SC Year Two Study GuideMichele Goedde

Alison WitheyApril 2008

With input from the tired girl materials, Beth Jensen and Janel Fox. Study team to the stars!

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Index

Pages 2-9 MedicationsPages 10-12 Theory overviews Pages 13-16 BowenPages 17-20 MRIPages 21-24 StructuralPages 25-29 NarrativePages 30-33 Solution-FocusedPages 34-39 DSM & Diagnosis

Psychotropic Medications

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AntidepressantsHalf-life = how fast it clears the system. A medications half-life is the time it takes for its

concentration in the body to be reduced by half.

SSRI’s = selective serotonin reuptake inhibitors • the most widely prescribed antidepressants. Increases transmission of serotonin that has

been inhibited.• SSRIs seem to relieve symptoms of depression by blocking the reabsorption (reuptake) of

serotonin by certain nerve cells in the brain. This leaves more serotonin available in the brain. As a result, this enhances neurotransmission — the sending of nerve impulses — and improves mood. SSRIs are called selective because they seem to affect only serotonin, not other neurotransmitters.

• Citalopram (Celexa) • Escitalopram (Lexapro) • Fluoxetine (Prozac, Prozac Weekly) • Paroxetine (Paxil, Paxil CR) • Sertraline (Zoloft) • Side Effects: SNRI’s = Serotonin and norepinephrine reuptake inhibitors • Antidepressant medication that increases the levels of both serotonin and norepinephrine by

inhibiting their reabsorption into cells in the brain.• Medications in this group of antidepressants are sometimes known as dual reuptake

inhibitors • Duloxetine (Cymbalta) • Venlafaxine (Effexor, Effexor XR)

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Antidepressants cont… NDRI = Norepinephrine and dopamine reuptake inhibitors • antidepressant medication that increases the levels of both norepinephrine and dopamine by

inhibiting their reabsorption into cells. • Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL)

Tetracyclics • Instead of inhibiting the reabsorption of certain neurotransmitters as other antidepressants

do, tetracyclic antidepressants prevent neurotransmitters from binding with nerve cell receptors called alpha-2 receptors. This indirectly increases the levels of norepinephrine and serotonin in the brain.

• Mirtazapine (Remeron, Remeron SolTab)

Tricyclic• inhibit the reabsorption (reuptake) of serotonin and norepinephrine. To a lesser extent, also

inhibit reabsorption of dopamine. • among the earliest of antidepressants, hitting the market in the 1960s, remained the first line

of treatment for depression through the 1980s.• Amitriptyline • Amoxapine • Desipramine (Norpramin) • Doxepin (Sinequan) • Imipramine (Tofranil) • Nortriptyline (Pamelor) • Protriptyline (Vivactil) • Trimipramine (Surmontil)

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Antidepressants cont…Combined reuptake inhibitors and receptor blockers • dual-action antidepressants • both by inhibiting the reabsorption (reuptake) of neurotransmitters into nerve cells and by

blocking nerve cell receptors • Trazodone , Nefazodone, Maprotiline MOAI’s• Must go on a special diet if taking this med• When you go off you must wait 2 weeks before taking other drugs• are a class of powerful antidepressant drugs prescribed for the treatment of depression.

They are particularly effective in treating atypical depression, and have also shown efficacy in helping people who want to quit smoking.

• Due to potentially lethal dietary and drug interactions, MAOIs had been reserved as a last line of defense, used only when other classes of antidepressant drugs have been tried unsuccessfully

• In the past they were prescribed for those resistant to tricyclic antidepressant therapy, but newer MAOIs are now sometimes used as first-line therapy. They are also used for treating agoraphobia or social anxiety. Currently, the availability of selegiline and moclobemide provides a safer alternative, although these substances are not always as effective as their predecessors.

• MAO inhibitors can also be used in the treatment of Parkinson's disease (by affecting dopaminergic neurons), as well as providing an alternative for migraine prophylaxis.

• Phenelzine (Nardil) • Tranylcypromine (Parnate) • Isocarboxazid (Marplan) • Selegiline (Emsam)

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Antipsychotics and Mood StabilizersAntipsychotics• Also known as neuropeltics. Used to treat psychosis. • Used for schizophrenia and bipolar disorder. BP for severe mania• Atypica Antipsychotics: Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, • High Potency Antipsychotics: Haldol, Prolixin, Navane, Stelazine• Mid – potency antipsychotics: Moban, Trilafon, Loxitane• Low Potency antipsychotics: Thorazine, Serentil Mellaril• Side Effects

Mood Stabilizers• Used for the treatment of mood disorders bipolar and schizoaffective • Primary bi-polar drugs used• Most mood stabilizers are anticonvulsants, with the important exception of lithium, which is

the oldest and best known mood stabilizing drug. Called anticonvulsants as they were first used for epilepsy

• Most so-called mood stabilizers are purely antimanic agents, meaning that they are effective at treating mania and mood cycling and shifting, but are not effective at treating depression.

• Lithium most common. Effective in the treatment of the acute manic phase of bi-polar. More effective in the treatment of the manic episodes than the depressed.

• The rest are anticonvulsants – depakote, lamictal, tegretol, Topamax, Neurontin, Trileptal, Gabitril

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Anxiolytics and Psychostimulants Anxiolytics = Used to treat anxiety. Anxiolytics are generally divided into two groups of medication, benzodiazepines and non-

benzodiazepines.Benzodiazepines (benzo’s – minor tranquilizers)• Benzodiazepines are prescribed for short-term relief of severe and disabling anxiety. Common

medications are lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), and diazepam (Valium).

