Psychotherapy Essentials to Go Achieving Psychotherapy Effectiveness
-
Upload
teodorescu-virgiliu -
Category
Documents
-
view
74 -
download
8
description
Transcript of Psychotherapy Essentials to Go Achieving Psychotherapy Effectiveness
PSYCHOTHERAPYESSENTIALSTOGO
AchievingPsychotherapyEffectivenessMolynLeszcz
ClarePain
JonHunter
RobertMaunder
PaulaRavitz
SERIESEDITORS:PaulaRavitzandRobertMaunder
W.W.NORTON&COMPANY
NewYork|London
ANORTONPROFESSIONALBOOK
Contents
Acknowledgments
SeriesIntroduction
1IntroductiontoAchievingPsychotherapyEffectiveness
2LearningObjectives
3CommonFactorsandtheImportanceofRelationships
4DevelopingaSharedUnderstandingofaClient’sRelationalWorld
5EngagingintheProcessofTherapy
6AccountingforTrauma
7FinalThoughtsGlossary
LessonPlans
Quiz
AppendixA:Role-PlayTranscripts
AppendixB:PracticeReminderSummary
AppendixC:AnswerKey
AppendixD:TherapistWorksheet:AssessingandReflectingonCommunication
AppendixE:RecommendedReadings
References
PracticeReminderCard
OTHERTITLESINTHESERIESINCLUDE:
CognitiveBehavioralTherapyforDepressionMarkFefergrad&AriZaretsky
CognitiveBehavioralTherapyforAnxietyMarkFefergrad&PeggyRichter
InterpersonalPsychotherapyforDepressionPaulaRavitz,PriyaWatson,&SophieGrigoriadis
MotivationalInterviewingforConcurrentDisordersWayneSkinner&CarolynneCooper
DialecticalBehaviorTherapyforEmotionDysregulationShelleyMcMainandCarmenWiebe
MolynLeszcz
Forallwhohavetaughtme.
ClarePain
Dedicatedtoallthosewhoworktohealfromtraumaticexperiences.
JonHunter
Formykids,whohavetaughtmesomuch.
RobertMaunder
ForMomandDad.
PaulaRavitz
Formyfamily.
SeriesIntroduction
Psychotherapyworks.Meta-analysesdemonstratethatpsychotherapyreducesthesymptomsandimpactofthementaldisordersthatmostcommonlyinterferewithpeople’slives,includingdepression,anxiety,andtheextraordinarychallengesthatemergefromconcurrentaddictions,mentalillnesses,andpersonalitydisorders.Theconsensustreatmentguidelinesthatprovideclinicianswithevidence-baseddirectionfortreatingdepression,anxiety,andothermentaldisordersrecommendpsychotherapy,sometimesasafirstlineoftreatment.
Atthesametime,practicingeffectivepsychotherapyisverychallenging.Foronething,treatmentguidelinesrecommendspecificmodalitiesofpsychotherapyforspecificdisorders,suchasInterpersonalPsychotherapy(IPT)fordepression,CognitiveBehavioralTherapy(CBT)fordepressionoranxiety,MotivationalInterviewing(MI)formentalhealthissuesandsubstanceabusedisorders,andDialecticalBehaviorTherapy(DBT)forborderlinepersonalitydisorder.Therapistsworkingatthefrontlinesofmentalhealthcareseealloftheseproblems,butacquiringextensivesupervision,training,andcertificationinanyoneofthesemodalitiesiscostlyandchallenging,andbeinganexpertinalltypesofpsychotherapyisvirtuallyimpossible.Howcanafront-linetherapistusethecoreskillsofdifferentmodalitiesofpsychotherapyeffectivelytohelphisorherclientsovercomethedebilitatingeffectsofmentalillness?
PsychotherapyEssentialstoGorespondstothechallengethattherapistswhoarenot(yet)expertsfaceinacquiringthecoreskillsofpsychotherapy.Itisdesignedtobeusefulforbothnewtherapistsandthosewhoaremoreexperiencedbutwanttolearnthecoretechniquesofdifferenttypesofpsychotherapy.Italsoisarefreshercourseonthetechniquesthatexperiencedtherapistsarealreadyfamiliarwithandcanbeusedforteachingcounselingtechniquestohealthworkers.
Thisprojectemergedinresponsetotheneedsofmentalhealthcareworkerswhowerefacingextraordinarychallenges.Workingincommunityclinicsinremote,underservicedareas,theseclinicianswereunabletoprovidepsychotherapytotheirclientsbecausetheyhadminimalpsychotherapytrainingandlimitedmeansofacquiringit.Caseloadswereoftenheavyandresourcesforreferringclientstopsychotherapistswereextremelylimited.Theseclinicianswantedtobutwereunabletousepsychotherapeutictechniquestohelptheirclientswhoweresufferingfromdepression,anxiety,andconcurrentdisorders.Needlesstosay,itwasnotfeasibleforthesehealthworkerstoobtainthetraining,observation,andone-to-onesupervisionthatarerequiredtobecomeexpertsinspecificmodalitiesofpsychotherapy.Surely,therewasabetteralternativethanprovidingnopsychotherapyatall!
Drawingonthewealthofexpertiseofthecontributingauthorsinthisseries,whoareallfacultyorstaffathospitalsaffiliatedwiththeUniversityofToronto,wecreatedthemanualsandvideosthatareatthecoreofthePsychotherapyEssentialstoGomaterialsaswellasalloftheaccompanyinglessonplansinordertomeettheneedsofcliniciansand
theirclients.Themanuals,videosandlessonplansworked.Wetestedthematerialsthatwedevelopedwithhealthcareworkersofseveraldisciplinesandlevelsofexperience—fromthecaseworkersincommunitymentalhealthcareclinicswhoseneedsinitiatedtheprojectandtomedicalstudents,nurses,familymedicineandpsychiatryresidents,andsocialworkers.Theirknowledgeincreased,theyusedthetechniquesthattheyhadlearned,andtheyreportedthattheyhadbecomemoreconfidentandeffectiveclinicians,evenwithdifficultclients.Evenseasonedtherapistsbenefitedfrombrushinguponthespecifictherapyprotocols.
ThefirstfivebooksandDVDsofthePsychotherapyEssentialstoGoseriesteachtheskillsofMotivationalInterviewing,CognitiveBehavioralTherapy(foranxietyandfordepression),DialecticalBehaviorTherapy,andInterpersonalPsychotherapy.Thesematerialsarenotintendedtoreplacefulltrainingintheseevidence-supportedpsychotherapeuticmodels;rather,theyintroduceanddemonstratetechniquesthatcliniciansandstudentscanintegrateintotheircareofpeoplewithcommonmentalhealthproblems.
ThissixthbookanditsaccompanyingDVDaddresspsychotherapyeffectivenessacrosseverymodalityoftherapy.Regardlessofwhichtypeofpsychotherapyatherapistprovides,doingpsychotherapyrequirestherapiststobeflexibleandresponsivetotheirclients.Alsotherapistsandclientsmustformandsustainastrongworkingrelationship:thetherapeuticalliance.Ineverymodalityofpsychotherapy,agoodtherapeuticallianceleadstogoodclinicaloutcomes.Withsomeclientsthechallengesencounteredinformingandmaintaininganallianceprovideawindowontheinterpersonaldifficultiesthatruninterferenceinsomeoftheirotherimportantrelationships.Thisbookonpsychotherapyeffectivenesssynthesizesthemostimportantcommonfactorsofpsychotherapiesandprovidesatherapistwithanapproachtounderstandingandmanagingchallengestoestablishingandmaintainingatherapeuticalliance.
Learningpsychotherapymeanschanginghowyoubehaveasaclinician—andchanginghabitualbehaviorisnotoriouslydifficult.Learningnewprofessionalbehaviortakestimeandpractice—youneedtoexperienceanewwayofbehaving;itisn’tenoughtoreadaboutitorhearaboutit.Experientiallearningismosteffectivewhenitincludesdemonstration,modeling,andpractice.Foreachbookintheseries,wesuggestthatyoufirstwatchtheDVD,thenreadtheaccompanyingtext,andthenfollowtheinstructionsinthelessonplanstopracticeandconsolidateyourlearning.Takethequizbeforestartingthisprocessinordertoassessyourknowledgeandyourneeds,andthentakeitagainafterhavingcompletedallofthelessons,inordertoassessyourprogress.Afterward,usethesummarycardofpracticeremindersinyourdailyclinicalwork.
Forthoseinterestedinmoretraining,furtherreadingandclinicalsupervisionarerecommended.WehopethatthetechniquespresentedintheseintroductoryPsychotherapyEssentialstoGomaterialswillexpandyourclinicalrepertoireandwillimproveyourcompetenceandconfidenceinworkingwithclientswithmentalhealthproblems.
Notesaboutlanguage.First,thosewhoprovidecareandtreatmentforpeoplewithmentalhealthproblems,andindividualswhoreceivethatcare,preferawiderangeof
namesforthoseroles,andsomehavestrongfeelingsabouttheirpreferences.Forthesakeofconsistency,throughoutthisserieswerefertotheformerindividualsas“therapists”(occasionallyoptingfor“clinicians”forthesakeofsomevarietyofexpression)andthelatteras“clients.”Wedothisinspiteofthefactthatsomemodalitiesofpsychotherapyareexplicitaboutwhichtermsarepreferable.Wehopethesearereadtobetheinclusiveandnonprescriptivechoicesthatareintended.Second,thegenderofthetherapistsandclientswearediscussingisirrelevant.Wehaveadoptedtheconventionofreferringtothetherapistasfemaleandherclientasmale,forthesakeofeconomyoflanguage.Whendiscussingdevelopmentalprocesses,thechildwehaveinmindistheonewhowillgrowupintoaclient,sowehavegenerallymadehimmaleaswellforconsistency.Whendiscussingachildandhisorherprimarycare-provider,wecalltheadultinthatroleaparent,acknowledgingthatthereareotherswhoalsoservetheparentingrole.
PaulaRavitzandBobMaunder
1::IntroductiontoAchievingPsychotherapyEffectiveness
EachofthepreviousbooksinthePsychotherapyEssentialstoGoseriesisderivedfromaspecifictypeofpsychotherapythatisdescribedinamanualandsupportedbyevidence.Thisbookisalittledifferent.Justlikeitspredecessors,itisgroundedinevidence-supportedpsychotherapypractices;however,unliketheotherinstallmentsofthisseries,AchievingPsychotherapyEffectivenessdoesnotdescribeaparticularmodality.Instead,wefocusontheories,principles,andpracticesthatimprovetheeffectivenessofalmostanytypeofpsychotherapy.Weprovideananswertothisquestion:Whatcanimproveatherapist’seffectiveness?
Theauthorscometothisquestionfromdifferentdomainsofexpertise,fromInterpersonalPsychotherapy,grouppsychotherapy,andpsychotherapeuticapproachestotraumaandtoadaptingtoseriousillness.Differenttypesofpracticeledustofavordifferentmodelsofpsychotherapy,buteachofusturnstoevidencetodeterminetheelementsofourworkthataremostvaluableandmostimportanttoteachandreinforce.Theevidenceleadsustoagreeontheessentialingredientsthatarecommontoeffectivepsychotherapiesofeverytype,andthisbookprovidesaworkingsynthesisofthoseingredients.AchievingPsychotherapyEffectivenessendeavorstohelpyoutobecomethemosteffectivepsychotherapistthatyoucan,regardlessofthemodelofpsychotherapythatyoupractice.
2::LearningObjectives
Thefollowingobjectiveswillhelpyoutofocusyourlearningasyoureadthetext,viewtheDVD,andcompletethelessonplans.
Attheendofthisbook,wehopethatyouwillbeabletoachievethesegoals:
1.Listthetherapists’qualitiesthatcanpromoteatherapeuticalliance.
2.Developanunderstandingwithyourclientsaboutrelationshipsthatshapedtheirinternalworkingmodels,patternsofattachment,andinterpersonalpulls.
3.Recognizethepotentialimpactofunresolvedtraumaandlearnhowandwhentoaskaboutit.
4.Understandtherisksandchallengesthatcanleadtonegativepsychotherapyoutcomes,includingtransference-countertransferencedynamics.
5.Recognizeandusealliancestrainsastherapeuticopportunities.
6.Expandyourreflectivecapacityandtherapeuticrepertoirebyusingmentalizingandmetacommunication.
3::CommonFactorsandtheImportanceofRelationships
OneofthekeyprinciplesofthePsychotherapyEssentialstoGoseriesistoidentifyandrecommendpracticesthathavethestrongestevidenceforcontributingtoeffectivepsychotherapy.Followingthisprinciple,AchievingPsychotherapyEffectivenessbeginswithfindingthatthereismuchmorethatdistinguisheseffectivefromineffectivetherapiststhanthatwhichdistinguishestheeffectivenessofdifferentmodelsoftherapy(Barthetal.,2013).Thebesttherapistsaffordtheirclientstwicethelikelihoodofimprovementandhalfthelikelihoodofdeterioratingcomparedtolesseffectivetherapists(Baldwin&Imel,2013),whereasthedifferenceineffectivenessbetweendifferentmodelsoftherapyismuchlessdramatic.Whiletraininginanevidence-basedmodeloftherapyisimportant,LuborskyparaphrasesthedodobirdinAliceinWonderlandtoconcludethat“allmodelshavewonandalldeserveprizes”(Luborskyetal.,2013).Therefore,thecentralfocusofAchievingPsychotherapyEffectivenessistoguideatherapistregardinghowbesttouseherselfasatherapeuticagent—whichistosayweemphasizetheevidence-basedpsychotherapistmorethanevidence-basedpsychotherapies.
THECOMMONFACTORSOFPSYCHOTHERAPYTheevidenceaboutwhatdeterminespsychotherapyoutcomessuggeststhatthegreatestimpactisduetofactorsthatarecommontoallmodelsofpsychotherapy,includingastrongtherapeuticalliance,empathyandcollectingclientfeedback,consensusaboutgoals,collaboration,positiveregard,therapistgenuineness,andatherapist’sabilitytoadapttoherclientandtomanagethetensionsandstrongemotionsthatariseintherapy(Norcross&Lambert,2011;Norcross&Wampold,2011).Eachcontributiontoimprovementthatismadebyspecifictechniquesofparticulartherapies,attitudesthataclientbringsintotherapy(suchasmotivation),changesthatoccurintheclient’slifethatareentirelyoutsideoftherapy,andtherapistcharacteristicsisimportantbuthasasmallereffect.
Byattendingtotheessentialcommonfactors,effectivepsychotherapistsestablishwhatWampold(2001)describesasa“healingcontext.”Inthisbookweemphasizethatmanyofthesegoalsdependonthetherapist’sabilitytounderstandaclient’srelationalworld,tomentalize1,and,inturn,tocommunicatemeaningfully.
THECENTRALITYOFRELATIONSHIPEffectivepsychotherapyoccurswithinatherapeuticrelationshipthatisco-constructedbytherapistandclient,arelationshipinwhichbothindividualsreiterativelyaffecteachother.Whateverproblemsbringaclientintotherapy,thebenefitsofpsychotherapywillemergefromanewrelationshipexperiencethatempowershimtogrow,develop,andhealinternaldeficits,despiteoftenreflexivelyreenactingproblematic,familiarrelationaldynamicsduringtherapy.Wepresentanumberoftechniquesandprinciplesthatcanbeeasilyintegratedwithinvariousmodelsoftreatmenttoimproveoutcomes.Whilethisguidebookemphasizesonespecificcontext—situationsinwhichthetherapeuticrelationshipbecomesstrained—thecoreskillsweteachareusefulinalltherapeuticcontexts.Theseskillsarementalizing,metacommunication,andattentiontointerpersonaldynamics.
ADilemmaofPsychotherapyPeoplecometopsychotherapyformanyreasons,oftensimplyforreliefoftheburdenofsymptomsofdepressionoranxiety;theyoftendonotidentifythemselvesashavingdifficultiesinrelationships.Nonetheless,theroleoftherelationshipiscentraltothepracticeofeffectivepsychotherapy,andrelationaldynamics,especiallybetweentherapistandclient,arealwaysimportant.Theproblemsthataclientidentifiesmayhaveemergedbecauseofunderlyingrelationshipproblems(suchasconflict,loss,orloneliness),ortheymayacttointerferewithcurrentrelationships.Inanycase,psychotherapyaimstotreattheseproblemsusingthepowerofahealingrelationship,whichwillinevitablybeshapedbytheproblemsthataclienthasbroughttotherapy.
Althoughmostclientswouldnotarticulateitinthisway,itishelpfultostartwiththeassumptionthatformingarelationshipwithatherapistpresentsaclientwithadilemma.Heapproachesthisnewrelationshipwithbothhopeanddread—dreadthattherapyisgoingtobearepetitionofpreviousrelationshipsthatfailed,orinwhichhewasshamed,punished,orrejected.Therapybecomespartoftheclient’sproblemifitre-createsthisold,familiarpatternofrelating.Butclientsalsohaveahope—thatthistimeitwillbedifferent;
thatatherapistwillhelpthemhealandrecover(Leszcz&Malat,2011;Mitchell,1993).Thechallengeoftherapyistobeginarelationshipthatcouldgointhatnegativedirection(becomethe“sameoldthing”)andinsteadturnitintoaconstructiveandreparativerelationship.Inthatsense,therapyiseitherpartoftheproblemorpartofthesolution.Inordertomaximizetheoddsthattherapywillcontributetothesolution,atherapistmustremainflexibleandattuned,eveninthefaceofevocativeinterpersonalforces,andbeabletomoveintoanoptimaltherapeuticposturethatisshapedbytheneedsoftheclient.
ANAPPROACHTOPSYCHOTHERAPEUTICEFFECTIVENESSOurapproachtoachievingpsychotherapyeffectivenessfollowsasequencethatisfirmlyrootedinanunderstandingofthepowerofrelationshipdynamics.First,weattendtothefoundationofthetherapeuticrelationship,whichisthetherapeuticalliance.Second,wedeepenourempathicconnectionbyunderstandingtheclient’srelationalworldandfindingconstructivewaystocommunicatethatunderstanding(Elliott,Bohart,Watson,&Greenberg,2011).Wedothisbylearningabouthisearlyattachmentrelationships(there-and-then),hiscurrentrelationships(there-and-now),andthedynamicsoftransferenceandcountertransferencewithinthetherapeuticrelationship(here-and-now).Third,welearnabouttherepetitivepatternsofunhappy,self-fulfillingsequencesthatmayrecurintheclient’slife(theseexperiencesofthedreaded“sameoldthing”arealsoreferredtoasmaladaptiveloops)andattendtohowwe,astherapists,mayinadvertentlybe“hooked”intothesepatternswhileinthetherapeuticrelationship.Fourth,werecognizetherapeuticopportunitiestothenget“unhooked,”usingtechniquessuchasmentalizingandmetacommunicationtorepairstrainsinthetherapeuticallianceandpromotenewwaysofunderstandingandexperiencingrelationships.Oneofthemostpowerfulskillsofaneffectivepsychotherapististhecapacitytobe“present”enoughwithinthealliancetobecomehookedintointeractionsthatriskreinforcingherclient’sunhappyoldpatterns(notmerelyattendingtothetechnicalaspectsofadherencetoamodelofpsychotherapy),tothennoticeandappreciatewhatisbeingre-createdandgetunhookedbyaddressingthepatternsinanonblamingfashion(Hill&Knox,2009).Finally,weexaminetheimpactoftrauma,whichissocommonandinfluencestherapysomarkedlythateverytherapistmusttakeitintoaccount.
ANAPPROACHTOPSYCHOTHERAPYEFFECTIVENESS
Buildastrong,positivetherapeuticalliance
Developasharedunderstandingofaclient’srelationalworld
•Earlyattachmentrelationships
•Currentrelationships
•Transferenceandcountertransference
Identifyself-fulfillingpropheciesthatreinforcepathogenicbeliefs(maladative
loops)
Whenbehaviorallyoremotionallyhooked.getunhooked
•Mentalizing
•Metacommunication
Taketheimpactoftraumaintoaccount
THETHERAPEUTICRELATIONSHIPANDTHETHERAPEUTICALLIANCEThetherapeuticrelationshipstartswithelementsthatarefundamentalinreasonableperson-to-personinteractions,suchasrespectanddecencyand,withthetherapist’sdemonstrationofpresencethroughpsychologicalavailability,empathy,responsiveness,andinterest(Viederman,1999).However,thetherapeuticrelationshipalsohasspecificelementsthatrequiredeeperdiscussion:thetherapeuticalliance,transference,andcountertransference.
Theevidenceisstrongthatthetherapeuticalliance—asexperiencedbytheclient—isasignificantpredictorofpositiveoutcomeacrossalltreatments(Horvath,DelRe,Fluckiger,&Symonds,2011;Martin,Garske,&Davis,2000).Thetherapeuticallianceisthegroundinwhichtherapytakesroot,soaneffectivetherapistneedstoestablishanallianceasthefirstfocusofanypsychotherapy.Inparticular,themoreshecangainconsensuswithherclientsaboutthegoalsandtasksoftreatment,themoreeffectivetreatmentwillbe.
Aneffectivetherapistbuildsthealliancebyengaginginacollaborationinwhichshetreatstherapyasajointundertaking(Horvathetal.,2011).Theheartofthisworkishercapacitytobuildrapport,remainingalerttoactionsthathinderaffiliationbetweenaclientandhistherapist.Themostsubstantialofthesebarriersaretherapistbehaviorsthatconvey
judgment,blame,shame,orinterpersonalcontrol.Ontheotherhand,atherapeuticrelationshipgoesbeyondmeresupport.Inordertoachievethegoalsthatatherapistandclienthavenegotiated(suchasalleviatingsymptomsandproblems),thereisaninevitablebalancebetweenvalidationoracceptanceofaclient“justasheis”andpromotingchange.Itisimportantthatatherapist’scommitmenttobesupportive,empathic,andengageddoesnotblockherfromchallengingtheclient’smaladaptivebehaviors,suchassubstanceabuse,thatcontributetopoorfunctioningandimpedepositivechange.Oneofthekeyskillsrequiredtopromotechangeistofindpalatablewaystosayunpalatablethings.
Toagreewithaclientaboutgoals,atherapistneedstounderstandhiscoreconcerns.Sheworkstofindawaytomakesenseoftheseconcernstogetherwithhim,usingwordsandconceptsthataremutuallyaccessible.Theoryandtechnicallanguageshouldbeavoidedbecauseitmayinadvertentlydistanceatherapistfromherclientorleadtoafalsesenseofagreement.
Finally,butcrucially,atherapistmustremainattentivetotheboundariesofethicalpractice.Shemustalwaysmakechoicesintheserviceofadvancingherclient’sinterests.Seetheboxentitled“ATherapist’sResponsibilities”foraverybriefoverview(toreflectontheethicsofpracticingpsychotherapyinmoredepth,seePope&Vasquez,2010).
ATHERAPIST’SRESPONSIBILITIES
Psychotherapyrequiresaprofessionalrelationship,whichplacesfiduciarydutyandresponsibilitiesonatherapistbeyondthoserequiredinotherkindsofrelationships.
Allofthesuggestionsinthisbookaretobeappliedwithinthefollowingframeworkofethicaltherapy:
•Atherapistmustbeadequatelytrained(and/orsupervised)tobecompetentinthetreatmentthatheorsheprovides.
•Atherapistmustconformtotheprofessionalandethicalstandardsofhisorherprofession.
•Atherapistmustremaincognizantoftheimbalanceofpowerthatisinherentinthetherapyrelationship.Forminganyotherkindsofrelationshipswithaclient,suchassocial,sexual,orfinancialrelationshipscontravenesatherapist’sfiduciaryandethicalduties.
•Whenconsideringcrossingaboundary,suchaswhenatherapistconsidersgreaterself-disclosurethanistypical,atherapistmustassessifthischoiceisintheserviceofherclient’sgoalsratherthanherown.
1Thisbookintegratesconceptsfromseveralpsychologicaltheoriesandschoolsofpsychotherapy.Wehavebeenjudiciousinalsoadoptingtechnicaltermsfromthesesources,inanefforttoavoidthelackofclaritythatcomesfromjargon.Nonetheless,psychotherapyisaspecializedtaskthatrequiressomespeciallanguage.Whentechnicaltermsarefirstintroduced,theyappearinitalicsandaredefinedintheglossaryattheendofthisvolume.
4::DevelopingaSharedUnderstandingofaClient’sRelationalWorld
Inadditiontolearningfromaclientaboutwhateversymptoms,struggles,orproblemsbroughthimintotreatment,therearethreekindsofinformationaboutrelationshipsthatcanbeusedtounderstandaclient’srelationalworld.First,atherapistcangatherinformationaboutherclient’sdevelopmentalhistory,suchashowheinteractedwithmembersofhisfamilyoforiginandtheeventsthatcontributedtoresilienceortoproblemsinchildhoodandyouth.Second,atherapistcanunderstandherclient’scurrentrelationships,suchaswithhisspouseorromanticpartner.Third,aneffectivetherapistlooksataspectsofthetherapeuticrelationshipitself,particularlythetransferencerelationship.Itmaynotalwaysbenecessarytoinvestigateeachoftheseareasinthesamedepthforeveryclient,buttheyarecomplementarywaysoflearningabouthisrelationalworld.Wenowlookateachsourceofrelationshipinformationinturn.
RELATIONSHIPSINACLIENT’SDEVELOPMENTALHISTORYWeunderstandaperson’searliestrelationshipsbyusingattachmenttheory,whichstipulatesthataclient’sexperienceinimportantdevelopmentalrelationships,especiallywithhisprimarycareprovidersorparents,haslefthimwithasetofexpectationsbothaboutwhatwillhappenincloserelationshipsandhowbesttorespondtoothers.Thisinternalworkingmodel,developedinresponsetothousandsofinteractionswithhis
caregivers,determineshowheunderstandshimselfinrelationshiptoothers(Bowlby,1969).Onecouldcallthisacognitiveschemaaboutwhatonecanexpectfromoneselfandfromothers.Itisn’tthelabelthatisimportant;itistheideathatone’sexperienceofrelationshipsshapesone’ssubsequentexpectationsandbehaviors.
AValidatingEnvironmentMostfundamentally,achildiscriticallydependentonhiscaregivers’abilitytotakehisinnerlifeseriously—meaningthathisparentunderstandshimtobeadevelopingindividualwithamindofhisown.Ifhisparentstreathimasanindividualwithhisowndesires,hopes,opinions,intentions,preferences,ambitions,andfantasies,hewilldevelopthecapacitytoreflectonandunderstandmentalstates,andhewillseehisinnerlifeandtheinnerlivesofothersassalientandimportant.Theabilitytoreflectinthiswayiswhatismeantbythecapacitytomentalize.Theparentalqualitiesthatpromotethisdevelopment(avalidatingenvironment)notonlypromotementalizingandempathywithothers,butalsofacilitateachild’sdevelopingresiliencetoadversity,abilitytotoleratefrustrationandsuffering,andcapacitytoadapttotheneedsofthepresent(Fonagy&Bateman,2008;Lyons-Ruth&Jacobvitz,2008).Thevalidatingenvironmentprovidedbyagood-enoughparent(Winnicott,1971)providestheconditionsthatenableachildtodevelopasecurebase.Forachild,asenseofhavingasecurebasemeansbeingabletotakehisorherownphysicalandpsychologicalsafetyforgranted.Asecurebaseprovidesconfidence,fromwhichhecancomfortablyexplorehisworldindependently,confidentthathecanreturntothesafehavenofhisparent’ssolaceandprotectionwhensomethingfrightenshim(Bowlby,1969).Thereisacloseanalogyintherapy,whereatherapist’ssupportofasafeandpredictabletherapeuticenvironmentactsasasecurebasefromwhichaclientcanexplorehisinnerworld,thedynamicsofhisrelationships,andsolutionstoproblems.
QUALITIESOFAVALIDATINGPARENTALENVIRONMENT
•Primarycaregiverswho
•takeachild’sinnerlifeseriously
•understandthatachildisaseparateindividual
•are“goodenough”
•responsive,caring,andcurious,butnotperfect
•attemptto“read”achild’ssignalsandrespondappropriately
•respondtofearwithprotection
•respondtoinjurywithcomfort
•respondtoautonomywithrespect
•respondtoachievementwithpride
Foravarietyofreasons,suchastheirownexperienceswithaparent’sinaccessibilityduetodepression,poverty,deficitsinsocialsupport,substanceabuseortraumatization,somecaregiversfailtovalidatetheinnerlifeoftheirchildren.Aninvalidatingcaregivermayreject,ignore,mock,orotherwiseminimizeanddisavowachild’semotionalreactionsandinnerexperience.Inthisenvironment,achildbecomesconfusedandmistrustfulofhisownemotionsandresponsesand(likehisparent)failstodeveloptheskillsnecessarytorecognize,clarify,orcarefullydiscriminatebetweenthevariouscontentsofhisinnerworld.Lackingacomfortablecuriosityabouthisinnerlife,hispsychologicaldevelopmentsuffers.Achildwhogrowsupinsuchanenvironmentispronetofeelinginsecureandtohavinganinternalworkingmodelthatperpetuatesnegativeexpectationsofhimselfandothers.Whensuchamodelisusedtopredict,makesenseof,andrespondtothebehaviorofothersincurrentrelationships(whetherornot“referringtothemodel”isconscious),itusuallyleadstoproblems.
InfantandChildhoodAttachmentAttachmentbehaviorsarethewaysinwhichachildsignalsneedtohisparentwhenhefeelsfrightened.Childrencometodifferinthebehaviorsthattheyfavorasresponsestofearwhenparents’responsestotheirchildren’sstrategiesrewardorextinguishparticularfear-basedbehaviors.Theinternalworkingmodelguidesattachmentbehaviorsbyencodingthebestunderstandingthatisavailabletoachildaboutwhattoexpectfromhisparentandhowtorespond.Thus,whenachildwithsecureattachmentisfrightened,heshowsdistressandtriestogetclosetoaparent,basedonhisexperiencethathisparentrespondsreliablyandeffectivelytohisneedforcomfortandprotection.Theirtimeinphysicalcontactwitheachotherworks;thechildfindssolaceandisreadytoexploreagainshortlyafterthethreatisgone.Anotherchildmayhavelearnedtoactivateattachmentsignalsveryquicklywhenevenmildlydistressed.Thischildishypervigilantfortheavailabilityofothers,andhisexpressionsofneedaremoreeasilytriggeredandmoreintense.Alternatively,attachmentbehaviorsmaybecomerelativelydeactivated,withmutedexpressionsofdistressandarelativelackofinterestin,ordevaluationof,thepresenceofothers(Ainsworth,Blehar,Waters,&Wall,1978;Shaver&Mikulincer,2002).Oncereinforcedandestablishedintheinternalworkingmodel,theseattachmentbehaviorstendtopersistintoadulthoodandoftenunderliepersistentdifficultiesinrelationships,producingsufferingandinterferingwithcoping.Thisiswhythesebehaviorsareimportantfortherapiststounderstand.
Ifatherapistwantstogetabetterimpressionofthequalitiesoftheenvironmentinwhichaclientgrewupin,shecanaskaboutdevelopmentalrelationships(usingquestionslikethosefoundintheboxentitled“ExploringaClient’sDevelopmentalRelationships”)andtailorthequestionstotheindividual’scircumstances,beingcuriousabouthowparticulareventsfeltandwhattheymeanttotheclient.Ofcourse,askingaboutaclient’schildhoodrelationalenvironmentdoesnottellatherapisthisattachmentstyle—butitdoesallowherclienttosharewithherhisunderstandingofwhathewasadaptingtowhenhewasgrowingup.Thewayhetalksabouttheseexperienceswillalsogivehercluesabouthowhehasmanagedthatadaptation—Isheoverwhelmedwithemotion?Doeshedismisstheimportanceoftheseexperiences?Ishediscombobulatedandvague,orishesuccinct,clear,andthoughtful?(Hesse,2008).
EXPLORINGACLIENT’SDEVELOPMENTALRELATIONSHIPS—THEREANDTHEN
Whenyouwereupsetasachild,whatwouldyoudo?
Whatmadeyouhappyorexcitedasachild?
Howdidyourespondtobeingseparatedfromyourparents?
Howdidyoumanagewhenyoufeltrejected?
Wereyoueverfrightenedofyourparents?
Whatdidyoulikebestaboutyourmomordad(orwhoeverraisedtheclient)?
Pleasedescribeyourrelationshipwithyourmomordad(orwhoeverraised
theclient).
Pleasegivemesomeexamplesfromyourlifethatwillbringthosedescriptionstolife.
PATTERNSINACLIENT’SCURRENTRELATIONSHIPSItisalsoimportanttoreviewaclient’scurrentrelationshipstolookformaladaptivepatterns(especiallyifheisunabletoseetherecurrentpatternsortheirlinkstoearlierrelationships).Onceagain,attachmenttheorygivesusanefficientlensthroughwhichtoexamineourclients’relationships.
AdultAttachmentAdultsusetheirinternalworkingmodelofexpectationsandassumptionsaboutthemselvesinrelationtootherstorelateinwaysthatarefairlyconsistentovertime.Identifyingthesepatternsinpsychotherapystartswithobservingaclient’sexpressionsofdistress,observinghisattitudestowardclosenessandintimacy,listeningtothewaysandwordsheusesinordertospeakabouttheseissues,andthenmakinginferencesabouttheassumptionsencodedinhisinternalworkingmodel.
Secureattachmentisthepatterninwhichtheattachmentsystemworksmostsuccessfullytofacilitateflexibleandmutuallysatisfyingreciprocalrelationshipsandeffectiveaffectregulation.Importantly,secureattachmentisalsocharacterizedbyawell-developedcapacitytomentalize.Manypeoplewhoseproblemsbringthemtopsychotherapyhaveoneofthreetypesofinsecureattachment.
Preoccupiedinsecureattachmentischaracterizedbyahyperactivatedattachmentsystemwithexcessiveexpressionsofdistress,intensehelpseeking,anexpectationofpainfulrejectionorabandonment,andintenseanxietyaboutbeingalone.Itcanbeinferredthatapreoccupiedindividualhasaninternalworkingmodelbuiltonassumptionsofpersonalfragilityandunworthinessandabeliefthatotherswillrespondtothatunworthinesswithinconsistentattentionorabandonment.
