Foster acceptance of unwanted private experiences which are out of personal control Facilitate commitment and action towards living a valued life Increase psychological flexibility: the ability to contact the present moment and the psychological reactions it produces, as a fully conscious human being, and based on the situation, to persist with or change behaviour for valued ends In other words, ACT is to create a rich, full and meaningful life, while accepting the pain that inevitably goes with it. The Acceptance and Commitment Therapy explained using a hexagon. Six core pathological processes correspond to the six core intervention processes. ACT Model Of Psychopathology The six psycho-pathological processes are: Loss of contact with the present moment (preoccupation with a conceptualized past or future) Cognitive Fusion Experiential avoidance Self-as-content (Over-identification with a conceptualized self) Remoteness from values Lack of committed action (Impulsive/ineffective/avoidant/‘mindless’ action) Fusion: The client who is approaching the therapist fused with all sorts of negative thoughts, unhelpful evaluations about themselves and others, painful memories from the past, E.g., I am bad, I do not deserve, I will never get better, I am tired etc. Worrying, ruminating etc. are the manifestations of fusion. Experiential Avoidance: Experiential avoidance means “attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences even when doing so creates harm in the long-run“(Hayes, Strosahl, Wilson, 1999). Humans are tempted to try avoiding negative thoughts and emotions whenever they occur. In addition, this is a strategy, which can work extremely well in some contexts. For example, not going for a social gathering is a common way of feeling less nervous – that is experiential avoidance. However, it can also interfere with important aspects of life. Examples are putting of important tasks due to the discomfort it causes, not using opportunities to avoid fear of failure, not engaging in social activities because of anxiety etc. However, this is a trap, which always forces the person to move away from what he/she really wants to do. Experiential avoidance can work in the short term, but it does not work in the long term. 101 CU IDOL SELF LEARNING MATERIAL (SLM)
Fusion and avoidance always go together. When people have depressive thoughts such as “I am not good”, “No one likes me”, “I am a failure”, they also try to get away from such thoughts using other behaviour such as drinking, smoking, over involvement in eating or other addictions. Dominance of Conceptualized Past Or Future: Humans may spend a lot of time absorbed in thoughts about the past or the future. Instead of being fully conscious of present experience, we may operate on automatic pilot. Fusion and avoidance lead us to a loss of contact with reality experience. It causes thoughts over things that have already happened in the past and fantasize the future, anxious about what is happening next, and, in the meantime, they miss out the life that they have in the present moment. They lost touch with their own psychological world and physical world in the present moment. Lack of Values Clarity: People often forget their values and directions when they fused with painful thoughts, trying to run away from situations causing discomfort and absorb by concerns about past and future. E.g., depressed clients often lose their connections with the desire of their life and become incapable of contributing to others or being productive. They also neglect their health and well-being. Then the client helped to understand the incongruence between the values and their current behaviour or circumstances. Unworkable Action: Unworkable actions are patterns of behaviour that keeps us away from a life that we really want to live and make our life even more miserable and painful. Often impulsive activities have an adverse effect on the quality of life E.g., excessive involvement in activities such as drinking alcohol, watching TV, eating, procrastination, attempting suicide etc. Attachment to conceptualized self: We all have a story about ourselves, i.e., a description about ourselves, our past and about our future. It could be positive or negative. When we fuse with these self-description, whether it is positive or negative it causes problem. Fusing with the self-concept that I am strong and independent creates high self-esteem, but sometimes it prevents people from asking or accepting help from others when they really need. When they fuse with negative self-description, it affects their self-esteem adversely and creates problems. ACT Model Of Therapeutic Interventions Before coming to the six core processes of ACT intervention we need to understand a concept called creative hopelessness. In the case of clients who need behaviour change, usually they come to therapist after attempting various techniques to manage the difficulties. In ACT, the therapist helps the client to examine the workability of those strategies. Many of 102 CU IDOL SELF LEARNING MATERIAL (SLM)
those strategies may seem to be controlling and trying to get away from unwanted feelings and experiences. This initial exploration in this direction helps client to realize the unworkability of those strategies in their context and the necessity of trying another one that could give long-term benefits. In ACT terminology, it known ‘creative hopelessness’. Actually, this is the starting point of creating a space for a new way of dealing with the problem. This state is ‘creative’ as it prepares the person to use entirely new strategies. Defusion: This is the opposite of cognitive fusion, which we have seen as the first item in the pathological processes. This is about stepping back and noticing thoughts rather than being caught up with the thoughts. The aim of diffusion is to reduce the impact of unhelpful thoughts on us. It helps us to detach from our thoughts and evaluate or assess objectively. This helps us to understand how human language affects our self-concept and thoughts. Acceptance: This is the antidote to experiential avoidance. It means making room for the painful feelings, emotions and experiences instead of fighting or resisting with them or let go of the discomfort. It helps us to live a value-directed life in the midst of pain and suffering. This will allow our feelings to come and go with a kind and open stance without draining us or holding us back. Contacting the present moment (Mindfulness): Mindfulness allows us to being touch with the present moment. This means deliberately bringing our awareness in to physical world around us and to the psychological world within us. Instead of operating on automatic pilot this will help us to be here and now. Mindfulness allows us to engage fully in what we are doing. Self as context: There are two distinct elements of life: the thinking self and observing self. Thinking self-activates generating thoughts, beliefs, judgments, plans etc. The observing self is aware of whatever we are thinking, felling, planning etc. As we go through our life, there are many changes occur to us such as bodily changes, our attitudes, beliefs etc. The observing self is the same throughout our life, but it observes the changes in us as if it is someone else. The observing self makes us more human, and this is more important for developing self- kindness and self-compassion. Value clarification: Clarifying one’s values is essential for creating a meaningful life. The therapy can start with clarifying the values of the client. This easily achieved through asking questions such as ‘what matters you most in your life?’ What gives life meaning? On the other hand, ‘what do you want to do with your brief lifetime on this planet?’ Valued Living Questionnaire (VLQ) (Wilson & Groom, 2002) used to elicit values. This gives an idea about the client how he/she wants to behave in his/her day-to-day life. In ACT, this known as ‘chosen life directions’, also called the ‘compass’ of life. It is important to know the difference between values and goals. Values are ongoing patterns of activity, which 103 CU IDOL SELF LEARNING MATERIAL (SLM)
cannot be achievable or completed, but goals are achievable and completed. Values have transformational power and are reinforcing. In ACT, the client helped to understand the incongruence between the values and their current behaviour or circumstances. Committed Action: Translating values into congruent actions is the next process in the interventions using ACT. This means helping the client to set realistic goals to fulfil their values or live a life in our chosen direction. Under this section, the client helped to develop SMART (specific, meaningful, adaptive, realistic and time framed) goals. In order to fulfil the values of being a good dad, the person has to take committed action in the direction of his values. ACT also requires a concrete therapeutic relationship or working alliance between the therapist and the client. The Advantage of ACT is using a number of metaphors, worksheets and exercises that anyone can easily understand. There is no ACT technique that therapists can use with every client. Even the terminology or nature of questions to elicit avoidance or personal values will be different for each client. Therapists need to be sensitive to the unique presentation and situation of each person they work with. The order of the treatment processes also will vary according to the nature of the problem of the client e.g., In the case of severe emotional problems due to experience of trauma in the past, the strategy diffusion to be used only after doing a lot of work around validating the pain, self- compassion, acceptance etc. Otherwise, the client may think that the therapist has not taken their emotional state seriously and labelled as ‘simple’ or silly’. If the therapists use ACT techniques in their personal life and get convinced of the benefits before trying it to their clients. The more we apply the strategies in our life the better we will be able to use with our clients. This reminds us of the words of Mahatma Gandhi “Be the change that you want to see in the world”. 5.5.1 The Selective Use of Supportive, Re-educative, and Reconstructive Approaches Supportive Therapy: Is to bring the patient to an emotional equilibrium as rapidly as possible, with amelioration of symptoms, so that the patient can function at approximately his or her norm. An effort made to strengthen existing defences as well as to elaborate better “mechanisms of control.” Co-ordinately, one attempts to remove or to reduce detrimental external factors that act as sources of stress. There is no intent to change personality structure, although constructive characterological alterations may develop serendipitously when mastery has restored, and successful new adaptations achieved. There are times when supportive therapy is all that is needed to bring about adequate functioning. This is the case where the basic ego structure is essentially sound, having broken down under the impact of extraordinary severe strains that sap the vitality of the individual. A 104 CU IDOL SELF LEARNING MATERIAL (SLM)
short period of supportive therapy will usually suffice to restore equilibrium. On the opposite end of the pathological scale, those victims so deeply scarred by childhood experiences that the radical surgery of intensive psychotherapy could only increase the disfigurement. The only practical thing we can do for some of these casualties is the topical cosmetic repair of symptom alleviation so that they can live more comfortably in spite of their handicaps. While we do not yet possess the diagnostic tools to assess accurately which patients will benefit most from supportive expedients, some therapists rely on the pragmatic principal of resorting to supportive therapy where measures that are more extensive fail to produce an adequate response. On the other hand, where caseloads are overwhelming, therapists may be inclined to utilize supportive measures as a routine, reassigning patients for educational or reconstructive approaches where results are not satisfactory. Since supportive therapy attempts the achievement of symptom relief or symptom removal, the question presents itself regarding the value of symptomatic cure. Among the most solecistic of legends is the notion that elimination of symptoms is shallow if not worthless. This notion stems from the steam engine model of psychodynamics that conceives of energy in a closed system, bound by symptomatic defences, which when removed, releases new, more dreadful troubles. This is in spite of the fact that physicians from the time of Hippocrates have applied themselves to symptom removal in both organic and functional ailments with little or no baneful consequence. Yet, legends survive from one generation to the next. The presumed dangers of symptom removal are now as threatening to some younger therapists as they were to their teachers. Little proof offered of a causal relationship between the fact of symptom relief or removal and any pathological sequelae. The evidence persuades that supposedly precipitated disasters are either coincidental or the product of inept therapeutic interventions (Spiegel, H. 1966). The complaint, then, that symptom removal is an arbitrary, incomplete, irrational, and unsatisfactory approach in psychotherapy is apocryphal. Yet, we cannot entirely dismiss the anecdotal accounts and experimental studies (Szasz, 1949; Browning & Houseworth, 1953; Seitz, 1953; Jones, HG, 1956; Paneth, 1959; Crisp, 1966; Bruch, 1974a) of infelicitous effects, but overall, the empirical evidence for symptom substitution is not consistent. A callous therapist who batters away with any technique without adapting tactics to the immediate reactions and sensitivities of patients may become a greater instrument of harm than of help. The transference reaction can negate any therapeutic benefits; indeed, it may itself be responsible for a therapeutic debacle. Experience convinces that supportive measures, carefully and selectively applied, because of desirable symptom alleviation, promote substantive behavioural benefits. In summary, symptom relief or removal is an essential goal in any useful psychotherapeutic program. It may occur “spontaneously” or be brought about by a variety of methods, such as by drugs, by conditioning techniques, by faith and prayer, and by insight. While one may not agree with Eysenck (1960a) that elimination of a symptom cures the neurosis, there is evidence that it contributes to a better adjustment and to the elimination of auxiliary symptoms clustered 105 CU IDOL SELF LEARNING MATERIAL (SLM)
around the original complaints. Regard any therapy that leads to enlightenment and greater self-understanding without symptom relief legitimately as a mediocre success. If not a failure. However, this does not mean that symptom control should constitute the sole objective of therapy. Undermining of the basis of the individual’s symptoms, the resolution of past conditionings and current conflicts that nurture more symptoms expands one’s potentials for happiness and creativity. While such an objective may come about as a by-product of symptomatic change, its studied achievement should be an important target. In many patients receiving supportive therapy, consequently, an effort made to motivate them toward some kind of reeducative or reconstructive change in order to insure greater permanence of results. Supportive measures utilized as the principal treatment or as aides to reeducative or reconstructive psychotherapy. They employ as: 1. A short-term exigency or expedient for sound personality structures shortly submerged by transient pressures that the individual could not handle. 2. A primary long-term means of keeping chronically sick patients in homeostasis. 3. A way of “ego building” to encourage a dedication to reintegrate psychotherapeutic tasks. 4. A temporary expedient during insight therapy when anxiety becomes too strong for existing coping capacities. An understanding of how and when to do supportive psychotherapy is, therefore, indispensable in the training of the psychotherapist. Supportive therapy does not work in many cases where the problems with authority are so severe that the patient automatically goes into competition with the helping individual, depreciating, seeking to control, acting aggressive and hostile, detaching himself or herself, or becoming inordinately helpless. These reactions, appearing during therapy, may act as insurmountable resistances to the acceptance of even supportive help. Therapies with designations of “palliative psychotherapy,” “social therapy,” “situational therapy,” and “milieu therapy” fall into the supportive category. Many of the tactics utilized are similar to those in casework and counselling. Among procedures employed in supportive therapy are guidance, tension control and release, environmental manipulation, externalization of interests, reassurance, prestige suggestion, pressure and coercion, persuasion, and inspirational group therapy. Reeducative: Normative reeducative strategy is at the core of organisational change. R. Chin and K. Benne introduced the strategy as shared power strategy. The objective of this strategy is to expose employees to new values and norms and the need to adopt these new values and norms. Based on rational/ scientific evidence or emotional appeals. This strategy implemented by focusing mainly on system renewal, people in the organisation. Here it is important to employ an educational strategy with learning through experience as its highlight. The strategy also promotes dealing with real problems by using a planned strategy. For this strategy to be successfully implemented the organisation needs to identify a change agent at 106 CU IDOL SELF LEARNING MATERIAL (SLM)