Non-benzodiazepines• Buspirone (BuSpar) is a serotonin 1A agonist. It lacks the sedation and the dependence

associated with benzodiazepines and causes much less cognitive impairment. It may be less effective than benzodiazepines in patients who have been previously treated with benzodiazepines as the medication does not provide the sedation that these patients may expect or equate with anxiety relief. Also Atarax

Benzodiazepine Hypnotics – insomnia meds: Flurazepam/Dalmane, Restoril, ProSem, Doral,

HalcionNon-Benzodiazepine Hypnotics: Ambien, Sonata, Benadryl

Psychostimulants• Dexedrine – used for ADHD and narcolepsy• Adderall –ADHD• Ritalin – most commonly used med I the treatment of ADHD in kids and adults. Ritalin is a

stimulant so with kids that have ADHD it has an opposite effect. • Straterra • ProDexedrine – used for ADHD and narcolepsy• Provigil - narcolepsyvigil - narcolepsy

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Drugs commonly abused/causing depression

Central nerve system depressants • calming effect- alcohol, barbiturates, benzodiazepines Central nervous system • stimulants amphetamines, cocaine, nicotine, Hallucinogens and dissociative drugs • both categories of drugs that alter a persons' state of mind and mood. Hallucinogens can

cause a person to hallucinate--that is to see, hear, or feel things that aren't actually real. Hallucinogens include LSD, Mescaline (Peyote), Psilocybin, and Psilocyn (Mushrooms). Dissociative drugs, such as Ketamine or PCP, alter a persons state of mind and mood but do not cause a person to hallucinate. Dissociative drugs cause a person to detach, or dissociate, from his or her surroundings.

Drugs that cause depression• Alcohol• Hypertensives• Bcp’s• Steroids

• Works well for depression and anxiety – paxil• For anxiety only? BuSpar

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Theory Overview

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Theory Waves• First Wave: Individual Psychology

– Jung, Rogers, Freud, Skinner, Gestalt– Intra psychic (the lowest place on the

waterline) psychoanalyctic– Objective based reality, facts, cause and

effect– Search for underlying pathology– Etiology – cause of development of problem– Linear thinking: bad mother = bad child– Therapist is the expert

• Second Wave: Systemic/Behavioral– Bowen, Minuchin, Nagy, Satir– Structural, MRI (1950’s)– Complimentarity/Reciprocity– Emphasis on here and now – present– Intro to ideas of family structure, rules,

boundaries– Communication Models– Ineffective functioning of systems– Interventions focusing on interrupting

patterns of action and interaction– Defined problems as being between people:

relational vs. in people

• Third Wave: Social Constructivism/Post Modernism– Berg, Papp, Betty Carter, White

(1970’s/80’s)– World of meaning and stories people tell– Collaboriative/competency based– Client has the solution, tx collaborative– Focus on possibilities, strengths, abilities

and resources– Dominant vs. preferred– How stories are contextualized– De-pathologize– Treatment focus on change and preferred

outcomes– Less to do with technique and more to do

with therapeutic relationship.

• Fourth Wave– Mindell, Rosenburg– Biology, spirit, unknown, mystery, mind– Mind/body connection

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Third WaveMilton Erickson – Competency Based Therapist• Allowed clients to teach him• Did not rely on one single theory• Focus on present and future• People could change rapidlyBrief Family Therapy Center• Home of Solution Focused Brief Therapy• MRI = focus on problems• BFTC = focus on solutions• Resistance is not a part of this theory• Focus on exceptions, future orientedConstructivism and Social Constructivism• Philosophical stance rooted in biology and physical properties of perception• Multiple ways of understanding – many realities• No single theory is more true/correct• Meaning making is through interactions and talking with others• Re-authoring, re-writing: theraputic dialogue leads to re-creation/creation of new

reality

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Bowen Theory overview Murray Bowen, Guerin, Michael Kerr, Betty Carter, Monica Mc Goldrick

• Multigenerational family therapy developed out of natural systems theory• Focus is on “the present in the past”• Problems reside in the family, not the individual (2nd wave)• First to develop family systems thinking• Bowen believed:

– If the therapist is grounded in theory, they would be able to remain detached from the emotional field of family

– The child w/the most emotional problems was the least differentiated and adapted to stabilize the system

• Human relationships are driven by two counter-balancing life forces: individuality and togetherness

• There is chronic anxiety in life. The antidote is differentiation which improves adaptiveness.

_____________________________________• Scale of differentiation: differentiated vs. fused vs. individuation vs. cutoff• Basic social learning is based on FOO; is non-negotiable

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Bowen 8 Key Concepts1. Differentiation of Self: self from other and thoughts from feelings2. Triangles: binding the anxiety of two by including a third; automatic reactive process.

Dyad is inherently unstable.3. Nuclear Family Emotional Process: emotional forces in family that operate over the years

in recurrent patterns. An ex is often fusion. Lack of Differentiation X Anxiety = Fusion Between Spouses.

4. Family projection process: process by which parents transmit lack of diff on to children. Projection of problems on future generation. Forming an alliance with a child. The process by which parents project part of their immaturity to one or more children.

5. Multigenerational transmission process: parents transmit anxiety from generation to generation. This refers to the transmission of a family projection process.

6. Sibling position – birth order7. Emotional cutoff: people managing their unresolved emotional issues with parents,

siblings, and other family members by reducing or totally cutting off emotional contact with them. The greater the emotional fusion, the more likely cutoff.

8. Societal emotional process: (parallels family system) The concept of societal emotional process describes how the emotional system governs behavior on a societal level, promoting both progressive and regressive periods in a society. Classism, heterosexism, poverty

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Basic level of Differentiation: Largely determined by the degree of emotional separation a person achieves from foo, and is not dependent on the relationship process

Functional Differentiation: basic + social training and environmental, is dependent on the relational process

Pseudo-self: knowledge and beliefs acquired from others that are incorporated by the intellect and negotiable in relationships with others (created by emotional pressure and can be modified by emotional pressure)

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Bowen Tips/Test answers

• A low differentiated person marries a similarly differentiated (or not) person• Over/under function: similar to complimentarity• Family Projection process: triangling – forming an alliance w/a child• You ID who the parents triangle with by noting the child w/the most symptoms• Low differentiated people tend to be bound up by emotions (vs. observe and not

react)• Societal regression: direct correlation btwn family systems and societal systems.