Indismissinginsecureattachment,theoppositebehaviorisobserved.Feelingsofinsecurityinrelationshipsaredefendedagainstbyavoidingintimacyandmutingexpressionsofvulnerability;closerelationshipsaredevaluedandhelpisnotsought(norevenapparentlyneeded,ifonejudgesfromoutwardappearancesonly).Onecaninferaninternalworkingmodelinwhichothersarethreateninganddisappointing,andoptimalsecuritydependsonself-relianceandself-containment.
Finally,aninternalworkingmodelthatcombinesnegativeexpectationsofothers(asrejecting,frightened,frightening,shaming,ordisappointing)andoneself(asfragileorunworthy)resultsinconflictingaffectiveandinterpersonalstrategies,suchassaying“I’mfine”whileconveyingtheoppositenonverbally.Itisasthoughtheclientisreachingoutforhelpand,atthesametime,fearingthepersonwhosehelptheyareseeking.Thisirresolvabledilemmaandmixedmessagingleaveapersonstuckinanuntenablebind.
Thisstateofdisorganizedinsecureattachmentisoneofpainfulisolation,neitherfeelingokayonone’sownnorabletoseeksupportfromothers.2
ThePullofInterpersonalBehaviorAsecond,alliedmodelforunderstandingcurrentrelationshipsisrepresentedbytheinterpersonalcircumplex,articulatedbyKiesler(1996).Theinterpersonalcircumplexprovidesaframeworkforunderstandingmanyrelationalbehaviorsandproblems.Similartoattachmenttheory,thecircumplexdescribesuniversalbehaviorsthatarenottheresultofmentalillnessbutdoleadtocommoninterpersonalproblems.Thecircumplexusesdimensionsofrelationshipforcesplottedontotwoindependentaxestodescribethewaysinwhichpeopleinteract.Theinterpersonalcircumplexclarifieshowaperson’sinterpersonalbehaviorhelpsdeterminethekindofinterpersonalresponsethatheorshepullsfromanotherperson.Thismodelcomplementsthevalueofunderstandingaclient’sinternalworkingmodelbyfocusingattentiononhowhisinterpersonalbehaviorbecomesaforcethatinadvertentlyinfluencesthebehaviorofothers—settingupafamiliarsequenceofinteractions,whichmaybeproblematicenoughforustoidentifythemasmaladaptiveloops.
Theverticalaxisofthecircumplexrepresentstheroleofpowerinrelationships,withextremesofdominanceatthenorthpoleandsubmissionatthesouthpole.Thehorizontalaxisreferstotheroleofaffiliation,orhowcloseapersonlikestobewithothers.Ithastheextremesofcold,distant,orhostilebehaviorinthewestandwarm,friendly,oraffiliativebehaviorintheeast.Interpersonalbehaviorcombinesbothaxes—forexample,aclientcanbehostileandsubmissiveatthesametimeasoccursinangrywithdrawal,apatternthatlivesinthesouthwestquadrant.Alternativelyapersonmightseekaffiliationthroughsubmission,whichoccursinpreoccupiedattachmentandismappedinthesoutheastquadrant.
Ingeneral,interactionsamongpeoplefollowtworules.First,affiliationtendstopull
foramatchingresponse.Ifaclientisfriendly,othersarelikelytowanttobefriendlyback,whereasifsomebodyisdisengagedorhostile,itfeelsnaturaltootherstokeeptheirdistance.Second,powerrelationshipstendtobereciprocal,sothatwhenaclientactsinadominantway,theotherperson,perhapshistherapist,mayfeelapulltorespondwithsubmission(e.g.,tofeeldisempoweredorsilenced).Similarly,aclientwhoissubmissivetendstounintentionallyelicitdominatingresponsesfromothers,suchasexertingcontrol.3Whenthesedynamicinterpersonalpullsarerigidandextreme,theytendtoperpetuateinterpersonalproblemsinself-fulfillingmaladaptiveloops(discussedfurtherbelow).
INTERPERSONAL“PULLS”INTHECIRCUMPLEX
Attitudesandbehaviorsonthepowerdimensionusuallypullforanopposite,reciprocalresponse
•Dominanceusuallypullsforasubmissiveresponse
•Submissionusuallypullsforadominantresponse
Attitudesandbehaviorsontheaffiliationdimensionconsistentlypullforamatching,complementaryresponse
•Friendlinesspullsforafriendlyresponse
•Coldnessorhostilitypullsforacoldorhostileresponse
Thesepatternshelpatherapisttounderstandhowotherpeoplereacttoherclient.Theyalsohelpatherapisttoappreciatehowherowntendenciestobehavewithaclientlineupwiththebehaviorthathisapproachtopowerandaffiliationtendstopullfromothers.Usingthisunderstandingfromtheinterpersonalcircumplexallowsatherapisttomonitorifsheiseitherrepeatingpreviousproblematicinteractionsorprovidinganew,therapeuticexperience.Asshebecomesattentivetothesepatterns,atherapistcanchoosetointentionallyresistthepulls,forthegoodofthetherapy.Forexample,maintaininganaffiliativeresponsetoaclientwhenhisbehaviorpullsfordisengagementmayhelphimtobreakoutofthesedistancingpatternsanddiscovernewwaysofbeingclosetoothers.Thetherapist’saimshouldbetorecognizethepattern,identifythepull,andthenusethatknowledgetoavoidrepeatinganundesirableinteraction,sometimesbysimplycommentingonthepatternwithoutjudgment.Whenatherapistrespondsinwaysthatdisconfirmherclient’sexpectations,itallowsthembothtoprocesswhatishappeningwithoutblameorshame.
TheseinterpersonaldynamicscanbeobservedintheexamplesoftherapyportrayedintheDVD.JoelWalkerishostileanddominant,apresentationthatisoff-puttingandwouldtypicallypullatherapistwhoisnotattentivetothedynamicintoanunhelpfulpositionofangrydisengagement.KatherineMarksisbothdisengaged(fromthetherapistandherself)anddisempowered,whichwilltypicallypullhertherapisttowardadistancingandoverlycontrollingstance.
Oftenitisnotuntilthetherapisthasinadvertentlyreactedtothepullthatshecan
recognizewhatishappening.Thishastheadvantageforthetherapistofanexperientialunderstanding—andfromthisexperiencethetherapistcanconsiderhowshewillintentionallytrytoresisttheproblematicpullonthenextoccasionitoccursandthenhelptheclienttobegintochange.Ifthepullappearstobetypicalofinterpersonalproblematicinteractionsoutsideofthetherapyrelationship,thiscanprovideapowerfultherapeuticopportunity.Gettinghookedbytheseinterpersonalpullsandthengettingunhookedareimportantcomponentsoftherapistengagementthatwillbeaddressedfurtherbelow.
TRANSFERENCEANDCOUNTERTRANSFERENCEThethirdsourceofinformationaboutaclient’srelationshippatternsemergesduringthetherapyitself.Transferencereferstothe(sometimesunconscious)expectations,attitudes,andfeelingsthataclientdirectstowardhistherapistthatarebasedmoreonhispastexperienceswithothers(encodedintheinternalworkingmodel)thanonwhatishappeninginthepresenttherapeuticrelationship.Countertransferencereferstothecorresponding(sometimesunconscious)expectations,attitudes,andfeelingsthatatherapistexperienceswiththeclient.Countertransferencefeelingsmayincludepersonal,idiosyncraticreactionsofthetherapist’sbutoftenresultfromtheclient’sinterpersonalpullsusingtheinterpersonalcircumplexthatwedescribedabove.
TRANSFERENCE
Transferencecanbeevidentearlyintherapy.
Recognizingtransferencepatternshelpsatherapistunderstandaclient’sbasicpatternsofrelating.
Transferencehasanimpactonatherapist.Sheeitherreactstotransferencewithherowncountertransference,orsherespondswithamorethoughtfultherapeuticintervention.
Transferenceandcountertransferenceneednottakemanysessionstodevelop;theycanmanifestquickly.Recognizingatransferencepatterncanhelpatherapisttounderstandandworkwithaclient,especiallywhenatherapistincludesinthatunderstandingthereactionsthatshehastoherclient’stransference.Buthowcanonerecognizeaclient’spatternoftransferenceandone’sowncountertransference?
Onewaytotuneintoaclient’stransferenceistoobservetheemotionsandinterpersonalbehaviorsthatheexpressesmostcommonlyintherapy.Empiricalresearchsuggeststhatthesewilloftenconformtooneoffivecommonpatterns.First,theclientcanreactinasecure,engagedworkingrelationship,whichprovokeslittledifficulty.However,thepatternisusuallymorechallenging.Aclientmaymanifestapatternofbeing
predominantlyangry,anxious,avoidant,orsexualintherelationship(Bradley,Heim,&Westen,2005).Insecureattachmentisverycommonamongpeoplewhoseekpsychotherapy,andthereisaclosecorrespondencebetweensomeofthesetransferencepatternsandattachmentstyles,particularlythesecure,avoidant,andanxiouspatterns.
Countertransferencealsotendstofollowafewcommonpatterns.4Atherapistmayfeelthatshewantstogothatextramileforaclient,shemaywishthatshehadnevertakentheclienton,orshemayfeelunusuallyboredorannoyedduringtherapysessions(seethenextboxformoreexamples).Eachpatternprovidesimportantinformationabouthowherclientcanaffectothersbecausethetherapist’sreactionisoftensimilartoreactionsfromotherpeopleinherclient’slife.
COMMONPATTERNSOFEMOTIONALEXPRESSIONANDBEHAVIORTHATCANBEATTRIBUTEDTOTRANSFERENCE
•Secureandengaged
•Angryorentitled
•Anxiousandpreoccupied
•Avoidant
•Sexualized
COUNTERTRANSFERENCEISIMPORTANTINFORMATION
Yourcountertransference
•maybesimilartoresponsesbysignificantpeopleinthepatient’slife
•caninformyourunderstandingofthepatient’sinterpersonalproblems
•Recognitionofcountertransferencecanguidefurtherintervention
Thus,countertransferencemayprovideanothertypeofinformationabouttheinterpersonalinteractionsthataclientinadvertentlycreates(andthatcanleadtotheself-fulfillingprophecyofmaladaptiveloops,whichhebothdreadsandexpects).Forexample,ifatherapistisfeelingboredwithaclient,itmaywellbethatotherpeoplefeelboredwithhimaswellanddisengagefromfurtherinteraction.Others’disengagementreinforcesthisclient’slonelinessinhissufferinganddepriveshimofanopportunityforhelpfulsocialsupport.Understandingthesecluestodifficultiesandfindingaconstructive,nonblaming,empathicwayofexploringthemwithaclientcanprovideanewandpowerfullytherapeuticexperience(Betan,Heim,Zittel,&Westen,2005).
COMMONCOUNTERTRANSFERENCETHOUGHTSANDFEELINGS
Countertransferencethoughtsandfeelingsareinevitable.However,problemsariseifatherapistactsoncountertransference,withoutreflectingfirst.
Imaginehowdifferentatherapywouldbeifyouactedononeofthesecommonreactions:
•IwishIhadnevertakenthisclienton.
•Ifeeloverwhelmed.Ithinkthispersonwoulddobetterwithsomeoneelse.
•Thisclientismyfavorite.
•Iwanttodisclosemoreaboutmyselfandgotheextramileforthisperson.
•Ifeelattractedtothisclient.
•Ifeelbored,annoyed,andwatchtheclock.
•Iwanttoprotectornurturethispatient;Ifeelangryatpeopleintheirlife.
•Ifeelunappreciated,devalued,andfeeltheurgetocriticize.
GettingaDeeperUnderstandingofTransferenceDynamicsThenexttask,afterbuildinganallianceandbeingabletodescribeaclient’schiefcomplaintsandrecurrentstrugglesinrelationships,istogetadeeperunderstandingoftherelationaldifficultiesthatinterferewithhisgoals.Ausefulwaytoconceptualizetransferenceindynamictermsstartsfromthepremisethatalthoughclientsentertherapyformanyreasons—oftensimplyforreliefofsymptoms—thedynamicsoftransferencearisefromthecombinationofdreadthatoldrelationalpatternswillberepeatedalongsidethehopeforsomethingnewandbetter.Inordertoachievethelatter,aclientmustfirstremovetheobstaclestoresilienceorgrowththattypicallyresultfromdifficultearlylifeexperiences(Shedler,2010).
Inparticular,earlylifeexperiencesmayleadtotheformationofpathogenicbeliefsabouttheselfandothers—skewedexpectationsthatareencodedinaninsecureinternalworkingmodel.Thesebeliefscreateproblemssuchasself-doubt,self-loathing,distrust,fearofcloseness,feelingsofguiltandexcessiveresponsibilityforothers,shame,anddifficultieswithangerorassertiveness(Sammet,Leichsenring,Schauenburg,&Andreas,2007;Weiss,1993).Pathogenicbeliefsalsoshapeanindividual’sinterpersonalbehaviors(Shedler,2010).Thesebehaviorscanleadtoamaladaptiveloopinwhichexpectationsguideinteractions,whichcreateexperiencesthatreinforcetheexpectation—arepetitionthatispainfulanddestructive.Forinstance,apersonwhoanticipatesrejectionorshamefromothersmayprotecthimselfbywithdrawingprematurelyfrominteractions,whichincreasestheoddsofactualrejectionandconfirmsthepathogenicbeliefthatnoonewants
tobewithhim.Thissamepersonmightalsodismissthevalueoftherapy—essentiallytestingifhistherapistwillrespondintherejectingorshamingwaythathisbeliefspredict.Inpsychotherapy,weaimtomodifytheloopsothattheoutcomeismoreadaptiveandfunctional.
Pathogenicbeliefsarethefirststepinasequenceofmentalactivityandinterpersonalbehaviorsthattogethercanbeunderstoodasadescriptionoftheclient’sprimaryrelationaldifficulties.Beliefsthatareformedasclientstrytomakesenseofupsettinganddisappointingexperiencesinearlyrelationshipsguideinterpersonalbehavior.Moreaccuratelyinthecontextofpsychotherapy,old,familiar,destructivepatternsareinternalizedaspathogenicbeliefs—andleadtomisunderstandingcurrentcircumstances,andactinginawaythatleadstointerpersonalproblems(Strupp&Binder,1984).Thisisthe“loop.”Atherapistcangetasenseofthepathogenicbeliefs,andthebehavioralpatternstheycreate(andwhichwillplayoutinaclient’srelationshipsandinthetransference),byusingallthreesourcesofrelationshipdata:bytalkingaboutpastexperience(there-and-then);exploringcurrentrelationalepisodes(there-and-now);andpayingverycloseattentiontowhatgetsevokedwithinthetherapeuticencounter(here-and-now)(Luborsky,Popp,Luborsky,&Mark,1994).Forexample,aclient’spathogenicbeliefaboutbeingunworthywillinfluencehimtoexperiencehimselfasbeingnotvalued
orbeingcriticizedbythetherapist.Alternatively,aclientwiththatbeliefmayseektomasterthenegativeexpectationsbyturningthetablesonthetherapist(pushingheraway),dealingwithhisfearofshameandhumiliationbyshamingandhumiliatingthetherapist.Insuchaffectivelyloadedinteractions,itisespeciallyimportantforatherapisttopaycarefulattentiontoherowncountertransferenceand,infact,towelcomeitasusefuldataaboutwhatherclientmighthaveinhismindwhenheactswithhostility(orsubmission)towardher.
Bylookingforloopsofmisunderstandingandrepetitiveanddestructiveinterpersonalexperiences(especiallyhere-and-nowwithinthetransferenceandcountertransference),onecanunderstandaclientmoredeeply,whichinturnfostersmoreaccuratetherapistempathy.Aswewillsee,oneofthecommonwaysinwhichthetherapeuticalliancecanbestrainedorrupturediswhentreatmentinadvertentlyreconfirmstheclient’spathogenicbeliefsandreinforcesamaladaptiverelationalloop.Thatiswhentherapycanreinforcetheclient’sproblemratherthanprovidingasolution.Beingattentivetosuchloopscanhelpatherapisttosteerherclienttowardanewexperienceofrelationships.
2Thenomenclatureofadultattachmentpatternsdiffersindifferenttheoreticalmodels.Amorecompleteexplicationcanbefoundelsewhere(Maunder&Hunter,2012;Ravitz,Maunderetal.2010)alongwitharationaleforcombiningmodels.3Affiliativebehaviorveryconsistentlypullsforamatchingresponse.Responsesonthedimensionofpower,however,arenotalwaysreciprocal.Dominancethatiswarmoraffiliativeismorelikelytopullforasubmissiveresponsethandominancethatisdisengaged.Sometimesthelatterchallenge(asisillustratedbyJoelintheDVD)elicitsanequallyhostileresponse.4Wearefocusingonaspectsofcountertransferencethataredirectlyrelatedtowhatishappeningwithinthetherapeuticrelationshipandarecluestodifficultiesintheclient’sotherrelationships.However,thetherapist’spersonalityandinterpersonalsensitivities(whichexistirrespectiveoftheclientwithwhomsheisworking)canalsobeproblematic.Therapistswhotendtohavepooroutcomesshouldseekconsultationandrecognizetheirpotentialcontributions(Gabbard,1995).Collectingclientfeedbackabouttheirexperienceoftherapy,progress,andtheallianceisalsorecommended(Norcross&Wampold,2011).
5::EngagingintheProcessofTherapy
Effectivepsychotherapyisnotalwayssmoothsailing.Inevitablechallengesarisewhenatherapistlacksunderstandingorempathyorwhenshegetspulledintopositionsthatreplicatetheproblemandarenotpartofthesolution.Ideally,aneffectivetherapistfocusesonwhatishappeningbetweenherandherclientinamoment-to-momentfashion.Whileitiseasytofocusoncontent—thenarrativethatisunfolding—aneffectivetherapistknowsthatthedynamicsandprocessofthatinterchangeareevenmoreimportant.Theprocesstellsherwhatishappeningrightnow,inthemoment,notinthepast.Attendingtotheprocessstartswhensheaskstheessentialquestionofwhysomethingishappeninginthiswayatthismoment.Isshebeingexperiencedassomeonehelpful,empathic,andattuned?Oristhetherapistbeingexperiencedassomeonedismissive,rejecting,orcritical?Istherapybeingexperiencedbytheclientasenablinghimtofeelbetterovertime,ornot?Therapistscannotknowandmustnotassumetheyknowwhatisinthemindsoftheirclients,buttheycangentlyexplorethesekindsofquestionsinordertogetclientfeedbackthatimprovestheirunderstandingovertime.
Whentherapistsfeelchallengedorstressed,theirresponsescanbecomeunhelpfultothepatientandharmfultothetherapeuticrelationship.Becauseitishardtothink,beempathic,ormentalizewhenunderstress,therapistscanbecomehostile,antagonistic,defensive,orwithdrawninsteadofpausingtoreflectonamoreconstructiveresponse.Forinstance,acommonreactiontoaclientshamingoneistoreflexivelyshameback,andfewtherapistactionsaremoredamagingthanblamingordiminishingaclient(Kraus,Castonguay,Boswell,Nordberg,&Hayes,2011).Soaneffectivetherapistpaysalotofattentiontorecognizingandattendingtostrainsinthetherapeuticalliancewhentheyoccur.Becauseeverytherapyexperiencebecomesstrainedattimesandbecauseitisverylikelytooccurinthecontextofaclient’stypicalmaladaptiveinteractions,effectivetherapistsalwayskeepaneyeoutforevidenceofstrain.Isthisclientavoidingtalkingaboutarecentdifficultsession?Feelinglesshopeful?Moredemoralized?Lessmotivated?Morewithdrawn?Guarded?Doeshehavelessaccesstohisemotions?Isheavoidingormissingsessions?Hashebecomeflatteringandsubmissive?Often,ifwecaninterceptthesethreatstotheallianceearlywecanmakeverygoodtherapeuticuseofthem.Becausetheyoccurpreciselyatmomentsofinteractionthataremostemotionallyloadedforaclient,therapyislikelytotakeoneoranotherdirectionasaresultofhowatherapistdealswiththem;strainsinthealliancecanbeanopportunityforlearningandgrowth.Effectivetherapistsaresensitivetothatprocessandusetheirawarenesstopreventreinforcingaclient’stypicalmisunderstandingofothers’intentions,beliefs,andfeelings.
Tofullyengageinpsychotherapy,aneffectivetherapistneedstohavearangeofwaysinwhichsheusesherselftherapeuticallytoexpressconcernandunderstanding,andto
exploreandcommunicateabouttheprocessesthatreverberatebackandforthbetweenherselfandherclient.Sheneedstobegenuinelyinvolvedwiththetreatment—notsittingapartfromtheclient,sotospeak,butsittingwithhimanddemonstrating,bothinwhatshesaysandwhatshedoes,thatshereallymeanstobethereandwishestounderstand.Aneffectivetherapistshowsthatsheisnotgoingtoavoiddealingwithhotissuessuchasemotionallyoverwhelmingproblems,negativetransference,ortherapeuticimpassesbutthatshewillexplorethemwiththeclientinawaythatisengaged,respectful,andbearstheclient’sgoalsinmind.Mostimportantly,aneffectivetherapistdemonstratesthatshewillnotaddtotheburdenofshame,blame,orfaultthattheclientisalreadycarrying.Laterinthechapter,wediscussthetechniquesofmentalizingandmetacommunication,whichassistatherapistindealingwiththesehotissues.
TEARANDREPAIR:GETTINGHOOKEDANDGETTINGUNHOOKEDAwell-constructedandmaintainedalliancecontainsthetherapeuticprocessandkeepstheclientandtherapistengagedwithoneanotherthroughtheinevitableemotionalandrelationaloscillationsthatoccurintherapyandcreatestrain.Repairingthesestrainsiscriticaltosuccess;theiroccurrenceneednotunderminetheeffectivenessofpsychotherapy.Onthecontrary,strainsinthetherapeuticallianceareimportantopportunitiesforrecognizingtogetherwhathasgoneawryandhowitcaninformboththerapistandclientabouthowproblemsoccurinrelationshipsoutsideoftherapy.HillandKnox(2009)refertothetearandrepairofthetherapeuticrelationshiptounderscorethefactthattensions,disagreements,anddivergencewilloccurandthatthesearetherapeuticopportunities,butonlyifrecognizedassuch(Safran,Muran,&Eubanks-Carter,2011).
TEARANDREPAIR
Astrainedtherapeuticrelationshipoccurswhentensions,disagreements,divergence,andhurtfeelingsbetweentherapistandclientinterferewiththetherapeuticalliance.
Astrainedalliancecanberepairedandisanopportunityforaclientto
•Grow
•Seehimselfascapableofattainingagoodrelationship
•Experienceothersasemotionallyavailable
Inordertoturnastrainintoanopportunityforgrowthanddevelopment,atherapistneedstobecloseenoughtotheencountertofeelitsemotionalimpact,thatis,togethooked.However,shealsoneedstoretainthecapacitytoreflectandstepback,thatis,getunhooked,inordertoprovideatherapeuticresponsethatprocessestheexperiencewiththeclientratherthanenactingareactionthatconfirmsaclient’spathogenicbelief(Kiesler,1996;Leszcz&Malat,2011).Atherapistisaidedintheseinteractionsbyrecognizinghercountertransferenceandtheinterpersonalpullsevokedinherbyherclient,inaccordance
withtheinterpersonalcircumplexmodel.Beingsufficientlyengagedwiththeclientallowsonetofeelthepull(togethooked)buthavingaframeworktounderstandinterpersonalpatternsintherapyallowsonetodisengageandreflect(tounhook).Ifthetherapistisabletogenerateatherapeuticresponsethatisnovelfortheclientitmaydisconfirmhispathogenicbelief.Ofcoursethisinsightisdeepenedthroughsubsequentcommunication,jointexploration,and,mostimportantly,theexperienceofthetherapistasdifferentthanexpected.Thisexperientialconfirmationoftheclient’swishformorefulfillingrelationshipssetsafoundationforsafeexplorationandgrowthinthetherapy.
Itisnevercertaintoatherapist,inadvance,ifaparticularchoiceofwordsoractionwillbetherapeutic.Shejudgesthisfromtheclient’sfeedbackandresponse.Evidenceofbenefitisseenwhentheclientbecomesmoreemboldenedemotionally,moreself-referential,morereflective,morethoughtfulaboutwhatisgoingoninhisinnerworldandinthemindsofothers,andwhenhegainsmoreaccesstomemoriesofearlylifeeventsthathaveshapedtheoriginalpathogenicbeliefs(Weiss,1993).If,however,thetherapistbecomeshookedandsubmitstoherclient’sinterpersonalpullsinwaysthatcomplementthem,disconfirmationdoesnotoccur.Atthosetimestheclientbecomescaughtagaininhismaladaptiveloop,andherevertstohistypicalpatternsof,forexample,silence,defensiveness,oraggression.Thusonecanjudgethetherapeuticimpactofinterventionsbytheresponsestheyproduce.Whenindoubt,checkinandinquire—thisprovidesaquickopportunityforrealignmentifatherapistisnotprovidingthebenefitthatsheintends.
Gettinghookeddescribestheexperienceofatherapistbecomingdrawnintoreactingintheoldrelationalpatternsthatthepatientinadvertentlypullsfor(e.g.,ontheinterpersonalcircumplex).Thisisnotwrong;itisalmostinevitableingoodtherapiesinwhichthetherapistisreallyconnectedtotheclient.However,thetrickforaneffectivetherapististobeawarewhenthisishappeningsothatshecangetunhooked(Choi-Kain&Gunderson,2008).Unhookingrequiresthetherapisttoobserveherselfgettingunhelpfullycaughtupintheclient’srepetitiverelationalpattern,andshecanusethisasdatatoassisttheclientinbecomingmoreawareofit.Atherapistcangetunhookedbyreflectingontheprocessoftherapywiththeuseofmentalizingandmetacommunication.Althoughtheseusuallygohandinhand,wewilladdressthemoneatatime.
UNHOOKINGWITHMENTALIZINGReflectingontheprocessoftherapyisaformofmentalizing,whichisapowerfultherapeutictoolforpromotinggrowth,development,andresilience.Perhapsthemoststraightforwarddefinitionofmentalizingforourpurposesisthatitis“acapacitytoreflectonone’sownmindandthemindofothers.”Althoughmentalizingisimplicit(i.e.,unconscious)inmanyinterpersonalinteractions,ineffectivepsychotherapythetherapistmentalizesexplicitlyinordertohelptheclientovercomedeficitsinhisorherowncapacitytomentalize.
Mentalizinginvolvesappreciatingthatpeoplehavedifferentmentalstates,suchasbeliefs,desires,intentions,andemotionsthatguidetheirbehaviors.Understandingthe
presenceofthesestatesofmindinoneselfandothersclarifieswhypeoplebehaveinthewaystheydo.Anindividualwithstrongmentalizingcapacitycanappreciate,forinstance,thatsomeonewhofeelsthreatenedwillactdifferentlythanhewouldifhefeltsafe,thatwhatonewishesforwon’tnecessarilyoccurandthathowonelooksmightbedifferentfromhowonefeels.Ultimatelyonecanneverknowwhatisinanother’smind,butonecanmakeareasonableguessastohowanotherpersonisfeelingandexplorewithhimorhertoconfirmormodifytheguess.Mentalizingisaformofreflectionthatallowsustoappreciateourownandothers’intentionsasdifferentfromtheirbehaviors,andwecaninturnappreciatethenuanceofinteractions.
Mentalizingisacrucialcomponentofourmentallife,andaneffectivepsychotherapist“multitasks”aboutmentalizing.First,sheseesitasameansofunderstandingaclient’sdifficulty—appreciatingthatearlyadversityhasimpairedhiscapacitytoaccuratelymentalizeabouthisownmindandwhatisgoingoninthemindsofothers.Second,aneffectivetherapistemploysmentalizingasatherapeutictechnique,modelingreflectionbywonderingoutloudaboutherclient’smentalstate,forexample,ortheinnerlifeofapersoninananecdotetheclientrelates.Third,mentalizingisaskillaclientcanacquire,whichwillhelphimtoavoidhischaracteristicmaladaptiveloops.Whenaclientcanimprovehiscapacitytomentalize,hetakesamajorsteptowardresilienceandwell-being.Fourth,aneffectivetherapistisawareofherinnerexperiencesandpostulatesaboutherclient’sinnerexperiencesinordertoremainreflectiveandmovethetherapyforward.
UsingMentalizingtoUnderstandaClientWeearlierdescribedparentalcharacteristicsthatprovideachildwithavalidatingenvironment.Fundamentally,avalidatingparentappreciatesthetypeandintensityofachild’semotionalsignalsandisabletoconsiderpossiblereasonsforthemandconveyanexplanationofthechild’sinternalstatethatmakessensetohim,aswellasconveyingasenseofadultcontainmentormasteryofthestate.Thisprocessofreflecting,containing,andalleviatingfosterssecureattachmentandachild’scapacitytomentalize(Fonagy&Target,1997).Thesesameactivitiesofsupportandvalidationthroughreflecting,containing,andalleviatingarealsousefulforpsychotherapists,especiallywhenrespondingtoclientswhofeelinsecureinthepsychotherapeuticrelationship.
Growingupinaninvalidatingenvironmentleadsanindividualtoaninsecurepatternofattachmentanddifficultywithmentalizing.Thisdifficultycomesinseveralforms.Forexample,mentalizingcanbe“stuck”inanearlydevelopmentalphase,suchaswhenapersonassumesthattheeffectofanactisthesameasitsmotivation—“ifyoumakemeangry,itmustbebecauseyouwantedtomakemeangry.”Alternatively,mentalizingcanbechronicallydistortedbyrigidexpectationsofwhatothersarelikelytothink.Mentalizingcanevenbe“turnedoff”byachildwhen,forexample,hiscapacitytounderstandhisabusiveperpetrator’smindrevealshisabuser’shatred(orotherterrifyingintent).“Turningmentalizingoff”canbeunderstood(atleasthypothetically)asadeterminationthatitisbetternottoknowwhatothersthink,ifitistoofrighteningtobeawareoftheirthoughtsoronehasnopowertoprotestorleave(Choi-Kain&Gunderson,2008).
Aclientwithadismissingattachmentstylemayhaveexperiencedaparentwhowassopersistentlyunavailablethatthechild’sabilitytounderstandhismindwasundernourished,leadinghimtoceasetryingtounderstandhisownfeelingsandmotivationsorthoseofothers.Alternatively,aclientwithpreoccupiedattachmentmayhavefoundhisparent’smindtobeinconsistentlyavailableorattentive,whichcontributedtoamodeofmentalizingthatwasoverlyfocusedonfindingcluesaboutchangesinhisparent’smentalstate.Thischildbecameexquisitelyattentivetowhatothersmaythinkandfeel—watchingforwindowsofavailabilityandanticipatingdisappointmentorrejection.Itismerelyasubstitutionofoneterminologyforanothertosaythataninsecureadultwhomaintainsthesebiasesofperceptionandattributionhaspathogenicbeliefsabouthimselfandothers,whichputshimatadisadvantageininterpersonalrelationships.Asapsychotherapyclient,hewillrevealhisbiasedexpectationsviaproblemsinhiscurrentcloserelationshipsandbyhistransferencetothetherapist.
UsingMentalizingasaTherapeuticTechniqueTherearemanyforcesatworkinatherapeuticconversation,layeredwithinthedialogue.Whentheselayersfeelconfusing,mentalizingcaninformatherapistabouthowtoact.Forstarters,thelinkbetweensecureattachmentandeffectivementalizingisausefulguidebecauseitsuggeststhatprovidingasecuretherapeuticbaseisapreconditionfortheexplorationthatpsychotherapyrequires.Inattemptingtocreatethatsecuretherapeuticbase,aneffectivetherapistworksatbeing“goodenough”inappreciatingandattendingtoherclient’sdistress.Thisisapositionthatallowshertoacthelpfully,withoutbeingtooinhibitedbytryingtofindaperfectresponse.5Shetriestomaintainbothcuriosityaboutwhatisinherclient’smindandhumilityaboutthelimitsofherabilitytotrulyunderstandhim.Ofcourse,aneffectivetherapistalsoappliesthereflectivefunctiontoherself—mentalizingisfundamentallyinteractional,soapsychotherapistneedstoreflectonherownstateofmindaswellasherclient’sduringpsychotherapy—anattitudethatpredisposeshertoidentifyingandcatchingcountertransferencereactionsearlyandbeingabletofindthereflectivespaceinwhichtounhookfromimpasses.Aclientdevelopsasecurebasewithapsychotherapistsotheclientcanreturnandfeelsteadiedwithintheirrelationshipwhendistressedbytherapeuticexploration.Theeffectofprovidingthesefunctionsistohelpaclientdevelopmoreeffectivestrategiestoself-regulatehisdistress.
MENTALIZINGSTRATEGIES
Thinkingaboutthoughtsandfeelings
•Yourownandothers’
Helpingaclienttomentalizewellhelpshimorhertoappreciatethat
•Othershavemanydifferentbeliefs,understandings,andintentions
•Aperson’simpactisnotalwayswhatheorsheintends
•Sometimespeoplefeelonewayandactanotherway
Helpingaclienttoregulatehisemotionsmoreeffectivelyrequiresattendingtohislevelofarousal.Whenanyofusisinteractingwithanother,thereisarangeofoptimalarousal—azoneinwhichwearealert,attentive,andengagedwithoutbeingoverwhelmedorwithdrawn.Clientswholiveinstatesofinsecurity(andevenmoresoforthosewhohaveexperiencedtrauma)areoftentoohighlyaroused(thehypervigilanceandoverstimulationoffear)ortoounaroused(thenumbing,avoiding,anddissociationthatdefendagainstfear).Reflectioncannotoccureffectivelyineitherofthosestates,sothetherapistmustworkwiththeclienttohelphimtoreturntotheoptimalzoneofarousal(Ogden,Minton,&Pain,2006).Overtime,thetherapisthelpsaclienttowidenthisoptimalzoneand“makeroom”fortheextentofarousalthataccompaniesallofhisorheremotions.Effectivetherapistsaccomplishthisgoalbyusinginterpersonalstrategiessuchasprovidingsupportandvalidation,maintainingpresence,andbeingconsistent.Bymentalizingandpromotingaclient’scapacitytomentalizeitisreasonabletoexpectaclientwillreducenonmentalizingbehaviors,suchascuttingorbingingonfood,inordertoregulatehisemotions.