the same time ensure involvement of top-level administration. This strategy based on the belief that people are social creatures, and cultural norms are core to their group identity. It not only assumes that individuals are rational but gives equal importance to the socio- cultural influences in an organisation. According to this approach, change will occur after the employees involved in bringing about or affected by change are able change their older normative orientations to commit to new orientations related to the change to implement in the organisation. Change in this approach is not limited to knowledge, information and intellectual rationales but it also covers attitudes, values, skills and significant relationships. This strategy mainly focuses on group norms, personal values, and common goals. This is much effective compared to imposing change through authority and coercion. By utilising this approach, change becomes part of the organisational culture and thus receives the support of the social forces and group dynamics in an organisation. Changes can successfully implement when it is in trail bike with existing structures, attitudes, values, and norms in an organisation. The approach promotes collaborative working with the employees to identify problems and facilitate solutions. Its objective is to improve problem- solving capacities and mechanisms within a system, and develop new attitudes, values, skills, and norms for interaction amongst employees. The strategy not only promotes organisational change but also encourages participation and develops empowerment amongst the employees. Further teamwork promoted as the manager or the superior needs to work together with the employees in order to implement this strategy. It also results in optimal development and application of creativity and experience of the employees within the organisation. The three main elements of this strategy are attitudes, beliefs and values. Attitudes are feeling and beliefs that determine the way in which employees perceive their environment and behave. It described as modes through which employees express their feelings about the organisation, people in it and its structure, processes etc. Employee attitudes are extremely important in an organisation as they might reflect an underlying problem. If not dealt with at right time a negative attitude towards an organisation or its aspects can lead to development of major problems in an organisation. Positive attitude on the other hand will enhance the overall functioning of an organisation. Attitude plays an extremely important role when it comes to change. Change leads to development of number of insecurities amongst the employees that may lead to development of negative attitude towards change. Thus, before change process is initiated, the management needs to identify the presence of any negative attitude and deal with it. Normative re-educative strategy is once such strategy that directly focuses on the employee attitude and this can be termed as key to its successful long-term effects in an organisation. Beliefs described as certainty in the truth of a proposition. They base on experience, perception, communication reasoning etc. In an organisational set up beliefs of an employee are extremely important. The change process affects by the beliefs of employees about the change process. Thus, beliefs focuses on before the change process initiates. Values described, as an individual understands of what is wrong 107 CU IDOL SELF LEARNING MATERIAL (SLM)
and what is right, good or bad, preferable or not preferable. Values develop early in life and greatly determine an individuals’ behaviour. They are also extremely difficult to change. Values of employees are of extreme importance in an organisation as they determine the motivational level, behaviour and attitudes of an employee. In order to enhance the process of change in an organisation, the management needs to examine values of its employees. Though the strategy is time, consuming it is beneficial as it is long lasting and results in internalised change. Despite of these benefits, managers hesitate in using these strategies due to fear of losing control or shifting focus from organisational goals. Managers do play an important role in implementing this strategy, as their willingness to share power and interpersonal skills in terms of interacting, communicating and promoting participation is necessary for the implementation of the strategy to be successful. Reconstructive Approach, on the other hand, represents long-term development assistance, which could help people in the affected areas to rebuild their lives and meet their present and future needs. It considers reduction of future disaster risks. Rehabilitation may not necessarily restore the damaged structures and resources in their previous form or location. It may include the replacement of temporary arrangements established as part of emergency response or the upgradation of infrastructure and systems from pre-disaster status. An ultimate goal of psychotherapy is to reduce the force of irrational impulses and strivings and bring them under control, to increase the repertoire of defences and make them more flexible, and to lessen the severity of the conscience, altering value systems to enable the patients to adapt to reality and their inner needs. These aims are formidable because the various components of personality so forged into a conditioned system as to be almost impervious to outside influence. Homeostatic balances maintained to safeguard neurotic adjustment. Resistances block attempts to interfere with coping mechanisms and defences. To cut into the neurotic system in order to modify the structure of personality and to expand the potentials of the individual in all required dimensions are difficult and frequently unrewarding undertakings. Reconstructive psychotherapy is aimed at these objectives. Reconstructive psychotherapy is more or less traditionally rooted in the theoretical soil of a genetic-dynamic model of personality. This purports that past inimical experiences and conditionings have retarded the normal psychosocial growth process and are now promoting in the individual immature strivings and emotions that come into conflict with reality, on the one hand, and, on the other, with the person's own incorporated system of ideals and standards. Resultants are tensions, catastrophic feelings of helplessness, and expectations of injury that in turn invoke protective devices, most common of which is repression, a sealing- off process that blankets offending impulses, attitudes, and memories from awareness. However noble the attempt, repression of unacceptable strivings rarely succeeds in annihilating them, for their expression sought, from time to time, by powerful motivations of impelling need. The filtering of offensive impulses into conscious life promotes bouts of anxiety and whips up the defences of the ego, which, while ameliorating anxiety, may be 108 CU IDOL SELF LEARNING MATERIAL (SLM)
destructive of adjustment. Additionally, repressed strivings may express themselves as symptoms. The direct or disguised operations of repudiated strivings, and the defences that mobilizes against them, promote attitudes and values that disorganize interpersonal relationships. Reactions develop that are opposed to judgment and common sense. While individuals may assume they are acting like adults, emotionally they are behaving like children, projecting into their present life the same kinds of fears, misinterpretations, and expectations of hurt that confronted them in their early years, as if time nor reality considerations have altered materially the patterns learned in the past. As long as individuals protect themselves from fancied hurt by circumscribing their activities, they may manage to get along; but should they venture beyond their habitual zone of safety, the precarious balances they have erected will be upset. Were we to treat a patient according to this hypothesis, we would consider that his or her symptoms were manifestations of a general collapse in adaptation, and our therapeutic effort would be directed toward correcting disorganizing drives that were destructive to the patient’s total adjustment. The objective, therefore, expands toward personality growth and maturation, toward heightened assertiveness and greater self-esteem, and toward more harmonious interpersonal relationships. In quest of these objectives, we would strive for a strengthening of the patient’s ego, which, involved hitherto in warding off anxiety through the marshalling of neurotic defences, has been unable to attend to the individual’s essential needs. Instrumentalities toward ego strengthening are, first, greater self-understanding and, second, the living through with a new kind of authority, as vested in the therapist, of experiences that rectify residual distortions in attitudes, feelings, values, and behaviour. Increasingly, psychotherapists, directing their efforts toward reconstructive changes, have drawn for inspiration on psychoanalytic theories and methods, although some have tended to label the ideas and tactics that they employ with tags that mask their origin. Accordingly, during the past half century, many ingredients of psychoanalytic thinking have permeated into the very fibre of American psychiatry and psychology and have fashioned a good number of its trends. In turn, psychoanalysis has influenced by contemporary developments in the psychiatric and psychological fields. It has consequently lost many of its esoteric qualities while acquiring a firmer anchoring in scientific experiment. Reconstructive psychotherapy distinguishes from supportive and reeducative therapy by the degree and quality of insight mobilized. In supportive therapy, efforts at insight are minimal. In reeducative therapy, they are more extensive, but they focuses on relatively conscious problems. The traditional objective in reconstructive therapy is to bring the individual to an awareness of crucial unconscious conflicts and their derivatives. Reconstructive psychotherapy strives not only to bring about a restoration of the individual to effective life functioning, through the resolution of disabling symptoms and disturbed interpersonal relationships, but also to promote maturation of emotional development with the creation of new adaptive potentialities. The methods employed in bringing unconscious aspects to 109 CU IDOL SELF LEARNING MATERIAL (SLM)
awareness originally developed and described by Sigmund Freud, who had the happy faculty of illuminating the most obscure concepts with a refreshing verbal simplicity. Included are such techniques as free association, dream interpretation, the analysis of the evolving transference, the use of strategically timed interpretations, and dealing with resistances to the content of unconscious material. An understanding of the genetic determinants of the individual’s personality and of the relationship of these determinants to the operative present- day character structure are component aspects of the therapeutic process. To do reconstructive therapy, the therapist must have received special training, which ideally includes a personal psychoanalysis and the successful treatment of a number of patients under the supervision of an experienced psychoanalyst. As has been indicated previously, reconstructive personality changes sometimes occur spontaneously during the course of supportive and reeducative therapies or upon completion of these treatments because of more congenial relationships with people. For instance, the individual may work out serendipitously, in the medium of a relationship with a helping agency or reeducative therapist, such archaic strivings as infantile dependency needs, unyielding fears of rejection or overprotection, intense detachment, and untoward aggression. The patient may even spontaneously connect the origin of such impulses with unfortunate childhood conditionings and experiences. Any changes developing in this way, however, are more or less fortuitous. In reconstructive psychotherapy, the treatment situation deliberately planned to encourage change by a living through, with insight, of the deepest fears and conflicts. Treatment objectives determines by the needs of patients, their motivations, and capacities for change. We converge on these objectives with special psychotherapeutic techniques, always mindful of the fact that patients are the ultimate arbiter of how far they will go toward cure. If they possesses a readiness for change, they may achieve surprising development even with short-term superficial approaches; if there is an inherent resistance to change, the most dedicated depth manoeuvres may scarcely move them from their neurotic stalemate. 4 An aspect of all good psychotherapies is facilitation of proclivities for change by rectifying faulty incentives and resolving obstructive resistances. Another requirement is the use of therapeutic measures that potentially can bring about the objectives toward which our treatment efforts pointed. First, by supportive stratagems we may focus our sights on a reduction of the patients’ suffering and an elimination of their symptoms. Through these measures, patients additionally restores to a more propitious level of functioning with a healing of their shattered sense of mastery. Second, with reeducative therapy we may aim for a correction of disturbed patterns of behaviour with the object being to help patients utilize the resources already possessed to the fullest in quest of a more satisfactory work, interpersonal, and social adjustment. Finally, by employing reconstructive measures we may strive for the development of new resources through resolution of personality blocks, which have strangled maturity, mindful of the many obstructions that lie in our path. To illustrate how supportive, reeducative, and reconstructive approaches employed in practice, we may 110 CU IDOL SELF LEARNING MATERIAL (SLM)
consider the case of a patient who applies for therapy after the onset of an emotional illness characterized by tension, depression, anxiety, loss of appetite, insomnia, and gastrointestinal symptoms, especially hyperacidity. The patient in explaining his upset attributes it to challenging work pressures brought about by a shift in his position from a relatively routine one to that involving considerable responsibility. 5.5.2 Restoration of Mastery through Supportive Symptom Relief or Removal In reviewing his history, it appears that the patient has up to the onset of his work problem, made a satisfactory adjustment. He has a good home life; he enjoys his children and loves his wife; he is an excellent provider who conscientiously performs his work duties; he belongs to a number of social organizations; and he fraternizes with the usual quota of friends. According to this record, it would seem reasonable to scale our goals toward bringing him back to where he was prior to his illness. We might calculate that once his symptoms eliminated or under control, he would have the best chance of recovering his equilibrium. With this in mind, we might attack his symptoms along several different lines. First, we may attempt to subdue them by the administration of medicaments, such as antacids for hyperacidity, tonics for anorexia, hypnotics for insomnia, and Xanax for anxiety and depression. If his depression is intense, we might consider a tricyclic antidepressant drug. The patient trained in progressive muscular relaxation in an attempt to relieve his taut muscular state. He may be reassured to the effect that his problem is irremediable and persuaded to utilize his will power to get well. He removed from his environmental situation. By absenting himself from existing areas of stress, he may experience an assuaging of tension and other symptoms. Instead of these efforts, attention focused on the patient’s work difficulty, reasoning as follows: “Here is a man who is involved in a work situation that is too difficult for him to handle. Competitiveness demanded by his present job is not for one with his kind of personality. Prior to the unhappy job change, he was getting along adequately. The treatment objective, then, is for him to obtain another position to which he will be able to adjust satisfactorily.” Assuming that his vocational situation is the primary source of his difficulty, the patient to appreciate that he cannot and should not adjust to extreme competitive stresses, and he may be encouraged to return to his old position or to seek a type of work that avoids competition. Where the patient is willing to give up his present job and to secure a less burdensome one, he may manage to regain his customary equilibrium. Environmental difficulties may exist in addition to the work problem that upset the patient, rendering it additionally impossible for him to make an adequate adjustment. For example, were our patient to suffer from a marital or family difficulty in conjunction with his work problem, our focus in therapy would of necessity expand utilizing marital or family therapy. These measures are obviously all aimed at symptom relief or removal. The philosophy behind such approaches is that symptoms impair the functional efficiency of the psyche as if a diseased gall bladder upsets the entire digestive system. Suggestion, persuasion, “thought 111 CU IDOL SELF LEARNING MATERIAL (SLM)
