Summary with the 2nd Custom UL edition of Psychotherapy: Theory, Research & Practice by Wedding & Corsini

What is the book 'Psychotherapy: Theory, Research & Practice by Wedding & Corsini about'? - Chapter 0

The book Current Psychotherapies is written by Danny Wedding and Raymond J. Corsini. Wedding was professor and chair of Behavioral Sciences and Neuroscience at the American University of Antigua. Corsini was an encyclopedist and lexicographer in the field of psychology. This version of the book is specifically compiled for the Universiteit Leiden by Kim de Jong, assistant professor of Clinical Psychology.

The book explains all the currently used forms of psychotherapy: psychodynamic, client-centered, behavioral, cognitive, family, positive, and multicultural psychotherapy. The chapters are divided by form of psychotherapy. Each chapter deals with how the psychotherapy was developed, what theories it is based on, what mechanisms and treatments it exists of, and what the relationship with other systems of psychotherapy is. The reader also learns who benefits from what type of treatment and what therapists need to keep in mind for each type.

This custom edition is for psychology students, but the book is also used widely in counselling, psychology and social work. It gives its readers a complete understanding of what psychotherapy entails.

This second edition has two more chapters than the original book. These new chapters are about positive psychotherapy and multicultural psychotherapy. Both forms of psychotherapy are relatively new (but based on old principles and theories) and are growing fast in popularity within psychotherapy.

How did psychotherapy develop in the 21st century? - Chapter 1

Different views of psychotherapy have undergone major changes, the visions of psychotherapy have completely changed and new visions have emerged. There are different types of psychological treatments that started in the twentieth century, but these have gone through drastic changes which led to improvement of mental health practices.

When and how did psychotherapy start?

People have been dealing with mental problems for as long as we know. They have therefore always been looking for solutions. Examples of these solutions were ceremonial healing rituals in shamanistic societies and religiophilosophical lectures, meditation, and simple bedrest in the Mediterranean region. Hellenist physicians slowly began to understand that the brain did not only have a role in storing knowledge, but was also the source of depression, delirium and madness. Hippocrates was one of the first Western physicians who saw that most conditions had a cause in the body, not in the wrath of the Gods. It took a long time for these insights to develop into the psychotherapy as we now it today, wich only emerged clearly in the eighteenth century.

When and how did the research into the unconscious mind begin?

Scientific research into the unconscious probably started in the seventeenth century under the influence of Leibniz. Leibniz researched what the role of subliminal perceptions (stimuli that are not consiously perceived) in our daily life was. In the nineteenth century, physician Mesmer and philosopher Schopenhauer were very big. They influenced the ideas of Freud, Adler and Jung. Mesmer was considered to be the founder of hypnotherapy. In addition, he thought that behavior was formed by the unconscious. The psychotherapy-related science of the nineteenth century, can be divided in three movements. These are discussed in the following sections.

What was the influence of the natural science empiricists?

Fechner and von Helmholtz were important scientists in the nineteenth century. They conducted research in cognitive science. Fechner investigated the sleep-wake rhythm, with special attention to dream sleep. He also researched the topic of how much psychological stimulation is required to transfer ideas from the unconscious to the conscious mind. This was the beginning of research of the contemporary working memory. Von Helmholtz discovered the phenomenon of unconscious inference, the unconscious representation of an object, constructed by knowledge from the past.

Fechner and von Helmholtz's ideas fall under the so called organicist tradition. They formed the basis for Freud's ideas. One of the organicists, Kraeplin, had been looking for solutions to mental illness for years. He started classifying problems in a way that was the predecessor of the current DSM.

What was the influence of the psychologist-philosophers?

The development of psychotherapeutic treatments has been influenced much more by philosophers than by scientists. Schopenhauer published in the early nineteenth century a work that was regarded as the basis of field of psychology. His idea was to treat mental disorders in a non-biological way. Schopenhauer's work mainly focused on sexuality and the unconscious.

Carus suggested that the conscious communicates with the unconscious, while the person himself is not fully aware of this process. For instance, in conversations between the therapist and client, both experience transfer and counter transfer. The (unconscious) transfer from the therapist's part already takes place at the first meeting.

Von Hartmann and Nietzsche built on the views of Schopenhauer and Carus. Nietzsche thought that conscious thinking was based on unconscious experience. He stated that people lie to themselves even more than they do to others.

What was the influence of the clinician-researchers?

Many discoveries were made in clinical settings during the nineteenth century. These discoveries were related to, among other things, personality psychology and psychotherapy. The researcher, Benedikt, developed a way to treat pathogenic secrets. This became an important part of Jung's analytical psychotherapy. Psychotherapeutic treatments are subject to constant change. Yet, professionals often stick to the techniques that started to develop in the nineteenth century.

What is the connection between biology and psychotherapy?

When something happens in the environment, the neurobiological pattern in the brain changes. Skills that are sufficiently stored in the brain are difficult to unlearn; education implies permanence. However, skills can disappear as a result of brain damage.

Grawe argued that psychotherapy appears to have its effects through changes in gene expression at the neuronal level. The retrieval of dysfunctional memories from the past does not lead to improvement. Good therapists teach patients not to worry about dysfunctional memories. They help their patients to improve their well-being. The main goal of psychotherapy is neuronal restructuring that helps patients experience positive changes. The human central nervous system is plastic, which means that environmental changes, however small, affect brain expression.

There has been tension between supporters of different theories for years. This conflict could be resolved by systematic integration of different variables. Nurture is formed by nature. We are genetically oriented to look for an environment in which we can develop. Different environmental experiences impact our gene expession and influence the development of character traits.

Evolutionary psychology is close to behavioral genetics. There are at least 400 different universal traits as a result of our evolved genes. Pinker states that therapists treat people with the same genetic basis, since all people share unique human background. The events in the patient's life make him different.

What is the connection between culture and psychotherapy?

Multicultural therapy is much more complex than therapy in a homogeneous culture. When the therapist and the patient have different cultural backgrounds, it is important whether the therapist comes from a majority or minority culture.

What is the importance of language in psychotherapy?

It is difficult to help patients when you know little about their culture. Language and use of metaphors play an important role in this. When the therapist is misunderstood due to cultural differences, this can damage the relationship with the patient. It is therefore important that efforts are made for therapists of a particular culture to help patients of different culture, according to the laws of that culture.

What are the issues with evidence-based treatments?

Patients usually talk with their therapist one time a week. For the rest of the week, patients will experience events in daily life that can undermine the treatment plan. Most events are uncontrollable and unpredictable. In psychotherapy, small, insignificant and inconsiderate additions can make all the difference.

What is important in the research on psychotherapy?

Much research has been conducted in the past decade into identifying the active mechanisms that help patients change. However, there is still a lot that is unknown. We need to know more about neurobiology and its interaction with the environment to be able to understand these mechanisms.

To describe the therapeutic outcomes, different situational, somatic and psychological variables need to be considered. By looking at these variables, problems can be divided into classification systems such as the DSM and the ICD. These systems help to see which treatment form is most suitable for the individual.

In psychotherapy, it is more important to know what works than why it works. Some forms of therapy are easier to describe in a manual than others. Therapies in a manual are therefore not automatically better than other therapies. Handbooks also do not cover everything, because every person is different and experiences different events. Therapeutic judgment is important here.

Psychological treatments based on scientific research are currently the norm. This is also important for reimbursing the costs of psychological therapies.

Psychotherapy is an umbrella term for various forms of therapy aimed at improving the well-being of clients. Psychotherapists must work according to the established standards for their profession.

What makes someone a good therapist?

A particular disorder often has a particular treatment that works best, regardless of the psychotherapist's preferences. The therapist must therefore put the client's interests above his own. In addition, research has shown that some therapists treat one type of disorders much better than others. It is unclear what is the reason for this.

There are a lot of personal reasons for students to choose to specialize in a particular area of ​​expertise. Students should therefore focus their professional careers on certain types of problems, as it is not often the case that all types of problems can be treated equally successfully. The student's personality and competences determine which patients can and cannot be treated.

To choose the right treatment for a person, the right diagnosis must first be made. It is therefore also important that the therapist has good diagnostic skills.

How does psychodynamic psychotherapy work? - Chapter 2

Psychoanalysis is not the same as Freudian theories. There are different theories and treatment models based on the psychoanalytic view. Many of these models show similarities, but there are certainly also differences. Psychoanalysis is based on several basic principles:

• People are motivated by wishes, fantasies and knowledge from the unconscious (unconscious motivation).
• People are interested in facilitating the conscious knowledge about the unconscious motivation.
• Painful or threatening feelings, fantasies and thoughts are avoided.
• It is stated that people are ambivalent about change.
• The therapeutic relationship is used to investigate the client's self-destructive psychological processes.
• The therapeutic relationship is used to bring about change.
• The client is made aware that the past and present maintain self-destruction.

What are the basic concepts of the psychoanalysis?

According to Freud, the unconscious mind consists of psychic functions in which impulses, wishes and memories are taken from the conscious mind. Many contemporary psychoanalysts no longer see the unconscious in this way. Some of them do believe in the existence of the ego propagated by Freud. Others prefer not to speculate about processes such as the ego and the id. There is currently a general way of thinking that our experiences and actions are influenced by unconscious psychological processes and that these psychological processes are unconscious in order to avoid pain.

What is the role of fantasies in psychoanalysis?

Fantasy is important for the psychological functioning and understanding of experiences, especially on a relational level. Fantasies can be either conscious (daydreaming) or unconscious. According to Freud, the unconscious fantasies were linked to sexuality or aggression. It was later believed that fantasy is important for regulating self-confidence, a sense of security, and trauma victory. Because fantasies largely take place in the unconscious, yet play an important motivational role, they are important to psychoanalysts.

What are primary and secondary processes?

The primary process of the psyche is primitive psychological functioning. It starts at birth and takes place on an unconscious level for the rest of the life. No distinction is made between past, present, and future.

The secondary process is conscious mental functioning. This functioning can be characterized as logical, sequential and orderly. It forms the basis for rational thinking and reflection.

What are defense mechanisms?

Defense mechanisms are intrapsychic responses to situations that evoke unconscious fears or anticipate "psychological danger." These mechanisms make overwhelming emotions manageable for someone. Examples of defense mechanisms are intellectualization (talking about the situation and keeping emotional distance), projection (the threat is projected onto someone else) and reaction formation (the threat is denied and the person claims to feel opposite feeling). Kleinian theory suggested the defense mechanism 'division'. This means that the individual does not have both good thoughts and negative emotions towards another person but rather creates two separate images of him. Klein argues that young children often use this mechanism in order to maintain their attachment style. During development, one learns that ambivalent feelings about one person are fine, and the split images are reunited into one. However, people with psychological problems do not learn this, so they continue to use this defense mechanism. This leads to ever-changing feelings about others, making relationships very difficult.

What does transfer mean in psychoanalysis?

Transfer is an important part of Freud's theory. This term refers to clients transfering past events to the current situation. An example is a woman who has always behaved uncooperatively towards her parents and, instead of consciously remembering it, now behaves in the same way towards her therapist. According to Freud, the process of transfer was not a threat to remembering a certain past event. Rather, it played an important role in the psychoanalysis. By reviving the past in the therapeutic relationship, the therapist could provide the client with insight into how the past influences present relationships.

What is the difference between one- and two-person psychologies?

Over the years, the focus of psychotherapy has shifted from one-person psychology to two-person psychology. Freud argued that the therapist can be seen as an observer acting as a white canvas onto which a client can project. This is now refered to as 'one-person psychology'. It was later thought that the therapist and the client are both part of the therapeutic process, 'two-person psychology'. After all, they influence each other on both a conscious and an unconscious level. The therapist's goal should be to understand and help the client. To achieve this goal, the therapist must explore himself first. The more complex the client's problems, the more self-insight is required from the therapist.

How is psychoanalysis viewed nowadays?

The first Western psychotherapeutic model was psychoanalysis. Many later psychotherapies arose from the premises of psychoanalysis. Beck and Ellis pioneered with cognitive therapy, but their original area of ​​expertise was again psychoanalysis.

It is difficult to compare psychoanalysis with other treatment methods. This is because psychoanalysis is not just a form of therapy, but a way of thinking. However, psychoanalysis is less and less popular in the psychological practice. This has more than one cause. Firstly, psychology is developing more towards biological explanations. Cognitive behavioral therapy is the most famous form of therapy today and treatments must all be evidence-based. Public opinion also plays a role: psychotherapy is characterized as arrogant, offensive and elitist. This is contradictory to the way psychoanalysis began, but psychoanalysts have been guilty of a lack of receptiveness to valid criticism and empirical research.

Lastly, the United States has come to play a bigger role in psychotherapy. People in the U.S. were traditionally more optimistic than people in Europe when psychotherapies were developed. This was caused by the scholars in Europe being more used to poverty, conflict, oppression and war. This optimism is good but has also led to a misunderstanding of the complexity of the human mind. When there are problems, Americans tend to search for a 'quick fix method'. This is also why a lot more Americans take antidepressants. This has caused psychoanalysis to lose in popularity, but also to show differences in different countries. Psychoanalysis is a lot more optimistic in the U.S. but is used for a patient a lot shorter than in Europe.

What does the history of psychoanalysis look like?

Freud was influenced by various cultural and intellectual trends in the nineteenth and twentieth centuries. He was originally interested in French neurological and psychiatric developments. For example, hypnosis was used to treat hysteria. There were clients with dramatic psychological problems (such as sudden blindness) that could not be explained organically.

Freud also met Breuer. Breuer treated a client with hysterical symptoms that were not only somatic, but also psychological. The latter was new at the time. The psychological treatment led to symptom relief for the client. The client called this the 'talking cure'.

Those discoveries led to the idea that hysterical symptoms arose from suppression of emotions. These emotions showed up in the form of physical symptoms. Hypnosis would help clients recall the memories and eventually heal them.

How did psychoanalysis begin?

Freud's hypnosis therapy was not reliable enough to bring back lost memories. This led to Freud developing the free association technique. Clients were encouraged to share their thoughts without being reluctant to do so or guided in a certain direction.

The goal of psychoanalysis turned into pursuit of the truth. Hypnosis was very sensitive to suggestion, while psychoanalysis was supposed to help people discover unpleasant truths about themselves.

What was the shift from seduction theory to drive theory?

Freud's seduction theory stated that sexual problems were the origin of psychological problems. Later, he suggested that fantasy and instinctive drive were important. Not all clients suffered sexual trauma in childhood.

Sexual instincts, however, remained important in Freud's line of thought: they would play a role in individual's development. Freud's perspective evolved from simple causation to a more complex school of thought with memory as the building block. This led to the development of the drive theory. In addition, Freud immersed himself in the psyche that cannot be observed directly. He focused on hidden childhood fantasies.

At the beginning of the twentieth century, Freud came up with his theory about the libido. This refers to the psychic energy that can be activated by both external and internal stimuli, leading to tension or discomfort. The energized energy had to be discharged, which led to pleasure. This discharge could take place in many ways. When something repeatedly led to discharge, the tendency to do so grew. This was called the pleasure principle. Psychological development, according to Freud, was linked to sexual development (psychosexual theory).