Oncethetherapeuticrelationshipissufficientlystable,atherapistcanemphasizeseveralmentalizingstrategies.Thesecanhelpaclientmanageemotionsmoreeffectively,gentlypromoteunderstandingofhimselfandothers,andincreasehisabilitytoconstructacoherentnarrativeabouthimself.Thisinturnhelpsaclienttohaveaclearersenseofhowhislifeandproblemshaveevolved,agreaterempathytowardhimselfandothers,anenhancedabilitytofunctioninhiscurrentcircumstances,andthecapacitytoexpresshimselfeffectively.
Twousefulmentalizingstrategiesaremodelingandcontrarymoves.Atherapistmodelsmentalizingbyadoptinga“notknowing”therapeuticstance,exhibitingcuriosityaboutherclient’sinnerworld(andherown)bylabelingaffectandbycommunicatingaboutinternalstatessuchasemotions,wishes,andvulnerabilities.Modelingbringsmentalizingaliveinthehere-and-now.Itisoftenhelpfultowonderaloudaboutintentions—eitherthoseoftheclientorofanotherpersonwithwhomhehasinteracted.Questionssuchas“Whatdoyouthinkhewastryingtodo?”or“Icanseethatmadeyouangry,butwhydoyouthinkitdid?”requestamentalizingresponse.Whatdidthatotherpersonhaveinmind?Wastheirobjectiveorimaginedintentequivalenttotheoutcome?
Acontrarymoveisaninvitationtoaclienttomovehisattentionbetweendifferingperspectivesoraspectsofexperience.Onecanaskquestionsintendedtomoveaclient’sattentionbetweenthoughtsandfeelings,betweenthinkingaboutoneselfandthinkingaboutothers,betweenafocusonaninternalversusanexternalperspective,orfromastanceofcertaintytooneofgreaterdoubt.Forinstance,aclientmaybecaughtinnonreflectiveruminationthatisfocusedonanoverlyintellectualanalysisofaninteraction.Thecontrarymoveistoencouragetheclienttolookatthesameissuefromtheperspectiveoftheemotionsofthepeopleinvolved.Similarly,iftheclientisfocusingonlyonhimself,onecanencouragehimtoconsidertheperspectiveofanotherperson.
MENTALIZINGTECHNIQUES
Modelmentalizingofself
•Communicationofmentalstates
•Reflectiononmentalstates
•Wonderingaboutintentions
Usea“not-knowing”stance
Usecontrarymoves
Collaborateincreatingacoherentnarrative
Thetimingofatherapist’srequesttoherclienttoseeaninteractionfromtheother’spointofviewisimportant,anditisbestutilizedwhencombinedwithempathywithinatherapeuticalliance.Ifperspective-takingquestionsareaskedtooearlyon,aclientmaythinkthetherapistisnotawareofhisdifficultiesoristakingthesideoftheother.Thisislikelytoreinforceaclient’spathogenicbelief.
CASEEXAMPLE:HELPINGACLIENTTOMENTALIZE
Bypracticingandmodelingmentalizing,atherapisthelpsaclienttoacquirethiscapacityforhimself.Whenaneffectivetherapistthinksoutloud,forexample,sheinvitesherclienttodothesameforhimself.Itisalsohelpfultoacknowledgewhenitisapparentthataclientismentalizing,ortopausetheprocessandrewindwhenheisnot.
Aclientwhosecapacitytomentalizehadincreasedoveracourseofpsychotherapywasdescribinganexperienceinacoherentmanner.Hisnarrativehadacleartimeline,hecommunicatedhowhefelteffectively,andhecommunicatedhisunderstandingoftheotherpeopleintheseencounters.Whenheshiftedtodescribeaninteractionwithhisbrother,however,hisnarrativebecameincoherent.Henolongerusedcompletesentences,losteyecontactwiththetherapist,andbegantotalkaboutdetailsthatwerebesidethepoint.Ratherthanfocusingonthecontentofthedisputebetweensiblingshewasdescribing,histherapistchosetoidentifyforhimthechangeinhisstateofmindandmodeofcommunicationthatshehadobserved.Sheconveyedthatshefelt“lost”inthemoment,andsheaskedhimto“rewind”towhenhestoppedbeingcoherent.Shenotedthathehadlosttrackofhisthoughtswhenshewastalkingaboutrelationshipsthatcarriedalotofbaggageforhim.Thissimpleobservationbroughthimbacktothehere-and-nowofthetherapy.Inresponse,theclientdescribedtheextentoftheunderlyinganxietythatheexperiencedwhenspeakingabouthisbrother.Thisreturntomentalizingabouthimselfallowedhimtoexperiencehisincoherenceasalapse(duetothefamilialtensionsthatwerestillabletodiscombobulatehim)ratherthanasalackofprogress.Thetherapistcongratulatedhimforhissuccessindealingwithnonfamilyissues,andsheidentifiedthe
challengesthatremainedwithinthefamily.Thetherapeuticconversationthenmovedontoreflectontensionswithhisolderbrother.Mentalizingenabledhimtorestorehisabilitytothinkclearlyandhebegantospontaneouslygenerateideasforwaystoapproachananticipatedfutureinteraction.
RemainingReflectiveIfthereareaspectsofherownlife,betheyhistoricalorcurrent,whichareactivatedbyaclient,theresultingcountertransferencecanderailthetherapyunlessshereflectsuponthesethings.Amentalizingperspectivecanbeprofoundlyusefulforclarifyingavagueandunsettlingcountertransference.Questionsinformedbymentalizingcangoalongwaytowardexplicatingwhyatherapistfeelsacertainwaywithacertainclient.Forexample,atherapistmaywonder“WhydoIfeelthisparticularkindofdiscomfortwiththisclient?,”“Whodoesthisclientseemeas?,”“WhodoesthisclientthinkIseethemas?,“Whodoesthisclientremindmeof?,”or“Whatdoesthisclientthinkmyintentionwas?”Anotherbarriertolearningaboutaclient’swishesandintentoccurswhenatherapistimposes(ofteninadvertently)anassumedgoalonthepsychotherapy—suchaswantingherclient(orassumingthatherclientwants)tostaymarriedortoregainemployment.
Finally,atherapist’sabilitytomentalizecanbechallengedwhenaclient’sinternalworkingmodelprescribesasetofexpectationsaboutothersandhowheshouldbehaveinrelationships.Adismissingindividual,forinstance,mayassumethatotherswillbeunavailableandthereforeacttoincreaseinterpersonaldistance.Ifatherapistdoesnotreflect,shemayinadvertently“accepttheinvitation”andworkwiththisclientinanemotionallydisengagedanalysisofproblems.Suchanapproachwouldservetoreinforcethemaladaptivelooptowhichitgivesrise,ratherthanchallengeit,andwouldnothelptheclienttochange.Similarly,apreoccupiedclientwhosignalshisattachmentneedsexcessivelymaypullhistherapistinto“crisismode,”leadingtoaffectivelyoverchargedinteractionsandafailuretomaintainappropriateboundaries.Withoutreflection,atherapistslipsintore-engagingwithamaladaptiveloop,ratherthanprovidingatherapeuticallydisconfirminginteraction—andshebecomespartofareenactmentoftheprobleminsteadofbeingpartofatherapeuticprocessthatpromotesthediscoveryofsolutions.
UNHOOKINGWITHMETACOMMUNICATION:TURNINGIMPASSETOOPPORTUNITYOnewaytoturnanimpasseintoatherapeuticopportunityistocollaborativelyreflectonwhathastranspired.Thisallowsatherapistandclienttothinktogetherandtrytounderstandwhythisishappeninginthiswayatthispointintime.Assumingwecannotforcertainknowwhatisinthemindoftheclient,thisisanimportantquestionforthetherapisttofirstaskherself.Inposingthisquestiontoherself,atherapistcreatesreflectivespace,whichreducesherreactivityandallowshertothinkaboutthepotentialmeaningandimpactofthisexperience.Ofcourse,aneffectivetherapistdoesnotstopatposingthis
questiontoherselfandreflectingonitsanswer;shealsofindstherightwayandmomentinwhichtoenlisttheclientinthereflection.Sheseekstofindpalatablewaysofdiscussingunpalatablethings.Astherapists,wemustbeabletospeakaboutwhatwethinkisrelevant,inwaysthatareasnoninjuriousaspossible,thataretimedwell,andthatallowustoalignourimpactandourtherapeuticintent(Yalom&Leszcz,2005).
METACOMMUNICATION
Judicioustherapisttransparencyor“thinkingoutloud”
•Blendsassertivenesswithtentativeness
Collaborativereflectiononwhathasjusttranspired
•Whyisthishappeninginthiswayrightnow?
Effectivemeta-communication
•Isusedtofurtheratherapeuticgoal
•Isrelevantandwelltimed
•Isnoninjurious,validating,andilluminating
•Hasanimpactontheclientthatalignswiththerapeuticintent
Metacommunicationiscommunicatingaboutcommunication(Kiesler,1996;Safranetal.,2011;Wachtel,2011).Thetherapist’scapacitytoemploymetacommunicationtoworkwithmomentsoftensioninthetherapeuticallianceisattheheartofeffectivetherapeuticwork.Itallowshertocapitalizeonstrainsintheallianceandpreventsimpassesandstalematesfrombecomingentrenched.Atherapistemploysmetacommunicationatthesepointsbecausesheismindfulthatimpassesintherapyoftenoccurwhenaninteractionisreinforcingapathogenicbeliefratherthandisconfirmingit.Metacommunicationmayinvolvejudicioustherapisttransparencyor“thinkingoutloud,”aswhenthetherapistselectivelysharesherownemotionalreactiontoachargedtherapeuticmomentinordertoopenexplorationandfosterreflection.Whenshedoesthis,sheismindfulnottoassumethatsheknowswhythetensionsoremotionsareemergingorwhatmightbeinherclient’smind.Insteadsheassumesverylittle,adoptingamannerthatisbothstraightforwardandtentative.Duringthisprocess,itisimportantthatatherapistremainfocusedonvalidatingratherthanblamingherclient.Astherapistsgainmoreexperiencetheybecomemorecomfortablewithjudiciousself-disclosure(e.g.,transparentcommunicationaboutwhatisoccurringinthehere-and-nowofthetherapeuticinteractions)andrecognizethatitispossibletodeepentheirconnectionwithclientswithoutfallingdowntheslipperyslopeofboundaryviolationsandheightenedclientdependence.Thisskillisattheheartofmaximizingone’suseofselfasatherapeutictool.
CASEEXAMPLES:MENTALIZINGANDGETTINGUNHOOKEDWITHMETACOMMUNICATIONANDJUDICIOUSSELF-DISCLOSURE
InDr.Pain’sinteractioninthefirstroleplaywithKatherineMarks(seeDVD),thetherapistdirectlyaddressesherobservationofachangeinthequalityofherinteractionwithherclient.
Dr.Pain:I’mgettingafeelingthat,aswe’vebeentalking,insteadoffindingawaytotalktoeachotheraboutthethingsthatpuzzleyou,oryou’dliketoexplore,theoppositeishappening.IfeellikeI’minadvertentlysortofchasingyououtoftheroom.Thatsomehow,whatbeganasaverytentativecuriosityisnowmovingtowardfeelinglessengagedhere.Howhaveyoufeltinthelastwhilesincewebeganthissession?
Inthiscommentthetherapistdrawsonherexperienceofcountertransferencewhensheuseshersenseoffeelinglessengagedasdata.Shementalizesaboutherownshiftfromcuriositytodisengagement,andsheasksKatherinetoreflectonherownexperienceinthehere-and-now.RevealingherownexperienceandalsoaskingKatherinetoreflectfostermentalizing.Atthesametime,Dr.Painacceptsresponsibilityfortheroleshemayinadvertentlyhaveplayedinthisshift.Byputtingherfeelingintowords,Dr.PainusesmetacommunicationtoexplorethefluctuatingpullsofengagementbetweenKatherineandher.
Katherine:Whatever,whateverhappenshereisnotgoingtomakeanydifference.That’ssortofhowitfeelstomebecauseIcan’tbe,Ican’tbehelped.Ijust,youknow,it’sallfine,it’sallgood,Ijustcan’tbehelped.
Katherine’sresponseistorevealapathogenicbeliefthatshecannotbehelped,whichmayunderlieherdistancingandsubmissivestance.Katherine’sexpressionofthisbeliefprovidesanopportunitytounderstandherexperienceandtoavoidthemaladaptiveloopthatwouldoccurifthetherapistbecamelessengagedandthusreinforcedKatherine’sexpectation.
InDr.Leszcz’sinteractionduringthefirstroleplaywithJoelWalker(seeDVD),heexperiencestensioninthetherapeuticalliancewhenJoelbecomesactivatedinanangry,dismissivestate.
Joel(interrupting):I’mnotsomewackocreep,right,youknow,that’snot,there’snothinglikethatgoingon,okay?There’snothinguntowardhappeninginmyfamilyhome,okay?Let’smakethatabsolutelyclear.
Dr.Leszczchoosestoprocessthistensioninthehere-and-nowofthetherapeuticrelationship,askingtheclienttomentalizewhatmaybeinDr.Leszcz’smind.
Dr.Leszcz:Doyouthinkthat’swhatI’mthinking?
Joel:Idon’tknowwhatyou’rethinking.ButI’mnot,I’mnotgonnaletyouaskthatquestion.Okay,just,endofstory.
Dr.Leszcz:IcantellyouwhatI’mthinking.
Dr.Leszczproceedswithtentativeandjudiciousself-disclosure.Hetriesto
resistthehostilepullofJoel’sconfrontationtoprovideanexperiencethatdisconfirmsJoel’sfearofbeingjudgedandcriticized.HementalizeswithJoelbyempathicallyconveyinghispreliminaryunderstandingofwhatmaybeinJoel’smind.
Dr.Leszcz:I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe….I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.
5Thismayaccountforwhytherapistswhoareveryself-criticalareoftenlesseffective—theydemandtoomuchfromthemselvesandtheirinevitabledisappointmentcontaminatesthetherapeuticrelationship(Henry,Strupp,Butler,Schacht,&Binder,1993).
6::TakingAccountofTrauma
Traumaticexperiencesinchildhoodorlaterlifeareextremelycommonamongpeoplewhoseekpsychotherapy.Asaresult,effectivepsychotherapistsmusttaketraumaintoaccount,andtheyuseideasandtechniquesthatassistclientstosettleandresolvesymptomsarisingfromunresolvedpasttraumaticexperiences.Katharine’sDVDsectionscapturesomeoftheideasthatunderpinourapproachtoassistintheresolutionoftraumaticexperiences,andtheseportionsoftheDVDcanbeviewedwhilereadingthissection.
Traumaisubiquitousandisespeciallycommonamongpeopletreatedformentalhealthproblems(e.g.,seeFriedmanetal.,2002;Neria,Bromet,Sievers,Lavelle,&Fochtmann,2002;Saxeetal.,1993).Becausetheseindividualsareusuallydiagnosedwithdisordersotherthanposttraumaticstressdisorder(PTSD),theroleofatraumaticpastandhowitcontinuestoaffectthepresentoftengolargelyunrecognizedbytheseclientsandtheirtherapists.Thisoversightandthereasonsforitarecentraltoanunderstandingofthecomplexityoftrauma.
Aclient’sfailuretorecognizeanassociationbetweenpasttraumaticeventsandcurrentsymptomsandproblemscanbeunderstoodtobetheresultofpsychologicaldefenses.Thepresentemotionaldistressis“unlinked”fromitscausesasawaytoavoidandtrytomanagewhatisoftenaverydysregulatedemotionallifecreatedbythepasttrauma.Althoughthisdisconnectionbetweenthememoryoftraumaandcurrentsymptomsandproblemsisinsomewaysaneffectivedefense,itnonethelessbecomespartoftheproblemofunresolvedtrauma—yetanotherexampleofapatterncreatedbyaclienttohelpthemwithdistress,whichturnsouttobemaladaptive.
Fortherapists,theroleoftraumaisoftenunderrecognizedindisordersotherthanPTSD.IfaclientdoesnothaveclearPTSDsymptoms,therapistsmayassumethatpasttraumasarenotactivelycontributingtotheclient’scurrentdistress.However,PTSDisactuallyanunusualoutcomeofpsychologicaltrauma.Inanurban,nonclinicalpopulation,Kesslerandcolleagues(1995)foundthatwhereas60%ofpeoplehadexperiencedalife-threateningevent,theprevalenceofPTSDwasonly5%to10%.Therefore,mostpeople’sdistressfollowingatraumaticexperiencesettlesdownwithinafewweeksandtheyregainorretaintheirusualabilitytofunction.Forthosewhosesymptomsdonotresolve,depressionisamorecommonconsequenceoftraumathanPTSD(Galeaetal.,2002).
Theessenceofatraumaticeventisthatitprovokesaprofoundlyaversivestateoffearorterror.Thesestatesarediscerniblebytheirconsequences:excessivearousal,intrusivememories,andavoidanceofremindersandmemories.Ifthesesymptomsfailtoresolve,othersymptomsmayariseandbecomemoreprominent.Theseincludelow-grade,chronicdepression,oftencombinedwithperiodsofgeneralizedanxiety,panic,oranger.
Furthermore,traumatizedindividualsoftenrespondtothesubstantialemotionaldysregulationthattheyexperiencewithbehavioralmeasuresintendedtoreducetheintensityoftheiremotions,suchasdrugandalcoholuse,self-injury,andotherhigh-riskbehaviors.Suchclientsoftenalsohavemedicallyunexplainedsymptoms,amnesias,dissociativeexperiences,animpoverishedrelationallife,andadeeplynegativeself-image.Thisbroadrangeofchronicsymptoms,deficits,andimpairedfunctiondisguisesthelinkbetweentheeventsthatgeneratedthefearandaclient’sreactiontothem.
BEINGATTUNEDTOTRAUMA
Traumaisprofoundlyaversiveandleadsto
•Excessivearousal,intrusivememories,andavoidance
•Depression,anxiety,andanger
•Problemsregulatingfeelings
•Medicalsymptoms
•Memorygapsanddissociation
•Relationshipproblems
Furthercomplicatingmatters,thefactthatatherapistdoesnotrecognizetherolethatunderlyingtraumaisplayinginherclient’sproblemsisusuallyalignedwiththewaysthattheclientdefendshimselfagainstthinkingabouthispast.Anindividualinthisstateisnotinaposition(yet)toconsiderthebenefitsofreflectingonandintegratinghisexperienceoftraumaintoanarrativeorautobiographicalaccountofhislife—hecannotyetmentalizeabouthisexperience.
Ofcourse,notallclientswithmixed,chronicpsychiatricsymptomshaveexperiencedtrauma.However,becausetheprevalenceoftraumaticexperienceissohighamongpeoplewithmentalillness,traumasymptomsoftenco-occuralongsidevirtuallyallothermentalhealthdisorders.Itiseasytooverlooktraumasymptoms,forinstance,inaclientwithadisease,suchasschizophrenia,thatisveryclearlynottheconsequenceoftrauma.
AstherapistsweneedtoguardagainsteitherassumingthateveryonewhoexperiencestraumawilldevelopPTSD,orfailingtoconsiderthepotentialroleoftraumawhenconfrontedwithaclientwhohasacomplexgroupofsymptomsandproblems.Inthisway,wecanavoidbecomingunwittingco-conspirators,whohelpclientshidefromtheirterrifyingpastsandallowtheirunsuccessfulanddysfunctionalavoidantadaptationstocontinue.Insuchasituation,effectivetherapyencouragesboththetherapistandclienttoconsideridentifyingandexploringtherelationshipbetweenthepastandtheproblemsofthepresent,withtheassumptionthatfindingawaytousefullyaddressaclient’sunresolvedexperienceswillreducehissufferingandimprovehiscurrentandfuturequalityoflife.
PATHSTOUNRESOLVEDTRAUMA
Whydosomepeoplefailtorecoverfromtraumaticexperiences?Whydotheyremaindistressed,losefunction,anddeveloppsychiatricdisorders?Therearetwoproposedroutestochronic,unresolvedtraumaticsymptoms.Thefirstrouteisthatpreviouslywell-adjustedadultsmaynotbeabletoresolvethecumulativeimpactofmultipletraumaticexperiences,asisseeninmembersofthemilitarywhoaredeployedtoofrequently(Klineetal.,2010).Thecombinationofrecurrentexposure,alackofsupport,andinadequatetimetorecovercaneventuallyoverwhelmanindividual’sresilienceandproducesymptomsanddysfunction.Thesecondrouteisfoundintraumasurvivorswhohavehadaninvalidatingchildhood(Linehan,1993).Ofnote,mostclientswhoarechronicallysymptomaticaftertraumahaveexperiencedmanytraumaeventsaswellasachildhoodinachronicallyinvalidatingenvironment.
Achildraisedinaninvalidatingenvironmentisill-preparedforsubsequenttraumaticexperiences.Theinvalidationmeansthathehashadlittlepracticeatknowinghisownstrongemotionsandrespondingtothemwithcompassion.Whensuchapersonisexposedtoaterrifyingevent,heisunabletounderstandortoleratehisresponseandbecomessymptomatic.Similarly,heisnotabletoaccuratelyidentifyothers’emotionalcommunications,whichmakesitconsiderablymoredifficulttorecognizeoracceptcompassionandassistancefromothers.Furthermore,ifthetraumaoccurredwithinhishomewithcaregiverswhowerefrightening,frightened,orwereunableorunavailabletooffersolaceandprotection,thetraumaticexperiencesbecomeinextricablyjoinedtotheexperienceofinvalidation.6
ASKINGABOUTTRAUMAThefirstwayoftakingtraumaintoaccountwithanewclientistoaskabouttraumaticeventsinhislife.Thisshouldusuallybedoneduringtheinitialassessmentbutcanalsobedonelaterintreatment.Askinggentlyandappropriatelyaboutadultorchildhoodexperiencesthatwerefrighteningisusuallyagoodplacetobegin,regardlessofaperson’sdiagnosisorsymptoms.
ASKINGABOUTTRAUMA
Askinggentlyandappropriatelyismoreamatteroftoneandtimingthanofchoosingperfectwords;uselanguagethatisfamiliarandcomfortabletoyourclient.
Samplequestions:
•Hasanythinghappenedtoyouthatfrightenedyouagreatdeal?
•Doyouthinkyouhavegottenoverit?
•Hasanyonephysicallyorsexuallyhurtyouasanadult?Asachild?
•Idon’twanttodistressyouwiththesequestionsbutIthinkthatitmighthelpustofigureoutwhatyou’resufferingwithrightnow.Doyouagree?
Iftheclientisbecomingoverwhelmed,slowdowntheprocess:
•Switchfromenquirytoempathicvalidation,or
•Acknowledgethetimeisnotrightandchangethesubject
Sometimesaclientbecomeslesscoherentwhenhespeaksoftraumaticevents,reportingtheseeventswithoutanyemotionalcolororseemingtobetoooverwhelmedwithemotiontoarticulatetheirexperience.Asaclientattemptstodescribeatraumaticexperiencethesyntaxofhislanguagemaychangetobecomelessclear,suchthathenolongerusesorderlyconnectedsentences,forinstance(seethecaseexample“HelpingaClienttoMentalize”).Thisincoherenceisahintthattraumaticmemoriesarenotyetadequatelyincorporatedwithinhisautobiographicalnarrative.
UNDERSTANDINGTRAUMATICEXPERIENCESANDPROMOTINGACCEPTANCEANDINTEGRATIONHearingthefactsofthetraumaticeventdoesnot,initself,tellatherapistwhatisdisturbingherclient.Indeed,hearingtheclientreporthistraumaticexperiencescandistanceatherapistbecauseofherownreactiontoit.Forexample,especiallyattimesofemotionalintensity,itiseasyforatherapisttofallintothetrapofassumingthatsheknowsorfeelsthesameastheclient,effectivelysubstitutingherownreactionforherclient’s.Althoughunderstandable,whenthisoccurstheclient’sownexperienceandanycluestothemeaningthetraumahadforhimbecomelost.Toavoidthis,thetherapistneedstokeeptheclientcentrallyinherattention;itistheclient’sexperiencethatmustremainthetherapist’sfocus.Inthiswayhereffortstomentalizeabouttheclient’sexperiencewillfacilitateusefulunderstandingabouttheaspectsoftheeventsthatweretoofrighteningordifficultfortheclienttoresolve.Understandingtheeventwithintheindividual’suniquepersonalhistoryhintsatthemeaningthatitholdsforhimandwhyhehasnotresolvedtheexperienceandrecovered.Aneffectivetherapistnotesherownreactionstoaclient’straumastory(hercountertransference)butholdstheminmindasuseful,potentialinsightsintothepatient’sexperience—distinctfromherclient’sexperienceandthemeaningheattributestoit.
ASSESSINGIFTRAUMAISRESOLVED
Isthepastdisturbingexperiencefrequentlyontheclient’smind?
Whomhastheclienttoldabouttheevents?
Whatisitliketellingyounow?
Howmuchhastheclientintergratedtraumaticmemoriesintohisorherlifestory?
Isthelanguagethataclientusestodescribethetroublingeventsasymbolic,linguisticdescriptionthattakesitsaudienceintoaccount?
Inassessingtraumaticexperiences,aneffectivetherapistaskstheclientifthepastdisturbingexperiencefeelsrelativelyresolvedorwhetheritisonhismindalotofthe
time,and,ifso,howmuchofthetime.Whomhashetoldabouttheeventsandwhatisitliketellingthetherapistnow?Atherapistobserveshowmuchtheclienthasintegratedhispastintothestoryhetellsabouthislife.Shenoticesthefluencyorlackofitthataclientusestodescribethetroublingevents:isitasymbolic,linguisticallysophisticateddescriptionthattakesitsaudienceintoaccount?Forexample,canhetellhistherapistoneaccountofhissexualassault,hisfamilydoctoranotherequallytrueaccount,andhisnewromanticpartneranother—eachtailoredtothespecificrelationshipsinvolved?Tobeabletoadaptanarrativeabouttraumatodifferentcircumstancesandlistenerswhilemaintainingitsaccuracyisastrongindicatorofasuccessfulpsychologicalresolutionofthememories(andagoodcapacitytomentalize).Oristhestoryonlyaccessiblewhentriggeredbyambientremindersthatleavetheclientstrugglingwithapastexperiencethatseemstosuddenlyhappenagainasthoughforthefirsttime,experiencednotaslanguagebutwiththesenses?Thelattersituationindicatesthatthetraumaisunresolved.
Allenstatesthattheaimofhelpingaclientresolvehispastisto“makesense”ofit,tohavethecapacitytoreflectuponthepastwithinthesafetyofthetherapeuticallianceandtodevelopacompassionateattitudetowardhimself(Allen,2013).ContrarytoformalguidelinesforthetreatmentofPTSD,whichrecommendthataclientbe“desensitized”tohisorhertrauma(Foa,Keane,Friedman,&Cohen,2014),wesuggesta“softer”goal—topromoteacceptanceandintegrationofthetraumaticexperiencesintoaclient’slife.Indeed,foraclientwithacomplexmultisymptompresentation,desensitizationisnotappropriateorhelpfuluntilsubstantialstabilityhasbeenachieved(Herman,1992).
WorkingtoRecognizeandResolvetheExperienceofBetrayalWhenItIsExperiencedinTherapyOneofthereasonsforattendingspecificallytounresolvedtraumaticexperienceisthatclientswhohavesufferedbothtraumaandinvalidatingchildhoodenvironmentsconsistentlyhavedifficultyformingatrustingrelationshipwithothers,includingatherapist.Tounderstandthis,considertheenvironmentinwhichsuchexperiencesoccur.Overwhelminglyfrighteningexperiencesarenotnecessarilypsychologicallytoxic—unlessthevictimsarealsoabandonedintheprocess(orafterward)bythepeopleintheirliveswhomtheycountonforprotectionandsecurity.Thetherapistinadvertentlyandunconsciouslyremindstheclientofthepersonwhoshouldhavehelpedhimduringorafterhistraumaticexperience,butdidn’t.Consciousorunconsciousmemoriesofthisbetrayalemergewhentheclienttalksorthinksaboutthetraumaintherapy.Foraclientinthissituationthecombinationoftraumaandbetrayalisexperiencedasbeingindivisible.Ratherthanrecognizingthathisparents,caregivers,orotherlovedadultsfailedhim,aclientinthissituationhasdevelopedthepowerfulhabitofblaminghimself.Hisemotionsoffearorterrorhavebeenreplacedbyhelplessnessandshame,self-blame,self-hatred,andmistrust.Whenthispotentcombinationemergesinthetherapeuticrelationship(intransferenceandcountertransference),itprovidesboththerapistandclientwiththeopportunitytounderstandtogetherwhattheclientneededtorecoverbutlacked.
Aslongasatraumaticeventisonlyknowableasasensoryexperience—aphysicalre-
livingtriggeredbycurrentevents—aclientremainsvulnerabletobeing“hijacked”andcognitivelydisorganizedbyhispast.Forsuchaclient,inordertochangethecriticalandderogatoryself-judgmentthatpreventshimfromthinkingcompassionatelyabouthisownpast,heneedstheexperienceofaninterestedandnoncoerciveclinicianwhoiscapableofforming,andmaintaining,atherapeuticrelationship:adjustingherparticipationintherelationshipmomentbymomenttomodulatehislevelofarousal;tosupportgoodjudgment;andtomodelmentalizingbyhelpingtoexploreanddifferentiatethoughts,emotions,andsomaticexperiences.Inthisway,aneffectivetherapisthelpsherclienttolinkemotionswithcausesandtodistinguishresponsesfrompresenteventsfromreactionstothepast.
6Felittiandcolleagues(1998)havedemonstratedthatadultswhowereexposedtodifferenttypesofchildhoodadversity(includingphysicaltrauma,sexualtrauma,neglect,livingwithafamilymemberwithmentalillnessoraddictions,andotherformsofadversity)areatagreaterriskformentalhealthproblemsaswellashavinghigherphysicalmorbidityandmortality.Forexample,aboyexposedtosixormoretypesofadversityhasa46-foldgreaterlikelihoodoflaterbecominganinjectiondruguserthanaboywhoisnotexposedtothesetypesofadversity.Needlesstosay,exposuretochildhoodadversityisalsolinkedtodeficitsinmentalizinganddifficultyusingrelationshipseffectivelytoregulatestrongemotions.
7::FinalThoughts
Whichfactorsdistinguishmoreeffectivefromlesseffectivetherapists(Norcross,2011;VanWagoner,Gelso,Hayes,&Diemer,1991)?Theevidencetellsusthateffectivetherapistsmaintainagoodrelationalpresence.Theymanifestwarmthandanauthenticinterestintheirclients.Theyhavecapacityforreflectionandtheyrefrainfromreactingautomatically.Whentheygethookedintonegativecountertransferentialresponses,theycanusethemasanopportunitytostepbackandreflectonthemaladaptiveloopthatistemporarilybeingreinforcedorrepeatedwithinthecontextoftreatment.Theyseethenegativeexperiencetheyhavewithaclientasanopportunityforrepair—anopportunitythattheyseektocapitalizeonthroughmentalizingandmetacommunication.Effectivetherapistsemphasizetheadaptivenatureoftheirclients’effortsratherthanfindingfault,blaming,orshaming.Theyfindtherightbalancebetweenaffiliationandcontrol,avoidingtheunproductiveextremesofovercontrolanddisengagement.Effectivetherapistsalsokeepinmindthattraumaisendemicandthatitsimpactcanmanifestinemotionaldysregulationandrelationshipproblems.Theyareabletokeepthetraumaperspectiveinmindastheyworkwiththeclient’sdeclaredchiefcomplaint.Importantly,therapistswhoareeffectivearemindfulofthepowerimbalanceintreatmentandthewayinwhichjudgmentandhostilitycanbeexperienced,evenifunintended.
Atherapist’spersonalcharacteristicsalsohaveaneffect.Therapistswithanxiousattachmentstylesareoftentooeagertowintheirclients’endorsementtomaintainobjectivityandmayhavedifficultyendingtherapy.Aperfectionisttherapist’snegativeself-assessmentcanleadhertobetoodemandingofherself.Inturnthiscanspilloverintothetreatment,imbuingitwithasenseofharshjudgment.Anobsessivetherapist’sinflexibleadherencetoatreatmentmodeloftenleadshertooverlookthinkingaboutprocess,orbeingabletorevisetherapeuticresponsivenesswithaless“adherenttothemodel”butamoreresponsivealternativeapproach(Castonguay,Boswell,Constantino,Goldfried,&Hill,2010;Krausetal.,2011).
Effectivetherapistsdonotassumethattheirtherapeuticintentionautomaticallypredictstheeffectontheclient,butratherwillinquirehowtheclientisexperiencingwhatishappeningintherapy(Hill&Knox,2009).Thisisasimportantinprocessingnegativeexperiencesasitisinprocessingpositiveexperiences.Weoftenneglecttheimportanceofprocessingthepositiveandcelebratoryelementsoftherapy,whichcanbeofgreatvalueindistinguishingpastfrompresent.Itispreciselythisjointsharedexplorationthatconsolidateslearningandtherapeuticgainsandprovidestheexperientialdisconfirmationofnegativeexpectationsthatclientsoftenneedfortherapytowork.
Finally,effectivetherapistsaremindfuloftheirfiduciaryresponsibilitieswithregardtoboundaries.Theyrecognizethatsituationsinwhichtheyplacetheirneedsaheadoftheir
clientsareneveracceptable.
Atherapistcanbehighlyeffective—regardlessofthespecificmodalityofpsychotherapythatsheuses—byattendingtoprocessandusingthetherapeuticrelationshipasameansofprovidingherclientwithexperiencesthatinterruptthemaladaptiveinterpersonalcyclesthathehasbroughtintotherapy.Bydoingthis,aspectsoftraumaticexperiencesareintegratedandtheclientcandevelopandbecomemoreresilientwhilecreatinganewrelationalmatrix.
Althoughnotwocoursesofeffectivetherapyareexactlythesame,andeverysessionpresentstherapeuticchoicesinwhichthereisnoobviousrightorwrongcourse,aneffectivetherapistcannonethelessbeguidedbyevidence-basedprinciples.Inthisbookwedescribedasequencethatservesasaguide(althoughnotarecipe)foreffectivepsychotherapyinalmostanymodalityandthatpromotestherapeuticbehaviorassociatedwithbeinganeffective,evidence-basedtherapist.