As one regresses the other follows. • Biological, social, psychological observed phenomenon are all interrelated• There is order and predictability to human family relationships (individuality vs.

togetherness)• Goal of Therapy: Not to change people or solve problems

– Differentiate self– Change the individual within the context of the system– Decrease anxiety

• Therapist is guide and coach, objective observer, monitor own reactivity• Client must initiate – or do the FOO work – therapist cannot. • Tx cannot ask clients to do their work – must do own

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Bowen Interventions• De-triangulating – respond to triangle effort by pushing both people together to

respond differently• Focus on the pattern of the relationship: pattern vs. content• Reduce emotional cut-off from past

– All people have some degree of unresolved emotional attachment to their parents.– Level of cutoff is influenced by degree of differentiation: there is an attempt to distance by avoiding contact.

• Focus on optimal functioning vs. normalcy (non-normative) not looking to change the family structure. Looking to create health within family system.

• Symptoms are a result of the level of differentiation in the relationship system. high anxiety high symptoms

• There is chronic anxiety in life, it is the primary promoter of all physical and emotional symptoms

• The cure/antidote to prevent this anxiety is differentiation. A reduction of anxiety will relieve symptoms and differentiation will improve adaptiveness.

• To not act automatically but to maintain more of the self in highly charged relationship systems leads to differentiation. (taking I stance)

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Key Therapeutic TechniquesKey Therapeutic Techniques• Process Questions: designed to find out what is going on inside people and between them,

“when your boyfriend insults you how do you deal with it?” Designed to slow people down, diminish reactive anxiety and start them thinking. Helps to identify how client participates in interpersonal problems.

• Relationship Experiments: designed to help clients experience what it is like to act counter to their usual automatic emotionally driven responses.

• Genograms• The therapy triangle: therapist should try to remain free of emotional entanglements in order to

avoid feel stuck or stalemated.• Coaching – ask process questions designed to help clients cultivate responses. • The “I” position – take a personal stance and say what you feel. • Displacement stories: tell stories (or recommend movies) that minimize defensiveness.

Conditions of behavior change• Therapists must be able to tolerate anxiety.• Therapists must practice differentiation and avoid triangulation.• Therapists ask questions to foster self-reflection and direct them to individuals one-at-a-time.• Individuals are encouraged to look for their own role in processes.• Therapy requires an awareness about the entire family (even though it does not need to include

the presence of the entire family).• Differentiation requires cultivating a personal relationship with everyone in the extended family.17

MRI Overview (customers and windowshoppers)(Madanes, Bateson, Haley, Weakland, Segal)

• Focuses on problem at hand, in the present, focusing on strength vs. pathology• Alter the client’s concept of reality

– Challenge clients current perception– Offer the other unconsidered options/actions– Alter the original frame of reference

• Use logic, use illogic and paradox• Prescribe more of the symptom• Dysfunction framed as problem behavior vs. problem• Problem is the goal for therapy• Focus on persistence and change in the present vs. resolution of the past• Insight not required for change• People enter in to therapy to get relief• Change in behavior produces change in feelings• Interactions between people become problems• Family life cycles are points of change/symptoms• Customer is the most stressed

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MRI• Behavior Directives: assignments, tx tracks the sequence. Attempts reviewed at next session• Paradoxical Injunctions: Asking the family to do something that seems in opposition of the goals

of treatment: 1) Prescription: do more of the same. 2) Restraining: warning the family of the dangers of change/encourage go slow 3) positioning: exaggerating the problem

• Influence client to give up “problem maintaining solutions/behaviors”• Specific goals – small and achievable, action plans• Operate covertly from outside the family system vs. joining• Change occurs through client carrying out therapists instructionsKey Terms:• First order change = family patterns of interactions and sequences are altered at the behavioral

level only• Second order change = change to the system (family belief system• Unique interventions• Pathogenic double bind• Paradox – any intervention that seems odd, novel or unique• Double bind: complex comm pattern, pattern is repeated, involves command not to do

something on threat of punishment, involves 2nd abstract injunction that contradicts the primary injunction. 2nd abstract injunction also becomes under threat of punishment and contradicts primary. 3rd demands a response and prevents escape.

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MRI Key Principles• Symptom or problem oriented – behavior focused – making behavioral

interventions. Problem centered pragmatic focus on changing behavioral sequences

• The presenting problem is both representative of the problem and an index of progress (done w/therapy when the problem is alleviated)

• Therapist assumes responsibility for change• The family defines the problem and is ready to address it• Sees the problems as repeating unsuccessful behaviors. Problem is in

attempted/failed solutions.• Uses a team consisting of observers (reflecting team) and a therapist• Paradoxical seemingly illogical interventions often succeed at changing the families

behavior • As with all strategic therapies the goal of treatment is to change the presenting

complaint rather than interpret the interactions of the family or to explore the past.

• Focus is on here and now not past and why and feelings• Homework assigned

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MRI Tips/Test answers

• Developed in 1950’s based on comm’s theory from 2 sources:– Bateson – in Palo Alto group– Then Erickson – who applied cybernetics to comm patterns (SolnFoc also has roots with

Erickson• Typically thought of as “brief” therapy• Is directive• Talks about “client position” meaning – their beliefs, the values to which the

patient is committed and has gone on record. • The “customer” is the person most in distress• The MRI “prescriptives” are: (4)

– Do more of the same, do something different, restraining, paradox• Maneuverability in MRI/Strategic is: Tx freedom. The tx ability to take purposeful

action despite fluctuating obstacles or restrictions. Maintaining a relatively passive state that remains constant. A therapeutic freedom. Keeping options open. Being non-committed and fluid. Means of enhancing: timing and pacing.

• Paradoxical Intervention = compliance based, comply to a directive to defy the directive (the intervention) and improve.

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Structural (Minuchin, Aponte, Montalvo)

• Goal is to release the family members from their stereotyped roles and functions so the system can mobilize resources, create an effective hierarchical structure.

