New Approaches to Integration in Psychotherapy [1 ed.] 1583917543, 1583917551, 9781583917541, 9781583917558

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New Approaches to Integration in Psychotherapy Eleanor O’Leary and Mike Murphy

Routledge Taylor & Francis Group an informa busi

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Digitized by the Internet Archive in 2023 with funding from Kahle/Austin Foundation

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New Approaches to Integration in Psychotherapy

“a significant contribution to the field of integration in psychotherapy” Professor Maria Gilbert, Head of Integrative Psychotherapy & Supervision courses, Metanoia

Institute, London

“This is a book to read and re-read as part of the journey of discovery that we are all engaged in as researchers, academics, practitioners and, of course, as human beings” Professor Helen Cowie, University of Surrey, from the foreword

Psychotherapy is an area that has seen huge growth in prominence and practice. The range of theoretical schools that have emerged means that practitioners are striving to amalgamate and synthesise new approaches and theories. New Approaches to Integration in Psychotherapy provides a snapshot of the latest theoretical and clinical developments in the field of integration. Eleanor O’Leary and Mike Murphy bring together contributors from a range of theoretical backgrounds who present new frameworks, theoretical integrations, clinical developments and related research. They critique existing research and provide a thorough overview of the historical development of the movement towards integration in psychotherapy. The book is divided into three sections, covering the following subjects in depth: @ e e

Frameworks and Theoretical Integrations Professional and Clinical Integrations and Special Populations Issues for Professional Consideration

This book will be welcomed by anyone interested in investigating integrative approaches to psychotherapy. In particular, it will have direct relevance to academics involved in training and research on psychotherapy, psychotherapists, counsellors and clinical psychologists. Professor Eleanor O’Leary is Head of the Department of Applied Psychology at University College Cork, Ireland, and has been Visiting Professor at Stanford University, and the University of Malaga Mike Murphy is a lecturer in the Department of Applied Psychology, University College Cork and a graduate of applied psychology and medical science and is attached to the Counselling and Health Studies Centre at University College Cork Contributors:

Nicola Barry, Patrizia Collard, José Navarro

Gongora, Alex H.S. Harris,

Peter J. Hawkins, Argyroula E. Kalaitzaki, Mike Murphy, Joannis N. Nestoros, Eleanor O’Leary, Christina F. Papaeliou, Nikitas E. Polemikos, Geraldine Sheedy, Samuel D. Standard, Ronny Swain, Carl E. Thoresen, Jarl Wahlstr6m, Konstantia A. Zgantzouri

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New Approaches to Integration in

Psychotherapy

Edited by Eleanor O’Leary and Mike Murphy

THE LIBRARY OF TRINITY COLLEGE DUBLIN autHoriseo: . OS . Routledge

Taylor & Francis Group

LONDON AND NEW YORK

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First published 2006 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA

Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York, NY 10016 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2006 selection and editorial matter, Eleanor O’Leary & Mike Murphy; individual chapters, the contributors Typeset in Times by Garfield Morgan, Mumbles, Swansea, West Glamorgan Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall Paperback cover design by Sandra Heath All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data New approaches to integration in psychotherapy / edited by Eleanor O’Leary and Mike Murphy.

p. cm. Includes bibliographical references and index. ISBN: 1-58391-754-3 (alk. paper) — ISBN: 1-58391-755-1 (pbk. : alk. paper) 1. Eclectic psychotherapy. |. O'Leary, Eleanor. Il. Murphy, Mike, 1973— RC489.E24N49 2006 616.89'14—dc22

2005043529 ISBN10: 1-58391-754-3 hbk ISBN10: 1-58391-755-1 pbk ISBN13: 978-1-58391-754-1 hbk ISBN13: 978-1-58391-755-8 pbk

To Eleanor’s brothers, John and Bob, and her sister, Joan, who have supported her in so many ways throughout life and

To Emer, who has shown Mike great encouragement and patience throughout the editing of this book, and for many years previously

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Contents

List of contributors Foreword Acknowledgements PART

|

Frameworks 1

2

XVil

and theoretical

integrations

The need for integration ELEANOR O’LEARY A framework for integrative psychotherapy ELEANOR O’LEARY AND MIKE MURPHY

3

Person-centred gestalt therapy ELEANOR O’LEARY

4

The narrative metaphor and the quest for integration in psychotherapy

iZ

2

38

JARL WAHLSTR6M 5

Gestalt reminiscence therapy ELEANOR O’LEARY AND NICOLA BARRY

6

Hypnoanalysis: An integration of clinical hypnosis and psychodynamic therapy PETER J. HAWKINS 7 Integrative psychotherapy of schizophrenic symptoms: Recent developments JOANNIS N. NESTOROS

50

61

74

viii

ee

Contents OT en ee

oN

ee

eee

8 Multimodal stress therapy: An integrative approach PATRIZIA COLLARD

PART

88

Il

Professional and clinical integrations special populations

and

9 The integrative collaboration of a psychologist with a psychiatrist JOANNIS N. NESTOROS, KONSTANTIA A. ZGANTZOURI AND NIKITAS E. POLEMIKOS 10

ee

Some practical issues in working integratively with children and parents

103

105

116

NIKITAS E. POLEMIKOS AND CHRISTINA F. PAPAELIOU 11

12

13

14

Psychosocial interventions in families with an ill member: Possibilities and experiences JOSE NAVARRO GONGORA

129

Ameliorating interrelating within families of psychotic persons: An integrative approach ARGYROULA E. KALAITZAKI AND JOANNIS N. NESTOROS

141

Breathing and awareness: The integrating mechanisms of cognitive-behavioural gestalt therapy in working with cardiac patients ELEANOR O°LEARY Integrating the personal and professional development of therapists ELEANOR O’LEARY AND GERALDINE SHEEDY

PART

167

III

Issues for professional 15

155

consideration

Integrating spiritual and religious factors into psychological treatment: Why and how ALEX H.S. HARRIS, SAMUEL D. STANDARD AND CARL E. THORESEN

177

179

Contents

16

Integration of ethics and practice RONNY SWAIN

PART

ix

192

IV

Conclusion

205

17

Psychotherapy integration: a journey in small steps ELEANOR O’LEARY AND MIKE MURPHY

207

Index

212

Contributors

Nicola Barry is a lecturer in the Department of Applied Psychology, University College Cork, where she is involved in counselling and guidance counselling training. She is also a counselling psychologist in private practice. Dr Patrizia Collard is a senior lecturer at the University of East London, and a psychotherapist, stress management consultant, trainer and coach who applies her integrative approach to organizations, groups and individuals. She has worked for many years as a university lecturer, teacher and actress. She lived in the Far East for nine years (Hong Kong and China), where she developed a holistic approach combining multimodal therapy and sensory awareness mindfulness training. Patrizia is a member of many governing bodies such as the British Association for Behavioural and Cognitive Psychotherapy, the United Kingdom Council for Psychotherapy, the International Stress Management Association, the Association for Coaching, the Austrian Association for Behaviour Therapy, the Institute for Health Promotion and Education and Obsessive Action. Professor José Navarro Gongora is Professor of Family and Couple Therapy at the University of Salamanca (Spain). He studied philosophy and psychology in Madrid and obtained his PhD in psychology in Salamanca University. He is currently Director of the Masters Programme in Interventions in Psychotherapy, within which he runs a crisis project. He has published a number of books on family therapy, psychosocial problems related to medical conditions and inter-partner violence. His main interest is the psychosocial aspects of crises and chronic conditions. Dr Alex H.S. Harris is currently a researcher at the Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine. He has coauthored several articles and book chapters on the role of spiritual and religious factors in health and disease, and served as guest associate editor of the special

Contributors

xi

issue on “Spirituality and Health” of the Journal of Health Psychology. His current research interests include clinical decision-making, the treatment of substance use disorders, the role of forgiveness in health and disease processes, and the diffusion and dissemination of clinical innovations. Professor Peter J. Hawkins trained in counselling psychology and psychotherapy and, in the past two decades, in clinical hypnosis. He is Co-Director of the Ericksonian Institutes in Madrid and Northern Portugal (Porto) and President of the European Institute of Psychotherapy. He has taught hypnosis courses in most European countries as well as in Russia, China, Uzbekistan, and the USA and continues to teach hypnosis accreditation programmes in both Portugal and Italy, where he is a visiting professor in psychotherapy. As well as teaching he is actively engaged in research and writing, with published books in Spanish, Greek, and Russian. His specific interest in clinical hypnosis is in the field of stress-related problems; he is currently completing a book on this topic.

Dr Argyroula E. Kalaitzaki received her PhD in clinical psychology from the University of Crete, Greece, and the European Diploma in the Psychological Therapies from the European Institute of Psychotherapy. She has worked as an adjunct professor of clinical psychology at the University of Crete and is currently employed as an assistant professor of psychology in the School of Health and Social Welfare at the Higher Technological Educational Institute of Crete. She is the author of numerous articles, book chapters and conference papers, and has considerable clinical and research experience. Her research interests include the investigation of interpersonal relating within the families of persons with psychotic symptoms and the effectiveness of integrative psychotherapy in improving negative interrelating. Mike Murphy is a lecturer in the Department of Applied Psychology, University College Cork and a graduate of the National University of Ireland in both applied psychology and medical science. At present he is conducting research in the area of cognitive functioning in older adults. Professor Joannis N. Nestoros was born in Cyprus and studied medicine at the University of Athens. His postgraduate training included a rotating internship at the Toronto General Hospital, a specialization in psychiatry at McGill University, Montreal, and a postdoctoral fellowship in neurophysiology, Department of Physiology, McGill University. His academic positions have included assistant professor in clinical

psychiatry at McGill University and, at the University of Crete, associate professor and subsequently professor of clinical psychology; Chairman,

xii

Contributors

Department of Psychology; clinical psychology.

and

Director,

postgraduate

training

in

Professor Eleanor O’Leary is Head of the Department of Applied Psychology, University College Cork, Director of the Counselling and Health Studies Centre, University College Cork and Director and Principal Investigator of the Cork Older Adult Intervention Project. She is known internationally for her research and writings in the field of older adults and gestalt therapy. She was an invited speaker on outcome and process research in old age at the International Congress of Psychology in Beijing in 2004. A fellow of the Psychological Society of Ireland, she received the Outstanding Contribution to Psychology Award of that society in 2000. Eleanor was a Visiting Professor at Stanford University and the University of Malaga; and is a chartered counselling and health psychologist of the British Psychological Society; a founding member of the European Association of Counselling, the European Institute of Psychotherapy, the Irish Association of Counselling and Psychotherapy, and the Irish Gestalt Society; and honorary life chairperson of the Irish Gestalt Society. She serves on the Boards of Directors of the International Gestalt Therapy Association and the European Institute of Psychotherapy.

Dr Christina F. Papaeliou studied at the University of Crete and received a PhD in developmental psychology from the University of Edinburgh. She is a lecturer in psychology at the University of the Aegean, Department of Preschool Education and of Educational Planning, Rhodes. Her research interests include child development, abnormal child psychology, early mother—infant interaction, language development and developmental language disorders, topics on which she has published journal articles. At present she is completing a book on early language development. Christina is a member of the International Society of Infant Studies and the Hellenic Psychological Society, and was a member of the Scientific and Organizing Committee of the Panhellenic Conference on Psychological Research. Professor Nikitas E. Polemikos holds a PhD in educational psychology from New York University He was trained in Gestalt therapy at the Gestalt Training Center in New York. For the past 20 years he has taught at the University of the Aegean, where he is now a professor of developmental psychology. He also practises counselling and psychotherapy. His research interests focus primarily on child development and developmental disorders.

Geraldine Sheedy is Director of the SouthWest Counselling Centre, Killarney, Ireland, and a counselling psychologist and psychotherapist. She has been a student of Buddhist wisdom and meditation for over a

Contributors

xéiii

decade, with a special interest in the body—mind relationship in counselling. Geraldine has worked in Ireland and overseas as a teacher/ lecturer and counsellor, and enjoys combining her love of travel with her quest for self-knowledge. Dr Samuel

D. Standard

is Coordinator

of Spinal Cord

Injury Patient

Education at Fletcher Allen Health Care in Burlington, Vermont.

He is

currently investigating the role of telemedicine peer support networks in post spinal cord injury adaptation, as well as the role of self-efficacy in predicting spinal cord injury health outcomes. Samuel speaks widely on the topic of forgiveness, particularly as it relates to health, well-being, and life change. His dissertation “The effects of a forgiveness intervention on salivary cortisol, DHEA and psychosocial variables” received a 2001 American Psychological Association Dissertation Research Award. Dr Ronny Swain is senior lecturer in the Department of Applied Psychology, National University of Ireland, Cork. He trained in gestalt therapy with the Irish Gestalt Centre and is accredited as a counselling psychologist in Ireland and the UK. He has served as Chair of the Board of Professional Conduct of the Psychological Society of Ireland and Convenor of the Ethics Committee of the Irish Association for Counselling and Psychotherapy, and has contributed to the formulation and revision of ethical codes for five professional bodies in Ireland. His principal current responsibility is as Director of the department’s postgraduate training course for guidance counsellors, to which he brings a strong person-centred orientation. The ethical analysis in Chapter 16 is based on issues arising from this course. Professor Carl E. Thoresen is Professor Emeritus of Education, Psychology and Psychiatry/Behavioral Sciences at Stanford University. Currently he serves as Senior Fellow at Santa Clara University in the Spirituality and Health Institute, which he helped to establish. He recently served on the NIH Office of Behavioral and Social Science Research’s Expert Panel, critically reviewing the scientific evidence linking spirituality and religion with health. Recent publications include several reviews of the spirituality and health connection, articles on spiritual modelling based on Al Bandura’s social cognitive theory, effects of spiritual skills on psychosocial and physical health factors (e.g. perceived stress, depression, compassion and forgiveness), and the role of volunteering to help others on health, including mortality. He has, with others, also been evaluating various health and spiritual effects of teaching college students spiritual skills (e.g. meditation, slowing down, one-pointed attention, compassion and forgiveness).

Professor Jarl Wahlstrém is a Professor of Clinical Psychology at the Department of Psychology, University of Jyvaskyla, Finland. He has

xiv

Contributors

advanced training in family and systems therapy and some 30 years’ experience as a clinical psychologist, family therapist, trainer and consultant and since 1985 has been a university teacher. Currently he is heading a national integrative postgraduate specialization programme in psychotherapy for psychologists in Finland. His main research interest is in psychotherapy discourse, a topic on which he has published in several international journals and books. Dr Konstantia A. Zgantzouri is a clinical psychologist and psychotherapist. She holds a PhD in clinical psychology from the University of Crete, and a diploma in psychological therapies from the European Institute of Psychotherapy. Her PhD thesis on psychotherapy processes in psychoses received the David Feinsilver Award from the David Feinsilver Foundation. Konstantia’s research interests and publications are mainly focused on psychotherapy processes (in-session events and session outcome) and integrative psychotherapy. At present she is an adjunct professor at the Department of Pre-Primary Education, University of Ioannina, Greece, and a practising clinician in social and counselling services at the Technological and Educational Institute, Athens.