Inparticularwehaveemphasizedtheprocessesinvolvedinturningtherapeuticmomentsofimpasseortensionintoopportunitiesforchange.Theelementsofatherapeuticrelationshipwiththemostrobustevidenceforeffectiveness—astrongtherapeuticalliance,therapistempathy,andcollectingclientfeedback—allcanbeenhancedthroughuseofmentalizingandadynamic,relationallyinformedunderstanding.
Glossary
Attachmentbehaviorreferstoactionstakenbyapersonwhenarealorimpliedthreatactivateshisorherattachmentsystem—theactionsaredirectedtowardobtainingahelpfulresponsefromthepersontowhomtheyareattached(e.g.,parentorromanticpartner).Attachmentbehaviormayincludeexpressingdistress(inordertoattractacare-providingresponse),seekingproximitytotheother,ordistancingtheotheremotionallyoractually(inordertoavoidnegativeconsequencesofexpressingdistress).
Attachmenttheoryisawayofunderstandingcloserelationships.Infantattachmentdescribescertainaspectsoftherelationshipofaninfanttoanadultwhoparentshimorher.Attachmenttheoryfocusesontheinterpersonaldynamicsoffeelingthreatenedbyadirectthreatorbytheimpliedthreatofseparation.Thesedynamicsincludetheinfant’sexpressionofdistressorseekingofproximitytoaparent,theparent’sresponsetotheinfant,andtheeffectsofaparent’sresponseontheinfant.Adultattachmenttheorydescribesanalogousdynamicsthatoccurbetweenadultswhodependoneachotheremotionally,especiallyromanticpartners.
Contrarymovesareatechniqueemployedbyatherapisttopromotementalizing.Thetherapistoffersacommentorquestionthatinvitestheclienttoconsideradifferentperspective(e.g.,thoughtsratherthanfeelingsorviceversa),anexternalversusaninternalperspective,oranotherperson’spointofview.
Countertransferencereferstoaspectsofthetherapist’sinnerthoughtsandfeelingsduringtherapywithaclient.Expertsdisagreeastowhichaspectsofatherapist’sthoughtsandfeelingsarecountertransferenceandwhicharenot.Thenarrower,classicalviewisthatcountertransferenceismostlyorentirelyunconsciousandconstitutesatherapist’sreactionstotheclient’stransference.Inthisbookwetakeabroaderview,includingallaspectsofthetherapist’s(typicallyautomatic)reactionstoaparticularclientthatareatleastsomewhatdifferentfromwhatheorshemightusuallythinkorfeelwhenworkingwithotherclients.
Dismissingattachmentisapatternofinsecureadultattachmentinwhichexpressionsofdistressorinterpersonalneedaremuted,self-relianceishighlyvalued,intimacyanddependenceareavoided,andintimate,committedrelationshipsarerelativelydevalued.
Disorganizedattachmentisapatternofinsecureattachment.Inadults,disorganizedattachmentisrecognizedwhenapersondisplayssignsthatpotentiallytraumaticattachmentevents(e.g.,abuse,ordeathofaparent)areunresolved.Clinically,disorganizedattachmentissometimesaccompaniedbyconflictingattachmentbehavior(e.g.,experiencingsimultaneousurgestobothseekandavoidclosecontact).
Thetermgood-enoughparentwascoinedbyDonaldWinnicott.Itreferstoaparent
whoprovidesavalidatingenvironmentandemphasizesthatthisdoesnotrequireexpertiseorperfection.
Here-and-nowreferstorelationshipprocessesthatoccurwithinthetherapeuticrelationshipandare,therefore,maximallyavailableforobservationandinquiry.
Theinternalworkingmodelisacognitive-affectiveschemathatservestopredictlikelyoutcomesofattachment-relatedevents.Basedonearlyinteractions(especiallywithparents),theinternalworkingmodelispositedbyattachmenttheory,whichencodesexpectedoutcomesofattachmentinteractions(e.g.,rejectionorprotection)
Theinterpersonalcircumplexisadiagramthathelpstounderstandhowoneperson’sbehaviorinfluencesanotherperson’sresponse.Thecircumplexincludestwoaxes,whichrepresenttwowaysinwhichpeopleinteract.Thefirstaxisisaboutdominance,whichrangesbetweenactinginawaythatissubmissiveandactinginawaythatisdominantofothers.Thesecondaxisisaboutaffiliationandrangesbetweenactingtoincreaseclosenesstoothersandactingtoincreasedistancefromothers.Becausethesetwoaxesareindependentofeachother,interpersonalbehaviorcanbedescribedasacombinationofaperson’spositionontheaxisofdominanceandthisperson’spositionontheaxisofaffiliation.
Interpersonalpullsareforcesthatoccurbetweenpeopleaccordingtothepositionoftheirbehaviorontheinterpersonalcircumplex.Forexample,oneperson’sdominantbehaviorinfluencesanotherpersontobesubmissive(dominancepullsforitsopposite).Ontheotherhand,oneperson’sfriendlybehaviorpullsforanotherpersontoalsobefriendly(affiliationpullsforamatchingresponse).
Amaladaptiveloopisacircularprocessinwhichaperson’sexpectationofhowheorshewillbetreatedbyothersleadstobehaviorthatunintentionallyelicitsaresponsefromanotherpersonthatconfirmsthebelief.Itisaspecifictypeofself-fulfillingprophecy.Forinstance,apersonwhoanticipatesrejectionorshamefromothersmayprotecthimselfbywithdrawingprematurelyfrominteractions,whichincreasestheoddsofactualrejectionandconfirmsthepathogenicbeliefthatnoonewantstobewithhim.
Mentalizingreferstoasetofcognitiveprocessesthatallowapersontoobserveandthinkabouthisorherownthoughtsandfeelings,andtoimaginewhatsomeoneelseisthinkingorfeeling.Mentalizingimpliesthatapersoniscuriousaboutthoughtsandfeelings,reflectsonthem,andlooksforindicationsthathisorherideasaboutthoughtsandfeelingsneedtobemodifiedattimes.
Metacommunicationiscommunicatingaboutcommunication.Inpsychotherapy,metacommunicationmayenrichthecontextofcommunication(e.g.,thinkingoutloud,tosharetheemotionalcontextofcommunication)ormaybeusedtoclarifywhatisexpressed(e.g.,byexplicitlyattendingtobothverbalandnonverbalexpression).
Atherapistengagesinmodelingbybehavinginawaythataclientcanemulate.Atherapistwhodisplaysacuriousandreflectivestancetowardhisorherownthoughts
andfeelings,forexample,demonstratestheskillofreflectivethoughtforaclientwhotendsnottobereflective.
Pathogenicbeliefsarebeliefsaboutothers’thoughtsandfeelingswhoseaccuracyisunquestionedanduntested(andare,therefore,ofteninaccurate),suchthatbehaviorbasedonthosebeliefstendstoelicitundesirableresponsesfromothers.Whenthoseundesirableresponsesreinforcethebelief,theself-reinforcingcycleiscalledamaladaptiveloop(seeabove).
Preoccupiedattachmentisapatternofinsecureattachmentinwhichexpressionsofdistressorinterpersonalneedareamplified,needsforacceptanceanddependenceareprominent,andindividualagencytomaintainandrepairrelationshipsisineffectiveorabsent.
Presenceisacharacteristicofeffectivetherapiststhatreferstoacompositeofvaluabletraitsandbehaviors:availability,responsiveness,empathy,interest,genuineness,andpositiveregard.
Theprocess(noun)isthewayinwhichsomethingintherapyhappens,ratherthanthenarrativecontentofthething.Forexample,theprocessinonemomentoftherapymightbethattheclientistellingastorywhilethetherapistlistenscarefullyandreflectsonthestory.Thisprocesscanbedescribedwithoutreferringtothenarrativecontentofthestory.
Toprocess(verb)intherapyreferstoworkingsomethingthrough:understandingit,breakingitintoitscomponentparts,placingitincontext,andtestinguntestedassumptionsaboutit.Inthisway,atherapistandclientmightprocessamomentoftensionormiscommunicationtofullyunderstandwhathappenedandresolveanyremainingconflict.
Secureattachmentisapatternofattachmentinwhichintimateandreciprocalrelationshipsarevaluedandactivelymaintained,expressionsofdistressorinterpersonalneedareflexibleandproportionatetocircumstances,andindividualagencytorepairrelationshiprupturesiseffective.
Inchildhoodattachment,securebaseisthenameofafunctionthataparentservesforachildwhentheparent’spresenceisadependablesourceofcomfortandconfidence.Theparent,underthesecircumstances,servesasabasefromwhichthechildcanexploreindependentlyandtowhichheorshecanreturnwhendistressed.
Self-disclosureinpsychotherapyreferstoatherapistcommunicatingpersonalinformation.Self-disclosureispotentiallyharmfulwhenitservesthetherapist’sneedsratherthantheclient’sneeds,andsoitmustbeusedcautiouslywithadequatethoughtaboutbothwhatisbeingexpressedanditsvalueinadvancingtherapeuticgoals.
Therapeuticalliancereferstothecollaborativeworkingrelationshipbetweenatherapistandclient.Itincorporatesattitudesofmutualtrustandrespect,sharedgoals,andanimplicitcontracttoworktogetherintherolesoftherapistandclient.
There-and-nowreferstorelationshipprocessesthatoccurwithincontemporaryrelationshipsoutsideoftherapy,suchasbetweenaclientandhisorherspouseorfriend.
There-and-thenreferstorelationshipprocessesthatoccurredwithinpastrelationships,suchaschildhoodrelationshipsbetweenaclientandhisorherparents.
Transferencereferstoaspectsoftheclient’sinnerthoughtsandfeelings.Expertsdisagreeastowhichaspectsofaclient’sthoughtsandfeelingsaretransferenceandwhicharenot.Thenarrower,classicalviewisthattransferenceismostlyorentirelyunconsciousandconstitutesaclient’sreactionstothetherapistthatarebasedentirelyonexperiencesinearlierrelationshipsandfantasiesaboutthoserelationships,especiallychildhoodrelationshipswithparents.Inthisbookwetakeabroaderview,includingallaspectsoftheclient’sautomaticreactionstothetherapist.
Avalidatingenvironmentisoneinwhichachild’scaregiversacknowledgeandrespecthisorherdesires,hopes,opinions,intentions,preferences,ambitions,andfantasies.Validationdoesnotimplyconstantpraiseoracceptance(e.g.,ofmisbehavior),butitdoesimplythatthechild’scaregiversconsiderthechild’sinnerlifetobeimportantandthattheywanttounderstanditandempathize.
LessonPlans
(SeeAppendixCforanswers.)
LESSONPLAN#1EstablishinganAllianceandUnderstandingoftheClient
Thefirststepsofpsychotherapy,regardlessoftreatmentmodality,aretoestablishanallianceandapreliminarysharedunderstandingwiththeclientaboutthedifficultiesthatbringhimtoseekhelpandthetreatmentgoals.ReviewChapters1–4andanswerthefollowingquestions.
1.Whatarethequalitiesofatherapistthatcanimprovetherapeuticalliances?
2.Gettinganunderstandingofaclient’sgoalsfortherapyisimportant.Sometimesclientshavedifficultyansweringdirectquestionsaboutwhatbringsthemtotreatment,whytheyaresuffering,orexactlywhattheyhaveasachiefcomplaint.Whatareexamplesofindirectwaystoaskabouttreatmentgoals?
3.Whatsourcesofdatacanbeusedtounderstandaclient’srelationalproblemsandsuffering?
4.Practicingpsychotherapyrequiresthetherapistandclienttobecomebothobserversandparticipantsintheirpresentexperiences.Thisincludesbeingawareofmoment-to-momentchangesinemotionalstatesornarrativecoherenceduringsessions.Howcanthishelpaclienttochangeunderlyingpathogenicbeliefsthatperpetuatedifficultiesinrelationships?
5.Describetransferenceandcountertransferenceandwhytheyareimportantinpsychotherapy.
6.ADULTATTACHMENT:Fillinthefollowingtabletocharacterizedifferingfeaturesofthehistories,behaviors,andinterpersonalconsequencesofadultattachmentstyles.
SECURE PREOCCUPIED DISMISSING DISORGANIZED
Careproviders’characteristics
Attachmentbehaviors
Others’experiencesofthisperson
7.THEINTERPERSONALCIRCUMPLEX:Wherewouldyouplaceeachoftheclientsonthetapeddemonstrationsontheinterpersonalcircumplex,andwhatwouldyoupredictregardinginterpersonalpullsonandresponsesfromothers?
HOMEWORK:Ittakespracticetobecomeattunedtoprocesselementsinpsychotherapyasmarkersoftherapeuticopportunitiesandasdatatobetterunderstandaclient.Reflectingontherapeuticprocessesretrospectively,youcaneventuallydeveloptheabilitytodoitinrealtime,duringasession.UsetheAssessingandReflectingonCommunicationworksheet(AppendixD).Withyourclients,learnmoreabouttheirrelationshipsinthepastandpresent,keepinginmindtheimpactoftrauma.Begintonoticeaffectivelychargedordifficult-to-respond-tomomentsoftensioninasessionandtrytotrackyourownandyourclient’sinnerexperiences(feelings,thoughts)duringthesemoments(includingcountertransferenceandtransference).Usetheattachmentandcircumplexframeworkstoinformandmakesenseofyourunderstandingofclients,takingintoaccountyourknowledgeoftheirearlylivesandcurrentrelationships,alongwithyourexperiencewithinthetherapeuticalliance.
LESSONPLAN#2Tear-and-RepairProcesses:UsingMentalizingandMetacommunication
Applyingarelationalframeworktoclinicalpracticehelpstherapiststounderstandhowearlylifeexperiencesshapecurrentrelationshipdifficulties.Opportunitiesemergewithinthetherapeuticalliancethatcandisconfirmaclient’spathogenicbeliefs(whicharenegativeexpectationsofothersencodedinaninternalworkingmodel).Thislessonreviewshowatherapistcanunderstandcountertransferencereactionsoralliancetensionsasdata,resistdistancinginterpersonalpulls,andusetherapeutictechniquesofmentalizingandmetacommunication.ReviewChapter5,readthetranscripts,andwatchtheroleplaysontheDVDbetweenJoelWalkerandDr.Leszcz.Thenanswerthefollowingquestions.
1.Describementalizingandlistwaystouseitwithaclient.
2.Describemetacommunicationandhowitcanbetherapeuticallyusedduringmomentsoftensioninthealliance.
3.Aneffectivetherapistalternatesbetweenexploring,activelylistening,validating,clarifyingfactualdata,andconfrontingclientsonmaladaptivebehaviors(especiallybehaviorsthatraisesafetyconcerns).Whatarethesignsthatindicateatherapistshouldsloworpauseexplorationinfavorofprovidingvalidationandsupport?
4.Describedifferingwaysinwhichatherapist’sabilitytoremainreflectiveand
therapeutically“present”canbechallengedbyaclientwhoisdismissingversusaclientwhoispreoccupiedinhisattachmentstyle?
5.Whatshouldatherapistdowhentherearesafetyconcerns?
6.BelowisanexcerptofcommunicationbetweenJoelWalkerandDr.Leszczthatbeginswithadifficult,challengingmoment.Considerthissequenceasamaladaptiveloop.Usingtheinterpersonalcircumplexandtransference/countertransferencedynamics,howcanyouunderstandthisinteraction?
THECOMMUNICATION/INTERACTION
T:Istillneedtogetasenseofwhyyourwifefeelssheneedstousethatleverage[ofaccesstoyourdaughter]togetyoutodosomethingortobedifferentortochangesomething.IneedtounderstandthatifIcan.
C:(interruptsangrily):I’mnotsomewackocreep,right,youknow,that’snot,there’snothinglikethatgoingon,okay?There’snothinguntowardhappeninginmyfamilyhome,okay?Let’smakethatabsolutelyclear.
T:Doyouthinkthat’swhatI’mthinking?
C:Idon’tknowwhatyou’rethinking.ButI’mnot,I’mnotgonnaletyouaskthatquestion.Okay,just,endofstory.
T:IcantellyouwhatI’mthinking.I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe….I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.
T:IcantellyouwhatI’mthinking.I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe….I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.
C:Well,theydon’twanttobearoundme.Sarahdoesn’tanyway.
T:“Peopledon’twanttobewithyou.”Thatgeneratessomefeelingsforyourightnowandthatwouldbeprettypainful,Iwouldimagine.
C:Youknowwhat,it’spainfulifyouwanttobewiththem.
T:Whatwe’retalkingaboutobviouslytouchesalotoffeelingforyou….DoyouthinkwhenSarahasksyou,orevenwhenIaskyouhowyou’refeelingthatthere’s,thatitmightbecomingfromaplaceofinterestorconcern?
C:Whatconcernthough,youknow?Whatconcern?Youknow?Youtellme“whatareyoufeeling,”Imean,howdoIknowyou’renotsayingtome“what’swrongwithyou?”Right?
T:Isthatwhatyouhear?“What’syourproblem?”Irealizethisisveryhardforyou.
C:Idon’tknow,ah,Idon’tknow.Youknow,dowehavetotalkaboutthis,Imean….YouaskmetotellyouwhatI’mfeeling,right?Sarahasksmetoo,“what’sgoingon,whatareyoufeeling,”whatever,it’slike,it’s,it’s“whyareyouthewaythatyouare?”That’sbehindeveryquestion,there’ssomethingwrongwithyou.“Why?”
7.Therearemanyrightwaystorespondtherapeuticallytoamomentofstrain.Affectandemotionaremarkersoftherapeuticopportunity.Continuingwiththesession,describehowthetherapistrespondstothisaffectivelychargednodalmoment?
8.Asimportantasitistorecognizeandworkwithcountertransferenceandinterpersonalpullstoguidetherapeuticprocesses,itisalsoimportanttoregisterevidenceoftherapeuticbenefit.Describethreekindsofimprovementthataclientmayreportordisplaythatwouldbeevidenceofbenefit.
HOMEWORK:Tryusingmentalizingand,whereappropriate,metacommunicationtoexpandyourrangeofengagingintheprocessoftherapy.Techniquesfrombothapproachescanbeintegratedintoyourworkwithclients,regardlessofthespecificmodalityyouuse.
Ittakespracticetobecomeawareofprocesselementsinpsychotherapyasmarkersoftherapeuticopportunitiesandasdatatobetterunderstandaclient.Reflectingontherapeuticprocessesretrospectivelyhelpstherapiststodeveloptheabilitytodoitinrealtime,duringasession.Continuetomakeuseofthetherapistworksheet(AppendixD)toidentifyaffectivelychargedordifficult-to-respond-tomomentsoftensioninasessionandnoticewaystoidentifythiskindofmoment:theclient’swords?youremotionalresponse?theclient’sfacialexpression?youroryourclient’sbodylanguage?Reflectontheinnerexperiences(feelings,thoughts)ofyouandyourclient(includingcountertransference).Usethetheoriesdiscussedinthisbooktoorganizeyourunderstandingoftheclientinthesemoments,aswellastheprocessesofandchangesthatoccuroveracourseoftherapy.Beattunedtoimpactsofyourresponsivenessandcommunicationwiththeclient.
LESSONPLAN#3TakingTraumainAccount
BothclientsontheDVDandtranscribedsessionshavehistoriesoftrauma.ThislessonontakingtraumaintoaccountfocusesonKatherineMarksandherworkinpsychotherapywithDr.Pain.
ReviewChapter6ontraumaaswellasthetranscriptsandDVDsegmentsofKatherine’ssessionswithDr.Pain.Rememberthatthesecondroleplayissession#6;inthepriorsessionKatherinehadspokenaboutherexperienceofbeingrapedwhenshewas14yearsoldandthebetrayalofbeingabandonedbyadultswhofailedtoprotectorhelpherafterward.
1.Whichemotionisconsideredtobeatthecoreoftrauma?
2.Whataresomeoftheclinicalphenomenathatcanalertustothepossiblepresenceof
aninvalidatingchildhood?Whichcaregiverscouldnotprovideadequatesafetyandreassurance?
3.Howcommonistrauma?Howmighttraumaaffecthealth?Howmighttraumaaffectrelationships?
4.Whendoesatherapistscreenfortrauma?
5.Howistraumaassessed?
6.Listfivequestionsthatatherapistcouldusetoaskabouttrauma.
7.Describetwowaysofunderstandingwhysomepeoplefailtorecoverfromtraumaticexperiencesandsufferfromchronic,unresolvedtraumaticsymptoms.
8.Moment-to-momentattunementtomentalstatesandfeelingsbyusingmentalizingaidsatherapeutichealingprocess.Reflectonthefollowingtwosegments.Howdoyouunderstandtheclient’sambivalenceaboutengagingintreatmentinthefirstsegment?
THECOMMUNICATION/INTERACTIONFROMSESSION#3
C:I’mjustnotthatinteresting,right?Imean,it’sjust,Ihavenothingreallygoingon,there’snothingreallywrong,there’snothingreallythematter,it’sjust…
T:Sorrytointerrupt,I’mjustwondering…Ihearwhatyou’resayingandIcanseethatyou’renotinacutedistress,ifthat’swhatyoumean,butit’salmostlikeyoudaren’thopeforsomethingandmaybetellmeifI’minthewrongballpark,butitfeelslikeyouwouldliketo,somehow,hopeorexperiencesomethingtoreflecton,toseewhat’smissing.
C:Yeah,butIdon’tknowhowtogetthere.
T:I’mgettingafeelingthat,aswe’vebeentalking,insteadoffindingawaytotalktoeachotheraboutthethingsthatpuzzleyou,oryou’dliketoexplore,theoppositeishappening.IfeellikeI’minadvertentlysortofchasingyououtoftheroom.Thatsomehow,whatbeganasaverytentativecuriosityisnowmovingtowardfeelinglessengagedhere.Howhaveyoufeltinthelastwhilesincewebeganthissession?
C:Whatever,whateverhappenshereisnotgoingtomakeanydifference.That’ssortofhowitfeelstomebecauseIcan’tbe,Ican’tbehelped.Ijust,youknow,it’sallfine,it’sallgood,Ijustcan’tbehelped.
T:Thatsoundslikeyou’refeelingupset.Canyoustaywiththatfeelingandtalkfromitalittlebit?
THECOMMUNICATION/INTERACTIONFROMSESSION#6
T:Andtheweekend’sirritability…
C:Right.Right.Yeah.
T:What?
C:Well,I’m,Imean,Iguesspartofmeisbeginningtoseethatitwasn’tjustmyfault.Thatotherpeoplecouldhavesteppedintohelpmeinwaysthattheydidn’t.Um,butIstillputmyselfinharm’swaysothere’sthisthinggoingon.Istill,Iwasstillthestupidpersonwhoputmyselfintothesituationso…
T:Sothere’sonetendencytotakethatkindofblameandthenthere’sthisotherkindoftendencytosayasyoujustdid,theycouldhavebeenmorehelp.Andthere’sthatsortofirritableexperienceovertheweekend.SoI’mwonderingifthatkindof[thinkingthat]“it’smyfault”[andthensubsequentlythinking],“wellactually,Iwas14”…
C:Yeah,um,andtheforgivenessofthat,right?Theforgivenessoftheparentswhoweren’tthere.Theforgivenessofthefriends,who,youknow,didn’tthinkitwasanybigdeal,right?So,Ijustforgave,Ijust,youknow,itwasmyfaultandyouknowhowcouldtheyunderstand?AndIthinkifIwere,ifithappenedtomydaughter,ifithappenedtomykids,Iwouldbe,right,I’dbe.
T:What?
C:Well,I’dberightthereforthem.I’dberightthere.Imean.
T:Youwouldn’tblamethem?
C:No,Imean,no.So,again,I’mstucktryingtofigureouthowtothinkaboutthis.Imean,itfeelslikeit’ssortofnewinformation.
T:Whichpartisnew?
C:Thefactthattherecouldhavebeenmorehelp.Therecouldhavebeenadifferentresponse.
T:Canyouthinkoutloudaboutthat?
C:Well,youknow,I’vefeltlikedamagedgoods.Foryears,Ifeellikedamagedgoods…
T:Whatdoesthatfeellike?
C:ItfeelslikeI’mconstantlyneedingtoapologizeandtomakeupforandtodotherightthingbyandtodomorethanand—it’sexhausting[T:Umhum].It’sexhausting.
9.Describehowtherapeutictechniquesofmentalizingormetacommunicationareemployedintheabovetwosegments.
HOMEWORK:Rememberinghowcommontraumaisinclinicalpopulations,whenassessingnewclientsremembertoaskabouttrauma.Watchforsignsofdisorganizationandmomentsofnarrativeincoherence.Workwithinzonesofoptimalarousal;whenneeded,slowdownexplorationinfavorofsupportoruseacontrarymovebyshiftingthefocus.Rememberhowahistoryofunresolvedtraumamightaffectaninternalworking
modelandexpectationsofothersthatwereadaptiveinpast,butnotnecessarilyadaptiveortrueinthepresent.Treatingtraumaisnotabout“findingoutthetruth”ortryingtomakeupfortheclient’spast.Insteadthetherapisthasthepossibilityofbeingwiththeclientandfacilitatingherorhismoment-to-momentexperienceofbeingabletotalk,think,remember,feel,andstaygroundedinthepresentwiththeother(thetherapist).Thiscapacitycandevelopandtendstoputthepastintothepast,disconfirmingoldfearsandreplacingthemwithgreaterconfidenceaboutthefuture.
LESSONPLAN#4UnderstandingandWorkingTherapeuticallywithClients
Thiscase-basedlessonwillhelptoconsolidateprinciplesandtechniquesthatimproveyourpsychotherapyeffectiveness.Usearelationship-focusedunderstandingtomakeclinicallyreasonedtherapeuticresponsesinthefollowingcases.Employmetacommunicationandmentalizingresponsesthatareguidedbyyourunderstandingofattachment,interpersonalpulls,transference/countertransferencedynamics,andtheimpactoftrauma.
Case#1
Danielleisawomaninherearly50swhorecentlydiscoveredthatherbreastcancer,treatedtwoyearspreviously,hasspread.Sheisanarticulatewomanwhohasnopasthistoryofpsychiatricillness.Shelivesaloneandiscurrentlyonsickleavefromherlong-standingworkasaprimaryschoolteacher.Sheisanactivememberofherchurchcommunity.Heroncologistnoticedthatshewasdepressedandtearfulthroughoutherlastvisitandhadsuggestedthatitcouldbehelpfultospeakwithatherapistduringthisstressfultimeofbeingtreatedforcancer.Thetherapistwasaskedtoseehertoprovidecounselingsupport.
Daniellehadherfirstchemotherapytreatmenttwoweeksago.Aclosefriendofferedtospendthenightwithherfollowingthattreatment,butDaniellerefused.ByeveningDaniellehadhadseveralboutsofnauseaandvomitingandwasfeelingpoorlyphysicallyandsomewhataloneintheworld.Neverthelessshecalledherfriendandtoldhershewasalright.Thetherapistasksherwhyshedeclinedherfriend’shelp.Danielleanswers,“IhadthisideaIwouldbebetteroffonmyown.”Followingthatverydifficultnight,shehadcalledherfriendinthemorningtobedriventotheemergencyroom,wheresherequiredintensivemedicaltreatment.
1.WhatisyoursenseofDanielle’sattachmentstylebasedonthisbriefvignette?Whatotherinformationwoulditbehelpfulforthetherapisttoknowinordertoenhanceherunderstandingoftheclient’smaladaptiveloopsandinternalworkingmodel?
WhenDaniellespeaksaboutherdevelopmentalrelationshipsandearlychildhood,shesaysthatsheneverknewherfatherbecauseshegrewupwithasinglemother.Hermotherwasaregisterednurseintheirremote,ruralcommunity.Daniellesaysshewas
ahighlyrespectedwoman,“thestrongsilenttype.”Althoughothersinthecommunitywenttohermotherforadvice,Danielleherselftendednottogotohermotherbecauseshefoundhertobetoobusyandemotionallyunresponsive.Instead,whensheneededemotionalsupport,Danielleturnedtotwopeersandthemotherofoneofthosepeers,whowasamoreresponsiveandavailableindividual.AsDanielledescribesherrelationshipwithhermother,thetherapistcomments,“LetmeseeifI’munderstanding.Itsoundslikeyourmotherwasagoodcitizenwhohelpedmanypeople,butyoulookedforemotionalsupportelsewherebecauseshewasn’tsoavailabletoyou?”Danielledoesn’tdirectlyanswerthequestion,butbecomestearfulandsays,“Thereissomethingaboutbeingtakencareof.”Shethenelaboratesthatshedeclinespeople’soffersofhelpbecauseshefeelscrowdedandexposedasifshewerethecenterofattention,preferringtoslipintotheshadows.Afewmomentslater,referringtopeoplethatareprayingforherandherillnessshesays,“I’mnotjustsad,I’mscaredtobeloved….Idon’tknowwhattodowiththat,Iwanttorunaway.”
2.Usingprinciplesofmentalizing,howmightthetherapistrespondatthismoment?
Case#2
Miltonisa40-year-oldunmarriedfatheroftwoadultchildrenwhowasraisedbyothersinhisextendedfamily.Heisestrangedfrombothofhisparentsandneverknewthemwell.Hewasreferredtopsychotherapybyhisfamilyphysicianforhelpwithchronicdepression.Hehasanextensivehistoryoftrauma,includingchaoticearlylifecircumstances,sexualabusebyafamilymember,andabruptseparationsfromcareproviders.Healsohasahistoryofpoly-substancedependence.Followingparticipationinanaddictionstreatmentprogram,Miltonisintheearlystageofrecovery,attendinggroupstopreventrelapse.
Thisweekheaskshistherapisttofilloutareportthathasbeenrequestedasaresultofanassault.Sheissurprised.Althoughshewasawareofhischildhoodsexualabuse,shedidn’tknowthathehadbeenassaultedasanadult.Miltonhadn’ttoldthetherapistabouttheassault,althoughinanearliersessionhehadvaguelyalludedtostressthathesaidhedidn’twishtospeakof.InthissessionMiltonbecomesangry,statinghecan’tbelievethatshehasn’tunderstoodthefullstoryfromthesnippetshehasmentioned.Hesaysthathesometimesfeelstheassailant’shandsaroundhisneckinflashbacks.Hehasnightmaresoftheassaultandtellshistherapistthattheassailanthadthreatenedtokillhim.Shesays,“Okay,nowtherearesomethingsaboutthetraumathatarebeginningtostringtogether.”Miltonbecomestearfulandthetherapistregistershischangeinaffectfromangertosadness,andsays,“It’sbeenatoughyearanditisawfultohavetoremembertheassaultsothatIcanfilloutareportforyou.“SheexperiencesMiltonasmorepresentintheroomwithherashereplies,“Yeah,Idon’tliketothinkaboutthisstuff.”
3.Takingtraumaintoaccount,whatdoyouthinkabouttheclient’searlierreluctancetodiscloseordiscussdetailsoftherecentassault,andthetherapist’snotpushingto
pursuethis?
4.Usingmetacommunicationandmentalizing,howmightthetherapistrespondtothismomentofstraininthetherapeuticalliance?
Case#3
A42-year-oldnarcissisticprofessionalwithahistoryofgeneralizedanxietyarrivesforhisappointmentwithhistherapist.Theclienthadearlierdescribedgrowingupwithamotherwhosedemandsonhimwereunrelenting,inconsistent,andunpredictable,oftenleavinghimfeelingangry,isolated,andoverwhelmed.Thetherapistarrivesafewminuteslate,thenneedstotakeanurgentcallthatdelaysthebeginningofthesessionby15minutes.Uponbringingtheclientintotheoffice,thetherapistapologizesandaskshowtheclientexperiencedthewait.Theclientsays,“Whenyouwereafewminuteslate,itdidn’tbothermebecausethathappens,butthenwhenyouwentintoyourofficeanddidn’tcomeouttogetmeimmediately,Istartedtogetangrierandangrierthinkingthatyouweredoingsomethingelseinsteadofcomingtoseeme.Ilookedattheclockandpromisedmyselfthatifyouweren’toutin10minutes,Iwouldleaveandyoucouldgotohellifyouthoughtyouwouldgetpaidforthemissedsession.”Thetherapistresponds,“I’mgladthatyou’restillhereandthatwearemeeting.I’dliketotalkwithyouaboutwhatyouthoughtaboutandwhatyouwentthroughinordertoactuallystayandallowustomeet.”Theclientsaysthatashebegantothinkaboutleavinginangerandwasbecomingmoreupset,hetookamomenttoreflectandsaidtohimselfthistherapisthasbeengenerallyprettyconsiderateandresponsive,butsometimesthingshappen.Hechosetogivethetherapistthebenefitofthedoubtandstay.
5.Howmightthetherapistusemetacommunicationtodealwithanactionthathasbeenfrustratingtoaclientandthenbegintoprocesstheeventwithinthehere-and-nowofthesession?
6.Inthiscase,howmightaninternalworkingmodelformedearlyinlifeaffecttheclient’scurrentexpectationsinrelationships?Howdoestheclient’scapacitytomentalizerelatetotheseexpectations?
Case#4
Cherylisa37-year-oldbusinesswomanwholiveswithherfiancé.Shehasstruggledwithchronicdepressiondatingbacktoheradolescence.Shebecamedepressedaftertheacrimoniousbreakupofherparents’marriagethatfollowedthediscoverythatshehadbeensexuallyassaultedbyheruncleasachild.Thesymptomsofdepressionhaveremittedoverthepastyearofpsychotherapy,whichhasusedamentalizing-basedapproachinwhichshehasmostlydiscussedcurrentaspectsofherexperienceandattimesreflectedonherpasttraumas.Shehasdevelopedmoreappreciationandcompassiontowardherselfasayoungpersonwhosufferedthesexualassaultsandthenthedissolutionofherhome.
Lastmonth,shedisclosedthedetailsofthesexualassaultstoherfiancéwitharesultantpositiveexperienceoffeelingunderstoodandcaredfor.Thiswasthefirsttimeshehadtoldanyoneotherthanhertherapist.Lastweekshetoldhertherapistwhensheandherfiancéwentforpremaritalcounselingfromtheirpastor,shecalmlymentionedthesexualassaults.Shefeltabletosharethiscomponentofherexperiencewiththepastor,becauseshefeltitwasimportantto“getitonthetable.”