What did Jung and Bleuler add to psychoanalysis?

In the beginning, there were few followers of Freud's ideas. This changed with the publication of his book ''The interpretation of dreams''. He attracted the attention of Bleuler, who wanted to unravel the thought processes of psychiatric patients. He did experiments together with Jung. They used a word association task to associate response time with emotionally charged words. They used Freud's theories about the unconscious as a basis. The delayed response to emotional words would be due to the unconscious mind, since these words were perceived as threatening by the patient and thus were suppressed.

Treatment methods emerged based on Freud's theories. Because Bleuler and Jung's psychiatric clinic was used as a learning centre for other professionals, Freud's ideas became increasingly popular. However, his ideas were also criticized. For example, Jung disagreed with Freud that sexuality is the motivating force. In addition, he thought that Freud's theory of the unconscious was limiting. Eventually the paths of Freud and Jung separated and Jung came up with his own theories, united in analytic or Jungerian psychology.

What is the ego in structural theory?

Freud's work on the ego and the id formed the basis of the structural theory. The id is the unconscious, instinctive part of the mind. The ego arises from the id and creates awareness of reality. The ego looks at whether the id's urges and impulses can be fulfilled or should be fulfilled at all and slows them down if necessary. The superego is a divisional part of the ego and functions as the conscience; the superego looks at personal values ​​and norms. The superego is partly conscious and partly unconscious. The ego must ensure that the id and the superego are in balance. The superego is originally very self-destructive. Psychoanalysis should help people realize this.

What is the object relationship theory?

The object relationship theory describes the process of creating internal representations in relation to significant others. This theory is based on Klein's and Freud's theoretical frameworks.

What is the current status of psychoanalysis?

American ego psychology is also called classical psychoanalysis. This theory focused on the drive theory of motivation and psychosexual development. Freud's ideas about 'transfer' are also important in classical psychoanalysis. The therapist has to remain anonymous, so that the client can project more easily. In addition, the therapist has to adopt a neutral attitude and is not allowed to grant the direct wishes of the client.

The object relationship theory was unknown in the U.S. Many American practitioners of classical psychoanalysis had increasingly divergent ideas. Sullivan argued that sexuality was not the greatest motivator, but the desire for relationship. In addition, he stated that you could not understand people when you do not see them in their environment or when you do not look at interpersonal relationships. Thus, in the therapeutic relationship one should consider both the client and the therapist. This led to interpersonal psychoanalysis.

Kohut was particularly interested in the treatment of narcissism. He wanted to understand how someone developed a self-image and what the self-confidence capacity was. The therapist's empathetic attitude would play an important role in changing the client's self-image.

Relational psychoanalysis was rampant in America in the 1950s and 1960s of the twentieth century. This theory attempted to build a bridge between Sullivan's ideas and the more general psychoanalytic views.

In the sixties of the twentieth century, more attention was paid to the human urge to enter into relationships. Freud's theory was dropped. A therapist could never function as a white canvas because each therapist brings his own unique subjectivity. A therapist can never observe a client 100% objectively.

Current American ego psychology has evolved into modern conflict theory. This concerns the conflict between unconscious wishes and the defense against them.

Lacan was one of the later psychoanalysts. He was critical of American ego psychology. He stated that the ego (the sense of self) was an illusion. There is a lack of self, as the self is constructed by interpersonal relationships.

What personality theories are there in psychoanalysis?

The main personality theories are the conflict theory, object relationship theory and development stop models.

What does conflict theory say about personality?

According to conflict theory, the intrapsychic conflict is important for identity development. Underlying and conflicting wishes can create personality aspects that are the result of a compromise between those wishes.

What does object relationship theory say about personality?

The object relationship theory states that internal representations influence how people perceive others and how relationships are formed. Bowlby's attachment theory implies that anyone has an instinctive urge to seek closeness with caregivers. These caregivers are attachment figures. Young children develop internal working models that allow them to predict the response of attachment figures. Because of that, interaction with others is important. On the other hand, object relationship theory holds that internal models are formed by experiences with others and unconscious wishes and fantasies.

According to Klein, people are born with instinctive passions related to love and aggression that come from unconscious fantasies about interpersonal relationships. These emotions already exist before meeting others. To perceive another as harmless, young children divide their image of that person into two parts; a good and a bad part. Through cognitive and emotional development and contact with others, children eventually learn to combine the good and bad images into one coherent image of the person.

Klein's ideas are unsystematic and difficult to understand. A contemporary of Klein, Fairbairn, suggested a more systematic theory: internal objects are captured when someone withdraws from external reality because the caregiver is not available at the moment. The child then creates an internal reality as a replacement. In short, the internal objects are similar to Bowlby's internal working models, since both concepts are about the representation we have about the relationships with others. Fairbairn states that we project our internal objects onto others and that we are therefore looking for a romantic partner who resembles our caretakers, for example. This projection ensures that we can predict others and respond to them in a learned manner.

What do development arrest models say about personality?

Examples of developmental arrest or developmental stop models are Winnicott's development theory and Kohut's self-psychology.

Winnicott suggests that a child starts his life in a state where he thinks anything is possible. At some point, the child finds out that this is not the case and that the mother is unable to fulfil all wishes. This creates an understanding of the difference between fantasy and reality. When the mother puts her own needs before those of the child, the child creates a false self as a self-protection mechanism. This can lead to the child alienating from himself. When the process from all-rounder to non-all-rounder mother slows down, the child can adapt without trauma (optimal disillusion).

Kohut states that mental health problems arise when caregivers cannot provide a good environment. According to Kohut, one can only create a coherent self-image if parents adapt to the needs of the child. However, it is inevitable that parents will not always succeed in this. The child must deal with this, which also shapes the cohesive self-concept.

What is the connection between psychotherapy and psychoanalysis?

In this section the differences between psychotherapy and psychoanalysis and the connection between the two are described, to explain what psychotherapy entails.

What makes psychoanalysis different from psychoanalytic therapy?

There is a clear distinction between psychoanalysis and psychoanalytic (psychodynamic) therapy. Psychoanalysis includes defining characteristics, while psychoanalytic therapy is based on psychoanalysis, but does not include all the elements. Psychoanalysis is more long-lasting and intensive than psychoanalytic therapy and it has an open end where psychoanalytic therapy has a closed end. In addition, psychoanalysis has a number of therapeutic guidelines:

• Clients need to understand their unconscious motivations.
• The therapist should not give clear direction or advise.
• The therapist's own values ​​should not affect the client.
• The therapist should keep himself anonymous as much as possible and tell little about himself.
• The therapist should act as a neutral observer and interfere as little as possible in the client's process.
• The client is lying on a bench while the therapist is sitting upright.

Contemporary psychoanalysts no longer take into account all of the guidelines.

The sections below are about the standards of psychotherapy, which finds its basis in psychoanalysis but has been formed in its own direction.

How should therapeutic cooperation in psychotherapy work?

The client and the therapist have to cultivate good relationship, where both work together. In North America, Greenson argued that it was important to distinguish between the terms ''transfer'' and ''collaboration''. Transfer is distorted, while collaboration is based on the rational contemporary image that the client has of the therapist.

Bordin's ideas were influenced by Greenson's thinking. Bordin argued that the strength of the collaboration depended on the extent to which the therapist and client reached consensus on treatment goals and the quality of the relationship.

What is the role of transference and countertransference in psychotherapy?

Early interpersonal experiences determine how someone sees people in the present. The therapeutic relationship provides the client with opportunities to scrutinize early relationships. The therapist can help to understand how fearful relationships affect the present.

Countertransfer is the therapist's response to the patient, whether consciously or not. This response is the result of the therapist's unresolved conflicts. Freud argued that countertransfer did not help therapy. The contemporary definition of countertransfer describes all therapeutic responses. It is also believed now that countertransfer can actually help the client. The interaction between the client and the therapist influences the feelings the therapist experiences. This is called the transfer-counter transfer matrix.

What is the role of resistance in psychotherapy?

Resistance is acting in such a way that the therapeutic process is undermined. Resistance often arises in the unconscious and is a way of avoiding pain. It is considered problematic in early psychoanalytic theories. Nowadays its usefulness is recognized because it tells something about the psychological state of the client.

What is the role of intersubjectivity in psychotherapy?

It has previously been discussed that there is room for (counter) transmission in the therapeutic relationship, but this is considered incomplete. The relationship would result in a new product (analytical dyad). Mitchell argues that the intersubjective contact between client and therapist is the basis of the therapy because it contributes to the understanding of flexible relationships. When a client projects transfer to the therapist, the therapist can recognize it in himself and attribute it to his own character, or the therapist does not recognize this and characterizes it as transfer.

What is the influence of the therapist in psychotherapy?

The client and the therapist influence each other both consciously and unconsciously. The collaboration between the two ensures that the client becomes aware of his own relational schemes.

Current psychoanalytic ideas imply that the therapist cannot be an independent observer, but is a part of the client's process because the communication between the therapist and client influences the client and because therapists are never completely transparent to themselves.

Why are empathy and interpretation important in psychotherapy?

Empathy is being able to understand and relate to the client's feelings. This is important for the collaboration between client and therapist. Kohut was the first to attach importance to empathy in psychoanalysis.

Interpretation is the therapist's attempt to help clients become aware of their intrapsychic experiences and unconscious relationship patterns. A distinction is often made between the correctness and usability of the interpretation:

• Correctness: to what extent does the interpretation correspond to real aspects of the unconscious functioning of the client?
• Quality or usability: to what extent can the interpretation be used to change? Timing, depth and empathetic quality are all crucial.

An interpretation can therefore be correct, but useless. A therapist has to be aware of both aspects of interpretation.

What is the role of clarity, support and advice in psychotherapy?

Today's supporters of psychoanalysis argue that clarity, support and advice are also important in the therapeutic process of change. This differs from the traditional psychoanalytic emphasis on refraining from providing too much reassurance or advice, as it could work as guidance in a direction that does not help the patient. But nowadays people find that clients can be helped even less if they feel overwhelmed, confused or anxious. This is why clarity, support and advice have come to play an important role in psychotherapy.

How should psychotherapy be terminated?

One of the most important parts of the treatment is the closing phase. This helps the client to consolidate the positive changes. If this phase is not performed properly, it can have a negative effect on the treatment process. Both the client and the therapist can decide to end the therapy. Ideally, this should be in dialogue between the client and the therapist, but in reality it often happens that people stop therapy earlier for various other reasons. Frustration from too little progress can also make the client decide to end therapy. It is helpful to schedule a number of closing sessions after the decision to discontinue therapy.

What are the mechanisms of psychotherapy?

The important processes in psychotherapy are listed below.

What is the process of making the unconscious conscious?

The intended change in psychoanalysis is related to unconscious processes of which the client must become aware.

What is the mechanism on motional insights?

The client is made aware of the unconscious because verbal interpretations provide insight into the unconscious that is responsible for experiences and actions. The emphasis has always been on emotional insights, which ensure that the new understanding of the client is emotionally charged. An important method for this is the use of transfer interactions.

What is the process of creating meaning and reconstructing memories?

Many clients start psychotherapy because they have difficulty constructing meaningful life stories. Reiff argued that traditional healing methods helped people deal with psychological pain through signification. Psychoanalysis tries to do the same.

Creating a life story based on childhood experiences can reduce feelings of self-guilt. The client learns to accept himself. In addition, it can help the client discover what is meaningful to him.

What is the process of increasing self-representation?

Many clients find it difficult to see the relationship between their symptoms and their internal and interpersonal conflicts. They do not recognize their own role in sustaining destructive patterns. Through a better understanding of the symptoms and their interconnectivity, the client becomes empowered to change his circumstances but also accepts that there are limitations.

How can preserving emotions be used?

The therapist must learn to pay attention to his own emotions in the process with clients. How is it possible to help a client when we feel the same? Bion called this process ''preservation''. Normal development provides a defense mechanism for children by projecting threatening feelings onto the parents. In the psychotherapeutic relationship, threatening feelings are projected onto the therapist.

What is the process of break and repair?

Relational breaking and repair or rupture and repair is seen as one important part of the change process. Infants learn from face-to-face interactions with their mother how to break away from someone and then repair disruptions in relatedness. Some people have not learned this skill correctly. Ferenczi has found that therapists can help clients to develop this skill by working through the disapoitments that clients might have with the therapy or therapist.

How can psychoanalysis be applied?

Psychoanalytic therapy is not suitable for everyone. The client must be willing to practice self-awareness and should not perceive the therapy as too threatening. Long-term treatment can also be a deterrent. Psychoanalysis is best suited for neurotic individuals with a strong ego and the ability to self-reflect.

The psychoanalytic theories and techniques can be applied in different settings. In addition, they can be integrated into other forms of therapy.

What evidence is there for psychoanalysis?

There are several studies that support psychoanalysis. A meta-analysis found an effect size of .97 for general symptom improvement. The effect sizes increased enormously in a long-term follow-up after treatment.

Another meta-analysis showed that long-term psychoanalysis was more effective than short-term other forms of therapy.

Many studies of psychotherapy are naturalistic in nature. They find positive effects.

How has psychotherapy evolved in a multicultural world?

Psychotherapy was initially intended for Western Europeans with neurotic problems. Because psychotherapy was increasingly embraced, it was applied in more multicultural settings and tackled diverse problems. The psychoanalysis states that the unconscious is prejudiced in terms of cultures and classes. This affects our daily interactions. For instance, when a therapist treats someone from a different cultural background, this impacts the transfer-transfer matrix.

In addition, people in many cultures are not encouraged to self-reflect, which can cause the therapist to develop a defensive attitude.

How does client-centered therapy work? - Chapter 4

Client-centered therapy originated in 1940 from Rogers' ideas. This psychologist is now considered to be one of the most important psychologists of the twentieth century. Client-centered therapy focuses on the client and their own wishes and thoughts.

What are the basic concepts of the client-oriented treatment?

The client-centered approach differs from the medical approach by considering man as one individual, rather than emphasizing a diagnosis. Almost all therapies are therapist-oriented. The client should receive those parts of the therapy that are tailored according to his needs.

What is the role of motivation in client-oriented therapy?

Goldstein argued that each individual should be viewed as a whole with its own driving force (actualizing tendency). Rogers argued that this driving force is part of a more general formative force. According to him, all living organisms evolve into better and more complicated versions of themselves.

Theoretically, a person can develop into a fully functioning person according to Roger's idea in an optimal environment.

What is the human nature according to client-oriented therapy?

In the therapeutic relationship, everyone is unique. Rogers states that every living being goes through an organic value process. Congruence is the state of "wholeness" and integration into the experience of the individual. This is the hallmark of psychological adjustment. Congruence is the opposite of defensive behavior and rigidity. While Rogers argues that each person is unique in the therapeutic process, becoming more congruent in client-centered therapy is a universal outcome.

