Psychotherapy

Module 1 – Introduction to Psychotherapy

Unit – 1 Definitions of Psychotherapy, Varieties of Psychotherapy: Supportive therapy, Re - educative
Therapy, Reconstructive Therapy.
Definition
Perhaps the most acceptable definition of Psychotherapy given by Wolberg (1967), which is as follows:
"Psychotherapy is the treatment by psychological means, of problems of an emotional nature, in which a
trained person deliberately establishes professional relationship with the patient, with the object of:
Removing, modifying or retarding existing symptoms; Mediating disturbed patterns of behavior and
Promoting positive personality growth and development.
Definition Explained
This formulation requires additional elaboration.
Psychotherapy is the treatment.
It constitutes a form of treatment.
Psychological means. Psychotherapy is a generic term covering the entire spectrum of psychological
treatment methods.
These range from designed maneuvers of the therapist-patient relationship to indoctrinations fashioned to
change value systems, to tactics aimed at intrapsychic processes, and to conditioning techniques that attempt
to alter neural mechanisms.
Problems of an emotional nature. - Emotional problems are diverse, influencing every facet of human
functioning.
They are manifest in distortions in the individual’s psychic, somatic, interpersonal, and community life.
Manifestations of emotional illness are thus multiple, involving the total human being.
A trained person. In search of relief, the individual is apt to involve oneself in a relationship with a friend
or authority.
Deliberately establishing a professional relationship. The relationship, the core of the therapeutic process,
is deliberately planned and nurtured by the therapist. The therapeutic relationship is a collaborative
undertaking, started and maintained on a professional level toward specific therapeutic objectives. More
than one therapist (co-therapist, multiple therapists) may work together.
The patient. An individual in psychotherapy receiving treatment is best called a patient rather than some
other designation such as a client. The therapist may relate capably to more than one patient during a
session, as in marital or group therapy. The object is removing existing symptoms. A prime goal in therapy is
to eliminate the patient’s suffering as well as to remove the handicaps imposed by symptoms.
Modifying existing symptoms. Despite our wish for complete relief, certain circumstances may militate
against this objective.
Chief deterrents are inadequate motivation, diminutive ego strength, 1 and limitations in the patient’s
available time or finances.
Retarding existing symptoms. -There are some malignant forms of emotional illness, such as certain
fulminating schizophrenic and organic brain disorders, in which psychotherapy, no matter how adroitly
applied, serves merely to delay an inevitable deteriorative process.
Mediating disturbed patterns of behavior. The recognition in recent years that many occupational,
educational, marital, interpersonal, and social problems are emotionally inspired has extended the use of
psychotherapy into fields hitherto considered provinces of the psychologist, teacher, sociologist, religious
leader, and lawmaker.
Realization that the character structure is involved in all emotional illness has broadened the objectives of
psychotherapy from mere symptom relief or removal to correction of disturbed interpersonal patterns and
relationships.
Promoting positive personality growth and development.
The final use of psychotherapy is as a vehicle for personality maturation.
This has introduced a new dimension into the field of psychotherapy—a dimension that deals, on the one
hand, with problems of immaturity of the so-called normal person and, on the other, with characterologic
difficulties associated with inhibited growth previously considered inaccessible to treatment.
Counseling and Psychotherapy

Counseling is customarily defined as a form of interviewing in which clients are helped to understand
themselves more completely in order that they may correct an environmental or adjustment difficulty.

Guiding and helping people to make rational decisions, to organize plans for constructive pursuits, to seek
out the best available community resources to satisfy immediate and future needs, and to overcome
reluctancies toward and fears of action are among the tasks of the counselor.

A wide variety of professional and paraprofessional paid and volunteer workers function in this way as
counselors.

Client seek help for a host of problems, some real, some projections of inner distress.

And it is the duty of the counselor to distinguish between the two.

Other Definitions Of Psychotherapy

1. “Psychotherapy is the formal treatment of patients using psychological rather than physical or
chemical agents, principally verbal communication.”

2. “Psychotherapy may be defined as the treatment of emotional and personality problems and
disorders by psychological means.”

3. “Psychotherapy is a planned and systematic application of psychological facts and theories to the
alleviation of a large variety of human ailments and disturbances, particularly those of psychogenic origin.”

4. “Psychotherapy is…a cooperative enterprise for clarifying purposes and modifying attitudes in the
direction of greater integrity of personality.”
Varieties of psychotherapy

Supportive Therapy

Supportive psychotherapy occurs in almost every doctor-patient encounter and is the psychotherapy
provided to the vast majority of patients who are seen in psychiatric clinics and mental health centres. n the
late 19th century, Freud began to develop the techniques of psychoanalysis, which served as a foundation
for all the other psychotherapeutic modalities. Most of Freud’s patients were members of the upper classes
of Viennese society and had significant ego strengths, and their problems were mainly intra-psychic. In
contrast, many of the patients seen by psychiatrists and residents today suffer from extra-psychic problems,
such as poverty, social and political oppression, and abuses of power in relationships that threaten to
overwhelm their coping capacities. For these patients, supportive therapy is the treatment of choice.

Supportive psychotherapy is a dyadic treatment that uses direct measures to ameliorate symptoms and to
maintain, restore, or improve self-esteem, ego functions, and adaptive skills. It was developed in the early
20th century, and its objectives are more limited than those of the psychodynamic therapies. This therapeutic
modality focuses especially on developing adaptive capacities that take into account the patient’s
limitations, including:

• Personality issues, such as deficits in character structure and defense mechanisms

• Native ability (eg, impaired reality testing, decreased cognitive functioning, lower IQ, learning
disabilities)
• Problems associated with life circumstances (eg, lower levels of education, low socioeconomic
status, limited social support systems, problems related to migration)
Supportive therapy can serve as the first bridge out of social isolation and marginalization, since the 2 most
important elements of supportive therapy are the therapeutic alliance, which allays anxiety, helps support the
patient’s healthy defenses, and enhances adaptive skills; and conversational style. This style avoids analytic
abstinence and engages the patient in a collaborative discussion that decreases the power differential.

Supportive therapy is also the treatment of choice in individuals with severe personality disorders, at least in
the initial phases of treatment. Many individuals with personality disorders resent and fear the power
differential that results from a more analytic stance, given that many of them have experienced abuses of
power in early life. If the power differential is not addressed early in the treatment, it can destroy the
therapeutic relationship.
Supportive therapy may include educating the patient and family members about the illness and about the
patient’s potential and limitations, establishing realistic goals, addressing issues in the life of the patient that
will reduce stress and anxiety, and helping the patient and the family improve their adaptive skills. It may
also include limit setting and appropriate reward and punishment with children, and helping the patient, the
family, and others involved to understand the patient’s functional and cognitive limitations.
Supportive psychotherapy is a type of therapy that primarily focuses on providing emotional support,
encouragement, and validation during difficult life circumstances or psychological challenges.
Your therapist will encourage you to talk about your feelings, concerns, and problems in a safe,
nonjudgmental environment. They may also offer practical advice or guidance on how to address specific
issues.

Supportive psychotherapy is mostly focused on helping you work through present and immediate concerns,
including relationship issues, family conflicts, or work-related stress. If you have a history of trauma that
feels overwhelming to try to approach head-on ― this therapeutic technique can help you improve your
overall mental health before doing so.
The specific techniques used in supportive psychotherapy may vary depending on the needs of the client,
but some common techniques include:
Active listening: The therapist listens carefully to your concerns and validates your feelings.
Empathy: The therapist shows empathy and understanding towards your situation, helping you feel
supported.
Encouragement: The therapist provides encouragement and positive feedback, helping you build self-
confidence and a sense of accomplishment.
Psychoeducation: The therapist provides information about mental health issues and coping strategies,
helping you develop greater insight and understanding.
Problem-solving: The therapist helps you identify and address specific problems or challenges.
Reframing: The therapist helps you view your situation from a different perspective, reframing negative
thoughts and emotions in a more positive light.
Holding and containment: It is a technique in supportive therapy which means the ability of the therapist
to be there for the person provides a point of stability and security in his or her otherwise disorganized
world. The comfort these people have in knowing that you are there for them can calm them when they are
under stress. Often in therapy, the best intervention is to listen and do nothing rather than to do something
that is ineffective or even destructive.
Genuineness: Genuineness has a major emphasis in supportive therapy. Therapists who are genuine are
open, honest and sincere, and the relationship which they involve is not simply mirrors or blank screens.
Therapists are real people in real encounters. So in supportive therapy some minimal self- disclosure is
appropriate, by doing that therapist acknowledges that his or her life is not as perfect as the client assumes.
At the same time therapist should be careful about the fact that, it is inappropriate to discuss specific aspects
in their life and should not break the professional boundary between the therapist and the client.
Explanation: In supportive therapy explanation means educating the client and the family about the illness,
symptoms and components of treatment, which gives a better idea to the clients as well as family about the
nature of illness, prognosis and role of family in the management of illness.
Advice: People approach for supportive therapy usually has limited coping skills so therapist uses the
technique, advice more frequently in supportive therapy then in other forms of psychotherapy. In supportive
therapy therapist usually gives advice about the treatment, how to seek help, how to deal with everyday
problems, and also about social and interpersonal skills.
Catharsis: Catharsis means emotional release and it is a main technique in supportive therapy. To develop a
trusting therapeutic relationship is the core of supportive therapy. Only within a trusting relationship, client
may be able to disclose events in their lives that they have been unable to discuss with anyone else.
Re – educative Therapy
A form or stage of psychotherapy in which the patient is taught or, better allowed to learn to himself more
effective ways of dealing with problems and relationships. It can be effective only by modifying the
patient’s feelings and reactions. The patient gradually learns how to handle a social situation, marital, or
occupational problem that has caused stress and anxiety. Examples of this type of therapy include short-
term, solution-oriented, reality, cognitive restructuring, and behavior modification.
Objective:
•Deliberate efforts at readjustment
•Modification of behaviour directly through positive and negative reinforcers
•Interpersonal relationships with deliberate efforts at environmental readjustment, goals modification, and
•the living up to existing creative potentialities with or without insight into conscious conflicts.
Approaches:
• Behaviour therapy • Cognitive therapy • Client-centred therapy • Therapeutic counselling • Mindfulness •
Dialectic behaviour therapy • Reeducative Group therapy • Family therapy • Psychodrama
Re-constructive Therapy
Re-constructive therapy is contrasted with supportive therapy and it is also distinguished from re-educative
therapy. However, the line between the three approaches is not a sharp one, since supportive and re-
educative therapy may have a constructive effect and the re-constructive approach always contains
supportive and re-educative components. In this therapy, the relief of symptoms is indirectly achieved since
it comes about through a revision or reorganization of the patient’s basic attitudes toward himself as well as
his relationship with other people.

According to the dictionary, re-constructive therapy is a form of therapy, such as psychoanalysis that seek
not only to alleviate symptoms but also to produce alternations in maladaptive character structure and to
expedite new adoptive potentials; this aim is achieved by bringing into consciousness and awareness of
insight into conflicts, fears, inhibition, and their manifestation.
t may be required two to five years of therapy and delves into all aspects of clients’ life. Emotional and
cognitive restructuring of the self-take place.

Re-constructive psychotherapy is directed toward basic and extensive modification of an individual’s

character structure by enhancing his/her insight into personality development and adaptive responses.
Objectives:
• Insight into unconscious conflicts with efforts to achieve extensive alterations of character structure
• Expansion of personality growth with development of new adaptive potentialities
Approaches: • Psychoanalysis • Psychoanalytic therapies 9 • Analytic group therapy
Positive outcomes include the following:
• A greater understanding of self and others.
• More emotional freedom.
• Development of potential abilities.
• Heightened capacity for love and work
NATURE:
1. The re-constructive style of therapy contains many of the conventional characteristics of psychotherapy
in which the counselor focuses on manifest and dynamic content. Manifest content refers to the client’s
overt expression – his verbal communication and that aspect of behavior that can be seen – (his expressive
movements, postures, initial reactions, and personal mannerisms). Dynamic content is essentially influential
– the inferred forces that are presumably purposive for the behavior observed, for example, hostility, fear,
guilt, or depression.

2. The goal of re-constructive therapy, through identifying manifest content and dynamic content is to
reshape the client’s learned behavior pattern of coping with non-productive problems.
3. The re-constructive style of therapy is systematic, discriminating, and objective. The style is systematic
in that it has an opening, a middle and an end, contains the following characteristics:

• The counselor makes implicit assumptions.

• The counselor focuses on the dynamics of past events.
• The counselor makes explicit references to that feeling.
• The counselor relates emotions and feelings to the present situation.
• The counselor becomes a supportive person
4. Re-constructive therapy is non-directive. The client allows and encourages them to verbally express
himself.
5. The effect of re-constructive style on the client was determined by analyzing verbal data, specified by
the six dependent variables:

Interpretation: An interpretation is operationally characterized as a strategy whereby the counselor

associates two client’s proclamations together which have been expressed by a client during any session.
Interpretations are by and large statementing which connects or clarifies observations.

Probing : A probe operationally characterized as a method that accommodates an assessment of counselor

speculation, identified with a client’s correspondence. Prob is by and large inquiries that inspire additional
information from the client.
Clarification : A clarification is operationally characterized as a strategy that accommodates the repetition
of a formerly equivocal or clashing assertion. Clarification proclamations repeat the client’s statement yet
suggesting, utilizing explicit action words or inflections, that there is some doubt or question concerning the
counselor regarding the significance of the client remarks. The assertions will be an open-ended comment.
Restatement : A restatement is operationally characterized as a procedure whereby the counselor brings
content from the counselee’s previous experience to hold up under upon new content being by and by
examining. Restatements will coordinate the counselee’s assertions in a period viewpoint proclamation
about past sentiments and behavior to present behavior and emotions.
Reflection : A reflection is operationally characterized as a method whereby the counselor repeats the client
remark, giving acknowledgment fundamentally to the emotions and the primary substance of the statement.
Reflections are articulations that are most straightforwardly identified with the client’s stated intent,
observation, and sentiments.
Summarization: A summarization is operationally characterized as a procedure whereby the counselor, in
the wake of tuning in to the client for a given period, restates need or more than the counselee has
expressed. Summarizing articulations by and large coordinate is given data so the client can deal with all the
more viably with those perspectives he sees as generally significant.
Unit 2 - Stages and outline of Psychotherapy, Basic Ingredients of Psychotherapy.
Stages of treatment
The development of any form of psychiatric treatment, and particularly the development of psychotherapy,
may be considered as divided into four stages or phases, each of them with its own sub-phases and
characteristic elements. The correct order and development of each stage is essential if therapeutical
progress is to be made, and it may be necessary at times to modify the overall strategy according to the stage
of the relation. Multidimensional treatment makes exhaustive use of the principle of step-by-step
development, and an ongoing analysis is carried out of the necessary tac-tics for each step, without ever
overlooking the need to adapt this to the overall strategy.
1. The commitment is the initial stage in which the patient and the therapist decide to devote much of
their time, energy, and capacity to establish relations to the achievement of therapeutical targets.
Sometimes the therapist finds himself strongly reluctant to enter this stage, and when this is the case he
must choose not to treat the patient, or at least he must delay the treatment until he has identified and
remedied the causes of his reluctance. The patient can commit himself immediately, unconsciously and
automatically or he may require beforehand an exploratory period.
The elements influencing the decision to be taken by the patient are:
1) His perception of the therapist, or the extent to which he considers him to be competent, empathic and
well disposed towards the patient, as well as whether he possesses a power which the patient lacks and
would like to acquire.
2) The intensity and quality of his motivation. The most warm and skilled of therapists may immediately
drive away a patient who is merely seeking to satisfy his sadomasochist needs, unless he manages to
convince the patient to change his motivation or entice him with the prospects of the arduous efforts
needed for the change to come about.
3) The technical suitability or the extent to which the education, personality and past experiences of the
patient fit the proposed therapeutical methodology. Some patients can offer stiff resistance to certain
techniques whereas they will accept others more readily, and due account must be taken of this when the
initial therapeutic approach is drawn up. Sometimes it may be necessary to apply a tailor-made
technique during the commitment stage, delaying the most effective and indicated methodology for later
stages.
2. The process is the most complex stage and constitutes the central body of the treatment. It can be
divided into three concurrent aspects: the search for patterns, the, gathering of new information and the
consolidation. The relative importance of each aspect varies according to the kind of problem and the
type of patient but, in any case, in the initial stages of this step the sensation of psychic movement is
more important than the nature of that movement. The process must make the patient experience that he
is becoming aware of something, and this is more important than what he is becoming aware of.
Searching for patterns: Psychic phenomena and their behavioural manifestations do not occur just in
any way, but rather they follow some more or less idiosyncratic rules and paths which we call patterns.
Pathological patterns are characterized by their excessive rigidity, and by the fact that they are not in
keeping with their present context, are unsuitably repetitive, and are harmful to the patient.
The acquisition of new information is the part of the process which develops in the patient the
cognitive and emotional structures necessary for correcting his mis-takes, offsetting his defects and
solving his conflicts.
 3. The change stage follows the process and represents its conclusion and success. There are three
important aspects in this stage which need to be consolidated to en-sure permanent therapeutic
results. The first is the repudiation of the illness relinquishing all related elements, including pleasant
ones such as the positive relation with the therapist, and useful ones such as the many ways in which
responsibility can be shirked due to being ill. This process of repudiation or relinquishment is akin to
grief, and the patient has to get over all his reasons for remaining ill and assure him-self that, in spite
of these reasons, he prefers his new healthy state of functioning. We must remember that, in addition
to the well-known secondary gains which all pathologies involve, there is a Primary Gain which can
be conceptualized as the (neurotic) prevention of a harm which seems even greater than that inflicted
by the symptoms. The success of this stage re-quires the complete and thorough acceptance of this
"Greater Evil", through the work of the psychotherapeutic process. The other two aspects of the
change are the initiation of free, appropriate and voluntary patterns of action, that replace old pa-
thological behaviors, and the sustaining of these patterns through the creation of men-tal structures
capable of detecting, interrupting, and neutralizing any pathological repetitive or vicious-circle
mechanism which might appear. Frequently, this means the persistent adoption of mental hygiene
habits and the permanent application of personal psychological techniques for preventive purposes.
4. The termination stage constitutes the "graduation" of the patient as an expert in the functioning of his
own mind, and it implies that the therapist and the patient recognize each other as mature,
autonomous, and independent individuals. This is the stage where positive transference relations,
regressive forms of dependence, and childish idealizations have to be solved definitely. In this phase,
the patient be-comes aware of his own strength and realizes that he alone is responsible for his own
life. The three interventions of the therapist during this stage are:
1) the abdication of his role and the granting of his teachings and methods, which now belong to the
patient,
2) the handing over of per-mission for the patient to develop his life and act on his own
responsibility 3) the definitive acknowledgement of the patient's autonomy, and the affirmation of his
own autonomy with respect to the patient. Although in some cases extremely fast, this stage often
lasts longer than the rest of the treatment, either in the form of memories and fantasies concerning
the therapist, particularly at times of stress, or as sporadic requests for isolated visits to the therapist.

Or
1) Pairing
Empathy, positive regard and affirmation, congruence and genuineness, goal consensus, and collaboration
are crucial for success. As clients, these elements help us build enough trust in our therapist to take the
often-scary step out of our problem and into a therapeutic alliance with our therapist.
This phase also helps to build hope, as discussed in my post "Hope: A
Foundation of all Psychotherapy that Works."
Stories, frames, and metaphors shared by our therapist help us see our problems as human and help us see
our therapists as simply human themselves. Therapists and clients are looking for a close match or fit with
each other. The closer our therapist matches our values, language, metaphors, and our position on the
problem, the better the fit.
2) Recognizing Patterns
All therapists look for repetitive patterns in their clients’ lives. These include both positive and problematic
patterns. It is just as important to build on clients' strengths, as it is to address their identified problems. My
post, "Nine Dots: A Key to Psychological Problems?" covers the essence of these vicious cycle patterns.
Here, therapists ask clients to define their problem, ask what they have done about it, find out what they
usually do about it, how that has typically worked, and what others have tried to do or suggested for them to
do about it (including what other therapists have suggested). Identifying vicious cycle patterns is the
ultimate target. Vicious cycle patterns in couples, for example, and commonly effective therapies to resolve
them may be found in the post, "What Do All Troubled Couples Share?"
3) Orienting Toward Change
Clear, agreed-upon goals are strongly associated with successful therapy across all approaches. In all
therapies, therapists target exactly what shifts clients need to make in their problem patterns. The therapist
needs to know the pattern of the vicious cycle to understand how to shift it. The classic vicious cycles
around depression, for example, can be tracked in the post "The Two Faces of Depression."
The therapist’s theoretical position on problems and their rationale for treatment come in here as well. This
is the point when therapists need to align with what will make sense to us as clients and engage us in an
alliance for change. This leads to the next phase of collaboration and building a therapeutic alliance.
4) Collaborating on a Plan
The work of therapy is done through alliance—collaboration. Finding the best fit between client and
therapist on an understandable, sensible, and workable frame and rationale for treatment is crucial to
building a strong alliance. Frames and rationales may include theoretical explanations, research-based
explanations, developmental explanations, frames fitting spiritual or cultural traditions, and many more. Of
course, the closer the frame fits our worldview, values, and beliefs the better. This is the focus of the post,
"The Hero's Journey: Finding Therapy That Fits."
5) Engaging Treatment
Treatment often begins before treatment starts: Saying that treatments start at a set stage to engage treatment
isn't really right. In fact, treatment begins at times even before the first session. Clients may have gotten a
recommendation to a given practitioner based upon their reputation for success, creating a halo of hope even
before seeing the therapist. In many ways, the same can be said about the other preceding phases—each step
often starts before a client even meets their therapist.
Assessment & treatment are inseparable: Similarly, therapists’ theoretical perspective shapes the type of
questions they ask, what they attend to, follow up on, and even whom they may include in sessions.
Assessment and intervention are essentially inseparable. They influence and shape the course of interaction
and information in an evolving co-created “truth” about the clients’ problem as well as about the therapist.
The dance of intervention, so to speak, begins immediately. Therapist interests through the early part of any
session may focus on history, on interpersonal relationships, on thoughts and beliefs, on pure behavior
sequences, social networks, on the way the client reacts in the moment to the therapist, or combinations of
all of these and more.
Treatment rationales guide interventions: The rationale our therapist used to explain therapy creates a
framework for treatment. As that treatment rationale makes sense to us, so does the fit between clients and
therapists. Interventions and procedures must make sense to both clients and therapists because those new
solutions often seem counterintuitive from our original understanding of our problem.
Interventions must shift problem patterns: What matters is that the interventions create new shifts to initiate
virtuous cycle patterns. Treatment techniques and procedures may include, for example, in-session
enactments, two-chair dialogues, Socratic questioning, modeling, rehearsals, in-session bonding and
affirmations, interpretations, homework assignments, and a range of other specific treatment techniques.
What matters is that those interventions shift our problem-generating solutions.
6) Supporting Success
All effective therapists note and support positive pattern shifts, and support client ownership of those
changes. The goal is to support an evolving virtuous cycle consistent with agreed-upon goals. Client
ownership of these changes is important across treatments. In many ways, most treatments explain problems
as reasonable reactions to the course of historical and current stressors and events. It doesn't matter if the
type of treatment is dynamic, interpersonal, behavioral, cognitive, emotional, or other frames and
explanations. However, they consistently affirm the clients’ distress as a product of their situation and their
treatment successes as due to the client's own efforts.
Change as Personal, Positive & Pervasive: Most treatments cast problem patterns, while distressing and
understandably negative, as transient and situational. The movement is from clients viewing their problems
as personal, negative, and pervasive to owning their strengths, resilience, and successes in the face of such
adversity as personal, positive, and pervasive.
7) Sustaining the Change
All evidence-supported treatments include some final phase where they build resilience and engage in
relapse prevention. All treatments acknowledge the potential for future life challenges and potential relapse
into the original problem cycles. The goals of all treatments are to sustain changes once they occur and
continue the virtuous cycles.
Predicting & Prescribing: Most all successful treatments use the idea of predicting and prescribing as
treatment concludes.
Predicting: Clinicians usually warn clients of the hurdles ahead. They discuss future challenges and even
rehearse responses in sessions. Under the idea that “forewarned is forearmed,” clients and therapists
collaborate as they predict future obstacles.
Prescribing: Turning to the idea of prescribing, the usual approach before ending treatment is, once clients
have developed a new, sustained patterned resolution, to have clients actively confront old situations,
thoughts, and emotions. First, if clients find themselves relapsing into old patterns, they learn something
they can discuss and address in following sessions. Second, deliberately trying to reengage in old responses,
formerly viewed as coming on spontaneously, offers another paradox. It's reassuring not to be able to bring
on the old problem. It is contradictory, for example, to have a panic attack in a controlled and deliberate
way.
The Family Doctor Model: In most contemporary treatments, therapists cast themselves in the same light as
family practitioners. Clients always assume they will return to a trusted family doctor after recovering from
a recent illness. This goes as well for psychotherapists. Most therapists now welcome clients back for
booster sessions—a practice actively supported by the literature.
Basic ingredients of psychotherapy
It is important to identify the processes that are inherent in effective psychotherapy, which can also be found
in other non-psychotherapeutic helping relationships such as counselling but are not nurtured. All good
psychotherapeutic systems contain these ingredients.
Interviewing procedures: Communication is an essential between the therapist and the patient. While
practitioners of varying theoretical orientations have different methods of interviewing, most interviewing
procedures contain the following. The therapist must scrutinize the patient9s verbalizations and use directive
techniques towards facilitating communication, in a language understandable by the patient. The therapist
must have an awareness of non-verbal behaviours. These procedures also include the knowledge of how to
maintain the flow of patient9s verbalizations towards free association or specific themes. There must be an
awareness of inculcating insight through a variety of techniques including interpretation. There must also be
an understanding of how to terminate an interview.
Establishment of a working therapeutic relationship: The therapeutic process greatly depends on the
establishment of empathetic contact with the patient. This relationship is a must in reconstructive therapy to
allow for the process of working through. It also greatly improves the progress in supportive and re-
educative therapy. While these techniques are not they include generating expectations of help, gaining the
patient9s confidence, convincing the patient that the therapist wants and is able to help, motivating the
patient, and clarifying any misconceptions about therapy.
Determination of the sources and dynamics of the patients problems : Different psychotherapies search
for and explain the patient9s problems in different terms, either through environmental elements
accentuating stress, conditionings that compel repetitive patterns of behaviours, distorted interpersonal
relationships, or unconscious conflicts causing anxiety. Despite these theoretical orientations that include
Freudian or Pavlovian theories, it is essential for the patient to be aware of the <fact that one is being
victimized by repetitive patterns that force one to actions opposed to a productive life= to promote problem
resolution (Wolberg, 2013). Psychotherapeutic systems aim to bring about awareness of the problem through
the exploration of the unconscious, challenging of defences, and development of a more wholesome
conception of self and interpersonal relationships. Behavioural therapies do not focus too much on
development of insight, rather there is a credence on relearning.
Utilization of insight and understanding in the direction of change: Insight is not sufficient to bring
about behavioural change, and various techniques are needed to bring about change. Techniques are utilized
to promote problem solving and reality testing, to create incentives for change, to accept personal limitations
while fulfilling creative potential to the highest degree to help cope with anxiety, to deal with resistances
blocking action, to encourage adjustment to conditions that can9t be changed, and to correct environmental
distortions. This relearning dimension is most stressed upon by behaviour therapies.
Resistance and the readiness for change Therapeutic efforts can be greatly blocked by the patient’s
resistance. Resistances can oppose the establishment of a working relationship, cooperation with the
techniques used by the therapist, acceptance of explanations, facing reality or accepting maturity, the search
for conflicts or genetic material, or giving up the therapeutic situation when termination is necessary. Some
resistances can be seen in the form of acting out, <forced flight into health,= transference, or self-
devaluation. An individual9s readiness to change can influence the therapy process. Readiness to change is
the extent to which patients have resolved their resistance to change, either with therapy or spontaneously.
Patient variables There are several variables that the patient brings into therapy that can hamper or
impede the therapeutic process. These include their symptoms, attitudes towards the therapist, expectations,
and intensity and pervasiveness of childhood distortions. The most important however, is whether the patient
will utilize the relationship with the therapist for objectives inimical to therapeutic goals= (Wolberg, 2013).
In the case of a patient who is very detached, the maintenance of defences that prevent the patient from
being manipulated or controlled offer more reinforcement for the patient than the rewards that can be
provided by therapists, suggesting client motivation is also an important factor.
Therapist attitudes and operant conditioning Appropriate therapist attitudes are essential for learning,
as they form reinforcers to influence client behaviour. Warmth, empathy, and understanding lower anxiety
and relieve patient tensions, thus promoting positive feelings. In dynamic therapy, the therapist will promote
exploration of zones that are mostly repressed or resisted. The therapist rewards the patient when
approbative verbal and non-verbal responses are used. Revaluations might take place when patients place
material in the context of the past, this also allows for emotional catharsis, wherein the patient can learn to
tolerate the material being talked about. Anxiety-provoking past experiences and their current associations
can also be made extinct through the schedules of reinforcement. In behaviour therapy, the patient is
exposed to reinforcers which extinguish self-defeating reactions and accentuate more adaptive ones.
Symptom relief and newer, more adaptive patterns of behaviour also occur. Apart from theoretically oriented
measures, the therapeutic relationship itself provides a relearning experience which can be generalized to
other interpersonal relationships. Furthermore, it is important to note that good psychotherapists are not
neutral, detached, or cold. Despite their passivity and non-interference, elements of their communication
have a certain degree of empathy and understanding towards the patient. Those who are not effective
psychotherapists are cold and detached, lacking in empathy, are uninvolved, and usually stimulate negative
therapeutic reactions in the patient.
Countertransference An effective system of psychotherapy recognizes the negative effects of
countertransference. Prejudiced attitudes of the therapist can interfere with the working relationship and can
hinder the patient9s progress. However, if used effectively, countertransference can be used to identify the
nature of feelings and attitudes that are being projected onto the therapist.
Environmental variables : the environment in which the individual functions influences change. during
and after the treatment. A culture that reinforces destructive behaviour will neutralize therapeutic efforts,
whereas one which reinforces healthy behaviours will encourage therapeutic efforts. Recognition of the
patient9s environment will allow the therapist to focus on certain elements that have to be changed or
adapted to.
Termination of therapy Therapeutic termination must be planned. There should be an analysis of
dependency needs, the patient should be empowered to take a more directive approach into probing and
assuming responsibility, independence and assertiveness should be encouraged, patients are prepared for
relapses, and are equipped with self-understanding gained in therapy.
Unit 3 – Psychotherapist and Psychotherapy Client, Psychotherapeutic Relationship
Characteristics Of Successful Clients
Motivation- The term motivation is a broad one that clinicians use to describe a range of client behaviors
associated with readiness tor treatment and ability to engage productively in that process particularly
important aspects of client motivation include engagement in and cooperation with treatment and a
willingness to self-disclose. confront problems.
Positive But Realistic Expectations For Treatment- Therapy and counseling are hard work for both
clients and clinicians. For people to persist in that process and tolerate the increased anxiety it often causes.
as well as the commitment of time and resources. they must beliee that treatment has something positive to
offer chem and that, at the end o] that process, they will be better oft than they were before treatment.
Full Participation In Treatment- Clients who succeed in treatment freely present their concems.
collaborate with the clinician in a mutual endeavor. and take steps to improve their lives. They develop a
problem-solving attitude and maintain positive expectations of
Clinician Skills, Training, And Experience
Appropriate Interpersonal Skills- As already mentioned, successful therapists need to possess appropriate
interpersonal skills and be "able to communicate a caring, respectful attitude chat affirms a client's Basic
Sense Of North“.
Professional Orientation, Identity and Ethics- Includes knowledge of the history of our profession, roles
and functions of mental health professionals.
Social and cultural foundations of the profession- Includes cultural sensitivity, appreciation. knowledge,
and competence: understanding of social problems and their causes and remedies: and skills in outreach,
prevention. social change advocacy, coalition building, and community organization and intervention.
Human growth and development- Includes knowledge of theories of individual development family
development, personality development, cognitive development, and sexual development; ability to
distinguish between healthy and unhealthy growth and development and ability to provide information on
and facilitate healthy development
THERAPIST VARIABLES
PERSONALITY FACTORS
Untrained person with a concerned manner and empathic personality will get better immediate results,
especially with sicker patients, than a highly trained therapist who manifests a “deadpan” detached
professional attitude. One should not assume from this that a therapist with a pleasing personality without
adequate training will invariably get good results. Some of the available research alerts us to the fact that the
level of therapist expectations and the triad of empathy, warmth, and genuineness do not invariably represent
the “necessary and sufficient” conditions of effective therapy. A welltrained therapist, however, who also
possesses the proper “therapeutic” personality is by far best qualified to do successful therapy and should be
also consider some other variables also since we may be dealing here with different classes of patients, i.e.,
patients seeking a warm, giving authority as contrasted to those who want less personal involvement and
greater ability to probe for and resolve defenses in quest of more extensive self-understanding. Two
personality qualities are especially undesirable in a therapist doing therapy:
*First and most insidious is detachment. A detached therapist will be unable, within the time span of
treatment, to relate to the patient or to become involved in the essential transactions of therapeutic process.
A detached person finds it difficult to display empathy. To put it simply, one cannot hatch an egg in a
refrigerator. A cold emotional relationship will not incubate much change in treatment. * second quality that
inimical to doing good therapy is excessive hostility. Where therapists are angry people, they may utilize
select patients as targets for their own irritations. A patient has enough trouble with personal hostility and
may not be able to handle that of the therapist. A therapist, exposed to a restrictive childhood, having been
reared by hostile parents, or forbidden to express indignation or rage, is apt to have difficulties with a patient
who has similar problems. Thus the patient may be prevented from working through crippling rage by the
subtle tactic of the therapist changing the subject when the patient talks about feeling angry, or by excessive
reassurance verbal attack on the patient, or by making the patient feel guilty.
CHOICE OF TECHNIQUES
Technical preferences by therapists are territories ruled by personal taste rather than by objective identifiable
criteria. As has been previouslyindicated,it matters lit-tie how scientifically based a system of psychotherapy
may be or how skilfully it is implemented-if a patient does not accept it, or if it does not deal directly or
indirectly with the problems requiring correction, it will fail. Because of the complex nature of human
behavior, aspects that are pathologically implicated may require special interventions before any effect is
registered. Prescribing a psychotropic drug like lithium for an excited reaction in a psychopathic personality
will not have the healing effect that it would have in violent outbursts of a manic-depressive disorder.
Unfortunately, some therapists still cling to a monolithic system into which they attempt to wedge all
patients, crediting any failure of response to the patient’s resistance.
SKILL AND EXPERIENCE IN THE IMPLEMENTATION OF
TECHNIQUES
The history of science is replete with epic struggles between proponents of special conceptual systems.
Contemporary psychotherapists are no exception. In a field as elusive as mental health it is little wonder that
we encounter a host of therapies, some old, some new, each of which proposes to provide all the answers to
the manifold problems plaguing mankind. A scrupulous choice of techniques requires that they be adapted to
the needs and learning capacities of patients and be executed with skill and confidence. Understandably,
therapists do have predilection’s for certain approaches and they do vary in their facility for utilizing them.
Faith in and conviction about the value of their methods are vital to the greatest success. Moreover,
techniques must be implemented in an atmosphere of objectivity.
To function with greatest effectiveness, the therapist should ideally possess a good distribution of the
following:
Extensive training : Training in many parts of the country, has become parochial, therapists becoming
wedded to special orientations that limit their use of techniques. Accordingly, patients become wedged into
restricted interventions and when they do not respond to these the therapeutic stalemate is credited to
resistance. Over and over, experience convinces that sophistication in a wide spectrum of techniques can be
rewarding, especially if these are executed in a dynamic framework. Whether personal psychoanalysis is
essential or not will depend on what anxieties and personal difficulties the therapist displays in working with
patients. The fact that the therapist does not resort to the discipline of formal analytic training does not imply
being doomed to doing an inferior kind of therapy. Indeed, in some programs, where the analytic design is
promoted as the only acceptable therapy, training may be counterproductive. Nevertheless, ifa therapist does
take advantage of a structured training program, which includes exposure to dynamic thinking and enough
personal therapy to work out characterologic handicaps, this will open up rewarding dimensions, if solely to
help resolve intrapsychic and interpersonal conflicts that could interfere with an effective therapeutic
relationship. Irrespective of training, there is no substitute for management under supervision of the wide
variety of problems that potentially present themselves. It is important that therapists try to recognize their
strong and weak points in working with the various syndromes. No matter how well adjusted therapists may
be, there are some critical conditions that cannot be handled as well as others. They may, when recognizing
which problems give the greatest difficulties, experiment with ways of buttressing shortcomings.
Flexibility in approach : A lack of personal investment in any one technique is advantageous. This requires
an understanding of the values and limitations of various procedures (differential therapeutics), experience
in utilizing a selected technique as a preferred method, and the blending of a variety of approaches for their
special combined effect. Application of techniques to the specific needs of patients at certain times, and to
particular situations that arise, will require inventiveness and willingness to utilize the important
contributions to therapeutic process of the various behavioral sciences, accepting the dictum that no one
school has the monopoly on therapeutic wisdom.
PATIENT VARIABLES
THE SYNDROME OR SYMPTOMATIC COMPLAINT
By and large techniques do operate as a conduit through which a variety of healing and learning processes
are liberated. How the techniques are applied, the faith of therapists in their methods, and the confidence of
the patient in the procedures being utilized will definitely determine the degree of effectiveness of a special
technique. But techniques are nevertheless important in themselves and experience over the years with the
work of many therapists strongly indicates that certain methods score better results with special problems
than other methods. Where repressions are extreme, classical psychoanalysis, intense confrontation,
hypnoanalysis, narcoanalysis, and encounter groups have been employed in the attempt to blast the way
through to the offensive pathogenic areas. Understandably. Patients with weak ego structures are not
candidates for such active techniques, and therapists implementing these techniques must be stable and
experienced. Antisocial personalities subjected to a directive, authoritarian approach with a firm but kindly
therapist sometimes manage to restrain their acting-out, but require prolonged supervised overseeing.
Apart from the few selected approaches pointed out above that are preferred methods under certain
circumstances, we are led to the conclusion that no one technique is suitable for all problems. Given
conditions of adequate patient motivation and proper therapist skills, many different modalities have yielded
satisfactory results. It is my feeling however, that whatever techniques are employed, they must be adapted
to the patient’s needs and are most advantageously utilized within a dynamic framework.
Transference reactions may come through with any of the techniques, even with biofeedback and the
physical therapies. Alerting oneself for transference, one must work with it when it operates as resistance to
the working relationship. Unless this is done our best alignment of method and syndrome will prove useless.
The fact that certain techniques have yielded good results with special syndromes and symptoms does not
mean they will do so for all therapists or for every patient. Interfering variables, such as will henceforth be
described, will uniquely block results or will make the patient susceptible to other less popular methods.
SELECTIVE RESPONSE OF THE PATIENT TO THE THERAPIST
At its core the patient’s reaction to the therapist often represents how the patient feels about authority in
general, such emotions and attitudes being projected onto the therapist even before the patient has had his
first sessions. The patient may rehearse in advance what to say and how to behave, setting up imaginary
situations in the encounter to come. Such a mental set will fashion feelings that can influence the direction
of therapy. Thus, if the patient believes that authority is bad or controlling, oppositional defenses may be
apparent during the interview. These global notions about authority and the reactions they sponsor are
usually reinforced or neutralized by the response to the therapist as a symbol of an actual person important
to the patient in the past (transference). Some characteristic in the therapist may represent a quality in a
father or mother or sibling and spark off a reaction akin to that which actually had occurred in past dealings
with the person in question. Or the reaction may be counteracted by a defense of gracious compliance or
guarded formality. Confidence in one’s therapist is enormously importanteven when the therapist’s ideas of
the etiology or dynamics of the patient’s difficulty are wrong. The patient’s acceptance of explanations
proffered with conviction can have a determining influence on the patient. They are incorporated into the
patient’s
belief system and sponsor tension reduction and restoration of habitual defenses. Through what means this
alchemy takes place is not clearly known, but suggestion, the placebo effect, and the impact of the
protecting relationship offered by the therapist undoubtedly play a part. Sometimes unpredictable elements
operate in the direction of cure.
SELECTIVE RESPONSE OF THE PATIENT TO THE THERAPIST’S
TECHNIQUES
Patients occasionally have preconceptions and prejudices about certain techniques. Hypnosis, for example,
may be regarded as a magical device that can dissolve all encumbrances, or it may connote exposing oneself
to Svengali-like dangers of control or seduction. Misconceptions about psychoanalysis are rampant in
relation to both its powers and its ineffectualities. Frightening may be the idea that out of one’s unconscious
there will emerge monstrous devils who will take command-for example, the discovery that one is a
potential rapist, pervert, or murderer. Should the therapist have an inkling as to what is on the patient’s mind,
clarification will then be in order. The manner of the therapist’s style is also apt to influence reactions of
rage at the therapist’s passivity, balkiness at what is considered too intense activity, anger at aggressive
confrontation. Some patients are frustrated by having to talk about themselves and not being given the
answers.
Since psychotherapy is in a way a form of reeducation, the learning characteristics of a patient should best
correspond with the techniques that are to be used. Problem-solving activities are often related to the kind of
processes found successful in the past. Some patients learn best by working through a challenge by
themselves, depending to a large extent on experiment. Some will solve their dilemmas by reasoning them
out through thinking of the best solution in advance. Others learn more easily by following suggestions or
incorporating precepts offered by a helpful authority figure. Some are helped best by modeling themselves
after an admired person, through identification with that person. Some patients work well with free
association,others do not. Some are able to utilize dreams productively, or behavior modification, or
sensitivity training or other methods. It would seem important to make the method fit the patient and not
wedge the patient into the method.
While empirical studies tell us little about factors that make for a good patient therapist match, we may
speculate that the personalities, values, and physical characteristics of both patient and therapist must be
such that severe transference and unfavorable countertransference problems do not erupt to interfere with
the working relationship. A giving accepting warm, and active but not too interfering or obnoxiously
confronting manner in the therapist is most conducive to good results.
READINESS FOR CHANGE
Another important factor is the individual’s readiness for change. This is a vast unexplored subject. A person
with a readiness for change will respond to almost any technique and take out of that technique what he or
she is prepared to use. What components enter into a satisfactory readiness for change have not been exactly
defined, but they probably include a strong motivation for therapy, an expectation of success, an availability
of flexible defenses, a willingness to tolerate a certain amount of anxiety and deprivation, the capacity to
yield secondary gains accruing from indulgence of neurotic drives, and the ability either to adapt to or
constructively change one’s environment Patients come to therapy with different degrees of readiness to
move ahead. Some have worked out their problems within themselves to the extent that they need only a
little clarification to make progress, perhaps only one or two sessions of therapy. Others are scarcely
prepared to proceed and they may require many sessions to prepare
themselves for some change. We may compare this to climbing a ladder onto a platform. Some people are at
the bottom of the ladder and before getting to the top will need to climb many steps. Others will be just one
rung from the top, requiring only a little push to send them over to their destination.
In therapy we see people in different stages of readiness for change, and we often at the start are unable to
determine exactly how far they have progressed. One may arrive at an understanding of what is behind a
patient’s problem rapidly. From this we may get ar idea that benefits will occur with little delay. Yet in
relation to readiness for change, the patient may still be at the bottom of the ladder. Others are at a point
where almost any technique one happens to be using will score a miracle. We may then overvalue the
technique that seems to have worked so well and apply it to many different patients with such conviction
that the placebo effect produces results.
DEGREE AND PERSISTENCE OF CHILDISH DISTORTIONS
The distorted images of childhood, the ungratified needs, the unwholesome defenses, may persist into adult
life and influence the speed, direction, and goals of therapy. These contaminations may obtrude themselves
into the therapeutic situation irrespective of what kinds of technique are practiced. Insidiously, they operate
as resistance and they can thwart movement toward a mature integration, no matter how persistent and
dedicated the therapist may be. Where severe traumas and deprivations are sustained in early infancy,
especially prior to the acquisition of language, the damage may be so deep that all efforts to acquire that
which never developed and to restore what never existed will fail. Transference with the therapist may
assume a disturbingly regressive form and, while the genetic discoveries may be dramatic, the patient,
despite intellectual understanding. Will not integrate any learning and will fail to abandon patterns that end
only in disappointment and frustration. Very little can be accomplished under such circumstances in
shortterm therapy, and even long-term depth therapy may lead to nothing except a transference neurosis that
is difficult to manage or resolve. Lest we be too pessimistic about what may be accomplished through
psychotherapy, there are some patients who, though seriously traumatized, may when properly motivated be
induced to yield the yearnings of childhood and to control if not reverse the impulses issuing from improper
discipline and unsatisfied need gratification. But this desirable achievement will require time, patience and,
above all, perseverance.
APTITUDE FOR DYNAMICALLY ORIENTED PSYCHOTHERAPY
Practically all people who apply for help in managing emotional problems can be approached successfully
with supportive and educational therapies. Eligibility for dynamically oriented treatment, however, requires
some special characteristics. Some of the available research indicates that patients who respond best to
psychodynamically oriented therapy need treatment the least. What this would imply is that persons with
good ego strength can somehow muddle along without requiring depth therapy. That this is not always so
becomes obvious when we examine the quality of adaptation of these near-to-healthy specimens. In view of
the shortage of trained manpower, we may want to look for characteristics in prospective candidates for
therapy that have good prognostic value.
The following positive factors have been emphasized:
1. Strong motivation for therapy (actually coming to therapyrepresents some commitment)
2. Existence of some past successes and positive achievements
3. Presence of at least one good relationship in the past
4. A personality structure that has permitted adequate coping in thepast
5. Symptomatic discomfort related more to anxiety and milddepression than to somatic complaints 6.
An ability to feel and express emotion
7. A capacity for reflection
8. Desire for self-understanding
9. Adequate preparation for therapy prior to referral
10. Belief systems that accord with the therapist’s theories.The patient’s expectations, age, and
socioeconomic status are not too significant, provided the therapist and patient are able to communicate
adequately with each other.
CHOICE OF GOAL AND FOCUS
If a patient through therapy expects to be a Nobel Prize winner, the patient will be rudely disappointed and
soon lose faith in the therapist. There are certain realistic limits to how much we can accomplish through
treatment, the boundaries largely being determined by the patient’s dedication to the assigned task. Added to
these are the curbs imposed by the many therapist variables soon to be considered. A great deal of tact will
be required in dealing with inordinate expectations so as not to undermine further the already existent
devalued self-image The selection by the patient of the area on which to concentrate during therapy is a
legitimate and understandable theater around which initial interventions can be organized. It may not be the
most culpable area stirring up trouble for the patient. But to push aside the patient’s concerns with a
symptom or a disturbing life situation and insist on attacking aspects of problems the patient does not
understand or is not motivated to accept will lead to unnecessary complications and resistances. It is far
better to work on zones of the patient’s interest at the same time that we make connections for the patient
and educate the need to deal with additional dimensions.
In attempting to choose the most productive arena for intervention we must keep in mind the fact that
behavior is a complex integrate of biochemical, neuro-physiological, developmental, conditioning,
intrapsychic, interpersonal, social, and spiritual elements intimately tied together like links in a chain.
Problems in one link cybernetically influence other links.
PSYCHOTHERAPEUTIC RELATIONSHIP
The therapeutic relationship refers to the relationship between a healthcare professional and a client or
patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial
change in the client. The therapeutic relationship is the connection and relationship developed between the
therapist and client over time. Without the therapeutic relationship there can be no effective or meaningful
therapy. This applies to all forms of counselling and psychotherapy, and regardless of the theoretical
orientation of your therapist or counsellor, the relationship developed between you will be considered of
high importance. There are mainly three major elements in therapeutic alliance.
Resistance
Transference
Counter transference
RESISTANCE: Resistance is loosely defined as a client’s unwillingness to discuss a particular topic in
therapy. For example, if a client in psychotherapy is uncomfortable talking about his or her father, they may
show resistance around this topic.
TRANSFERENCE : Transference is a phenomenon within psychotherapy in which the feelings a person had
about their parents, as one example, are unconsciously redirected or transferred to the present situation. It
usually concerns feelings from a primary relationship during childhood.
COUNTER TRANSFERENCE : counter-transference occurs when the therapist projects their own
unresolved conflicts onto the client. This could be in response to something the client has unearthed.
Although many now believe it to be inevitable, counter-transference can be damaging if not appropriately
managed.
ROGERIAN THERAPEUTIC ALLIANCE
According to Rogers (1977), three characteristics, or attributes, of the therapist form the core part of the
therapeutic relationship – congruence, unconditional positive regard (UPR) and accurate empathic
understanding.
Congruence: Congruence is the most important attribute, according to Rogers. This implies that the
therapist is real and/or genuine, open, integrated and authentic during their interactions with the client. The
therapist does not havea façade, that is, the therapist’s internal and external experiences are one in the same.
In short, the therapist is authentic. This authenticity functions as a model of a human being struggling
toward greater realness. However, Rogers ’concept of congruence does not imply that only a fully self-
actualized therapist can be effective in counseling (Corey, 1986). Since therapists are also human, they
cannot be expected to be fully authentic. Instead, the person-centered model assumes that, if therapists are
congruent in the relationship with the client, then the process of therapy will get under way…Congruence
exists on a continuum rather than on an all-ornothing basis (Corey, 1986).
Unconditional Positive Regard (UPR): This refers to the therapist’s deep and genuine caring for the client.
The therapist may not approve of some of the client’s actions but the therapist does approve of the client. In
short, the therapist needs an attitude of “I’ll accept you as you are.”
According to Rogers (1977), research indicates that, the greater the degree of caring, prizing, accepting, and
valuing the client in a no possessive way, the greater the chance that therapy will be successful…BUT, it is
not possible for therapists to genuinely feel acceptance and unconditional caring at all times (Corey, 1986).
Accurate Empathic Understanding: This refers to the therapist’s ability to understand sensitively and
accurately [but not sympathetically] the client’s experience and feelings in the here-andnow. Empathic
understanding implies that the therapist will sense the client’s feelings as if they were his or her own without
becoming lost in those feelings (Corey, 1986).
In the words of Rogers (1975), accurate empathic understanding is as follows: “IfI am truly open to the way
life is experienced by another person…if I can take his or her world into mine, then I risk seeing life in his
or her way…and of being changed myself, and we all resist change. Since we all resist change, we tend to
view the other person’s world only in our terms, not in his or hers. Then we analyze and evaluate it. That’s
human nature. We do not understand their world. But, when the therapist does understand how it truly feels
to be in another person’s world, without wanting or trying to analyze or judge it, then the therapist and the
client can truly blossom and grow in that climate.”
LUBORSKY, (1976 )
Two types of helping alliances were identified:
Type I, more evident in the beginning of therapy
Type 2, more typical of later phases of treatment.
Type I alliance – “A therapeutic alliance based on the patient’s experiencing the therapist as supportive and
helpful with himself as a recipient
Type 2 alliance – “ A sense of working together in a joint struggle against what is impeding the patient on
shared responsibility for working out treatment goal a sense of we-ness”.
Strength of both Type I and Type 2 alliances were associated with the likelihood of improvement.
COGNITIVE BEHAVIORAL APPROACH
Cognitive-behavior therapy (CBT) stems from learning theories; it was developed during the second half of
the twentieth century. The CBT approach focuses on the clients’ ways of thinking and behaving, as well as
the relationship between their thoughts, their actions/reactions, and how they feel. As its name implies, it
works by identifying and modifying the thoughts and behaviors that may be causing difficulties to the
clients, which then helps to improve their mood. More recently, Acceptance and Commitment Therapy
(ACT) and mindfulness are complementary strategies which have been added to the CBT approach in order
to increase the clients’ capacities to be present in the moment and to cope with their emotional insecurity.
The goal of CBT is to teach clients that while they cannot control every aspect of the world around them,
they can take control of how they interpret and deal with things in their environment. Cognitive-behavior
therapy is generally short-term (three to six months) and focused on helping clients deal with a very specific
problem. During the course of treatment, clients learn how to identify and modify maladaptive thought
patterns that have a negative influence on their behaviors. The underlying concept behind CBT is that our
thoughts and feelings play a fundamental role in our behavior.
With the use of evidence-based strategies such as systematic desensitization or cognitive restructuring, CBT
enables clients to be actively in problem-solving. The CBT approach is commonly used in the treatment of
a wide range of disorders including anxiety disorders
(phobias, generalised-anxiety, etc.), addictions, mood disorders (depression or mania), communication
difficulties, as well as selfesteem and confidence issues.
ALLIANCE AS PAN – THEORETICAL FACTOR
The alliance has evolved into one of the most researched psychotherapy process variables. In this paper it is
argued that migration of the concept of the alliance from its psychodynamic roots onto “Common Factor
Land” has brought not only great benefits but substantial challenges as well. Currently the alliance has no
consensual1 definition, nor has its relation to other relationship constructs been clearly charted. As a
consequence, alliance assessment tools have been substituted for a concept definition and taken over the
grounds that theorizing about a construct would normally occupy. The historical background of the events
that lead to the current state are reviewed and some consequences of positioning the alliance on the
conceptual space where Common Factors “live” are examined. Some possible avenues of moving the
alliance project forward and re-connecting the empirical research to clinical practice are explored.
FACTORS INFLUENCING ALLIANCE – OUTCOME
Type of treatment
Treatment length
Early versus late alliance
Client and therapist factors
A strong bond is crucial to the success of counselling and psychotherapy. It can be especially valuable to
clients who may have struggled forming relationships in their past, and those who experienced traumatic
events in their early years, leading them to find it difficult to form relationships in adulthood. Therapy
allows clients the chance to explore their relational attachments, bonds and experiences through their
relationship with their therapist, which is why this relationship is so important. Without the therapeutic
relationship there can be no therapy. Therefore, we know that this is a crucial part of therapy. In some ways
you could say that the relationship is the therapy. How the client and therapist engage matters in defining the
successes of therapy and counselling. This relationship is essential to establishing and promoting willingness
for the client to share and engage within the therapeutic space. The relationship will hopefully allow the
client to move toward more open behaviours and an increased level of self-awareness.
Life style and career development
Theories of Counseling and Psychotherapy
Includes the ability to establish a positive therapeutic alliance; knowledge of a broad range of well-accepted
treatment approaches and their use and implementation: ability to conduct effective interviews, formulate
appropriate treatment goals, develop sound treatment plans, and help clients in crisis, and consultation skills
Group Counseling and Psychotherapy—Includes understanding of group development and dynamics, the
various types of groups. and leader and member roles and functions; understanding of dynamics of group
cohesion: knowledge of effective approaches to group treatment; and awareness of the benefits, drawbacks,
and appropriate use of these approaches
Assessment and Appraisal- Includes knowledge of a broad range of assessment tools (e.g inventories to
assess personality, ability, career development) as well as their appropriate use: skills in presenting,
planning, and integrating assessment into the treatment process: ability to conduct intake interviews, mental
status examinations and observations; understanding of statistical concepts relevant to assessment and of
ways to demonstrate cultural competence in assessment: and awareness of when and how to make referrals
for assessment.
Research and Program Evaluation—Includes knowledge of the importance of research and of statistical,
technological and other procedures essential to conducting sound research skills in planning and conducting
research: and understanding of relevant research studies and how to use them to enhance professional
effectiveness
Diagnosis and Psychopathology—Includes knowledge of the hallmarks of healthy and pathological
personality and functioning; familiarity with the current edition DSM V, ICD 11 case conceptualization and
make an accurate multiaxial assessment; awareness of ways to assess and address dangerousness and risk in
clients; and awareness of when clients should be referred for psychiatric, neurological other evaluations

Understanding Mental Health

Wilmer and Sweeney (1992) advanced a holistic model for optimal health and functioning that delineates
five importa aspects of people's lives
Spirituality: values. beliefs. ethics. purpose and direction. optimism. inner peace
Self-Regulation: sense of worth. mastery of one's own life. spontaneity and emotional responsiveness. sense
of humor. creativity, awareness of reality. physical health Work: paid employment. volunteer experiences,
child rearing. homemaking, and education that provide psychological. social, and other rewards
Friendship: positive interpersonal relationships and social supports that provide rewarding activities and
interactions love: intimate. trusting. sharing. and cooperative long-term relationships .
Helping Relationships: Stages

The helping relationship is a constant throughout the counseling or psychotherapeutic

process. The relationship must be present from the initial meeting between the client and the
counselor or therapist and continue through closure. Viewing the helping relationship as a
constant throughout the helping process leads to visualizing this process from a
developmental perspective. The clients may exhibit fear, anxiety, and resistance. Such
reactions should not be seen as lack of commitment to change. It indicates that they need to
be understood in terms of the unknown nature of this developing alliance and the fact that this
may be the first time the client has experienced this type of interaction. There should build up
trust, safety, and understanding as this relationship develops.