control,” progressive relaxation, purposeful forgetting, the plunging of the self into extroverted activities, and behavioural techniques are among the devices aimed at the symptom, as if it were a foreign body whose presence obstructed an otherwise intact psychic mechanism. In some cases, this type of therapy may score substantial successes. Indeed, formal psychotherapy may not even be needed in certain personality types who are able to forestall emotional collapse by practicing such devices as “riding their symptoms,” substituting innocuous for painful thoughts, engaging in distracting pursuit of social activities, and observing a punctilious performance of ritual and prayer. In justification of these methods, that many persons are not motivated to accept treatment that is more intensive. In these cases, the mastery of symptoms helps individuals gain freedom from excruciating distress and sometimes permits them to order their lives in a more fulfilling way. One must not overestimate what accomplishes. While the manipulation of the patient’s environment toward alleviation or removal of stressful circumstances. Alternatively, the employment of other supporting measures might be helpful in some cases, in other results would be singularly barren, especially where the individual victimized by inner conflicts that create these symptoms, projects onto the environment sustaining the family and environmental distortions about which he or she complains. Results are poor also when the environmental difficulty has overwhelmed the individual with a substantial shattering of present defences. Here, infantile defences may regressively be revived that cripple the patient’s adaptive resources to a point where, even though the environmental disturbance has abated, the patient burdened with continuing problems. We may compare a situation with that of a man suffering from a minor heart ailment that does not incapacitate him so long as no great strain imposed on his circulation. Should a severe shock or catastrophic happening occur, or should he engage in physical work that is beyond his endurance, the resources of the heart may fail, producing cardiac damage with symptoms of circulatory failure that remain long after the initiating stress has disappeared. The same applies to a personality disorder around which the individual has managed to organize his or her life. When circumstances remove erected safeguards and the individual propels into a situation he or she cannot handle, severe disorganization may result that persists from this point on. Environmental adjustment may also fail because patients feel tied to their life situation no matter how inimical they may be, considering it an inevitable eventuality they have no right to challenge, let alone change. The individual to sources outside of the self usually credits any tension and anxiety that accompany this acceptance. 5.5.3 Modification of Disturbed Attitudes through Reeducative Therapy An investigation may disclose that our patient’s inability to endure competition at his place of work may not be due so much to an environmental peculiarity as it is to the fact that unique ideas and attitudes possessed by the patient make competition an inacceptable or dangerous circumstance. When we examine the exact nature of his disturbed attitudes, we may find that the patient victimized by a tangle of contradictory character trends that inspire personal 112 CU IDOL SELF LEARNING MATERIAL (SLM)
insecurity, promote devaluated self-esteem, and impair relationships with people. For example, we may observe that a basic character trend is that of dependency, which operates insidiously, causing the patient to ally himself with some other person who is a symbol of strength and omniscience. The patient relates to this person as if the latter were a powerful and providing parental agency. Accordingly, the individual may assume a passive role, exhibiting little spontaneity and initiative, anticipating that these needs and demands will automatically be satisfied. Competition poses a threat to the dependency need, for it puts the responsibility on his own shoulders, which he believes to be too fragile to bear the burden of dutiful pressures. Other character trends may exist that both reinforce and oppose his dependency. While he has managed to keep a tenuous emotional balance up to the time of the present crisis, the alteration of his vocational situation has disrupted his equilibrium, threatening his sense of mastery and precipitating catastrophic fears and anticipations of disaster. He may be aware of how dependent he is and may even resent this dependency as opposed to his best interests; yet security is so bound to this trend that he may be unable to subdue its operation. When we inquire further into the circumstances underlying the presumably good adjustment prior to the outbreak of his illness, we find that the patient’s security maintained by the satisfaction of his dependency. So long as this has been gratified, he has been able to get along splendidly. Ungratified, he has been riddled with disquieting fears and threatened with an ill-defined sense of restlessness. Investigating the conditions prevailing at the onset of the patient’s illness, we discover that for some time prior to the onset, the wife has been withdrawing her attention from the patient and transferring it to her brother and his wife who have, because of financial pressures, moved into the patient’s home. As her interest increasingly diverted from the patient, his feelings of insecurity and resentment expanded. The more importunate his demands, the less she responded, until finally he reacted like an abandoned child in a rejecting world. His helplessness and fears of aggression mounted, until the very act of going to work constituted a challenge that taxed his capacities. Promotion to a more responsible position was the last straw that precipitated a breakdown in adaptation. Because of this discovery, we may attempt as a goal to inculcate in the patient some awareness of his dependency as well as of other disorganizing attitudes and strivings. The eventual object here is the retraining of reaction patterns. Thus, we might try to bring our patient to an understanding of the attitudes and designs that he habitually exploits, and we would demonstrate to him which of these facilitate and which obstruct his adjustment. Next, we would help him to apply this knowledge toward modifying or changing his behaviour. We would also evaluate his assets and his liabilities to see how much he had minimized the former and exaggerated the latter. We may attempt to shortcut the therapeutic process by behavioural desensitization slowly exposing the patient to increments of anxiety associated with his job responsibilities, or we may employ assertive training. The mastery of graded tasks, both in fantasy and in reality, abetted by positive reinforcements from the therapist, may enable him to overcome the imagined liabilities of competitiveness and to brace himself to accept hardier burdens. 113 CU IDOL SELF LEARNING MATERIAL (SLM)
In the course of strengthening his adaptive reserves, with or without the guidance of the therapist, he may begin to realize the depth of his dependency. He may become cognizant of how compliant he is to authority, overestimating the virtues of others to the minimization of his own abilities and capacities. He may recognize that his fear of competition is actually associated with anticipating hostilities from people or with the belief that in pitting himself against others he would come out second best, thus exposing himself to ridicule. He may discover also that he harbours ambitions that are totally beyond possibilities of fulfilment, contributing to his sense of defeat. Cognitive therapy may help rectify faulty attitudes and self-statements. The patient would probably be surprised to learn that his character patterns regarded as problems, since he has accepted them as normal for himself. As soon as he realizes that his patterns are responsible for much of his turmoil, he may supply with a valid motivation to alter his scheme of life. While this motivation in itself would not be enough to produce the desired change, his patterns constituting the only routes that he knows to security and self-esteem, it might help him to approach his problems from a different perspective. Faced with his usual difficulties, the patient would as a rude, be unable at first to give up his destructive drives. Knowledge that frustration or pain was inevitable to their pursuit would not be enough to get him to relinquish whatever gratifications followed their exploitation. However, even the mere cognizance that his attitudes were responsible for his plight would be healthier from a therapeutic viewpoint than the conviction, existing previously, that sources of misery lay outside of himself. Eventually, when he realized that his suffering did not compensate for the dubious gratifications accruing from indulgence of immature drives and when he understood that his reactions interfered with important life goals, the patient might begin experimenting with congruous ways of relating. Once convinced that creative attitudes were possible, a long period of experiment and training would be necessary before habitual values abandoned. Generally, habits that have persisted over a long time do not vanish within a few weeks or a few months. In spite of good resolutions, automatic responses operate in line with established routines. Struggle is inevitable until control win over old patterns, and new ones take their place 5.5.4 Personality Growth and Maturity through Reconstructive Therapy The most ambitious objective we could achieve in therapy, and the most difficult to achieve, would be a replacement of neurotic character strivings with those, which will enable the person to develop new potentials toward self-actualization. This objective advantageously reached through elimination of anxieties and fears that were rooted in experiences and conditionings. Important also would be the development of ego strengths to a point where they could cope realistically with inner strivings and environmental pressures. The individual would evolve into a free agent with the willingness to make independent decisions and to take the consequences of his or her acts. There would be an adaptive choice of ends and means and an ability to act without undue restraint from others. Capacities to plan his or her life and to develop goals and ideals in harmony with the disciplines of society would be vital. 114 CU IDOL SELF LEARNING MATERIAL (SLM)
A sense of inner freedom, independence, assertiveness, and self-reliance would, furthermore, add to the dimensions of a well-balanced personality. To achieve these objectives in our patient with the work difficulty, it would be necessary to eliminate the source of his problem rather than only to control its effects. This would necessitate an understanding of the roots of his disorder with resolution of factors that continue to sponsor regressive defences. We would strive to expand our patient’s sense of self so that he might outgrow the need to fasten himself to a parental figure for purposes of emotional support. The focus of our treatment would be the therapeutic relationship into which the patient would project his most intense and unconscious impulses and conflicts. Were we to treat our patient with the work problem according to these principles we would become involved in a more or less extensive therapeutic procedure that would have to go beyond the mere correction of his work difficulty. Indeed, we would consider the vocational disorder as but one aspect of the problem, and our therapeutic effort directed toward mediating disorganizing drives that issued from excessive dependency and a devalued self- image and that were destructive to his total adjustment. The patient, by becoming aware during therapy of contradictory forces within him would gradually realize that he was harbouring attitudes that were a carry-over of early conditionings. The most powerful happening leading to such awareness would be transference to the therapist toward whom he would express and live through vital early formative experiences. Our exploratory process would take the patient back to the genetic origins of his difficulty. For instance, it might reveal the patient’s mother as a woman who had prevented him from achieving that type of independent assertiveness that enables a child to resolve his dependent ties. It would demonstrate how the mother’s own neurotic needs sponsored a cloying overprotectiveness that kept the patient infantilized and helpless. It would bring out how his efforts at aggressive defiance met with uncompromising harshness, until he gave up in his attempts at independence and shielded himself by complying with his mother’s demands. It might uncover passive wishes, fears of violence in the assumption of a desired masculine role, and a host of other unconscious conflicts that engendered by his early experiences. It would finally expose his infantile impulses as living on in his adult life, transferring themselves to those with whom the patient became intimately involved. His wife would reveal as a figure toward whom the patient reacted as if she were a reincarnation of his mother. Partly because of her own impulses and partly because the patient had manipulated her into a parental role, the wife might be shown as having responded by mothering him. In this protective atmosphere, the patient had made a tolerable adaptation even while he repressed desires for freedom and growth. Interpreting the wife’s withdrawal as rejection, the patient had reacted with intense hostility. This he needed to smother for fear of losing every vestige of his wife’s affection. His increasing helplessness soon reached an intensity where he could no longer carry on. At this point, he faced with a greater work challenge in the form of added responsibility and continuing at work meant coping with further stress. The patient reacted to this threat, as a child would react— by screaming for help. Reconstructive 115 CU IDOL SELF LEARNING MATERIAL (SLM)
psychotherapy would bring the patient to an awareness of these facts challenging him to stand up to the drives sponsored by his past. The taming of irrational impulses, the expansion of the repertory of adaptive defences toward greater flexibility and balance, and the reduction of the severity of the conscience with a more wholesome adjustment to inner promptings and demands are ambitious objectives. This is the complex task of reconstructive psychotherapy, which, implemented by a trained and skilled therapist, offers the individual the greatest opportunities for constructive personality growth. However, whether it can be achieved, or whether we might have to contend with the more partial goals described under supportive and reeducative approaches, will be adjudicated by the patient’s readiness and capacities for change, which most advantageously will be influenced toward a constructive end by a knowledgeable and empathic therapist. 5.6 CLINICAL UTILITY Using PST, like any other treatment approach, depends on identifying patients for whom it may be useful. Patients experiencing a symptom relating to life difficulties, including relationship, financial or employment problems, realized by the patient in a realistic way, may be suitable for PST. Frequently, such patients feel overwhelmed and at times confused by these difficulties. Encouraging the patient to clearly define the problem(s) and deal with one problem at a time can be helpful. A simple, single page worksheet shown in Figure 5.6. A typical case study in which PST may be useful is presented in Table 2. By contrast, patients whose thinking is typical character by unhelpful negative thought patterns about themselves. Their world may more readily benefit from cognitive strategies that challenge unhelpful negative thought patterns (such as cognitive behaviour therapy [CBT]. Some problems not associated with an identifiable implementable solution, including existential questions related to life meaning and purpose, may not be suitable for PST. Identification of supportive and coping strategies along with, if appropriate, work around reframing the question may be more suitable for such patients. 116 CU IDOL SELF LEARNING MATERIAL (SLM)
Table 5.1: Stages of Problem-Solving Therapy Problem solving therapy used with patients experiencing depression who are also on antidepressant medication. It initiates with medication or added to existing pharmacotherapy. Intuitively, we might expect enhanced outcomes from combined PST and pharmacotherapy. However, research suggests this does not occur, with PST alone, medication alone and a combination of PST and medication each resulting in a similar patient outcomes. In addition to GPs, PST may be provided by a range of health professionals, most commonly psychologists. General practitioners may find they have a role in reinforcing PST skills with patients who developed their skills with a psychologist, especially if all Better Access Initiative sessions with the psychologist have been utilised. 117 CU IDOL SELF LEARNING MATERIAL (SLM)
Figure 5.1 Problem Solving Therapy Worksheet The intuitive nature of PST means its use in practice is often straightforward. However, this is not always the case. Common difficulties using PST with patients and potential solutions to these difficulties have previously discussed by the author and are summarised. Problem solving therapy may also have a role in supporting marginalised patients such as those experiencing major social disadvantage due to the postulated mechanism of action of empowerment of patients to address symptoms relating to life problems. Of action includes empowerment of patients to address symptom causing life problems. Social and cultural context considered when using PST with patients, including conceptualisation of a problem, its significance to the patient and potential solutions. General practitioners may be concerned that consultations that include PST will take too much time. However, Australian research suggests this fear may not be justified with many GPs being able to provide PST to a simulated patient with a typical presentation of depression in 20 minutes. Therefore, the concern over consultation duration linked to established patterns of practice than the use of PST. Problem solving therapy may add an increased degree of structure to complex consultations that may limit, rather than extend, consultation duration. 118 CU IDOL SELF LEARNING MATERIAL (SLM)
Figure 5.2. A typical Case Study 5.7 SUMMARY Problem-solving has a deep bonding with the process of thinking. A problem/issue refers to a type of disagreement or challenge that exists between one set of circumstances and another. The individual desires to highlight this aspect. There are three major phases in problem-solving. One is preparation. The second is bringing solutions to the fore. The third is examining the solutions that the individual has managed to generate. Problem-solving may take place in the presence or absence of insight. It combines synthetic thinking, metacognition, and analysis. Similar to several other cognitive processes, problem-solving displays its own unique nature too. It is complicated, as well as dynamic in nature. Various kinds of thought processes come into display, in alignment with the specific nature of each problem. 119 CU IDOL SELF LEARNING MATERIAL (SLM)
