Theories of psychotherapy and counseling concepts and cases

Other Psychotherapies 621 many creative techniques other than the ones discussed here, the techniques need to be used by a director who can be creative yet take control of the psychodrama so that emotional destructiveness does not take place. Being able to recognize psychopathology as it emerges in participants is important to prevent damage to others. For example, a manipulative or sociopathic individual who plays the role of an auxiliary may take pleasure in making comments that point out the protagonist’s inadequacies in a hurtful way. Although spontaneity and creativ- ity are important products of psychodrama, they must be subservient to the posi- tive goals of insight, growth, and understanding of individuals (Blatner, 2000). Since the pioneering work of Moreno, psychodrama has continued to grow and develop. In the United States there are more than 400 certified practitioners, and throughout the world more than 15,000 people are trained in psychodrama techniques. Increasingly, practitioners of psychodrama integrate its use with other theories (Adam Blatner, personal communication, January 3, 2010). The American Society for Group Psychotherapy and Psychodrama (ASGPP) provides training and sets standards for the practice of psychodrama and publishes the Journal of Group Psychotherapy, Psychodrama, and Sociometry. Some practitioners have extended Moreno’s work and have applied it to individual treatment of children in which they are encouraged to act out imaginative ideas. For example, Hoey (1997) describes a 13-year-old girl whose mother died when she was 6 and who had lived in several foster homes but was about to be adopted. To encour- age expression Hoey said, “Shall we make up a story about a girl like you? A girl who’s lived in lots of places and now has at last found somewhere where she can be happy?” (p. 109). Creativity characterizes those who use psychodrama, and several have combined it with art therapies and drama therapy, while others have used it within a psychodynamic framework (Garfield, 2003). Summary Developed by Jacob Moreno in the 1930s, psychodrama makes use of creativity and spontaneity to help individuals test reality, develop insight, and express feel- ings. In a psychodrama, the therapist takes on the role of the director, choosing the protagonist ( the focus of the psychodrama), and uses auxiliaries to play the role of significant others in the protagonist’s concerns. Auxiliaries are volunteers from the audience. Using a mixture of playfulness and seriousness and techniques such as role reversal and mirroring, psychodrama offers ways to help individuals grow and see themselves in different ways. The therapist ensures that the psychodrama is a positive experience by seeing that participants are helpful in their roles. References Blatner, A. (Ed.). (2003). “Not mere players”: Psycho- drama applications in everyday life. In J. Gershoni Blatner, A. (2000). Foundations of psychodrama: History, (Ed.), Psychodrama in the 21st century: Clinical and theory, and practice (4th ed.). New York: Springer. educational applications (pp. 103–115). New York: Springer. Blatner, A. (2005). Psychodrama. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (7th Borgatta, E. F. (2007). Jacob L. Moreno and sociometry: A ed., pp. 405–438). Belmont, CA: Brooks/Cole– mid-century reminiscence. Social Psychology Quarterly, Thomson. 70(4), 330–332. Blatner, A. (2007). Morenean approaches: Recognizing Casson, J. (2007). Psychodrama in miniature. In C. Baim, psychodrama’s many facets. Journal of Group J. Burmeister, & M. Maciel (Eds.), Psychodrama: Psychotherapy, Psychodrama & Sociometry, 59(4), 159–170. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

622 Chapter 15 Advances in theory and practice (pp. 201–213). New Kim, K. W. (2003). The effects of being the protagonist York: Routledge. in psychodrama. Journal of Group Psychotherapy, Psychodrama & Sociometry, 55(4), 115–127. Corey, G. (2008). Theory and practice of group counseling (7th ed.) Belmont, CA: Brooks/Cole–Thomson. Landy, R. J. (2008). The couch and the stage: Integrating words and action in psychotherapy. Lanham, MD: Corsini, R. J. (1966). Role playing in psychotherapy. Jason Aronson. Chicago: Aldine-Atherton. Marineau, R. F. (2007). The birth and development of Dayton, T. (2005). The living stages: A step by step guide to sociometry: The work and legacy of Jacob Moreno psychodrama, sociometry, and group psychotherapy. (1889–1974). Social Psychology Quarterly, 70(4), Deerfield Beach, FL: Health Communications. 322–325. Duffy, T. K. (2008). Psychodrama. In A. L. Strozíer & J. Moreno, J. L. (1934). Who shall survive? A new E. Carpenter (Eds.), Introduction to alternative and approach to the problem of human interrelations. complementary therapies (pp. 129–151). New York: Washington, DC: Nervous and Mental Disease Haworth Press. Publishing. Feasey, D. (2001). Good practice in psychodrama: An ana- Moreno, J. L. (1947). Theatre of spontaneity: An lytic perspective. London, England: Whurr. introduction to psychodrama. Beacon, NY: Beacon House. Fields, C. D. (2007). Sociometry 1937. Social Psychology Quarterly, 70(4), 326–329. Moreno, Z. T. (1987). Psychodrama, role theory, and the concept of the social atom. In J. K. Zeig (Ed.), The Fox, J. (Ed.). (1987). The essential Moreno: Writings on psy- evolution of psychotherapy (pp. 341–366). New York: chodrama, group method, and spontaneity. New York: Brunner/Mazel. Springer. Schacht, M. (2007). Spontaneity-creativity: The psycho- Garfield, S. (Ed.). (2003). Transference in analytic psy- dramatic concept of change. In C. Baim, chodrama. In J. Gershoni (Ed.), Psychodrama in J. Burmeister, & M. Maciel (Eds.), Psychodrama: the 21st century: Clinical and educational applications Advances in theory and practice (pp. 21–39). New (pp. 15–30). New York: Springer. York: Routledge. Hoey, B. (1997). Who calls the tune? A psychodramatic ap- Yablonsky, L. (1976). Psychodrama: Resolving emotional proach to child therapy. London: Routledge. problems through role-playing. New York: Basic Books. Kellermann, P. F. (2007). Let’s face it: Mirroring in psy- chodrama. In C. Baim, J. Burmeister, & M. Maciel (Eds.), Psychodrama: Advances in theory and practice (pp. 83–95). New York: Routledge. Creative Arts Therapies Creative arts therapies include art, drama, dance movement, and music thera- pies, as they all use creative expression to bring about therapeutic change. Some individuals take advantage of the opportunity to express themselves nonverbally through these media, which leads to increased self-esteem, more productive self- expression, and/or improved social interaction with others. Creative arts therapies emphasize client use of the artistic medium rather than observation of artistic works. However, music therapists often use record- ings in dealing with client affect and moods. The quality of the patient’s produc- tion is of little importance compared with the meaning that patient and therapist can derive from the work and its ultimate helpfulness to the patient. In this re- gard, therapists rarely participate in creative expression with clients so as not to inhibit the client, whose work is often artistically inferior to the therapist’s. In most cases, creative arts therapists work as part of a psychotherapeutic team, although increasingly they may work independently, doing psychotherapy as well as creative arts therapy. Traditionally, they have worked in hospitals and Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Other Psychotherapies 623 institutions for the mentally disabled, particularly with individuals whose verbal communications are limited. Their qualifications are a combination of knowledge and talent in their own area of artistic endeavor, including knowledge of techniques and forms of artistic production, as well as education in working psychotherapeutically with patient problems. Although certain theories of psy- chotherapy that emphasize enactment, such as gestalt therapy, fit well with crea- tive arts therapy, creative arts therapists have varied backgrounds, and they may combine any one or more of the therapies discussed in this book with their crea- tive specialty. The National Coalition of Creative Art Therapies, which includes six creative arts therapy associations, represents more than 15,000 members. Because psychoanalysis was particularly influential in the 1930s to the 1950s, some creative arts therapists, especially art therapists (Vick, 2003) have been edu- cated to take a psychoanalytic approach to their work. The development of creative arts therapy has been rapid, taking place within the last 40 or 50 years. Each specialty has at least one association: American Art Therapy Association, Association for Dance and Movement Psychotherapy United Kingdom, National Association for Drama Therapy, and the American Music Therapy Association. Additionally, specialties have one or more journals that publish their contributions: Art Therapy: Journal of the American Art Therapy Association, The Arts in Psychotherapy: An International Journal, American Journal of Dance Therapy, and The Journal of Music Therapy. Several institutions throughout the world offer master’s degree programs in several areas of the creative arts therapies. The variety of approaches available to creative arts therapists is seen not only through their journals but also through textbooks and books of readings on music, art, drama, and dance therapies. Because these therapies are quite spe- cialized and are usually an adjunct to other psychotherapies, only a brief over- view can be given in this chapter. Art Therapy The broad purpose of art therapy is to help patients deal with emotional conflicts, become more aware of their feelings, and deal with both internal and external problems. To reach these goals, art therapists, when appropriate, pro- vide instruction in the use of a variety of art materials. Typically, materials are selected that fit the needs of the client and the issue being addressed. For exam- ple, pastels, crayons, or felt-tip pens might be used when patients are free- associating or using art to express feelings. Other times, clay, paper, canvas, watercolors, or finger paints may be used, depending on the circumstance (Malchiodi, 2003, 2005; Rubin, 2010; Vick, 2003). These materials aid in bringing about the expression of images that are in the human mind before individuals learn to verbally articulate their needs. Art expression provides the opportunity to depict images that cannot be ex- pressed verbally, to show spatial relationships (such as the patient to his father and mother), and to express oneself without worrying about what one is saying. Unlike verbal expression, art expression is more likely to give a feeling of being creative and to provide the opportunity to increase one’s energy level while working physically to develop a tangible product. Furthermore, products of artis- tic creativity can be referred to in later days or weeks, unlike verbal expression, which fades quickly (Malchiodi, 2005; Rubin, 2010). Suggestions for creative ex- pression may come from the patient, therapist, or both. Therapists may suggest exercises such as having a patient draw an image of herself and then discuss Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

624 Chapter 15 how that image relates to the patient’s view of herself. Other exercises might in- clude drawing oneself as one would like to be, drawing one’s family, or drawing particular family relationships. In their education and training, art therapists learn the application of a great variety of art media, as well as techniques to help clients express themselves. As art therapy has developed, so have the variety of means for expression and the populations that therapists work with. With the development of technology has come the use of video recording, easy-to-use photographic equipment, com- puter graphics, and other methods that aid in creative expression (Rubin, 2010). As art therapy has changed, some art therapists have combined music, movement, and psychodrama in their work. The types of problems and populations that art therapists work with have also expanded to include bereaved children, battered women, incest survivors, group therapy patients, and Alzheimer’s patients (Malchiodi, 2005). A brief example of how art therapy might be used can be seen in Wadeson’s (2001) work with Craig, a young man hospitalized with a diagnosis of paranoid schizophrenia. Appearing threatening and dangerous to the staff, Craig was able to make gains by expressing secret desires through his love for drawing and to reduce his sense of isolation through his creative expression and discussion with the art therapist. In describing a drawing, Figure 15.1, that was done on notebook paper with pencil and blue ink, Craig said that the picture represented himself. The underneath part is “strong and grasping,” the sphere is “selfless” and represents his “mind.” He explained that the roots are holding the sphere and that basically the underneath shows “control” of the body over the mind. “In order for the mind to ex- ist, the body controls or comforts it,” he said. (Wadeson, 2001, p. 315) In discussing the relevance of Craig’s artwork, (Payne, 2006), Wadeson be- lieved that his art expression provided an opportunity to build a bridge from his fear that people would take his secrets away to interaction with others. Through Wadeson’s interest in Craig’s imagery, he was able to build trust and to describe his strange inner world to someone he felt understood him. This small example helps show one of many different ways that art therapists may work with patients to help them explore their inner world, to increase communi- cation with others, and to cope more effectively with a variety of problems. Dance Movement Therapy The goals of dance movement therapy are to help individuals grow and to inter- relate psychological and physiological processes through movement or dance. Individuals can come to understand their own feelings, images, and memories, as well as those of others, by expressing themselves through movement or dance. Although dance movement therapy has its origins in the application of structured dances to individual expression, dance movement therapists rarely teach dances but tend to encourage expression through movement exercises, often making use of music. Approaches to patients are creative and spontaneous, as dance movement therapists attend to the moods and physical positions of their clients. Implicit in the work of dance therapists is their acknowledgment of the impact that body and mind have on each other as seen in physiological tension, body image, and ordinary movement (Loman, 2005; Payne, 2006). Dance movement therapy allows clients to experience both emotional and physiological feelings Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Other Psychotherapies 625 Image not available due to copyright restrictions simultaneously, which can lead to a better understanding of self. In groups, reaching toward another person, stretching to touch that person, or holding or being held by group members can help interpersonal relationships, as can the awareness of feelings expressed in the bodily movements of others. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

626 Chapter 15 Techniques of dance movement therapy are very varied, depending on the nature of the individual or group the therapist is working with. One technique is that of exaggeration, in which clients are encouraged to exaggerate a movement, such as a shrug of the shoulder. The client can then be asked to communicate the feeling verbally or to continue moving. Sometimes therapists may find it helpful to copy the actions of a group member to empathically understand what the group member may be experiencing physiologically and affectively. However, this must be done in a way that does not appear to mimic or make fun of the client. Another approach is to translate a client issue into an action. For example, the client wishing to separate from his mother may gradually step backward from the therapist, moving toward the other end of the room, and possibly sharing the experience as he does so. Knowing the clients’ cultural background can influence the methods that dance movement therapists use (Hanna, 2004). A vast variety of approaches can be used with clients, ranging from professional dancers to autistic children to those with neurological disabilities. There are many ways that dance movement therapy can be done with groups (Nicholas, 2003). An application of dance movement therapy to seven male adults in a ther- apeutic community shows how creative approaches to movement can help indi- viduals who are resistant and suffering from severe psychological disorders. It seemed like a sign of growing trust when participants started to express more of the anger stored within. They found ways of venting their frustration in punch-like clapping and stomping movements and sometimes even shouting. An evocative image that emerged was Mike Tyson the boxer. When Jeremy complained of obses- sive thoughts, which prevented him from stopping talking, I asked him to translate them into movements. His response was a crescendo of fists, shaking violently, and kicking movements. So he found ways of physical outlet for his nervous mental en- ergy and was eventually able to contact some of the depression which was under- neath his anger. Then he could even allow the group to hold him in the middle of the circle and rock him soothingly. (Steiner, 1992, pp. 158–159) And another exercise: For what seemed a long time we stayed with small repetitive movements, patting the body, clapping hands, then I introduced my circular band, made of old ties strung to- gether. Everyone held it in one hand and we made some round movements with it. Asked what we were doing, Nigel said “stirring” and Jeremy added “in a cauldron.” Encouraged to add ingredients, Nigel put in his sorrow, Jeremy his mother, then me because I had annoyed him by changing “his” music, David added his confrontation, and Billy his anxiety. Thus the group had created a container for the difficult feelings each person experienced. (p. 160) These brief excerpts suggest how dance movement therapists, using their cre- ativity, can work with individuals to help them integrate psychological and physical processes. Not only do the patients express themselves but they also communicate through bodily energy, rhythm, and touch. Drama Therapy The most recently developed of the creative arts therapies, drama therapy can take many forms (Jones, 2007; Landy, 2005, 2008). As defined by Jennings (1992), “Drama therapy is a means of bringing about change in individuals and groups through direct experience of theatre art” (p. 5). For some drama thera- pists, psychodrama is a form of drama therapy. The range of drama therapeutic Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Other Psychotherapies 627 approaches runs from Shakespeare to the use of puppets and masks. Jennings (1992) gives an example of how a drama therapist can use lines from Shakespeare’s King Lear, focusing on King Lear’s relationship with his daughters to explore with middle-aged women their relationships with their aging fathers. With seriously ill children, drama therapy allows children to express their emo- tions by playing roles in fairy tales (Bouzoukis, 2001). Drama therapy has also been used to help children who display problematic sexual behavior by dealing with underlying complex emotional and psychological processes (LeVay, 2005). Drama therapy has many diverse applications. James (1996) gives an exam- ple of a man in his early 20s with limited intellectual functioning who felt “the odds are stacked against me” (pp. 30, 31). Jennings became “the odds” and the young man pushed against him. Later, the young man said that this exercise in- creased his confidence in his abilities. Although rare, at times it can be helpful to have an audience, such as when a group of patients receiving antipsychotic med- ications acted out Dickens’s A Christmas Carol (Andersen-Warren, 1996). Applica- tions of drama therapy reflect knowledge of and expertise in the theater along with a knowledge of theories of psychotherapy (Landy, 2005, 2007, 2008). In the practice of drama therapy, both drama therapists and their clients can take a dramatic role or the traditional client–therapist roles. In the application of drama therapy, the therapist can direct therapy, observe it, lead a group in imag- ery exercises, and experience a creative exercise, such as a pretend journey, with a group ( Johnson, 1992; Jones, 2007). Drama therapists may improvise a play, use puppets, or use a sand tray (a tray with different toy figures, toy buildings, trees, and so forth). Because they may play many different roles (including that of psy- chotherapist) with a client and possibly touch the client, transference and coun- tertransference issues can develop more quickly than they might in other forms of therapy (Johnson, 1992). Although this can be true when working with groups, it is accentuated when working individually with clients. In individual drama therapy, Landy (1992) suggests that drama therapists must attend to the boundaries between client and therapist and to whether cli- ents put too much distance between themselves and the drama therapist or not enough. If the client is underdistanced, the therapist needs to have some distance from the client; if the client is too distant from the therapist, the therapist needs to bridge that gap. Landy gives an example of how the therapist might respond with an overdistant client using an elephant and mouse enactment. For example, the client in the role of the mouse makes himself very small. His move- ments are tiny. His voice is barely audible. He avoids any contact with the therapist in the role of elephant. The therapist fills herself up with the role. As the mouse shrinks, she expands. The smaller he becomes, the larger the therapist becomes. She trumpets, flailing her trunk; she swaggers around the room, knocking things off the table, threatening to crush the mouse under her big, round, wrinkled foot. In her full- ness being most threatening, challenging, clumsy, provocative, the therapist/elephant acts at being under-distanced. (Landy, 1992, p. 101) Aware of her role, the therapist may wish to project the image of a large clumsy authority figure to provoke a response from the client. In this role, the ther- apist is an actor, ready to suggest that the client change roles with her and play the elephant while she plays the mouse. If the client has difficulty playing the mouse, it is the drama therapist’s role to help the client do so. If appropriate, she may play a clever mouse, who can trick the elephant as in a fable, or may encourage the cli- ent to play that role. The therapist goes beyond role playing, using acting and Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