Foreword

This scholarly book addresses the thorny problem of integrating over 400 different approaches to psychotherapy. The first editor is highly respected and internationally known while the second is taking his first steps in the world of academic publishing. The editors achieve integration in a number of different ways — through a critique of existing research, through reflection on the experiences of practitioners and their clients, and through an overview of the historical development of psychotherapy itself. The book challenges traditional orthodoxies and draws on the established wisdom that practitioners in the course of their own professional development have always incorporated into their therapeutic work, namely ideas, concepts and techniques from different perspectives. The intuitive grasp of this perspective is illustrated through the voice of the client, which is generously interspersed throughout the book. For example, we read of Gloria’s conclusion, in the famous

training video, that a combination

of Gestalt and

client-centred approaches would be perfect. However, the authors take us further than mere eclecticism by identifying complex and diverse ways of defining the concept of integration, and lead us through a thoughtful examination of the ways in which the concept has achieved not only tolerance but mainstream adoption in the field. The fact that this discipline is often riven by feuds and factions makes it all the more significant that a book like this should be written. As Eleanor O’Leary indicates, one of the principal values of the search for integration lies in the process of discussing the complex issues involved as researchers, trainers, practitioners, supervisors, and theoreticians from different traditions join in the debate. Help-

ful diagrams and flow-charts enable the reader to capture such complexity in a visual way. A critical task facing the authors of such a book is to integrate social and cultural factors at different levels of relationship, to include not only family and friendship relationships but also work and social relationships as well as wider societal and cultural conditions and values within the ongoing context of the natural world. It is especially significant to read that multicultural issues are viewed right from the beginning as a central aspect of

xvi

Foreword

their integrative theoretical framework. The editors also indicate the potential of psychotherapy to integrate different modes of response in clients — cognitive, bodily, emotional, and behavioural — in order to create

holistic understanding of the problems that they bring to therapy. As the editors point out, ‘““The healed and healthy client is thus a well-rounded human being’. By inference, the healthy psychotherapist is also a wellrounded, integrated human being with a curious mind that is open to new discoveries throughout a lifetime. There are fascinating chapters on a range of methods, for example, person-centred Gestalt therapy, narrative metaphor, Gestalt reminiscence therapy, and hypnoanalysis. We read about an integrative approach to schizophrenia, and of practitioners working integratively with parents and children or with wider family networks. We also read about integrative practice where professionals from different backgrounds collaborate. We learn about the integration of the personal and the professional development of therapists, and we are shown how to integrate spiritual and religious factors into psychological treatment. Finally, Chapter 16 addresses the issue of integrating ethics into practice. This is a book to read and re-read as part of the journey of discovery that we are all engaged in as researchers, academics, practitioners and, of course, as human beings living in time. Professor Helen Cowie University of Surrey October 2005

Acknowledgements

We would like to say mile buiochas to the following: Professor Gerry Wrixon, President, University College Cork, Ireland, who granted Eleanor a sabbatical which allowed her to complete this book our colleagues, Dr David O’Sullivan, who assisted in the collation of early drafts of the chapters, Nicola Barry who commented on Chapter 13: and Professor Max Taylor our wonderful team in the Counselling and Health Studies Centre, Lena O’Rourke,

Patrizia

Setola,

Diane

Gillan,

Ciara

Staunton,

Julie

O’Donoghue, Eoin Landers and Thomas Reilly, who supported both of us in myriad ways, especially in the final days of the book’s completion all our contributors who gave of their expertise and time our friends, Eileen McSweeney, Deirdre O’Shea and Sr Finbarr Morrissey, who commented on some of the chapters Joanne Forshaw, Dawn Harris and Claire Lipscomb of Routledge, who were always at hand to respond to any query Dr Waseem Alladin, who recommended Routledge as a publisher Professor Alfredo Fierro Bardaji, Dean, Faculty of Psychology, University of Malaga and Professors Carl Thoresen and Edward Haertel, Stanford University, who were gracious hosts to Eleanor during her sabbatical Dr Alice Elliott, San Diego, who has shared her experiences of Carl Rogers and Fritz Perls with Eleanor over the years Dr Miguel Garcia Martin, Dr Almudena Gimenez De La Pena, Joan Shearman, Pamm Moore, Mark Franklin and Tom Chou, who were

invaluable sources of support to Eleanor during her sabbatical Eleanor’s nephews (Martin, Denis, Eoin, Dermot,

Shane, Robert and

Kevin) and nieces (Sarah, Alice and Maeve), who bring so much joy to her life all those who support Mike and Eleanor in their own work, including the work of the Counselling and Health Studies Centre.

xviii

Acknowledgements

We also wish to thank:

Vilma Hanninen for permission to translate a line from a paper entitled “Sisdinen tarina, elama ja muutos [Inner narrative, life and change]’’, and include it in Chapter 4. The poet Lefteris Poulios and the Kedros Publishing Company of Athens, Greece, for permission to include in Chapter 7 excerpts from the poem entitled “Magnetic Mountain”’. Sage Publications Ltd for permission to reproduce Figure 12.1 from ‘The interpersonal octagon: an alternative to the interpersonal circle’ by Birtchnell, J. in Human Relations, Volume 47, pp. 518 & 524, 1994. AP Watt Ltd, on behalf of Michael B. Yeats, for permission to include

an excerpt from the poem ““Among School Children” in Chapter 14. Thomson Publishing Services for permission to include a quote from Shakespeare’s Hamlet in Chapter 14. Penguin Bocks Ltd and Scribner, an imprint of Simon & Schuster Adult Publishing Group, for permission to include an excerpt from Peter Shaffer’s Equus in Chapter 16.

Part:

Frameworks

integrations

and theoretical

alan ow

Os: bese bm, Ses

Chapter1

The need for integration Eleanor O’Leary

The necessity for a movement towards integration within psychotherapy is apparent when we consider that there are purportedly 400 different approaches

(Arkowitz,

1995;

Feltham,

1999;

Feltham

& Horton,

2000;

Karasu, 1986); that research studies show that the majority of the main therapeutic approaches are equally effective (Glass et al., 1993; Lambert, 1992; Mahoney et a/., 1989; Norcross & Newman,

1992; Smith et al., 1980)

and that between one-third and a half of practitioners in the US label their approaches “integrative” or “eclectic” (Norcross & Goldfried, 1992). The history of the origin of the movement has been outlined by Beitman et al. (1989), Goldfried and Newman (1992), Castonguay and Goldfried (1994), Arkowitz (1995), Gold (1996), and Hawkins

and Nestoros (1997).

Some of the earliest integrative initiatives are ascribed to French (1933), Kubie (1934) and Sears (1944), who discussed parallels between psychoanalysis and conditioning. Originally, psychotherapy integration consisted, for the most part, of attempts to combine these two approaches, with authors such as Dollard and Miller (1950) and Alexander (1963) endeavouring to translate the language of psychoanalysis into learning theory. Gold (1996) pointed out that Alexander’s observation that insight into unconscious processes often followed behavioural change rather than the reverse moved psychotherapy away from a unidirectional view of change. According

to Arkowitz

(1992:

267-8),

Wachtel’s

(1977) work

was

“the

most comprehensive and successful attempt to integrate behavioral and psychodynamic approaches” and “‘one of the most influential books in the entire field of psychotherapy integration’; Gold (1996: 7) referred to it “as a model of integration at both a theoretical and a technical level’. Wachtel’s endeavour developed into what is called the integrative psychodynamic approach (Wachtel & Wachtel, 1986; Wachtel & McKinney, 1992). Central to the theory is the cyclical nature of causal processes whereby experiences from the past linger and lead to present difficulties. In 1973, the controversy within psychology and psychiatry over new methods led Thoresen to develop an approach that integrated the behavioural approaches with those that were more experiential and humanistic

4

O'Leary

in orientation. He called this synthesis “behavioural humanism” and demonstrated how behavioural interventions could be instrumental in realising humanistic goals and objectives. It was not until the 1980s that integration in psychotherapy came into its own

and became

clearly delineated

1996;

(Gold,

of interest

as an area

Goldfried & Newman, 1992). Arkowitz (1995) has maintained that the term “psychotherapy integration” was not even used until then. However, by 1994 integration had become a developing movement (Castonguay & Goldfried,

1994). Authors

such as Norcross

and Newman

(1992:

7) and

Hawkins and Nestoros (1997: 35) identified the following factors as leading to this development: the inadequacy of single theories; the equality of outcomes among therapies; the commonalities among therapies; the proliferation of psychotherapies, and socio-economic contingencies. In addition, Norcross and Goldfried spoke of opportunities for observation and experimentation with various different treatments, the identification of the significance of therapeutic commonalities to outcome variance, the growth of a professional network for integration and of short-term problem-focused psychotherapy, while Hawkins and Nestoros stressed personal characteristics, the therapeutic encounter, the complementary nature of different orientations and convergence (i.e. that as psychotherapeutic approaches develop, they take on characteristics of other schools and become more similar).

Three approaches to integration within psychotherapy have become generally recognized, namely technical eclecticism, theoretical integration, and common factors. Before these are examined in detail, a brief note on eclecticism and integration is timely. Norcross & Grencavage (1989: 233) viewed eclecticism as technical, divergent, selective, collective, atheoretical, empirical, and realistic. In addition, they held that eclecticism selects from among many and applies what is, the parts and the sum of the parts. Integration,

on the other hand,

is theoretical,

convergent,

idealistic, and

unifying, and, according to these authors, constructs something new, blends the parts, and is greater than their sum. The

term

‘“‘technical

eclecticism’

was

devised

by Lazarus

(1967)

and

refers to the fact that psychotherapists can use techniques and interventions from different approaches without necessarily agreeing with their theoretical underpinnings

(Lazarus,

1992). Arkowitz

(1995) claimed

that there

was little focus on the field in the published literature, although psychotherapists were using it in practice. However, Lazarus was already writing on the subject of multimodal therapy (cf. Chapter 8) as early as 1973, with technical eclecticism as its guiding orientation. Technical eclecticism concerns itself primarily with seeking the best treatment for an individual with a problem. Its proponents seek to integrate two or more interventions or techniques, which they apply methodically and in sequence. Once the sequence has been determined, the precise method is viewed as being pertinent to other individuals with similar problems and characteristics.

The need for integration

5

Psychotherapists who use this approach believe that a variety of interacting factors are effective in psychotherapy, and do not concern themselves greatly with either the theoretical or research underpinnings of the methodology. Lazarus (1995: 38) held that the questions in technical eclecticism are “‘ What treatment, by whom, is most effective for this individual, with those specific problems, and under which set of circumstances?” Theoretical integration is a synthesis of two or more theories of psychotherapy, which includes the best elements of these theories. In comparing it with an eclectic approach, McLeod (1993) commented on its goal of bringing together elements from different theories and models into a new gestalt; Gold (1996:

12) stated that while some writers have pointed to its

complexity and significance, others have criticized it as “overly ambitious and essentially impossible . . . because of the scientific incompatibilities and philosophical differences among the various schools of psychotherapy”’. London (1988) went so far as to call theoretical integration “theory mushing’’. Some examples of theoretical integrations that seek to avoid this criticism are given in the present book. For example, by combining two approaches based on humanistic perspectives, person-centred gestalt therapy (Chapter 3) avoids the incompatibility of philosophical underpinnings referred to by Gold. The quest for common factors began early in the history of integration. In 1936, Rosenzweig held that the success of the different psychotherapeutic approaches had more to do with their common elements than with their theoretical foundations. Differing views as to the nature of these common factors have been proposed. Rosenzweig stressed the therapist’s personality, interpretations, and the complementary effects of varying psychotherapeutic approaches; Garfield (1957) listed empathic therapists, emotional release, and self-understanding.

Gold (1996) held that common

factors are of two kinds — supportive and technical. Supportive factors arise from the relationship, while technical factors provide new learning experiences including the opportunity to test new skills in action. Writings (e.g. Clarkson, 1997) and research (e.g. Hynan, 1981) have focused on the relationship as the common factor in many psychotherapies. Lazarus (1992) considered this to be the soil in which techniques were planted while Goldfried (1980) viewed it as the foundation of all psychotherapies. When success is considered from the perspective of clients, the relationship has been

found

to be the most

effective

factor (Luborsky

ef al., 1983;

O’Malley et a/., 1983). In a study of 123 second-level students who had sought counselling for various issues (O’Leary, 1982), an increase in client-perceived

empathy was associated with an increase in self-acceptance in 67 participants. Forty one of those 67 also reported an increase in the acceptance of others. Thus, positive change occurred irrespective of participants’ problems. Strupp (1979) and Lipsey and Wilson (1993) concluded that, in general, positive changes were due to the relationship between therapist and client.

Most approaches pay some attention to the role of the relationship in therapy. In discussing this issue, Corey (1996: 456) observed that ““The existential, person centered and gestalt views are based on the personal relationship as the crucial determinant of treatment outcomes. It is clear that some other approaches — such as rational emotive therapy, cognitive behavior therapy and behavior therapy — do not ignore the relationship factor, even though they do not give it a place of central importance.” Reality therapy, psychoanalysis and psychodynamic therapy could accurately be added to the latter list. Apart from the three aforementioned approaches to integration, Schwartz (1991) distinguished between fixed or relatively stable systems and open systems. The latter allow for ongoing evaluation and appraisal and are characterized by adaptable boundaries that facilitate the inclusion of new research findings from meta-analytic studies in the model. The resulting new integration can then be evaluated. Open systems were also advocated by Horton (2000) and O’Brien and Houston (2000). The latter authors speak of

the interdependence and possible mutual enrichment of numerous psychological therapies. Previous publications in this area include works by O’Leary (1993, 1997a, 1997b). O’Brien and Houston provide a guide to integrative therapy that combines an emphasis on the therapeutic relationship with a framework for the process of integrative psychotherapy and the assessment of its therapeutic effectiveness. The framework outlined in Chapter 2 is a further example of an open system. Although such systems will of their very nature be general, it is important that the underlying assumptions are clear and capable of being subjected to research. The

research

of Lambert

(1992)

and

Duncan

and

Moynihan

(1992)

indicated that the approach to integration in psychotherapy should not be an either/or decision with respect to the three main orientations but rather a combination. Approaches identified as possessing common factors can be combined with theoretical integration approaches, with a probable increased prediction of outcome. Nevertheless, obstacles exist to the movement towards integration in psychotherapy. Hawkins and Nestoros (1997: 53-57) named seven: (1) partisan zealotry and territorial interests of different psychotherapies and their adherents; (2) divergent visions of life, health, psychopathology and change; (3) inadequate empirical and clinical research on psychotherapeutic change and insufficient evaluation of psychotherapy (including integrative) outcomes; (4) lack of a common language for psychotherapies; (5) insufficient training in eclectic and integrative psychotherapy; (6) differences in the effectiveness of psychotherapies and (7) the proliferation of different schools of eclectic and integrative psychotherapies. The definitions of approaches to integration in psychotherapy provided thus far are useful in that they reflect various strands within the movement. However, it is important that all these endeavours be subjected to research

The need for integration

7

initiatives that use both new and old paradigm methodologies. Otherwise, the proliferation of the original models will be repeated. Notwithstanding the differing approaches in the movement towards integration, one of its chief values lies in the discussions that bring together theoreticians, practitioners, trainers and researchers from different traditions. Since this movement is only 20 years old, participants are free of the necessity of maintaining rigid boundaries in its development. Hence it is to be hoped that when differences are encountered, they will be viewed as opportunities to be worked through in the process of establishing integration rather than as occasions when polarizations and conflicts will develop. A truly integrative orientation involves developments that can be subjected to the fire of research in order to discover whether they are true gold or mere yellow dross! An integrative framework will need to include the major research findings to date regarding the effectiveness of psychotherapy. In addition, cultural differences will need to be taken into account. Some (e.g. Sue ef al., 1996) advocate a separate multicultural theory of counselling. However, in my psychotherapeutic experience in East Africa, China, Finland, the UK, and the USA, I have been able to work for many years within existing theoretical frameworks: I attribute this to (1) the establishment of empathy that allowed me to understand such issues as the tribal pressure in East Africa regarding the choice of a husband; (2) my congruence, which permitted me to admit ignorance of particular cultural practices where appropriate; and (3) my unconditionality, which ensured that I accepted individuals irrespective of their behaviour. Raising awareness of multicultural issues allows their incorporation into an integrative framework, thus preventing a further splintering of psychotherapy. The movement towards integration is still very much in its infancy. Arkowitz (1995) held that a problem with both theoretical integration and the common factors approach was that they were more like general perspectives than formal theories, and that it was thus difficult to derive testable hypotheses. New paradigm methodologies offer new avenues that can aid in overcoming this difficulty by providing either support or rejection of the stated constituents of new theoretical integrations. When applied to audio or video transcripts of sessions, open-ended questionnaires and/or interviews, these approaches can provide a rich source of data relating to

approaches to integration, derivation of hypotheses, concepts, and the revision of theory. The lack of teaching of new research paradigms in the curricula of many psychotherapy training centres, and the dearth of research exposure to data analytic techniques (such as content analysis, thematic analysis, grounded theory and discourse analysis), both serve to inhibit research. An advantage of qualitative data analytic methods is the relative ease with which they can be taught to trainee psychotherapists and used in the work of scientist/

8

O'Leary

practitioners. Analyses resulting from such methods, however, are timeconsuming, and cost and time factors should not be underestimated. Nonetheless, such exploratory research is particularly important in a developing field. Ultimately, confirmatory research is needed. It is important that in our zeal to attain the ultimate trophy of integration, we do not run before we can walk. Although large goals are desirable, smaller ones are welcome as they can often provide the intermediate steps. Developments in the major approaches to date occurred in this manner. For example, person-centred therapy began from the simple reflection of content or feeling by therapists and it was only later that the main hypothesis, namely that the core conditions of empathy, congruence and unconditional positive regard lead to progress in clients, came to be explored (O’Leary, 1982). It is important to realize that, irrespective of the approach to integration that is used, it is the needs of clients that are the central concern. The extent to which an approach achieves the goals of clients is a measure of its success. Integrations within psychotherapy hold much promise insofar as, of their very nature, they include more than any single approach. Clarkson (1995: vii) spoke of “the dawning realisation that the ultimate or grand truths . . . have all been found to be fundamentally flawed as singular definitions of reality”. It may be that ultimate success from the point of view of clients depends on whether therapists recognize what frame clients are operating from and match their interventions to these frames. The next chapter provides a framework for such an approach.