ACT proves to be an efficacious form of alternative therapy for several types of cases connected to behavioural modifications. ACT helps patients to enhance their social functioning, as well as improve their standard of life. Patients with psychosocial problems engage in an array of avoidance behaviours ,without understanding that they can only give short-term benefits. Firstly, pragmatism is deeply pluralist, recognising the validity of diverse types of interests, perspectives, and forms of knowledge. Being anti-essentialist and anti- foundationalist, pragmatists are suspicious of any effort to privilege a lone viewpoint. As we have argued, RCTs provide crucial information about the relative efficacy of specific interventions. This value in no way undermines the position that ethnographic case studies provide rich understandings of the dynamics involved in a community health intervention, or that action research develops sophisticated practical knowledge of social change processes. The pragmatist believes that such methodologies refuse to compete with one another, for each one of them has a distinct purpose to serve. Secondly, pragmatism’s pluralism does not lead the way to epistemological or moral relativism. Viewing knowledge as a tool that brings us into an almost satisfactory relation with the world, knowledge evaluated for whether it works for us in alignment with a specific objective or interest. Human interests, from a realist point of view, considered to taint knowledge, making it somehow less true. The pragmatist’s viewpoint suggests that human interests are not the enemy of productive inquiry but the key to making our inquiry productive and useful, providing the criteria against which knowledge judged. Making moral choices among these interests, is a political and social activity, which should include critical assessment of the interests served. Thirdly, pragmatism refers to a completely strategy-focussed viewpoint. It believes that the foundation for knowledge lies in actual human activities. Therefore, it refuses to trust debates that are purely intellectual. These debates focus on concepts that have no connection with their practical foundation. As Pierce (1878) states, if recommendations/proposals are useful to have around, and are worth debating, they tend to initiate concrete distinctions for action. This is an argument that pragmatists put forward. The strictest exploration of ideas lies in checking out if they actually operate in practice or not. To illustrate, and so pragmatist health research would prioritise the creation and evaluation of workable and useful intervention programmes. These three characteristics demonstrate the distinctiveness of the pragmatist perspective for health research. The major contribution of pragmatism is to bring some clarity to debates over method, by suggesting that methods, and knowledge, should be judged, not absolutely according to a ‘hierarchy of evidence’, but according to how well they serve specific interests. This brings the user of research – whether academic, health professional, activist or service user – to the fore in the evaluation of knowledge. Knowledge evaluated according to whether it has useful consequences for 120 CU IDOL SELF LEARNING MATERIAL (SLM)
the user’s desired action. The criterion of usefulness and then tempered by the critical analysis of which interests are being served by that action. 5.8 KEYWORDS S.M.A.R.T. A mnemonic acronym, it provides the criteria for outlining the goals. To illustrate, the objectives could be personal growth, management of projects, and handling of employee-performance. S refers to specific, while M refers to measurable. In the commonest expansion of the term, A becomes attainable/achievable, R points towards relevant, and T suggests time-bound. Gastrointestinal Tract refers to the digestive system in human beings and various animals. It begins from the mouth, and proceeds towards the anus at the base of the spine. The tract comprises of different organs. The food enters the mouth first, before proceeding further. The rest of the digestive system extracts the nutrients from this food, for creating energy. The waste matter leaves the body through the anus, as faeces. Ethnography refers to a specific arena of anthropology. It takes up the perusal of diverse cultures. In fact, ethnography conducts thorough explorations of cultural phenomena, in alignment with the viewpoint of the focus/subject of the investigation. Infantile comes into play as a combining word with specific medical terminology. This terminology focuses on medical ailments that afflict new-borns and infants. Some examples are infantile spasms, infantile dystonia or reduction in muscle tone, etc. Palliative Psychotherapy refers to a unique type of medical caregiving therapy. This therapy is interdisciplinary in nature and strives to improve the life of suffering patients to the maximum. It hopes to do so by ending the suffering experienced by these patients, who are victims of severe, complicated illnesses. 5.9 LEARNING ACTIVITY 1. Which therapy would you implement if a client is so stubborn to leave his addictions in problem-solving treatment and why? ………………………………………………………………………………………………… …………………………………………………………………………………………………. 2. Conduct a survey by visiting nearest hospital about the therapies session and list down the measures of outcome. ………………………………………………………………………………………………… …………………………………………………………………………………………………. 121 CU IDOL SELF LEARNING MATERIAL (SLM)
5.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Explain ACT therapy. 2. Give an explanation about valued living questionnaire. 3. What is reconstructive psychotherapy? 4. Write a short note on acceptance and commitment Therapy- ‘A Pragmatic Approach to Behaviour Change’. 5. Write a short on therapy framework. Long Questions 1. Explain the history of problem-solving treatment. 2. Explain the types of therapy. 3. Illustrate acceptance and commitment therapy. 4. Explain types of therapy problem solving. 5. Illustrate any clinical utility using problem-solving treatment. B. Multiple Choice Questions 1. Problem-solving therapy has the model of ___________ at its foundation. a. Stress b. Well-being c. None of these d. Stress and well- being 2. Experiential avoidance means ________. a. Efforts to stop thinking b. Feelings, memories c. Bodily sensations and other kinds of internal happenings d. All of these 3. RFT provides an understanding of the power of _______. a. Verbal behaviour and language. b. Behaviour and Personality c. Emotions and Physicality d. Language and Personality 122 CU IDOL SELF LEARNING MATERIAL (SLM)
4. Which one amongst the lot outlined below, does not classify as an objective of human behaviour? a. Predicting b. Monitoring c. Repatriation d. Describing 5. Which approach represents long-term development assistance? a. Reeducative b. Reconstructive c. Supportive d. Acceptance Answer 1 d) 2 d) 3 a) 4 c) 5 b) 5.11 REFERENCES Textbooks Feldman, R . S. (2008). Essentials of Understanding Psychology. New Delhi: Tata McGraw Hill. Galotti , K.M. (2008). Cognitive Psychology In and Out of the Laboratory. Canada: Nelson Education. Reference Books D'Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive approach to clinical intervention (3rd ed.). New York: Springer Publishing Co Nezu, A. M., & Nezu, C. M. (in press). Problem-solving therapy. In S. Richards & M. G. Perri (Eds.), Relapse prevention for depression. Washington, DC: American Psychological Association. Websites https://www.verywellmind.com/ https://www.healthline.com/ 123 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT - 6 PSYCHOTHERAPY Structure 6.0 Learning Objectives 6.1 Introduction 6.2 Solution Focused Psychotherapy 6.3 Development 6.4 Therapy Framework 6.5 Acceptance and Commitment Therapy- A Pragmatic Approach to Behaviour Change 6.5.1 The Selective Use of Supportive, Reeducative, and Reconstructive Approaches 6.5.2 Restoration of Mastery through Supportive Symptom Relief or Removal 6.5.3 Modification of Disturbed Attitudes through Reeducative Therapy 6.5.4 Personality Growth and Maturity through Reconstructive Therapy 6.6 Clinical Utility/ Application of Integrative Counselling 6.7 Strengths of Psychotherapy 6.8 Limitations of Psychotherapy 6.9 Summary 6.10 Keywords 6.11 Learning Activity 6.12 Unit End Questions 6.13 References 6.0 LEARNING OBJECTIVES After studying this unit, student will be able to: Describe the solution focused based therapy. Explain the acceptance of commitment therapy. 124 CU IDOL SELF LEARNING MATERIAL (SLM)
Discuss the development of psychotherapy. Describe the clinical utility of psychotherapy. 6.1 INTRODUCTION Psychotherapy is typically thought of as a loosely structured verbal interaction between a therapist and client, an interaction modelled on the doctor-patient relationship. It is a popular image that owes much to the pervasive cultural influence of Freud and psychoanalysis. However, psychotherapy has always encompassed a more diverse array of techniques, delivery configurations, and goals. As a general label, it can cover almost any psychological procedure addressing individual or group well-being or self-understanding. It employs a range of discursive strategies and instrumental techniques – including interpretation, suggestion, injunction, exposure, and practice. Specific psychotherapeutic techniques can be roughly grouped according to overarching theoretical models of personhood that vary in terms of complexity and breadth. Some models restrict themselves to relatively narrow accounts of behavior and learning, while others add more elaborate structural accounts of personality and mental processes, and a few extend to totalizing, person-in-society worldviews. To complicate matters further, different theoretical models have conceived of the problems that therapy addresses, and the benefits it can bestow, in markedly different terms. Therapeutic programs thus range from brief sessions targeting discrete problems, to seemingly interminable odysseys of personal discovery. Whereas some merely aim to achieve symptomatic relief and practical payoffs, others set their sights on achieving freedom from troubling emotions and painful experience, and some make more expansive promises of personal fulfilment and self-understanding. Despite repeated attempts to standardize psychotherapeutic practices, they have continued to evolve in a hydra-headed fashion, making it difficult to think of psychotherapy in singular terms. We ought to speak of psychotherapies, rather than psychotherapy per se. The everyday language and accessible techniques that psychotherapists necessarily employ also makes it hard to draw professional boundaries around their work and separate it from that of counsellors, life coaches, clerics, and alternative healers. Nonetheless, the term “psychotherapist” has come to denote something of an occupational title in most Western democracies, representing highly-trained professionals with an integral role in most health services. This is a far cry from the marginal status psychotherapy had at the turn of the 20th century when it represented an alternative form of treatment for those suffering from “nervous” illnesses. For the wider public, psychotherapy has taken on the aura of brand name, a widely recognized option for dealing with the age-old questions of existence and the common complications of modern life Psychotherapy represents a key technology of contemporary selfhood, one primarily oriented to individual adjustment. However, it also possesses a transformative capacity that extends beyond the individual client. All forms of psychotherapy – even the most pragmatically instrumental – are grounded in a shared cultural framework. But most also attempt to 125 CU IDOL SELF LEARNING MATERIAL (SLM)
transcend these shared understandings by introducing new ways of interpreting personal experience, challenging received assumptions and norms. Because psychotherapeutic attitudes have circulated well beyond the consulting room, they have both reflected and reshaped the values of modernity. Psychotherapy has helped usher many shades of emotionality into public view. It has made the personal political in ways that have reframed hitherto private conduct and has inspired significant re-negotiations of what it means to live the ‘good’ life. 6.2 SOLUTION FOCUSED PSYCHOTHERAPY In form, solution-focused brief therapy combines techniques from Milton Erickson (de Shazer, 1982, 1985; Erickson, 1980), with the focus on meanings and attributions of cognitive therapy (Beck et al., 1979), and the goal orientation of behavior therapy (Martin & Pear, 1983; Turner, Calhoun & Adams, 1981; Walker et al., 1981). As is characteristic of other psychotherapy approaches, the therapeutic interview is seen as the primary form of intervention in the solution focused model. However, the interview is different from other treatment approaches in that it consists largely of specialized questions, avoiding confrontation and interpretation. In contrast to the more direct methods of cognitive and behavioural treatment, solution-focused treatment uses questions indirectly to reframe the client's cognitive frame of reference, establish treatment goals, and initiate client change (Gingerich, de Shazer & Weiner-Davis, 1988). Explanations about the treatment are typically viewed as unnecessary by the SFBT therapist. The avoidance of educational techniques is a distinct departure from typical cognitive-behavioural treatment (Beck et al., 1979). There is no mention of \"cognitive distortions\" and indeed, the symptoms of depression may be implicitly positively refrained by the questions used. J. T. Beck & Strong (1982) demonstrated that positive connotation of depressive symptoms had a robust therapeutic effect, a finding which we also encounter in clinical work. Three types of questions in solution-focused therapy appear to address serendipitously the three negative frames of reference identified by Seligman (1990) as underlying depression. These three are: 1) the exception questions; 2) the outcome questions; and 3) the coping and/or extemalization questions (Berg & Miller, 1992; de Shazer, 1988; Walter & Peller, 1992; White, 1984). While there are other types of questions used by SFBT therapists (such as the scaling questions) these will not be discussed in this article, so that the focus is kept on the correspondence between Seligman's model and the SFBT practices. 6.3 DEVELOPMENT OF THERAPY The sheer diversity of psychotherapy introduces us to the first of many challenges associated with writing its history. Current compendiums list over one hundred recognized theoretical orientations and practical approaches. Different forms of psychotherapy have developed in interconnected ways within particular disciplines or branched from one to another. Thus, 126 CU IDOL SELF LEARNING MATERIAL (SLM)
important strands are not captured by conventional histories dealing with one psyche-related discipline in isolation (Rosner, 2014). Then there is the problem of where to start. We could trace continuities in the practice of psychotherapy back to antiquity. This would take us through the ebb and flow of spiritual healing, the pastoral role of church, the writings of Enlightenment scholars, the counselling practices of Classical Greece, and the (often unacknowledged) influence of non-Western philosophies (Ehrenwald, 1991; Pols, 2018). But delving so far back is open-ended and unwieldy. Moving toward the present calls for a decisive starting point. But as Shamdasani (2017) observed, no such point exists. Modern-day proponents of particular approaches have deepened this uncertainty, with some choosing to emphasize their links with the wisdom of the ancients, while others claim their approach represents a clean break from an “unscientific” past. One thing we can be clear about is that psychotherapy did not commence with Freud. Nor did he coin the term “psychotherapy” or even the label “the talking cure.” But Freud and his immediate precursors did mark the beginning of the modern era, when a set of quasi scientific techniques labelled “psychotherapy” were first deployed. Tracing these precursors and the origin of the term thus offers a pragmatic and instructive point of departure. Just before the turn of the 20th Century, Sigmund Freud introduced psychotherapy to the world. His pioneering ideas were good for the most part, and his technique of “Free Association” and his “Analysis” provided decent results for his patients. He called his therapy Psychoanalysis, and it became popular throughout the Western World. It was the “Model T Ford” of therapies. However, this therapy was only available to the rich as it involved hours and hours of therapy for years on end. In the early 1950’s, an American psychologist, B.F. Skinner showed North Americans that therapy did not need to look at past childhood experiences in order to help those with emotional difficulties. Skinner’s approach was called Behavior Therapy. Its principles were based on how all species (including human beings) learn. In the 1960’s, American psychologists added to Skinner’s techniques and created what we know as Cognitive Behavior Therapy. It is based on what we think about our experiences. This approach is the most commonly used to this day. Like all therapies it has its strengths and weaknesses. During this same period, another approach was being perfected by the German American Dr. Frederick “Fritz” Perls. He called it Gestalt Therapy. Not only did it deal with what we thought about our daily experiences, but also with how we felt about them. It dealt with our total experience (this is where the German word “Gestalt” comes from). 6.4 THERAPY FRAMEWORK Psychodynamic therapy aims to increase a client's awareness of how their past influences their present feelings, thoughts and behaviours. With young children, psychodynamic therapy often takes the form of play therapy. A number of overlapping and distinct cultural literatures evolved out of the civil rights movements of the 1960s. These literatures have made several advances, progressing from the 127 CU IDOL SELF LEARNING MATERIAL (SLM)