7.WhatdoyouthinkaboutCheryl’sbeingabletotalkaboutthesexualassaultwithbothherfiancéandtheircounselor?
HOMEWORK:Inthisbook,youlearnedtopayattentiontoyourclients’earlyattachmentrelationships(there-and-then),currentrelationships(there-and-now),andthepresentdynamicsoftransferenceandcountertransferencewithinthetherapeuticrelationship(here-and-now).Youhavelearnedtorecognizethepotentialimpactofunresolvedtraumaandtobeattentivetorepetitivepatternsofunhappy,self-fulfillingsequencesthatmayrecurthroughmaladaptiveloops,includinghowyou,asatherapist,mayinadvertentlybehookedintothesepatternsinthetherapeuticrelationship.
Asafinalhomeworkassignment,useAppendicesBandDtoreflectonyourclientsandbeintouchwithallcomponentsofyourexperienceofthem:yourthoughts,youremotions,yourassociations,andyourinteractions.Considerthetherapeuticalliancesyouhavewithyourclients,boththestrengthsandthetensionsthatoccur.Deepenyourempathicconnectionsbyusingyourownexperiencestounderstandyourclients’relationalworlds.Considerconstructivewaystocommunicatethisunderstandingwithclients.Identifytherapeuticopportunitiestousementalizingandmetacommunicationwithinanoptimalzoneofarousaltorepairstrainsintherapeuticalliancesandpromotenewwaysofunderstandingandexperiencingrelationships.
Quiz
(SeeAppendixCforanswers.)
1.Thetherapeuticalliance:
a.Islessimportantthanthetherapeuticmodelwithregardtotheoutcomeofthepsychotherapyprocess.
b.Representselementsoftheclient-therapistrelationshiprelatedmainlytotransferenceandcountertransference.
c.Isbothaspecificandcommonfactor,becausethealliancemustbeestablishedwithinthespecificmodelapplied.
d.Whenruptured,cannotberepaired.
e.Intheclient’sassessmentislessimportantthanthetherapist’sassessmentofthetherapeuticalliance.
2.Approachesandconsiderationstorepairtherapeuticalliancerupturesinclude:
a.Usingcontentsolutionstoprocessproblems.
b.Understandingstrainsintheallianceasopportunitiestodisconfirmpathogenicbeliefs.
c.Neverviewingtreatmentaspartoftheproblembutpartofthesolution.
d.Redoublingthefrequencyofinterpretationsorattendingtocognitivedistortions.
e.Focusingmoreoninsightthanrelationalexperiencesbecauserelationshipsarelessimportant.
3.Whichofthefollowingstatementsisfalse?
Metacommunication:
a.Itinvolvescommunicationaboutmeta-analyticresearch.
b.Itinvolvesbothidentifyingandmakinguseoftheclient’sinterpersonal“pulls,”patterns,andimpact.
c.Ithasthepotentialtointerruptthe“maladaptivetransactioncycle.”
d.Itinvolvesexplorationandcommunicationaboutovertandcovertcommunicationanditsovertandcovertinterpersonalimpacts.
e.Itcaninvolvethetherapeuticuseofcountertransference.
4.AllofthefollowingelementspromoteastrongtherapeuticallianceEXCEPT:
a.Competenceinmanagingemotionalstrain
b.Sympathy
c.Positiveregard
d.Genuineness
e.Responsiveness
5.Pooroutcomesinpsychotherapymay:
a.Beduetotheimpactofthetherapist’sself-doubt,anger,oravoidanceofchallengingclients.
b.Berelatedtoanincompleteorinaccurateassessment.
c.Reflecttherapistcontributionsrelatedtoaninflexiblerelianceonaparticulartechnique.
d.Beduetosubtlehostilityordisingenuousempathyfromthetherapist.
e.Alloftheabove
6.Transference
a.Isonlyevidentlaterinacourseofpsychotherapy.
b.Shouldneveraffectatherapist.
c.Isdiagnosedaccordingtoaclient’sDSMorICDdiagnosis.
d.Haspatternsthatincludebeingpredominantlyangry,anxious,avoidant,orsexualized.
e.Isunrelatedtoattachmentstyle.
7.Countertransference:
a.Canbeunderstoodasunconsciousandsometimesovertattitudesandfeelingsthatthetherapistcarriestowardtheclient.
b.Mayinterferewithoptimalunderstandingandresponsivenesstotheclient.
c.Maycontributetooptimalunderstandingandresponsivenessasavaluablesourceofclinicaldata.
d.Isa“jointcreation”ofboththeclientandtherapist.
e.Alloftheabove
8.Regardingethicalpracticeandresponsibilitiesinpsychotherapy,allthefollowingstatementsaretrueEXCEPT:
a.Boundariesprotecttheframeandintegrityofthetreatment.
b.Boundariesareintendedtoreinforcepowerimbalancesbetweenthetherapistandclient.
c.Boundariesareessentialtomaintainaspartofthetherapist’sfiduciaryandethicalresponsibilities.
d.Atherapistmustconformtothepracticestandardsofhisorherprofessionandbe
trainedand/orsupervisedtobecompetentinthetreatmentprovided.
e.Therapistsareheldtoprofessionalstandardsofobjectivescrutinywithrespecttomanagingboundaries.
9.Todevelopasharedunderstandingofaclient’srelationalworld,itishelpfultolearnabout:
a.Developmentalhistoryandrelationships
b.Currentsignificantrelationships
c.Unresolvedtrauma
d.Aspectsofthehere-and-nowtherapeuticrelationshipsuchastransference
e.Alloftheabove
10.Thecircumplexdescribesinterpersonalimpactsorpullsthatcontributetothemaladaptivetransactioncycle.Whichofthefollowingstatementsistrue?
a.Thereisareciprocal,oppositeresponsetointerpersonalexpressionsofaffiliation.
b.Anexampleofthereactiontoa“hostile-dominant”interpersonalpullistorespondwithcomplianceandfriendliness.
c.Clientsmayinadvertentlyworsenrelationshipsthroughtheinterpersonalpullstheygenerate.
d.Metacommunicationisineffectiveatbreakingthemaladaptivetransactioncycle.
e.Maladaptivecyclesonlyapplytopersonality-disorderedclients.
11.Foratherapisttounderstandaclient’sinternalworkingmodelandattachmentstyle,inferencescanbemadefromobservationsaboutallEXCEPT:
a.Aclient’sexpressionsofdistress
b.Attitudestowardclosenessandintimacy
c.Expectationsofresponsesfromothersintimesofneed
d.Socioeconomicstatus
e.Helpseeking
12.Achild’sattachmentstyle:
a.Emergesasthebestadaptationtoacomplexenvironmentandisencodedinaninternalworkingmodel.
b.Isinfluencedbysocialstressors,resources,socialsupports,andqualitiesofparenting.
c.Shapesexpectationsofothers’responsiveness.
d.Affectsresilience.
e.Alloftheabove
13.Avalidatingenvironmentinearlychildhoodpromotesthedevelopmentofattachmentsecurityandisfosteredbyparentsorprimarycaregiverswho:
a.Focusmainlyonthechild’sachievements.
b.Areperfectlyresponsive,spending100%ofthetimebeingfocusedonthechild.
c.Viewthechildnotasaseparatebeing,butasanextensionofthemselves.
d.Respondtothechild’sfearsoastorestoreasenseofsafetytothechild.
e.Disavowthechild’semotionalreactions.
14.Adultattachmentstyles:
a.Canbedividedintosecureandinsecuretypes.
b.Canbedividedintoorganizedanddisorganizedtypes.
c.Reflecttheinternalworkingmodeloftheindividual.
d.Helpthetherapistunderstandtheclient’ssenseofhimselforherselfandtrustofothers.
e.Alloftheabove
15.Whichattachmentstyleischaracterizedby“dialed-up”attachmentbehaviorswithamplifiedexpressionsofdistress,intensehelpseeking,anexpectationofrejectionorabandonment,andanxietyaboutbeingalone?
a.Secure
b.Preoccupied
c.Dismissing
d.Disorganized
e.Noneoftheabove
16.AllofthefollowingaretrueEXCEPT:
a.Unresolvedtraumaunderliesinsecureordisorganizedattachmentpatternsofrelating.
b.UnresolvedtraumaalwaysleadstoPTSD.
c.Unresolvedtraumaisassociatedwithmentalizingdeficits.
d.Unresolvedtraumaaffectsaclient’sself-esteem.
e.Unresolvedtraumamakesitmoredifficulttoformtrustingrelationships.
17.ThesequelaeofunresolvedtraumaincludeallEXCEPT:
a.Emotionaldysregulation
b.Substanceabuse
c.Medicallyexplainedsymptoms
d.Impulsivity
e.Relationshipproblems
18.MentalizingtechniquesincludeallEXCEPT:
a.Usinga“knowing”stancetomakeinterpretations
b.Usingcontrarymoveswithshiftingfocusofexplorationbetweenthoughts-feelings,experiences,andperspectives(internal-external,self-other).
c.Modelingmentalizing
d.Encouragingtheclienttothinkandtomakesenseofhisexperiences.
e.Beingreflective
19.Thetear-and-repaircycleinpsychotherapy:
a.Makesuseofalliancetensionsastherapeuticopportunities.
b.Usescountertransferenceandmetacommunication.
c.Providespotentialdataaroundaclient’srelationalpulls.
d.Requiresthetherapisttoberesponsiveratherthanreactive.
e.Alloftheabove
Jacobisa45-year-oldsinglemanwhoisemployedasanofficetemp.Heoftenleavesworkwithfatigue,stomachupset,andgeneralizedbodypain.Nospecificcausehasbeenfoundforhisphysicalcomplaints.
Jacob’sprimarycareprovidertendstowincewhenhecomesforanappointment;Jacobisalwaysupsetandneedy,andthefamilydoctor,havingrunoutofthingstorecommend,feelsfrustratedandineffective.Hereferredhimforpsychotherapyforanxiety,andheexplainedtoJacobthatpsychotherapycouldbehelpfulifhissymptomsarerelatedtostress.
Jacob’spsychotherapisthaslearnedthathisdevelopmentalyearswerechaoticandscary.Hewasraisedbyasinglemotherwhohadanunreliableincomeandoftenblamedthechildrenfortheirrelianceonher.Jacob’smotherdevelopeddiabeteswhenJacobwas12,andsheoftencomplainedthatitwasbecauseofthestressinherlife.
AfterseveralpsychotherapysessionsJacobremainshighlydistressed.Hedescribeshisphysicalandpsychologicalsymptomstothetherapistinadesperatetoneofvoice,shiftingfromonecomplainttothenextwithoutanyapparentrationale.Thetherapistfeelshopelessandoverwhelmedandnotatallsurehowtohelphim.ThetherapiststartstothinkabouthowtotransferJacob’scaretoanothertherapist.
20.WhatisyourinitialimpressionofJacob’sattachmentpattern?
a.Secure
b.Preoccupied
c.Dismissing
d.Disorganized
e.Maladaptive
21.Basedontheinformationyouhave,wherewouldyoumapJacobontheinterpersonalcircumplexandwhatresponseswouldyouexpecthimtopullfromothers?
a.Hostile/disengaged-Dominant(northwest),pullingfordisengagingdominancefromothers.
b.Hostile/disengaged-Submissive(southwest),pullingfordisengagingsubmissivenessfromothers.
c.Affiliative/friendly-Dominant(northeast),pullingforaffiliativesubmissivenessfromothers.
d.Affiliative/friendly-Submissive(southeast),pullingforaffiliativedominancefromothers.
e.Noneoftheabove
Maryisa28-year-oldgraduatestudentseekingpsychotherapyforchronicstrugglesinrelationships.Duringtheinitialsession,sheoftenlaughsandissarcastic,statingsheknowswhyshestrugglesandexpectsthatpsychotherapywillnothelp.Towardtheendofthefirstsession,shementionsthatshebelievesshehasneverknownwhatitistofeelhappy.
22.WhatisyourinitialimpressionofMary’sattachmentpatternofrelating?
a.Secure
b.Preoccupied
c.Dismissing
d.Disorganized
e.Invalidated
23.Basedontheinformationyouhave,wherewouldyoumapMaryontotheinterpersonalcircumplexandwhatresponseswouldyouexpecthertopullfromothers?
a.Hostile/disengaged-Dominant(northwest),pullingfordisengagingdominancefromothers.
b.Hostile/disengaged-Submissive(southwest),pullingfordisengagingsubmissivenessfromothers.
c.Affiliative/friendly-Dominant(northeast),pullingforaffiliativesubmissivenessfromothers.
d.Affiliative/friendly-Submissiveness(southeast),pullingforaffiliativedominancefromothers.
e.Noneoftheabove
24.ImportantaspectsofthetherapeuticalliancetobeawareofincludeallEXCEPT:
a.Collaborativeagreementonthegoalsoftherapy.
b.Attendingtotherelationshipbetweenthetherapistandclient
c.Consideringthenegativeexpectationsoftreatment.
d.Theclient’sabilitytobepsychologicallyminded.
e.Therelationshipwiththetherapistasatemplatefortheclient’sdifficulties.
25.Characteristicsoftheexemplarypsychotherapistasperceivedbycolleagueshavebeendescribedasincluding:
a.Capacitytobereflectiveratherthanreactive.
b.Genuineinterest,caring,andcommitment.
c.Empathiccapacityandconceptualability.
d.Self-awarenesswiththecapacitytocontainanxietyandrecognizelimitsandfit.
e.Alloftheabove
AppendixA:Role-PlayTranscripts
(RefertotheenclosedDVDforthefullvideo.)
ROLEPLAY#1:JoelWalkerandDr.LeszczEstablishingatherapeuticallianceandexploringpsychotherapygoals
Inthisroleplayofthefirstsession,weareintroducedtoJoel,whoisclearlyanunwillingparticipantintheprocessofpsychotherapy.
C:YouknowIwasreferredhere,right?Thisisnotmygambit.I’mnotthrowingmyselfatyourfeet.
T:AndI’mgoingtoaskyousomequestions—[C(interrupts):Okay,yup,fine,sure,fine].Hopefullythiswillbeusefultoyou[C(interrupts):Okay].Alright?Appreciatethat.
T:Tellmewhyyourfamilydoctorisrecommendingthis.Whatyourunderstandingis?
[Elicitingtheclient’sperspective]
C:Well,I’mnotamindreaderImean,Idon’tknowwhathe’sthinking,but,Imean,he’ssayingtome,like,Idon’tthinkit’sasmuchaboutwhathe’sthinkingasitisaboutwhatmywife’sthinking.
T:Uhhuh.
C:So,youknow,Ithinkshe’sbehindthismorethananything,sothat’s,that’swhereI’mstuck[T:Umhum].Right?So,youknow,Imean.Yeah,that’sjustwhereI’mstuck.It’slesshimthanitismywife.
T:Isee.
C:So,soI’mhere.Takingupyourvaluabletime.LikeIendupbeingtheguywhohasto,hasto,ah,youknow.Anyway,soyouknow,Imean,doyourworst.Iknowwhat’scoming.
T:Youknowwhat’scoming.
C:Yeah.
T:Tellmewhatyouthinkiscoming.
[Exploringexpectationsinthehere-and-now]
C:Well,youknow,you’regonna,you’regonnaaskmeaboutmychildhoodandstuffandthenyou’regonnatellmewhyI’msomessedup.Andyouknow,Ijustkeepworking,andah,andmaybewehumorsomepeopleandmywifesoftensupabitaboutsomethingsthatsheshouldchilloutabout.
T:So,inmeetingwithmethere’ssomethinginthisforalotofpeoplebutnotforyou.
T:So,ifyouweretomoveonfromwhereyouarerightnow,Joel[C:yeah],Joel,what
wouldthatlooklike?Whatwouldthatbelikeforyouinyourlife?Howwouldyoubefeelingdifferently?
[Exploringtreatmentgoals]
C:HowwouldIbefeelingdifferent?It’snotaboutfeelingdifferent,it’sabouttakingcareofotherpeoplewho,whogathertheseopinionsbecauseperiodicallypeoplepointtheirfingersatmeandsay,youknow,loser,soyougodothis.
T:You’vemadeacoupleofcommentsaboutyourselfthatyouattributetootherpeopleaboutbeingaloser—what’shappenedrecentlythatthishascometoahead?
C:(Exhaling)Look,thesituation,whatI’mtalkingaboutisthat,um,mywifegavemethebootrecently—soIcouldjustleaveandIcouldjustleaveitallbehind,Idon’treallywanttodothat.Mywifealsohasourdaughter.Soshekindofgetstocalltheshots.
T:Andyourdaughter’sa,abigpieceofthisforyou.What’syourdaughter’sname?
C:Charlotte.She’sthree.
T:Sopartofwhatbringsyouhereistryingtogetsomethingbackon,ontherailssothatyoucancontinuetoseeCharlotte.
[Validatingthechiefconcern]
C:Well,that’sthepowershe’sgot,doctor.Imean,shecansay,well,youknow,Imean,youdothis,youdothat,oryoudon’tgettoseeCharlotte.Andyouknow,IcouldarguethatbecauseI’mherdad[T:Right].ButImeanwecouldarguetothepointwherewe’regoingtocourtandhowmuchtimeandmoneyisthatgoingtowaste?
T:Sure,sure.WhyisyourwifeblockingyoufromseeingCharlotteatthismoment?
C:She’snotsomuchblockingme,shewon’tletme,ah,seeheronherownbutyouknowthere’snoreasonforit.It’sapowermove.MydaughterandIhaveafinerelationship.IalwaysdoeverythingIcanformydaughter—whereversheis,she’snotgonnahavethesamehousethat,that,Igrewupin.She’sjustnotgonnahavethat.
T:Right.
C:And,andso,it’sapowermove.’Causeyouknowshe,mywife,um[pause],mywife,um,mywifeknowsthatshecan,shecancontrolmethatway.
T:SoyourwiferecognizesbecauseofyourattachmenttoCharlotte,shecanusethatforleverage.
[Expressingempathy]
C:[continues]…sothat’s,youknow,that’swhyI’mhere.
T:Istillneedtogetasenseofwhyyourwifefeelssheneedstousethatleveragetogetyoutodosomethingortobedifferentortochangesomething.IneedtounderstandthatifIcan.
[Usinganot-knowingstancetochallenge]
T:Theremaybevalue…
[C(interrupts):I’mnotsomewackocreep,right,youknow,that’snot,there’snothinglikethatgoingon,okay?There’snothinguntowardhappeninginmyfamilyhome,okay?Let’smakethatabsolutelyclear.]
T:Doyouthinkthat’swhatI’mthinking?
[Usingmetacommunicationtoprocessthealliancetension]
C:Idon’tknowwhatyou’rethinking.ButI’mnot,I’mnotgonnaletyouaskthatquestion.Okay,just,endofstory.
T:IcantellyouwhatI’mthinking.I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe…I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.
[Silence]
T:Soifit’salrightwithyou,Joel,I’mgoingtocontinuetoaskyousomequestions.
C:I’mtryingtotellyoueverythingIknow.
T:WhatdoyouthinkSarahwantstobedifferentinhowyouarethatledhertosay“you’releavingandyoucan’tseeCharlotteuntilyougetsomehelp”?
[Askingtheclienttomentalize]
C:Youknow,Ijustthinkthatmaybewhatshewantsisadifferentguy.
T:Areyoudifferentthanyou’vebeenrecently?Havetherebeensomechangesgoingonforyou?
C:Changes?No,well,youknowI’vebeenworking;I’vebeenworkingalot.
T:Haveyoubeenfeelingmoreangry,moreupset?
C:I’malwaysunderpressure.
T:Yeah,whatkindofpressure?
C:Ihaveabusinessjob.Ihavetoperformandsometimesit’stense.Andthat’sjustthewayitis.
T:Whatdoyoudo,Joel?
C:Icontrol,ah,Icontrolinventoryforadepartmentstore,alltheinventory.Wedothebuying,wedothechoosing,wegetittothestores,sothere’salotofdecisionstobemade.There’sadozenpeopleunderme.
T:Andthisisatough,toughclimateforthatkindofbusiness.
[Expressingempathy]
C:Yeah,itisnotgettinganyeasier,yeah.
C:Imean,youknow,youjusthavetodowhateveryouhavetodosometimes.Sometimes
youhaveto,ah,sometimesyouhavetousethewhip.
T:Thewhip.
C:Yeah.
T:Atwork.
C:Yeah.Notliterally,I’mbeingmetaphorical.
T:Iunderstoodthat.Buttellmewhatusingthewhipmightlooklikeatwork.
C:Ah,somepeople,youneedtogetupintheirgrillabit,youknow.Justdependsonwhoitis.Youhavetopushtheirbuttons,sometimesyouhavetodothat,youknow.It’snotpersonal;youjustgottomeetyourtargets.
T:Haveyoubeenusingthewhipmorerecently?
C:More?Idon’tknow.
T:Howaboutathome?
[Exploringsafetyconcerns]
C:Ihaven’tbeenhomeinsixmonths.
T:Beforethat,sayayearago.
C:Idon’tusethewhipwithmydaughter.
T:That’simportantforyoutoconveytome.
[Usingmetacommunicationtobuildapositivealliance]
C:Well,okay.It’sthetruth.Like,Imean,mydaughterisnot,mydaughterisnotlikethesepeoplewhoworkwithme,youknow?
T:Thatmakessense,Iunderstandthat.Um,butI’minterestedinyouruseofthe,ofthatmetaphor,thewhip.
C:It’sjustthefirstthingthatcameintomyhead.
T:That’sokay;I’mnotfindingfaultwithitatall.I’mjustcuriousaboutitsuse,aboutthemeaningtoyou.I’lltellyouwhatI’mthinking:whenyou’reunderpressureyouputpressureonpeoplearoundyou.
T:Andwith,withCharlotte,itsoundslikethat’sarelationshipthere’smuchlessconcern.Youwanttoseeher[C(interrupts):It’snotaboutthat].Yeah,it’snotaboutthat,whatisitabout?
C:It’snotabusinessrelationship.LikeImean,it’s,it’s,itwas,afamily,right?LikeevenwithSarah,I’mnottakingthatstuffhome,we’retryingtohavealittlesocietyinthehouse,whichisafamily.
T:Iseehowimportantitisforyou,Joel,topreservethatfamily,andyourrelationshipwithCharlotte.HowimportantisitforyoutopreserveyourrelationshipwithSarah?
C:ifitwerejustaboutCharlotte,I’dprobablybetalkingtoalawyerrightnow.
T:SoyoualsowanttopreservetherelationshipwithSarah?
C:Well,Ido,Idon’tknow.Maybethat’spieinthesky,Idon’tknow.
T:Well,hardtoknowatthismoment,butit’simportantinformationforyoutosharewithme.
T:Howareyoufeelingrightnow,Joel,aswe’retalking?
[Seekingclientfeedback]
C:Well,I’mfeeling,atthismoment,I’mfeelingabitantsy.
T:Antsyaboutwhat?
C:It’s,ah,well,youknow,ImeanIdon’tspendalotofdays,youknow,shootingthebreezeaboutmypersonallifewithpeople.Youknow?
T:I’msureit’snotaneasythingforyoutodo.
C:Well[sighs],maybenot.
T:CertainlywhenyoucameinIpickedupalotof,ah,alotofangerandsomeantagonismaboutbeinghere.
[Metacommunicatingtorepairthealliancetension]
C:Look,man,youcanpileonwiththatstuffallyouwant;Imeanthefactisthatitwasnotmychoice.
T:Yeah,Iunderstandthat.WhydidyousayIcouldpileonwiththat?DoyoufeellikeI’mpilingonwhenImakethatcomment?
C:Well,youknow,likeantagonistic,angry,givemethelaundrylistof,youknow,whateverdespicablethingsyou’reseeinginme.There’snooneelsehere;youcanmakemefeelhoweveryouwant,goahead.
T:I’mnotfeelinganythingakintodespicable.LetmetellyouwhatI’mpickingup.Letmerunitbyyou,Joel,andtellmewhatyouthink.Ithinkyou’reunderalotofpressure,Ithinkyou’refeelingalotofapprehensionaboutimportantrelationshipsinyourlife.Youmadeaveryimportantcommentthatwedidn’tfocusonearlierabout“youwanttomakesurethatCharlottegrowsupinadifferentkindofhomethantheoneyougrewupin.”Myhunchisthatwhenyouusethemetaphorofcrackingthewhip,thatyoumightknowmoreaboutwhatit’slikeonbothsidesofthat.
C:Yeah.
T:AndyouwanttomakesurethatyouprotectCharlottefromwhatyougrewupwith.IknowI’mstretchingherebecauseIdon’thavealotofinformationbutI’mbasingthatuponsomeofthethingsyou’resayingandalsohowI’mfeelingwithyou.
C:Look,whatevermypastis,ismypast.And,um,it’sover,I’mnotinterestedreallyin,ah,inrelivingitandthepeoplewhowereinstrumentalinthatpast.Youknow.Theydon’tmatter,thethingthatmatters,isthat,ah,Charlottegetstoexistinadifferentreality.
T:Exactly.AndIthinkmaybewehavefoundsomecommonground.Youdon’twanttorelivethepast…
C:No.
T:…andIdon’twantyoutorelivethepast,andmyconcernisthatsomethingsareputtingpressureonyou.You’veusedlanguageindescribinghowyouthinkI’mthinkingaboutyou—thatleadsmetobelievethatyouexpectmetobecriticalandattackingandI’mnotfeelingthatway.I’mawareofyourangerbutI’mmorecuriousaboutitthan,ah,angrywithit.I’mhopingwecanhaveanopportunitytocontinuetotalkaboutthattogether.
[Questioningthepathogenicbeliefaboutothers’judgment]
C:[Sigh]Idon’tknow.I’malittleconfused.LikeIjust,ah,like…[sigh]
T:Howwouldyoufeel,Joel,aboutcomingbacktoseemeasecondtime?Sowecantalkalittlebitmoreaboutthis?
C:Yeah,IguessIcould.
T:Okay,Iwould,Iwouldbepleasedifyouweretochoosetodothat.
T:Joel,we’regonnaneedtowinddowninjustafewminutesbutIwantedtogiveyousomefeedbackbeforeweendandhopefullymakeaplanfornextsteps.I’mhopingthatIcanbehelpfultoyouandthatmeetingtogetherwouldbeuseful.ButletmegiveyoualsoalittlemoreinformationaboutwhatIthinkwemightbeabletofocuson.Andletmeknowhowthissitswithyou.Atonelevel,there’ssomeantagonism,andmaybeevensomehurtthatliesbeneaththat.ButIalsowasawarethattherewereanumberofpointswhereyoutouchedonsomerealtenderness,especiallyaroundCharlotteandmaybeevenaboutSarahandmyreadingisthatsomething’sgettingintheway,andthattalking,workingintherapy,mightbehelpfultoyou.Yousaidearlierthat’sit’sveryimportantforyoutomakesureCharlottegrowsupinadifferenthomethanthehomeyougrewupin…
[Developingasharedunderstanding]
C:Yup.
T:Ah,andsometimesdespitepeople’sbestefforts,ah,thepastcreepsupintothepresent.
C:NotwithCharlotte.
T:That’sgood.Ah,howdoyoufeelabouttheprospectofmeetingagain?
C:YouknowI,Idon’tknow,Imean,ah,beforecominginhereIwouldn’thaveimaginedthat,ah,soIsupposethatmeansnowIcanimagineit.
ROLEPLAY#2:KatherineMarksandDr.PainEstablishingatherapeuticallianceandexploringpsychotherapygoals
ThisisKatherine’sthirdpsychotherapysession.Inthetwosessionsthatprecededthis,ahistorywasgathered.Katherinewouldliketherapybutshe’sambivalent.Shewouldliketohopebutcannot,andshemightevennothavemuchofasenseofwhatshewants.Duringthissegmentthetherapisttriestoclarifytheclient’sgoals.
C:Umhum,soum,reallyitwasmyfriendwho,ah,suggestedthatIcomeandtalktoyou.
T:Whydidshethinkitwouldbehelpful?
C:Idon’tknow[laughing].I’mnotsure.I’mnotsure.ButIthought,sure,I’llgotalktosomeone,Iguess,sortofexplorewhat’sgoingon.
T:Toexplorewhat’sgoingon,okay.Thatsoundsgood.Whatwouldyouliketoexplore?
[Askingaboutchiefconcernsintheclient’swords]
C:Idon’tknow,uh,IguessIfeelalittlebitlost,Idon’tknow….It’slikethingsarehappeningaroundme,Idon’tknowhowtoexplainit.
T:WouldithelpifIaskedyouwhat,ifeverythingwentwellifweworkedtogether,whatwouldbedifferentifwehadasuccessfultherapy?[C:Uhhuh]Whatwouldchange,whatwouldfeeldifferent?
C:[Chuckles]Um,mylife,Imean,youknowmy,mywholelifewouldchange.
T:Yourwholelifewouldchange?Whatwouldchange?
[Exploringtreatmentgoals]
C:Um,Idon’tknowwhetherit’s,um,aneasinessaboutthingsorthere’s…
T:Insidethingswouldfeeleasier?
C:Uhhuh.Um,Idon’tevenknowactuallywhatImeanbythat,um.Idon’tknow.
T:Maybeit’sdifficulttoimaginewhatthingsyou’dliketofeelchangeinsideyoubutsomethingseemstohaveappealedtoyou.Anditseemstobeaninsidething.Yourwholelifewouldbedifferentbutyou’dfeeleasierinside[C:Uhhuh].Areyoufeelingthatrightnowaswesitandtalk?
[Exploringinthehere-and-now]
C:Ifeelreallylostactually.I’mnotquitesure.
T:Lost,okay.Andwhatdoeslostfeellike?
[Encouragingreflection]
C:Sortof,hmmm,notknowingwhichwaytogo,notknowinghowtomakedecisionsaboutthings,um,I,notknowingwhatIwanttodo,iftherewasanythingIwantedtodo.Idon’twantanything.Ihaveno,um,needofanything.That’sthefeeling,I’m
feelingquitedisengaged,sortof…I’mjustnotthatinteresting,right?Imean,it’sjust,Ihavenothingreallygoingon,there’snothingreallywrong,there’snothingreallythematter,it’sjust…
T:Sorrytointerrupt,I’mjustwondering….Ihearwhatyou’resayingandIcanseethatyou’renotinacutedistress,ifthat’swhatyoumean,butit’salmostlikeyoudaren’thopeforsomethingandmaybetellmeifI’minthewrongballpark,butitfeelslikeyouwouldliketo,somehow,hopeorexperiencesomethingtoreflecton,toseewhat’smissing.
[Returningtofocusontreatmentgoals]
C:Yeah,butIdon’tknowhowtogetthere.
T:I’mgettingafeelingthat,aswe’vebeentalking,insteadoffindingawaytotalktoeachotheraboutthethingsthatpuzzleyou,orthatyou’dliketoexplore,theoppositeishappening.IfeellikeI’minadvertentlysortofchasingyououtoftheroom.Thatsomehow,whatbeganasaverytentativecuriosity,isnowmovingtowardfeelinglessengagedhere.Howhaveyoufeltinthelastwhilesincewebeganthissession?
[Metacommunicatingoninterpersonalpulls]
C:Whatever,whateverhappenshereisnotgoingtomakeanydifference.That’ssortofhowitfeelstomebecauseIcan’tbe,Ican’tbehelped.Ijust,youknow,it’sallfine,it’sallgood,Ijustcan’tbehelped.
T:Thatsoundslikeyou’refeelingupset.Canyoustaywiththatfeelingandtalkfromitalittlebit?
[Encouragingmentalizingofafeeling]
C:Ah,it’swayeasiertonotknowthantoknowthatyoucan’tbehelped,Iguess,Idon’tknow.[tearful]
T:Itmakesyoucry?
C:I,uhhh,Ijustfeellikea,Ifeellikealostcause,I’malostcause,right[crying]?
T:Youknow,Inoticedyou’vestoppedlookingatmecompletely.
[Reflectingonbehaviorinthehere-and-now]
C:Idon’tknow,Idon’tknow.[sighing]Uh,I,Idon’twanttobeseenlikethis,Iguess,Idon’twanttobeseenlikeIneedhelporthatIcan’tgethelporthatI,youknow…
T:Butyou’rehere.
C:ButI’mhere.[Sighs]Ireallyhavenothingtocomplainabout.Right?
T:Itseemstomethatthere’sasortofwavelikemovementhere.Youcomeinwithalittletinyglimmerofhope;you’dliketofeeleasierinsideandwhenwestarttotalk,it’slikeyouwithdrawandIaskyouaboutthatandthere’sthehopeagain.
[Mentalizingabouttheclient’sinternalexperiences]
C:Uhhuh
T:Withtears,withrealworrythatyoucan’tbehelped,thatit’snotgoingtowork.[C:Uhhuh].Isthatawholenewsetofexperiencesforyousincethechildrenleft?Oristhispartofwhatyouhave,youlivewith?
C:Thisisold.
T:Thisisold?What’sold?
[Usinganot-knowingstance]
C:Um,awholebunchofthings,Iguess,um,feelingthatIbetterjusttakecareofmyself.Um,it’snotquitethat,um,Ireally,justreallynothingbig,it’sjustthatIdon’t,Idon’tthinkthatanybodycanreallyhelpme.ItjustfeelslikeI’mwhining;IfeellikeI’mwhining.
T:Youfeellikeyou’rewhining?Ifeellikethere’salmostakindofanurge,adesiretoaskforasortofhelpinghand.There’ssomethingthatyoufeelwouldbenefitfromabitofhelpatthistimebutitfeelslikequiteadangerousthingforyoutoconsider.You’resupposedtobeself-reliantcompletely.Tobeseentoneedabitofassistanceorsupportwouldbeasignof,woulditmakeyoufeelvulnerable,orwoulditbeasignofweakness?
C:Umm,I’mnotsureitwouldbethere,Iguess.
T:You’renotsurethatthehelpinghandwouldbethere?[C:Yes].Okay.
C:Soitwouldjustbewayeasiernottoask.
T:Sowhat’sthedangerofasking?Here.
[Processinginthehere-and-now]
C:Ofallthedangers[sigh],Iguessitwouldbeamiss;youknowwe’dmisseachother,youwouldmiss.
T:Soyou’daskforhelpandIwouldsortof…
C:Thinkitwassomethingelseandthen…
T:Okay,okay.WhatwouldImiss?