References Alexander, F. (1963). The dynamics of psychotherapy in light of learning theory. American Journal of Psychiatry, 120, 440-448. Arkowitz,

H. (1992).

Integrative

theories

of therapy.

In D.K.

Freedheim

(ed.),

History of psychotherapy. A century of change (pp. 261-303). Washington, DC: American Psychological Association. Arkowitz, H. (1995). Common factors or processes of change in psychotherapy. Clinical Psychology. Science and Practice, 2, 94—100. Beitman, B.D., Goldfried,

M.R., & Norcross, J.C. (1989). The movement toward integrating the psychotherapies: An overview. American Journal of Psychiatry,

146, 138-147. Castonguay, L.G. & Goldfried, M.R. (1994). Psychotherapy integration: An idea whose time has come. Applied and Preventive Psychology, 3, 159-172. Clarkson, P. (1995). The therapeutic relationship. London: Whurr. Clarkson, P. (1997). The archetypal situatedness of supervision: Parallel process in place. In P. Clarkson (ed.), On the sublime: In psychoanalysis, archetypal PSychology and psychotherapy (pp. 279-288). London: Whurr. Corey, G. (1996). Theory and practice of counseling and psychotherapy. Pacific Grove, CA: Brooks/Cole.

The need for integration

9

Dollard, J. & Miller, N.E. (1950). Personality & psychotherapy. New York: McGraw-Hill. Duncan, B. & Moynihan, D. (1992). Applying outcome research: Intentional utilization of the client’s frame of reference. Psychotherapy, 31, 294-301. Feltham, C. (1999). Against and beyond core theoretical models. In C. Feltham (ed.), Controversies in psychotherapy and counselling (pp. 182-193). London: Sage.

Feltham,

C. & Horton,

I. (2000).

Handbook

of counselling and psychotherapy.

London: Sage. French, T.M. (1933). Interrelations between psychoanalysis and the experimental work of Pavlov. American Journal of Psychiatry, 89, 1165—1203. Garfield, S.L. (1957). Introductory clinical psychology. New York: Macmillan. Glass, C.G., Victor, B.J., & Arnkoff, D.B. (1993). Empirical research on integrative and eclectic psychotherapies. in G. Stricker & J.R. Gold (eds), Comprehensive handbook of psychotherapy integration (pp. 9-26). New York: Plenum. Gold, J.R. (1996). Key concepts in psychotherapy integration. New York: Plenum. Goldfried, M.R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. Goldfried, M.R. & Newman, C.F. (1992). A history of psychotherapy integration. In J.C. Norcross & M.R. Goldfried (eds), Handbook of psychotherapy integration (pp. 94-129). New York: Basic Books. Hawkins, P.J. & Nestoros, J.N. (1997). Psychotherapy: New perspectives on theory, practice, and research. Athens, Greece: Ellinika Grammata. Horton, I. (2000). Integration. In C. Feltham & I. Horton (eds), Handbook of counselling and psychotherapy (pp. 283-285). London: Sage. Hynan, M. (1981). On the advantages of assuming that the techniques of psychotherapy are ineffective. Psychotherapy: Theory, Research and Practice, 18(\),

11-13. Karasu, T.B. (1986). The specificity versus nonspecificity dilemma: Toward identifying therapeutic change agents. American Journal of Psychiatry, 143, 687-695. Kubie, L. (1934). Relation of the conditioned reflex to psychoanalytic technique. Archives of Neurology and Psychiatry, 32, 1137-1142. Lambert, M.J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J.C. Norcross & M.R. Goldfried (eds), Handbook of psychotherapy integration (pp. 94-129). New York: Basic Books. Lazarus, A.A. (1967). In support of technical eclecticism. Psychological Reports, 21, 415-416. Lazarus, A.A. (1973). Multimodal behavior therapy: Treating the “BASIC ID”. Journal of Nervous & Mental Disease, 156(6), 404-411. Lazarus, A.A. (1992). Multimodal therapy: Technical eclecticism

with minimal

integration. In J.C. Norcross & M.R. Goldfried (eds), Handbook of psychotherapy integration (pp. 231-263). New York: Basic Books. Lazarus, A.A. (1995). Multimodal therapy. In R. Corsini & D. Wedding (eds), Current psychotherapies (Sth edn, pp. 322-355). Itasca, IL: F.E. Peacock. Lipsey, M.W. & Wilson, D.B. (1993). The efficacy of psychological, educational, and behavioral treatment: Confirmation from meta-analysis. American Psychologist, 48, 1181-1209.

10 We

O'Leary mn

NO

ee Na

gts

ee

London, P. (1988). Metamorphosis in psychotherapy: Slouching toward integration. Journal of Integrative and Eclectic Psychotherapy, 7(1), 3-12. Luborsky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous & Mental Disease, 171(8), 480-491. McLeod, J. (1993). An introduction to counselling. Buckingham, UK: Open University Press. Mahoney, M.J., Norcross, J.C., Prochaska, J.O., & Missar, C.D. (1989). Psychological development and optimal psychotherapy: Converging perspectives among clinical psychologists. Journal of Integrative and Eclectic Psychotherapy, 8, 251-263. Norcross, J.C. & Goldfried, M.R. (eds) (1992). Handbook of psychotherapy integration. New York: Basic Books. Norcross, J.C. & Grencavage, L.M. (1989). Eclecticism and integration in counselling and psychotherapy: Major themes and obstacles. British Journal of Guidance and Counselling, 17, 227-247.

Norcross, J.C. & Newman, C.F. (1992). Psychotherapy integration: Setting the context. In J.C. Norcross & M.R. Goldfried (eds), Handbook of psychotherapy integration (pp. 3-45). New York: Basic Books. O’Brien, M. & Houston, G. (2000). Integrative therapy: A practitioner's guide. London: Sage. O'Leary, E. (1982). The psychology of counselling. Cork, Ireland: Cork University Press. O'Leary, E. (1993). Empathy in the person centred and gestalt approaches. British Gestalt Journal, 2, 111-115.

O'Leary, E. (1997a). Towards integrating person centered and gestalt therapies. The Person Centered Journal, 4, 14—22. O’Leary, E. (1997b). Confluence versus empathy.

The Gestalt Journal, 20(1), 137-

154. O'Malley, S.S., Suh, C.S., & Strupp, H.H. (1983). The Vanderbilt Psychotherapy Process Scale: A report on the scale development and a process—outcome study. Journal of Consulting & Clinical Psychology, 51(4), 581-586. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Schwartz, G.E. (1991). The data are always friendly: A systems approach to psychotherapy integration. Journal of Psychotherapy Integration, 1(1), 55—69. Sears, R.R. (1944). Experimental analysis of psychoanalytic phenomena. In J.M. Hunt (ed.), Personality and the behavior disorders (pp. 191-206). New York: Ronald Press. Smith, M.L., Glass, G.V., & Miller, T.I. (1980). The benefits of psychotherapy. Baltimore, MD: Johns Hopkins University Press. Strupp, H.H. (1979). Specific versus non-specific factors in psychotherapy. Archives of General Psychiatry, 36(10), 1125-1136. Sue, D.W.,

Ivey, A.E., & Pedersen,

P.B. (eds) (1996). A theory of multicultural

counseling and therapy. Belmont, CA: Brooks/Cole. Thoresen, C.E. (1973). Behavioral humanism. In C.E. Thoresen (ed.), Behaviour modification in education (pp. 98-122). Chicago: University of Chicago Press.

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Wachtel, E.F. & Wachtel, P.L. (1986). Family dynamics in individual psychotherapy: A guide to clinical strategies. New York; Guilford Press. Wachtel, P.L. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York: Basic Books. Wachtel, P.L. & McKinney, M.K. (1992). Cyclical psychodynamics and integrative psychodynamic therapy. In J.C. Norcross & M.R. Goldfried (eds), Handbook of Psychotherapy Integration. New York: Basic Books.

Chapter 2

A framework for integrative psychotherapy Eleanor O’Leary and Mike Murphy

This chapter provides a framework for integrative psychotherapy which focuses primarily on the internal integration of clients and the modes of communication within the therapeutic relationship that must be developed in order to promote it. This internal integration is one of the goals of integrative psychotherapy and consists of four main elements — feelings, behaviours, bodily sensations and cognitions. In the integrated individual, the movement between these dimensions is fluid and dynamic, with interactions occurring between the four elements as illustrated in Figure 2.1. The circular nature of the diagram illustrates that there is no “higher” or “lower” level in relation to the value of these four elements — rather a freeflowing movement between all dimensions of the person ensures internal integration. This framework resembles the approach of multimodal therapy (cf. Chapter 8) insofar as the four dimensions are also mentioned by Lazarus (1981). However, we not only consider them as dimensions and ways of communicating with oneself and others but also stress the importance of the integration of these elements within clients so as to allow holistic contact with experiencing and healing to occur. This healing emerges with the therapeutic relationship as the background and springboard for its development. Whereas multimodal therapy focuses on assessment, profile and treatment, the motivating force of therapists in the present framework is the internal integration of clients that occurs in the context of an understanding and authentic relationship. The four elements involved in internal integration are now considered in terms of development, evolution and culture. The importance of emotions and bodily sensations is apparent in the person from a very early age. Research evidence (e.g. Izard et al., 1995) suggested that signs of emotions are present in early infancy, while Piaget (Flavell, 1963) spoke of “sensorimotor intelligence” as being the identifying label for cognitive development up to 18 months/two years. He held that development begins with the baby’s use of senses and movement to explore the world, and viewed ages two to seven (the pre-operational stage) as the period during which children use symbols to represent their earlier

A framework for integrative psychotherapy

=

13

Cognition om

Bodily sensation

a BOUNDARY OF THE PERSON

Figure 2.1 Internal integration of the person.

sensorimotor discoveries. This concurs with Ivey (1986: 83) who stated that “development can start only in sense-based experience”. However, cultural differences influence rate of development.

For example,

Berk (2000:

147)

stated that ““Among the Kipsigis of Kenya and West Indians of Jamaica, babies hold their heads up, sit alone and walk considerably earlier than do North American infants’. She went on to say that this occurs through the deliberate teaching of motor skills by Kipsigis parents and the provision of a highly stimulating formal handling routine by the West Indians. The sensorimotor dimension also features in the theory of Donald (1991), who identified three transitions in the evolution of human cognition. The “before” and ‘after’ of these transitions provide a clear picture of the layered development of human communication and are particularly relevant to the field of therapy. The “before” of the first cognitive— evolutionary transition (from ape to Homo erectus) involved the sensorimotor ability of the ape which still exists in humans and provides valuable data that we can employ to experience and communicate. The “after” of this transition includes the ability to mime or re-enact events and is used in the areas of psychodrama and gestalt therapy, e.g. in the technique of reenactment. By means of this technique, clients can identify past or present feelings associated with a past negative or positive experience. Enactments, or “experiments” as they are frequently termed in gestalt therapy, “are based upon the principle that learning requires action” (O’Leary, 1992: 57). The second transition (Homo erectus to Homo sapiens) resulted in the emergence of human speech and of the use of symbols in representation. Speech has formed the basis of therapy throughout the past century, with

14

O’Leary and Murphy

most approaches viewing it as the sine qua non of their foundation. The cognitive-behavioural, psychodynamic, psychoanalytic and humanistic/ existential orientations pay attention to speech in the disclosure of the content of a person’s experience. The approach of Freud, the father of psychotherapy, has been termed the “the talking cure” (Wiener, 1999). Good-quality interpersonal contact involves speech. Within psychotherapy, its importance can vary considerably from identifying an issue or problem to using the many dimensions of speech to enhance the therapeutic process. These vocal dimensions include pitch, intensity, timbre and pace. The noting of these characteristics provides a far more comprehensive understanding of the speech content and helps therapists to become aware of what precisely the client is saying. The speed of clients’ speech is an important factor that can reflect national, regional and cultural differences.

For example, a psychotherapist from the slow-speaking Home Counties of England might incorrectly perceive the normal rapid rate of speech of a client from Ireland as indicative of anxiety or agitation, while an Irish therapist might view the rapid pace of an agitated client from the Home Counties as perfectly normal. Rate of speech can also differ when psychotherapists and clients do not share a first language. For example, if one of the dyad is a native English speaker and the interaction occurs in English, the English speaker will usually need to speak more slowly. It is also important to be conscious of the use of colloquialisms. Even in an island as small as Ireland, there are marked differences in regional vernaculars such that a person from some areas of Cork city might utter a sentence whose meaning would be utterly inaccessible to a person from Belfast, e.g. “lamp the gatch on that feen!”’ (look at that man’s gait!). The first author has found herself being addressed as ‘‘duck”’ on the streets of Glasgow, while newly arrived Irish emigrants to the USA were frequently embarrassed in their use of the complimentary term “homely” on discovering that to Americans it meant “ugly”! Having discussed the developmental, evolutionary and cultural aspects of human experience and modes of human communication, we now consider each of the four elements essential to internal integration.

Elements essential to internal integration Cognition

Cognition, in the context of this chapter, refers to an intellectual, rational means of understanding the world, experiencing life, and communicating and expressing that experience and understanding to others. Too often, the view of society is that cognition is more desirable or represents the highest expression of human achievement, resulting in cognitive ability being used

A framework for integrative psychotherapy

15

as a way of establishing superiority over others. This view of cognition has seen the suppression of emotion to a considerable extent in Western society. It is, of course, the case that cognition plays a vital role in human functioning and experience, but despite its central role, the mind is not the person. The person is a complex interaction of mind, body, feelings and behaviours residing for the most part in an interpersonal/group context. All these elements need to be taken into consideration in an integrative psychotherapy, with the psychotherapist viewing cognition as part of the whole person rather than as the highest accomplishment. It is important to take a balanced view of the cognitive/intellectual mode since it is all too easy to under- or over-emphasize its importance (depending on one’s theoretical underpinning). In our framework, cognition is one of a number of equally important factors in human experiencing.

Emotion

“Affect” and “emotion” have historically proven very resistant to definition (Reber, 1995). In this chapter, we use the term “emotion” to mean a largely involuntary, non-intellectual, and subjective response to events and circumstances. Happily, although it is difficult to define, almost everybody knows what the word means! Emotion can give meaning to life and its expression is an important element of healthy living. The work of Ekman (1999) on basic emotions has shown universal patterns of expression. Emotional expression, according to Rogers (1961), is related to patient progress in counselling, while suppression of emotions was found by Gross and Levenson (1997) to result in increased sympathetic activation of the cardiovascular system. More recently, O’Leary and Barry (2000) held that the exploration of feelings is a valuable component of therapeutic work with older people. The expression and working through of unfinished feelings allow their dissipation, resulting in a healthier relationship both within individuals and with others.

