Counseling, Psychotherapy

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  1. 1. May 27, 2015 Demetrios Peratsakis, LPC
  2. 2. AGENDA I. Introductory Comments: The Role of the Therapist, Contracting and the Presenting Problem II. How Tos of ordering Directives and Tasks III. Demonstration (the importance of watching others work) a) Empty Chair b) Guided Imagery c) Early Recollections (time permitting)
  3. 3. 1. Autonomy is an Illusion Man is a social being. His problems ---and therefore the solutions to them, are entirely relational. Look to how others, real or imagined, living or dead, participate in sustaining the problem (s) 2. Behavior is Purposive We behave in such a way as to elicit a particular response in others. That response reaffirms our beliefs about who we are and how we need to behave in order to belong with others. Look to re-invent the Self through how one thinks about the world and themselves in relation to others (Personhood); reconcile cut-offs; increase social skill competencies and meaningful belonging 3. Symptoms are Remedies that have become Problems Strategies and solutions for adapting to change determine the development or absence of symptoms. Problems organize behavior and interaction, giving them functional value and power. Look to change the symptom to change the structure to change the system; and vice versa 3 Lesson # 1 A good therapist is an Anthropologist, one who studies humankind and the culture within which individual behavior must be understood Man is the only creature who refuses to be what he is - Albert Camus
  4. 4. Lesson # 2 A good therapist is willing to immerse themselves in the despair of another persons suffering, to be one with them in the desolation of their fear, their shame, or their rage . The great obstacle to this intimacy, is ones own terror of being swallowed up or blown away. A therapist must be willing to give up control, in order to acquire power.
  5. 5. Lesson # 3 A good therapist learns how to See, not simply to look Seeing is the insight that occurs when one transcends their own belief about a symptom or behavior and apprehends the purpose that it serves, how it reaffirms identity, mediates distress, and controls and organizes behavior Suicide can be an act of revenge, Depression a means of enslaving others, Anorexia a form of self-sacrifice
  6. 6. Vignette: As the fathers drinking worsened, he became more combative and abusive while mom grew progressively more listless and depressed. When the maternal grandmother mother passed, mom became even more depressed and their only child, a 17 year old daughter, began having serious problems in school and displaying risk-taking and self-harm behaviors. This year, she received a DWI and after a final break up with her boyfriend her behavior became more problematic, resulting in frequent hospitalizations and suicide attempts. The parents have rallied to support her, growing more concerned after suspecting her of vomiting after meals in order to keep her weight down. After a recent hospitalization from a failed attempt to over-dose the father took a more active role and become more involved in his daughters treatment, even speaking of attending AA. The hospital diagnosed her with a borderline personality disorder and placed her on medication. Upon discharge, she was brought into treatment by the parents. Question:
  7. 7. 7 Lesson # 4 A good therapist takes charge and directs change 1. Therapy is the practice of new ways of thinking and behaving. 2. The therapist is responsible for the outcome of treatment, including if it fails and insight and change do not occur. 3. Change is forced (and fostered) through a continuous string of highly deliberate tasks and directives.