C:WhatI’mreallytryingtosay.
T:AmImissingitnow?
C:Idon’t,youknow,thisis,Imean,I’mnotsosurewhatI’mtryingtosaysoIcan’tputthatpressureonyou,Imean.
T:It’sjustawelloffeelingsthat’sjustunderthesurface.Canyousaysomething,whatyou’refeelingthatseemstobubblerightup?
[Encouragingmentalizingoffeelings]
C:What,Idon’tknowwhatyouwantmetosay[crying].Idon’tknowwhatyouwantme
tosay.Idon’tknowwhattosay…
T:Thefeelingsjustsortofebbawayandyou’renotquitesurewhat’shappening?Sohowisthissofar?Mysenseisyou’reriskingalittleherebyhelpingmeunderstandthisebbandflowofwishingtoreachoutandthenbeingquitenervousandwithdrawing.
C:Umhum.Itfeels,um,it’snotwhatIexpected,tosaytheleast.Itfeelsrisky,itfeelsodd…
T:Odd?
[Usinganot-knowingstance]
C:Odd,becauseIdon’t,Ididn’tknowIwasgoingtodothis,cryorfeelanythingreally.
T:Soyousurprisedyourselfalittlebit.
C:Umhum[sniffling].Umhum.
T:TheclearestthingI’veheardisthatthedangerisifyoureachoutyourhandforsomehelp,Imightmissit;misstheentirepoint.Missyou,mis-communicate.
C:Itislike,um,asyou’respeakingit’slike,ah,themissingislikeaperformance,it’slikeIdoaverygoodperformanceofallthethingsthatIdoinmylife.Andsopeoplerespondtothat.I’mgood,youknow?I’magoodwife;I’magoodmother,andmissingsomehow.Butit’snotanybody’sfault.
T:Soyou’reverygoodathelpingotherpeople.Growingyourchildrenup,beingawifetoyourhusband,beingaworker,andnowthechildren,don’tneedyouasmuchorasintenselyastheyhavedoneforthelastcoupleofdecades.Itseemsthatthis,thisperformanceaspectorthis“somethingmissingfeeling”comesuptoyourattentionabitmore.
C:Butthenagain,like,youknow,Ithink,amIjustwhining?AmIjust,whycan’tI,whycan’tIletpeopleknowwhatIwantordon’twant?
T:Whycan’tyouletpeopleknowwhat?Well,yousortofhavehere,haveyou?Haveyoutoldmewhatyouwanthere?
C:Yeah…
T:Well,let’smakesureI’veunderstoodthat.Whatwouldyoulikehere?
[Seekingclientfeedback]
C:Iguesstoreconnecttosomethingortogetclarityaboutsomethinginsideofmethatjust,I,Iguessitjustfeels,missing.
T:Right,right.Sothat’swhatyou’dlike.AndthedangeristhatIwon’tgetitandyouwillthenbeforcedintoasortofperformanceofgoodpatientor…[C:Uhhuh.]“Thankyouverymuch,doctor,thatwaslovely”orwhatevertheperformancewouldbe?
C:Icandothatreallywell.
T:Well,I,Ihearthat,yeah.Itcomestomymindthatforyouitseemstobedangerousto
say,“Something’smissingI’mnotclear,IthinkIcouldfeelawholelotdifferent.”Yousaidyourlifewouldbeentirelydifferentiftherapyweresomehowtohitthespot.Butit’sabitdangeroustobeabletobeawareofthosethings?
C:Ortoaskforthem.Imean,whatifI’mnotworthit?I’mnotworthit,right?I’mnot…
T:Youshouldn’twanttohavemorebecauseyou’renotworthit?
[Questioningthepathogenicbeliefoflowself-worth]
C:Well,itfeelslikeitwouldbeeasyenoughforsomeonetojustbrushmeoff,just…
C:Orit’stoomuchtroubleor,justno.
T:No?
C:Justno.
T:So,gosh,thatmustbequiteariskif“no”comestomind.Yousaidthiswasn’tquiteasyouhadexpected.Yousaidyousortofsurprisedyourselfwithtearsandfeelingscloserthanyouimaginedperhaps?Andhowbraveitistocomehereandexpectano,orhalfexpectano.
C:Uhhuh.
T:IcanseethethoughtsbutIcan’t…
C:…hearthem.
T:Itsoundedlikethat,ah,whatwereyou…
C:It’saninterestingidea.I’dneverthoughtaboutbraveryinthatrespect.
T:Youdon’tthinkofyourselfascourageous?Incominghere,uncertain,ambivalent,puttingwhatyou’dlikeonthetable,askingforsomehelp?
C:Imean,Iguessthelastquestionthenis,amIhelpable?Like,canIbehelped?
T:Whatdoyouthink?Tellme…there’ssomethingaboutthewayyou’reaskingmethatquestion.
[Usinganot-knowingstanceinsteadofreassuring]
C:Well,I,atthispointIknowIwanttobehelped.Um,whichisnotwhatIcameinwithreally.I’mnotsure;itmaybebiggerthananyonecanhelpmewith.Itmaybeabigproblem,itmaybe…unsolvable.Youknow,I’mtryingtogetapictureofwhat,what,Ican’tgetapictureofwhatitisthatI,thathelplookslike.
T:Ithoughtforamomentyouweregoingtoaskmedirectly,willyouhelpme,andthenwe…
C:[laughing]
T:AndIthought,well,thatwouldbe,thatwouldbe…
C:Verybrave.
[Demonstrating“presence”withpositiveregard]
T:Wonderful.Yeah,thatwouldbeterrificifyouasked.Imeanitwouldseemtometobesomethingyouactuallywanttodo,notparticularlyperformance-related.
ROLEPLAY#3:JoelWalkerandDr.LeszczUsingcountertransference,mentalizing,andmetacommunication
We’regoingtolooknowatsession2betweenJoelandhistherapist.Joelhasdifficultyrelatingandexpressingemotions,buthegeneratesstrongfeelingsinthetherapist.Thetherapistfeelsunderattack.HefeelstheneedtoprovehimselfandwantsJoeltoseehimaspartofsomethinghelpfulratherthanasashaming,humiliating,orcrushingforce.That’sapowerfulmotifinJoel’slife.ThefactthatthisthemeisbroughtintothesessionischallengingbutgreatnewsbecauseitmeansJoelandthetherapistareclosetoJoel’scoreconcerns.
T:Morning,Joel.Goodtoseeyouagain.There’salotthatIwanttoaskyouaboutbutbeforeIdothatIwanttoaskyouhowyoufeltaboutthelastmeetingandaboutcomingbacktotoday’smeeting.
[Seekingclientfeedback]
C:Ithoughtaboutit.YouknowitwasdifferentthanIexpectedsoitwasokaytocomebackforsure.
T:Canyoutellmethewaysinwhichitwasdifferentthanwhatyouexpected?
C:I,IknowIdidn’treallyfeellikeabagofshittalkingaboutallthisstuff,right?Ah,andah,andIguessthatwasdifferentthanIexpected.Iguess,youknow,withtheresponsethatyouhadwas,Iguess,differentthanIexpected.
T:Yeah,Iwanttothinkaboutthat,IwanttolearnmoreaboutthatbutI’mgladthatitfeltdifferentinapositivewayfromwhatyouexpected.Thatphrasethatyouuse,“abagofshit,”isthathowyou’vebeenfeeling?
[Askingaboutconcernsusingtheclient’swords]
C:SometimesIdo.SometimesIdo.
T:Canyoutellmeaboutthat?
C:It’sjustsomethingallmylifethat’shappened.Imean,Idon’texpectthattochangereally.
T:Yousaidallyourlife?Goingbacktowhen?
C:Well,youknow,likeallmylife,right?Youknow?Whenisitsomethingyoucanchangeandwhatisjustacharactertrait,right?Youknow,you’rejustthatguy,right?I’mthatguyandthat’showIgettofeel,that’sall.
T:Howdoyouthinkyoucomeacross?
[Encouragingreflectiononinterpersonalimpact]
C:Well,Idon’tknow.ItrynottocomeacrossatallwhenI’mfeelinglikethat.Youknowsometimesyou’rearoundpeoplewhenyou’refeelingthatway.Lotoftimesit’sthemthat’smakingyoufeelthatway.Or,whatever,but,youknow,it’dbebetterjustto,justtotryandshutthehellupandgetthroughit.
T:Uhhuh.Sojustkindofshutdown,keepyourheaddown;justtrytogetthroughit.
C:Hey,ifyoucandoit,that’swhatyoudo.
T:Whathappensifyoucan’t?
C:Well,Idon’tknow,Idon’tknow.Youknowit’dbenicetobetheinvisiblemanforafewminutesbutIcan’tdothat,so,youknow…Well,it’shardwhenyourwifekicksyououtofthehouse.
T:Whatwouldyourwifesay—Iknowthis,you’regoingtotellme“askSarah”—butsinceSarahisnothere,whatwouldSarahsayaboutthisidentificationassomebodypeoplewanttogetawayfrom?
[Exploringinterpersonalpulls]
C:Idon’tknow!She’dprobablysay,“Ican’ttalktoyouwhenyou’relikethis.”
T:Ican’ttalktoyouwhenyou’relike[C:Yeah!]thisbecauseofwhat?
C:That’sthepartyou’dhavetoaskherabout,um,…look,I’llbehonestwithyou,there’sapartofmethatsaysthat’sjustfinebecauseIdon’twanttotalkrightnow,youknow?So,so,youknow,backoff.
T:Whenyousay“rightnow,”you’retalkingaboutrightnowherewithyouandme?Oratthispointintimeinyourlife.
[Exploringthehere-and-nowalliancetension]
C:It’sbeginningtobeabitofboth.Imean,whatdoyouwantmetosay?
T:Well,there’snothingthatIparticularlywantyoutosay.WhatI’mthinkingisthatyou’vecarriedaroundafeelingofbeingworthlessandsomebodypeoplewanttogetawayfrom.Andthat’satoughwaytogothroughlifeandI’mconcernedthatyou’vebeenfeelingmorethatwayrecently.Andthatitmaybemakingittoughforyoutobewithpeople—eventhepeoplethatyouwanttobewith.
[Mentalizingabouttheclient’sexperienceswithothers]
C:It’snottoughformetobearoundthepeoplethatIcareabout,it’s,ah,it’stoughforthemtobearoundme.That’swhatIget.
T:Thatit’stoughforthemtobearoundyou?
C:Well,theydon’twanttobearoundme.Sarahdoesn’tanyway.
T:“Peopledon’twanttobewithyou.”Thatgeneratessomefeelingsforyourightnowandthatwouldbeprettypainful,Iwouldimagine.
[Expressingempathy]
C:Youknowwhat,it’spainfulifyouwanttobewiththem.
T:Yeah.
T:Whatwe’retalkingaboutobviouslytouchesalotoffeelingforyou.CanIaskyou,
Joel,totrytotracksomeoftheemotionofwhatyou’reintouchwithrightnow?
[Exploringhere-and-nowfeelings]
C:Trackit?
T:Yeah,payattentiontoit,commentonit,describeit.
C:Idon’tknow.It’sjust,it’sjust,that,ah,that…it’slikewhenSarahwouldsay“tellmewhatyou’refeeling,tellmewhatyou’refeeling.”Andyouknow,itjust,andIwould,youknow,it’sjust,like,“whatdoyouwantfromme?!”Idon’tknow…I’msorry,I’msorry,I’msorry,Ijust…
T:You’resorryaboutwhat?
C:Idon’tknow,like,like,what…
T:IthinkyouletmeintosomethingreallyimportantrightnowandI’mgratefultoyouforthat,becauseI’maskingyoutodosomethingthatsoundslikeSarahhasaskedyoutodothatisveryhardforyoutodo,andthatistotrytotalkabouthowyouarefeelingwhenyou’refeelingreallybadlyaboutyourself.AndIthinkthathowyourespondtothat,ifthisisakindofwindowintothat—what’shappeningwithyouandme—isthatyougetangry,andthenyoufeelregretful.Andyoukindofjustcollapseinonyourself.Anditdoes,Ithink,asyou’vearticulated,leadpeopleyouwanttobecloseto,leadthemtowanttowithdrawfromyou.
[Metacommunicatingaboutmaladaptiveloops]
T:DoyouthinkwhenSarahasksyou,orevenwhenIaskyouhowyou’refeelingthatitmightbecomingfromaplaceofinterestorconcern?
[Challengingpathogenicbeliefsbyaskingtheclienttomentalize]
[Silence]
C:Whatconcernthough,youknow?Whatconcern?Youknow?Youtellme“whatareyoufeeling,”Imean,howdoIknowyou’renotsayingtome“what’swrongwithyou?”Right?
T:Isthatwhatyouhear?“What’syourproblem?”Irealizethisisveryhardforyou.
C:Idon’tknow,ah,Idon’tknow.Youknow,dowehavetotalkaboutthis?Imean…YouaskmetotellyouwhatI’mfeeling,right?Sarahasksmetoo,“what’sgoingon,whatareyoufeeling,”whatever,it’s,like,it’s,it’s,“Whyareyouthewaythatyouare?”That’sbehindeveryquestion,there’ssomethingwrongwithyou.“Why?”
T:You’veidentifiedsomeveryimportantthingsthatIthinkwarrantourattention.Youfeelverybadlyaboutyourselfanditsoundslikeit’sbeengoingonforalongtime.Idon’tknowthefulldimensionofwhythatis,howthathascometobe.ButwhatIhearinyourrelationshipwithSarahandwhatIfeelhereisthatit’shardforyoutofeelsupportedandyou’remuchmorelikelytofeelcriticizedandI’mawareevenwhenI’msayingthattoyou,itmayfeelforyoulikeI’mpilingon.Ireallyamnot,it’sreallynotwhatIintend[C:Right].Itsoundstomelikeyouhavebeenreallyquitealoneforalong
time.Thatanykindofoverturesomebodymakestowardyou,eveniftheyarecomingfromapositionofcaringaboutyou,feelslikethey’regoingtoexposeyoutomorecriticism.
[Metacommunicatingtoseekasharedunderstanding]
C:Okay.
T:ItwouldbehelpfulformetoknowifwhatI’msayingtoyoufeelslikeit’sintherightballpark?
C:Youknow,maybeitis,Idon’tknow.LikeImean,it’s,likemyperspectiveisdifferentthanyours’cuzyou’re,you’relookingatitfromoutside,right?SoyouknowIgetto,Igettofightformyselfright?That’smyperspective.
T:Feelsforyoulikeyou’vebeendoingalotoffightingforyourself.
C:Ihaveto.
T:Youhaveto.Good.
C:Doesn’teverybody?
T:Ithinkyou’vehadtodoalotmorefightingthanalotofpeople.Well,that’swhatIhopewe’llbeabletotalkabouttogether.
ROLEPLAY#4:KatherineMarksandDr.PainUsingcountertransference,mentalizing,andmetacommunication
ThisfollowingsegmentisfromKatherine’ssixththerapysession.Inthesessionthatprecededthis,Katherinehadrecalleddetailsofherrapeatage14,aswellasthefailureofpeoplearoundhertohelpheratthetime.Wecanhypothesizethatherfamilywereunable,unwilling,oruncertainofhowtoassistherthroughthattime.ThisfailuremayberelatedtoKatherinecomingtofeelundeservingofhelpandunabletoconnectdeeplywithherselforothers.
T:Howwasthelastsession?Anythoughts,feelings,reflections?
[Checkingforfeedback]
C:Youknow,thesessionitselfisabitofabluractually.Um,yeah.But,ontheweekendfollowingthat,um,Iwasbothexhausted—justexhausted—andsortof,um,Iwouldn’tsaydepressedbutsortofreallyirritable,justsnappy,just,youknow,nothingisrightiswhatitfeelslike.
T:Doyouthinkyou’rerelatingthattothesessionalittlebit?
C:Ican’t,yeah;Ican’trememberfeelingthatwaybeforeactually.
T:Feelingsnappy,irritable?
[Mentalizingfeelings]
C:Yeah.
T:Okay.Sodoyouremember…Iagreewithyou…Ineverkindofrememberwordforwordwhatwesay,butI’mjustwonderingifthereisawayinthatthatsnappinessorirritabilityrelatestohowyou’redoingintherapy,let’ssay,orgenerallyhowthingsfeel.
C:Um.Idon’tknowhowtoanswerthat.Iguess,youknow,I…IguessI’mfindingoutnewinformation.I’mfindingoutmoreaboutmyself,whyI’mfeelingwhatI’mfeeling.Butthat’ssortof,Ithink,tellingyouwhatyouwanttohear.Idon’tactually,right,so…
T:Wereyouperforming?
[Seekingasharedunderstanding]
C:Iwas.Sorry,um,yeah,sothey’rehardactually.Thesesessionsarehardforme.Yeah,andIguessyouknow,thelastone,itdefinitelyfeltconnectedtothesession,thatIreallyjustwantedtolayinbedallweekend.That’swhatIwantedtodo.
T:Andthat’ssortofrelatedto…Youknow,letmetellyouwhatIremember.BecauseIrememberformeit,feltlikeabitofamarkerbecauseyoufairlyspontaneouslyrelatedthisperformancemodeasyou’vedescribedwithasensethattherecouldbemorebutyou’renotquitesureifyou’reentitledtofeelbetter,performless,andlivemoreorbemore.Youkindofrelatedthattotherapethatyou’vealwaysremembered,Ithink,
whenyouwere14.Andasyousaidlasttimequiteclearly,thatthatwasoneofthelasttimesyouremembertryingtoreachoutforhelp,inthemonthssubsequenttotherape.Thatyouwouldhavelikedsomemoresupport.You’dhavelikedtohavepeoplehelpyou,yourfamilybethereabitmoreforyou.Andyettodayyou’renotquitesure…whenIjogyourmemorydoesthatcomebackabit?
[Modelingmentalizingandlinkingtraumatopresentexperience]
C:It,itdoes.It’smuchclearerwhenyourelayitbacktomethanIthinkmyexperienceofit.Um,it,yeah,becauseit’s…myexperienceofit,especiallyduringthemonthsafterwardswasthatitwassomethingthatIdid.Right?Thatitwasmyfault.Ihadputmyselfinharm’sway.Thatwasthephrase,“Iputmyselfinharm’sway,whatwasIthinking?”Yeah,toget,um,my,bothmyparentsto,yeah…Notexactly,sono,theywerecompletelyincapableof,of,ah,beingthere,understandingtheeffectthatithadonme.That’swhereweendeduplastweek.Theywerecompletelyincapableofunderstandingtheeffectthishadonme.Right.
T:Andtheweekend’sirritability…
[Encouragingmentalizingoffeelings]
C:Right.Right.Yeah.
T:What?
C:Well,I’m,Imean,Iguesspartofmeisbeginningtoseethatitwasn’tjustmyfault.Thatotherpeoplecouldhavesteppedintohelpmeinwaysthattheydidn’t.Um,but,Istillputmyselfinharm’swaysothere’sthisthinggoingon.Istill,Iwasstillthestupidpersonwhoputmyselfintothesituationso…
T:Sothere’sonetendencytotakethatkindofblameandthenthere’sthisotherkindoftendencytosayasyoujustdid,theycouldhavebeenmorehelp.Andthere’sthatsortofirritableexperienceovertheweekend.SoI’mwonderingifthatkindof“it’smyfault,”“well,actually,Iwas14.”
C:Yeah,um,andtheforgivenessofthat,right?Theforgivenessoftheparentswhoweren’tthere.Theforgivenessofthefriends,who,youknow,didn’tthinkitwasanybigdeal,right?So,Ijustforgave,Ijust,youknow,itwasmyfaultandyouknowhowcouldtheyunderstand?AndIthinkifIwere,ifithappenedtomydaughter,ifithappenedtomykids,Iwouldbe,right,I’dbe…
T:What?
C:Well,I’dberightthereforthem.I’dberightthere.Imean.
T:Youwouldn’tblamethem.
[Validatingthattraumavictimsarenotatfault]
C:No,Imean,no.Soagain,I’mstucktryingtofigureouthowtothinkaboutthis.Imean,itfeelslikeit’ssortofnewinformation.
T:Whichpartisnew?
C:Thefactthattherecouldhavebeenmorehelp.Therecouldhavebeenadifferentresponse.Hmm…
T:Canyouthinkoutloudaboutthat?
C:Well,youknow,I’vefeltlikedamagedgoods.Foryears,Ifeellikedamagedgoods.ImeanI’m…
T:Whatdoesthatfeellike?
C:ItfeelslikeI’mconstantlyneedingtoapologizeandtomakeupforandtodotherightthingbyandtodomorethanand—it’sexhausting[T:Uhhuh].It’sexhausting.
T:Andthenewinformationis…isitfromourvantagepointasadultwomen,wewouldn’t,wecouldn’tpossiblyimaginehowa14-year-oldwouldputherselfinharm’sway.
C:No,andyouknowthekindof…becausemymother’snotawful.Likeshe’s,she’sanempathicperson.But,withyouknow,somanydifferentpeople,um,andthenjusttohavethatabsence.Itwasreallylikethat,right?“Whatdidyoudo,howcouldthishavehappened?”Youknow,almost“howcouldyouhavedonethistous?”whichislike…ButnowIreallydon’tknowwhattodowiththisinformationbecausereallyitjustpissesmeoffnowmorethanIcanevenimagine,um.Probablymorethanpissesmeoffbut,youknow,Idon’tknowwhattodowithit.
T:Do?
C:Withthisinformation,withthiswaythatI’mfeeling,with,thatit’snotokay.It’snotokay.
T:What’snotokay?
C:Thattherewasnoonethere.
T:Howdidyoumanage?
[Contrarymove:Shiftingfocusfrominternalexperiencetobehavior]
C:[Sighing]Um,Ijust,Iwascompletelydeadinside.Iwasjustsortofnumb.Ididreallywellinschool.IdideverythingthatIwassupposedtodo.
So,allthispastweekend,Iwasjustexhausted.Iwasexhausted,right.AndIwasjustfeelinglikeIdidn’twanttodoanything.AllIwantedtodowaslayinbed,really.Andnoonewasgoingtoletmedothat.Ihadneighborswhowerecalling,Ihadmyhusbandtryingtogetmetomakedinnerforhim,Ihad,youknow,mymothercallingaboutmydad.Anditwaslike“justleavemealone,leavemealone.”SoImanagedtobackthemalloff.Idon’tknowhowIdiditactuallybutImanagedtobackthemalloffandstayinbedfortheentireweekend.Ifeltreally,Idon’tknow,indulgent,butitwasgreat![Laughter]Itwaslikereallygreat.Iwas,youknow,andIcan’tremember…I’veneverdonethatbefore.Yeah,I,yeah,mymotherwasshocked.Shewas,like,Iwasverycurt,Iwasjustverycurt.AndI’mnevercurtwithher,right,becauseshe’sso,she’stheperfectmother.SoIjustsaid,“Notnow,I’mbusy.”“Whatareyoudoing?”
“I’mlayinginbed,”youknow,“gotalktoDadyourself,Ican’t,Ican’tsolvethisforyou.”AndI,thatwasit.Hungup.
T:Andwhatwasthatlike?
[Mentalizingofpositiveemotions]
C:Itwasreally,itwasreallyfun.Itwasreallyfun.
T:Whatdidyoudoinbed?
C:Iread.[Laughter]IreadallthebooksthatsitbesidemybedandIneverevergettoreadbecauseIjustnevergettoreadthem.Ijustread,Ididnothing,really.Imean,Ijustread,itwasgreat.
T:Icanfeelit.
[Modelingmentalizing]
C:Itwas![Laughter]Itwasgreat.Justtodonothing,foranyone.Todonothingforanyone.Igotuptogotothebathroom,thatwasit.Thatwasit!Andmaybegetsometoast.Butthatwasit.Like,Imean,honestly,forgetit,likemyhusbandwasinshock,hethoughtIwasreallysick.
T:Hewasworriedaboutyou?
C:Hewasworried.Hewasworried.Itdidn’tstophimfromaskingmetomakedinnerbuthewasworriedaboutme.ButIdidn’tmakehimdinner.SomaybeIdon’tknow.
T:Wow.
C:Iknow.Itwasgood.
T:Itwasgood.
C:I’llhavetodothatagain!It’sverygood.
T:Sohowdoesthatrelatetoourworkhere?Tellmeaboutthat.We’vecomeonabitofajourneyandnowsuddenlywe’relaughingbecauseyoudecidedtogoonstrike.
[Metacommunicatingaboutthehere-and-now]
C:Right.
T:Orgoonareadingbinge[C:Areadingstrike].Yes.Sohowareyoudoing?
C:Ifeellighter.IfeellighterthanIdid,absolutely.IfeelwaylighterthanIdidlastsession.Um,Ifeelmore,Idon’tknow…morelikeme?Morelike,yeah.
T:Feelstomelikethere’smoreofyouintheroom.IfeellikeI’mnotsortofrunningaroundsomehowchasingyouor…itfeelslikeyou’rerightthereandwecanconnectinaway.
C:Yeah,andIdon’t,Idon’t,Idon’tfeellikeI’mperforming.Thatwasonethingforsure.IdidnotfeellikeIwasperformingthisweekend.Ishouldn’thavebeenthisexhausted.Performanceisexhausting,right,nottherealthing[T:Yes,yes].Thisdoesn’t,thisfeels
AppendixB:PracticeReminderSummary
(RefertotheenclosedPracticeReminderCard.)
AchievingPsychotherapyEffectiveness:AHealingContext
Therapistqualitiesandcharacteristicsthatpromoteatherapeuticalliance
Empathy,Responsiveness,Interest,Rapport,PositiveRegard,Genuineness,andtheabilitytomanagestrainandrepairtensionswithinthealliance
RELATIONSHIPS:Developasharedunderstandingoftheclient’srelationshipsthatshapedhisorherinternalworkingmodel,attachmentpatternsofrelating,interpersonalpulls,pathogenicbeliefs,andmaladaptiveloops.
Enquireaboutanddiscover:
•Developmental,earlylife,significantrelationships(e.g.,withcareproviders)
•Whatwererelationshipslikewhentheclientwasyounger?
•Howwereupsettingfeelingsmanagedinthefamily?
•Whatwerespecificrelationships,suchaswithaparent,like?
•Towhatextentwasthehomeenvironmentfrighteningandchaotic,orstableandreliable?
•Currentrelationships,todiscoversocialsupportsalongwithinadvertentinterpersonalpulls
•Noteextremesofdisengaging,distancingversusaffiliative,enmeshed;dominantversussubmissive,passive
•Rememberthatinterpersonalpullsareopposinginthedimensionofpower,andcomplementaryinthedimensionofaffiliation
•Historyofunresolvedtrauma,itscomplexsequelae,andfeelingsofunderlyingfear
•Theexperienceofthetherapeuticalliance(e.g.,interpersonalpulls,transference/countertransference)
ATTACHMENTPATTERNSOFRELATING
Secure Preoccupied Dismissing Disorganized
Careproviders’characteristics
Goodenough Inconsistentlyresponsive
Mostlyunresponsive
Frighteningorfrightened
Attachmentbehaviors Fullrangeandflexible
Dialedup Dialeddown Unclassifiable,fluctuatesunpredictably
Others’experienceofthisperson
Trustworthy,reliable
Overwhelming,needy
Distant,aloof Discombobulating
ATear-and-RepairPsychotherapyProcess
Becloseenoughtotheclienttoriskgettinghookedintomaladaptiveloops,whileretainingthereflectivecapacitytousethosemomentstherapeutically.Seektoprovideexperientialdisconfirmationofpathogenicbeliefsandexpectations(e.g.,ofharm,negativejudgment,disinterest)byrespondinginwaysthatchallengemaladaptiveloopsandfosterapositivesenseofselfwithempathy.Emphasizetheadaptivenatureofyourclient’sefforts.Beattunedtointerpersonalconsequences,thetransference/countertransferencedynamic,andtrauma.
ANAPPROACHTOPSYCHOTHERAPYEFFECTIVENESS
Buildastrong,positivetherapeuticalliance
Developasharedunderstandingofaclient’srelationalworld
•Earlyattachmentrelationships
•Currentrelationships
•Transferenceandcountertransference
Identifyself-fulfillingpropheciesthatreinforcepathogenicbeliefs(maladativeloops)
Whenbehaviorallyoremotionallyhooked.getunhooked
Mentalizing
Metacommunication
Taketheimpactoftraumaintoaccount
Mentalizing
Thinkingaboutthoughtsandfeelings—yourownandothers’.Mentalizinghelpsclientstoappreciatethatothershavemanydifferentbeliefs,understandings,andintentions;aperson’simpactisnotalwayswhattheyintend;andsometimespeoplefeelonewayandactanotherway.
Modelmentalizing
•Reflectonmentalstates
•Communicateaboutmentalstates
•Wonderaboutintentions
Usea“not-knowing”stance
•Beopenandcuriousaboutwhatisinyourandothers’minds
Usecontrarymoves
•Askquestionstovaryfocusbetweenthinking,feeling,andfromdifferingperspectives(e.g.,self/other,internal/external)
Collaborateincreatingacoherentnarrative
Metacommunication
Therapistandclientthinktogethertounderstandandrepairamomentoftensionasashareddilemma,withoutassumingparallelswithotherrelationships.
Withnoninjurious,validating,therapeuticintent:
•Acceptresponsibilityforcontributingtothetension.
•Highlightthatweaffecteachother;modelreflection.
•Exploretheclient’sexperienceofthehere-and-now.
•Becuriousaboutstatesofmind.
•Reflectcollaboratively:Whyisthishappeninginthiswayrightnow?
•Judiciously,tentatively,andreflectively:
•Thinkoutloudaboutsubjectiveperspectives
•Seekunderstanding
•Shareemotionalreactions
Remembertheimpactofunresolvedtrauma
Unresolvedtraumacanunderlieexcessivearousal,intrusivememories,avoidance,depression,anxiety,anger,problemsinregulatingemotions,medicallyunexplainedsymptoms,memorygaps,dissociation,self-harmbehaviors,substanceabuse,andrelationshipproblems.
•Arethedisturbingtraumaticexperiencesontheclient’smindfrequently?
•Istheclientreflectiveaboutthetrauma?
•Whomhastheclienttoldabouttheevents?
•Whatisitliketellingyounow?
•Howmuchhastheclientintegratedtraumaticmemoriesintohisorherlifestory?
AppendixC:AnswerKey
LESSONPLAN#11.Thequalitiesofatherapistthatcanimprovetherapeuticalliancesincludeaccurateempathy,rapport,psychologicalavailability,positiveregard,responsiveness,interest,genuineness,andtheabilitytorecognizeandrepairalliancestrains.
2.Examplesofindirectwaystoaskabouttreatmentgoalsincludeaskingquestionssuchasthefollowing:Ifthiswastohelpyou,iftherapywassuccessful,whatwouldthatlooklike?Whatwouldthatbelikeforyouinyourlife?Howwouldyoufeeldifferently?Howwouldworkoryourrelationshipsbedifferent,orhowyoufeeldifferentlyaboutyourself?Ifwecouldlookahead6monthsfromnow,whatwouldbedifferentforyou?Ifaskingquestionslikethesedoesnotyieldacleargoal,asanextstepthetherapistmighthavetotentativelysuggestwhatsheunderstandsthegoalmightbe.Todothis,thetherapistcansynthesizeinformationandofferahypothesisaboutthetreatmentgoalandthenseekfeedbacktoensuretheworkiscollaborative.
3.Thetherapistconsidersmultiplesourcesofdatainordertoinformanunderstandingofaclient’srelationalproblemsandsuffering.Theseincludeearlylifeandcurrentsignificantrelationships,historyoftrauma,relationalepisodes,andthehere-and-nowmomentsofinteractingwithinthetherapeuticrelationship.Takingalltheseintoaccount,atherapistcangleanasenseoftheclient’sattachmentstyle,pathogenicbeliefs,andinterpersonalpulls.
4.Awarenessofmoment-to-momentchangesinemotionalstatesornarrativecoherenceduringsessionscanhelpaclienttochangeunderlyingpathogenicbeliefsthatperpetuatedifficultiesinrelationships.Affectivelychargedmomentsservetomarkmaterialtofurtherexploreandprocess.Itistherapeuticallyproductivetowonderaboutandexplorewhyatopic,person,recollection,orsomethingaboutaninteractionleadsaclienttobecomeirritable,overwhelmed,discombobulated,ordisengaged.These“tipoftheiceberg”reactionsareessentialtoexamine.Intheprocessofexplorationwithinasafetherapeuticmilieu,aclientcanmakelinkstounderlyingpathogenicbeliefsortounresolvedtraumaticexperiences.Maladaptiveinterpersonalbehavioralloopsmayappearduringmomentsoftensionordisconnectioninthetherapywhentheclientexpectsthetherapisttorespondasothershaveintheirsignificantearlyrelationships.Whenthisoccurs,itisatherapeuticopportunityforrepairinwhichtheclientcanlearnexperientiallythatwhatwastrueinthepast,isnotnecessarilytrueinthepresentorinfutureinteractions.Aclient’sexperienceofatherapistasresponsive,caring,genuine,andinterestedcreatesahealingcontextinwhichtobereflectiveratherthanreactive.Thispermitstheclienttobemoreemotionallyregulated,moreinsightfulintohisorherimpacts,andmoreawareofhisorherinterpersonal,behavioralchoices.Insightgleanedfromtherapeuticprocessinginthehere-and-nowstrengthensself-confidenceandbuildsamorepositive
self-image,whichovertimeimprovescurrentrelationships,thushelpingtochangeunderlyingbeliefsandresolvemaladaptive,self-perpetuatingproblematicloops.
5.Transferenceandcountertransferenceareimportantinpsychotherapy.Transferencereferstothesometimesunconsciousexpectations,attitudes,andfeelingsthataclientdirectstowardhistherapistthatarebasedmoreonhispastexperienceswithothers(encodedintheinternalworkingmodel)thanonwhatishappeninginthepresenttherapeuticrelationship.Countertransferencereferstothecorrespondingexpectations,attitudes,andfeelings,whicharealsosometimesunconscious,thatatherapistexperiencestowardtheclient.Countertransferencemayprovideanothertypeofinformationabouttheinterpersonalpullsthatleadtomisunderstandingsbetweenaclientandothers.Whentherapistsfeelchallengedorstressed,andhavestrongnegativecountertransference,theirresponsescanbeharmfultothetherapeuticrelationship.Becauseitishardtothink,beempathic,ormentalizeunderstress,therapistscanbecomehostile,antagonistic,defensive,orwithdrawnwheninthegripofastrongcountertransferencefeeling,insteadofpausingtoreflectonamoreconstructiveresponse.Understandingthesehere-and-nowdynamiccluestodifficultiesinmomentsofalliancestrain,andfindingaconstructive,nonblaming,empathicwayofexploringthemwithaclientcanprovideapowerfultherapeuticexperience.