If this does not occur, emotions

damaging attitudes; for example, unexpressed transform into an attitude of hostility.

can harden

into more

anger

over

can,

time,

Bodily sensations As embodied individuals, we experience the world through both our minds and our bodies. The body is necessarily involved in the moment-to-moment process of living and registers this process. To exclude it is to deny one of the greatest sources of information in therapy. Attention to the present involves focusing on physical and sensational experiencing. Smith (1985) wrote in some detail on this experiencing as a

16

O’Leary and Murphy

age

a

a

a

a

means of facilitating a broader awareness. He identified a number of indicators that he associated with energy dynamics and that are particularly important in therapy, including: e

tension, indicating muscular contraction that occurs when the flow of communication is interrupted hot spots, relating to a build-up of energy that has not been discharged cold spots, denoting a denial of aliveness where a part of the body has been deprived of energy.

Exploration of what a client is currently experiencing in their bodies can play a major role in the identification of feelings in therapy. The body may be likened to a barometer which, with time and practice, can be used to monitor the state of feeling within. Thus, a sensation in the stomach when attended to may be identified as a particular feeling (e.g. nervousness). The reverse process also applies.

Behaviour

In the context of the present framework, behaviour refers to external observable action (or indeed inaction) on the part of individuals. Like sensation, behaviour can be a very powerful tool in helping to understand our own and others’ responses both to the world and to events within and without. It can also act as a means of actively expressing oneself. An integrative psychotherapist who is at ease with his or her body can assist clients who are blocked in the area of movement to become free and develop their repertoire of psychomotor skills. Behaviour translates words into actions, allowing greater integration to occur. Each of the four cation for both psychotherapists such modes are e

e

elements outlined above can serve as a mode of communiclients and therapists. A particular skill of integrative is the ability to identify the primary mode of clients. Four as follows:

When individuals speak cognitively, there is no allusion to their emotions, body sensations or perceptions. Such individuals may express depression through observing that there is no possibility of success or accomplishment in their lives, or that they are not sufficiently capable or competent. They may even recognize that such beliefs are irrational, but this may not help them to overcome their problems. When individuals speak affectively, they usually express themselves in feeling words. Such individuals may describe depression in terms of sadness, hopelessness and/or a sense of guilt.

A framework for integrative psychotherapy

e

e

17

When individuals communicate behaviourally, they engage in observable acts. Thus, they may present with a lot of documents relating to themselves and introduce their issues in terms of current behaviours or behaviours they wish to achieve. Such people may express depression through posture, downcast eyes, lack of eye contact, hunched shoulders. When individuals express themselves through bodily sensations, they refer to the five senses. They may describe sensations in the belly, chest or any other part of the body.

One mode is usually primary for any given individual, therapist or client. Therapists have to discern which form of communication (cognitive, emotional, behavioural, bodily) is being used by the client. Differentiating these major means provides a map for psychotherapists, resulting in ease in professional interaction. Irrespective of their principal mode of communication, it is their ability to focus and respond to the communicative modality of clients that makes them truly integrative. Thus, a therapist whose main mode is cognitive, in interacting with a client whose primary style is affective, will need to reply from an affective dimension in order to establish communication. The same is true of all other permutations. Both an open attitude and an ability to respond in any of the four are necessary on the part of integrative psychotherapists. Without these, they are unable to communicate with clients in an optimal manner. In the initial meeting, clients are viewed as holistic beings possessing the possibility of communication in all four dimensions. Their primary mode of communication presents itself very early in the therapeutic relationship and integrative psychotherapists work in this form with them. They note, during the first section of the first therapy session, which style is predominant for clients and respond using it. This identifying and responding emerges primarily from a desire to understand rather than from an assessment orientation on the part of therapists. To paraphrase the words of Harper Lee (1989 [1960]: 33) in To Kill a Mockingbird: “You never really understand a person until you consider things from his [her] point of view . until you climb into his [her] skin and walk around in it.” In this instance, the “skin” is composed of thoughts, feelings, body experiences and behaviours. The main mode is used until such time as an empathic understanding has been established. This usually occurs in the first two sessions (Aspy, 1972; O’Leary, 1982) and is increased thereafter (O’ Leary, 1982). An interesting example of a striving to understand was the work of Frieda Fromm-Reich, who copied the non-verbal behaviours of clients in order to allow her to enter their worlds more fully (O’Leary, 1982). The perception by clients of the ability of therapists to understand is central to their internal integration and to the therapeutic relationship, and is outlined in more detail in Chapter 3.

18

ae

O’Leary and Murphy

Coie heats tininst, 6

REESE

eee Oe IPs a

As stated above, the majority of clients have a primary mode of expression while they use the others less frequently. To become whole individuals, a balance of access to these various modes needs to be estab-

lished. The psychotherapist has to judge whether the main mode of clients permits them to contact their issues initially. If not, a different style needs to be employed. For example, if the contacting of emotions occurs cognitively, affective experiencing will need to occur for closure to be brought to any traumatic or unfinished situation. No amount of skill on the part of integrative psychotherapists will result in clients changing from their predominant to their secondary forms of communication unless clients are both ready and willing to explore these other modes. Readiness will usually depend on the extentto which each of the modes has been previously used by clients, as well as on the ability of psychotherapists to facilitate the use of these secondary modes. Holistic solutions of issues and problems will depend on the accessing of secondary modes of communication to support the primary mode. Thus, irrespective of the primary (cognitive, affective, bodily or behavioural) orientation of the therapist, integrative psychotherapists must have competence in interacting at all four levels.

The use of different modes holistic understanding

of responding to create

As therapy progresses, therapists use different modes to create holistic understanding. For example, clients whose predominant mode of communication is within a cognitive frame may be using this mode to avoid experiencing the emotions associated with unpleasant experiences in the past. If therapists continue to interact from within a cognitive—cognitive frame only, clients are unlikely to tap into the emotional and bodily dimensions of these experiences. Simple questions such as ““How do you feel about . . .?” can move clients eventually into re-owning emotion associated with the experience. Unless this emotion is processed, healing occurs at a cognitive level only; insight rather than awareness is achieved, the psychotherapeutic equivalent of stitching only a part of a laceration. Insight is Cognitive awareness while holistic awareness incorporates all four modes. The healed and healthy client is thus a well-rounded human being. Similarly, if the main mode of presentation is affective, therapists may enquire “What do you think about . . .?” The result is that clients are able to reflect on the emotions and body sensations experienced and identify the thoughts to which these feelings and sensations are related. In this manner, cognitive understanding is established. Development can move from cognition to emotion and sensation, or vice versa. What is important is that any missing dimension comes into the field of awareness of clients and is processed by them.

A framework for integrative psychotherapy

19

Bodily sensations are particularly helpful for cognitive individuals who cannot easily connect with their emotions. Often, predominantly cognitive individuals will state that they are experiencing overload in their work and that they have an unpleasant sensation, e.g. that their shoulders are hurting them, without necessarily connecting the two events. With appropriate intervention by therapists, the connection between the pain and overload will enter their awareness. The following excerpt illustrates the use of the four different modes of responding in enhancing internal integration in a client within the therapeutic relationship. DERMOT: As I told you the last day, Alice and I got on very well for the first ten years of our marriage. I had to work very hard because of the mortgage on our house but I did not mind because we were creating a future together. THERAPIST: And how did you feel at the time? DERMOT: I felt um ...um... that we were making progress. THERAPIST: And how did it feel to be making progress? DERMOT: I felt content . . . During the ten years I had to stay late at work frequently as I was trying to advance my career and Alice seemed to understand that. She was so considerate in fact that she often phoned me to ascertain what time I would be home so that she could have a hot dinner waiting for me. THERAPIST: And how did that make you feel? DERMOT: Comforted, taken care of, em... special. However, two years ago, I came home early one eveningem...em...tofind...em... (sighs) the light on upstairs . . . I took no notice. I thought she was just doing something there. . .em:... However ...em’...em.... (sighs) I. ..em ... Went into the hallway ...em...and called her name and, em, she did not answer. I still took no notice soem... decided toem... go... em... upstairs... (sighs) em...em...found them... (sighs) em... em... it’s very difficult em... it’s very difficult . . with a man I had never seen before in the room with her. THERAPIST: That surely was difficult for you. DERMOT:

Well, em...em...

I had been working late and I was, eh... I

wasem...em...I was hoping that we would still be in time to go toa late film together, so, em... you can imagine the scene that greeted me. Em... (sighs) ... a strange man in our bedroom. THERAPIST: And how did you feel? DERMOT: (sighs) ...em...em... I was lost for words. THERAPIST: So you were not able to speak? DERMOT: No, I just stood there, lost for words. THERAPIST: And what were you feeling? don’t know. DERMOT: Oh,em...em...I...em...I

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O’Leary and Murphy

THERAPIST: You don’t know. Could you give yourself a moment? DERMOT: (sighs) Shocked. THERAPIST: Shocked. About what precisely? DERMOT: That this woman that I loved was actually doing this. THERAPIST: And what were you thinking? DERMOT: That she should not have done it... that I was imagining it (sighs) ... that em...

it just could not...

(sighs) be real, em...

THERAPIST: So you felt let down? DERMOT: (sighs) ... I suppose that is what you’d call it — actually, it was... em... stronger than that . . . a sense of betrayal. THERAPIST: Have you any sense of that betrayal now? DERMOT: Wellem... (sighs) ...em... out ... no more energy.

(sighs)

...em...1

feel washed

THERAPIST: So you feel washed out... Are you aware of this washed-out feeling in your body? DERMOT: Yeah, my legs feel very tired .. . yeah the backs of my knees. My head feels heavy. THERAPIST: Can you show me where your head is heavy? DERMOT: (points to the whole head from forehead to nape of neck) It’s so em daemons heavy THERAPIST: And if you were to give your head a voice, what would it say? For example, you could say “I am Dermot’s head and I feel whatever’. DERMOT:

Iam Dermot’s head,em...

(sighs),em...I feel (sighs) feel, feel

a need to lie down on a soft, soft pillow. I do not want to think about Alice ... (sighs) I do not want to see her... (sighs) ... 1do not want to speak to her. THERAPIST: So you want to lie down on a soft pillow? DERMOT: (sighs) Oh yes, yes .. . forget it all for now. THERAPIST: Can you do that? DERMOT: Ah, lie down? Gosh — no, I’ve got to be back to work em... . THERAPIST: And what time will you finish work? DERMOT: At five o’clock. THERAPIST: And can you lie down then? DERMOT: Lie down at five o’clock,em...em... well yes I could. I could... I feel so, .. . my head is so heavy and my legs so tired that I think that’s a good idea. THERAPIST: And how long will you be able to lie down for? DERMOT: Until I collect Maeve, my daughter, from gymnastics. THERAPIST: And when will that be? DERMOT: At seven o'clock. THERAPIST: So you will have two hours’ rest? DERMOT: Yes. THERAPIST: Well Dermot we have just five minutes to the end of our session. What did you learn today?

A framework for integrative psychotherapy

21

DERMOT: Well, I told you my problem, but the big thing is thatem...em.. I know I’m really tired and need to sleep a lot before the vee session .Thank you. THERAPIST: Thank you too. This passage illustrates the initial cognitive style of disclosure of Dermot. Since this is the second session, the therapist responds in a feeling mode to which Dermot responds in a cognitive manner. However, when the therapist persists with a feeling approach, the client does likewise, enabling the individual to identify his sense of betrayal. Later in the session, the bodily experiencing connected with the cognitive and affective modes is identified, allowing the behaviour that needs to be implemented as an initial priority to be discussed and a commitment made to it. In this manner, all four modes are incorporated. Future sessions can focus on the working through of feelings and the identification of other behaviours that may need to occur. Environment

and

culture

Internal integration does not take place in isolation but in the context of one’s life, social relations (including family relationships, friendships, social relationships in general) and the culture in which people live. Behaviours are action-emotional sensory complexes that occur in environmental contexts. Not only the internal lives of individuals but also the internal processing of the environment as perceived by clients, form part of the counselling process. Irrespective of the objective reality that is occurring in the environment, it is frequently the perception of clients that determines whether it is an issue or problem for them. Rogers (1980) illustrated graphically how the sprouting of potatoes occurred in the cellar of his childhood family home. A little shaft of light was sufficient in the midst of the dark, dank cellar to allow the sprouting to occur. Similarly, integrative psychotherapists can bring this nurturing condition to light up the environmental darkness surrounding problems of clients. Frankl’s derivation of meaning while in a Nazi concentration camp is another illustration of how meaning can be attained in the direst of human conditions (Frankl & Lasch, 1992). Aspects of the environment that are frequently involved in either the increase or decrease of problems or issues of clients include family and friendship relationships, work and social relationships in general, societal and cultural conditions, values and the natural world. This holistic integration of the person and the environment is illustrated in Figure 2.2. The directionality between internal and external environmental factors is reciprocal, i.e. each affects the other. The therapeutic relationship can be viewed as a microcosm of helping interactions with people in general. Thus,

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O’Leary and Murphy

SOCIAL RELATIONS IN GENERAL

Cognition

= Cowan

Bodily sensation

BOUNDARY OF THE PERSON

Figure 2.2 Holistic integration of the person and the environment.

attention to this relationship will assist in the enhancement of these interactions through clarifying and working through their various dimensions. All therapy occurs within a cultural context and this influences the kinds of outcomes clients seek from therapy. Body expression as a means of communication will vary according to the particular culture in which clients reside, for example Mediterranean people use gesture far more frequently than those from Anglo-Saxon cultures. In addition, the perceived pool of psychological problems varies from culture to culture. We have but to reflect on such practices as “honour killings”, female circumcision/clitoridectomy and hara-kiri (Japanese ritual suicide) to realize that the emphasis in the work of integrative psychotherapists will vary according to the culture in which they practise.

A framework for integrative psychotherapy

23

implications for training and ongoing professional development Based on the material outlined thus far, trainees in integrative psychotherapy will need to have knowledge of more than one theoretical approach as well as intervention skills that deal with the four modes of responding. Furthermore, the dynamic interaction of the person and the environment demands attention to interpersonal and contact skills. It is advisable that therapists who wish to practise integratively should undertake skills training in the areas in which they hold least expertise, thus expanding their skills bases. In this manner, as Samuels (1997: 143) stated, “passion for one

approach is replaced by passion for a plurality of approaches” and thus integration can occur.

Discussion

Historically, frameworks for integrative psychotherapy have rested on what psychotherapists do, as is the case with theoretical integration, the search for common factors, and technical eclecticism. The present framework abandons adherence to any one of these approaches to integration and focuses instead on the internal integration of clients, the therapeutic relationship and the matching of therapist responding with the primary modality of clients. The framework provides a possible meta-structure for theoretical integration as well as a theoretical basis for technical eclecticism. The approach to integration centres on psychotherapists entering and understanding the world of clients through identifying the primary modality of their clients and subsequently facilitating the emergence of all four modalities so that holistic solutions to issues and problems can occur. However, at all times the needs of clients are paramount. We hold that a holistic treatment by integrative psychotherapists will resolve the issues of most clients coming to psychotherapy. Our framework differs from technical eclecticism in that the latter seeks to ascertain a sequence of interventions that can be applied systematically for individuals with similar problems and characteristics, while we hold that the whole range of modalities needs to be applied to a particular problem to ensure its complete closure. A necessary starting point is the ability of therapists to understand the world of clients so that they can both identify the primary modality of clients and match their interventions with a similar modality. In the absence of such an integrative approach, clients can reach the end of therapy having dealt with only one aspect of their issue(s). Therapies that depend solely on one modality may be dealing only with the more obvious external manifestations of the issue.

