usually are independent-minded.) (Mosak)



"I HAVE TROUBLE WITH SPELLING": I tend to be a rebel (Spelling is a high conformity subject.) (Mosak)



"I'M A PROCRASTINATOR" : (Artificial cliff-hanger) Look how great I must be to pull it off at the last minute. (Mosak). “I can control or punish others” (Peratsakis)



"I'M AN ALCOHOLIC": I (a) control my world through my drinking, and (b) set up artificial supports to see me thru life, and (c) con others into my service through the tyranny of my sickness. (Mosak) 28



“I TAKE COPIOUS NOTES IN CLASS": I intend to forget what I hear. (Gold)



"I DAYDREAM A LOT": I can't get what I want in reality. (In fantasy I can set it up my way and no one can interfere with it or my greatness.) (Especially conquering hero) (Mosak)



"I'M A 'JOINER' ": I must find my place (because I don't feel I have one) or I must continually prove to myself that I'm acceptable. (Mosak)



REGRESSION: "I want to go back to old ways"-has only not yet integrated new learnings. (Gold)



UNCONSCIOUS: That which I don't want to remember, or which is irrelevant at this time.



OBESITY not organically caused: Purpose: Avoid questions of intimacy, especially with opposite sex. Also provides "padding" between self and others. Provides a reason for complaining that others do not pay attention to me. (Mosak)



CYNICISM: "Life is at fault, not me."



EMOTIONAL BLIND SPOTS: "If I don't look at it, it will go away." (Mosak)



RESISTANCE "You and I have different goals and I won’t compromise mine." (Mosak); “I am scared and too frightened to go forward” (Peratsakis)



RETREAT: "Nothing ventured, nothing lost." (Mosak)



CONTRITION AND SELF-DISPARAGEMENT: By blaming myself, I (a) forestall punishment and (b) fish for compliments.



SUFFERING (As defense): (The louder you suffer the more you are playing to the grandstand.) (a) Since I feel bad, I'm entitled to make demands (b) Amount of my suffering proves my nobility (c) You'll be sorry! (d) I have a right to my own way; look how I suffer when I don't get it.



POOR PENMANSHIP: I secretly rebel. I outwardly appear to cooperate, but inwardly I don't go along. (Mosak)



CATATONIC: I fear the destructive potential of my rage. If I move, the world will tumble down.

I am the most powerful person.



RAGE: I must control (will to power) (Mosak)



CRYING: (when not in sufficient physical pain) It's your (somebody else's) fault. (Mosak)



INFIDELITY: an act of revenge; “Take that!” (Peratsakis)



LYING/THEFT: an act of cleverness aimed to punish; I’m smarter than you! (Peratsakis) 29



SUICIDE THREAT (not true hopelessness): You will suffer for hurting me! (Peratsakis)



INSANITY: I’m not responsible for my conduct (Peratsakis)



DEPRESSION (not physiogenic in origin): Silent temper tantrum (Peratsakis)



SAYS ONE THING BUT DOES ANOTHER/WORDS AND ACTIONS DONT MATCH: Believe what one does and doesn’t do; that shows true intent (Peratsakis)

Differential Diagnoses While Harold Mosak contributed much to the field of Adlerian psychotherapy, he often cited two simple techniques for differentiating the origin of presenting complaints as psychological or non-psychological.

One is the “Miracle Question”, first created by Alfred Adler and the second is a subtraction series for determining a neurological concern, both captured on YouTube, in 2009: https://www.youtube.com/watch?v=aA_HiybvUY4 1.

“THE” Question (first created by Adler): “If I was to use my magic wand and it got rid of this symptom and it never return what in your life would be different?”

If the person states that the pain they are experiencing would no longer hurt, it may be a signal that the condition it may not be psychological. If they sate some other goal or circumstance that they might then achieve, there is a good chance the condition is psychological.

2. Serial 7 Subtraction Test “I would like you to start from a 100 and take 7 away from that; then take 7 away from that number, all the way down…”

It should be given, orally, three (3) separate times. Four Types of mistaken responses are typical:  Type I Error: 100, 93, 85……….-> The person misses by one (over or under); common “check-book” error often as a result of test anxiety or experiencing an anxiety disorder. 

Type II Error: 100, 93, 86, 76, 66, 56…..-> The person is perseverating, common in some schizophrenias and neurological disorders

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

Type III Error: 100, 93, 86, 89…….-> The person, especially if they repeat such an error run, should be referred to a neurologist



Type IV Error: 100, 82, 59, 0….-> The person should immediately be referred for neurological testing.

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Clinical Syndromes and Topics of Interest

1. Depression Highlights key issues and treatment options General Causes and Treatments of Depression Depression is a biochemical, social and psychological syndrome. In broad terms, the main cause may be  biochemical in nature 

develop as a natural response to disappointment , discouragement ,or loss



develop as an adaptive response to trauma, such as severe loss or violence, or as a means of coping during early life to conditions of familial strife or social deprivation

There are several forms of normative and para-normative depressive disorders noted in the literature, which is a descriptive categorization with regards to symptom expression, duration and so on and does not necessarily denote any distinction in the clinical process. As a general rule, being “sad” is a normative response, whereas being “depressed” is often denoted as a clinical syndrome. The National Institute of Mental Health highlights the following areas: Major depression - severe symptoms that interfere with the ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes.

Persistent depressive disorder - depressed mood that lasts for at least 2 years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for 2 years.

Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations).

Postpartum depression, many women experience after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming.

Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer.

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Premenstrual Dysphoric Disorder, or PMDD, is a depression that may affect women during the second half of their menstrual cycles.

Complicated Bereavement, prolonged Situational Depression/Adjustment disorder initially triggered by a stressful or life-changing event, such as job loss, the death of a loved one or trauma.

Bipolar disorder or manic-depressive illness, is not as common as major depression or persistent depressive disorder. It is characterized by cycling mood changes, such as extreme highs (e.g., mania) and extreme lows (e.g., depression).

General Signs of Depression Signs and symptoms include: ◦

Persistent sad, anxious, or "empty" feelings

◦

Feelings of hopelessness or pessimism

◦

Feelings of guilt, worthlessness, or helplessness

◦

Irritability, restlessness

◦

Loss of interest in activities or hobbies once pleasurable, including sex

◦

Fatigue and decreased energy

◦

Difficulty concentrating, remembering details, and making decisions

◦

Insomnia, early-morning wakefulness, or excessive sleeping

◦

Overeating, or appetite loss

◦

Thoughts of suicide, suicide attempts

◦

Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

◦

Treating Normative Depression

◦

Pervasive sadness (depression) is a natural reaction to severe loss, hurt and grief.

33

General course of treatment/Grief counseling In general, depression without therapy should be contra-indicated; more specifically, the standing Rule of Thumb is Mild to Moderate Depression: Therapy Moderate to Severe Depression: Therapy + Medication Treatment ingredients may include: 

Medication (may/may not be indicated)



Working through and reconciling Loss and Trauma



Working through issues related to the expression or suppression of Anger



Increasing meaningful activity and reconnecting to others and goals



Rebuilding and empowering the individual and their sense of self

Reasons for Suicide: The main reason for Suicide is Depression; #1 reason for Depression is Loss Loss has many forms 

Loss of a loved one



Loss of a valued possession (house, car, heirloom, etc)



Loss of prestige, job, status or lifestyle



Loss of a familiar way of being



Loss of a body part, function or ability



Loss of a goal

Suicide may also occur as a response to extreme hopelessness and futility in the face of overwhelming pain or may be an act of revenge, targeted to punish another in an enduring fashion (see Depression and Revenge).

34

Common Models and Stages of Loss ◦

Loss, Grief, Loneliness, Adjustment

◦

Denial; Anger; Bargaining; Acceptance; Worrying and Guilt (“Death” Model)

◦

Initial Awareness; Strategies to Overcome Loss; Full Awareness and Impact of Loss; Empowering of the Self; Transcending the Self

Tactics for Working through Complications in Treating Depression 1. Assess risk (acuity) of suicide and develop a plan; alcohol and drugs increase impulsivity 2. Address underlying feelings of Guilt/Remorse, Anger/Rage, and Shame 3. Clarify “fact” from “fiction” (guilt vs guilt feelings; pity vs pity-pot) 4. Negotiate “amends”, an enormously powerful remedy for wrongful acts and thoughts 5. Use imagery for residual pain “confession”)

(pain management; “Ghost” and “Revenge” techniques;

6. “Fill the hole” that loss has left: letters; foundation; new relationships; meaningful activity; 7. Reconnect to others, activities and daily chores; address long-standing cut-offs 8. Postpone major decisions and attend to proper health (exercise, rest, nutrition, stress, etc) 9. Confront distortions in self-image and social competency ; use Image Enrichment (Ego Building) 10. Review benefits and drawbacks of Medication Management for anxiety or depression as an interim or long-term support

Complicated Syndromes Associated with Depression Depression may accompany, precede or cause several problem syndromes, each of which must be regarded within their own right: ◦

Suicide and Self-Injurious Behavior

◦

Eating Disorders

◦

Major illnesses, including HIV/AIDS, heart disease, stroke, cancer, diabetes, and Parkinson's 35

◦

Post-partum depression

◦

Depression in Childhood due to parent’s depression or illness, divorce, or parental abuse divorce

◦

Alcohol or Drug Dependence

◦

Depressive Style of Life (“Victims”)

◦

Anxiety Disorders, including PTSD, OCD, Phobias and Panic Attacks

◦

Trauma*

◦

Life-long Depressives: adult victims of prolonged childhood trauma, including neglect, abuse or severe discouragement*

* Highlighted, below, due to their unique treatment considerations

From “How To Process Grief….” ; Health and Human Services publication Tip #48: 1. Recognize when a client has significant unresolved grief. People with repressed grief are often irritable, controlling, and opinionated; have apparent feelings on the surface that are denied or displaced by the individual; show a lot of perfectionism and are judgmental toward others; have difficulty accepting feedback (positive or negative) from others; are obsessive in thought and compulsive in their behavior; and lack spontaneity in life.

2. Educate about grief. In much the same way that counselors help people with substance use disorders understand their illness through psychoeducation, counselors can be immensely helpful to people with unresolved grief by helping them understand that their behavior and unhappiness come from feelings that can be changed.

3. Explore the client's experience with grief. People with unresolved grief often see their emotions as their enemy. It may be that their grief has, in the past, poured out inappropriately or in overwhelming volume. They may feel that to experience feelings that have been repressed will cause them to lose control or “fall apart.” They may also feel deeply ashamed of exposing powerful feelings. It is useful to have this information to understand a client's resistance to exploring grief..

4. Create safety for expressing feelings. Feelings that have been unsafe in the past have to find a safe place for expression. This not only means a safe environment, such as the counselor's office, but also safety in knowing the emotion can be controlled as it emerges. It is important to learn where the client has felt safe to expose disavowed feelings in the past and how that environment 36

can be recreated today. In addition, the client needs to know that he or she can stop the emotion if it becomes overwhelming. It is helpful for the counselor to give the client specific permission to stop anytime he or she feels the emotions are becoming too overwhelming.

5. Facilitate grieving. Experiencing the emotions that have been repressed is usually accompanied by telling the story that contains the emotions. This process is grieving. Counselors need to pay close attention to how the client is responding to experiencing emotions. Some clients, especially those with traumatic histories (physical, psychological, and relational trauma) will re-experience the trauma as they have the feelings about it. The counselor needs to ask the client how he or she is experiencing the work. In addition, the counselor should encourage the client to tell the counselor if it feels as though they are moving too quickly toward something too painful to experience.

6. Get closure on events that precipitated the grief. This involves saying goodbye—letting go of or finishing unfinished business and forgiving self and/or others. Grieving is a process that may take substantial time to finish. It is often done in small doses over time. In short-term treatment settings, the counselor may only be able to help the client initiate the process.

Special Consideration: Trauma A broad spectrum of traumatic events can lead to complications in mood, such as anxiety, depression, rage, shame, and guilt or in one’s sense of self and being in the world Accidents, Natural Disaster, Illness, Injury         

Accidental Physical Injury Fire Industrial Accident Work Accident Invasive Medical Procedures Injury or Illness Motor Vehicle Accident Natural Disaster Property Loss

Threat or Harm to Others     

Death of a Loved One Injury or Illness of a Loved One Threat to a Loved One Witness to Violence Suicide of a loved one 37

Threat or Harm to Self  Adult Sexual Assault  Captivity  Childhood Sexual Abuse  Combat & Military Sexual Trauma  Communal Rejection (Scapegoating, Shunning)  Cults and Entrapment  Domestic Violence  Physical Assault  Rape  Robbery  Sexual Harassment  Threat of Physical Violence  Torture  Victim of Crime  Victim of Violence  Witnessing Traumatic Event Treating Victims of Trauma (modified from Tori DeAngelis) 

Prolonged-exposure therapy, developed for use in PTSD, a therapist guides the client to recall traumatic memories in a controlled fashion, eventually regaining mastery of thoughts and feelings around the incident.



Cognitive-processing therapy, a form of cognitive behavioral therapy, or CBT, developed to treat rape victims and later applied to PTSD. This treatment includes an exposure component but places greater emphasis on cognitive strategies to help people alter erroneous thinking that has emerged because of the event.



Stress-inoculation training, another form of CBT, where practitioners teach clients techniques to manage and reduce anxiety, such as breathing, muscle relaxation and positive self-talk.



Other forms of cognitive therapy, including cognitive restructuring and cognitive therapy.



Eye-movement desensitization and reprocessing, or EMDR, where the therapist guides clients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events.

38



Medications, specifically selective serotonin reuptake inhibitors. Two in particularparoxetine (Paxil) and sertaline (Zoloft)-have been approved by the Food and Drug Administration for use in PTSD.



Systems Therapy, for its perspective on relational issues, including power, guilt, rage and shame: 

Anger is critical to empowerment and can help ameliorate feelings of victimization and betrayal



Treatment must include separating Guilt from Guilt feelings and Depression from Shame



Forgiveness and making amends are critical element in the healing process: asking/giving forgiveness; punishing/endure the victim’s hurt and anger; acts of contrition; healing the trauma and transcending the trauma; developing trust and finding a new way to be in the world with others.



Trauma is prone to developing “ghosts”; restless “hauntings” and residual feelings and fears



“If you could talk about it…..what’s the worst thing he would say? And then what? And then what would happen?”

Special Consideration: Life-long, Depressive Neurosis Depressive Lifestyle: Prolonged and profound trauma in childhood often leads to the development of a personality style and method of social interaction characterized by feelings of worthlessness and guilt and the belief that one is inferior to others and a “victim” of life’s hardships. When this occurs, the behavior becomes intransigent and profoundly shapes one’s view of the self, of others, and of the world at-large. As the inability to control what occurs to them is a driving theme, the individuals develops and comes to rely on passivity and the lack of acceptance of responsibility and power as a means of coping. The ensuing depression, is an immensely powerful and demanding means of placing others in one’s service and, thereby, controlling their actions and moving to a position of superior influence.

Adler referred to this disposition as the “Depressive Life-style” and provided an extremely unique set of perspectives on this syndrome: • Depression is a Power issue; it controls others and puts them in one’s service • Hopelessness is the “noble struggle of good intention, unsullied by risk” (Peratsakis) 39

• In many families the rule is that you cannot express anger, although sadness and illness are acceptable • Depression is a substitute (denial) for anger and a principle cause for the development of a depressive • “Depressives” develop a continual cycle between feelings of guilt and depression • Guilt and Shame are alibis for refusing to change • Others feel manipulated and angry, then guilty for expecting too much of one so depressed • “Depressives” avoid responsibility for life, while ensuring that their own needs are continually met • Efforts to lift the person from their depression are met with heightened symptoms and veiled threats • The role is characterized by a poor self-image, good intentions and feelings of inadequacy (social inferiority)

2. Shame, Betrayal and Revenge Shame results from comparison of the self's action with the self's standards, as derived from others.

“Ghosts” are the continual reply of negative messages (“voices”) used to reaffirm the feelings of worthlessness. Self-harm as a form of retribution or penance.

Draft Notes on Shame 

Feelings of Inadequacy: Adler



Mild forms include Shyness and Embarrassment



Guilt: “I’ve done something wrong”; Shame: “I am somehow wrong”



It affects our identity (our sense of who we are), our sense of vulnerability and safety, our intimacy with others, and our self-esteem. Shame can affect self-esteem in markedly different ways – we may feel either better or worse than others. o

are exposed

o

are a fraud 40



o

have no voice

o

are powerless

o

have to cover up

o

want to disappear

o

are foolish

o

are too needy

o

are too vulnerable

Examples of how children are shamed (Adapted from Jane Middleton-Moz "Shame And Guilt: Masters of Disguise" Health Communications 1990): o

When the parent or caretaker indicates that a child is not wanted.

o

When a child is humiliated publicly.

o

When disapproval is aimed towards the child's entire being rather than the specific behavior.

o

When a child must hide part of his being in order to be accepted, for example, his needs, joys, sorrows, hostilities, fears, mistakes, successes.

o

When a child's emotional or physical boundaries are violated as occurs in overt or covert abuse.

o

When children feel that they have no privacy, e.g. parents who go through their personal belongings or diaries.

o

When events or gifts that are important to the child are treated with indifference.

o

When a child feels that the parents are somehow different from other powerful figures in their world, e.g. immigrant parents, racial minority, poverty.

o

When a child feels that a parent or member of the family is somehow flawed compared to other adult figures in his or her world, e.g. where a family member is alcoholic or has a physical or mental disability, and that difference is never discussed or the child can't express feelings about the impact of that difference.

o

When trust in important adult figures is damaged or destroyed through inconsistency or neglect.

41

o

When a child grows up with adults who are ashamed and feel powerless in the world.

o

When a child is made to feel flawed, worthless, unlovable, or unwanted in the broader world or community, e.g. learning disabilities, inappropriate dress compared with peers.

o

When a child is consistently blamed for the actions or emotional state of the parent or the child cannot live up to the unrealistic expectations of the parent.

o

When parents use silent disgust as a way of disciplining, children feel that their entire being is bad and there is no opportunity to repair the relationship.

1. Guilt or remorse = you have broken a rule or standard or done something wrong; The behavior or action is bad or wrong. Self-harm as a form of retribution or penance.

2. Betrayal is the breaking of one’s trust for another. Harm by another, resulting in the desire for retribution, for revenge.

Addiction (In DRAFT) This is an extremely broad area of concern with multiple legal, ethical, biomedical and sociocultural components.

Counseling and psychotherapy are critical consideration for treatment and recovery from alcohol and drug use dependence. In this regard traditional substance use therapy models where often rigid and prescriptive. Newer evidence suggests that meeting the client where they are and organizing a treatment plan unique to that individual is a superior approach to treatment (SAMHSA; http://www.samhsa.gov/treatment/substance-use-disorders) Other important consideration of a more general nature:            

Addiction is very complex, but treatable. It affects brain and body function, emotion and behavior.

Treatment works best when tailored to the individual, same as with mental health problems.

People need to have quick access to treatment.

Effective treatment addresses all of the patient’s needs, not just his or her drug use.

Staying in treatment long enough is critical.

Counseling and other behavioral therapies are the most commonly used forms of treatment.

Medications are often an important part of treatment, especially when combined with behavioral therapies.

Treatment plans must be reviewed often and modified to fit the patient’s changing needs.

Treatment should address other possible mental disorders.

Medically assisted detoxification is only the first stage of treatment.

Treatment doesn't need to be voluntary to be effective.

Drug use during treatment must be monitored continuously.

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 

Treatment programs should test patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as teach them about steps they can take to reduce their risk of these illnesses.

How is drug addiction treated?

Successful treatment has several steps:      

detoxification (the process by which the body rids itself of a drug) behavioral counseling medication (for opioid, tobacco, or alcohol addiction) evaluation and treatment for co-occurring mental health issues such as depression and anxiety long-term follow-up to prevent relapse A range of care with a tailored treatment program and follow-up options can be crucial to success.

Treatment should include both medical and mental health services as needed. Follow-up care may include community- or family-based recovery support systems.

How are medications used in drug addiction treatment?

Medications can be used to manage withdrawal symptoms, prevent relapse, and treat co-occurring conditions.

Withdrawal. Medications help suppress withdrawal symptoms during detoxification. Detoxification is not in itself "treatment," but only the first step in the process. Patients who do not receive any further treatment after detoxification usually resume their drug use. One study of treatment facilities found that medications were used in almost 80 percent of detoxifications (SAMHSA, 2014).

Relapse prevention. Patients can use medications to help re-establish normal brain function and decrease cravings. Medications are available for treatment of opioid (heroin, prescription pain relievers), tobacco (nicotine), and alcohol addiction. Scientists are developing other medications to treat stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. People who use more than one drug, which is very common, need treatment for all of the substances they use.

Opioids: Methadone (Dolophine®, Methadose®), buprenorphine (Suboxone®, Subutex®, Probuphine®), and naltrexone (Vivitrol®) are used to treat opioid addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings.

Naltrexone blocks the effects of opioids at their receptor sites in the brain and should be used only in patients who have already been detoxified. All medications help patients reduce drug seeking and related criminal behavior and help them become more open to behavioral treatments.

Tobacco: Nicotine replacement therapies have several forms, including the patch, spray, gum, and lozenges. These products are available over the counter. The U.S. Food and Drug Administration (FDA) has approved two prescription medications for nicotine addiction: bupropion (Zyban®) and varenicline (Chantix®). They work differently in the brain, but both help prevent relapse in people trying to quit. The medications are more effective when combined with behavioral treatments, such as group and individual therapy as well as telephone quitlines.

43

Alcohol: Three medications have been FDA-approved for treating alcohol addiction and a fourth, topiramate, has shown promise in clinical trials (large-scale studies with people). The three approved medications are as follows: Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some patients. Genetic differences may affect how well the drug works in certain patients.

Acamprosate (Campral®) may reduce symptoms of long-lasting withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (generally feeling unwell or unhappy). It may be more effective in patients with severe addiction.

Disulfiram (Antabuse®) interferes with the breakdown of alcohol. Acetaldehyde builds up in the body, leading to unpleasant reactions that include flushing (warmth and redness in the face), nausea, and irregular heartbeat if the patient drinks alcohol. Compliance (taking the drug as prescribed) can be a problem, but it may help patients who are highly motivated to quit drinking.

Co-occuring conditions: Other medications are available to treat possible mental health conditions, such as depression or anxiety, that may be contributing to the person’s addiction Medication therapy can be critical to reducing desire as well as blunting symptoms associated with dependence, including anxiety and depression.

Alcoholism: Topirimate (Topomax), Baclofen (Lioresal Or Gablofen®), Naltrexone, Disulfiram (Antabuse), Campral (Acamprosate), Ondansetron (Zofran), Chantix (Varenicline) and Gabapentin (Neurontin) to name a few.

Opioids: Methadone (Dolophine®, Methadose®), buprenorphine (Suboxone®, Subutex®, Probuphine®), and naltrexone (Vivitrol®) are used to treat opioid addiction.

An understanding of some basic tenets of counseling with this population may be beneficial.

1. Despite the most ardent protestations, good will or other verbal and written assurances to the contrary, one must believe what one does and does not do as the greater portrayer of intent.

2. Substance abuse counselors invest heavily in “contracting” or motivational interviewing; in essence, up-front work to determine the motivation and desire for change, as well as to fully examine the barriers, challenges and supports. All counselors should acquire this expertise; it vastly improves one’s assessment and goal-setting work.

3. One should never moralize or shame. Despite the feeling of superiority many users enjoy, they also experience a level of shame and degradation believing, rightfully, of the social morays against dependence and coveted use. Their shame and self-blame are pervasive and should not be added to in the immature belief that this will hasten them into change.

4. Similarly, one should never enable a user. Most users enjoy a sense of superiority or accomplishment that they are able to obtain their drug of choice and retain their life-style by 44

means that circumvent others and the rules, regulations and expectations they impose. This, in fact, adds greatly to the excitement component of addiction referenced below. Let natural consequences serve as the most prudent, and effective, parent.