  8. 8. Purpose: To force and foster change Tasks (rituals/scenarios) and Directives (instructions) provide practice in new ways of thinking, feeling and behaving Mechanics: 1. Define and Assign Task: Scripting and Prescribing a. Assume authority (power) to direct new experience b. Session as a safe haven for change c. Directives are simple commands: keep them behavioral; ie Talk to her; Get up and go sit next to him; Get them to behave d. Tasks are complex commands: To assign, pretend that you are a Director (therapist) on a movie set: introduce the scene (task) and instruct (directive) the actors (clients) behavior while filming the scene (allowing work to be done): Simple introductions, include: Lets try something; Lets do an experiment; Some people find this helpful; Im going to have you try something that may be uncomfortable; What if, we do this. a. Homework is failure prone: make it highly scripted; make behavior independent of others; predict difficulty or failure 2. Staying on Task a. Once a task has been assigned the therapist's job is to continually redirect any straying or delay back to the task, while working on their own anxiety, impatience and need to rescue. b. Push-back is to be expected, but not accepted. Two forms of challenge: - Fear Anxiety or Angst: comfort the fear and encourage them back to task (This is very hard; Lets slow down and try again) Morbid Dread: push; if task cannot be completed, focus on the fear: What is the worse that would happen?; Whats happening now? - Power-play Aimed at the therapist. Dis-arm, dis-engage and redirect the power-play. Address resentment and anger 3. Button-up and Review Simple endings, include: Was that worse than you thought it would be?; How bad was that; what should we do different next time? Lets stop, thats enough hard work for now; I pushed you pretty hard, how pissed-off are you with me? Demetrios Peratsakis, LPC 8
  9. 9. 1. Create a new symptom. 2. Move to a more manageable symptom; ie chores versus attitude 3. I.P. another family member. (create a new symptom-bearer) 4. I.P. a relationship 5. Reframe or re-label the meaning of the symptom (ie. It seems that her school phobia helps her stay home with mom; should we be worried about mom also? 6. Change the intensity of the symptom/pattern. (Inflate/Deflate) 7. Change the frequency or rate of the symptom/pattern 8. Change the duration of the symptom/pattern 9. Change the time (hour/time of day/week/month/year) of the symptom or pattern. 10. Change the location (in the world or body) of the symptom/pattern 11. Change some quality of the symptom or pattern (ie. use of imagery to impact elements) 12. Perform the symptom without the pattern; short-circuiting. 13. Perform the pattern without the symptom. 14. Change the sequence of the elements in the pattern 15. Interrupt or otherwise prevent the pattern from occurring. 16. Add (at least) one new element to the pattern. 17. Break up any previously whole element into smaller elements 18. Link the symptoms or pattern to another pattern or goal 19. Point to disparities Demetrios Peratsakis, LPC 9
  10. 10. Empty Chair Techniques
  11. 11. Use of Chairs: 6 sample Tasks Chairs are relatively convenient and available props that can be used to illustrate relational issues and dynamics or to heighten and lower tension and confrontation among members within a session. As such, they make the covert, overt, and allow new forms of alignment and communication to be practiced: 1. Open Forum: Set two seats side by side, or facing each other, in the middle of the room and ask Who wants to work? 2. Decision Making: Set two chairs facing each, several feet apart; define each chair as representing the opposing or counter-point-of-view in a dilemma. 3. Confronting: Set two chairs back-to-back (not touching). Angry/Volatile clients are encouraged to begin a dialogue. 4. Co-therapist: Set two chairs, side by side, with a third several feet away from both. Have client sit adjacent to you and ask their aide in helping the client. ie. Chris, tell me what Chrissy needs to do to become the new-Chris, Christina? 5. Greek Chorus: Set empty chair off to the side of the therapist. Use the Ghost therapist as a contrarian Greek Chorus meta-message of refusal to change. Demetrios Peratsakis, LPC 11
  12. 12. 6. Ghost: Advanced technique requiring a relaxation directive 6. A. Make an estranged or cut-off member visible Ghosts are family legacies, myths, and legends as well as dead and estranged members whose persona have presence and meaning to the individual or group. They may be good ghosts or bad ghosts, and may be as simple as a family or personal rule or value or a more complex, over-riding philosophy or vantage point on how to behave, interact and even think. Good ghosts can provide support and nurturance; bad ghosts can be inexorable in their demands and ruthless in their punishments. Ghosts often haunt due to guilt, shame, retribution or vengeance. Anger and rage can be elixirs. Make covert issues and rules, overt: (ie. Temper = adversary that one can battle) Work through what makes the ghost more/less restlesswhat issue needs to be put to rest? Write a letter, epitaph or will to the Ghost, emphasize disparities and similarities; develop a new legend or myth; make a voodoo- doll; create a ritual for taming the ghost Reconnect to estranged partners and members Hold a sance or conduct an exorcism Prescribe the phantom 6. B. Make a volatile emotion such as Rage or Shame controllable This is an excellent technique for acquiring greater mastery of something heretofore experienced as not under ones control, such as emotional (ie. rage, sadness) or physical pain. Picture the feeling that youre having What color is it? What is its shape? Its size? What texture does it have? Whats its temperature? Can you change its shape.its color.its temperature..its texture. Now, make it larger/smaller; hotter/cooler; more rough/smoother; less red/more red; taller/shorter. For homework, sit and relax and practice changing the one thing we have agreed to (always move to less toxic) Demetrios Peratsakis, LPC 12
  13. 13. How I view the World? How I view Myself? How I view the Others?