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References Aspy, D. (1972). Toward a technology for humanizing education. Champaign, IL: Research Press. Berk, L.E. (2000). Child development (Sth edn). Needham Heights, MA: Allyn & Bacon. Donald, M. (1991). Origins of the modern mind: Three stages in the evolution of culture and cognition. Cambridge, MA: Harvard University Press. Ekman, P. (1999). Basic emotions. In T. Dalgleish & M. Power (eds), Handbook of

cognition and emotion (pp. 45—60). Chichester, UK: Wiley. Flavell, J.H. (1963). The developmental psychology of Jean Piaget. Princeton, NJ: Van Nostrand. Frankl, V.E. & Lasch, I. (1992). Man’s search for meaning: An introduction to logotherapy (4th edn). Boston: Beacon Press. Gross, J.J. & Levenson, R.W. (1997). Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology, 106(1), 95-103. Ivey, A.E. (1986). Developmental therapy. San Francisco: Jossey-Bass. Izard, C.E., Fantauzzo, C.A., Castle, J.M., Haynes, O.M., Rayias, M.F. & Putnam, P.H. (1995). The ontogeny and significance of infants’ facial expressions in the first 9 months of life. Developmental Psychology, 31, 997-1013. Lazarus, A.A. (1981). The practice of multimodal therapy. New Y ork: McGraw-Hill. Lee, H. (1989 [1960]). To kill a mockingbird. London: Arrow Books. O'Leary, E. (1982). The psychology of counselling. Cork, Ireland: Cork University Press. O’Leary, E. (1992). Gestalt therapy: Theory, practice and research. London: Chapman & Hall. O’Leary, E. & Barry, N. (2000). Counselling older adults. In I. Horton & C. Feltham (eds), Handbook of counselling and psychotherapy (pp. 642-647). London: Sage. Reber, A.S. (1995). Dictionary of psychology (2nd edn). London: Penguin. Rogers, C.R. (1961). On becoming a person. Boston: Houghton Mifflin. Rogers, C.R. (1980). A way of being. Boston: Houghton Mifflin. Samuels, A. (1997). Pluralism and the future of psychotherapy. In S. Palmer & V. Varma (eds), The future of counselling and psychotherapy. London: Sage. Smith, E.W.L. (1985). The body in psychotherapy. Jefferson, NC: McFarland. Wiener, D.J. (ed.) (1999). Beyond talk therapy: Using movement and expressive techniques in clinical practice. Washington, DC: American Psychological Association.

Chapter 3

Person-centred gestalt therapy Eleanor O’Leary

In 1985, I met Carl Rogers for the first time. Prior to this, I had communicated with him regularly during the 1970s as I investigated the core conditions and core outcomes of the person-centred approach for my PhD (O’Leary, 1979). The venue for the meeting was a person-centred programme at the University of California, San Diego, where, much to my surprise, Carl asked me if I would like to visit his home. As the reader may imagine, I enthusiastically agreed. The conversation that ensued during that visit centred on integration in psychotherapy, although neither of us explicitly referred to the term. On hearing that I had completed gestalt therapy training in Ireland and that I was now going to undertake further training with Erving and Miriam Polster, Carl asked me why I had left the person-centred approach. I replied that I did not consider that I had left it since I valued the core conditions but that I was not yet satisfied that I knew precisely how client change occurred. Gestalt therapy supplied the missing part of the equation for me. Thus, my first formulation in the area of theoretical integration was born. Subsequently, when I viewed the Gloria film (Shostrom,

1964), I realized that this insight of mine had

already been uttered by that well-known client. Having been counselled consecutively by Rogers, Perls and Ellis, she stated that a combination of the approaches of Rogers and Perls would be perfect for her. However, there is no evidence in the literature that either Rogers or Perls gave any consideration to this idea. Various

works

(Cochrane

& Holloway,

1974; Stanley & Cooker,

1977;

Miller-O’ Hara, 1984) have spoken of the integration of the two approaches but have not, for the most part, outlined the precise nature of underlying assumptions, core conditions, tasks, and outcomes. In a previous article (O’Leary, 1997), I pointed out that such an integration should include the relationship emphasis of the person-centred approach with the selfsupport and interdependence emphasis of gestalt therapy. The remainder of the chapter is devoted to this theoretical integration and will consider its assumptions, the therapeutic relationship, core conditions and task— outcomes.

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O’Leary

Assumptions Person-centred gestalt therapy is based on the premise that emotional, social, and spiritual development continues up to the point of death provided that individuals do not experience significant cognitive decline. Human beings are viewed as possessing inherent positive tendencies, an assumption outlined by both Maslow (1954) and Rogers (1951). Since both person-centred therapy and gestalt therapy are humanistic approaches, their integration in person-centred gestalt therapy is based firmly on existential and humanistic underpinnings that emphasise present experiencing, personal responsibility, choice, and freedom. Each of these will now be considered. Present experiencing involves feelings, thoughts, behaviours, and bodily experiencing. Participants are invited to attend to these dimensions, thus capturing their internal moment-to-moment process. Such processing allows individuals to attend to the “how” and “what” of their experiences. Clients can be invited to examine how they are blocking expression of emotion or avoiding consideration of a particular issue. For example, in the case of anger, individuals who use an expressionless tone are invited to explore this lack of expression in order to discover its underlying basis. Thus, natural expressiveness and unblocked processing emerge or are rediscovered. This discovery allows them to choose whether or not they want to continue to do what they have previously been doing. Structuring of experience and mobilizing of self-support occur as participants process “how” and “what” questions (O’Leary, 1992). Present experiencing includes events from the past and associated feelings that have not been processed fully at the time of their occurrence but continue to intrude into the present lives of individuals. For example, a label

(such

as

“‘adult

child

of an

alcoholic’)

that

describes

the

past

experience of some individuals, is seen as useful only when the effects of the previous trauma are still alive in their current experiencing. Similarly, the future is viewed as important to the extent that it exists in the present for individuals, and either distracts them from that present or allows them to plan for the future. Being a healthy adult requires individuals to be responsible for themselves. Thus, therapists assist clients to move from depending on others (including their therapists) to acting from their own felt experiencing. Only clients themselves can decide to change any aspect of their behaviour. Thus, change is closely connected to the development of self-support. Rather than seeing their lives as being outside their control, they begin to view themselves as having a choice in the many experiences that occur.

Choice exists in the present. Individuals are constantly being pulled between the external demands of the environment and their own internal needs. The awareness of choice allows people to accommodate to these

Person-centred gestalt therapy

27

external and internal environments. Unfortunately, many individuals continually adjust to the external environment without considering whether such adjustment is toxic or healthy for them. They do not pay attention to their internal needs. As a result, their quality of life and, in some instances, their health become affected. With choice comes freedom, without which it is likely that resentment will develop. Such freedom allows self-empowerment to occur as clients acknowledge that previously unrecognized choices exist in their lives. Taking charge of their own lives lessens their dependence on others although it does not exclude interdependence, where individuals ask for the support they need when circumstances require it, e.g. in bereavement or at a time of injury. This sense of empowerment develops within the contextual dimensions of their lives. Person-centred gestalt therapy acknowledges that people’s actions and communications impact those individuals with whom they come in contact. However, the type of response made always lies within the control of the responders. The therapeutic environment provides a confidential context in which the impact of these environmental influences can be explored and worked through. Self-imposed constraints are examined while unavoidable limitations on the freedom of participants are acknowledged.

The relationship: the healing dynamic The relationship is central in person-centred gestalt therapy. This relationship is distinguished from friendship relationships in that, in individual therapy, professional development groups or group therapy, a client/ individual seeks out a professional counsellor/facilitator, presents a particular problem or issue, hopes for a solution and usually pays for the service. These relationships thus fall into the category of professional helping relationships in that one of the parties is recognized as possessing certain expertise that the other does not. Relationships in person-centred gestalt therapy occur in many forms, such as the relationship of a client with a therapist, the relationship of a trainee or professional in a personal development group with the facilitator, or the relationship of group members with the group therapist. The differing contexts will affect the nature of the relationship depending on where an individual is situated on a dependence-self-support continuum. The more self-supporting individuals are, the more they are ready to explore their issues and to be authentic; the more wounded, the more understanding they require in order to trust the relationship. Sometimes the latter group lack acceptance of others to such an extent that they are unable to continue in counselling, as was the case for 56 (45%) of 123 second-level students receiving personcentred therapy in a study conducted in Ireland (O’Leary, 1982). In person-centred gestalt therapy, healing is viewed as occurring through the therapeutic relationship. This relationship leads to developmental

28

O’Leary

growth provided that individuals are open to emerging experience. It is enhanced by certain attitudes that therapists offer, including the desire to be empathic towards clients, to accept them as they are and to be real persons with them. These attitudes, called core conditions,

allow clients to come

closer and closer to their internal experiencing of feelings, sensations, thoughts and behaviours. Contact functions are central to the establishment of the core conditions. These functions, according to Kepner and Brien (1970) and Satir (1976), involve the five senses although Polster and Polster (1973) added two more,

namely movement and speech. The relationship in person-centred gestalt therapy can be enhanced or lessened depending on therapists’ use of the contact functions. For example, listening and speaking are central to the process of counselling and play a significant role in the quality of empathy offered by therapists. The core conditions of person-centred gestalt therapy are akin to those outlined by Rogers (1961) with the modification that Barrett-Lennard’s (1962) use of unconditionality is employed rather than Rogers’ unconditional positive regard. In addition, the word “authenticity” rather than ““congruence”’ is used, since it is part of everyday parlance and is understood by most people. The wisdom gleaned from Polster and Polster (1973) in terms of contact functions enhances the core conditions of empathy and authenticity. The

core

conditions

Empathy The word “empathy” comes from the Greek empatheia, which refers to an active valuing of another person’s feeling experience (O’Leary, 1997). It is an attitude towards others that is most frequently experienced in the therapeutic setting. Although it can be a part of other kinds of relationships, the time involved in establishing empathy makes it difficult for it to be part of day-to-day friendships or family relationships. Indeed, it could be argued that empathy within friendship is actually co-dependence if only one of the friends is empathic. Empathy is contact that allows therapists to listen to clients, to express their understanding and to receive feedback on the accuracy of this expressed understanding (Barrett-Lennard, 1976). Empathy, as outlined by Rogers (1951, 1980) and considered in depth by O’Leary (1993), forms part of person-centred gestalt therapy. Rogers defined it as containing five elements, namely the ability of therapists: (1) to assume the internal frame

of reference of clients; (2) to perceive the world as clients do; (3) to perceive clients as they perceive themselves; (4) to lay aside any external frame of reference; and (5) to communicate their understanding to clients. The first

Person-centred gestalt therapy

29

four of these elements help to elucidate the listening step of empathy. Barrett-Lennard

(1976)

added

another

element,

namely,

checking

the

accuracy of the feedback. All these steps are involved in the definition of empathy in person-centred gestalt therapy. In a previous article, (O’Leary, 1993: 113) I have pointed out that “empathy may be likened to two tuning forks in the same key. When one is struck, the other picks up the sound emitted by the first, while losing nothing of its own essential nature. Empathy is tuning into the wavelength of the client. Counsellors must attune themselves to that particular wavelength.” Different types of empathy have been proposed. For example, Carkhuff (1969) distinguished between interchangeable empathy responses (where clients’ communication is accurately captured and reflected back without adding or subtracting any data) and additive empathy responses (where counsellors help clients to bring to awareness deeper, unexpressed feelings). Although associated with the person-centred approach, empathy is also a feature of gestalt therapy, which enhances and broadens the attitude adopted by the therapist. This empathic attitude can be clearly seen when the gestalt therapist says to the client, “I notice that you are clenching your fist”. I have previously stated (O’Leary, 1993) that empathy can be communicated as effectively through the overt recognition of clients’ non-verbal as through the expression of their verbal behaviours. The ability of therapists to retain the boundary between their own emotional life and that of their clients has been emphasized in gestalt therapy (O'Leary, 1997). If this does not occur, confluence may develop. Perls et al. (1951:

118) described confluence as occurring “when there is no discrimi-

nation of the points of difference or otherness that distinguish them”’. Unlike unhealthy confluence, empathy is a conscious choice on the part of therapists: in empathy, the recognition of separateness and relatedness coexist (O’Leary, 1997). Unconditionality

Unconditionality involves always being there for clients within the context of the therapeutic relationship. Hence, it is time-limited and bounded by a

professional context. It allows individuals to present themselves as they are, with all their vulnerabilities, and therapists to be there for them irrespective of felt degree of liking. The avoidance of both labelling and judgements of the behaviour of clients assists in the establishment of this process. Unconditionality leads to the development of trust when clients realize that therapists will be there for them as persons no matter what occurs. It does not mean that therapists agree with all clients’ behaviours, but rather that they accept them as persons. Thus, person-centred gestalt therapists would consider the abusing activity of sexual abusers to be a crime while accepting them as persons. However, this unconditionality can often be a

30

O'Leary

difficult attitude to acquire for therapists who have been victims of abuse themselves, and requires personal development work on their part. Unconditionality may be difficult to establish if clients have difficulty in trusting others. As early as 1939, Fromm considered that a failure to accept oneself is accompanied by a basic hostility towards others, while Horney (1939) went so far as to conclude that individuals who cannot attribute positive values to themselves are incapable of attributing them to other people. Individuals may present with such a low level of trust that they are unable to participate in therapy. However, if they share this issue, they can come to the realization that such a lack is mostly due to themselves rather than to others. Therapists can then invite clients to explore how they trust themselves. Authenticity Becoming authentic or congruent is central to person-centred gestalt therapy. In previous writings (O'Leary, 1982; O’Leary & Keane, 1997), I have referred to congruence as possessing the following characteristics: becoming one’s true self, excluding any pretence of acting or of being what one is not, and being honest and open. Authentic individuals seek to become ever more self-aware and self-accepting and not to play professional roles. Their abilities, talents and skills blend naturally into their everyday living. Within and outside their work environments, they are at ease with themselves since they are devoid of roles. Rogers (1961) believed that counsellors could only help others to the extent that they themselves had grown as individuals. He stated that “the degree to which I can create relationships which facilitate the growth of others as separate persons is a measure of the growth I have achieved in myself” (p. 56). Person-centred gestalt therapists attend to their own personal growth both during and after their professional training. Rosenblatt (1980), a gestalt therapist, stated that what therapists need to rely on is not their technique but their personal development and the quality of their contact with others. Authenticity can be both an attained and a becoming state. It is attained insofar as therapists are real in certain areas of their lives. Yet to be fully congruent is an ideal state. Authenticity can be viewed as a continuum on which some people remain at a fixed point throughout life while others progress. The more therapists engage in personal growth and development, the more likely it is that their authenticity will be enhanced. The

task—outcomes

The therapeutic process of clients within person-centred gestalt therapy consists of task—outcomes, so named because they are simultaneously its tasks and its outcomes. Eight different task—outcomes can be identified: (1)

Person-centred gestalt therapy

31

the sharing of stories; (2) the development of the ability to express feelings and accept them; (3) the awareness of the role of bodily experiencing; (4) the development of holistic awareness through the internal processing of experiences; (5) the growth of self-responsibility; (6) the development of interdependence rather than an unhealthy dependence on others; (7) the acquisition of the ability to centre and ground oneself; and (8) the completion of feelings relating to unfinished experiences in the past. Although they are not named as task—outcomes, reference is made to all of them in gestalt therapy literature (Perls ef al., 1951; Polster & Polster, 1973), while three of them — (2), (4) and (5) above — are central in personcentred literature.

The three phases of person-centred

gestalt therapy

These eight task—outcomes are viewed in person-centred gestalt therapy as occurring within three major phases of therapy, namely orientation, middle and final, which will now be outlined.