Rogers' view of man is both optimistic and naive. He did not see people as good or bad, although critics say Rogers believed in the good in people.

What is the role of the therapist in client-oriented therapy?

Therapists who work according to client-centered approach, believe in the client's inner resources. These inner sources are focused on growth and self-awareness. This method is expressed in a non-directive attitude of the therapist.

The overarching goal of client-centered therapy is to create an environment in which the individual can pursue and achieve their own goals. The therapist presents himself as a moral compass. He guides the client on a path without choosing the direction.

If one wants to work as a therapist according to Rogers' principles, he will have to cultivate an open, authentic and empathic relationship with the client. The norms and values ​​of the therapist must be adjusted to congruence, unconditional acceptance of others. According to Rogers, one cannot be trained to become a client-oriented therapist, since one has to work from his own norms and values ​​system.

How should the relationship between therapist and client be in client-oriented therapy?

Research focused on psychotherapy states that the therapeutic relationship contributes to a positive outcome of psychotherapy. This is in line with Rogers' philosophy. The therapeutic attitude should imply freedom and safety. What the client wants to do with this is up to him. The client is important contributor to the therapy.

The relationship between the client and therapist cannot be predicted in advance, as they are two unique individuals. The therapist aims to respond to requests from the client. Therapists assume that the client is perfectly capable of pursuing their own goals.

These are the main conditions a therapist has to meet in order for client-oriented therapy to work:

• Congruence: the therapist must continuously assimilate, integrate and symbolize with the conscious experiences. When someone is aware of and accepts their inner experiences, this person is integrated and 'whole'. A therapist may be in a congruent state, even if he does not unconditionally accept the client or experiences insufficient empathic understanding.
• Unconditional acceptance: the therapist should be warm and nonjudgmental towards the client. The client should feel accepted. Ideally, there is unconditional acceptance from the start, but therapists say they can accept the client better when they understand their motives. The therapist should assume that the client makes the best choices depending on the circumstances.
• Empathetic Understanding: the therapist must understand the client's expressions, meanings, and story. An open attitude is crucial in this. In addition, the therapist must put his own opinion in the background.

What is important for the client of client-oriented therapy?

The most important part of the therapy consists of the perception of the client's self. Most clients who receive therapeutic counseling have a diminished self-interest, which is a large part of the self-concept. Successful therapy is often associated with a more positive self-esteem.

In addition to progress on the self-concept, clients often also made progress on the direction of evaluation. A focus shift takes place; others no longer form the basis for their own values ​​and norms, the self now forms this basis. This is because the attitude towards others and the self becomes more positive as a result of the therapy.

Many clients also improve on the concept of 'experience'. The experience of the self is often very rigid when a client starts therapy and shifts to a more open and flexible experience.

The client's self-image becomes more positive and realistic when he feels unconditional acceptance and empathic understanding from the therapist.

What other systems have emerged from Roger's therapy?

• Pre-therapy. (Prouty)
• Experiential or focus-oriented therapy. (Gendlin)
• Emotion-focused therapy (EFT). (Greenberg and Elliott)
• Integrative models. (Bohart and Worsley)

In the current psychological field, a contrast has emerged between client-centered therapy and medical models. In addition, various psychologists question the equality of people, based on which client-centered therapy is based.

What is focus-oriented therapy?

Gendlin's focus-oriented therapy is based on the experience processes in the body. A change of feeling occurs when one listens to bodily sensations. Rogers also paid attention to the physical sensations in his school of thought. The therapeutic attitude is no longer responsible for therapeutic success, but the client's process of experience.

In the original client-oriented therapy, attention is paid to the physical sensations of the client, but this is not the basis; it distracts the client from the experience of the self as a whole.

What is emotion-oriented therapy?

Rice's emotion-oriented therapy was based on the therapist's calling function. The therapist aims to increase the client's experience and to help him access his own emotions. Thus, the focus of this therapy is more on the emotional experience than on the client himself.

Cain argues that emotion-oriented therapy is a mixture of client-centered therapy, existentialism and Gestalt principles. The emotion-oriented therapy is evidence-based. The therapist helps the client unravel blocked feelings by paying attention to emotional triggers.

Prouty's pre-therapy was influenced by the theory of experience. Clients with intellectual disabilities or psychotic/schizophrenic complaints, have formed the basis of pre-therapy. It is not the equal contact between the client and therapist that is central (Rogers), but the restoration of contact with non-communicative clients. The therapist copies or names the attitude and actions of the client.

What is positive psychology?

Seligman's positive therapy is based both on the client-centered therapy and the humanistic therapy. Instead of focusing on problems, positive psychology focuses on the positive (including flow experiences, optimism and the subjective sense of well-being), client's strengths.

What is feminist psychology?

Feminist psychotherapy focuses on the oppressed position of women. It was stated that the normative forms of psychotherapy were aimed at controlling women. The male founders of therapeutic treatment thus received a female counterpart. Most therapies, however, continued to see the inner psyche as the source of psychological problems. The aim was to allow women to adapt to their role in the community. Feminist psychology was based on ethics and stated that it was not the female psyche, but the social structures in society that caused psychopathology.

What is the history of the client-centered treatment?

The basic principles of client-oriented method did not work effectively. Rogers initially started from diagnostics, measuring, testing, etc. but eventually came to the conclusion that there was insufficient effect. This meant that Rogers did not position himself as an expert.

How did client-centered treatment begin?

Rogers' ideas became increasingly radical. The origin of the client-oriented therapy is the presentation of newer concepts in psychotherapy that Rogers held in 1940. He then wrote a book to further explain his ideas. This book focused on the client; the client started therapy with conflicts and a negative attitude and ended the therapy with insights, independence and a positive attitude. This would be achieved by the attitude of the therapist, who does not advise or adopt specific attitudes.

According to Rogers, the therapeutic personality should focus on congruence, unconditional acceptance and empathetic understanding, which is important for all other forms of psychotherapy as well.

In 1957 Rogers set up a large research project aimed at people with schizophrenia and the client-centered approach. Two important findings emerged:

• The clients who experienced the most empathy were the most successful in therapy.
• The client's, and not the therapist's, thoughts about the therapeutic relationship were closely related to success or failure.

What is the current status of client-centered treatment?

There is an organization that focuses on client-centered therapy: the Association for Development of the Person-Centered Approach (ADPCA). In addition, there are are magazines: the Person-Centered Review and the Person-Centered Journal. The ADPCA holds annual meetings and also hosts annual workshops, both of which are particularly popular with middle-class white people. People of all ages are interested. The most recent collaboration is the World Association for Person-Centered and Experiential Psychotherapy and Counseling with the journal Person-Centered and Experiential Psychotherapy.

What personality theories are there in the client-centered method?

Rogers' ideas came together in his theory of therapy, personality and interpersonal relationships. Client-centered therapy is based on the following assumptions:

1. The existence of each person is influenced by an ever-changing world of experience, of which the individual is the center.
2. The organism, or individual, responds to its environment (its reality) as it is perceived.
3. The organism responds as an organized whole to this world of experience (field of experience).
4. Part of this world of experience is gradually differentiated as the "I".
5. The "I" is formed by a fluid yet consistent conceptual pattern of perceptions, characteristics and relationships during the evaluative interaction process with its environment and with others, along with attached values.
6. The organism has a fundamental aim: to realize itself, to maintain itself and to form a whole as an experiencing/conscious organism.
7. The optimal perspective to understand a person's behavior is from the internal frame of reference of the individual.
8. Behavior is a crucial and purposeful attempt to satisfy one's own needs, within the perceived field of experience.
9. This goal-oriented behavior is accompanied by emotions, in which the experience emotions is related to the observed behavior, leading to the maintenance and completion of the organism.
10. The organism (individual) directly perceives values ​​as its own interests, although these are sometimes unconscious and somewhat distorted, inherited from others.
11. The individual's experience is either i) symbolized, perceived and organized in connection with the "I", ii) ignored because there is no perceived connection with the "I" structure, iii) without or with distorted symbolization because the experience is inconsistent with the "I" structure.
12. Usually, the behavioral forms that the organism adopts are consistent with its own self-image.
13. Some behaviors stem from experiences and needs that have not been symbolized. Such behavior can be inconsistent with the "I" structure and is not recognized as "own" by the individual.
14. When the self-image (can) be connected to all the sensory and internal experiences of the organism (individual) on a symbolic level and the connection seems meaningful, psychological adjustment occurs.
15. Psychological maladjustment occurs when the organism does not have meaningful sensory and internal experiences, which are thus not symbolized or organized within the Gestalt of the "I" structure. In this case, there is a fundamental or potential psychological tension.
16. Any experience that is inconsistent with the organized "I" structure can be experienced as a threat, and the more such experiences occur, the more difficult it is to maintain the "I" structure.
17. When there is no threat to the "I" structure at all, inconsistent experiences can be observed and investigated, and the "I" structure is modified to assimilate such experiences.
18. If the individual can integrate all their sensory and internal perceptions into one consistent "I" structure, it will lead to a better understanding of others and accept them as separate individuals.
19. As an individual perceives and accepts more of his organic (meaningful) experiences, his own value system, which relied heavily on the internalization of distorted symbols, will be replaced by an ever-changing valuation process.

Rogers' personality theory is seen more as growth-oriented than as development-oriented. However, this does not take into account Rogers' thoughts on children's sensitivity. He argued that part of the developing world of the child is the self-concept. Children can see certain experiences as positive, and others as negative and threatening, without having to be able to express this in words. This affects the self-concept.

What are the important concepts of client-oriented therapy?

There are several important concepts to understand in light of the client-oriented method:

• Experience: the private world of an individual. Some experiences are conscious, others not.
• Reality: the private world of the perception of the individual. It is about the perceptions associated with the environment of the individual. Change in perception, caused by therapy, leads to a change in reality.
• The organism's actualizing tendency. Everyone has an actualizing tendency to maintain and enhance themselves. Psychotherapy helps clients get clarity about what is important to them. Behavior becomes goal-oriented. This tendency can be seen as the driving force of the individual, the need to be healthy and make his own choices.
• The internal frame of reference: the perceptual field of the individual. It is the way someone perceives the world.
• The self, the concept of self and self-structure. This is about self-image, the image someone has of themselves in interpersonal relationships.
• Symbolization. This makes an individual aware of their own experiences. Symbolizations are denied when they are not related to the self-perception of the individual.
• Psychological adjustment or maladjustment. The degree of congruence between a person's sensory and visceral experiences and the self-concept determines whether someone is psychologically adapted. When someone does something that is opposite to their self-concept, this results in less congruence. The self experiences then have to be adjusted to become congruent again.
• Organismic valuing process. Individuals make value judgments based on their feelings. The individual's value judgment forms the basis of his own values ​​and behavior.
• The fully functioning individual. Individuals who can adapt well to their experiences and who can symbolize their experiences are fully-functioning. There is a lot of study to what makes these individuals function so well. Empirical studies show that fully functioning individuals have a positive self-concept, greater physiological responsiveness and an efficient use of the environment.

Why are congruence, empathic understanding unconditional acceptance important in client-oriented therapy?

Rogers states that a client goes through constructive personality changes when he experiences that the client-oriented principles are met: unconditional acceptance and empathetic understanding. Congruence is essential for this. This is a list of conditions that have to be met in order for a therapeutic relationship to work well:

What is congruence?

Therapeutic growth is created through congruence. Congruence is transparent communication and accurate symbolization of experiencce in the internal self-awareness of the therapist. The therapist should be open and clear about his feelings in the relationship with the client.

1. There is psychological contact between the client and the therapist.
2. The client experiences a state of incongruity and is vulnerable or anxious.
3. The therapist experiences a state of congruence.
4. The therapist experiences unconditional acceptance from the client.
5. The therapist experiences and communicates an empathic understanding of the client's internal frame of reference.

What is empathetic understanding of the internal frame of reference?

Empathetic understanding means that the therapist responds affectively and expresses himself. According to Rogers, it is about an attitude and not about behavior. He gives no guideline for this attitude. The most important thing seems to be the inner empathic attitude towards the client.

What is unconditional positive regard?

Unconditional positive regard is about warm acceptance, non-possessive care and non-judgmental openness towards the client as a person. The therapist should be aware of this in the professional relationship.

What does the psychotherapeutic process look like?

The client is seen as the architect of his own therapy, with which the client-oriented therapy clearly distinguishes itself from other forms of therapy. The therapist tries to understand the client's world based on what the client shares. The more common form of therapy, during which the first meeting is about discussion of expectations, diagnoses and duration of therapy, does not apply here. The client decides when the therapy is to end, for example this may already be after the first hour, but it can also last for years.

When a client asks a direct question, the therapist answers it according to his ability. However, he must do this in a non-directive manner. In client-centered therapy, the client is seen as the expert of his own therapy.

What paradigms can be used to look at psychotherapy?

The client's self-concept is undergoing a change, which means that the client can function more effectively. Two theoretical perspectives precede this:

• The traditional paradigm: change comes from discovering hidden or repressed feelings that can create vulnerability and fear.
• Zimring's paradigm: people become persons through interpersonal interaction within the prevailing cultural framework. Zimring states that as long as someone is not aware of the unconscious, there is a bad psychological adjustment. He talks about two types of internal context; the objective and the subjective context. The latter represents the client's internal frame of reference.

How can client-centered therapy be applied?

Client-centered therapy does not focus on the problem, but on the individual. The therapist does not assume in advance that the client has a problem; each individual is seen as a dynamic whole.

There are several criticisms of client-centered therapy:

• Client-centered therapy focuses primarily on middle-class white people.
• Concerning the severe axis II personality disorders, the client-oriented therapy has insufficient effect.
• Reflection is only used and no validated therapy is offered.

During therapy, a client can act as someone with a group role. This is part of his identity. It is not the intention to organize the therapy in such a way that more autonomy is sought.

Feminist, humanistic and psychodynamic supporters criticize client-centered therapy as there is no psychoeducation. However, this criticism is not justified, because this does not take place according to the applicable standards, the client does get related insights.

Even when the client expresses a self-description derived from the medical model, such as "I have depression," this self-description is accepted and respected by the therapist, although his diagnoses are not the starting point of the client-centered therapy. The fact that the nature of the client-centered therapy is non-diagnostic does not mean that no people with clinical problems are helped. Someone can always be helped, according to the client-oriented therapy, regardless of the diagnostic label, because someone is more than this label. Rogers states that making a diagnosis is a waste of time.

Client-centered therapy is often seen by others as not working for clients with serious problems. However, there are people with serious problems that have been helped according to the client-oriented method. In addition, the client-oriented therapy is very valuable in terms of recognition. In this form of therapy, a client can express dissatisfaction with the use of medication, without the therapist immediately identifying the disadvantages of stopping that use of medication. Client-centered therapy assumes that the client is able to choose and follow up useful forms of treatment.

When requested by the client, a client-centered therapist can provide information about other forms of therapy. This remains non-directive information, as the client is then free to decide to try a different form of therapy.