628 Chapter 15 directing skills to help the client become more aware of emotions, develop inter- personal skills, and deal with a variety of psychological problems. Music Therapy Like other creative arts therapies, music therapy can be applied in several ways. Music therapists make use of music both as a basic stimulus and for its therapeu- tic applications (Crowe, 2004). Just as retail stores use background music to make the mood of customers more conducive to buying, music therapists may use rhythmic music to stimulate patients or soothing music to calm them down (Frohne-Hagemann, 2007). The therapeutic function of music is seen through many activities such as solo singing, singing accompanied by the music therapist, and drumming. Music therapists may use music to encourage nonvio- lent behavior, increase verbal behavior, and reduce stress (Crowe, 2004). Although music therapy is used for individuals with diverse problems, such as drug abuse, it is used most frequently for individuals with severe disabilities, such as learning disabilities, schizophrenia, autism, speech and language disorders, visual disabil- ities, and Alzheimer’s disease. For example, (Rio, 2009) shows how music can be used by caregivers for helping older people who suffer from dementia. The theoretical approaches of music therapists can vary widely, from an em- phasis on behavioral evaluation and change (Crowe, 2004) to Odell-Miller’s (2003) use of music as a means of enriching psychoanalytic therapy, especially for transference and countertransference issues. One example of the creativity of music therapists is Rogers’s (1993) work with sexually abused clients. Different musical instruments, particularly percussion instruments, can be assigned to rep- resent different individuals in a child’s life. Different instruments may be assigned differing roles for personas. A clear example is a child “B” who repeatedly used a large conga drum to symbolize his father, a small xylophone to represent his mother and a smaller handchime to represent himself. These instruments were then physically positioned to indicate the strength of the rela- tionships between family members. In addition, the way the instruments were played had a clear symbolic meaning; “B” associated the large conga drum with his father and on one level perceived his father as being very dominating; “B” then played the conga very gently. A clear distinction between the visual and auditory perceptions of the conga was apparent (the contrast between size of the instrument and the way it was played). This contrast can be subsequently explored. (Rogers, 1993, p. 211) This exercise can be seen as a type of musical sculpture, with the physical distance between instruments a part of the sculpture. However, therapists may often improvise and encourage clients to spontaneously express themselves in an active way with a variety of instruments to disclose mood or feeling. Sometimes such exercises may be initiated by the client and other times by the music therapist. In discussing music therapy, Crowe (2004) describes the physiology and spiri- tuality of music therapy as well as collaboration with other arts therapies, and broad applications to many different populations. Music therapy helped children who have been hospitalized due to trauma as a result of events related to the ter- rorist attacks of September 11, 2001 (Loewy & Stewart, 2004). As meta-analyses show, music therapy has been helpful in promoting social involvement and increasing emotional and cognitive skills with individuals with dementia (Koger, Chapin, & Brotons, 1999). For such individuals, music that helps people reminisce about earlier times in their lives can be helpful (Ashida, 2000). In a group of adoles- cents in residential treatment, hip-hop music was helpful because adolescents were Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Other Psychotherapies 629 able to relate to the rappers’ life struggles as played out in the lyrics of the music (Ciardiello, 2003). Music therapists make use of their knowledge of the physiologi- cal and psychological processes of individuals, as well as their knowledge of the aesthetic and physical properties of music. Summary The creative arts therapies, which include art, dance movement, drama, and mu- sic, use innovative therapeutic techniques to encourage the expressive qualities of clients. Although often working with severely disturbed patients, creative arts therapists work with all populations, both individually and in groups. Increas- ingly there is a trend for creative arts therapists to combine modalities, such as art and drama therapies. Some creative arts therapists work primarily in an adjunctive role with psychotherapists; others may combine psychotherapy with their creative modality. References Dramatherapy: Theory and practice 2 (pp. 5–18). London: Routledge. Andersen-Warren, M. (1996). Therapeutic theatre. In S. Mitchell (Ed.), Dramatherapy: Clinical studies Johnson, D. R. (1992). The dramatherapist’s in-role. In (pp. 108–135). London: Kingsley. S. Jennings (Ed.), Dramatherapy: Theory and practice 2 (pp. 112–136). London: Routledge. Ashida, S. (2000). The effect of reminiscence music ther- apy sessions on changes in depressive symptoms in Jones, P. (2007). Drama as therapy: Theory, practice and elderly persons with dementia. Journal of Music research. New York: Routledge. Therapy, 37, 170–182. Koger, S. M., Chapin, K., & Brotons, M. (1999). Is music Bouzoukis, C. E. (2001). Pediatric dramatherapy: therapy an effective intervention for dementia? A They couldn’t run so they learned to fly. London: meta-analytic review of literature. Journal of Music Kingsley. Therapy, 36, 2–15. Ciardiello, S. (Ed.). (2003). Meet them in the lab: Using Landy, R. (1992). One on one: The role of the dramathera- hip-hop music therapy groups with adolescents in pist working with individuals. In S. Jennings (Ed.), residential settings. In N. E. Sullivan, E. S. Mesbur, Dramatherapy: Theory and practice 2 (pp. 97–111). N.C. Lang, D. Goodman, & L. Mitchell (Eds.), Social London: Routledge. work with groups: Social justice through personal, com- munity, and societal change (pp. 103–117). New York, Landy, R. J. (2005). Drama therapy and psychodrama. NY: Haworth Press. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 90–116). New York: Guilford. Crowe, B. (2004). Music and soul making: Toward a new theory of music therapy. Lanham, MD: Scarecrow Landy, R. J. (2007). Drama therapy: Past, present, Press. and future. In I. A. Serlin, J. Sonke-Henderson, R. Brandman, & J. Graham-Pole (Eds.), Whole person Frohne-Hagemann, I. (Ed.). (2007). Receptive music ther- healthcare Vol 3: The arts and health (pp. 143–163). apy: Theory and practice. Germany: Zeitpunkt Musik. Westport, CT: Praeger. Hanna, J. L. (2004). Applying anthropological methods Landy, R. J. (2008). The couch and the stage: Integrating in dance/movement therapy research. In R. F. Cruz words and action in psychotherapy. Lanham, MD: & C. F. Berrol (Eds.), Dance/movement therapists Jason Aronson. in action: A working guide to research options (pp. 144–165). Springfield, IL: Charles C. Thomas. LeVay, D. (2005). “Little monsters”? Play therapy for children with sexually problematic behavior. In James, J. (1996). Dramatherapy with people with learn- C. Schaefer, J. McCormick, & A. Ohnogi (Eds.), In- ing disabilities. In S. Mitchell (Ed.), Dramatherapy: ternational handbook of play therapy: Advances in as- Clinical studies (pp. 15–32). London: Kingsley. sessment, theory, research, and practice (pp. 243–262). Lanham, MD: Jason Aronson. Jennings, S. (1992). “Reason and madness”: Therapeutic journeys through King Lear. In S. Jennings (Ed.), Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

630 Chapter 15 Loewy, J. V., & Stewart, K. (2004). Music therapy to help Payne, H. (Ed.). (2006). Dance movement therapy: Theory, traumatized children and caregivers. In N. B. Webb research and practice (2nd ed.). New York: (Ed.), Mass trauma and violence: Helping families and Routledge. children cope (pp. 191–215). New York: Guilford. Rio, R. (2009). Connecting through music with people with Loman, S. T. (2005). Dance/movement therapy. In C. dementia: A guide for caregivers. London: Jessica A. Malchiodi (Ed.), Expressive therapies (pp. 68–89). Kingsley. New York: Guilford. Rogers, P. (1993). Research in music therapy with sexu- Malchiodi, C. A. (2003). Handbook of art therapy. New ally abused clients. In H. Payne (Ed.), Handbook of York: Guilford. inquiry in the arts therapies: One river, many currents (pp. 197–217). London: Kingsley. Malchiodi, C. A. (2005). Art therapy. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 16–45). New York: Rubin, J. A. (2010). Introduction to art therapy: Sources & Guilford. resources (rev. ed.). New York: Routledge. Nicholas, M. (2003). Introduction: Action methods in Steiner, M. (1992). Alternatives in psychiatry: Dance group therapy. In D. J. Weiner & L. K. Oxford movement therapy in the community. In H. Payne (Eds.), Action therapy with families and groups: Using (Ed.), Dance movement therapy: Theory and practice creative arts improvisation in clinical practice (pp. (pp. 141–162). London: Routledge. 103–105). Washington, DC: American Psychologi- cal Association. Vick, R. M. (2003). A brief history of art therapy. In C. A. Malchiodi (Ed.), Handbook of art therapy (pp. Odell-Miller, H. (Ed.). (2003). Are words enough? 5–15). New York: Guilford. Music therapy as an influence in psychoanalytic psychotherapy. In L. King & R. Randall (Eds.), The Wadeson, H. (2001). An eclectic approach to art ther- future of psychoanalytic psychotherapy (pp. 153–166). apy. In J. A. Rubin (Ed.), Approaches to art therapy: Philadelphia: Whurr. Theory and technique (2nd ed., pp. 300–317). New York: Brunner/Mazel. Summary Five different therapeutic approaches have been discussed, with each having disparate views on how to produce therapeutic changes. Asian therapies empha- size reflection and contemplation, with some approaches suggesting the impor- tance of responsibility and obligation to others. Body psychotherapies stress attending to posture, movement, and physique to assess psychological problems and then to make interventions that may be physical or psychological. Interper- sonal therapy is a research-based approach to treating depression that uses treat- ment manuals to specify procedures. An established approach, psychodrama is active, done in groups and often in front of an audience. It features the enactment of personal problems. The creative arts therapies use music, artworks, movement, and dramatic expression to help clients express their feelings and become more aware of social interactions. Although each of these approaches is quite different from the others, each provides its unique approach to the application of psychotherapy. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

C H A P T E R 16 Comparison and Critique Outline of Comparison and Critique BASIC CONCEPTS OF PERSONALITY CRITIQUE GOALS OF THERAPY Psychoanalysis ASSESSMENT IN THERAPY Jungian Analysis THERAPEUTIC TECHNIQUES Adlerian Therapy DIFFERENTIAL TREATMENT Existential Therapy BRIEF PSYCHOTHERAPY Person-Centered Therapy CURRENT TRENDS Gestalt Therapy Behavior Therapy Common Factors Approach Rational Emotive Behavior Therapy Treatment Manuals and Research-Supported Cognitive Therapy Reality Therapy Psychological Treatment Psychotherapy Constructivist Theories Postmodernism and Constructivism USING THE THEORY WITH OTHER THEORIES Solution-focused RESEARCH Personal construct theory Outcome Research Narrative Future Directions GENDER ISSUES Feminist Therapy MULTICULTURAL ISSUES Family Systems Therapy FAMILY THERAPY GROUP THERAPY 631 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

632 Chapter 16 I n this chapter, I compare theories across each of psychotherapies, interpersonal psychotherapy, psychodrama, and creative arts therapies) are the areas discussed in this book, which provides described very briefly, they are not included in this some background for a critique of the limitations review. and strengths of each theory. To compare theories, I have summarized the basic concepts Following this comparison, I describe what of personality, goals, essential approaches to I consider to be the major limitations and strengths assessment, and the most common techniques of each theory. These views are subjective and applied by each theory. Also, I have selected two reflect opinions formed from contrasting various disorders—depression and anxiety—to compare aspects of theories with each other. This critique the treatment indicated for the major theories of theories is brief so that you may supplement discussed in this book. I also summarize and my views with your own perceptions of the compare how each theory deals with brief strengths and weaknesses of the theory. Both the psychotherapy, current trends, how theories make comparison of the theories and the critique that use of other theories, research trends, gender and I provide should help you as you read about cultural issues as they affect theories differentially, theoretical integration in Chapter 17. Chapter 17 and applications of theories to couples, families, and will illustrate three common integrative theories as groups. Because the five separate theories well as provide information about how you can discussed in Chapter 15 (Asian therapies, body integrate theories, if you choose to do so. Basic Concepts of Personality This section compares the basic concepts of major theories of psychotherapy by grouping theories into three overlapping areas: those that emphasize unconscious processes and/or early development, those dealing with current experience and/ or issues related to living, and those dealing with changing actions and/or thoughts. The key concepts associated with each theory are listed for comparison purposes in Table 16.1. Theories that deal with unconscious forces and/or early development are psychoanalysis, Jungian theory, and Adlerian theory. Concepts of conscious and unconscious forces, as well as the structure of personality (id, ego, and superego), are important to varying degrees to each of the four psychoanalytic views: Drive theory emphasizes psychosexual development, ego psychology focuses on de- fense mechanisms, and object relations theory uses concepts that concern the in- fant’s relationship with the love object (mother). In self psychology, attention is paid to the importance of the development of narcissism. In relational psycho- analysis, particular attention is paid to the developing relationship between the patient and the psychoanalyst, and the subjective views of the patient are highly valued. Whereas psychoanalytic theory focuses on different views of childhood development, Jungian theory is particularly concerned with the unconscious— more specifically, the collective unconscious. To understand Jungian theory, one must have a grasp of the importance of archetypes, a few of which are listed in Table 16.1. Although Adler believed in the importance of unconscious processes, he was particularly interested in individuals’ beliefs, their contributions to soci- ety, and their interest in others. Whereas psychoanalysis, Jungian analysis, and Adlerian therapy focus on past issues and development, existential, person-centered, and gestalt therapy stress present interaction. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 633 Table 16.1 Concepts Basic to Theories of Personality Psychoanalysis Jungian Analysis Adlerian Therapy Unconscious Conscious Style of life Conscious Personal unconscious Social interest Structure of personality Collective unconscious Inferiority and superiority Archetypes Birth order Id Ego Persona Superego Anima, animus Defense mechanisms Shadow Drive theory Self Psychosexual stages Personality attitudes Ego psychology Introversion Defense mechanisms Extraversion Adaptive functions Personality functions Adult development Thinking and feeling Object relations Sensing and intuition Childhood relationship with mother Personality development Individuation Childhood Transitional object Adolescence Good-enough mother Middle age True and false self Old age Splitting Self psychology Person-Centered Therapy Gestalt Therapy Narcissism Selfobject Development of the need for positive Figure and ground Grandiosity regard Contact with self and others Idealized parent Contact boundaries Relational psychoanalysis Conditionality Disturbances of contact Interactions with others Relationships and self-regard boundaries Communication type Fully functioning person Perception of relationships Introjection Intersubjectivity Projection Retroflection Existential Therapy Deflection Confluence Being-in-the-world Awareness Four ways of being Unfinished business Umwelt Rational Emotive Behavior Therapy Cognitive Therapy Mitwelt Eigenwelt Responsible hedonism Automatic thoughts Überwelt Humanism Cognitive schemas Time and being Rationality Cognitive distortions Living and dying Unconditional self-acceptance Freedom, responsibility, and choice All-or-nothing thinking Isolation and loving Meaning and meaninglessness Self-transcendence Striving for authenticity Behavior Therapy Classical and operant principles Positive reinforcement Negative reinforcement Extinction (Continued ) Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