The orientation phase of person-centred gestalt therapy

In the orientation phase, clients view the problems that they bring to therapy as outside of themselves (Rogers, 1951) and share these problems in the form of story (a feature of gestalt therapy) (Polster, 1987). An example was provided by Cathy, a participant in a workshop, as follows. CATHY: I got burnt out with all the things going on in the city, horrible things were happening... and bussing to the school and...umm... Dan was drinking more and more so we decided to leave and were going to travel or go camping all summer from coast to coast and then back again... When we got out to California which is where Dan’s family was...umm... we didn’t have any money to come back and that’s kind of when it started you know . . . Dan didn’t work. He sat around smoking pot, building bookcases and being in union with nature. Cathy’s self-disclosure is in concrete terms with a focus on what Dan, rather than what she, did. This demonstrates the factual nature of disclosure in the

orientation phase. Clients tend to speak in great detail about externals and other people rather than about themselves. Acting in this manner allows Cathy to ignore the consequences of Dan’s actions on herself. In beginning disclosures, what is revealed by clients is monitored carefully with personal communication being centred on the sharing of ideas, achievements and circumstances in their lives. Since this sharing is often in

32

O’Leary

terms of what others did or are doing to them, clients view themselves as victims

rather

than

active

contributors

to their

own

difficulties,

thus

avoiding any sense of blame or guilt. However, they can experience a sense of helplessness since they feel that they are not responsible for the particular difficulty and that they cannot contribute to its solution. There is usually a checking of therapists to see if they are accepting these initial disclosures. As therapy progresses and clients begin to feel understood by therapists, they gradually identify and express feelings relating to their problems and issues. Both gestalt therapy and the person-centred approach abound in literature on this sharing of feelings (e.g. O'Leary, 1982, 1992; Polster & Polster, 1973). However, the movement to self-disclosure of feelings is gradual. Initially, when they are expressed, individuals are likely to view them as bad or shameful. Non-expression is often equated with control, yet true control involves the ability to express feelings appropriately. Invitations by therapists to own feelings through “I” statements are an effective way of enabling clients to get in touch with them (O’Leary, 1992). Issues brought to therapy by clients are usually presented in story form. Stories are particularly useful when one is dealing with difficult experiences, since the familiarity of the story can serve as a comfort. Using this familiar vehicle of communication can provide a point of entry to underlying painful experiences including unfinished situations (wherein feelings accompanying an experience remain unexpressed or not fully expressed) either from the past or the present that affect present functioning. Since unfinished situations press for attention and expression, their disclosure can result in a feeling of release. Thus, guilty individuals will often feel relief when admitting their misdeeds.

Polster and Polster (1973: 36) stated that when

unfinished business becomes “‘powerful enough, the individual is beset with preoccupation, compulsive behaviour, wariness, oppressive energy, and much self-defeating behaviour’. Resentments, according to Perls (1970), are the most common kind of unfinished business, involving demands that have not been made explicit. Since the experienced anger or hurt was never expressed, the emotion has grown into an enduring state of resentment which insists that the other person feel guilty. In this orientation phase of therapy, clients increase in awareness of their own bodily sensations. This can occur through therapists inviting them to pay attention to their physical experiencing when they either relate their stories or speak of feelings. Thus, the process can be either from the body to feelings or vice versa. The optimal direction will depend on the primary modality of the client (as outlined in Chapter 2).

The middle phase of person-centred gestalt therapy The middle phase is characterized by clients’ growing awareness of themselves as they process what is occurring internally, accept their feelings,

Person-centred

gestalt therapy

33

develop a sense of responsibility for themselves and recognize the value of interdependence. Gestalt therapists view awareness as being at the heart of their approach, while internal processing is reflected in references by Rogers (1961: 151) as coming closer and closer to ‘‘organismic processing”’. The processing of experience is the foundation of awareness. Without it, awareness cannot occur. Processing involves attention to the moment-bymoment experiencing of the individual. Like the waves in Shakespeare’s poem (Sonnet LX; Vendler, 1997), each experience takes the place of that which went before. The more clients engage in processing, the clearer their internal lives will become. Processing allows them to stay in the present moment and, by doing so, change occurs. From a gestalt therapy perspective, Beisser (1970) referred to this phenomenon as the paradoxical theory of change, while Rogers (1961) spoke of the flow of this process as emerging when individuals experience themselves as received, welcomed and understood as they are. In this phase, the goal of awareness is to bring individuals closer and closer to their ever developing and dynamic selves. The self is not viewed as a fixed entity but as ever evolving and growing. A feeling of excitement can emerge as clients realize that what they are and can become is ever increasing provided that they attend to their internal processing and developing awareness of themselves. In this middle phase of therapy, there is a greater acceptance of personal feelings, as is illustrated in a passage from Denis, a participant in a five-day workshop in the USA. DENIS: What people . feelings group, I find and

I realized was, I often expose my feelings to please other . . In this group, I have been staying in touch with what I need to express for myself... every time I do that in the feel content .. . and so what I’ve been staying with is trying to know that place.

The excerpt illustrates how important becoming aware and expressing his feelings for himself rather than for others was for Denis. The awareness of the rich tapestry of their world begins to develop for clients in this phase. They begin to explore how toxic or healthy feelings relating to their experiences are for them and are freed within themselves to attend to both verbal and nonverbal dimensions. In 1961, Rogers referred to feelings as bubbling up and seeping through with surprise or fright initially. Gradually, growing delight in them begins to occur. The tears of grief, the sighs of regret, the soft voice of love, the loud tone of anger, all begin to be part of the healthy development of the client. Bodily experiencing of feelings continues to develop in this phase. Ownership of feelings is part of the responsibility for the self that begins to emerge. Often members experience, for the first time, a sense of what

34

O'Leary

being adult really means. Outside of therapy, they may lean on others for support of different kinds. These supports can be subtle and so expected that individuals do not see their own lack of responsibility. For example, college-going students who live at home may not contribute to the practical day-to-day running of the home. The more individuals have been cosseted by their environment, the less likely they are to move rapidly to a selfsupporting stage. In this phase, clients become aware of unhealthy environmental support and begin the journey towards self-support. They realize that they cannot demand anything of others but rather that they can make a request to which others are free to respond as they choose. For example, individuals such as spouses, partners, girlfriends/boyfriends or friends whose birthdays have been ignored, and who are sorely disappointed, come to realize that they could have been more proactive in reminding their loved one of the occurrence. Growth in responsibility eliminates thoughts such as “If he/she loved me, he/she would have remembered”. Thus, self-support and interdependence begin to come into focus in the middle phase of therapy. Some individuals may consider that they have a right to be taken care of by others. As they become more self-supporting, they realize that they can do many things for themselves for which they previously depended on others. They gradually become aware of the difference between dependence and interdependence and they begin to realize that “‘the importance of interdependence and cooperation exists in tandem with self-support”’ (O'Leary; 19923122), Through their interaction with therapists, clients become aware of how their values,

self-disclosure,

expression

of themselves,

adherence

to the

familiar, and bodily communication affect their interpersonal interactions. They become more flexible and fluid in these interactions. This does not mean that others will view their ongoing growth in the same positive light. As people develop, they leave behind old patterns of dependency and focus on what they want. Those who have profited from their former dependent pattern may have difficulty in adapting to the new situation and view it with anxiety. Awareness thus leads to greater inner direction and selfsupport, and less unhealthy dependence on others. A balancing of receiving and giving begins to develop in the relationship of clients with others as their former dependence is replaced. The final phase of person-centred gestalt therapy

The characteristics of clients in the final phase include their ability to attend further to their ongoing internal processing, to identify any areas that may need closure, to be centred in themselves and to be able to say goodbye to therapists. In this final phase, individuals have integrated feelings relating to their past and present into their ongoing self-experiencing. They have come to

Person-centred gestalt therapy

35

accept these feelings to such an extent that they can allow them to flow both fully and immediately. They can experience the tears of their grief or the force of their anger. They have dropped negative evaluations and learnt that emotion can either enrich or control them. They realize that feelings exist and are neither good nor bad since they are not moral in themselves. In person-centred gestalt therapy, clients view themselves as constantly changing and developing over time. They are able to engage actively and spontaneously in their present experiences and feelings. These feelings are owned and there is a matching of them with thinking and expressing. Clients begin to experience themselves as fully human, fully alive (Powell, 1976). As they approach the conclusion of therapy, clients are usually more centred and grounded in themselves. Perls (1969: 57) spoke of the value of being centred as follows: ‘“‘achieving a centre, being grounded in oneself, is about the highest state a human being can achieve”. Being centred involves the freedom of attending to matters as they arise rather than behaving from a past or future focus. Centredness eliminates rumination and the endless and fruitless mental activity that accompanies it. It involves accepting, expressing and working through unfinished feelings and usually coincides with a sense of calm and of being at peace with oneself and the world. However, it is difficult to maintain this sense of centredness since there are ongoing demands from the environment. In the final phase, clients become aware that the nature of living means

that everyone, including themselves, has unfinished business in their lives and they explore this unfinished business whenever it occurs. They also realize that since living is a dynamic process, personal development will continue until death unless they experience cognitive deterioration. Although they have changed in the process of therapy, they realize that this is only part of a progressive and ongoing growth process. Subsequent to therapy, it can be easy for individuals to return to former patterns of behaviour and, although the awareness

gained will continue to exist, they

will need to continue to find ways to nourish its development in their everyday life situation. Returning frequently to their internal experiencing will assist them in the maintenance of this awareness. Saying goodbye is one of the tasks of the final stage of therapy. It usually brings a feeling of loss, since the safety and confidentiality experienced in therapy are for many rarely experienced in everyday life. In person-centred gestalt therapy, clients are invited to share how they feel about leaving. This allows them to express precisely what they want to disclose in an unstructured way. Some clients use this invitation to describe in great detail the learnings that were important for them. Verbalizing what these have been allows ownership and an increased awareness of them. The following excerpt illustrates the learning that occurred for Sarah during a five-day US workshop.

36

O'Leary

SARAH: and the other thing I wanted to share was this image that came to me this morning which fits for me in my life because I spend a lot of time practically next to nature. I realize the process ... nature... my life, you go, and you are quiet and you are there . . . to regain yourself and if you’re there long enough . . . and that’s what it feels like the internal process .. . but I realize that I’m not afraid to express myself. I was afraid to reveal myself, I just don’t want to do it for the wrong reason, I just want to do it for myself. The excerpt demonstrates how Sarah’s getting in touch with her internal process required both time and an atmosphere of quietness. In referring to learning at the termination of experiences, Clarkson (1989: 123) stated: “Learning to appreciate our experiences at points of completion seems to be one of the most significant and profound moments of existence.” Conclusion

Person-centred gestalt therapy integrates two humanistic approaches to therapy and is based on existential and humanistic assumptions. Healing is viewed as occurring during three phases of therapy through a relationship that offers empathy, unconditionality and authenticity coupled with the completion of eight task—outcomes by clients. This integration, the author believes, provides a more powerful framework than either therapy on its own. References Barrett-Lennard, G.T. (1962). Dimensions of therapists’ response as causal factors in therapeutic change. Psychological Monograph, 76, 562. Barrett-Lennard, G.T. (1976). Empathy in human relationships: Significance, nature and measurement. Australian Psychologist, 11(2), 173-184. Beisser, A. (1970). The paradoxical theory of change. In J. Fagan & I.L. Shephard (eds), Gestalt therapy now. Theories, techniques, applications (pp. 77-80). New York: Harper Colophon. Carkhuff, R.R. (1969). Critical variables in effective counsellor training. Journal of Counselling Psychology, 16, 238-245. Clarkson, P. (1989). Gestalt counselling in action. London: Sage. Cochrane, C.T. & Holloway, H.L. (1974). Client centered therapy and gestalt therapy: In search of a merger. In D.A. Wexler & L.N. Rice (eds), Innovations in client centred therapy (pp. 259-287). New York: Wiley. Fromm, E. (1939). Selfishness and self-love. Psychiatry, 2, 507-523. Horney, K. (1939). New ways in psychoanalysis. New York: Norton Press. Kepner, E. & Brien, L. (1970). Gestalt therapy: A behaviouristic phenomenology. In J. Fagan & I.L. Shepherd (eds), Gestalt therapy now: Theories, techniques, applications (pp. 39-46). New York: Harper Colophon.

Person-centred gestalt therapy

37

Maslow, A.H. (1954). Motivation and personality. New York: Harper & Row. Miller-O’Hara, M. (1984). Person centred gestalt: Toward a holistic synthesis. In R.F. Levent & J.M. Schlien (eds), Client centred therapy and the person centred approach (pp. 203-221). New York: Praeger. O'Leary, E. (1979). The counselling relationship: Core conditions and core outcomes. Unpublished PhD thesis, National University of Ireland, Cork. O'Leary, E. (1982). The psychology of counselling. Cork, Ireland: Cork University Press. O'Leary, E. (1992). Gestalt therapy: Theory, practice and research. London: Chapman & Hall. O’Leary, E. (1993). Empathy in the person centred and gestalt approaches. British Gestalt Journal, 2, 111-115. O'Leary, E. (1997). Confluence versus empathy. The Gestalt Journal, 20(\), 137-154. O'Leary, E. & Keane, N. (1997). Person centred therapy. In P. Hawkins & J. Nesteros (eds), Psychotherapy. New perspectives in theory, research and practice (pp. 131-146). Athens, Greece: Ellinika Grammata. Perls, F.S. (1969). Gestalt therapy verbatim. Highland, NY: The Gestalt Journal. Perls, F.S. (1970). Dream seminars. In J. Fagan & I.L. Shepherd (eds), Gestalt therapy now: Theories, techniques, applications (pp. 204—233). New York: Harper Colophon. Perls, F.S., Hefferline. R. & Goodman,

P. (1951). Gestalt therapy: Excitement and

growth in human personality. New York: Julian Press. Polster, E. (1987). Every person's life is worth a novel. New York: Norton. Polster, E. (1995). A population of selves: A therapeutic exploration of personal diversity. San Francisco: Jossey-Bass. Polster, E. & Polster, M. (1973). Gestalt therapy integrated. New York: Vintage. Powell, J. (1976). Fully human, fully alive. Niles, IL: Argus. Rogers, C.R. (1951). Client-centred therapy. New York: Houghton Mifflin.

Rogers, C.R. (1961). On becoming a person: A therapist’s view of psychotherapy. London: Constable & Constable. Rogers, C.R. (1980). A way of being. Boston: Houghton Mifflin. Rosenblatt, D. (1980). The dynamic process of support contact. Gestalt Journal, 3, 64-68. Satir, V. (1976). Making contact. Berkeley, CA: Celestial Arts. Shostrom, E.L. (1964). Three approaches to psychotherapy. Santa Ana, CA: Psychological Films. Stanley, C.S. & Cooker, P.G. (1977). Gestalt therapy and the core conditions of communication facilitation: A synergistic approach. In E.W.L. Smith (ed.), The growing edge of gestalt therapy. New York: Wiley. Vendler, H. (1997). The art of Shakespeare's sonnets. Cambridge, MA: Belknap Press.

Chapter 4

The narrative metaphor and the quest for integration in psychotherapy Jarl Wahlstrom

Within psychology, the past two decades have witnessed a move from a preoccupation with objectivistic and rational models to an understanding of human conduct in terms of constructionist, relativistic, and relational perspectives. The narrative approach situates itself within this “postmodern wave”’ (Kvale, 1990) of psychological thinking. This chapter approaches the issue of psychotherapy integration from this perspective. Many therapeutic orientations have turned towards holding transformations in personal meaning-making as the core of therapeutic change, and the concept of narrative has been used as a heuristic device in the description and understanding of such transformations. The narrative approach in psychology has been introduced by, among others, writers such as Bruner (1986), Holstein and Gubrium

(2000) and

Sarbin (1986), and in psychotherapy by McLeod (1997), Neimeyer Mahoney (1995), Parry (1991), Parry and Doan (1994), Rosen Kuehlwein

and and

(1996), Russell (1991), Schafer (1992), and White and Epston

(1990). Many writers, advocating a social constructionist understanding of human mind and action (Gergen, 1991; Harré, 1983; McNamee & Gergen, 1992; Shotter & Gergen, 1989), have contributed to the advancement of the

narrative as a basic metaphor for how persons construct and process knowledge. Recent publications, looking at how narratives work in different treatment contexts, examine a variety of topics, such as emotions and psychopathology (Sarbin & Keen, 1998), attachment and the therapeutic process (Holmes, 1999), physical illness (Frank, 1998; Weingarten & Weingarten Worthen, 1997), trauma (Meichenbaum, 1999; Sewell & Williams, 2002; Wigren, 1994), acute psychosis and schizophrenia (Holma & Aaltonen, 1998; Lysaker et al., 2001), dreams (Groves, 1997), empathy (McLeod, 1999: Omer, 1997), resilience (Neimeyer & Levitt, 2001), families with adolescents (Zimmerman & Dickerson, 1994), and supervision and case formulation

(Bob, 1999). Today narrative formulations inform theory-building in therapeutic orientations as different as humanistic—existential (Richert, 1999), cognitive—behavioural (Meichenbaum, 1995), cognitive—constructivist

The narrative metaphor and integration

39

(Goncalves, 1995; Ramsay, 1998), and solution-focused (Eron & Lund, 2002) approaches. Taking all this into account, it is not surprising that the narrative has been offered as a promising metaphor for integration in psychotherapy (e.g. Gold, 1996; Hermans & Hermans-Jansen, 1995). In this chapter, however, I do not aim at a comprehensive review of the literature on the topic but rather at bringing forth some ideas as an invitation to further dialogue. I wish to explore how an adoption of the narrative metaphor challenges our understanding of psychotherapy as a professional and social activity, and how a reframed understanding could form a platform for new kinds of discussion on differences and convergences among the therapeutic

orientations.