The following developmental stages show our conceptualization of this relationship-building:

Stage 1: Relationship development. This stage includes the initial meeting of the client and
counselor or therapist, rapport building, information gathering, goal determination, and
informing the client about the conditions under which counseling will take place (e.g.,
confidentiality, taping, counselor/ therapist–client roles)

Stage 2: Extended exploration. This stage builds on the foundation established in the first
stage. Through selected techniques, theoretical approaches, and strategies, the counselor or
therapist explores in depth the emotional and cognitive dynamics of the client, problem
parameters, previously tried solutions, and decision-making capabilities of the client. There is
also a reevaluation of the goals determined in Stage 1.

Stage 3: Problem resolution. This stage, which depends on information gained during the
previous two stages, is characterized by increased activity for all parties involved. The
therapist role include, facilitating, demonstrating, instructing, and providing a safe
environment for the development of change. The client’s activities focus on reevaluation,
emotional and cognitive dynamics, trying out new behaviors

Stage 4: Termination and follow-up. This stage is the closing stage of the helping
relationship and is cooperatively determined by all persons involved. Methods and
procedures for follow-up are determined prior to the last meeting.

HELPING RELATIONSHIPS: CORE CONDITIONS

The concept of basic or core conditions related to the helping relationship has its basis in the early
work of Rogers. This concept incorporates a set of conditions that, when present, enhance the
effectiveness of the helping relationship. The terminology for these conditions varies from author to
author but generally includes the following: empathic understanding, respect and positive regard,
genuineness and congruence, concreteness, warmth, and immediacy.
Empathic Understanding
Empathic understanding is the ability to feel with clients as opposed to feeling for clients. It is the
ability to understand feelings, thoughts, ideas, and experiences by viewing them from the client’s
frame of reference. The counselor or therapist must be able to enter the client’s world, understand the
numerous aspects that make up that world, and communicate this understanding so that the client
perceives that he or she has been heard accurately.
Respect and Positive Regard
Respect and positive regard are defined as a belief in each client’s innate worth and potential and the
ability to communicate this belief in the helping relationship. This belief, once
communicated, provides clients with positive reinforcement relative to their innate ability to take
responsibility for their own growth, change, goal determination, decision making, and eventual
problem solution. Personal characteristics or behaviors that enhance a counselor or therapist’s ability
to provide respect and positive regard include:
• The capacity to respect oneself
• The capacity to view oneself as having worth and potential
• The capacity to model and communicate this positive self-image to clients
• The capacity to recognize and manage one’s own control needs
Genuineness and Congruence
Genuineness and congruence describe the ability to be authentic in the helping relationship. The
ability to be real as opposed to artificial, to behave as one feels as opposed to playing the role of the
helper. The capacity for self-awareness and the ability to demonstrate this capacity through words
and actions
• The understanding of one’s own motivational patterns and the ability to use them
productively in the helping relationship
• The ability to present one’s thoughts, feelings, and actions in a consistent, integrated, and
honest manner
• The capacity for self-confidence and the ability to communicate this capacity in a facilitative
way in the helping relationship.
Concreteness
Concreteness is the ability not only to see the incomplete picture that clients paint with their words
but also to communicate to clients the figures, images, and structures that will complete the picture.
In the process of exploring problems or issues, clients often present a somewhat distorted view of the
actual situation.
The capacity for abstract thinking and the ability to read between the lines
• The willingness to risk being incorrect as one attempts to ill in the empty spaces
• The belief in one’s own competence in analyzing and sorting through the truths and partial
truths in clients’ statements
• The ability to be objective while working with clients in arriving at the reality of clients’
situations
Warmth
Warmth is the ability to communicate and demonstrate genuine caring and concern for clients. Using
this ability, counselors and therapists convey their acceptance of clients, their desire for clients’ well-
being, and their sincere interest in finding workable solutions to the problems that clients present.
Personal characteristics or behaviors that enhance a counselor or therapist’s ability to demonstrate
warmth include:
The capacity for self-care, and the ability to demonstrate this capacity in both actions and words
• The capacity for self-acceptance, basing this acceptance on one’s assets and liabilities
• The desire for one’s own well-being, and the ability to demonstrate this desire through both
words and actions
• The desire to find, and successful personal experience in finding, workable solutions to one’s
own problems, and the ability to communicate this desire through words and actions
Immediacy
Immediacy is the ability to deal with the here-and-now factors that operate within the helping
relationship. These factors are described as overt and covert interactions that take place between the
client and the counselor or therapist. Personal characteristics or behaviors that enhance a counselor
or therapist’s ability to use immediacy effectively include, but are not limited to, the following:
• The capacity for perceptive accuracy in interpreting one’s own feelings for, thoughts about,
and behaviors toward clients
• The capacity for perceptive accuracy in interpreting clients’ feelings for, thoughts about, and
behaviors toward the counselor or therapist
• The capacity for and willingness to deal with one’s own issues related to clients on a personal
as opposed to an abstract level
• The willingness to confront both oneself and clients with what one observes to be happening
in the helping relationship

HELPING RELATIONSHIPS: STRATEGIES

The term strategies refers to skills gained through education and experience that define and direct
what counselors or therapists do within the relationship to obtain specific results and to move the
helping relationship from problem identification to problem resolution.
The strategies into the following categories: (a) strategies that build rapport and encourage client
dialogue, (b) strategies that aid in data gathering, and (c) strategies that add depth and enhance the
relationship.

Strategies That Build Rapport and Encourage Client Dialogue

Attending and Encouraging: These strategies use the counselor or therapist’s posture, eye contact,
gestures, facial expressions, and words to indicate to clients not only that they are being heard but
also that the counselor or therapist wants them to continue sharing information. Example
Encouraging Counselor/Therapist: (smiling) Please tell me what brought you in today.
Restating and Paraphrasing: It means feeding back thoughts and feelings that the client verbalizes.
Restating involves repeating the exact words used by the client. Paraphrasing is repeating the
thoughts and feelings of the client but in the words of the counselor or therapist.
Example Client: I don’t know why I do these dumb things. It’s almost as if I did not want a
relationship. Restating Counselor/Therapist: You don’t know why you do dumb things. It may be that
you don’t want a relationship. Client: I do want a relationship, but each time I get close I seem to do
everything in my power to destroy it.
Reflecting Content and Reflecting Feeling: These strategies enable the counselor or therapist to
provide feedback to the client regarding both the ideas (content) and the emotions (feelings) that the
client is expressing. By reflecting content, the counselor or therapist shares his or her perceptions of
the thoughts that the client is expressing. Example Client: “Sabotage” is a good word. It’s like I see
what I want, but instead of moving toward it, I take a different path that leads nowhere. Reflecting
Content Counselor/Therapist: You have a good idea of what you want, but when you see it
developing, you turn and walk the other way.
Clarifying and Perception Checking: These strategies enable a counselor or therapist either to ask
the client to define or explain words, thoughts, or feelings (clarifying) or to request confirmation or
correction of perceptions he or she has drawn regarding these words, thoughts, or feelings
(perception checking).
Example Client: If what you say is true, I’m a real jerk. What chance do I have to be happy if I run
away every time I get close to someone else? Clarifying Counselor/Therapist: You say you want to
be happy. What does “happy” mean to you?
Summarizing- This strategy enables the counselor or therapist to do several things:
first, to verbally review various types of information that have been presented in the session; second,
to highlight what the counselor or therapist sees as significant information based on everything that
has been discussed; and third, to provide the client with an opportunity to hear the various issues that
he or she has presented.
Effects Of Extratherapeutic Aids On Psychotherapy
The climate of successful therapy depends on a number of factors that are operative in all good
helping situations.
1. Hope. Patients approach the ministrations of the therapist with assured expectancy. A
sanguine anticipation of success is present. Therapists have confidence in their methods and theories.
This activates the placebo effect.
2. Trust. Patients see their therapists as sincere, honest, reliable, guileless, trustworthy,
undeceitful, unaffected, straightforward, and authentic beings. Therapists display respect for their
patient in spite of the latter’s pathological behavior. Therapists also reveal their own genuineness.
3. Freedom to respond. Patients permit themselves to think, feel, and act without restraint.
This permits them to verbalize freely and to unburden themselves. Therapists encourage freedom in
reactivity. This sponsors emotional catharsis.
4. Faith. Patients have a conviction that therapists possess the percipience, sensitivity, wisdom,
experience, skill, and ingenuity to understand basic presenting problems and difficulties and to know
what to do about them. Therapists convey assuredness, positiveness, and empathic understanding.
This facilitates the suggestive factor.
5. Liking. Patients conceive of their therapists as empathic individuals who relate to them
personally and warmly; in turn, therapists feel a non-possessive warmth toward the patients. This
releases dynamic ingredients present in all human encounters (dyadic and larger groups) that
constructively influence attitude change.
Significant Variables that Influence Psychotherapy
Multiple variables enter into the psychotherapy treatment gestalt that bear upon results for the good
or bad. At the outset it is necessary to recognize that no psychotherapeutic method exists today that is
applicable to all patients or germane to the styles of all therapists.
First, they offer a unique kind of interpersonal relationship in which one feels accepted for what one
is and where judgments concerning attitudes and behavior do not agree with habitual expectations.
Second, there is an explicit and implicit reinforcement of selected responses with the object of
overcoming important behavioral deficits and of extinguishing maladaptive habit patterns.
Third, there are direct or indirect attempts made at cognitive restructuring, through various
instrumentalities, such as (1) persuasive arguments and proffering of philosophical precepts, (2) the
exploration of conscious and unconscious conflicts aimed at the inculcation of insight, and (3) the
provision of a corrective behavioral and emotional experience within the matrix of the patient-
therapist.
Since help from present-day research is so problematic, we must depend on clinical hunches in
sorting out the significance of the many variables in psychotherapy. For convenience we may group
these into:
1. Patient variables , 2. Therapist variables, 3. Social and environmental variables
4. Transferential and counter-transferential variables , 5. Resistance variables
Patient Variables
The Syndrome or Symptomatic Complaint techniques are nevertheless important in themselves and
experience over the years with the work of many therapists strongly indicates that certain methods
score better results with special problems than other methods. Thus symptoms associated with
biochemical imbalances, as in schizophrenia or affective disorders, may be relieved with proper
psychotropic medication, for example, neuroleptics in the case of schizophrenic thinking disorders,
antidepressant drugs in depressive states, and lithium for manic excitement and bipolar depressions.
While thinking disorders in schizophrenia are helped by neuroleptics, problems in social adjustment
are better mediated by behavior therapy, family therapy, and counseling.
Individual or group therapy in schizophrenia, provide no strong evidence for or against the value of
psychotherapy. Behavioral extinction procedures have been utilized to manage gross pathological
behavior, like violence and destructive tantrums in psychotic autistic children, especially when
coupled with differential reinforcement of constructive behavior.
Combined drug and psychosocial therapy is thus best in most depressions.
In hyperkinetic children it is generally found that we may be able to reduce the overactivity with
psychostimulant medications, like (Ritalin® and Dexedrine®), plus behavioral forms of
reinforcement of positive behavior or such mild aversive techniques as removing the child with
disturbing behavior to a “time-out” room for a few minutes. Certain psychosomatic conditions, such
as muscle spasms, migraine, hypertension and arrhythmia, may sometimes be helped by
biofeedback.
Behavioral operant reinforcement techniques and systematic desensitization are being used in
anorexia nervosa.More recently progress has been reported with anorexia and bulimia utilizing
antidepressants. Smoking control, it is claimed, is best handled by multicomponent treatment
packages that program a reinforcement of non-smoking behaviors and utilize smoking suppressive
tactics (Bernstein & McAlister, 1976) supplemented by nicotine gum chewing. Stimulus satiation,
i.e., rapid smoking to satiation, is temporarily effective but the physical side effects must be
considered.
Hypnosis is also useful in combination with follow-up behavioral methods. In enuresis behavioral
approaches (such as a urine alarm bell) are claimed to be superior to dynamic psychotherapy and
imipramine. Behavioral therapy has moved toward recognizing the importance of cognitive factors
(such as irrational self-statements and false attributes)
Sexual disorders (voyeurism, fetishism, sadomasochism, exhibitionism, transvestism), though
difficult to treat, are approached by some therapists with aversive therapy, such as electrical
stimulation for transvestism. Sexual dysfunctions (impotence, frigidity, dyspareunia, vaginismus,
anorgasmia, premature ejaculation) do well with various behavior therapies, hypnosis, and dynamic
psychotherapy.
Of all of these programs, the Masters and Johnson techniques have proven most popular and have in
the opinion of some authorities been made more effective when blended with psychodynamic and
interpersonal techniques
Phobias that have their origin in conditioning experiences seem to respond more rapidly to
systematic desensitization, flooding or graded exposure to a phobic object
About two-thirds of patients with anxiety reactions are helped by both dynamic psychotherapy and
behavioral techniques, such as systematic desensitization, progressive relaxation, “participant
modeling” (i.e., the therapist modeling how to master anxiety), and temporary drug therapy.
Some obsessive-compulsive disorders respond to such antidepressants as clomipramine
(Anafranil®), others come under control with aversive behavioral techniques when they resist every
other type of manipulation. Prolonged exposure to thoughts or situations that provoke compulsive
rituals combined with blocking of the patient from engaging in such rituals has yielded some
successes. Relationship difficulties are particularly suited for group therapy, marital therapy, and,
especially where children are involved, family therapy.
Responses to different methods will vary.
There is a story of a Gideon Bible (which may be apocryphal) that illustrates this. As is known,
practically all hotel rooms contain, as part of the general equipment, a Bible placed there by the
Gideon Society, which in the front pages are suggested reading for the weary traveler. For instance, if
one is in need of salvation, the reference is to John 3:3; or desires peace to neutralize anxiety, Psalm
46; or relief in the time of suffering, Psalm 41; or consolation in conditions of loneliness, Psalm 23.
In a certain hotel Bible opposite Psalm 23, there was written in the margin this inscription: “If after
reading this Psalm you are still lonesome, upset, and feel life is not worthwhile,
Degree and Persistence of Childish Distortions
The distorted images of childhood, the ungratified needs, the unwholesome defenses, may persist
into adult life and influence the speed, direction, and goals of therapy. These contaminations may
obtrude themselves into the therapeutic situation irrespective of what kinds of technique are
practiced.
 Selective Response of the Patient to the Therapist- the patient’s reaction to the therapist often
represents how the patient feels about authority in general. Confidence in one’s therapist is
enormously important—even when the therapist’s ideas of the etiology or dynamics of the patient’s
difficulty are wrong. Since psychotherapy is in a way a form of reeducation, the learning
characteristics of a patient should best correspond with the techniques that are to be used.
Aptitude For Dynamically Oriented Psychotherapy
A persons with good ego strength can somehow muddle along without requiring depth therapy.
However the following positive factors have been emphasized:
1. strong motivation for therapy (actually coming to therapy represents some commitment);
2. existence of some past successes and positive achievements;
3. presence of at least one good relationship in the past;
4. a personality structure that has permitted adequate coping in the past;
5. symptomatic discomfort related more to anxiety and mild depression than to somatic
complaints;
6. an ability to feel and express emotion;
7. a capacity for reflection;

Therapist Variables
Personality Factors: A well-trained therapist, however, who also possesses the proper “therapeutic”
personality is by far best qualified to do successful therapy.
Choice of Techniques: No one technique can serve to ameliorate all maladies that burden
humankind.
Skill and Experience in the Implementation of Techniques: A scrupulous choice of techniques
requires that they be adapted to the needs and learning capacities of patients and be executed with
skill and confidence.
Social And Environmental Variables
Social and environmental variables are probably the most neglected of factors in psychotherapy and
sometimes among the most important. An environment, that rewards for constructive behavior will
reinforce therapeutic gains. Treatment may be considered incomplete if it does not prepare the
patient for contingencies that will have to be faced when treatment is over. Adolescents who belong
to gangs, for example, who learn to control delinquent behavior, may find themselves rejected by
their peers for abiding by the law.
An alcoholic helped to give up drink may not be able to remain dry so long as membership in a
wine-tasting club continues. During therapy a thorough review of what the patient will be up against
after termination will be urgently needed. Either the patient will have to modify a destructive
environment, if this is possible, or will have to separate from it. Thus the adolescent and the
alcoholic will need to find new friends.
Transferential And Counter-transferential Variables
Where the therapist is more ambitious, or the patient requires more sessions to get well, around the
eighth session a change often occurs in the image of the therapist that can precipitate a crisis in
treatment. The patient begins to realize that the therapist is not a god, does not have all the answers,
and even possesses feet of clay. This disillusionment may exhibit itself in a forceful return of
symptoms, and a crediting to the therapist of ineffectual or evil qualities. Therapist may detect from
the patient’s manifest behavior is in the form of resistance to treatment. The patient will complain
about not getting well while breaking appointments or coming late for sessions and will delay the
payment of bills for therapy. Whether personal psychotherapy is mandatory for all therapists in
training as a means of preventing obstructive countertransference is a question about which there is
much debate.
Readiness for Change
A person with a readiness for change will respond to almost any technique and take out of that
technique what he or she is prepared to use.
Common Elements in All Psychotherapies
Interviewing Procedures
Establishment of a Working Therapeutic Relationship
Determination of the Sources and Dynamics of the Patient's Problem: Cognitive learning is present
in all therapies. The different psychotherapies attempt to search for and to explain the patient’s
emotional difficulties in varying terms, such as discordant elements in the environment that mobilize
stress, distorted interpersonal relationships that prevent the individual from selffulfillment,
conditionings that rigidly dragoon the patient to destructive behavior, and unconscious conflicts that
mobilize anxiety and interfere with a realistic adjustment.
Utilization of Insight and Understanding in the Direction of Change
Resistance and the Readiness for Change
Patient Variables
Therapist Attitudes and Operant Conditioning: They constitute powerful reinforcers that strongly
influence the patient’s behavior. Attitudes of empathy, warmth, and understanding tend to promote
positive feelings in the patient; they relieve tension and lower the anxiety level.
Countertransference, Environmental Variables, Termination of Therapy.

Unit 4 - Eclectic approach and Integrative approach

Eclectic approach
Eclectic therapy is a type of therapy that seeks to directly meet the client and their needs by drawing
from multiple therapy approaches in order to select the best treatment for each individual client. It
can be viewed as a combination of different therapy approaches that is tailored to each client
depending on their problems, goals, and expectations.
This type of therapy is the most common approach to therapy because it is so versatile.
Gordon Paul, an early proponent of eclectic therapy, captured the essence of this type of therapy
when he described it as an approach that seeks to determine, “What treatment, by whom, is the most
effective for this individual with that specific problem, under which set of circumstances, and how
does it come about”.
The heart of eclectic therapy involves understanding each client as a unique person with their own
particular problems and then selecting research based techniques from across different types of
therapy in order to help that client grow in a personally meaningful way.
? How Eclectic Therapists Select Their Techniques and Underlying Beliefs?
Despite the fact that it is flexible and pulls from multiple therapeutic approaches depending on the
needs of the client, eclectic therapy is a very intentional approach to mental health therapy.
Therapists purposefully select techniques based on established criteria.
There are four general concepts that define how therapists choose what they do:

• Theoretical integration Technical eclecticism Common

• factors Assimilative integration
An eclectic therapist using the theoretical integration method of therapy adheres to two or more
established, researched based theoretical approaches and combines them to draw from the best of
each according to each client’s needs. For example, a counselor might combine personcentered
therapy with CBT to help clients overcome obstacles. This mental health professional would select
strategies and ideas from these two theories when working with all clients, and the specific tools
used would vary according to an individual client’s needs.
Technical (think “technique”) eclecticism means that a therapist, rather than adhering to a small
number of therapeutic approaches, selects techniques from a wide variety of different therapies
depending on what is needed. The clinician selects a technique that is shown by research to help a
particular issue. Often, therapists use Systematic Treatment Selection (STS), a research-based system
developed by Larry Beutler and John Clarkin consisting of 18 principles and guidelines to help
determine the very best techniques for a given client and problem.
Common factors eclectic therapy is based more on core elements essential to healing than on
specific tools and techniques. Therapists gravitate toward the underlying belief systems of therapies,
such as unconditional positive regard, hope, trust, and empathy as well as driving factors like
correcting emotions, changing beliefs, or providing honest feedback to clients to help them see
themselves more clearly.
Assimilative integration is an approach in which a solid grounding in one theoretical approach is
accompanied by a willingness to incorporate techniques from other therapeutic approaches. In
technical eclecticism, the same diversity of techniques is displayed, but without a binding theoretical
understanding.
Assimilative integration is particularly useful in that theory can help in understanding the needs of
the patient, and then several different approaches to technique can help tailor-make a treatment that
fits with that particular understanding.
Example : Eclectic Therapy for Anxiety
After learning more about the client and their experience with anxiety, an eclectic therapist would
create a plan that draws from acceptance and commitment therapy (ACT), cognitive behavioral
therapy, and positive psychology.
Techniques from ACT, such as acceptance and mindfulness, would help a client stop struggling
against anxiety and begin living fully in their present moment rather than stuck in worries about the
past or future.
The therapist would select specific CBT techniques like learning about automatic negative thoughts
and thought stopping, to help clients change unhealthy thinking that is contributing to anxiety. As
treatment progresses, the therapist would eventually add techniques from positive psychology such
as identifying and using character strengths to help the client increase selfconfidence.

Pros of an Eclectic Approach

• It’s flexible to accommodate different clients’ needs rather than a one-size-fits all approach to
therapy
• It is useful for multiple and complex problems (usually, people see a therapist for more than
one issue or a single issue that is multifaceted)
• The techniques used are research-based and shown to be effective
• The therapy is adapted to the client rather than the client having to fit into a set model
Cons of an Eclectic Approach

• It can feel unpredictable or confusing

• It might seem like the therapist is using a trial-and-error approach
• There isn’t a clear, obvious, or predictable structure.
Integrative approach
Integrative therapy incorporates multiple schools of therapy into one approach. Other therapies are
typically based on a single model, and therapists who work within the same model have similar goals
and approaches. Integrative therapy, on the other hand, allows therapists to work in a more flexible
manner, tailoring their goals and approach to each client. In most cases, this means a combination of
psychodynamic, cognitive behavioral, and humanistic therapies. needs. Integrative therapy is
effective in helping people to manage a range of concerns, including anxiety, depression, and
personality disorders.
It works based on evidence-based research. It pays particular attention to establishing a positive
client/therapist relationship, and research shows that is important for successful treatment.
4 Key Concepts of Integrative Therapy
Integrated therapy is based on these four concepts:
1.There is no single theory that explains all human behavior: Integrative therapists may refer to more
than one theory when they think about their clients and how their symptoms began.
2.Different approaches may work for different clients: People are unique by nature. What works for
one person may not work for another.
3.The therapist should tailor their approach to the client: For therapy to be effective, therapists need
to take into account their client’s specific problems and history and use this information to guide
their approach.
4.The relationship between a client and therapist is an important component of successful therapy:
The therapeutic relationship can be a powerful vehicle of change. Components of a positive
therapeutic relationship include empathy, congruence, and unconditional positive regard.
Syncretism v/s Eclecticism
Eclectic therapists generally do not subscribe to common set of principles since eclectic approach is
based on differences rather than similarities. Hence there are several eclectic approaches. Each
eclectic therapists functions based on specific training received, experience, probably with bias and
on case by case basis with no common set of principles.
Syncretism
There is a very thin line between integration or eclecticism and syncretism. In words of Norcross &
Tomcho. “Some self- designated eclectic or integrative counsellor’s are, in actuality, Practicing
syncretism : an arbitrary and unsystematic blending of concepts of two or more of the 400 plus
schools of psychotherapy. Their pluralistic intentions are to be commended, but their haphazard
hybrids are an outgrowth of pet techniques and inadequate training”.
The uncertainty of eclectic psychotherapy is primarily due to two factors. Firstly, the theory has been
largely ignored in the Eclectic stance and secondly, in the attempt to include as many as possible
diverse methods or techniques, there is little concern for their compatibility or orderly integration
.Under this condition, eclecticism takes the form of syncretism. Therefore, Syncretism can be
described as the combination of different and Often contradictory beliefs, while merging practices
of diverse schools of thought.
UNIT 5: RESEARCH IN PSYCHOTHERAPY

• Research in psychotherapy is still burdened by many handicaps. Yet the literature is replete
with studies flaunting impressive statistics that "prove “the superiority of one brand of
psychotherapy over others or downgrade all forms of psychotherapy as worthless or limited
at best.
• And still do not possess a model of psychotherapy research that we can consider uniquely
applicable to the special problems .
• Research in psychotherapy to this date has had surprisingly little impact on contemporary
clinical practice.
Effectiveness of psychotherapy

• Moreover, it appears that when psychotherapy and medications are withdrawn (ie, the
psychotherapy is terminated or the course of medication is finished), the effects of
psychotherapy are longer lasting in that, at various times following the end of treatment, a
greater number of clients who have been on medication relapse. It appears that
psychotherapy provides clients with skills with coping with the world and with their
disorder.
• Moreover, clients who have received previous courses of medication become resistant t
additional course of medication, whereas they do not become resistant with additional
course of cognitive therapy. As a general class of healing practices, psychotherapy is
remarkable effective. In clinical trials, psychotherapy results in benefits that far exceed
the benefits of those who do not get psychotherapy.
• Indeed, psychotherapy is more effective than many commonly used evidence- based
medical practices, some of which have side effect sand are quite expensive .
• In addition, psychotherapy is as effective as medications for prevalent mental disorders, is
longer lasting, and is less resistant to additional courses.
Measuring therapeutic improvement
 • Present-day outcome studies shows impressive statistics about the effectiveness of
psychotherapy that contradict published negative reports . General procedures for the
measurement of outcome have been detailed by a number of authorities, including Waskow
and Parloff.
• The primary concern is identifying the specific variables that are significant to measure and
that give us reliable and valid data.
• Another concern also are the research designs that can best provide answers to our questions
about outcome.
• The instruments that are used for the gauging of outcome must be selected carefully,
recognizing that no one instrument is suitable for different patient populations and for
varying forms of psychotherapy. Among the measures in use today are: self-reporting that
deals with the patient's daily functioning, broad anamnestic materials in the popular
Minnesota Multiphasic Personality Interview ;data from family and friends; a "Community
Adjustment Scale; therapist assessment scales ;material from community agencies or
members problems exist in any attempt to measure the results of psychotherapy or to verify
its empirical propositions:
• problems in applying scientific method to evaluation studies:
1.There is disagreement as to which observable phenomena are worthy of observation.
2.The data available for study are difficult to manipulate and control, interfering with
conditions ripe for experiment.
3.It is cumbersome to qualify the quantitative data of psychotherapy due to the complexity of
the variables involved.
4.Available units of measurement are ill-defined, interfering with comparisons and with the
synthetization of similarities and differences into a homogeneous unity.
5.Theoretic prejudices and personal biases make for a loss of objectivity and an interference
with the ability to utilize imagination in hypothetic structuring
6.The absence of an accepted conceptual framework that can act as a basis for
communication obstructs the formulation of inferential judgments regarding order in the
observed phenomena blocking the deduction of valid analogies justified by the available
facts, and hindering the exploration of causal connections between antecedents and
Consequences.
7.The reliability of our results is distorted by a variety of other difficulties that are related to
special problems of the therapist, the resistances of the patient, the amorphous status of
diagnosis, the prejudiced selection of the sample, the involvements of outside judges, coders,
and raters, the inability to employ adequate controls, the interferences of adventitious non-
specific changes, and certain complexes inherent in the psychotherapeutic process itself.
Efficiancy and efficacy of therapy
• The effectiveness of psychotherapy for disorders are by conducting studies
• The efficacy of treatment is determined by a clinical trials in which many variables are carefully
controlled to the efficacy of treatment is determined by a clinical trials in which many variables are
carefully controlled to demonstrate that the relationship between the treatment and outcome add
relatively unambiguous
• efficacy studies emphasise the internal validity of experimental design through a variety of means
These and other strategies are used to enhance the ability of investigator to make causal inference
based on findings.
Effectiveness study
• conducted in natural clinical settings when the interventions is implemented without same
level of internal validity that is present in clinical trials it emphasis external validity of
 experimental design. Treatment dose not controlled and therapist other adherence treatment
Guidelines neither highly specified nor monitored.
• therapist tend to be those working in clinical settings and may or may not receive.
• Seligman conducted an efficacy study and wrong method for empirically validating
psychotherapy as it is done
• Effectiveness studies are needed to determine what treatment work on field.
• Effectiveness studies do not require relaxation of methodological rigour instead it is done by
steps like broadening sample size.
positives of efficacy studies

• Randomization is homogeneous
• Specification of treatment procedures
• Method for assuring fidelity of treatment delivery
• Blind rating
• Rigorous strong control group
• Inclusion- exclusion criteria
• Operationally defined outcomes
• Able to draw strong causal inference including the attribution of treatment effects to
treatment rather than a variety of other variables
Positives of effectiveness studies

• Use of typical practitioners and settings variable amount of treatment Mixtures of treatment
• inclusion of patients with multiple disorders measures of improvements other than symptom
relief
• Careful assessment of characteristics of settings
 MODULE 2
PSYCHOANALYTIC PSYCHOTHERAPY
Unit 1
The Psychoanalytic Theory is the personality theory, which is based on the notion that an individual gets
motivated more by unseen forces that are controlled by the conscious and the rational thought. Personality
theory has been influenced more by Sigmund Freud than by any other individual. His system of
psychoanalysis was the first formal theory of personality and is still the best known. Freud’s influence has
been so profound that more than a century after his theory was proposed it remains the framework for the
study of personality, despite its controversial nature. It would be difficult to comprehend and assess the
development of the field of personality without first understanding Freud’s system. Sigmund Freud was born
in Freiberg, Moravia, in 1856. Sigmund Freud has maintained his place as the central figure in
psychoanalysis since the early 1900s.For some psychoanalytic and psychodynamic practitioners, he remains
a source of inspiration and brilliance.
Structure of Personality

The personality has three parts: the id, the ego, and the superego The id is present at birth and is part of the
unconscious. The id is the site of the pleasure principle, the tendency of an individual to move toward
pleasure and away from pain. The id does not have a sense of right or wrong, is impulsive, and is not
rational. It contains the most basic of human instincts, drives, and genetic endowments.
The ego is the second system to develop, and it functions primarily in the conscious mind and in the
preconscious mind. It serves as a moderator between the id and the superego, controlling wishes and desires.
The ego is the site of the reality principle, the ability to interact with the outside world with appropriate
goals and activities. The superego sets the ideal standards and morals for the individual. The superego
operates on the moral principle which rewards the individual for following parental and societal dictates.
Guilt is produced when a person violates the ideal ego denying or ignoring the rules of the superego.
Developmental Stages

• Oral stage is centered on the mouth as a source of pleasure.

• Anal stage is centered on the anus and elimination as a source of pleasure.
• Phallic stage is centered on the genitals and sexual identification as a source of pleasure. Oedipus
Complex is described as the process whereby a boy desires his mother and fears castration from the
father, in order to create an ally of the father, the male learns traditional male roles.Electra Complex is
described a similar but less clearly resolved in the female child with her desire for the father, competition
with the mother and thus, learns the traditional female roles.
• Latency stage is a time of little sexual interest in Freud’s developmental view. This stage is characterized
with peer activities, academic and social learning, and development of physical skills. Genital stage
begins with the onset of puberty. If the other stages have been successfully negotiated, the young person
will take an interest in and establish sexual relationships.
Ego Defense Mechanisms
Were believed by Freud to protect the individual from being overwhelmed by anxiety. He considered them
normal and operating on the unconscious level. Some of the ones most often referred to are:

• Repression is the defense mechanism whereby the ego excludes any painful or undesirable thoughts,
memories, feelings or impulses from the conscious.
• Projection is the defense mechanism whereby the individual assigns their own undesirable emotions and
characteristics to another individual.
• Reaction Formation is the defense mechanism whereby the individual expresses the opposite emotion,
feeling or impulse than that which causes anxiety.
• Displacement a defense mechanism whereby the energy that is generated toward a potentially
dangerous or inappropriate target is refocused to a safe target.
• Sublimation is a positive displacement is called whereby the frustrating target is replaced with a
positive target.
• Regression is the defense mechanism whereby returns to an earlier stage of development.
• Rationalization is the defense mechanism in which an individual creates a sensible explanation for an
illogical or unacceptable behavior making it appear sensible or acceptable.
• Denial is a mechanism whereby an individual does not acknowledge an event or situation that may be
unpleasant or traumatic.
• Identification or introjection is a defense mechanism whereby a person takes on the qualities of another
person to reduce the fear and anxiety toward that person.
• Isolation a defense mechanism in which the individual screens out painful feelings by recalling a
traumatic or painful event without experiencing the emotion associated with it.
VIEWS OF HUMAN NATURE

• Deterministic; behavior is determined by the unconscious motivations that have evolved through
psychosexual stages. According to Freud, our behavior is determined by irrational forces,
unconscious motivations, biological and instinctual drives as these evolve through key psychosexual
stages in the first 6 years of life.
• Instincts are central to the Freudian approach.
• Freud’s view of human nature is considered to be dynamic, meaning that there is an exchange of
energy and transformation. Freud used the term catharsis to describe this release of this energy.
• Freud saw the personality as composed of a conscious mind, a preconscious mind and an
unconscious mind. The conscious mind has knowledge of what is happening in the present. The
preconscious mind contains information from both the unconscious and the conscious mind. The
unconscious mind contains hidden or forgotten memories or experiences.
• Freud did not present us with a flattering or optimistic image of human nature. Quite the opposite.
He suggested that each person is a dark cellar of conflict in which a battle continually rages. Human
beings are depicted in pessimistic terms, condemned to a struggle with our inner forces, a struggle
we are almost always destined to lose. Doomed to anxiety, to the thwarting of at least some of our
driving impulses, we experience continual tension and conflict. We are endlessly defending ourselves
against the forces of the id, which stand ever alert to topple us.
• In Freud’s system, there is only one ultimate and necessary goal in life: to reduce tension. On the
nature–nurture issue, Freud adopted a middle ground. The id, the most powerful part of the
personality, is an inherited, physiologically based structure, as are the stages of psychosexual
development. However, other parts of our personality are learned in early childhood, from parent–
child interactions.
 • Although Freud recognized universality in human nature, in that we all pass through the same stages
of psychosexual development and are motivated by the same id forces, he asserted that part of the
personality is unique to each person. The ego and superego perform the same functions for everyone,
but their content varies from one person to another because they are formed through personal
experience. Also, different character types can develop during the psychosexual stages.
• On the issue of free will versus determinism, Freud held a deterministic view: Virtually everything
we do, think, and dream is predetermined by the life and death instincts, the inaccessible and
invisible forces within us. Our adult personality is determined by interactions that occurred before
we were 5, at a time when we had limited control. These experiences forever hold us in their grip.
• Freud also argued, however, that people who underwent psychoanalysis could achieve the ability to
exercise increased free will and take responsibility for their choices. “The more the individual is able
to make conscious what had been unconscious, the more he or she can take charge of his or her own
life” (Solnit, 1992, p. 66). Thus, Freud suggested that psychoanalysis had the potential to liberate
people from the constraints of determinism.
• Freud’s overall picture of human nature, painted in these bleak hues, refl ects his personal view of
humanity, which darkened with age and declining health. His judgment of people in general was
harsh. “I have found little that is ‘good’ about human beings on the whole. In my experience, most of
them are trash” (Freud, 1963, pp. 61–62). We can see this stern judgment in his personality theory.