5. Physiological/biological addiction aside, most substance abusers are addicted to a life-style. One that bears such excitement and sense of renewal that many refer to it as “adolescence”. This is critical, as we tend to minimize the importance of the socio-cultural in favor of the bio-medical components of addiction. Recovery is from the life-style, not the drug. If one considers the results or “goals” of addiction one cannot better understand both its inexorable pull and the possible path to true sobriety: a. Euphoria b. Invincibility c. Spontaneity d. Socialness e. Freedom from pain and shame* f.

Excitement*

g. Lawlessness h. Superiority/Getting-over* To effectively compete with this one must build excitement, meaning and purpose as a substitute into the client’s life. Healthy eating and self-care are not sufficient. The three asterisked are, to my mind, the most compelling. Accordingly, one should build in 1) means for obtaining and sustaining excitement; 2) healing of old trauma, guilt feelings and shame; and 3) meaning and purpose to offset inflated and non-substantive power that comes from a false sense of superiority over others. Naturally, few investments bear greater meaning than spirituality or work to aide and heal others.

Addiction involves “secrecy” and defiance. Both exciting power-plays against society and intimate associates. In many respects, it is a means of controlling others while abandoning responsibility for such control. This passive-aggressive style masks depression and rage and is a complicated display of inadequacy that builds shame and blame and hurt, which in turn, feeds the desire for relief from such unconscionable behavior. And yet, the addict is doing as they please and continually frustrating others in their attempts to control their actions and lifestyle. Like anger, the power is false and requires continual reaffirmation to sustain it. Shame is relived, injustices are relived, and satisfaction and excitement are obtained by winning one’s power45

struggles with others. The simple message being that you cannot control me and you can’t hold me accountable because I’m addicted.

It’s a win-win interactional scenario that when added to a high level of social and sexualized excitement makes for a formidable way of interacting that is difficult to relinquish. Few things can truly compete with it, which is why sobriety is difficult and relapse so common. Given this challenge, contracting must be viewed as the first most critical intervention. Why give up so much excitement, so much glam and so much feel-good? Eliminating shame and destruction from one’s life is rarely a sufficient goal for treatment. One must move toward sobriety and a goal of passion and purpose, not merely a route to escape the fallout from one’s dependence.

Interventions 1. The ‘rebelliousness’ inherent in this adolescent life-style is very susceptible to paradox and paradoxical intention.

2. While no excitement surpasses intimate and meaningful involvement with others, high risk behavior in a controlled fashion may sate the thrill-seeking tendency long enough to work toward more stable supports 3. Target the underlying power-plays by addressing cut-off, relationship counseling and previous traumas.

4. Addicts carry enormous rage. It often is communicated in passive-aggressive ways, such as by depression continuing to use, abject defiance or failure. Tap into the anger and examine more overt means of seeking revenge or retribution.

5. Focus less on attempts to reduce drug or alcohol use. While this may seem paradoxical, a focus on abstinence becomes a simple power-play between the client and therapist. To win, the client must fail or continue to use. This is a set up for failure and is, typically, a trap. Because the therapist harbor s a desire to see the individual stop (moral imperative) they find clever means by which to seduce or pressure the client into abstinence. True respect for the client is to recognize and validate their control and power.

46

Fetishism A recent (February 2016) case prompted a summary of central consideration to treating fetishism: It is important to note that sexual norms are highly dependent on cultural attitudes and morays and that the human appetite for sexual gratification is very broad and varied. Given this, it may be unclear where one’s legal and professional ethics lay. Clearly, as mandated reporters we customarily have concerns with behavior that is illegal or that infringes on the rights and well-being of another. As therapists, however, we must be mindful of our own moral prejudice and focus on that which client finds unwelcome or problematic.

1. Paraphilia involve issues of power and intimacy characterized by strong moral judgement and excitement. Arguably, these are the basis for their connection to sexual pleasure.

2. Fetishism is a sexual fixation on an inanimate object or non-sexual body part as a means of obtaining sexual gratification. More common in men, it appears to begin in puberty, an important consideration in the development and, perhaps retention of the behavior into young adult and later life. The particular method of sexual pleasure is meaningful, its significance tied to the representative object’s original owner or the relationship identified with it.

3. People are highly motivated toward sexual arousal and spend a considerable amount of time actively imagining and fantasizing about the next opportunity. In paraphilia, excitement is not limited to the act itself as the entire enterprise, from anticipation and planning to seeking and securing, carries strong sexualized energy. The parallel to a substance disorder or “addiction” lifestyle is striking. Moreover, there is a secretive, taboo quality to the act that enhances, if not results in, its excitement; if sex is taboo, then fetishism is one of the top taboos of taboos. Given its relative rarity as a presenting problem, less than 1% in the general psychiatric population, we can presume that few individuals desire cessation to the urges and fantasies. The two principal exceptions to this are 1) when disclosure comes as a result of discovery, such as by a spouse or law enforcement, plunging the individual(s) into crisis, or 2) as an intentional addition to its inherent excitement exposure brings.

4. Typically, guilt, shame and contrition accompany the acts. This contributes to feelings of selfloathing and depression for those who consider their urges and impulses invasive and unwelcome.

Like cutting/self-mutilation, fetishisms provide a means of releasing anxiety and tension, as well as collecting it.

5. Given that most find fetishisms objectionable, this provides an effective means of avoiding intimacy. The object is understood as an acceptable substitute for a true partner, thereby avoiding rejection and the further loss of self-esteem.

Motivation for treatment can be very low, given that most individuals are able to satisfy their urges in a manner that is private and does not interfere with public life. Any strategy, therefore, must include a clear and concise challenge to the interest, motivation and value of change. While some forms of aversion therapy have been found useful, most clinicians prefer not to employ punitive measures such as shock therapy or parings with negative stimuli. A more favorable format includes broadening and blunting of 47

the fixation and exploring more controllable, and perhaps more acceptable, forms of sexual arousal and gratification, including the use of pornography and masturbation. Cognitive-behavioral work as well as fantasy and guided imagery techniques can be helpful in behavior rehearsal and for reshaping fantasy and urges. Medication should be considered for reducing anxiety and leveling periods of depression.

Counseling should focus on intimacy, sexual identity and rules for how power is expressed and interpreted.

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Lessons and Training Seminars (2 hours)

49

Notes on the Practice of Psychotherapy Demetrios Peratsakis, LPC November 2015

Responsibilities of the Practitioner Despite its commonplaceness, counseling can be very prone to failure. To maximize the opportunity for success the therapist must be exceedingly well trained 

They must possess a good working contextual framework for understanding human behavior (theory)



They must be knowledgeable in clinical syndromes, how they develop and the role that symptoms play within the individual’s sense of self and their relationship systems



They must understand that although our prejudice is to view the individual as the loci of problems, that as social beings whose problems are by-products of our relationship systems, we must continually identify and call attention to the relational components that create and maintain them.



They must be knowledgeable in matters related to mood and emotion, including anger, sadness, guilt, fear and hurt and their corresponding manifestations such as violence, depression, shame, anxiety and revenge



They must have mastery over simple as well as advanced psychotherapeutic techniques and understand the interplay between assessment, intervention, and change



They must have insight into their own problems, values, and beliefs and how this benefits and detracts from the therapeutic milieu



They must have insight into the stigmas and morays surrounding complex social conditions such as addiction, homosexuality, single-parenthood and extra-marital affairs



They must understand how common misconceptions about cognitive ability or intelligence, even among treating professionals, can effect treatment and service options



They must understand the major disability categories, including intellectual and developmental disabilities, mental health and substance use disorders for children as well as adults

Having responsibility for the treatment process, the therapist must understand their role in creating and controlling the opportunity for change. A trained therapist 

is active and personable in session, seeing the primary task as one to educate the client(s) about the benefits and dangers of change, while providing them the opportunity to do so



is responsible for the outcome of the treatment, including if it fails and insight and change do not occur 50



controls therapy by their own behavior, by what they accept and do not accept



gives directives, prescribes rituals and orders tasks within session and for homework



manipulates mood; escalating and diffusing distress, joy, sadness and rage



manipulates space and time and interrupts behavior cycles, sequences and other patterns



challenges, blocks, re-directs and reframes communications



sits within arm’s reach of the client, moves people, and re-partners members in collusions, alliances and triangles



ascribes overt meaning to covert intent



believes what is done or not done, not what is said



regards behavior and emotion as purposive and moves to match behavior with belief, belief with behavior, and both with intent



never rescues, allowing the client(s) to act due to duress



never asks for permission, never accepts “secrets”, never parents (gets parents to parent)



understands that how therapy ends is more important than how it begins



understands that if one is not actively discouraging, one is passively encouraging



understands that every referral is a forced referral



understands reluctance (“nothing ventured, nothing lost”) and that the therapeutic process is a dynamic struggle for change and sameness



understands that clients have a right (at times an obligation) to leave, to not change, or to die



understands that treatment structure is arbitrary and that one can and should redefine the duration, length, place and frequency of therapy



crafts the session as an arena to practice new ways of thinking and behaving



accepts that the treatment process is isomorphic and transforming and is willing to be subject to change and growth as well



never (ever) works harder than the client(s)



never (ever) moves ahead until the directive or work assignment is done; and



never (ever) interrupts the opportunity for change 51

Contracting for Therapy August 27, 2016 Individualism is an illusion; as social beings, we do not exist outside the context of others. While each of us may view ourselves as independent and separate, our personality and sense of self was forged by family, then friends and the society at-large. There is, therefore, a relational component to each of our actions, beliefs and behaviors that reaffirms our way of being in the world and shapes our adaptation to the continuous myriad of changes that constitute existence (Tasks of Adulthood; Family Life Cycle). Our success in continually changing while retaining important elements of our sameness is what defines the success of our adaptation and consequently whether problems will arise that warrant remedy.

Few areas of clinical work seem to be as misunderstood and undervalued as “contracting”, the determination of the goal of treatment that the therapist and client(s) agree to work toward. As a rule, its importance is best understood by Substance Abuse clinicians who devote most of their energy to this phase of treatment (Motivational Interviewing), understanding that exploring the purpose and value of change is a necessary condition before embarking on it. 

Therapy begins with “contracting”, a highly sophisticated process whereby agreement is drawn on ◦ what is the chief complaint (presenting problem or symptom) ◦ what is the desired goal (s) or outcome of treatment ◦ how is success to be understood or measured, in behavioral terms, and ◦ who is to participate in session and under what terms or conditions



While labels and diagnoses may be useful as short-hand descriptors, they represent the beliefs of others and can readily cloud one’s initial impressions as to the current level of functioning and motivation for change. They are also individual and dissuade concentration on the relational component of the problem.



Presenting Problems and symptoms are manifestations of dysfunctional structures or patterns of behavior and serve as a metaphor for the change that is needed. They are purposive as stop-gap measures that preserve a level of safety between the imperative to change and the desire to remain the same. Exploring the history of the Presenting Problem is therefore critical to understanding the problematic sequence and pattern of behaviors that maintain it.



Motivation for change and treatment avoidant behaviors and obstacles are important to periodically review and reaffirm. Given the impetus for sameness, the desire as well as the risk of change must be continually reevaluated. Is the price of change worth the investment in time, energy and consequence?



Perspectives on Symptom Development 2. Behavior (and emotion) is purposive (Adler) 

The individual continually reaffirms their worldview and the manner in which they must interact with others 52

3. Problems are a product of social relationships (Adler) 

Individuals develop relationships with individuals that reaffirm their own affirmations



There is a relational component to every normative and para-normative event



Individuals and families undergo developmental change (stages)

5. Social interaction develops structure whose pattern of behavior and rules determine the effectiveness of functioning or the development of symptoms (Minuchin). Similarly, faulty adaption to change will concretize over time into dysfunctional structures (Haley).

6. Despite being unwanted, symptoms play an important role in the safety and well-being of the individual and their family or social system: ◦

◦ ◦ ◦ ◦ ◦ ◦

“When anxiety increases and remains chronic for a certain period, the organism develops tension, within itself or in the relationship system; the tension may result in physiological symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen) Symptoms are a defense against anxiety (Freud) Structural: change the system, in order to change the symptom (Minuchin) Strategic: change the symptom, in order to change the system (Haley/Madanes) Problems are faulty interactions among people during adaptation to life-cycle changes Symptoms are safe-guarding mechanisms (Adler) Treatment is sought not for change, but due to the failure to adequately adapt to change.

Symptom = “Adaptive response” (Haley) = “Solution” that is now the “Problem”.

5. The presenting problem is both a representation of the problem and an index of progress 6. Timing: symptoms typically manifest during periods of duress (crisis or impasse) ◦

Normative (universal issue, even if not experienced): marriage, parenthood, families with adolescents, ‘empty nest’, partner/child death, aging

◦

Para-normative (common but not universal issue): divorce, re-marriage, trauma, war, severe illness

7. Removal of a symptom or problem can threaten the individual and the system: ◦ ◦ ◦ ◦

a worsening of the existing symptom or problem (rebound); the creation of a new symptom, symptom-bearer or problem (deflection); the development of physical or psychiatric illness (conversion); or the abandonment of treatment (escape) 53

8. Treatment failure or failure to change will be used to justify ◦ the severity of the symptom and the struggle ◦ the inadequacy of the member to change ◦ the inadequacy of the therapist to accomplish change

As one begins the contracting process, several questions are helpful to keep in mind: 1. Why now?

Why has the client(s) come for treatment now? Why not two months ago or two months from now?

Typically, there is a very specific reason why someone seeks treatment at a particular time.

Sometimes it is apparent, such as Probation and Parole referred them or they just recently relocated to the area. More often, however, some change in circumstance has prompted the need to seek help and understanding that change can give you great insight into to the root of the problem. It is usually a stressor, such as Mom’s boyfriend just moved back in, it’s the anniversary of a parent’s death, or a child is going off to school for the first time. Most often, it is a reaction or some difficulty to a normative life-cycle change, such as the youngest child moving off to school or retirement. Timing is an interesting variable in treatment.

2. Why this particular symptom?

Most symptoms are the direct result of the stress and chronic tension that results from unresolved conflicts or trauma. It’s always of interest to speculate as to the form that symptoms take. An adolescent seeking revenge or a means to exert self-control may become bulimic or anorexic, suicidal, or fail in school or at work. Sometimes the form of expression is coincidental to some association; moreover, however, the expression has meaning, either to the individual or to the relationship system. People are symbolic creatures; we find or create meaning in acts, tokens, symbols and images, especially those that have power. Ask yourself: is there something significant or meaningful about the particular dysfunction or symptom expressed? Is it a statement of some kind, and if so, who is it directed to and what is it saying? Keep in mind that even when a behavior or pattern of behavior does not begin for a specific purpose, if it is repeated, chances are that it acquire functional value, which can become meaningful and powerful and what we then call a symptom. Understanding symptom development and its management is a core function of therapy.

This is, in great part, the basic premise of family systems therapy: that symptoms evolve as reactions to stress or a failed adaptation to change that acquire functional value and become a primary or preferred way of reconciling distress within the relationship system. So, for a richer picture of the 54

problems presented as concerns during the first-phase of counseling, one must look beyond the symptom and the bearer of the symptom (symptom-bearer or Identified Patient), to who the connecting members are and what purpose role the problem holds for them. Ask yourself: “If the Presenting Problem was not the problem what else would be?”

To better understand the role that symptoms may serve, one needs to more closely examine the presenting problem. It’s very common for individuals to have a very specific Presenting Problem, or “reason” for seeking treatment. While the given purpose may be somewhat benign, such as “I was court-ordered” or “ the school said we need to see someone”, more often the Presenting Problem is a statement of what the client(s) believes is unwanted or in need of being “fixed”. As such, the client(s) will view the cessation or alleviation of the problem as the ‘cure’ and, therefore, as the goal of the therapy. In essence, “if you could help us fix this, all would be good and we would be happy”.

3. Who are the ghosts?

In the example cited above we have a rather simple (over-simplified) explanation of how a problem may arise and be maintained by the family. This is often more obscure when working with adults or when a child is not the Identified Patient. This, then requires a broadening of one’s perspective to consider individuals outside the person’s apparent sphere of influence or in their past.

While our tendency is to think of ourselves as discrete individuals, we are incapable of defining ourselves in the absence of our relationship to others. Moreover, our problems are by-products of the thoughts and behaviors that we adopt as a consequence of our relationship with others. It therefore makes sense to investigate, early on, who else participates in the Presenting Problem or dysfunction and how. While they typically reside with or near the person(s) attending treatment, the connection may not always seem apparent, especially if there are cut-offs or the persons are estranged or deceased. That does not diminish the importance (or severity) of their expectations or rules.

Having an understanding of who else is “in the room” ----the “ghost(s)”, can provide great insight into what perpetuates the problem, as well as how best to promote the healing necessary for reconciliation and moving on. The simple rule is to track the series of interactions that uphold the symptom or problem and examine the “legs” of the triangle to comprise the individual’s pattern of behavior. There is always “triangulation”, the process by which power is redistributed or tension reduced, and triangles, basic relationships between the individual and others and between a symptom and those embedded in its functional value.

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Notes on the Practice of Psychotherapy Demetrios Peratsakis, LPC Copyright © February 08, 2016

The Family Psychotherapy Process Family Counseling is the preferred method of treatment when the Presenting Problem (PP) involves a child or a youngster as the Identified Patient (IP). The role of the therapist is to work with the Executive (Parenting) Subsystem to accept responsibility for the family’s problem and work as a team to put in place an appropriate solution. Conflict, trauma and other obstacles that impede the cooperation must be remedied along the way.

Family Dynamics Belonging is a necessary condition of the human experience. As the primary social group, the family helps ensure that basic needs are met, socialization occurs, and that members cooperate to navigate the complex social relationships of human interaction. Many skills are central to this, chief among them trust and the intimacy it creates.

As competing interests surface and lead to disagreement conflict must be negotiated and, as necessary, mediated by the parents or executive subsystem. Unresolved, conflict deteriorates trust and undermines intimacy.

Given the interest in seeking treatment, the therapist can presume that the parenting system has reached an impasse and is voiding its natural abilities as adults to properly guide and re-direct the children. This originates from one of two circumstances: a) dysfunction or impairment in the psychological healthiness of one of the parents; or b) sustained conflict within the couple or executive relationship, typically due to a long standing history of mistrust and betrayal. If a child is the Identified Patient, tension has invariably been deflected through concern about his or her behavior or welfare (triangulation). The interactional pattern that is formed will be characterized by enmeshment with one of the parents or collusion between a parent and child(ren) against the remaining parent. In dire circumstances, both mechanisms are present.

For this reason, four key, interrelated concepts are explored below. The first two, power and intimacy, are fundamental if often opposing dynamics; they are associated with trust and support and therefore with the ability of the family to display cooperation. The third is trauma, which may result in inadequacy in a parent or as unresolved conflict between members. Unresolved trauma impacts the power dimension of the parenting roles. Lastly, it is important to examine the family’s ability to cope with life’s processes of growth and their consequent imperative to change (Family Life-cycle).

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Power and Intimacy A strong, interrelated connection exists in relationships between Intimacy and Power. Intimacy creates power by strengthening the trust agreement between persons that share a common purpose or goal. Power increases the safety and protective value of sharing, thereby increasing closeness and the social bond.

Both come into play when a trust agreement is violated and the betrayal leads to mistrust or trauma.

Power  Influence and control within the relationship system  Determines style of communication and decision-making (how love, caring, anger, and so on is expressed and understood)  Defines level of trust for meeting and not meeting personal and group needs  Establishes rules for interdependence and independence, for closeness and distance between members, for who participates and joins  Is expressed in socially defined structures characterized by parental and intergenerational influences. In a healthy family, everyone cooperates in conflict resolution, problem solving and decision making, with the parents (executive subsystem) providing the final say  Power structures, include: a) Rules: pattern of interactions or behavior; how (and when) things are to be done and by whom b) Hierarchies: who directs others, typically through established levels of authority and responsibility; the executive/parental subsystem should serve at the top c) Alliances (Coalitions, Collusions; Triangles): relationships and agreements around issues to add or detract power for a common cause or purpose and thereby shape outcome. Unresolved power struggles lead to covert partnering in the form of collusions and triangles to alleviate stress or reconcile power imbalances. d) Roles: expectations of behavior within a given setting of who participates and how; established assignments for performing specific functions and tasks i. Roles or positions are assigned/assumed from the Family of Origin, then added to in time ii. They consist of patterns of behavior that are expected to be maintained; they acquire “moral character” and are relatively enduring iii. Role behavior is reciprocal and interactive with other roles iv. Roles and positions have “status”, thereby determining placement on the power-hierarchy, leading to alliances, collusions and triangulations e) Symptom: a pattern of interaction involving an unresolved struggle for power. As the pattern rigidifies, triangulation, acts of revenge, dysfunctional alliances, illness and other methods are employed to disengage the impasse and unbalance the stalemate or deadlock. Cooperation erodes permitting pressures to mount and tensions to develop in one of the partners, the couple’s relationship or one or more of the children. This will result in “physiological symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen).

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Efforts to tip the balance of power and preserve functionality may occur in overt or covert ways: a) collusion: gaining power through alliances with others (ie. Parent and child against other parent) b) inadequacy: retaliating or neutralizing others through failure, incompetence, illness or depression c) violence: over-powering through rage, bullying, intimidation or verbal, physical and sexual abuse d) vengeance: weakening through hurt, including punishing, withholding, suicide, and acts of revenge Intimacy Closeness, affection and trust in a relationship, developed and expressed through sharing vulnerabilities, and enjoying positive involvement, and shared understanding. Intimacy structures include: a) Boundaries are proximity measures defined by the level of comfort with emotional sharing, interdependence, and intensity between members. A product of the level of intimacy and trust in the relationship, it is balanced by the degree of separateness or independent personhood (individuation) of the individuals. When not appropriately balanced, the connectivity between members is reciprocal; over-involvement (enmeshment) in one relationship usually means that the same person is disengaged or under-involved (diffuse) from someone else. For example, i. A wife who is enmeshed with a child and disengaged from her husband, or ii. A father who is very close and enmeshed with his older son who hunts with him, and disengaged with his daughter who is quietly depressed and cutting herself Rule of Thumb: healthy boundaries are moderate and balanced; the “Goldilocks” measure is symbolized by lines (“boundaries”) that denote the relationship’s degree of permeability:  Too Soft: Diffuse, too weak, too open, or “enmeshed”; symbolized as “…………………….”  Too Hard: Rigid, too fortified, too closed, or “disengaged”; symbolized as “________________”  Just Right: Appropriate, retain a healthy balance; symbolized as “._._._._._._._._._._._” b) Subsystems: relatively enduring subgroupings within the family based on age (or generation), gender and interest (or function); ie. parental, spousal, sibling, men/women. Common denominators/characteristics, shared “rights” or “plights”, provide a vehicle for intimacy.

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a. Alliances: Power structures of shared purpose that create the opportunity for cooperation and therefore intimacy. b. Love, Friendship and Sex: specialized relationships that increase intimacy (pair-bond) through trust and a common agreement on the terms of the use of power.

Trauma (see Notes on Trust, Revenge and Forgiveness) Trust is the fundamental agreement between people to risk hurt in exchange for acceptance and love. This is the marital contract that is at the core of the parenting, and therefore the executive subsystem.

It is for this reason, that the consequences of betrayal are so dire to the ability and interest to be mutually supportive and effectively cooperative, a key process of marriage and the parenting role. When anger and resentment become defining characteristics of the relationship, the less assertive member will rely on more passive-aggressive methods to control and punish. Invariably, children will enter the power struggle and become embedded in the dysfunctional pattern between the couple. Comfort and solace may be found by one’s relationship with a child, creating a level of dependency and hyper-responsiveness we call enmeshment. Where power-plays occur the weakened or at-risk parent may collude with a child (children) to leverage control and aide in determining outcome.

Disengaging the power-play and addressing the unresolved conflict in the marriage is key for the trust agreement to be renewed and the child disentangled from the adult power and intimacy structures.