Psychotherapy as conversation My starting point is the particular quality of psychotherapy as a conversational mode

of treatment (Anderson

& Levin, 1998: Wahlstrém,

1990).

Each therapeutic encounter is established as a complex situation of interaction that includes two or more persons. In such situations, persons are present as embodied, physical individuals, and perceive and sense each other as such. In therapeutic sessions, as in any other interpersonal situation, the participants evoke in each other an abundance of sensations, reactions and feelings. A vast amount of these materialize on a level of nonand pre-verbal interaction. Still, I would like to argue, the sine qua non of psychotherapy as distinct from other treatment modalities is the use of words as specific and decisive tools of treatment. This idea was expressed by Thomas

Szazs who, according to Kenny (1988), referred to the use of

healing words, Recovery

iatroi logoi, as the basis of recovery

through

conversation,

therefore,

can

be seen

in psychotherapy. as the common

element of all psychotherapeutic modalities. But then we are bound to ask: recovery from what and how? A short answer to the first part of this question could be: recovery from a disturbed sense of agency. The process of recovery, again, can be conceptualized as a process of change of personal meanings given to actions, experiences and relationships. Such changes may be facilitated through the creation of various interpersonal conversational formats and can be described and understood as arising from restructuring or “‘re-visions” (Parry & Doan, 1994) of personal and collective narratives. Different psychotherapeutic approaches give different descriptions and understandings of how such change-facilitating conversational formats can be created. Looking at differences among approaches, we see that, in part, different schools give different descriptions of shared practices, and, in part, they offer genuinely diverse solutions to the problem of how to establish curative conversations. A fruitful exchange of views on commonalities

40

Wahlstrom

Oe

ee ek

a

a ag

a ne

ee

and differences between psychotherapeutic approaches could be reached within a theoretical discourse recognizing the common conversational basis of all psychotherapies. The growing interest in narrative approaches shown by representatives of diverse therapeutic traditions seems to point towards such a discourse.

A disturbed sense of agency There are a large variety of life situations that invite a person, or somebody in a person’s close environment, to seek help from conversational therapies. Such situations can be seen as having in common the experience of a disturbed sense of agency on the part of one or more persons. Efrain ef al. (1986) look upon such life situations as “rubs” in the act—context relationship within some sphere of the life of individuals. In some domain of activities, their doings are not in accord with expectations or understandings. There are actions individuals are expected to, or wish to, undertake, but do not; or actions taken that are not expected or wished for by either themselves or members of the close community. It is in this sense that what presents itself can be described as a problem of agency (Anderson & Goolishian, 1992). According to Efrain et al. (1986), these “‘rubs” are indicative of conflicted

positions of individuals within their social matrix. Usually the “‘rubs”’ are experienced by them as psychological symptoms, e.g. shifting moods, disturbing emotions, ambivalent loyalties, oscillating thoughts, fears, impaired decision-making, compulsive actions and sensations of confusion. I have previously argued (Wahlstrém, 1992), from a family systems point of view, that these individually experienced problems can, in the last resort, be related to difficulties of coordination of actions between members of the immediate social community of individuals, including themselves. What they can, or cannot, do is intimately bound to how their doings are positioned in the matrix of mutual actions constituted by the collaborators in that community. The coordination of actions is related to the social management of meanings (Cronen ef al., 1985) among members of action and speech communities. Practical activities correspond to semantic and textual networks that render practical activity realizable. The coordination of actions does not require that the collaborating actors possess identical significations of shared experiences and situations, but anomalies of meaning usually result in disturbed agency. An anomaly of meaning arises from some kind of conflict between an act or a proposition and the context through which this act or proposition gains meaning. Such an anomaly often brings about confusion and/or conflict at the level of action. It is difficult to do that to which you cannot give meaning.

The narrative metaphor and integration

41

Aspects of narratives Theorists adopting the narrative metaphor “are concerned with the way our mode of living reflects the representational structures that are imposed on our experience” (Murray, 1989: 177). The concept of narrative can be seen as a shorthand expression of what I refer to above as the semantic and textual networks rendering social and individual action possible. The anomalies of meaning, which have an impairing effect on a person’s sense of agency, can be seen as related to conflicted collective and individual narratives. Hanninen (2000) pointed out that, despite the increasing use of the term in different human sciences, there is no common understanding of how the concept of narrative should be defined. A narrative is usually understood to be a cognitive device or a heuristic through which persons create order out of experiential chaos (Ramsay, 1998) and render the uncommon comprehensible (Bruner, 1990). A narrative brings temporal structure to the flow of experience; it is conceived of as having a beginning, a middle and an ending. There is a quality of drama to narratives (Hanninen, 2000). Events are presented as embedded “in a moral and emotional tension field where fortune and misfortune, danger and rescue, honour and shame, defeat and

victory, unity and separation struggle with each other and turn into each other” (Hanninen, 2000: 126, my translation). By introducing plots into the flow of experience, narratives represent events as interconnected, and thus as caused and understandable. The structuring power of narratives over experience is both retroactive and proactive; past events are pictured as meaningfully connected, and ongoing and future experience will be selected to fit into the evolving plot of a narrative under creation. A distinction should be made between narratives as inner or outer performance. The personal narrative can be seen as “a heuristic by which individuals organize personal experience and identity” (Ramsay, 1998: 44). A personal narrative provides structure for organizing thoughts, motivations, memories, and life experiences. The natural ambiguity of life is thus decreased and coherence and internal consistency increased. Personal narratives are tools for the construction of personal meanings, a view that is also held by Goncalves and Machado (1999). The narrative, as told, is formed through the public presentation of personal narratives (Hanninen, 2000; Neimeyer, 2000). The act of narration is a social performance, which, only if successful, confers on its author a provisional fictional identity that meets with social validation. The performed narrative makes use of socially formed means of presentations such as words, pictures, symbols, metaphors, syntactic rules and discursive devices. A public narrative not only makes use of these tools and resources but is also informed and formed by them. A personal narrative can be made public in many versions and, in fact, will be, according to the social context

42

Wahlstrom

in which the story is told, and in relation to the rhetorical goals adopted by the narrator in that context.

The narrative production of identity According to Harré (1983), the primary realities of human existence consist of an unlimited array of persons and networks of symbiotic interactions (including both deeds and talk) between them. Individuation and the construction of identities result from processes of privatization and personalization of those networks. These processes are grounded in and shaped by a social and moral order that is based on collective systems of material production and on cultural modes of creation and maintenance of honour and value. The goal of individuation and identity construction is for individuals to find a place for themselves in the social order (Murray, 1989). From the developmental point of view, this is realized through psychological symbiosis between the future person (child) and a competent social actor (parent). In psychological symbiosis, the dominant and socially more experienced partner performs psychological tasks on behalf of the less experienced one. Harré (1983) described the construction of individuality as the transformation of public and collective social and discursive practices into private and individual ones. In his model, psychological space (1.e. the different forms psychological action takes) can be depicted as a two-dimensional grid that contains axes of display (public versus private) and realization (collective versus individual). This grid gives four fields or domains, which distinguish between different forms of display and realization of actions and practices: the public—collective, the collective—private, the private—individual, and the individual—public. In the production of individuality, four different forms of transition between the four domains may be distinguished. Through the process of appropriation, public and collective practices are adopted as private (performed by individuals on their own and displayed only to themselves), although still collective in their form of realization. One example of such a practice is egocentric speech as described by Vygotsky (1969), where individuals use public—collective forms of speech individually as a means of regulating their own activity. Appropriation as a mode of transformation of psychic activity is, according to Vygotsky, based on the ability of human beings to produce stimuli for themselves. Through this process, the individual human mind is created as a reflection of collectively produced linguistic forms and social practices. Through a second mode of transition, these appropriated and privatized collective forms of activity are transformed into genuinely individually realized ones. For instance, what we conceive of as personal will can be understood to form initially as the ability of developing individuals to take

The narrative metaphor and integration

43

requests of others privately into themselves, and later to transform these requests into personal (individual) ones, thus recreating the “‘voice of others” in their “own voice’’. Such idiosyncratic transformations are performed through the use of inner dialogues. An inner dialogue is a discursive practice that enables the realization of reflexive forms of activity, i.e. where individuals gain the ability to take psychological acts onto themselves. Thus, the transformation of appropriated activity forms into genuinely individual ones enables individuals to take possession of their own development. It could be argued that a necessary prerequisite of such transitions is the capacity of individuals for bearing solitude. Individualized activity forms and discursive practices, appropriated by individuals from the collective to the private, and transformed from the private to the individual, are returned to the public domain through a process of publication. Here the idiosyncratic transformations of appropriated collective activity forms are brought out in the public arena. But the destinies of these publications are not only determined by individuals themselves; it is also a question of how they are received. The realization of individualized practices in public display carries individual experience over into the social order. Through conventionalization, these personal innovations are adopted into the social and moral order. They thus become part of the current theories of personal being — the shared understanding of what it means to be a person — that are celebrated in the particular cultural context. According to Harré (1983), the social being of persons is created by the presentation of self in the public. The personal being is the product of appropriations and transformations of social resources including the local theory of selves. Thus, in his account, all psychological forms stem from appropriations and transformations of social forms, and human experience results from collective and individual interpretations of what nature provides; for example, emotions are interpretations of personal states, and these interpretations are always rendered within a moral order. Individuality forms when personal being becomes the person’s own project. This happens when psychological symbiosis dissolves and individuals take over the work of the dominant member of the dyad and thus create selfknowledge, self-mastery, and uniqueness. Murray (1989) pointed out the predominance of narrative in unique appropriations of the social order by individuals. According to him, there is a metaphoric relationship between prevailing “theories” of self and personhood and the experiences of individuals themselves. The apparent paradox inherent in Harré’s model — that a sense of personal self is gained only through social meanings — is resolved through the notion that social meaning is lived. Personal identity includes a sense of biographical uniqueness and a personalized point of view. According to Murray, “in Harré’s framework, it is the necessity of living out the appropriated social meanings

44

Wahlstrom

that reserves the place for point of view, and therefore the narrative sense of self” (Murray,

1989: 180-181).

This corresponds to Hanninen’s (2000) idea of a circulation of narratives. Persons make sense of their situation and create life projects according to narrative models drawn from the rich cultural sources of stories. The personal stories resulting from such sense-making inform and guide choices and

action

that form

the actual,

situationally

grounded

drama

of life.

Actions transform situations, thus changing the conditions of putting narrative life projects into effect. The events of life — the drama of life projects as they have been and are realized — are displayed in public as performed narratives. The telling of lived experience renders individual drama a part of the social drama of interaction between people, and a constituent of the cultural narrative resource, thus completing the circulation of narratives. This circulation is not unidirectional but moves back and forth between the different performances of narratives.

Psychotherapy projects

as symbiosis: joint work on identity

The preceding accounts of a constructionist and narrative approach to individualization and the production of identity have been formulated from a developmental point of view. This, however, is a lifelong process. Persons are repeatedly involved in the task of establishing and executing identity projects. Such endeavours become particularly pertinent in life situations where individuals find themselves facing a sense of disturbed or lost agency. As mentioned above, such circumstances often result in a decision to seek

help from conversational therapy. From this point of view, all forms of psychotherapy can be seen as joint work on identity projects involving a psychological symbiosis between the therapist as a “competent” social actor and the client as a “novice’’. Having stated this, it seems appropriate to recall that the word “therapy” originates from the Greek word therapon, which translates into English as ‘“‘servant”’. Therapon denotes a servant who is most faithful and devoted, and serves his/her master/mistress in a graceful and unselfish manner. Accordingly, the expertise of the therapist as ‘““competent”’ does not relate to problems in life but rather to the process of re-negotiating such problems. Being in some ways “‘novices”’ of the process, clients are, at the same time, the ‘“‘masters/ mistresses” of their own life project.

Comparison

and integration of therapeutic modalities

When one is approaching the question of comparison and integration of psychotherapeutic modalities from a narrative and constructionist point of view, one possibility is to look at how different therapeutic practices

The narrative metaphor and integration

45

contribute to the re-negotiation and re-formation of identity projects and individuality. McLeod (1997) held that all therapies are narrative therapies, i.e. all modalities of psychotherapy contribute to the re-storying of personal and lived narratives and to the establishment of new identity projects. This is the theoretical ground for looking at the narrative approach as a basis for integration in psychotherapy. Integration, however, can be achieved not on a loose notion of “everything being basically the same” but rather as a result of a critical investigation of similarities and differences. Harre’s (1983) model of identity formation through transitions between activity forms and Hanninen’s (2000) notion of circulation of narratives seem to be useful in such an investigation. It could be argued that the dyadic format of conversations characteristic of different forms of individual psychotherapy ts particularly apt to serve as a context for searching for and restructuring individual transformations of life experience. The dyadic conversation format grants the possibility for the externalization of inner dialogues, thus providing space for the re-transformation of individualized experiences and activity forms. The psychotherapist gains an exclusive position as a solitary listener, perhaps representing more an internalized other than an actual social audience. The therapist provides a context for restorying of personal narratives. In individual psychotherapy, space moves primarily from the domain of private-and-individual back to the collectiveand-private, and again — retransformed — to the private-and-individual. In therapeutic modalities based on multi-person conversational formats, such as group and family therapies, the public domain of psychological activity gains more importance. These therapeutic modalities include, in their session formats, persons who are present in the position of an actual social audience to each individual client. Thus, publication as a discursive

practice is introduced as an important form of therapeutic talk. The position of the therapist is not so much that of an “icon”’, representing the externalized

inner other, as that of a collaborative

conversationalist

in a

public and collective process of discourse. In this context, the narrative performed in the act of telling becomes the prominent medium of change. There is, however, an essential difference between groups and families as speech communities. Persons participating in therapy groups usually meet only within the context of the group sessions. Although they are present as actual

audiences

for each

other,

they are

not collaborators

outside

the

therapy situations. In couple and family therapy, the participants are jointly involved as protagonists in a shared narrative of life as drama. In the narratives told within family therapy sessions, those present are protagonists in one another’s stories, each one adopting his or her personal view of the events and experiences related. A substantial part of the therapeutic work will, therefore, consist of negotiating and re-negotiating the plots and meanings of stories told during sessions as well as the re-telling and reliving of these stories between sessions.