• Map the underlying structure; intervening (unbalance) and transform an ineffective structure• Engage as coach – prescribe the course of action both inside and outside of room• Search for strength and adaptability• Watch for actions not verbal accounts• Reframe “thank goodness johnny is skipping school so he can stay at home to help you”3 characteristics of psychosomatic families

1. Enmeshment is common;2. Subsystems function poorly;3. Diffused boundaries between family members = no individuation.

Process:1. Join and assume leadership, accommodating (tx behaves in ways similar to family. Pacing and

idiosyncracies)2. Assess family structure and interactions3. Monitor family dysfunctional sets4. Restructure transactional patterns

Connections• Non-linear; focus is on the process• Therapist is both inside and outside of the box (system)• Structure defines function – if there is a strong family structure the family will be more functional

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StructuralStructural assumptions:• Clear ideal standard of what “functional” is• There are generic, universal and idiosyncratic transactional (structural) patterns in families. • Symptoms are logical responses to family structure (as structure becomes functional, symptoms

will be relieved)• Therapist is in charge, instrument of change, the director• Change of structure is main goal• Alliance – close, positive group• Coalition – group closed and formed against• Cross-generational coalition –

– when 2 people come together against a 3rdAponte:• Hierarchy

– Alliance/affiliations (join and oppose each other)• Boundaries: Hierarchy role: who’s in, who’s out• Alignment: who’s with who?• Power: who influences the outcome

• Complimentary = • Homeostasis =• Transactional Patterns = • Mimesis = mimicking

Structural Techniques:Family Mapping: showing the

boundariesTransactional Styles: Enmeshed

or disengagedEnactments: act out conflict that

is occurring at home or in the moment in the room

Change structure of family: sitting positions in room, direct conversations

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Structural TermsKey Concepts• Change of structure is main goal• Hierarchy

– Alliance/affiliations (join and oppose each other

– Power (decision making)– Coalitions (triangles)

• Boundaries – define the amount and kind of contact.

– Healthy Boundaries: maintain separateness while emphasizing belonging

– Clear (open, allows negotiation and accommodation

– Rigid (disengagement– Diffuse (enmeshment)

• Subsystems – spousal, parenting, sibling• Importance of family cycles• Mapping family (structure diagram,

specific to the problem)• Detouring when the family pretends

nothing is going on

Interventions• Establish hierarchy by asking the parents

first• Reframing (different interpretations)• Set up enactments (conflicts) and observe

spontaneous structural dynamics• Physically change proximity/distance• Direct people to talk directly to each other

without intervention of others; decide who participates (boundary making)

• Stroke and kick• paradox• Unbalancing – purposeful alignment with

different members of the family to tip the balance of power w/in subsystem or btwn

• Increase intensity; crisis induction; confusion

• Build on family strengths• Action oriented rather than words

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Structural Cont…5 characteristics of enmeshment

1. A (negative) change in 1 person will reverberate through the family.2. Boundaries can be easily crossed.3. Inadequate performance in other subsystems.4. No room for individual privacy.5. Intense emotional reactivity.

3 characteristics of overprotective families.1. Over-nurturing.2. No Autonomy in Children.3. Child manufactures symptoms as a way of protecting adults.

What are 4 psychosomatic family patterns?1. Enmeshed family.2. Overprotective family.3. Rigid family.4. Lack of conflict resolution family.

What is the main characteristic of a rigid family?1. Parents won’t allow child to go through developmental stages.2. What are 3 fundamental assumptions of Structural Family Therapy?

What are 3 fundamental assumptions of Structural Family Therapy?1. Context affects inner experience;2. Change the context and inner experience will change;3. Therapist is a critical part of the context 25

Structural Cont…

What do you look for when assessing family interactions?1. Family hierarchy;2. Sybsystem functionality3. Alignments and coalitions4. Permeability of current boundaries;5. Flexibility or rigidity.

Key tasks of monitoring family processes1. Boundary Making;2. Enactment;3. Unbalancing.

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Structural Tips/Test Answers• Although there are no normal families, and all families have problems, an ideal family has a

hierarchy of subsystems in which the parents are in charge and a spousal subsystem in which there is mutual give and take

• Function is determined by how families cope with specific events and life cycle changes through inappropriate changes in structure; flexibility.

• Complimentarity (according to Bateson) used by Minuchin The concept of marital complimentarity has been used to describe dyadic (i.e., two-person) relationship patterns in which an individual's behavior and coping strategies differ from that of their spouse, but the two styles or patterns of behavior fit together in a dynamic equilibrium or active balance with one another

• Transactional questions are: • The scapegoat in structural is the IP in Bowen• An individuals symptoms are best understood rooted in the context of family transactional

patterns• Boundaries: rules that dictate how family members act within the family to protect and regulate

the family system– 3 types: healthy (separate while emphasizing belonging, rigid/non-flexible, diffuse/enmeshed

• Unbalancing is a technique• Reframing is an act of re-labeling an event or situation• Context = people are acting and reacting in their social groups. Meaning comes from context in

structural therapy (in Narrative meaning comes from meaning/process)What 3 things are at the crux of change?1. Family rules and realignments2. Patterns that support undesirable behavior3. Sequences of interaction

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Narrative Therapy(Michael White/David Epston and Focault)

• Interested in how problems become oppressive in peoples lives• Problems influenced by culture, social, religious, political• Focus on unique outcomes – an alternate story• Emphasis on meanings people construct through interactions• Vocab: escape, overcome, heroes, heroines• Influenced by Bateson – communications theory and complimentarity• Based on Focault work on power and knowledge: individual truths shape our lives. Criticizes

dehumanizing processes of institutions and experts. People influenced by dominant oppressive narratives.

• Loosening the grip of one story to re-author a new• Can work on chronic and serious problems• Externalizes problem – client is not the problem, the problem is the problem, depatholigizes• Reality and health are relative• social construction (social construct) is a concept or practice which may appear to be natural

and obvious to those who accept it, but in reality is an invention or artifact of a particular culture or society.