The client can decide to take someone during therapy because of, for example, a dysfunctional relationship. This is not a problem for the therapy, but the therapist's ethical commitment will always lie with the client, not the person he brings with him.

What client-centered treatment is there?

Treatment is a term that many client-oriented supporters do not like to use. They prefer to speak of conversations. Client-centered therapy studies have focused particularly on adults, as client-centered therapy is intended for them. This is a list of forms of client-centered treatment:

• Play therapy. Taft's play therapy impressed Rogers. A student of Rogers, Axline, shared his enthusiasm and ideas about client-centered therapy. She has made important contributions to research into play therapy with children, among other things.
• Client-oriented group processes. The principles of client-centered approach were also applied in group therapy.
• Client-oriented education in the form of classroom teaching. Rogers taught according to traditional methods. Then he started to develop his own method of teaching, based on the client-oriented approach. This meant that the content of what he taught the students was partly determined by them.
• Intensive groups. In the 1960s, Rogers developed a 15-step method for the fundamental meeting group. The effective encounter arises when one is open and honest about his feelings in the group and another responds fully empathically.
• Peace and conflict resolution. The person-centered movement in the 1980s focused on achieving peaceful solutions for large groups in conflict with one another. Rogers argued that when a conflict group can operate in an empathic, honest, and caring manner, the negative stereotypes of the other group fade and are replaced by personal and human feelings of connection.

What evidence is there for client-centered therapy?

Clients do not often ask for scientific evidence, but it must be possible to provide it. In addition, a therapist should be able to explain why the therapy is working as it is. However, hardly any quantitative studies have been done on client-centered therapy.

What is evidence for the common factors of self-centred therapy?

Rosenzweig stated that the effect of psychotherapy can rest on what all forms of therapy have in common. This is the Dodo conjecture. The Dodo effect states that all forms of psychotherapy show comparable effect sizes. This is supported by various meta-analyses.

The outcomes of therapy can be therapeutic or extra-therapeutic. Therapeutic outcomes arise from the therapist, the relationship with the therapist and the techniques the therapist uses. Extratherapeutic factors include the client's environment, the client's problems, and events that affect the course of therapy.

Research into common factors states that the therapy relationship is an important factor for therapeutic change. Therapeutic techniques contribute much less.

The specific myth states that the idea that different disorders require a different approach is incorrect.

What is evidence for some core conditions of self-centred therapy?

A meta-analysis found a positive connection between acceptance/empathy and the treatment outcome. A review of several studies showed that the relationship variables and the client's perception of the relationship with the therapist contribute positively to the outcomes of the therapy. However, many studies used for this meta-analysis and review are not entirely client-oriented.

There is also evidence that supports the idea of the self-determining client; the idea that the individual is intrinsically motivated to achieve autonomy and competence and to enter into relationships.

Empirically supported treatments are considered to be the best treatments for a specific disorder. Studies must have been conducted with experimental and control groups and a double-blind procedure. The latter is possible in drug research, but not in a therapeutic relationship. In addition, it is difficult to determine what to do with the control group, as it is often not ethically justified to withhold treatment from them.

Wampold argues that treatment is not immediately less valuable if it is not empirically validated. There is no evidence-based evidence regarding client-centered therapy. Moreover, congruence fluctuates naturally during the therapeutic session, along with unconditional acceptance and empathy.

What is the role of client-centered therapy in a multicultural world?

Rogers argues that client-centered therapy can be used indiscriminately in all cultures and by all ethnicities. The client-oriented approach does not start from differences between groups, unless the client himself identifies differences. The idea that client-centered therapy is for everyone does not always hold true, since the therapists also have their prejudices in some cases.

How does behavior therapy work? - Chapter 6

Behavioral therapy aims to change factors in the environment in order to change the behavior of the individual and the way in which the individual responds to the environment. Behavior is a broad concept and includes motor behavior, psychological reactions, emotions and cognitions. Most behavioral therapists use a mixture of traditional techniques and CBT. Common qualities of those therapies are:

• The goal is behavioral change.
• The origin of behavioral therapy lies in empiricism.
• It is believed that behavior has a function.
• It is about problem behavior that is now causing problems, and not the original problem behavior.
• Active form of therapy.
• Transparency.

What is the relationship between behavioral therapy and other therapies?

Behavioral therapy has many similarities with other psychotherapies, especially those that are short-term and directive, such as cognitive therapy and rational emotional behavioral therapy. Behavioral therapy is completely opposite to the psychodynamic approach. The ideas about the unconscious are not shared. In addition, psychodynamics states that therapists must undergo their own treatment to be able to offer good treatment. This does not apply to therapists who work according to behavioral therapy. The psychodynamic theory also states that behavioral change, the goal of behavioral therapy, is not achieved since the origin of the problem is not addressed.

Other psychotherapies, such as Adlerian psychotherapy and Gestalt therapy, share more similarities with behavioral therapy.

What is the history of behavioral therapy?

Contemporary aversion is quite similar to behavioral therapy and was used a long time ago. Contemporary behavioral therapy began in the early twentieth century. The foundation was laid by the classical conditioning of Pavlov. In addition, Watson studied the process of classical conditioning in humans. For example, he set up the Little Albert experiment. Watson is often seen as the founder of behaviorism: only behavior that can be observed is important. Unobservable behavior should not be investigated. In addition to classical conditioning, operant conditioning was also presented (Skinner and Thorndike). According to the principle of operant conditioning, rewards increase behavior whereas punishments reduce behavior. Skinner was the first to use the term 'behavioral therapy'.

How did behavioral therapy begin?

Wolpe developed the technique ''systematic desensitization'', an early form of exposure therapy. A person is slowly confronted mentally with his anxiety while relaxation techniques are applied. The underlying process was called ''reciprocal inhibition'' . In modern therapy, systematic desensitization is hardly used anymore, but fear confrontation in real life is used. Relaxation techniques do not seem to contribute and are often not applied.

Lazarus worked with conditioning therapy. He later suggested changing the name to behavioral therapy.

Eysenk was the developer of the first form of behavioral therapy. His students created behavioral therapy for different types of problems. Skinner' students came up with the first treatment methods based on operant conditioning.

What is the current status of behavioral therapy?

Behavioral therapy was used together with Ellis' ideas about rational emotional therapy and Beck's ideas about cognitive therapy. Bandura stated that one learned positive or negative behaviors by observing others (social learning/modelling/social-cognitive theory). Acceptance-based behavioral therapies (mindfulness- based therapies) are also influenced by behavioral therapy. The intention is for the clients to become aware of what is important to them.

What personality theories are there in behavioral therapy?

The trait theories of personality state that everyone shows a unique behavioral pattern and that this can be understood by looking at the personality traits. For example, Cattel suggested 16 personality traits. The five-factor model by Costa and McCrae is currently popular. This model shows the five most important factors for behavior:

• Openness.
• Conscientiousness.
• Extraversion.
• Agreeableness.
• Neuroticism.

Each of the above personality factors is a collective name for different traits. Behaviorists believe that behavior is caused by the environment (nurture) and not by character traits (nature).

Which concepts are important in behavioral therapy?

Behavioral therapy emphasizes the importance of learning. In this section, important concepts of behavioral therapy will be covered.

What is classical conditioning?

In the classical conditioning process, a conditioned stimulus is paired with an unconditioned stimulus. The latter is originally related to a response (the unconditioned response). By combining the conditioned stimulus with unconditioned one, the unconditioned response is coupled to the conditioned stimulus (conditioned response). This process can explain certain emotions in certain situations.

When the conditioned stimulus is presented without the unconditioned stimulus, the conditioned response will eventually disappear. This process is called extinction. By subsequently reconnecting the conditioned and the unconditioned stimulus, the conditioned response can quickly return. This is called reinstatement.

What is operant conditioning?

In operant conditioning, behavior is influenced by associated consequences. These are the concepts that operant conditioning is based on:

• Reinforcement; positive reinforcement involves a type of behavior followed by a reward. With negative reinforcement, an unpleasant stimulus is removed.
• Punishment is a detrimental event in response to a certain behavior, so that this behavior will be less likely to occur. Positive punishment is when behavior is followed by an unpleasant consequence. Negative punishment is about desired stimulus being removed after certain behavior.
• Extinction is the elimination of a certain behavior because it no longer has a positive consequence.
• Distinctive learning arises when you learn that a response is empowered in one situation, but not in another. This may explain why someone behaves differently in one situation than in another.
• Generalization is showing a certain learned behavior in a different situation than the one you learned it in.

What is vicarious learning?

Vicarious learning or observational learning consists of copying behavior from others and applying it yourself.

What is instructed learning?

One can also learn by reading or hearing about certain things. Instructed learning is also referred to as rule-governed behavior.

What is the relationship between behavioral therapy and psychotherapeutic theories?

According to behavioral therapy, all of our behavior is taught through associations, consequences, observations, and rules learned through communication. The way of learning according to behavioral therapy is very structured and active. Clients must complete assignments in the behavioral therapy setting as well as at home. It is stated that many of the intended behavioral changes occur through the assignments given as homework. In addition, clients are expected to apply what they learn in the therapeutic sessions in daily practice.

How does behavioral therapy deal with the therapeutic relationship?

A common criticism of behavioral therapy is that little value is attached to the therapeutic relationship. Several studies show that the therapeutic relationship is indeed not very important, and that therapy can also be followed via computer. On the other hand, there is also a lot of research that states that the therapeutic relationship is important for the success of the therapy. For example, in behavioral therapy, the empathic attitude of the therapist can act as a positive reinforcer.

An important part of behavioral therapy is to continue to motivate the client, so that he puts enough time and energy into the therapy. A technique such as motivational interviewing prior to behavioral therapy can help.

How does behavioral therapy deal with the psychotherapeutic process?

Behavioral therapy usually involves the client having an individual session with the therapist. Group therapy can also be chosen, or a session can be held with significant others. When family members reinforce negative behavior, it can be useful to involve them in the therapeutic process.

Most sessions last an hour but this can vary. Group sessions in particular can take a lot longer. Most sessions take place at the office, but if the problem requires it, the session can also take place in other settings. The majority of behavioral interventions take place in 10-20 sessions, although exceptions can also be made, often depending on the severity of the problem. In all cases, the goal of the therapy is to stop the need of therapy. The strategies taught during therapy also aim to be applicable after completion of it.

How does behavioral therapy deal with ethics?

It is often incorrectly assumed that behavioral therapy has a compulsive character. Behavioral therapy only works when the therapeutic relationship is supportive for the client. In addition, the client's commitment to the therapeutic assignments is an important factor in the success of the therapeutic intervention. The feeling of control the client has also contributes to the success of the treatment. Those conditions are difficult to enforce.

There is a power difference between the therapist and the client, and the therapist can influence the client. It is therefore important that the therapist is sufficiently aware of this and only exercises a positive influence.

Determining the treatment goals is often done in consultation between the client and therapist. When the goals of the therapist and the client are not equal, the chances of treatment success are reduced.

A difference with other therapies is that things can be put into practice in behavioral therapy. This is especially the case with fears. It is important that the therapist maintains his confidentiality, for example when the client encounters a friend during the therapeutic session. Therapist and client often devise a scenario in advance for this type of situation.

What are the mechanisms of psychotherapy?

The treatment effects of behavioral therapy are assigned to the learning principles that the client is taught. In addition, the client's change process is attributed to information processing models, emotion processing and cognitive restructuring.

Recent research is aimed at predicting what makes someone benefit more from behavioral therapy. The presence of psychopathology, severe depression or anxiety, stressful life events, and poor motivation and compliance with treatment can cause someone to have less successful outcomes after CBT.

How can behavioral therapy be applied?

Behavioral therapy can be used for anxiety disorders, panic disorders, obsessive-compulsive disorders, post-traumatic stress disorders, depression, eating disorders, schizophrenia, developmental disorders, cardiovascular disease prevention and other health-related problems, such as epilepsy and migraine. All these applications have been investigated.

Can behavioral therapy help people with anxiety disorders?

Much research has been done to treat anxiety disorders with behavioral therapy, with which the effect has been demonstrated. There are several behavioral strategies such as exposure, relaxation techniques and cognitive techniques that make a positive contribution. There are differences in which strategy works best depending on the problem.

Can behavioral therapy help people with depression?

There are several cognitive behavioral techniques that contribute to the treatment of unipolar depression. Examples are problem-solving training and cognitive restructuring. These techniques also help to prevent relapse. In addition to behavioral therapy, other forms of therapy have also been proven effective in the treatment of depression.

Can behavioral therapy help people with addiction?

Motivational interviews can be used to help people get rid of their addictive disorder. However, many treatments are still used that prove to be ineffective.

Can behavioral therapy help people with schizophrenia?

Social skills training can be very helpful for people with schizophrenia. However, it is important to combine behavioral therapy with antipsychotics.

What does behavioral treatment look like?

There are many different strategies that can be used in behavioral therapy.

How does behavioral evaluation work?

A behavioral evaluation takes place before the start of the treatment. This evaluation also takes place during and often also after treatment. This behavioral evaluation has several functions:

• Identifying the behavior to be adjusted.
• Determining the best course of treatment.
• Determining the impact of the treatment.
• Determining the treatment effectiveness.

Multiple methods are often used during behavioral therapy. In addition, behavior that occurs in multiple situations is often tackled. Behavior that is tackled often causes stress and can be harmful to the client or others.

Functional analysis is an important part of the behavioral evaluation. The purpose of it is to discover the sustaining factors of the behavior to be changed. Environmental variables are often manipulated and the effect on the target behavior is examined. This is often a difficult process to implement in practice. Tools such as interviews and questionnaires are often used. ABC also helps with this. A stands for antecedent, B for behavior and C for consequence.

Behavioral interviews are useful because they provide insight into seriousness, development and duration of behavior. Antecedents and consequences are also identified.

Behavioral observations are about assessing the ABC. This can be done in natural environment (naturalistic observation) or in a simulated environment (analogue observation). Observations can also be made by videotaping the client.

A disadvantage of behavioral observation is reactivity. When the client knows that he is being observed, he can adjust his behavior accordingly. This makes the observation less useful.

A common use in behavioral therapy is keeping a diary. Clients can also be asked to measure behavior. Journals are used for a baseline of problem behavior and to provide the client with more insight into the particular behavior.

Clients can complete evidence-based questionnaires like self-report scales. This is a quick and cheap way to measure behavior.

Sometimes the physiological responses of the client are considered. For example, regular blood pressure measurements can be taken into account to determine the impact of treatment.

How does a treatment plan work?

Treatment goals are set before the start of treatment. These goals must be specific, measurable, realistic and achievable. Two methods can be used to determine treatment strategies:

• The results of the functional analysis can be used to set up a treatment plan.
• The diagnostic profile of the patient can be used to set up a treatment plan.

How do strategies focused on exposure work?