Life-cycle Life-cycle is the context within which developmental change occurs. Stress develops into symptoms at points of intersection when family of origin rules (Vertical stressors) are too rigid and insufficiently flexible to adapt smoothly to trauma or normative developmental change. This is illustrated in the diagram below which denotes the concentric context we are each embedded within (Systems Levels) and the merging pressure to remain the same (Vertical Stressors) and the imperative to change (Horizontal stressors):

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Carter and McGoldrick identify six family life cycle stages and their respective processes and tasks, somewhat modified herein. Because the processes are universal, understanding the Stages helps identify and predict inherent in the developmental changes each family undergoes.  Launching the young adult/Differentiation of self in relation to the Family of Origin Each member is born into a uniquely formed inter-generational social group (family of origin) that defines their identity and remains an integral part of their life until death. The challenge is for each member to retain the benefits of remaining an integral part of their birth family while sufficiently separating to form one’s own adult life and new social unit, a process that the entire family contributes to and supports and paves the way for how other siblings may “graduate”. While a culminating event, separation occurs incrementally through childhood and accelerates through adolescents. Most problems intensify if not wholly originate, from difficulties encountered during this stage (and adolescents). Barring childhood trauma from sexual abuse, war or catastrophe, this period is most prone to trauma as power struggles intensify between the executive subsystem and the rising young adult.

Tasks: ◦ due to greater autonomy and independence, parents can no longer require compliance or obedience; power must be renegotiated; threat and shame are less effective, requiring greater mutual agreement the young adult must separate without becoming cut-off, fleeing or getting themselves ejected ◦ the young adult must accept emotional responsibility for self and clarify own values & belief system ◦ the young adult must develop intimate peer relationships with the prospects of pair-bonding and sex ◦ the young adult must establish self in work/higher education and a path to financial independence ◦ family members provide support by accommodating to change in roles, functions, and chores ◦ family members provide flexibility to allow movement in and out of the family ◦ parents (executive subsystem) must provide continued support without enabling Problems ur when young adults fail to differentiate themselves from their family of origin and recreate similar, typically flawed emotional transaction patterns in their own adult social relationships and in their family of formation. While work, school and adult peer relations can provide an opportunity to reconcile unresolved issues these also provide a venue in which to reaffirm them. Serious problems occur when families do not let go of their adult children encouraging dependence, defiance or rebellion.Derailment  Developing the Couple Relationship: Intimacy and Trust ◦ The task of this stage is to accept new members into the system and form a new family separate and distinct from the couple’s families of origin.

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◦ Couples may experience interpersonal difficulties in intimacy and commitment. The development of trust and mutual support is critical ◦ Negotiation of the sexual component of the relationship system ◦ Negotiation of Power, boundaries and rules of the marriage; identifying/protecting against threats ◦ Problems consist of enmeshment (failure to separate from a family of origin) or distancing (failure to stay connected).  Parenting/Families with Young Children ◦ Child-rearing and the task of becoming caretakers to the next generation ◦ Adjusting marital system to make space for child (ren) ◦ Joining in childrearing, financial, and household tasks ◦ Realignment of relationships with extended family to include parenting and grand-parenting roles ◦ Couples must work out a division of labor, a method of making decisions, and must balance work with family obligations and leisure pursuits. ◦ Problems at this stage involve couple and parenting issues, as well as maintaining appropriate boundaries with both sets of grandparents.  Families with Adolescents ◦ In stage four, families must establish qualitatively different boundaries for adolescents than for younger children. Individuation accelerates and movement in and out of the family increases. ◦ Problems during this period are typically associated with adolescent exploration, friendships, substance use, sexual activity and school; peer relations take a primary place as does self-absorption ◦ Parents may face a mid-life crisis as they begin to regard their own life accomplishments and foresee the promise of an empty nest or diminishment of the parenting role; refocus on midlife marital and career issues ◦ Increasing flexibility of family boundaries to include children's independence and grandparent's frailties; beginning shift toward joint caring for older generation  Launching Children and Moving On ◦ The primary task of stage five is to adapt to the numerous exits and entries to the family ◦ Renegotiation of marital system as a dyad ◦ Development of adult to adult relationships between grown children and their parents ◦ Realignment of relationships to include in-laws and grandchildren ◦ Dealing with disabilities and death of parents (grandparents) ◦ Problems may arise when families hold on to the last child or parents become depressed at the empty nest or due to loss. Ease of separation tied to contentment in the marriage/adult life and future plans ◦ Problems can occur when parents decide to divorce or adult children return home

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 Families in later life ◦ The primary task of stage six is adjustment to aging and physical frailty ◦ Maintaining own and/or couple functioning and interests in face of physiological decline; exploration of new familial and social role options ◦ Support for a more central role of middle generation ◦ Making room in the system for the wisdom and experience of the elderly, supporting the older generation without over-functioning for them ◦ Dealing with loss of spouse, siblings, and other peers and preparation for own death. ◦ Life review and integration ◦ Problems consist of difficulties with retirement, financial insecurity, declining health and illness, dependence on one’s adult children, the loss of a spouse or other family members and friends.

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The Family Therapy Process

1. Join the executive subsystem as a coach, build an alliance with each member and accommodate to the family’s temperature and style: 1. Review practical concerns, including access to treatment, update to referral source, billing, required participants, and household basics and so on 2. Determine the source of power and who can mobilize the family to action well as to return and continue attending treatment 3. From the onset, challenge assumptions about the Identified Patient (IP) and the symptom; examine its purpose to the Identified Patient, the family and its members 4. From the onset, challenge assumptions about the Presenting Problem; track the interactional pattern that maintains it and examine what it fosters as well as avoids 5. Continually do a temperature check of reactions clinical directives and challenges to the symptom or presenting problem; address overt and covert expressions of anger 6. Consistently validate the family’s power; take a one-down position and reframe progress as the family’s love for and commitment to one another 7. Create intimacy through use of self and personal history, family bragging, praise, celebrations, teamwork and friendly competitions 8. Consistently reaffirm the inherent privilege of the family’s acceptance (of the therapist) and their courage in sharing their pains, their secrets and their shames 2. Empower the Parenting/Executive Subsystem While families undergo Life-cycle stages, child-focused problems, by default, refer to the authority and responsibilities inherent in the parenting or executive team. Accordingly, family therapy centers almost exclusively on the task of parenting and child-rearing and addressing those obstacles to its effective operation. a) Empower the Parenting or Executive Subsystem Make it a Team  Join as a coach and mentor  Define its membership, role and authority  Create a partnership “truce” and implement a new time-line or identify  Foster cooperation and mutual support 63

    

Teach decision-making and conflict-resolution skills Provide education on developmental and life-cycle task processes Explain the purpose of power-plays, symptoms, dysfunctions and illnesses Help members practice expressions of mutual support and tenderness Ally with the Executive Subsystem as Co-therapists o Strategize and plan interventions and solutions o Model appropriate behavior; adult issues should be handled in couple session o Block inappropriate communications and collusions/coalitions o Practice parenting in session

Remove Obstacles to Effective Team Work  Remedy distrust due to hurt from old or recurring betrayals  Confront power-plays and misuse of power, including bullying and displays of inadequacy or powerlessness  Block interference from in-laws, family and friends  Address unresolved personal dysfunction, family-or-origin issues and trauma The goal of therapy, therefore, is to produce one of two outcomes: a. to engage the parent(s), keeping the child as the IP, until the power-play can be disengaged and redirected toward resolving the Presenting Problem (PP), then fully moving the focus unto the couple’s relationship to work through their conflicts and betrayals. If the coupe moves toward separation and divorce, the therapist can expect to either treat the (“marry”) the remaining spouse in treatment or else have the system revert to its previous child focus. b. to engage the parent, keeping the child as the IP while beginning to address the underlying trauma or dissatisfactions. The therapist then nudges the parent into individual therapy or else can expect the system to revert to a child focus.

3. Make kids age appropriate Throw kids out of spousal alliances; match authority, responsibilities and benefits by age; promote (or demote) older teens and young adults with “parental” responsibilities. During emergencies, single-parents may temporarily promote an older teen/young adult into the exec subsystem, but generally the custodial parent must go it alone with support from the therapist, other adult(s) or group.

4. Get parents to parent Adult(s) are presumed to be sufficiently equipped to parent effectively unless they cease to display such competency for a specified purpose. The reason (s) is always tied to issues of power: 64

i. the custodial adults are at an impasse due to unresolved conflict which has resulted in a power-struggle or power-play ii. the ineffectual adult has surrendered their power and adapted a sense of inadequacy due to trauma, fear or depression iii. the ineffectual parent has surrendered their power as a direct act of defiance or revenge, or iv. the ineffectual parent(s) has worry over abandonment and is avoiding individuation in a more appropriate manner.

5. Get parents to address individuation issues with teens and young adults (see Life Cycle) 6. Challenge power inequities: 1. dis-engage and redirect power-plays toward a common purpose, task or problem 2. Ensure that functions are clarified, roles are assigned and that authority (power) matches responsibility 3. Bridge disengaged members and cut-offs and create breathing room and independence for enmeshed members; interrupt/block inappropriate communications and direct proper exchanges. Be careful family doesn’t collude against this effort.

7. Address hurt, trauma and trust issues as major barriers to effective governance and growth 8. Examine ghosts Confront family myths, cut-offs, or other legacy issues that interfere or serve as road-blocks to effective problem-solving or growth. Do this verbally, through imagery and through empty-chair techniques.

9. Force enactment Encourage in-session practice of new behavior patterns and new forms of expression; assign related homework, continually reaffirming that behavior rehearsal is critical to solidify new ways of being.

10. Have fun and get the family to laugh!

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“Listening with the Third Ear” and Validation Demetrios Peratsakis, PD, LPC, ACS © 2016

Listening with the “Third Ear” is a term coined by Theodor Reik to refer to the art of “active listening” to that which is implied by a speaker about their emotional state.

It is the equivalent of listening to what an individual says, and does not say, in order to “read between the lines” and better understand what they are attempting to communicate. In particular, it is a method of attentive listening for the hurt and the pain an individual is carrying, for their fear and foreboding, their feelings of worry, guilt and remorse, of shame, or of anger and blame. In the practice of psychotherapy, it is the unspoken message that speaks the loudest!

It takes considerable concentration and energy by the therapist and requires that they still their own anxiety and internal noise, their own impatience with wishing to get somewhere or to accomplish something. It does not disregard the therapist’s direction, but rather allows it to be suspended while the experience is shared. Suspending one’s own “internal dialogue”, however, is challenging and takes practice. With sufficient mastery, the therapist is able to subtly shift and explore or to validate and move forward. This is especially critical to healing trauma, where simply being with someone in a moment of utter completeness lets them feel heard and cared for and not alone. In so doing, the therapist is more genuine, more authentic, and helps focuses the session on the here-and-now.

Listening, Encouraging and Validating Research suggests that overall effectiveness in communication is comprised of 55% body language, 38% tone of voice and sounds, and only 7% on the spoken word. “Listening with the Third Ear”, therefore, must take into greater consideration the subtleties and nuances reflected between and around the spoken word. In addition, attention should be given to body language and facial gestures, which may conform to one’s emotions or endeavor to mask it.

People are generally more open in their communication when they are not challenged directly but encouraged indirectly to speak. The emotion must then be validated to be accepted by the speaker and, ultimately, “owned”. There are several ways to encourage and validate what is heard by the “Third Ear”:      

Sit close; hunkering down and slightly into the speaker communicates attentiveness and closeness Make periodic, not sustained, eye contact that is short in duration, but direct Making eye contact often communicates who speak or not; instead, look between people or at the floor rather than directly when inviting answers to a question or who will volunteer Looking directly at the client’s body language may modify it; the therapist must learn to watch with their peripheral vision Listen to pauses; when do they occur, for how long, and what is immediately said afterward (and to whom) Same for sighs or hesitations (when and with whom) 66

      

Listen for the level of commitment to taking action; reluctance or desire, fear and worry Is the body pulled into itself or open, hands relaxed or wringing, fingers drumming or flexing, etc.

Does the body shift sideways toward or away from another, forward or back?

Do not interrupt when someone is working Spend less time on the past week/past events and focus on the here-and-now Be mindful that certain actions may discourage greater sharing of emotions, such as giving tissues; checking the time, looking away/bored or fidgeting Validate the emotion or feeling tone: o reflect back what has been said by rephrasing or restating o validate the emotion that is heard: ie. “you sound upset, you sound angry…..” Notice that a less toxic alternative (“you sound upset…”) is offered first. o validate the emotion that is implied: ie. “Most people are upset or angry when…..” o validate the emotion by role-modeling: ie. “I would be upset and angry” “ when that happens I feel upset and angry” o validate the emotion by authority/”mind reading”: ie. “You are upset and angry….”

Pay attention to your own intuitive hunches and impressions. While we may express feelings in different ways, emotions are universal and you can recognize them when you hear them, if you listen to what is said as well as to that which is not spoken but implied. Validate the feeling, and then explore it. At the heart of the trauma are hurt, sadness and anger. Shame and guilt, which often accompany these, hardens them into depression and the desire for revenge.

There reverse is, therefore, true: to heal trauma, work through the feelings of guilt and shame and allow for the safe expression of anger and revenge, trusting that depression and anxiety will lessen, and the individual will become freer to move forward. Connecting the individual to meaningful involvement, especially trustworthy and intimate relations, will sustain and deepen the gain providing restorative as well preventative resiliency.

The opportunity to experience such intimacy in session, no matter how brief or fleeting, is a profound expression of caring comparable in some ways to love. .

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Notes on the Practice of Psychotherapy Demetrios Peratsakis, LPC September 30, 2015

On the Essence of Being and Psychotherapy

1. Believing is Seeing Action, that combination of behavior, emotion and will, is purposive; not merely within the act itself but within a larger, teleological context within which the individual defines themselves, others and their beingness in the world.  All behavior and emotion is purposive; as such, it expresses and reaffirms how one sees themselves, others and the world within which they and others exist  Insight is not always a sufficient, nor necessary, prerequisite for change  When one thinks differently, one behaves differently  When one behaves differently, one thinks differently 2. One Equals None  One does not exist without others  We are highly social beings that are born very dependent and cannot be fully understood outside the familial context  Problems are by-products of social relationships and do not exist outside the relational context.

3. Change is Permanent  Change is a continuous characteristic of life (Life Cycle)  How one adapts to change will determine whether they, or others, will incur problems  Today’s solution, typically becomes tomorrow’s problem 4. Power Controls  Power, the ability to influence change, is at the core of every interaction  A Problem is the result of a of a power-play, real or symbolic, between the individual and others, the individual and society, the individual and themselves  The role of psychotherapy is to disengage and redirect the Power-play

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5. Truisms  Psychotherapy is the highly deliberate art of manipulating experience.  One comes for therapy not because one desires change, but because one failed to accommodate to change  The difference between counseling and psychotherapy is the degree to which the therapist is willing to accept personal responsibility for change  Therapy must be a continuous opportunity to practice new ways of thinking, behaving and feeling; a new way of being  The client knows that you know that they know that you know  The goal of therapy is to discover the price one must pay for the change they desire  Therapy is failure-prone; to increase the likelihood of success, master technique  Expect to “kill” your first fifty clients  As a therapist Power comes from a. authenticity, even in the stark ugliness of another’s acts and dreams, b. the ability to “see” the hidden purpose of behavior and mood c. the deliberateness in what one accepts and does not accept before proceeding  Never work harder in therapy than your clients  Believe what one does and does not do, not what one says  Never parent children unless you are planning on adopting them  You can be a therapeutic friend or a friendly therapist; never both  Never let a client tie your hands; never ask for permission unless you are willing to accept a “No”  Success is measured by the distance one has come  Some clients are vampires and some therapist slayers  Nothing impedes therapy more, than the therapist’s own fears  Never do more than is necessary  The Ideal is unreal 69

 Change in any part, will induce change in the whole  Never interrupt when work is being done; always interrupt when work is not being done  When all else fails, a. prescribe the symptom b. invite a consultant or co-therapist to session c. convert the client to a therapist d. pronounce the client cured  One must be willing to immerse themselves in the pain or rage or insanity of another  Match behavior with belief, belief with behavior, and both with intent  Make the covert, overt  How therapy ends is more important than how it begins  If one is not actively discouraging, one is passively encouraging  Sit within arm’s reach of the client  Every client is a forced referral  To change the symptom, challenge its power; to challenge its power, change its reality  Betrayal demands revenge  Suicide and depression are very powerful forms of revenge

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Notes on the Practice of Psychotherapy Demetrios Peratsakis, LPC October 28, 20015

The Goal of the Therapy Process

Overall Goals of Treatment and of the Therapist While clients seek treatment for relief from the distress of their situation or symptom(s) the job of the therapist is to create a remedial process by which adjustment to change can occur.

This should be done in a supportive and caring manner, the therapist calling into question one’s customary way of being while coaxing and cajoling change. To do so, the therapist must challenge the meaning and power of the problem while providing opportunities to practice new ways of thinking, behaving, feeling and interacting. When done skillfully clients change, modifying their sense of self and their relationship to others and to the world at-large.

In this regard, the clinical session is an incubator for work with the process of therapy becoming a long series of opportunities created deliberately to experience change.

Confrontation and Challenge In clinical terms, “challenging” is the process of confronting the client’s interpretation of events, the basis for how information is incorporated into reaffirming one’s own belief system.

“Effective confrontation promotes insight and awareness, reduces resistance, increases congruence between the client’s goals and their behaviors, promotes open communication, and leads to positive changes in people’s emotions, thoughts and actions” MacCluskie (2010).

Linda Finley (Finlay, L. Relational Integrative Psychotherapy: Process and Theory in Practice, Chichester, Sussex: Wiley, 2015) listed several key principles to effective challenging: 1)

It helps to believe in the value of challenge: it plays a vital role in moving a client towards new ways of thinking, feeling and behaving. And, while we might find challenging hard to do, authentic, honest straight, well-meaning comments may actually be less damaging than empathic confluence or ‘pussyfooting’ around.

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2)

Challenging should be done relationally. In the early stages of therapy, simply attuning to the client in a non-judgmental way may be all the challenge that is needed. Later, once the relationship is in place, and trust has been established, more muscular/provocative challenges might be appropriate.

3)

Challenges issued need to be in the clients’ interest and not simply be a self-serving product of our own frustration, impatience or irritation. Sometimes this is easier said than done, particularly if we’re caught up in powerful counter-transferences and projective identifications. So we need to be reflexive about our urge to challenge towards finding more constructive modes which can be received in non-defensive ways.

4)

Empathy and compassion need to be to the fore when challenging such that our clients will hopefully be able to understand that our challenges arise out of caring concern. In other words, the challenge occurs in the wider context of the therapy. When giving such challenges, it can be useful to use the ‘on the other hand...’ type of intervention. For example, “I can feel something of how hard it is for you to talk about that. On the other hand, I think it would be helpful to put it into words.” Or, “I’m hearing you say you’re calm. On the other hand, I see your foot tapping and I’m wondering if your body is saying something different(?)”.

5)

Aim for a proportionate, optimal level of challenge. Too much challenge when the person isn’t ready to receive it, can be shaming, overwhelming and destructive, and is likely to just cement defensive resistance. Insufficient challenge means we end up in confluence, colluding with cosy stagnation.

6)

Asking permission to challenge or to give feedback can pave the way. “I’d like to offer you a challenge. Are you up for it?” Then the client is enlisted as an ‘ally’ and the challenge is dialogical rather than a one-way exercise of power.

7)

It can help to encourage self-challenge towards enabling the client to be more self-aware and take responsibility for choices. For example: “As you’re sharing these different stories of dating with me, I’m seeing a bit of pattern where it seems you tend to end up feeling used and betrayed. Is this a familiar pattern? Would you be willing to think about your own role in this?”

8)

Often it is more productive to challenge unused strengths rather than weaknesses. To give an example, it might be more constructive to acknowledge the client’s capacity to care for others if not themselves, rather than calling them an unhealthy ‘rescuer’.

9)

Challenge may often best issued with shared gentle humor – of course, this needs to evolve mutually (laughing with, not at) and be sensitively done.

10)

We, too, need to stay open to being challenged (e.g. by clients or by our supervisor) if we are to grow and develop as therapists. At the very least it can provide a useful way of modeling the behavior for clients.

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Interventions and Tactics While confrontation can take several forms, a directive is a very discreet intervention given as a prescription, homework, exercise, ordeal or other form of assignment. 

Directives are very deliberate, often manipulative, tasks assigned to provide practice in new ways of thinking and behaving



Task performance provides an opportunity for reassessment and, in turn, redirection

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If resistance to a task occurs, the apprehension should be confronted and the power-play, if present, disengaged and redirected



Ordering a task or directive: ◦

Simple introductions that communicate the experimental nature of the task work best. This denotes that the experience is exploratory and time-limited. Examples include: “Let’s try something…”; “Some people find this helpful…” ; “Let’s do an experiment…”; “I’m going to have you do something that may be uncomfortable… ”

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Typically, it is beneficial to advise the client that the task may be difficult or prone to failure. This increases the likelihood of success through lower expectations or a recoil.

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Once a directive is given, it is important to expect that the task is acted upon until complete.

While some apprehension is natural, outright refusal must be immediately addressed before moving forward. Irrespective of the rationale, it is likely a power-play with the therapist.

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Once a task has been assigned, the therapist's job is to redirect any straying or delay back to task, itself. This can build tension within the therapist who may become inpatient and feel an urgency to rescue the client from their discomfort. If the client is unable to complete the task, the therapist should explore a) what would happen had the task been able to be completed, and b) what was going on for the person while struggling to complete the task.

Contracting Contracting is an exceedingly complex and sophisticated process by which agreement is reached to provide clinical treatment toward a specified goal or outcome, While unwanted, the symptom or presenting problem will likely have acquired functional value, serving both as a source of stress and its release, and providing a focal point around which behavior is organized and patterned. It is, therefore, of great importance to assess the potential consequences and risk to change.

A common, misconception is that therapy begins once the presenting problem has been sufficiently clarified; in actuality, it is the very act of clarification that is the true onset of therapy:

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Why is the client seeking treatment at this time? Why not a month or two ago, or next month or the month after? What has changed to create the urgency at this time?

◦

What is it about the problem that is so objectionable? Does it happen all the time or is it selective with regard to circumstance, time, people or place?

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The symptom must have a relational component. A reliable treatment plan must, therefore, who participates, in real or imagined ways, in the pattern of dysfunctional behavior. Begin by exploring who the problem affects and how.

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Validate the person who has the power to return the member(s) to treatment and take care to not alienate them. In the same manner, one must validate the Presenting Problem, returning to reaffirm its importance after each bout of challenge to its authenticity and role.

◦

Contract goals must have concrete, behavioral components that are measurable and that can be clearly delineated for evaluating progress and risk. How does one determine success and what is a reasonable timeframe to achieve that particular goal?

Challenging the Symptom and the World View A good psychotherapist continually asks herself “What, or who, would be the problem if this was not?

Individualism is an illusion. As social beings, we do not exist outside the context of others. While each of us may view ourselves as independent and separate, our personality and sense of self was forged by family, then friends and the society at-large. There is, therefore, a relational component to each of our actions, beliefs and behaviors that reaffirms our way of being in the world and shapes our adaptation to the continuous myriad of changes that constitute life (see Tasks of Adulthood; Family Life Cycle). Our ability to continuously change while retaining important elements of our sameness is what defines the success of our adaptation and consequently whether problems will arise that require remedy. 

Therapy begins with “contracting”, a highly sophisticated process whereby agreement is drawn on ◦ what is the chief complaint (presenting problem or symptom) ◦ what is the desired goal (s) or outcome of treatment ◦ how is success to be understood or measured, in behavioral terms, and ◦ who is to participate in session and under what terms or conditions



While labels and diagnoses may be useful as short-hand descriptors, they represent the beliefs of others and can readily cloud one’s initial impressions as to the current level of functioning and motivation for change. They are also individual and dissuade concentration on the relational component of the problem.



Presenting Problems and symptoms are manifestations of dysfunctional structures or patterns of behavior and serve as a metaphor for the change that is needed. They are purposive as stop-gap measures that preserve a level of safety between the imperative to change and the desire to remain the 74

same. Exploring the history of the Presenting Problem is therefore critical to understanding the problematic sequence and pattern of behaviors that maintain it. 

Motivation for change and treatment avoidant behaviors and obstacles are important to periodically review and reaffirm. Given the impetus for sameness, the desire as well as the risk of change must be continually reevaluated. Is the price of change worth the investment in time, energy and consequence?