634 Chapter 16 Table 16.1 Concepts Basic to Theories of Personality (Continued) Behavior Therapy (continued) Rational Emotive Behavior Therapy Cognitive Therapy Classical and operant principles Irrational beliefs about Selective abstraction Generalization Competence and success Mind reading Discrimination Love and approval Negative prediction Shaping Being treated unfairly Catastrophizing Safety and comfort Overgeneralization Observational learning principles Labeling and mislabeling Self-efficacy A-B-C theory of personality Magnification or Attention and retention processes A. Activating event minimization Motivational processes B. Belief Personalization Motor reproduction processes C. Consequence Disturbances about disturbances Reality Therapy Constructivist Therapies Feminist Therapy Family Systems Therapy Responsibility Solution-focused Developmental gender Communication patterns Choice theory Listen to complaint differences Systems theory Psychological needs Motivation to change Attend to expectations for Schema theory and Feedback Belonging solutions multiple identities Homeostasis Power Bowen’s intergenerational Freedom Narrative therapy Gilligan’s ethic of care Fun Client stories Relational cultural approach Choosing Setting Differentiation of self Doing Characterization model Triangulation Thinking Plot Family projection process Feeling Theme Emotional cutoff Physiology Narrative empathy Multigenerational Choosing “crazy” transmission process behavior for Minuchin’s structural approach control Family structure Boundary permeability Alignments and coalitions Haley’s strategic approach Power in relationships Communication Symptom focus Existential therapy is distinguished by its attention to issues important to be- ing human: living, death, freedom, isolation, loving, meaning, and meaningless- ness. Person-centered therapy is concerned with issues that develop or interfere with experiencing self-worth. Awareness of self and contact with self and others, concepts very much related to experiencing the present, are the essence of gestalt therapy. The behavioral and cognitive therapies are concerned with how people act, learn, and think. In particular, behavior therapists focus on classical and operant principles of behavior, as well as observational learning. In rational emotive be- havior therapy (REBT), focus is on the irrational belief systems of individuals that create unhappiness for them. Cognitive therapy attends to thinking and distor- tions in thought processes that lead to ineffective ways of feeling, behaving, or thinking. Also focusing on doing, thinking, and feeling, reality therapy empha- sizes the individual’s role in being responsible for or taking control of her own behavior. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 635 Whereas the theories that have just been described attend to psychological factors that affect personality development, feminist therapy examines sociologi- cal factors—such as gender and cultural differences—as they relate to the devel- opment of individuals and their relationships with others. Also going beyond the individual, family therapists point out the importance of the relationship of mem- bers within a family to each other and how these relationships affect individual personality. In general, each of these theories provides a distinct way of seeing the world that has an impact on its approach to therapy. Constructivist therapies (solution- focused and narrative) emphasize clients’ ways of seeing the world or their the- ory of personality, while integrative theories systematically address the overlap of theories. However, there are several instances of overlap between theories, particularly cognitive, behavior, and REBT therapies, that integrate cognitive and behavioral principles. Sometimes different terms are used for similar con- cepts in very different theories. For example, Kernberg uses the term splitting to describe the tendency of individuals (particularly those with a borderline disor- der) to see things as all good or all bad, whereas Beck uses the cognitive term all-or-nothing thinking to describe a similar process. For most theories, the concepts that are basic to the theories of personality are quite well developed. In Table 16.1, only the most important are listed. Goals of Therapy Following from basic concepts about human personality, goals of therapy for each theory are a reflection of those concepts that the theorists believe are impor- tant aims for clients and therapists. Table 16.2 summarizes, in very brief form, aspects of human experience that are seen as the focus of therapeutic change. In general, the emphasis on specificity and clearly defining change is more impor- tant for cognitive and behavior therapies than for others. Because therapeutic goals are all stated differently for each theory, comparisons of the goals of ther- apy are somewhat difficult to make. Assessment in Therapy In essence, goals guide therapists as to where they are going; assessment helps them find markers to guide them in bringing about therapeutic change. Although some therapists may make use of personality inventories to learn more about the client, many put the most emphasis on initial interviews, as well as on the ther- apy sessions, as the assessment process continues throughout therapy. For theo- ries that have cognitive and behavioral goals, the assessment techniques tend to be very specific, with client thoughts and behaviors clearly described. For cogni- tive therapy, diagnostic classification systems may help guide therapy, along with specific observations and reports. For other therapies, such as Jungian, exis- tential, person-centered, gestalt, family, and constructivist therapies, therapeutic goals are not closely related to the DSM-IV-TR classification system, and assess- ment methods are unique to each therapy. The brief summary of assessment ap- proaches in Table 16.3 describes concepts, tests, and methods that provide a basis for making therapeutic change. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

636 Chapter 16 Table 16.2 Goals of Therapy Psychoanalysis Change in personality and character structure; resolve unconscious conflicts within self; reconstruct and reinterpret childhood Jungian Analysis experiences. Adlerian Therapy Existential Therapy Drive Theory—increase awareness of sexual and aggressive drives. Person-Centered Ego Theory—understand ego defenses and adapt to external world. Therapy Object Relations-Relational Psychoanalysis—explore and resolve Gestalt Therapy separation and individuation issues. Behavior Therapy Self Psychology—resolve issues dealing with self-absorption or Rational Emotive idealized parents. Behavior Therapy Cognitive Therapy Individuation; integration of the conscious and unconscious leading to individuation. Reality Therapy Constructivist Increase social interest, change self-defeating behaviors, solve Therapies problems, modify or change lifestyle. Feminist Therapy Authenticity; find a meaning for existence and pursue it; fully Family Systems experience existence. Therapy Become more self-directed, increase positive self-regard; the client chooses goals. The person’s feelings, perceptions, thoughts, and body are in har- mony with each other; awareness leads to growth, responsibility, and maturity. Change specific target behaviors that are clearly and accurately defined. Perform functional analysis, when appropriate, to specify goals. Minimize emotional disturbances, decrease self-defeating behaviors, learn a philosophy that will reduce the chances of being disturbed by overwhelming irrational thoughts. Remove biases or distortions in thinking to function more effec- tively and bring about more positive feelings, behavior, and thinking. Help individuals take responsibility for and meet needs for belong- ing, power, freedom, and fun in satisfying ways. Solution-focused—make specific goals; solve problems, rate progress. Narrative therapy—see lives (stories) in positive ways rather than problem saturated. Should include changes in societal institutions as well as personal issues; also build self-esteem, improve interpersonal relationships, examine gender roles, and accept one’s own body. Bowen—reduce family stress level and help members become more differentiated. Minuchin—alter coalitions and alliances in the family to bring about changes. Haley—focus on specific goals; strategies planned to reach goals. Therapeutic Techniques Although the various theories have developed techniques growing out of their views of individuals’ personalities, some of the techniques or methods overlap, and practitioners borrow from other theories. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 637 Table 16.3 Assessment Approach Psychoanalysis Family and social history, structured or unstructured Trial analysis Jungian Analysis Projective techniques—Rorschach, Thematic Apperception Test Adlerian Therapy Examine archetypal material in dreams and fantasies Projective techniques Existential Therapy Measures of attitude and function—Gray-Wheelwright, Myers-Briggs, Singer-Loomis Person-Centered Therapy Analyze lifestyle, make observations about family dynamics, birth Gestalt Therapy order, and examine early recollections. Examine basic mistakes (self-defeating behaviors). Behavior Therapy Assess assets. Questionnaires may be used in addition to interviews. Rational Emotive Listen for themes of isolation, meaninglessness, responsibility, and Behavior Therapy mortality. Also, assess ability to face life honestly. Dreams, objective Cognitive Therapy tests, and projective tests may help. Reality Therapy Assessment occurs as therapists empathically understand clients. Constructivist Therapists perceive and construct patterns from patients’ words, Therapies bodily movements, feelings, and sensations, as they occur. They Feminist Therapy may do this by focusing on the experiencing cycle, which contains these elements as well as others. Family Systems Therapy Inquire about antecedents and consequences of behavior; use behavioral reports, ratings, observations, and physiological measurements; use experimental methods to assess progress. Assess thoughts and behaviors using interviews and specific questionnaires; use A-B-C theory to identify problems. Techniques include interviews with detailed questioning, self- monitoring, thought sampling, and scales and questionnaires about specific problems or attitudes. Use interviews and self-evaluation questionnaires to find what cli- ents “really want” and to assess needs for belonging, power, free- dom, and fun. Also assess doing, thinking, feeling, and physiology. Solution-focused—assess motivation, map sequence of behaviors with mindmaps. Narrative—view lives as positive rather than as problem saturated. Caution against traditional psychological assessment; focus on in- cluding sociological factors such as violence, discrimination, and gender role. In general, make observations about patterns of family interactions. For example, most therapists in the course of their work with clients are likely to respond empathically (person-centered therapy) at some point in therapy (particu- larly during early stages or when clients present emotional issues). The less active techniques of free association and interpretation are usually associated with longer-term therapies such as psychoanalysis and Jungian analysis. More confron- tive and direct techniques (confrontations, questions, and directions) are used in brief psychoanalysis and in cognitive, behavioral, REBT, gestalt, and reality thera- pies. In psychoanalysis and Jungian analysis, techniques emphasize bringing un- conscious processes into conscious awareness. In Adlerian, cognitive, and REBT Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

638 Chapter 16 therapy, techniques focus more on cognitive than on behavioral or emotive pro- cesses. In behavior and reality therapy, attention is paid first to changing ways of doing but also to beliefs and feelings. In gestalt therapy, primary attention is to awareness of verbal and nonverbal processes, often bringing out emotional feel- ings, whereas person-centered therapists empathize with their client’s experience. Although existential therapists may make use of techniques from any of the previ- ous theories, they attend to issues that are of importance in being human. Feminist therapists may make use of a number of these methods but also examine the social and cultural context and factors outside the client that influence her problems. Family therapists may respond to individuals in a family using some of these ap- proaches but most often are likely to examine the system first and make interven- tions that may have an impact on two or more members of a family. When solution-focused therapists use techniques, attention is paid to how clients view so- lutions to their problems and how interventions can be made that fit with the stor- ies of their problems. For convenience, the primary therapeutic techniques that are associated with each theory are listed in Table 16.4 so that further comparison can be made. Table 16.4 Therapeutic Techniques Psychoanalysis Jungian Analysis Adlerian Therapy Free association Bring unconscious into conscious Immediacy Neutrality awareness Encouragement Empathy Acting as if Analyzing resistance Interpretation of dreams, fantasies Catching oneself Interpretation (dreams, free Active imagination Creating images Creative techniques: poetry, Spitting in the client’s soup association, etc.) Avoiding the tar baby Analysis of transference art, sandplay Push-button technique Countertransference Transference Paradoxical intention Relational responses Countertransference Task setting and commitment Brief psychoanalysis Homework Questions Restatements Confrontations Interpretation (limited) Existential Therapy Person-Centered Therapy Gestalt Therapy Techniques are not generally used; Necessary and sufficient conditions Empathic responding rather, conditions are present and for change: Enhancing awareness Awareness statements and questions issues are addressed Psychological contact Emphasizing and enhancing Conditions Psychological vulnerability Congruence and genuineness awareness through Therapeutic love Unconditional positive regard or Verbal behavior Resistance Nonverbal behavior Transference acceptance Feelings Issues addressed Empathy Dialogue Living and dying Perception of empathy and Enactment Freedom, responsibility, and choice Dreams Isolation and loving acceptance Awareness of self and others Meaning and meaninglessness (Continued) Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 639 Table 16.4 Therapeutic Techniques (Continued) Existential Therapy (continued) Person-Centered Therapy Gestalt Therapy Frankl’s logotherapy techniques Awareness of avoidance Attitude modulation Taking risks Dereflection Creativity Paradoxical intention Socratic dialogue Behavior Therapy Rational Emotive Behavior Therapy Cognitive Therapy Systematic desensitization Disputing irrational beliefs using Structured sessions Imaginal flooding A-B-C-D-E model Guided discovery In vivo techniques Specifying automatic thoughts Virtual reality Cognitive approaches Homework Modeling techniques Coping self-statements Cognitive interventions Teaching others Live Problem solving Understanding idiosyncratic Symbolic meaning Role playing Emotive techniques Participant Imagery Challenging absolutes Covert Role playing Reattribution Cognitive-behavioral techniques Shame attacking Labeling of distortions Self-instructional training Forceful self statements Decatastrophizing Stress inoculation and dialogue Challenging all-or-nothing thinking Relaxation techniques Listing advantages and Assertiveness Behavior methods Exposure and ritual prevention Activity homework disadvantages Reinforcement Cognitive rehearsal Skill training Insight Reality Therapy Constructivist Therapies Feminist Therapy Family Systems Therapy Process Solution-focused Gender role analysis and Friendly involvement Pretherapy change intervention Family systems therapy Exploring total behavior Bowen’s intergenera- Evaluating behavior Complimenting Cultural analysis and Planning to do better Miracle question intervention tional approach Commitment to plans Scaling Genograms Assessing motivation Power analysis and Interpretation Therapist attitudes Exception-seeking intervention Coaching Don’t accept excuses Assessing motivation Detriangulation No criticism “The message” Assertiveness training Minuchin’s structural Don’t give up Narrative therapy Reframing and relabeling Telling the story Demystifying therapy approach Strategies Externalizing the problem Family mapping Questioning Unique outcomes Accommodating and Being positive Alternative narratives Metaphors Positive narratives joining Humor Questions about the Enactment Confrontation Changing boundaries Paradoxical techniques future Reframing Support for client stories Haley’s strategic approach Straightforward tasks Paradoxical tasks Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