• Non-directive theory, non-linear• “the person is not the problem, the problem is the problem”

Narrative Therapy

Therapy Treatment• Collaborate to name the problem• Personify the problem and attribute negative intentions• Investigate how the problem has been disruptive• Discover when the client was not dominated by the problem• Find historical evidence for competence• Evoke speculation about the future about the clients future• Listen to the problem saturated story for meaning, social construction, affect• Look for unique outcomes (exceptions when client was not controlled by problem)• Re-author story to alternative story• Second order change – look at beliefs rather than coping

Narrative Therapy Externalization• Externalizing separates the problem from the person• “how is that problem affecting your life”• Breaks the habitual reading and re-telling of the problem saturated story• Unique outcomes: reveal gaps in the story, reveals previously neglected facts that

contradict the problem saturated story, “tell me a time when anxiety did not keep you from what you wanted to do”

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Narrative TherapyTerms• Ultimate truth stories• Personal agency• Dominant stories• Deconstruction – questioning

assumptions in order to deconstruct unproductive stories in order to reconstruct new and more productive ones. Challenging assumptions.

• Separate the problem from the client• Denied stories• Unique outcomes: “sparkling event”

when exception becomes reality• Landscape of consciousness• Loosen clients hold on story, co-

create/re-author a preferred narrative----------------------------------------------------------Key Principles• Realities are socially constructed• Realities are constructed through

language – no essential truths• Realities are organized and maintained

through narrative• The person is not the problem, the

problem is the problem

Key Factors:Foreshadowing – forecasting questions

based on what I know and see here. How is what I am seing going to show up in the future?

Back Shadowing – how does the present dilemma make sense to the person’s history? Legitimize, Historicize

Side Shadowing – Who else aren’t we seeing? We can see the obvious but what else is there? How does the unseen contribute to what I am not seeing.

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Narrative TherapyInterventions• Intervention is the questions• Assessment – tell me the story, what do you

prefer to happen?• Mapping – create mental picture of how

problem influences the persons life. • Help client “unpack” their stories offering a

different perspective. Open space for new stories

• Externalize problem – give it a name• Relative influence questions –Relational

influence of problem. • Reading between the lines• Reauthoring the story• Reinforce the story (letters, certificates, etc.

Format for Story Development• Begin with unique outcome• Confirm the unique outcome

represents a preferred event• Plot the story in the landscape of

action• Plot the story in the landscape of

consciousness• Ask about a past time that has

something in common with the unique outcome or the meaning of the unique outcome

• Plot the story of the past event in the landscape of action

• Plot the story of the past event in the landscape of consciousness

• Ask questions to extend the story into the future

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• 4 Assumptions:• People have good intentions and don’t want

problems• People are profoundly influenced by the the

discourses around them (social constr)• People are not their problems• People can develop alternative empowering

stories once they are separated from disempowering stories (re-authoring)

Narrative Tips/Test Answers• Historicizing – using people from the past who would not be surprised by a

positive outcome• Uses reflective teams• “Sparkling Event” moment when the exception becomes reality.• Directs the family to pay attention to the meaning of the problem in the family’s

life• Intention is not important (also Sol’n Foc)• Similar to Sol’n focused exception to the problem. Narrative pays attention to the

affect and meaning of the problem. SF does not.• Different than Sol’n focused second – order change. Change in beliefs not just

coping• Different than structural – stories are the architect of the family not the parents• Problem Saturated Stories – stories influence what we notice andhow we interpret

it and responses perpetuate the problem story.• Follow up questions to ask:

• Landscape of Action questions - • Landscape of consciousness questions – what those involved in the action know think or feel

or do not know think or feel. • Landscape of identity -

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Solution Focused Tips/Test answers• People: Berg, DeShazer, O’Hanlon, Erickson roots• Sol’n oriented therapist offer insights • Intervention: is the interview• Soln’ focused has no/does not work with paradox (only look one direction

vs. MRI)• Does not focus on the etiology (origin/cause) of the problem (deShazer)• Directs the family to pay attention to the meaning of the problem in the

family’s life• Goal: to resolve the problem and/or the client experiences relief• Clients are known as “customers” as in MRI (if only one choice, MRI) • The customer is the person most motivated to change.• Uses amplifying to at exceptions (EARS)• EARS (• Scaling questions are used to gauge termination• The purpose of the miracle question is to establish goals• Intention is not important (also Narrative)

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Solution Focused (Kim Soo Berg, DeShazer, O’Hanlon, Werner-Davis, Erickson)

Assumptions• Problem is not a symptom of

something else• Goal is for client to experience relief• People have strengths and resources

to find their own solutions; empower clients to solve their own problems

• Change will happen when client makes perceptual or cognitivue shift and does something different

• 2nd order change as a ripple effect; clients leran new relationship between problems and solution

• Easier to find solutions than solve problems

** Works well in crisisDoesn’t dwell on problemStrength/resource basedNormalizes rather than pathologizesIntention is not important

Key Concepts• Look for random and deliberate

exceptions to the problem (family strengths are the clues to the solution)

• Focus on solution (what works) vs. problems (what doesn’t work)

– If it’s not broke, leave it– Do more of what works– Don’t do what doesn’t work, do

something different• Focus on the present and future• Why is not important• Client is competent to make choices

that are good for them (collaborative w/therapist)

• Goal setting is important, client leads goal setting: focus should be on what and how; important to client

• Future and goal oriented• No paradox

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Solution Focused

Solution Focused – CustomersThe visitor: join, engage and see the problem, agree with the problemThe complaintant: the client doesn’t see themselves as a part of the problem; the

therapist is supposed to acknowledge and applaud the client and offer limited suggestions, primarily in the vein of observation (observe what happens this week.)

The customer: Is interested and committed to solving problems and their work can be action oriented (do these 3 things this week) most motivated

Interventions:• The interview is the intervention• Miracle Questions: take the focus off the client’s story about the problem• Speak clients language• Complement parenting ability when parents complain of kids• Ask questions that focus on how clients see solution• Focus on unique strength (positive reframe)• Emphasize hard work of the goal for saving face, blame the problem not the client

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Solution Focused (interventions cont…)

5 Primary Questions1. Pre-session change: what have you noticed since you 1st made the appt.

Since coming to therapy what has changed for the better?2. Exceptions: what would it take for it to happen again? Look for past

successes3. Miracle Question: what would change, who would notice, circular

questions, how would things be different, define goal.4. Scaling questions: used to measure self esteem, progress or change of

relationship; it’s motivating; determine termination5. Coping questions: highlight strengths. Why is it not worse? How have

you managed?