Perspectives on Symptom Development 4. Behavior (and emotion) is purposive (Adler)  The individual continually reaffirms their worldview and the manner in which they must interact with others 5. Problems are a product of social relationships  Individuals develop relationships with individuals that reaffirm their own affirmations  There is a relational component to every normative and para-normative event  Individuals and families undergo developmental change (stages) 7. Social interaction develops structure whose pattern of behavior and rules determine the effectiveness of functioning or the development of symptoms (Minuchin). Similarly, faulty adaption to change will concretize over time into dysfunctional structures (Haley).

8. Despite being unwanted, symptoms play an important role in the safety and well-being of the individual and their family or social system: ◦

◦ ◦ ◦ ◦ ◦ ◦

“When anxiety increases and remains chronic for a certain period, the organism develops tension, within itself or in the relationship system; the tension may result in physiological symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen) Symptoms are a defense against anxiety (Freud) Structural: change the system, in order to change the symptom (Minuchin) Strategic: change the symptom, in order to change the system (Haley/Madanes) Problems are faulty interactions among people during adaptation to life-cycle changes Symptoms are safe-guarding mechanisms (Adler) Treatment is sought not for change, but due to the failure to adequately adapt to change.

Symptom = “Adaptive response” (Haley) = “Solution” that is now the “Problem”.

9. The presenting problem is both a representation of the problem and index of treatment progress 10. Timing: symptoms typically manifest during periods of duress (crisis or impasse) ◦ Normative (universal issue, even if not experienced): marriage, parenthood, families with adolescents, ‘empty nest’, partner/child death, aging

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◦

Para-normative (common but not universal issue): divorce, re-marriage, trauma, war, severe illness

11. Removal of a symptom or problem can threaten the individual and the system: ◦

a worsening of the existing symptom or problem (rebound);

◦

the creation of a new symptom, symptom-bearer or problem (deflection);

◦

the development of physical or psychiatric illness (conversion); or

◦

the abandonment of treatment (escape)

12. Treatment failure or failure to change will be used to justify ◦

the severity of the symptom and the struggle

◦

the inadequacy of the member to change

◦

the inadequacy of the therapist to accomplish change

As the sequence of behavior maintains the dysfunctional interaction, its interruption will, necessarily, alter the symptom, presenting a direct challenge to its rigidity and inevitability. Ways to interrupt the sequence include reversing the order of the steps (having the symptom come first), removing a step or adding a new one, removing a member of the loop or adding a new one, and practicing the sequence at times and places that are not customary (controlling the symptomatic pattern).

Behavior rehearsal or demonstrating the sequence in session is a subtle yet profound means of identifying the steps of the sequence while creating an opportunity to experience and exercising control over the symptom: t)

Create a new symptom.

u) Move to a more manageable symptom v) I.P. another family member. (create a new symptom-bearer) w) I.P. a relationship x) Reframe or re-label the meaning of the symptom. y) Change the intensity of the symptom/pattern. (Inflate/Deflate) z) Change the frequency or rate of the symptom/pattern aa) Change the duration of the symptom/pattern bb) Change the time (hour/time of day/week/month/year) of the symptom or pattern. cc) Change the location (in the world or body) of the symptom/pattern dd) Change some quality of the symptom or pattern.

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ee) Perform the symptom without the pattern; short-circuiting. ff) Perform the pattern without the symptom. gg) Change the sequence of the elements in the pattern hh) Interrupt or otherwise prevent the pattern from occurring. ii) Add (at least) one new element to the pattern. jj) Break up any previously whole element into smaller elements kk) Link the symptoms or pattern to another pattern or goal ll) Point to disparities Note: 3.

4.

A-D courtesy of Minuchin and Fishman; E – courtesy of Adler; F-S courtesy of O’Hanlon, 1982.

Pattern or element may represent a concrete behavior, emotion, or individual family member.

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Notes on the Practice of Psychotherapy Demetrios Peratsakis, LPC, ACS Copyright Š October 14, 20015; revised December 05, 2016

Working with Emotional Pain and the (Two) Three Forms of Depression While only partly understood, the role of emotion and its influence on human behavior is of critical interest to the counselor. Historically, we have moved from consideration of the emotions as passive experiences, something that happens to you, to a more active one whereby emotion is viewed as an important form of communication. The simplicity of this notion can be somewhat misleading, however.

Communication is more appropriately understood as the foundation of culture and as the most fundamental insurer of the preservation of the species. It is exceedingly dynamic and purposive.

In this regard, communication shapes the manner in which we think, feel and interact and must have meaning and significance to the individual (Adlerian Psychology) as well as to society at-large (Evolutionary Psychology). The expression of emotion, therefore, is consistent with the individual’s beliefs about themselves, of the world, and of the manner in which they need to interact with others.

This makes it a cornerstone concern for psychotherapy and, in particular, for the treatment of emotional pain, typically expressed as depression, anxiety or hurt.

General treatment premises on emotional pain due to loss and trauma: 1. Thought is the precursor and driver of emotion. Its particular expression is based, first and foremost, on the individual defining the experience as positive or negative. The experience does not occur in isolation, however, and can only be understood within a context that is meaningful to the individual; emotion is as purposive as behavior in helping to shape social experience and interaction.

2. As natural, protective responses to fear and pain the primary emotions of anger and sadness have a psychobiosocial component which can be thought of as the fight (anger) / flight (fear/depression) response to negative experience. In evolutionary terms, the purpose of anger is to communicate dominance or control and the intent to protect oneself from harm. Sadness, provides an opportunity for self-healing and elicits a caring and nurturing response in others, which is an important source of group cohesion and social binding.

3. Anger and sadness are inseparable, with one often expressed as a substitute for the other. Both control and influence others and, as such, have underlying power.

4. Prolonged feelings of guilt, shame, fear and anger typically lead to a sense of worthlessness and despair, resulting in depression. Shame and guilt develop a cyclic pattern with depression, oscillating between the striving for action and the withdrawal to inactivity, creating a pervasive sense of despair.

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5. While anxiety creates a preparedness to act, inaction can lead to tension and stress. This failure to act can contribute to feelings of inadequacy, resulting in hopelessness and depression. One way to think about anxiety is that it is the body’s reminder that one is angry and needs to act.

6. In some families or social units the expression of anger is so toxic that it is more acceptable to be depressed, physically ill, or mentally unstable.

7. Trauma, betrayal and shame require a sense of justice and retribution. Revenge is a means of mobilizing oneself past depression and rage. Planning for punishment and revenge must be carefully scripted and, naturally, within legal and ethical parameters. To the extent practicable both the transgressor and the aggrieved should be a part of the planning process; the therapist is responsible for safety.

8. Depression, like suicide, can serve as a powerful means of controlling others. Each, can be a highly effective form of revenge, typically tied to one, long-time antagonist. To alleviate the depression or to reduce the potency of the threat of suicide the therapist must tap into the underlying anger and work to disengage and redirect the existing power-play.

Main Reasons for Seeking Treatment    

The effects of trauma are cumulative and change the way one thinks and feels about themselves and others Unresolved, trauma expresses itself as Depression, Anxiety, or Hurt It is fueled by Anger, Shame and Guilt, whose principal victims are trust, intimacy and one’s personal sense of safety Reconciling Anger, Shame and Guilt will lift the Depression and Anxiety.

Loss The impact of grief and remorse due to loss depends highly on the form of loss and the opportunity for closure or amends. As varied triggers can rekindle its effects, it is a pervasive pain or longing that may take several forms: o o o o o o o o

loss of a loved one through death (complicated bereavement); absence due to prolonged hospitalization, incarceration, excessive work, military service, addiction, separation or divorce, cut-off or expulsion; ambiguous loss (no closure) such as POW, run-away, kidnapping, or infertility; loss of a valued possession, heirlooms or important material goods; loss of loss of a familiar way of being, body part, function or ability; loss of prestige, job, status or lifestyle; loss of a goal or sorrow over a missed opportunity; and regret or guilt over an action taken or failed to in order to harm another/breach of trust

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Fear and Dread The fight-flight response fixated or grounded in dread of some person, situation or event. When not fixated it may be experienced as generalized anxiety; the inability to act on fear (fight or flee) is anxiety.

Warfare or Prolonged Conflict Disagreement on the nature or direction of the outcome of important matters or ongoing embattlement causes chronic tension and hypervigilance, which is exhausting. Exhaustion is similar, if not identical, to depression in its effects. Power, intimate to conflict, is the need or desire to influence outcome.

Unresolved conflict leads to power-struggles and power-plays.

Disaster A sudden often cataclysmic event such as an accident or a natural catastrophe, that causes great damage, loss or sense of victimization.

Violence, including victimization, war, and rape Betrayal Including treachery, sabotage, domestic abuse, infidelity, and incest. As a violation of the basic trust agreement that allows intimacy due to one’s willingness to risk vulnerability, betrayal may be the most complicated form of trauma; it requires punishment and revenge to ameliorate the hurt and retribution and redemption by the perpetrator to escape its guilt and shame.

Treatment specific issues: For working purposes it is helpful to think about Depression as having three, distinct forms, the first and second merely degrees of the same: Simple Depression: Sadness or sorrow, often accompanied by feelings of anger, guilt or shame.

A normative response to harm, loss, disappointment or rejection. The mood and thoughts draw others on and foster nurturing and the opportunity to self-heal; a pulling into one’s self for self–reflection and perspective. a. Degree of Worthlessness (sense of helplessness and despair) and discouragement is low or nonexistent b. The Depression or sadness is used for healing of the self c. Improvement and healing occur with or without the help and support of others d. May occur at any time or age. The cause of the depression may or may not be associated with others and revenge may or may not be needed or beneficial e. Others feel sympathetic and find joy in helping f. The number one reason for depression is loss, which may take several forms, as noted above.

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Complicated Depression: Sorrow and heartache as a consequence of loss or trauma that results in prolonged or ongoing problems in function; mixed with anger, shame, guilt, expressing itself as anxiety and depression or emotional pain.

Depending on how pervasive the loss or prolonged the trauma, one’s thoughts of themselves and the world can be changed, creating complication in identity and function. It may result in guilt, shame, anger and/or rage, which can result in despair, either through a sense of helplessness or worthlessness or both. a. Degree of Worthlessness and discouragement is high, yet it likely does not create irreparable damage to the self. It is not a life-long image of the self in relation to others, although it can have life-long residual fall-out b. The Depression is used to protect the self from additional or further harm (safe-guarding) and typically develops in concert with sustained anxiety or tension. c. Improvement and healing occur better and faster when supported by others, especially when empathy by other survivors is present d. May occur at any time or age as a single trauma or prolonged episode of harm. It often occurs in a social context or its aftermath has close social implications. Revenge can be an important and needed method of healing e. Others feel empathetic, although may also experience anger, disgust or rejection f. The number one reason for Complicated Depression is trauma; it is often associated with suicidality

Depressive Life-style: Depression as a means of socializing and interacting with others Depressives are depression-prone individuals who place others in their service through the use of their helplessness. They reaffirm their feelings of worthlessness through self-recrimination and guilt. Despite their professed good intentions they are very resistant to change, typically evidencing life-long themes related to a sense of hopelessness and despair, failure, and feelings of guilt and shame. Depressives are passive-aggressive and elicit feelings of anger and resentment in others. This interpersonal style is extremely intractable in its dominance over others. Suicidality may be used as a threat or manipulative ploy. Psychotherapists find Depressives highly oppositional to any attempt to lift them from their depression; these are your therapist-slayers. a. Degree of Worthlessness (sense of helplessness and despair) and discouragement is pervasive and an integral part of the identity of self in relation to others b. Depression is used to control others and place them in one’s service. There is a nobility to the struggle of reaching for superiority from feelings of worthlessness c. Improvement requires considerable re-socialization. Personal discouragement is high and ingrained to the point that efforts to improve threaten the identity of worthlessness. Hopelessness, despair, good intention (guilt) and continual failure reaffirm the sense of worthlessness. Depressives recoil from attempts to uplift the depression and improve the individual’s self-esteem and image of self. d. Depression occurs as means of coping during an early history of prolonged or severe discouragement or repeated trauma. Depressives develop their life-style from childhood, typically in a neglectful, abusive or over-controlling home environment. Adult victims of early, pervasive childhood abuse often develop depressive life-styles. Depression develops as a means of controlling others. e. Others feel placed upon and resentful 81

f.

The number one reason for the development of a Depressive Life-style is a pervasive, prolonged early life development with caretakers whose parenting style was exceedingly over-protective/overpampering (Adler), neglectful or abusive.

Assessment Simple and Complicated Depression are but degrees of emotional pain, demarcated by the extent of disabling and the corresponding need for intervention. The third form, Depressive Life-style, is an insidious form of interaction or being in the world whereby others are controlled by the failures and inadequacies of the individual. It is a subversive form of power that uses depression and remorse as a means of avoiding responsibility and placing others in one’s service (Adler). The individual is not cognizant of their controlling tendencies and genuinely experiences themselves as hopeless and forlorn.

Others experience them as passive-aggressive and resent the dramatic ploys and need to continually rescue them for the challenges and necessary work of life.

In any of the above, others may feel put-upon, resentful and even reluctant to continually provide support; with the depressive, however, one experiences anger and resentment, often feeling manipulated and used.

It is often difficult to evaluate the full impact of events on individuals, their families and their social systems, especially when compounded by unrelated stressors and concerns.

Lastly, it should be noted that a more comprehensive interview is necessary to determine the cause and extent of emotional pain. The pain will express as depression or anxiety or a mix with the prevailing experience being one of hurt. It is fueled by anger, shame and guilt, the most difficult of which to express constructively being rage. Commonly, where rage and anger are readily expressed, guilt and shame are not. Where shame and guilt are readily expressed, the open and direct expression of the underlying anger is typically problematic.

Three simple measures can provide additional insight: 1. A comprehensive history of the event or life-history of the individual; 2. A thorough understanding of the pattern of interaction surrounding the presenting problem; and 3. The feelings elicited in others, including the psychotherapist A fourth, responsiveness to treatment can be a more difficult measure to initially ascertain. In simple and complicated depression, the depressed individual responds, even marginally, to effort and inclination to comfort and support. With depressives, the effort to lift the individual from their depression or enhance their sense of self-esteem and regard is thwarted and countered in an effort to retain a sum-zero gain or reaffirm their belief in their own sense of worthlessness and shame.

It is important, therefore, that clinicians acquire a level of comfort with tapping into the anger that underlies client guilt and shame. This is a serious challenge, when the therapist has been raised in a family whose expression of anger is regarded as toxic and unacceptable. In some families, the rule against anger is so severe that individuals are encouraged to express their pain as depression, or illness or even insanity.

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D. Peratsakis Note: The following diagrams are an attempt to illustrate the relationships between Anxiety and Depression to Shame Guilt and Anger.

While counselors often focus on Guilt and Shame, they tend to miss the more toxic, underlying issue of Anger and the desire for revenge. This is what often fuels the development of the symptom and its design of retribution against others.

The Power associated with Guilt and Shame and its corresponding role in emotional pain and trauma cannot be overstated. While the Symptom serves as a reducer of anxiety in the system, it may also serve as a powerful act or Revenge.

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Emotional Pain: the relationship between Anger, Guilt and Shame Anger, or moral outrage, is one’s emotional experience against others to a perceived injustice or transgression due to Shame or Guilt. It is the collective voice of others that make us feel ashamed for having done wrong or being wrong

Trauma Emotional Pain Over Time

Sadness

Fear

Shame

Guilt

Anger

Anxiety

Rage

Depression

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Trauma: the Development of Depression and Rage Demetrios Peratsakis, LPC, ACS; copyright Š March 2016; r October

Overlapping and cyclic emotional strands

Trauma: Disaster; Victimization; or Betrayal, including Abuse, Infidelity and Incest

Blame/Helplessness Faulty sense of power; the sense of empowerment comes from a continual reactivation of the feelings of harm from the trauma or betrayal. Often, as self-pity or blame, it can result in helplessness or the over-powering of others, either of which avoids responsibility. The effects of trauma are cumulative.

Treatment Consideration for Depression and Anxiety: 1. Resolve conflict and disengage and redirect the power-play; practice enacting new ways of behaving and interacting.Challenge the meaning and the power of the depression and its symptoms; examine how it avoids responsibility and controls others 2. Tap underlying fear and anger; seek acknowledgment and de-escalation; examine betrayal and work on revenge, forgiveness and redemption 3. Bridge emotional cut-offs; fill loss; and connect to meaningful activity and relationships; develop a sense of purpose and rekindle spiritual being-ness 4. Consider medication and safety/suicide planning, as needed. Look to self-care and general health

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Development of Presenting Problems or Symptomatic Behavior Patterns Demetrios Peratsakis, PD, LPC, ACS

Presenting Problem Or Symptomatic Behavior Note: Tracking the sequence of interactions surrounding the PP (who does what, when) or the IP’s behavior will denote the dysfunctional transactional pattern that preserves the symptom.

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Simplified Model on the Origin of Presenting Problems Demetrios Peratsakis, PD, LPC, ACS Copyright © April 2016 Presenting Problems and Symptoms are by-products of Adjustment Complications and Unresolved Trauma Episodes (A.C.U.T.E.)

Resulting Outcomes:  Power-struggles (Unresolved Conflict)  Failure; Sabotage, Self-harm/Suicidality  Emotional Cut-offs and Avoidances

Conflic t

+ / --

Treatment:  Disengage and redirect the existing powerplay; resolve conflict; enact new behavior and ways of interacting  Tap the underlying fear and anger; examine betrayal and work on revenge, forgiveness and redemption (hope)  Employ “positive self-thinking, acknowledge (acceptance) of self and other’s point of view, form a plan of action with small steps forward” (R. Sherman)  Bridge cut-offs; fill loss; connect to meaningful activity and relationships  Self-care; medication, if needed -- Depression and Rage should lift --

* Adjustment Complication: Complications adapting to change, either Traumatic or Normative/Paranormative (see Family Life Cycle). Adjustment complication(s) can become prolonged and compressed (cumulative/echoing). ** Fear: Fear (flight) and Anger (fight) motivate to safety which when thwarted promotes anxiety: Conditioned fear; fear of pain, fear of loss, fear of non-gain, fear of extinction, fear of uncertainty, fear of failure. ** Loss: Loss takes many forms, including: Loss of a loved one; loss of a valued possession or heirloom; loss of prestige, job, status or lifestyle; loss of a familiar way of being; loss of a body part, function or ability; loss of a goal. Major changes result in loss of a familiar way of being and may include anxiety, depressed mood or disturbance of conduct.

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Notes on the Practice of Psychotherapy Demetrios Peratsakis, PD, LPC, ACS Copyright © November 11, 2015

Note: This subject crosses several broad areas of specialized work, including Trauma/PTSD, Sexual Abuse, Domestic Violence and Couples Therapy. Further readings should be specific to the casework.

Trust, Betrayal, Revenge and Forgiveness Trust is the fundamental agreement between people to risk hurt in exchange for acceptance and love.

It is a loyalty pact whose pledge is to consider the best interests of another and, above all else, to protect them from possible harm. It is for this reason, that the consequences of betrayal are so dire.

In no uncertain terms, betrayal is a trauma. The extent of it will determine whether the trust is repairable and the kind of remedy that would satisfy its breach. Extreme betrayals, such as incest, rape, infidelity or abuse, are so toxic that acts of contrition, punishment and forgiveness may be necessary to the healing process.

Prologue To forgive and not forget is, in essence, to not forgive at all. While people are extremely resilient and adept at negotiating the intricacies of social interaction they are particularly susceptible to the nuances of love and affection. Emotional closeness and intimacy develops trust which carries with it specific expectations and terms that if violated results in betrayal and hurt. In this regard the capacity to trust and love can be marred if the wrong is not righted and the betrayal not atoned for with equal or greater justice.

It is never too late to right a wrong; nor is it ever too late to seek revenge or forgiveness.

While withholding one’s forgiveness can, in itself, be an effective means of punishing another, most wish for atonement and the opportunity to see a wrong righted in real terms of equal or greater justice.

Betrayal mars the capacity for trust, rendering the victim of betrayal, love. Shame and Guilt are insufficient forms of self punishment, as is Worry. Like “confession”, they can be ways of excusing one’s behavior without truly making and amends or changing. More often than not, “change” is the only true apology; needing “revenge” and “contrition” to wipe-the-slate-clean.

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Trust Trust is essential to nurturing and bonding and includes a collection of very dynamic processes that, by their nature, are in continuous flux: intimacy, mutual protection and the agreement to work toward shared goals and interests (social cooperation).

In stark contrast, one is also motivated by self-interest and the drive for personal fulfillment. This dichotomy creates continual dilemmas that must be reconciled by the individual, dyad or family system. The healthfulness of a relationship may be measured by its capacity for trust and its ability to continuously negotiate such differences: how capable are members at employing decision-making and problem-solving skills to remedy conflicts to each person’s satisfaction? The struggle to control the outcome of a decision or event (power-play) is an inherent component of social relations and a defining by-product of all social interactions.

For this reason, we regard power as fundamental to interpersonal dynamics and a core driver in the misuse of trust as a means of controlling others. When power is used unjustly, anger and resentment occur; when a defining characteristic of the relationship, the less assertive member will rely on more passive-aggressive methods to control and punish. In extreme circumstances, revenge may take the form of attention-seeking, self-harm, failure, inadequacy or the development of socially controlling symptoms such as phobia or depression.

Betrayal Betrayal can occur for a number of reasons, including dissatisfaction, jealousy, punishment and lust.

Typically, both relationship members experience shame, with the victim incurring feelings of hurt and anger and the violator guilt and remorse. Untreated, especially if a severe or chronic pattern of offense, feelings of worthlessness and depression will develop and become relatively entrenched. If the breach is serious, it may ultimately require some form of retribution, without which forgiveness will be difficult and reconciliation less assured.

By their nature, few betrayals are more devastating than when committed by family members or lovers. Ironically, many victims will perpetrate abuse and betrayal upon others, especially when anger has been generalized into rage.

Forgiveness Redemption can occur if the individual acknowledges and apologizes for the pain that they have caused and if the victim is able and ready to surrender their suffering. The victim’s anger may be valuable in assisting the individual to feel empowered, to retaliate or to seek safety and protection.

Where power-plays occur, there is often great reluctance to forgo punishing the offender without sufficient remorse or assurances about future conduct. Reliving the hurt, re-energizes the anger, which has positive as well as negative consequences depending on the freedom and willingness to act.

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For this reasons, forgiveness is often necessary for a relationship to move forward and for the trust agreement to be renewed.

The treatment goal, therefore, should be to help move the offender toward ownership and repentance, and the victim toward revenge and absolution.

Treatment Relationships undergo stress, relying on various methods to attain relief including triangulation, a coalition or alignment with a third person, issue or condition (ie. symptom). Triangulation deflects tension within the dyad by reducing the directness of the conflict. It may also be used by one of the members to unbalance a power-play and tip the outcome of an issue toward their desired result.

The therapist must be mindful that, by their very participation, they become a part of a triad and are subject to triangulation. This can be exceedingly strong, at times volatile, especially when conflict exists between a couple, such as partners or parents, or a highly enmeshed dyad, such as a mother and a sickly child. In these circumstances, it is common that the dyad will scapegoat the therapist or else continuously attempt to engage the therapist in shifting the balance of their power-plays.

When trust is neither repairable nor desired the goal of treatment should be in assisting members with separation work, including legal recourse or divorce. In these circumstances, it is not unusual for the therapist to retain a working contract with one member of the dyad or system. In fact, this outcome is often the premeditated purpose for therapy being sought: one member secretly plots to solicit the therapist’s aid in escaping the relationship or else hopes to utilize “therapy” as a safe place from which to abandon their partner and leave them in the therapist’s care.

It is important, therefore, to clarify the motivation and commitment of the partners. Do they wish to remain in a workable relationship despite the blame and mistrust or do they wish to work through the pain necessary for an eventual reconciliation? If the latter, the reasons for doing so must be carefully examined and an inventory of obstacles and challenges taken and discussed. Strengths, complementarities and shared investments between members, such as family, children, or business holdings, can be triangulated by the therapist to help incentivize the work. In almost all instances, it is beneficial to create a new time-line, a new beginning from which all future behaviors may be judged (intent) and progress toward redemption evaluated: 1. The therapist creates a new point in time, a “new history”, demarcating the current moment from any betrayal or failure of the past. This may be done by introducing a “cease fire” or “truce”, a way of symbolically acknowledging that irrespective of what has previously occurred the parties are willing to “give it another try”. The new pledge is to refrain from adding further damage to the relationship until reparations are complete. Typically, this measure is readily endorsed by the perpetrator, with the victim displaying ambivalence or a reluctance to surrender their mistrust. The therapist should recognize this concern and 91

encourage the victim to retain their misgivings until such time as a fully satisfactory “deal” can be reached. Validating the power of the victim is important to making the power-play overt and reducing the likelihood of its expression in more insidious ways.