GOALS OF PSYCHOANALYTIC PSYCHOTHERAPY

• Helping the client bring into the conscious the unconscious. Helping the client work through a
developmental stage that was not resolved or were the client became fixated.
• Help the client adjustment to the demands of work, intimacy, and society.
• Often restructure personality rather than reduce symptoms, the process can last for several years.
• Psychoanalysis and psychodynamic psychotherapy are designed to bring about changes in a person’s
personality and character structure. In this process, patients try to resolve unconscious conflicts
within themselves and develop more satisfactory ways of dealing with their problems. Self-
understanding is achieved through analysis of childhood experiences that are reconstructed,
interpreted, and analyzed.
• The insight that develops helps bring about changes in feelings and behaviors. However, insight
without change is not a sufficient goal (Abend, 2001). By uncovering unconscious material through
dream interpretation or other methods, individuals are better able to deal with the problems they face
in unproductive, repetitive approaches to themselves and others.
• The emphasis in bringing about resolution of problems through exploration of unconscious material
is common to most approaches to psychoanalysis. For Freud, increasing awareness of sexual and
aggressive drives (id processes) helps individuals achieve greater control of themselves in their
interaction with other (ego processes). Ego psychoanalysts emphasize the need to understand ego
defense mechanisms and to adapt in positive ways to the external world. For object relations
therapists, improved relationships with self and others can come about, in part by exploring
separation and individuation issues that arise in early childhood. Somewhat similarly, self-
psychologists focus on the impact of self-absorption or idealized views of parents that may cause
severe problems in relating with others in later life, and they seek to heal these early experiences.
Relational analysts may have goals similar to object relations analysts and self-psychologists. The
differences among these approaches are oversimplified here.In clinical work, psychoanalysts may
have one or more of these goals in their work with patients.
 • There are some general goals that many psychoanalytic and psychodynamic therapists have in
common (Gabbard, 2004, 2005).
• Patients should become more adept at resolving unconscious conflicts within themselves. As a result
of psychodynamic or psychoanalytic therapy, patients should know themselves better and feel more
authentic or real. As a result of understanding their own reactions to other people, patients should
have improved relationships with family, friends, and coworkers. Patients should be able, after
therapy is completed, to distinguish their own view of reality from real events that have taken place.
These goals apply to all systems of psychoanalysis.
ROLE OF THE COUNSELOR
To encourage the development of transference, giving the client a sense of safety and acceptance. The client
freely explores difficult material and experiences from their past, gaining insight and working through
unresolved issues. The counselor is an expert, who interprets for the client.
UNIT 2 : MAJOR TECHNIQUES
Although psychoanalysts make use of different listening perspectives from drive, ego, object relations, self
psychology, and/or relational psychology, they tend to use similar approaches to treatment. In their goals for
therapy, they stress the value of insights into unconscious motivations. In their use of tests and in their
listening to patients’ dreams or other material, they concentrate on understanding unconscious material.
Depending on whether they do psychoanalysis or psychoanalytic therapy, their stance of neutrality and/or
empathy toward the patient may vary. However, both treatments deal with the resistance of the patient in
understanding unconscious material. Techniques such as the interpretation of transference or of dreams can
be viewed from the five perspectives, as can countertransference reactions (the therapist’s feelings toward
the patient). Applying these perspectives to dream interpretation, to a transference reaction, and to
countertransference issues can clarify these different approaches and show several ways that treatment
material can be understood.
Techniques of classical psychoanalysis
Free association, interpretation of dreams, and transference, as well as countertransference issues, are the
cornerstones of psychoanalytic treatment
FREE ASSOCIATION
Traditional psychoanalysts begin each session the same way. They encourage clients to ‘‘Say whatever
comes to mind.’’ This is the basic rule in psychoanalysis; a variation of this approach is used in most
psychoanalytically oriented therapies. The basic rule is designed to facilitate emergence of unconscious
impulses and conflicts. To use the basic rule, analysts adhere to the following guidelines. First, to let
unconscious impulses and conflicts rise to consciousness, distractions or external stimuli must be
minimized. This is one reason why Freud used a couch. If the client lies on a couch and the analyst sits
behind it, the analyst cannot be seen; the analyst’s distracting facial expressions are eliminated. Greater
emphasis can be placed on what facial expressions (or thoughts and feelings) the client imagines the analyst
is experiencing. Second, the client’s internal stimuli are mininized. When free associating, it’s best not to be
too hungry or thirsty or physically uncomfortable. If clients come to analysis hungry, thoughts about food
will flood into their free associations. Similarly, if the client is physically uncomfortable, it will distract from
the free association process. Even potential leaks in confidentiality associated with reporting information to
insurance companies can inhibit the free association process (Salomon, 2003). Third, cognitive selection or
conscious planning is reduced. Free association is designed, in part, to counter intentional or planned
thought processes. For example, if a client comes to therapy with a list of things to talk about,
psychoanalytic practioners might interpret this as resistance. You may wonder, ‘‘Why would the client’s
planning for the session be considered resistance?’’ The answer is that conscious planning is a defense for
keeping control over sexual, aggressive, and other impulses. Traditional psychoanalytic theory presumes
that these impulses are adversely affecting the client and need to be brought to consciousness. For
contemporary theorists, client list making might be an interpersonal control strategy deserving collaborative
exploration; awareness might be enhanced rather than the unconscious motives uncovered.
When patients are asked to free-associate, to relate everything of which they are aware, unconscious
material arises for the analyst to examine. The content of free association may be bodily sensations, feelings,
fantasies, thoughts, memories, recent events, and the analyst. Having the patient lie on a couch rather that sit
in a chair is likely to produce more free-flowing associations. The use of free association assumes that
unconscious material affects behavior and that it can be brought into meaningful awareness by free
expression. Analysts listen for unconscious meanings and for disruptions and associations that may indicate
that the material is anxiety provoking. Slips of the tongue and omitted material can be interpreted in the
context of the analyst’s knowledge of the patient. If the patient experiences difficulty in free-associating, the
analyst interprets, where possible, this behavior and, if appropriate, shares the interpretation with the patient.
DREAM ANALYSIS
( manifest dream converted into latent dream)
Manifest dream : narrative reconstruction of bits and pieces of dream memory.
Latent dream : underlying meaning of dream containing repressed desires and conflicts.
A trained psychoanalyst interprets dream symbols and links it to patient’s life story and free association to
arrive at latent content.
In psychoanalytic therapy, dreams are an important means of uncovering unconscious material and
providing insight for unresolved issues. For Freud, dreams were “the royal road to a knowledge of the
unconscious activities of the mind” (Freud, 1900). Through the process of dream interpretation, wishes,
needs, and fears can be revealed. Freud believed that some motivations or memories are so unacceptable to
the ego that they are expressed in symbolic forms, often in dreams. For Freud, the dream was a compromise
between the repressed id impulses and the ego defenses. The content of the dream included the manifest
content, which is the dream as the dreamer perceives it, and the latent content, the symbolic and unconscious
motives within the dream. In interpreting dreams, the analyst or therapist encourages the patient to free-
associate to the various aspects of the dream and to recall feelings that were stimulated by parts of the
dream. As patients explore the dream, the therapist processes their associations and helps them become
aware of the repressed meaning of the material, thus developing new insights into their problems. Although
Freud focused on repressed sexual and aggressive drives, other analysts have used other approaches to
dream interpretation and emphasized an ego, object relations, self, or relational approach.
Freud discovered some general forms of distortion or concealment by which the drives of the unconscious
achieve expression in the conscious. These are according to Freud known as condensation, displacement,
dramatization, and secondary elaboration, popularly called the mechanism of dream work. Analysis of
dream indicates that through the process of dream work, a single element of manifest content represents
several latent thoughts.
All dreams deal with wishes which for some reason cannot be accepted into the conscious and working
state. Every dream is an attempt to put aside a disturbance of sleep by means of a wish fulfillment. Because
the path to motor discharge is closed in sleep, the wish fulfillment of a repressed impulse is toned down.
Condensation: It is an unconscious mechanism by which dream work is accomplished. A single item of the
manifest content of the dream may be formed of parts of several ideas and wishes of the latent content. This
is done by the mechanism of condensation. The most important feature of condensation consists in fusing
many latent elements possessing a common denominator in one idea or picture.
Displacement: Every wish of the individual has some emotional tone attached to it In the conscious
expression the affect centres upon the more significant idea. But when the idea is unconscious and under
repression and when it is not affected by the ego, the affect or feeling tone may be displaced to less
significant ideas. The ideas in the manifest content due to displacement may be very confused or misleading.
What seems to be an important item in the manifest content due to its emotional attachment may not be
really so significant in the latent content. Similarly, highly significant ideas belonging to the latent content is
represented by an apparently insignificant idea in the manifest content. Thus, an important affect is attached
to an unimportant idea. Displacement is responsible for much of the quality of bizzareness in dreams.
Displacement is thus an unconscious mechanism by which the manifest content of the dream is purposely
centred elsewhere than upon the essential aspects. A person saw a dream that he has written a botanical
monograph of a certain plant. Analysing this dream Freud could trace many subtle connections to complex
inter-personal relationship with his colleague. In this monograph, Freud found that the troublesome
unconscious attitudes of the dreamer were conveniently displaced.
Dramatization: In the process of becoming conscious in the dream wishes have to be converted into more
or less concrete visual images. This conversion of abstract ideas into concrete symbols constitutes what
Freud regards as dramatization of the wish. Freud therefore opines that the process whereby the latent dream
thoughts are expressed in terms of visual images is called the process of dramatization. By means of
dramatization, the true meaning of the dream is concealed to cheat the ego.
Through the procedure of dramatization, the manifest dream content persistently portrays a present action or
series of actions mostly through the medium of visual imagery such as pictures. More often abstract words
are replaced by pictographs of their original concrete meanings. Freud opines “clearly what has to be
accomplished by the dream work is the transformation of the latent thoughts as expressed in words, into
perceptual images”.
Secondary elaboration: Secondary elaboration makes the dream coherent and meaningful. Its main function
is to bring distorted products of dream work more into harmony with the standards of conscious thinking,
i.e., to make sense of the dream. The secondary elaboration tries to give a reasonable meaning to the dream
and by that conceals its real meaning and significance. Thus it is a spontaneous but wholly inaccurate dream
interpretation. It tends to constitute the various parts of the dream to a unified whole which can be
assimilated by the general content of consciousness. Secondary elaboration is achieved by means of
rearrangement and interpolation.
The effect of this rearrangement and interpolation is to further disguise the real meaning and distort the
relationships of the underlying latent thoughts. According to Blum (1969) through this technique an attempt
is made by the ego to connect the condensed, displaced and symbolic parts of the dream in a manner at least
somewhat consistent with conscious logic. In other words, the ego’s more advanced secondary process of
thinking is not completely suspended during dream formation. This pulling together of a senseless mass of
thought fragments is mainly illusory from a logical stand point and the underlying emotional tone of the
basic impulses remains unchanged. Hence, by the technique of secondary elaboration out of largely
disconnected and distorted pictures, some coherent story is made. The material of the secondary elaboration
is secured from the preconsciousness. While reporting dream even careful reporters add something to the
dream and subtract something from it to enhance the dramatic effect of the report and to achieve a greater
degree of coherence.
This is otherwise called secondary elaboration. Here a consistent and presentable feature is given to a
smaller, uncorrelated and incoherent dream. Secondary elaboration is related to our conscious mental
mechanism, and it makes the dream more complex. According to Freud (1938), the first three of the four
mechanisms of dream work are processes which operate in the unconscious state. The last one i.e., the
secondary elaboration is however related to ones conscious mental life. It starts when the individual is
awake while the other three processes continue completely in the unconscious state when the individual
dreams. Earnest
Jones (1957) thus comments, “secondary elaboration is closely related to rationalization.” To avoid the
process of secondary elaboration in dream the analyst usually instructs the dreamer to write down the dream
immediately after he visualizes it.”
The Dream :
To illustrate three different ways to interpret a dream, Mitchell (1988, pp. 36–38) uses a fragment of a
dream. The dreamer is riding a subway, not knowing where, and feeling physically and mentally burdened.
The dreamer has several bags and her briefcase. She lets her attention wander elsewhere and leaves her bags
and briefcase to explore whatever has caught her attention. When she returns to her seat, her briefcase is
gone and then she is very angry at herself for doing this. A feeling of great terror follows.
Interpretation Using Freud’s Drive Model :
There is an emphasis on examining how various drives are represented.
Different objects of the dream have different meanings. The underground tunnel is symbolic of the anal
drive. The train is a phallic symbol. The briefcase represents castration, and is a vaginal representation. The
relational portion of the dream is less important. People are not important for themselves, but they are
related to drives and defenses. People in the dream would be objects of desire and punishment. The conflict
in the dream is over the missing briefcase and the self-criticism and implied fear of punishment. Having
desire (a drive) and what happens as a result of that is an important theme in the drive model interpretation
of the dream.
Interpretation Using Object Relations :
The dream is viewed as representing how the dreamer sees herself and how she sees herself in relationship
to others. One way she relates to others is through a compulsive loyalty that helps her feel close to others
emotionally. Yet there is also a part of her that wants to impulsively pursue her own interests, but this may
risk separating herself from others. The fear is that if she pursues her own desires instead of attending to the
needs of others, she will not know who she is or how to establish connections with others. This issue could
be the major focus of her analytic treatment. In therapy, she may start to see her self differently in terms of
the way she relates to others (including the analyst).
Interpretation Using Self Psychology :
The focus is on the patient’s sense of self, on who she is as a person, including her fears and feelings.
Questions arise as to whether she feels overtaxed with concerns. Perhaps she may be worried about being
too impulsive. Or perhaps she is afraid of becoming weaker. The briefcase represents the self that exists and
is reflected in her family’s view of her. She may have a distorted belief that she has to be responsible in
order to be valued by her family. In this way, the loss of the briefcase symbolizes the possibility of losing
her sense of who she is as a person.
Depending on the analyst’s or therapist’s point of view and the nature of the patient’s problem and disorder,
an analyst or therapist might use any of these means of understanding the unconscious material in a dream.
Additionally, an ego psychology approach might reveal a different way of understanding the dream. In
interpreting the dream, Mitchell (1988) makes use not only of the dream itself but also of the variations
within the recurring dream and, particularly, knowledge of the patient that he has gathered during the several
years of analysis.
FREUDIAN SLIPS
A Freudian slip, or parapraxis, refers to what you might also call a slip of the tongue. It’s when you
mean to say one thing but instead say something entirely different. It commonly happens when you’re
talking but can also occur when typing or writing something down and even in your memory (or lack
thereof). It was the famed psychoanalyst Sigmund Freud who described a variety of different types and
examples of Freudian slips in his 1901 book, “The Psychopathology of Everyday Life.” Freud wrote that
speech blunders are the result of a “disturbing influence of something outside of the intended speech” like
an unconscious thought, belief, or wish. He also addressed the problem of forgetting names, saying that it
may sometimes be related to repression. In his view, unacceptable thoughts or beliefs are withheld from
conscious awareness, and these slips help reveal what is hidden in the unconscious. According to
psychiatrist Sigmund Freud, the slip is interpreted as the emergence of the contents of the unconscious mind.
For example, a woman might mean to tell her friend, “I am so in love with John.” But instead of saying
John’s name, she might say the name of her ex-boyfriend instead. Her friend might then interpret her slip to
mean that she is still in love with her ex-boyfriend. Sigmund Freud argued that the the contents of the
unconscious mind are hidden by a variety of mechanisms of repression. Sometimes in speech, inattention,
distraction, or strong emotions can help the contents of the unconscious mind come out.
Freudian Slip in Popular Culture
Freudian slips are commonly used as humorous devices in literature and movies. The term is commonly
applied to many different errors in speech, but Freud originally intended to use the term only for a limited
number of slips that he believed to be the result of the workings of the unconscious mind. There are many
alternative explanations for Freudian slips, including speech habits, difficult or complex sentences,
exhaustion, or thinking about something else while speaking. Contemporary mental health professionals do
not generally use Freudian slips as therapeutic tools to gain insight into clients’ minds.
ANALYSIS OF TRANSFERENCE
One of the unique and most lasting contributions of Freud’s work was his discussion and analysis of
transference (Luborsky, 1985). In the past half century, more than 3,000 books and professional journal
articles have been published on transference phenomena (Kivlighan, 2002). As Kivlighan stated, ‘‘From a
strictly classical stance, transference is a client distortion that involves re-experiencing oedipal issues in the
therapeutic relationship’’(p. 167). Gelso and Hayes (1998) provide a more modern definition of transference
that goes beyond oedipal issues:
The client’s experience of the therapist that is shaped by the client’s own psychological structures and past
and involves displacement, onto the therapist, of feelings, attitudes and behaviors belonging rightfully in
earlier significant relationships. (p. 51, italics in original) more than anything else, transference is
characterized by inappropriateness. As Freud stated, transference ‘‘exceeds anything that could be justified
on sensible or rational grounds’’ (Freud, 1958). This is because transference involves using an old map to try
to get around on new terrain, and, simply put, it just doesn’t work very efficiently ( J. Sommers-Flanagan &
R. SommersFlanagan 2009). Consequently, one way to detect transference is to closely monitor for client
perceptions and treatment of you that don’t fit correctly. Of course, to effectively monitor for inaccuracies in
your client’s perceptions, you must know yourself well enough to identify when your client is treating you
like someone you aren’t.
Transference is a tendency in which representational aspects of important and formative relationship ( such
as with parents and siblings) can be both consciously experienced and Or unconsciously described to other
relationships ( Levy, 2009).
The relationship between patient and analyst is a crucial aspect of psychoanalytic treatment. In fact, Arlow
(1987) believes that the most effective interpretations deal with the analysis of the transference. Learning
how to construct interpretations and to assess their accuracy is an important aspect of psychoanalytic
training (Gibbons, Crits-Christoph, & Apostol, 2004). Patients work through their early relationships,
particularly with parents, by responding to the analyst as they may have with a parent. If there was an
emotional conflict in which the patient at age 3 or 4 was angry at her mother, then anger may be transferred
to the analyst. It is the task of the analyst to help patients work through their early feelings toward parents as
they are expressed in the transference.
Transference is a psychology term used to describe a phenomenon in which an individual redirects emotions
and feelings, often unconsciously, from one person to another. This process may occur in therapy, when a
person receiving treatment applies feelings toward—or expectations of—another person onto the therapist
and then begins to interact with the therapist as if the therapist were the other individual. Often, the patterns
seen in transference will be representative of a relationship from childhood.
The concept of transference was first described by psychoanalyst Sigmund Freud in his 1895 book Studies
on Hysteria, where he noted the deep, intense, and often unconscious feelings that sometimes developed
within the therapeutic relationships he established with those he was treating.
Types of transference
Positive transference : in psychoanalysis, a patient’s transfer onto the analyst or therapist of those feelings
of attachment, love, idealization, or other positive emotions that the patient originally experienced toward
parents or other significant individuals during childhood.
Negative transference : Negative transference is the psychoanalytic term for the transference of negative
and hostile feelings, rather than positive ones, onto a therapist.
Sexual transference : Erotic transference is a term used to describe the feelings of love and the fantasies of
a sexual or sensual nature that a client experiences about their therapist. Erotic countertransference is about
the therapist’s feelings about their client.
Apart from this there is also another types of transference are exists namely; early transference and late
transference
Early transference : Some patients manifest intense transferences or transference-like reactions in the
earliest hours of psychotherapy. Although these reactions may actually represent transference, they may also
arise from other sources, such as aspects of a patient’s character, displacements from former therapists,
impaired reality testing, information about the therapist, and therapist’s behavior.
Late transference : late transference is more likely to be useful in analysis. It is also good for therapeutic
relationship.
Transference Interpretation
Tactful ( tricky) comment that clarifies and links the patient’s experience of others outside of therapy with
that of the therapist in therapy and to the patient’s experience of past relationship with caregivers ( Levy,
2009).
Analysis and interpretation of transference
 • Analysis of transference is the central technique in psychoanalysis
• Allow the client to achieve here and now.
• Reveal hidden conflicts ( problems with parents or siblings) By interpretation clients are enable to
work through past conflict that are keeping them fixated and help them growth emotionally.
• Transference neurosis and its resolution
• Total play of mental process is permitted consistently feelings and attitudes of the past emerges and
is projected.
• Correct interpretation is easy the patient to understand insight.
• Ego getting strengthen and more and more tolerate inner conflicts along with associate anxiety /
negative outcome.
• When they re-experience of neurosis in a non – punitive, non – judgemental environment and
tolerance / acceptance of the id drives ( intense emotions) leads to insight and resolution, and finally
character change.
Evidence of transference outcome

• Transference interpretation were negatively correlated to outcome, particularly for those with low object
relations quality.
• Good treatment plan brings good outcome.
• Random control trials confirm that transference interpretation are highly effective even for people with
low quality of object relations.
ANALYSIS OF RESISTANCE
During the course of analysis or therapy, patients may resist the analytical process, usually unconsciously,
by a number of different means: being late for appointments, forgetting appointments, or losing interest in
therapy. Sometimes they may have difficulty in remembering or free-associating during the therapy hour. At
other times resistance is shown outside therapy by acting out other problems through excessive drinking or
having extramarital affairs. A frequent source of resistance is known as transference resistance, which is a
means of managing the relationship with the therapist so that a wished or feared interaction with the analyst
can take place (Horner, 1991, 2005).
Psychoanalysis is a style of psychotherapy originally developed by Sigmund Freud. Resistance was
originally defined within the context of psychoanalysis. In psychoanalysis, resistance is loosely defined as a
client’s unwillingness to discuss a particular topic in therapy. For example, if a client in psychotherapy is
uncomfortable talking about his or her father, they may show resistance around this topic. While the client
may be comfortable talking about other family members, they might change the subject every time their
father comes into the conversation. If the therapist continues to probe this topic, the client may even show
resistance by missing therapy appointments or discontinuing therapy.
Resistance can take many forms in psychotherapy and affect a client’s behavior in many ways. The
following is a list of some forms of resistance which a client may use to keep from dealing with certain
topics with therapist.

• Silence or minimal discussion with the therapist

• Wordiness or verbosity
• Preoccupation with symptoms
• Irrelevant small talk
• Preoccupation with the past or future
• Focusing on the therapist or asking the therapist personal questions
• Discounting or second-guessing the therapist
 • Seductiveness
• False promises or forgetting to do what is agreed upon
• Not keeping appointments
• Failing to pay for appointments
• Denial of transference ( not accepting the unreal nature of transference relation)
• Resistance cure
• Therapist turns ‘active’ when resistance is observed.
• Not seen as negative behavior, but normal part of therapy.

Therapist work towards resistance cure by;

*Encouraging observance of basic rules
*Attacking resistance through interpretation
* discussion of the unconscious material emerging from free association, slips, dreams etc.
Therapist help patient to retract normal relation and regress to the transference relation.
Interpretation of transference is the chief mean of resolving resistance and recognize the origin of the
anxiety and inner conflicts ( which means, identifying the specific area that will exhibit resistance
; Eg : childhood, relationship with parents, job related areas etc.)
Here are some general considerations when dealing with what seems to be resistance from a client.
Reframe the idea of ‘control’
If you suspect your client is concerned with ‘losing control’, you can talk about how you use hypnosis,
coaching or counselling only to increase the client’s control and freedoms. We might talk about how the
phobia or cigarette addiction or depression had been seeking to control the person and how hypnosis can
help them become free.
Allow for any response with greater choice
When we hypnotize someone, or, in fact, do any form of psychotherapy with them, we really need to respect
their freedom. People’s unconscious need for a sense of autonomy may feel greater than their need to
overcome their problem. Even if that problem has a devastating impact on their life.
Use permissive language
When clients are resistant, they may be looking out for language from you that confirms their hidden bias
that this is a confrontational tussle rather than a collaborative situation from which they can benefit. To
counter this, we can be directive in a way that comes across as the opposite. The key is using permissive
language, such as:
“Perhaps…” “maybe…” “I wonder if…” “I really don’t know…”
Give credit to your clients
However wonderful your therapeutic skills, the real therapy is done by your client. We need to thank them,
and give them the credit for what they’ve achieved. For example:
“Wow, I’m pretty impressed at how skilled you are at relaxing!”
INTERPRETATION
To be meaningful to the patient, material that arises from free association, dreams, slips of the tongue,
symptoms, or transference must be interpreted to the patient. Depending on the nature of the material, the
analyst may interpret sexually repressed material, unconscious ways the individual is defending against
repressed memories of traumatic or disturbing situations, or early childhood disturbances relating to
unsatisfactory parenting. Analysts need to attend not only to the content of the interpretation but also to the
process of conveying it to the patient (Arlow, 1987). The patient’s readiness to accept the material and
incorporate it into his own view of himself is a significant consideration. If the interpretation is too deep, the
patient may not be able to accept it and bring it into conscious awareness. Another aspect of interpretation is
the psychological disorder that the patient presents to the therapist. Interpretation in work with individuals
with borderline disorders may serve different functions than in less complex disorders (Caligor, Diamond,
Yeomans, & Kernberg, 2009). Being attuned to the patient’s unconscious material often requires that the
analyst be attuned to her own unconscious processes as a way of evaluating the patient’s unconscious
material (Mitchell, 2000). In general, the closer the material is to the preconscious, the more likely the
patient is to accept it.
Traditional analysis views the unconscious as so charged with conflicted material that even free association
doesn’t allow direct access. Instead, ego defenses, designed to protect clients from their unconscious
knowledge, distort information rising up from the unconscious, resulting in what’s called unconscious
derivatives. Depending upon the analyst’s particular perspective, the derivatives may reflect primarily
instinctual conflicts or primarily relationship or attachment conflicts.
The Freudian analyst’s job is to listen for and interpret unconscious derivatives. This process is anything but
simple. The analyst cannot just sit back and make interpretation after interpretation of unconscious
derivatives. Fenichel (1945) stated the reason for this:
The unprepared patient can in no way connect the words he hears from the analyst with his emotional
experiences. Such an ‘‘interpretation’’ does not interpret at all. (p. 25)
Fenichel is saying that analysts must prepare clients before using interpretation. Proper client preparation
involves steps described in the following sections.

Developing a Therapeutic Alliance

The term therapeutic alliance was first discussed by Freud (1958; originally published is 1911). He
emphasized that a reality-based attachment between analyst and client was crucial and needed to coexist
with the simultaneously occurring positive or negative transference distortions. Later, Zetzel (1956) was the
first to actually use the term therapeutic alliance. Consistent with Freud, she believed that if clients had early
parent-child interactions characterized by trust and affection, their ability to develop a positive therapeutic
alliance was enhanced. Overall, it’s easier to defensively disregard input from someone even potentially
helpful feedback when you don’t like the source.
Role Induction
When clients aren’t given information about how psychoanalytic therapy proceeds, they often feel confused
or annoyed. This is especially the case if you use interpretation as a therapy technique. The term role
induction refers to a process wherein therapists educate clients about their role in the therapy process ( J.
Sommers-Flanagan & R.Sommers-Flanagan, 2009).
Timing
Once a therapeutic relationship is established and role induction information provided, interpretation
becomes a potential therapy tool.
However, even then, psychoanalysts should proceed carefully. Fenichel (1945) articulated this point: since
interpretation means helping something unconscious to become conscious by naming it at the moment it is
striving to break through, effective interpretations can be given only at one specific point, namely, where the
patient’s immediate interest is momentarily centered.
In this excerpt Fenichel is emphasizing that timing is essential. Here are several tips for timing
interpretations:
Watch for when the client is just a step away from becoming aware of something new.
Wait for the client to show positive regard for you.
Wait until you can say the interpretation clearly and articulately; if the interpretation is muddled in your
mind, it probably won’t be helpful.
Wait until you have enough data to support your interpretation; in other words, you should be able to
explain, based on your observations of the client and what he or she has said, why you’re pointing out
particular patterns and connections.
COUNTERTRANSFERENCE
Countertransference was originally defined as the therapist’s tendency to see the client in terms of his or her
own previous relationships. In that sense, it’s the same as transference, but it occurs when the transference is
directed from the therapist toward the client. Freud conceptualized countertransference as a negative factor
in therapy: ‘‘Recognize this counter-transference … and overcome it,’’ he counseled , because ‘‘no
psychoanalyst goes further than his own complexes and internal resistances permit’’(Freud, 1957) as stated
elsewhere, ‘Countertransference consists of emotional, attitudinal, and behavioral responses that are
inappropriate in terms of intensity, frequency, and duration’’ ( J. Sommers Flanagan & R. Sommers-
Flanagan, 2009). When working with clients, it’s helpful to pay attention to your own emotions, thoughts,
impulses, and behaviors. For example, during a session you may notice that you feel irritated or annoyed
with a client. If you’re the sort of person who occasionally feels annoyed with others, your feelings may not
require much scrutiny other than simply noting they’ve come up. However, when your annoyance is strong
(intensity), comes up often (frequency), and sticks with you for a considerable length of time (duration),
then you may be suffering from countertransference.
Psychoanalytic therapists approach their reactions to the patient (countertransference) from different
viewpoints. Moeller (1977) presents three different positions on countertransference.
First, the traditional interpretation of countertransference is the irrational or neurotic reactions of therapists
toward the patient.
Second, a broader usage of the term refers to the therapist’s entire feelings toward the patient, conscious or
unconscious (Gabbard, 2004). Eagle (2000) warns that therapists should not assume that all their thoughts
and feelings during the therapy hour reflect the patient’s inner world.
The third view sees countertransference as a counterpart of the patient’s transference. In other words, the
feelings of the patient affect those of the therapist and vice versa. In this third way of viewing
countertransference, the therapist might think, “Am I feeling the way my patient’s mother may have felt?”
Thus, therapists try to understand (or to empathize with) their patient, their own feelings, and the interaction
between the two. A great variety of positions have been taken on countertransference issues.
Content of the counter transference
Basic ( love, anger turning away)
Psychopathology of the patient ( psychotic, depressive, borderline) Elements in the analyst’s life ( sick,
recently pregnant, traumatized event)
Specific content as a function of a stage of therapy ( beginning, middle, termination)
Four Types of Counter-Transference
There are four manifestations of counter-transference. Three of these can potentially harm the therapeutic
relationship.
Subjective: The therapist’s own unresolved issues are the cause. This can be harmful if not detected.
Objective: The therapist’s reaction to their client’s maladaptive behaviors is the cause. This can benefit the
therapeutic process.
Positive: The therapist is over-supportive, trying too hard to befriend their client, and disclosing too much.
This can damage the therapeutic relationship.
Negative: The therapist acts out against uncomfortable feelings in a negative way, including being overly
critical and punishing or rejecting the client.
Counter-transference is especially common in novice therapists, so supervisors pay close attention and help
them become more self-aware. The mental health community supports seasoned clinicians by urging them to
seek peer review and supervisory guidance as needed. Rather than eliminate counter-transference altogether,
the goal is to use those feelings productively.
Unit 3
Phases of psychoanalysis
According to Arlow 1995 treatment is composed of four phases: the which opening phase and the
development, working through, and resolution of the transference.
THE OPENING PHASE
This phase has two parts. The first consists of a set of interviews during which the client's problem is
determined and a decision is made as to the appropriateness of analysis. The structure of the analytic
situation is explained, particularly the delineation of the responsibilities of the therapist and the client. If the
therapy proceeds after the first few sessions, then the second part of the opening phase begins. The client
continues to assume the position on the couch, and everything he or she says and does is observed and
recorded (Arlow, 1995, pp. 31--32). The therapist thereby compiles a comprehensive file of conscious and
unconscious material. The therapist uses these dreams, fantasies, projections, free associations, and early
memories, as well as emergent life themes, to facilitate client insight during subsequent phases of therapy.
THE DEVELOPMENT OF TRANSFERENCE
The development and analysis of transference constitute an important therapeutic phase. The client's feelings
for the therapist, who has become a significant figure in the client's life, are used to demonstrate how the
client perceives, interprets, and responds to the present in the same ways he or she responded to significant
persons in the past. By understanding how this past behavior influences and determines present behavior, the
client can learn to make more appropriate decisions. Concomitant to the analysis of transference, the
therapist must be aware of the possibility of countertransference: the therapist's unresolved feelings for
significant others may be transferred to the client. Any countertransference’s must be analysed and worked
through. This step in the analysis is necessary so that the therapist's unresolved feelings will not interfere
with the analysis of the client's transference (Arlow, 1995, p.32). The analytic process is enhanced by both
the therapist and the client gaining a conscious awareness into the emergent transference and
countertransference aspects of their ongoing relationship.
WORKING THROUGH TRANSFERENCE
This phase overlaps with the previous phase. The working through of one transference usually precipitates
the recall of a significant event that in turn leads to further insights. Working through the transference is an
evolving process, and with each working through there is further clarification and understanding . Many
clients manifest resistance during therapy.
Resistance is either the active or the passive opposition of the client to the therapist's attainment of the
therapeutic objectives. Even though at the conscious level the client wants help, he or she uses defense
mechanisms to avoid bringing to the surface unconscious, usually repressed, material such as painful
memories or guilt feelings. Working through client resistance is an important aspect of the therapist's role in
the psychoanalytic process.
THE RESOLUTION OF TRANSFERENCE
When the client and the therapist believe that the client's major conflicts have been worked through, a date is
set for termination of the therapy. The purpose of this phase is to resolve the client's neurotic attachment to
the therapist. Several aspects of this phase are common. One is that the client may be reluctant to give up the
relationship and may maintain dependency on the therapist. The resolution of this aspect of therapy
represents the finishing touches to the client's therapy. Sometimes further memories, related to the
interpretations made earlier in the treatment, emerge. It is important to work through any grandiose fantasies
or wishes the client may have regarding his or her condition after therapy is terminated
Finally, psychoanalytic therapy focuses exclusively on how the client's mind works (Giovacchini, 1977).
The therapist's views are not imposed on the client. The therapy is centered in interpretation within the
context of transference . A unique and powerful characteristic of psychoanalysis is the therapist's ability and
willingness to allow transference to develop with the objective of increasing the client's autonomy by
extending his or her control over inner, primitive forces.
Relationship between the client and the therapist
There can be two kinds of therapists that can be seen in a typical psychoanalytic therapy session

• The classic analyst The current relational analyst

• The classic analyst mostly stands outside the relationship, sometimes gives comments, and provides
interpretation to the client.
• The current relational analyst is not detached from clients, rather they are more focused on the here
and now interaction with the client and they find it more useful in creating rapport and gathering
background information from the client.
• Therapist and clients mostly hold a transference relationship. Clients and therapist go through a
working through process, where they both tackle unconscious material and defenses.
• Therapists must be well aware of countertransference where in the therapists own unconscious
conflict comes out and projects them into the client.
• Not call countertransference feelings are bad, but other cases may seem beneficial to both client and
therapist.
Critique of psychoanalysis
Although psychoanalytic theory laid the foundations for much of modern psychology, it is not without its
flaws. Psychoanalysis is still practiced today, and psychoanalytic theory has been updated to fall more in
line with current knowledge about human behavior and the brain, but there are many criticisms of the theory
and its applications.
One of the largest criticisms of the psychoanalytic theory is that it places far to much emphasis on
childhood. For one, Freud’s theory says that personality development occurs during childhood, but many
modern psychologists say that this development is lifelong. A similar criticism is that the minds of children
do not attain as much trauma that Freud linked many psychological illnesses to. Means the human beings
work fruitlessly to repair damages of sexual damages of sexual frustations in childhood.
Also, criticism has been raised against Freudian slips, saying they do not arise from unconscious motives,
but rather confusion in word retrieval from memory. Also, Freud’s ideas of repression are rebuked by most
modern psychologists who say repression is a rare phenomenon and that intense stress and pain actually
causes better remembrance of an event. One other criticism of his theory was directed on his idea of the
unconscious mind. Critics stated that the unconscious mind did not consist of hidden or repressed,
passionate emotions. Instead, it was underlying information such as cognition, memory, perception, as well
as emotion, but generally not the repressed kind.
Freud theory is not just unitary. And also, he did not accept another therapist in this field.
Classic psychoanalysist have superiority feeling and Inflexibility. criticism of psychodynamic theory as
defined by Freud, is that it is sexist. Freud believed women were inferior to men. He also believed men had
stronger superegos. Women’s weaker superegos made them more prone to anxiety. It’s important to
remember that Freud predominantly treated and studied middle-aged women in Vienna. Many of the
hypotheses or assumptions of psychoanalytic theory cannot be tested by empirical means, making it nearly
impossible to falsify or confirm; and the theory was not developed through the application of the scientific
method but from (likely highly subjective) personal reports from Freud on his experience with clients.
But contribution to psychology field is irreplaceable and great remarkable.
Unit 5
Sifneos' Short-Term Anxiety-Provoking therapy
Peter E. Sifneos (1972, 1979) is based at the Beth Israel Hospital in Boston, where he developed his
technique of Short-Term Anxiety-Provoking Psychotherapy (S-TAPP).
Selection. Sifneos uses a set of strict selection criteria:
(1) Ability to have a very limited main complaint, and to stick to it.
(2) Evidence of meaningful past relationships (mature object relations) so the patient will interact well with
the therapist, and be capable of emotional involvement.
(3) Flexibility in the interview. This is evidenced by the operation of an observing ego (ability to distance
one's self from the immediate material), and flexibility and range of affect.
(4) Above average intelligence and psychological sophistication. (5) Motivation for change-real change, and
not just symptom relief.
There are seven subcategories within this criterion:
(a) Ability to see that symptoms are psychological in nature.
(b)Capacity for introspection, and the capability to give an honest report of emotional problems (this rules
out projection and acting-out as primary defenses).
© Active participation in the treatment. The patient must be active with the therapist's comments, and be
able to argue back with the therapist in the first session.
(d) Curiosity to understand themselves.
(e) Realistic expectations of psychotherapy.
(1) Willingness to make sacrifices for the treatment.
If the patient meets six to seven of the above qualities, they are possessing good motivation; meeting five
criteria is rated as fair motivation, four criteria is classed as questionable motivation; and finally, less then
four rates a candidate as unmotivated.

Sifneos treats a wide variety of patients, including those with; anxiety attacks, depression, phobias, mild
obsessional symptoms, and physical symptoms. In fact, even more common than symptoms are patients
with problems in interpersonal relationships. These might involve problems with romantic relationships or
authority figures. The duration and severity of symptoms are not necessarily part of the inclusion criteria.
Sifneos finds that unresolved oedipal problems, and difficulty with separation and loss usually respond best
to this treatment (1984a).
Sifneos has described the use of S-TAPP with patients with physical symptoms whose origin is
psychological, and with phobic and mildly obsessive compulsive patients (1984a, 1985). He has found
(1985) that this technique can be used in a modified form with these patients provided that they have good
ego strength, and have predominantly positive feelings for both parents. With anxious patients with early
separation issues, ambivalence and characterological passivity, the problems are more serious and require
long-term psychotherapy. With phobic patients, the more focused the phobic symptom, the easier it is to
treat, while the more diffuse the symptom, the better the patient is suited for long-term treatment.
Technique. Before the actual treatment begins, the therapist and patient agree on a psychoanalytic
hypothesis of the patient's problems which becomes the focus of the treatment (Sifneos, 1985). In addition,
the outcome criteria are written at the end of the first evaluation session. There is no end date or number of
sessions proscribed at the onset of treatment.
Rather, the patient is given a "flexible but brief time interval" (Sifneos, 1984a, p. 49) as an estimate of the
length of treatment. Flegenheimer has reported (1982) that 90% of Sifneos' cases are seen for 12 to 1
session, while roughly 10% last 16-20 sessions, and none are seen beyond 20 sessions. Sifneos' method
consists of the following basic techniques (1985):

(1) The therapist is very active.

(2) Both parties remain with the focus.
(3) A working alliance is absolutely necessary, that is, a sense of working together.
(4) The mainly positive transference feelings are used very early on in the treatment.
(5) The patient is confronted very early in the process, in an anxiety provoking fashion.
(6) Interpretations are made which link past and present.
(7) There is frequent use of problem solving with the patient.
(8) There is "recapitulation at times of resistance" (Sifneos, 1985).
(9) Any early preoedipal issues are avoided and are seen as a way of avoiding the anxiety induced by the
therapist's interpretations The first part of the treatment is to make the patient aware of the central conflict,
and then Sifneos and the patient come to an agreement about what the central conflict is, Sifneos' technique
is more emotionally intense than is Malan's. Sifneos sees himself as a teacher (Burke, White and Havens,
1979), provoking patients, instructing them about themselves, and showing them new coping. mechanisms.
Quite often, the therapist will link the patient's feelings for the therapist with the patient's feelings for
important people in the past. When resistance arises, the therapist becomes even more active with
interpretations assuming it may be due to transference issues. Sifneos uses a different technique often with
interpretation, than other clinicians in the field. Rather than working first on understanding the defenses, he
interprets the underlying conflict directly, which increases the patient's anxiety and resistance, hence the
name of his technique (Sifneos, 1984b). Sifneos also feels that because free association is not used, and
because the treatment is short term, no transference neurosis sets in. He then stops the treatment before any
transference neurosis develops (Sifneos, 1984b). He states that many other short-term practitioners disagree
with this, and feel that a transference neurosis does arise in many short-term therapies.
Unlike most other short-term practitioners, Sifneos feels detailed notetaking is essential during treatment
sessions to capture accurately he wording of patients. This allows the therapist to be able to repeat and use
the patient's phrases in interpretations in subsequent sessions. Often, the therapist takes a direct educational
stance, showing the patient how, with the new insights gained in treatment, the patient can use more
adaptive ways of handling problems in his or her life. He feels that S-TAPP also uses principles from
learning theory and behavior modification, for example, reinforcement and reward to patients for their work.
He feels this helps patients internalize their new learning.
In addition, Sifneos has found that S-TAPP progresses fairly smoothly in patients with unresolved oedipal
problems, who have mainly positive feelings for both parents. Where negative feelings are more salient,
however, the treatment becomes more difficult, and usually longer. Termination occurs when there is
behavior change, or more adaptive handling of problems by the patients. This is viewed as sufficient
evidence of progress.
Outcome. Sifneos, in his 1979 book, reports on his various research studies. He examines efficacy by rating
subjects on a number of very specific outcome criteria. Overall, the majority of patients show symptom
relief, increased self-esteem, and improved insight and coping abilities. In a 4year long-term follow-up of 21
patients, percentages of patients improving was found to be as follows: 82% had improved self-esteem; 58%
had moderate symptom relief, 91% had. increased self-understanding; and 86% had new attitudes and
behavior patterns (p. 169).
Sifneos (1984a) reports on two other outcome studies. In the first, 23 patients were followed-up at 1-3 years
post-treatment. Seventeen patients were rated as being much better, and six patients were judged to be a
little better. These six had issues of loss in addition to unresolved oedipal described conflicts, which is a
factor Sifneos has lengthening the course of treatment. In the second research study, a group of 14 patients
who had physical symptoms in addition to psychological problems were studied, with complaints such as
pain, migraine, impotence, insomnia, diarrhea, anorexia, overeating and skin problems These patients were
part of a larger study of 48 patients investigating the effectiveness of S-TAPP Thirteen of these subjects were
in the experimental group, and received short term anxiety-provoking therapy, while the one control subject
was on a wait-list to receive nawan S-TAPP. Of these 14 subjects with physical symptoms, only one was
subsequently rated as unchanged both physically and psychologically. It is not clear which patient this was,
although we can assume that this one patient must have been the control subject. In 5 of the remaining 13
patients, the physical symptoms had dissipated, and in 7 others the physical problems were much better. In
fact, only in one subject, were the somatic symptoms rated as only slightly better. The author concludes
then, that S-TAPP is effective not only for psychological complaints, but for somatic symptoms as well.
Strupp's Time-Limited Dynamic Psychotherapy
Hans Strupp developed his technique of Time-Limited Dynamic
Psychotherapy (T-LDP) at Vanderbilt. His technique is also highly based on the results of his many studies
on what makes dynamic psychotherapy successful with patients. Binder and Strupp (1991) explain that the
approach attempts a "greater integration of classical and interpersonal psychoanalytic theory and technique"
(p. 138), with the more recent studies of countertransference reactions. It is a combination of psychoanalytic
theory with a theory of personality based on object relations and interpersonal theories of development. The
method examines internalized object relations as they are played out in the relationship with the therapist.

Selection. Patients who can benefit from this treatment include those whose internalized object relations are
marked by: "1. coherent and identifiable interpersonal themes, (2) appreciation of the distinction between
oneself and others, and (3)a capacity for concern and integrity in human relationships" (Binder & Strupp,
1991, p. 139). Patients who would be ruled out include those who are psychotic, whose object relationships
are very disorganized, and those who have no desire to study their interpersonal relationships. This method
does not rule out any other particular diagnostic categories.
Technique. The technique aims to:
(1) Create a safe environment in which the patient can replay dysfunctional relationships.
(2) Allow these patterns to emerge.
(3) Aid patients in observing what they are repeating in the present.
(4) Help the patient examine what is behind these dysfunctional patterns.
The main way to begin to accomplish the above goals is to begin to look closely at the therapist-patient
relationship. A specific number of sessions is not set, but a termination date might be set at the outset of
treatment.
The overarching goal of T-LDP is to improve interpersonal functioning. In studying patient's interpersonal
functioning, the concept of the "Cyclical Mala-daptive Pattern (CMP)" (Binder & Strupp. 1991, p. 140) is
used. It has to do with patients’ repetitive patterns of interpersonal relationships, and their intro-ject. In this,
it is somewhat similar to Luborsky's concept of the core Conflictual Relationship Theme. These ideas are
based on the work of Harry Stack Sullivan and other interpersonal theorists. The CMP has four components
(Binder and Strupp, 1991): (1) "acts of self (p. 140) towards others, (2) "expectations about others'
reactions" (p. 140): (3) "acts of others toward self" (p. 140), or how do other people respond to the patient,
and (4) "acts of self toward self" (p. 140), or the introject.
When the treatment begins, a central "maladaptive interpersonal pattern" (p. 140) is identified. Then, in each
session, the therapist identifies a theme which is related to this focus. This theme is seen in the interplay of
the therapist-patient relationship. The therapist may clarify and interpret conflicts which are seen in the
patient's relationships outside therapy. Eventually, final interpretations involve relating similar patterns in
relationships both inside and outside the treatment room. The therapist explores all aspects of a person's
interpersonal relationships as they are related to the therapist, and looks for ways to relate these back to the
therapeutic relationship. Unlike several of the other short-term therapists, the patient's receptiveness to
potential interpretations is taken into account before offering an interpretation. The therapist's in T-LDP is
somewhat distanced and analytical and the main approach manner is one of exploration rather than
education. This is very different from the educative styles of Davan-loo, Sifneos and Malan The CMP
method first explores the here and now relationship in a careful fashion, and links are not made to past
relationships until the patient can first see the current CMP which is in operation, and understand it.
Secondly, the therapist looks for similar patterns in other relationships the patient currently is engaged in.
Thirdly, the therapist and patient search for the origin of the interpersonal patterns. The feeling of the
therapy at this point is more exploratory than aggressive or forceful. Finally, a full interpretation is made
only after the patient makes a past-present relationship connection themselves (without help from the
therapist).
Outcome. Two major studies on psychotherapy outcome are cited by Binder and Strupp (1991) and Strupp
and Binder (1984), which concentrate on the factors that relate to good outcome in psychotherapy. The
Vanderbilt I study examined a group of college students treated with T-LDP and found that outcome was
related to the quality of the therapeutic relationship, that is, if the patient felt "accepted, understood, and
liked by the therapist" (Binder and Strupp, 1991, p. 157), the outcome was more likely to be successful. The
second study, or the Vanderbilt II study found that therapists trained to use the T-LDP techniquewith a
training manual may often not be as effective as more experienced therapists because they are simply
rehearsing lines. The reader is referred to Strupp and Binder's 1984book for a more detailed description of
these studies.
Davanloo's Intensive Short-Term Dynamic Psychotherapy
Davanloo initiated his work on Brier Therapy in 1962 from the Montreal
General hospital on brief therapy in 1962. He termed his technique Short Term Dynamic Psychotherapy or
S-TDP (1980, 1978). More recently,
Davanloo (1987) refers to his method as Intensive Short-Term Psychotherapy (IS-TDP). For a more in-depth
review description of the therapeutic process, the reader is referred to Davanloo (1978, 1980,1990).
Selection. Davanloo conducts a very detailed evaluation interview, in which trial interpretations are made in
order to see how the patient responds and to judge from this if the patient is appropriate for this type of
treatment. The evaluation occupies a central place in Davanloo's treatment, and may take up to 3 hours total
in separate interviews. The patient must have the following characteristics:
(1) Psychological Mindedness. The patient must have the capacity for
introspection and be able to report their thoughts and feelings.
(2) Intelligence. It is important for the patient to be of above average intelligence.
(3) Response to Interpretation. This is one of the most important aspects, because with this, Davanloo is able
to see how the patient actually responds to his technique.
(4) Quality of Relations. This is seen in the type of relation the patient forms with the evaluator.
(5) Handling of Affect. Davanloo provokes a considerable amount of affectin therapy, so the patient needs
the ability to tolerate strong affect and not develop symptoms as a result.
(6) Defensive Organization. The defenses must be flexible, and must not be solely primitive in nature (e.g.,
projection, acting-out, or denial). Despite these desirable qualities for the traditional Davanloo technique, in
recent years Davanloo has sufficiently modified his technique to make it accessible not only to more highly
resistant depressed and characterological patients, but also to patients with more functional disorders such as
the various psychosomatic disorders (Davanloo, 1987).
He currently (1988) views as contraindications to IS TDP, the following: sociopathy, borderline personality
disorder, alcoholism or drug abuse, psychosis, bipolar illness, or very fragile ego structure. Technique
Davanloo's technique is close to classical analysis with its focus on interpretation of "drive-defense
constellations" (Rasmussen and Messer, 1986).
The patient is given a full psychodynamic formulation of the problem, linking the transference, present
relationships, and past figures, Freud presented the technique of free association for discovering the patient's
resistances and moving beyond them to the unconscious thoughts and feelings. Davanloo, in order to hasten
the process of traditional psychoanalysis has developed a very active technique, which applies pressure on
the ego, to lead to a revealing of the unconscious. There is no present time limit, but an estimate is given.
Davanloo has found that the therapy may take 5-10 sessions if the focus is oedipal and the patient is very
motivated. The treatment might extend to 5-15 sessions if the patient is motivated, but issue is loss. Patients
with more severe problems, including the more serious obsessive/compulsive and phobic symptoms, are
seen from 15 to 40 sessions. Approximately 33% of those seeking treatment with Davanloo are seen this
long. The focal issue is shared with and agreed upon with the patient. The therapist in STDP is neutral, and
does not give advice. Davanloo works with the patient at a very high level of emotional intensity. He
introduces the patient into IS-TDP with confrontations which are intended to elicit the underlying thoughts
and feelings.
(1) Opening Phase. In the opening phase (the first five sessions), the concentration is on feelings about the
therapist, or transference feelings. The technique involves, at this point, constant questioning of the patient
to find out what the patient feels in the moment. Subtle signs of resistance are brought to the patient's
attention immediately, such as eye movement, changes in posture, etc. As the patient's defenses are
mobilized in response to this confrontation, the defenses themselves are challenged, until the patient is able
to express anger directly and without reservations. This process is repeated over and over again, until the
resistance decreases and the material emerges in the midphase of treatment.
(2) Midphase. The midphase of treatment involves less focus on transference and more emphasis on the
patient's material. There is frequent repetition of interpretations until the patient acknowledges them.
(3) End. The end of treatment occurs when there is a cessation of the initial symptoms. Termination is brief,
and the patient's mastery over the initial problems is reviewed. If the focal conflict involved is loss,
termination might be longer (5-6 sessions), instead of one session for oedipal issues.
Although the above categories still broadly outline his method, in recent publications, Davanloo has
modified and refined both his initial evaluation sessions (trial therapy), and the entire process, which he now
terms "unlocking the unconscious" (1989). With more seriously disturbed patients, more preparatory work
must be done to "restructure the egosyntonic defenses to ego-dysto-nic" (Davanloo, 1988, p. 101) ones
before unlocking the unconscious. Davanloo describes his technique of unlocking the unconscious as
consisting of the following phases (Davanloo)."
Phase 1
a. Inquiry...

b. Rapid identification and clarification of patient's defenses.

Phase 2 Pressure, leading to resistance.

Phase 3 Clarification of defenses.
a. Clarification, challenge to defenses, leading to rising transference increased resistance.
b. Challenge directed against the defenses...
c. Challenge directed toward the therapeutic alliance.
d. To make the patient acquainted with his defenses and
e. To turn the patient against his own defenses.
Phase 4 Transference Resistance.
a. Clarification and challenge to transference resistance.
b. Head-on collision with the transference resistance....
c. Exhaustion of resistance...
Phase 5 Intrapsychic Crisis.
a. breakthrough of the complex transference feeling the triggering
mechanism for unlocking the unconscious.
b. Interpretive phase.
c. The first direct view of the multifoci core neurotic structure.
Phase 6 analysis of the transference.
Phase 7 Inquiry, completing. history.
Phase 8 Direct view of the multifoci core neurotic structure and its relation to patient's symptom and
character disturbances apeutic plan." and psychother
This is the basic technique for triggering a "major unlocking of the unconscious" (Davanloo, 1987, p. 100),
much of which can be done in one interview. Thistrial therapy, with neurotics, leads to a view of the "core
neurotic structure" (Davanloo, 1987, p. 100). With very resistant, depressed and psychosomatic patients,
however, an excess of early challenging raises their anxiety level, which leads to an increase in symptoms.
Therefore, with this group, the defense mechanisms are first restructured, then more challenge can be
applied toward discovering the unconscious. The main technique for working with very resistant clients is as
follows (Davanloo, 1987, p.100):
(1) A push for the unconscious (UCS) feelings, which increases resistance.
(2) A challenge of the resistance, which increases the transference.
(3) A challenge of the transference-resistance.
(4) Confronting the transference-resistance directly.
(5) Transference feelings come to the fore-the "triggering mechanism".
(6) "Mobilization of the UCS therapeutic alliance, and the first unlocking of the UCS."
(7) "Systematic analysis of the transference..."
(8) Past (C) and distant past (P) conflicts emerge, allowing a view of the UCS and neurotic conflicts.

This technique is used with most resistant patients, including character dis orders. However, with patients
who have functional disorders, such as migraine and irritable bowel syndrome or chronic depression, this
technique has to be modified, since the patient frequently is unable to distinguish between the feelings, of
rage, for example, and anxiety. The feelings thus go directly into the symptom. The technique of
restructuring is used first in these cases. Initially, with this sort of patient, the therapist is very careful not to
arouse an undue amount of anxiety, and the relationship between the transference, current and past feelings
is repeatedly analyzed. This phase is referred to as consolidation. Only after this restructuring phase can the
therapist proceed to the unlocking of the UCS. After the restructuring phase with these patients, the
interview can proceed with further challenge, reduction of pressure, and eventually a release of the impulse
and insight. What is unique to this technique as applied to this population is the use of a reduction of
pressure, asopposed to the constant use of pressure and challenge for the usual technique. This modification
allows therapists using IS-TDP to greatly increase the range of diagnostic categories with which they can
successfully work. In addition, this method of challenging the resistance, since it is more powerful than
interpretation alone, allows the work to be more broadly focused, rather than having to focus only on one
particular issue.