EARS: Elicit, Amplify, Reinforce, Start Again (Berg tactic to amplify and get at exceptions)

• Normalize and re-framing• Not in to paradox• The interview is the intervention

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Stages of Engaging with the FamilyTimothy Weber and Feline Levine

The presession1. Prelude to the therapeutic encounter2. The initial phone call3. Generating hypotheses

The session4. The greeting5. The orientation6. Exploring the background (history) 7. Exploring the foreground (problems and attempted solutions)8. Defining goals9. The prompt10. The contract

The Post Session11. Debriefing

DSM IV & Diagnosis

Depressive Disorders

• Depressive Disorders– Major Depressive Disorder, single episode– Major Depressive Disorder, recurrent– Dythymic Disorder– Depressive Disorder NOS

• PMDD

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Depression: Major

Depression - major; Unipolar depression; Major depressive disorder• Major depression is when five or more symptoms of depression are present for at least 2

weeks. These symptoms include feeling sad, hopeless, worthless, or pessimistic. In addition, people with major depression often have behavior changes, such as new eating and sleeping patterns. Major depression increases a person's risk of suicide.

Causes • The exact cause of depression is not known. Many researchers believe it is caused by

chemical imbalances in the brain, which may be hereditary or caused by events in a person's life.

• Some types of depression seem to run in families, but depression can also occur in people who have no family history of the illness. Stressful life changes or events can trigger depression in some people. Usually, a combination of factors is involved.

• Each year, more than 18 million Americans -- men and women of all ages, races, and economic levels -- have depression. It occurs more often in women.

• Women are especially vulnerable to depression after giving birth. This is a result of the hormonal and physical changes. While new mothers commonly experience temporary "blues," depression that lasts longer than 2-3 weeks is not normal and requires treatment.

• Major depression can occur in children and teenagers, and they can also benefit from treatment.

Major Depressive DisorderMust have 5 or more of the following symptoms. Must be present for 2 week period. Dysthymia

is 2 years.• Depressed mood (children irritable mood)• Diminished interest in once pleasurable activities• Significant weight loss/gain• Insomnia/hypersomnia• Restlessness, slowing down as observed by others• Fatigue or loss of energy• Diminished ability to think, concentrate, indecisiveness• Feelings of worthlessness/guilt• Recurrent thought of death

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Depressive Disorders• Major Depressive Disorder, Single Episode

– Presence of a single major depressive episode not better accounted for by schizoaffective disorder

– Never been a manic, mixed or hypomanic episode– If the full criteria are met for a MDE specify its current clinical status and/or features– If the full criteria are not met for a MDE specify the current clinical status of the MDD or

features of the most recent episode. (partial remission, full remission, chronic, etc)

• Major Depressive Disorder, recurrent– Presence of 2 or more major depressive episodes– To be considered separate episodes there must be an interval of at least 2 consecutive

months in which criteria are not met for a MDE.

• Major Depressive Episode– 5 or more of the following have been present during the same 2 week period and

represent a change from previous functioning. At least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure

– Depressed mood, diminished interest or pleasure in all or almost activities of the day, nearly every day. Signif. Weight loss/weight gain or decrease/increase in appetite, insomnia or hyper insomnia, psychomotor agitation or retardation nearly every day, fatigue or loss of energy nearly every day, feelings of worthlessness or excessive guilt

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Depressive DisordersDysthymia is a chronic form of depression characterized by moods that are consistently low, but

not as extreme as in other types of depression.Causes • The exact cause of dysthymia is unknown. Although the symptoms are not as severe as those

of other forms of depression, affected people struggle nearly every day with low self-esteem, despair, and hopelessness.

• As with major depressive disorder, dysthymia occurs more frequently in women than in men and affects up to 5% of the general population. Dysthymia can occur alone or in conjunction with more severe depression or other mood or psychiatric disorder.

Symptoms • The main symptom of dysthymia is low, dark, or sad mood nearly every day for at least 2

years. Other symptoms can include:• Poor appetite or overeating • Insomnia or hypersomnia• Low energy or fatigue• Low self-esteem • Poor concentration • Feelings of hopelessness

Depressive Disorder NOS• PMDD- in most menstrual cycles during past year symptoms (of depression) regularly

occurred. Must be severe enough to interfere with work, school or usual activities and be entierly absent for at least 1 week most menses

Bi - Polar• Manic depression/Bipolar affective disorder: Bipolar disorder is characterized by periods of

excitability (mania) alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.

• Causes Bipolar disorder affects men and women equally and usually appears between the ages of 15 and 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.

• Bipolar disorder results from disturbances in the areas of the brain that regulate mood. During manic periods, a person with bipolar disorder may be overly impulsive and energetic, with an exaggerated sense of self. The depressed phase brings overwhelming feelings of anxiety, low self-worth, and suicidal thoughts.

• There are two primary types of bipolar disorder. – bipolar disorder I have had at least one fully manic episode with periods of major

depression. In the past, bipolar disorder I was called manic depression.• People with bipolar disorder II seldom experience full-fledged mania. Instead they

experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of major depression.

• A mild form of bipolar disorder called cyclothymia involves periods of hypomania and mild depression, with less-severe mood swings. People with bipolar disorder II or cyclothymia may be misdiagnosed as having depression alone.

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Bi-Polar cont…

• The manic phase may last from days to months and include the following symptoms: Elevated mood , Racing thoughts , Hyperactivity , Increased energy , Lack of self-control , Inflated self-esteem (delusions of grandeur, false beliefs in special abilities, Over-involvement in activities , Reckless behavior, Spending sprees , Binge eating, drinking, and/or drug use , Sexual promiscuity , Impaired judgment , Tendency to be easily distracted , Little need for sleep , Easily agitated or irritated , Poor temper control

• These symptoms of mania are seen with bipolar disorder I. In people with bipolar disorder II, hypomanic episodes involve similar symptoms that are less intense.