2. Once an agreement has been reached, the therapist should solicit some “act of good faith” that each partner can perform in order to exemplify their willingness to uphold the new truce.

Care should be taken to render the act as a “token” of good intent, keeping it simple and in behavioral terms to reduce the likelihood of failure or sabotage by the partner or other member in the mix. The difficulty of the undertaking should be continually reaffirmed.

3. It is difficult for forgiveness to occur without some genuine expression of remorse. While several therapies address the issue of trust and betrayal, most gloss over the natural imperative for revenge. Likewise, few exploit the enormous benefit of repentance and the admission of guilt to the victim without which repair of the trust agreement will be less secure. The alternatives for demonstrating these expressions are rather limitless and best left to the creative energies of the victim and offender: Sample “Acts of Contrition” (to make amends; penance) for the perpetrator: • • • • • • • • •

get on their knees and beg for forgiveness talk about their own shame; describe their own weakness write a letter, poem or newspaper ad of apology contact relatives, children, peers or co-workers and “confess to their sin” allow the victim to slap or spit in their face arrange and participate in a “public humiliation” destroy or damage a favored possession/give away a cherished belonging hold a “confessional” sacrifice a favored activity or need

Sample “Acts of Revenge” (planned punishment) for the victim: • retaliate (retaliation is an effective, yet controversial, means of punishing another; the therapist must be careful about condoning illegal or “immoral” behavior) • redefine the terms and purpose of the relationship; include zero-tolerance for abuse • arrange a structured separation, using therapy as the common meeting stage • meet with an attorney for guidance on a legal course of action • create a “voodoo-doll” or “target” of the perpetrator, ie. collage of hate, a letter of revenge • arrange for a period of indentured servitude (by agreement with perpetrator) • client is now punishing someone in small doses, in different ways. Have them imagine a way that they could make this person suffer in one, big enough way to call-it-even.

• wish a major illness or disease on some one.

• establish a ritual that would help them channel their upsetment throughout the week 92

• recovery therapy: explore childhood abuse and prior traumas and victimizations, including intergenerational trends; use guided imagery/empty chair/cbt to “re-grow” the individual, seek revenge or practice controlling anxiety, depression and shame  revenge through empowerment: increased skill proficiency  revenge through empowerment: care for self  revenge through empowerment: moving on and succeeding in life, love and work  kill the “ghosts”: admonishments and “I told you so”s from family, friends and self • ask client(s) to write a will, include everyone that has ever hurt them and what they have done. Ask that they include what they want each to know and what they have left them.

• ask client to get on bended-knees at victim's feet and beg for forgiveness. Public humiliation is a powerful punishment. Have victim and antagonist agree on form; victim chooses place and time.

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Notes on the Practice of Psychotherapy Demetrios Peratsakis, LPC February 2016

Fetishisms A recent case prompted a summary of central consideration to treating fetishism: It is important to note that sexual norms are highly dependent on cultural attitudes and morays and that the human appetite for sexual gratification is very broad and varied. Given this, it may be unclear where one’s legal and professional ethics lay. Clearly, as mandated reporters we customarily have concerns with behavior that is illegal or that infringes on the rights and well-being of another. As therapists, however, we must be mindful of our own moral prejudice and focus on that which client finds unwelcome or problematic.

6. Paraphilia involve issues of power and intimacy characterized by strong moral judgement and excitement. Arguably, these are the basis for their connection to sexual pleasure.

7. Fetishism is a sexual fixation on an inanimate object or non-sexual body part as a means of obtaining sexual gratification. More common in men, it appears to begin in puberty, an important consideration in the development and, perhaps retention of the behavior into young adult and later life. The particular method of sexual pleasure is meaningful, its significance tied to the representative object’s original owner or the relationship identified with it.

8. People are highly motivated toward sexual arousal and spend a considerable amount of time actively imagining and fantasizing about the next opportunity. In paraphilia, excitement is not limited to the act itself as the entire enterprise, from anticipation and planning to seeking and securing, carries strong sexualized energy. The parallel to a substance disorder or “addiction” lifestyle is striking. Moreover, there is a secretive, taboo quality to the act that enhances, if not results in, its excitement; if sex is taboo, then fetishism is one of the top taboos of taboos. Given its relative rarity as a presenting problem, less than 1% in the general psychiatric population, we can presume that few individuals desire cessation to the urges and fantasies. The two principal exceptions to this are 1) when disclosure comes as a result of discovery, such as by a spouse or law enforcement, plunging the individual(s) into crisis, or 2) as an intentional addition to its inherent excitement exposure brings.

9. Typically, guilt, shame and contrition accompany the acts. This contributes to feelings of selfloathing and depression for those who consider their urges and impulses invasive and unwelcome.

Like cutting/self-mutilation, fetishisms provide a means of releasing anxiety and tension, as well as collecting it.

10. Given that most find fetishisms objectionable, this provides an effective means of avoiding intimacy. The object is understood as an acceptable substitute for a true partner, thereby avoiding rejection and the further loss of self-esteem.

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Motivation for treatment can be very low, given that most individuals are able to satisfy their urges in a manner that is private and does not interfere with public life. Any strategy, therefore, must include a clear and concise challenge to the interest, motivation and value of change. While some forms of aversion therapy have been found useful, most clinicians prefer not to employ punitive measures such as shock therapy or parings with negative stimuli. A more favorable format includes broadening and blunting of the fixation and exploring more controllable, and perhaps more acceptable, forms of sexual arousal and gratification, including the use of pornography and masturbation. Cognitive-behavioral work as well as fantasy and guided imagery techniques can be helpful in behavior rehearsal and for reshaping fantasy and urges. Medication should be considered for reducing anxiety and leveling periods of depression.

Counseling should focus on intimacy, sexual identity and rules for how power is expressed and interpreted.

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Clinical Case Supervision Demetrios Peratsakis, LPC, ACS October 08, 2016

“If you change the way you look at things, the things you look at change” -Wayne Dyer

Orientation to practice There are literally several hundred forms of psychotherapy, each with its own perspective on human behavior and the origin and treatment of problems. Likewise, there are numerous perspectives on supervision and how best to provide guidance and professional development to counselors. Ultimately, good supervision, like good counseling, should be transformational.

This Orientation is predicated on the following premises: 

Psychological problems originate from unresolved interpersonal conflict or trauma caused by disaster, illness or abuse.



We interpret, then feel and act accordingly. As social beings we must continually adapt to one another’s change, in turn creating what others respond to (mutual causality).

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The goal of therapy is adjustment (adaptation) to major life events; it may include the need to heal trauma, reconcile conflict or remedy injustice.

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The therapy session is a primary venue for the practice of new ways of thinking, feeling and behaving, as well as a medium through which to experience intimacy and acceptance.

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Supervision includes the Supervisor, Counselor and Client (Supervision Triad). The model of choice herein is one of mentorship and mutual exploration and learning for growth.

Purpose of Family Counseling and Psychotherapy 1. Common Family Therapy Goals 

to prevent transactional sequences from repeating by interrupting the family's covert hierarchical structure. Change the structure to change the symptom (Minuchin)



problem-resolution; change the symptom to change the structure and hierarchy (Haley)

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re-stabilizing family equilibrium (Bowen)

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develop choice; discover purpose to behavior or symptom and basic mistakes associated with coping to correct faulty assumptions and conclusions (Adler)

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problem solving as a means to resolving conflict and healing trauma (Common/Peratsakis)

2. Common Family Therapy Terms and Concepts 

Problems, and their solutions, are by-products of social interaction. Insight is an unnecessary precondition to change.

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Identified Patient (IP): the symptom bearer that serves as the nexus of the family’s organization and stress diffuser.

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Presenting Problem (PP): the symptom or problem presented as the cause of pain

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Purposiveness: Behavior and Emotions that reaffirm the individual’s sense of belonging

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Differentiation of Self: demarcation between emotional reactivity and thought; self and others

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Life Stages/Family Life-cycle: normative transitions that occur through the individual and family’s life span. As change occurs the family and its members must adjust to it. Adaptation to such change determines functional success and whether “symptoms” will develop.

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Multigenerational transmission: intergenerational influences. Use of the GENOGRAM.

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Triangles: triangulation; collusions and alliances. Means of mediating anxiety and reconciling power inequities

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Family Projection Process: triangulation; the creation of an IP or scapegoat for mediating anxiety

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Emotional cut-off: power issue; extreme distancing to cope with anxiety, anger or revenge

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Structures: family organizational components, such as subsystems, hierarchy, roles, boundaries and rules for fulfilling functions and tasks (ie. parenting) a. Hierarchy: distribution of power b. Roles: function/responsibilities, membership, authority c. Boundaries: adaptability; degree of openness and flexibility to change in relationships Problems arise when boundaries are too rigid or too diffuse i. Enmeshment: exceedingly porous boundary between members resulting in hypersensitivity to each other’s thoughts and feelings ii. Disengagement: exceedingly rigid boundary between members resulting in inadequate support and indifference to each other’s thoughts and feelings d. Rules: who participates in what, with whom, and how 97

e. Use of STRUCTURAL MAPPING (depicting hierarchy and boundaries) 

Joining: accommodating to the family’s tone, language and style

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Unbalancing: creating disequilibrium to foster new alternatives; challenging the world view

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Enactment: directive to re-enact problem transaction in session

 Directives: prescribing new sequences of behavioral interactions, including Ordeals and Rituals 3. Parts of the Therapy Process Treatment begins with the earliest contact; if one envisions the actual, limited number of sessions to treatment, the overall goal, as well as the purpose of each session meeting, becomes highly crystalized. 







Pre-Contact Preparation o

Basics: meeting space, transportation, forms & releases, Supervisor, etc.

o

Appointment setting: connecting, referral purpose, participants, etc.

Contracting (an exceedingly sophisticated component that typically determines success) o

Joining and accommodating language, tome and style

o

Assessing and challenging the Presenting Problem (PP) or Identified Person (IP)

o

Setting initial goal with time-frame, membership, expected outcomes, etc.

Mid-pointing o

Refining goal(s) of treatment or re-contracting

o

Re-assessing progress; evaluating the partnership

o

Re-calibrating toward termination

Termination o

Reaching closure

o

Post-therapy supports, predictions and re-connection possibilities

Purpose of Clinical Supervision “No significant learning occurs without a significant relationship” - Dr. James Comer The Client, Counselor, and Supervisor form an intimate relationship system called the Supervisory Triad.

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A unique arrangement, its principle purpose is the acquisition of insight as to the process of change.

Just as therapy provides the opportunity to examine one’s own beliefs and thereby modify one’s own behaviors, so too supervision is a reflective process of self-examination, insight and growth. A core function of supervision is evaluation & feedback to the supervisee(s) on their strengths and weaknesses and areas that need to be developed, enhanced or improved (Watkins, 1997). 

To teach, train, and empower the supervisee on their route to becoming an effective clinician able to serve as a positive agent for change with their clients.

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To continually assess the supervisee’s skills and provide learning experiences that upgrade their knowledge and experience, such as live supervision and various treatment modalities.

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To empower the supervisee to assume professional and personal risk for their professional growth and development in a confidential, safe and supportive environment.

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To help protect the welfare of clients and ensure the supervisee is practicing within the guidelines of the profession. The supervisor’s role includes responsibility as a gatekeeper for the profession.

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To help the supervisee improve self-awareness and taking responsibility for their clinical practice by adhering to a framework for clinical supervision.

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To challenge the supervisee’s thinking about the profession, including theoretical premises, the roots of clinical syndromes and the nature of change.

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To work with the supervisee to maintain the quality of the process of clinical supervision.

As with all intimate relationships, the Supervisory Triad is prone to “blind-spots”, areas around which one avoids, denies, or transfers the true nature of their feelings or beliefs to others. Typically, these are the areas of high sensitivity within ourselves that are resistant to insight.

Reflection & Resonance The Transference and Counter-transference processes are specific expressions of unresolved issues between the client and therapist. Similar processes occur between the supervisee and supervisor (parallel process) and within the supervisor-supervisee-client triad (isomorphism). Often used interchangeably, Isomorphism is a construct with philosophical roots in structural and strategic family systems theory that 99

focuses on inter-relational aspects of supervision, whereas Parallel Process is a construct coined by the psychodynamic school of thought and focuses on unconscious, intrapsychic occurrences in supervision. 

Parallel Process Parallel process is an intra-psychic or internal, interpersonal dynamic that occurs in both counseling and supervision (Bradley & Gould, 2001). It is the transference/counter-transference of feelings and attitudes between individuals: it occurs when the emotional resonance expressed between the client and the therapist is reflected in the therapist-supervisor relationship.

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Isomorphism Echoing within inter-relational transactions that “presents itself as replicating structural patterns between counseling and supervision” (White & Russell, 1997). When replicating patterns between counseling and supervision occur, the role of the supervisee and supervisor duplicate the role of client and counselor (White & Russell, 1997): 1) the counselor brings the interaction pattern that occurs between themselves and the client into supervision and enacts the same pattern but in the client's role, or 2) the counselor takes the interaction pattern in supervision back into the therapy session, now enacting the supervisor's role.

Attributes of a Good Supervisor 

A clinical supervisor must be open, honest, and aware of her own strengths and weaknesses. She must be willing to share her own uncertainties and failures.

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She must see her role as a teacher and mentor, and value the relationship and provide support

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She must be self-reflecting, able to give and receive constructive feedback, empathy, and support, as well as be comfortable with direct challenge and the expression of frustration, anger and fear.

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She must possess advanced knowledge of a variety of clinical methods and technique, demonstrate them and be open to the supervisee witnessing (and critiquing) her work.

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She must provide a variety of clinical learning experiences, including live consultation, live supervision and small group case consultation and training.

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She must understand the underpinnings of isomorphism & parallel processes in supervision.

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She must be willing to hold the therapist accountable, require that they be prepared, and work in tandem to identify what may be working in therapy and what has not, and why.

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She must monitor the limitations of the counselor and be willing to intervene to protect the client.

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She must value the supervision process as a medium for personal transformation & growth

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Counselor Preparation for Supervision 1. Counselor-supervisees are students; as such, they should be prepared with all necessary documentation and client materials, have completed their assignments and forged a bond with their immediate instructor.

2. They should keep an up to date list of Active Clients and a history of session and supervisory meeting dates.

3. Each New Case presented should include, at minimum, the following information a. Referral source, date and initial reason. If client initiated, their stated purpose for seeking treatment. b. Genogram, socio-gram or summary of relational issues or snap-shot of the client system, including individual backgrounds, such as medical conditions; medications; presntation/hygiene; occupation/education level; and living arrangements; as well as more dynamic artifacts, such as life-cycle issues; deaths, births and anniversary dates; family roles, rules, myths and legacies; trauma events and cut-offs and sources of support and distress c. The Presenting Problem, including the contract for therapy goal(s), participants and expected duration d. An analysis of who needs to participate and why; what’s the hypothesis on reason from seeking treatment. e. Number of sessions to date, frequency of treatment and format 5. Active Case presentations should include the information above as well as a summary of treatment to date: a. Overview of treatment goal (s), number of sessions and progress or change to date b. Relationship with counselor c. Details on how the Presenting Problem, Symptom(s) or Pain has changed d. Plans for Termination date and work 6. Counselors are also expected to a. Follow directives, study assignments, as appropriate to their level demonstrate a working knowledge of counseling theory, core theoretical constructs, basic counseling techniques and the major elements inherent in specialty issues b. Join with the client(s), use one’s self in therapy, bond with the client(s)assume risk 101

c. To be receptive to feedback on clinical work, progress and personal growth, including receptivity to supervision d. To participate in professional training, conference development, peer supervision, and community-wide presentations

Case Overview for Presentation in Supervision 1. If more than one participant indicates seating pattern and who spoke first.

2. Presenting Problem/Reason for seeking treatment (include each member’s belief).

3. When did the Presenting Problem first appear (Dates/Reoccurrences)?

4. Related or correlating events to date of first appearance/Life-cycle issues.

5. Previous Action Taken; track interactional pattern (who does what and when?).

6. Who else does the problem affect? How? 7. Has anyone else exhibited this (include all families and intergenerational)?

8. What does the client/couple/family see as the most important concern to first begin work on?

9. If counseling was successful and this problem no longer existed, how would life be different -per the client(s)?

10. Family “spokesperson”” member(s) most apt to work for change? Member(s) most concerned about change?

11. Conceptual Summary a. Genogram b. Predominant Issues/Life-cycle c. Structural mapping d. Presenting Problem and Purpose of Symptom(s) e. Factor(s) motivating treatment at this time? f.

Specific strategy/interventions made to date and client(s) reactions?

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12. Treatment recommendation a. Method: modality, participants, frequency, and duration b. Goal(s) (short-term/long-term) c. Therapist’s expectations for change

Common Problems in Supervision There are times when problems arise in the supervisory process which could be an indication of concerns that may indicate the Counselor is experiencing difficulties: General Process 

conflict or boredom with the supervisor

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ambivalence about the field or frustration with one’s own personal abilities

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problems at work or of a personal nature

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conflicting directives from peers and others, or

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unidentified resonance or “blind spots” resulting from Parallel Process and Isomorphism

Indicators 

recent change in supervisee behavior, especially withdrawal, aloofness, or avoidance.

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decreased participation in meetings, quality of interaction becoming poor or guarded.

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change in overall style of interaction, such as combativeness or sullenness.

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over-compliance with supervisor suggestions.

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supervisee appearing preoccupied, seeming distant or annoyed, seeming stressed or nervous.

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supervisee confusion or passive-aggressive responses to directives and recommendations

Specific Problems 

Isomorphism/Parallel process resonance : unresolved personal conflict or trauma activated by the treatment (counselor-client) or supervisory relationship (supervisee-supervisor) that goes unrecognized or unaddressed, resulting in “blind spots”, transference/counter-transference and the replication of intergenerational patterns, rules, and roles.

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

Skewed power dynamics of the relationship (one-up, one-down as norm, especially for beginning practitioners) o Supervisee continually feeling over-powered; high reactivity to limit-setting and rule and role enforcement by the supervisor o Misuse of power by the supervisor; fostering feelings of inadequacy, inferiority or shame (abuse)

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Putting the supervisor on a pedestal: idealization of the supervisor or continual need for acceptance or approval

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Supervisor having a continual need to be seen as knowledgeable and competent

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Personal dislike or disdain for the client, supervisee or supervisor

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Sexual or romantic attraction by to the client, supervisee or supervisor

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Cultural bias (over-identification or under-sensitivity) between the counselor and client or counselor and supervisee due to age, gender, religion, political viewpoints, sexual orientation or personal beliefs

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Shame: feeling ashamed or guilty that one is unable to treat or guide successfully

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Using one’s own personal philosophy or our world-view as the default perspective in treatment

The supervisor should raise their concerns and be open to the need to modify their own style of teaching as well as the need to re-evaluate the growth of the counselor and target their training more appropriately

Sample Models of Supervision Chapter 3 of the Clinical Supervision Guidelines for the Victorian Alcohol and Other Drugs and Community Managed Mental Health Sectors; prepared for Mental Health, Drugs & Regions Division Department of Health, November 2013: 3.1 Psychoanalytic Foundations of Clinical Supervision Psychoanalysis as a discipline was founded by Sigmund Freud towards end of the 19th century. From the beginning of his working life, Freud was discussing his ideas and practices with others and they with him, although the terms clinical consultation and clinical supervision had not yet been adopted. As far back as 1902, he was involved as teacher, mentor and observer in the work of young doctors practicing to become psychoanalysts. This early type of supervision was didactic in form and the work centered on the patients’ dynamic processes.

Other helping professions began to develop their own supervision practices at this time and it is difficult 104

to know who influenced whom, or precisely in what order events unfolded. Social workers in the U.S. were introducing supervision as a “supportive and reflective space” (Carroll, 2007, p. 34) and other types of welfare workers were picking up these ideas at, or around the same time.

No matter which discipline or what form of clinical supervision one practices, psychoanalytic concepts have brought much richness to clinical supervision in all its phases. Freud’s psychodynamic ideas of parallel process and creating a working alliance are foundational across models of clinical supervision, having “informed the work of supervisors of all orientations” (Bernard & Goodyear, 2009 p. 81). It is believed that Max Eitington of the Berlin Institute of Psychoanalysis first made supervision a formal requirement for psychoanalytic trainees in the 1920s, just as mandatory standards for both coursework and observational treatment of patients were established by the International Psychoanalytic Society (Carroll 2007; Bernard & Goodyear, 2009).

The two schools of thought on clinical supervision that competed for dominance in the 1930s were the Budapest School and the Viennese School. The former held the concept of clinical supervision as a “continuation of the supervisee’s personal analysis” (Bernard & Goodyear, 2009, p. 82) which meant having the same analyst (supervisor) performing dual roles as both therapist and supervisor. In therapy, the focus would be on the supervisee’s transference issues in relation to the analyst; in supervision, the focus would be on the supervisee’s countertransference issues in relation to his or her own clients. The latter school held the idea that the supervisee’s transference and countertransference issues were both to be processed in therapy, so that supervision was retained as a teaching forum.

A psychodynamic model which emerged later on, in the 1970s, had a wide resonance for many practitioners both inside and outside psychoanalytic circles. This work marks the beginning of the supervisee as the center and focus of the supervision process. Ekstein and Wallerstein conceptualized clinical supervision as both “a teaching and learning process that gives particular emphasis to the relationships between and among patient, therapist and supervisor and the processes that interplay among them” (Bernard & Goodyear, 2009, p. 82).

Thus, the focus was on teaching rather than providing therapy, with the aim being for the supervisee to understand the overt and covert dynamics between supervisor and supervisee; to learn how to resolve difficulties which arose, and to develop the skills necessary to help his or her clients in the same fashion.

In the past decade, two psychodynamic therapists and supervisors, Mary Gail Frawley-O’Dea and Joan E. Sarnat, introduced a fresh psychodynamic supervision model in their book The Supervisory Relationship: A Contemporary Psychodynamic Approach (O’Dea, M.G. and Sarnat, J.E. , 2001, New York: Guilford Press), which suggested a new philosophical and practical position for the supervisor in relation to the supervisee. Previously viewed as an objective expert with a mastery of theory and technique, the supervisor in this model is afforded space to act less the dispassionate expert and more an active participant in the unfolding process of supervision. Thus, his or her authority “resides in the supervisorsupervisee relational processes” (Bernard & Goodyear, 2009, p. 82), rather than in the absolute, immutable position of the all-knowing superior. In such a relationship, both parties acknowledge a mutual influence and the supervisory stance shifts effectively from that of outside, reflective observer to 105

informed and purposefully influential insider.

Points to remember about psychodynamic supervision: 

Process and relationship oriented, with a focus on intrapsychic phenomena and interpersonal processes, in order to develop insight and provide containment



Close parallels between therapy and supervision

References for this section: Bernard & Goodyear (2009); The Bouverie Centre (Moloney, Vivekananda & Weir, 2007); Carroll (2007).

3.2 Clinical Supervision Based on Counseling Models In the 1940s - 1950s, there was another shift in the delivery of clinical supervision. The new models which emerged were based upon and tightly bound to the counseling theories and interventions of the practicing supervisor.

3.2.1 Person-Centered Supervision Carl Rogers, the founder of a humanistic, person-centered model of therapeutic practice, did not differentiate greatly between therapy and supervision, but simply shifted his role during sessions depending upon what his supervisees required at the time - personal therapy, or professional supervision.

As with the psychodynamic models, the person-centered model, to be effective, relied upon a strong and trusting relationship between supervisor and supervisee.

Rogers was among the first to use electronically recorded interviews and clinical transcripts in supervision (Bernard & Goodyear, 2009, p. 83), rather than relying only on the self-report of those he supervised. Carl Rogers’ influence on both therapy and clinical supervision practices has been profound. Though Rogers’ approach is less focused upon today in the U.S., it is still widely taught in the UK and many of the skills learnt by new practitioners world-wide can be traced back to him.