Davanloo's technique, in general, requires fairly consistent neutrality on the part of the therapist, more so
than the other short-term techniques described in this paper. Therapists need to be constantly alert to changes
occurring with the patient. Because the therapy moves so rapidly, the therapist must make psychodynamic
formulations quickly and with ease. Davanloo's interpretations have been generally described as 'penetrating
and relentless' (Rasmussen and Messer, 1986).
Outcome. From a group of patients treated between 1963 and 1974, 115 were judged to have had a
successful treatment. Gains on the 40% of patients followed up on at 2 to 7 years were found to be
maintained (Flegenheimer, 1982). In another large research study, Davanloo (1980) found that 115 out of
130 patients were successfully treated with S-TDP in an average of about 20 sessions.
MODULE 3 : HUMANISTIC THERAPIES.
UNIT 1: CLIENT-CENTERED THERAPY: VIEWS
ABOUT HUMAN NATURE, GOALS OF PSYCHOTHERAPY, THERAPEUTIC RELATIONSHIP
The person-centered approach is based on concepts from humanistic psychology, many of which were
articulated by Carl Rogers in the early 1940s. Of all the pioneers who have founded a therapeutic approach,
for me Rogers stands out as one of the most influential figures in revolutionizing the direction of counselling
theory and practice. My opinion is supported by a 2006 survey conducted by Psychotherapy Networker
(“The Top 10,” 2007), which identified Carl Rogers as the single most influential psychotherapist of the past
quarter century. Rogers has become known as a “quiet revolutionary” who both contributed to theory
development and whose influence continues to shape counseling practice today (see Rogers & Russell,
2002).
Rogers’s basic assumptions are that people are essentially trustworthy, that they have a vast potential for
understanding themselves and resolving their own problems without direct intervention on the therapist’s
part, and that they are capable of self-directed growth if they are involved in a specific kind of therapeutic
relationship. From the beginning, Rogers emphasized the attitudes and personal characteristics of the
therapist and the quality of the client–therapist relationship as the prime determinants of the outcome of the
therapeutic process. He consistently relegated to a secondary position matter such as the therapist’s
knowledge of theory and techniques.
This belief in the client’s capacity for self-healing is in contrast with many theories that view the therapist’s
techniques as the most powerful agents that lead to change (Tallman &amp; Bohart, 1999). Clearly, Rogers
revolutionized the fi eld of psychotherapy by proposing a theory that centered on the client as the agent for
self-change (Bozarth, Zimring, &amp; Tausch, 2002). Contemporary person-centered therapy is the result of
an evolutionary process that continues to remain open to change and refinement (see Cain &amp; Seeman,
2002).Rogers did not present the person-centered theory as a fixed and completed approach to therapy. He
hoped that others would view his theory as a set of tentative principles relating to how the therapy process
develops, not as dogma. Rogers expected hi model to evolve and was open and receptive to change.
View of human nature
A common theme originating in Rogers’s early writing and continuing to permeate all of his works is a basic
sense of trust in the client’s ability to move forward in a constructive manner if conditions fostering growth
are present. His professional experience taught him that if one is able to get to the core of an individual, one
finds a trustworthy, positive center (Rogers, 1987a).
Rogers firmly maintained that people are trustworthy, resourceful, capable of self understanding and self-
direction, able to make constructive changes, and able to live effective and productive lives. When therapists
are able to experience and communicate their realness, support, caring, and nonjudgmental understanding,
significant changes in the client are most likely to occur. Rogers expresses little sympathy for approaches
based on the assumption that the individual cannot be trusted and instead needs to be directed, motivated,
instructed, punished, rewarded, controlled, and managed by others who are in a superior and “expert”
position.
He maintained that three therapist attributes create a growth-promoting climate in which individuals can
move forward and become what they are capable of becoming:
(1) congruence (genuineness, or realness),
(2) unconditional positive regard (acceptance and caring),
(3) accurate empathic understanding (an ability to deeply grasp the subjective world of another person).
According to Rogers, if therapists communicate these attitudes, those being helped will become less
defensive and more open to themselves and their world, and they will behave in prosocial and constructive
ways. Rogers held the deep conviction that “human beings are essentially forward-moving organisms drawn
to the fulfillment of their own creative natures and to the pursuit of truth and social responsiveness”
(Thorne,1992, p. 21). The basic drive to fulfillment implies that people will move toward health if the way
seems open for them to do so.
Broadley (1999) writes about the actualizing tendency, a directional process of striving toward realization,
fulfi llment, autonomy, self-determination, and perfection. This growth force within us provides an internal
source of healing, but it does not imply a movement away from relationships, interdependence, connection,
or socialization. This positive view of human nature has significant implications for the practice of therapy.
Because of the belief that the individual has an inherent capacity to move away from maladjustment and
toward psychological health, the therapist places the primary responsibility on the client.
The person-centered approach rejects the role of the therapist as the authority who knows best and of the
passive client who merely follows the dictates of the therapist. Therapy is rooted in the client’s capacity for
awareness and self-directed change in attitudes and behavior. The person-centered therapist focuses on the
constructive side of human nature, on what is right with the person, and on the assets the individual brings to
therapy. The emphasis is on how clients act in their world with others, how they can move forward in
constructive directions, and how they can successfully encounter obstacles (both from within themselves
and outside of themselves) that are blocking their growth. Practitioners with a humanistic orientation
encourage their clients to make changes that will lead to living fully and authentically, with the realization
that this kind of existence demands a continuing struggle. People never arrive at a final state of being self-
actualized; rather, they are continually involved in the process of actualizing themselves.
Therapeutic Goals
The goals of person-centered therapy are different from those of traditional approaches. The person-centered
approach aims toward the client achieving a greater degree of independence and integration. Its focus is on
the person, not on the person’s presenting problem. Rogers (1977) did not believe the aim of therapy was to
solve problems. Rather, it was to assist clients in their growth process so clients could better cope with their
current and future problems. Rogers (1961) wrote that people who enter psychotherapy often ask: “How can
I discover my real self? How can I become what I deeply wish to become? How can I get behind my facades
and become myself?” The underlying aim of therapy is to provide a climate conducive to helping the
individual become a fully functioning person. Before clients are able to work toward that goal, they must
first get behind the masks they wear, which they develop through the process of socialization. Clients come
to recognize that they have lost contact with themselves by using facades. In a climate of safety in the
therapeutic session, they also come to realize that there are other possibilities. When the facades are put
aside during the therapeutic process, what kind of person emerges from behind the pretenses?
Rogers (1961) described people who are becoming increasingly actualized as having
1) An openness to experience,
2) A trust in themselves,
3) An internal source of evaluation, and
4) A willingness to continue growing.
Encouraging these characteristics is the basic goal of person-centered therapy. These four characteristics
provide a general framework for understanding the direction of therapeutic movement. The therapist does
not choose specific goals for the client. The cornerstone of person-centered theory is the view that clients in
a relationship with a facilitating therapist have the capacity to define and clarify their own goals. Person-
centered therapists are in agreement on the matter of not setting goals for what clients need to change, yet
they differ on the matter of how to best help clients achieve their own goals (Bohart, 2003).
Relationship Between Therapist and Client
Rogers (1957) based his hypothesis of the “necessary and sufficient conditions for therapeutic personality
change” on the quality of the relationship: “If I can provide a certain type of relationship, the other person
will discover within himself or herself the capacity to use that relationship for growth and change, and
personal development will occur” (Rogers, 1961, p. 33). Rogers (1967) hypothesized further that
“significant positive personality change does not occur except in a relationship” (p. 73). Rogers’s hypothesis
was formulated on the basis of many years of his professional experience, and it remains basically
unchanged to this day.
This hypothesis (cited in Cain 2002a, p. 20) is stated thusly:
1. Two persons are in psychological contact.
2. The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious.
3. The second person, whom we term the therapist, is congruent (real or gen- uine) in the relationship.
4. The therapist experiences unconditional positive regard for the client.
5. The therapist experiences an empathic understanding of the client’s internal frame of reference and
endeavours to communicate this experience to the client.
6. The communication to the client of the therapist’s empathic understanding and unconditional
positive regard is to a minimal degree achieved.
Rogers hypothesized that no other conditions were necessary. If the therapeutic core conditions exist over
some period of time, constructive personality change will occur. The core conditions do not vary according
to client type. Further, they are both necessary and sufficient for therapeutic change to occur. From Rogers’s
perspective the client–therapist relationship is characterized by equality. Therapists do not keep their
knowledge a secret or attempt to mystify the therapeutic process. The process of change in the client
depends to a large degree on the quality of this equal relationship. As clients experience the therapist
listening in an accepting way to them, they gradually learn how to listen acceptingly to themselves. As they
find the therapist caring for and valuing them (even the aspects that have been hidden and regarded as
negative), clients begin to see worth and value in themselves. As they experience the realness of the
therapist, clients drop many of their pretenses and are real with both themselves and the therapist.
This approach is perhaps best characterized as a way of being and as a shared journey in which therapist and
client reveal their humanness and participate in a growth experience. The therapist can be a guide on this
journey because he or she is usually more experienced and more psychologically mature than the client. This
means that therapists are invested in broadening their own life experiences and are willing to do what it
takes to deepen their self-knowledge. Thorne (2002b) delivered this message: “Therapists cannot
confidently invite their clients to travel further than they have journeyed themselves, but for person-centred
therapists the quality, depth and continuity of their own experiencing becomes the very cornerstone of the
competence they bring to their professional activity” (p. 144).
Rogers admitted that his theory was striking and radical. His formulation has generated considerable
controversy, for he maintained that many conditions other therapists commonly regard as necessary for
effective psychotherapy were nonessential. The core therapist conditions of congruence, unconditional
positive regard, and accurate empathic understanding have been subsequently embraced by many
therapeutic schools as essential in facilitating therapeutic change. These core qualities of therapists, along
with the therapist’s presence, work holistically to create a safe environment for learning to occur (Cain,
2008). We now turn to a detailed discussion of how these core conditions are an integral part of the
therapeutic relationship.
Congruence, Or Genuineness
Congruence implies that therapists are real; that is, they are genuine, integrated, and authentic during the
therapy hour. They are without a false front, their inner experience and outer expression of that experience
match, and they can openly express feelings, thoughts, reactions, and attitudes that are present in the
relationship with the client. The quality of real presence is at the heart of effective therapy, which Mearns
and Cooper (2005) capture thusly: “When two people come together in a wholly genuine, open and engaged
way, we can say that they are both fully present” (p. 37). Through authenticity the therapist serves as a
model of a human being struggling toward greater realness. Being congruent might necessitate the
expression of anger, frustration, liking, attraction, concern, boredom, annoyance, and a range of other
feelings in the relationship.
This does not mean that therapists should impulsively share all their reactions, for self-disclosure must also
be appropriate and well timed. A pitfall is that counselors can try too hard to be genuine. Sharing because
one thinks it will be good for the client, without being genuinely moved to express something regarded as
personal, can be incongruent. Person-centered therapy stresses that counseling will be inhibited if the
counselor feels one way about the client but acts in a different way. Hence, if the practitioner either dislikes
or disapproves of the client but feigns acceptance, therapy will not work. Rogers’s concept of congruence
does not imply that only a fully self- actualized therapist can be effective in counseling.
Because therapists are human, they cannot be expected to be fully authentic. If therapists are congruent in
their relationships with clients, however, trust will be generated and the process of therapy will get under
way. Congruence exists on a continuum rather than on an all-or-nothing basis, as is true of all three
characteristics.
Unconditional Positive Regard and Acceptance
The second attitude therapists need to communicate is deep and genuine caring for the client as a person, or
a condition of unconditional positive regard. The caring is non possessive and it is not contaminated by
evaluation or judgment of the client’s feelings, thoughts, and behavior as good or bad. If the therapists’
caring stems from their own need to be liked and appreciated, constructive change in the client is inhibited.
Therapists value and warmly accept clients without placing stipulations on their acceptance. It is not an
attitude of “I’ll accept you when . . .”; rather, it is one of “I’ll accept you as you are.” Therapists
communicate through their behavior that they value their clients as they are and that clients are free to have
feelings and experiences without risking the loss of their therapists’ acceptance.
Acceptance is the recognition of clients’ rights to have their own beliefs and feelings; it is not the approval
of all behavior. All overt behavior need not be approved of or accepted. According to Rogers’s (1977)
research, the greater the degree of caring, prizing, accepting, and valuing of the client in a nonpossessive
way, the greater the chance that therapy will be successful. He also makes it clear that it is not possible for
therapists to genuinely feel acceptance and unconditional caring at all times. However, if therapists have
little respect for their clients, or an active dislike or disgust, it is not likely that the therapeutic work will be
fruitful.
Accurate Empathic Understanding
One of the main tasks of the therapist is to understand clients’ experience and feelings sensitively and
accurately as they are revealed in the moment-to-moment interaction during the therapy session. The
therapist strives to sense clients’ subjective experience, particularly in the here and now. The aim is to
encourage clients to get closer to themselves, to feel more deeply and intensely, and to recognize and resolve
the incongruity that exists within them. Empathy is a deep and subjective understanding of the client with
the client. Empathy is not sympathy, or feeling sorry for a client. Therapists are able to share the client’s
subjective world by tuning in to their own feelings that are like the client’s feelings. Yet therapists must not
lose their own separateness. Rogers asserts that when therapists can grasp the client’s private world as the
client sees and feels it—without losing the separateness of their own identity—constructive change is likely
to occur.
Empathy helps clients
(1) Pay attention and value their experiencing;
(2) See earlier experiences in new ways;
(3) Modify their perceptions of themselves, others, and the world; and
(4) Increase their confidence in making choices and in pursuing a course of action.
Accurate empathic understanding implies that the therapist will sense clients’ feelings as if they were his or
her own without becoming lost in those feelings. It is important to understand that accurate empathy goes
beyond recognition of obvious feelings to a sense of the less clearly experienced feelings of clients. Part of
empathic understanding is the therapist’s ability to reflect the experiencing of clients. This empathy results
in clients’ self-understanding and clarification of their beliefs and worldviews. Accurate empathy is the
cornerstone of the person-centered approach (Bohart & Greenberg, 1997). It is a way for therapists to hear
the meanings expressed by their clients that often lie at the edge of their awareness. Empathy that has depth
involves more than an intellectual comprehension of what clients are saying. According to Watson (2002),
full empathy entails understanding the meaning and feeling of a client’s experiencing. Empathy is an active
ingredient of change that facilitates clients’ cognitive processes and emotional self-regulation. Watson states
that 60 years of research has consistently demonstrated that empathy is the most powerful determinant of
client progress in therapy. She puts the challenge to counselors this way: “Therapists need to be able to be
responsively attuned to their clients and to understand them emotionally as well as cognitively. When
empathy is operating on all three levels—interpersonal, cognitive, and affective—it is one of the most
powerful tools therapists have at their disposal” (pp. 463–464).
 Unit 2 Techniques of Client-Centered Therapy
For person-centered therapists, the quality of the counselling relationship is much more important than
techniques. Rogers (1957) believed there are three necessary and sufficient techniques.
(1) Empathy
(2) Unconditional Positive Regard
(3) Congruence
(4) Concreteness
(5) Active Listening
(6) Reflection of Feeling Non-Directedness
Empathy may be subjective, interpersonal, or objective. “Subjective empathy enables a counsellor to
momentarily experience what it is like to be a client, interpersonal empathy relates to understanding clients
phenomenological experiencing, and objective empathy uses reputable knowledge sources outside of a
client’s frame of reference”. In therapeutic situations, empathy is primarily the counsellor’s ability to feel
with the clients and convey this understanding back to them. This may be done in multiple ways but,
essentially, empathy is an attempt to think with, rather than for or about, the client and to grasp the client’s
communications, intentions, and meanings. Rogers (1975) noted, ‘the research keeps piling up and it points
strongly to the conclusion that a high degree of empathy in a relationship is possibly the most potent and
certainly one of the most potent factors in bringing about change and learning.
Empathy is a multidimensional concept. In 1964, Rogers identified three ways of empathic knowing. Clark
(2010a) described these:
Subjective empathy : enables a counselor to momentarily identify with a client through intuitive reactions
and fleetingly imagine and experience what it is like to be a client.
Interpersonal empathy : the counselor attempts to grasp [and feedback] the phenomenological
experiencing of a client from an immediate or extended perspective.
Objective empathy : features a counselor’s use of theoretically informed observational data and reputable
sources in the service of understanding a client.

Unconditional positive regard, also known as acceptance, is a deep and genuine caring for the client as a
person-that is, prizing the person just for being (Rogers, 1961, 1980). For a healthy self to emerge, a person
needs positive regardlove, warmth, care, respect, and acceptance. But in childhood, as well as later in life, a
person often receives conditional regard from parents and others. Feelings of worth develop if the person
behaves in certain ways because conditional acceptance teaches the person to feel valued only when
conforming to others wishes. Thus, a person may have to deny or distort a perception when someone on
whom the person depends for approval sees a situation differently. An individual who is caught in such a
dilemma becomes aware of incongruities between self-perception and. experience. If a person does not do as
others wish, he or she will not be accepted and valued. Yet if a person conforms, he or she opens up a gap
between the ideal self (what the person is striving to become) and the real self (what the person is). The
further the ideal self is from the real self, the more alienated and maladjusted a person becomes.
Congruence is the condition of being transparent in the therapeutic relationship by giving up roles and
facades (Rogers, 1980). It is the counsellor’s readiness for setting aside concerns and personal
preoccupations and for being available and open in relationship with the client. Congruence as the degree of
accuracy between experience, communication, and awareness. A high degree of congruence means that
communication (what one is expressing), experience (what is occurring), and awareness (what one is
noticing) are all nearly equal. One’s observations and those of an external observer would he consistent in a
situation that has high congruence. Small children exhibit high congruence. They express their feelings so
readily and completely that experience, communication, and awareness are much the same for them. A child
who is hungry is all hungry, right now! When children are loving or angry, they express these emotions fully
and completely. This may account for the rapidity with which children flow from one emotional state to
another Full expression of their feelings prevents the accumulation of the kind of emotional baggage that
adults often carry with them into new encounters. Congruence is accurately described by the Zen Buddhist
saying: When I am hungry, I eat when I am tired, I sit; when I am sleepy, I lie down.
Incongruence occurs when differences emerge between awareness, experience, and comable to listen
acceptably to communication. For example, people exhibit incongruence when they appear angry (fists
clenched, voices raised, cursing) but insist otherwise, even when pressed. Incongruence is also evident in
people who say they are having a wonderful time yet act bored, lonely, or ill at ease. Incongruence, more
generally, is the inability to perceive accurately, the inability or unwillingness to communicate accurately or
both. Since 1980, person-centered counselors have tried a number of other procedures for working with
clients, such as limited self-disclosure of feelings, thoughts, and values (Corey, 2009).
Motivational interviewing (MI) has also grown out of the person-centered approach and has been used to
help ambivalent clients more clearly assess their thoughts and feelings as they contemplate making changes.
“Typically MI is differentiated from Rogers style in that MI is directive, attending to and reinforcing
selective change talk regarding the presenting behavioral problem” (Mason, 2009, p. 357). At the heart of
person-centered counselling regardless of procedures, is that clients grow by experiencing themselves and
others in relationships (Cormier, Narius, Osborn, 2009). Therefore, Rogers (1967) and person centered
counselors of today believe that &quot;significant positive personality change cannot occur except in
relationships (p. 73). Methods that help promote the counselor-client relationship include, but are not
limited- to, active and passive listening, accurate reflection of thoughts and feelings, clarification.
Summarization, confrontation, and general or open-ended leads. Questions are avoided whenever possible
(Tursi Cochran, 2006).
Concreteness is the ability not only to see the incomplete picture that clients paint with their words but also
to communicate to clients the figures, images, and structures that will complete the picture. In the process of
exploring problems or issues, clients often present a somewhat distorted view of the actual situation.
Concreteness enables the counselor or therapist to help clients identify the distortions in the situation and fit
them together in such a way that clients are able to view the situation in a more realistic fashion. The
concreteness helps clients clarify vague issues, focus on specific topics, reduce degrees of ambiguity, and
channel their energies into more productive avenues of problem solution. Concreteness serves three
important functions:
(1) It keeps the therapist’s response close to the clients feelings and experiences.
(2) It fosters accurateness of understanding in the therapist, allowing for early client corrections of
misunderstanding.
(3) It encourages the client to attend to specific problem areas.
The counsellor assists the client in expressing her/his feelings and experiences in concrete and specific
terms. Minimal verbal response: The counsellor uses umm hmm, oh, yes to communicate to the client s/he is
listening without interrupting the client train of thought. By responding in specific and concrete terms to
long, general, vague ramblings of the client, the therapist helps the client to sift out the personally significant
aspects from the irrelevant aspects. Although it might appear that questions of the who, what, when, where,
and how type would be useful.
Active listening is a bit of a misnomer. Yes, you are listening to the client. In fact, truly listening to the
client without exhibiting judgment is a fundamental part of person-centered therapy. But, active listening is
not just listening. It is listening in such a way as to let the client know that you understand what is being
said.The skill of attending starts from the very first moment you make contact with the client, in person or
by telephone, and continues throughout their therapy.
Body language - One way to show a client you are paying attention is through body language. You want to
maintain eye contact, lean slightly forward, and keep an open style of communication (e.g., arms and legs
uncrossed).
Attend to the client’s physical needs-Make sure that the room is fully accessible for the client, and that it
meets their needs (e.g. in temperature, privacy and comfort).
Sit comfortably-The way you sit can give important clues into how much you are attending. Being relaxed
and comfortable allows you to focus on your client and not on yourself. Sometimes, leaning forward
towards the client indicates how intently you are listening to them. Be aware of your body language-Sitting
with your arms crossed can be seen as a barrier, as can waving your arms around. Try to sit with a calm and
open posture.
Listen more than you speak-Greek philosopher Epictetus said: ‘We have two ears and one mouth so that we
can listen twice as much as we speak.’ This is a good listening-to-responding ratio.
Respond accurately and empathically-Good listening skills should be matched by accurate responding to
both the thoughts and feelings that the client expresses in the therapy room. Be as accurate as you can with
empathic responses.
Make eye contact-The best way of showing someone you are listening to them is by making eye contact.
This shows that you are paying attention and are giving your full attention to them. Try to be as natural as
possible when doing this and avoid looking as if you are staring at them. Do be aware that in some cultures,
it is seen as disrespectful to look someone in the eye.
Be thoughtful of the client’s wishes-Each client will have their own individual needs and wishes; it is good
to accommodate these if possible. For example, a therapist might cover up a mirror in the practice room
because the client struggles with self-image.
Pay attention to endings-Make sure that endings are planned for, and offer the appropriate referral or
signposting of support if the client requests it.
Reflection -Another part of active listening is verbally responding to what is being said. In many therapies,
the therapist is trying to interpret what the client means and see it through their own lens. In person-centered
therapy, you do not try and change the meaning but rather simply reflect the client in an effort to further
understanding.
Paraphrase - It is quite easy to misunderstand a client’s meaning. The goal in active listening is to clarify
what is being said so you know you are hearing what they want you to hear. One way of doing this is to
paraphrase their comments to ensure you are understanding their meaning.
Tone - Your tone of voice is an important consideration in person-centered therapy. Your tone should remain
even and supportive. Large inflections may be interpreted by the client as a judgment or a lack of empathy.
Reflection Of Feeling In counseling, the reflection of feelings is a technique used to describe a clinician’s
understanding of a client’s words and have them confirm the therapist interpretation. It begins with the
therapist paraphrasing what they think their client said for them to double-check if it is correct or not so that
the professional knows whether the client has understood them or not. Repeating what the client has shared
about his or her feelings; this lets the client know the therapist is listening actively and understanding what
the client is saying, as well as giving them an opportunity to further explore their feelings.
Example: Client: I didn’t know what to do, I was so confused and angry. Counsellor: So you are feeling
confused and angry. Reflection of feelings means that a counsellor helps the client explore their thoughts,
feelings, and emotions in depth. This process allows for healing and growth to happen in clients.
Reflection of feelings may seem like a small task, it can help the counsellor understand what type of therapy
would be best for the client. This will allow the counsellor to provide a more tailored experience that will
help the client feel better and move forward. A reflection can often be attempted in both individual and
group settings, but it is more often used during individual one-on-one sessions. This is done because clients
can give better feedback when not among other people. As opposed to using reflection of feeling only during
the session, counsellors may also try and reflect feelings that their clients made outside of the session to see
how they have done and whether or not they are improving. The whole point of reflection of feeling is to
help the client express themselves better by making sure their therapist knows what they mean.
This can help them find out more about whats going on with the person and better understand what might
trigger their feelings. When clients feel that they have been understood, it can be easier for them to open up
and share more about whatever is troubling them. This technique helps the therapist understand whats going
on in the clients life and gives them a better idea of how to help them resolve whatever issues they might
have. By going over the session with a client and reflecting on their feelings, counselors can be sure that
they are not missing details that could end up being helpful in their sessions.
Reflections of feeling are a way to help clients identify deeper meanings behind their feelings. It allows
them to better understand themselves and other people by analyzing their feelings and reflecting on the
meaning of these feelings.
Types of Reflections
Counselors can reflect a wide range of information, but reflections typically include one or more of the
following:
Content Reflecting content involves repeating back to clients a version of what they just told you.
Reflecting content shows the client you understand and are listening to them. Typically, reflecting content
alone is not as powerful as reflecting content with emotions and/or meaning.
Emotions Reflecting a client’s emotions is often useful for heightening the client’s awareness of and ability
to label their own emotions. It is important that counselors have a wide emotional vocabulary, so they can
tailor their word choice to match a level of emotional intensity that is congruent with a client’s experience.
Feeling word charts are useful for reviewing a wide range of feeling words.
Meaning
As existential theorists observe, humans are meaning making creatures. Reflecting a client’s meaning can
increase the client’s self-awareness while encouraging emotional depth in the session.
Therapist uses reflection of feeling to restate and explore the client’s affective (feeling) messages. The
response may capture both feeling and content, but the emphasis is on feelings. You validate the client by
conveying accurately an understanding of the client’s feelings. This process leads to the establishment of
rapport and the beginning of a therapeutic relationship.
Helps to:
• Convey understanding
• Gain insight into client’s emotional responses to life
• Validate client’s emotional response
• Manage the emotions of the client
• Identify feelings and sort out multiple meanings
• Discriminate among various feelings
• You want to mirror or match client’s affective message/response in intensity
Appropriate to use when:
• Exploring the extent and depth of a problem;
• There is a need to normalize the client’s feelings;
 • Be sure to attending to the client’s non-verbal reactions because sometime they may not match
verbal message
Inappropriate to use:
• In premature exploration of feelings
• Overanalyzing client’s reactions
• To minimize client’s problem

Non-Directedness: Nondirective therapy can also be called client centered therapy, transpersonal therapy,or
person-centered therapy. Non-directiveness refers to allowing clients to be the focus of the therapy session
without the therapist giving advice or implementing strategies or activities. Non-directiveness refers to the
method of allowing the client to drive the therapy session; therapists should refrain from giving advice or
planning activities for their sessions. This type of therapy is generally thought to be based on the ideas and
practices of Carl Rogers.
It usually requires therapists to exercise three main traits: unconditional positive regard, empathy, and
congruence. A nondirective therapy session may primarily be led by the client as they speak about anything
on their mind or any concerns they may be experiencing. This type of therapy usually empowers the client to
dig deeper, get to know them better, and uncover potential solutions. If nondirective therapy sounds like a
beneficial option for you, you may wish to try it through an online therapy platform for added convenience.

UNIT 3- Gestalt Psychotherapy: Views About Human Nature, Key Concepts

Gestalt Therapy
Gestalt therapy is associated with Gestalt psychology, a school of thought that stresses perception of
completeness and wholeness. Frederick (Fritz) Perls (1893–1970) is credited with establishing Gestalt
therapy and popularizing it both through his flamboyant personality and his writings. Laura Perls (his wife)
and Paul Goodman helped Perls develop and refine his original ideas. A number of other theorists,
particularly Joen Fagan and Irma Lee Shepherd (1970), developed the model further.

View of Human Nature

Fritz Perls (1969a) practiced Gestalt therapy paternalistically. Clients have to grow up, stand on their own
two feet, and “deal with their life problems themselves”. Perls’s style of doing therapy involved two
personal agendas: moving the client from environmental support to self-support and reintegrating the
disowned parts of one’s personality. His conception of human nature and these two agendas set the stage for
a variety of techniques and for his confrontational style of conducting therapy. He was a master at
intentionally frustrating clients to enhance their awareness.
The Gestalt view of human nature is rooted in existential philosophy, phenomenology, and fi eld theory.
Genuine knowledge is the product of what is immediately evident in the experience of the perceiver.
Therapy aims not at analysis or introspection but at awareness and contact with the environment. The
environment consists of both the external and internal worlds. The quality of contact with aspects of the
external world (for example, other people) and the internal world (for example, parts of the self that are
disowned) are monitored. The process of “reowning” parts of oneself that have been disowned and the
unification process proceed step by step until clients become strong enough to carry on with their own
personal growth. By becoming aware, clients become able to make informed choices and thus to live a more
meaningful existence. A basic assumption of Gestalt therapy is that individuals have the capacity to self-
regulate when they are aware of what is happening in and around them. Therapy provides the setting and
opportunity for that awareness to be supported and restored. If the therapist is able to stay with the client’s
present experience and trust in the process, the client will move toward increased awareness, contact, and
integration (Brown, 2007).

The Now One of the main contributions of the Gestalt approach is its emphasis on learning to appreciate and
fully experience the present moment. Focusing on the past and the future can be a way to avoid coming to
terms with the present. Polster and Polster (1973) developed the thesis that “power is in the present.” It is a
common tendency for clients to invest their energies in bemoaning their past mistakes and ruminating about
how life could and should have been different or engaging in endless resolutions and plans for the future. As
clients direct their energy toward what was or what might have been or live in fantasy about the future, the
power of the present diminishes. Phenomenological inquiry involves paying attention to what is occurring
now. To help the client make contact with the present moment, Gestalt therapists ask “what” and “how”
questions, but rarely ask “why” questions. To promote “now” awareness, the therapist encourages a dialogue
in the present tense by asking questions like these: “What is happening now? What is going on now? What
are you experiencing as you sit there and attempt to talk? What is your awareness at this moment? How are
you experiencing your fear? How are you attempting to withdraw at this moment?” Most people can stay in
the present for only a short time and are inclined to find ways of interrupting the flow of the present. Instead
of experiencing their feelings in the here and now, clients often talk about their feelings, almost as if their
feelings were detached from their present experiencing. One of the aims of Gestalt therapy is to help clients
become aware of their present experience. Gestalt therapists recognize that the past will make regular
appearances in the present moment, usually because of some lack of completion of that past experience.
When the past seems to have a significant bearing on clients’ present attitudes or behavior, it is dealt with by
bringing it into the present as much as possible. When clients speak about their past, the therapist may ask
them to reenact it as though they were living it now. The therapist directs clients to “bring the fantasy here”
or “tell me the dream as though you were having it now,”striving to help them relive what they experienced
earlier.

Unfinished Business When figures emerge from the background but are not completed and resolved,
individuals are left with unfinished business, which can be manifest in unexpressed feelings such as
resentment, rage, hatred, pain, anxiety, grief, guilt, and abandonment. Because the feelings are not fully
experienced in awareness, they linger in the background and are carried into present life in ways that
interfere with effective contact with oneself and others: “These incomplete directions do seek completion
and when they get powerful enough, the individual is beset with preoccupation, compulsive behavior,
wariness, oppressive energy and much self-defeating behavior” (Polster & Polster, 1973). Unfinished
business persists until the individual faces and deals with the unexpressed feelings. The effects of unfinished
business often show up in some blockage within the body. Gestalt therapists emphasize paying attention to
the bodily experience on the assumption that if feelings are unexpressed they tend to result in some physical
sensations or problems. The impasse, or stuck point, is the time when external support is not available or the
customary way of being does not work. The therapist’s task is to accompany clients in experiencing the
impasse without rescuing or frustrating them. The counselor assists clients by providing situations that
encourage them to fully experience their condition of being stuck. By completely experiencing the impasse,
they are able to get into contact with their frustrations and accept whatever is, rather than wishing they were
different. Gestalt therapy is based on the notion that individuals have a striving toward actualization and
growth and that if they accept all aspects of themselves without judging these dimensions they can begin to
think, feel, and act differently based on the notion that individuals have a striving toward actualization and
growth and that if they accept all aspects of themselves without judging these dimensions they can begin to
think, feel, and act differently.

Contact and Resistances to Contact

In Gestalt therapy contact is necessary if change and growth are to occur. Contact is made by seeing,
hearing, smelling, touching, and moving. Effective contact means interacting with nature and with other
people without losing one’s sense of individuality. Prerequisites for good contact are clear awareness, full
energy, and the ability to express oneself (Zinker,1978). Miriam Polster (1987) claimed that contact is the
lifeblood of growth. It is the continually renewed creative adjustment of individuals to their environment. It
entails zest, imagination, and creativity. There are only moments of this type of contact, so it is most
accurate to think of levels of contact rather than a final state to achieve. After a contact experience, there is
typically a withdrawal to integrate what has been learned. Gestalt therapists talk about the two functions of
boundaries: to connect and to separate. Both contact and withdrawal are necessary and important to healthy
functioning. Gestalt therapists also focus on interruptions, disturbances, and resistances to contact, which
were developed as coping processes but often end up preventing us from experiencing the present in a full
and real way. Resistances are typically adopted out of our awareness and when they function in a chronic
way, can contribute to dysfunctional behavior. Because resistances are developed as a means of coping with
life situations, they possess positive qualities as well as problematic ones. Polster and Polster (1973)
describe five different kinds of contact boundary disturbances that interrupt the cycle of experience:
introjection, projection, retroflection, deflection, and confluence.

Introjection is the tendency to uncritically accept others’ beliefs and standards without assimilating them to
make them congruent with who we are. These introjects remain alien to us because we have not analysed
and restructured them. When we introject, we passively incorporate what the environment provides rather
than clearly identifying what we want or need. If we remain in this stage, our energy is bound up in taking
things as we find them and believing that authorities know what is best for us rather than working for things
ourselves.

Projection is the reverse of introjection. In projection we disown certain aspects of ourselves by assigning
them to the environment. Those attributes of our personality that are inconsistent with our self-image are
disowned and put onto, assigned to, and seen in other people; thus, blaming others for lots of our problems.
By seeing in others, the very qualities that we refuse to acknowledge in ourselves, we avoid taking
responsibility for our own feelings and the person who we are, and this keeps us powerless to initiate
change. People who use projection as a pattern tend to feel that they are victims of circumstances, and they
believe that people have hidden meanings behind what they say.

Retroflection consists of turning back onto ourselves what we would like to do to someone else or doing to
ourselves what we would like someone else to do to or for us. This process is principally an interruption of
the action phase in the cycle of experience and typically involves a fair amount of anxiety. People who rely
on retroflection tend to inhibit themselves from taking action out of fear of embarrassment, guilt, and
resentment.

Deflection is the process of distraction or veering off, so that it is difficult to maintain a sustained sense of
contact. We attempt to diffuse or defuse contact through the over use of humor, abstract generalizations, and
questions rather than statements (Frew, 1986). When we deflect, we speak through and for others, beating
around the bush rather than being direct and engaging the environment in an inconsistent and
inconsequential basis, which results in emotional depletion.
Confluence involves blurring the differentiation between the self and the environment. As we strive to blend
in and get along with everyone, there is no clear demarcation between internal experience and outer reality.
Confluence in relationships involves the absence of conflicts, slowness to anger, and a belief that all parties
experience the same feelings and thoughts we do. This style of contact is characteristic of clients who have a
high need to be accepted and liked, thus finding enmeshment comfortable.

Energy and Blocks to Energy

In Gestalt therapy special attention is given to where energy is located, how it is used, and how it can be
blocked. Blocked energy is another form of defensive behavior. It can be manifested by tension in some part
of the body, by posture, by keeping one’s body tight and closed, by not breathing deeply, by looking away
from people when speaking to avoid contact, by choking off sensations, by numbing feelings, and by
speaking with a restricted voice, to mention only a few. Much of the therapeutic end eavour involves finding
the focus of interrupted energy and bringing these sensations to the client’s awareness. Clients may not be
aware of their energy or where it is located, and they may experience it in a negative way. One of the tasks
of the therapist is to help clients identify the ways in which they are blocking energy and transform this
blocked energy into more adaptive behaviors. Clients can been couraged to recognize how their resistance is
being expressed in their body. Rather than trying to rid themselves of certain bodily symptoms, clients can
be encouraged to delve fully into tension states.

Goals of Gestalt Psychotherapy & Therapeutic relationship

Gestalt psychotherapy is a humanistic approach to therapy that focuses on promoting self-awareness,

personal growth, and integration of different aspects of the self. It was developed by Fritz Perls and his
colleagues in the 1940s and 1950s. The primary goal of Gestalt therapy is to help individuals develop a
heightened sense of self-awareness and to take responsibility for their thoughts, feelings, and actions.

Goals of Gestalt therapy

The goals of Gestalt psychotherapy can vary depending on the individual and their specific needs, but some
common objectives include: Self-awareness: Gestalt therapy seeks to increase clients' awareness of their
thoughts, emotions, and behaviors as they occur in the present moment. By becoming more attuned to their
immediate experience, individuals can gain insight into their patterns and make choices that are more in line
with their authentic selves. Personal responsibility: Gestalt therapy encourages individuals to take ownership
of their thoughts, feelings, and actions. It emphasizes that individuals have the power to make choices and
take responsibility for the consequences of those choices, empowering them to create meaningful change in
their lives. Integration and wholeness: Gestalt therapy aims to help individuals integrate fragmented aspects
of themselves and develop a sense of wholeness. By exploring and understanding different parts of their
personality, clients can work towards resolving conflicts and finding greater harmony within themselves.
Enhancing interpersonal skills: Gestalt therapy recognizes the significance of relationships and interpersonal
interactions. It aims to help individuals improve their communication skills, develop healthier relationships,
and establish boundaries that promote their well-being. Supportive exploration of unresolved issues: Gestalt
therapy provides a safe and supportive environment for individuals to explore unresolved issues from their
past that may be impacting their present experiences. By gaining insight into these unresolved issues, clients
can work towards resolution and healing. Encouraging creativity and spontaneity: Gestalt therapy values
creativity and spontaneity as pathways to self-expression and personal growth. Therapists may employ
various experiential techniques, such as role-playing, empty-chair dialogues, or expressive arts, to facilitate
clients' exploration and expression of their thoughts and feelings.
Therapeutic Relationship
The therapeutic relationship in Gestalt psychotherapy plays a crucial role in achieving these goals. The
therapist provides a supportive and non-judgmental space for clients to explore their experiences. The
qualities of the therapeutic relationship in Gestalt therapy include: Presence and authenticity: The therapist
strives to be fully present and authentic, establishing a genuine connection with the client. This helps create
a safe and trusting environment for the client to explore their thoughts, emotions, and behaviors. Empathy
and acceptance: The therapist demonstrates empathy and acceptance towards the client, creating a space
where the client feels understood and valued. This helps the client develop self-acceptance and self-
compassion. Collaboration: The therapist and client work together as equals, collaboratively exploring the
client's experiences and co-creating the therapeutic process. The therapist encourages the client to take an
active role in their therapy and supports their personal growth. Awareness of the therapeutic relationship:
The therapist pays attention to the dynamics and patterns within the therapeutic relationship itself. This
allows for the exploration of how the client relates to others and can provide insights into their broader
patterns of relating Experimentation and exploration: The therapist encourage the client to experiment with
new behaviors, thoughts, and emotions within the therapeutic relationship. This helps the client develop
awareness and try out alternative ways of being and relating. Overall, the goals of Gestalt psychotherapy and
the therapeutic relationship in this approach are aimed at fostering self-awareness, personal responsibility,
integration, and authentic expression, ultimately supporting clients in their journey towards growth and
well-being.

UNIT 4 TECHNIQUES OF GESTALT THERAPY

1) Focusing On Here and Now
One of the main contributions of the Gestalt approach is its emphasis on learning to appreciate and fully
experience the present moment. Focusing on the past and the future can be a way to avoid coming to terms
with the present. The past is gone, and the future has not yet arrived, whereas the present moment is lively
and exciting. The past is important, but only insofar as it is related to our present functioning. Gestalt
therapy’s focus on the here and now encompasses the past and helps influence the future (Melnick &amp;
Nevis, 2005).

According to Perls (1969), “Nothing exists except the here and now… The past is no more. The future is not
yet…. Likely to be congruent-to have our minds, our bodies, and our emotions integrated. Gestalt therapy
takes place in the here and now. The therapist reacts in a genuine, empathic, and transparent way to the
client’s material. This transparency may include disclosure from the therapist, but any disclosure must be
made in the best interest of the client.Finally, Evans (2009) cautions that the use of the here and now is not a
technique to be selected for the use with the client, but a way of being that reflects the I-thou relationship
found in all humanistic therapies (Buber,1970; Yontef,1993).
Phenomenological inquiry involves paying attention to what is occurring now. To help the client make
contact with the present moment, Gestalt therapists ask “what” and “how” questions, but rarely ask “why”
questions. To promote “now” awareness, the therapist encourages dialogue in the present tense by asking
questions like these: “What is happening now? What is going on now? What are you experiencing as you sit
there and attempt to talk? What is your awareness at this moment? How are you experiencing your fear?
How are you attempting to withdraw at this moment?”. One of the aims of Gestalt therapy is to help clients
become aware of their present experiences.
Gestalt In Groups
The Gestalt group process provides many opportunities for using present- centeredness to increase
awareness and bring about change, and the group process offers a greater chance to awaken unfinished
business in members through their present-centered interactions (Schoenberg & Feder, 2005).In Gestalt
groups, the participants bring past problem situations into the present by reenacting the situation as if it were
occurring now.
Most Gestalt experiments are designed to put clients into closer contact with their ongoing experiencing
from moment to moment, and some Gestalt groups have a very tight focus on the here and now. A basic
ground rule of Feder’s (2008a) interactive, here-and-now approachis that participants agree to devote their
attention and efforts to their experiences that directly pertain to what is taking place within the group. There
are disadvantages to this exclusive here-and-now focus if the past and the future are discarded. E.
Polster(1987a) observes that too tight a focus, with a highly concentrated emphasis on the here and now, will
foreclose on much that matters, such as continuity of commitment, the implications of one’s acts,
dependability, and responsiveness to others.

2) Dreamwork
Dreams occupy an important place in gestalt therapy. Perls viewed dreams as the royal road to integration
rather than the royal road to the unconscious, as Freud had viewed them. Perls believed that the parts of a
dream represent projections or aspects of the dreamer. Awareness comes from assuming the various role or
parts of the dream and enacting the dream as though it is happening in the present. This approach to
understanding dreams puts the client in charge of the process. It allows people to take responsibility for their
dreams, see their dreams as a part of themselves, increase integration, and become aware of thoughts and
emotions reflected in the dream that they might otherwise disown.

The Gestalt approach does not interpret and analyze dreams. Instead, the intent is to bring dreams back to
life and relive them as though they were happening now.The dream is acted out in the present, and the
dreamer becomes a part of his or her dream. The suggested format for working with dreams includes making
a list of all the details of the dream, remembering each person, event, and mood in it, and then becoming
each of these parts by transforming oneself, acting as fully as possible, and inventing dialogue. Each part of
the dream is assumed to be a projection of the self, and the client creates scripts for encounters between the
various characters or parts. All of the different parts of a dream are expressions of the client’s own
contradictory and inconsistent sides, and, by engaging in a dialogue between these opposing sides, the client
gradually becomes more aware of the range of his or her own feelings.

Dreamwork In Groups
Consistent with its no interpretive spirit, the Gestalt approach does not interpret and analyze dreams.
Instead, the intent is to bring the dream back to life, to recreate it, and to relive it as if it were happening
now. Group members don’t report their dreams or talk about them in the past tense. Instead, they are asked
to tell the dream as if it were happening in the present. Dreamers become immersed in their dreams with
more vitality when they narrate dreams as though they are happening now. Members can be asked to
identify with a segment of the dream and to narrate their dream from a subjective perspective. Group
members may be asked to transform key elements of the dream in to dialogue and become each part of the
dream. The group context allows them to play out parts of the dream as present events.

Dreams contain existential messages; they represent our conflicts, our wishes, and key themes in our lives.
By making a list of all the details in a dream remembering each person, event, and mood, and then acting
out (“becoming”) each of these parts as fully as possible, one becomes increasingly aware of one’s opposing
sides and of the range of one’s feelings. Dreams can be used in groups quite creatively “as a starting point
for discoveries about present relationships with other group members or the therapist or with a recognition
of an existential position which bears exploration using the dream only as a point of departure”. In working
with dreams in Gestalt style, dreamers can focus on questions such as “What are you doing in the dream?”
“What are you feeling?” “What do you want in the dream?” “What are your relationships with other objects
and people in the dream?” “What kind of action can you take now?” and “What is your dream telling you?”
Group experiments can emerge out of the dream work of individuals in a group. Zinker (1978) has
developed an approach he calls dream work theatre, which goes beyond working with an individual’s dream.
After a dream is reported and worked through by a participant, a group experiment is created that allows
other members to benefit therapeutically from the original imagery of the dreamer. Each plays out a part of
the dream. This offers the group participants many opportunities for enacting certain dimensions of the
dream that relate both to the dreamer and to their own life.

3) Roleplay
Role-play, in various forms, is an essential tool of gestalt therapists. Although Perls was influenced by
Moreno’s psychodrama, gestalt therapy rarely uses other people to play roles, in part because that might
encourage fragmentation. Rather, an empty chair is more often used to represent a role. Role-play can help
individuals to experience different feelings and emotions and better understand how they present and
organize themselves. “Role-playing in supervised groups seems to promote reflection and insight not only
for students in the patient and therapist roles but also for peers observing the group sessions” (Rønning &
Bjørkly, 2019, p. 415). Indeed, learning and practicing techniques in such a safe and controlled environment
can promote competent practitioners. Role-playing has emotive, cognitive, and behavioral components” that
can create disturbances that help clients change “unhealthy feelings to healthy ones” (Corey, 2013). Typical
role-play includes two or more people re-enacting a specific problematic scenario–actual or imagined–
sufficiently authentic to evoke an emotional reaction. For example, the therapist may play the role of parent
or teacher, using words, mannerisms, and responses gathered (by systematic questioning) from the child to
explore a situation (Hackett, 2011). As a therapeutic technique, role-play offers helpful insight into how
individuals view their environment and function interpersonally.For that reason, it can be particularly
effective in the treatment of trauma,enabling therapist and client to revisit earlier experiences through re-
enactment (Hackett, 2011). The two-chair or empty chair method is a common type of role-play intended to
help become aware and resolve conflicts, develop clarity, and gain insight into all aspects of a problem
(strumpet & Goldman,2002).
4) Empty chair:
The empty-chair technique is one way of getting the client to externalize the introject, a technique Perls
used a great deal. Using two chairs, the therapist asks the client to sit in one chair and be fully the top dog
and then shift to the other chair and become the underdog. • The dialogue can continue between both sides
of the client. Essentially, this is a roleplaying technique in which all the parts are played by the client. In this
way the introjects can surface, and the client can experience the conflict more fully. The conflict can be
resolved by the client’s acceptance and integration of both sides. • This exercise helps clients get in touch
with a feeling or a side of themselves that they may be denying; rather than merely talking about a
conflicted feeling, they intensify the feeling and experience it fully. Further, by helping clients realize that
the feeling is a very real part of them, the intervention discourages clients from disassociating the feeling. •
The goal of this exercise is to promote a higher level of integration between the polarities and conflicts that
exist in everyone. The aim is not to rid oneself of certain traits but to learn to accept and live with the
polarities.
5) Rules and games of gestalt therapy
The techniques of Gestalt therapy belong to two sets of guidelines, either rules or games. The rules are few
and are expressed and described at the outset. The games, though, are numerous and no definitive list is
possible since an ingenious Gestalt therapist may devise new ones from moment to moment. The rules
definitely are not intended as a dogmatic list of do’s and don’ts, rather, they are offered in the spirit of
experiment to facilitate the maturation process.
The rules include:
(1) the principle of the now, state: The idea or the now-, of the immediate moment, of the content any
structure of present experience is one of the most potent, most pregnant, and most elusive principles of
Gestalt Therapy.” Now is a functional concept referring to what the organism is doing. What the organism
did five minutes ago is not part of the now. An act of remembering a childhood event is now, i.e., the
remembering is now (Yontef, 1972). Gestalt therapy experiments operate in the now in this functional sense
(Levitsky &Perls, 1970). The Gestalt therapist attempts to keep the focus on the present ongoing situation
and on what “is”,The discussion of history (the past) is discouraged, while relating authentically in the now
and communicating in the present tense is encouraged. We can remember the past (which is no more) and
anticipate the future (which is not yet), but only the now exists (Foulds, 1972, pg. 49)”
(2) I and thou; Gestalt therapy involves the interaction of at least two people, in individual therapy, the
patient and the therapist (Simkin, no date). Polster (1966, pg. 5-6) describes the Ithou relationship:
“encounter, the interaction between patient and therapist, each of whom is in the present moment a
culmination of a life’s experiences. They may engage simply, saying and doing those things which are
pertinent to their needs, the therapist offering a new range of possibility to the patient through his
willingness to know the truth and to be an authentic person”.
(3)”it” language and “I” language; this rule deals with the semantics of responsibility and involvement; as
it is common for persons to refer to their bodies, acts, and behaviors in the third person, “it” language.
Instead of “it is trembling” (referring to the hand), say “I am trembling”. Through the simple, and seemingly
mechanical, method of changing “it” language into “I” language a person learns to identify more clearly
with the particular behavior in question and to assume responsibility for it (Levitsky , 1970). Changing “it”
to “I” is one example of the Gestalt game techniques which allow a person to more fully experience who
they are and assume responsibility for themselves. Some of those are expressed by Foulds (1972, pg. 51): “If
an but are replaced by and, I cant is replaced by I won’t, I feel by I am, and I feel guilty by I resent and I
demand. It and you are changed to I, and verbs are substituted for nouns. by, because, should, ought,
supposed to, and have to are worked with in depth by asking the person to verbalize his rationalizations.
(4) Use of the awareness continuum; the use of the awareness continuum, the “how” of experience, is
absolutely basic to Gestalt therapy. Many of the Gestalt-awareness experiments direct a person to their
awareness continuum. Levitsky and Penis (1970, pg. 143) say: “The awareness continuum has inexhaustible
applications. Primarily, however, it is an effective way of guiding the individual to the firm bedrock of his
experience and away from the endless verbalizations, explanations, interpretations. Awareness of body
feelings and of sensations and perceptions constitutes our most certain - perhaps our only certain -
knowledge. Relying on information provided in awareness is the best method of implementing Perls’s
dictum ‘lose your mind and come to your senses”
(5) No gossiping; As with other Gestalt techniques, the no gossiping rule is designed to promote direct
confrontation of feelings ar.d to prevent avoidance of feelings. Gossiping is defined as “talking about an
individual when he is actually present and could just as well be addressed directly (Levitsky Perls, 1970, pg.
144).
The following is a list describing same of the more common Gestalt therapy techniques:

Games / Exercise

(1) Games of dialogue; In trying to effect integrated functioning, the Gestalt therapist seeks out whatever
divisions or splits manifested in the personality. One split is the famous “top-dog” and “ under-dog” the top-
dog moralizes, specializes in should, and is bossy and condemning, while the under-dog remains passively
resistant, making excuses and finding reasons for delay (Levitsky & Perls, 1970). When the top- and under-
dog split, as well as other conflicts appear, the patient is asked to create an actual dialogue between the two
components of self, The dialogue game can also be used for various parts of the body (i.e., right hard vs. left
hand, lower half of body vs. upper half). The dialogue can also be developed between the patient and some
significant person, whether the significant other is present or not. The patient simply addresses the person, in
the here-and-now, imagines a response, often replies to the response, and so on.
(2) Unfinished business; Whenever unfinished business (unresolved. Feelings) is identified, the patient is
asked to complete it. The dialogue is one method for expressing, unfinished business with a significant
person. Unfinished business may prevent other behaviour from occurring smoothly.
(3) Playing the projection; A patient looks around the room and picks an object that stands out vividly for
him. He then identifies with his object, i.e., making statements as if he were the object, describing it by
saying “I” instead of “it”. Interesting knowledge occurs when using this technique (Enright, 1971). Another
way of using this technique is, for example, a person who says “I can’t trust you” may be asked to play the
role of an untrustworthy person to discover his own inner conflict in this area (Levitsky Perls, 1970).
(4) Reversals; One way a Gestalt therapist approaches certain symptoms and difficulties is to help the
patient to realize that most behaviour commonly represents the reversal of underlying or latent impulses.
The person is asked to role-play the opposite of a particular feeling or behaviour that he is manifesting to
excess, (i.e., the patient claims to suffer from inhibition; he will be asked to play an exhibitionist). The
person is asked to be very sensitive to his experience in playing reversals, and to be aware of tapping into
previously unrecognized feelings (Foulds, 1970b).
(5) Exaggeration: client accentuate unwitting movement or gestures .so, the inner meaning of these
behaviour become more apparent.
(6) Making the rounds: this exercise is employed when the counsellor feels that a particular theme or
feeling expressed by a client should be faced by every person in the group. the client may say for instances
“I can’t stand anyone.” The client is then instructed to say this sentence to each person in the group, adding
some remarks about each group member. The round exercise is flexible and may include nonverbal positive
feeling, too. By participating in it, client become more aware of inner feeling.
(7) The “I take responsibility” game; Gestalt therapy considers all overt behaviour, sensing, feeling, and
thinking acts by the person. Patients frequently disown or alienate those acts by using the “it” language,
passive voice, etc. One technique involves asking the patient to add after each statement he makes “......and I
take responsibility for it” (Levitsky and Perls,1970). Foulds (1972) calls this identification or “owning” (pg.
50),
UNIT 5: APPLICATION AND EVALUATION OF HUMANISTIC THERAPIES

Person Centered Therapy

Application: Person-centered therapy has evolved through diversity, inventiveness, creativity, and
individualization in practice (Cain, 2010). In newer versions of the person-centered approaches, group
facilitators have greater freedom to participate in the relationship, to share their reactions, to confront clients
in a caring way, and to be active in the therapeutic process (Bozarth, Zimring, &Tausch, 2002;
Kirschenbaum, 2009; Lietaer, 1984). Current formulations of the approach assign more importance to
therapists’ bringing in their own here- and-now experiences, which can stimulate members to explore
themselves at a deeper level. These changes from Rogers’s original view of the counselor have encouraged
the use of a wider variety of methods and a considerable diversity of therapeutic styles. The person-centered
approach to groups has been applied to diverse populations including therapy clients, counselors, staff
members of entire school systems, administrators, medical students, groups in conflict, drug users and their
helpers, people representing different cultures and languages, and job training groups. As the group
movement developed, the person-centered approach became increasingly concerned with reducing human
suffering, with cross-cultural awareness, and with conflict resolution on an international scale.