640 Chapter 16 Differential Treatment As has been mentioned previously, theories vary to the degree that they apply different techniques or methods to different disorders. To contrast theoretical ap- proaches, it is more helpful to compare how different theories can be applied to the same disorder than it is to different ones. Table 16.5 gives examples, for most of the theories, as to how a theory can be applied to a particular disorder for a specific client. Because clients differ on so many variables (age, gender, family history, type of problem, temperament, and so forth), it is not possible to say “Use this technique for this disorder.” In Table 16.5, a very brief description is given for very complex cases described in this book for the purpose of compari- son for depression and anxiety. Returning to the original case in the appropriate chapter can provide much more information about how a particular theoretical orientation might be used to deal with a client. Because of the particular interests of therapists, certain disorders have come to be associated with different theories. Table 16.5 Theoretical Approaches Applied to Two Different Disorders Chapter and Theory Depression Anxiety 2. Psychoanalysis Mary, 3 years—deals with defense me- Sam’s way of caring and comforting others 3. Jungian Analysis is related to his eagerness to take care of chanisms and transference. the analyst. 4. Adlerian Therapy A young woman’s dreams reveal her Beth—dream material in a dream series sadness about the death of her brother 5. Existential Therapy reveals unconscious aspects of and the loss of a romantic relationship. depression. 6. Person-Centered Robert builds self-esteem through en- Therapy Sheri—early recollections provide insight couragement, avoids defeat, lessening into distorted perceptions. anxiety. 7. Gestalt Therapy Catherine accepts her dispiritedness by Nathalie must make difficult choices due 8. Behavior Therapy bringing detachment to her awareness. to her son’s behavior toward a friend who later committed suicide. 9. Rational Emotive A female graduate student assumes more Behavior Therapy responsibility for self as a result of ther- A young man is continually brought to apeutic empathic listening. the present to deal with his issues. 10. Cognitive Therapy A 27-year-old woman deals with feeling Claire—anxious about husband being 11. Reality Therapy worthless by using the two-chair away and son’s football games. Learns technique. relaxation and worry prevention. 13. Feminist Therapy Jane, 29—behavior is assessed in detail and Ted experiences strong anxiety on a train; she learns self-, time, and child therapist disputes irrational beliefs. management. Amy—negative thoughts are identified Penny, 14—develops new beliefs and be- and modified through questions. comes more assertive with brothers. Randy, a college student, takes and Paul, a 38-year-old lawyer with AIDS maintains control over anxious makes use of the Socratic method, the feelings. dysfunctional thought record, and the three-question technique. Teresa, 40, little energy—focus is on mak- ing choices to do small things and fol- lowing plans to carry out choices. Ms. B., a graduate student, deals with iso- lation and guilt by seeking social sup- port and joining relevant groups. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 641 For example, much of Freud’s early work was with female patients who pre- sented symptoms of hysteria. Kohut’s work with narcissistic clients has linked this disorder with self psychology. Behavior therapy has been applied to treatment of phobias. Both feminist therapy and gestalt therapy have been used with people who have experienced traumas due to violence (posttraumatic stress disorder). Some disorders are quite common, and I have tried to give a number of different examples of how theorists approach these problems (alcoholism and drug abuse: existential therapy, gestalt therapy, and cognitive therapy; obsessive-compulsive disorder: existential, cognitive, REBT, behavior, and reality therapy; borderline dis- orders: object relations, Jungian, Adlerian, existential, person-centered, and feminist; eating disorders: Adlerian therapy, reality therapy, and feminist therapy). Examining how different theoretical approaches can be applied to a variety of disorders can increase understanding of the theoretical approach. Due to indi- vidual differences in clients, in therapists, and in lack of fit between psychologi- cal disorders and theories of psychotherapy, prescribing a previously developed treatment plan or method for a specific disorder should be done while consider- ing its appropriateness for the client. Brief Psychotherapy In the 1930s and 1940s, much of psychotherapy was psychoanalytically based treatment, which often lasted several years and required three to five sessions per week. Because of the high cost and time investment from therapist and client, brief methods of psychotherapy have become more and more common. Additionally, many clinics and community services limit the number of sessions per client due to great demands on agency services. Likewise, health maintenance organizations and insurance companies often restrict the number of sessions that they will pay for. Because of these restraints on the length of therapy and because of the large number of practitioners of psychoanalytic therapy, much effort has been directed toward providing a short-term alternative to psychoanalysis that also is consis- tent with a psychoanalytic view of personality. In Chapter 2, Luborsky’s Core Conflictual Relationship Theme method requiring less than 20 sessions is ex- plained. Often brief psychoanalytic therapy tends to limit goals, select patients carefully, focus on specific problems, and be more confrontive and directive than traditional psychoanalytic therapy. Not all theories have been adapted to a brief or short-term model of psycho- therapy. Jungian therapists may work for a year or two with patients and may occasionally stop therapy for a few years and then resume it later. Existential therapy is often used with other theories. When applied with a psychoanalytic perspective, it may be as lengthy as psychoanalytic therapy. However, Frankl’s logotherapy is a briefer, more focused method. Both person-centered and gestalt therapies tend to rely on clients to determine the duration of therapy and do not normally use a brief psychotherapeutic method. In contrast, Adlerian therapists often see their clients, on average, for about 20 sessions, with most clients being seen for less than a year. When needed, they do work within a time limit and prefer to do that rather than limit the goals that they address. Behavior therapy, REBT, cognitive therapy, and reality therapy tend to be short-term treatments; however, a number of factors may determine length of ther- apy. For behavior therapists, therapy length can depend on the number of target Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

642 Chapter 16 behaviors addressed, the strength of anxiety, or the type of therapy used. For ex- ample, a gradual application of behavioral methods takes longer than does flood- ing. Likewise, imaginal procedures often require more sessions than in vivo exposure. For behavior therapy, REBT, and cognitive therapy, length of treatment is shorter for phobias, and moderate forms of depression than for borderline or obsessive-compulsive disorders. Other factors affecting treatment length are the range and number of problems and the client’s willingness to do homework. Many of these comments also apply to reality therapy, in which treatment length varies greatly, with more frequent sessions being needed in the beginning of ther- apy than toward the end. The problem resolution and symptom relief methods of constructivist therapies (solution-focused and narrative therapies) often require fewer than 10 meetings. For feminist therapy, because it may be combined with any of the theories listed previously, treatment length varies widely. Considerable attention has been paid to brief therapy in family therapy. Be- cause it may be logistically difficult to get family members together, because some do not wish to attend therapy sessions, and because many family problems present crises, there has been an effort on the part of several family therapy theorists to develop brief methods. The long brief therapy approach of the Milan Associates typically requires about 10 sessions at monthly intervals. Creative ap- proaches such as family systems therapy and constructivist therapies are likely to continue in their popularity as demands for cost-effective solutions with minimal delays are sought by patients, therapists, social agencies, health maintenance or- ganizations, insurance companies, and governmental agencies. Current Trends This section will discuss three trends. The first to be discussed is that of common factors. Psychologists have examined a variety of studies to determine the com- mon factors that make up effective psychotherapy. In contrast to this approach, other researchers have focused on specific treatment methods using treatment manuals, called research-supported psychological treatments psychotherapies. Rather than look for factors across many therapies that lead to effective therapy, research-supported psychological treatments examine which theories should be used for which conditions and which disorders. Another influence, which is not related to the common factors or research-supported psychological treatments approach, is that of postmodernism, or social constructionism, which focuses on how clients view their own lives. Common Factors Approach Trying to understand the factors that are common to change in psychotherapy and counseling has been an effort that has taken place over a 50-year period. Sev- eral writers have shown how attending to and studying common factors can be helpful in the assessment and treatment phases of psychotherapy (Imel & Wampold, 2008; Sparks, Duncan, & Miller, 2008; Weinberger & Rasco, 2007). Also, Castonguay and Beutler (2006) describe in detail in their book, Principles of Therapeutic Change That Work, important factors that are considered in under- standing components of psychotherapy and counseling. They divide these factors into participant factors and relationship factors. Participant factors include charac- teristics of the client or therapist, such as gender, ethnicity, attachment style, cop- ing style, resistance, and expectations. Relationship factors are attributes of the Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 643 therapeutic interaction and include the therapist’s skills that affect the client’s im- provement. Some of these relationship factors include empathy, positive regard, congruence, the working relationship between therapist and client, consensus about the goals of therapy, self-disclosure, and quality of interpretations. In their book, Castonguay and Beutler (2006) describe how these factors, as well as fac- tors specific to a disorder, affect treatment of depression, anxiety disorders, per- sonality disorders, and substance-abuse disorders. Extensive research on these and other variables helps to describe factors that are common to effective therapy across a wide variety of problems. Treatment Manuals and Research-Supported Psychological Treatment Psychotherapy In contrast to the common factors approach, the use of treatment manuals and research-supported psychological treatment is specific for each disorder. Usually designed from one or two theoretical points of view, treatment manuals provide guidelines to therapists as to how to proceed in helping individuals with a spe- cific problem such as fear of blood. Treatment manuals are also effective for training graduate students and others as therapists because they provide guide- lines about therapeutic procedures. As health maintenance organizations (HMOs) have desired proof of brief, effective therapy, treatment manuals have been use- ful in replicating a procedure and showing its effectiveness. Those therapies that provide specific techniques for different problems, such as behavioral and cogni- tive therapies, are most likely to use manuals. Much effort has focused on research-supported psychological treatments. As seen in the text, most (but not all) research-supported psychological treatments use behavioral and cognitive approaches. Those research-supported psychological treatments that were mentioned in the text and are considered well established as applications for specific disorders are listed below (Nathan & Gorman, 2007; Research-Supported Psychological Treatments, 2009). These treatments are summa- rized very briefly in Table 16.6 to illustrate some of their most common methods. In their review of psychotherapy and research, Lambert, Bergin, and Garfield (2004) describe the emphasis on research-supported psychological treatments psychotherapy (empirically supported treatments) and the development of treat- ment manuals. They believe that their popularity is due to the popularity of cog- nitive and behavior therapies, the specificity of the DSM-IV-TR, and the requirements by managed care organizations to make treatment more uniform, more effective, and less expensive. There are also efforts by developers of research-supported psychological treatments therapies to make them more us- able. For example, Franklin and Foa (2007) have examined how to make expo- sure and ritual prevention that is used to treat obsessive-compulsive disorder less time intensive in its initial stages. They also examine the issue of training therapists to treat obsessive-compulsive disorder when they may rarely encoun- ter it with their patients. Efforts to make research-supported psychological treat- ments more available to therapists in general practice continue to be a concern (Nathan & Gorman, 2007). However, as Nathan (2007) notes practitioners have been reluctant to use research-supported psychological treatments. Postmodernism and Constructivism Postmodernism, a philosophical movement that has been applied to psychother- apy, has had influences on most theories of therapy, especially solution-focused and narrative therapies. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

644 Chapter 16 Table 16.6 Research-Supported Psychological Treatments Described in the Text Short-term psychodynamic therapy (Chapter 2) Depression: These therapies focus on increasing patients’ insight into their depression. Some common themes include a focus on how past experiences influence current func- tioning and the expression of emotions. Other issues are the therapeutic relationship and dealing with uncomfortable topics. Luborsky’s Core Conflictual Relationship Themes method described in Chapter 2 is one of the therapies that is used. Therapy is time limited and includes approximately 16 to 20 sessions. Gestalt Therapy (Chapter 7) Depression: Some studies suggest that process experiential therapy has been shown to be efficacious in treating depression. Process experiential therapy combines person-centered therapy with gestalt methods, such as use of the empty-chair technique. Behavior Therapy (Chapter 8) Depression: Reinforce patient activities and social interactions, rate moods and record events, increase daily activities, and use social skills training. Obsessive-compulsive disorder: Exposure and ritual prevention are used for an hour or two several times a week. Exposure to the event, such as germs, provokes discomfort. Indivi- duals refrain from rituals. General anxiety disorder: Techniques include progressive muscle relaxation, self-monitoring, countering automatic thoughts, and worry behavior prevention. Phobic disorders: In vivo or imaginal exposures, as well as virtual reality therapy, are used for most phobias. Posttraumatic stress disorder: In eye movement desensitization reprocessing (EMDR), a client history is taken and EMDR is explained. Desensitization takes place when the therapist uses hand movements. The client describes thoughts and images and increases positive thoughts. The therapist focuses on targeted behavior and searches for bodily tensions. Borderline disorder: Linehan’s dialectical behavior therapy (DBT) was designed specifically to deal with borderline disorder. Teaching mindfulness to clients is an important aspect of (DBT). DBT includes individual therapy, group therapy , and instructions on how to manage client crises. Cognitive Therapy (Chapter 10) Depression: Assessment of automatic thoughts, cognitive schemas, dysfunctional beliefs. Counters dysfunctional thinking through use of the Socratic method, three-question tech- nique, the Daily Thought Record, and other thought-challenging techniques. Anxiety: Identify the schema of hypervigilance; assess use of catastrophizing, personaliza- tion, magnification, selective abstractions, overgeneralization, and other beliefs. Counter these beliefs with Socratic method and cognitive techniques such as challenging absolutes. Obsessive-compulsive disorder: There is a focus on dealing with obsessive thoughts that in- clude overestimation of threat, intolerance of uncertainty, too much responsibility, perfec- tionism, mental control, and overimportance of thoughts. One method of dealing with OCD is the thought-action fusion model that attempts to counter the avoidance that indi- viduals use in trying to deal with obsessional thoughts. Substance abuse: Focus on being drug free and free of other problems. Deal with cravings and a lack of pleasure from nondrug sources. Focus on dysfunctional beliefs that are antici- patory, relief oriented, and permissive. Change belief system through assessing beliefs, list- ing addictive beliefs, developing control beliefs, and practicing activating these new beliefs. Interpersonal Therapy (Chapter 15—Other Psychotherapies) Depression: Deal with grief, interpersonal disputes, role transitions, or interpersonal defi- cits. Specific strategies for each are used. The therapy relationship is used to encourage relationships outside of therapy. Common skills used are encouragement of affect, clarifi- cation, and communication analysis. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 645 Constructivist ideas remind therapists of the importance of understanding and attending to the clients’ ways of seeing their own lives and not imposing a theory in such a way that preconceived ideas about clients interfere with treatment (Nei- meyer, 2009). In essence, therapists are recommended to take a step back to see if they are viewing clients’ worlds the way their clients do. The postmodern movement has also given theorists an opportunity to show how their theory is consistent with a constructivist point of view. The postmod- ern movement, which values the client’s view of reality at least as much as the therapist’s, is consistent with an approach that values both genders and all cul- tures equally. The modern, as opposed to postmodern, view is rarely defended by theorists because it can sound like “I know more about my client than he does” or “My view of reality is superior to that of my client.” Because of the postmodern influence, almost all theories described in this text can be described as being flexible and consistent with the postmodern position. Most theories show how they can be open to working with the way clients construct reality. Although these trends do not include all of the concerns that each group of practitioners focuses on, they do represent major issues affecting the practice and theoretical development of various theories. Using the Theory with Other Theories As Lambert, Bergin, and Garfield (2004) have noted, there has been a marked trend since the 1950s toward integration of theories. As shown in the next chap- ter, theories have become increasingly integrative. Some practitioners who sub- scribe primarily to one theory may find theory A to be helpful, whereas another may find theory B to be useful. For example, one cognitive therapist may find the experiential techniques of gestalt therapy to be helpful, whereas another may find Erickson’s adult developmental model (ego psychology) to be helpful. Although most therapies are becoming increasingly integrative by incorpo- rating techniques from other theories, two discussed in this book are not moving in this direction. Those person-centered therapists who consider Rogers’s six con- ditions to be necessary and sufficient would restrict their approach to empathy, acceptance, and genuineness. Reality therapists make use of a specific model in helping their clients develop control and responsibility in their lives. Although they may use some behavioral techniques, such as positive reinforcement, the structure of reality therapy may make it difficult to more fully integrate ideas from other therapies. In contrast, existential and feminist therapists must make use of other methods because these approaches do not have a sufficient core of techniques to allow complete reliance on the theory. Thus there is considerable divergence in the way many theories are practiced. Research The approach of theories of psychotherapy toward research is extremely uneven. Relatively little outcome research has been done with approaches other than cog- nitive therapy and behavior therapy. In this section, I discuss outcome research related to cognitive therapy and behavior therapy, along with research directions germane to specific theories discussed in this book. I then conclude with a few predictions about the future directions of research in psychotherapy. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