6.Thefollowingtablecharacterizesimportantfeaturesofthehistories,behaviors,andinterpersonalimpactsofadultattachmentstyles.
Secure Preoccupied Dismissing Disorganized
Careproviders’characteristics
Goodenough Inconsistentlyresponsive
Mostlyunresponsive
Frighteningorfrightened
Attachmentbehaviors Fullrangeandflexible
Dialedup Dialeddown Unclassifiable,fluctuatesunpredictably
Others’experienceofthisperson
Trustworthy,reliable
Overwhelming,needy
Distant,aloof Discombobulating
7.THEINTERPERSONALCIRCUMPLEX:Wherewouldyouplaceeachoftheclientsonthetapeddemonstrationsontheinterpersonalcircumplex,andwhatwouldyoupredictregardinginterpersonalpullson,andresponsesfrom,others?Theclientsportrayedintheroleplaysbothexpectlittleofothers,andtheyareemotionallydistant,butindifferentways.WhereasJoelcomesacrossasantagonisticandadversarial,expectingcriticismorharmfromothers,Katherinecomesacrossascompliantanduncertain,expectingothersnottobeinterestedortocare.Itishelpfultounderstanddistancinginterpersonalimpactsonothers,includingthetherapist.
Joelmapsontothehostiledominant(northwest)quadrantofthecircumplex.Hisdistancingandoverpoweringbehaviorevokeshostilityandwithdrawalfromothers(i.e.,theyfeelpulledtowardhostilityandwithdrawal).Thus,Joel
mayinadvertentlyevokewhathedreads:ahostileresponseinwhichtheotherpersonbecomesinterpersonallydistant.Awareofthesepulls,thetherapistintentionallyresistsbyremainingproximallyaffiliatedandactive.
Thisisanexampleinwhichbehavioronthedimensionofpowerpullsforamatching,hostileresponseratherthanpullingforitsopposite.(Dominancethatiswarmoraffiliativeismorelikelytopullforasubmissiveresponse.)
Katherinemapsontothesouthwestquadrantofthecircumplex,beingdisempoweredanddisengaged.AlthoughsheisnotovertlyadversariallikeJoel,sheisnonethelessdistancing.Inthefaceofhersenseofpowerlessness,otherswillbepulledtorespondbybeingoverlyactive(andthisunderestimationofhercapacityforself-efficacywouldleadthemtoact“for”her,whichwouldservetoperpetuateherdisempoweredstance).Onthehorizontal,affiliativeaxis,althoughsheisnothostile,Katherineisdisengaging,holdingnoexpectationsofothersasbeinginterestedorhelpful.Notehowsheoftentellsthetherapistthatshedoesn’tthinksheneedshelp.Thissetsupthepossibilityofthetherapistsimplyagreeingandoverlookingherstruggles.Therefore,theresponsethatKatherine’sbehaviorpullsforwouldinadvertentlyevokearecapitulationofanearlyexperienceofbeingoverlookedinatimeofneedanddistress.
LESSONPLAN#21.Mentalizingisaprocessofreflectingonwhatisinone’sownmindandthemindsofothers.Whenwementalizeweunderstandthatintentionsaren’tvisibleandmaycontradictactions.Mentalizingcanbeusedinpsychotherapytreatmentinthefollowingways.
a.Atherapistcanmentalizetounderstandaclient’sdifficulty.Thismaybeespeciallyimportantwhenearlyadversityimpairsaclient’scapacitytoaccuratelymentalize
abouthisownmindandaboutthemindsofothers.
b.Atherapistcanmodelmentalizingtofosteraclient’sreflectivethinkingandcommunicationofmentalstates.
b.Atherapistcanuseanot-knowingstancebyshowinghumilityaboutherlimitedabilitytotrulyunderstandaclientandbyexhibitingcuriosityaboutaclient’sinnerworld.
b.Atherapistcanusecontrarymovesbystrategicallyshiftingaclient’sattentiontodifferingaspectsofexperienceordifferentperspectives.Contrarymovesareespeciallyusefulwhenaclientisinaruminative,nonmentalizingstateofmind,overlyfocusedononeoftheextremesofthedimensionsof(1)thoughtversusemotions;(2)innerversusexternalexperiences;(3)self-focusedversusother-focused.
b.Atherapistcanusementalizingasameanstocollaborativelycreateacoherentnarrative,tofostergreaterself-awareness.
b.Mentalizingisalsoagoaloftreatmentbecausementalizingisaskillthatcanbeacquiredtobuildresilienceandwell-being.
2.Metacommunicationisatherapist’scommunicationabouttheprocessesofcommunicationthatoccurbetweenthetherapistandclient.Itisusedtounderstandamomentoftensionasashareddilemma,withoutassumingparallelswithotherrelationships.Thetherapistspeaksabouthersubjectiveperspectiveandawareness,andsheexplorestheclient’sexperienceinthehere-and-now,withcuriosityaboutinternalstatesofmind.Thetherapistacceptsresponsibilityforhisorherownunwittingcontributiontotensions,whichservestoemphasizethewaysweaffecteachother,andmodelsamentalizing,reflectivestancefortheclient.Duringthisprocessitisimportantthatatherapistfocusonvalidatingratherthanblamingtheclient.Appliedwithtactandcare,metacommunicationcanbeusedasaninterventiontohelpclientstounderstandandchangetheirroleintheinterpersonalpatternsthatcontributetosuffering.
3.Atherapistcanbeattunedtoanumberofsignalstosloworpauseexploration.Indicatorsofaneedtoslow,pause,orchangetacticsincludeaclientbeingextremelydisengaged,dissociating,or,attheotherextreme,beingoverlyaroused,andaffectivelydysregulated.Thisisespeciallyimportantforclientswithinsecureattachment,inordertofosterareflectiveprocess.Helpingaclienttoregulatehisemotionsrequiresattendingtohislevelofarousal.Thereisarangeofoptimalarousal—azoneinwhichwearealert,attentive,andengagedwithoutbeingoverwhelmedorwithdrawn.Clientswhohaveexperiencedtraumaareoftentoohighlyaroused(thehypervigilanceandoverstimulationoffear)ortoounaroused(thenumbing,avoiding,anddissociationthatdefendagainstfear).Reflectioncannotoccureffectivelyineitherofthosestates,sothetherapistmustworkwiththeclienttohelphimtoreturntoamoreflexiblestate,inwhichexplorationandtherapeuticprocessingcanoccur.Overtime,thetherapisthelpsaclienttowidentheoptimalzoneand“makeroom”forthe
extentofarousalthataccompaniesallofhisemotions.Effectivetherapistsaccomplishthisgoalbyusinginterpersonalstrategiessuchassupportandvalidation,maintainingpresence,andconsistencyinthetherapy.
Inthesemomentsinwhichaclientisoveraroused,ordisengaged,atherapistcanshiftfromexplorationtovalidation,orshecanfocusmomentarilyonanothersubject,lettingtheclientknowthatsheisdoingthistoprovideamomenttoregaincomposure.Atherapistcansubsequentlyusemetacommunication,withcuriosityandreflection,tomakeitclearthatsomethingshifted.Withanot-knowingmentalizingstance,shecancheckinwiththeclientandseekfeedback,askingtheclienthowheisdoingandwhetherthetherapistmayhaveinadvertentlydoneorsaidsomethingthataffectedtheirtherapeuticprocessinanegativeway.Alternatively,contrarymovescanbeusedtoreestablishatherapeuticprocesswhenthetherapistishookedintofeelinglikewithdrawing,controlling,oractingonacountertransferencereaction,suchasarguingwithoropposingtheclient.Itcanbehelpfultorewindtothemomentwhenthecountertransferencefeelingsbeganandthenrestorementalizingprocessesbyusingacontrarymove.
4.Atherapist’sabilitytoremainreflectiveandtherapeutically“present”canbechallengedbyclientswhoareinsecureintheirattachmentstyle.Aclient’sinternalworkingmodel,whichprescribesasetofexpectationsaboutothersandhowheshouldbehaveinrelationships,maychallengeatherapist’sabilitytomentalizeandcanincreasethepotentialforreenactmentofamaladaptiveloop.Adismissingindividualmayassumethatotherswillbeunavailableandthereforemayacttoincreaseinterpersonaldistance.Ifatherapistdoesnotreflect,shemayinadvertently“accepttheinvitation”andworkwiththisclientinanemotionallydisengagedanalysisofproblems.Suchanapproachwouldservetoreinforcethemaladaptivelooptowhichitgivesrise,ratherthanchallengeit,andwouldnothelptheclienttochange.Similarly,apreoccupiedclientwhosignalshisattachmentneedsexcessivelymaypullhistherapistinto“crisismode,”leadingtoaffectivelyoverchargedinteractionsandafailuretomaintainappropriateboundaries.Withawarenessofthesedynamics,atherapistcanprovideatherapeuticinteractionthatdisconfirmspathogenicbeliefsandpromotes
understanding,self-compassion,andself-efficacywiththediscoveryofsolutions.
5.SAFETYCONCERNS:Whenatherapistisconcernedabouttheriskofself-harmorharmtoothers,includingcircumstancesofdomesticviolence,itisimportanttoaskquestionstoclarifyfacts,actions,andintentions.Avoidancecangeneratemoretensionandunease.Whentherearehighlevelsofconcernaroundsafetyrisk,involveorconsultwithothermentalhealthspecialistsregardinginterventionsthatensurethesafetyofall(e.g.,activatingreferraltoemergencyservicesornotifyingchildren’saidservices).Domesticviolenceiscommonandmustbeassessedandmonitored.Atherapistactivateshelpwhennecessary,suchascomingupwithsafeexitplansandoptionsforalternativehousing,orinvolvingsocialservicesandthepolice.AnexampleofaskingquestionsaroundsafetyriskisillustratedinthetranscribedroleplaywhenDr.LeszczseekstoclarifyJoel’smentionof“thewhip”byinquiringaboutbothworkandhome.
6.SomeoftheinteractionsbetweenJoelandDr.Leszczillustrateamaladaptiveloopusingtheinterpersonalcircumplexandtransference/countertransferencedynamicstoaidinunderstanding.Joelanticipatesthathewillbejudgedorcriticized,andherespondswithdefensive,hostile,anddismissivebehavior.Thisattitudewouldevokeadistancing(andpotentiallyhostile)countertransferencereactioninthetherapist.Thisisanexampleofamomentof“tear”thatcansubsequentlybeusedforthetherapeuticprocessingof“repair.”Thestraininthetherapeuticallianceisrepairedbyprocessingtheinteractionwithareflective,engaged,andaffiliativestance.Tocounterthepullofahostileanddisengagedcountertransferenceresponse,thetherapistunderstandsitasdata.Usingthisinformation,heseekstoreducetheclient’ssenseofvulnerabilitybybeingtransparentandexpressinganintentiontoremainengaged.
7.Therearemanyrightwaystorespondtherapeuticallytoamomentofstrain.Affectandemotionaremarkersoftherapeuticopportunity.Inthissequencethetherapistusesmetacommunicationandmentalizingtoaddresstensionsinthealliance.Thetherapistrespondstothisaffectivelychargednodalmomentbyaskingtheclienttomentalizeaboutwhatmaybeinthetherapist’smind,tryingtoresistthehostilepulloftheclient’sangrydistancing.Mentalizingwiththeclient,hecounterstheclient’sexpectationofcriticism.Inthisprocessingofthealliancestrain,maladaptiveloopsandunderlyingpainfulpathogenicbeliefsoftheinternalworkingmodelarerevealedwithinthehere-and-nowofthesession.Thisopensupimportantcorestrugglesforfurtherexploration.
8.Asimportantasitistorecognizeandworkwithcountertransferenceandinterpersonalpullstoguidetherapeuticprocesses,itisalsoimportanttoregisterevidenceoftherapeuticbenefit.Herearethreekindsofimprovementaclientmayreportordisplaythatwouldbeevidenceofbenefit:
a.Thepresentingcomplaintsofsymptomsordistresswilllessenorremit.
b.Theclientwillreportimprovedoverallfunctioning,inhisrelationships,work,orotheraspectsofhislife.
c.Theclientwillbemoreemotionallyemboldened,present,reflective,and
thoughtfulaboutwhatisgoingoninhisinnerworldandinthemindsofothers,withgoodnarrativecoherenceaboutself-referentialpastexperiences.
LESSONPLAN#31.Whichemotionisconsideredtobeatthecoreoftrauma?Fear.Itistraumaticforpeopletobebothterrifiedandtrapped.Itisalsoterrifyingtofeelaloneinatimeofgreatfearandneed—whetherornotoneisactuallyalone.
2.Clinicalphenomenathatcanalertustothepossiblepresenceofaninvalidatingchildhood,orcaregiverswhocouldnotprovideadequatesafetyandreassurance,includeemotionaldysregulation;impulsivity;relationshipproblems;narrativeincoherence;andsubstanceabuse.
3.Howcommonistrauma?Howmighttraumaaffecthealth?Howmighttraumaaffectrelationships?Studiessuggestthatupto60%ofclientsinoutpatientmentalhealthcaresettings,andasmanyas90%ofinpatientpsychiatricpatientshaveexperiencedatleastonetraumaticevent.Traumaaffectsthementalandphysicalhealthofanaffectedindividualinmultipleways,includinghighersymptomratesandpoorerfunction.Commonpsychologicalproblemsareaffectdysregulation,self-harm;mood,anxiety,personality,substance,anddissociativedisorders;andmedicallyunexplainedsymptoms.Poorerphysicalhealthinvolvesahigherriskofearlymorbidityandmortalityandapoorerhealthself-evaluation.Ahistoryofneglectorabusecanunderlieinsecureordisorganizedattachmentpatternsofrelatingandmentalizingdeficits,whichcanaffectaclient’sself-esteem,abilitytoformtrustingrelationships,andqualityoflife.
4.Whendoesatherapistscreenfortrauma?Traumaisassessedwitheveryclient,atthetimeoftheinitialassessmentandduringthecourseoftherapy.
5.Howistraumaassessed?Traumaisassessedinmanyways.Initiallytraumaisassessedbygentlebutdirectquestionsaboutexperiencesinwhichaclienthasbeenveryfrightened.Atherapistalsoobserveshowaclientdescribeshisorherrelationshipsandexperiences.Narrativeincoherence,includingveryvagueoroverlyinclusivedescriptions,cansignalanuntoldhistoryofabuseorneglect.Ifaclientbecomesoverlyaroused,overwhelmed,orhasanincongruentlackofaffectinthemidstofspeakingaboutunresolvedtraumaticexperiences,thetherapistcanrecognizeempathicallythattheclientisdistressedandsuggestheswitchthesubjecttoanareaoflessstresstohelptheclientregainhisemotionalbalance.Traumaexpertsdescribethezoneofoptimalarousal,whichcanbequitenarrowforclientssufferingfromunresolvedtraumaticexperiences;theyareconsequentlyeitherhyper-orhypo-arousedwhentryingtotalkabouttheirexperienceinanassessment.
6.Questionsthatatherapistcouldusetoaskabouttrauma:
a.Whomhaveyoutoldabouttheevents?
b.Whatwastheirreaction?
c.Whatisitliketellingmenow?
d.Howoftenisthetraumaonyourmind?
e.Whereareyouwithregardtohealingthisdifficultexperience?
7.Therearedifferingwaysofunderstandingwhysomepeoplefailtorecoverfromtraumaticexperiencesandsufferfromchronic,unresolvedtraumaticsymptoms.
a.Therecanbeacumulativeimpactofrecurrentexposuretotraumaticexperiences,asisseeninmembersofthemilitarywhoaredeployedtoofrequentlywithalackofsupportandinadequatetimetorecover.
b.Traumasurvivorswithahistoryofaninvalidatingchildhoodenvironmentcombinedwithanexperienceofmultipletraumaticeventscanalsohavechronicpsychiatricsymptoms,poorfunctioning,andinterpersonaldifficulties.Aninvalidatingchildhoodmakesitconsiderablymoredifficulttorecognizeoracceptcompassionandassistancefromothers.Furthermore,iftraumaoccurswithinachild’shomewithcaregiverswhoarefrightening,frightened,orunableorunavailabletooffersolaceandprotection,thetraumaticexperiencesbecomeinextricablyjoinedtotheexperienceofinvalidation.
8.Moment-to-momentattunementtomentalstatesandfeelingsbyusingmentalizingaidsinthetherapeutichealingprocessandunderstandingofaclient.MakingsenseofKatherine’stentativenessinthefirstsessionistricky.Initiallyshemakesagoodargumentforwhysheshouldn’tbeintherapyandthetherapistmaybepulledintobeinginagreementwithher.Katherinewouldliketherapybutmayfeelthatshe’sdamagedandhaslowself-esteem;thussheisnotabletoexpressorbeintouchwithherneedandwishforhelp.Shewouldliketohopebutshecannotbecauseshefeelsthatshehasnorighttohope.Thetraumaticrapecombinedwiththebetrayalsheexperiencedwhenherparentsdidnotrespondortaketheassaultseriouslyconvergedtoshapealowexpectationofothers.Thiscomestolifeinherambivalenceaboutbeingattunedtoherowninternalfeelingsorthoughts.
9.Byemployingmentalizingandmetacommunication,thetherapistexploresanawarenessofanddiscussionoftheimpactsofearlylifeexperiences,includingtheresponsesofotherswhoshapedtheclient’ssenseofself.Thetherapisttriestofocusonboththecurrentandpresentexperiencesoftheclientwithmoment-to-momentattunement,fosteringreflectionwithinazoneofoptimalarousal,usinganot-knowingstance,andencouragingmentalizingbytheclientaboutherown14-year-oldselffromthevantagepointofthepresent.Thetherapistthenhelpshertomakelinks—toseethatlifeexperienceshaveanimpactonhersenseofselfandonhercognitiveexplanationsandideasaboutherselfaswellasonemotionalstates.
LESSONPLAN#41.WhatisyoursenseofDanielle’sattachmentstylebasedonthebriefvignette?Basedontheclient’sself-relianceandreluctancetoexpecthelpfromothers,herattachmentappearstobedismissing.Inlightofthis,thetherapistwilllistenforsignsofavoidance
thatmaynotbeadaptiveinthesecurrentcircumstances,inwhichDanielleneedshelpfromothers.
Whatotherinformationwoulditbehelpfulforthetherapisttoknowinordertoenhanceherunderstandingoftheclient’smaladaptiveloopsandinternalworkingmodel?Aswell,hertherapistcaninquireaboutconfidantes,closerelationships,andDanielle’srelationshipswithcareprovidersearlierinherlife,explainingthatlearningaboutpastrelationshipsisoftenhelpfulforunderstandingcurrentstrugglesinrelationships.Examplesofhelpfulquestionsincludethefollowing:Whatwererelationshipslikeforyouwhenyouwereyounger?Howwereupsettingfeelingsmanagedinyourfamily?Howwereyoudisciplined?Tellmeaboutyourrelationshipwithyourfatheroryourmother?Whatwereyourmotherandfatherlike?Whenyouwereafraid,whodidyougoto?Whatwasyourhomeenvironmentlike(e.g.,frighteningandchaotic,orstableandreliable)?
Inthecaseofdismissingattachment,thereisoftenacareproviderwhowasconsistentlyunresponsive.Adismissingclienttypicallytendstobeself-reliantandself-sufficientincurrentrelationships,toexpectlittleofothers,andtobehaveinwaysthatcreateinterpersonaldistance,asDanielledoeswhensheturnsdownherfriend’sofferofhelp.
ThetherapistmayalsobealerttoevidencethatDanielleisdistancingherselfinthehere-and-nowofthetherapeuticrelationship.
2.Usingprinciplesofmentalizing,howmightthetherapistrespondatthismoment?ThetherapistcanmodelmentalizingbyofferingwhatisinhermindinresponsetoDanielletellingheraboutherexperience.Shemayalsoofferavalidating,empathicreflectionaboutwhatsheimaginesDanielleisexperiencinginternally.Forexample,shecouldsay,“Icouldbeoffhere,butIhavethesenseofyoubeingsimultaneously
thisscaredchildwhofeelsshecannotreachout,andanadultwhoinfacthasquiteadeepcapacitytocopewiththedifficultcircumstancesoflivingwithcancer.”
Alternatively,shecanuseacontrarymoveandshiftfocustofostermentalizing.BecauseDanielle’sfocusissituatedinternallyinastateofemotion(feelingsadandscared),thetherapistcouldaskheraquestionthatshiftsherfocustoanexternalperspectiveandaskabouthersenseofwhatmightbeinthemindsofthoseotherswhoareofferingtohelpandtoprayforher.Forexample,“Whatdoyoumakeoftheparishioners’wishingtohelpyou?”Recognizingherlegitimateneedsandthecaringintentionsofsomeofherfriendsmayleadtoagreateracceptanceofherownsenseofvulnerability.
Athirdoptionwouldbetomentalizeaboutthethoughtsandfeelingsofthosewhotrytoofferhelp.“Iwonderwhatitfeelslikeforafriendwhooffershelpwhenyouareunabletoreceiveit.Maybeyouhavebeeninthatpositionandcanrememberwhatitfeltliketoberefused?”Daniellemayrecognizethatitcanbehurtfulandupsettingwhenaclosefriendinneedkeepsafriendatbay.Thesurprisingrecognitionmaypromoteafreshlookatwhysheiscompassionatetoothersbutdeniesthemthechancetobecompassionatetoher.
3.Takingtraumaintoaccount,whatdoyouthinkaboutMilton’searlierreluctancetodiscloseordiscussdetailsofarecentassault,aswellasthetherapist’snotpushingtopursuethis?
Thisclienthasanearlyhistoryoftraumacoupledwitharecenttraumaticevent.Unresolvedtraumacanbefragmentingtoaclient’scoherencewhenunderstress.ByrespectingMilton’swishtoavoidthetopicatfirst,thetherapistavoidspromptingtooearlyadisclosurebyMilton,whichcouldberetraumatizingifitistooforcefuland
mistimed.However,inretrospect,thetherapistmayhavebeenabletohelpMiltontospeakmoreabouttheassault.Thiscanusuallybedonebyexplainingtheneedtotheclient,emphasizingthattakingitslowlyandstayinggrounded(i.e.,withinazoneofoptimalarousal)mayallowhimtoshareafewfacts.Inthisway,thetherapistcouldhelphimthinkaboutthetraumatherapeutically.
Whenthereisahistoryofacuteorchronictrauma,itisespeciallyimportanttokeeptheimpactsoftraumainmind,asdescribedinchapter5.Thereisoftenatensionbetweenopposites.Forinstance,theclientturnstothetherapisttohelpresolvehisdistressandatthesametimeexperiencesthetherapistasfailinghim,aspreviouskeypeopleinhislifehad.Thetherapistalsohastobeawareofinterpersonalpullstoeitherrescuetheclient,ortodistanceherselffromhim.Theremaybeothercountertransferencereactionstotheclient’spainfulaffectsaswell.Thetherapistmayfeelhookedintoadistancinginterpersonalpullandmaybeconfusedbytheclient’slossofnarrativecoherencewhenhespeaksaboutthetrauma.Usingthisknowledge,thetherapistcanusementalizingtounderstandthesedilemmasandtopromoterepairandreengagementintherapeuticprocessing.
4.Usingmetacommunicationandmentalizing,howmightthetherapistrespondtothismomentofstraininthetherapeuticalliance?Thetherapistcanspeakabouthersubjectiveperspectiveandawareness,acceptingresponsibilityforherowncontributiontothemisunderstandingbysayingsomethinglike,“Idon’tmeantoupsetyou.Youareright.Ihadn’tunderstoodthatyouhadbeenassaultedasanadult.Perhapsyouwantedmetoknowwithouthavingtogointoit.Itsoundslikeitwasprettyfrightening.Iwishtohelp,andIknowyouneedmetofilloutthisreportandwe’llgettothis.ButI’mtryingtosortoutwhatmayhavehappenedbetweenus.Whydoyouthinkwedidn’ttalkaboutthismore?Whatdoyouthinkhappened?”Then,shecanexploretheclient’sexperienceinthehere-and-now,withcuriosityabouthisinternalstateofmindandappreciationofhisfearanddistress—“Aswe’retalkingaboutthis,Iwanttocheckinwithyou.Howareyoufeeling?Doyoufeelsafeinthisroom?Whatareyouthinking?”Thismodelsamentalizing,reflectivestanceforthe
client.Thiscanhelptorepairthealliancetension,provideexperientialdisconfirmationofhisnegativeexpectationsofothers,andmovetowardincreasinghiscapacityforinteractingwithreflectionandawareness.
5.Howmightthetherapistusemetacommunicationtodealwithanactionthathasbeenfrustratingtoaclient,inordertobegintoprocesstheeventwithinthehere-and-nowofthesession?Thetherapistcanusemetacommunicationtotalkaboutthemomentofstraininthetherapeuticalliance.Shecanasktheclientiftheycantalkaboutwhathappenedandhisreactions.Firstapologizingforthelateness,shecanconveythatsheisgladthattheclientstayedandtheycaninfactmeet.Thenshecanbegintoexplore:forexample,“Let’shavealookathowmydelayinseeingyoumadeyoufeelandwhattheimpactofthatisonourrelationship.”
Metacommunicationprinciplesguidethetherapisttoexpressempathy,identifythemomentofchange,andacknowledgehisorherroleinamomentoftension,apologizingifappropriateformissingsomethingorupsettingtheclient.Acollaborativediscussionoffeelings,suchasanger,andimpactswithinthehere-and-nowcanaidintherapeuticprocessing.Developingamutualunderstandingofanalliancetearparadoxicallycreatesanopportunityforrepairthatcanhelpaclientfeelvalidatedandrespected,emotionallyregulated,calmer,andreflectivewithinthesafetyofthealliance,ratherthanreenactingamaladaptiveloop.
6.Inthiscase,howmightaninternalworkingmodelformedearlyinlifeaffecttheclient’scurrentexpectationsinrelationships?Howdoestheclient’scapacitytomentalizerelatetotheseexpectations?Aninternalworkingmodelcanmisleadclientstoexpectpeopletobehaveorrespondascareprovidersdidearlierinlife.Thisclientmayexpectotherstobeunresponsiveanddemanding,reactingtotheirownconcernsinsteadofhavinghiminmind.Deficitsinhisabilitytomentalizemakeitdifficultforhimtoappreciatethatothersmaywellhavedifferentbeliefs,understandings,andintentionsthanheexpects.Ashedevelopshisabilitytomentalize,hecancometorealizethataperson’simpactisnotalwayswhatisintended.Thinkingaboutandimaginingwhatisinthemindofsomebodyelseandoneselfisatthecoreofmentalizing.
7.Whatdoyouthinkaboutthisclientbeingabletotalkaboutthesexualassaultwithbothherfiancéandtheircounselor?Thisclientistakingtheriskofsharingthefactshewassexuallyassaultedasachildwiththosewhoareclosetoher.Sheseemstowantherfiancéandpastortoknowmoreaboutwhosheis.Perhapspriortotherapyshe
wouldhaveexpectedherrelationshipstofallapartasherparents’marriagedidwhenhersexualassaultwasrevealed.Sheisattemptingtoincludeandultimatelyintegrateherpastintoherautobiographicalnarrative.Herabilitytoadaptherstoryoftraumatodifferentcircumstancesandlistenersisanindicatorofasuccessfulpsychologicalresolutionofthetraumaticmemories(andagoodcapacitytomentalize).Itwouldbehelpfulinthiscasetoprocessthispositivestepandcelebratorymomentintherapy,acknowledgingherabilitytoshareherexperienceofassaultasrepresentativeofhertherapeuticgains.
MultipleChoiceQuizAnswerKey1.c.Thetherapeuticallianceisbothaspecificandcommonfactor,becausethealliancemustbeestablishedwithinthespecificmodelapplied.
2.b.Approachesandconsiderationstorepairtherapeuticalliancerupturesincludeunderstandingstrainsintheallianceasopportunitiestodisconfirmpathogenicbeliefs.
3.a.Thefollowingstatementaboutmetacommunicationisfalse:Metacommunicationinvolvescommunicationaboutmeta-analyticresearch.
4.b.Sympathy
5.e.Pooroutcomesinpsychotherapymay:
•Beduetotheimpactofthetherapist’sself-doubt,anger,oravoidanceofchallengingclients.
•Berelatedtoanincompleteorinaccurateassessment
•Reflecttherapistcontributionsrelatedtoaninflexiblerelianceonaparticulartechnique.
•Beduetosubtlehostilityordisingenuousempathyfromthetherapist.
6.d.Transferencepatternsincludebeingpredominantlyangry,anxious,avoidant,orsexualized.
7.e.Countertransference:
•Canbeunderstoodasunconsciousandsometimesovertattitudesandfeelingsthatthetherapistcarriestowardtheclient.
•Mayinterferewithoptimalunderstandingandresponsivenesstotheclient.
•Maycontributetooptimalunderstandingandresponsivenessasavaluablesourceofclinicaldata.
•Isa“jointcreation”ofboththeclientandtherapist.
8.b.Regardingethicalpracticeandresponsibilitiesinpsychotherapy,thefollowingstatementisfalse:
•Boundariesareintendedtoreinforcepowerimbalancesbetweenthetherapistandclient.
9.e.Todevelopasharedunderstandingofaclient’srelationalworld,itishelpfultolearnabout:
•Developmentalhistoryandrelationships
•Currentsignificantrelationships
•Unresolvedtrauma
•Aspectsofthehere-and-nowtherapeuticrelationshipsuchastransference
10.c.Thecircumplexdescribesinterpersonalimpactsorpullsthatcontributetothemaladaptivetransactioncycle.Clientsmayinadvertentlyworsenrelationshipsthroughtheinterpersonalpullstheygenerate.
11.d.Foratherapisttounderstandaclient’sinternalworkingmodelandattachmentstyle,inferencescanbemadefromobservationsaboutallEXCEPTsocioeconomicstatus.
12.e.Achild’sattachmentstyle:
•Emergesasthebestadaptationtoacomplexenvironmentandisencodedinaninternalworkingmodel.
•Isinfluencedbysocialstressors,resources,socialsupports,andqualitiesofparenting.
•Shapesexpectationsofothers’responsiveness.
•Affectsresilience.
13.d.Avalidatingenvironmentinearlychildhoodpromotesthedevelopmentofattachmentsecurityandisfosteredbyparentsorprimarycaregiverswhorespondtothechild’sfearsoastorestoreasenseofsafetytothechild.
14.e.Adultattachmentstyles:
•Canbedividedintosecureandinsecuretypes.
•Canbedividedintoorganizedanddisorganizedtypes.
•Reflecttheinternalworkingmodeloftheindividual.
•Helpthetherapistunderstandtheclient’ssenseofhimselforherselfandtrustofothers.
15.b.Whichattachmentstyleischaracterizedby“dialed-up”attachmentbehaviorswithamplifiedexpressionsofdistress,intensehelpseeking,anexpectationofrejectionorabandonment,andanxietyaboutbeingalone?Preoccupied.
16.b.AllofthefollowingaretrueEXCEPT:unresolvedtraumaalwaysleadstoPTSD.
17.c.ThesequelaeofunresolvedtraumaincludeallEXCEPT:medicallyexplainedsymptoms.
18.a.MentalizingtechniquesincludeallEXCEPT:usinga“knowing”stancetomakeinterpretations.
19.e.Thetear-and-repaircycleinpsychotherapy:
•Makesuseofalliancetensionsastherapeuticopportunities
•Usescountertransferenceandmetacommunication
•Providespotentialdataaroundaclient’srelationalpulls
•Requiresthetherapisttoberesponsiveratherthanreactive
20.b.WhatisyourinitialimpressionofJacob’sattachmentpattern?Preoccupied.
21.d.Basedontheinformationyouhave,wherewouldyoumapJacobontheinterpersonalcircumplexandwhatresponseswouldyouexpecthimtopullfromothers?
•Affiliative/friendly-Submissive(southeast),pullingforaffiliativedominancefromothers
22.c.WhatisyourinitialimpressionofMary’sattachmentpatternofrelating?
•Dismissing
23.a.Basedontheinformationyouhave,wherewouldyoumapMaryontotheinterpersonalcircumplexandwhatresponseswouldyouexpecthertopullfromothers?
•Hostile/disengaged-Dominant(northwest),pullingfordisengagingdominancefromothers
24.d.ImportantaspectsofthetherapeuticalliancetobeawareofincludeallEXCEPTtheclient’sabilitytobepsychologicallyminded.
25.e.Characteristicsoftheexemplarypsychotherapistasperceivedbycolleagueshavebeendescribedasincluding:
•Capacitytobereflectiveratherthanreactive
•Genuineinterest,caring,andcommitment
•Empathiccapacityandconceptualability
•Self-awarenesswiththecapacitytocontainanxietyandrecognizelimitsandfit
AppendixD:TherapistWorksheet:AssessingandReflectingonCommunication
WHATWASTHECOMMUNICATION/INTERACTION?
Whatisyourunderstandingoftheclient’sexperienceandfeelingsinthatinteraction?
Whatcountertransferenceorpullsdidyoufeel?
Howdoesthisfitwithyourunderstandingoftheclient(attachment,interpersonalpullsonthecircumplex,historyofunresolvedtrauma)orpathogenicbeliefsencodedinaninsecureinternalworkingmodelthatwaspreviouslyadaptive?
Understandingthisinteractioninthisway,howwouldyouplantorespondifamomentlikethiswasrepeated?*
Inapsychotherapysession,ifamomentofinteractionfelttenseorwasdifficulttorespondto,usetheabovetoreflectonyourin-sessionexperiences,responses,interpersonalpulls,andunderstanding.
Secure Preoccupied Dismissing Disorganized
Careproviders’characteristics
Attachmentbehaviors
Others’experienceofthisperson
*Aimtoclinicallyrespondinwaysthat(1)validateaclient’sfeelings(i.e.,sadness,anger,fear,anxiety,worry,disappointment,orfrustration);(2)areexpressedwithgenuineinterest,empathy,andpositiveregard;and(3)donotmakeaclientfeeloverwhelmedordefensive(i.e.negated,dismissed,criticized,judged,invalidated,interrupted).