Exposure therapy is a behavioral therapy technique that has been the subject of a great deal of research. This technique is mainly used for anxiety disorders. The technique involves confronting the client with a scary stimulus. Vivo exposure is exposure to an anxiety-provoking stimulus in real life. Imaginary exposure involves imagining fear-inducing stimulus. This form of exposure is particularly suitable for people with post-traumatic stress or compulsive thoughts. Interoceptive exposure occurs when client's physical fears (such as palpitations) are aroused, until the client no longer finds these physical sensations frightening.

The exposure technique is often applied slowly. A fear hierarchy is developed together with the therapist to see what kind of things give more fear than others. This makes it possible to keep practicing with fearful situations, without overwhelming the patient. There are several guidelines for exposure:

• The technique works best if it is predictable and practiced often.
• Long exercises are often more effective than short exercises.

How does response prevention work?

Response prevention is the inhibition of bad behavior in order to break the association between stimulus and response.

How does operant conditioning work?

Operant conditioning-based therapy is called applied behavior analysis. This form of therapy involves breaking the reinforcement and punishment patterns. Differential reinforcement is the reinforcement of the absence of unwanted behavior and the reinforcement of the prevention of desired behavior. Another operant strategy is to use a token economy, where clients receive tokens for desired behavior. These tokens can be exchanged for reinforcers. In contingency management, the environment of the client is adjusted in such a way that undesired behavior is no longer endorsed. Aversive conditioning means that a certain behavior is accompanied by a negative consequence. Behavior change based on punishment does not seem to be effective in the long run.

How does relaxation training work?

Examples of relaxation training are diaphragmatic breathing (works against hyperventilation), guided mental images (works against stress and tension) and progressive relaxation (works against muscle tension). The latter technique is the most scientifically studied and can be applied successfully in many cases.

How does stimulus control work?

Stimulus control refers to behavior that is controlled by a specific event. This mainly concerns behavioral problems. For example, there may be an incorrect connection; someone with sleeping problems, for example, will associate their bed with staying awake instead of sleeping.

How does modelling work?

By looking at others we learn how to behave. In this way we can ''learn'' a fear but also unlearn anxiety. This strategy of modelling is often used in conjunction with other strategies.

How does behavioral activation work in depression?

Depression is believed to be caused by a shortage of positive reinforcers, with the client moving into an increasingly deep negative spiral with fewer and fewer reinforcement options. Through behavioral activation, the therapist schedules a number of activities for the client to implement more reinforcers. Marshall developed some basic principles for behavioral activation:

1. To change how you feel you have to change what you do.
2. Life events can cause depression, but erroneous coping strategies can help maintain depression.
3. Understanding what precedes the client's behavior helps determine helpful treatment strategies.

How does social skills training work?

Social skills training uses modelling, improving feedback, behavioral exercise, among others. As a result, clients learn to function better in social situations. This training can have an effect in various forms of psychopathology. Social skills training starts with discovering the problems at hand, without being judgmental.

How does training in fixing the problem work?

Solving problems is very difficult for a number of people. The training to fix problems consists of several steps:

1. Define the problem.
2. Investigate possible solutions.
3. Evaluate the solutions.
4. Choosing the best solution.
5. Apply the solution.

How does acceptance-based behavioral therapy work?

Part of the process is learning to accept unwanted thoughts and emotions. One technique that can be used for this is mindfulness. It is used in acceptance and commitment therapy. The therapy involves accepting unwanted thoughts, becoming aware of one's own values ​​and adjusting the thoughts in accordance with one's own values. Another form of therapy is dialectical behavioral therapy; cognitive behavioral techniques are combined with mindfulness techniques.

What evidence is there for behavioral therapy?

In recent years, short-term treatment has increasingly become the norm. The most validated and structured forms of psychotherapy come from CBT.

Is behavioral therapy evidence-based?

To be evidence-based, the therapy must be well established and effective. When varying results are found, a therapy is called conflicting. Strong scientific support arises when well-controlled interventions have been conducted that indicate that the intervention works better than a placebo. More support for CBT has been found for particular types of issues.

How should data be collected for behavioral therapy?

There are clients who do not benefit entirely from a therapy. For that reason, it should be considered which treatment is performed for a specific individual and in which situation the treatment is effective.

To work empirically, the therapist must be aware of his own biases. He must collect data throughout the treatment to test assumptions and evaluate intervention effects.

In single-case experimental studies, a baseline is first established and treatment is compared to this baseline to measure effectiveness. An example is the reversal design.

What is the relationship between behavioral therapy and multicultural psychotherapy?

Several basic principles of behavioral therapy are considered to be universal. However, behavioral treatments are not universally effective, especially because of the therapeutic relationship. It is a challenge to be able to properly treat people who are culturally sceptical. Cultural differences and language differences can contribute to problems in the therapeutic relationship. Moreover, there is little scientific information on the treatment of ethnic minorities.

How does cognitive therapy work? - Chapter 7

Cognitive therapy is based on the idea that people respond to life events through a combination of cognitive, affective, motivational and behavioral responses based on evolution and individual learning. The cognitive system is about the way in which people experience, interpret and give meaning to events. This system works in conjunction with the affective, motivational and physical system to process environmental information and respond accordingly. Improper responses can be due to misconceptions, misinterpretations or dysfunctional, idiosyncratic (personal) interpretations of situations. Cognitive therapy attempts to improve information processing. By adjusting the cognitive system you can also adjust all other systems.

What are the basic concepts of cognitive therapy?

Information processing is crucial for the survival of any organism. All systems involved in survival, so all cognitive, behavioral, affective and motivational systems, are made up of schemes. Schemes contain people's perception of themselves and others and their own perception of goals, expectations, memories, fantasies and previous learning experiences. These schemes have a strong influence on the information processing process. Sometimes this can cause people to process new information incorrectly. If that is the case, you speak of a bias. This can take the form of a cognitive shift towards selective interpretation when you systematically judge things with prejudice. For example, depressed people have a cognitive shift towards negativity, and anxious people have a shift towards danger. Contributing to these shifts are cognitive vulnerabilities: certain attitudes or core beliefs that cause people to interpret events in a certain way.

In the past, cognitive theory emphasized that cognitions caused changes in other systems. Now the cognitive theory sees all systems as cooperating units, also known as modes. Modes are networks of cognitive, affective, motivational and behavioral schemes that compose the personality and help to interpret the environment. Primal modes are universal. They are often unconscious and cannot be controlled. Primal thinking is rigid, automatic and biased. Smaller modes, such as talking or studying, are under conscious control.

What are the strategies of cognitive therapy?

Cognitive therapy is a collaboration between client and therapist that examines together what the dysfunctional perceptions are and how they can be changed. The client behaves like a researcher who interprets stimuli, but is temporarily thwarted by his own information processing system. Through guided tours, the therapist and the client jointly search for the causes and structure of the client's misconceptions and dysfunctional beliefs. They try to visualize, as it were, the story of the development of the disorder. Collaborative empiricism and exploration are applied in the Socratic dialogue. This dialogue is conducted in 4 steps:

1. The therapist asks informal questions.
2. The therapist listens.
3. The therapist makes a summary.
4. The therapist asks analytical questions.

In therapy, a lot of use is made of reality testing in which personal conclusions are continuously evaluated. The purpose of this is to bring the information processing system to a more neutral state rather than the biased one full of prejudices as it is in right now. There are three ways to deal with dysfunctional modes:

1. Deactivate biased perception by distraction or reassurance.
2. Adjust the content and structure of perception.
3. Create a custom mode (often follows step 1).

However, long-term change is unlikely to occur unless someone's underlying core beliefs are modified.

What types of techniques are used in cognitive therapy?

Cognitive therapy mainly focuses on correcting prejudices and other fallacies and adjusting core beliefs. In addition to purely cognitive techniques, behavioral techniques are also often applied. Examples include social skills training, role-playing, behavioral exercises and exposure therapy.

What is the relationship between cognitive therapy and other systems?

Both psychodynamic therapy and cognitive therapy assume that behavior can be influenced by unconscious beliefs. However, according to cognitive therapy, these beliefs are not buried very deeply in the person's unconscious. Cognitive therapy focuses on the connections between symptoms, beliefs and experiences. Cognitive therapy is highly structured and short-term (12-16 weeks), with an active therapist attempting to change information processing processes by using logical reasoning and behavioral experiments.

Cognitive therapy and Rational Emotional Behavioral Therapy (REBT) share the idea that the emphasis in psychological dysfunction is on cognition and they both see it as their job to change these maladaptive ideas. The therapist assumes an active and directive role in this. REBT has the idea that confronting irrational ideas causes them to disappear, while cognitive therapy is more focused on investigating these ideas in order to negate them rather than attack them. Cognitive therapy is more likely to use an inductive model to test irrational ideas, while REBT is more likely to use a deductive model. REBT uses the word ''irrational'', a cognitive therapist uses the word ''dysfunctional''. According to cognitive therapy, disorders have a typical cognitive content (cognitive specificity), REBT focuses more on the 'musts' and other imperatives underlying certain disorders.

Cognitive therapy and behavioral therapy have a number of things in common:

• There is an empirical basis.
• The focus is on the current problem.
• There is a requirement for problems to be explicitly identified.
• There are similar consequences.

However, cognitive therapy supports the idea of an inner emotional life that can be adjusted through active cooperation and learning. People are active participants in their environment who assess and evaluate stimuli themselves. It is very important in cognitive therapy that there is a clear cognitive change and not just behavioral change.

What is the history of cognitive therapy?

Cognitive therapy is derived from three main sources:

1. The phenomenological approach to psychology.
2. Structural and in-depth psychology.
3. Cognitive psychology.

The phenomenological approach states that the image that people have of themselves and their environment forms the basis of their behavior. Structural and in-depth psychology come from the ideas of Kant and Freud's hierarchical structure. Cognitive psychology was developed by George Kelly.

What was the beginning of cognitive psychology?

The founders of cognitive therapy are Beck and Ellis. Beck conducted research on depression in the 1960s and found that the psychoanalytic theory in which he was trained did not match his findings. Psychoanalysis saw depression as a self-centred anger expressed in thoughts and dreams. Beck previously recognized a negative bias that led to dysfunctional information processing. Ellis confronted patients with their ideas and tried to convince them that they were unrealistic, while Beck took on the role of a colleague who investigates with the client. Several professionals with behaviorist backgrounds, such as Bandura, Mahoney and Meichenbaum, have also left their mark on cognitive psychology.

What does research into the cognitive model tell us?

Current research into the theoretical background and therapeutic efficacy of cognitive psychology has shown positive results in many different forms of psychopathology. People with depression often have many cognitive misconceptions, which can be tackled with cognitive therapy. Cognitive therapy also shows good results with anxiety disorders.

The cognitive specificity hypothesis states that there is a separate cognitive profile for each psychiatric disorder. This hypothesis has now been proven for many different disorders. In addition, cognitive psychology is less likely to relapse than other treatment methods for anxiety and depression.

Cognitive therapy can also have a positive effect on people who deal with suicidal thoughts. An important factor for suicide risk is the feeling of hopelessness. People who have a high risk of suicide and who receive a short form of cognitive therapy are 50% less likely to make a new suicide attempt.

How is psychotherapy integrated?

There are various modalities in which the principles of cognitive psychology are incorporated. For example, Young's schema therapy focuses on non-helpful basic assumptions developed early in life. Mindfulness-based cognitive therapy uses acceptance and meditation techniques to promote resilience and prevent relapse into depression.

Beck has developed various assessment scales to diagnose psychiatric disorders and cognitive problems. The most famous is Beck Depression Inventory (BDI) . Others are: the Beck Hopelessness Scale , the Beck Anxiety Inventory , the Beck Self-Concept Test , the Beck Youth Inventories , the Clark-Beck Obsessive-Compulsory Inventory , the Suicide Ideation Scale , the Suicide Intent Scale , the Dysfunctional Attitude Scale , the Sociotropy-Autonomy Scale , the Personality Beliefs Questionnaire.

There are several treatment centres that provide outpatient cognitive treatment. Research and treatment with cognitive methods is also conducted at many universities worldwide. Information about cognitive psychology for professionals has been published in the International Cognitive Therapy Newsletter. Cognitive therapy can provide drastic improvement in a short time.

What personality theories are there in cognitive therapy?

Cognitive therapy emphasizes the importance of information processing processes. When someone has to respond to their environment, various cognitive, emotional, motivational and behavioral schemes are triggered. According to cognitive psychology, personality is the interaction between an innate disposition and the environment. Personality traits are basic schemes or interpersonal strategies developed in response to the environment. The symptoms in psychopathology are on the same continuum as normal emotions, but they are manifested in an extreme version. People can be predisposed to a disorder, but the disorder is ultimately caused by their own response to stressors.

What is cognitive vulnerability?

Each person has their own set of personal vulnerabilities that make them susceptible to psychological problems. Vulnerabilities are connected to personality, which in turn is formed by temperament and cognitive schemes. Cognitive schemes can be adaptive or dysfunctional and also general or specific. People can also have competitive schemes. In personality disorders, schemes are activated too quickly and violently.

From which dimensions can personality problems arise?

There are two main dimensions of personality that influence the development of psychiatric disorders:

1. Social dependence (sociotropy).
2. Autonomy.

Dependent people are more likely to fall into mental illness as a result of disrupted relationships. Social dependence includes concepts like proximity, care, autonomy, goal setting, self-determination and self-imposed obligations. Most people display a mix of both, although purely autonomous or purely dependent people do exist.

Which concepts are important in cognitive therapy?

The learning history and important life events of an individual are important. Psychological problems are often caused by various interacting factors. Social learning theory and reinforcement are also crucial. Part of the social learning theory is the personality concept, which consists of a reflection of schemes and underlying assumptions.

What is the causality theory of cognitive therapy?

The causality theory of cognitive therapy suggests that psychological distress is caused by an interplay of innate, biological, developmental and environmental factors. There is never just one cause.

What are cognitive distortions?

Cognitive distortions are systematic errors in reasoning:

• Random inference: to draw a conclusion without evidence or even a counter-proof conclusion.
• Selective abstraction: assessing a detail of the situation, ignoring the context.
• Overgeneralization: using an incident to create a rule.
• Magnification and minimization: seeing something as much more serious (catastrophizing) or less serious (denial) than it is.
• Personalization: connecting external events to yourself for no reason.
• Black and white thinking (dichotomous thinking): seeing experiences either as a complete success or as a failure, without a middle ground.

What are the different cognitive models like?