646 Chapter 16 Outcome Research In recent years, research on cognitive and behavioral therapies (including REBT) has been so abundant that meta-analyses have not only been applied to these therapies but also have been done with diagnostic categories, such as depression and general anxiety. In Chapter 8, examples of studies using behavior therapy with obsessive-compulsive disorder, anxiety disorder, and phobia are given. Chapter 10 has examples and summaries of treatment findings for depression, general anxiety, and obsessive-compulsive disorders. Some outcome research has also been done on psychoanalytic treatment. However, this research is more difficult than research on cognitive and behavioral therapies because treatment is lengthy, concepts are difficult to define, and consistency of application of thera- peutic techniques is more difficult to ensure. As described in Chapter 2, a few notable studies have been done with relatively small groups of patients (often about 100 or fewer), with research efforts in these studies taking place over a pe- riod of 30 years or more. General research findings show that almost all thera- peutic treatments showed greater improvements among treatment groups than among control groups that receive no treatment. Comparisons between treatment methods do not show clear patterns and present challenges to the design of stud- ies to show useful differences. Research procedures and concepts that have been studied for different theo- ries vary widely. Table 16.7 is a synopsis of the areas of research related to theo- ries of psychotherapy. Future Directions In summarizing extensive research, Lambert, Bergin, and Garfield (2004) state that about “50% of patients who enter treatment in clinical settings will show clinically meaningful change after 13 to 18 sessions of treatment. An additional 25% will meet the same standard after approximately 50 sessions of once- weekly treatment” (p. 11). They raise concerns that limiting treatment may nega- tively affect patients with relatively severe problems that most need treatment. Lambert, Garfield, and Bergin (2004) believe that psychotherapy research should attend to studying problems in treatment and changing the course of treatment to make it successful. They also see the increase of computer-based interventions that individuals can use in their homes. Viewing mental health as a deep societal problem, they believe that more funding for psychotherapy research should be given and that mental health should be considered a more important part of gen- eral overall health systems. Another issue concerns the use of typical patients in psychotherapy research rather than studying patients who are selected for re- search in evaluating research-supported psychological treatment (Lambert, 2007; Lambert & Vermeersch, 2008). Gender Issues For many years, the practice of psychotherapy and particularly psychoanalysis appeared to be influenced by the values of male psychotherapists. Chesler (1972) was an early critic of the practice of psychotherapy, claiming that it deva- lued aspects of women’s roles. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 647 Table 16.7 Research Directions of Theories of Psychotherapy Psychoanalysis Major areas of research exploration have included defense mechanisms, infant–mother bonding, and the working alli- Jungian Analysis ance. Considerably more outcome research has been done Adlerian Therapy using brief psychodynamic therapies than using long-term Existential Therapy psychoanalytic therapy or psychoanalysis. Person-Centered Therapy Most research efforts have examined Jung’s attitudes and functions of personality. There have been some cross- Gestalt Therapy cultural studies on archetypes. Behavior Therapy Rational Emotive Topics of research include birth order, social interest, early Behavior Therapy recollections, and lifestyles, with a few studies being done Cognitive Therapy on therapeutic interventions. Reality Therapy Research on group therapy has been done, as well as research on existential issues such as death, anxiety, spiritu- Constructivist ality, and responsibility. Therapies Feminist Therapy Carl Rogers’s interest in research was partly responsible for a great deal of study on empathy, genuineness, and accep- Family Systems tance in the 1960s and 1970s. Newer research questions the Therapy measurement and definitions of these concepts. Some recent therapy research addresses the issue of who will benefit most from different kinds of therapeutic interventions. Some areas of controlled research include studies of specific therapeutic techniques such as the empty-chair method and research into contact boundary disturbances. Researchers have carried out many outcome studies and have developed a variety of measures of therapeutic prog- ress, symptoms, and related issues. In addition to outcome research, issues relating to the im- portant concept of irrational beliefs have been examined to provide more information about the definition and descrip- tion of this topic. Cognitive therapy researchers have studied concepts that define depression as well as the treatment of depression itself. Additionally, the effectiveness of therapy with many other disorders has been a topic of investigation. Glasser has deemphasized the importance of research more so than have most other theorists or practitioners of theories. Nevertheless, some research has been done with convicted offenders, high school students, drug abusers, and couples. New methodologies have been developed for solution-fo- cused and narrative therapies. There are more outcome studies on solution-focused than narrative therapies. There have been a few studies comparing feminist therapy to other approaches. Also, some researchers have examined the values and techniques that are important to feminist therapists. Although there has been some research on the effectiveness of a variety of family systems approaches, it is relatively limited. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

648 Chapter 16 Although a number of theories were concerned with gender issues before Chesler’s writings, feminist therapists have had an impact on the attention given to gender and cultural issues as they affect the practice of therapy. Gender issues and how they are dealt with in therapy are summarized here. Although Freud has been criticized for devaluing women and their role, such comments have not generally been applied to his contemporaries, Jung and Adler. In psychoanalysis, notions of castration anxiety and penis envy have been widely criticized, along with implications made from these concepts that women are lacking in qualities that men possess. Furthermore, object relations theory has been criticized because of its emphasis on the mother–child role and lack of at- tention to the father’s responsibility and parenting. In Jungian analysis, gender is addressed through the study of archetypes. Animus and anima archetypes, which represent the other-sex aspects of an individual, were thoroughly ad- dressed in Jungian therapy. Additionally, female analysts were prominent in the early development of Jungian therapy. For Adler, gender roles were important throughout his theoretical writings. An early advocate of women’s rights, Adler saw how neurotic men used stereotypes of masculinity to mask their feelings of inferiority. Adlerians work to help clients deal with gender-role stereotypes. For existential, person-centered, and gestalt therapists, gender roles are of- ten seen as they relate to important theoretical concepts. For existential thera- pists, major existential themes of living, responsibility, and meaningfulness affect all individuals, although they may affect males and females differently. When clients hold gender-stereotyped views of themselves or others, a blockage in developing authenticity exists. With regard to genuineness, acceptance, and empathy, Rogers saw these concepts as universally important and believed that therapists should be empathic to gender-related concerns, such as homo- sexuality. For gestalt therapists, men and women may respond differently to awareness experiments, but empowerment to deal with problems generally re- sults. Miriam Polster (1992) noted that empowerment and awareness need to be directed not only toward individuals but also toward making society more re- ceptive to women’s power. Cognitive and behavior therapists (including REBT and reality therapy) gen- erally use terms that are not related to gender. These therapies tend to emphasize client responsibility. For clients who are unable to make their own choices, such as severely learning-disabled individuals, behavior therapists are particularly careful in not introducing gender bias. Although rational emotive behavior thera- pists are aware that irrational beliefs differ for men and women, they attend to the irrational beliefs about gender roles in their therapeutic work and have de- scribed issues in their writings that affect women in society. Cognitive therapists are aware of the cognitive schemas or beliefs that individuals have about their gender roles, whether toward the place of women in society or toward gay, les- bian, bisexual, or transgendered people (GLBST), and help their clients examine and challenge them. Reality therapists help their clients become more responsi- ble: some men by developing more self-control and some women by not letting others take control of their lives. Each of these therapies approaches gender value issues from its own conceptual perspective. Naturally, feminist therapy has had the greatest impact on gender issues in therapy. The techniques of gender, cultural, and power analysis and intervention specifically examine and attempt to change roles as experienced by the individual and society as a whole. More so than most therapies, feminist therapy has been concerned about gender roles as they affect GLBST clients. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 649 Roles and relationships of males and females within the family have been an area of concern for family systems therapists. Influenced by feminist therapy, family systems therapists have examined power issues within the family struc- ture and ways in which couples share family duties and responsibilities. Because of the contribution of feminist therapy and the awareness of therapists about gender issues within each of the theories described in this sec- tion, beginning therapists are likely to be exposed to ways in which gender roles affect their own value systems and their practice of psychotherapy or counseling. Multicultural Issues To some extent, the infusion of cultural issues into theories of psychotherapy has depended on the interest of the theorists and their adherents. As theories have become more widely known, therapists have applied theoretical principles to their work with a variety of clients from different cultures and have written about this experience, informing their colleagues about the interaction between culture and therapy. Research-supported psychological treatments practices have also been viewed in the context cultural diversity (Sue & Sue, 2008). For Freud, Jung, and Adler, cultural issues have been prominent, but for very different reasons. Freud’s late-19th-century Viennese background influ- enced his observations about psychological disorders and early childhood de- velopment. Erik Erikson’s work with Native Americans helped to expand the influence of cultural values on theoretical views of developmental stages. In contrast to Freud, Jung took an active interest in different cultures, traveling widely throughout the world to learn about legends and folklore. Current Jung- ian analysts are required to have a wide knowledge of myths and folktales in order to understand the collective unconscious of their patients. For Adler, cul- tural issues are inherent in social interest as it is applied to one’s family, neigh- borhood, and social group. Regarding the practice of psychoanalysis, a continuing issue is the expense of long-term psychotherapy and its availability to individuals who may not have sufficient wealth to afford it, including those from minority groups. For existential, person-centered, and gestalt therapy, cultural issues emerge in very different ways. Regarding existential therapy, there are similarities be- tween Eastern thought and existential philosophy, which is based primarily on Western European ideas. The themes of living, responsibility, and meaningful- ness tend to be universal, cutting across cultures. For Rogers, bringing his thera- peutic approach to promote peace and ease conflict between peoples of different nations was an area that he devoted much attention to during the last 20 years of his life. His emphasis on genuineness, acceptance, and empathy as core condi- tions for change represent cultural values that many found congruent but that others questioned. In a very different way, cultural issues have emerged in ge- stalt therapy. Because a focus on developing awareness can bring emotional relief that helps individuals deal with cultural injunctions, it can also create an experi- ence that may be difficult to integrate with previously learned cultural values. Although existential, person-centered, and gestalt therapies are related in the sense that existential thought has an impact on their theoretical model, each the- ory addresses cultural issues differently. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

650 Chapter 16 In general, cognitive and behavioral therapies, including REBT and reality therapy, have tended to promote self-sufficiency and responsibility in indivi- duals, which can conflict with cultural beliefs and values. However, recent writ- ings in each of these theories have showed the application of the theory to people from a broad range of cultural groups. In its emphasis on gender, cultural, and power issues, feminist therapy at- tends to cultural factors that can affect clients’ psychological functioning. Being aware of one’s own attitudes and prejudices regarding people from other cul- tures is a significant aspect of feminist therapy. Techniques of power and cultural analysis and intervention lend themselves to application to people from many different cultures. For solution-focused and narrative therapies, culture is embedded in the cli- ents’ descriptions of their problems. In narrative therapy and personal construct therapy, culture is found as a part of the setting, characters, plot, and theme. With regard to the practice of family therapy, a knowledge of cultural tradi- tions and values is particularly helpful. Cultures vary as to child-raising prac- tices, relationships with members of extended and immediate families, and traditions such as wakes and weddings. The behavior and attitudes of family members may be appropriate in some societies but inappropriate in other cul- tural circumstances. Being aware of one’s own values and biases regarding people of different cultures and having a knowledge of cultural values and customs and an under- standing of how theoretical and cultural perspectives interact can help therapists practice their theoretical orientations effectively with clients from diverse cultural backgrounds. Family Therapy Although theories of psychotherapy differ in terms of how much attention is de- voted to family therapy as compared with individual therapy, all apply their the- ory to individual and family therapy. Relatively few Jungian and existential therapists do family work, preferring individual therapy. Family systems therapy differs from most other family therapy approaches in that the family is viewed as a unit and attention is paid to dysfunctions within the unit rather than to one in- dividual’s behavior. Naturally, there are times when family therapists attend to individuals and when nonfamily therapists examine the entire system. This is de- scribed fully in Chapter 14. More and more, therapists are doing all combinations of therapy: individual, couples, and family. As with individual therapy, integration is a growing trend, as therapists combine or make use of aspects of several family systems therapies along with ideas about individual and family therapy from other theories of psychotherapy. Group Therapy Just as approaches to individual therapy vary greatly, depending on theoretical orientation, so do approaches toward group therapy. Some therapies (Adlerian, behavior, REBT, cognitive, and reality therapies) tend to be structured, Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 651 emphasizing the leader’s role in educating and directing group members. Others (psychoanalytic, Jungian, existential, gestalt, and feminist therapies) tend to be more open and unstructured. For some theoretical orientations (gestalt, person- centered, and feminist therapies), group approaches are considered as important as individual and are sometimes preferable, whereas for Jungian therapy, group processes are seen as an adjunct to, but not a substitute for, individual therapy. Major features of each theory’s contribution to group therapy are described in Table 16.8. Table 16.8 Group Therapy Approaches Psychoanalysis Briefly, psychoanalytic group therapy often focuses on free associa- tion, dreams, and other material as it relates to underlying uncon- Jungian Analysis scious behavior and early childhood development. Drive and ego Adlerian Therapy therapists are likely to focus on repressed and aggressive drives as they affect group members, as well as the use of ego defenses. For Existential Therapy object relations therapists and relational psychoanalysis, issues of Person-Centered separation and individuation as they affect the psychological pro- Therapy cesses of group members and group interaction are a major focus. Gestalt Therapy For self psychologists, attention is paid to how group members inte- grate self-concern with concern about others in the group. In general, psychoanalytic group therapists differ as to how much they interpret group processes and deal with transference and countertransference of members to the group leader and other group members. Used as an adjunct to individual analysis, Jungian groups may make frequent use of dream analysis and also use active imagination. A variety of creative approaches to group therapy characterizes Adlerian work. Lifestyle groups help members analyze their life- styles, which include family relationships, relationships with siblings, and early recollections. Group leaders summarize results of a brief lifestyle analysis, and they and group members make suggestions for change. Other Adlerian groups may combine lectures on social interests, lifestyle, and courage with exercises to promote change. A variety of existential themes are incorporated, and members deal with questions about how meaningful their lives are, how they deal with freedom and responsibility, how they relate to others, and how they behave authentically. Group members relate to each of these issues and discuss how they affect different group members. Rogers believed strongly in the positive power of groups. For him, the leader’s role was to facilitate the group, with the notion that the leader could work toward being a participant. In general, the group was unstructured, but the group leader attended to the need to have safety and growth within the group. Rogers devoted a major part of his later life to using groups to develop trust between social or political groups who opposed each other. A frequent treatment of choice of gestalt therapists, most gestalt groups use a variety of exercises and experiments to develop awareness among group members. Encouraging open and direct contact between group members, group leaders set limits and work on issues such as family conflicts. (Continued) Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