Points to remember about person-centered supervision: 

Process and relationship focused, with genuineness, warmth and empathy being imperative relational traits

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Exploration of self, both personally and in the context of the work, is essential to the process, with movement towards differentiation and self-actualization the goal of both therapy and supervision



Encompasses both teaching and therapy: 106

“I think my major goal is to help the therapist to grow in self-confidence and to grow in the understanding of himself or herself, and to grow in the therapeutic process...Supervision for me becomes a modified form of the therapeutic interview” (Rogers, cited in Bernard & Goodyear, 2009, p. 83).

3.2.2 Cognitive-Behavioral Supervision Cognitive-Behavioral Supervision, like the various models of therapy related to it, emerged in the 1960s.

It was a far cry from what had come before, in that the focus shifted dramatically away from the relationship and dynamic processes existing between supervisor and supervisee (or therapist and client) to the development of practice skills. Becoming an effective therapist, like becoming an effective person, involved mastering specific tasks and learning to think in ways which were beneficial to the personal or professional self, whilst taking actions to extinguish (in CBT terms) unhelpful thinking and behaviors that create problems. Thus, success as a therapist depended upon one’s ability to learn the work and to do it well, rather than on a good fit between therapist and client.

The tasks assigned to supervisees in clinical supervision would mimic that offered to clients in therapy, such as imagery exercises and role playing. As with cognitive behavioral therapy, this type of clinical supervision would hold that it is the intervention which counts, and specific interventions lead to specific outcomes, if followed precisely and faithfully. Assessment and close monitoring of supervisees was routine, as it was considered essential to the work that they both understood and properly utilised the theory and practice of the therapy, as expressed in the treatment manuals.

CBT in its current form, or forms, is more variable and open to influence than fifty years ago. For instance, more attention is now paid to relationship than in the past, and ideas from Eastern philosophy have been incorporated into the work by some practitioners (e.g., mindfulness, meditation). Similarly, these ideas tend also to be incorporated into clinical supervision and training in CBT work.

Points to remember about cognitive behavioral supervision: 

Instructional and skills-based (or strategy-based), with focus on achieving technical mastery, e.g., how to challenge negative automatic thoughts



Explicit and specific goals and processes followed, e.g., negotiating agendas at the beginning of each session

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Use of behavioral strategies with supervisee, e.g., role play and visual imagery

3.2.3 Family Therapy (Systemic) Supervision Family Therapy (Systemic) Supervision theory and practice has been documented since the 1960s, with 107

family therapists taking the unique step of making therapy a highly interactive and involved team effort, by observing their colleagues’ clinical work with families and engaging with them and the client family as part of the treatment team.

Although family therapy had been emerging for several decades, it broke through as a formal discipline with its own clear set of ideas in the 1950s, as a direct result of the work of an anthropologist named Gregory Bateson, and his colleagues at the Palo Alto Institute. Findings from The Bateson Project created a paradigmatic shift in the field of family therapy and refocused the energies of its practitioners. Family therapists began to understand the family as an interactive system; to pay close attention to communications between family members; to view causality as circular rather than linear and to believe that change could start with any member of a family, thereby impacting the whole. These ideas influenced the way in which family therapy clinical supervisors approached their work with supervisees, as supervisees were themselves understood to be part of an interlocking group of systems, all of which affected how they performed their work (e.g., family of origin; interaction with the client’s family system and the supervisory system).

There were several models of family therapy and it was considered essential that clinical supervision be consistent with the model of therapy that the supervisee was learning to practice. Despite differences in opinion regarding how problems emerged and what might help to solve them, all models held in common the role of the therapist as “active, directive and collaborative” (Liddle et al., cited in Bernard & Goodyear, 2009). This was also the case with clinical supervision, in which supervisors were highly engaged with their supervisees.

It was then and is now common practice for clinical supervisors to observe the work of their supervisees.

Sometimes this was (and is) done live, as in training programs, with the supervisor offering interventive suggestions via phone through a one-way mirror to the supervisee during sessions. This is a unique contribution of family therapy to the practice of clinical supervision that is called simply “live supervision.” More common is for supervisees to present recorded sessions of their work with clients and/or to offer written transcripts of sessions, which are then reviewed and discussed in clinical supervision sessions.

Another unique contribution of family therapy to clinical supervision is the reflecting team, a therapeutic model introduced by Norwegian family therapist Tom Andersen in 1985. A reflecting team is a group of therapists who observe a colleague conducting a family session, then have an open conversation with one another, observed by the colleague and client family, about what they noticed in the session. This is done respectfully and thoughtfully, with great care and consideration taken in relation to the possible impact of their observations. The idea is to generate fresh possibilities for the clients and to offer multiple perspectives and a sense of hopefulness. In the same way, a reflecting team can observe a family session facilitated by a supervisee, focusing their reflective comments on what they noticed in the supervisee’s work. This is common practice in training programs, where a group of supervisees might act as a 108

reflecting team, under the guidance of a clinical supervisor.

Points to remember about systemic supervision: 

Focus on relational approach to understanding of and intervention in presenting problems



Makes explicit connections between people and the wider social context

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Greater use of direct observation and live supervision (compared to other supervision models)



Supervisor’s role is that of director or consultant



Focus on the supervisee’s position within the broader system

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Principles and techniques used in therapy are congruent with those used in supervision and may be applied to supervisee, e.g., strategic interventions, family of origin exploration

References for this section: Bernard & Goodyear (2009); The Bouverie Centre (Moloney, Vivekananda & Weir, 2007); Carroll (2007).

3.3 Developmental and Social Role Model Approaches to Clinical Supervision Developmental and social role model approaches to clinical supervision have been in use since the 1950s, but began to gain great popularity during the 1970s and 80s.

Developmental models There are many models of clinical supervision that can be defined as developmental, which can be further categorized into three types: stage developmental models; process developmental models and life-span developmental models. These focus on the developmental stages of the supervisee in relation to the clinical supervision process. Clinical supervisors are also understood to go through developmental stages as they hone their talents and skills in their work with supervisees.

Stage developmental models describe supervisees moving through progressive stages in their professional maturity and within the supervisory relationship. The beginning counselor is seen as highly motivated, but with only limited awareness and quite dependent on the supervisor. Over time and through experience gained, the counselor becomes more consistently motivated, more fully aware, but less self-conscious, and more autonomous. An example of a stage developmental model is The Integrated Developmental Model (IDM) developed by Cal Stoltenberg, Brian W. McNeill and Ursula Delworth.

Process developmental models are those which focus on processes in the supervisee’s work which “occur within a fairly limited, discrete period” (Bernard & Goodyear, 2009, p. 92).

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Examples include: 

Reflective models of practice - models which encourage the use of reflection to improve practice, by focusing on an experience in a counselor’s professional practice which is having an emotional or intellectual impact that requires deeper understanding. Originally based on the concepts of John Dewey in the 1930s, these models continue to be developed and widely used today.



The Loganbill, Hardy and Delworth model - a counselor development model based on processes which are “continually changing and recursive” (Bernard & Goodyear, 2009, p. 94) and expressed by characteristic attitudes towards the work, the self and the supervisor. A key difference in this model is that it dismisses ideas of linear progression through stages in favour of continual cycling through “with increasing.. .levels of integration at each cycle” (Bernard & Goodyear, 2009, p. 94).



Event-based supervision - a task focused model in which the supervisor and supervisee focus on analyzing how the supervisee has managed particular discrete events in his or her work.

Supervisee and supervisor decide where to focus their attentions by either a direct request of the supervisee, or by the supervisor picking up on subtler, or less direct, cues.

Task-focused developmental models of clinical supervision, such as Michael Carroll’s, break down supervision into a series of manageable tasks. In Carroll’s integrative model (which is also a version of social role model), he suggests the following seven central tasks of clinical supervision: creating the learning relationship, teaching, counseling, monitoring (e.g., attending to professional ethical issues), evaluation, consultation and administration.

Lifespan developmental models, such as The Ronnestad and Skovholt Model, focus on the development of counselors across the lifespan, rather than just the few years when they are new to their work. This six-stage model begins with “The Lay Helper Phase” and ends with “The Senior Professional Phase” (Bernard & Goodyear, 2009, p. 98), and is unique in articulating the differing needs in clinical supervision for counselors at each stage of their professional lives.

Social models Social role model approaches to clinical supervision focus on the roles, tasks, foci and functions of clinical supervision. Two examples are Hawkins and Shohet’s “Seven-eyed Model,” (originally called the “Double Matrix Model”) and Holloway’s “Systems Approach to Supervision (SAS).”

The “Seven-Eyed Model” (Hawkins and Shohet) recognizes that the clinical supervisor employs different roles or styles at different times, but also concedes that the role or style, is likely to be most influenced by the particular focus of the work at the time. This is a process model, which stresses attending to the 110

processes that occur during supervision and within the supervisory and therapy relationships. Hawkins & Shohet coined the term the “good enough” supervisor, alluding to the object-relations idea of the “good enough” mother (i.e. one does not have to be perfect, or get everything right). They believe that a primary and consistent role of the supervisor is that of providing containment for the supervisee.

The “Seven-Eyed Model” of supervision is called such because it recommends seven areas of focus for exploration in supervision: (1) content of therapy session; (2) supervisee’s strategies and interventions with clients; (3) the therapy relationship; (4) the therapist’s processes (e.g., countertransference or subjective experience); (5) the supervisory relationship (e.g., parallel process); (6) the supervisor’s own processes (e.g., countertransference response to the supervisee and to the supervisor-client relationship), and (7) the wider context (e.g., organizational and professional influences).

Holloway’s “Systems Approach to Supervision Model” is integrative and comprehensive, taking into account a number of factors which impact upon supervision. Holloway recommends that five systemic influences and relationships be considered: (1) the supervisory relationship (phase, contract and structure); (2) the characteristics of the supervisor; (3) the characteristics of the institution in which supervision occurs; (4) the characteristics of the client, and (5) the characteristics of the supervisee.

Holloway then offers a task and function matrix for conceptualizing the supervision process, in which the five functions are: monitoring/evaluating, instructing/advising, modeling, consulting/exploring, and supporting/sharing. The five tasks of the matrix are: counseling skills, case conceptualization, professional role, emotional awareness and self-evaluation. The matrix provides twenty-five task-function combinations.

The tasks and functions together are said to equal process, and all are conceptualized to be built around the “body” of supervision, the relationship.

Points to remember about developmental and social role model approaches to clinical supervision: 

Historically, a point of transition when the focus of supervision shifted from the person of the worker to the work itself

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Conceptualize clinical supervision as related to, but separate from, counseling, and as a unique process requiring its own practice principles, knowledge base, and skill set

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Focus on the tasks, roles and behaviors in clinical supervision

References for this section: Bernard & Goodyear (2009); The Bouverie Centre (Moloney, Vivekananda & Weir, 2007); Carroll (2007).

3.4 Postmodern Approaches to Clinical Supervision Postmodern approaches (a.k.a. Social Constructionist or Post-Structural models) to therapy and clinical 111

supervision have been emerging since the 1980s and include narrative therapy models, solution-focused models and feminist-influenced models. The therapeutic models built upon postmodernist ideals began to have a heavy influence on the practice of therapy in general and on family therapy, specifically, in the 1990s, which inevitably changed the practice of clinical supervision for those involved. This was considered to represent a major paradigm shift in the practice of systemic therapies in particular. The philosophical perspective of postmodernists, in their various disciplines, is that: “Reality and truth are contextual and exist as creations of the observer...grounded in their social interactions and informed by their verbal behavior” (Philp, Guy, & Lowe, cited in Bernard & Goodyear, 2009, p. 86).

Thus, there is no objective, observable reality or one truth, but multiple realities and truths based on a wide range of human experience and interpretation, expressed predominantly through language - itself a tool with which we construct our worlds.

Anyone practicing narrative, solution-focused, or any other type of therapy underpinned by a postmodern world view, would give a strong emphasis to language and would understand the power implicit in words. Practitioners of these models attempt to understand the client’s world as the client understands it and do not assume a shared reality or truth between themselves and others. Since knowledge is not held as absolute, open and reflective questions which maintain a stance of curiosity in relation to the client is a hallmark of the work. These traits would be apparent in clinical supervisors as well as therapists.

Although there are significant differences in the various models of clinical work and supervision which fall under the umbrella of postmodernism, they have some shared qualities which are distinctive to them.

Firstly, the role of the clinical supervisor is more consultative than supervisory, with the relationship being valued as a collaboration and dialogue being guided by questions rather than answers. There are some clinical supervisors working from these modalities, in fact, who refer to themselves as consultants and their supervisees as colleagues, no matter the difference in their levels of experience.

This leads to the second distinctive feature of these models, which is that there tends to be a very conscious effort to avoid emphasizing hierarchical differences between supervisor and supervisee and in fact, to minimize those differences in status as much as possible. Thirdly, there tends to be a strong focus on the strengths and successes of the supervisee, with a view to building upon those, rather than close analysis of perceived failures or faults.

Special mention should be made here of Johnella Bird, from The Family Therapy Centre in Auckland, New Zealand, who has emphasizes the use of relational language and what she calls “prismatic dialogue” in evoking directly the voices of all the participants (including the client) in counseling and supervision. To this end, a thirty to forty minute long prismatic interview (that is, one in which the counselor is invited to consider aspects of the situation from the position of client) is audio-taped, and the tape taken back to the client for comment and reflection. According to Bird (2006) counselors: 112

“...experience a sense of movement as they engage in prismatic dialogue. Invariably this movement produces awareness of new possibilities for therapeutic directions and conversations. I believe one of the principal tasks of super-vision is to liberate the mind in order to foster the counselor’s sense of creativity.”

Points to remember about postmodern models of supervision: 

Focus on subjective experience

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Multiple truths are understood in relation to context

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Strong emphasis on language and its relationship to power (dominant discourse)

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Supervisor’s role is that of consultant

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Effort to subvert hierarchy; striving towards equality between supervisee and supervisor

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Focus on the supervisee’s strengths

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The client’s perspective is included directly where possible

References for this section: Bernard & Goodyear (2009); Bird (2006); The Bouverie Centre (Moloney, Vivekananda & Weir, 2007); Carroll (2007 Counselors at Different Levels of Clinical Development The counselor needs be a transformation agent. This must be done with immeasurable caring and respect, perhaps even love.

Consider“ ...if the therapist doesn’t change, then the patient doesn’t, either” -Carl Jung “Psychoanalysis is in essence a cure through love” -Sigmund Freud (1906) “The greatest privilege is to share in the unspeakable dread and heartache of another” - D. Peratsakis Therapy allows for the continuous possibility of a genuine, human-to-human encounter. As the counselor develops greater “therapeutic relational competence” (Watchel, 2008), their power as an agent for change grows. Both the therapist and client grow together through their authentic encounter with each other (Connell et al.,1999; Napiers & Whitaker, 1978): 

Be authentic and fully accept and care for the person, not despite their foibles and imperfections, but because of them.

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Push for the outpouring of shame, sadness or rage, despite your own primal fear of losing control or being consumed.

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Find compassion for the vileness of another’s thoughts, actions or past and discover “What is not so terrible about them?”

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Fully embrace that the outcome of therapy is your responsibility and that clients do not fail but are failed by therapy.

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Make session a safe haven in which to practice new ways of thinking, feeling and interacting. Do so by your own willingness to experiment, be in the moment, and experience risk.

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Whenever possible, pull clients into your own energy, optimism and sense of hope.

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Self-disclose; it is “an absolutely essential ingredient in psychotherapy – no client profits without revelation” (Yalom).

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Freely step into the abject terror of another’s pain knowing that for at least those few moments, the other is no longer alone.

First Level Counselors/Beginning Practitioners Common Characteristics 

Lacks integrated perspective on human nature, including ethical, legal, occupational, and familial considerations. Tendency to oversimplify the development of self-process.

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Tendency to match theories against their own personal experiences; this tends to develop a prejudice for the model that merely fits their own experiences best.

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Tendency to overuse one model, developing an over-simplistic understanding of complex structures. This generalizes behaviors and creates “types” of clients, thereby minimizing individual differences.

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Tendency to minimize importance of self-awareness and personal growth.

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Tendency to over-focus on learning new information and performing newly acquired skills, in lieu of understanding the process of therapy and the client’s unique perspective and story.

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Tendency to over-focus on self, including own anxiety about being a clinician, lack of skills and knowledge, and the likelihood that they are being regularly evaluated; preoccupations detract from treatment with cookbook answers and session-to-session planning; less energy for study.

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Tendency to be fearful of more genuine, intimate contact with client, to smooth over volatile issues, to avoid inclusion of more volatile members and to minimize issues that resonate within one’s own life. Reluctance to engage client material at a deeper level, especially pain and shame.

Training Issues in Clinician Supervision 

Practical concerns: supervision requirements; caseload size/mix; treatment space; clinical forms and documentation; etc.

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Supervisee anxiety: provide support and encouragement; promote autonomy and risk-taking; continuously monitor potential risks to clients; be available to consult or co-facilitate.

Target overall development in understanding of human nature, culture, and clinical theory and practical skills:

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o

Train on various theoretical approaches; purpose and process of treatment; symptom development and management; role of therapist; intervention tactics and techniques; therapy modalities (individual, couple, family, group); etc.

o

Train on Practical Skills: authenticity and personal risk; accommodation and joining; assessment; challenging; contracting; assigning tasks and directives; assigning homework; teaching problem-solving and resolving conflict; etc.

o

Train on High-risk concerns: threats; trauma; harm to self or others; depression & anxiety; domestic violence; etc.

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Observe work using role-plays, case presentation, two-way mirror, videotape, and live supervision

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Self-growth: use of self in session; comfort with intensity as well as intimacy; personal issues that impact client care; cultural competency and sensitivity to difference; the supervisory triad (isomorphism and parallel process); burn out and self-care; etc.

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Legal and ethical issues: mandated reporting,; duty to warn; civil commitment orders; NGRI; subpoenas; confidentiality (42CFR2/HIPAA); separation, divorce and child-custody decrees; Advanced Directives; Human Rights laws; etc.

Professional development, including current events and policies related to the counseling field;

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Second Level Counselor/Moderately Experienced Practitioners Common Characteristics 

Demonstrated continuation of proficiencies in theoretical premises and core skill competencies.

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Clear growth across various domains, including greater preoccupation with client centered care (versus self as counselor); a greater sense of independent functioning and autonomy from the 115

supervisor; broader use of a range of technique; improved use of self; longer-term strategizing in client care; and improved understanding of the therapy process from contracting to termination. 

Caution: this period often evidences fluctuating levels of motivation by the counselor, including periods of resistance, ambivalence, and lethargy. This can lead to conflict between the supervisee and supervisor and may also result in a deeper understanding of clinicians’ skills and personal characteristics; typically, therapist confidence is shaken by an increased knowledge of the complexity of the recovery process; frustrations with client progress and satisfaction; treatment failure; etc. Supervisee tendency to lay more blame on client for lack of change.

Training Issues in Clinician Supervision  

Encourage broader experimentation; reduce frequency of supervisor directives; allow counselor to propose and select interventions. Require supervisee demonstrate technique and present to peers on cases and clinical issues. Arrange peer co-facilitation.

Encourage more open dialogue and cooperative planning between counselor and clients. Require treatment planning in stages.

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Increase caseload size and complexity of assigned clients; challenge supervisee’s work by forcing them to articulate their conceptualizations of the client, the interventions they chose, and possible alternatives and their predictable outcomes.

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Vary treatment modalities (ie. couple, family therapy); encourage presentations select topic areas to various audiences; increase outside training and reading assignments; arrange peer case supervision and (limited) clinical supervision under guidance

Level Three Counselors/Advanced Practitioners Common Characteristics 

Counselor is able to fully empathize with, and understand the client’s perspective on the world, their goals and desire for change and has a better understanding of human behavior and the therapeutic process.

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Counselor motivation has stabilized with an improved appreciation of their own skill ability and limitations. Improvement in skill should have reduced treatment outcome variability, improved dexterity in contracting, and promoted more sophisticated challenging.

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Autonomy increases: counselor has a deeper understanding of treatment methods, accepting of supervisor with different orientation, broad ethical knowledge, is able to switch tracks with clients, and appropriately uses self in therapy.

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Is able to lead clinical discussion, supervise Level One counselors, present subject matter expertise, able to present in court and to law enforcement, comfortable ease in individual, group, 116

couple family and multi-family therapy modalities. Able to handle high risk and extremely complex client profiles and syndromes.

Clinician Supervision Issues 

Role of supervisor is to guide the supervisee toward mastery and integration of all domains, from assessment to treatment to aftercare. Supervision becomes considerably more collegial, and there becomes a much less differentiation of expertise and power in the supervisory relationship.



Structure in supervision usually comes from the supervisee, rather than the supervisor. That is, this level of clinician knows what they need from supervision at any given time. Supervision takes on the facilitative tone (support, caring, confrontation when needed) as opposed to the structured one (specific interventions such as live observations). A common form of supervision with Level 3 therapists is collegial, informal group supervision. While they can work with a level 2 or even 1 supervisor, they really need a level 3 supervisor.

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Supervisor develops preference for Level One counselors (“open and eager”) and Level Three counselors (collegial); greater reluctance to accept and work with Level 2

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Need for therapist to move toward supervision of peers and Level 1 supervisees

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Group Supervision “Group supervision is the regular meeting of a group of supervisees (a) with a designated supervisor or supervisors, (b) to monitor the quality of their work, and (c) to further their understanding of themselves as clinicians and the clients with whom they work, and of service delivery in general. These supervisees are aided in achieving these goals by their supervisor(s) and by their feedback from, and interactions with, each other.” Bernard and Goodyear (2009) 

Types: 1) Case consultation: one member presents for the purpose of feedback, support and discussion of theory and technique; 2) Peer supervision: a group of similarly trained or skilled individuals (e.g., all addiction counselors, clinicians at a certain developmental level), meeting regularly for mutual supervision and support, which may or may not include a group leader or supervisor; and 3) Team supervision: typically a mixed group with a defined leader or leaders, often with intra-disciplinary or interdisciplinary members at various skill levels (e.g. students to level 3 clinicians).

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Size: Groups should not be so large that members are shortchanged nor so small to be unduly impacted by disruptions such as absences or dropouts. The average group should be no less than 4-6 supervisees and no greater than 12.

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Benefits: o Economics of time, costs and expertise. o Skill improvement through vicarious learning, as supervisees observe peers conceptualizing and intervening with clients. o Group supervision enables supervisees to be exposed to a broader range of clients and syndromes than any one person’s caseload o The normalization of supervisees’ experiences o Supervisee feedback of greater quantity, quality and diversity; other supervisees can offer perspectives that are broader and more diverse than a single supervisor o Quality increases as novice supervisees are likely to employ language that is more readily understood by other novices o The group format enriches the ways a supervisor is able to observe a supervisee o The opportunity for supervisees to learn supervision skills and the manner in which supervisors approach providing guidance

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Limitations: o The group format may not permit all individuals to get what they need. o Less skilled members may monopolize the available time. o Group dynamics, such as personality conflicts and inter-member competition, can negatively affect learning. o The group may devote too much time to issues of limited relevance to, or interest for some group members; o Group supervision does not have a parallel process to individual supervision. While group supervision could potentially help one out with their group processes, (depending on the modality) a large portion of discussions in group supervision is regarding individual work with clients.

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Group Supervision Supervisory Tasks o

Assume an active stance in the group; one that steers a careful course between over- and under-control

o

Assert yourself as necessary to redirect the group; impose limits, set Agenda, etc.

o o

Listen to and then following the group, challenging direction as necessary Be able to choose the right fights when inevitable conflicts emerge between supervisees or within the group itself

o

Communicate clearly just what you want to happen. Be confident, but not autocratic

o

As the leader be able to process the groups interaction style and level of development to understand where members are, rather than where you wish them to be.

Conflicts in Supervisory Directives It is very common for counselors to receive conflicting feedback from supervisors and peers. This may broaden one’s insight or create confusion and paralysis. 