There are cognitive models for any disorder that try to explain what the disorders are and how they came to be:

• Depression is characterized by a cognitive triad of problems. A depressed person has a negative view of themselves, the world and the future. In addition, he sees himself as incapable, abandoned and worthless. The future is pessimistic and the feeling of hopelessness can lead to suicide attempts. Different motivational, behavioral, emotional and physical symptoms are identified. Other symptoms are increased dependence and indecision.
• Anxiety disorders are caused by the excessive or disrupted functioning of survival mechanisms. Someone with an anxiety disorder has an exaggerated or incorrect assumption about danger and is no longer reasonable in that regard. In addition, there is also a problem with recognizing signs of safety.
• Mania is the opposite of depression. Manic people have a cognitive shift to the positive and try to see something positive in everything, ignoring negative signals. This results in unrealistic expectations, exaggerated views on equity, value and performance that lead to euphoria and pride.
• Panic disorders are characterized by a tendency to view any inexplicable symptom or feeling as a sign of impending disaster. There is too much focus on physical or psychological experiences and these people are overly vigilant. There is an inability to see symptoms and interpret disaster realistically.
• When someone has experienced a panic attack in a certain situation, they will avoid this situation. Agoraphobia is a panic disorder in which the expectation of such an attack causes a number of autonomic symptoms (palpitations, accelerated breathing, etc.) which are then seen as signs of an attack, indeed causing the real attack.
• Phobias are exaggerated fears which lead people to avoid certain situations. If they cannot, very intense fear is experienced. Here too, avoidance plays an important role.
• Paranoid states arise in people who are prone to think that other people treat them unjustly. They are primarily concerned with the injustice of alleged attacks, oppositions or infringements rather than the actual loss.
• OCD, obsessive compulsive disorder, results in people who judge certain situations that most people consider safe to be dangerous. As a result, they continue to doubt whether they have taken the correct precautions for their own safety or that of others (turn off the gas, close the window, lock the door). In addition, they have an exaggerated sense of responsibility that makes them believe they are responsible for actions that can harm other people. Compulsions are attempts to prevent danger by performing certain rituals.
• Suicidal behavior has two characteristics: a high degree of hopelessness and a difficulty in solving problems.
• Anorexia nervosa represents a mix of maladaptive ideas that revolve around a central assumption: "my weight and figure determine my value and social acceptability." In addition, there are disturbances in perception.
• Schizophrenia consists of a complex collaboration between neurobiological, environmental cognitive and behavioral factors. Because the brain cannot integrate these functions, people become more vulnerable to stressors, and this can lead to strange thoughts and behavior. For example, perception processing problems along with negative self-schemes can cause auditory hallucinations.

What is the relationship between cognitive therapy and psychotherapeutic theories?

The goal of psychotherapy is to correct erroneous information processing and to help the patient find the beliefs that cause maladaptive behavior and emotions. Cognitive and behavioral techniques address unhelpful thoughts and teach patients a more realistic way of thinking. The therapist does not directly mention that the thoughts are unrealistic but cast a doubt on the thoughts. The patient then chooses to reject or retain certain thoughts himself. Negative thoughts are not replaced by positive ones, rather the starting point is that thoughts must be rational and correct. The intended cognitive change takes place at different levels: voluntary thoughts, continuous and automatic thoughts, underlying assumptions and basic thoughts. The voluntary thoughts are the easiest to tackle, the basic thoughts are the most difficult. Automatic thoughts are created by having certain underlying assumptions. Basic thoughts are fixed in cognitive schemes.

How does cognitive therapy deal with the therapeutic relationship?

There is always a partnership. The patient contributes a lot, after all he has to express his thoughts and name his sensations. In addition, the patient receives homework after each session. The therapist acts as a guide and catalyst. In cognitive therapy, the starting point is the patient's thoughts. Flexibility is an important skill that is required from the therapist. This means that the therapist adjusts his techniques to the patient's symptoms. Usually, after each session, the therapist asks for feedback from the client to increase collaboration.

What are the definitions that cognitive therapy leans on?

Fundamental concepts in cognitive therapy are collaborative empiricism, Socratic dialogue, and explorations or guided discovery. In collaborative empiricism, the patient and the therapist look for dysfunctional interpretations. The patient is seen as a scientist who has temporarily drawn the wrong conclusions. Socratic dialogue is a way of conversing in which the patient gains insight through the therapist's questions. These relate to clarifying problems, identifying thoughts and assumptions, examining the significance of events for the patient, and assessing the consequences if maladaptive thoughts and behaviors are not changed. Guided discovery means finding out what the patient's misperceptions and beliefs are and what links them to past events. New experiences gained in therapy give the patient a realistic perspective.

What does the psychotherapeutic process look like?

The end goal is for the client to learn how to use the principles of therapy on his own.

How does the first session of cognitive therapy go?

First contact consists of building a relationship, obtaining important information (diagnosis, history, current life course, psychological problems, attitude to treatment, motivation for treatment) and providing symptom relief. The first sessions are also used to make the patient more familiar with cognitive therapy. In order to achieve rapid symptom relief at the beginning of therapy, the focus is often on a specific problem. A functional analysis is used to determine the problem; it focuses on the problem elements and cognitive analysis on the thoughts of the patient when he experiences a certain emotion.

In the first sessions, the therapist is often more active than the patient. The patient receives homework immediately after the first session. This is often aimed at recognizing the connections between thoughts, feelings and behavior. In later sessions, the patient increasingly takes an active role in determining the homework. Early troubleshooting can motivate the patient to continue treatment.

How do later sessions of cognitive therapy go?

Later sessions focus more on thinking patterns than symptoms. The emphasis is therefore more on cognitive than behavioral techniques, because the dysfunctional thoughts are often deeply rooted. When automatic thoughts are perceived, assumptions can be addressed.

During the course of therapy, the patient is given more responsibility in identifying problems and solutions. The therapist makes a shift from teacher to advisor.

How does the end of the treatment go?

The duration of treatment depends on the severity of the problem. With unipolar depression, a weekly treatment in 15-25 weeks can be considered. In case of more severe depression, an extra weekly session is planned in the beginning.

Patient characteristics also determine the duration of treatment. If a patient finds it more difficult to let go of thoughts, the treatment will take longer. It is always made clear that there is a length of time attached to the therapy and that it is not a continuous process. Patients are taught that the goal is to become their own therapist. A problem list provides insight into the therapy successes.

The goal of cognitive psychology is not healing the patient but teaching the patient to recognize non-helping thoughts and adapt them to reality. The prognosis, for example the chance of relapse, is also discussed.

After completing the therapy, one or two 'booster' sessions will take place.

What are the mechanisms of psychotherapy?

There are three mechanisms common to all successful therapies:

1. An understandable framework.
2. The emotional involvement of the patient in the problem situation.
3. Reality testing in that situation.

In cognitive therapy, changes take place as the patient learns to recognize his thoughts. He learns to subject thoughts to a reality check and adjust cognitions. Change can only take place when the patient experiences a certain thought pattern as threatening.

Who can be helped with cognitive therapy?

Cognitive psychology is best applied when there are clear cognitive problems. In the past, only severe mental problems were tackled, but now cognitive therapy is also applied for personality disorders. Family/group and inpatient/outpatient therapy is also possible. Cognitive therapy can also be combined with medications. For unipolar depression, medication is not necessary but for psychotic disorders a combination is preferable. When a patient understands reality correctly (and does not, for example, have delusions), cognitive therapy works best. In addition, concentration and memory must be in order.

Cognitive therapy uses specific learning techniques to monitor negative automatic thoughts and discover the connections between cognition, affect and behavior. The goal is to replace unhelpful thoughts with realistic ones. There are a lot of different cognitive techniques that can be used in therapy:

• The patient's automatic thoughts are often found through verbal techniques. Their interpretation is not explored but rather their meaning, especially when the thoughts are fairly neutral but the patient does experience strong emotions.
• Logical analysis is also used to discover automatic thoughts.
• Discovering non-helpful assumptions is often very difficult, as few patients can identify them directly. Assumptions can be seen as themes in automatic thoughts.
• The what-if technique is used when preparing for frightening consequences. This works especially in patients who avoid something.
• The re-attribution technique proposes alternative causes for events when a patient feels that something is 'his fault'.
• Redefinition is used when people are anxious and feel they are the centre of attention.
• In the case of intrusive imagery, often trauma-related, direct modifications can take place to reduce the impact.

Cognitive therapy does not only use cognitive techniques, but combines those with behavioral techniques. Behavioral techniques are used in cognitive therapy for adjusting automatic thoughts, skills training, relaxation or when being exposed to fears. Behavioral techniques that are often used in cognitive therapy:

• Homework ensures that the client can continue to practice what he has learned between sessions.
• Hypothesis testing provides a more realistic picture.
• Exposure therapy provides information about the patient's feelings and helps the patient get a more realistic view of the fear.
• Behavioral exercise and role playing are used to practice skills.
• Distraction techniques serve to reduce strong emotions and negative ideas.
• Activity planning provides structure and dedication. Activities are generally rated on a ten-point scale for fun.
• Ascending task exercises ensure that a patient can do something at a non-threatening level and then take it one step further.

Most sessions last around 45 minutes. Before the start of the session, the patient is often asked to complete a questionnaire. Confidentiality and informed consent for video recordings are mandatory. The recorded material can also be used again in therapy. When possible, others who are close to the patient are also involved in the treatment. Problems can also arise in therapy. For example, a patient may misunderstand the therapist, which can be addressed with cognitive techniques. There may also be unrealistic expectations about the time it takes for a change to occur.

Beck and others designed guidelines for dealing with difficult patients:

• Keep in mind that the patient has a problem, he is not the problem.
• Stay optimistic.
• Identify and deal with your own dysfunctional cognitions.
• Stay task-oriented rather than client-oriented.
• Maintain a problem-solving attitude.

What evidence is there for the cognitive therapeutic approach?

Randomized controlled trials demonstrate a clear and validated treatment effectiveness. Meta-analyses provide a complete picture of the treatment. Cognitive therapy is based on empirical studies. Randomized controlled trials have shown success in depression and anxiety disorders in particular.

What is the relationship between cognitive therapy and multicultural psychotherapy?

The patient's thoughts, values ​​and attitudes are partly determined by his cultural background. The cultural background is not attacked in the therapy, but attention is paid to the meaning of the thoughts. Cognitive therapy is used worldwide.

How does family therapy work? - Chapter 11

Family therapy offers a form of psychotherapy that takes the context of family into account. Family members are assisted in identifying and changing problematic, maladaptive and repeated relationship patterns. In family therapy, there is often an identified patient (the one who is often thought of as the causative agent of problems within the family) who is perceived as someone who exhibits problem behaviors that are maintained through dysfunctional transactions within the family or between the family and the environment.

What are the basic concepts of family therapy?

Family therapy started as a result of individual therapy in the 1950s. Therapists always saw that certain achievements and advances in therapy were negated by family members. As a result, the focus of the individual was moved to the family as the cause of psychopathology: ''family reference framework''. This involves looking at reciprocal causality: how does each family member influences the other members.

How does a family function as a system?

Family therapists pay attention to the structure within a family: the processes within a family and how they develop, adapt and change over time. A family is an ever-changing, living, complex and sustainable system with causal relationships and related parts that together are more than just a group of individuals.

The family is seen as a system that functions through wholeness and organization. A system consists of units that are related to each other. These units are organized around these relationships. These combined units together produce a whole greater than the sum of its parts. If one part changes, it has an effect on the entire system.

Bateson's philosophy has inspired people to see the family as a system. He talked about the family as a cybernetic system.

What does the cybernetic knowledge theory say about family?

Cybernetic science has brought about clinical changes. For example, pathology is seen as part of the social environment and not just person-specific. In addition, interaction patterns are examined. This causal process in which each cause is the effect of a previous cause but at the same time also becomes the cause of a subsequent event is called circular causality. This is therefore fundamentally different from the simple, non-reciprocal view of linear causality in which a cause leads to an effect, as in a stimulus response relationship.

The cybernetic system subscribes to a kind of feedback loop; there is a dynamic balance which is maintained by the family. When a crisis or disruption develops, the family members try to maintain or regain the stable situation (the family homeostasis). Negative feedback prompts recovery to a calm, stable situation. Positive feedback leads to more change by increasing the deviation from the normal situation. The latter can be important in breaking through dysfunctional patterns and reaching a new level.

What are the subsystems, boundaries and larger systems of the family?

Families are living subsystems in which all group members perform certain tasks and functions. Sometimes certain subsystems form within the family, such as father and daughter against mother and son. However, there are three subsystems that are always maintained within a family:

• Spouses.
• Parents.
• Siblings.

Problems within the marital subsystem lead to problems in the whole family. Effective spouses provide security and teach their children commitment by setting a good example of a healthy marriage. An effective parent subsystem provides care, guidance, boundaries and discipline. Siblings teach each other to negotiate, collaborate, compete and bond.

Boundaries are invisible lines that separate (sub)systems. These boundaries can be rigid and lead to little contact between family members. The other extreme is when there are diffuse boundaries and it is no longer clear what the roles are within the family. This makes them interchangeable and the family members are too involved in each other's lives. In disrupted families, the boundaries are too rigid and the family members feel isolated from each other. In entangled families, the boundaries are too diffuse and the family members are involved in each other's lives.

Flexible boundaries lead to a better information flow. As a result, the family is open to new experiences and able to change dysfunctional patterns. In that case, the family functions as an open system. However, when the boundaries are difficult to cross, the family is not open to new experiences, which often results in a suspicious attitude towards the outside world and the family functions as a closed system. Ultimately, no system is completely disrupted, entangled, open or closed, but all families are somewhere on the continuum.

What are post-modern challenges of cybernetics?

The disadvantage of cybernetics is that all information is limited to an outsider's observants: the therapist. The second order cybernetics focuses on the effect of the therapist on the observed family and the effect of the family on the therapist. The perceptions of each family member's current problems are taken more seriously and seen as important, even though these views are completely different from each other. It is not possible as an observer to get a completely objective picture of the situation, because for the therapist, just as for the family members, everyone constructs their own reality. In addition, family therapists nowadays pay more attention to the influence of society and the environment on the functioning of the family.

What is the importance of gender awareness and culture sensitivity in family therapy?

Nowadays more attention is paid to the role of gender, cultural background, ethnicity and social class. These are interactive and cannot be viewed separately. Family therapists observe a gender-sensitive view, trying not to reinforce stereotyped, sexist or patriarchal attitudes. In addition, family therapists try to take a pluralistic view, in which the cultural context and the way in which the family is organized (stepfamily, single parent, gay couples, etc.) are always compatible. Many therapists have a certain white middle class perception of what makes a good family, but these values ​​do not apply to all cultures and social classes. The development of culture-sensitive therapy has been necessary in order to be able to continue to apply adequate family therapy in today's multicultural societies.

What is the relationship between family therapy and other systems?

There are a number of other psychotherapies that are similar to family therapy. For example, the object-relationship theory from psychoanalysis perspective emphasizes on the search for important persons (objects) in our lives from the moment we are born. Object relationship therapists are more concerned with unconscious childhood processes that now determine personality whereas family therapists focus on current interpersonal problems.

Adlerian's psychotherapy has some similarities with family therapy. For example, there is much less pressure on the biological or instinctive urges, such as in psychoanalysis, and both have a holistic view of the family and the individual. Still, in Adlerian's psychotherapy, little attention is paid to dysfunctional patterns.

Rogerian's therapy has had a great influence on family therapy. Family therapists place great value on exercising Rogers' sufficient and necessary conditions, but often take a more leading stance than is usual in humanistic psychology.