call for cultural awareness and acceptance to highlighting the need for cultural competence, the need for understanding of relational therapeutic dynamics, and the need to attend to the complexities involved in treating ethnic minority clients. Recently, the U.S. Surgeon General’s report Mental Health: Culture, Race, and Ethnicity identified several key areas in which culture is likely to have an impact (U.S. DHHS, 2001). The report described the historical context and current status of multiple groups, the prevalence of problems, key cultural influences, and issues affecting diagnosis. It identified high-need populations and discussed the availability, accessibility, and utilization of mental health services. Other authors have also highlighted significant areas in which culture is likely to play a role. For example, D. W. Sue and Sue (2003) underscored the importance of understanding differences in cultural worldviews, socio-political issues, assumptions and biases as barriers to effective treatment, and cross-cultural communication styles. In developing a framework for research, Rogler, Malgady, and Rodriguez (1989) recommended improving cultural understanding along five domains, including understanding (a) cultural factors in the emergence of a problem, (b) help seeking and service utilization, (c) factors that may affect accurate diagnosis, (d) therapeutic and treatment issues, and (e) posttreatment adjustment. This framework is important because it underscores the temporal sequence of problem development in relation to service delivery and highlights areas where culture is likely to play a role. Although understanding cultural influences on mental health is a good first step, professionals who want and need cultural competence are left with little insight about how to implement this understanding into actual improvements in clinical practice. Culturally competent practice guidelines for adapting treatment for diverse clientele are sorely needed. The most widely accepted definition of cultural competency refers to the possession of cultural self-awareness, knowledge, and skills that facilitate delivery of effective services to ethnically and culturally diverse clientele. In describing the complexities of cultural competence, Lo and Fung (2003) added that it is also important to distinguish between generic and specific cultural competencies, or between the knowledge and skill sets needed in any cross-cultural encounter versus those that are necessary to work with a specific ethnocultural group. Two basic aims of cultural competence are to enhance the therapist’s ability to deliver culturally effective clinical services and to broaden their perspective on how to improve the helping relationship. A common but problematic assumption made by health care professionals is that learn ing about the client’s culture will help these professionals become more culturally effective. However, this way of thinking reinforces the problematic assumption that the difficulty of culture is located in the client as the other, rather than in the cultural difference between the client and the provider. Hardy and Laszloffy (1995) stressed the importance of an interactional perspective between the client and the provider, noting that cultural competence requires therapist cultural self-awareness as well as an understanding of the client. They developed a cultural genogram to help clinicians become more aware of their cultural identities. Also emphasizing an interactional perspective, S. Sue, Ivey, and Pedersen (1996) proposed a theory of multicultural counselling and therapy composed of six 128 CU IDOL SELF LEARNING MATERIAL (SLM)
propositions each with multiple corollaries. Abbreviated here, the propositions include (a) multicultural counselling and therapy is a meta-theory of psychotherapy that takes culture into account, (b) both client and therapist identities are formed and embedded within a cultural context and multiple levels of experience, (c) therapist and client identities influence attitudes and self– other relations, (d) therapy outcomes are likely to improve if the therapist uses modalities and defines goals that are consistent with the cultural values and life experiences of the client, (e) helping roles should be defined broadly and multiple resources should be utilized, and (f) a liberation of consciousness and an improved understanding of self– other relations should be a basic goal. These corollaries were developed to help provide a framework for the multicultural counselling movement, which has been labelled the fourth force among therapy movements (Pedersen, 1990). Cultural competence training programs that focus on interactional issues have also been developed. For example, Pedersen (1988, 1997) developed a program that focuses on awareness and understanding of the culture- centred context and on developing and implementing culture-centred skills. Key to understanding interactional perspectives is the ability to identify and address hidden messages in therapy dialogue. Pedersen (2000) proposed a triad training model composed of understanding the verbal exchange between the two parties, including the internal dialogues of the therapist and the client. He emphasized that culturally competent therapists strive to hear the positive and negative messages that their clients are thinking, but not necessarily saying. In addition, a number of books have been written to provide greater instruction on addressing clinical issues relevant to specific populations, including women of diverse identities (Comas-Diaz & Greene, 1994), minority families and children of Color (McGoldrick, Pearce, & Giordana, 1996; Webb, 2001), those with diverse sexual orientations (Perez, DeBord, & Bieschke, 2000), the elderly (Duffy, 1999), and the poor (Acosta, Yamamoto, & Evans, 1982). Despite these advances, there is still no uniform methodology or framework for adapting and modifying treatment interventions for ethnic minority groups or for implementing such adaptations into widespread practice. Rogler, Malgady, Costantino, and Blumenthal (1987) recommended that consumer-oriented practical approaches be taken, such as increasing accessibility to bilingual/bicultural staff, selecting therapy orientations that are congruent with the client’s cultural background, and modifying treatments to fit the needs of the client. However, even in ethnic-specific centres, where clinicians are bilingual and have had some training on cultural sensitivity and awareness, training mechanisms may not have systematically provided specific skills or frameworks for incorporating cultural issues into treatment. Many training programs in cultural competency tend to be general and descriptive in nature, leaving professionals with an increased awareness of important issues but with few practical skills to incorporate into clinical practice Many mental health practitioners already make their own personal modifications to therapy to better meet the needs of diverse clientele. However, these modifications may not be systematic or driven by a clear conceptual framework. Experts of cultural competency have addressed this concern by developing frameworks to guide therapeutic adaptations. For 129 CU IDOL SELF LEARNING MATERIAL (SLM)
example, D. W. Sue (1990) suggested targeting three major domains to improve client– therapist relationships when treating ethnic minorities, including culture bound communication styles, socio-political facets of nonverbal communication, and counselling as a communication style. These recommendations highlight understanding and improving subtleties in communication that may interfere with the therapeutic process. Other psychologists, such as Bernal, Bonilla, and Bellido (1995), created a framework for developing culturally sensitive interventions. They suggested considering eight different dimensions, including language, persons, metaphors, content, concepts, goals, methods, and context, when adapting therapy for culturally diverse clientele. For example, the dimension of persons involves addressing ethnic/racial similarities and differences between the client and the clinician. Issues of content involve cultural knowledge and information about the values, traditions, and customs of the culture. The principle of context involves consideration of changing contexts that might increase risk for acculturative stress problems, disconnect from social supports and networks, and reduced social mobility. This framework has been used to guide adaptations in cognitive– behavioural and interpersonal treatments for depressed Puerto Rican adolescents, and these adapted treatments have been shown to be efficacious in randomized controlled trials (Rossello & Bernal, 1996, 1999) Psychotherapy Adaptation and Modification Framework These frameworks serve as initial foundations from which to understand cultural issues in treatment, develop the psychotherapy adaptation and modification framework (PAMF) to help guide therapeutic adaptation for ESTs. In creating this framework, I reviewed the literature on cultural competency, discussed issues of cultural adaptation with expert therapists, and reflected on my own personal experiences in treating ethnic minorities in community, medical, and school settings. Furthermore, I combined two systems of cultural principles I have developed in my previous work on cultural competency (Hwang, Lin, Cheung, & Wood, in press; Hwang, Myers, Abe- Kim, & Ting, 2006). This work lays the foundation for my current line of research, which focuses on developing and testing the effectiveness of a culturally adapted CBT manual for Chinese Americans. The first framework, the cultural influences on mental health model, was developed to identify salient domains that culture influences (Hwang et al., 2006). Culture is posited to affect different domains including (a) the prevalence of mental illness, (b) etiology of disease, (c) phenomenology of distress, (d) diagnostic and assessment issues, (e) coping styles and help-seeking pathways, and (f) treatment and intervention issues. Because of the multitude of ways in which culture can influence mental health, these domains are not all inclusive, but rather provide a starting point for understanding the most salient ways in which culture influences the development and treatment of psychopathology. For example, cultural differences in the expression of distress (e.g., somatization vs. worry) could influence diagnostic accuracy, which could in turn impact psychologists’ ability to reliably estimate the prevalence of certain psychiatric disorders. What people believe about the causes of their problems (e.g., bodily problems causing depression or depression causing physical health problems) also plays a role in where they seek help (e.g., a primary care or mental health 130 CU IDOL SELF LEARNING MATERIAL (SLM)
facility) and their confidence in the treatment given (e.g., talk therapy is effective or talking about the problem makes it worse). Moreover, how a culture defines mental illness and people’s own self-definitions of having or not having a mental illness can also affect these different domains. The cultural influences on mental health model focuses on highlighting the systematic interrelations of each of these domains and provides target areas for treatment interventions. The second framework is part of a model that incorporates 18 therapeutic principles for understanding and treating Chinese American clients. These principles were initially developed in an effort to modify CBT for Chinese Americans (Hwang et al., in press). The principles fall into three core areas, including general guidelines for adapting CBT to meet the needs of Chinese American clients, strengthening the client–therapist relationship, and understanding Chinese notions of self and mental illness. I have synthesized these frameworks to create the PAMF, which consists of six therapeutic domains and 25 therapeutic principles. The domains include the following: (a) dynamic issues and cultural complexities, (b) orienting clients to psychotherapy and increasing mental health awareness, (c) understanding cultural beliefs about mental illness, its causes, and what constitutes appropriate treatment, (d) improving the client–therapist relationship, (e) understanding cultural differences in the expression and communication of distress, and (f) addressing cultural issues specific to the population. Table 1 lists each domain, the therapeutic principles associated with each domain, and a description that explains the rationale for each modification. I used a practical and consumer- driven approach to help practitioners who want and need cultural competency to make the shift between cultural awareness and clinical application. Broader domains identify general areas that practitioners should think about when modifying their approach for treating their clients. More specific therapeutic principles provide detailed instruction on the types of adaptations that may be important to make for a particular group. Corresponding rationales help the practitioner understand why some of these modifications should be made and how they might be beneficial. This three-tiered approach to presenting cultural adaptations to therapy was developed to make the PAMF more accessible, user friendly, and adaptable for use with other diverse populations. 131 CU IDOL SELF LEARNING MATERIAL (SLM)
6.5 ACCEPTANCE AND COMMITMENT THERAPY- A PRAGMATIC APPROACH TO BEHAVIOUR CHANGE Acceptance and Commitment therapy (ACT) (pronounced as the word ‘act’) is an evidence based psychological intervention, which helps managing a wide range of problems. It is an empirically supported mindfulness based cognitive-behavioural therapy. This therapy based on Relational Frame Theory (RFT), a school of research focusing on human language and cognition. RFT provides an understanding of the power of verbal behaviour and language. ACT is rooted in the pragmatic philosophy of functional contextualism (Hayes, 1993). Functional contextualism explains the role of context in understanding the nature and function of an event. Major Goals of ACT Foster acceptance of unwanted private experiences which are out of personal control Facilitate commitment and action towards living a valued life Increase psychological flexibility: the ability to contact the present moment and the psychological reactions it produces, as a fully conscious human being, and based on the situation, to persist with or change behaviour for valued ends. In other words, ACT is to create a rich, full and meaningful life, while accepting the pain that inevitably goes with it. The Acceptance and Commitment Therapy explained using a hexagon. Six core pathological processes correspond to the six core intervention processes. ACT Model of Psychopathology The six psycho-pathological processes are: Loss of contact with the present moment (preoccupation with a conceptualized past or future) Cognitive fusion Experiential avoidance Self-as-content (Over-identification with a conceptualized self) Remoteness from values Lack of committed action (Impulsive/ineffective/avoidant/‘mindless’ action) Fusion: The client who is approaching the therapist fused with all sorts of negative thoughts, unhelpful evaluations about themselves and others, painful memories from the past. E.g., I am bad, I do not deserve, I will never get better, I am tired etc. Worrying, ruminating etc. are the manifestations of fusion. 132 CU IDOL SELF LEARNING MATERIAL (SLM)
Experiential Avoidance: Experiential avoidance means “attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences even when doing so creates harm in the long-run“(Hayes, Strosahl, Wilson, 1999). Humans are tempted to try avoiding negative thoughts and emotions whenever they occur. In addition, this is a strategy, which can work extremely well in some contexts. For example, not going for a social gathering is a common way of feeling less nervous – that is experiential avoidance. However, it can also interfere with important aspects of life. Examples are putting of important tasks due to the discomfort it causes, not using opportunities to avoid fear of failure, not engaging in social activities because of anxiety etc. However, this is a trap, which always forces the person to move away from what he/she really wants to do. Experiential avoidance can work in the short term, but it does not work in the long term. Fusion and avoidance always go together. When people have depressive thoughts such as “I am not good”, “No one likes me”, “I am a failure”, they also try to get away from such thoughts using other behaviour such as drinking, smoking, over involvement in eating or other addictions. Dominance Of Conceptualized Past Or Future: Humans may spend a lot of time absorbed in thoughts about the past or the future. Instead of being fully conscious of present experience, we may operate on automatic pilot. Fusion and avoidance lead us to a loss of contact with reality experience. It causes thoughts over things that have already happened in the past and fantasize the future, anxious about what is happening next, and, in the meantime, they miss out the life that they have in the present moment. They lost touch with their own psychological world and physical world in the present moment. Lack Of Values Clarity: People often forget their values and directions when they fused with painful thoughts, trying to run away from situations causing discomfort and absorb by concerns about past and future. E.g., depressed clients often lose their connections with the desire of their life and become incapable of contributing to others or being productive. They also neglect their health and well-being. Then the client helped to understand the incongruence between the values and their current behaviour or circumstances. Unworkable Action: Unworkable actions are patterns of behaviour that keeps us away from a life that we really want to live and make our life even more miserable and painful. Often impulsive activities have an adverse effect on the quality of life E.g., excessive involvement in activities such as drinking alcohol, watching TV, eating, procrastination, attempting suicide etc. ACT Model of Therapeutic Interventions 133 CU IDOL SELF LEARNING MATERIAL (SLM)