Applying the Person-Centered Approach to Group Work in Schools

This philosophy forms the foundation for transforming traditional schools into schools where children are
free to learn and where the human dimensions of the student-teacher relationship are prized. When these key
values are applied to education at all levels, Rogers and Freiberg demonstrate that a transformation of
education can take place. They summarize research that has been done on person-centered education and
conclude “that a human approach is a fundamental precondition and foundation to learning and, in a great
many ways, is more appropriate than traditional approaches to learning”. Of expression. Axline’s (1964)
classic book, Dibs: In Search of Self, is an excellent example of a person-centered approach adapted to play
therapy. In read- ing about Dibs, the power of listening, empathy, warmth, and engagement becomes
evident. Axline (1964, 1969) demonstrates the healing power of play with children. There are many ways to
adapt Axline’s basic ideas and methods of person-centered play therapy in small group work. Play can be the
medium through which children express their feelings, bring their conflicts to life, explore relationships, and
reveal their hopes and fears. In a person-centered group with children, play therapy is often the medium of
expression. Axline’s (1964) classic book, Dibs: In Search of Self, is an excel- lent example of a person-
centered approach adapted to play therapy. In reading about Dibs, the power of listening, empathy, warmth,
and engagement becomes evident. Axline (1964, 1969) demonstrates the healing power of play with
children. There are many ways to adapt Axline’s basic ideas and methods of person-centered play therapy in
small group work. Play can be the medium through which children express their feelings, bring their
conflicts to life, explore relationships, and reveal their hopes and fears. In addition to play, other expressive
techniques, which are an outgrowth of the person-centered approach, can be used in group work with
children such as art, music, and movement. Because children’s verbal communication skills may be limited,
these nonverbal and expressive approaches can provide clues to what children are feeling and trying to
communicate The focus of child-centered play therapy is on the child rather than the problem, the present
rather than the past, feelings rather than thoughts or acts, under- standing rather than explaining, accepting
rather than correcting, the child’s direction rather than the therapist’s instruction, and the child’s insight
rather than the therapist’s knowledge. Play group therapy can be appropriately applied to counseling
children in elementary school (Landreth, 2002). Child-centered group play therapy can help children learn to
become responsible in interpersonal relationships, to explore their behavior, to cope with stress and anxiety,
and to find satisfaction in living with others. The group experience allows children to process their personal
concerns on both an intrapersonal and interpersonal level.

Application to Multicultural Groups

Person-centered multicultural counseling is an effective way to facilitate learning across age, race, ethnicity,
and geographic location (Cornelius-White, 2005, 2007). The respectful and accepting nature of person-
centered counseling, coupled with its phenomenological perspective, makes it appropriate for people from a
wide range of ethnic, cultural, and socioeconomic backgrounds. Person-centered theory emphasizes the
importance of valuing and understanding people, of viewing them from their own frame of reference, of
building a positive client-clinician relationship, and of attending to the client’s world through that person’s
perspective. Although person-centered theory and treatment do reflect American ideals of independence,
self-direction, and individuality, many aspects of this approach are also relevant to a diverse and
multicultural society. These include: The emphasis on people's rights to their own opinions and thoughts The
importance placed on respect, genuineness, acceptance, and empathy
• The focus on people's own experience and frames of reference The emphasis on personal growth and self-
actualization The interest in relationships and commonalities among people The attention to present-moment
awareness and the immediacy of the counseling situation. These perspectives are pertinent to all people,
regardless of cultural background.

Evaluation Of Person-Centered Counseling

Limitations Although I deeply appreciate the person-centered philosophy, this approach provides little
structure for group members. Both active support and directive interventions can be extremely
helpful in promoting client change. Person- centered group leaders typically do not employ directive
strategies, nor do they believe it is the facilitator’s job to devise and introduce techniques and
exercises as a way of helping the group do its work (Boy, 1990). I prefer the value of action; of
therapeutic direction, if it is needed by clients; and of more directive skills than are generally found in
this approach.
Contributions And Strengths of The Approach
Many person-centered practitioners would argue that this approach is sufficient for all the stages of a group’s
development. The approach encourages members from the outset to assume responsibility for determining
their level of investment in the group and deciding what personal concerns they will raise. A main strength
of this approach is the emphasis on truly listening to and deeply understanding the clients’ world from their
internal frame of reference. Empathy is the corner- stone of this approach, and it is a necessary foundation
upon which any theory rests (Bohart, 2003; Bohart& Greenberg, 1997; Cain, 2010). Critical evaluation,
analysis, and judgment are suspended, and attention is given to grasping the feelings and thoughts being
expressed by the others. I see this form of listening and understanding as a prerequisite to any group
approach, particularly during the early stages when it is essential that members feel free to explore their
concerns openly. Unless the participants feel that they are being understood, any technique or intervention
plan is bound to fail.

Gestalt Therapy Application and Current Use of Gestalt Therapy

Current Trends in Gestalt therapy integrate relational themes, emotion focus, and attachment theory and the
use of experiments in a relational therapy. Clients explore topics of identity, trauma, childhood abuse, and
other developmental bruises that may have shaped their early years (Finlay & Evans, 2009). Gestalt
therapists focus on the relationship and use much more caring confrontations than was the norm in the
1970s. They help clients to understand the subjective interconnectedness of everything, while also helping
them to take responsibility for their own feelings and actions. Topics such as male identity, women’s
aggression, and ruptures in the therapeutic alliance may all be fodder for discussion in the here and now of
the therapy session. For example, the therapist and client might discuss the client’s feelings of shame and
guilt that resulted from her parent’s overly strict socialization process, how that shame is erupting in her
current relationship with her husband, what triggers it, and how it impacts the therapy session.
Application to Diagnostic Groups
Case studies in the literature show Gestalt therapy being adapted for treatment of a wide range of problems
that impact emotion regulation including sexual trauma, narcissistic self-hatred, shame, and aggression
(Bloom & Brownell, 2011). Clinicians who work with children and adolescents will find Gestalt play
therapy, as developed by Virginia Oaklander (1994, 1997), to be a highly experiential, existential “here-and-
now” philosophy for work with children (Blom, 2006). As mentioned earlier, Gestalt family therapy
combines a systemic perspective with field theory and provides an integrative and holistic model for couples
counseling (O’Neill, 2012). Gestalt therapy may be helpful to people with eating disorders including
anorexia nervosa and bulimia nervosa (Angermann, 1998), people with substance use disorders (Clemmens,
2005), and for people who channel emotional concerns into their bodies. Such people might be diagnosed
with somatoform disorders (often called psychosomatic illnesses) in which they report physical complaints
that have no medical basis.
Application to Multicultural Groups

Thus, Gestalt innately attends to “cultural difference, historical background, And social perspectives”
(Mackewn, 1997, p. 51). When working with people from a variety of cultures, therapists must be careful to
select culturally appropriate interventions that respect non-Western European communication styles.
Traditional Asian or Native American clients may view direct and confrontational forms of therapy such as
Gestalt to be lacking in respect and sensitivity (Duran, 2006). Similarly, clients from cultures that value
restraint of strong emotions, unassertiveness, or filial piety, as do many Asian cultures, are likely to feel
uncomfortable or intimidated if the counselor uses role- plays, behavioral rehearsal, or the Gestalt empty
chair technique (Sue & Sue, 2008). Rather than taking a universal perspective or a one-size-fits-all
approach, Sue and Sue recommend therapists show respect for the client’s cultural background and adapt
their techniques, interventions, energy level, and tone of voice to match the client’s. Recognizing when
Gestalt techniques such as the empty chair or the hot seat should not be used is equally as important as
knowing when to use them.

Application to Other Groups

Gestalt therapy has been used with low-achieving adolescents and high school students (Strumpfel&
Goldman, 2002); to help middle school students deal with the suicide of a classmate (Alexander & Harman,
1988); and to help pregnant women prepare for the birth of their children. Gestalt therapy’s present
orientation, as well as its use of powerful exercises, can quickly bring all aspects of an issue into awareness
and encourage closure as well as growth. Used skillfully, and adapted to the needs of a Particular client or
group, the range of this approach is almost unlimited.

Current Use of Gestalt Therapy

Gestalt therapy is flexible enough to be easily integrated with a broad range of other treatment systems. The
empty chair and two-chair dialogues of Gestalt therapy as well as other strategies also have been integrated
into new process-experiential therapies discussed earlier in Chapter 8. The gestalt approach to dreamwork,
as well as the use of role-plays, continues to play a prominent part in treatment.

Evaluation Of Gestalt Therapy

Limitations

Gestalt techniques are not for everybody. They can be powerful motivators for change, or have limited
applicability, especially with people who have severe cognitive disorders or impulse control disorders-acting
out, delinquency, and explosive disorders-or with people who have sociopathic or psychotic symptoms
(Saltzman, 1989). Gestalt techniques may even cause harm if not used care- fully (Wagner-Moore, 2004).
Other criticisms of the therapy include that it focuses too much on felt bodily sensations and not enough on
cognitions, and that getting in touch with internal polarities to relieve emotional problems sounds too much
like blaming the victim.

MODULE 4: EXISTENTIAL PSYCHOTHERAPY

UNIT 1: OVERVIEW OF THE EXISTENTIAL VIEWPOINT, EXISTENTIAL
PHILOSOPHY
Existentialism is concerned with the living experience of becoming and originates from the Latin root
“exsistere,” which literally means “to stand forth” or “to become.” Humanism comes from the Greek
tradition of “knowing thyself” (Schneider & Krug, 2010). Thus, “existential-humanism," although a
seemingly static name, actually references the dynamic process of becoming and knowing oneself.

Existential therapy can best be considered as a way of thinking rather than as a particular style of practicing
group therapy. It is not a separate school or a neatly defined, systematic model with specific therapeutic
techniques. Universal human concerns and existential themes constitute the background of most Groups.

The existential approach rejects the deterministic views of traditional psychoanalysis and behaviorism and
emphasizes our freedom to choose what to make of our circumstances. It is a dynamic approach that focuses
on the underlying givens or the four ultimate concerns that are rooted in human existence: freedom,
existential isolation, meaninglessness, and death (Yalom, 1980, Yalom & Josselson, 2011). Existential
therapy is grounded on the assumption. That we are free and therefore responsible for our choices and
actions. We need to be the pioneers of our lives and to find models that will give us meaning. Even though
we sometimes cannot control things that happen to us, we have complete control over how we choose to
perceive and handle them. Although our freedom to act is limited by external reality, our freedom to be
relates to our internal reality. One of the goals of the therapeutic process is to challenge clients to discover
alternatives and to choose among them. Schneider and Krug (2010) state that existential therapists are
mainly concerned about helping. People to reclaim and reown their lives. Schneider and Krug identify four
essential aims of existential-humanistic therapy:

(1) to help clients become more present to both themselves and others;
(2) to assist clients in identifying ways they block themselves from fuller presence;
(3) to challenge clients to assume responsibility for designing their present lives; and
(4) to encourage clients to choose more expanded ways of being in their daily lives.

As van Deurzen (2002a) has indicated, existential therapy is ultimately a process of exploring clients’ values
and beliefs that give meaning to living. She adds that the aim of existential therapy is to invite clients to take
action that grows out of their honest appraisal of their life’s purpose. The therapist’s basic task is to
encourage clients to consider what they are most serious about so they can pursue a direction in life. The
existential approach assumes the Individual’s capacity to make well-informed choices about his or her life.
Group Leaders cannot assume that they alone know the purpose of the group; rather, it is up to each
participant to create this purpose.
A major aim of therapy Is to encourage clients to reflect on life, to recognize their range of alternatives, and
to decide among them. Once clients begin the process of recognizing the ways in which they have passively
accepted circumstances and surrendered control, they can start on a path of consciously shaping their own
lives. Yalom (2003) emphasizes that the first step in the therapeutic journey is for clients to accept
responsibility: “Once individuals recognize their role in creating their own life predicament, they also
realize that they, and only they, have the power to change that situation”. One of the aims of existential
therapy is to challenge people to stop deceiving themselves regarding their lack of responsibility for what is
happening to them and their excessive demands on life.
Existential therapy is an attitude toward life, a way of being, and a way of inter- acting with oneself, others,
and the environment. Rooted in 19th-century western European philosophy, existential philosophy was
applied to psychotherapy by the Swiss psychiatrists Ludwig Binswanger and Medard Boss. Other existential
psychotherapists, both in the United States and in Europe, have examined a vari- ety of issues as they affect
the human experience.
Existential therapists, in their focus on individuals’ relationships with them- selves, others, and the
environment, are concerned with universal themes. In this chapter, the existential themes provide a means of
conceptualizing personality and of helping individuals find meaning in their lives through the
psychotherapeutic process. All individuals are "thrown" into the world and ultimately face death. How they
face their own deaths and those of others is an important concern of existential therapists. Individuals are
seen not as victims but as responsible for their own lives, with the ability to exercise freedom and make
choices. Dealing with the anxiety that can evolve from these concerns is an aspect of existential therapy.
Forming relationships with others that are not manipulative but intimate is a goal of existential therapy that
often arises from a sense of isolation and loneliness. Finding a sense of meaning in the world has been a
particular concern of Viktor Frankl and those who use his logo therapeutic techniques. Most existential
psychotherapists take an attitudinal or thematic approach to therapy and do not focus on techniques,
although Frankl does describe some specific existential techniques.
Exploring existential themes is done in group therapy. In existential group therapy, there is an emphasis not
only on relationships between members of the group but also on individuals’ experience of their own sense
of themselves. Existential issues transcend culture and gender, although certain biological and social
realities are encountered differently, depending upon one’s gender or cultural identification.

Philosophy Of Existential Therapy

Existential psychotherapy developed from the early work of European philosophers. Perhaps the first was
Kierkegaard, who wrote of the anxiety and uncertainties in life. Emphasizing subjectivity and the will to
power, Nietzsche popularized existential thought in 19th-century Europe. Developing existentialism further,
Heidegger and Jaspers worked out sophisticated systems of existential philosophy. A more pessimistic view
of existentialism was put forth by the French philosopher Sartre. Additionally, theologians have made
important statements that combine elements of their particular beliefs and existentialist philosophy. Also,
writers such as Dostoyevski, Camus, and Kafka have dealt with existential themes in their plays, novels, and
other writings. Familiarity with the views of these writers, theologians, and philosophers provides a
background for understanding existential psychotherapy.

Existential Philosophers
Søren Kierkegaard, the Danish philosopher, has been called the grandfather of existentialism (Lowrie,
1962). Kierkegaard viewed individuals as desiring to be eternal, like God, but having to deal with the fact
that existence is temporary. When possible, individuals forget their temporal nature and deal with trivial
issues of living. In adolescence, an awareness of one’s finiteness emerges, and individuals must deal with
the torment, angst, and dread that result, issues of philosophical and personal interest to Kierkegaard.
Without this experience, individuals merely go through the motions of living and do not directly confront
issues of choice and freedom (Gron, 2004). Dealing with this uncomfortable state is a task of becoming
human and a focus of Kierkegaard’s work.
The German philosopher Friedrich Nietzsche (1844–1900) emphasized the importance of human
subjectivity. He believed that the focus on the rationality
of individuals was misleading and that the irrational aspects of human nature played an important role. In
particular, he emphasized the dynamics of resentment, guilt, and hostility that individuals attempt to repress
(May, 1958a). In his development of the concept of “superman,” Nietzsche argued that individuals who
allow themselves to develop their “will to power” are creative and dynamic, achieving positions of
leadership. By truly realizing their own individual potentialities and courageously living out their own
existence, individuals seek to attain Nietzsche’s concept of “will to power.” Although Kierkegaard’s views
were based on theology and Nietzsche’s on a “life force,” both emphasized the subjective and irrational
nature of individuals that was to have a direct impact on other existential philosophers and psychotherapists.
Phenomenology, as it was developed by Edmund Husserl (1859–1938), has been part of the evolution of
existential psychotherapy. For Husserl, phenomenology was the study of objects as they are experienced in
the consciousness of individuals. The methodology of phenomenology includes intuiting or concentrating on
a phenomenon or object, analyzing aspects of the phenomenon, and freeing oneself of preconceptions so
that the observer can help others understand phenomena that have been intuited and analyzed.
Phenomenological concepts have been important for many gestalt and existential writers. Phenomenological
concepts have been important for many gestalt and existential writers.

A practicing psychiatrist who later became a professor of philosophy, Karl Jaspers (1883–1969) sought to
develop a philosophy that would encompass all problems related to the existence of humanity. He emphasise
on being oneself, which is attained not only through self-awareness but also through communication with
others via discussion, education, politics, and other means.
Known widely because of his novels, plays, and articles, Jean-Paul Sartre (1905–1980) dealt with issues
concerning the meaning of human existence. Sartre emphasizes that, no matter what a person has been, he
can choose to be different.

Not only have philosophers contributed to the development of existential thought but also theologians have
made important contributions, notably Martin Buber (1878–1965) on existential dialogue, Gabriel Marcel
(1889–1973) on trust, and Paul Tillich (1886–1965) on courage. Combining existential philosophy with a
Jewish Hasidic perspective, Buber emphasized the betweenness of relationships. There is never just an I.
There is also a thou, if the person is treated as a human individual. If the person is manipulated or treated as
an object, the relationship becomes I-it.

From a Catholic perspective, Marcel described the person-to-person relationship, focusing on the being-by-
participation in which individuals know each other through love, hope, and faithfulness rather than as
objects or as an “it.” The Protestant theologian Paul Tillich is best known for his emphasis on courage,
which includes faith in one’s ability to make a meaningful life, as well as a knowledge of and a belief in an
existential view of life. These philosophers have emphasized relationships with others and with God, in
contrast to Sartre’s pessimistic view of the meaning of existence.

Originators Of Existential Psychotherapy

The Swiss psychiatrist Ludwig Binswanger (1881–1966). A major contribution of Binswanger, expressed in
Being-in-the-World (1975), was his view of fundamental meaning structure, which refers to the unlearned
ability of individuals to perceive meaning in their world and to go beyond specific situations to deal with life
issues. This universal ability to perceive meaning, also called existential a priori, provides individuals with
the opportunity to develop their way of living and the direction of their lives. By focusing on the patients’
views of their world and their present experience, Binswanger was able to help them understand the
meaning of their behavior and become their own authentic selves through understanding their relationships
with their world, their associates, and themselves (Bühler, 2004).

Another Swiss psychiatrist, Medard Boss (1903–1990), was also quite familiar with Freud, having been
analyzed by him in Vienna. Although trained by several psychoanalysts, Boss was also influenced strongly
by the philosophy of Martin Heidegger. Integrating existentialism with psychoanalysis in Psychoanalysis
and Daseinsanalysis (1963), Boss outlines universal themes that individuals incorporate to varying degrees
in their being-in-the-world. Boss emphasized that individuals must coexist in the same world and share that
world with others. In doing so, individuals relate with varying degrees of openness and clarity to others
(spatiality of existence) and do so in the context of time (temporality of existence). The mood of individuals
determines how they relate to the world. For example, a sad person is aware of misfortunes, and a happy
person is attuned to enjoyable events in relationships. Another important existential theme is guilt, which
occurs when we make choices and, in doing so, must reject a variety of possibilities. Guilt for not following
through on those possible choices can never be fully relieved. For example, the person who decides to
become a lawyer rather than a minister may never fully come to terms with the decision. Finally, by being
mortal, individuals have the responsibility to make the most of existence. These existential themes greatly
affected Boss’s view of his patients and his psychotherapeutic work.

Although having basic views that are consistent with those of Binswanger and Boss, Viktor Frankl, born in
Vienna in 1905, expressed and developed his approach to psychotherapy differently. Like Boss and
Binswanger, Frankl was also influenced by his study of psychoanalysis. However, his experience in German
concentration camps was to affect his development of existential psychotherapy by bringing him in constant
contact with existential issues such as guilt and mortality. Important concepts for Frankl (Gould, 1993) deal
with the individual’s freedom and responsibility for oneself and others.

Logotherapy, a concept based on the idea that the most fundamental drive for individuals is to understand
the meaning of their existence, was developed eloquently in Frankl’s popular book Man’s Search for
Meaning (1963/1992) and can be seen in the context of Frankl’s life in Victor Frankl—Recollections: An
Autobiography (1997). Although Frankl made use of specific techniques, his emphasis was not on
techniques but on dealing with existential or spiritual questions that focus on the realization of values, the
meaning of life, and the meaning of time for the individual (Hillmann, 2004). A journal, the International
Forum for Logotherapy, contains articles related to techniques of logotherapy and Frankl’s view of
existential therapy.

Recent Contributors to Existential Psychotherapy

• Rollo May
• Yallom
• James Bugental

The best-known contemporary writer on existential psychotherapy, Rollo May (1909–1994) was influenced
by the ideas of Binswanger and Boss, but his greatest influence, both personally and professionally, was
Paul Tillich, especially through The Courage to Be (1952). Throughout May’s articles and books, he deals
with important existential issues such as anxiety, dealing with power, accepting freedom and responsibility,
and developing individual identity. An example of his early work is The Meaning of Anxiety (1950, 1977).
May’s familiarity with anxiety came not only from his readings but also from a 2-year hospitalization for
tuberculosis.

In Man’s Search for Himself (1953), May wrote about the anxiety and loneliness that confront individuals in
modern society. Two edited books (May, 1961; May, Angel, Ellenberger, 1958) were important in bringing
together related approaches to existential psychology and therapy. As can be seen by the titles, many of his
books develop significant existential themes: Love and Will (1969), Power and Innocence (1972), The
Courage to Create (1975), and Freedom and Destiny (1981). In one of his last books, The Cry for Myth
(1992), May combined a long-term interest in the classics with his interest in existentialism. May’s approach
to psychotherapy shows an integration of psychoanalytic concepts with existential themes.
Perhaps the most thorough and comprehensive explanation of existential psychotherapy can be found in
Yalom’s (1980) text. Yalom (1931–) presents an in-depth approach to existential psychotherapy by dealing
with the themes of death, freedom, isolation, and meaninglessness. His therapeutic approach can be seen in
books of his published case studies, Love’s Executioner (1989) and Momma and the Meaning of Life The
frequent use of case material in his textbook, as well as the material in his casebooks, is helpful to
psychotherapists who wish to focus their attention on the existential themes of their patients.

Another writer who has brought together approaches to existential therapy is James Bugental (1915–2008).
His writings focus on helping patients develop an existential understanding of themselves through a search
for authenticity (Bugental, 1978, 1981; Schulenberg, 2003). In his work, he takes a humanistic focus that
stresses the ability of individuals to enhance their awareness and to self-actualize. The existential themes he
develops are similar to, but not identical to, those of Yalom (Krug, 2008), for example, change, contingency,
responsibility, and relinquishment. Bugental’s Psychotherapy Isn’t What You Think (1999) illustrates his
therapeutic approach, which focuses on in-the-moment experiences during the therapeutic session.

Unit 2: Key concept of existential therapy – view of human nature, capacity for self - awareness,
freedom and responsibility, the search for meaning, existential anxiety and guilt.

Existential therapy
Existential therapy is not a singular therapy but rather a rich aggregate of many therapeutic practices that
organize around a shared concern: the lived experiences of human beings. It is a dynamic approach that
focuses on the underlying givens or the four ultimate concerns that are rooted in human existence: freedom,
existential isolation, meaninglessness, and death. Existential therapy is grounded on the assumption that we
are free and therefore responsible for our choices and actions. This approach does not focus on merely
applying problem-solving techniques to the complex task of authentic living, nor does it aim to cure people
in the traditional medical sense.
Key concepts of Existential therapy
Key concepts of the existential approach include self-awareness, self-determination and responsibility,
existential anxiety, death and nonbeing, the search for meaning, the search for authenticity, and
aloneness/relatedness. These key existential concepts guide the practice of group work by providing a way
to view and understand individuals in the group.

1. Self-awareness
The capacity for self-awareness separates us from other animals and enables us to make free choices. The
greater our awareness, the greater our possibilities for freedom. In group work, the basic existential goal of
expanding self-awareness and thereby increasing the potential for choice is pursued by helping members
discover their unique “being-in-the-world.”
2. Self-determination, freedom and personal responsibility
Another existential theme is that we are self-determining beings, free to choose among alternatives and
therefore responsible for directing our lives and shaping our destinies. Viktor Frankl, an existential
psychiatrist, stresses the relationship between Freedom and responsibility and insists that ultimate freedom
can never be taken from us because we can at least choose our attitude toward any given set of
circumstance. Frankl believes human freedom is not freedom from conditions but the ability to take a stand
in the face of conditions. Frankl’s brand of existential therapy, logotherapy (logos = meaning), teaches that
meaning in life cannot be dictated but can only be discovered by searching in our own existential situation.
Indeed, we have the will to meaning, and we have the freedom to find meaning in how we think and in what
we do. Frankl believes the goal is not to attain peace of mind but to experience meaning in a healthy
striving. It is essential that we recognize and accept our part in creating the quality of our existence, for life
does not simply happen to us. We are capable of actively influencing our thoughts, feelings, and actions.
3. Existential anxiety
Existential therapists view anxiety as providing potentially instructive signals that can assist individuals to
live more authentically. Existential anxiety is the unavoidable product of being confronted with the givens of
existence: death, freedom, existential isolation, and meaninglessness. Existential anxiety is the basic unease
that we experience when we become aware of our vulnerability and our inevitable death. From the
existential viewpoint, anxiety is an invitation to freedom and not just a symptom to be eliminated or
“cured.” Anxiety results from having to face choices without clear guidelines and without knowing what the
outcome will be, and from being aware that we are ultimately responsible for the consequences of our
actions. Existential anxiety is basic to living with awareness and being fully alive.
4. Death and non-being
The existential therapist considers death as essential to the discovery of meaning and purpose in life. Death
awareness is an awakening experience that can be a useful catalyst for making significant life changes.
5. The search for meaning
The struggle for a sense of significance and purpose in life is a distinctively human characteristic. We have
the capacity to cultivate meaning and awe in our lives. We can also conceptualize, imagine, invent,
communicate, and physically and psychologically enlarge our world. We search for meaning and personal
identity, and we raise existential questions: “Who am I? Frankl (1963) has devoted his career to developing
an existential approach to therapy that is grounded on the role of meaning in life. According to him, the
central human concern is to discover meaning that will give one’s Life direction. He views existential
neurosis as the experience of meaninglessness. He believes that even suffering can be a source of growth
and that if we have the courage to experience our suffering, we can find meaning in it.
6. Search for authenticity
Discovering, creating, and maintaining the core deep within our being is a difficult and never-ending
struggle. Van Deurzen (2002a) suggests that such authentic living is more of a process than a static end
result. Living authentically entails engagement in doing what is worthwhile as we see it. Existential guilt is
rooted in the realization that we inevitably fall short of becoming what we could become, which means that
we are always in debt to life to some extent. Existential guilt grows out of a sense of incompleteness and the
realization that we are viewing life through someone eyes. Ultimately loss of the sense of being becomes
psychological sickness.

7. Aloneness and relatedness

Existential isolation refers to our aloneness in the universe. Even though we find meaning in connections
with others, we enter the world alone and we leave the world alone. We must manage the tension between
our wish for relatedness with others and the reality of our aloneness. Because awareness of our ultimate
aloneness can be frightening, some of us try to avoid it by throwing ourselves into casual relationships and
frantic activities, trusting that they will numb us to our fears and anguish.

View of human nature

The existential perspective on human nature emphasizes individual freedom to choose one’s values and
meaning in life. Through the process of defining values and discovering meaning in life, human beings are
faced with basic existential questions such as “Where have I come from? Why am I here? Where am I
going? What do I value?”. Existential therapy does not view human nature as fixed, fatalistic, or
deterministic; rather, individuals are seen as constantly changing and evolving in accordance with their
values and meaning in life. Yet, it is awareness in the present moment that allows one to choose freely and
responsibly to that which he or she is becoming. Thus, existential therapy views humans as having a
dynamic nature due to one’s freedom to choose values and meaning in the present moment.
Psychopathology results when one avoids existential anxiety and nonbeing. The development of
psychological problems also occurs with people who live inauthentically; that is, they lie to themselves. As
Prochaska and Norcross (2010, p. 101) state, “Lying is the foundation of psychopathology,” from an
existential perspective. Psychopathology is often associated with imbalanced levels of being-in-the-world.

First, existential therapy’s major treatment goals include embracing freedom and authenticity. The focus is
on one’s freedom to choose and define oneself in an authentic and honest manner. Second, authentically
maintaining harmonious relationships with all four levels of being-in-the-world is consistent with a biblical
perspective. Third, existential therapy can become stoical and nihilistic. Due to an overemphasis on the
meaninglessness of life, the ultimate emptiness of humankind, and mortality and death, the client may
become overwhelmed with feelings of hopelessness. Fourth, the therapeutic relationship serves as a major
healing factor in existential therapy. The person of the therapist and the provision of therapeutic love and
authentic caring for the client is consistent with the biblical perspective of agape love (1 Cor. 13) that deeply
cares and touches others. Fifth, the existential therapist assumes a sacred responsibility of helping clients
find meaning in their lives.

Freedom and responsibility

Freedom to live our own lives carries with it the responsibility to do so. Existentialists believe that
individuals do not enter or leave a structured universe that has a coherent design (May & Yalom, 2005).
Rather, in their pursuit of freedom, individuals are responsible for their own world, their life plans, and their
choices. Although the terms freedom, responsibility, and choice may first appear unrelated, they are
integrally related, as we are free to choose in what ways we will be responsible for leading our lives and,
implicitly, what values are significant to us.

Although freedom appears to be a principle that human beings would value positively, Camus and Sartre see
it more negatively. To be truly free, individuals must confront the limits of their destiny. Sartre’s position is
that individuals are condemned to freedom (1956). They are responsible for creating their own world, which
rests not on the ground but on nothingness. In his writings, Sartre gives the feeling that individuals are on
their own, like people walking on a thin veneer that could open, leaving a bottomless pit. Sartre believes that
our choices make us who we really are.

Responsibility refers to owning one’s own choices and dealing honestly with freedom. Sartre uses the term
bad faith to denote that individuals are finite and limited. For an individual to say, “I can’t treat my children
well, because I was abused as a child” or “Because I didn’t go to a good high school, I can’t go to a good
college” is to act in bad faith by blaming someone else for the problem and not examining one’s own
limitedness. The person who compulsively hand washes can, from an existential point of view, be seen as
acting in bad faith.

Meaning and Meaninglessness

Questions about the meaning of life may haunt people at various times during their lives: Why am I here?
What about my life do I find meaningful? What in my life gives me a sense of purpose? Why do I exist? As
May and Yalom (2005) point out, human beings need a sense of meaningfulness in their lives. A sense of
meaning provides a way of interpreting events that occur to the individual and in the world, and it furnishes
a means for the development of values as to how people live and wish to live.
Sartre, Camus, and others have written about the absurdity of life and have dealt fully with the question of
meaninglessness. Others, such as Frankl (Hillmann, 2004), have focused on the importance of the
development and search for meaning in one’s life. Frankl has been concerned that individuals do not look at
the spiritual meanings in their lives or beyond material values. Paradoxically, Yalom has found that people
who are terminally ill have found meaning in life far beyond what they had prior to their illnesses. The
following is an example of one of Yalom’s patients who found meaning in the face of death.

Anxiety
For May (1977) as well as other existentialists, anxiety is viewed more broadly than by most other
psychotherapy theorists, and it is separated into two major types (May & Yalom, 2005), normal anxiety and
neurotic anxiety. A significant subset of normal anxiety—and the focus of attention by existential
psychotherapists—is existential anxiety (Cohn, 1997). Although anxiety has physical manifestations, it
arises from the basic nature of being. Individuals must confront the world around them, deal with unforeseen
forces (“the thrown condition”), and in general develop a place within their world. For May and Yalom
(2005), normal anxiety has three features that differentiate it from neurotic anxiety.

First, it is appropriate to the situation that the individual deals with in his life. Second, normal anxiety is not
usually repressed. For example, a severe illness may make us come to terms with our death. Third, normal
anxiety can provide an opportunity to confront existential dilemmas, such as dying, responsibility, and
choices. Existential anxiety has been the source of interest for a number of existential writers. Tillich
(Weems, Costa, Dehon, & Berman, 2004) discusses the relationship of existential anxiety to depression and
apprehension. Lucas (2004) sees existential anxiety as deriving from regret for not having made a choice in
one’s past. This regret may lead one to have a sense of existential guilt for betraying oneself.

In contrast, neurotic anxiety is a reaction that is blown out of proportion or inappropriate for the particular
event. For example, the man who is so afraid of disease that he washes his hands several times before and
during a meal is experiencing neurotic anxiety. The anxiety is out of proportion to the situation, destructive,
and of little value to the patient. Furthermore, the patient may have repressed fears that may be a source of
this anxiety. In this example of neurotic anxiety or obsessional neurosis, there is an existential component.
The individual is unable to control his anxiety about disease that may lead to his death. The individual
compulsively washes his hands rather than dealing with the uncertainty of life. Existential therapists often
help their patients develop awareness of their courage to deal with the existential issues that underlie
neurotic anxiety.

Guilt
Existential guilt, which acknowledges that guilt is inherent in being human, is a beneficial emotion for
healing and personal growth. Neurotic guilt means we take too much responsibility for our relationships and
the world. Denial or avoidance of guilt means we take too little responsibility for our relationships and the
world.

Often in our culture, guilt is not considered a valuable emotion. It is viewed as an emotion that inhibits us
from feeling good about ourselves and life. It is viewed as an emotion that doesn’t serve a positive purpose.
There are four ways to engage with guilt. Three types of guilt are inhibiting or destructive. However, the
fourth way is engaging with existential guilt, which is useful and constructive.
Neurotic Guilt

The guilt that we are most familiar with is neurotic guilt. This guilt is inhibiting. This is a guilt we get
caught up in. We let it define us. We obsess over an action. We criticize ourselves and feel we are not good
people.

For example, I don’t pay attention to my partner when it is important to my partner that I do. I stew over that
I didn’t pay attention when I should have. I think of myself as a bad person. I obsess over what I have done.
Even if I have apologized, I continue to blame myself. I don’t accept my insensitivity as a part of being
human. I don’t accept that I am fallible. I don’t accept that sometimes I won’t live up to the person I thought
I was. I slap a scarlet G-for-Guilty on my forehead. Even if my partner has forgiven me for my insensitivity,
I still don’t forgive myself. I believe I am totally responsible for everything that happens in the relationship.
That isn’t true healing for the relationship. There isn’t personal growth and learning for me.

We are also familiar with the denial or avoidance of guilt. These ways of engaging with guilt are destructive.

Denial of Guilt
In denial of guilt, I don’t take any responsibility for my actions. Acknowledging my guilt creates too
vulnerable a feeling because then I would be accepting that I am fallible. Instead, I blame the other person.
For example, I deny any guilt around my partner feeling ignored. It is their fault for being overly sensitive or
for not understanding me.

Avoidance of Guilt
In avoidance of guilt, I also don’t take any responsibility for my actions. Acknowledging that I should feel
guilty again creates too vulnerable a feeling. I would have to recognize that I am fallible. I believe, or
pretend, that everything is okay or that what I did was no big deal.
For denial or avoiding feelings of guilt, there won’t be healing between my partner and me. There isn’t any
personal growth and learning for me.

Existential Guilt
Existential guilt is different from the above three ways of engaging with guilt. First and foremost, existential
guilt acknowledges that guilt is inherent in being human. It is part of the human condition for all of us. This
is acknowledging that I am fallible. I won’t always be my best self. I accept this. I acknowledge that I will
act in ways that cause pain. My action that caused pain is not the sum of who I am. While I feel bad about
my actions, I don’t define myself by them, deny them or avoid them. I don’t blame myself or the other
person.

Unit 3: The Therapeutic Process- Goals of Existential Psychotherapy, Therapist’s Function and Roles

Goals of Existential Psychotherapy

Authenticity is the basic goal of psychotherapy. In therapy, clients learn how their lives are not fully
authentic and what they must do to realize the full capability of their being (Cooper, 2003; Craig, 2009). As
Frankl states, “Clients must find a purpose to their existence and pursue it. The therapist must help
them achieve the highest possible activation” (1965, p. 54). As an individual develops an awareness of
having a task to pursue in life, he will be better able to actualize significant values. Similarly, van Deurzen-
Smith (1998) believes that the aim of therapy is to help individuals become authentic and recognize when
they are deceiving themselves.

Therapy should help clients understand their beliefs and values, have confidence in them, and make choices
based on them that can lead to new directions in living. A sense of aliveness comes from therapy as the
individual see’s life with interest, imagination, creativity, hope, and joy, rather than with dread, boredom,
hate, and bigotry.

For May, “the aim of therapy is that the patient experiences his existence as real” (1958b, p. 85). The
focus is not on curing symptoms but on helping individuals fully experiences their existence. Another way
of viewing this is that neurotic individuals are overconcerned about their Umwelt (the biological world)
and not sufficiently concerned with their Eigenwelt (their own world).

In these terms, the goal of psychotherapy is to help the individual develop his Eigenwelt without being
overwhelmed by the therapist’s Eigenwelt. The therapist must be with the patient as he experiences
Eigenwelt. In learning about the patient, May (1958b) does not ask, “How are you?” but rather, “Where are
you?”

May wants to know not just how patients feel and how they describe their problems but how detached
patients are from themselves. Do patients seem to be confronting their anxiety, or are they running away
from their problems? As May (1958b, p. 85) points out, it is often easier to focus on the mechanism of the
behavior rather than the experience in order to reduce anxiety. For example, a patient who reports symptoms
of agoraphobia (a fear of being out in public places or outside home) may describe his physical anxiety
when he leaves the house and how far he is able to go without attending to the overall dread and anxiety that
he experiences because of his limitations. Although the cure of agoraphobia may be a by-product of
existential therapy, the goal is to have the individual experience his own existence and become fully alive
rather than adjust to or fit cultural expectations.

Therapist’s Function and Roles

Existential therapists give central prominence to their relationship with the client. The relationship is
important in itself because the quality of this person-to-person encounter in the therapeutic situation is the
stimulus for positive change.

Therapists with this orientation believe their basic attitudes toward the client and their own personal
characteristics of honesty, integrity, and courage are what they have to offer. Therapy is a journey taken by
therapist and client that delves deeply into the world as perceived and experienced by the client. But this
type of quest demands that therapists also be in contact with their own phenomenological world. Vontress,
Johnson, and Epp (1999) state that existential counseling is a voyage into self-discovery for both client and
therapist.

Buber’s (1970) conception of the I/Thou relationship has significant implications here. His understanding of
the self is based on two fundamental relationships: the “I/it” and the “I/Thou.” The I/it is the relation to time
and space, which is a necessary starting place for the self. The I/Thou is the relationship essential for
connecting the self to the spirit and, in so doing, to achieve true dialogue. This form of relationship is the
paradigm of the fully human self, the achievement of which is the goal of Buber’s existential philosophy.
Relating in an I/Thou fashion means that there is direct, mutual, and present interaction. Rather than prizing
therapeutic objectivity and professional distance, existential therapists strive to create caring and intimate
relationships with clients.

Therapists invite clients to grow by modeling authentic behavior.

If therapists keep themselves hidden during the therapeutic session or if they engage in inauthentic behavior,
clients will also remain guarded and persist in their inauthentic ways. Bugental (1987) emphasizes the
crucial role the presence of the therapist plays in this relationship. In his view many therapists and
therapeutic systems overlook its fundamental importance. He contends that therapists are too often so
concerned with the content of what is being said that they are not aware of the distance between themselves
and their clients. “The therapeutic alliance is the powerful joining of forces which energizes and
supports the long, difficult, and frequently painful work of life changing psychotherapy. The
conception of the therapist here is not of a disinterested observer-technician but of a fully alive human
companion for the client”.

THE THERAPEUTIC RELATIONSHIP

The focus of existential therapy is that of two individuals being in the world together during the length of the
therapy session. This authentic encounter includes the subjective experience of both therapist and client,
which takes place during the present. The therapist’s attitude toward the patient, referred to by Yalom (1980)
as therapeutic love, is central to other therapeutic issues, including transference and resistance. The process
of existential therapy, which has the therapist–patient relationship as a major focus, differs among existential
therapists. For example, Bugental (1987) describes an approach that features a developing and deepening
relationship with the client and an exploration of the inner self. These issues are described in more detail in
the following paragraphs.

Therapeutic Love : The therapeutic relationship is a special form of the I–thou relationship (Buber, 1970).
Yalom writes of the relationship as a “loving friendship” (1980, p. 407) that is nonreciprocal. In other words,
the client may experience the therapist in a variety of ways, but the therapist strives to develop a genuine
caring encounter that does not encumber the client’s growth with the therapist’s personal needs. In a sense,
the therapist is in two places at once, authentic with herself and authentically open to the client (Buber,
1965; Yalom, 1980). By truly caring for the client, the therapist helps intimacy between client and therapist
to grow. Even though the client may be angry, hostile, untruthful, narcissistic, depressed, or unattractive in
other ways, there should be a feeling of authentic love for the client (Sequin, 1965). As the therapeutic
relationship develops, clients experience an atmosphere of true openness and sharing with the therapist.

Resistance : Resistance, from an existential point of view, occurs when a client does not take responsibility,
is alienated, is not aware of feelings, or otherwise is inauthentic in dealing with life. Resistance is rarely
directed at the therapist but is a way of dealing with overwhelming threats, an inaccurate view of the world,
or an inaccurate view of self. Expressed in resistance are not only the fears of clients but also their own
courageous way of dealing with themselves and their world. Clients display resistance in the therapy hour by
whining, complaining, talking about insignificant material, being seductive with the therapist, or otherwise
being inauthentic. The therapist attempts to establish a real and intimate relationship with the client, being
supportive of the client’s struggle with such issues (van Deurzen, 2001). Schneider (2008) sees resistance as
blockages to potentially important material. He is cautious or tentative and may discuss the issue indirectly
rather than directly. An example of a cautious comment would be “I wonder if I’m pushing too hard right
now”.

Transference : As Cohn (1997) points out, too great a focus on the transference relationship interferes with
an authentic relationship with the client. Bugental (1981) recognizes that some resistances “are acted out
through the transference”. He believes that it is important to recognize when the client’s attention implicitly
or explicitly focuses on the therapist. For example, if the client continually praises the therapist inordinately
for her help, the therapist may explore how this behavior is an acting out of relationship issues with the
client’s mother or father. Then the client and therapist can make progress in the process of developing a real
and authentic relationship. In this way the therapist is focusing on what is happening in therapy in the
present rather than attending to unconscious content as a psychoanalyst would (Davis, 2007).

The Therapeutic Process : Throughout the therapeutic process, existential therapists are fully present and
involved with their clients. If they become bored, look forward to the end of the hour, or lose their
concentration on the client, the therapists are not achieving an authentic encounter with their clients.
Although existential therapists would agree on the importance of the authentic therapeutic encounter, the
process in which therapists proceed varies, as they encounter issues that inhibit the development of
authenticity. In dealing with them, they May disclose their own feelings and experiences when doing so
helps clients fully develop their own sense of authenticity. In the movement toward authenticity, therapists
explore important existential themes such as living and dying; freedom, responsibility, and choice; isolation
and loving; and meaninglessness.

LIVING AND DYING

As Yalom has observed, “Death anxiety is inversely proportional to life satisfaction” (1980, p. 207). When
an individual is living authentically, anxiety and fear of death decrease. Yalom notes two ways that
individuals choose to deny or avoid issues of dying: belief in their own specialness and belief in an ultimate
rescuer who will save them from death. Recognizing these issues helps the therapist deal directly with issues
of mortality. Such issues may confront those who are grieving, those who are dying, and those who have
attempted suicide. Ways that existential therapists work with these issues are described in this section.

Yalom (1980) shows the many ways that individuals try to support a view that they are invulnerable,
immortal, and will not die. The notion of narcissism emphasizes the specialness of the individual and the
belief that he is invulnerable to illness and death. Coming to grips with death may be gradual or sudden.
Another defense against our own mortality is a belief in an ultimate rescuer. When patients develop a fatal
illness, they must confront the fact that no one will save them. Often, they may become frustrated and angry
with physicians who cannot perform magic, and they cannot believe that the doctor will fail them. Other
examples of the “ultimate rescuer” are people who live their lives for others: spouse, parent, or sibling. They
invest all of their energy in an interpersonal relationship that cannot save them when they are dying.

Dealing with grief is a common therapeutic task of the therapist. The loss may be that of a parent, a spouse,
a child, a friend, or a pet. Existential therapists deal openly with grief and emotions such as ambivalence,
guilt, and anger. Furthermore, Yalom (1980) shows how individuals confront their own deaths when dealing
with the deaths of loved ones. Often dreams show material that deals not only with the death of the loved
one but also fear of one’s own death. In dealing with death, therapists must be aware of their own belief
systems and their own fears and anxieties. If the therapist chooses to deny her own anxieties regarding
death, it is likely that she may avoid the issue of death when working with a client. To deal with suicidal
patients is to deal with those who may choose death over life.

FREEDOM, RESPONSIBILITY, AND CHOICE

Frequent themes in counseling and psychotherapy are choices and decisions that clients must make. The
existential therapist sees a client as being thrown into the world with the opportunity to make purposeful and
responsible choices. The existential point of view allows clients to experience their freedom of being in the
world and its inherent responsibilities.

Freedom : The existential therapist sees freedom as an opportunity to change, to step away from the client’s
problems, and to confront oneself (Fabry, 1987). Despite what may have happened in the past—child abuse,
traumatic incidents, financial deprivation—clients have the freedom to change their lives and find meaning
in their lives (van Deurzen, 2009). This is why many existential therapists prefer to work in the present
rather than dwell on the past. They may talk about the past as it affects the present, but the focus is on the
client’s freedom to change. Although it can be exhilarating, this freedom to change can be terrifying as well.
It is not unusual for adolescents to complain about their family and their lack of freedom in not being able to
come and go as they please, not being able to smoke, and so forth. Rather than empathize with the
restrictiveness that adolescents feel and help them to develop assertiveness, the existential therapist would
assist adolescents in discovering their ability to make their own choices (Van Deurzen, 2001).

Responsibility : With freedom comes responsibility (Schneider, 2008). Therapists encounter vast
differences in their clients’ willingness to accept responsibility for themselves and their current situations.
Clients may often blame parents, bosses, spouses, or others for their difficulties. In assisting the client in
becoming more responsible, the therapist assumes that clients have created their own distress. Therapy
progresses as clients identify their own role in their problems and stop blaming their parents, spouses, or
others. Therapists’ comments about responsibility are made at appropriate points, bearing in mind timing, or
kairos (Ellenberger, 1958), the critical point at which to intervene.
Choice : In describing the process of choice, May (1969) delineates the process as wishing, willing, and
deciding. Some individuals are so depressed that they have few wishes, and in such a case the therapist must
help the individual become more aware of feelings. Other clients may avoid wishing by acting impulsively
or compulsively. In other words, they act but do not think about what they want. By “willing,” individuals
project themselves onto a point at which they will be able to decide. Willing involves the ability to change
and to decide. When the individual decides, action follows. Implicit in this process is the responsibility for
one’s own wishing, willing, and deciding. This responsibility may be felt strongly by clients when they find
themselves panicked in deciding important issues such as whether to leave an unsatisfactory job or to get
married. When dealing with choices, the existential therapist recognizes the importance of client decision
making as opposed to therapist decision making (Cooper, 2003). The following example illustrates
succinctly how Bugental deals with a client’s indecisiveness.

Issues of freedom, responsibility, and choice are intimately related. Experiencing a sense of freedom can
cause clients to fear or to welcome the responsibility that falls upon them for the choices that they make in
their own lives. As seen in the case of Betty, by taking responsibility for themselves, clients decrease the
isolation and loneliness in their own lives.

ISOLATION AND LOVING

Individuals enter the world alone and leave the world alone. An awareness of the individual’s relationships
with others constitutes an integral part of existential treatment. Exploring feelings of loneliness and isolation
is an important aspect of a therapeutic relationship. As adults grow away from their families, issues of
developing new and loving relationships exist. Those who come to therapy often show an inability to
develop intimacy with others. The most severe categories of psychological disturbance paranoia and
schizophrenia show an extreme isolation in which the patient may be unable to communicate to others on
the most basic levels. For the existential therapist, the challenge is to bring intimacy and therapeutic loving
into the relationship to affect the loneliness of the client.

Yalom’s (1980) concept of therapeutic love, deals directly with the loneliness of the client. In writing about
therapists’ love, Bugental (1981) cautions that dependency can develop and the patient may not establish
intimacy with others, only with the therapist. He gives the example of Kathryn, who made frequent phone
calls, requested special meetings, and presented several crises. By setting limits, he was, with difficulty, able
to stabilize the relationship. The therapeutic relationship is not a reciprocal one, as the client receives love
but does not have to give it. In that sense, it can be an inaccurate representation of the relationships that the
client seeks, which requires loving and giving from both individuals. Therapists communicate that along
with the sense of loving and intimacy that comes with genuine caring, reciprocal giving relationships
increase the meaningfulness of life.
MEANING AND MEANINGLESSNESS

Helping clients and people in general find meaningfulness in their lives has long been a concern of Frankl
(1969, 1978, 1992, 1997). As Hillmann (2004) shows, meaning is a basic concept throughout Frankl’s
thoughts on therapy and is the key to the mentally healthy self. If an individual searches for the meaning of
life, he will not find it.

Meaning emerges as one lives and becomes concerned with others. When individuals focus too much on
themselves, they also lose a perspective on life. For Frankl, helping a patient who is self-absorbed by
searching for causes of anxiety and disturbance only makes the person more selfcentered. Rather, for Frankl
(1969), the solution is to look toward events and people in which the client finds meaning.