AppendixE:RecommendedReading
Tofurtherexploreevidence-basedaspectsofpsychotherapy,attachment,theinterpersonalcircumplex,mentalizing,metacommunication,andtheimpactoftrauma,readtheseauthoritativeworks.
Allen,J.G.,Fonagy,P.,&Bateman,A.(2008).Mentalizinginclinicalpractice.Arlington,VA:AmericanPsychiatricPublishing.
Bateman,A.W.,&Fonagy,P.(2012).HandbookofMentalizinginMentalHealthPractice.Washington,DC:AmericanPsychiatricPublishing,Inc.
Bowlby,J.(1969).Attachmentandloss:Vol.1:Attachment.NewYork,NY:BasicBooks.
Fonagy,P.,Gergely,G.,Jurist,E.,&Target,M.(2005).Affectregulation,mentalization,andthedevelopmentoftheself.NewYork,NY:OtherPress.
Kiesler,D.J.(1996).Contemporaryinterpersonaltheoryandresearch.NewYork,NY:JohnWileyandSons.
Lanius,R.A.,Vermetten,E.,&Pain,C.(2010).TheImpactofEarlyLifeTraumaonHealthandDisease:TheHiddenEpidemic.Cambridge,UK:CambridgeUniversityPress.
Mikulincer,M.,&Shaver,P.R.(2007).Attachmentinadulthood:Structure,dynamics,andchange.NewYork,NY:Guilford.
Norcross,J.C.(2011).Psychotherapythatworks:Evidence-basedresponsiveness(2nded.).NewYork,NY:OxfordPress.
Safran,J.D.,&Muran,J.C.(2000).Negotiatingthetherapeuticalliance:Arelationaltreatmentguide.NewYork,NY:Guilford.
vanderKolk,B.A.,MacFarlane,A.C.,&Weisaeth,L.(1996).Traumaticstress:Theeffectsofoverwhelmingexperienceonmind,bodyandsociety.NewYork.NY:Guilford.
Weiss,J.(1993).Howpsychotherapyworks:Processandtechniques.NewYork,NY:Guilford.
Acknowledgments
ProducingPsychotherapyEssentialstoGohasdependedonandbenefitedfromthesupportandexpertiseofmanypeople.Wewishtoacknowledgeandthankthemanyexpertswhoprovidedthefoundationsonwhichtheapproachdescribedinthisbookwasbuilt:PeterFonagy,AnthonyW.Bateman,JonG.Allen,EphiBetan,JeremyD.Safran,J.ChristopherMuran,BesselvanderKolk,RuthLanius,JohnBowlby,DonaldJ.Kiesler,andJohnC.Norcross.WearegratefultotheOntarioMinistryofHealthandLong-TermCarewhoprovidedfundingtotheeducationaloutreachpilotprojectteamoftheNorthernPsychiatricOutreachProgramattheCentreforAddictionandMentalHealth(CAMH);NancyMcNaughton,WayneWard,andtheUniversityofTorontoStandardizedPatientProgram;RobertSwensonandRobertG.CookeandtheOntarioPsychiatricOutreachProgram;theUniversityofTorontoDepartmentofPsychiatry;theMountSinaiHospitalDepartmentofPsychiatry;theMountSinaiPsychotherapyInstitute;theMorganFirestonePsychotherapyChair;ScottMitchellandtheCanadianMentalHealthAssociation’snorthernOntariobranchexecutivedirectorsandhealthcareworkers.Wealsowishtothankalltheactorswhobroughtthematerialtolife,TomandReetMaeandJoryLyonsofMaeStudios,andConnieKim,aswellasAndreaCostella-DawsonfromW.W.Nortonforherpersistence,help,andsupportoftheseries.
References
Ainsworth,M.,Blehar,M.,Waters,E.,&Wall,S.(1978).Patternsofattachment:ApsychologicalstudyoftheStrangeSituation.Hillsdale,NJ:LawrenceErlbaumAssociates.
Allen,J.G.(2013).Restoringmentalizinginattachmentrelationships:Treatingtraumawithplainoldtherapy.Washington,DC:AmericanPsychiatricPublishing.
Baldwin,S.A.,&Imel,Z.E.(2013).Therapisteffects:Findingsandmethods.InM.J.Lambert(Ed.),BerginandGarfield’shandbookofpsychotherapyandbehaviorchange(6thed.).NewYork,NY:JohnWileyandSons.
Barth,J.,Munder,T.,Gerger,H.,Nüesch,E.,Trelle,S.,Znoj,H.etal.(2013).Comparativeefficacyofsevenpsychotherapeuticinterventionsforpatientswithdepression:Anetworkmeta-analysis.PLoS.Med.,10,(5)e1001454.
Betan,E.,Heim,A.K.,Zittel,C.C.,&Westen,D.(2005).Countertransferencephenomenaandpersonalitypathologyinclinicalpractice:Anempiricalinvestigation.Am.JPsychiatry,162,(5)890–898.
Bowlby,J.(1969).Attachmentandloss:Vol.1:Attachment.NewYork,NY:BasicBooks.
Bradley,R.,Heim,A.K.,&Westen,D.(2005).Transferencepatternsinthepsychotherapyofpersonalitydisorders:Empiricalinvestigation.Br.JPsychiatry,186,342–349.
Castonguay,L.G.,Boswell,J.F.,Constantino,M.J.,Goldfried,M.R.,&Hill,C.E.(2010).Trainingimplicationsofharmfuleffectsofpsychologicaltreatments.AmericanPsychologist,65,(1)34–49.
Choi-Kain,L.W.,&Gunderson,J.G.(2008).Mentalization:Ontogeny,assessment,andapplicationinthetreatmentofborderlinepersonalitydisorder.Am.JPsychiatry,165,(9)1127–1135.
Elliott,R.,Bohart,A.C.,Watson,J.C.,&Greenberg,L.S.(2011).Empathy.Psychotherapy(Chic.),48,(1)43–49.
Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,
Edwards,V.etal.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathsinadults:Theadversechildhoodexperiences(ACE)study.Am.JPrev.Med.,14,(4)245–258.
Foa,E.B.,Keane,T.M.,Friedman,M.J.,&Cohen,J.A.(2010).EffectivetreatmentsforPTSD:PracticeguidelinesfromtheInternationalSocietyforTraumaticStressStudies(2nded.).NewYork,NY:Guilford.
Fonagy,P.,&Bateman,A.(2008).Thedevelopmentofborderlinepersonalitydisorder—amentalizingmodel.JPers.Disord.,22,(1)4–21.
Fonagy,P.,&Target,M.(1997).Attachmentandreflectivefunction:Theirroleinself-organization.Dev.Psychopathol.,9,(4)679–700.
Friedman,S.,Smith,L.,Fogel,D.,Paradis,C.,Viswanathan,R.,Ackerman,R.etal.(2002).Theincidenceandinfluenceofearlytraumaticlifeeventsinpatientswithpanicdisorder:Acomparisonwithotherpsychiatricoutpatients.JAnxietyDisord.,16,(3)259–272.
Gabbard,G.O.(1995).Countertransference:Theemergingcommonground.Int.JPsychoanal.,76(Pt3),475–485.
Galea,S.,Ahern,J.,Resnick,H.,Kilpatrick,D.,Bucuvalas,M.,Gold,J.etal.(2002).PsychologicalsequelaeoftheSeptember11terroristattacksinNewYorkCity.N.Engl.JMed.,346,(13)982–987.
Henry,W.P.,Strupp,H.H.,Butler,S.F.,Schacht,T.E.,&Binder,J.L.(1993).Effectsoftrainingintime-limiteddynamicpsychotherapy:Changesintherapistbehavior.JournalofConsultingandClinicalPsychology,61,(3)434–440.
Herman,J.(1992).Traumaandrecovery.NewYork,NY:BasicBooks.
Hesse,E.(2008).Theadultattachmentinterview:Protocol,methodofanalysis,andempiricalstudies.InJ.Cassidy&P.R.Shaver(Eds.),Handbookofattachment:Theory,researchandclinicalapplications(2nded.,pp.552–598).NewYork,NY:Guilford.
Hill,C.E.,&Knox,S.(2009).Processingthetherapeuticrelationship.Psychother.Res.,19,(1)13–29.
Horvath,A.O.,DelRe,A.C.,Flückiger,C.,&Symonds,D.(2011).Allianceinindividualpsychotherapy.Psychotherapy(Chic.),48,(1)9–
16.
Kessler,R.C.,Sonnega,A.,Bromet,E.,Hughes,M.,&Nelson,C.B.(1995).PosttraumaticstressdisorderintheNationalComorbiditySurvey.Arch.Gen.Psychiatry,52,(12)1048–1060.
Kiesler,D.J.(1996).Contemporaryinterpersonaltheoryandresearch:personality,psychopathology,andpsychotherapy.NewYork,NY:JohnWileyandSons.
Kline,A.,Falca-Dodson,M.,Sussner,B.,Ciccone,D.S.,Chandler,H.,Callahan,L.etal.(2010).EffectsofrepeateddeploymenttoIraqandAfghanistanonthehealthofNewJerseyArmyNationalGuardtroops:Implicationsformilitaryreadiness.Am.JPublicHealth,100,(2)276–283.
Kraus,D.R.,Castonguay,L.G.,Boswell,J.F.,Nordberg,S.S.,&Hayes,J.A.(2011).Therapisteffectiveness:Implicationsforaccountabilityandpatientcare.PsychotherapyResearch,21,267–276.
Leszcz,M.,&Malat,J.(2011).Theinterpersonalmodelofgrouppsychotherapy.InJ.I.Kleinberg(Ed.),TheWiley-Blackwellhandbookofgrouppsychotherapy(1sted.).NewYork,NY:JohnWileyandSons.
Linehan,M.(1993).Skillstrainingmanualfortreatingborderlinepersonalitydisorder.NewYork,NY:Guilford.
Luborsky,L.,Popp,C.,Luborsky,E.,&Mark,D.(1994).Thecoreconflictualrelationshiptheme.PsychotherapyResearch,4,(3and4)172–183.
Luborsky,L.,Rosenthal,R.,Diguer,L.,Andrusyna,T.P.,Berman,J.S.,Levitt,J.T.etal.(2002).Thedodobirdverdictisaliveandwell—mostly.ClinicalPsychology—ScienceandPractice,9,(1)2–12.
Lyons-Ruth,K.,&Jacobvitz,D.(2008).Attachmentdisorganization:Geneticfactors,parentingcontexts,anddevelopmentaltransformationfrominfancytoadulthood.InJ.Cassidy&P.R.Shaver(Eds.),Handbookofattachment:Theory,researchandclinicalapplications(2nded.,pp.666–697).NewYork,NY:Guilford.
Martin,D.J.,Garske,J.P.,&Davis,M.K.(2000).Relationofthetherapeuticalliancewithoutcomeandothervariables:Ameta-analyticreview.JConsult.Clin.Psychol,68,(3)438–450.
Maunder,R.G.,&Hunter,J.J.(2012).Aprototype-basedmodelofadult
attachmentforclinicians.Psychodyn.Psychiatry,40,(4)549–573.
Mitchell,S.A.(1993).Hopeanddreadinpsychoanalysis.NewYork,NY:BasicBooks.
Neria,Y.,Bromet,E.J.,Sievers,S.,Lavelle,J.,&Fochtmann,L.J.(2002).Traumaexposureandposttraumaticstressdisorderinpsychosis:Findingsfromafirst-admissioncohort.JConsult.Clin.Psychol,70,(1)246–251.
Norcross,J.C.,&Lambert,M.J.(2011).Evidence-basedtherapyrelationships.InJ.C.Norcross(Ed.),Psychotherapyrelationshipsthatwork:Evidence-basedresponsiveness(2nded.,pp.3–24).NewYork,NY:OxfordUniversityPress.
Norcross,J.C.,&Wampold,B.E.(2011).Evidence-basedtherapyrelationships:Researchconclusionsandclinicalpractices.Psychotherapy(Chic.),48,(1)98–102.
Ogden,P.,Minton,K.,&Pain,C.(2006).Traumaandthebody:Asensorimotorapproachtopsychotherapy.NewYork,NY:W.W.Norton.
Pope,K.S.,&Vasquez,M.J.T.(2010).Ethicsinpsychotherapyandcounseling:Apracticalguide(4thed.).NewYork,NY:JohnWileyandSons.
Ravitz,P.,Maunder,R.,Hunter,J.,Sthankiya,B.,&Lancee,W.(2010)Adultattachmentmeasures:A25-yearreview.JournalofPsychosomaticResearch69(4)419–432.
Safran,J.D.,Muran,J.C.,&Eubanks-Carter,C.(2011).Repairingallianceruptures.Psychotherapy(Chic.),48,(4)80–87.
Sammet,I.,Leichsenring,F.,Schauenburg,H.,&Andreas,S.(2007).Self-ratingsofpathogenicbeliefs:Astudybasedonpsychodynamiccontrol-masterytheory.PsychotherapyResearch,17,494–503.
Saxe,G.N.,vanderKolk,B.A.,Berkowitz,R.,Chinman,G.,Hall,K.,Lieberg,G.etal.(1993).Dissociativedisordersinpsychiatricinpatients.Am.JPsychiatry,150,(7)1037–1042.
Shaver,P.R.,&Mikulincer,M.(2002).Attachment-relatedpsychodynamics.Attach.Hum.Dev.,4,(2)133–161.
Shedler,J.(2010).Theefficacyofpsychodynamicpsychotherapy.Am.
Psychol,65,(2)98–109.
Strupp,H.H.,&Binder,J.L.(1984).Psychotherapyinanewkey:Aguidetotime-limiteddynamicpsychotherapy.NewYork,NY:BasicBooks.
VanWagoner,S.L.,Gelso,C.J.,Hayes,J.A.,&Diemer,R.A.(1991).Countertransferenceandthereputedlyexcellenttherapist.Psychotherapy:Theory,Research,PracticeandTraining,28,(3)411–421.
Viederman,M.(1999).Presenceandenactmentasavehicleofpsychotherapeuticchange.JPsychother.Pract.Res.,8,(4)274–283.
Wachtel,P.(2011).Therapeuticcommunication:Knowingwhattosaywhen(2nded.).NewYork,NY:Guilford.
Wampold,B.E.(2001).Thegreatpsychotherapydebate:Models,methodsandfindings.Hillsdale,NJ:LawrenceErlbaumAssociates.
Weiss,J.(1993).Howpsychotherapyworks:Processandtechniques.NewYork,NY:Guilford.
Winnicott,D.W.(1971).Playingandreality.Harmondsworth,UK:Penguin.
Yalom,I.,&Leszcz,M.(2005).Thetheoryandpracticeofgrouppsychotherapy(5thed.).NewYork,NY:BasicBooks.
Index
Pagenumberslistedcorrespondtotheprinteditionofthisbook.Youcanuseyourdevice’ssearchfunctiontolocateparticulartermsinthetext
[Pagenumbersinitalicrefertoillustrationsorboxedtext.]
Aacceptance
ofclient,12
oftraumaticexperience,61
affectandemotion
client’sself-regulatorycapacity,44–45,144–145
effectsofinvalidatingexperienceinchildhood,18–19
identifyingtransference,28,29
affiliation
ininterpersonalcircumplex,24–25,135
therapeuticgoals,63–64
alleviating,42
anxiousattachmentstyle,64
arousal
paceoftherapyandclient’slevelof,144–145
therapeuticgoals,44–45
traumasymptoms,54–55,150–151
attachment
adultmanifestationofchildhoodexperiences,22–23
assessmentof,9,20–21,153–154
developmentalsignificanceof,16,19–20,135
attachment(continued)
informationofinternalworkingmodel,19,20
insecureformsof,22–23,42–43,134,142
quizquestions,95–97,98–100,160–161
secure,22,134,142
theory,67
intherapeuticrelationships,41–42
therapist’sanxiousstyle,64
Bbeingpresent,9–10,35
betrayalintrauma,61–62
Cchange
acceptanceofclientand,12
commonfactorsofpsychotherapy,6
disconfirmingclient’spathogenicbeliefsfor,38–39
effectiveuseofstrainsintherapeuticalliancefor,37–38,148–149
goalsfortraumatherapy,61
signsofimprovement,149
therapeuticallianceasmechanismof,7,140–141
therapistqualitiesasmechanismof,5–6
circumplexmodel
pullsin,25,25
purposeof,23–24,69
quizquestions,95,98–100,162
structure,24,24–25,69,135
therapeuticusesof,25–27,38–38,74–75,142–143
client’srelationalworld
assessingcurrentpatternsin,21–27,134,140
developmentalhistoryof,16–21,133–134,140,153
formationofpathogenicbeliefsand,31–34
quizquestions,94,160
scopeofassessmentof,15–16,16
therapeuticsignificanceof,6,8
seealsoattachment;circumplexmodel;interpersonaldynamics
cognitiveschema,16–17
communication
fordiscussingtherapeuticgoals,11–12
therapist’sskills,6
seealsometacommunication
confidence,17
containing,42
contrarymoves,136–137
defined,46,68
therapeuticusesof,46,144,146
countertransference
inassessingclient’straumaexperience,59–60
associatedthoughtsandfeelings,30
clinicalsignificanceof,29,29–30,48
defined,27,68,141
interpersonalcircumplexand,27
quizquestions,93–94,159
recognizing,28–29
role-playtranscripts,121–132
therapeuticprocessingof,48,141–142,148,149
D
depression,traumaand,54,55
desensitization,61
development
assessingclienthistory,15,16–21,21
attachmenttheoryof,16–17,135
ofinsecureattachments,42–43
withinvalidatingcaregiver,18–19,42
invalidatingchildhoodastraumariskfactor,57
obstaclestomentalizingability,42
ofpathogenicbeliefs,31–34
invalidatingenvironment,17–18,41–42,96
dismissinginsecureattachment,22–23,42,68,134,142,153–154
disorganizedattachment,23,68,134,142
domesticviolence,147–149
Eeffectivepsychotherapy
coreskillsfor,7
cross-modalityprinciplesof,1–2,6
determinantsof,6,7
learningobjectivesfor,3–4
obstaclesto,35–37
sequentialapproachto,9–10,66,136
therapistqualitiesasdeterminantof,5–6,63–66
emotionalself-regulation
paceoftherapyandclient’scapacityfor,144–145
therapeuticgoalsandstrategiesfor,44–45
empathy
developmentof,inchildhood,17
insequentialapproachtoeffectivepsychotherapy,9
aspsychotherapyoutcomefactor,6
ethicalpractice
quizquestions,94,160
safetyconcerns,147–149
therapist’sresponsibilities,13,13,65
evidence-basedpractice,5–6,66
Ffear,astraumaoutcome,55,149
feedback,client,6,39,109,118,121,126
Ggenuineness,therapist,6
goals,therapy
communicationabout,12–13,139–140
aspsychotherapyoutcomefactor,6
role-playtranscripts,12–13,139–140
good-enoughparent,17,68
good-enoughtherapist,43
Hhealingcontext,6
here-and-now,9,33–34,68
role-playtranscriptsexploring,104,114,115,117,123,124,132
hookingandunhooking,9–10,27,38–40,49–50,51–52,63,136
Iinternalworkingmodel
attachmentexperienceindevelopmentof,16,18–19,20,22–23,135
defined,16–17,68–69
interpersonalcircumplexmodeland,23–24
mentalizingcapacityand,48–49,157–158
pathogenicbeliefsin,31
quizquestions,95
interpersonaldynamics
circumplexmodel,23–27,38–39,69,74–75,95,135,142–143
quizquestions,94–95,160
therapist’sattentionto,ascoreskill,7
seealsoclient’srelationalworld;therapeuticalliance
Llessonplans
establishingalliance,73–75
tear-and-repairprocesses,76–79
therapeuticprocess,83–90
traumaconsiderationsintherapy,79–83
Mmaladaptiveloops
assessment,33–34
attachmentexperienceindevelopmentof,19–20
challengingclient’s,12,136
clinicalsignificanceof,9
defined,9,69
interpersonalcircumplexmodelof,23–24
pathogenicbeliefsinformationof,31–33,32
reflectiontopreventengagementwith,48–49
seealsohookingandunhooking
mentalizing
benefitsof,40–41,136
caseexamplesof,47,51–52,121–132
client’sinternalworkingmodelaschallengeto,48–49,157–158
clinicalsignificanceof,6,7,9,41
defined,40,69–70,144
developmentofcapacityfor,17,41–43
lessonplan,76–79
modeling,45–46,136,144
toprocessalliancetension,156
quizquestions,97–98,161
therapeuticusesof,41,43–46,46,144,146,152,154–155,400
metacommunication
ascoreskillforeffectivepsychotherapy,7
defined,50,70,137,145
goalsof,137–138
lessonplan,76–79
toprocessalliancetension,156–157
quizquestions,92,159
role-playtranscripts,121–132
therapeuticusesof,9,50,145,152
modeling
defined,70
ofmentalizing,45–46,136,144
Nnot-knowingstance,46,52,136,144,146
inrole-playtranscripts,106,116,117,120
Ppathogenicbeliefs
clinicalsignificanceof,31–34
defined,70
disconfirming,intherapy,38–39
exploringandprocessing,140–141
formationof,31,32
perfectionisttherapists,64
positiveexperiences,64–65
positiveregard,therapist’s,6
posttraumaticstressdisorder,53–54,61.seealsotrauma
powerrelationships
ininterpersonalcircumplex,24,25,135
preoccupiedattachment,22,42–43,70,134,142
presence,therapist’s,9–10,63,70,146–147
process,therapy,35–37,70,75,79
processing,therapeutic,26,52,64–65,70–71
pullofinterpersonalbehavior,25,25–27,69,142–143,149
Qquizquestions
assessment,98–100
attachmentrelationships,160–161
attachmentstyle,95–97
circumplexmodelofinterpersonalbehavior,162
client’srelationalworld,94–95,160
ethicalpractice,94
internalworkingmodel,95
mentalizing,97–98,161
metacommunication,92,159
tear-and-repairprocesses,98,161
therapeuticalliance,91–93,101,159
transferenceandcountertransference,93–94,159
trauma,97,161
validatingenvironment,161
Rreflection
toavoidengagementinmaladaptiveloop,48–49
challengestotherapist’scapacityfor,146–147
collaborative,49–50
asqualityofeffectivetherapists,63
therapeuticusesof,42,43–44
resilience,17
Ssafetyconcerns,147–149
secureattachment,19,22,71,134
securebasefordevelopment,17–19,22,43–44,71
self-blame,client,61–62
self-disclosure,50,71
self-fulfillingprophecies,9,10,32.seealsomaladaptiveloops,136
shaming
intherapy,36
traumaexperienceand,62
Ttear-and-repairprocesses,37–38,38,76–79,98,136,148,156–157,161
therapeuticalliance
beingpresentwithin,9–10
building,11–12,12,73–75
client’sapprehensiononenteringinto,8
clinicalsignificanceof,6,7,8,9,11,66,159
collaborativereflectionin,49–50
defined,71
effectiveuseofstrainsin,4,9,36–38,50,148–149,156–157
gettinghookedandunhookedin,9,27,38–40,49–50,51–52,63,136
goalsettingand,12–13
interpersonalcircumplexmodelforevaluating,26–27
mentalizingtoprocesstensionin,52
quizquestions,91–93,101,159
role-playtranscripts,103–120
safeenvironmentfor,17–18,43–44
strategiesforrepairing,9–10,148
therapeuticrelationshipand,10–11
therapistqualitiesandskillsforbuilding,8–9,37,133,139
therapiststressaschallengeto,36
therapisttransparencyin,50
seealsocountertransference;tear-and-repairprocesses
therapeuticrelationship
betrayalintraumaand,61–62
tearandrepairof,38
therapeuticallianceand,10–11
fortraumatreatment,62
seealsotherapeuticalliance
therapistqualities
adaptabilitytoissuesarisingintherapy,6
beingpresentwithinalliance,9–10
coreskillsforeffectivepsychotherapy,7
determinantsofeffectivepsychotherapy,5–6,63–66
exemplary,101,162
genuineness,6
judicioustransparency,50
obstaclestoeffectivepractice,64
professionalresponsibilities,13
topromotetherapeuticalliance,133,139
forpromotingtherapeuticalliance,8–9,37
there-and-now,9,33,71
there-and-then,9,33,71
tolerancetofrustration,17
transference
clinicalsignificanceof,27,28,31
defined,27,71–72,141
mentalizingperspectivetoexamine,48
quizquestions,93,159
recognizing,28,29
therapeuticprocessingof,9,31
transparency,therapist,50
trauma
assessment,58–59,60–61,138,150–151
characteristicsofunresolved,60–61
clinicalsignificanceof,53,55–56,64,138,149–150
implicationsfortherapy,79–83
invalidatingchildhoodandriskof,57
obstaclestorecoveryfrom,151
overcomingexperienceofbetrayalin,61–62
pathstounresolved,56–58
posttraumaticstressdisorderand,54
quizquestions,97,161
recognizingexistenceandeffectsof,53–54,56
symptoms,54–55,55,149
therapeuticrelationshipfortreatmentof,62,155–156
therapistreactiontoclient’saccountof,59–60
treatmentgoals,61
Vvalidatingenvironment,17–19,41–42,57,72
quizquestions,96,161
ADVANCEPRAISE“Anextraordinarilylucidandhelpfuldiscussionofthetenetsandtechniquesofpsychotherapy.Thepresentationdrawsoncurrentresearchandthecasepresentationsarenotonlygrippingbutalsostuddedwithbriefcleardiscussionsofthereasonsforeachtherapistcomment.Asuperbtrainingmanualfortherapists.”
—IrvinYalom,ProfessorEmeritus,StanfordUniversityandauthorof“The
GiftofTherapy”“Atlast!Hereisthatrarity,abookthatactuallytellsyouhowtodothejobofpsychotherapy—layingoutthedetailedworkingsofformingatherapeuticalliance,deepeningemotionalengagement,tactfullytacklingtrauma,andtransformingtherapist-clientrelationshipstrainintotherapeuticopportunity.Theaccessible,learning-orientedformat,withextensiveannotatedextractsfromtherapysessions,provideidealteachingmaterialforallmentalhealthprofessionals.Simplewithoutbeingsimplistic,demystifyingwhileacknowledgingcomplexity,readableandreliable,energizingyetevidence-based,itisdestinedforaplaceineverytherapist’sandwould-betherapist’sbackpack.”
—JeremyHolmes,MD,FRCPsych,SchoolofPsychology,UniversityofExeter,UK
MolynLeszcz,MD,FRCPC,DFAGPA,isProfessorandChair(Interim)attheDepartmentofPsychiatry,UniversityofTorontoandthePsychiatrist-in-ChiefatMountSinaiHospital.Hisacademicandclinicalworkhasfocusedonbroadeningtheapplicationofpsychotherapywithinpsychiatry.Dr.LeszczisaDistinguishedFellowoftheAmericanGroupPsychotherapyAssociationandco-chairedtheirSciencetoServicesTaskForceleadingtopublicationofClinicalPracticeGuidelinesforGroupPsychotherapy.WithIrvinYalom,heco-authoredthe5theditionoftheTheoryandPracticeofGroupPsychotherapy(2005).Hisresearchhasfocusedongrouppsychotherapy.ClarePainMD,MSc,FRCPC,DSc(Hons),isAssociateProfessorattheDepartmentofPsychiatry,UniversityofToronto,DirectorofthePsychologicalTraumaProgramatMountSinaiHospital,ConsultantattheCanadianCenterforVictimsofTorture,Co-projectdirectoroftheTorontoAddisAbabaPsychiatryProjectandCoordinatoroftheUniversityofToronto-AddisAbabaCollaborationProgram.Herclinicalfocusisontheassessmentandtreatmentofpatients,includingrefugees,whocontinuetosufferfromtheeffectsofpsychologicaltrauma.
JonathanHunter,MD,FRCPC,isAssociateProfessorattheUniversityofToronto,whereheheadstheDivisionofConsultation-LiaisonPsychiatry.HeisHeadofPsychosocialServicesintheMarvelleKofflerBreastCentreatMountSinaiHospitalandafoundingmemberoftheCollaborativeMentalHealthcareNetworkoftheOntarioCollegeofFamilyPhysicians.Hisclinicalandresearchinterestsincludethepsychiatricandpsychotherapeuticcareofcancerpatients,theroleofearlylifeexperienceandattachmentinadaptationtodisease,andtheimportanceofmentalizingintreatment.
RobertMaunder,MD,FRCPC,isProfessorattheDepartmentofPsychiatry,UniversityofTorontoandHeadofResearchatMountSinaiHospital’sDepartmentofPsychiatry.Hisprimaryresearchinterestisintheroleofinterpersonalattachmentinhealth.
PaulaRavitzMD,FRCPC,isAssociateProfessorandAssociateDirectorofthePsychotherapies,HealthHumanities&EducationScholarshipDivisionintheDepartmentofPsychiatryattheUniversityofTorontoandMountSinaiHospitalMorganFirestonePsychotherapyChair.Heracademicfocusisonthepractice,teaching,dissemination,andresearchofevidence-supportedpsychotherapytreatmentsinmentalhealthcare.
PRACTICEREMINDERCARD
ACHIEVINGPSYCHOTHERAPYEFFECTIVENESS
Therapistqualities&characteristicsthatpromoteatherapeuticalliance:
empathy,responsiveness,interest,rapport,positiveregard,genuineness,&theabilitytomanagestrainandrepairtensionswithin
thealliance
Developasharedunderstandingofaclient’srelationalworld-Earlyattachmentrelationships
-Currentrelationships-Transferenceandcountertransference
IdentifymaladaptiveloopsthatreinforcepathogenicbeliefsMAPPINGINTERPERSONALPULLSONTHEAXESOF
THEINTERPERSONALCIRCUMPLEX
Anattachmentstyleemergesasthebestadaptationtoacomplexenvironmentandisencodedineachindividual’sinternalworking
modelATTACHMENTPATTERNSOFRELATING
Secure Preoccupied Dismissing Disorganized
Care-providers’characteristics
Goodenough Inconsistentlyresponsive
Mostlyunresponsive
Frighteningorfrightened
Attachmentbehaviors Fullrangeandflexible
Dialedup Dialeddown Unclassifiable,fluctuatesunpredictably
Others’experienceofthisperson
Trustworthy,reliable
Overwhelming,needy
Distant,aloof Discombobulating
ATear&RepairPsychotherapyProcess
Respondempathically,challengingmaladaptiveloopsandfosterapositivesenseofself.Disconfirmpathogenicbeliefsandexpectationsabouttheselfandothers(e.g.ofharmornegativejudgment).
Metacommunication:torepairanalliancetension•Acceptresponsibilityforcontributingtothetension,highlightinghowweaffecteachother.
•Exploretheclient’sexperienceinthehere-and-now.
•Collaborativelyreflectonwhythisishappeninginthiswayrightnow,thinking“outloud”aboutsubjectiveperspectivesandemotionalreactions.
Mentalizing:toappreciatethatothershavedifferentbeliefs,understandings,andintentions;thataperson’simpactisnotalwayswhattheyintend;andthatpeoplecanfeelonewayandactanother.
•Collaborateincreatingacoherentnarrative.
•Modelmentalizing.Communicateaboutmentalstates.Wonderaboutintentions.
•Usea“not-knowing”stance.Beopenandcuriousaboutwhatisinyourandothers’minds.
•Usecontrarymoves.Varyfocusbetweenthinking/feeling,self/other,internal/external.
Unresolvedtraumacanunderlieproblemswithrelationships,regulatingemotions,medicallyunexplainedsymptoms,memorygaps,dissociation,self-harm,andsubstanceabuse.
•Arethedisturbingtraumaticexperiencesontheclient’smindfrequently?
•Howmuchhastheclientintegratedtraumaticmemoriesintohisorherlifestory?
•Istheclientreflectiveaboutthetrauma?
•Whohastheclienttold&what’sitliketellingyounow?
Copyright©2015byPaulaRavitz,RobertMaunder,MolynLeszcz,ClarePain,andJonHunter
Allrightsreserved
FirstEdition
Forinformationaboutpermissiontoreproduceselectionsfromthisbook,writetoPermissions,W.W.Norton&Company,Inc.,500FifthAvenue,NewYork,NY10110
Forinformationaboutspecialdiscountsforbulkpurchases,pleasecontactW.W.NortonSpecialSalesatspecialsales@wwnorton.comor800-233-4830
BookdesignbyKristinaKacheleDesign,llcProductionmanager:LeeannGraham
TheLibraryofCongresshascatalogedtheprintededitionasfollows:
Ravitz,Paula,author.
Achievingpsychotherapyeffectiveness/PaulaRavitz,RobertMaunder,MolynLeszcz,ClarePain,JonHunter.—Firstedition.
p.;cm.—(Psychotherapyessentialstogo)
“ANortonProfessionalBook.”
Includesbibliographicalreferencesandindex.
ISBN978-0-393-70826-4(paperback)
I.Maunder,Bob(BobG.),author.II.Leszcz,Molyn,1952-,author.III.Pain,Clare,author.IV.Hunter,Jon,1958-,author.V.Title.VI.Series:Psychotherapyessentialstogo.
[DNLM:1.Psychotherapy—methods—Handbooks.2.Psychotherapy—methods—ProblemsandExercises.3.ClinicalCompetence—Handbooks.4.ClinicalCompetence—ProblemsandExercises.5.MentalDisorders—therapy—Handbooks.6.MentalDisorders—therapy—ProblemsandExercises.7.Professional-PatientRelations—Handbooks.8.Professional-PatientRelations—ProblemsandExercises.9.PsychotherapeuticProcesses—Handbooks.10.PsychotherapeuticProcesses—ProblemsandExercises.11.TreatmentOutcome—Handbooks.12.TreatmentOutcome—ProblemsandExercises.WM34]
RC480.5
616.89’14—dc23
2014027699
ISBN:978-0-393-70826-4(pbk.)
ISBN:978-0-393-70999-5(e-book)
W.W.Norton&Company,Inc.,500FifthAvenue,NewYork,N.Y.10110www.wwnorton.comW.W.Norton&CompanyLtd.,CastleHouse,75/76WellsStreet,LondonW1T3QT