652 Chapter 16 Table 16.8 Group Therapy Approaches (Continued) Behavior Therapy Therapists often function as coaches, giving feedback, teaching, demonstrating, and modeling to individuals who share similar Rational Emotive target behaviors. Common types of behavior therapy groups are Behavior Therapy social skills training, in which clients often role play events in Cognitive Therapy their lives, and assertiveness training, in which individuals learn to discriminate among types of behavior and try out asser- Reality Therapy tiveness skills. Feminist Therapy Therapists function educationally, in a direct manner, showing clients how they blame and damn themselves for their behavior. Clients learn to apply REBT principles to their behavior. The thera- pist may suggest homework and enlist cooperation from members in helping each other with problems. Assessing specific behaviors and cognitions is one of the functions of cognitive therapists. They work collaboratively with group members to suggest changes in behavior inside and outside therapy. Specific change strategies focus on cognitive and behavioral interventions. Some groups are targeted toward specific disorders, others toward specific techniques, such as problem-solving groups. Often used as a follow-up to individual reality therapy, group therapy uses the same process of change applied in individual therapy. Principles of choice theory are followed by asking such questions as, What are you doing? What is working for you? What needs to be done to make things better? Therapists take an active approach in encouraging behavior change. Consciousness-raising groups were the impetus for the develop- ment of feminist therapy. A variety of groups focus now on issues such as homelessness, sexual abuse, battered women, and issues related to different ethnic groups. A major focus in feminist therapy groups are gender role issues, which may be dealt with through a variety of therapeutic approaches, including gestalt, solution- focused, and psychoanalytic theories. Group therapy has several features that individual therapy does not: input from peers, multiple feedback, efficient use of therapists’ time, and obser- vational learning. For these reasons, group therapy is likely to continue to be attractive to practitioners of most theories. Organizational problems do pres- ent themselves, especially for therapy groups that require a certain type of member, such as incest survivors. Advertising or publicity may be used for such groups. I have tried to summarize the most important aspects of the theories of per- sonality, therapeutic techniques, and important applications of therapies. Not all significant features have been included. The focus to this point has been on describing differences between theories to show their special features. Next, I describe what I believe are the strengths and weaknesses of each of the theories. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 653 Critique Basically, when theorists criticize other theories, they find fault with them for not being similar to their own theory. The more dissimilar the two theories, the more numerous and emphatic the criticisms. For example, behavior therapists could criticize psychoanalysis for overemphasizing biology and early childhood devel- opment, for not defining concepts clearly, for speculating about unobservable constructs such as the unconscious and ego, for not having testable concepts, for being incredibly inefficient in the frequency and duration of therapy to bring about change, and for having less effective treatment methods than behavior therapy. When criticizing cognitive therapy, behavior therapists have far fewer criticisms. Chiefly, they focus on the emphasis that cognitive therapists may give to unobservable thought processes, but they are less critical of their terms, the testability of procedures, and the effectiveness of therapy. When criticizing cognitive and behavior therapy, psychoanalysts are likely to see the therapies as somewhat similar in that they are superficial and focus on surface issues, pay lit- tle attention to past development, tend to ignore unconscious processes such as dreams and fantasies, and do not deal with the importance of parent–child rela- tionships or with the development of individual personality. Any theory can be criticized by using the concepts of personality and psychotherapy of another the- ory as the basis for criticism. The more dissimilar a critic’s values are from those of the theorist, the greater the chance that the theory will not be respected or treated seriously. For example, values of faculty in academic departments of psychology may favor precise defi- nition, quantitative research, brief therapeutic interventions, and observable be- havior, values more compatible with cognitive, behavioral, and REBT therapies than other theories discussed in this book. By contrast, many practicing thera- pists may have values that stress relationships with clients, understanding many different personality constructs, the influence of the past on the present, and spir- itual and unconscious processes, all of which are more compatible with therapies other than behavior, cognitive, and REBT theories. In the discussion that follows, I identify common major limitations and strengths of each theory, devoting one paragraph to limitations and one paragraph to strengths. Psychoanalysis Many of the criticisms of psychoanalysis have just been mentioned. Additionally, psychoanalysis can be criticized because it reflects the experiences and values of theorists arising from their own life experiences and observations about patients, which the theorists try to apply to everyone. Just because Freud may have expe- rienced Oedipal feelings and observed Oedipal feelings in his patients does not make it a universal concept. Likewise, Erikson experienced many identity crises in his life and observed them in many others; saying that this is an important construct for most people does not follow logically. Many of the psychoanalytic concepts, such as those just mentioned, are often difficult to define, and psycho- analytic writers may have different definitions in mind when describing a con- cept such as the ego or transference neurosis. Some critics complain that psychoanalytic writers describe developmental concepts as if everyone has the same cultural experience without looking at the importance of social interactions in later life. A practical criticism of psychoanalysis is that the treatment is Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

654 Chapter 16 extremely time consuming and costly. When psychoanalytic concepts are used in brief therapy, therapists are limited in their goals and in the type of patients they can work with, whereas behavior and cognitive therapists (including Adlerian, REBT, and reality therapists) do not operate with such restrictions. The strengths of psychodynamic therapies are that they allow individuals to explore, in depth, their early childhood and past as they affect their current func- tioning, using a drive, ego, object relations, self psychology, or relational model, or a combination. Explanations have been developed to understand resistance, anxiety, and ego defense mechanisms that relate to the individual’s psychological functioning. The development of ego, object relations, self psychology, and rela- tional psychoanalysis provides a broad framework for understanding many psy- chological disorders. Additionally, brief therapies make psychoanalytic approaches more available to those who cannot afford long-term psychotherapy or psychoanalysis. Jungian Analysis From an empirical point of view, Jung’s theory is the least scientific of all the ma- jor theories described in this book. Other than concepts of attitudes and functions (for example, introversion-extraversion), his constructs are the most difficult to define and the least clear and are more like religion than science. Jungian analysis is a long, slow process focusing on bringing unconscious processes into conscious awareness. Little research has been done on concepts such as the collective un- conscious and archetypes, and there is no published research on the effectiveness of Jungian analysis. It can be argued that Jungian concepts are not useful or de- finable and that Jungians are more interested in relating their knowledge about folklore and myth to convoluted archetypes than they are in helping patients with their problems. A strength of Jungian analysis is its emphasis on the spiritual aspects of hu- manity, something not measurable by scientific experimentation. Jung’s ideas help individuals look inside themselves and understand aspects of their personal and collective unconscious that were previously unavailable to them. Moreover, insight and creativity can develop in the process of Jungian psychotherapy. Fur- thermore, Jungian analysis provides a means of understanding others’ cultures, history, and religion, fostering intellectual development. Individuals wanting greater self-understanding and insight into their self-development rather than re- moval of specific symptoms are likely to find Jungian analysis instructive and helpful. Adlerian Therapy Criticisms of Adlerian therapy are that it does a variety of things but none of them in depth. Because of its emphasis on looking at the past through early re- collections and birth order, Adlerian theory is often viewed as simplistic and as fully examining neither conscious nor unconscious processes. Its concepts are dif- ficult to test, and little research supports the effectiveness of its psychotherapeutic approach. Regarding the practice of psychotherapy, too much emphasis may be given to individuals’ perceptions of early recollections. Also, many unrelated techniques may be used to bring about change. By focusing on the importance of social interest, the theory tends to ignore important aspects of individual Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 655 development. Too much emphasis is placed on changing beliefs and not enough on changing behaviors. The strength of Adlerian psychotherapy is its diversity. It takes into consider- ation the importance of familial and social factors and their impact on growth and development. It is a practical approach, goal oriented and emphasizing both social and psychological factors. Techniques are geared to change beliefs and behaviors, often within short time periods. More than most therapies, it has an educational emphasis that can be applied to individuals, couples, and fami- lies. Perhaps because it is a growth model that acknowledges perceptions of past development and incorporates many therapeutic strategies, it can be applied to a very broad range of client problems. Existential Therapy The major criticism of existential psychotherapy is that it is not a system of psy- chotherapy. Rather, it is a general framework of concepts or issues that some Western European philosophers have seen as important. Although some of the themes may relate to individual anxieties and problems, not all do. Existential therapy offers no guidelines for therapists, and with the exception of a few tech- niques offered by Frankl, no suggestions for methods for therapists to use. Many of the ideas are intellectual, and clients who are more practical or are not college educated may have difficulty with the philosophical nature of the concepts. Much of the focus in existential psychology is on the negative—death, meaning- lessness, and anxiety. Existential psychotherapy offers few specific suggestions for dealing with these issues. The strength of existential therapy is that it attends to concerns of being hu- man. Other therapies tend to ignore why we are here, why we exist, and our re- sponsibility to ourselves and others. Existential therapy encourages individuals to take a look outside themselves and find meaning in their lives by examining relationships with others as well as confronting major internal life issues. Throughout our lives, people confront many existential crises—marriage, di- vorce, responsibility for family, death of loved ones, and guilt over past behavior. Existential therapy provides new ways of viewing and understanding such problems. Person-Centered Therapy Rogers’s view of psychotherapeutic change has been criticized as vague, naive, and limiting. Rogers ignores the unconscious, pays relatively little attention to past de- velopment, and follows the client wherever she leads. Empathy is seen as being the cure-all for problems; no consideration of behavioral or cognitive principles is given. Some critics believe that Rogers’s view that core conditions are necessary and sufficient for change is simplistic and inaccurate and does not reflect current research. Another criticism is that the therapist is overvalued; there is more to ther- apeutic change than being empathically understood for an hour or two a week. Many other theorists believe that empathy is not enough for many clients. Thera- peutic progress requires structure and direction for specific change. Because clients need direction and suggestions not provided by the person-centered therapist, other therapies should be used to supplement person-centered therapy. Then again, Rogers has been widely acknowledged for his enormous contri- bution to psychotherapy by focusing on the client–therapist relationship and on Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

656 Chapter 16 the importance of acceptance, genuineness, and empathy from the therapist. Many therapists find that these concepts are clear and easy to grasp and that they promote client growth and understanding. Although more research is needed, much research has studied the validity of the concepts and shows them to be valuable. Person-centered therapy is particularly suited to couples, family, and group counseling, where the focus is on understanding each other. Many people can profit from the understanding of their experiences, feelings, attitudes, and values that emerges from an empathic relationship with a therapist. Gestalt Therapy Criticisms of gestalt therapy have focused on its powerful emotional effect, which can lead an individual to become vulnerable and confused. Also, gestalt therapy, especially Perls’s work, has been characterized as developing the individual while sacrificing or ignoring relationships with others. Although dealing with bodily processes, it does not go as far in integrating the mind and body as do body psychotherapies (Chapter 15). The concepts are rather vague and unsystem- atic. In the hands of therapists who have difficulty separating their own needs (for example, power or sex) from those of the client, gestalt therapy has the po- tential to damage clients by confusing their awareness of self with awareness of the therapist’s needs. When practiced by a competent therapist, gestalt therapy can help indivi- duals experience feelings and awareness rather than just talk about them. Experi- mentation in gestalt therapy can develop self-understanding and willingness to apply this learning to relationships outside therapy. As a result, clients often be- come more creative and assertive in their work and in relationships. Although it should be used with caution with individuals who are suffering from severe dis- turbances (such as borderline disorders), gestalt therapy can be particularly help- ful for those people who are anxious or inhibited. Behavior Therapy Sometimes criticized as a piecemeal approach, behavior therapy draws from clas- sical and operant conditioning as well as social learning theory. Attempts to de- velop an all-encompassing theory of behavior that can be adapted to psychotherapy have failed. Although criticisms that behavior therapy ignores feelings and manipulates its patients no longer apply, behavior therapy can still be criticized for focusing too much on target behaviors and not sufficiently on the whole person or on developmental factors. Changing symptoms may not bring about significant or meaningful change. Furthermore, behavior therapy is seen as focusing too much on changing an individual’s behavior; it does not attend sufficiently to a variety of environmental and social conditions. Important exis- tential and social constraints on behavior tend to be ignored. Behavior therapists have produced a large quantity of research that attests to the effectiveness of their techniques. This research has supported the develop- ment of rating and observational techniques, as well as specific therapeutic inter- ventions for many problems. The therapist and client work together, using the therapist’s knowledge of techniques to bring about change in a variety of beha- viors, including depression, phobia, and sexual disorders. Behavior therapy, of- ten combined with cognitive therapy, is particularly well suited for problems in which a specific target behavior can be identified. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 657 Rational Emotive Behavior Therapy Criticisms of REBT are both theoretical and practical. Ellis’s theory can be seen as a collection of cognitive and behavioral techniques, along with a predilection for convincing clients that their beliefs are wrong. Rather than a coherent theory, REBT tries to convince clients to think more rationally and, if that does not work, tries some other behavioral or cognitive approaches. Unlike cognitive ther- apies, REBT does not apply different techniques for different disorders. Disputing irrational beliefs, done with all types of problems, can be seen as a way of brow- beating clients into changing beliefs, even when they are not convinced to do so. Because REBT focuses so much on cognitive strategies, it tends to ignore behav- ioral and affective ones. Ellis pioneered the use of cognitive techniques to bring about therapeutic change in a few sessions or months rather than a few years. His approach is comprehensive and makes use of many different strategies and techniques, but it also helps individuals change irrational beliefs so that future crises and pro- blems can be avoided. The approach is active, featuring homework and role playing as well as record keeping. Ellis’s own writings have helped to relieve guilt about sexuality and encouraged individuals to help themselves by no lon- ger blaming themselves. Patients with disorders in which irrational beliefs are an important component, such as anxiety, depression, and phobias, can find REBT helpful. Cognitive Therapy Like REBT, Beck’s cognitive therapy can be criticized as being simplistic and mere common sense. Rather than straightforward, his concepts of automatic thoughts and cognitive schemas may not be easy for clients to grasp, as they are constructs rather than observable behaviors. Although cognitive therapists say that they do attend to clients’ feelings, their emphasis on cognitive distortions can be seen as blaming the client and not being empathic with his distress. There is an overemphasis on the client’s responsibility for problems and not enough at- tention to social forces such as violence that cause problems. Convincing clients that their thinking is distorted, even when added to behavioral and affective ap- proaches, is insufficient to deal with complex client problems. More than any other theoretical approach, Beck and his colleagues have care- fully studied specific cognitive techniques to be used for different psychological disorders. In particular, much work has been done that demonstrates the effec- tiveness of cognitive approaches to depression and anxiety. Cognitive therapists take a collaborative approach with clients, working with them to bring about changes in thoughts, feelings, and behaviors. By incorporating behavioral, affec- tive, and experiential strategies in a structured manner to bring about specific changes, cognitive therapy represents a broad and effective approach. Reality Therapy Glasser’s reality therapy has been criticized for being superficial and simplistic. It is a process that clients must accept. Childhood development, transference, dreams, and unconscious processes are ignored. An artificial mechanistic model, using a car as an analogy, oversimplifies very complex human behavior. Existen- tial issues and deep emotions get short shrift in this problem-solving approach. Guidelines are quite simplistic, whereas the actual practice of reality therapy Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