In concentrating on the importance of values and meaning in life, Frankl has developed an approach called
logotherapy (Hillmann, 2004; Schulenberg, Hutzell, Nassif, & Rogina, 2008). Four specific techniques help
individuals transcend themselves and put their problems into a constructive perspective: attitude modulation,
dereflection, paradoxical intention, and Socratic dialogue. In attitude modulation, neurotic motivations are
changed to healthy ones. For example, motivations to take one’s life are questioned and replaced by
removing obstacles that interfere with living responsibly. In dereflection, clients’ concerns with their own
problems are focused away from them. For example, clients who experience sexual performance difficulties
may be asked to concentrate on the sexual pleasure of the partner and to ignore their own. Similarly,
paradoxical intention requires that patients increase their symptoms so that attention is diverted from them
by having them view themselves with less concern and often with humor. Guttmann (1996) considers
Socratic dialogue to be the main technique in logotherapy. It can be used to guide clients to find meaning in
their lives, assess current situations, and become aware of their strengths.

Some existential therapists object to Frankl’s approach, which appears to them to emphasize techniques over
existential themes (Yalom, 1980). They prefer to help individuals become more fully aware of meaning in
their lives by looking for issues that interfere with the process of finding meaning. As the therapist and the
patient engage in their relationship, and as the therapist works authentically at creating a caring atmosphere,
those issues that trouble the client are shared and meaningfulness emerges from their work together.

These themes living and dying; freedom, responsibility, and choice; isolation and loving; and meaning and
meaninglessness—are interrelated. They all deal intimately with issues concerning the client’s existence or
being in the world. Engaging the client, showing therapeutic love, and involving oneself with the client are
all ways of entering the client’s world. They show clients that they are not alone and that they can be aided
in their struggle with existential themes.
UNIT 4: THERAPEUTIC TECHNIQUES AND PROCEDURESLOGOTHERAPY, PARADOXICAL
INTENTION, DE REFLECTION

LOGOTHERAPY

Logotherapy is a therapeutic approach that helps people find personal meaning in life. It’s a form of
psychotherapy that is focused on the future and on our ability to endure hardship and suffering through a
search for purpose. Psychiatrist and psychotherapist Viktor Frankl developed logotherapy after surviving
Nazi concentration camps in the 1940s. His experience and theories are detailed in his book, “Man’s Search
for Meaning.” Frankl believed that humans are motivated by something called a “will to meaning,” which is
the desire to find meaning in life. He argued that life can have meaning even in the most miserable of
circumstances and that the motivation for living comes from finding that meaning.

Frankl believed that it was possible to turn suffering into achievement and accomplishment. He viewed guilt
as an opportunity to change oneself for the better and life transitions as the chance to take responsible action.
In this way, Logotherapy is aimed at helping you to make better use of your “spiritual” resources to
withstand adversity. Three techniques intended to help with this process include dereflection, paradoxical
intention, and Socratic dialogue.

PARADOXICAL INTENTION

Paradoxical intention is a technique that invites you to wish for the thing that you fear most. This was
originally suggested for use in the case of anxiety or phobia in which humour and ridicule can be used when
fear is paralyzing.

Socratic Dialogue

Socratic dialogue is a tool used to help you through the process of selfdiscovery by noticing and interpreting
your own words. During Socratic dialogue, your therapist listens closely to the way you describe things and
points out your word patterns, helping you to see the meaning in them. This process is believed to help you
realize your own answers—often, these are already present within you and are just waiting to be discovered.

Logotherapy may improve resilence —or the ability to withstand adversity, stress, and hardship. This may
be due to the skills that this form of therapy encourages people to develop

Paradoxical intention

(PI) is a psychotherapeutic technique used to treat recursive anxiety by repeatedly rehearsing the anxiety-
inducing pattern of thought or behaviour Paradoxical intention has been shown to be effective in treating
psychosomatic illnesses such as chronic insomnia, public speaking phobias, etc. by making patients do the
opposite of their hyper-intended goal, hindering their ability to perform the activity. Within the framework
two techniques have been developed: ‘paradoxical intention’ and anxious behaviours are a result of
performance anxiety due to the inability to perform an action, leading to a vicious circle of anticipatory
anxiety. Paradoxical intention teaches the patient to distance themselves from the action, gain control over it
and eventually, bring about its removal. It attempts to break this circle by replacing the pathogenic fear with
a paradoxical wish. Furthermore, by learning to appreciate the humour in their exaggerated responses,
individuals observe the non-catastrophic consequences of their fear-inducing stimuli first-hand, accepting
the unlikelihood of the feared anxiety-producing outcome occurring.

Paradoxical intention is mainly employed to combat discomfort associated with internal causes while fear of
external stimuli can still be treated through conventional treatments such as systematic desensitisation,
cognitive behavioural therapy, etc. For example, if the patient has a fear of public speaking, paradoxical
intention would be employed only if the feelings of apprehension stem from an internal source, e.g. having
an increased heart rate leading to a heart attack and not due to external factors such as the size of the crowd,
their judgement, etc. In this case, the therapist would prescribe the individual to present to the public while
focusing on the most salient aspect of their fear – in this case, trying to increase heart rate Paradoxical
intention has been shown as an effective therapy in the treatment of chronic to eradicate the anxiety
associated with the inability to sleep by instructing patients to do the opposite and attempt to stay awake. By
asking patients to keep their eyes open, while lying comfortably in a dark room without sleeping, they are
taught to understand the non-disastrous implications of staying awake and thus, the anxiety associated with
it diminishes

DEREFLECTION

While paradoxical intention counters anticipatory anxiety by ridiculing your symptoms, dereflection
counters self-observation by “ignoring” your symptoms.

The key word in paradoxical intention is “intention;” the key word in dereflection is “attention.”

The phenomena that paradoxical intention and dereflection come to address are not necessarily disparate
experiences but one tendency superimposed upon another. What starts as anticipatory anxiety (and the
hyper-intention that comes with it) quickly slides into hyper-reflection.

Take a simple example of something that happened to me. I was doing a makeshift repair on our window
blinds. The string was thick relative to the hole, and my fingers were clumsy relative to the angle.

At first I was hyperintending, saying to myself, I’ve got to get this done… now!! I soon started watching
myself with a running commentary going through my head about how awkwardly I was doing it. Of course
at that point the thread slipped out of my hands.

As if anticipatory anxiety is not bad enough, it becomes worse by looking at yourself. What starts as trying
too hard to make something happen turns into doubting whether or not I can make this happen. Anticipating
failure, you watch to see how you will fail.

So we have the person pay attention to something other than his self. It is important to understand that when
applying dereflection, you are not diverting attention from the problem, but putting the focus where it
belongs. Turning the focus away from the self is not a “distraction technique.” It is a technique that takes
your attention away from your self-distraction. Self-observation distracts you from your meaning. What is
“your meaning?” Your meaning consists of whatever you are meaningfully engaged in and occupied with in
the here-and-now that deserves your attention. In one of the cases Frankl brings a young man had a speech
disturbance which began at the age of six when lightning struck near him. The man was told to resign
himself to the fact that he won’t be a public speaker. Therefore he was free to pay attention only to the
“what” of his speech and not the “how.”

When trying to force himself to speak properly, he was fixated on “getting it right.” When watching his own
performance his was fixated on his self.

His fixation, or hyper-reflection of self was distracting him from reflecting on what was important, namely
the content of what he wanted to say. Dereflection reoriented him to the task at hand and to his mission in
life. It replaced his self-concern with self-commitment. We’ve already seen how paradoxical intention
restores a basic sense of trust in life. Dereflection does the same. In anticipatory anxiety you are fearfully
anticipating what will happen. It makes no difference, by the way, whether you want something to happen or
you want to avoid something happening. In either case you are trying to control the results. In hyper-
reflection you are worried about how well you will do.

Paradoxical intention and dereflection bring the awareness that you don’t need to be concerned with the
results. You can trust that whatever the results will be is good, and they are in any case not up to you.

Unit 5: Application And Evaluation Of Existential Psychotherapy, Case Study

Existential Therapy

Existential therapy is more a way of thinking than any particular style of practicing psychotherapy (Russell,
2007). It is neither an independent nor separate school of therapy, nor is it a neatly defined model with
specific techniques. Existential therapy can best be described as a philosophical approach that influences a
counselor’s therapeutic practice. This approach is grounded on the assumption that we are free and therefore
responsible for our choices and actions. We are the authors of our lives, and we design the pathways we
follow. The existential approach rejects the deterministic view of human nature espoused by orthodox
psychoanalysis and radical behaviorism. Psychoanalysis sees freedom as restricted by unconscious forces,
irrational drives, and past events; behaviorists see freedom as restricted by sociocultural conditioning. In
contrast, existential therapists acknowledge some of these facts about the human situation but emphasize our
freedom to choose what to make of our circumstances. A basic existential premise is that we are not victims
of circumstance because, to a large extent, we are what we choose to be. A major aim of therapy is to
encourage clients to reflect on life, to recognize their range of alternatives, and to decide among them. Once
clients begin the process of recognizing the ways in which they have passively accepted circumstances and
surrendered control, they can start on a path of consciously shaping their own lives.
Application: Therapeutic Techniques and Procedures

The existential approach is unlike most other therapies in that it is not technique oriented. There is a de-
emphasis on techniques and a priority given to understanding a client’s world. The interventions existential
practitioners employ are based on philosophical views about the essential nature of human existence. These
practitioners prefer description, understanding, and exploration of the client’s subjective reality, as opposed
to diagnosis, treatment, and prognosis (van Deurzen, 2002b).

Van Deurzen (1997) identifies as a primary ground rule of existential work the openness to the individual
creativity of the therapist and the client. She maintains that existential therapists need to adapt their
interventions to their own personality and style, as well as being sensitive to what each client requires. The
main guideline is that the existential practitioner’s interventions are responsive to the uniqueness of each
client (van Deurzen, 1997; Walsh & McElwain, 2002). Van Deurzen (2002a, 2002b) believes that the
starting point for existential work is for practitioners to clarify their views on life and living. She stresses the
importance of therapists reaching sufficient depth and openness in their own lives to venture into clients’
murky waters without getting lost. The nature of existential work is assisting people in the process of living
with greater expertise and ease. Van Deurzen (1997) reminds us that existential therapy is a collaborative
adventure in which both client and therapist will be transformed if they allow themselves to be touched by
life. When the deepest self of the therapist meets the deepest part of the client, the counseling process is at
its best. Therapy is a creative, evolving process of discovery that can be conceptualized in three general
phases.

Phases of Existential Counseling

During the initial phase of counseling, therapists assist clients in identifying and clarifying their assumptions
about the world. Clients are invited to define and question the ways in which they perceive and make sense
of their existence. They examine their values, beliefs, and assumptions to determine their validity. This is a
difficult task for many clients because they may initially present their problems as resulting almost entirely
from external causes. They may focus on what other people “make them feel” or on how others are largely
responsible for their actions or inaction. The counselor teaches them how to reflect on their own existence
and to examine their role in creating their problems in living. During the middle phase of existential
counseling, clients are encouraged to more fully examine the source and authority of their present value
system. This process of self-exploration typically leads to new insights and some restructuring of values and
attitudes. Individuals get a better idea of what kind of life they consider worthy to live and develop a clearer
sense of their internal valuing process. The final phase of existential counseling focuses on helping people
take what they are learning about themselves and put it into action. Transformation is not limited to what
takes place during the therapy hour. The therapeutic hour is a small contribution to a person’s renewed
engagement with life, or a rehearsal for life (van Deurzen, 2002b). The aim of therapy is to enable clients to
find ways of implementing their examined and internalized values in a concrete way between sessions and
after therapy has terminated. Clients typically discover their strengths and find ways to put them to the
service of living a purposeful existence.

Clients Appropriate for Existential Counseling

What problems are most amenable to an existential approach? A strength of the perspective is its focus on
available choices and pathways toward personal growth. For people who are coping with developmental
crises, experiencing grief and loss, confronting death, or facing a major life decision, existential therapy is
especially appropriate. Some examples of these critical turning points that mark passages from one stage of
life into another are the struggle for identity in adolescence, coping with possible disappointments in middle
age, adjusting to children leaving home, coping with failures in marriage and work, and dealing with
increased physical limitations as one ages. These developmental challenges involve both dangers and
opportunities. Uncertainty, anxiety, and struggling with decisions are all part of this process.

Van Deurzen (2002b) suggests that this form of therapy is most appropriate for clients who are
committed to dealing with their problems about living, for people who feel alienated from the current
expectations of society, or for those who are searching for meaning in their lives. It tends to work well with
people who are at a crossroads and who question the state of affairs in the world and are willing to challenge
the status quo. It can be useful for people who are on the edge of existence, such as those who are dying or
contemplating suicide, who are working through a developmental or situational crisis, who feel that they no
longer belong in their surroundings, or who are starting a new phase of life. Bugental and Bracke (1992)
assert that the value and vitality of a psychotherapy approach depend on its ability to assist clients in dealing
with the sources of pain and dissatisfaction in their lives. They contend that the existential orientation is
particularly suited to individuals who are experiencing a lack of a sense of identity. The approach offers
promise for individuals who are struggling to find meaning or who complain of feelings of emptiness.

Application to Brief Therapy

How can the existential approach be applied to brief therapy? This approach can focus clients on significant
areas such as assuming personal responsibility, making a commitment to deciding and acting, and expanding
their awareness of their current situation. It is possible for a time-limited approach to serve as a catalyst for
clients to become actively and fully involved in each of their therapy sessions. Strasser and Strasser (1997),
who are connected to the British school of existential analysis, maintain that there are clear benefits to time
limited therapy, which mirrors the time-limited reality of human existence. Sharp and Bugental (2001)
maintain that short-term applications of the existential approach require more structuring and clearly defined
and less ambitious goals. At the termination of short-term therapy, it is important for individuals to evaluate
what they have accomplished and what issues may need to be addressed later. It is essential that both the
therapist and client determine if short term work is appropriate, and if beneficial outcomes are likely.
Application to Group Counseling

An existential group can be described as people making a commitment to a lifelong journey of self-
exploration with these goals: (1) enabling members to become honest with themselves, (2) widening their
perspectives on themselves and the world around them, and (3) clarifying what gives meaning to their
present and future life (van Deurzen, 2002b). An open attitude toward life is essential, as is the willingness
to explore unknown territory. Recurring universal themes evolve in many groups and challenge members to
seriously explore existential concerns such as choice, freedom and anxiety, awareness of death, meaning in
life, and living fully.

Yalom (1980) contends that the group provides the optimal conditions for therapeutic work on responsibility.
The members are responsible for the way they behave in the group, and this provides a mirror for how they
are likely to act in the world. Through feedback, members learn to view themselves through others’ eyes,
and they learn the ways in which their behavior affects others. Building on what members learn about their
interpersonal functioning in the group, they can take increased responsibility for making changes in
everyday life. The group experience provides the opportunity to participants to relate to others in meaningful
ways, to learn to be themselves in the company of other people, and to establish rewarding, nourishing
relationship.

In existential group counseling, members come to terms with the paradoxes of existence: that life can be
undone by death, that success is precarious, that we are determined to be free, that we are responsible for a
world we did not choose, that we must make choices in the face of doubt and uncertainty. Members
experience anxiety when they recognize the realities of the human condition, including pain and suffering,
the need to struggle for survival, and their basic fallibility. Clients learn that there are no ultimate answers
for ultimate concerns. Although they confront these ultimate concerns, they cannot conquer them
(Mendelowitz & Schneider, 2008). Through the support that is within a group, participants are able to tap the
strength needed to create an internally derived value system that is consistent with their way of being.

A group provides a powerful context to look at oneself, and to consider what choices might be more
authentically one’s own. Members can openly share their fears related to living in unfulfilling ways and
come to recognize how they have compromised their integrity. Members can gradually discover ways in
which they have lost their direction and can begin to be more true to themselves. Members learn that it is not
in others that they find the answers to questions about significance and purpose in life. Existential group
leaders help members live in authentic ways and refrain from prescribing simple solutions.

Summary and Evaluation

As humans, according to the existentialist view, we are capable of self-awareness, which is the distinctive
capacity that allows us to reflect and to decide. With this awareness we become free beings who are
responsible for choosing the way we live, and we influence our own destiny. This awareness of freedom and
responsibility gives rise to existential anxiety, which is another basic human characteristic. Whether we like
it or not, we are free, even though we may seek to avoid reflecting on this freedom. The knowledge that we
must choose, even though the outcome is not certain, leads to anxiety. This anxiety is heightened when we
reflect on the reality that we are mortal. Facing the inevitable prospect of eventual death gives the present
moment significance, for we become aware that we do not have forever to accomplish our projects. Our task
is to create a life that has meaning and purpose.

As humans we are unique in that we strive toward fashioning purposes and values that give meaning to
living. Whatever meaning our life has is developed through freedom and a commitment to make choices in
the face of uncertainty. Existential therapy places central prominence on the person-to-person relationship. It
assumes that client growth occurs through this genuine encounter. It is not the techniques a therapist uses
that make a therapeutic difference; rather, it is the quality of the client–therapist relationship that heals. It is
essential that therapists reach sufficient depth and openness in their own lives to allow them to venture into
their clients’ subjective world without losing their own sense of identity. Because this approach is basically
concerned with the goals of therapy, basic conditions of being human, and therapy as a shared journey,
practitioners are not bound by specific techniques. Although existential therapists may apply techniques
from other orientations, their interventions are guided by a philosophical framework about what it means to
be human

Existential Therapy Applied to the Case of Stan

The counselor with an existential orientation approaches Stan with the view that he has the capacity to
increase his self awareness and decide for himself the future direction of his life. She wants him to realize
more than anything else that he does not have to be the victim of his past conditioning but can be the
architect in redesigning his future. He can free himself of his deterministic shackles and accept the
responsibility that comes with directing his own life. This approach emphasizes the importance of the
therapist’s understanding of Stan’s world, primarily by establishing an authentic relationship as a means to a
fuller degree of self-understanding. Stan is demonstrating what Sartre would call “bad faith” by not
accepting personal responsibility. The therapist confronts Stan with the ways in which he is attempting to
escape from his freedom through alcohol and drugs. Eventually, she confronts his passivity. She reaffirms
that he is now entirely responsible for his life, for his actions, and for his failure to take action. She does this
in a supportive yet firm manner.

The counselor does not see Stan’s anxiety as something negative but as a vital part of living with uncertainty
and freedom. Because there are no guarantees and because the individual is ultimately alone, Stan can
expect to experience some degree of healthy anxiety, aloneness, guilt, and even despair. These conditions are
not neurotic in themselves, but the way in which Stan orients himself and copes with these conditions is
critical.

Stan sometimes talks about his suicidal feelings. Certainly, the therapist investigates further to determine if
he poses an immediate threat to himself. In addition to this assessment to determine lethality, the existential
therapist may view his thoughts of “being better off dead” as symbolic. Could it be that Stan feels he is
dying as a person? Is Stan using his human potential? Is he choosing a way of merely existing instead of
affirming life? Is Stan mainly trying to elicit sympathy from his family? His therapist challenges Stan to
explore the meaning and purpose in his life. Is there any reason for him to want to continue living? What are
some of the projects that enrich his life?

`What can he do to find a sense of purpose that will make him feel more significant and alive? Stan needs to
accept the reality that he may at times feel alone. Choosing for oneself and living from one’s own center
accentuates the experience of aloneness. He is not, however, condemned to a life of isolation, alienation
from others, and loneliness. The therapist helps Stan discover his own centeredness and live by the values he
chooses and creates for himself. By doing so, Stan can become a more substantial person and come to
appreciate himself more. When he does, the chances are lessened that he will have a need to secure approval
from others, particularly his parents and parental substitutes. Instead of forming a dependent relationship,
Stan could choose to relate to others out of his strength. Only then would there be the possibility of
overcoming his feelings of separateness and isolation.

Follow-Up: You Continue as Stan’s Existential Therapist

Use these questions to help you think about how you would counsel Stan using an existential approach:

• If Stan resisted your attempts to help him see that he is responsible for the direction of his life, how
might you intervene?

• Stan experiences a great deal of anxiety. From an existential perspective, how do you view his
anxiety? How might you work with his anxiety in helpful ways?

• If Stan talks with you about suicide as a response to despair and a life without meaning, how would
you respond?

Contributions of the Existential Approach

The existential approach has helped bring the person back into central focus. It concentrates on the central
facts of human existence: self-consciousness and our consequent freedom. To the existentialist goes the
credit for providing a new view of death as a positive force, not a morbid prospect to fear, for death gives
life meaning. Existentialists have contributed a new dimension to the understanding of anxiety, guilt,
frustration, loneliness, and alienation.

One of the major contributions of the existential approach is its emphasis on the human quality of the
therapeutic relationship. This aspect lessens the chances of dehumanizing psychotherapy by making it a
mechanical process. Existential counselors reject the notions of therapeutic objectivity and professional
distance, viewing them as being unhelpful. This is put quite nicely by Vontress and colleagues (1999):
“Being an existential counselor would seem to mean having the courage to be a caring human being in an
insensitive world.
• The subjectivity of the client is a key focus in understanding significant life changes.

• A full presence and commitment of both therapist and client are essential to life-changing therapy.

• The main aim of therapy is to help clients recognize the ways in which they are constricting their
awareness and action.

• A key focus of therapy is on how clients actually use the opportunities in therapy for examining and
changing their lives.

• As clients become more aware of the ways in which they define themselves and their world, they can also
see new alternatives for choice and action.

• In situations involving transference and countertransference, therapists have an opportunity to model

taking responsibility for themselves while inviting their clients to do the same.

Limitations and Criticisms of the Existential Approach

A major criticism often aimed at this approach is that it lacks a systematic statement of the principles and
practices of psychotherapy. Some practitioners have trouble with what they perceive as its mystical language
and concepts. Some therapists who claim adherence to an existential orientation describe their therapeutic
style in vague and global terms such as self-actualization, dialogic encounter, authenticity, and being in the
world. This lack of precision causes confusion at times and makes it difficult to conduct research on the
process or outcomes of existential therapy

According to van Deurzen (2002b), the main limitation of this approach is that of the level of maturity, life
experience, and intensive training that is required of practitioners. Existential therapists need to be wise and
capable of profound and wide-ranging understanding of what it means to be human. Authenticity is a
cardinal characteristic of a competent existential practitioner, which is certainly more involved than
mastering a body of knowledge and acquiring technical skills. Russell (2007) puts this notion nicely:
“Authenticity means being able to sign your own name on your work and your life. It means you will want
to take responsibility for creating your own way of being a therapist”.

MODULE 5 : GROUP THERAPY AND FAMILY THERAPY

UNIT 1: GROUP THERAPY-STAGES IN THE DEVELOPMENT OF A GROUP: INITIAL,

TRANSITION, WORKING, FINAL.

Group therapy has the advantage of being more efficient than individual therapy because it serves more
people at the same time. Also, it offers some benefits that individual therapy does not.

Although groups vary in size, they frequently have between 6 and 10 members and 1 or 2 leaders. An
advantage of group therapy, when compared with individual therapy, is that participants can learn effective
social skills and try out new styles of relating with other members of the group (Corey, 2008).
Also, group members are often peers and provide, in some ways, a microcosm of the society that clients deal
with daily. Because groups exist to help members with a variety of problems, group members can offer
support to each other to explore and work on important problems. Also, groups help individuals become
more caring and sensitive to the needs and problems of others.

Although most groups are therapeutic in nature, focusing on the development of interpersonal skills or
psychological problems, others are more educational in function, teaching clients skills that may be useful in
their lives.

Theorists differ as to the value they place on group therapy. Some practitioners of theories view groups
primarily as an adjunct to individual therapy (for example, Jungian therapists), whereas others give central
importance to group therapy, often suggesting it as a treatment of choice (as do Adlerian, person-centered,
and gestalt therapists).

The four stages of group therapy are;

• Initial stage
• Transition stage
• Working stage
• Final or understanding stage

Group Therapy – Initial Stage

The first stage of a group is the initial stage. The purpose of the initial stage of a group is to establish
expectations of what the group is going to be like. These expectations include trust, roles, and goals.
Confidentiality and conflict need to be addressed immediately.

Also, any culture concerns must be dealt with. The counselors are there to explain the process and to support
each member when dealing with confrontation.

The group members must be participatory and involved.

Group Therapy – Transition Stage

The transition stage is a very difficult stage to get through. This stage comes after the initial stage and is
when most of the group members feel anxious about sharing their feelings with strangers. Some members
become defensive and resistant while others may be shy and fearful.

It is the role of the counselor to keep the transition period on track and as pleasant as possible. This stage can
be extremely uncomfortable for the counselor as they may be confronted, belittled, or attacked. If the
counselor is good at leading groups, the group will learn to trust and respect the counselor during this stage
by leaving the negativity out. this includes listening and giving advice.
Group Therapy – Working Stage

Once the transitional stage has settled, group members will start to feel comfortable enough to really get into
the deeper issues that the group was designed for. This is called the working stage.

Each member is able to explore their thoughts and emotions which may be triggered by someone else’s
words. The counselor in this stage will guide the group through this process using techniques and challenges
that bring out emotions.

A good counselor will know how to guide by using minimal words themselves. Counselors should be able to
read each group members verbal and non-verbal language. Group members in this stage need to be honest
about their feelings and not be afraid to speak their mind. They should not feel as though they are being
judged or criticized and if they are, it is the counselor’s job to address these issues.

Group Therapy – Final / Understanding Stage

Lastly, the final stage is when the group understands that they are no longer going to be together. This stage
allows the group members to reflect on their experience and decide how they will use the knowledge that
they acquired in their future occurrences.

This stage often comes with feelings of sadness and separation. During this stage, feedback is very
important. Group members will be encouraged to give feedback to other group members as well and in the
end it is up to each member to decide what to do with the experience that they received.

All groups are progressive and very unique. Some groups get a lot from their experience while others leave
empty handed. The success of a group is a combination of how each group member performed and how well
the group leader was able to lead and keep everyone on track.

Either way, group work as proven to be quite successful. The stages of the groups vary in length and
duration and also depend on the goals and purpose of each group. If a group leader leads a successful group
they will know because the group members will be able to change successfully with the help of the group
experience.

UNIT 2: PSYCHODRAMA, TRANSACTIONAL ANALYSIS, APPLICATION AND EVALUATION.

PSYCHODRAMA

Psychodrama, an experiential form of therapy, allows those in treatment to explore issues through action
methods (dramatic actions). This approach incorporates role playing and group dynamics to help people gain
greater perspective on emotional concerns, conflicts, or other areas of difficulty in a safe, trusted
environment. Developed by Psychiatrist Dr. Jacob Levy Moreno (1889‐1974).

EACH PSYCHODRAMA INCLUDES

The protagonist: The person whose story or issue is presented through guided dramatic action.
The auxiliary egos: Group members who assume the roles of significant others in the drama. This may
include significant people, objects or even aspects of the self or a person’s internal world, e.g. ‘my optimistic
self’ or ‘my internal critic.’

The audience: Group members who witness the drama and who may become involved in auxiliary roles.

The stage: The physical space in which the drama is conducted.

The director: The trained psycho-dramatist who guides participants through each phase of the session.

TECHNIQUES OF PSYCHODRAMA

Mirroring: The protagonist is first asked to act out an experience. After this, the client steps out of the scene
and watches as another actor steps into their role and portrays them in the scene.

Doubling: The job of the “double” is to make conscious any thoughts or feelings that another person is
unable to express whether it is because of shyness, guilt, inhibition, politeness, fear, anger, etc. In many
cases the person is unaware of these thoughts or at least is unable to form the words to express how they are
feeling. Therefore, the “Double” attempts to make conscious and give form to the unconscious and/or under
expressed material. The person being doubled has the full right to disown any of the “Double’s” statements
and to correct them as necessary. In this way, doubling itself can never be wrong.

Role playing: The client portrays a person or object that is problematic to him or her.

Soliloquy: The client speaks his or her thoughts aloud in order to build self-knowledge.

Role reversal: The client is asked to portray another person while a second actor portrays the client in the
particular scene. This not only prompts the client to think as the other person, but also has some of the
benefits of mirroring, as the client sees him- or herself as portrayed by the second actor.

GROUP THERAPY

Group therapy is a form of psychotherapy that involves one or more therapists working with several people
at the same time. This type of therapy is widely available at a variety of locations including private
therapeutic practices, hospitals, mental health clinics, and community centers. Group therapy is sometimes
used alone, but it is also commonly integrated into a comprehensive treatment plan that also includes
individual therapy. Group therapy meetings may either be open or closed . Open sessions, to which new
participants are welcome to join at any time. Closed session, to which only a core group of members are
invited to participate.

TYPES OF GROUP THERAPY

Group therapy can be categorized into different types depending on your mental health condition as well as
the clinical method used during the therapy. The most common types of group therapy include:

• Cognitive behavioral groups.

 • Interpersonal groups.
• Psycho-educational groups.
• Skills development groups.
• Support groups.

EVALUATION OF GROUP THERAPY

Group counselors evaluate their groups to determine whether group goals and objectives, including those of
individual participants, have been met. It is also important to know whether the group was implemented as
planned, because this affects its outcomes. Thus, evaluation helps group leaders determine the success of
their groups. The use of formal evaluation procedures and measurement instruments helps group leaders to
systematically organize, categorize, and review information on group process and outcomes. Evaluation
helps answer important questions about the degree to which these goals have been met as well as associated
questions concerning the quality of the group process and the efficacy of various interventions. Using
evaluation helps leaders and participants focus on the development of effective group processes and work
toward their individual and collective goals. Group counselors receive feedback that can be used to improve
their leadership skills.

TRANSACTIONAL ANALYSIS

Eric Berne (1910-1970) is the originator of transactional analysis (TA). He received an MD degree from
McGill University in Montreal in 1935 and then completed psychiatric training at Yale University. TA is
unique in its effort to avoid psychological jargon. The language of TA is easy to understand, using such
terms as parent, adult, child, strokes, games, rackets, decisions, and redecisions. Its use of clear, simple
language helped TA become attractive not only as a form of therapy but also as a self help approach. TA has
become an example of an emerging school of counseling that emphasizes the role of interpersonal
relationships in psychological functioning. One of the first major theories of counseling to focus on
interpersonal relations.

The interpersonal orientation is reflected in the name of the theory (i.e., transactional analysis suggests that
people can learn to understand and enhance the transactions and communication patterns between people).
TA possesses a rich tapestry of concepts with which to generate a theory of personality. The concepts that
can be used to provide an in-depth understanding of personality dynamics include stroking, the games
people play, and the four life positions.

Berne (1961, 1964) believed that people have the capacity to determine their own destiny but that few
people acquire the necessary self-awareness to become autonomous. Berne (1961) also stressed the
importance of early life experiences in personality development, suggesting that people develop scripts. At
that time that they follow throughout life. These scripts are derived from parental messages and other
sources, such as fairy tales and literature.
Key concepts :

The Interpersonal Perspective

TA is considered one the first major theories of counseling to emphasize the role of interpersonal functioning
in mental health. Many of the key concepts in TA are directed at understanding and enhancing interpersonal
relations. Prochaska and Norcross (2002) noted that in TA, psychopathology is understood as a
manifestation of intrapersonal (within the individual) and interpersonal (between people) forces. Regardless
of the origins of a psychological disorder, it is always interpersonal in terms of its expression. TA is
therefore usually conducted in group counseling to encourage interpersonal expression. In this format,
clients can gain valuable insights into their problems and learn how to use TA techniques and other
counseling strategies to overcome their difficulties.

Ego States

Berne identified the three ego states of parent, adult, and child. The parent ego state represents the person’s
morals and values. Attitudes, feelings, and behaviors we incorporate from our parents or caregivers. It can be
either critical or nurturing. The critical parent attempts to find fault, whereas the nurturing parent is
supportive and promotes growth. The adult ego state is the rational thinking dimension. Ability to process
and act based on present emotions and information. It is devoid of feelings and acts as a mediator between
the child and parent ego states. The child ego state is the uninhibited side of the personality, characterized by
a variety of emotions such as fear, happiness, and excitement. Thoughts, feelings, and behaviors we
experienced as a child. The child ego state has two dimensions: the free child and the adapted child. The free
child is uninhibited and playful, whereas the adapted child is rebellious and conforming. An egogram can be
used to assess the relative strengths and weaknesses of the various ego states. The egogram “reflects the
type of person one is, one’s probable types of problems, and the strengths and weaknesses of the
personality”.

Transactional Analysis

The concept of transactional analysis involves analyzing transactions between people. It entails assessing the
three ego states of parent, adult, and child of each person to determine whether the transactions between
people are complementary, crossed, or ulterior. Complementary transactions occur when each person
receives a message from the other person’s ego state that seems appropriate and expected. Crossed
transactions occur when one or more of the individuals receives a message from the other person’s ego state
that does not seem appropriate or expected. Ulterior transactions occur when a person’s communication is
complex and confusing. In these transactions, a person sends an overt message from one ego state and a
covert ulterior message from another ego state. The ulterior message can be communicated verbally,
nonverbally via body language, or by tone of voice.
Games People Play

Berne (1964) defined games as “an ongoing series of complementary ulterior transactions progressing to a
well-defined, predictable outcome”. These games are usually played at an unconscious level, with the people
involved unaware they are playing a particular game. Some of the games people can play are “Now I’ve got
you, you SOB,” and “Kick me.” Although game. Playing results in bad feelings for both players, it also
offers payoffs for the participants.

The Four Life Positions

Life positions are basic beliefs about self and others, which are used to justify decisions and bBerneehavior .
Berne (1961) suggested that in developing life scripts, people put themselves in the role of being “OK” or
“not OK.” They also tend to see others as basically friendly (OK) or hostile (not OK).
The following four possible life positions represent combinations of how people define themselves and
others:

1. “I’m OK, you’re OK” represents people who are happy with themselvesand others.

2. “I’m OK, you’re not OK” suggests people who are suspicious of others,could have a false sense of
superiority, or may be suffering from a mental disorder such as paranoia.

3. “I’m not OK, you’re OK” indicates people who have a low self conceptand feel inadequate in relation to
others.

4. “I’m not OK, you’re not OK” implies people who have themselves andlife and may even be suicidal.

Life Scripts

“A life plan made in childhood, reinforced by parents, justified by subsequent events, and culminating in a
chosen alternative”. It is an unconscious life plan. A major part of personality structure relates to the life
scripts that are created beginning in childhood. A life script is composed of parental messages-for example, a
parent saying, “You’re my darling angel” and complementary messages from other sources that may include
fairy tales, movies, and literature. These messages create a role that a person identifies with and acts out
throughout life.
For instance, a person could identify with the Superman character and I play the role of the “good person
who comes to the rescue” in interpersonal relations. Another possible life script is identifying with the
Cinderella character, which might lead to feelings of self-pity, being taken advantage of, and never having a
chance to get out and have fun.

Strokes

A stroke is defined as a unit of recognition. (Berne 1971). “A stroke is a unit of attention which provides
stimulation to an individual”. (Woollams and Brown: Transactional Analysis 1978). TA suggests that the
basic motivation for social interaction is related to the need for human recognition, or strokes. Strokes can
be physical, verbal, or psychological and can be positive, negative, conditional, or unconditional. Positive
strokes tend to communicate affection and appreciation and are essential to psychological development. A
negative stroke is one experienced as painful.
A conditional stroke relates to what you do.
An unconditional stroke relates to what you are.
TA attempts to identify what types of strokes are important to clien and encourages them to take an active
role in getting these strokes.

The Counseling Process

The ultimate goals of TA are to help clients become autonomous, selfaware, and spontaneous and have the
capacity for intimacy (Berne, 1961). Following are some of the short-term goals TA uses to help clients
achieve these ultimate goals: Making new decisions, called redecisions, regarding their behavior and
approach to life
Rewriting their life script so they feel OK about themselves and can relate effectively to others
Ceasing to play games that confuse communication and interfere with authentic interpersonal functioning.
Understanding their three ego states of parent, adult, and child and how they can function in an effective and
complementary fashion.
Avoiding communicating in a manner that promotes crossed or ulterior transactions.
Learning how to obtain and give positive strokes
The counseling process in TA is educative in nature.
The therapist takes on the role of teacher, providing clients information on how to use the TA concepts.
TA emphasizes cognition in its approach by showing clients how they can use their intellect to apply TA
principles to overcome mental disorders.
The counseling process in TA is also active, in that it emphasizes the importance of clients doing something
outside of counseling via homework assignments.

In addition, TA relies on the use of a counseling contract, which the therapist and the client develop together.

The contract is very specific in identifying the counseling goals, treatment plan, and roles and
responsibilities for achieving these goals.

TA can be a useful, visual theory that a leader can use to educate and frame the behaviors of group members.

By educating the members on the different ego states, members can reflect on their past (Parent, Child) and
bring it into the present (Adult) and identify where some of these behaviors and thoughts are coming from.

Transactional analysis is considered to be one effective method of enhancing relationships with oneself and
with others.

Techniques

Structural analysis is a technique that helps clients become aware of their three ego states and learn to use
them effectively.

Transactional analysis helps clients learn to communicate with complementary transactions (e.g., adult to
adult).

Script analysis is a process that explores the type of life script the client has developed and how it can be
rewritten in a more effective manner.

Analysis of games involves clients identifying what games they play and how the games interfere with
interpersonal functioning.

UNIT 3: FAMILY THERAPY-FAMILY ASSESSMENT, FAMILY LIFECYCLE, FAMILY

GENOGRAM

FAMILY THERAPY

A form of psychotherapy that focuses on the improvement of interfamilial relationships and behavioral
patterns of the family unit as a whole, as well as among individual members and groupings, or subsystems,
within the family. Family therapy is the branch of psychiatry which sees an individual's psychiatric
symptoms as inseparably related the family in which he lives. Thus the focus of treatment is not on the
individual, but the family.

HISTORY

Family therapy is a relatively new development that came about in the mid twentieth century as an
adjunction to individual treatment and refers to the treatment of the family as whole. When the family
therapy movement initially arose in the mid-1900s, it was considered revolutionary. Specifically, they
opposed the widely accepted notion that psychological symptoms originated from solely within the mind of
the individual. Instead, they believed that psychological symptoms were a by product of the dysfunctional
families in which the clients lived. One individual may exhibit the symptoms, but the problem actually
belonged to the entire system.

1910s -Richmond (1917) published Social Diagnosis. An early social worker, she advocated for including
fathers in welfare interviews and the family in treatment; she paid particular attention to emotional bonding
and cohesion. 1920s Adler established more than 30 child guidance clinics in Vienna; Adlerian-oriented
clinics were also established in the United States. The Marriage Consultation Center in New York opened its
doors in 1929, thanks to the work of Abraham and Hannah Stone.

1930s Ackerman (1938) published The Unity of the Family in the Archives of Pediatrics. Rogers (1939)
published Clinical Treatment of the Problem Child, in which he acknowledged the impossibility of having
lasting effects on children’s problems without involving parents. 1940s The American Association of
Marriage Counselors is formed in 1941 (later to become the American Association for Marriage and Family
Therapy in 1978). Bowen began clinical work in 1946 at the Menninger Clinic, treating schizophrenic
children. His work led to rich theory development emphasizing family member differentiation and triangles.
Levy (1943) and Fromm-Reichmann (1948) began attending to the mother’s role and parenting style when
treating schizophrenic children. Whitaker began conducting biannual conferences in 1946 where colleagues
met to discuss and observe one another’s work with families. Bowlby (1949) began using family interviews
as a secondary form of treatment to complement his individual approach.

In his Field Theory manuscript (1951), Lewin established that groups are more than the sum of their parts.
Don Jackson (1954) began documenting patterns of shifting disturbance among family members: when
treatment was successful with one family member, symptoms would arise in another. Bateson, Haley,
Weakland, and Jackson focused on schizophrenic communication among family members, publishing
Toward a Theory of Schizophrenia (1956).Lidz, Cornelison, Fleck, and Terry (1957) began attending to the
role fathers and marital relationships play in schizophrenic families. Whitaker (1958) developed an
experiential approach for working with families at the Atlanta Psychiatric Clinic. Jackson and Weakland
(1959) first published the notion that symptoms preserve homeostasis among family members, emphasizing
that problems occur in contexts.Satir (1964), a contributing member of the Palo Alto Group published
Conjoint Family Therapy Minuchin began his career, focusing on family patterns and structures with urban
poor families. He was named the director of the Philadelphia Child Guidance Clinic in 1965. In 1967
Selvini-Palazzoli and colleagues form the Institute for Family Studies in Milan.

The 1970s and 1980s are referred to as the golden age of family therapy, when treatments, centers,
theoretical concepts, and core publications flourished (Nichols & Schwarts, 2007, p. 27). This time period
was characterized by the excitement and optimism that new and radical ideas bring. While inspiration was
gathered from these innovative and creative therapists, the originality of their concepts began dissipating
over the years, and the energy they generated in the 1970s and 1980s leveled off. While there continue to be
many followers of original family therapy models, new energy is infiltrating the field via critiques and
developments from evidence-based, feminist, multicultural, and postmodern perspectives.

Regardless of approach, the roots of family therapy lie in fundamental systemic concepts.

Family therapists use a wide variety of theoretical philosophies and techniques to bring about change in
dysfunctional patterns of behaviour and interaction, some therapists may focus on the here and now.
Families are composed of units of individuals engaged in continuing interrelationships that significantly
influence mutual behaviors. Pathology in one member can have a determining effect on the entire family
system, which, in turn, will modulate the degree and form of individual dysfunctions. Therapeutic
interventions therefore must concern themselves with the organizational distortions of the family as a
system. It follows from this that correction of psychopathology in any one or more members presupposes
restructuring of the family organization, which is, to say the least, a difficult undertaking.

GOALS

Desirable goals of family therapy include resolution of conflicts improved understanding and
communication among family members, enhanced family solidarity, and greater tolerance for and
appreciation of individuality (Zuk,1974).

To reduce dysfunctional behaviour of individual family members.

To resolve or reduce intra family relationship conflicts.

To improve family communication skills. To heighten awareness and sensitivity to other family members to
meet their needs.

To strengthen the family ability to cope with the major life stressors and traumatic events.

To improve integration of the family system into the social system.

ASSESSMENT

Family therapy usually begins with a thorough assessment of the family’s functioning. In fact, the
assessment process continues throughout therapy. Assessment practices may vary according to the particular
approach to family therapy that the therapist uses, but they typically focus on such issues as defining the
presenting problem, understanding family members’ beliefs about its causes, and appreciating the
relationships within the family (Griffin, 2002).

An important initial step in assessing a family is to assess who, exactly, the family includes. The
configuration of families can differ greatly across cultures. Some clients may include numerous “aunts,”
“uncles,” “cousins,” or other relatives who are not technically related but unquestionably function as family.
Others may exclude close relatives who they see as extraneous or outcast from the family. Simple questions
such as “Who do you consider family?” or “Who lives with you?” can go a long way toward helping the
clinical psychologist understand the client’s perception of family (Fontes, 2008; Grieger, 2008).

One helpful technique for understanding the family configuration and relationships within the family is the
genogram. Another essential part of the family assessment process is an appreciation of the family’s current
developmental stage. It is unfortunate but undeniable that clinical psychologists assessing a family must pay
attention to the issue of abuse and violence. As the assessment phase leads into the therapy phase, it can be
critical for the family therapist to persuade the family that the problem is systemic rather than individual.

Often, families enter the therapy process with an identified patient or a family member whose symptoms are
most obvious or problematic. They may believe that the problem is contained within the identified patient
and that the role of other family members is minimal or nonexistent. In fact, they may contact the therapist
seeking individual therapy for a son, daughter, or other family member and have no expectation at all for
family therapy. With family members successfully “on board,” family therapy can commence with positive
expectations.

ISSUES

It is vital in family therapy to understand and to respect the cultural background. The therapist must not
deviate much from the accepted cultural system since this will offend some of the members and create
resistance. Guilt feelings, defensiveness, indignation and attacking manoeuvres may give way to more
rational forms of reaction when even a partial picture of the dynamics unfolds itself.

Another important point is the matter of establishing a verbal contract regarding the areas to be dealt with
and the hoped for objectives in order to avoid later misunderstanding. Great tact is needed in avoiding the
show of favoritism since members usually attempt to woo the therapist to their side in the arguments that
ensue. A delicate point is how to handle personal “secrets” revealed to the therapist during an individual
session, the exposure of which may have an unforeseen effect, good or bad, on the family. It is best that
then therapist treat the secret as confidential information and that members themselves make the decision
when, if ever, to reveal what they dread bringing to light.

Hostility that emerges in family therapy often derails the therapeutic process. Usually the hostility is directed
at a selected member who may be the identified patient or a parent who may be blamed for the events
leading to the crisis. The most difficult problem that the therapist will encounter in family therapy is the
need and the determined effort (despite protests avowing a desire for change) to maintain the status quo.Yet
there are healthy elements that exist in each family on which the therapist can draw.

It is important to emphasize these in therapy rather than the prevailing psychopathology. Family therapists
face a dilemma regarding diagnosis: DSM diagnoses apply to disordered individuals, but they work with
disordered family systems.

As mentioned earlier, Family therapy is a type of treatment designed to help with issues that specifically
affect families' mental health and functioning. It can help individual family members build stronger
relationships, improve communication, and manage conflicts within the family system. Some of the primary
goals of family therapy are to create a better home environment, solve family issues, and understand the
unique issues that a family might face.

FAMILY LIFE STAGES

Monica McGoldrick and Betty Carter in their respected work on the family life cycle describe its underlying
processes to be negotiated by

“the expansion, contraction, and realignment of the relationship system to support the entry, exit, and
development of family members in a functional way” (2003, 384).

Major life-cycle transitions are marked by fundamental changes in the family system itself (second order
changes) rather than rearrangements within the system (first order changes).

YOUNG ADULTHOOD

The “young adulthood” stage is defined as the period between the individual separating from the family and
forming a family of his or her own. This stage varies for families depending on socioeconomic factors,
cultural values, and job opportunities as well as on the health status of the individual and family members.

This phase of the life cycle includes those individuals in their 20s who have established separate dwellings
from their families, are post college or post military, and, for the most part, are financially independent. It
also includes those individuals who bypassed this stage by marrying young and divorcing within a few years
as well as those who are living together without formal commitment.

It may also include adult children of any age who have never left home and who, along with their families,
engage in the tasks associated with this phase of development. Just as physical separation from the family is
not synonymous with emotional differentiation from the family, remaining in the home because of cultural
values or limited economic and educational opportunities does not necessarily mean foreclosure of identity
formation. In many working-class families from diverse cultures, unmarried adult children are expected to
live at home and contribute a portion of their earnings to the family . Increasing costs of higher education
and limitations in the job market have forced middle-class children to prolong their dependence on the
family, especially for housing.
The key tasks for the individual at this stage of the life cycle are to become emotionally and financially
responsible. To achieve these goals the individual must differentiate the self from the family of origin;
develop intimate peer relationships; and establish vocational identity, work, and financial independence .
The essential task for the family is to support the young adult in her quest for identity and independent
functioning and to accept her adoption of new values and life choices.

In this phase, problems may occur because of perceived or actual expectations that the adult child will
comply with familial life plans and wishes at the expense of her own. Since the expectations may not come
directly from parents but indirectly from grandparents or other extended kin, or be prescribed by the
community , it is necessary to think more broadly than the nuclear family when assessing the dynamics of
the family.

BECOMING A COUPLE: FORMING PARTNERSHIP AND MARRIAGE

The stage of the new couple is one of the most complex and difficult transitions of the family life cycle
(McGoldrick et al., 1999). The two partners must renegotiate a variety of issues previously defined by each
as individuals and by their respective families and cultures. They must decide on the rules that will govern
their relationship and the boundary that will define them as a couple.

Recent trends, such as unmarried couples establishing households and the formation of committed
homosexual partnerships, require us to explore models of partnership other than traditional marriages. The
unifying element to these diverse couples is that they form a partnership with a goal of sharing a future
together and deciding whether to have children.

The new couple must successfully resolve are

(1) making a commitment to the marital or partnership dyad

(2) realignment of relationships with the extended family and friends to take the partner into
consideration.

(3) balancing the needs of the individual with those of the couple.

The ability of the partners to make a commitment to each other will be determined by the extent to which
they have achieved emotional differentiation from the family of origin and established an identity of their
own. Each partner should view the relationship as a means of enriching one’s self, not completing one’s self.
The couple also needs to achieve a balance between the need for intimacy and the need for individual
fulfillment. Finally, each has to grapple with expectations from parents and siblings in view of the partner’s
expectations.

FAMILY WITH YOUNG CHILDREN

This stage is a time for family expansion. New members are added, requiring more physical and emotional
space and additional financial resources. New pursuits regarding living conditions, work status, and/or
career development are explored. Even when individual and family are both progressing and basic family
relationships are positive.

The three main tasks of the family with young children are

(1) adapting the marital system to include children;

(2) sharing in childrearing, financial, and household responsibilities; and(3) realignment of familial
relationships to include new roles: parents, grandparents, siblings, aunts, uncles, and so on.

Another key issue at this stage of the family with young children is the formation and strengthening of the
sibling system. In this phase, siblings learn how to share, build alliances, and support each other.

Questions regarding sibling conflicts are commonly presented in medical visits. Sibling competition is
determined not only by the availability of parents but also by how parents relate to the children.

The birth of a child requires a major realignment of family relationships. When the first child is born,adults
move up a generation and assume caretaking responsibilities for the young generation. The couple’s own
emotional and sexual intimacy may be placed on the back burner as the couple struggles to meet the
demands of parenthood.

Parenting styles are defined and differences related to culture and family of origin may become pronounced
with the birth of a child. Additionally, the couple or single parent may have to renegotiate boundary issues
with the families of origin to accommodate the child’s relationship to grandparents and other extended kin.
Grandparents have to move to a less central role, supporting parents’ authority. In the case of single parents,
grandparents’ and other family members’ roles are negotiated differently, as they are most often needed for
caretaking functions. Depending on cultural and class background, older children are expected to help care
for younger siblings.

A crucial issue during this stage of the life cycle is the disposition of childcare responsibilities and
household chores. The lack of social provision for adequate childcare in our society and the decrease of
social support in general often cause children to be left without proper attention or force families, especially
women, to make sacrifices to attend to family needs.

FAMILY WITH ADOLESCENT CHILDREN

Adolescence calls for major changes in the family, involving a shift of the adolescent’s position within the
family and renegotiation of relationships at many levels: parent–child, grandparent–parent, husband–wife,
and others.

This is a time of intense emotions and polarizations between family members, especially between the
parents and the defiant adolescent. These conflicts typically involve a third person, such as a grandparent, a
sibling, an aunt or uncle, a friend, and, frequently, a helping professional.
As the adolescent searches for autonomy and independence—a life space beyond the boundaries of the
family—parental authority and control are challenged. Old rules and established values are questioned,
while new ideals and mores are proposed by the adolescent, causing conflict and challenging the stability of
the family. This process is less tumultuous when parents learn to be flexible enough to allow the youngster
room for new experiences and autonomy, and yet know when to be firm and clear about limits in order to
provide a point of reference for the experimenting adolescent. Developing flexible boundaries that allow the
adolescent to move in and out, to be dependent at times of vulnerability, and to be independent to the point
of taking serious risks is a stressful task for parents, especially in times of increasing violence in many
communities.