Before coming to the six core processes of ACT intervention we need to understand a concept called creative hopelessness. In the case of clients who need behaviour change, usually they come to therapist after attempting various techniques to manage the difficulties. In ACT, the therapist helps the client to examine the workability of those strategies. Many of those strategies may seem to be controlling and trying to get away from unwanted feelings and experiences. This initial exploration in this direction helps client to realize the unworkability of those strategies in their context and the necessity of trying another one that could give long-term benefits. In ACT terminology, it known ‘creative hopelessness’. Actually, this is the starting point of creating a space for a new way of dealing with the problem. This state is ‘creative’ as it prepares the person to use entirely new strategies. Diffusion: This is the opposite of cognitive fusion, which we have seen as the first item in the pathological processes. This is about stepping back and noticing thoughts rather than being caught up with the thoughts. The aim of diffusion is to reduce the impact of unhelpful thoughts on us. It helps us to detach from our thoughts and evaluate or assess objectively. This helps us to understand how human language affects our self-concept and thoughts. Acceptance: This is the antidote to experiential avoidance. It means making room for the painful feelings, emotions and experiences instead of fighting or resisting with them or let go of the discomfort. It helps us to live a value-directed life in the midst of pain and suffering. This will allow our feelings to come and go with a kind and open stance without draining us or holding us back. Contacting the present moment (Mindfulness): Mindfulness allows us to being touch with the present moment. This means deliberately bringing our awareness in to physical world around us and to the psychological world within us. Instead of operating on automatic pilot this will help us to be here and now. Mindfulness allows us to engage fully in what we are doing. Self as Context: There are two distinct elements of life: the thinking self and observing self. Thinking self-activates generating thoughts, beliefs, judgments, plans etc. The observing self is aware of whatever we are thinking, felling, planning etc. As we go through our life, there are many changes occur to us such as bodily changes, our attitudes, beliefs etc. The observing self is the same throughout our life, but it observes the changes in us as if it is someone else. The observing self makes us more human, and this is more important for developing self- kindness and self-compassion. Value clarification: Clarifying one’s values is essential for creating a meaningful life. The therapy can start with clarifying the values of the client. This easily achieved through asking questions such as ‘what matters you most in your life?’ What gives life meaning? On the other hand, ‘what do you want to do with your brief lifetime on this planet?’ 134 CU IDOL SELF LEARNING MATERIAL (SLM)
Valued Living Questionnaire (VLQ) (Wilson & Groom, 2002) used to elicit values. This gives an idea about the client how he/she wants to behave in his/her day-to-day life. In ACT, this known as ‘chosen life directions’, also called the ‘compass’ of life. It is important to know the difference between values and goals. Values are ongoing patterns of activity, which cannot be achievable or completed, but goals are achievable and completed. Values have transformational power and are reinforcing. In ACT, the client helped to understand the incongruence between the values and their current behaviour or circumstances. Committed Action: Translating values into congruent actions is the next process in the interventions using ACT. This means helping the client to set realistic goals to fulfil their values or live a life in our chosen direction. Under this section, the client helped to develop SMART (specific, meaningful, adaptive, realistic and time framed) goals. In order to fulfil the values of being a good dad, the person has to take committed action in the direction of his values. ACT also requires a concrete therapeutic relationship or working alliance between the therapist and the client. Advantage of ACT is using a number of metaphors, worksheets and exercises that anyone can easily understand. There is no ACT technique that therapists can use with every client. Even the terminology or nature of questions to elicit avoidance or personal values will be different for each client. Therapists need to be sensitive to the unique presentation and situation of each person they work with. The order of the treatment processes also will vary according to the nature of the problem of the client E.g., In the case of severe emotional problems due to experience of trauma in the past, the strategy diffusion to be used only after doing a lot of work around validating the pain, self- compassion, acceptance etc. Otherwise, the client may think that the therapist has not taken their emotional state seriously and labelled as ‘simple’ or silly’. If the therapists use ACT techniques in their personal life and get convinced of the benefits before trying it to their clients. The more we apply the strategies in our life the better we will be able to use with our clients. This reminds us of the words of Mahatma Gandhi “Be the change that you want to see in the world”. 6.5.1 The Selective Use of Supportive, Re-educative, and Reconstructive Approaches Supportive Therapy: Is to bring the patient to an emotional equilibrium as rapidly as possible, with amelioration of symptoms, so that the patient can function at approximately his or her norm. An effort made to strengthen existing defences as well as to elaborate better “mechanisms of control.” Co-ordinately, one attempts to remove or to reduce detrimental external factors that act as sources of stress. There is no intent to change personality structure, 135 CU IDOL SELF LEARNING MATERIAL (SLM)
although constructive characterological alterations may develop serendipitously when mastery has restored, and successful new adaptations achieved. There are times when supportive therapy is all that is needed to bring about adequate functioning. This is the case where the basic ego structure is essentially sound, having broken down under the impact of extraordinary severe strains that sap the vitality of the individual. A short period of supportive therapy will usually suffice to restore equilibrium. On the opposite end of the pathological scale, those victims so deeply scarred by childhood experiences that the radical surgery of intensive psychotherapy could only increase the disfigurement. The only practical thing we can do for some of these casualties is the topical cosmetic repair of symptom alleviation so that they can live more comfortably in spite of their handicaps. While we do not yet possess the diagnostic tools to assess accurately which patients will benefit most from supportive expedients, some therapists rely on the pragmatic principal of resorting to supportive therapy where measures that are more extensive fail to produce an adequate response. On the other hand, where caseloads are overwhelming, therapists may be inclined to utilize supportive measures as a routine, reassigning patients for educational or reconstructive approaches where results are not satisfactory. Since supportive therapy attempts the achievement of symptom relief or symptom removal, the question presents itself regarding the value of symptomatic cure. Among the most solecistic of legends is the notion that elimination of symptoms is shallow if not worthless. This notion stems from the steam engine model of psychodynamics that conceives of energy in a closed system, bound by symptomatic defences, which when removed, releases new, more dreadful troubles. This is in spite of the fact that physicians from the time of Hippocrates have applied themselves to symptom removal in both organic and functional ailments with little or no baneful consequence. Yet, legends survive from one generation to the next. The presumed dangers of symptom removal are now as threatening to some younger therapists as they were to their teachers. Little proof offered of a causal relationship between the fact of symptom relief or removal and any pathological sequelae. Reeducative: Normative reeducative strategy is at the core of organisational change. R. Chin and K. Benne introduced the strategy as shared power strategy. The objective of this strategy is to expose employees to new values and norms and the need to adopt these new values and norms. Based on rational/ scientific evidence or emotional appeals. This strategy implemented by focusing mainly on system renewal, people in the organisation. Here it is important to employ an educational strategy with learning through experience as its highlight. The strategy also promotes dealing with real problems by using a planned strategy. For this strategy to be successfully implemented the organisation needs to identify a change agent at the same time ensure involvement of top-level administration. This strategy based on the belief that people are social creatures, and cultural norms are core to their group identity. It not only assumes that individuals are rational but gives equal importance to the socio- cultural influences in an organisation. According to this approach, change will occur after the 136 CU IDOL SELF LEARNING MATERIAL (SLM)
employees involved in bringing about or affected by change are able change their older normative orientations to commit to new orientations related to the change to implement in the organisation. Change in this approach is not limited to knowledge, information and intellectual rationales but it also covers attitudes, values, skills and significant relationships. This strategy mainly focuses on group norms, personal values, and common goals. This is much effective compared to imposing change through authority and coercion. By utilising this approach, change becomes part of the organisational culture and thus receives the support of the social forces and group dynamics in an organisation. Changes can successfully implement when it is in trail bike with existing structures, attitudes, values, and norms in an organisation. The approach promotes collaborative working with the employees to identify problems and facilitate solutions. Its objective is to improve problem- solving capacities and mechanisms within a system, and develop new attitudes, values, skills, and norms for interaction amongst employees. The strategy not only promotes organisational change but also encourages participation and develops empowerment amongst the employees. Further teamwork promoted as the manager or the superior needs to work together with the employees in order to implement this strategy. It also results in optimal development and application of creativity and experience of the employees within the organisation. The three main elements of this strategy are attitudes, beliefs and values. Attitudes are feeling and beliefs that determine the way in which employees perceive their environment and behave. It described as modes through which employees express their feelings about the organisation, people in it and its structure, processes etc. Employee attitudes are extremely important in an organisation as they might reflect an underlying problem. If not dealt with at right time a negative attitude towards an organisation or its aspects can lead to development of major problems in an organisation. Positive attitude on the other hand will enhance the overall functioning of an organisation. Attitude plays an extremely important role when it comes to change. Change leads to development of number of insecurities amongst the employees that may lead to development of negative attitude towards change. Thus, before change process is initiated, the management needs to identify the presence of any negative attitude and deal with it. Normative re-educative strategy is once such strategy that directly focuses on the employee attitude and this can be termed as key to its successful long-term effects in an organisation. Beliefs described as certainty in the truth of a proposition. They base on experience, perception, communication reasoning etc. In an organisational set up beliefs of an employee are extremely important. The change process affects by the beliefs of employees about the change process. Thus, beliefs focuses on before the change process initiates. Values described, as an individual understands of what is wrong and what is right, good or bad, preferable or not preferable. Values develop early in life and greatly determine an individuals’ behaviour. They are also extremely difficult to change. Values of employees are of extreme importance in an organisation as they determine the motivational level, behaviour and attitudes of an employee. In order to enhance the process of 137 CU IDOL SELF LEARNING MATERIAL (SLM)
change in an organisation, the management needs to examine values of its employees. Though the strategy is time, consuming it is beneficial as it is long lasting and results in internalised change. Despite of these benefits, managers hesitate in using these strategies due to fear of losing control or shifting focus from organisational goals. Managers do play an important role in implementing this strategy, as their willingness to share power and interpersonal skills in terms of interacting, communicating and promoting participation is necessary for the implementation of the strategy to be successful. Reconstructive Approach, on the other hand, represents long-term development assistance, which could help people in the affected areas to rebuild their lives and meet their present and future needs. It considers reduction of future disaster risks. Rehabilitation may not necessarily restore the damaged structures and resources in their previous form or location. It may include the replacement of temporary arrangements established as part of emergency response or the upgradation of infrastructure and systems from pre-disaster status. An ultimate goal of psychotherapy is to reduce the force of irrational impulses and strivings and bring them under control, to increase the repertoire of defences and make them more flexible, and to lessen the severity of the conscience, altering value systems to enable the patients to adapt to reality and their inner needs. These aims are formidable because the various components of personality so forged into a conditioned system as to be almost impervious to outside influence. Homeostatic balances maintained to safeguard neurotic adjustment. Resistances block attempts to interfere with coping mechanisms and defences. To cut into the neurotic system in order to modify the structure of personality and to expand the potentials of the individual in all required dimensions are difficult and frequently unrewarding undertakings. Reconstructive psychotherapy is aimed at these objectives. Reconstructive psychotherapy is more or less traditionally rooted in the theoretical soil of a genetic-dynamic model of personality. This purports that past inimical experiences and conditionings have retarded the normal psychosocial growth process and are now promoting in the individual immature strivings and emotions that come into conflict with reality, on the one hand, and, on the other, with the person's own incorporated system of ideals and standards. Resultants are tensions, catastrophic feelings of helplessness, and expectations of injury that in turn invoke protective devices, most common of which is repression, a sealing- off process that blankets offending impulses, attitudes, and memories from awareness. However noble the attempt, repression of unacceptable strivings rarely succeeds in annihilating them, for their expression sought, from time to time, by powerful motivations of impelling need. The filtering of offensive impulses into conscious life promotes bouts of anxiety and whips up the defences of the ego, which, while ameliorating anxiety, may be destructive of adjustment. Additionally, repressed strivings may express themselves as symptoms. The direct or disguised operations of repudiated strivings, and the defences that mobilizes against them, promote attitudes and values that disorganize interpersonal relationships. Reactions develop that are opposed to judgment and common sense. While 138 CU IDOL SELF LEARNING MATERIAL (SLM)
individuals may assume they are acting like adults, emotionally they are behaving like children, projecting into their present life the same kinds of fears, misinterpretations, and expectations of hurt that confronted them in their early years, as if time nor reality considerations have altered materially the patterns learned in the past. As long as individuals protect themselves from fancied hurt by circumscribing their activities, they may manage to get along; but should they venture beyond their habitual zone of safety, the precarious balances they have erected will be upset. Were we to treat a patient according to this hypothesis, we would consider that his or her symptoms were manifestations of a general collapse in adaptation, and our therapeutic effort would be directed toward correcting disorganizing drives that were destructive to the patient’s total adjustment. The objective, therefore, expands toward personality growth and maturation, toward heightened assertiveness and greater self-esteem, and toward more harmonious interpersonal relationships. In quest of these objectives, we would strive for a strengthening of the patient’s ego, which, involved hitherto in warding off anxiety through the marshalling of neurotic defences, has been unable to attend to the individual’s essential needs. Instrumentalities toward ego strengthening are, first, greater self-understanding and, second, the living through with a new kind of authority, as vested in the therapist, of experiences that rectify residual distortions in attitudes, feelings, values, and behaviour. Increasingly, psychotherapists, directing their efforts toward reconstructive changes, have drawn for inspiration on psychoanalytic theories and methods, although some have tended to label the ideas and tactics that they employ with tags that mask their origin. Accordingly, during the past half century, many ingredients of psychoanalytic thinking have permeated into the very fibre of American psychiatry and psychology and have fashioned a good number of its trends. In turn, psychoanalysis has influenced by contemporary developments in the psychiatric and psychological fields. It has consequently lost many of its esoteric qualities while acquiring a firmer anchoring in scientific experiment. Reconstructive psychotherapy distinguishes from supportive and reeducative therapy by the degree and quality of insight mobilized. In supportive therapy, efforts at insight are minimal. In reeducative therapy, they are more extensive, but they focuses on relatively conscious problems. The traditional objective in reconstructive therapy is to bring the individual to an awareness of crucial unconscious conflicts and their derivatives. Reconstructive psychotherapy strives not only to bring about a restoration of the individual to effective life functioning, through the resolution of disabling symptoms and disturbed interpersonal relationships, but also to promote maturation of emotional development with the creation of new adaptive potentialities. The methods employed in bringing unconscious aspects to awareness originally developed and described by Sigmund Freud, who had the happy faculty of illuminating the most obscure concepts with a refreshing verbal simplicity. Included are such techniques as free association, dream interpretation, the analysis of the evolving transference, the use of strategically timed interpretations, and dealing with resistances to the 139 CU IDOL SELF LEARNING MATERIAL (SLM)