658 Chapter 16 requires many hours of training to deal with clients’ resistance to controlling their own behavior. Unlike many other therapies, reality therapy can be used with people who are resistant to change. It may be particularly effective for hard-to-reach groups such as juvenile offenders, prisoners, and substance abusers. In its emphasis on taking control of one’s own behavior and on the positive results that come with acting in accordance with reality principles, reality therapy can be attractive to many clients. Although the approach is not as easy to use as would first appear, with practice it can be used effectively with clients that other therapists might feel are not motivated to change. Constructivist Theories Constructivist theories (solution-focused and narrative) provide no real system for understanding individuals. They provide a framework that is too loose to assess the concerns of clients. Solution-focused therapy does not provide an adequate op- portunity to assess the full nature of the problem or background factors that have made the problems as difficult as they are. Instead, it rushes in to solve the prob- lem without knowing how it relates to other problems, other individuals, and events in the client’s life. Similarly, narrative therapy only offers the opportunity to hear the client’s story and then to make judgments about what parts of the story are “problem saturated.” Although externalizing the problem by saying “Anger has a voice that speaks to you” is a creative technique, it may be most appropriate for children and of limited application to serious problems. Telling and retelling the story from different points of view may not be enough to help clients make necessary changes in their lives. Constructivist theories do not take the thorough systematic approach that behavioral, cognitive, and other therapies do. Constructivist therapists understand the problem that clients present from the clients’ own point of view without having preconceptions (other theoretical ideas) intervene. Solution-focused therapy is brief and timely. Clients enter therapy because they want help with their problems, not to develop a relation- ship with the therapist, not to talk about their problems without doing things about them, but to find relief. Solution-focused therapy gets right to the point and through the exception and miracle questions helps individuals deal with a great variety of problems in their lives. Narrative therapy (both personal con- struct theory and Epston and White’s) also helps individuals understand their lives and see ways they have been thinking about their problems that are hurt- ing them. With the therapist’s help, clients find solutions that give them a way of viewing themselves, which helps to resolve problems. Unlike other theories, constructivist theories really value the input of clients in resolving their own problems. Feminist Therapy Because feminist therapy focuses so much on political and social change, individ- ual responsibility can be ignored. Rather than having any coherent theory, femi- nist therapy is a conglomeration of diverse ideas about gender development and issues related to treatment of women. Although feminist therapists claim not to be “male bashers,” elements of this tendency can be found in their writings. The question arises: Do feminist therapists treat women as more equal than men? An- other criticism of feminist therapy is that it is not a therapy but a collection of Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 659 suggestions about how to infuse feminist ideas into other theories, as feminist therapy does not have sufficient techniques to stand alone. The strengths of feminist therapy are that it has examined sociological fac- tors, most importantly gender and culture, and pointed out how changes can be made in the practice of psychotherapy to provide more effective therapy for both men and women. Already, feminist therapy has helped make therapists of all theoretical orientations aware of their own attitudes about gender and culture, as well as those of their clients. The political thrust of feminist therapy challenges therapists to work on changing political and social conditions that have contributed to the problems of individuals. Whether a therapist is a femi- nist therapist or informed by feminist therapy, these practitioners can help their clients by examining both psychological dysfunction and its environmental context. Family Systems Therapy The most frequent criticism of family systems therapy is that it tends to ignore individual dysfunction and focuses on interactions between family members. Rather than concentrate on a person’s problem (schizophrenia, for example), fam- ily systems therapists look at the family’s responsibility for the problem. Al- though Bowen and psychoanalytic approaches do look at the history of the family, structural, strategic, and experiential theories tend to examine present functioning and ignore family development. Many family systems therapies, es- pecially structural and strategic, may manipulate the family without their know- ing it by using paradoxical interventions. Such cases provide an authoritative relationship in which clients are unaware of what is being done to them and in- sight is not valued. Feminist therapy has criticized family systems therapy for not recognizing the wider social context that contributes to role expectations within families. Sometimes family therapists seem more enthralled with new creative approaches to dealing with families than they are with finding a cohesive method of family interventions. An important contribution of family systems therapy is to recognize that individual problems do not exist in a vacuum and that family members contrib- ute to each other’s functioning. By bringing the entire family into treatment, alliances between family members and styles of relating can be observed. The therapist then is able to help family members help each other resolve problems rather than to blame or focus on the “identified patient.” Over the last 30 or more years, there has been a trend not only to integrate various family systems therapies but also to integrate individual therapy into family therapy. The impor- tance of treating families can be seen by the fact that not only are there several approaches to family systems theory, but also each theory, except for Jungian analysis, treats family problems. In characterizing the limitations and strengths of various therapies, a few ob- servations can be made. Evaluations of therapies are subjective, based on the eva- luator’s values, attitudes, and experience as a therapist, client, or researcher. Clients vary greatly in their cultural background, age, family history, psychologi- cal disorder, gender, and many other factors. A therapy that may fit one client may be inappropriate for another. Although most therapies (other than Adlerian, behavioral, cognitive, and psychoanalytic) tend not to have differential treatment for different diagnostic disorders, they recognize psychological dysfunction and Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

660 Chapter 16 bring their perspective on therapy to the problem. By critiquing the limitations and strengths of various therapies, therapists are better able to decide which ap- proaches they want to use in their own approach to therapy. Summary Helping people with psychological problems gives therapists an opportunity to increase the satisfaction and happiness and improve the interpersonal relation- ships of other people. Almost all clients try to deal with their psychological suf- fering on their own or with the help of friends. Only when that has failed do they seek psychotherapy or counseling. The responsibility to help others ethi- cally and competently is a significant one. Theorists pass on to others their views of how to help individuals in distress. Along with the responsibility of using theory accurately are the satisfaction and excitement that come with helping. Without the theoretical ideas presented in this book, therapists and counse- lors would have few guidelines on how to proceed. The thousands of books and articles on ways to help and the research into the effectiveness of helping will continue to increase and to provide guidelines and assistance for the thera- pist. With continued research and increased therapeutic practice, the theories have become deeper and broader. They have become deeper in that the new as- pects or concepts of theories have been developed, critiqued, and modified fur- ther. For some theories, research has played an important role in determining aspects of the theory that are particularly effective or need modification. Theories also have become broader, as practitioners of one theory incorporate other tech- niques and concepts into their work. Additionally, some writers have taken an integrative point of view, essentially developing theories that are broadly based on the concepts and/or techniques of other theories. There are three integrative approaches that will be presented in the next chapter. Also, I will explain how you can use the theories described in the previous chapters to develop your own integrative theory. For the beginning therapist or counselor, this information can seem exciting at some times and overwhelming at others—overwhelming because there is so much information for beginning therapists, who may feel they need to know their theoretical preference right away. The development of a theoretical style is a gradual one, influenced by readings, by practicum and internship experience, and by supervisors’ opinions. I encourage readers who are choosing to become psychotherapists or coun- selors to be open to the selection of theoretical points of view. Although the fit between one’s own values and personality and those of a theory is important, fit is not the only consideration. Knowledge of the interaction of one’s own per- sonality and multicultural values is essential in effective psychotherapy and counseling. The type of client and the work a student anticipates doing often have an impact on the selection of theories. For example, many agencies impose a limit on the number of sessions they can offer their clients, so longer-term therapies (psychoanalysis and Jungian analysis) would be inappropriate in that setting. Some settings may fit well with certain theories: therapists and counselors working with juvenile delinquents may find that behavior or reality therapy approaches fit their needs, whereas those working with individuals in midlife crises may find existential therapy or Jungian analysis to be appropriate. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Comparison and Critique 661 Some therapists do make small or marked changes in theoretical orientation, depending on changes in their own personal development, the type of clients they work with, and the expectations of a new work setting. Openness to new information and ideas can be seen as a strength rather than as indecisiveness. Choosing the theory that fits best or integrating several theories of psychotherapy or counseling is a long-term process, subject to change due to whom and in what situation you may work. References Lambert, M. J., & Vermeersch, D. A. (2008). Measuring and improving psychotherapy outcome in routine Castonguay, L. G., & Beutler, L. E. (EDS.) (2006). Princi- practice. In S. D.Brown & R. W.Lent (Eds.), Hand- ples of psychotherapeutic change that work. New York: book of counseling psychology (4th ed., pp. 233–248). Oxford University Press. Hoboken, NJ: Wiley. Hesler, P. (1972). Women and madness. New York: Nathan, P. E. (2007). Efficacy, effectiveness, and the Doubleday. clinical utility of psychotherapy research. In S. G. Hofmann & J. Weinberger (Eds.), The art and science Franklin, M. E., & Foa, E. B. (2007). Cognitive treatment of psychotherapy (pp. 69–83). New York: Routledge. of obsessive compulsive personality disorder. In P.E., Nathan & J. M., Gorman (Eds.), A guide to Nathan, P. E., & Gorman, J. M. (Eds.). (2007). A guide to treatments that work (3rd ed.). New York: Oxford treatments that work (3rd ed.). New York: Oxford University Press. University Press. Imel, Z. E., & Wampold, B. E. (2008). The importance of Neimeyer, R. A. (2009). Constructivist psychotherapy: Dis- treatment and the science of common factors in tinctive features. New York: Routledge. psychotherapy. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (4th ed., Polster, M. (1992). Eve’s daughters: The forbidden heroism pp. 249–266). Hoboken, NJ: Wiley. of women. San Francisco: Jossey-Bass. Lambert, M. (2007). Presidential address: What we have Sparks, J. A., Duncan, B. L., & Miller, S. D. (2008). Com- learned from a decade of research aimed at improv- mon factors in psychotherapy. In J. L. Lebow (Ed.), ing psychotherapy outcome in routine care. Psycho- Twenty-first-century psychotherapies: Contemporary therapy Research, 17(1), 1–14 approaches to theory and practice (pp. 453–497). Hoboken, NJ: Wiley. Lambert, M. J. Bergin, A. E., & Garfield, S. L. (2004). Overview and future issues. In Lambert, M. J. Sue, D., & Sue, D. M. (2008). Foundations of counseling (Ed.), Bergin and Garfield’s handbook of psychotherapy and psychotherapy: Research-supported psychological and behavior change (5th ed., pp. 805–821). New treatments practices for a diverse society. Hoboken, York: Wiley. NJ: Wiley. Lambert, M. J., Garfield, S. L., & Bergin, A. E (2004). Weinberger, J., & Rasco, C. (2007). Empirically sup- Introduction and historical overview. In Lambert, ported common factors. In S. G. Hofmann & M. J. (Ed.), Bergin and Garfield’s handbook of psycho- J. Weinberger (Eds.), The art and science of psycho- therapy and behavior change (5th ed., pp. 3–15). New therapy (pp. 103–129). New York: Routledge. York: Wiley. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

C H A P T E R 17 Integrative Therapies Outline of Integrative Therapies WACHTEL’S CYCLICAL PSYCHODYNAMIC Processes of Change THEORY Consciousness raising Psychodynamic treatment Dramatic relief or catharsis Behavioral treatments Environmental reevaluation Strategies in understanding Self-reevaluation Rationale for using both approaches Self-liberation Other approaches used Social liberation Emphasis on therapeutic relationship Contingency management Working toward seamless interventions Counterconditioning Stimulus control Using Wachtel’s Cyclical Psychodynamics Helping relationships Theory as a Model for Your Integrative Theory Combining Stages of Change, Levels of Psychological Problems, and Processes of Theoretical integration Change Assimilative model Technical eclecticism Using Prochaska and Colleagues’ Transtheoretical Approach as a Model for Your PROCHASKA AND COLLEAGUES’ Integrative Theory TRANSTHEORETICAL APPROACH MULTIMODAL THERAPY Stages of Change Multimodal Theory of Personality Precontemplation Contemplation Behavior Preparation Affect Action Sensation Maintenance Imagery Cognition Levels of Psychological Problems Interpersonal relationships Drugs/biology Symptoms Firing order Maladaptive thoughts Interpersonal conflicts Goals of Therapy Family conflicts Intrapersonal conflicts Assessment Treatment Approach Tracking Bridging Using concepts from other theories Time tripping Deserted island fantasy technique Using Multimodal Theory as a Model for Your Integrative Theory 662 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Integrative Therapies 663 A lthough there are many integrative approaches By combining elements of several theories, therapists can make use of the benefits of many to psychotherapy, in this chapter I will describe theories. As Prochaska and Norcross (2010) show, three integrative theories. Wachtel’s cyclical psy- there are a wide variety of combinations of integrat- chodynamics combines the personality theory con- ing theories. For example, psychoanalytic-behavioral cepts and psychotherapeutic techniques of several integration was popular in the 1970s, and cognitive theories, principally psychoanalysis and behavior therapy in combination with behavioral, humanistic, therapy. Prochaska’s transtheoretical approach or psychoanalytic therapies was common in the examines many theories, selecting concepts, tech- 1980s. Their conclusions, shown in Table 17.1, are niques, and other factors that effective psychother- based on asking integrative psychotherapists to apeutic approaches have in common. Both cyclical label their own style (Garfield & Kurtz, 1977; Nor- psychodynamics and the transtheoretical approach cross & Prochaska, 1988). Data from 2003 show use a model called theoretical integration. Theoreti- the growing popularity of behavioral and cognitive cal integration combines the personality theory theories (Norcross, Karpiak, & Lister, 2005). How- concepts and techniques of two or more theories. ever, the data also show a broad range of pre- Similar to this model is the assimilative integrative ferences. This research examined only pairs of approach, in which the personality theory and the integrated therapies; it is likely that some therapists psychotherapeutic techniques of one theory are combine three or more therapeutic approaches in the major approach and one or more other theories their work. As Table 17.1 shows, an integrative are used to supplement it. In multimodal therapy, a approach of long-standing interest is that of beha- social learning view of personality is the focus vioral and psychoanalytic theories. Since the (Stricker & Gold, 2005). It influences the use of 1950s, therapists have used many ways to combine many treatment techniques, which have been therapies. As different therapeutic approaches drawn from many theoretical orientations. The developed, practicing therapists tried to integrate model it uses is called technical eclecticism. In tech- and blend different techniques and inform their col- nical eclecticism, one personality theory is selected leagues about their work. Integrative therapists have and techniques may be used from any theory, but described both skills needed to be competent as an they are used in a way that is consistent with the integrative therapist and training and supervision personality theory that has been selected. Integra- methods used in integrative therapy (Boswell, Nel- tive methods provide a means of systematically son, Nordberg, McAleavey, & Castonguay, 2010). combining many of the theories that have been The Journal of Psychotherapy Integration contains described in the previous chapters of this textbook. articles about issues important to the development As I describe each of the three integrative theories of integrative approaches to therapy. As shown in (cyclical psychodynamics, transtheoretical, and Chapter 1, many therapists practice integrative multimodal), I will explain a method that you can approaches to therapy. use in making an outline of your own theory that would be similar to each of these. Wachtel’s Cyclical Psychodynamics Theory Wachtel and his colleagues (Gold & Wachtel, 2006; Wachtel, 2008; Wachtel, Kruk, & McKinney, 2005) have developed an approach that combines behav- ioral and psychoanalytic ideas and techniques with conceptualizations and methods from some other theories. The integration of behavioral and psycho- analytic therapy would seem, at first, to combine two approaches that are too theoretically distant to be reconciled. However, this pairing has a long history, with Dollard and Miller (1950) developing a unified theory combining the insights of psychoanalysis with the scientific rigor of behavior therapy. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