Parents might also feel hurt or rejected by statements such as “I don’t want to be like my father or mother”
or “Get out of my life,” which represent the adolescent’s attempts to differentiate from the family and define
his or her self-identity.

The youngster’s ability to differentiate from others will depend on how well she can handle intense emotions
in the context of conflicting social expectations about sexual roles and norms of behavior dictated by family,
community, peers, and the media.

The physical and sexual changes that take place at this stage have a dramatic effect on how adolescents see
and evaluate themselves and radically alter how they are perceived by others. It is not uncommon for family
members to experience confusion and fear when adolescents begin to express their sexual interests.

The process of identity formation at this stage involves the adolescent’s gender and sexual identity.

Considering society’s bias toward heterosexuality, the physician has to be attentive to the particular needs of
gay, lesbian, and bisexual adolescents, whose conflicts of identity might be expressed through somatization,
repeated visits for unspecific complaints, suicidal ideation, or depressive symptoms. Ethnic minority youths
also face conflicts related to their experiences of racism or other prejudice in dating, groups, schools, and
work situations.

Families that have the most difficulty letting go of their children are those that have come to rely on them for
their support . In single-parent or divorced families, the oldest child often becomes an essential partner to the
parent, caught in a parentified position. The adolescent’s separation from the family becomes especially
difficult if the parent is not able to restructure his life and build new supports.

The independence of the youngest adolescent, the last to move on, can also be complicated when the marital
bond is fragile and the parents avoid dealing directly with their issues.

The adolescent’s development does not depend solely on individual abilities and family competence but, to a
large extent, on external factors: the economy, the availability of educational and occupational opportunities,
community support, and the influence of the media, to name a few. Many families are disempowered by the
intrusion of social institutions and, on occasion, well-intended professionals, which result in clashes of
cultural values that undermine their authority as parents. Their disciplinary approaches are criticized or
misunderstood, their cultural legacies are devalued, and determinations about their lives are made without
proper family participation.

The adolescent’s demands for more autonomy and independence tend to activate unresolved conflicts the
parents have within themselves, with each other, and with their own parents. In this regard, questioning
parents about their own adolescence will often promote understanding and healing across generations and
defuse parent–child conflicts.

FAMILY AT MIDLIFE

At this stage the renegotiation of the marital relationship is a central task. As the parents become less
involved with raising children, they can pay more attention to their own needs, assessing their satisfaction
with their personal lives, considering new directions, and often revising their marital arrangement. The
decision to pursue one’s own needs may pose a threat to the conjugal relationship or to the partner who
might expect the marriage to be centre stage.

There is a tendency for men and women to be going in opposite directions psychologically at this point
(McGoldrick, 1999). Men tend to become more interested in relationships and intimacy, while women’s
energies are more directed toward personal needs and experiences in the outside world, often resulting in
marital conflicts and estrangement. When one partner is disabled or significantly older, the disparity between
each spouse’s needs may strain the relationship. When the marital bond has been established on principles of
mutual care and respect, and companionship is valued by both partners, the couple has a better chance to
renegotiate their needs despite inevitable conflicts.

This transition has been seen negatively as a time of physical and psychological distress for women. It is at
this time that women typically experience menopause, to which their reaction will depend largely on their
social status and opportunities. When women have more control over their lives, they are less likely to
become anxious and symptomatic. Certainly, women whose only source of affirmation has been mothering
are more vulnerable to depression, though they usually recover after a period of adjustment. A significant
characteristic of this stage is the great number of entries and exits of family members: children leave, but the
family is enlarged by the addition of in-laws; grandparents become ill and die, while grandchildren expand
the family.

The renegotiation of the parent–child relationship as the child moves into adulthood is another important
task at this stage. For many families this is an easy and rewarding period, marked by the possibility of
forming positive relationships with grown children and sharing their accomplishments. For others, the
changing economics in our society have made launching difficult, when their adult children cannot support
themselves.
This group has been referred to as “the sandwich generation.” They are pressed by the needs of the young,
who may still be financially and emotionally dependent on them, and are also pressed by the needs of their
aging parents, who become increasingly dependent Women are almost always the main caretakers in the
family. The physical and emotional demands of caretaking make them more vulnerable to somatic and
psychological problems. When a family member has a flareup of a chronic illness or does not respond to
treatment, the physician should be alert to life-cycle issues, including burnout of the caretaker. Stress at this
stage may also signal unresolved issues from earlier life-cycle

stages.

FAMILY AT LATER LIFE

The family in later life is faced with the painful task of accepting and adjusting to the physical decline of
their older members. Adult children are required to make a shift in relational status with their aging parents
to reorganize their lives to provide them with emotional and physical support. Responses of anxiety, anger,
and confusion are not uncommon, as the younger generation tries to cope with the new situation. Past
unresolved family issues might emerge, amplifying these emotional reactions.

In general, most aging parents are reluctant to ask family members for support in an effort to maintain their
dignity and to avoid being seen as a burden in their children’s lives. However, some older adults become
totally dependent on the next generation, placing excessive demands on their children. Given time
constraints, financial pressures, and conflicting multiple demands on families these days, they are especially
challenged to fulfill their caregiving obligations to the older generation. When parents have been
independent and self-sufficient, adult children may fail to recognize a parent’s needs and delay making the
required shift of status in their relations with the ailing or aging parent.

Financial and caregiving demands are a major source of stress for the middle generation, at a stage when
they still might be involved with childrearing responsibilities as well as facing financial pressures related to
older children’s education and their own life changes. Geographic distance is often an additional factor
limiting availability of support and straining family relations. Women are especially burdened by becoming
the sole or main caregiver for their relatives. Physicians need to be alert to the high incidence of depressive
and somatic symptoms among caregivers. Grandparenthood can offer a “new lease on life” as it brings
opportunities for meaningful interactions and facilitates resolution regarding one’s mortality (Walsh, 1999).
The acceptance of one’s life and death, a major task at this stage, occurs when the individual is able to
achieve a sense of integrity versus despair

Death and terminal illness of the older generation are particularly emotional events for adult children, as
they are forced to face their own mortality and aging (Rolland, 1994). For widows and widowers, feelings of
loss, disorientation, and loneliness contribute to an increase in death and suicide rates during the first year,
especially for men. Advances in medical technology have extended life expectancy and allowed people to be
more functional to enjoy life into older age. Physical and psychological wellbeing will also depend on
financial security, access to health services, and social contacts.

GENOGRAM

A genogram is a popular tool graphic tool that provides detailed information on the interpersonal
relationship within a family. It takes into account the past and present aspects that impact the current
situation

Helpful for can be utilized to better assess the circumstances and the reaction of the people involved in a
problem.

In formulating interventions and devising ways for reconciliation and mending family relationship

Genograms depict how a problem has evolved and how it continues to affect the whole family.

The genogram can introduce cognitive change as it develops insight, provides awareness, and expands
understanding of the causality of longstanding issues within the family.

Creating a genogram has been reported to promote empathy and intimacy as clients understand more about
the narrative behind a family member’s current attitude and the issues they face.

Initiates a change in behaviour

One of the reasons why patients feel powerless to take control of their family relationship is due to the way
they react to the things their relatives say or do.

Revealing behavioral patterns that repeatedly lead to the same problems the clients face can help widen their
perspective. With this, they’ll be more open to change their behavior, take control of their emotions, and
experiment on a new lifestyle.

Points out strengths

A genogram isn’t all about pointing the weaknesses in the family relationship. It can also be used to identify
strengths that will act as the client’s support toward recovery from trauma or similar stressful circumstance

UNIT 4: MAJOR APPROACHES AND TECHNIQUES USED IN :

SYSTEMIC FAMILY THERAPY, STRUCTURAL FAMILY THERAPY, STRATEGIC FAMILY

THERAPY

SYSTEMIC FAMILY THERAPY

Theory of Family Systems Bowen’s theory of family systems is based on the individual’s ability to
differentiate his own intellectual functioning from feelings. This concept is applied to family processes and
the ways that individuals project their own stresses onto other family members. In particular, Bowen
examined the triangular relationship between family members such as the parents and a child. How
individuals cope with the stress put on them by the way other family members deal with their anxietiesis an
important issue for Bowen. He is particularly concerned with the ways children may distance themselves
emotionally, and also physically, from their families. One of the most significant aspects of Bowen’s theory
is how families can transmit over several generations psychological characteristics that affect the interaction
of dysfunctional families. Bowen’s view of multigenerational transmission and family interactions provides
an original way of viewing the family. Eight concepts form the core of his system of family therapy.

Differentiation Of Self : Being able to differentiate one’s intellectual processes from one’s feeling
processes represents a clear differentiation of self. Bowen recognizes the importance of awareness of
feelings and thoughts, particularly the ability to distinguish between the two. When thoughts and feelings are
not distinguished, fusion occurs. A person who is highly differentiated (Bowen, 1966) is well aware of her
opinions and has a sense of self. In a family conflict, people who are able to differentiate their emotions and
intellects are able to stand up for themselves and not be dominated by the feelings of others, whereas those
whose feelings and thoughts are fused may express a pseudo self rather than their true values or opinions.
For example, in a family with 10- and 12-year-old girls, the 10-year-old may have a mind of her own and be
clearer about what she will and will not do (differentiated) than the 12-year-old (fused). The 12-yearold who
is not able to express herself accurately (pseudoseli) may cause problems in relating that affect the whole
family. If there is poor differentiation, triangulation is likely to take place.

Triangulation : When there is stress between two people in a family, they may be likely (Bowen, 1978) to
bring another member in to dilute the anxiety or tension, which is called triangulation. When family
members are getting along and are not upset, there is no reason to bring a third person into an interaction.
Bowen believes that when there is stress in the family, the least-differentiated person is likely to be drawn
into the conflict to reduce tension (Goldenberg & Goldenberg, 2008). Triangulation is not limited to the
family, as friends, relatives, or a therapist may be brought into a conflict.

For Bowen (1975), a two-person system was unstable, and when there is stress, joining with a third person
reduces the tension in the relationship between the original two people. The larger the family, the greater the
possibility for many different interlocking triangles. Stepfamilies are likely to have many possibilities for
triangles (Cauley, 2008). One problem could involve several triangles, as more and more family members
are brought into the conflict. Bringing a third family member into a conflict (triangulation) does not always
reduce the stress in the family. Stress reduction depends, in part, on the differentiation level of the members
involved. For example, if two children who are arguing bring in a third member of the family (brother,
mother, or uncle), the tension between the two children diminishes if the other person does not take sides
and helps to solve the problem. If the person becomes excited or acts unfairly, however, stress between the
two children may continue (Nichols, 2008). From a therapeutic point of view, it is very important that the
therapist triangulates in a clear and differentiated way with a couple while attending to patterns of
triangulation in the family.
Nuclear Family Emotional Systems: The family as a system that is, the nuclear family emotional system is
likely to be unstable unless members of the family are each well differentiated. Because such differentiation
is rare, family conflict is likely to exist. Bowen (1978) believed that spouses are likely to select partners with
similar levels of differentiation. If two people with low levels of differentiation marry, it is likely that as a
couple they will become highly fused, as will their family when they have children.

Family Projection Process : When there are relatively low levels of differentiation in the marriage partners,
they may project their stress onto one child-the family projection process. In general, the child who is most
emotionally attached to the parents may have the least differentiation between feelings and intellect and the
most difficulty in separating from the family (Papero, 1983, 2000). For example, a child who refuses to go to
school and wants to stay home with his parents can be considered to have fused with his parents. How
intense the family projection process is depends on how undifferentiated the parents are and on the family’s
stress level (Bitter, 2009). The “problem child” can respond to the stress of his undifferentiated parents in a
variety of ways.

Emotional Cutoff :When children receive too much stress because of over involvement in the family, they
may try to separate themselves from the family through emotional cutoff. Adolescents might move away
from home, go to college, or run away. For younger children and adolescents, it may mean with- drawing
emotionally from the family and going through the motions of being in the family. Their interaction with
parents is likely to be brief and superficial. A child experiencing an emotional cutoff may go to her room not
so much to study but to be free of the family conflict.

Such a child may deal with everyday matters but withdraw when emotionally charged issues develop
between parents. In general, the higher the level of anxiety and emotional dependence, the more likely
children are to experience an emotional cutoff in a family (Titelman, 2008).

Multigenerational Transmission Process : In his approach to work with families, Bowen (1976) looked
not just at the immediate family but also at previous generations (Kerr, 2003). As mentioned previously, he
believed that spouses with similar differentiation levels seek each other out and project their stress and lack
of differentiation onto their children. If Bowen’s hypothesis was correct, then after six or seven generations
of increasingly fused couples, an observer could find highly dystunctional families who are vulnerable to
stress and to lack of differentiation between thoughts and feelings. Naturally, Bowen recognized that spouses
do not always marry at their own exact level of differentiation. In the concept of the multigenerational
transmission process, the functioning of grandparents, great-grandparents, great-aunts, great-uncles, and
other relatives may play an important role in the pathology of the family. To give an example, a great-
grandfather who was prone to emotional outbursts and experienced depression may affect the function of the
grandmother, who in turn affects the functioning of the father, who may in turn have an impact on the
psychological health of the child. Other issues besides differentiation affect family functioning.
Sibling Position: Bowen believed that birth order had an impact on the func tioning of children within the
family. Relying on the work of Toman (1961), he believed that the sibling position of marriage partners
would affect how they perform as parents. Concerned less with actual birth order than with the way a child
functioned in the family, Bowen felt that how one behaved with brothers and sisters had an impact on how
one acts as a parent. For example, an oldest brother may have taken care of his younger brother and sister in
his family and thus may take on a role of responsibility with his children, this might be particularly true if
his wife did not take much responsibility with her siblings, as could be the case if she is the youngest child
(Bitter, 2009).

Societal Regression: Bowen extended his model of family systems to societal functioning Just as families
can move toward undifferentiation or toward individuation, so can societies. If there are stresses on
societies, they are more likely to move toward undifferentiation. Examples of stresses could be famine, civil
uprisings, or population growth. To extend Bowen’s model to societies, leaders and policymakers should
distinguish between intellect and emotion when making decisions and not act on feelings alone.

Bowen’s theory of family structure goes beyond the immediate family system to cross generations. His
interest was in how the personality of individuals affects other members in the family. He was particularly
interested in the individual’s ability to differentiate intellectual processes from feelings and the impact of this
individual’s ability on other family members. These views bear a direct relationship to his beliefs about the
goals of family therapy.

THERAPY GOALS

In attending to the goals of therapy, Bowen was interested in the impact of past generations on present
family functioning. As he set goals in working with families, he listened to the presenting symptoms and,
even more important, to family dynamics as they relate to differentiation of family members and to
triangulation. More specifically, he sought to help families reduce their general stress level and to find ways
to help family members become more differentiated and meet their individual needs as well as family needs
(Kerr & Bowen, 1988).

TECHNIQUES OF BOWEN’S FAMILY THERAPY

In Bowen’s system of family therapy, an evaluation period precedes therapeutic intervention. The process of
taking a family history is aided by the use of a genogram, a diagram of the family tree that usually includes
the children, parents, grandparents, aunts and uncles, and possibly other relatives. In bringing about family
change, Bowen used interpretation of his understanding of intergenerationtional factors. In his writings,
Bowen (1978) saw himself as a coach, helping his patients analyze the family situation and plan strategies
for events that are likely to occur. In this work, he often focused on detriangulation, a way of changing
patterns of dealing with stress. The effectiveness of coaching, interpreting, and detriangulating depends on
effective evaluation of family history.
Evaluation interview : Characteristic of Bowen’s therapeutic work are objectivity and neutrality. Even in
the initial telephone contact, Bowen (Kerr & Bowen, 1988) warned against being charmed into taking sides
in the family or in other ways becoming fused with the nuclear family emotional system. The family
evaluation interviews can take place with any combination of family members. Sometimes a single family
member can be sufficient if that person is willing to work on differentiating his own feelings and intellectual
processes rather than blaming other family members.

In taking a family history, Bowen attended to triangles within the family and to the level of differentiation
within family members. Because there is usually an identified patient, Bowen family therapists listen for
ways in which family members may project their own anxieties onto that patient. How that patient responds
to the family is also important. Is he emotionally cut off from other family members? In taking the family
history, the therapist attends to relationships within the family, such as sibling position, but also relationships
within the parents families of origin. Because intergenerational patterns can get complex, therapists may use
a genogram to describe family relationships.

Genograms : The genogram is a method of diagramming families and includes sig nificant information
about families, such as ages, sex, marriage dates, deaths, and geographical locations. Genograms not only
provide an overview of the extended family but also may suggest patterns of differentiation that reach back
into a family of origin and beyond. A genogram provides the opportunity to look for emotional patterns in
each partner’s own extended family. As Magnuson and Shaw (2003) show, genograms can be used for
couples and families with issues such as intimacy, griet, and alcoholism, and for identifying resources within
the family. Diagrams, as well as genograms, can serve specific purposes in family therapy (Butler, 2008).

Interpretation : Information from genograms is often interpreted to family members so that they can
understand dynamics within the family. By maintaining objectivity, the therapist is able to see patterns
within the current family that reflect patterns in the family of origin. To do so, it is important that therapists
themselves be well differentiated so that they ask thinking questions rather than feeling questions and avoid
being drawn into triangles with their patients. One way that Bowen (1978) kept objective enough to make
astute interpretations was by having the conversation directed to him rather than from one family member to
another.

Detriangulation : When possible, Bowen tried to separate parts of a triangle directly. When dealing with
family problems, he often saw the parents or one of the parents. He then worked with them on ways to
develop strategies to deal with the impact of their own emotional stress on the identified patient or other
family member. In general, Bowen preferred to work with the healthiest member of the family, the person
who was most differentiated, so that that person could make changes in various stressful family
relationships.

A hallmark of Bowen's work was the calm manner with which he tried to deal with the emotionality that
exists between family members. His goal was to reduce anxiety as well as resolve symptoms, which he did
by looking at self- differentiation not only within the individual and the family but also within the family of
the parents. To do so he used tools such as a genogram and discussed the relationships that went beyond the
nuclear family to aunts, uncles, and grandparents. An illustration of his approach will help demonstrate his
methods.

STRUCTURAL FAMILY THERAPY

Structural therapy, developed by Salvador Minuchin, helps families by dealing with problems as they affect
current interactions of family members. Therapeutic approaches emphasize changing the nature and intensity
of relationships within the family both inside and outside the therapy session.

Concepts of Structural Family Therapy

How families operate as a system and their structure within the system are the focus of Minuchin’s work
(Bitter, 2009; Minuchin, 1974; Minuchin, Colapinto, & Minuchin, 2007). By attending to the organization of
the family and the rules and guidelines family members use to make decisions, Minuchin forms an
impression of the family. Although family members differ in the power they have in making decisions, the
ways family members work together are indications of the degree of flexibility or rigidity within the family
structure. Minuchin uses concepts such as boundaries, alignments, and coalitions to explain family systems

Family Structure : For Minuchin (1974), the structure of the family refers to the rules that have been
developed over the years to determine who interacts with whom. Structures may be temporary or long-
standing. For example, two older brothers may form a coalition against a younger sister for a short period of
time or for several years. It is Minuchin’s view that there should be a hierarchical structure within the family,
with the parents having more power than the children and older children having more responsibilities than
younger children. Parents take different roles; for example, one parent may be the disciplinarian, and the
other may provide sympathy to the children. Eventually children learn the rules of the family about which
parent behaves in what way and to which child. When new circumstances develop, such as one of the
children going off to college, the family must be able to change to accommodate this event. Being aware of
family rules, and thus the structure, is important for therapists in deter mining the best way to help
dysfunctional families change. Within the family system are subsystems that also have their own rules.

Family Subsystems : For a family to function well, members must work together to carry out functions.
The most obvious subsystems are those of husband-wife, parents-children, and siblings. The purpose of the
husbandwife or marital sub- system is to meet the changing needs of the two partners. The parental sub-
system is usually a father-mother team but may also be a parent and/or another relative who is responsible
for raising children. Although the same people may be in the marital subsystem and the parental subsystem,
their roles are different, although overlapping. In sibling subsystems, children learn how to relate to their
brothers or sisters and, in doing so, learn how to build coalitions and meet their own needs, as well as deal
with parents. Other subsystems may develop, such as when the oldest child learns to make dinner for the
family when the mother or father drunk. Thus, a child-parent subsystem develops. Such alliances may arise
depending on the roles, skills, and problems of the individual members. Who does what and with whom
depends on boundaries that are not always clearly defined.

Boundary Permeability :Both systems and subsystems have rules as to who can participate in interactions
and how they can participate (Minuchin, 1974). These rules of interaction, or boundaries, vary as to how
flexible they are. Permeability of boundaries describes the type of contact that members within family
systems and subsystems have with each other. A highly permeable boundary would be found in enmeshed
families, whereas non permeable or rigid boundaries would be found in disengaged families. For example, if
a seventh-grade child who had previously been performing well in school brings a note home from a teacher
saying that he is failing English, the child may be told by his father not to let this happen again, to change
his behavior, and that there will be no further discussion of this issue. In this case, the boundaries are rigid
and the family is relatively disengaged from the child. In an enmeshed family, the father, mother, brother,
and sister may inquire about the child’s grades. The siblings may tease, the father may be distressed, and the
mother may check frequently during the week to see if the child is doing his homework. During dinner the
parents may discuss this event with the entire family so that there is little separation between family
members. In general, boundaries refer to how a family is organized and follows the rules; they do not
address the issue of how family members work together or fail to work together.

Alignments And Coalitions : In responding to crises or dealing with daily events, families may have typical
ways that subsystems within the family react. Alignments refer to the ways that family members join with
each other or oppose each other in dealing with an activity. Coalitions refer to alliances between family
members against another family member. Sometimes they are flexible and sometimes they are fixed, such as
when a mother and daughter work together to control a disruptive father. Minuchin uses the term triangle
more specifically than does Bowen to describe a coalition in which “each parent demands that the child side
with him against the other parent” Thus, power within the family shifts, depending upon alignments and
coalitions.

In the family system, power refers to who makes the decisions and who carries out the decisions. Being able
to influence decisions increases one’s power. Thus, a child who aligns with the most powerful parent
increases her own power. Because certain decisions are made by one parent and other decisions by the other
parent, power shifts, depending on the family activity. In an enmeshed family, power is not clear, and
children may ask one parent permission to do something even it the other parent has said “no”.

When the family’s rules become inoperative, the family becomes dysfunctional. When boundaries become
either too rigid or too permeable, families have difficulty operating as a system. If the family does not
operate as a hierarchical unit, with parents being the primary decision makers and the older children having
more responsibility than younger children, confusion and difficulty may result. Alignments within the family
may be dysfunctional, such as parents who are arguing over money both asking the oldest child to agree
with them (triangulation). Whereas Bowen was particularly interested in family function across generations,
Minuchin is more concerned with the current structure of the family, especially as he sees it within the
therapeutic transaction.

GOALS OF STRUCTURAL FAMILY THERAPY

By making hypotheses about the structure of the family and the nature of the problem, structural family
therapists can set goals for change. Working in the present with the current family structure, structural
family therapists try to alter coalitions and alliances to bring about change in the family. They also work to
establish boundaries within the family that are neither too rigid nor too flexible. By supporting the parental
subsystem as the decision-making system that is responsible for the family, therapists work to help the
family system use power in a way that functions well. The techniques that family therapists use to bring
about these changes are active and highly attuned to family functioning.

TECHNIQUES OF STRUCTURAL FAMILY THERAPY

The structural approach to family therapy is to join with the family and to focus on current and present
happenings. To do this, structural therapists may often use “maps” that provide a shorthand description of
boundaries and subsystems as they have an impact on the family. By accommodating to family customs, the
therapist can act like a member of the family to improve the understanding of family interactions and to gain
acceptance. By having a family enact a problem in the treatment session, the therapist can experience the
interactions within sub- systems. Suggestions can then be made tor changing the power structure and
boundaries within the family.

Bringing about change by increasing the intensity of interventions and reframing problems is among the
approaches to therapeutic change that are described.

Family Mapping : Whereas Bowen uses the genogram to show intergenerational patterns of relating,
Minuchin uses diagrams to describe current ways that families relate. Maps of family interaction allow
therapists to better understand repeated dysfunctional behavior so that strategies for modification can be
applied.

Accommodating And Joining :To bring about change within a family, Minuchin (1974) believes that it is
important to join a family system and accommodate to its way of interacting. By using the same type of
language and telling amusing stories relevant to the family, he seeks to fit in. One example of joining the
family is mimesis, which refers to imitating the style and content of a family’s communications. For
example, if an adolescent sprawls on his chair, the family therapist may do likewise. Similarly, structural
therapists use tracking to follow and make use of symbols of family life. For example, if an enmeshed
family uses the phrase “our life is an open book,” a structural therapist may attend to issues in which family
members are too deeply involved in each others’ activities and may later make use of the “open book”
metaphor as a way of helping families clarify their boundaries. By joining a family system, a structural
therapist not only has a good understanding of the family’s systemic operation but also is in a good position
to make changes in it.

Enactment : By instructing the family to act out a conflict, the therapist can work with problems as they
appear in the present rather than as they are reported. This allows the therapist to understand the family’s
coalitions and alliances and then to make suggestions for changing the family system. For example, the
therapist may give specific instructions for the family to enact an argument about not doing homework.
Having seen the argument enacted, the therapist is more aware of boundaries and coalitions and thus is
prepared to make powerful interventions.

Intensity : How a suggestion or message is given is extremely important. By repeating the message,
changing the length of time of a particular interaction, or other means, change can be facilitated. For
example, if parents are overprotective, the therapist may suggest that parents not nag the child about his
homework, not ask as many questions about school, and not monitor how his allowance is spent. Although
these messages differ, they all stress that the child be given more responsibility. Intensity can be achieved in
enactment by having the family draw out an interaction or repeat it. As the therapist becomes familiar with
the family’s style of interacting and its boundaries, more suggestions for change develop.

Changing Boundaries : As the therapist observes the family interacting either in an enactment or in general
presentation, the therapist uses boundary marking to note boundaries in the family. To change boundaries,
therapists may rearrange the seating of the family members and change the distance between them. They
may also wish to unbalance the structure so that power within a subsystem changes. For example, in an
enmeshed family, where children have too much power, the therapist may decide to side with one of the
parents to give that person power in dealing with the child. If the husband is indecisive, the thera- pist may
reinforce his suggestions and agree with him. It is the therapist's conscious choice as to which family
member to agree with, affiliate with, or exclude from an interaction. In dealing with family systems, the
therapist can also interpret events to change the power structure and mode of interaction within the family.

A creative way to address boundary issues is to use the Family Boundaries Game (Laninga, Sanders, &
Greenwood, 2008). This is a life-size board game in which members of the family become game pieces, like
a rook in chess. This game provides an opportunity for family members to learn their roles in the family and
to follow rules in the family as well as take turns in their interaction with other family members. This game
also promotes change in the family members and in their relationships to each others.

Reframing : There are several ways to see an event or situation or to reframe it. The therapist may wish to
give a different explanation so that a constructive change can occur in a family situation. Writing about
anorexia, Minuchin, Rosman, and Baker (1978) suggest a number of ways of reframing an anorectic girl’s
behavior. By labeling behavior as “stubborn” and not as “sick,” the adolescent no longer is the sole source of
the problem, as a family can deal with stub-bornness in several ways, whereas “sickness” makes the problem
the adolescent’s and one that is out of her control. Because parents are likely to see anorexia as the child's
problem, reframing allows the family therapist to present anorexia as a family problem that can be
approached by changing subsystems, boundaries, and coalitions.

STRATEGIC THERAPY

Concerned with treating symptoms that families present, Haley (1923– 2007) takes responsibility for what
occurs in treatment and designs approaches for solving family problems. By focusing on the problem,
strategic therapists design the best way to reach the family’s goals. In developing his approach, Jay Haley
was influenced by Milton Erickson (Haley, 1973), who was known for his use of hypnotic and paradoxical
techniques.

CONCEPTS OF STRATEGIC THERAPY

Like Minuchin, Haley observes the interaction among family members, attending particularly to power
relationships and to the ways parents deal with power. Viewing relationships as power struggles, Haley
(1976) is interested in understanding how relationships are defined. Thus, a communication from one person
to another is an act that defines the relationship (Haley, 1963). When a mother says to her son, “Your room
is messy,” she is not only reporting on the state of the room but also commanding the son to clean it up. If
the son does not clean up the room, he is engaging in a power struggle with his mother. Important to Haley,
as well as to Minuchin, is the concept of hierarchy, in which the parents are in a superior position to the
children in terms of making decisions and adhering to family responsibilities. Like Minuchin, he is
concerned with family triangles such as those in which one parent is overinvolved with the child and the
other is under involved. What separates structural from strategic approaches is the attention given by
strategic family therapists to symptoms. For Haley, symptoms are an unacknowledged way of
communicating within the family system, usually when there is no other solution to a problem. For strategic
therapists, the symptom is often a metaphor (Madanes, 1981) for a way of feeling or behaving within the
family. Contained in a metaphorical message are an explicit element (such as “my stomach hurts”) and an
implicit element (“I feel neglected”; Brown & Christensen, 1999). For example, the child who says “I have a
stomach ache” may be communicating pain that his mother feels in an interaction with her husband. In
listening to a symptom being described, strategic therapists look for the message being communicated as a
metaphor of the symptom. They recognize that the symptom may be an ineffective attempt to solve the
problem.

GOALS

Consistent with the emphasis on working with the system is the value placed on choosing goals (Keim,
2000). Although the therapist may ask family members why they have come and what they want to
accomplish, the therapist ultimately decides on the goal. Such goals may be intermediate as well as final and
must be concrete and not vague. The goal to reduce anxiety must be stated in such a way that the therapist
knows which family members are experiencing anxiety, in what way, and in which situations. There must be
sufficient information so that therapists can plan strategies to reach goals. For example, if a daughter is
anxious because her completion of chores at home is met by criticism from her parents, the therapist might
have an intermediate goal of having just the father make requests, and later have another intermediate goal
of having the mother and father agree on the chores they want their daughter to do. For each goal, specific
methods for accomplishing them are designed by the therapist. In recent years, strategic therapy has focused
more on helping family members show love and caring in interventions and less on power in the family
relationships.

TECHNIQUES OF STRATEGIC FAMILY THERAPY

Because the presenting problem is the focus of strategic therapy, tasks to alleviate the problem or symptom
are its cornerstone. Having family members complete tasks is important for three reasons (Haley, 1976).
First, tasks change the way people respond in therapy. Second, because therapists design the task, their role
is important, and they are likely to be listened to. Third, whether or not tasks are completed, information
about the family is obtained. When working with a task, strategic family therapists must select ones that are
appropriate to the family, design them, and help the family complete them.

Generally, tasks are of two types: straightforward tasks, where the therapist makes directions and
suggestions to the family, and paradoxical tasks for families that may resist change.

Straightforward Tasks :When strategic family therapists judge that the family they are trying to help is
likely to comply with their suggestions, they may assign a straightforward task. By talking with the family
and observing family boundaries and subsystems, the therapist will be able to help the family accomplish its
goals (Madanes, 1981). Sometimes suggestions can consist of relatively simple advice to families, but more
often families require suggestions to change a variety of ways members interact with each other (Papp,
1980). Just because tasks are assigned does not mean that each member of the family will be cooperative.

To gain cooperation from family members, Haley (1976) suggests several ways to ensure they complete
tasks. Before suggesting tasks, therapists should explore what the family has done to solve the problem so
they do not make suggestions that have been tried and failed. By examining what happens if the problem is
not solved, then, family members are more likely to appreciate the importance of doing something about the
problem. When tasks are assigned, they should be relatively easy to accomplish, clearly explained, and fit
the ability level of the children as well as the adults who will complete the task. In strategic family therapy,
the therapist is clearly the expert, and she may make use of her status as the expert to get the family to
comply with her instructions. Designing tasks, particularly metaphorical tasks, takes experience and
confidence.

Sometimes therapists give a family a task that is a metaphor for the way the therapist believes members need
to behave in order to alleviate the symptom. In such cases, family members are not aware of the purpose of
the tasks. Sometimes tasks can be given to solve relatively simple problems that are a metaphor for much
more difficult and complex problems.
Paradoxical Tasks : Basically, paradoxical suggestions are those that ask the family to continue the
behavior for which they are requesting help, but in such away that whether they comply or not, positive
change will result. In a sense, the therapist is trying to get the family to decide not to do what they have been
asked to do. Families are often confused by why the therapist is not asking them to change. Use of
paradoxical directives takes experience and confidence on the part of the therapist, and they are used only
when the family resists straightforward suggestions.

Weeks and L’Abate (1982) discuss several types of family behavior that may be appropriate for paradoxical
interventions. When family members fight among themselves, argue, or contradict each other’s statements,
they may not be providing sufficient support for the use of straightforward tasks, or parents may not be
sufficiently responsible to help children carry them out. When children and adolescents challenge or do not
listen to their parents, it may be difficult for parents to make use of straightforward suggestions.

In describing the use of paradoxical tasks, Papp (1980, 1984) has suggested three steps: redefining,
prescribing, and restraining.

The first step is to redefine the symptom in terms of the benefits it provides for the family. As Goldenberg
and Goldenberg (2008) suggest, anger can be called love, suffering can be seen as self-sacrifice, and
distancing can be used as a way of reinforcing closeness. In prescribing the symptom, the family is
encouraged to continue what they have been doing because if they do not there will be a loss of benefits to
the family. Thus, an angry child may be asked to continue to be angry and throw tantrums. In prescribing the
symptom, the therapist must be clear and sincere in the rationale. When the family starts to show
improvement, the therapist tries to restrain the growth or change in order to keep the paradox working. For
example, a couple who argue frequently and has been told to argue over kitchen chores may report that they
are fighting less. Rather than reinforce the change, the strategic family therapist may caution the couple to
be careful; otherwise, one or the other might lose the powerful position relative to the other. In doing this,
the therapist never takes credit for the change or acts sarcastically. Throughout the process of using
paradoxical tasks, the therapist shows concern for the family and, when change occurs, may express surprise
but also hope that change can take place.

UNIT 5: BEHAVIORAL AND COGNITIVE-BEHAVIOURAL FAMILY THERAPY, APPLICATION

AND EVALUATION.

COGNITIVE-BEHAVIORAL FAMILY THERAPY (CBFT) Cognitive-behavioral family therapy

(CBFT) was born as the family therapy correlate to cognitive- behavioral therapy. That is, it integrates
behaviourism and cognitive approaches and applies them to family systems. Because of its flexibility and
continued evolution, CBFT is able to focus on a variety of problems, from promoting changes within
individuals in families to altering family interaction styles. Furthermore, CBFT provides the fundamental
principles and techniques to various empirically supported interventions and programs.
THEORETICAL FRAMEWORK

Core Concepts The main concepts of CBFT are rooted in behaviourism and cognitive-behavioral therapy.
First, within the paradigm of behavioursim, operant conditioning is used as the central mechanism of
change. Social learning theory is incorporated by interpreting symptoms as learned responses and
emphasizing the impact of social reinforcers on shaping behaviors. Social exchange theory is also a primary
component of CBFT, asserting that people strive to maximize rewards and minimize costs in relationships.
Thus, behaviors can be changed directly by maximizing positive exchanges and minimizing negative
exchanges.

Second, from the perspectives of cognitive therapy, CBFT posits that an individual’s perceptions and
inferences are shaped by relatively stable underlying schema, which can be learned early in life from
primary sources which then influence an individual’s automatic thoughts and emotional responses in
significant relationships. Given the amount of shared experiences within a family. Individuals often develop
jointly held beliefs that constitute a family schema. If the family schema involves cognitive distortions, it
may result in dysfunctional interactions.

THEORY OF CHANGE

As an integration of behavioursim, CBT, and system theory, CBFT views thoughts and behaviors as central
to the (dys)functioning of the family. Thus, the underlying principle of CBFT is that the behavior of one
family member leads to certain behaviors, cognitions, and emotions within the other family members. Those
other family members then affect the cognitive and behavioral pro cesses of the original family member in
what is known as a feedback loop. Accordingly, the most efficacious pathways to change are seen as those
that directly alter dysfunctional thoughts and behavioral patterns in a family system through changes at the
individual and relationship levels. Specifically, the basic premise of behavioursim is that behavior is
maintained by its consequences. Thus, behavior will change when the contingencies of reinforcement are
altered. According to behavioursim, the general intent of therapy is to extinguish undesired behavior and
reinforce positive alternatives. Similarly, the central tenet of a cognitive approach is that our interpretation of
other people’s behavior affects the way we respond to them. Accordingly, the primary aim of CBFT is to
help family members recognize distortions in their thinking. Restructure it, and modify their behavior in
order to improve their interactional patterns. Furthermore. With the incorporation of systems theory. CBFT
maintains the focus on interactive aspects of the family rather than on internal processes of individuals.
CBFT therapists take on the roles of experts, teachers. Collaborators, and trainers. Therapists help families
identify dysfunctional behaviors and thoughts and then work with them to set up behavioral and cognitive-
behavioral management programs that will assist them in bringing about change. Families then carry out the
programs as the therapists monitor the progress and setbacks. Throughout the process. Therapists need to
take an active role in designing and implementing specific strategies and are required to have persistence
patience. Knowledge of learning theory, and specificity in working with families.
RATIONALE FOR THE MODEL

As the term implies, CBFT is the deliberate and theory based integration among cognitive therapy, behavior
therapy and family therapy. As such, its history can be seen as paralleling the history of cognitive-behavioral
therapy (CBT) generally. At its most basic, CBFT has its roots in behavior therapy. During the 1960s and
early 1970s, behaviourists applied learning theory, with a particular focus on stimulus and response, to
family systems in order to train parents in behavior modification. Parallel to the addition of a cognitive
component to traditional behavior therapy practices, behavioral family therapy soon transitioned to
cognitive-behavioral family therapy with an added emphasis on the need for attitude change to promote
behavior modification. Here. The system of the family was the focus of not just behavioral plans to
encourage more adaptive responses to stimuli, but also helping family mem- bers see how their thinking
about themselves and each other in the family can facilitate growth.

POPULATIONS IN FOCUS

CBFT has been used across diverse presenting problems and forms of psychopathology. With the foci on
increasing parenting skills and facilitating positive family interactions, CBFT has proved effective for
families with conduct problems, oppositional defiant disorder (ODD). Child anxiety, depression. Pediatric
obsessive-compulsive disorder (OCD), pediatric bipolar disorder. Eating disorders, attention deficit hyper
activity disorder (ADHD), and trauma symptoms. CBFT has also been found to be effective across various
cultures and subcultures. For example. Research conducted in several countries with families from various
racial and socioeconomic groups has demonstrated the efficacy of psychoeducational behavioral family
therapy in reducing family stress and patient relapse of major mental disorders.This approach is largely
based on CBET principles and procedures. Another example is trauma-focused cognitivebehavioral therapy
(TF-CBT) which has been applied in multiple cultures and proved to be feasible for treating traumatized
children of an Asian population. Although there is limited empirical evidence for the cultural sensitivity of
CBFT. Some multi- cultural strengths can be addressed based on its tenets. First, CBFT asserts that each
individual is different in his or her own right. Thus, CBFT therapists are taught to be careful in
understanding and defining behavioral norms and recognizing that family values and relational interactions
differ between families and between cultures. Second, a centraltenet of CBFT is that the therapist partners
with the family throughout the therapeutic process. As a result, differences in cultures are discussed and
brought to light so that all members of the process understand expectations and norms. Last but not least, its
fundamental concepts tend to be easily understood across diverse populations.

STRATEGIES AND TECHNIQUES USED IN MODEL

CBFT applies cognitive-behavioral principles and techniques to family systems. In CBT for individuals,
assessment and education are basic and important components and a focus across the treatment. The same is
true for CBFT. Within CBFT, we can divide the primary interventions into two categories: those that assess
and modify behavior patterns and those that assess and modify distorted and extreme cognitions.
ASSESSMENT AND EDUCATION

In order to intervene with families, several aspects of their functioning have to be understood include- ing
how the system functions in different contexts, the unique strengths, and problematic characteristics of each
family member and the family as a whole and how the interactions between family members maintain or
detract from optimal functioning. As a result, the therapist constantly assesses different behavioral and
cognitive patterns within and between family members. Although assessment never really ends, it tends to
begin with a functional analysis of the behaviors of the family members. The functional analysis derives
from three main sources of information: individual and joint interviews with the family members, self-report
questionnaires and inventories, and the therapist’s behavioral observation of family interactions. In addition,
other methods of assessment can include more formal psychological testing and appraisals, consultation with
previous therapists and other mental health providers genograms, assessing motivation to change, and
identifying automatic thoughts, core beliefs, cognitive distortions, and schema. Number of valid and reliable
measures have been developed to provide an overview of key areas of family functioning. For example,
questionnaires developed to assess general family functioning include the Family Environment Scale

(Moos and Moos 1986), The Family Assessment Device (Epstein cet al. 1983) , and the Self Report Family
Inventory (Beavers et al. 1985). Other, more specialized assessment tools include the Family Adaptability
and Cohesion Evaluation Scales-II (Olson et al. 1985). Family Coping

Coherence Index (McCubbin et al. 1996). And the Family of Origin Inventory (Stuart 1995). In addition to
written measures. CBFT therapists often rely on observational assessment tools such as observing family
members” interacting as they normally would or providing the family with specific topics for discussion in
order to obtain a behavioral sample of the family. Once the therapists have completed a functional analysis
of family behavior, they move to an instructor role as they teach families about the cognitive-behavioral
model. This includes providing a brief didactic overview and periodically referring to specific concepts
during the therapy. In this way. The families can better understand the roles their cognitive distortions have
played in the interactions and how they inadvertently reinforce undesirable behaviors. It is also important for
families to understand and buy into the idea that improvements in relationships often happen through
deliberate, rule-governed strategies(such as direct instruction and skill training) and that most problems are
solvable with constructive skills and actions. Thus, families may be encouraged to attend lectures, read
books and watch videos together, and have discussions based on what they have heard, read, or seen.

INTERVENTION TECHNIQUES

CBFT emphasizes behavior change. The cognitive component of the intervention comes into play when
clients” attitude sand assumptions get in the way of positive behavior changes

Interventions to Modify Behavior Patterns

The interventions in this category can be summarized into two main sections: operant conditioning and
contracting and skills training. They have the common characteristics of being operationally definable,
precise, and measurable. They are usually applied in combination so that family members learn individually
and collectively how to give recognition and approval for desired behaviors instead of rewarding
maladaptive ones.

These fundamental behavioral concepts can lead to significant change in a short period of time.

Operant conditioning is used most effectively in parent-child relationships where the aim is to increase
desirable behavior patterns of children by modifying the contingencies of reinforcement coming from the
adults. There are several examples of operant conditioning interventions.

Contingency contracting is a specific, usually written schedule or contract describing the terms for the
exchange of behaviors and reinforcers between family members. One action is contingent, or dependent, on
another. For example, parents might use a point system or “token economy to reward children for specific
behaviors such as doing chores or speaking nicely. The parents also work with the children to decide which
behaviors should be a focus of change and which might not be a priority. “Charting” is a skill whereby
families are taught to keep an accurate record of the children’s problematic behavior. They are taught how to
specially define the behavior and in what quantity it should be recorded such as every day or every time it
happens. This can be used when parents want to establish a baseline of the occurrence of targeted behavior
before and after the intervention in order to assess it across time. It should be noted here that charting is both
a tool of assessment and the intervention because the charting itself often changes behaviors without other
intervention being necessary. Another example of an operant behavioral technique is based on the “Premack
principle whereby family members must first do less pleasant tasks before they are allowed to engage in
pleasurable activities. Here, the more pleasant tasks serve as positive reinforcers for the less pleasant ones.
Finally, in order to apply these operant techniques to the level of the family. “behavior-change agreements
are used. Here, each family member learns that when they engage in a specific behavior, another family
member will be prompted to engage in a different behavior and so on. Rather than setting this up as a “tit for
tat” negotiation, it is used to delineate how each person’s behavior affects and is affected by the behaviors of
the other members of the family.

The most commonly used skill trainings are communication training, problem-solving training, and
parenting skills training. Communication training improves skills for expressing thoughts and emotions, as
well as for listening effectively to others. Therapists begin by presenting instructions to family members
about specific behaviors involved in each type of expressive and listening skill with the assistance of
handouts describing the communication guidelines. They then coach the families during session and often
model good skills for them. Session skills are then practiced as homework in order to increase and maintain
improvement. In problem-solving training, therapists use verbal and written instructions, modeling, and
behavioral rehearsal and coaching to facilitate effective problem-solving with family members. The steps
include achieving a clear specific definition of the problem. Generating specific behavioral solutions to the
problem, evaluating the advantages and disadvantages of each alternative solution, and selecting and
agreeing on implementing one solution. Finally, the main aim of parenting skills training is to change
parents responses to children by educating parents about operant learning principles, developing their ability
to observe children’s behavior systematically, and coaching them in using developmentally appropriate skills
to set constructive limits on children’s behavior and reinforce positive behaviors. As parents learn better
ways to ask for good behavior, children learn better ways of behaving. Parents are also taught that if they
give up focusing on less important behaviors (e.g. wearing a coat in colder weather), more important
behavioral changes are more likely to be incorporated. Here, the therapist begins by defining a specific
problem behavior and monitoring it in regard to its antecedents and consequences. The parents are then
trained in social learning theory with verbal and performance training methods Verbal methods involve
didactic instruction, as well as written materials, with the aim of influencing thoughts and messages.
Performance training methods may involve role-playing, modeling, engaging in behavioral rehearsal, and
prompting with the focus on improving parent-child interactions that are easily understood by the children,
given their current level of development. Regardless of the form of the training. Parents are asked to chart
the problem behavior over the course of treatment. Successful efforts are rewarded through encouragement
and compliments by the therapist.

Interventions to Modify Distorted and Extreme Cognitions

Generally speaking, this category of interventions includes(1)cognitive restructuring techniques. Which aim
to help family members better monitor the validity (how accurate one’s thoughts are) and the
appropriateness (the utility of one’s beliefs) of their cognitions, and (2) self-monitoring skills, by which
therapists teach family members how to actively and consciously assess and intervene their cognitions in
any given situation.

Specifically, in order to restructure the cognitions, therapists can teach older family members to identify
automatic thoughts and associated emotions and behaviors and identify cognitive distortions and label them.
Children can also be taught to identify and express their emotions appropriately. Then, therapists can test
and challenge the automatic thoughts and reinterpret them by considering alternative explanations. In this
process, some specific techniques are commonly used. For example, “behavioral experiments,” where
families are encouraged to test their pre dictions that particular actions will lead to certain responses from
other members, can provide first hand evidence in order to reduce one’s negative expectancies. When family
members attempt to identify their thoughts and responses that occurred in past incidents and have difficulty
recalling pertinent information, imagery or role- playing techniques can be helpful to recollect the past
interactions. Furthermore, the “downward arrow technique can be used to track the associations among one’s
automatic thoughts and to identify the underlying core beliefs beneath one’s automatic thoughts.

Self-instructional training is a form of self. Management that focuses on people instructing themselves. It is
assumed that problems may be based on maladaptive self-statements and self instruction affects behavior
and behavioral change. In self-instructional training. A self-statement can serve as a practical clue in
recalling a desirable behavioral sequence, or it can interrupt automatic behaviors or thought chains and
thereby encourage more adaptive coping strategies. In families, it is more often employed in helping
impulsive children modulate their impulsivity through deliberate and task-oriented “self- talk”.

In conclusion, CBFT uses behavioral and cognitive interventions to both assess behavior across time and
change it for more adaptive family inter actions. Most commonly, behavioral components play a larger role
than cognitive ones, but both categories provide the therapist with a large “tool box of possible interventions
for different families, presenting problems, and pathology.

INTERVENTION MODELS

There are a number of specific types of therapy based on the general principles of CBFT. For example.

Parent-child interaction therapy (PCIT) addresses child

behavioralproblems with a two- stage intervention model including a relationship enhancement phase and a
discipline phase (Galanter et al. 2012).

Functional family therapy (FFT) is a family-based, empirically supported treatment for behavioral problems,
especially with adolescents (Alexander and Rob- bins 2018).

Triple P (positive parenting program) it is the best known and most adaptable program. Triple P is a
parenting and family support system designed to prevent and treat behavioral and emotional problems in
children and teenagers and create family environ ments that encourage children to realize their potential. The
sophistication of this program is that it has been used in number of different formats including work with
individual parents groups of parents, agencies working with parents, and even govemment agencies states
responsible for the dissemination of parenting guidelines (Sanders and Turner 2017).

RESEARCH ABOUT THE MODEL

Research on the effectiveness of CBFT is extensive in terms of individual outcomes but lean in terms of
family outcomes. The outcome studies have focused mostly on the effectiveness of behaviourally oriented
family interventions in treatment of major mental disorders in individual members, such as the
psychoeducation and train- ing in communication and problem-solving skills (Mueser and Glynn 1999),
rather than on alleviating general conflict and distress within the family. For example, some studies have
demonstrated the efficacy of training parents in behavioral interventions for conduct disorders (Forgatch and
Patterson 2010). Other studies provide empirical support for behavioral family therapy for childhood ADHD
(Kaslow et al. 2012). There is also strong evidence for the effectiveness of family- based/family-focused
CBT in the treatment of childhood anxiety disorders (Kaslow et al. 2012), adolescent eating disorder (Le
Grange et al. 2015), pediatric bipolar disorder (West et al. 2014), pediatric OCD (Selles et al. 2018). Trauma
symptoms (Kameoka et al. 2015). And prevention of suicide attempts (Asarnow et al. 2017).

Little research has been conducted on CBFT for difficulties in the family as a whole, either in adapting to
developmental life-stage changes or in coping with external stressors affecting the family (Datilio and
Epstein 2016). However, CBFT principles and methods have been adapted to the treatment of a variety of
problems that families face in coping with forms of dysfunction in individual members and have
demonstrated their effectiveness, such as estrangement in family of origin (Dattilio and Nichols 2011).
Another example is that, a psychoeducational parenting program, rooted in cognitive-behavioral principles,
has been found to be especially effective as an intervention for at-risk parenting behavior, such as child
abuse (Nicholson et al. 2002).
 Module 6: Play Therapy

Unit: 1 Play Therapy-Goals for therapeutic process

Play, a fundamental feature of childhood, is essential to children’s brain development and holistic
functioning (Perry & Szalavitz, 2006). Through play, children communicate and make sense of their
experiences comparable to the way adults use words in “talk therapy” (Bratton, Ray, & Landreth, 2008;
Landreth, 2012; Schaefer & Drewes, 2014). In play therapy, children also use play to explore relationships,
build mastery, release energy, experience catharsis, develop coping strategies, and develop socially (Gil &
Drewes, 2005; Landreth, 2012; Ray, 2011).