Existential therapy is very concerned with being aware of the present moment, but according to family therapists, there is too much emphasis on the organized whole of the individual. Behavioral therapists have a linear view of causality and are also too focused on the individual.

What is the history of family therapy?

The fathers of family therapy are Freud, Adler and Sullivan. Adler elaborated on Freud's psychoanalysis and put more emphasis on the family. Sullivan argued that people are the product of their interpersonal situations. He laid the foundation of family therapy as it currently exists. Bertalanffy developed the general system theory in 1940, introducing the concept of circular causality. In 1961, John Bell developed the family group therapy in which he applied social and behavioral therapy techniques to family systems.

How did research on schizophrenia, psychopathology and delinquency lead to the development of family therapy?

In the 1950s, a group of researchers started looking at the role of family in the development of schizophrenia. Bateson speculated that the cause was the parents' double-blind communication. Double-blind communication is saying one thing but doing the opposite. Other causes of schizophrenia in children, include a toxic marriage (where one person dominates the other) and a marital split (where the two parents undermine each other to gain the child's affection and loyalty). Bowen argued that the symbiotic bond between mother and child could lead to schizophrenia. Pseudomutuality (Wynne) is a type of attachment within a family, in which it is pretended the family is functioning well while this is by no means the case. This is the beginning of recognizing the pervasive influence of family on a person's mental health, although, we now know, it cannot cause schizophrenia.

Ackerman argued that family sessions aimed to unravel interlocking forms of psychopathology. He argued that one family member's problems cannot be understood without the other family members.

Minuchin worked with delinquent youth from deprived neighborhoods. He developed several therapeutic techniques to restore disrupted family ties.

What is the current status of family therapy?

Nowadays there is an integration of different therapeutic approaches within family therapy. No technique suits every person and every situation. Both functional family therapy and multi-system therapy are useful in tackling delinquent youth and adolescents with behavioral problems. Goldenberg investigated the different directions of family therapy and came up with a list of eight theoretical views discussed in the following sections.

What is object relationships family therapy?

Object relationships family therapy is a psychodynamic view of family therapy. Introjections (memories of loss or disappointment) influence current relationships. Treatment takes place by making people aware of their unresolved past problems.

What is experiential family therapy?

The basic principle of this humanistic or systematic view of family therapy is that families with problems need a growth experience. This can be obtained through experience with an interested congruent therapist. The therapist should be very open and revealing. Building self-confidence and learning to communicate openly and adequately is central.

What is transgenerational family therapy?

The idea that transgenerational family therapy is based on is that individual problems of family members arise and are maintained by the connections with other members. The stronger a person's bond with the family, the more vulnerable he or she is to family stress. The degree of individuality also has to do with the ability to be influenced by family events. So it is not good to be attached to your family because it makes you vulnerable to family conflicts. Problem behavior is passed on to the next generation, because problem children seek partners who had the same experiences.

What is structural family therapy?

Structural family therapy is aimed at answering questions on how families are organized and what rules they have. Treatment focuses on removing rigid transactions to enable family reorganization.

What is strategic family therapy?

In strategic family therapy, the therapist creates new strategies for the family to counteract unwanted behavior. Paradoxical interventions (indirect tasks to specify certain symptoms) are used. Family insight is not sought, but members are given tasks to change those aspects of the system that perpetuate problematic behavior.

Systematic family therapy is a variant that works well for psychotic patients and people with anorexia. This therapy assumes that there is competition in the family. Asking circular questions is a good technique.

What is cognitive behavioral family therapy?

In cognitive behavioral family therapy, restructuring is used to counter dysfunctional beliefs, attitudes or expectations in a family. Family members are taught how to assess their beliefs from now on, in order to counteract problems in the future.

What is social constructionist family therapy?

Everyone constructs their own reality. There is no standard example of a good family, because everyone is different and functions differently. In social constructionist family therapy, the therapist asks the question, “what are the beliefs you have now and how do they work for you?”

What is narrative family therapy?

How you talk about your family influences how you feel. In narrative family therapy, there is no interest in how the problem started, but in how it affected the family. The therapist's job is to rid the family of a hopeless feeling. He does this by imparting externalization: seeing the problem as something outside yourself instead of being part of you. Life is not one story but has multiple aspects and there are always possibilities.

What personality theories are there in family therapy?

Family therapists argue that behavior arises in the relationship with others. The individual personality is seen as existing, but at the same time as a part of a larger system: the family. This system is seen as part of one overarching system: society. It is the therapist's job to see the individual within the family system.

How a therapist sees personality depends on the theory he supports. For example, family therapists with psychodynamic view see individuals as people looking for important relationships with others. Success or failure is decisive for the rest of life. Behavioral family therapists believe that all behavior has been learned. Personality arises through conditioning and modelling. Cognitive family therapists think that certain ideas are taught that influence a person's behavior. If these cognitions are wrong, they can lead to negative and dysfunctional behavior.

Many family therapists view personality from a family life cycle perspective. In each family, certain events take place that can be profound, both positive and negative. The way in which they are handled determines the personality of the family members. Both change and continuity are typical of a family's life cycle. Normally, change is slow and the family has time to adapt, but sudden changes can cause the balance to be disrupted to such an extent that adjustment is no longer possible. During this period it is often possible to help the family achieve a higher level of functioning.

Which concepts are important in family therapy?

There are some crucial concepts to have in mind in order to understand how family therapy works:

• Family rules. A family can be seen as a rule-based system. The interactions between family members follow stable patterns. The redundancy principle describes the limited set of rules and interaction options within a family. A lack of rules for dealing with change leads to a dysfunctional family.
• Family stories and assumptions. Some families see the world as friendly, trustworthy, just, ordered and predictable and themselves as capable individuals. Other families have a negative view of the world and see it as threatening, unstable and unpredictable. These families will more often form a front against the outside world.
• Pseudo-mutuality and pseudo-hostility. Pseudomutuality means that a family keeps the appearance that everything is going well in the family, while this is not the case. Pseudo-hostility is precisely the constant arguing and fighting within a family, so as not to let deeper feelings emerge. There is a fear that family members will become too connected or too hostile if they do share deeper emotions.
• Mystification. Mystification is twisting someone's experiences by denying what happened. This can be a minor thing to say to a child who is not tired at all, “you are tired, go to bed,” but it can also take on larger forms. For example, you often see that during sexual abuse or abuse within the family, the victim is mystified by denying that this may actually have happened.
• Scapegoats. You often see that there is a scapegoat in dysfunctional families. This person is blamed for all problems within the family. Often scapegoats participate in this process themselves by actually taking on the role they are given, which makes it impossible to behave differently after awhile.

What is the relationship between family therapy and psychotherapeutic theories?

There is no uniform family therapy, but all types of family therapists do have some basic concepts:

1. People are products of their social connections and family relationships should be included in efforts to help the individual.
2. An individual's symptoms arise in the relational context and interventions are most effective when these dysfunctional interpersonal relationships are changed.
3. Individual symptoms are maintained through family trades.
4. Family therapy is more effective than individual therapy.
5. Subsystems and boundaries provide clues about the organization of a family.
6. Traditional diagnostics do not understand family dysfunction.
7. Changing dysfunctional patterns and getting a better picture of yourself and your family are the main goals.

When the interpersonal relationships within a family are emphasized, the therapy changes from a monadic model to a diadic. It is important to always try to create a di- or triadic model, because in a monadic model everything is the fault of the individual, while in di- and triadic models the interactions are to blame. Symptoms of a family member's problem often balance family homeostasis. However, the idea that a family must have a dysfunctional member to maintain balance is not desirable. First order changes are changes within the system that do not change the system in itself, such as, for example, giving more household tasks to the children. Second order changes are fundamental changes in the system itself (giving more responsibilities to the children). The latter creates a new situation in which the parents become less controlling and the children more self-determining. Most problems are of the first order, but sometimes it is necessary to provide second order solutions in order to fundamentally change a situation.

What does the psychotherapeutic process look like?

Partnership with the family is central for successful results.

Family therapy starts when a client asks for help. This help is sought by one or more family members outside the family.

As many family members as possible are present at the first session of family therapy, each member should be welcomed as an individual. It is important that the therapist does not become extremely sympathetic with one of the family members. The therapist tries to learn as much as possible about the family.

The therapist wants to create a partnership with the family in a way that is appropriate for the family concerned. Every family member should feel safe to express themselves.

What is important for a therapist to understand the family functioning?

The therapist considers a number of points:

• Does the whole family need treatment?
• What led to the symptoms?
• Which intervention are we going to apply?

Therapists who work with cognitive behavioral family therapy often conduct a behavioral analysis of the family's behavioral patterns, using questionnaires. This clarifies the seriousness of the problem.

Therapists who work with experiential family therapy spend less time on family history. They mainly look at the present. The family assessment is more informal in nature.

Minuchin argues that a therapist gets a better idea of ​​the family by interacting with them rather than using a formal assessment process. Many professionals share this view.

How can a therapist understand the family history?

Therapists who work according to the object relationship theory argue that the family history is important to understand family functioning. Evaluating conversations can be used to get to know the history. Bowen drew up a family genogram, constructing a three-generation family tree. This makes repeating family patterns obsolete.

Satir drew up a life course for each family member. In that way, family members can get a better understanding of how their mutual relationships have developed.

Structural and strategic family therapists pay less attention to the history of the family and the family members, but focus on family organization, cooperation within the family and its hierarchy.

Therapists working from the social construction framework find it important to understand how family members perceive the world.

How can a therapist facilitate change?

Therapeutic techniques to change the functioning of the family include:

• Reframing or redetermining: labeling behavior differently from a positive perspective.
• Therapeutic double-bind: letting family members express the symptoms ("arguing extra well"), to show that this act is voluntary.
• Enactment or replay: performing a role play. The therapist can provide directions.
• Family formation or sculpting: one member places the rest of the family in a lineup. The result says something about that family member's feelings about relationships within the family.
• Circular questioning: questions answered by all members, where everyone has a different answer. The rest of the family learns that their view of the situation is not the only correct one, but there are also other views.
• Cognitive restructuring: trying to change the perceptions of the family members in order to change behavior in the whole family.
• The miracle question: the therapist asks the question: “A miracle has happened and everything is good again! What has changed?" With this you can see how everyone would like to see everything and how this should be done. Therapy goals become clear.
• Externalizing: putting the problem outside of the family instead in the family. For example, not "mother is depressed", but "mother is controlled by depression".

What mechanisms of psychotherapy play a role in family therapy?

Family therapists often take an active role in solving problems in families. The focus is mainly on the present. Past experiences are only used to solve present problems. Family therapists try to help clients achieve structural, behavioral, experiential and cognitive changes. Structural change is achieved by breaking through rigid and repeated patterns and setting new, functional rules and boundaries. Behavioral change is achieved by doing homework assignments, role plays, paradoxical interventions and learning from experiences. Experience-oriented change is achieved by experiencing what was previously locked in the subconscious. People learn this by communicating better and expressing themselves emotionally to each other. Cognitive change is adjusting thinking patterns and expectations.

How can family therapy be applied?

Even when therapists work with individuals, the context of problem behavior is considered. There are often problems between parent and child. Sometimes, for example, young people are in conflict with their parents or with society. Minuchin's structural approach can be applied to bring about changes and to adapt outdated rules. This allows clear boundaries and more flexible rules to be drawn up. Intergenerational problems are also common when parents raise their children in a country other than where they come from. This creates a clash between the traditional norms and values ​​of the parents and the new norms and values ​​of the children. In marital problems, both spouses often have individual problems and their interrelational problems do not really contribute to their happiness. Couples who enter therapy together are more likely to succeed than couples who seek individual help.

What is the role of the family therapeutic perspective?

Family therapy looks at the origin and maintenance of problem behavior. Changing dysfunctional patterns of the family system is the goal of the intervention. The type of problem determines the type of intervention. Family therapy is a challenge for the therapist, as individual needs should be addressed while being seen within the overarching family system. The therapist must remain objective and simultaneously become part of the family processes in order to bring about change. The social construct family therapy looks at equality within the family and the cooperation between family members.

What are (contra) indications for family therapy?

Family therapy is not the best choice for every mental disorder. Family therapy is really useful for relationship problems. Sometimes family members do not want to cooperate or it is too late to revive uprooted relationships. In this case, family therapy can provide little help. It may also be the case that someone with serious problems disturbs the family so severely that working with the whole family is impossible.

What should be the duration of treatment?

The nature and severity of the problem determine the duration of treatment. The complexity of the family ties and the treatment goals also play a role. The therapist's view also has an influence: for example, the structural approach works in a shorter time than the object relationship approach.

What should the treatment environment be like?

Almost all psychotherapists have embraced the idea of ​​family therapy. It can be performed both in a clinical and in-hospital settings.

What treatment stages are there to go through?

Most family therapists want to see the whole family at the first session. After getting acquainted, the next steps differ, as some therapists attach more importance to, for example, the history than others. The sessions that follow are often used to teach family members to redefine the problem and view it in the family context. Members then learn that everyone contributes to the problem in question. Ultimately, family members learn effective coping skills and better ways to understand others. An internal support system is finally created, making further therapy unnecessary.

What evidence is there for family therapy?

It is known from evidence-based research that the treatment method, the therapist and the therapeutic relationship are very important for the success of the therapy. Unfortunately, there is little supporting evidence for the contribution of the system. Most studies have focused on cognitive and behavioral therapy. Research into the effectiveness of family therapy is difficult, because not every family member will benefit equally from the treatment. (Multi) system therapies seem to be effective in behavioral disorders. These methods are based on social learning methods.

What is the relationship between family therapy and multicultural psychotherapy?

It is important for therapists to have knowledge of the changing world, as migration is increasing and we are increasingly entering a multicultural world. It is important that the therapist is aware of prejudices. The client's internal frame of reference should help the therapist see the world through his eyes.

How does positive psychotherapy work? - Chapter 13

What are the basic concepts of positive psychotherapy?

Psychotherapy started off as a therapy that was focussed on people's troubles, on the negative aspects of people's lives. This kind of therapy is based on the assumption that uncovering childhood traumas, untwisting faulty thinking, or restoring dysfunctional relationships is curative. This makes sense, but clients usually want more than to just be relieved of their troubles; they want to feel more joy, satisfaction, zest, and courage, not just less sadness, fear, anger, or boredom. They want to enhance their strengths, not just remediate their weaknesses.

Positive psychotherapy (PPT) was developed by therapists who believed that traditional therapy did not make their clients happy, but just empty. In PPT, clients are taught to employ their highest and intact recourses to meet life's challenges. PPT helps clients to know their strengths and learns them to cultivate positive emotions, strengthen positive relationships and give meaning to their lives.

PPT is not meant to replace traditional psychotherapy, but can be seen as an extension of it. The therapist has to find the right balance in the positive and negative methods he uses.

What is the relationship between positive psychotherapy and other systems?