664 Chapter 17 Table 17.1 Most Frequent Combinations of Theoretical Orientations Combination 1976* 1986 2003 Behavioral and cognitive % Rank % Rank % Rank Cognitive and humanistic Cognitive and psychoanalytic 54 12 1 16 1 Cognitive and interpersonal 11 2 72 Cognitive and systems 36 10 3 72 Humanistic and interpersonal 4 12 64 Interpersonal and systems 11 3 <4 14 64 Psychoanalytic and systems 25 1 84 56 Interpersonal and psychoanalytic 57 47 Behavioral and interpersonal 49 38 Behavioral and systems <4 15 38 Humanistic and psychoanalytic <4 13 2 10 Behavioral and humanistic 57 2 11 Behavioral and psychoanalytic <4 12 2 11 84 1 13 49 <1 14 *Percentages and ranks were not reported for all combinations in the 1976 study (Garfield & Kurtz, 1977). Also data from Norcross and Prochaska (1988) and Norcross, Karpiak, and Lister (2005). Working in this tradition, Wachtel (Gold & Wachtel, 2006; Wachtel, 1977, 1991, 1993, 1997; Wachtel et al., 2005), with a background in psychoanalysis, has devel- oped a theory that intertwines psychoanalysis and behavior therapy. Others have been attracted to cyclical dynamics because of its emphasis on client strengths as well as relationship and family issues (Ornstein & Ganzer, 2000). Recognizing that anxiety is common to disorders treated by these methods, Wachtel has developed cyclical psychodynamics, a term that comes from his belief that psychological conflicts within oneself create problems in behavior and that problems in behavior create problems within oneself. For example, a person may feel unloved by her parents and be unassertive in her behavior, all the while feeling anger toward her parents. By acting unassertively, she may feel ignored and also feel rage. Thus, the intrapersonal conflict creates behavioral problems, and the behavioral problems create further intrapersonal problems. In treating patients, Wachtel moves back and forth between helping clients understand their behavior and changing it. Behavioral treatments include relaxa- tion, desensitization, and exposure to anxiety. Psychodynamic treatment includes helping the patient understand past and present unconscious conflicts and how they influence each other. Wachtel deals not only with past issues but also follows how unconscious processes emerge as the end product of anxiety. Thus, unconscious conflicts may cause problems or be the result of problems. Strategies in understanding the client and treating the client come from both behavioral and psychodynamic perspectives. Wachtel inquires into the unconscious problems of the client as well as the behaviors. Also, he may expose the client to anxiety, not just through behavioral procedures but also through interpreting and confronting unconscious processes. However, this exposure is done gradually, and change is brought about in small steps rather than in dramatic interventions. Wachtel was concerned that a purely psychoanalytic view would mean that individuals’ early experiences would appear to not be changed by experiences in Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Integrative Therapies 665 their later life. He was attracted to a behavioral point of view that is quite clear in the belief that recent events have an effect on future behaviors of the individual. He was also concerned that insight and knowing about one’s issues or problems would not be enough to bring about change. Being familiar with the work of Dollard and Miller (1950), he was able to integrate behavior therapy into psychoanalysis. Interestingly, Wachtel was not as enthusiastic about integrating cognitive therapy into psychoanalysis. He viewed psychoanalysis as cognitive in its emphasis on thinking about one’s concerns and bringing unconscious events into conscious awareness. He wanted to help individuals become more aware of their emotions and be able to change their behaviors. More recently, he has been influenced by a constructivist approach to cognitive therapy (Chapter 12) that fo- cuses on the ways clients think about and address their problems rather than a persuasive approach, such as disputing used in rational emotive behavior ther- apy (REBT) (Chapter 9), that focuses on persuading individuals to change irratio- nal behaviors. As the therapy process proceeds, clients are helped to develop insights into clarifying and interpreting thoughts, fantasies, and behaviors. As psychoanalysis and cognitive therapies have been influenced by constructivist approaches, so has Wachtel. This has caused him to take a sharper view of clients’ use of lan- guage and the way they view the world and the therapeutic relationship. Recog- nizing that many problems occur within the family, he has also integrated concepts from family therapy (Wachtel et al., 2005). Wachtel believes that it is not enough to identify and understand one’s fears, but that one must be exposed to the fear repeatedly in order to extinguish the behavior. Psychoanalytic interpretation provides one method to expose the fear and extinguish the behavior, as it is a way to help the patient deal with thoughts that have been previously avoided. He suggests that repeating such interpreta- tions is helpful in moving toward extinguishing the fear. Transference can be seen as viewing past experience not only for itself but also as it relates to the cli- ent’s current life. Like many current psychoanalysts, Wachtel emphasizes the importance of the client–therapist relationship. The relational psychoanalytic writings of Mitchell (1993) and others have been an important influence on cyclical psycho- dynamics. Wachtel (Wachtel et al., 2005) sees the therapist as collaborating with the client to make use of interpretations and not feel discouraged by them. In doing this, the therapist attends not just to the client’s discussion of past events but also to the reactions and interactions that occur in the present between client and therapist. Change in therapy is seen as being due in part to the effectiveness of the therapeutic relationship. An Example of Wachtel’s Cyclical Psychodynamic Theory: Judy The following example of Judy, in her mid-40s, who complained of chronic depres- sion and severe somatic symptoms, illustrates how therapists using the cyclical psy- chodynamic approach conceptualize their clients (Gold & Wachtel, 1993). In the beginning of therapy, Judy and the therapist examined the intrapsychic conflict– behavior–intrapsychic conflict–behavior circle (how psychological issues led to behavioral problems and vice versa) and Judy’s anxieties and motivations. Grad- ually, Judy saw that she was being exploited by others, that she was angry Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

666 Chapter 17 at this exploitation, and that she had developed a sense of helplessness about this problem. Exploration of psychodynamic issues, such as parental attach- ments, helped Judy make a link between past and present behavior. At this juncture, the therapist combined behavioral and psychoanalytic interventions to break the psychodynamic-behavioral cycle. The initial period of such interpretive work became the basis for more active interven- tions aimed at breaking Judy’s vicious circle of compliance, self-deprivation, and anger. The first exercise was a blend of dynamic insight and systematic desensitization. Judy was asked if she could imagine scenes in which she pleasurably spoke her mind in an angry or irritable way with her husband and friends. She gradually moved from timid and tiny expressions and imagery to scenes where her expressions of rage were violent and powerful. As Judy became more comfortable with these ideas and images, she spontaneously gained insight into her anxiety about anger, and about some of the un- conscious factors which reinforced her compliant behavior. Judy reported imagining herself frightening other people and taking pleasure in the power which that fear repre- sented. She also learned that her care taking behavior gave her a covert sense of power as well, as it unconsciously provoked fantasies of being better and more capable than the people to whom she acquiesced consciously. (Gold & Wachtel, 1993, pp. 69–70) An Example of Wachtel’s Cyclical Psychodynamic Theory: John N. The following example shows a more specific integration of behavioral and psy- choanalytic theory (Wachtel et al., 2005). It illustrates a “seamless” approach in which behavioral methods are intertwined with psychoanalytic interpretation. John N. sought therapy because he had failed five times to pass a licensing exam in his professional field (not specified in the case). He had been successful in his field and felt pressure to pass the exam. He had grown up in a prominent Boston family, who were concerned about social status and about being success- ful. John conveyed his own concern about social status and success in the thera- peutic hour. The therapy, unusual for cyclical psychodynamics, lasted only 8 sessions. It was successful in helping John pass the exam. Such a specific goal is not typical of cyclical psychodynamic work. This excerpt from the case illustrates the intertwining of behavioral techniques with psychoanalytic conceptualizations. The most interesting developments occurred when John imagined himself visiting the exam room the day before the exam. The aim in this set of imagery exercises was for him to acclimate to the setting in which the exam would take place and thereby to expe- rience a reduction in anxiety. He was asked to look carefully around the room, to touch the various surfaces such as the desk and walls, to experience the lighting, and so forth. When he began the imaging, however, a fascinating series of associations and new images came forth. At first he spontaneously had the association that the room seemed like a morgue, and then that the rows of desks seemed liked countless graves covering the site of a battlefield. Then he felt overcome with a feeling of impotence. I asked him if he could picture himself as firm and hard, ready to do battle. He did so (I left it ambiguous whether he should take this specifically to mean having an erection or as an image of general body toughness and readiness). He said he felt much better, stronger, and then spontaneously had an image of holding a huge sword and being prepared to take on a dragon. He associated this image to our various discussions of his treating the exam as a worthy opponent, taking it seriously yet being able to master it. He was exhilarated by this image, and I suggested he engage in such imagery at home between sessions, a suggestion he endorsed with great enthusiasm. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Integrative Therapies 667 In the next session, we began with his again picturing himself visiting the exam room the day before the exam. For a while, as he checked out the various features of the room, he felt quite calm and confident. But suddenly he felt a wave of anxiety, as if something was behind him. I asked him to turn around and see what was there. He reported seeing a large cat, a panther. Here I made a kind of interpretation. I offered that the panther represented his own power and aggression and that it was a threat to him only so long as he kept it outside of him or out of sight. I asked him if he could re-appropriate the panther part of him, adding that what he was feeling threat- ened by was his own power, his own coiled intensity. He pictured the panther being absorbed into himself and the anxiety receded. I then elaborated—quite speculatively, to be sure, but in a way rooted in the under- standing we had achieved together about the dynamics of his difficulty with the exam—on why it might be that he had chosen a panther in particular to represent the part of himself that needed to be re-appropriated. I noted that panthers were not only strong and purposeful but were also meticulous and supremely respectful of their prey. (Wachtel et al., 2005, pp. 182–183) These two samples of descriptions of a cyclical psychodynamic approach show how behavioral and psychodynamic concepts can be integrated into an active theoretical approach. Wachtel has developed this approach gradually, add- ing new concepts where needed to help bridge the gap between psychodynamic and behavioral and cognitive therapies. He has been interested in developing more seamless interventions, as illustrated in the preceding case. In this way the distinction between behavioral and psychodynamic techniques is smooth and not abrupt, with the therapist moving seamlessly from one approach to another. Wachtel also is concerned about social issues such as race (Wachtel, 1999, 2007) and their impact on individuals and the therapeutic relationship. The contribu- tion of relational psychoanalysis also helps to bring in relationship factors that are not directly related to psychoanalytic conceptualizations. In this way, Wachtel enriches cyclical psychodynamic therapy so that it is more than just a blend of behavior therapy and psychoanalysis. Using Wachtel’s Cyclical Psychodynamics Theory as a Model for Your Integrative Theory Wachtel’s theory uses a theoretical model called theoretical integration. He uses both the personality theory and the theory of therapy from two or more theories. For cyclical psychodynamics, he uses both the theory of personality and the the- ory of therapy of psychoanalysis, behavior therapy, constructivists therapies, and family therapy. He often goes back and forth from one theory to another. He uses techniques based on his understanding from these theories. You may wish to use his model to develop your own integrative theory. To do so, examine Table 17.2 and select two or more theories that you would like to combine. (The fewer the theories, the easier it will be to assemble an integrative theory). Even though you may be new to the study of theories of psychotherapy and counseling, you may want to try this out. It is likely that you may change your integrative theory several times should you decide to become a psychother- apist or counselor. You may find it helpful first to choose theories from Table 17.2. Then look at the theories of personality described in Table 16.1 on pages 633 and 634 to find the concepts basic to theories of personality that you would use. Next, look at the therapeutic techniques that would be used with each of the the- ories you select. These are listed in Table 16.4 on pages 638 and 639. Then you may wish to reexamine the chapters in which the theories that you have selected Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

668 Chapter 17 are discussed. By doing this, you would be following a specific model, theoretical integration, for integrating theories you may wish to use. Another model of integrating theories that is quite similar to theoretical inte- gration is the Stricker and Gold (2005) model. In the assimilative model, you would select one theory as the primary one and one or more others as secondary theories that you might draw from. Using Table 17.2, find the theory of personal- ity that you might use as well as the theory of therapeutic techniques. From Ta- bles 16.1 and 16.2, go to the chapters that describe the theories of personality and the therapeutic techniques you wish to use. For example, you could choose cog- nitive therapy as your primary theory and behavioral and feminist therapies as secondary theories. Table 17.2 Personality Theory and Theory of Therapy, Listed by Chapter, That May Be Used in Developing an Integrative Theory of Psychotherapy Chapter Title Personality Theory Theory of Therapy 2. Psychoanalysis (Assessment) (Techniques) Freud’s drive theory Psychoanalytic techniques 3. Jungian Analysis and Ego psychology Therapy Object relations Jungian techniques Kohut’s self psychology 4. Adlerian Therapy Relational psychoanalysis Adlerian techniques 5. Existential Therapy Jungian personality theory Uses techniques from other 6. Person-Centered Therapy theories 7. Gestalt Therapy Adlerian personality theory Reflecting techniques 8. Behavior Therapy Existential personality theory Gestalt experiential techniques 9. Rational Emotive Behav- Person-centered techniques Behavioral techniques ior Therapy Gestalt personality theory Acceptance and commitment Eye-movement desensitiza- 10. Cognitive Therapy Learning theory (classical tion and operant conditioning, Dialectical behavior therapy 11. Reality Therapy social learning theory) REBT techniques 12. Constructivist Disputing REBT personality theory Cognitive, emotive, and Approaches Activating event behavioral techniques Belief Cognitive therapy techni- Consequence ques Cognitive personality theory Challenging, labeling Cognitive schemas Process of reality therapy Cognitive distortions and the techniques Reality therapy personality Solution-focused personality theory techniques Solution-focused personality Personal-construct personal- theory ity techniques Personal-construct personal- Epston and White’s narrative ity theory techniques Epston and White’s narrative theory (continued) Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Integrative Therapies 669 Table 17.2 Personality Theory and Theory of Therapy, Listed by Chapter, That May Be Used in Developing an Integrative Theory of Psychotherapy (Continued) Chapter Title Personality Theory Theory of Therapy 13. Feminist Therapy: A (Assessment) (Techniques) Feminist personality theory Multicultural Approach Feminist techniques Bowen’s intergenerational combined with many other 14. Family Therapy theory theories, such as Structural family theory Psychoanalysis 15. Other Psychotherapies Strategic theory Behavioral and cognitive Experiential and humanistic Gestalt theories Narrative Mental Research Institute Bowen’s intergenerational theory techniques Long brief therapy (Milan) Structural family techniques Strategic techniques Asian personality theory Experiential and humanistic techniques Body psychotherapy person- Mental Research Institute ality theory techniques Interpersonal psychotherapy Long brief therapy (Milan) personality therapy techniques Psychodrama Asian psychotherapy techni- Creative therapies ques Body psychotherapy techni- ques Interpersonal psychotherapy techniques Psychodrama techniques Creative therapies techniques Prochaska and Colleagues’ Transtheoretical Approach I present the transtheoretical model described by Prochaska and colleagues (Prochaska & DiClemente, 2005; Prochaska, Johnson, & Lee, 2009; Prochaska & Norcross, 2010) because it has been the subject of more research than other inte- grative models and provides a thorough integration of theories discussed in this textbook. The developers of this transtheoretical model wanted an approach that would go beyond specific theoretical constructs and would encourage therapists to create new, innovative techniques by drawing the most effective ones from other therapies. Thus, they pick and choose constructs and therapeutic techni- ques from theories they wish to make into their own theory. They use the theo- retical integration model but in a very different way than Wachtel does. Rather than use theories in their entirety, they select constructs from various theories that flow together and make their own new theory. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

670 Chapter 17 Prochaska’s model is a change model, based on client readiness for change, type of problem that needs changing, and processes for techniques to bring about change. Client readiness for change has been addressed somewhat by Rogers (Chapter 6) but not by most other theories described in this book. No theory ad- dresses change as thoroughly as does the approach of Prochaska and his collea- gues. They describe five stages of change and then apply these to five levels of psychological problems. To help clients at various stages of readiness for change and with different levels of psychological problems, they suggest 10 processes of change, which are techniques that are drawn from different theories of psycho- therapy. Different techniques are used depending on the client’s readiness for change and the type of problem that the client presents. Stages of Change Prochaska and Norcross (2010) describe five stages of readiness for change: pre- contemplation, contemplation, preparation, action, and maintenance. In precon- templation, the client may have thoughts about changing but is not willing to do so. In contemplation, the client is seriously considering change, but not com- mitted. In preparation, the client intends to change and shows some behavioral changes. In action, the commitment is clear, with the client showing consistent change over a period of time. During the final stage, maintenance, the client works to continue change and to prevent relapse. These stages of change are not independent, and clients may experience problems at several stages at any time. These five stages would seem to be particularly appropriate to describe levels of commitment to stop smoking, a frequent application of the transtheore- tical model for Prochaska and his colleagues. Levels of Psychological Problems The five levels of change can be applied to five different categories of problems that differ in levels of complexity: symptoms, maladaptive thoughts, and inter- personal, family, and intrapersonal conflicts. Symptom problems might include a phobia of snakes. Maladaptive thoughts are negative beliefs such as “I am a terrible person.” Interpersonal conflicts include not getting along with indivi- duals in one’s life, such as colleagues at work. Family conflicts are often more complex because the relationships are more intimate. Intrapersonal conflicts are indecision and disagreements within oneself and may include intense anger or narcissism. Generally, transtheoretical therapists prefer to start dealing with symptoms or maladaptive cognitions and later deal with interpersonal, family, and intrapersonal conflicts. In general, behavioral therapies lend themselves to symptom change; cognitive therapies to maladaptive thoughts; family systems therapy to family problems; and gestalt, psychoanalytic, and existential therapy to interpersonal or intrapersonal conflicts (Prochaska et al., 2009; Prochaska & Norcross, 2010). Processes of Change In describing processes that bring about change, Prochaska and Norcross draw from all major theories described in this book. There are 10 processes of change (consciousness raising, dramatic relief or catharsis, environmental reevaluation, self-reevaluation, self-liberation, social liberation, contingency management, Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.