• The depressed phase of both types of bipolar disorder involves very serious symptoms of major depression: Persistent sadness , Fatigue or listlessness , Sleep disturbances , Excessive sleepiness , Inability to sleep , Eating disturbances , Loss of appetite and weight loss , Overeating and weight gain , Loss of self-esteem , Feelings of worthlessness, hopelessness and/or guilt , Difficulty concentrating, remembering, or making decisions , Withdrawal from friends , Withdrawal from activities that were once enjoyed, Persistent thoughts of death

• There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can worsen the symptoms.

• Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state.

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Bi-polar cont…• Outlook (Prognosis) • Mood-stabilizing medication can help control the symptoms of bipolar disorder. However,

patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.

• Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.

• Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with bipolar affective disorder require immediate emergency attention.

• Possible Complications • Stopping or improperly taking medication can lead to symptoms coming back and the

following complications:• Alcohol and/or drug abuse may be used as a strategy to "self-medicate." • Personal relationships, work, and finances may suffer as a result of mood swings. • Suicidal thoughts and behaviors are a very real complication of bipolar disorder. • This illness is challenging to treat. Patients and their friends and family must be aware of the

risks of neglecting to treat bipolar disorder.

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DSM IV Axis classificationsAxis I: The Fruit• Clinical Disorders and when a psychosocial or environmental problem

is primary focus of clinical attention it is recorded on Axis I also as a V code.

• Disorders diagnosed in childhood, infancy, substance related disorders, schizophrenia, psychotic disorders, mood disorders, anxiety, somatoform disorders, disassociate disorders, sexual and gender identity, eating/sleeping, impulse control, adjustment

• V71.09 if no dx

Axis II: The Jello• Personality Disorders and Mental Retardation • Noting prominent maladaptive personality features and defense

mechanisms• Usually people have more than 1 Axis II diagnosis• Paranoid personality, schizoid/schisotypal, anti-social, borderline,

histionic, narcissitic, avoidant, dependant, OCD• V71.09 if no dx

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DSM IV Axis classifications

Axis III: The Body• General medical conditions that are potentially relevant to understanding or

management of the individuals mental disorder• Pregnancy, childbirth, diseases of circulatory, respiratory, digestive system

Axis IV: Relational• Psychosocial and environmental problems• Problems with primary support group, social environment, educational,

occupational, access to healthcare, economic, legal, crime, exposure to disaster• Listed as V codes

Axis V: Gas• Global Assessment of Functioning• GAF or CGAF• GAF scores: beginning looking from the top down (highest functioning levels),

thinking of symptom severity and level of functioning. Stop at lowest number relative to whichever is worse (symptom or functioning).

• Used to report clinical judgement or an individual’s overall level of functioning

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V-Codes/OtherV Codes = used when symptoms are relational. Used when there is insufficient info to know

whether or not a presnting problem is attributable to a mental disorder ie parent/child/partner, sibling relational problem, physical, sexual, neglect, academic, identiy

Axis I• List V codes on Axis I when a presenting problem is symptomatic relationally to the primary

focus (presenting problem) Example:• ODD --primary focus• Conflicted child/parent relationship --- a presenting problem relating to ODDAxis IV• List psychosocial and environmental issues here IF relevant and have occurred within the

past year. Include any V Codes from Axis I here also.• V Codes are usually negative stressors but do include positive stressors (job promotion) if

having a problem adjusting.• Can list older stressors if attributable to current disorder – example: PTSD --can list combat

that occurred many years prior to current diagnosis.

DSM IV - Terms• NOS - enough info available to indicate class of disorder is present but further specification is

not possible due to insufficient information or does not meet specific clinical criteria. • Provisional – Enough info avail to make “working” diagnosis but clinician wishes to indicate a

significant degree of uncertainly 49

CouplesGottman• The 4 horsemen of the apocalypse:

– Contempt– Criticism– Scapegoating– Defensiveness

• Couple movement: against (stonewall), away, towards. • Helping couples ‘say yes’ to each other. Move towards with a ‘yes’ vs. away with a ‘no’• Developing trust and friendship.

Harville Hendrix• We were born whole and complete. • We became wounded during the early nurturing and socialization stages of development by our

primary caretakers (usually inadvertently). • We have a composite image of all the positive and negative traits of our primary caretakers

deep in our unconscious mind. This is called the Imago. It is like a blueprint of the one we need to marry someday.

• We marry someone who is an Imago match, that is, someone who matches up with the composite image of our primary caretakers. This is important because we marry for the purpose of healing and finishing the unfinished business of childhood. Since our parents are the ones who wounded us, it is only they who can heal us. Not them literally, but a primary love partner who matches their traits.

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Couples – IMAGO (Harville Hendrix)• Harville Hendrix (cont…)• Romantic Love is the door to marriage and is nature's selection process that connects us with

the just the right partner for our eventual healing and growth. • We move into the Power Struggle as soon as we make a commitment to this person. The

Power Struggle is necessary, for imbedded in a couple's frustrations lie the information for healing and growth.

• The first two stages of marriage, "Romantic Love" and the "Power Struggle," are engaged in at an unconscious level. Our unconscious mind chooses our partner for the purpose of healing childhood wounds.

• Inevitably our love partner is incompatible with us and least able to meet our needs and most able to wound us all over again.

• The goal of Imago Relationship Therapy is to align our conscious mind (which usually wants happiness and good feelings) with the agenda of the unconscious mind (which wants healing and growth). Thus, the goal of Imago therapy is to assist clients develop conscious, intimate, and committed relationships.

• The core practice of Imago therapy is the "Couple's Dialogue," in which a couple engages in a structured conversation, with or without an Imago Therapist.

• The Couple's Dialogue consists of Mirroring (repeating) each statement, Summarization, Validation ("That makes sense because ...") and Empathy ("I imagine that makes you feel ..."). This enables each partner to extend themselves to understand the experience of the other as different from their own. If you can work with an Imago therapist, he or she will help to deepen that dialog. 51

Couples - SPAMO

• Diagnostic tool. What constitutes a healthy couple. Treatment is a combo of other models.