There is rarely only one way of interceding; alternatives provide flexibility and spontaneity

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Peer observation may have as much (or more) validity and should not be discounted

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Paralysis often results from a fear of doing, the desire to please, or anxiety about being wrong

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Supervisees are responsible for following the directive of their assigned ‘primary’ supervisor

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Counselors, as well as supervisors, should pay attention to the suggestions they like the least

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Counselors must accommodate feedback to their own language, tempo, and way of working

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Counselors should avoid a method simply because it “feels safer” or is more “comfortable”

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If one is truly “stuck” or confused as to how to proceed, ask the client

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Learning to “trust one’s gut instincts” is the beginning of independence in counseling

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As counseling is only as good as the counselor, supervision is only as good as the supervisor

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Counselors should be coached on responsible spontaneity

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o

if one is clear on the plan for the session, one is free take whatever step fits best at the moment and fully experience the journey;

o

one must always be willing to abandon the plan, in order to go where one must be.

Supervision Formats 

In-supervision formal and informal case presentations

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Review of session progress note(s) and/or case file

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Review of video or audio recordings o

Supervisor reviews and provides feedback

o

Supervisor and supervisee review in tandem and discuss

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Consultation; prearranged intervention with counselor and client(s)

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Group supervision; Peer supervision; Multi-supervisor supervision

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Post-session interview(s) or treatment review(s) with client(s) directly

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Live supervision (supervisor is responsible for treatment outcome; J. Haley, 1996) 

Two-way mirror, tele-med link, monitor, or audio link

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Co-facilitate or supervisor in session as observer

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Greek Chorus arrangements

Live Supervision and Tasks Common to the Lead Supervisor 

In Live Supervision, you are in charge and responsible for the outcome of therapy/treatment

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Ensure an agreed upon format and have everyone follow the same model of treatment

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Decide, in advance, the extent of disclosure with clients of the team’s strategies and techniques

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Be prepared to redirect, block, reframe, or side-line directives by non-lead counselors

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Formats may include Supervisor/Counselor(s) alternating, Lead, Tag-team, Good Cop/Bad Cop

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Require that all participants must be prepared to practice before the group; they must practice

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Require that supervisee is fully prepared to present their case (see next slide)

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Do not permit mocking, horse-play or ridicule of clients or other counselors (either side of mirror)

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Follow 1 or 2 cases from first session to termination, whether the supervisee sees a concern or not 120



Demonstrate: how to effectively interview (therapy is competent interviewing; J. Haley)

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Demonstrate: how to move into the client’s emotional sphere, and then keep inching forward

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Demonstrate: how to introduce in-session tasks and force work by remaining undistracted/on-task

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Demonstrate how to introduce and reach agreement on the need to bring in critical participants

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Demonstrate: how to push for the pain, -the worry, the guilt and shame, the anger, the sorrow

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Demonstrate: how to button-up after each hard push and then at the end of a session

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Team Supervision December 12, 2016 Meeting

Common Group Problem Scenarios Member roles and participation issues  Dominating  Mute  “Expert” group members  Echoing the leader  Inattentive/disengaged  Defiance Feedback issues  Overly critical  Lack of constructive criticism  “Deaf” participants (not receptive to feedback)  Subgrouping (ganging up)  Challenging the leader Casework issues  Button pushing (hitting on personal issues)  Time-wasting on irrelevant issues  Collusion with the client  Presenting insufficient information  Ethical impropriety/placing consumer at risk

Feedback to the Case Presenter Topics of feedback may include: 

Commentary of overall treatment strategy

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Focus on “blind spots”

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Areas for clinical improvement (professional development)

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What would I do? (And how would I get there? See Contracting and Refocusing; page 15 and 45)

Case Presentation: OP Case Sample

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Contracting    

What is the chief complaint (presenting problem or symptom) What is the desired goal (s) or outcome of treatment How is success to be understood or measured, in behavioral terms, and Who is to participate and under what terms

Interviewing & Tracking PP and It’s History 

When did it start? What else was happening then?

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What attempts have been made to fix it? What worked? What did not work?

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What exactly happens?: “…and then what happens?” (sequencing)

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Who participates: who does what, when? (transactional pattern)

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What does the it prevent or safe-guard from happening: “what would happen if this was no longer a problem?” = purpose of PP or symptom

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Beware of the search for insight as a means to success

Typical Goal-setting Problems Common problems that occur during early contracting 

Cancellations and No-shows

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Too many PPs, too many IPs

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Disagreement on PP or IP

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Commitment to Tx is vague

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Client(s) refuses to do task or is belligerent to directive

Common problems that occur once treatment is underway 

Therapist finds themselves spinning in session or confused as to direction of treatment

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PPs/IPs continually shift; new “emergencies”

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Attendance gets “spotty”; misses homework

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Members change or refuse to attend

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Therapy is stalled, stuck or slow as molasses 123

Section 3:

Directives and Technique

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Section 3A: Casework Examples on Directives and Technique DP Clinical Notes: Case Study Messaging, Relabeling and Reframing; First Session/Depressed and Suicidal; December 2016 There is a considerable amount of literature on communication and neurolinguistics. Good reads can be found from Satir, Bateson, Watzlawick, Beck and Ellis on meta-communication, paralanguage, and double-bind and paradoxical statements. A good read on meta-messaging can be found here: http://www.cleanlanguage.co.uk/articles/articles/192/1/The-Role-of-Meta-comments/Page1.html ____________________________________________________________________________________ Note: The following is a brief recounting of the first session of work with a young man, aged 19, reporting depression and suicidal ideation. It is presented for illustrative purposes as some of the interventions are atypical and, as such, are helpful in understanding the broad range of interventions possible under the right circumstances.

People make extensive use of symbols in their communications, including labels, phrases and idiomatic expressions that convey poignant messages with social or personal meaning. Introducing these into session can serve as short-hand descriptors for ground already covered and are particularly helpful in “reframing” the pictures and language one uses to interpret their customary experience of reality. For example, the phrase “black sheep of the family” conveys the relatively universal plight of someone regarded as the outside or misbegotten member of the family. Creative re-use of such expressions can introduce new possibilities that alter elements of one’s customary identity and self-image. If a client complains that they feel like the “black sheep”, which typically carries a negative connotation, “black sheep” can be reframed as the “independent” or “strong minded one”. Similarly, if the client boasts that they are the “black sheep” meaning “rebel” or rogue by intent, one can twist the term to expose an underlying rule or message that advantages therapy: “yes, but black sheep get led to slaughter all the same” or “perhaps being the black-sheep is more about being sheepish than black?’

The case example below demonstrates the use of re-interpretation and reframing. The more specific to the relationship, the more meaningful the new language becomes. As always, that which is permissible is in large part defined by the relationship between the client and the therapist; the more provocative the relabeling, the greater the need to maintain a continual check on the “barometer” of the relationship. __________________________________________________________________________________ Client “Jonathan” is a white, active duty soldier who portrays himself as a “tough guy”. This helps him acclimate socially while also protecting himself from personal scrutiny.

The Presenting Problem began as a result of a sexual encounter that occurred between himself and his cousin 4 years ago. He reports the incident as involving fondling with no penetration although she has recently reported it as “rape”. A major family crisis and rift ensued, with her father, mother and herself on 125

the one side and his mother (the girl’s mother’s sister), father and himself, on the other. The families avoid casual contact and he feels responsible for the conflict and pain.

As an older (62) male therapist some of the more provocative moves and language described herein were deemed beneficial as a means of joining and accommodating to the client. They are referenced as examples of what may be permissible given the relationship and therapeutic alliance. Banter and teasing between men are often acceptable methods of bonding and forming intimacy. This can be particularly effective with young adults, especially when accompanied by cajoling and humor.

The perspective is Adlerian and Strategic; based on the Presenting Problem, the treatment strategy will include “making amends as a form of revenge and retribution” and reaching closure on the event as a step toward leaving home and working toward manhood.

Session The client presented in a braggadocio manner, a means of managing anxiety common to many young men; he “vice-gripped” my hand, made mocking comments about “psychiatry”, “strutted” around the office and so on. He reiterated the purpose of his visit (described first to me by phone) as being for his depression and so he “doesn’t just stick a gun in his mouth and blow his mother fuckin’ brains out”.

Tongue-in-cheek, I asked him to hold off on doing so, if possible, as ‘most people don’t kill themselves until after they’ve gotten to know me”. “Besides”, I mused, “they just cleaned the rugs and would probably blame your failure on my own incompetence”. He laughed, assured me he would not, and the banter between us began in a stereotypic form of male bonding toward intimacy. __________________________________________________________________________________ Note: Assuming a one-down position (deflating one’s own importance and ability) is an extremely powerful technique that a therapist should acquire some level of comfort in adopting, as necessary. It is an effective method of countering or dis-engaging power-plays, especially when “over-powering” is not a viable option. An immediate attack on the seriousness of suicide, and in particular its false sense of “nobility”, can be a life-or-death matter and must be undertaken with great care. When appropriate, the threat of suicide is re-labeled as a disingenuous act of revenge that is spiteful and a “cowardly” alternative to expressing one’s resentment in a more direct and appropriate manner. In essence, suicide is disempowered by exposing its underlying anger and attaching a vengeful intent to its motive (“making the ‘covert’, ‘overt”). Adler was the first major theorist to propose that the threat, act or ideation of suicide can serve as a formidable form of punishment or revenge, allowing the depressed individual to retaliate for a perceived injustice. It is important, therefore, to tap into the underlying anger and redirect the client’s actions toward a more meaningful, but acceptable, form of “retribution”. Typically, I couple the need for “revenge” with the need for “forgiveness” and “redemption” through making “amends”.

Highlights: 

Joined and immediately assessed for suicide risk, disengaging the power-play and urgency associated with the “threat” of suicide; checked for need to stabilize mood through medication.

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Relabeled his “depression” as “you’re simply angry with others” and the “anxiety” he was experiencing as “it’s your body’s way of telling you that you must act, that you need to do something about the anger you are carrying around for these people, but don’t know what to do”.

It is useful to reinterpret or more closely define the experience in relational or action terms. The proverbial belief that one must “come to a realization” or “acquire insight” as a prerequisite for change is somewhat limiting; one can bring the insight to the client or suggest a suitable alternative interpretation. This can expedite the change process.

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Explored the underlying remorse and sadness at the loss of his relationship with his aunt, of whom he is particularly fond and the impact to both of the families (shame)



Contracted for “mending the fences”. Discussed the difficulty, possible risks, and that it took unwavering courage and “manhood” to undertake such a challenge. I explained that only a true “warrior” would look to do what is just and noble and that his choice was to remain a “worry-er” or to become a “warrior”. This is a common turn of phrase that I use, introducing it as a means of creating a new visage, one in keeping with the moral aspirations of the military. He validated this, which gave me permission to push further: I wondered aloud if he would be willing to put his “strutting like a rooster” down long enough to take a more powerful step toward manhood (this is a flipping over of the customary paradigm). I indicated that lots of guys find it impossible to turn off their “crowing” or “cock-a-doodle-do” long enough to become true warriors. This term then became a symbol or idiom (icon) for the two-dimensionality of the bravado-visage; it was moved from “crow like a rooster” to “cock-a-doodle-do-ing” to “cock-a-doodle-do-shi*t”. Now, whenever he “struts” as a reluctance to allow his more viral emotions to surface he is asked to place his “cock-a-doodle-do-shi*t” to the side long enough to brave another step toward warriorhood. “Cock-a-doodle-do-sh*ting” was further relabeled as “silly” and “an old habit” that interferes with what he claims he wants to obtain. There are several twists and turns to this form of re-messaging as a means of unbalancing the world-view, creating a new vocabulary and, in turn, a new set of rules and self-messages.



Ending session and Buttoning-up: “Was this meeting as bad as you thought it might be? Should we try it just one more time and see if we can make things even worse? At least then if you killed yourself you could blame me all the more!” (This is a subtle shift of the “you” and “me” to the “we and “us”. “We” are now responsible and “you” are no longer alone.) This brought a laugh after which he was challenged to “try not to kill himself between now and the next session although if he did he should know that while others might get upset, that I would know better and consider it a “chicken-sh*t” move on his part; “more cock-a-doodle-do-sh*t”. In essence, the act of committing suicide was reframed as anger and the desire for revenge relabeled as a cowardly cop-out from responsibility. He was challenged to either sit and sulk on his “pity-pot”; “Of course, only a true warrior allows himself to be vulnerable and seeks to make amends; what is it that you would like to do?” This hit a strong chord and as an affront to his bravado. The reframing of the power of the suicide threat, while risky, was an effective method of de-escalating its potency and ‘spitting in the soup’ of its purpose. He was told that it was okay for him to be angry with me for saying so but that I hoped he wouldn’t “wimp out” and not return. He laughed and we bantered some more.

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

I ended session by discounting much of my own “silliness” as a ruse to get close enough to him so that I could experience some of the tremendous pain and anguish that he experiences. I assured him that it was understandable that he was angry at his family for making him feel ashamed, but that he also felt guilty and would need to be willing to own some of that himself if he was willing to make things right. (“willing to do so” has replaced “able to do so”). I thanked him for “putting up with me” as most folks tended to “ignore me because I am old”. Once again, this last, tonguein-cheek self-deprecation comment is a powerful example of “leveling the playing field” between oneself and the client, beginning the slow shift toward partnership as equals in the process of change. He now refers to me as the “old fucker”, and I couldn’t be more pleased.



Lastly, the client was assigned homework; to write a letter to his aunt, tell her that he misses her and that he needs her help to heal the family rift”. He was further directed to begin with an apology and that under no circumstances was he to mail it or share it with anyone yet: “Do it if you feel ready, but don’t make it a test. Stop if it becomes overwhelming, but go back to it if you can; if it’s too much, then stop, I certainly ‘don’t want you to commit suicide over it!”

_____________________________________________________________________________________ Notes: The making of amends is a powerful tool to forgiveness and healing. It “unsticks” the client and gets them moving from a passive mode (depression) into one of proactivity and control over one’s actions. When the client is experiencing shame and guilt, they are experiencing remorse. It is then of great importance to work toward the making of amends as critical step toward self-forgiveness and redemption.

DP Clinical Notes Case Example Contracting for Couple Therapy; couple do not agree on direction or pace of relationship Background: Gabrielle has been working with a life-long victim of trauma who initially sought treatment for depression and anxiety. Her immediate concern is her current relationship with a live-in boyfriend, the biological father of her newborn daughter of 4 months. She states that she wishes to get married but that he is reluctant, citing trust issues due to her infidelity, former drug use, and explosive behavior. Both parents are very invested in raising the child and he has expressed a willingness to attend session.

The client is also involved in a custody dispute over the fate of her six year old son who resides with his natural father. Gabrielle suspects this may be adding pressure to demonstrate a stable home life and that “marriage” represents a means of redeeming herself for prior “sins and wrongdoings”. _____________________________________________________________________________________ Note: Difficulty agreeing on the primary goal of therapy is a very common challenge. The client may be confused as to where to begin or fist need to purge long standing woes or complaints. They may be 128

experiencing urgency from several competing matters or be ambivalent as to the ability to find solace from their pain. When others are involved, they may complicate goal-setting by presenting different agendas or have varying degrees of interest in resolving the primary concern. Typically, these are a direct reflection of the client’s anxiety to beginning treatment or a pattern of avoiding an issue in order to stay safe and deflect from experiencing emotional pain: “if I don’t think about it, I won’t have to work on it and risk having to feel the pain”.

At times, however, the “confusion” or difficulty committing to a specific goal may be a purposeful need of the client’s to control the therapeutic alliance. In these instances, one often experiences the continual switching of presenting problems, confusion over the need for treatment, incurring new “emergencies” that preclude progress on the agreed upon agenda or inconsistency in attendance or punctuality.

It is for this reason that “contracting” is not merely the process of agreeing on the goal of therapy, it is an exceedingly critical part of the treatment process itself. _____________________________________________________________________________________ Treatment Strategy: Gabrielle and I agreed to hold a special session or “consultation” as a means of introducing a new start to therapy while obtaining a commitment to work on a single presenting concern (PP). This is a good way to push through an impasse, and can be introduced as a common method employed to “kick start” a more aggressive step in therapy. We ascertained that much of the current anxiety in the system is a result of couples’ conflict and ambiguity.

The couple was receptive to attending this “special” session, at which time each was asked to express what they hoped to accomplish within the hour or 90 minute session. In this instance, it also helped to introduce a male co-therapist as a means of “leveling” the playing field.

The session went well with both expressing a willingness to return. Since both expressed an investment in working on the relationship for the sake of their daughter we agreed to meet an additional time to see if we could reconcile their impasse. ____________________________________________________________________________________ Note: The co-therapy team agreed to NOT meet unless both members of the couple were in attendance.

This was deemed necessary to help ensure that the progress made by IP-ing the couple’s relationship could harden and that controlling the agenda and format of treatment retained. Structure is typically imposed by the therapist (s) by controlling the parameters of counseling.

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Technique: Since solidifying an agreement to work on the relationship is essential, the couple would be given an opportunity to make progress on their ambivalence and then asked to discuss the direction they would like assistance in obtaining: separation or marriage. It should be noted that while the girlfriend outwardly expresses a desire for “marriage” the couple’s “yes/no” position retains a level of safety for each of them, as no movement is possible. The indecision, however, adds to their pain and conflict, while the growth of their child will continue the pressure for change. Naturally, his “no, not yet” stance regarding marriage places the boyfriend in a position of some control.

Plan for Session Two: 1. Chairs for decision-making: “all the reasons I should get married” versus “all the reason I should NOT get married” 2. To expedite the decision-making process the girlfriend will be instructed to argue “against” marriage, while the boyfriend “for marriage”, the opposite of that which they espouse.

3. The couple will then be asked to discuss their decision until they can agree to work toward either end. This difficult agreement must be left to the couple to make and not interrupted. _____________________________________________________________________________________ Note: when faced with genuine indecision the therapist is unable to proceed, which is often a part of the purpose for the indecision: “nothing ventured, nothing lost”. Working toward either extreme will, typically, break the impasse and dissolve the ambiguity.

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Section 3B: Advanced Techniques for Individual, Group or Family Practice 1. Use of the Genogram a. Places the individual in family context b. Track familial trends and characteristics c. Make the client a co-therapist 



Intergenerational Issues and Trends; display Information; for at least three generations show: ◦

the client’s name, age, gender , occupation, spouse/partner, children, parents and siblings

◦

the wider family such as grandparents, uncles, aunties, and their pairings and children (include names, birth dates, ages, gender, occupation , highest level of education, dates of marriage, divorce, death, etc)

◦

how persons are related and the relationship between family members (adoptions, marriages, sources of stress/support, alliances/collusions, etc)

◦

Clinical and health issues such as child/partner abuse, drug and alcohol dependency, anxiety, depression, heart conditions, cancers, diabetes, etc.

◦

ethnic and cultural history of the family

◦

socioeconomic status of the family

◦

major nodal events and recent trigger issues, such as pregnancies, illnesses, relocations, or separations

Tracking and Interpreting ◦

post the client’s symptoms/concerns and trace similar patterns across member relationships

◦

look at roles and rules that may have bearing on the presenting problem (s); post myths, legends and value statements

◦

look at life-cycle, nodal events and triggers for timing surrounding the presenting problem(s)

◦

demarcate, by dotted inclusion lines, members who participates/in the presenting problem

◦

client(s) and therapist (s) share observations and interpretations from the genogram

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2. Use of Chairs (sample techniques) Chairs are relatively convenient and available props that can be used to illustrate relational issues and dynamics or to heighten and lower tension and confrontation among members within a session. As such, they make the covert, overt and allow new forms of alignment and communication to be practiced: 

“Center Stage”: Set a seat in the middle of the room and ask “Who wants to work?”



Highlight relationships (closeness/distance), pairings (alliances, collusions) and use proximity to diffuse or heighten stress



Decision Making: each chair represents an opposing or counter point of view



“Ghost” : Make an estranged member or covert issue visible; create a co-therapist and ask their aide in helping the client

3. Use of Sculpting 

Use members to “sculpt “family or group relations; look for power, proximity, triangles, collusion, alignments, etc. Examine roles and boundaries



Explore position of each/Place self in and out of picture



Sculpt the” ideal”

4. Use of Boundary Mapping: problems may be the by-products of inappropriate boundaries (emotionality); manipulate boundaries with tasks that push to its opposite extreme.

Ie. M

F

task

.….…… ______ Kids

M

F

______.............. ‘push’ to opposite

Kids

Key: ……………….………_ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _____________________ Enmeshed

Clear Boundaries

(Inappropriately diffuse boundaries

(Normal Range)

◦

Disengaged (Inappropriately tight boundaries)

Mark boundaries between partners, subsystems, or entire groups; examine skewed boundaries 132

◦

Give directives and assign tasks that push individuals with diffuse boundaries closer, enmeshed further apart. Firm up individual or relational identities and point to disparities or similarities

◦

Partner enmeshed persons with others in and members outside the nucleus; partner peripheral persons through teamwork, alliances and collusions

Sample Mapping Directives for Nudging Boundaries Problem Boundary Pattern: Dad is very peripheral; Mom is over-enmeshed with Daughter and Son:

M

F

Note: “Risk” comparison for three simple options for testing boundaries

……… ______ Kids (D and S)

M

F

………………

D

S

“The Girls versus the Boys” (relatively “safe” task; keeps mom attached) M

F

______ .............

Kids (D and S) “Mom’s is on vacation from doing laundry” (“riskier” task; removes mom)

M F ______________

“Us” versus “Them”

Kids (“riskiest” task; mirrors the marital subsystem) 5. Paradoxical Statements

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Paradoxical Statements are designed to “go with the resistance” by encouraging a behavior or belief that has been resistant to redirection (“reverse psychology”). The anticipated remedy is a ‘recoil’ reaction in the opposite direction than that suggested.

Ie. “Others don’t seem to truly understand your plight; you deserve to feel sorry for yourself, in fact, I’m concerned that you aren’t getting enough sympathy. Let’s plan on doubling the dose for the next few days…..”

Paradoxical Statements differ from their more sophisticated cousins, Paradoxical Interventions, which are more elaborate stratagems designed to “double-bind” the client system into change.

6. Acting “As If” Imagining oneself in a different way is an important step toward actualizing that change; behavior rehearsal helps habituate one to a higher level of comfort, especially if there is an idealized role. This should not be confused as a simple role-play, but rather a re-creation of the individual from how they see themselves to how they wish to be imagined or know. It is helpful to create an entirely different persona (intentional splitting) so that the new behavior can be seen as consistent with the new role that the client hopes to adopt (portrayal): “Andy, let’s try this: the next time you find yourself at the office feeling weak and puny, try acting as ‘Andrew’ would, unafraid and competent. What would he say and how? Pretending you are him (Andrew) tell your co-worker what you think of him. Now say louder….louder still!”

7. Spitting in One’s Soup Exposing the hidden agenda or motive can neutralize its utility and power; make the covert, overt.

This is especially helpful when it undermines the nobility often associated with good intentions.

To do so, point to the real motive of the client's behavior; for example: o o o

“Are you’re trying to make me feel angry, so that I can push you away and then you can tell yourself that nobody wants you?”

“You seem to be punishing her with your depression (incompetence); that’s a clever way to get even. You must be rally pissed at her!”

Turning to wife in session: “I wonder if he brought you so that I can take care of you while he leaves and escapes the marriage!”

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8. Imagery and Fantasy Work Imagery techniques create scenarios, including empty space, within which existing realms of emotion and behavior can be modified and new possibilities imagined.

Simple techniques include suggestion and projection, whereas more sophisticated techniques are hypnogogic in nature and require a high level of skill by the practitioner.

While progressive relaxation and imagery have many similarities, they differ in that relaxation focuses more on releasing tension in the body while guided imagery focuses more on visualizing pleasant scenes that invite relaxation and calmness. Guided imagery can be useful in achieving other ends, such as building positive affirming thoughts, increasing awareness of underlying thoughts or feelings, and enhancing motivation, but in Cherry's case, the primary goal is to reduce the feeling of being stressed and overwhelmed.