content of unconscious material. An understanding of the genetic determinants of the individual’s personality and of the relationship of these determinants to the operative present- day character structure are component aspects of the therapeutic process. To do reconstructive therapy, the therapist must have received special training, which ideally includes a personal psychoanalysis and the successful treatment of a number of patients under the supervision of an experienced psychoanalyst. 6.5.2 Restoration of Mastery through Supportive Symptom Relief or Removal In reviewing his history, it appears that the patient has up to the onset of his work problem, made a satisfactory adjustment. He has a good home life; he enjoys his children and loves his wife; he is an excellent provider who conscientiously performs his work duties; he belongs to a number of social organizations; and he fraternizes with the usual quota of friends. According to this record, it would seem reasonable to scale our goals toward bringing him back to where he was prior to his illness. We might calculate that once his symptoms eliminated or under control, he would have the best chance of recovering his equilibrium. With this in mind, we might attack his symptoms along several different lines. First, we may attempt to subdue them by the administration of medicaments, such as antacids for hyperacidity, tonics for anorexia, hypnotics for insomnia, and Xanax for anxiety and depression. If his depression is intense, we might consider a tricyclic antidepressant drug. The patient trained in progressive muscular relaxation in an attempt to relieve his taut muscular state. He may be reassured to the effect that his problem is irremediable and persuaded to utilize his will power to get well. He removed from his environmental situation. By absenting himself from existing areas of stress, he may experience an assuaging of tension and other symptoms. Instead of these efforts, attention focused on the patient’s work difficulty, reasoning as follows: “Here is a man who is involved in a work situation that is too difficult for him to handle. Competitiveness demanded by his present job is not for one with his kind of personality. Prior to the unhappy job change, he was getting along adequately. The treatment objective, then, is for him to obtain another position to which he will be able to adjust satisfactorily.” Assuming that his vocational situation is the primary source of his difficulty, the patient to appreciate that he cannot and should not adjust to extreme competitive stresses, and he may be encouraged to return to his old position or to seek a type of work that avoids competition. Where the patient is willing to give up his present job and to secure a less burdensome one, he may manage to regain his customary equilibrium. Environmental difficulties may exist in addition to the work problem that upset the patient, rendering it additionally impossible for him to make an adequate adjustment. For example, were our patient to suffer from a marital or family difficulty in conjunction with his work problem, our focus in therapy would of necessity expand utilizing marital or family therapy. These measures are obviously all aimed at symptom relief or removal. The philosophy behind such approaches is that symptoms impair the functional efficiency of the psyche as if a 140 CU IDOL SELF LEARNING MATERIAL (SLM)
diseased gall bladder upsets the entire digestive system. Suggestion, persuasion, “thought control,” progressive relaxation, purposeful forgetting, the plunging of the self into extroverted activities, and behavioural techniques are among the devices aimed at the symptom, as if it were a foreign body whose presence obstructed an otherwise intact psychic mechanism. In some cases, this type of therapy may score substantial successes. Indeed, formal psychotherapy may not even be needed in certain personality types who are able to forestall emotional collapse by practicing such devices as “riding their symptoms,” substituting innocuous for painful thoughts, engaging in distracting pursuit of social activities, and observing a punctilious performance of ritual and prayer. In justification of these methods, that many persons are not motivated to accept treatment that is more intensive. In these cases, the mastery of symptoms helps individuals gain freedom from excruciating distress and sometimes permits them to order their lives in a more fulfilling way. One must not overestimate what accomplishes. While the manipulation of the patient’s environment toward alleviation or removal of stressful circumstances. Alternatively, the employment of other supporting measures might be helpful in some cases, in other results would be singularly barren, especially where the individual victimized by inner conflicts that create these symptoms, projects onto the environment sustaining the family and environmental distortions about which he or she complains. Results are poor also when the environmental difficulty has overwhelmed the individual with a substantial shattering of present defences. Here, infantile defences may regressively be revived that cripple the patient’s adaptive resources to a point where, even though the environmental disturbance has abated, the patient burdened with continuing problems. We may compare a situation with that of a man suffering from a minor heart ailment that does not incapacitate him so long as no great strain imposed on his circulation. Should a severe shock or catastrophic happening occur, or should he engage in physical work that is beyond his endurance, the resources of the heart may fail, producing cardiac damage with symptoms of circulatory failure that remain long after the initiating stress has disappeared. The same applies to a personality disorder around which the individual has managed to organize his or her life. When circumstances remove erected safeguards and the individual propels into a situation he or she cannot handle, severe disorganization may result that persists from this point on. Environmental adjustment may also fail because patients feel tied to their life situation no matter how inimical they may be, considering it an inevitable eventuality they have no right to challenge, let alone change. The individual to sources outside of the self usually credits any tension and anxiety that accompany this acceptance. 6.5.3 Modification of Disturbed Attitudes through Reeducative Therapy An investigation may disclose that our patient’s inability to endure competition at his place of work may not be due so much to an environmental peculiarity as it is to the fact that unique ideas and attitudes possessed by the patient make competition an inacceptable or dangerous circumstance. When we examine the exact nature of his disturbed attitudes, we may find that 141 CU IDOL SELF LEARNING MATERIAL (SLM)
the patient victimized by a tangle of contradictory character trends that inspire personal insecurity, promote devaluated self-esteem, and impair relationships with people. For example, we may observe that a basic character trend is that of dependency, which operates insidiously, causing the patient to ally himself with some other person who is a symbol of strength and omniscience. The patient relates to this person as if the latter were a powerful and providing parental agency. Accordingly, the individual may assume a passive role, exhibiting little spontaneity and initiative, anticipating that these needs and demands will automatically be satisfied. Competition poses a threat to the dependency need, for it puts the responsibility on his own shoulders, which he believes to be too fragile to bear the burden of dutiful pressures. Other character trends may exist that both reinforce and oppose his dependency. While he has managed to keep a tenuous emotional balance up to the time of the present crisis, the alteration of his vocational situation has disrupted his equilibrium, threatening his sense of mastery and precipitating catastrophic fears and anticipations of disaster. He may be aware of how dependent he is and may even resent this dependency as opposed to his best interests; yet security is so bound to this trend that he may be unable to subdue its operation. When we inquire further into the circumstances underlying the presumably good adjustment prior to the outbreak of his illness, we find that the patient’s security maintained by the satisfaction of his dependency. So long as this has been gratified, he has been able to get along splendidly. Ungratified, he has been riddled with disquieting fears and threatened with an ill-defined sense of restlessness. Investigating the conditions prevailing at the onset of the patient’s illness, we discover that for some time prior to the onset, the wife has been withdrawing her attention from the patient and transferring it to her brother and his wife who have, because of financial pressures, moved into the patient’s home. As her interest increasingly diverted from the patient, his feelings of insecurity and resentment expanded. The more importunate his demands, the less she responded, until finally he reacted like an abandoned child in a rejecting world. His helplessness and fears of aggression mounted, until the very act of going to work constituted a challenge that taxed his capacities. Promotion to a more responsible position was the last straw that precipitated a breakdown in adaptation. Because of this discovery, we may attempt as a goal to inculcate in the patient some awareness of his dependency as well as of other disorganizing attitudes and strivings. The eventual object here is the retraining of reaction patterns. Thus, we might try to bring our patient to an understanding of the attitudes and designs that he habitually exploits, and we would demonstrate to him which of these facilitate and which obstruct his adjustment. Next, we would help him to apply this knowledge toward modifying or changing his behaviour. We would also evaluate his assets and his liabilities to see how much he had minimized the former and exaggerated the latter. We may attempt to shortcut the therapeutic process by behavioural desensitization slowly exposing the patient to increments of anxiety associated with his job responsibilities, or we may employ assertive training. The mastery of graded tasks, both in fantasy and in reality, 142 CU IDOL SELF LEARNING MATERIAL (SLM)
abetted by positive reinforcements from the therapist, may enable him to overcome the imagined liabilities of competitiveness and to brace himself to accept hardier burdens. In the course of strengthening his adaptive reserves, with or without the guidance of the therapist, he may begin to realize the depth of his dependency. He may become cognizant of how compliant he is to authority, overestimating the virtues of others to the minimization of his own abilities and capacities. He may recognize that his fear of competition is actually associated with anticipating hostilities from people or with the belief that in pitting himself against others he would come out second best, thus exposing himself to ridicule. He may discover also that he harbours ambitions that are totally beyond possibilities of fulfilment, contributing to his sense of defeat. Cognitive therapy may help rectify faulty attitudes and self-statements. The patient would probably be surprised to learn that his character patterns regarded as problems, since he has accepted them as normal for himself. As soon as he realizes that his patterns are responsible for much of his turmoil, he may supply with a valid motivation to alter his scheme of life. While this motivation in itself would not be enough to produce the desired change, his patterns constituting the only routes that he knows to security and self-esteem, it might help him to approach his problems from a different perspective. Faced with his usual difficulties, the patient would as a rude, be unable at first to give up his destructive drives. Knowledge that frustration or pain was inevitable to their pursuit would not be enough to get him to relinquish whatever gratifications followed their exploitation. However, even the mere cognizance that his attitudes were responsible for his plight would be healthier from a therapeutic viewpoint than the conviction, existing previously, that sources of misery lay outside of himself. Eventually, when he realized that his suffering did not compensate for the dubious gratifications accruing from indulgence of immature drives and when he understood that his reactions interfered with important life goals, the patient might begin experimenting with congruous ways of relating. Once convinced that creative attitudes were possible, a long period of experiment and training would be necessary before habitual values abandoned. Generally, habits that have persisted over a long time do not vanish within a few weeks or a few months. In spite of good resolutions, automatic responses operate in line with established routines. Struggle is inevitable until control win over old patterns, and new ones take their place 6.5.4 Personality Growth and Maturity through Reconstructive Therapy The most ambitious objective we could achieve in therapy, and the most difficult to achieve, would be a replacement of neurotic character strivings with those, which will enable the person to develop new potentials toward self-actualization. This objective advantageously reached through elimination of anxieties and fears that were rooted in experiences and conditionings. Important also would be the development of ego strengths to a point where they could cope realistically with inner strivings and environmental pressures. The individual would evolve into a free agent with the willingness to make independent decisions and to take the consequences of his or her acts. There would be an adaptive choice of ends and 143 CU IDOL SELF LEARNING MATERIAL (SLM)
means and an ability to act without undue restraint from others. Capacities to plan his or her life and to develop goals and ideals in harmony with the disciplines of society would be vital. A sense of inner freedom, independence, assertiveness, and self-reliance would, furthermore, add to the dimensions of a well-balanced personality. To achieve these objectives in our patient with the work difficulty, it would be necessary to eliminate the source of his problem rather than only to control its effects. This would necessitate an understanding of the roots of his disorder with resolution of factors that continue to sponsor regressive defences. We would strive to expand our patient’s sense of self so that he might outgrow the need to fasten himself to a parental figure for purposes of emotional support. The focus of our treatment would be the therapeutic relationship into which the patient would project his most intense and unconscious impulses and conflicts. Were we to treat our patient with the work problem according to these principles we would become involved in a more or less extensive therapeutic procedure that would have to go beyond the mere correction of his work difficulty. Indeed, we would consider the vocational disorder as but one aspect of the problem, and our therapeutic effort directed toward mediating disorganizing drives that issued from excessive dependency and a devalued self- image and that were destructive to his total adjustment. The patient, by becoming aware during therapy of contradictory forces within him would gradually realize that he was harbouring attitudes that were a carry-over of early conditionings. The most powerful happening leading to such awareness would be transference to the therapist toward whom he would express and live through vital early formative experiences. Our exploratory process would take the patient back to the genetic origins of his difficulty. For instance, it might reveal the patient’s mother as a woman who had prevented him from achieving that type of independent assertiveness that enables a child to resolve his dependent ties. It would demonstrate how the mother’s own neurotic needs sponsored a cloying overprotectiveness that kept the patient infantilized and helpless. It would bring out how his efforts at aggressive defiance met with uncompromising harshness, until he gave up in his attempts at independence and shielded himself by complying with his mother’s demands. It might uncover passive wishes, fears of violence in the assumption of a desired masculine role, and a host of other unconscious conflicts that engendered by his early experiences. It would finally expose his infantile impulses as living on in his adult life, transferring themselves to those with whom the patient became intimately involved. His wife would reveal as a figure toward whom the patient reacted as if she were a reincarnation of his mother. Partly because of her own impulses and partly because the patient had manipulated her into a parental role, the wife might be shown as having responded by mothering him. In this protective atmosphere, the patient had made a tolerable adaptation even while he repressed desires for freedom and growth. Interpreting the wife’s withdrawal as rejection, the patient had reacted with intense hostility. This he needed to smother for fear of losing every vestige of his wife’s affection. His increasing helplessness soon reached an intensity where he could no longer carry on. At this point, he faced with a greater work challenge in the form of 144 CU IDOL SELF LEARNING MATERIAL (SLM)