• In NA we live in “decapitated” couples. Neglect spousal role to take care of everything else.

• 2 roles in couple rela.– Nourish life together– Repair life together

• Tx should teach couple repair skills in the heat of conflict.

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“SPAMO” The five roles of people within a couples relationship.

S Spousal

___________________________

_____

P Parenting Role

___________________________

A Autonomy

___________________________

_____

M Manager

___________________________

O Others

1

1

1

1

1 2

2

2

2

2

*RBA

“Personal Bank Account”

Repair

TTT/DDD

Tough Talk Tools for Dealing

w/Difficult Differences

(Alignment)

(Attachment) friendship

(Authority) mentorship

(work, school, volunteerism)

“Second Family”

*OBA “Others Bank Account”

Money Chores

Boundaries

*PBA

“Relationship Bank Account” (justice and fairness)

“Self-nourishing”

(Alignment) Couples co-manage

Chores

Connection to others

*life-giving oxygen centers Dr. Timothy Weber

Couples

• Emotion Focused Therapy– The goal is to soften the messages. – Retract the feeling: Hearing the soft keys within the hard keys is the

key therapeutic goal. Listen to the hard feeling for what is behind the soft feeling.

– Then ask how FOO/history may be connected

• Evidence Based Psychotherapy– People want to establish therapy as a scientific approach. Using an

empirical approach: observation and information. What we see not just what we believe. Can be validated with info.

– With clients, “are you willing to try an experiment?”

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Couples (Random Tim Stuff)• Teach clients to think as researchers.• The best therapists are research oriented and teach clients to be research oriented.• Therapists should be thinking about a hypothesis about what is going on. Think systemically

looking at biological, psychological and social issues• Look for behavior descriptions that back the clients presenting issues.• Engage the clients in the process of deconstruction and then reconstruction.• Ask clients to establish personal responsibility, “what could you do to create a better outcome?”• Anticipatory Stress Inoculation: planting positive things in your future. Things to look forward

to. Reap benefits in the present.• Two goals of couples therapy:

– Reduce stress and Increase satisfaction• 3 Kinds of Therapy – ask what each thinks they are there for:

– decision, (time limited 5 – 10 sessions, marriage review)– Marriage– Divorce (ending gracefully)

• Normative Principles: how do healthy couples function? “Healthy Couples do XXX” to teach/coach

• “Resentment Rapsheet” events someone still feel bugged by. The arteries of intimacy are filled by the blood of love. Arteries are plugged by the plaque of resentment. “Healthy couples live more in the future than in the past”

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Couples (Random Tim Stuff)

Table of Trust

Forgiveness: having the heart and courage to transcend our right to be resentful in service of the common good.

Affairs: What makes an affair, an affair:1. Is there secrecy?2. Emotional intimacy3. Is there attractionThe greatest predictor of whether a woman will have an affair . Woman has a friend

who has had an affair. “are you talking to anyone about this person?” if talking with this person at more risk.

Greatest predictor of whether a man will have an affair: whether his father had an affair

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Congruency Reliability

Generosity

Dependability Vulnerability

Misc Stuff• Supervision: hierarchical and involves responsibility. Consultation does not.• Couples who argue can (according to Gottman) a form of stable relationship• The 4 horsemen of the apocolypse according to Gottman are:

– Contempt, criticism, stonewalling, defensiveness.• Post modernism is: (multiple reality)• Delusion = fixed false believe• First order change = a change in the rules of the system. Second order change = a

change in the system itself.• Homeostasis = a tendency to attempt to retain interior balance in configural

relationships. • Epistemology = the study of the nature of knowing. How we know what we know• Etiology = the cause or development of the problem• Anhedonia = the inability to experience pleasure

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Human Sexuality• Sexuality is an energy that brings our life to our systems, lives, bodies.• 6 levels of sexuality (David Duda)

1. Genetic - reproductive2. Physiological – pleasure3. Cultural – acceptance4. Emotional/psychological – fulfillment5. Yogic – healing and rejuvenation6. Spiritual – communion w/the divine

• Sexual Health (WHO definition): The integration of the somatic, emotional, intellectual and social aspects of sexual well-being, in ways that are positively enriching and that enhance personality, communication and love.

• Sexual Health Requires: positive and respectful approach to sexuality and sexual relationships. Possibility of pleasurable and safe sexual experiences. Free of coercion, discrimination and violence.

• Addressing sexual health in therapeutic settings– Break the ice– Lead with “intro” to sexual subjects/questions (addressing the entire picture of health)– Use plain language or client language– Non judgmental stance– Part of intake process– Provide info/resources

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In Couples Tx look at desire:1.When did it fizzle?2.Arousal disorders (prem ejac.)3.Orgasmic disorders

Human Sexuality

Schnarch:• Sexual difficulties are a normal part of a

relationship• Sexual health is a part of differentiation• Focus on what is going right• Sexuality is the “tissue sample” about what is

going on in the relationship

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Misc Stuff• 6 stages of change:

– Pre-contemplation, contemplation, preparation, action, maintenance, termination• Ecosystemic maping (weber/cebula) bigger than family map – contains all systems involved

w/family (legal, school, church)• CAGE:

– Cutoff/criticize, anger/annoyance, guilt, eye-opener• What is the most worrisome problem for therapists? Confidentiality• Psychodynamic = wider lens, psychoanalytic = deeper• Who are “constructivists” Von Forester, Watzlawick, Bateson (White is a social constructivist• Bateson’s complementarity has been used to describe dyadic (i.e., two-person) relationship

patterns in which an individual's behavior and coping strategies differ from that of their spouse, but the two styles or patterns of behavior fit together in a dynamic equilibrium or active balance with one another.

Interventions by Theory:Narrative = the questionsStructural = Solution Focused = the interviewMRI/Strategic =Bowen = set of techniques

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add

• Couples - michele• Sexuality – michele • Life span• attachment• Dsm• Addiction• Solution Focused - beth

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