Although various theoretical models of play therapy have been developed in its more than 100-year history,
Child-Centered Play Therapy (CCPT), based on Carl Rogers’s (1942) person-centered theory, is not only the
longest-standing play therapy modality in use today, CCPT is recognized as the most widely practiced
(Lambert et al., 2007) and researched (Bratton, Ray, Rhine, & Jones, 2005) approach in the United

States, and the approach has earned a strong international reputation (West, 1996; Wilson & Ryan, 2005).

Although a few directive play therapy approaches emerged in the first half of the 20th century (Hambidge,
1955: Levy, 1939), the humanistic movement was responsible for the advancement of the practice of play
therapy, most notably through the nondirective approach developed by Virginia Axline (1947). Based on her
belief in children’s ability to solve their own problems and heal through their own self-growth process,
Axline applied Rogers’ (1942) person-centered approach to her work with children. Rogers’ conviction in
every individual’s tendency towards self-actualization and positive growth was a cornerstone of Axline’s
nondirective play therapy. Consistent with Rogers’ approach, Axline placed an emphasis on the relationship
between the child and the therapist and on the importance of providing a supportive environment to facilitate
the child’s expression in the playroom setting. Axline popularized play therapy through the publication of
the book, Dibs in Search of Self (Axline, 1964). Clark Moustakas (1959) developed a similar
relationshipbased play therapy approach and highlighted the importance of respecting the child’s
uniqueness, focusing on the present moment in the therapist-child relationship.

The field of play therapy grew dramatically over the past three decades as numerous theorists, academicians,
and practitioners developed specific play therapy approaches based on their theoretical views and
experiences with children including gestalt play therapy (Oaklander, 1988), Jungian play therapy (Allan,
1988), Adlerian play therapy (Kottman, 1995), ecosystemic play therapy (O’Connor, 2001), cognitive
behavioral play therapy (Knell, 2009), prescriptive play therapy (Schaefer, 2001), integrative play therapy
approaches (Drewes, Bratton, & Schaefer, 2011), as well as approaches that espoused technical eclecticism.
However, outcome research to support the efficacy of play therapy approaches other than CCPT is scant.
Overview of CCPT Theory/Philosophy

CCPT is developed as a result of Axline’s (1947) application of the principles of person-centered theory to
children. As such, CCPT adheres to the basic assumptions underlying Rogers’s theory of personality and
recognizes the relationship between therapist and child as the primary mechanism of change.

Basic Assumptions

The child is the center of a constantly changing world of experience and responds to the perceptual field, his
or her reality, as an organized whole. Organismic experience includes all information available through the
senses and through internal feelings. The child has one basic actualizing tendency to move toward growth
and this actualizing tendency is expressed through goal-directed behavior.

Behavior is accompanied and facilitated by emotion and is best understood from within the child’s internal
frame of reference. From a child-centered perspective, all thoughts, feelings, and behavior are understood as
the child’s best attempt to meet his or her needs and to maintain and enhance the experiencing organism. As
the child interacts with the environment, a part of the perceptual field is differentiated into the self-structure
(Rogers, 1951).

The self-structure allows the child to make predictions about the environment and how others will relate to
him and provides a framework for the child to make sense of the world and find his place in his family,
society, and culture (Tolan, 2012). The self-structure is primarily developed in accordance with the values of
one’s parents or primary caregivers. As a child seeks to meet her need for positive regard, to be valued and
accepted by others, she develops conditions of worth. Values that are not experienced directly by the child
are introjected from others as if they were experienced directly. For example, a child falls and skins her knee
and reaches to be hugged by her parent. As she cries and seeks comfort from her parent, she is told not to
cry, pulled to her feet, and instructed to keep walking. Through this experience, the child learns, “I am only
valued and accepted if I am strong and self-sufficient.” She then denies or distorts her own experiences of
feeling vulnerable and desiring comfort from others in order to protect her self-structure and to maintain
love and acceptance from others. Throughout development, children’s experiences are accurately
symbolized and organized into the self-structure, ignored because they have no relationship to the self-
structure, or denied and distorted because they are inconsistent with the self-structure.

Within a child-centered framework, psychopathology is understood in terms of incongruence between one’s

self-structure (including one’s self-concept and one’s conditions of worth) and one’s real experience. When
one is unable to integrate one’s real, lived experiences into his self-concept and value system and either
denies, distorts, or ignores those experiences, he experiences psychological maladjustment.

Incongruence between the self-structure and real experience often creates “anxiety” or “vulnerability”
(Rogers, 1957) that is most often demonstrated in children through problem behaviors (Ray, 2011).
Therapeutic Goals and Process of Change

The primary goal in CCPT is to provide a safe and accepting environment that allows the child to experience
integration, self-direction, and growth. Rogers described the kind of nonthreatening environment necessary
for individuals to integrate experiences into the self-structure through the six necessary and sufficient
conditions for constructive personality change (Rogers, 1957).

Two persons are in psychological contact.

1. The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious.

2. The second person, whom we shall term the counselor, is congruent or integrated in the relationship.

3. The counselor experiences unconditional positive regard for the client.

4. The counselor experiences an empathic understanding of the client’s internal frame of reference and
endeavors to communicate this experience to the client.

5. The communication to the client of the counselor’s empathic understanding and unconditional positive
regard is to a minimal degree achieved (Rogers, 1957, p. 96).

The first condition refers to the necessity that the child and the counselor are in contact with one another in
such a way that each individual is experienced by and makes a perceptual difference to the other (Wilkins,
2010). The second condition refers to the individual’s state of tension resulting from incongruence between
the self-structure and one’s actual experience. This state of incongruence often results in confusion, anxiety,
and distress because there is a conflict between one’s feelings and behavior and one’s conscious desires.

The third, fourth, and fifth therapist-provided conditions of congruence, unconditional positive regard, and
empathic understanding promote a non-threatening environment that facilitates the child’s integration of his
experiences into his selfstructure according to his own organismic valuing process.

The sixth condition refers to the child’s perception of the counselor’s empathic understanding and
unconditional positive regard. The child’s perception of the counselor’s empathy and acceptance depends on
the counselor’s actual, congruent experience of empathy and unconditional positive regard toward the child,
on the counselor’s ability to effectively convey and communicate this experience, and aspects of the child’s
self-structure that may impact her ability to take in the counselor’s empathy and acceptance.

CCPT in Practice

Because children are in the midst of developing the ability to symbolize inner experiences into words, they
require an alternative to relying on verbal communication to express their feelings and thoughts. Play
provides the medium by which children can symbolize and express their inner experiences (Wilson & Ryan,
2005). In CCPT, children are provided play materials to allow them a developmentally responsive means to
express their emotions and experiences concretely and symbolically.
Through the child’s play and verbalizations, the therapist is able to enter into the child’s experience and gain
access to the child’s underlying feelings, needs, and desires. If for example, a child is referred by her parents
due to noncompliance and temper outbursts, the child’s play may reveal feelings of confusion and
powerlessness regarding her parents’ separation. The therapist can provide for the child’s safe expression of
her feelings and experiences in the playroom while working with the parents to help them better understand
and respond to the needs of their child.

According to Axline (1947), nondirective play therapy/CCPT is based on eight guiding principles. Axline
noted that the therapist should (1) develop a warm, friendly relationship with the child; (2) accept the child
exactly as he is; (3) facilitate an atmosphere of permissiveness so that the child is free to express self; (4)
recognize and reflect the child’s feelings in order to help him gain insight into his behavior; (5) honor the
child’s inherent capacity to solve his own problems; (6) allow the child to direct the therapy; (7) understand
that therapy is a gradual process and should not be hurried; and (8) establish only those limits necessary to
ground the child in the world of reality and make the child aware of his responsibility within the therapeutic
relationship.

The Playroom, Toys, and Play Materials

According to Landreth (2012) the optimal playroom size should be approximately 12 by 15 feet, although an
open space of any size may be used. Toys should be carefully selected to facilitate (1) a positive relationship
with the child; (2) expression of a wide range of feelings; (3) exploration of real experiences; (4) testing of
limits; (5) positive image; (6) the child’s self-understanding; (7) opportunities to redirect behavior that is
unacceptable to others (Landreth, 2012).

Additionally, toys should be representative of the cultural experiences of the child. Toys chosen for the
playroom can be broadly divided into five types: nurturing toys, aggressive toys, toys related to real-life
experiences, communication toys, and mastery toys. The arrangement of toys in the playroom should be
intentional and displayed on shelving that allows the toys to be easily accessible and visible to children.

Therapeutic Skills

The following verbal and nonverbal skills are considered essential to the application of CCPT theory to
practice: (a) reflecting nonverbal behavior, (b) reflecting verbal content, (c) reflecting feeling, (d) facilitating
decision making and returning responsibility, (e) facilitating creativity and spontaneity, (f) esteem building
and encouraging, (g) facilitating relationship, and (h) limit-setting. CCPT skills are not to be applied
mechanically. Rather, the therapist is responsive to the child’s present needs and applies skills based on
therapeutic intention. Nonverbal skills include being physically and emotionally attuned to the child,
showing genuine interest, and a tone of voice that matches the child’s affect. The therapist’s response is
made in a manner that is consistent with the child’s developmental level. Tone and rate of response should
match the intensity, degree of interaction, and the affect of the child.
Stages in Play Therapy

Therapy Process

Stages of the play therapy process involve the shared interactions between the therapist and the child,
experienced in the nonevaluative, freeing environment of the playroom, facilitated by genuine caring for the
child. The unique nature and individuality of the child are accepted and appreciated, and the child can
expand the horizons of self, based on the extent of acceptance inwardly felt and communicated by the
therapist. Stages of change in the play therapy process reflect the experiencing and expanding of the
possibilities of self.

Moustakas’ (1955) had an analysis of case studies of emotionally disturbed children in play therapy and
observed that children progress through five identifiable stages and eventually develop self-awareness.
Feelings are expressed everywhere in the child’s play, a child who is overly concerned with cleanliness and
neatness. May react with anxiety and may also express diffuse hostility towards the room, toys, and
therapist.

In the second stage, the child usually expresses ambivalent feelings that are generally anxious or hostile.
Example a child picked up puppets, banged each puppet on the table with disgust and threw them on the
floor, and said, “I don’t like any of them.”

The third stage is characterized by more focused direct negative feelings expressed toward parents, siblings,
and other persons in the child’s life. These feelings or attitudes are often evident in the symbolic play.
Example a child acted out strong negative reactions toward her parents and new baby by lining up the
mother, father, and baby family doll figures, and saying, “They’re robbers, and I’m going to shoot them” and
acting like shooting each of them.

In the fourth stage, ambivalent feelings are expressed again in the play but in the form of positive and
negative feelings and expressed toward parents, siblings, and others in the child’s life. Example Six-year-old
boy beats a bob doll and says “I’m going to beat you up, nobody likes you!” but he later takes the doctor kit
and bandage the bob doll.

The fifth stage is characterized by distinct, realistic positive attitudes and negative attitudes, with positive
attitudes predominating in the child’s play.

This final stage is an outcome of an understanding, accepting, and caring relationship established by the
therapist in which the child feels safe, whereby the uniqueness of each child is expressed more freely and
completely. The unique self is appreciated and accepted by the therapist, the child would internalise that
acceptance and the child begins to accept and appreciate one’s own uniqueness. Self-knowledge is expressed
through the facilitative process of play.
Hendricks (1971) found that children followed patterns in sessions:

Sessions 1 to 4: At this stage- children expressed curiosity, engaged in exploratory and creative play, made
simple descriptive and informative comments and exhibited both happiness and anxiety.

Sessions 5 to 8: children continued exploratory and creative play. Generalised aggressive play tends to
increase, expressions of happiness and anxiety continued, and spontaneous reactions were evident.

Sessions 9 to 12: Exploratory and aggressive play would decrease; play involving relationships would
increase; creative play and happiness are predominant; they also do more of nonverbal checking with the
therapist; and the child shares more information about family and self.

Sessions 13 to 16: there is more creative and relationship play; the aggressive play would increase; and
there is an increase in expressions of happiness, bewilderment, disgust, and disbelief.

Sessions 17 to 20: Dramatic play and role-play predominated, specific aggressive statements continue, and
relationship building with the therapist occurs.

Expression of happiness was predominant, and children continued to give more information about
themselves and family.

Sessions 21 to 24: Relationship play and dramatic role play predominated, incidental play increased.

Withee (1975) found that during the first three sessions, children gave the most verbal verification of the
counsellor’s reflections on their behaviours; they exhibited higher levels of anxiety; and engaged in verbal,
nonverbal, and play exploratory activities. During sessions 4 - 6, curiosity and exploration reduced and
aggressive play and verbal expression peaked. During sessions 7 -9, aggressive play reduced and creative
play increased. During sessions 10-12, relationship play is more and noncommittal play reduce. Sessions 13-
15, nonverbal expressions of anger and anxiety rose again, they also wanted to direct the therapist.

Differences also were found between boys and girls. Boys expressed more anger, made more aggressive
statements, engaged in more aggressive play, and made more sound effects. Girls exhibited more creative
and relationship play, happiness, anxiety, verbal verification of therapist responses, and verbalizations of
positive and negative thoughts.

As the play therapy process develops, children begin to express feelings more directly and realistically and
with more focus and specificity. Children initially engage in exploratory, noncommittal, and creative play. In
the second stage, children exhibit more aggressive play and verbalizations about family and self. In latter
sessions, dramatic play and a relationship with the therapist become important.

Anxiety, frustration, and anger are expressed.

The first phase of play therapy is commonly referred to as the initiation phase or exploratory stage. The
initial sessions are spent building a trusting relationship and fostering an environment of safety for the child
to express themselves freely. Children learn what to expect in each session, develop a bond with their
therapist, learn the roles of each participant, and become familiar with the toys and techniques that will be
utilized.

Children explore the playroom and the toys, questioning what things they can and cannot do in the
playroom. Some children will have the desire to touch and try out everything they see to gain awareness.
Other children may be hesitant and uncertain about what their role is in the playroom and look to the
therapist to take the lead.

Through empathic responses, encouragement, and returning responsibility, the therapist will empower the
child to take risks, initiate play, and ultimately take the lead. Children would experience permissiveness of
the playroom, where limits are rarely set except to avoid injury.

Some children walk into the playroom and instantly feel comfortable. Some children will take more time to
adjust to their surroundings. It may be useful to go by the pace of the child. Child may feel overwhelmed to
be left alone in an unfamiliar room with a new stranger. When trust is built between child and therapist.
Child will be excited to attend their weekly session, and there will be less behavioural concerns.

Child feels comfortable expressing themselves, understands their role in the process.

The next stage is referred to as the resistance phase, aggressive stage, or negative reaction stage. It
represents the shift from the comfortable to the uncomfortable - the loss of the familiar. Therapeutic issues
that are causing the behavioural symptoms to occur become the focus of treatment. Pleasantries and easiness
that have developed, are now shifting. Children are confronted with the recognition of their maladaptive
habits, and they have to make the decision to put in the work or keep fighting because it feels difficult. Child
may no longer want to attend therapy. Validate the concerns they express and encourage their capabilities,
such as- they can do difficult things.

This stage is characterised by emotional self-expression. Children might have more emotional outbursts,
desire more control, make more mistakes, and regress in behaviours they’ve previously mastered. These
signs are all part of developing emotional intelligence, confidence in self, self-control, and discovering more
adaptive ways of interacting with others.

The stages might last only a few sessions or they might last a few months.

Each child is different in the time they need.

The next stage is the growing phase or work phase. This is typically the longest phase of play therapy. Your
child shows up to each session ready to put in the hard work required for personal growth. They are
learning, healing, stepping out of their comfort zone, and making changes. You will notice positive advances
in their self-esteem, behaviours, communication, and overall outlook on life. They will utilize effective
coping skills with little prompting, demonstrate self-regulation, and build resiliency and flexibility. With
growth, there is also the occasional setback or regression, the old habits may creep back. Therapists could
show empathy and remain consistent with expectations.

Last is the termination phase. This occurs when children are consistently demonstrating their new skills with
ease, and behavioural and emotional needs have stabilized in multiple environments. The number of sessions
could be reduced to determine if the child can maintain progress with less support.

This can be a difficult time for the child as the secure relationship they have developed with the therapist
will start to change. There may be minor regressions. Child is equipped and prepared to handle situations.
Therapist will create opportunities in the last sessions for a healthy and happy closure. Follow up may be
done.

Unit 2: Catalyst for Change: Challenges To Therapeutic Process

Some of the common obstacles that patients face when trying to change a behaviour include:

Lack of information or skill Overweight: Patients may need information about portion control or the
actual caloric content of junk foods. Parents who are reluctant to vaccinate their children may need to
know the actual risks of infections caused by pertussis and pneumococcus and also need accurate
information about vaccine safety. A teenager who wishes to stop smoking may need information about
available, appropriate pharmaceutical products for smoking cessation. The clinician can provide
information directly or by distributing pamphlets and lists of appropriate books and Web sites.

Lack of confidence in ability to change: The clinician can assess the patient’s confidence about her
ability to change by using numeric rating scales. The clinician may ask, “On a scale of 1 to 10, how
confident are you that you can lose weight?” and

“What would it take to get you from a 3 to a 5?” A discussion of what skills the patient needs in order
to feel more confident may be helpful.

a) Misconceptions and misperceptions: Parents and patients may need clarification of misconceptions.
Overweight patients may need to know that skipping meals is not an effective way to lose weight. Parents
may need misconceptions about vaccines and their relation to autism addressed. Teenagers may need to
know that smoking may not really heighten their appeal to their peers.

b) Personal cost: A frequent obstacle to change is the perception that the new behaviour will require “too
much time” or “too much work.” The clinician can reassure the patient that the change process need not be
“all or nothing” and that an approach that is simple and gradual may be the best way to begin.

Environmental and logistical barriers: Logistical barriers to change may include financial cost. Healthy food
alternatives may be financially taxing to some families who may in turn seek fast food as a less costly
option. Environmental factors such as a safe location to exercise may be realistic barriers to weight loss. A
family without health insurance may choose to defer costly vaccines. The patient can be encouraged to look
at available community resources such as a local recreation center for a safe place to exercise or a public
health clinic for free vaccines.

Salience: The patient may perceive the new behaviour as not very important. The clinician can gauge
the patient’s perception of importance by asking, “How important is this to you?” Alternatively, the
clinician can once again use a numeric rating scale and ask, “On a scale of 1 to 10, how important is it
to you to?” An effective method for dealing with patients who resist change is to avoid the “you really
need to” type of confrontation and instead make a reflective statement such as, “It sounds like you are
not ready to tackle this right now” or “It sounds like this is not very important to you right now.”
Some patients may affirm that this is true at this time, but this approach may animate some patients
to respond by arguing back that they are indeed ready for change. The clinician can then encourage
the patient to expand on his or her thoughts with a simple, “Tell me what you are thinking or feeling.”
This type of interaction parallels the martial arts response to force by absorbing the force rather than
confronting it with more force.

Unit- 3 Conceptual Background and Play Therapy Room

Since the early 1900s, mental health professionals have embraced the value of play in child therapy due to
its developmental and growth producing properties. Play,a fundamental feature of childhood, is essential to
children’s brain development and holistic functioning (Perry & Szalavitz, 2006). Through play, children
communicate and make sense of their experiences comparable to the way adults use words in “talk therapy”
(Bratton, Ray, & Landreth, 2008; Landreth, 2012; Schaefer & Drewes, 2014). In play therapy, children also
use play to explore relationships, build mastery, release energy, experience catharsis, develop coping
strategies, and develop socially (Gil & Drewes,2005; Landreth, 2012; Ray, 2011). Although various
theoretical models of play therapy have been developed in its more than 100-year history, Child- Centered
Play Therapy (CCPT), based on Carl Rogers’s (1942) person-centered theory, is not only the longest-
standing play therapy modality in use today, CCPT is recognized as the most widely practiced (Lambert et
al., 2007) and researched (Bratton, Ray, Rhine, & Jones, 2005) approach in the United States, and the
approach has earned a strong international reputation (West, 1996; Wilson &Ryan, 2005).

History And Status

Like adult psychotherapy, CCPT has its roots in psychoanalysis (Landreth, 2012).The first psychoanalysts
believed that the root of adult personality problems was the repression and sublimation into the unconscious
of aggressive or sexual drives during childhood. Freud believed that the first 6 years of life are critical in
personality formation, and that children’s personalities are still in the process of development. Thus,
working with children in psychoanalysis was considered a viable treatment method. Freud himself described
his work with the father of “Little Hans,” but hi daughter, Anna Freud, developed the most well-accepted,
clinically focused theory of psychoanalysis with children (Lee, 2009). Even before Anna Freud published
her seminal work, Hug-Hellmuth, an influential child analyst and supporter of Sigmund Freud, began
writing about children’s dreams and the psychoanalysis of children (MacLean & Rappen, 1991). In her
work, Hug-Hellmuth (1920) described the use of play in the analysis of children, not as a means of
distracting them or holding their attention, but as a means by which the child could communicate to the
analyst and the analyst to the child.

Other psychoanalysts, such as Melanie Klein (1932) and Winnicott (1971), also developed approaches to
child analysis. Ginott (1961), another psychoanalytically-trained psychotherapist, also wrote on the
importance of play in addressing children’s developmental needs. Although Ginott’s most well-known work
on play therapy focused on group play therapy, his explanation of psychoanalytic theory, his instructions and
rationale for setting up a playroom, and his discussion of techniques of the child therapist can all be applied
to individual child analysis. Ginott emphasized the importance of allowing the children to take over the
direction of the play so that they could express freely their inner conflicts and feelings.

Similar to Hug-Hellmuth, Ginott believed that the adult’s role in the playroom was to be interested and
engaged, yet neutral. Although a few directive play therapy approaches emerged in the first half of the 20th
century (Hambidge, 1955: Levy, 1939), the humanistic movement was responsible for the advancement of
the practice of play therapy, most notably through the nondirective approach developed by Virginia Axline
(1947). Based on her belief in children’s ability to solve their own problems and heal through their own self-
growth process, Axline applied Rogers’ (1942) person-centered approach to her work with children.

Rogers’ conviction in every individual’s tendency towards self-actualization and positive growth was a
cornerstone of Axline’s nondirective play therapy. Consistent with Rogers’ approach, Axline placed an
emphasis on the relationship between the child and the therapist and on the importance of providing a
supportive environment to facilitate the child’s expression in the playroom setting. Axline popularized play
therapy through the publication of the book, Dibs in Search of Self (Axline, 1964). Clark Moustakas (1959)
developed a similar relationship-based play therapy approach and highlighted the importance of respecting
the child’s uniqueness, focusing on the present moment in the therapist-child relationship. Later proponents
of nondirective play therapy, including Louise Guerney (1983, 2000) and Garry

Landreth (1991, 2012), further refined Axline’s approach into what has become known in North America as
CCPT, but continues to be recognized as nondirective play therapy in the United Kingdom and elsewhere in
Europe (Bratton, Ray, Edwards, & Landreth, 2009). A significant development in the application of CCPT
was the development of filial therapy by Bernard and Louise Guerney in the 1960s (L. Guerney & Ryan,
2013). In this pioneering approach, parents received training and supervision in CCPT procedures to use
with their children (B. Guerney, 1964).

Building on the work of the Guerneys, in the 1980s Garry Landreth developed a more structured and
condensed 10-session filial therapy training format (Landreth & Bratton, 2006), which has developed strong
empirical support with diverse populations of families. Consistent with the Guerneys’ model, parents in
CPRT are taught child-centered play therapy (CCPT) principles, attitudes, and skills to use in weekly,
supervised parent-child play sessions as a treatment intervention that impacts children and their families on a
systemic level while addressing a range of problem behaviors and concerns. Landreth and Bratton (2006)
formalized the 10-session training model in a text, Child Parent Relationship Therapy (CPRT): A 10-Session
Filial Therapy Model, to distinguish the model from other filial therapy approaches.

The CPRT protocol was manualized by Bratton, Landreth, Kellam, and Blackard (2006) to provide
practitioners and researchers with a tool for ensuring treatment integrity in implementing the intervention.

The field of play therapy grew dramatically over the past three decades as numerous theorists, academicians,
and practitioners developed specific play therapy approaches based on their theoretical views and
experiences with children including gestalt play therapy (Oaklander, 1988), Jungian play therapy (Allan,
1988), Adlerian play therapy(Kottman, 1995), ecosystemic play therapy (O’Connor, 2001), cognitive
behavioral play therapy (Knell, 2009), prescriptive play therapy (Schaefer, 2001), integrative play therapy
approaches (Drewes, Bratton, & Schaefer, 2011), as well as approaches that espoused technical eclecticism.
However, outcome research to support the efficacy of play therapy approaches other than CCPT is scant.

CCPT In Practice

Because children are in the midst of developing the ability to symbolize inner experiences into words, they
require an alternative to relying on verbal communication to express their feelings and thoughts. Play
provides the medium by which children can symbolize and express their inner experiences (Wilson & Ryan,

2005). In CCPT, children are provided play materials to allow them a developmentally responsive means to
express their emotions and experiences concretely and symbolically. Through the child’s play and
verbalizations, the therapist is able to enter into the child’s experience and gain access to the child’s
underlying feelings, needs, and desires. If for example, a child is referred by her parents due to
noncompliance and temper outbursts, the child’s play may reveal feelings of confusion and powerlessness
regarding her parents’ separation. The therapist can provide for the child’s safe expression of her feelings
and experiences in the playroom while working with the parents to help them better understand and respond
to the needs of their child.

According to Axline (1947), nondirective play therapy/CCPT is based on eight guiding principles. Axline
noted that the therapist should (1) develop a warm, friendly relationship with the child; (2) accept the child
exactly as he is; (3) facilitate an atmosphere of permissiveness so that the child is free to express self; (4)
recognize and reflect the child’s feelings in order to help him gain insight into his behavior; (5) honor the
child’s inherent capacity to solve his own problems; (6) allow the child to direct the therapy; (7) understand
that therapy is a gradual process and should not be hurried; and (8) establish only those limits necessary to
ground the child in the world of reality and make the child aware of his responsibility within the therapeutic
relationship.
The Playroom, Toys, and Play Materials

According to Landreth (2012) the optimal playroom size should be approximately 12 by 15 feet, although an
open space of any size may be used. For example, in the case of schools where there may be no dedicated
space for a playroom, the counselor may create a portable play room with a selection of toys (Landreth,
2012). No matter the space, the therapist should be intentional about the play materials and toys. Toys
should be carefully selected to facilitate (1) a positive relationship with the child; (2) expression of a wide
range of feelings; (3) exploration of real experiences; (4) testing of limits; (5) positive image; (6) the child’s
self-understanding; (7) opportunities to redirect behavior that is unacceptable to others (Landreth, 2012).
Additionally, toys should be representative of the cultural experiences of the child. Toys chosen for the
playroom can be broadly divided into five types: nurturing toys, aggressive toys, toys related to real-life
experiences, communication toys, and mastery toys. The arrangement of toys in the playroom should be
intentional and displayed on shelving that allows the toys to be easily accessible and visible to children.
Landreth (2012) provided a comprehensive list of toys, play materials, and equipment for a fully equipped
playroom as well as a list of play materials to avoid.

Unit 4 : Selecting the Appropriate Media or Activity, Use of Miniature Animals

We use media or an activity as a way of engaging the child and enabling the child to tell their story. In
selecting media or activities it is important to remember that each child is different, both as an individual and
with regard to the issues and behaviours which need to be addressed. Each of the media or activities
available has different and particular properties. Therefore, we can match up the medium or activity with the
individual child and with that child’s abilities and needs. Factors which are of importance when selecting
media or activities include the following:

• The child’s developmental age

• Whether the child is being counselled individually or in a group

• The current counselling goals for the child

Suitability Of Media and Activities for Various Age Groups

For example, imaginative pretend play is an activity which is highly appropriate for pre-school
children between the ages of two and five years. This activity is less likely to appeal to pre-adolescents
or adolescents because of their cognitive maturity and ability to engage in abstract thinking. They are
likely to find working with miniature animals and symbols more appealing

Suitability of media and activities for various situations

Most often counselors work with children individually, but they sometimes work with sibling groups or
groups of children who have similar issues or have had similar experiences. At other times, counseling
occurs in a family setting.
While all of the media and activities are suitable for use in individual counseling sessions, some are not as
suitable for group or family work.

Suitability of media and activities for achieving goals

To gain mastery over issues and events

To gain mastery over past events and current issues, it is desirable for the child to do one of the
following:

● To re-experience past events or traumas of concern by re-enacting them, acting them out or re-explaining
them. In this process, the child may need to imagine how they could have changed their role in those events
so that they would have felt more comfortable. They might also need to engage in an activity, which will
enable them to experience, in their imagination, the effect of their changed role. In this way they can
experience a sense of mastery over the event or trauma.

● To simulate an event which will allow them to experience the feelings of power and/ or control which they
may not have experienced in previous instances.

● It follows that in order to gain mastery over past events, it is important to provide the child with the
opportunity to use media which allow for the creation of imaginary environments in which there can be
powerful roles. These roles might sometimes be fantasy roles which give the child superhuman abilities for
dealing with social and physical situations. Examples of the use of suitable media are:

● Books and stories can encourage the child to alter the story. The child can project outcomes which they
would have liked for themselves on to characters within the story.

● Drawing allows the child to make pictures which depict traumatic events. In these pictures the child can
depict themselves as powerful or in control.

● In the imaginary journey, the child is invited to revisit significant life situations. They can, in their
imagination, introduce new behaviours for themselves in order to achieve some sense of control or mastery
in situations where they were previously powerless.

● In imaginative pretend play, dramatic representation of powerful roles can be enacted.

● Painting and collage can be used in a similar way to drawing.

● Puppets and soft toys allow the child to assume powerful roles.

● Sand-tray work allows the child to create fantasy environments in which they can feel in control.

● Symbols and figurines can be used in the same way as puppets and are suitable for older children.

To be powerful through physical expression

Children feel empowered when they witness their ability to powerfully impact on their environment. In
counselling this can be achieved by providing activities and media that enable them to control the media and
to alter them, or to act out powerful roles. For example:

● A child might punch a lump of clay until it becomes flat.

● When using finger-painting, the child can dramatically alter their drawing or destroy the images in their
picture.

● In imaginative pretend play, the young child can attack a bean bag with a toy sword.

● Mock battles can be acted out between ‘good’ and ‘evil’ puppets. Similar work can be done with older
children using figurines.

● In sand-tray work a child can bury figures or objects in the sand to obliterate or conceal them.

● Engaging in these types of activities can be cathartic for the child as they symbolize in a concrete way the
child’s ability to impact on their environment.

To encourage expression of emotions

We have discussed the importance and benefits of encouraging and helping children to express their
emotions. Some media and activities lend themselves to the expression of emotion much more effectively
than others. For example:

● Clay tends to promote the expression of anger, sadness, fear and worry.

● Drawing allows the child to get in touch not only with their projected thoughts, but also with their
emotional feelings. Finger-painting tends to generate the emotions of joy, celebration and happiness.

● In painting and collage, the child may connect the texture of the material with emotional feelings.

To develop problem-solving and decision-making skills

At some point around the Spiral of Therapeutic Change the child will be required to explore options, to
make choices, to take risks, and to experiment with challenges and changing behaviours. Appropriate media
might include:

● Books and storytelling, where alternative solutions can be explored; for example, Little Red Riding Hood
might trap the wolf so that the child can rescue her grandmother before she gets eaten!

● Puppets and soft toys, where the child can make up a dialogue to solve problems between two or more
characters.

● Sand-tray work, where a child can rearrange a visual picture to accommodate different needs.
● Symbols and figurines, which can be used similarly to puppets and soft toys and are more suitable for
older children.

● Worksheets, which can be used to directly address problem-solving and decision making skills.

To develop social skills

In order to feel better in the future, many children may need to develop social skills. Often this involves
learning different ways of relating to others so that they can make friends, get their needs met, be
appropriately assertive, identify and live within sensible boundaries, and cooperate with others.

To develop adaptive social skills it is important for a child to understand and experience the consequences
of social behaviour. This can be achieved by the use of:

● An activity, such as playing a game with the child and giving the child feedback.

● Imaginative pretend play, which can help younger children to learn about and practise social skills.

● Puppets and soft toys, which can help children to learn about and practise socially acceptable behaviours.

● Worksheets, to address specific social skills issues.

To build self-concept and self-esteem

We have found that a child’s self-concept and self-esteem are almost inevitably affected adversely whenever
they experience troubling events or trauma. In order to build self-concept and self-esteem, the counsellor
selects activities and media which will promote self-fulfilment and independence in the child, and will
enable the child to explore, accept and value their strengths and weaknesses. Suitable media and activities
are as follows:

● Drawing, where comic strips can be created to illustrate the development of the child’s

own strengths. For example, a child might show their progression from infancy to the present, highlighting
memorable milestones.

● Finger-painting – this doesn’t require skill, so anything the child produces is likely to be an acceptable
product.

● Games can be selected which target the child’s specific skills and give them an opportunity to perform
well.

● Imaginative pretend play allows the child to experience roles such as being a leader or helper, and to
discover their unique strengths.

● Painting and collage can be used in a similar way to finger-painting.

● Specifically designed worksheets can be used to address issues related to self-esteem and self-concept.
To improve communication skills

Often when a child tells their story to friends and significant others, the story will sound confusing,
incongruent and sometimes difficult to believe. Activities which assist in highlighting the sequence of the
story, important themes related to the story, the child’s understanding of significant events, and how the
child felt at different times, are helpful. For example:

● Storytelling helps the child to develop communication skills.

● The imaginary journey allows the child to get in touch with memories and then to relate their perception
of events more easily.

● Imaginative pretend play encourages communication through dramatic role play.

● Miniature animals provide a visual picture, which usually encourages the child to talk about their
perceptions of relationships.

● Puppets and soft toys help the child to use words to express the feelings and perceptions of characters,
and allow the child to project their perceptions on to the characters.

● Using symbols in the sand tray can help a child to develop a visual picture of events they have
experienced and to place these in chronological order. The visual picture then enables the child to tell their
story and thus to practice communication skills.

To develop insight

If a child is to develop insight and understanding of themselves and others, they may need to understand
how their involvement in significant events occurred and how their experience fits into their wider social
system. For example:

● Books and storytelling can be used to develop insight by illustrating the reality of human behavior and the
inevitability of consequences of behavior

● Drawing allows the child to gain insight into their own involvement in events. This can be achieved by
inviting the child to draw a comic strip showing the sequence of past events.

● The imaginary journey allows the child to retrieve memories of their involvement in events and
experiences, and thus to gain insight.

● Imaginative pretend play allows young children to take on the role of others in play. Consequently, they
can develop insight into the motives and behaviours of themselves and others.

● The use of miniature animals enables the child to gain insight into relationships as animals are placed near
to each other or are distant from each other.
● Puppets and soft toys can be used with younger children, and symbols and figurines with older children, in
a similar way to imaginative pretend play.

● Use of the sand tray allows the child to develop insight into events by developing a visual picture of the
way in which events may have, or could have, occurred.

Properties of media and activities

Each type of medium and activity has its own unique and inherent properties.

Open-ended and expansive media and activities

Primarily, activities and media which are open-ended and expansive allow freedom of expression with no
particular boundaries or restrictions. They are activities which are flexible and movable, and often contain a
tactile or kinaesthetic element. For example, children can use their imagination to make any changes they
like while on an imaginary journey. In imaginative pretend play an unstructured drama can be created,
developed and changed at will. Finger-painting and clay have kinaesthetic and tactile qualities. No special
skill is required for any of these media and activities so there is very little experience of failure.

Media and activities which are functional and contained

These activities and media allow the child to experience a sense of containment and challenge. They
demand attention to detail and often have an end product or result. For example, if we invite a child to
construct a sculpture with LEGO® bricks, the child is focused on a specific task for which they need to
think and plan the construction, and we can expect a sculpture as the end product.

Media and activities which are familiar and stable

These provide an opportunity for simple, repetitive and sometimes stereotypic interaction. Using them
provides a sense of stability and predictability. For example, when using imaginative pretend play, familiar
and stable themes which are already well known to the child can be continually replayed. This is especially
useful for children who come from chaotic and unstable backgrounds.

Media and activities which are educational

These offer an opportunity for learning and for the acceptance and rejection of rules. They are structured, do
not require lateral thinking, and are progressive in that they require work towards an objective. For
example, when using worksheets the child builds on their knowledge of the content of the worksheet.

Use of Miniature Animals

Miniature animals are extremely useful when joining with a child and when trying to discover initial
information about how the child sees themselves and their family.

We will discuss about the use of miniature animals under

1. Materials needed

2. Goals when using miniature animals

3. How to use miniature animals

4. Counselling skills when using miniature animals

Materials Needed

A variety of small toy animals and other creatures is required.

Preferably there are a few animals or creatures included from each of the following groups:

• Domestic animals

• Tarm animalsJungle animals

• Zoo animals

• DinosaursReptiles (snakes, crocodiles, lizards)

• Insects (spiders, grasshoppers)

• Sea creatures (turtles, dolphins, whales).

It is preferable that the animals and other creatures are made of plastic and be appropriately coloured so that
they look realistic.

A variety of sizes and appearances is also useful, for example, some having a benign appearance, some an
aggressive appearance, and others seeming friendly. It is desirable to have both male and female animals,
and baby animals in some species.

The inclusion of dinosaurs is important; children like to make use of them, particularly the very large
aggressive-looking ones. It is important that all the animals are able to stand freely without support; children
become frustrated and distracted with animals fall over.

A large, flat work space is required when working with miniatures.

This can either be a table or floor.

Generally, we prefer to sit and work on the carpeted floor of our play therapy room.

Goals

The main goal is to enable the child to tell their story about their perceptions of their personal relationships
and their perceptions of other relationships within their family.

Working with miniature antimals enables the child to do the following:

• Explore past, present and future relationships with others;

• Gain a fuller understanding of their place in the family

• Explore fears related to their own future relationships:

• Fantasize about possible future relationships;

• Explore fears with regard to future relationships between others;

• Explore possible solutions to relationship problems.

Miniature animals can also be used to explore the child's relationships in other systems and situations;
for example, in school, in foster placement, during access visits and during visits to hospital for
medical procedures. Miniature animals can also be used in conjunction with sand-tray work.

How to use miniature animals?

The counsellor's task, when using miniature animals, is to encourage the child to focus on the
important relationships in their life and to tell their story with regard to these.

From this storytelling the counsellor can help the child to identify important themes and issues, and
can allow the child to experience any emotions which emerge.

Counselling skills when using miniature animals

• Use of observation

• Open ended question

Different Techniques in Play Therapy

The therapist may use techniques that involve:

● Miniature animals

● Sand tray work

● Working with clay

● Drawing

● Painting

● Collage and construction

Sand-Tray Work

• Sand-tray work can be very useful in helping a child to tell their story. We will discuss sand-tray
work under the following headings:

1. Equipment and materials needed

2. Goals of sand-tray work

3. How to use the sand tray

4. Counselling skills when using the sand tray

Equipment and materials needed

The only equipment required is the sand tray itself.

Materials required are symbols, figurines, and miniature animals.

⮚ The sand trays

The sand tray may be made of wood or plastic.

Ideally, it is square with sides of about 1 meter in length and about 150 mm high.

Wooden sand trays require a waterproof lining.

⮚ Symbols

The symbols used in sand tray work consist of a variety of small objects which are chosen because they have
properties that enable them to easily assure symbolic meaning.

We have collected our symbols over a period of time so that they include many different types of objects.

A useful set of symbols might include the following items:

⬥ General items

Rocks, stones and pebbles, feathers, shells, wood, small boxes with lids, marbles, candles, small paper flags,
old jewellery, A key, paper, A padlock, and ornaments.

⬥ Figurines and superheroes

Male and female figurines, toy soldiers, medieval knights, Catwoman, batman, transformers

⬥ Toy animals

Dragons, farm animals, zoo animals, jungle animals, domestic animals.

Goals of sand-tray work

Sand-tray work allows the child to use symbols within a defined space to tell their story. While telling their
story, the child has an opportunity to re-create in the sand tray, and in their imagination, events, and
situations from their past and present. The child may also explore possibilities. for the future or express their
fantasies in the sand tray.
Counseling skills when using the sand tray

When intervention is necessary while the child is telling their story, the counselor can make use of the
counseling skills

The skills detailed below are most useful and relevant to sand-tray work:

1. Observation

2. Use of statements

3. Use of questions

4. Giving instructions

5. Termination skills when using the sand tray.

Working with clay

Children have always played with clay however more recently it has become a valuable tool for play
therapists as it provides children with a natural method of connection and expression. Clay stimulates tactile
and kinesthetic senses, it allows children who have shut down or blocked their sensory and emotional
experiences to get in touch with them again. As these children become fully engaged in working with clay,
their increased sensitivity to kinesthetic sensation is likely to result in the useful expression of emotion. The
counselor can expect to see behaviors that are likely to reflect the child's inner processes. Therefore, the
counselor can observe the child’s nonverbal and verbal responses, and respond to these by using appropriate
counseling skills.

Materials required

● Soft, pliable clay is required.

● It is important that the clay is not too wet or sticky.

● Because, if it is, working with it will be unpleasant.

● Additionally, if the clay is too coarse and gritty it will be rough on the skin.

● Clay can be bought in blocks of about 30 cm 20 cm 10 cm from a craft shop.

● We prefer to work with clay on the floor, rather than on a bench so that the child can more easily join
with the clay, and work right beside it.

● Clay is very useful when working with children in groups.

● In a group selling. children can be encouraged to interact with each other as they work with the clay
and gain insight and understanding of other children in the group through sharing.

● This sharing can enhance the children's individual sense of belonging to the group.
● Additionally, clay work can be used to help children discover the consequences of their behavior
when in a group.

Goals when working with clay individually and in groups

● To help the child to tell and share their story by using the clay to illustrate elements of that story

● To enable the child to project inwardly contained feelings onto the clay so that they can be
recognized and owned.

● To help the child to recognize and deal with underlying issues.

● To help the child to explore relationships and to develop insight into those relationships.

● To enable a child to experience success and satisfaction in completing a creative task.

Additional goals when working with clay in a group

● To help the children gain insight and understanding of others.

● To increase a child's sense of belonging to a group.

● To help children discover the consequences of their behavior when in a group.

Making use of drawing and painting

● For children from the age of eight or nine years and upwards, drawing or painting which involves
fantasy is invaluable.

● It allows them to release socially unacceptable emotions, such as hate and anger, and to express
secrets and desires.

● The counselor might start by asking the child to create their own world on paper, using shapes, lines,
and colors, and might say, 'Think about your world as lines, shapes, and colors.

● Use the whole page to show me where the people, places, and things are in your world.

● The child can then be encouraged to move the paint around with their fingers.

● Once the process has started, the counselor can say to the child, 'Let's see if you can show me how
you're feeling, by making a picture out of the paint.

● Finger painting involves tactile and kinesthetic experiences.

● It can be soothing and flowing or it can encourage expansive and less controlled expression

● Finger-painting allows the child to make pictures and to change them quickly, or to cover them up or
erase them with more paint.

● The size of the paper is the only restraint or boundary, so the child can feel free and be expressive.
● Finger painting is sometimes best used as a warm-up exercise for children before they begin creating
more representational images with the use of brushes.

Collages

Collages add yet another dimension to the creative expression of children.

Similar instructions can be given to the child to those used for drawing or painting. Additionally, collage
allows the child to make connections between the texture of objects and emotional feelings to help a child to
make such a connection. The counselor might say, 'How does this sandpaper feel the child might reply
Scratchy, the counselor might then ask, If you were that piece of scratchy sandpaper, how would you feel?
Collage is a good medium to use when asking a child to make a selfportrait. A self-portrait in collage can
help the child to become more fully aware of their perception of themselves and can give them the
opportunity to move from superficial descriptions to greater self-disclosure. We might begin by inviting a
child to choose any of the materials provided to create a picture of themselves. Collage can be used with
older children to explore their perceptions of issues and events in their lives. Older children will often use
pictures and words of varying type sizes to make statements about current or past issues which are of
concern to them. Depending on the materials available. Collage can sometimes move into the activity of
construction.

Construction or sculpture

Many of the suggestions given for drawing, painting, and collage can be adapted for construction work or
sculpture. For example, the counselor might say, Make a tree to represent you. "Construction and sculpture
are often useful for children who are clumsy or awkward, or who have experienced little success in their
lives. As the child creates the sculpture, the counselor can observe the child's responses to failure, success,
decision-making problem solving and completing tasks. In instances where the construction may take time
to complete, the counselor can observe the way in which the child deals with delayed gratification and can
then make statements of observation about the child’s behavior like I notice that you are hard on yourself
when you make mistakes, or when things don't work out right, you seem to give up easily. The child's
awareness of their behavior is raised so that relevant issues can be addressed.

UNIT 5: Other techniques: Imaginary, journey, Books and stories Puppets and soft toys, Imaginative
pretend play Games

1. Imaginary journey

The imaginary journey can be used to help a child to get in touch with experiences which may have been
very painful for them and may have been repressed. Equally, it may be used as a way of helping a child to
renew contact with happy or pleasant experiences from the past. By sharing their experience of their journey
with the counsellor, the child can deal constructively with memories that have been brought into focus by
the journey. The child can work through emotional feelings which those memories have triggered and
address troubling thoughts and beliefs. The imaginary journey enables the child to get in touch with their
inner pain and then to deal with that pain through the counselling process, An imaginary journey can provide
a child with an opportunity to gain mastery over past issues and events so that they can feel as though they
had an active role in those events and were not just a passive and helpless observer. Consider the case of a
child who had witnessed and been troubled by the bullying of one of their friends in the playground. They
might feel guilty because they ran away and deserted their friend. In the imaginary journey the child might
reconstruct the scene, but instead of running away they might do something different, such as punching the
bully on the nose or telling a teacher about the bully.

Although these alternatives are not necessarily appropriate or acceptable for the child.

2. Books and stories

Storytelling is an interactive process between the child and the counsellor. Usually, children don't like
writing in counselling sessions. Many of the children who come to see us have previously had unsuccessful
experiences when attempting to be creative by writing stories. Because of this, we try to make story writing
an easy, enjoyable and positive creative experience. Usually, as a child develops a story, we write the story
down using a felt pen and a large sheet of paper. Sometimes a tape recorder is also used to record the story.

Goals specific to the use of story books

To help a child to normalize events in their life by letting them know that others have had similar
experiences. This goal can be achieved by reading stories which have themes similar to their own
experiences. To help reduce stigma related to socially unacceptable experiences, Children who have
experienced sexual abuse or domestic violence feel better about themselves when they know that other
children have been through similar experiences and have had similar feelings, they can discover this
by reading stories about other children having similar experiences. To help the child to recognize that
some events are unavoidable. For example, a child who has become ill and has to go to hospital may be
helped by reading a book about another child going to hospital and may thus identify with some of
that child's fears and hopes,

Goal specific to creating stories

Help a child to express wishes, hopes and fantasies. This is particularly useful for children who are
experiencing painful life situations and are telling untrue stories to avoid the pain of facing reality. For
example, a child who has no parents might be ashamed of being different from their friends and might find it
too painful to tell them the truth. Consequently, they might tell their friends that their parents are famous
people who are working overseas. By using storytelling, the counselor is able to help the child to recognize
that their stories are not true, but may be expressions of wishes.
Puppets and soft toys, imaginative pretend play, games

Puppets and soft toys

● Puppets and dolls are great first building blocks for pretend play.

● Encourage child’s fantasy world

● With own selection of play toys children can be anyone and do anything.

● Boys expressed more anger made , more aggressive statements, engaged in more aggressive play and
made more sound effects.

● Girls exhibited more creative and relationship play, happiness, anxiety, verbal verification of
therapist responses and verbalizations of positive and negative thoughts.

How to use it

● Because we use puppets and soft toys similarly, we will only refer to puppets in the following
discussion, although this discussion applies equally to soft toys.

● There are four ways of using puppets:

● Allowing the child to use the puppets spontaneously.

● Inviting the child to create and direct a puppet show.

● Combining the use of puppets with well-known fairy stories or fables.

● Using puppets in dialogue with the counsellor.

● As the child introduces the characters, the counsellor can engage in conversation as each character is
presented.

● For example, the counsellor might say, “Hello Jeddy. I’m looking forward to this show.

● This participation by the counsellor helps the child to feel more comfortable about the activity, sets
the scene and allows the child to project themselves onto the characters.

● Some children find it easy to make up a story and to act it out.

● Others find it more difficult.

● With these children we usually suggest themes for them to use, which are likely to address issues or
events relevant for the child.

● For example, we might suggest themes concerned with being moved from the family home into care,
or regarding access visits with an absent parent, or themes which reflect helplessness, fear or abandonment.
Imaginative pretend play

Children’s pretend play is a complex phenomenon.

It involves a myriad of process and behaviors that change from moment to moment. Different theoretical
School stressed the importance of pretend play in the Therapy process.

Psychodynamic, client-centered approach and cognitive behavioral approaches as well have proposed that
change occurred in the child through the process of play. It helps to child development Play is involved in
the development of many cognitive, affective and personality process that are important for adaptive,
functions in children.

Pretend play is important both in child development and in child psychotherapy. Pretend play involves
pretending the use of fantasy and make believes and the use of symbolism

Pretend play is natural form of creativity.

Young children can differentiate between make-believe play and reality.

Cognitive process: organization, divergent thinking, symbolism

Affective process: expression of emotion, comfort and enjoyment in play, emotion regulation and
modulation of affect, cognitive integration of affect

Interpersonal process : Empathy, interpersonal schema and communication

Games

● Games consist of certain rules

● It is more founded on ability to problem solving.

● A game like the Talking, Feeling, Doing Game can be used to work at a more unconscious level.

● These types of activities are tools to be used in any type of child therapy.

● There is no objective way to determine what games are “best” for an individual.

● The choice of games will depend on the setting, therapeutic orientation, and population being served.

● Generally, it is helpful to have a variety of game types.

● For example, card games, board games, and stacking games.

● It is also useful to have games that cover a variety of challenges, topics, and age groups.