added responsibility and continuing at work meant coping with further stress. The patient reacted to this threat, as a child would react— by screaming for help. Reconstructive psychotherapy would bring the patient to an awareness of these facts challenging him to stand up to the drives sponsored by his past. The taming of irrational impulses, the expansion of the repertory of adaptive defences toward greater flexibility and balance, and the reduction of the severity of the conscience with a more wholesome adjustment to inner promptings and demands are ambitious objectives. This is the complex task of reconstructive psychotherapy, which, implemented by a trained and skilled therapist, offers the individual the greatest opportunities for constructive personality growth. However, whether it can be achieved, or whether we might have to contend with the more partial goals described under supportive and reeducative approaches, will be adjudicated by the patient’s readiness and capacities for change, which most advantageously will be influenced toward a constructive end by a knowledgeable and empathic therapist. 6.6 CLINICAL UTILITY/ APPLICATION OF PSYCHOTHERAPY Medical ailments and psychological processes are inextricably linked, with significant shared variance in etiological, physical, and behavioural manifestations. Cardiac problems, behavioural health struggles (e.g., smoking, appetitive and addictive control problems), psychoneuroimmunology illnesses (e.g., autoimmune disorders), and “classic” psychological conditions (e.g., depression, anxiety) present with oft-complex psychophysiological constellations. Historical bifurcated distinctions between constitutional and psychological determinants have now been relegated to the realm of lore, with all but a marginalized handful of health care professionals fully acknowledging the mutually facilitative processes of somatic and psychological conditions. Despite the professional and, indeed, growing public awareness of the potentials of psychotherapeutic treatments for many health conditions (Kendall-Tackett, 2009; Woltmann et al., 2012), along with evidence suggesting the significant prevalence of primary care patients presenting with concurrent mental health conditions (Arbus et al., 2014; Azrin, 2014; Olfson, Kroenke, Wang, & Blanco, 2014; Petterson, Miller, Payne-Murphy, & Phillips, 2014; Stein et al., 2004), there is still a considerable absence of ill people seeking mental health treatment. Many individuals instead opt to seek “pure” medical-based assistance. Whether the reason for the underutilization of psychological services is anchored in stigma, lack of familiarity with the breadth of conditions amendable to psychotherapy, compromised access to mental health services, and/or greater familiarity with medical providers, what is unquestionable is that there is a large percentage of people who would benefit from mental health services but are never seen by a psychologist Integrated primary care (IPC; also referred to as behavioural health care or collaborative care)—the coalescence of mental health and medical services, often consisting of cotreating patients, in addition to collaborations with mental health practitioners located in either an independent practice or medical setting— demonstrates a successful bridge by which to overcome the formidable gap in health care services. Behavioural health consultants 145 CU IDOL SELF LEARNING MATERIAL (SLM)
(BHC) differ from traditional psychotherapists, commonly referred to as mental health specialty care therapists in the IPC literatures, in several distinct ways. A BHC’s work can consist of seeing patients in non-traditional settings, such as medical examining rooms, often for only a brief session (10 min or less), and frequently with time-limited treatment durations. A behavioural health consultant may see dozens of patients in a single day (often in a triage format), have less restrictive confidentiality parameters, be more symptom specific in their interventional foci, and may co-examine/ treat with medical providers (for review, see Breen Ruddy, Borrese, & Gunn, 2008). Behavioural health clinicians are not restricted to offering treatment at medical sites, with a large number of such psychotherapists working in collaboration with medical providers and seeing patients in an independent practice setting. Although the academic study of integrated primary care is only still in the embryonic stages, the extant evidence is quite promising, with research suggesting that IPC treatment outcomes are as good or superior to specialty treatment in addressing certain mental health issues (Bartels et al., 2004; Krahn et al., 2006) as well as being cost-effective (Cummings, O’Donohue, & Cummings, 2009; Domino et al., 2008; Katon, Roy-Byrne, Russo, & Cowley, 2002; Woltmann et al., 2012). Perhaps unsurprisingly, the main psychotherapeutic interventional modalities in such environments are shorter term, solution focused approaches. Given the symptom-specific nature of IPC, motivational interviewing, cognitive-behavioural approaches, and related stress-reduction models have found a secure place within this setting (Robinson & Reiter, 2007). Conspicuously absent from much of the mainstream primary care literature are psychoanalytic treatments. Although several psychodynamic clinicians have tested the waters in this domain (see Balint & Shelton, 2002; Covino, 2008; Kent & Blumenfield, 2011; Lichtman, 2010; Mollen, 2001; Moore, 2011; Stern, 1999; Wain & Gabriel, 2007 for work exploring the psychodynamic conceptualizations and treatments of medical conditions), a robust linkage has yet to be achieved. This may not seem shocking, even to (or especially with) psychoanalysts given the leaning toward longer term treatment coupled with the emphasis on the clearly explicated therapeutic parameters of psychodynamic psychotherapy and psychoanalysis proper. As such, the paucity of scholarly work applying analytic interventions in settings outside the traditional consulting room may perpetuate the belief in both analytic and nonanalytic circles that such an approach may not be a good fit within primary care. Davis (2009) made a strong case for the marriage between psychoanalytic treatments and medical settings. Articulating the benefits of psychodynamic therapists who consider such a professional expansion, Davis proposed that key factors for success include clinicians’ prompt responsiveness to patients and physicians, an appreciation of the value of “mere” symptom reduction, and for psychoanalytic psychologists to be more inclusive in treating the range of patients complete with various comorbid pathologies. This last point is contrary the traditionally narrow inclusion criteria by which to identify prospective patients deemed to be analysable, possessing the capacity for significant insight, or willingness to commit to lengthier treatment durations. Despite Davis’s (2009) excellent overview of the practicalities of including psychodynamic treatments in integrated care work, 146 CU IDOL SELF LEARNING MATERIAL (SLM)
such partnerships have been slow to develop. As such, this article further explores the applicability of psychodynamic treatment techniques to primary care. First, I review a well- used primary care assessment and intervention approach, followed by specific psychoanalytic views that are complementary to shorter term, symptom-specific pathologies. Next, I integrate such concepts into a regularly used primary care assessment and intervention paradigm. This is followed by a discussion of the relevance and usefulness of a psychoanalytic framework within primary care settings. Specifically, this article aims to illustrate how a psychodynamic assessment and case formulation has the potential for significant understanding of the meaning of symptoms, thus providing an avenue for treating certain patients using a psychoanalytically oriented approach, a modality not commonly associated with primary care work but capable of offering productive treatment outcomes. 6.7 STRENGTHS OF PYSCHOTHERAPY Help with Depression Depression is one of the most common mental health conditions in the world. It is more than sadness over a setback or a period of mourning after losing a loved one. It is chronic misery that hinders one’s quality of life. Depression often involves sleep problems, appetite changes, and feelings of guilt or apathy. Treatment can help individuals with these symptoms. Psychotherapy treatment for depression relies on trust and emotional support. An effective therapist provides people a comfortable, private setting to heal. Together, they examine the causes and potential solutions to their concerns. Therapists help depressed individuals build new ways of thinking and reacting. Therapy can allow people to return to the loved ones and activities that they care about most. Here are some types of depression that professionals often treat: Major Depressive Disorder has symptoms severe enough to impact daily life. It is the most commonly diagnosed form of depression. Seasonal Affective Disorder affects individuals during the colder months of the year. Dysthymia, also called persistent depressive disorder, lasts for at least two years. Its symptoms are milder than those of major depressive disorder. Depression is one of the most common mental health conditions in the world. It is more than sadness over a setback or a period of mourning after losing a loved one. It is chronic misery that hinders one’s quality of life. Depression often involves sleep problems, appetite changes, and feelings of guilt or apathy. Treatment can help individuals with these symptoms. Psychotherapy treatment for depression relies on trust and emotional support. An effective therapist provides people a comfortable, 147 CU IDOL SELF LEARNING MATERIAL (SLM)
private setting to heal. Together, they examine the causes and potential solutions to their concerns. Therapists help depressed individuals build new ways of thinking and reacting. Therapy can allow people to return to the loved ones and activities that they care about most. i. Major Depressive Disorder has symptoms severe enough to impact daily life. It is the most commonly diagnosed form of depression. ii. Seasonal Affective Disorder affects individuals during the colder months of the year. iii. Dysthymia, also called persistent depressive disorder, lasts for at least two years. Its symptoms are milder than those of major depressive disorder. iv. Generalized Anxiety is characterized by constant, intense anxiety. The worries often seem disproportionate to the concern. v. Social Anxiety involves high levels of stress within social settings. It can deter relationships and encourage isolation. vi. Phobias are unusual and intense fears of a setting, situation, or object. People with phobias go out of their way to avoid their triggers. vii. Selective Mutism is a social phobia most commonly seen with children. Children with selective mutism have the ability to speak. However, they find talking difficult in social situations outside the home. Help with Obsessions / Compulsions Obsessions are persistent, unwanted thoughts. Usually, obsessions are fixated on a particular topic or goal. Compulsions are repeated, irrational behaviors that individuals feel they must do. People often perform compulsions to relieve the stress caused by their obsessions. A mental health professional helps people with these conditions objectively examine their behaviors. They reveal an individual’s negative thought patterns and offer productive alternatives to the compulsions. With help, individuals can break the cycle of their distress. i. Obsessive Compulsive Disorder (OCD) involves repetitive rituals. Individuals with OCD experience intense anxiety if they do not perform these rituals. ii. Body dysmorphia causes individuals to fixate on perceived flaws in their physical appearance. iii. Hoarding involves collecting a large amount of objects. The clutter takes up disproportionate space in the home and affects one’s quality of life. iv. Trichotillomania compels people to pull out their own hair. v. Kleptomania refers to the compulsion to steal. Help with Relationships Psychotherapy can also help individuals improve their relationships. Mental health professionals focus on helping people open lines of communication with each other. People use this treatment to gain perspective on relationship problems that arise. They can also use therapy preventatively when they know trouble is on the horizon. 148 CU IDOL SELF LEARNING MATERIAL (SLM)
i. Family Therapy can involve both couples and children. Its general aim is to improve nurturing relationships. ii. Marriage Counselling is focuses on spousal relationship between two partners. Its goal is to resolve conflict and strengthen a couple’s bond. 6.8 LIMITATIONS OF PSYCHOTHERAPY It usually takes longer than CBT, sometimes lasting for several years. Therapy sessions are unstructured, although for some people, this might be a benefit, which means a therapy session could be spent talking about things that don’t immediately address your anxiety. Some people are uncomfortable talking about their history or past problems, which can delay any progress. Strategies can seem superficial, failing to address the \"real\" problem. Some people feel they are being talked out of emotions and are expected to use logic too often. 6.9 SUMMARY Psychotherapy is a complicated process and almost 100 years have passed since the use of systematic therapeutic approach. Psychotherapy can help one to gain better understanding of his/her condition or situation, identify and change behaviours or thoughts that negatively affect one’s life, understand relationships and experiences in a better way and develop self-awareness. Thus, in this unit we discussed about the concept of psychotherapy with the help of its definition and aim. We further focused on various schools of psychotherapy like Psychodynamic Therapy, Behaviour Therapy, Humanistic psychotherapy, Existential Psychotherapy, Gestalt therapy and Interpersonal Therapy. We also deal with various phases of psychotherapy and discussed the modalities of psychotherapy like individual therapy, group therapy, family therapy, couple’s therapy and child therapy. We also discussed about ethics in psychotherapy and factors that can influence psychotherapy. Psychoanalysis is a form of psychotherapy focuses on helping individuals gain insight into their hidden inner conflicts and repressed wishes. ACT is an effective alternative treatment option for many behavioural modifications. This therapy helps clients increase their social functioning and quality of life. Patients with psychosocial problems engage in a range of avoidance behaviours without understanding the fact that they only give short-term benefits. Firstly, pragmatism is deeply pluralist, recognising the validity of a variety of interests, perspectives, and forms of knowledge. Being anti-essentialist and anti- foundationalist, pragmatists are suspicious of any effort to privilege a single point of view. As we have argued, RCTs provide crucial information about the relative 149 CU IDOL SELF LEARNING MATERIAL (SLM)
efficacy of specific interventions. This value in no way undermines the position that ethnographic case studies provide rich understandings of the social dynamics of a community health intervention, or that action research develops sophisticated practical knowledge of social change processes. The pragmatist position is that these methods are not in competition with each other, because each serves a different purpose. Secondly, pragmatism’s pluralism does not result in epistemological or moral relativism. Viewing knowledge as a tool that brings us into a more or less satisfactory relation with the world, knowledge evaluated for whether it works for us in relation to a particular goal or interest. Human interests, from a realist point of view, considered to taint knowledge, making it somehow less true. From a pragmatist point of view, human interests are not the enemy of productive inquiry but the key to making our inquiry productive and useful, providing the criteria against which knowledge judged. Making moral choices among these interests, is a social and political activity, which should include critical assessment of the interests served. Thirdly, pragmatism is a thoroughly action-focused perspective. Believing that the grounding for our knowledge is in concrete human activity, pragmatists do not accept solely intellectual arguments about concepts dissociated from their practical base. If the ideas are worth having and worth discussing, pragmatists argue, they must make a concrete difference for action (Peirce, 1878). The most stringent test of ideas is whether they work in practice, and so pragmatist health research would prioritise the creation and evaluation of workable and useful intervention programmes. 6.10 KEYWORDS Exigency means by which an individual determines and assesses his or her limitations in the face of biological, physiological, social, or environmental actualities or exigencies. It enables the individual to distinguish between self and nonself and between fantasy and real life. Solution-focused brief therapy (SFBT) places focus on a person's present and future circumstances and goals rather than past experiences. In this goal-oriented therapy, the symptoms or issues bringing a person to therapy are typically not targeted. Pathology refers to enduring patterns of cognition, emotion, and behavior that negatively affect a person's adaptation. In psychiatry and clinical psychology, it is characterized by adaptive inflexibility, vicious cycles of maladaptive behavior, and emotional instability under stress. Rehabilitation The process of helping a person who has suffered an illness or injury restore lost skills and so regain maximum self-sufficiency. For example, rehabilitation work after a stroke may help the patient walk and speak clearly again. 150 CU IDOL SELF LEARNING MATERIAL (SLM)
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