How To Conduct Guided Imagery Relaxation Technique Ask the client to tell you about anything he or she has done before to relax. Use the client's knowledge and prior experience with what works and doesn't work to tailor the exercise to his or her particular needs. Ask the client if he or she is familiar with guided imagery and if he or she would be willing to try the exercise with you in the session. If the client says yes, then take a few minutes before you begin to explain the exercise and let the client know that he or she can stop at anytime if they feel uncomfortable for any reason. It is not uncommon for clients to become tearful during this type of exercise, and this is not necessarily a problem. Please note, however, that any form of relaxation exercise, guided meditation, or guided imagery can not only help clients relax but may trigger unwanted or unintended reactions such as increased anxiety or other powerful emotions. For clients with a history of psychological trauma, clients who have a psychological trauma diagnosis, or clients who have been diagnosed with a dissociative disorder or other psychiatric illness, special cautions should be taken. Any unusual reactions should be discussed with the client and reported to your clinical supervisor. It is very important to have tried the exercise before you introduce it. What follows is a script for a guided imagery relaxation exercise for a client who has stress-related symptoms, like Cherry's headaches. Please modify this script as necessary. Read this out loud to your client during a session, using a soft, calm, slow voice. You can also give a written copy of the exercise to the client to practice at home or record it so your client can listen between sessions. You might want to discuss in detail how the client might use such relaxation techniques independently.

1. This will take about 10 minutes. Sit in a comfortable position with both feet on the floor or lie down. If your feet are on the floor, take a moment or two to notice that the bottoms of your feet are making contact with the floor, which is part of a structure that is sitting on the earth and that you are making contact with the earth. If you lie down, take a moment or two to feel your entire body being supported by the bed or couch or floor and make note of the fact that the structure you 135

are in is sitting on the earth and you are being supported by the earth. (This helps the client feel grounded if any uncomfortable feelings arise.)

2. Close your eyes if you wish to; it's not necessary to close them. This will work just as well with your eyes open. If you keep your eyes open soften your gaze. Allow all the tiny muscles in your face to relax.

3. Imagine a place you like to be . . . a place where you feel peaceful, calm, relaxed, or quiet. It doesn't have to be a real place; it could be a place that you create for yourself right now. Some people imagine sitting on a beach, listening to the ocean, smelling the salt air, hearing the seagulls. Others imagine being in a mossy green forest with tall trees and birds singing and the smell of wildflowers. Still others imagine sitting on top of a mountain looking out over a valley that goes on forever and noticing the blue of the mountains in the distance and the solitude and peacefulness of the mountain top and the feel of a cool breeze and the smell of the fresh mountain air. Trust whatever image arises in your awareness.

4. Now, imagine yourself in this place. Look around. Notice whatever sights, sounds, smells, or sensations arise in your awareness. Choose a comfortable spot on the earth to sit or lie down.

Perhaps it is a soft bed of moss or a hollow in a white sand beach that molds to your shape. Allow your body to relax. Notice how the earth feels beneath you. Allow your body to relax as the earth supports your body. No need to hold yourself up. Look around you at the colors and shapes in your vision. Notice how you feel as you look at each one. Inhale and notice the smells. Listen to the sounds around you. Let yourself relax into the peaceful solitude of this quiet place. (Give the client some time to enjoy this space.)

5. Feel how peaceful and calm you are. Notice something about where you are that you will bring back with you to help you become calm. It may be the feel of the sun on your face, or the smell of the salt air, or the colors of your surroundings, or the way it sounds where you are, or a small object, such as a shell or round stone or a flower petal. Notice whatever that is and bring it back with you. Take a deep breath and release the breath on the exhale.

6. Slowly open your eyes and stretch. Remember what you brought back with you from your quiet place. Bring this image to mind and you can return to your peaceful, calm, quiet space whenever you want to relax.

After conducting this exercise with the client, make sure you spend several minutes debriefing the client. Pay particular attention to what was helpful in enhancing the client's sense of relaxation and if there were moments when the client felt uncomfortable or the anxiety or tension increased.

Let the client know that this is very common and that it simply means that the exercise needs to be adjusted. Work collaboratively with the client to make those modifications. Also, clients often feel that they haven't done the exercise correctly if they feel uncomfortable or have a hard time concentrating. Let your clients know that there is no right or wrong way to do the exercise and 136

with practice they will find what works for them. Pay particular attention to whatever your clients bring back with them from their quiet place. Spend time exploring this sensation, image, or feeling. This image can be a touchstone or anchor that clients can remember whenever they need to relax.

A Simple, non-guided, Imagery (Projective) Techniques Use: Self-disclosure (private logic), examining relational components (values, myths) and prompting potential for change (fears and dreads, hopes and wants).

These are fairly simplistic assignments that work well as “homework” or as a group or family exercise. The assignment may be collected (or not) and interpreted by the client (best choice), by others, or by the therapist (not a good solution unless it serves some greater purpose). a. “How I View…” 

“How I View the World”



“How I View Myself”



“How I View Men”



“How I View Women”



“How I View Marriage”



“How I View Sex”

b. Family Portrait “Draw your family (group; relationship; self ) the way you see them” “Draw your family (group; relationship; self) the way you wish they would be” d. Scribble (eyes opened or closed) 1. Scribble a picture 2. Give it a title 3. Explain it to the group (family; partner; therapist) 4. Get reactions from others d. “If’s” 

“If you had 24 hours to live…”

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   

“If you just won a billion dollars…”

“If you were shipwrecked on a deserted island with your 3 most precious items/people..”

“If you didn’t look the way you do, what would you look like?”

“If you had three wishes…”

e. Biography 

What is the title of your biography?



How much would it sell for?



Who would buy it?



If it were written by others, what title would it have?

Alternatively: Write your own eulogy/epitaph.

Who would attend your funeral and what would each say?

f.

Open Sentences (endless supply) 

“I am a good person because…”



“What I like most in others is…”



People really piss me off when they…”

g. Push-Button Technique •

Imagine pleasant situation and note accompanying feeling

•

Now imagine your distressing situation & note feelings You can control your feelings by what you think & imagine

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B. Guided Imagery and Fantasy Work Guided Imagery uses Relation Training to aide self-disclosure and identity integration. As intended, deeper relaxation states increase the likelihood that noxious issues will surface; additional caution is indicated when working with persons in crisis or prone to identity concerns, such as dissociation, fugue and depersonalization. Typically, the material that emerges becomes a primary source of reference and continued task assignments as treatment progresses.

How to Conduct a Deep Breathing Relaxation Technique 1. Ask the client to tell you about anything he or she has done before to relax. Use the client's knowledge and prior experience with what works and doesn't work to tailor the exercise to his or her particular needs. Ask the client if he or she is familiar with relaxation exercises and if he or she would be willing to try the exercise with you in the session. If the client says yes, then take a few minutes before you begin to explain the exercise and to let the client know that he or she can stop at anytime if he or she feels uncomfortable for any reason. Please note that any form of relaxation exercise, guided meditation, or guided imagery can not only help clients relax, but may trigger unwanted or unintended reactions such as increased anxiety or, with clients who have a history of trauma, a dissociative reaction. It is very important that you have tried the exercise before you introduce it to your clients and have an understanding of how to manage unintended or unpleasant experiences that can arise. What follows is a script for a deep breathing relaxation exercise for a client who has stress-related symptoms, like Cherry's headaches. Please modify this script as noted. Read this out loud to your client during a session, using a soft, calm, slow voice. You can also give a written copy of the exercise to the client to practice at home or record it so your client can listen between sessions.

2. This will take about 10 minutes. Sit in a comfortable position with both feet on the floor or lie down. If your feet are on the floor, take a moment or two to notice that the bottoms of your feet are making contact with the floor, which is part of a structure that is sitting on the earth and that you are making contact with the earth. If you lie down, take a moment or two to feel your entire body being supported by the bed or couch or floor and make note of the fact that the structure you are in is sitting on the earth and you are being supported by the earth. [This helps the client feel grounded if any uncomfortable feelings arise.]

3. Close your eyes if you wish to; it is not necessary to close them. This will work just as well with your eyes open. If you keep your eyes open, soften your gaze. Allow all the tiny muscles in your face to relax.

4. Notice your breathing. Is it shallow? Is it quick? Focus your attention on taking slow, deep breaths. Notice as you inhale that your stomach rises and as you exhale your stomach falls and you become more relaxed. Focus on the sensation of your stomach rising and falling. Inhale slowly and deeply and let your stomach rise with the breath. Exhale slowly and let your stomach fall and notice how you become more deeply relaxed. If you lose your focus or your mind wanders, gently return your attention to your breathing. Notice that you breathe in and breathe out. Just do this quietly for a little while, softly noticing that your stomach rises as you inhale and 139

falls as you exhale. Relax into each exhale. Feel yourself getting more and more relaxed.

Breathing in. (Count to five silently.) Breathing out. (Count to five silently.) You may hear things from outside or happening around you. Make note of them, then gently return your focus of attention back to your breath. Focus your attention on the physical sensation of relaxation in your body. Breathing in. (Count to five silently.) Breathing out. (Count to five silently.)

5. Notice whether there is any tension in your legs. As you exhale, notice that the tension melts away. Breathing in. (Count to five silently.) Breathing out. (Count to five silently.) Melting away the tension in your legs. Breathing in. (Count to five silently.) Breathing out. (Count to five silently.)

6. Repeat Step 4 for the following body parts: hips, back, arms, chest and shoulders, neck, jaw, cheeks, and forehead.

7. Now take a slightly deeper breath. Begin to get ready to open your eyes and become aware of what is going on around you. You don't have to do it right now; simply get ready to do it.

8. Notice how calm and relaxed you feel. Notice if there is an area of your body that feels particularly relaxed or if there is simply a general sense of relaxation. I invite you to bring this felt sense of relaxation with you as you become more aware of what is going on around you.

Okay, begin to become more aware, still feeling calm and relaxed. Okay, your eyes are open and you are aware of what is going on around you and you are calm and relaxed.

9. After conducting this exercise with the client, make sure you spend several minutes debriefing the client. Pay particular attention to what was helpful in enhancing the client's sense of relaxation and if there were moments when the client felt uncomfortable or the anxiety or tension increased.

Let the client know that this is very common and that it simply means that the exercise needs to be adjusted. Work collaboratively with the client to make those modifications. Clients often feel that they haven't done the exercise correctly if they feel uncomfortable or have a hard time concentrating. Let your client know that there is no right or wrong way to do the exercise and that with practice they will find what works for them.

10. For additional information on relaxation techniques, consult Stress Relief and Relaxation Techniques, by J. Lazarus (2000) or The Stress Management Handbook, by L. A. LeydenRubenstein (1999) Specific Tecniques

a. Early Recollections (relaxation first) 

What is the earliest memory you have? What is the very first thing in life that you remember?



Jot down the Story and what Age you were 140



What was the Mood of the story?



Give the story a Title

Note: as with most Imagery work the story is a snapshot of today

b. Good and Evil (relaxation first) 

Fantasize the “evil” part of you…



Fantasize the “good” part of you…

c. Sex Change (relaxation first) 

Picture that you have become a member f the opposite sex



What do you look like? (build, hair, eyes, features, etc)



What does it feel like to be this way? What career, etc do you have?



Pretend you’ve met someone who attracts you very much. What are they like?



What first attracted them to you? What do you want in a relationship with them?

e. Dreams (relaxation first) Pretend you are sleeping: 

Have a nightmare….an exciting dream….



“If you go to bed tonight and when you awoke a miracle had occurred and everything was going well in your life…”

e. Time Travel (relaxation first) 

It is 10 years/5 years from now… (picture ideal versus now)



Pick a time in history (past or future) that is the most appealing to you, a time you strongly desire to remain in…



Imagine that it was 5 minutes before this happened and you could do one thing to avert its occurrence, what would you do? Now imagine that it is 5 minutes after this entire episode has ended and you can look back and see what you might have done different….

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f.

Emotions Vary (relaxation first) This is an excellent technique for acquiring greater mastery of something heretofore experienced as not under one’s control, such as emotional (ie. rage, sadness) or physical pain. 

Picture the “feeling” that you’re having



What color is it?



What is its shape?



What texture does it have?



What’s its temperature?



Can you change its shape….it’s color….it’s temperature…..it’s texture…. Now, make it larger/smaller; hotter/cooler; more rough/smoother; less red/more red; taller/shorter. For homework, sit and relax and practice changing the one thing we have agreed to (always move to less toxic)

9. Ghosts and Exorcisms (relaxation first) Ghosts are family legacies, myths, and legends as well as dead and estranged members whose persona have presence and meaning to the individual or group. They may be “good” ghosts or “bad” ghosts, and may be as simple as a family or personal rule or value or a more complex, over-riding philosophy or vantage point on how to behave, interact and even think.

“Good” ghosts can provide support and nurturance; “bad” ghosts can be inexorable in their demands and ruthless in their punishments. 

Ghosts often ‘haunt’ due to guilt, retribution or vengeance; anger can be an elixir



“Empty chair” technique: place a chair in the room, make the Ghost visible and confront it; this is a highly effective technique for ongoing reference work (see Use of Chairs)



Make covert issues and rules, overt: (ie. “Temper” = adversary that one can battle)



Create concrete reminders: “band-aid” = hurt; coin = decision-maker; etc



Work through what makes the ghost more/less restless…what issue needs to be put to rest?

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Write a letter, epitaph or will to the Ghost, emphasize disparities and similarities; develop a new legend or myth; make a “voodoo-doll”; create a ritual for taming the ghost

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Reconnect to estranged partners and members

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Hold a séance or conduct an exorcism

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Prescribe the phantom Practice Exercise: Speaking to the Dead

10. Image-enrichment (Ego-building) Techniques a. Increase Differentiation Of Self; define and delineate Self-boundaries b. Increase sense of belonging; reconnect to others, meaningful goals and activities c. Employ Behavior Rehearsal; real and imagined practice d. Reframing: turn meaning and personal context from minus (-) into plus (+) e. Explore fears and dreads (“What bad would happen? And then what?”) f.

"Boasting" ("What else are you good at?"; "What is he/she good at?")

g. Hypnotic-suggestion. ("When did you first realize you could..."). h. Simple Paradox: exaggerate the symptom or complaint i.

Reduce "Buts" & "Shoulds"; move to acceptance of behavior truth. (Change "But" to "And“)

j.

"Doom" client to Success (direct task, prescribing frequency, duration, location, participants, et al. Predict sabotage & failures)

k. Examine progress and repeat sequence portions; gift-giving and rewards l.

Log all that is going well enough to Not want to change

m. Work through issues of Guilt, Anger and Shame n. Increase social competency: art, dance, wine, film, literature o. Increase sense of physical safety and health: vitamins, yoga, karate p. Pet therapy: new puppy, kitten or fish; volunteer at kennel q. Attach burdensome rituals to negative thought and behaviors r.

Therapist takes one-down position

s. Paradoxical Interventions; Prescribe symptoms, rules and myths t.

Heal trauma through (advanced) Ghost and Revenge techniques.

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Ghost techniques  Exorcizing the Ghost: confront the source of the trauma (adversary; illness, etc)  Exorcizing One’s Past: make the client the therapist and have them treat their past self  Born Again/In-Utero Re-growth: recreate one’s birth and life history  New Identity: create a new persona and history (ie. “that was the old way, the way Christine would have done it; tell me, now that you are Christina, how you would/will do it?”)

Revenge techniques  Improving the Torment: worry, guilt, and shame are insufficient forms of selfpunishment  Create a Torture Chamber or “Little Shop of Horrors”; draft a “Shit-ting on You” Will; plan the Other’s funeral; write a letter of revenge; build a collage of hate or “voodoodoll”  Public humiliation by agreement; this is a very powerful technique “Ego Reconstruction” and Advanced Guided Imagery (Deep Relaxation Techniques for Advanced Clinical Practice) These advanced practitioner guided imagery and fantasy techniques are hypnogogic in nature and require deep relaxation of the client(s) as a precursor to a directive a. Regression to the Womb: re-grow the individual b. Incredible Shrinking Man (Woman): Shrink person; go up the body, into the head and peer out the eyes. “What do you see?” c. In My Crib:  Imagine self; make small and place in the crib  Compare “big you” to “little you”  “Do you want to hold the little you?” “What would you say?”  “How does it feel to hold…?”

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 “How does it feel to be held….?” d. Advanced Integration (deep relaxation technique)  “Close your eyes, do not sleep, be fully aware…but don’t label anything…”  “Pay attention to what’s inside” (ie. “Without touching, can you feel your right index finger?”) e. Hypnagogic Suggestion (deep relaxation technique)

Behavioral and Cognitive Change; Problem-Solving Techniques

Fifteen Common Cognitive Errors 1. Filtering--taking negative details and magnifying them, while filtering out all positive aspects of a situation 2. Polarized thinking--thinking of things as black or white, good or bad, perfect or failures, with no middle ground

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3. Overgeneralization--jumping to a general conclusion based on a single incident or piece of evidence; expecting something bad to happen over and over again if one bad thing occurs 4. Mind reading--thinking that you know, without any external proof, what people are feeling and why they act the way they do; believing yourself able to discern how people are feeling about you 5. Catastrophizing--expecting disaster; hearing about a problem and then automatically considering the possible negative consequences (e.g., "What if tragedy strikes?" "What if it happens to me?")

6. Personalization--thinking that everything people do or say is some kind of reaction to you; comparing yourself to others, trying to determine who's smarter or better looking 7. Control fallacies--feeling externally controlled as helpless or a victim of fate or feeling internally controlled, responsible for the pain and happiness of everyone around 8. Fallacy of fairness--feeling resentful because you think you know what is fair, even though other people do not agree 9. Blaming--holding other people responsible for your pain or blaming yourself for every problem 10. Shoulds--having a list of ironclad rules about how you and other people "should" act; becoming angry at people who break the rules and feeling guilty if you violate the rules 11. Emotional reasoning--believing that what you feel must be true, automatically (e.g., if you feel stupid and boring, then you must be stupid and boring) 12. Fallacy of change--expecting that other people will change to suit you if you pressure them enough; having to change people because your hopes for happiness seem to depend on them 13. Global labeling--generalizing one or two qualities into a negative global judgment 14. Being right--proving that your opinions and actions are correct on a continual basis; thinking that being wrong is unthinkable; going to any lengths to prove that you are correct 15. Heaven's reward fallacy--expecting all sacrifice and self-denial to pay off, as if there were someone keeping score, and feeling disappointed and even bitter when the reward does not come Source: Beck, 1976

It is useful for a counselor to have a basic process for helping people achieve behavioral change. As the counselor and client work this process over and over, the client begins to incorporate the process into his or her behavioral change repertoire. One problem-solving process that works well for helping people achieve behavioral change is as follows: 1. Identify a behavior that can be addressed: 146

 

Keep it simple and achievable.

Break big problems down into smaller, achievable components.

2. Identify the goal (outcome) the client would like to achieve:  Make the goal measurable so the client can know when he or she has achieved it.  Explore ways the client has achieved similar goals in the past.

3. Identify barriers (internal and environmental) that might keep the client from achieving the goal. Frame the barriers in terms of something the client can control 4. Identify how those barriers can be overcome in specific behavioral terms. Make addressing the barrier something to do, rather than something not to do.

5. Identify supports needed to achieve success and specific steps to achieve success.

6. Elicit a commitment and take action to overcome roadblocks and achieve the goal.

How to Assess for Negative Self-Talk and Offer Alternative Responses The goal of this technique is to increase clients' objectivity about their thoughts; to demonstrate the connection between negative self-talk, unpleasant emotions, and unproductive behavior; and to differentiate between unrealistic and realistic meanings of events. When using this technique, the focus is on a specific thought, even though others will arise. One variation on this is to have the client identify situations such as homework and use that in the following session. The steps are: 1. Identify the situations that make the client feel uncomfortable.

2. For each uncomfortable situation, make a list of the uncomfortable feelings the client experienced after the situation.

3. Ask the client to identify the first thought that comes to mind when he thinks of the uncomfortable situation and has the negative feelings. Proceed to identify other thoughts (cognitions) that often arise with this situation and feelings. It is not uncommon that a theme can be elicited from the thoughts.

4. Identify how the thought(s) or theme limits the client's options in life.

Help the client identify different ways of thinking about the situation and feelings that can lead to better options.

5. Once the list of reasonable responses is completed, summarize it, go back through the list of feelings generated for that situation in Step 2, and discuss the decrease in intensity of each feeling for the new list of reasonable responses compared to the old, negative thoughts 6. Plan for continuing practice of this new skill.

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Interventions With Core Beliefs Core beliefs are the filters a person uses to make sense of different experiences. People with depressive symptoms often have core beliefs that lead to negative perceptions of their environment and negative thoughts about themselves, their potency, and their future. These core beliefs may cause people to interpret experiences in negative and all-or-nothing ways and to view consequences as irreversible.

Changing these core beliefs allows people to realistically assess their situations, decrease their distress and sadness, and improve their ability to respond to a situation with healthier behaviors.

Clients with depressive symptoms often have multiple core beliefs that affect these symptoms and their recovery from substance use. In this vignette, the client has many core beliefs, one of which is that if she stops driving her truck, her means for taking care of herself will be very limited. The counselor's challenge is to understand this and other core beliefs the client has and address them in a systematic and sensitive manner How To Assess for Beliefs 1. Listen carefully to grasp the underlying meaning of what the client is saying.

2. Elicit beliefs with such questions as “what makes you believe that?” or “how did you come by that belief?”

3. When the client offers a description of an experience that sounds like an entrenched belief, paraphrase the statement, and ask the client to confirm if that statement is true. If the client replies in the negative, ask him or her to describe what is true for him or her.

4. Explore the belief. (How long have you had the belief? How would your life be different if you did not believe this? How has holding this belief helped you in your life?)

5. Who else believes this? Is this a family belief? Does the client see this as a belief that all people (or all people in a certain group) hold?

How to Challenge Beliefs It is important to remember that a significant component of entrenched beliefs comes from cultural experience. Specific racial and ethnic groups hold beliefs that are rooted in their cultural experience and are completely valid in that context, although they may appear “dysfunctional” if one doesn't understand the cultural context. A culturally competent counselor will recognize that questioning or challenging a belief has to be done in the context of understanding cultural underpinnings and must be undertaken in a respectful, sensitive, accepting, and open manner.

1. Historically, resistance was thought to be a negative, defensive effort on the part of the client that, if allowed to prevail, would limit growth and recovery. Accordingly, direct confrontation (and, unfortunately, sometimes blaming and shaming) was used in an effort to cause clients to stop 148

resisting recovery contributions made by counselors. However, we now understand that all people resist change that threatens their current way of being and doing. When they come to understand that change is inevitable, and/or desirable, and that there are alternatives to current ways of being and doing that they can do and that are acceptable (even pleasurable) to them, resistance diminishes. When resistance is confronted head-on, the natural tendency for all of us is to dig in our heels and resist even further, like a tug of war. Rolling with the resistance allows the kind of nonjudgmental exploration that will permit clients to collaborate more fully in counseling, when they are ready to do so

How to Roll With Resistance Six techniques from motivational interviewing are described here for handling resistance. The first three are techniques based on the use of reflection and the last three are strategies for rolling with resistance.

1. The main way to handle resistance is to simply reflect it, not at a greater intensity, but enough to let the person know that she is being heard. An example of this would be to say, “This week has been really hard for you, and the stress of group on top of that feels like too much.”

2. You can amplify or emphasize the part of the statement that you are most tempted to argue with.

An example of amplified reflection would be “There is nothing you can do to make group a helpful experience for you.”

3. A third technique is to reflect both sides of the ambivalence (from earlier in the session or from another session), which allows the client to see his or her ambivalence. An example of this is “So, on the one hand, you feel that you can handle group by pretending the other members are part of a play, and, on the other hand, it feels as if this doesn't work when you are really stressed out.”

4. Reframing is taking the statement and recasting it. An example is “Group is actually other people's problems, not yours.” This can be used to take something that the client thinks is a strength and make it a concern, or something the client is embarrassed about and make it a strength. Agreement with a twist is a reflection and a reframe: “Right now group feels unbearable to you, but I wonder whether you have considered that it is actually other people's problems, not yours.”

5. Emphasizing personal choice is reinforcing with the client that ultimately the choice is hers or his, and that no one can make the choice for him or her: “You may decide that group will never be helpful to you, and that is your choice.”

6. Shifting focus is changing the subject to allow the anxiety about the issue to dissipate. “Tell me what you feel would be helpful to you.”

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