Almost all other systems in psychotherapy aim to address basic human deficiencies, and focus on negative thoughts, feelings, and behavior. This focus on the negatives, comes from evolution: our brain responds more strongly to negative experiences than to positive ones. This has helped people to stay save. Nowadays, we usually do not have to fear for our lives on a day-to-day basis, but our brain still focusses heavily on the negatives. This focus is also traditional psychotherapy because therapists start to focus on the things that the clients focus on.

This focus on the negatives in someone's mind, life, and behavior, has shown to be successful for a lot of people. However, about 30% to 40% of clients see no benefits and 5% to 10% even deteriorates during therapy. This is called the 65% barrier of traditional psychotherapy. Adherents of PPT believe that positive psychotherapy can help the people that cannot be helped with other forms of psychotherapy.

What is the history of positive psychotherapy?

Before World War II, psychology had three clear missions:

• Curing psychopathology.
• Making the lives of all people more productive and fulfilling.
• Identifying and nurturing high talent.

Because of the war, only the most necessary goal of psychology remained: curing psychopathology. This is when the focus of psychotherapy shifted to purely negative. In the DSM-5, there was no classifications of strengths until 2004. In the last half of the 20th century, there were only a handful of interventions that focused on positive resources of clients.

What is the current status of positive psychotherapy?

Positive psychotherapy came in the picture in 2009 when an issue of the Journal of Clinical Psychology focused on it. More and more positive psychotherapies were developed after that. Positive psychotherapy is now also being taught at the graduate level at numerous reputable institutions.

What personality theories are there in positive psychotherapy?

Positive psychology does not accept the notion that childhood alone determines adult personality and that we spend the rest of our lives futilely attempting to resolve sexual or aggressive impulses. In the view of PPT, most childhood events are relatively insignificant. A study by Ferguson has showed that there is no evidence at all for large effects of childhood events on adult personalities. A study by Bartels and Boomsma has suggested that around 40% to 50% of happiness comes from genetics and only 10% to 15% by life events. PPT also believes that happiness comes from optimism, spirituality and positive coping style, but it does believe that these are traits and skills that can be worked on.

On what assumptions is positive psychotherapy based?

PPT is based on three primary assumptions:

1. Psychopathology results when clients' inherent capacities for growth, fulfilment, and happiness are thwarted by sociocultural factors.
2. Positive emotions and strengths are authentic and as real as symptoms and disorders.
3. Effective therapeutic relationships can be built on explorations and analysis of positive personal characteristics and experiences.

Which concepts are important in positive psychotherapy?

PPT is based on two major theories:

• The PERMA conceptualization of well-being by Seligman.
• Seeing character strengths as active therapeutic ingredients, as is done by Peterson and Seligman.

What is PERMA?

The model of PERMA is used to divide the abstract concept of well-being into more concrete and measurable components:

1. Positive emotions about the past, present, and future: fulfilment, pride, hope, trust, confidence, etc.
2. Engagement: involvement and absorption in work, intimate relations and leisure. How much someone experiences flow, the state where someone is fully engaged in an activity, can be seen as an indication of how engaged that person is in his life.
3. Relationships: the feeling someone belongs somewhere between other people.
4. Meaning: the feeling someone belongs in and serves something bigger than oneself.
5. Accomplishment: achievements, promotions, awards and compliments, but also the feeling of satisfaction and fulfilment by the person that accomplishes these things.

What are character strengths?

Individuals who experience gratitude, forgiveness, humility, love, and kindness are more likely to report being happier and more satisfied with life. This is why PPT focuses on these character strengths. In PPT, therapists do not question what clients do wrong, but in what character strengths they can grow. If there is a problem, this is mostly because someone has not developed one character strength yet, or because someone uses one strength too much and neglects the other strengths. Peter and Seligman made a classification of virtues and the strengths that are involved in acquiring or protecting this virtue:

• Wisdom and knowledge come from the strengths of creativity, curiosity, open-mindedness, love of learning, and perspective.
• Courage comes from the strengths of bravery, persistence, integrity, and vitality or zest.
• Humanity comes from the strengths of love, kindness, and social intelligence.
• Justice comes from the strengths of citizenship, fairness, and leadership.
• Temperance comes from the strengths of forgiveness and mercy, humility and modesty, prudence, and self-regulation.
• Transcendence comes from the strengths of appreciation, gratitude, hope and optimism, humor and playfulness and spirituality.

In the DSM-5, the symptoms of the major psychological disorders are linked to the strengths that are lacking and the strengths that are there in excess.

What is the full life?

PERMA and character strengths make up the full life in PPT. The full life is not just the sum of all the components, but also the trust that this good life will remain and the capacity to make life even better.

What is the process of positive psychotherapy?

The process of PPT can be divided in three phases. All the phases focus on different character strengths and components of PERMA. This is divided this way because some of these things are needed to engage clients in the therapy and others rely on other strengths and PERMA-components so they cannot be focussed on first:

1. Phase one: orientation and focus on gratitude, engagement, and accomplishment.
2. Phase two: focus on meaning, forgiveness, relationships, gratitude, and accomplishment.
3. Phase three: focus on hope and optimism, meaning, engagement, relationships, and altruism.

Clients are also encouraged to keep a gratitude journal during their course of therapy.

What are the mechanisms of positive psychotherapy?

Walsh, Cassidy and Priebe have identified some potential mechanisms of change in PPT:

• Cultivation of positive emotions or reduction of attention. PPT exercises cultivate positive emotions that open our attentional resources.
• Positive appraisal or rewriting of memories. PPT can help clients to rewrite negative (or 'open') memories in more positive and nuanced forms.
• Therapeutic writing. Reflection and writing are a big part of PPT and can help with putting things in perspective.
• Resource activation or using strengths. PPT is aimed at teaching clients to translate their strengths into concrete, personally applicable actions.
• Experiential skill building. PPT exercises allow clients to develop their signature strengths and decide what they value in life.

Who can be helped with positive psychotherapy?

Components of positive psychotherapy, such as building strengths, keeping journals or writing gratitude letters, are already widely used in non-clinical settings. The theory behind PPT is also used in coaching, education and in organizations. It has shown to be very beneficial for all 'normal' people, so PPT aims to expand its influence. PPT can also help a wide range of psychologically disturbed individuals, but some benefit the most from a combination of traditional therapy and PPT.

Clients with symptoms of depression appear to benefit most from PPT.

What are contra indications for positive psychotherapy?

There is currently no evidence that PPT is helpful for clients experiencing acute symptoms of panic disorder, selective mutism, and paranoid personality disorder. PPT should also not be forced upon any client: if a client feels like the focus should be on his problems rather than his strengths, PPT will not be helpful. Therapists should also be careful when they treat people with a strong sense that they are the victim, or people with narcissistic characteristics. Both can use PPT for goals that they are not truly helped by. Patients with heavy trauma, should also focus on processing this before they can get helped by PPT.

It is also important for both the therapist and the client to keep in mind that improvement by PPT will not be linear and that some people respond better to PPT than others.

What evidence is there for positive psychotherapy?

There is a fast growing body of evidence for PPT. PPT exercises were initially validated individually. Now PPT as a whole is also validated by multiple studies. Overall, PPT has been shown to significantly lower symptoms of distress and enhance well-being.

What is the relationship between positive psychotherapy and multicultural psychotherapy?

In the Western world, we tend to view happiness as feeling good (hedonism). PPT is based on the notion that happiness comes from the pursuit of the good life (eudemonia). This makes that PPT needs to keep cultural differences in mind; what is a good life for one, can differ a lot from the good life of another. It also differs a lot what character strengths entail: courage looks different in different parts of the world. Therapists that have a different cultural background than their client, need to be aware of the cultural aspect of someone's life. It is important to discuss cultural values with the clients and their expectations about the meaning of specific strengths in their particular culture.

How does multicultural psychotherapy work? - Chapter 15

What are the basic concepts of multicultural psychotherapy?

Multicultural psychotherapies aim for cultural sensitivity in psychotherapy. Cultural sensitivity is awareness, respect, and appreciation for cultural diversity. Demographic changes in the United States and Europe have brought increasing numbers of culturally diverse individuals who are in need of psychotherapy. Multiculturalism acknowledges the presence of diverse worldviews where each culture is unique and dynamic, and needs to be understood within its own context. Multiculturalism is based on the idea of cultural constructionism: the process of constructing a worldview through social processes that contain cultural symbols and metaphors. Multiculturalism is becoming more and more popular in society, but has not fully reached dominant psychotherapy.

What is cultural competence?

Cultural competence is the competence to deal with differences in worldviews by understanding and respecting someone else's culture. When therapists have a different worldview than their clients and they lack cultural competence, this can lead to communication problems, misdiagnosis, or premature treatment termination. For a therapist to be culturally competent, he needs to:

• Be aware of his own worldview;
• Be able to examine his own attitude towards cultural differences;
• Be willing to learn about different worldviews;
• Develop and increase his multicultural skills;
• Value diversity;
• Manage the dynamics of difference;
• Acquire and incorporate cultural knowledge into his interventions and interactions;
• Adapt to his client.

What is empowerment?

Multicultural psychotherapy is focused on the empowerment of marginalized individuals. The traditional psychotherapies have only marginalized these individuals further, because the therapies were never adapted to them. Within their empowerment focus, multicultural psychotherapies subscribe to these assumptions:

• Reality is constructed in a context.
• Experience is valuable knowledge.
• Learning and healing result from sharing multiple perspectives.
• Learning and healing are anchored in meaningful and relevant contexts.

It is needed for therapists to be aware of structural discrimination and of their own privilege, in order to be able to focus on empowerment.

What is the relationship between multicultural psychotherapy and other systems?

Multicultural psychotherapy can be seen as an extension of other systems of psychotherapy. It enhances other treatments and can make therapies beneficial for more people. But multicultural psychotherapy also exposes what is going wrong in other forms of therapy when it comes to overlooking certain people and discriminating against them.

What is the history of multicultural psychotherapy?

Multicultural psychotherapy has the aim to enhance the relationship between the self and the other. This aim comes from the beginning of time and can be seen among others in Judaism, Christianity and Buddhism.

What was the beginning of multicultural psychotherapy?

Multicultural psychotherapy comes from psychological anthropology, ethnopsychology, cultural anthropology, psychoanalytic anthropology and folk healing. The interest in the other arrived in the mental-health fields from the 1940s. This was when the link between culture and psyche became important. It also became more and more necessary to understand what colonization had done to people's mental-health and how it had affected people's relationships. Feminism also gave rise to new questions on how oppression worked between different cultures and what the effects of oppression were for women of different cultures. Lastly, ethnic family therapy showed to be very beneficial for people, since it was discovered that a lot of family-issues came from cultural norms and the way a family's culture is treated by other cultures.

What is the current status of multicultural psychotherapy?

The importance of multicultural psychotherapy seems to be accepted nowadays, but there are still a lot of therapies that overlook cultural differences and psychotherapy is still mostly based on western culture.

What personality theories are there in multicultural psychotherapy?

Multicultural psychotherapists recognize the development of identity within several contexts, and view the self as an internal representation of culture. Minority identity development models propose that members of racial and ethnic minority groups initially value the dominant group and devalue their own group, then move to value their own group while devaluating the dominant group, and then integrate appreciation for both groups. These are the minority identity development stages:

1. Conformity: people internalize racism and choose values, lifestyles and role models from the dominant group.
2. Dissonance: people begin to question the dominant group's cultural values.
3. Resistance immersion: people endorse minority-held views and reject the dominant culture's values.
4. Introspection: people establish their racial ethnic identity without following all cultural norms and question how certain values fit with their personal identity.
5. Synergy: people experience a sense of self-fulfilment toward their racial-ethnic-cultural identity without having to categorically accept their minority group's values.

Racial identity development models extend to members of the dominant society. According to Helms, these are the stages of white American racial identity development:

1. Contact: people are aware of minorities but do not perceive themselves as racial beings.
2. Disintegration: people acknowledge prejudice and discrimination.
3. Reintegration: people blame the victim and engage in reverse discrimination.
4. Pseudo-independence: people become interested in understanding cultural differences.
5. Autonomy: people learn about cultural differences and accept, respect, and appreciate both minority and majority group members.

Which concepts are important in multicultural psychotherapy?

The following concepts are important to know in order to understand multicultural psychotherapy:

• Cultural self-awareness: understanding of the dominant culture's values in which therapists communicate and practice.
• The therapeutic relationship. Positive alliance between a therapist and his client, makes the therapy more effective. When the worldviews of the therapist and the client are different, there tends to be less positive alliance. It is important for therapists to recognize this and work on the relationship with his clients.
• Cultural empathy: respecting and appreciating other cultures, and the willingness to learn about another culture and adapt to a client.
• Ethnocultural transference and countertransference: a client's projection of feelings from previous relationships onto their therapist and the reaction of the therapist, that have an ethnic and cultural basis.

What are the mechanisms of multicultural psychotherapy?

Multicultural psychotherapists use the same tools as any psychotherapists, but they are mindful about how to use them and they focus on the cultural backgrounds of their clients.

How does multicultural psychotherapy deal with psychopharmacology?

Ethnocentrism has resulted in culturally diverse clients' mistrust of psychopharmacology. Medication that is prescribed is usually tested on people of western culture and can have unwanted effects on people of other cultures, because their problems are not exactly the same or because they want a different solution. Ethnopsychopharmacology has emerged out of the need to address this problem.

How can multicultural psychotherapy be applied?

The explanatory model of distress, the RESPECT model and the cultural genogram are examples of multicultural assessment that leads to culturally appropriate treatment.

What is the explanatory model of distress?

Clients' worldviews and experiences affect how they present their problems to their therapists. In order to be aware of the differences this can cause in how therapists understand their clients, therapists can use the explanatory model of distress. This model, created by Kleinman, makes therapists ask the following questions to assess the problems of their clients:

• What do you call your problem?
• What do you think your problem does?
• What do you think the natural course of your problem is?
• What do you fear?
• Why do you think this problem has occurred?
• How do you think the distress should be treated?
• How do you want me to help you?
• Who do you turn to for help?
• Who should be involved in making decisions about the therapy?

What is the RESPECT model?

The RESPECT model draws attention to the issues of race, power, and distrust that are frequently where among racially and ethnoculturally different clients in (group)treatment. RESPECT stands for Respect, Explanatory model, Social context, Power, Empathy, Concerns and Trust. These are all subjects that the therapists and clients need to discuss: how does the therapist see these concepts and how does the client? How can they come to a mutual understanding?

What is the cultural genogram?

A cultural genogram can be used to enhance a therapist's own cultural self-awareness. A cultural genogram focusses on the cultural views and norms of the therapists, but that of his whole extended family. This makes him better understand himself and where his cultural ideas come from.

What evidence is there for multicultural psychotherapy?

Multicultural psychotherapy is itself an advocate for more research. It does not want to be reductionistic about cultures, but wants everyone to be open to learn more about different cultures and how to help people from different cultural backgrounds effectively. Much more research is needed on a lot of different multicultural psychotherapeutical questions.