46

Wahlstrom

ele Diet ars eel

LR RD 1s

:

ET

OE

een

ee

ee

NG

Earlier in this chapter, I held that psychotherapy aims at diminishing disturbances of clients’ sense of agency. From a narrative point of view, such disturbances are seen to be related to inconsistencies and problems in individual and/or collective meaning-making. There is, though, an interesting difference in how such inconsistencies — or anomalies of meanings — are conceived of, depending on whether they are considered from the point of view of personal narratives or as lived drama. The concepts of coherence and authenticity seem to be appropriate when one considers how personal narratives contribute to the sense of agency of individuals. Looking again at collective narratives and the dramatic aspect of storying, the issue of how these performances afford coordination of actions seems relevant. Conclusions

The narrative and conversationalist approach to psychotherapy put forth here stresses the positions of therapists and clients as joint participants in an evolving process of reality construction. The therapeutic session can be conceived of as a stage on which, within the therapeutic conversation, new story-lines and narratives unfold. The goal of this process is to enable participants to take up new positions in respect to events or behaviours formerly represented as problems or symptoms. Such new positions, related to modifications in the individual and social systems of signification, help individuals

and

members

of social

collectives

(families,

groups,

social

networks) to regain a sense of agency and authority in their lives. This constructionist and narrative stance in thinking on psychotherapy orients therapists towards linguistic presentations, discourses, metaphors, stories and narratives, 1.e. the means of language through which social realities are collaboratively fabricated. Following these theoretical lines, all psychological therapies can be conceptualized as different modes of narrative and discursive therapies. From this point of view, the fundamental technical problem of psychotherapy is the question of how to establish change-facilitating conversational formats. The idea of a reflecting process (Andersen, 1990) holds that there should be opportunities for every participant in the therapeutic encounter to move from the position of an active conversationalist to that of an attentive listener. This gives participants the opportunity to shift constantly between an outer and an inner dialogue, thus encouraging different forms of narrative expression to materialize, and eventually to create space for reflections by individuals on personal meaning-making. The practice of psychotherapy can be seen as the offering of an abundance of narrative resources, both for professionals and for actual and prospective clients. These resources create new varieties of expressive and interpretive repertoires, forming the frames within which dramatic life events are given collective and individual meaning. By doing this, therapeutic practice gains

The narrative metaphor and integration

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meanings that go far beyond the walls of the consultation room. Therapy talk becomes subsumed into cultural theories on individuality, emotions, morals, and values. The narrative metaphor calls for an awareness of the political dimension of therapeutic work. As a ground for professional selfreflection, therapists, in a process of creative confluence (Gergen, 2000), have to consider how therapeutic narrative resources define the positions of clients and therapists as symbiotic partners in joint work on identity projects, and the cultural consequences of those definitions. References Andersen, T. (ed.) (1990). The reflecting team: Dialogues and dialogues about the dialogues. Broadstairs, UK: Borgmann. Anderson, H. & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee & K.J. Gergen (eds), Therapy as social construction (pp. 25-39). London: Sage. Anderson, H. & Levin, S.B. (1998). Generative conversations: A postmodern approach to conceptualizing and working with human systems. In M.F. Hoyt (ed.), The handbook of constructive therapies: Innovative approaches from leading practitioners (pp. 46-67). San Francisco: Jossey-Bass. Bob, S.R. (1999). Narrative approaches to supervision and case formulation. Psychotherapy, 36(2), 146-153. Bruner, J. (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press. Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Cronen, V.E., Pearce, W.B., & Tomm, K. (1985). A dialectical view of personal change. In K.J. Gergen & K.E. Davis (eds), The social construction of the person (pp. 203-244). New York: Springer-Verlag. Efrain, J.S.. Germer, C.K. & Lukens, M.D. (1986). Contextualism and _ psychotherapy. In R.L. Rosnow & M. Georgoudi (eds), Contextualism and understanding in behavioral sciences: Implications for research and theory (pp. 169-186). New York: Praeger. Eron, J. & Lund, T. (2002). Narrative solutions: Towards understanding the art of helpful conversation. In J.D. Raskin & S.K. Bridges (eds), Studies in meaning: Exploring constructivist psychology (pp. 63-97). New York: Pace University Press. Frank, A.F. (1998). Just listening: Narrative and deep illness. Families, Systems &

Health, 16(3), 197-212. Gergen, K.J. (1991). The saturated self. New York: Basic Books.

Gergen, K.J. (2000). The coming of creative confluence in therapeutic practice. Psychotherapy, 37(4), 364-369. Gold, J.R. (1996). Key concepts in psychotherapy integration. New York: Plenum Press. Goncalves, O.F. (1995). Cognitive narrative psychotherapy: The hermeneutic construction of alternative meanings. In M.J. Mahoney (ed.), Cognitive and constructive psychotherapies: Theory, research, and practice (pp. 139-162). New York: Springer.

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Goncalves, O.F. & Machado, P.P. (1999). Cognitive narrative psychotherapy: Research foundations. Journal of Clinical Psychology, 55(10), 1179-1191. Groves, J.E. (1997). The narrative and rhetoric of dreams: Six literary fragments by a novelist. American Journal of Psychotherapy, 51(1), 1-13. Hanninen, V. (2000). Sisdinen tarina, elama ja muutos [Inner narrative, life and change]. Acta Universitatis Tamperensis, monograph 696. Harré, R. (1983). Personal being. Cambridge, MA: Harvard University Press. Hermans, H.J. & Hermans-Jansen, E. (1995). Self-narratives: The construction of meaning in psychotherapy. New York: Guilford Press. Holma, J. & Aaltonen, J. (1998). Narrative understanding in acute psychosis. Contemporary Family Therapy, 20(3), 253-263. Holmes, J. (1999). Narrative, attachment and the therapeutic process. In C. Mace (ed.), Heart and soul: The therapeutic face of philosophy (pp. 147-161). Florence: Taylor & Francis/Routledge. Holstein, J.A. & Gubrium, J.F. (2000). The self we live by: Narrative identity in a postmodern world. New York: Oxford University Press. Kenny, V. (1988). Guest editor’s foreword. Irish Journal of Psychology, 9, i-iil. Kvale, S. (1990) Postmodern psychology: A contradictio in adjecto? Humanistic Psychologist, 18(1), 35-54.

Lysaker, P.H., Lysaker, J.T., & Lysaker, J.T. (2001). Schizophrenia and the collapse of the dialogical self: Recovery, narrative and psychotherapy. Psychotherapy, 38(3), 252-261. McLeod, J. (1997). Narrative and psychotherapy. London: Sage. McLeod, J. (1999). A narrative social constructionist approach to therapeutic empathy. Counselling Psychology Quarterly, 12(4), 377-394. McNamee,

S. & Gergen, K.J. (eds) (1992). Therapy as social construction. London: Sage. Meichenbaum, D.H. (1995). Cognitive-behavioral therapy in historical perspective. In B.M. Bongar & L.E. Beutler (eds), Comprehensive textbook of psychotherapy: Theory and practice (pp. 140-158). London: Oxford University Press. Meichenbaum, D.H. (1999). Behandlung von Patienten mit posttraumatischen Belastungst6rungen: Ein konstruktiv-narrativer Ansatz. Verhaltungsterapie, 9(4)

186-189. Murray, K. (1989). The construction of identities in the narratives of romance and comedy. In Shotter, J. & Gergen, K. (eds), Texts of identity: Vol. II (pp. 176-205). London: Sage. Neimeyer, R.A. (2000). Narrative disruptions in the construction of self. In R.A. Neimeyer & J.D. Raskin (eds), Constructions of disorder: Meaning-making frameworks for psychotherapy (pp. 207-242). Washington, DC: American Psychological Association. Neimeyer, R.A. & Levitt, H. (2001). Coping and coherence: A narrative perspective on resilience. In C.R. Snyder (ed.), Coping with stress: Effective people and processes (pp. 47-67). London: Oxford University Press.

Neimeyer, R.A. & Mahoney, M.J. (1995). Constructivism in psychotherapy. Washington, DC: American Psychological Association. Omer, H. (1997). Narrative empathy. Psychotherapy, 34(1), 19-27. Parry, A. (1991). A universe of stories. Family Process, 30, 37-54.

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Parry, A. & Doan, R.E. (1994). Narrative therapy in the postmodern world. New York: Guilford Press. Ramsay, J.R. (1998). Postmodern cognitive therapy: Cognitions, narratives, and personal meaning-making. Journal of Cognitive Psychotherapy, 12(1), 39-55. Richert, A.J. (1999). Some thought on the integration of narrative and humanistic/ existential approaches to psychotherapy. Journal of Psychotherapy Integration, 9(2), 161-184. Rosen, H. & Kuehlwein, K.T. (eds) (1996). Constructing realities: Meaning-making perspectives for psychotherapists. San Francisco: Jossey-Bass/Pfeiffer. Russell, R.L. (1991). Narrative, cognitive representations, and change: New directions in cognitive theory and therapy. Journal of Cognitive Psychotherapy, 5(4), 239-240. Sarbin, T.R. (ed.) (1986). Narrative psychology. New York: Praeger. Sarbin, T.R. & Keen,

E. (1998). Sanity and madness: Conventional and unconventional narratives of emotional life. In W.F. Flack & J.D. Laird (eds), Emotions in psychopathology: Theory and research (pp. 130-142). London: Oxford University Press. Schafer, R. (1992). Retelling a life: Narration and dialogue in psychoanalysis. New York: Basic Books. Sewell, K.W. & Williams, A. (2002). Broken narratives: Trauma, metaconstructive gaps, and the audience of psychotherapy. Journal of Constructivist Psychology,

15(3), 205-218. Shotter, J. & Gergen, K.J. (1989). Texts of identity. London: Sage. Vygotsky, L.S. (1969). Thought and language. Cambridge, MA: MIT Press. Wahlstrém, J. (1990). Conversations on contexts and meanings: On understanding therapeutic change from a contextual viewpoint. Contemporary Family Therapy, 12(5), 455-466. Wahlstrém, J. (1992). Merkitysten muodostuminen ja muuttuminen perheterapeuttisessa keskustelussa [Semantic change in family therapy]. Jyvdskyld Studies in Education, Psychology and Social Research, monograph 94. Weingarten, K. & Weingarten Worthen, M.E. (1997). A narrative approach to understanding the illness experiences of a mother and daughter. Families, Systems & Health, 15(1), 41-54. White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. Wigren. J. (1994). Narrative completion in the treatment of trauma. Psychotherapy, 31(3), 415-423. Zimmerman, J.L. & Dickerson, V.C. (1994). Using a narrative metaphor: Implications for theory and clinical practice. Family Process, 33, 233-245.

Chapter 5

Gestalt reminiscence therapy Eleanor O’Leary and Nicola Barry

The glorification of youth in modern culture may well have contributed to the reluctance of helping professionals to consider older adults as a priority with regard to the provision of counselling and therapy support. Some theories of old age (e.g. disengagement theory — Cumming et al., 1960; Cumming & Henry, 1961) have been complicit in constructing an image of later life that is synonymous with decline. However, the field of counselling psychology has begun to address the needs of this once neglected but rapidly growing section of the population. An overview (O’Leary, 1996) of research outcomes relating to counselling of older adults revealed that reminiscence therapy was an approach that held promise for working with this age group and that reminiscence could “improve life satisfaction and psychological well-being” (p. 149). An identified limitation of the approach was its primary focus on the processing of past experiences. This issue was addressed through the birth of an integrative approach — gestalt reminiscence therapy (O’Leary & Barry, 1998, 2000) — which may be applied in either an individual or a group context. This integration combines the storytelling of reminiscence therapy with the emphasis on feelings, unfinished business, contact, present centredness and responsibility of gestalt therapy. Gestalt reminiscence therapy is based on the assumption that older adults continue to develop in the emotional, social and spiritual dimensions of their lives up to the point of death. Through attending to this ongoing development, the approach endeavours to facilitate older adults in their journey towards enjoying full and satisfying lives. Factors such as personal choice and commitment to change are integral to this developmental process. Development is viewed as being contextually influenced — emerging from the interaction of people with their environment — and as being enhanced or constrained depending on the flexibility of both. Therefore, the context in which older adults live must be considered if their psychological needs are to be fully explored. While the emphasis is on the potential for enhancement of quality of life, the boundaries and finiteness of life are also acknowledged. Acknowledging that loss is part of all stages of human experience serves to counter the

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segregation of old age from the rest of the lifespan. The approach assists individuals in exploring their thinking and feelings about bereavement and death (including their own future death) in a relational context. Space is created to process these experiences, a process in which it may be difficult to engage with family members. Engagement with others in a group context provides support and adds to the ongoing appreciation of one’s own contribution in life. The goals of the approach will now be outlined. Goals

Three goals may be identified: raising self-esteem, living in the present, and increasing inner support. Raising self-esteem

Given that success is narrowly defined in contemporary society, one of the means that may be available to older adults to increase self-esteem is the sharing of individual stories in a group context. Working with stories provides rich opportunities for the facilitation of growth, as the narrative form allows not only the exploration of the past but also contact with the present and anticipation of the future. From reviewing studies in the field, Kovach (1990) suggested that reminiscence helps people to develop selfknowledge leading to improved self-esteem, contentment with both past and present, and improved affect.

Storytelling is a means through which individuals become known to themselves and to others. Through stories, older adults “own” significant aspects of their lives. They gain a sense of their own worth as their stories imbue them with status within the group. For example, the achievement experienced in raising a large family does not finish with their children reaching adulthood but lives on as a source of pride as they recount it to the group. A further example is given in the following passage. 1466 1467 1468 1470 1471 1472 1473 1474 1475

Mrs Sullivan

Mr Murphy =Ruth Mrs Sullivan Mr Murphy Mrs Sullivan Mr Murphy

Now Mr Murphy, you tell us your little story... (laughing ) It’s all right, I’m listening to you (“Tell me a story” (singing, in a hoarse voice) [No, now you'll have to tell us a little story (ina sober voice) The only stories I have are of wartime... Yes... But they can be very interesting too... Well, they can...

[ denotes overlapping speech

Mr Murphy’s initial dismissive attitude toward his own wartime stories is indicated in his use of the word “only”. However, the persistence of

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another member, Mrs Sullivan, results in him admitting that stories can be

interesting and he subsequently shares his achievements as an RAF pilot during the Second World War. The excerpt illustrates the integration of reminiscence and gestalt therapies through its focus on stories, a methodology of both. Furthermore, the communicative mode of singing used by one participant demonstrates the creative use of gestalt therapy. The use of song was a feature of this woman’s participation in the group and was employed by her frequently. This spontaneity was encouraged by the facilitator in a previous session when she explored whether participants liked to sing. Older adults’ appreciation of themselves is enhanced by the presence of an attentive audience that listens carefully and with interest. Bender ef al. (1999) pointed out that reminiscence groupwork can light the spark of selfregulation. An inherent feature of storytelling is self-disclosure. Its positive impact has been highlighted by a number of researchers. Derlega et al. (1993: 111— 112) summed up its benefits as follows: “‘Self-disclosure about personal events that are perceived as stressful can improve health as well as increase one’s self-esteem and ability to cope’. They stated that a positive relationship exists between non-disclosure and difficulties in physical and affective functioning. This has many ramifications for older adults, who may not feel that they have a voice concerning their own lives. Derlega et al. further noted that disclosure to others can provide access to various forms of social support such as esteem support and motivational support. Esteem support refers to the experience of being cared for and accepted by others at times when one’s feelings of self-worth are under threat, and is particularly important in instances such as strokes and paralysis. Sarason et al. (1990) have linked such acceptance to anxiety reduction. Expressions of warmth and concern from other members and the facilitator, coupled with the knowledge of one’s unique contribution to the group, can encourage acceptance of self. Group members may offer motivational support through encouraging each other in their attempts to cope with challenging situations. Self-esteem can be enhanced through realizing one’s importance in the group as both a provider and a recipient of feedback and support. As they become aware of previously unexplored aspects of themselves, the intrapersonal and interpersonal aspects of the lives of participants are augmented. In the supportive, non-judgemental atmosphere of the group, such assimilation can result in an expansion of self-knowledge and a realization that they are the agents of their own change.

Living in the present

Living in the present is an essential feature of healthy growth in old age. Such growth can be interrupted by unfinished business or demands from

Gestalt reminiscence therapy

the environment.

When

these demands

53

are excessive, attention is diverted

outwards, often resulting in a loss of centredness in the individual. To regain a sense of groundedness, it is necessary to turn attention inwards. Attention to one’s internal experiencing serves to balance feelings of helplessness that may be associated with an awareness of constraints in the external world. Thus, healthy current experiencing includes an awareness of what is significant in both the external and internal environments and what is figural. Focusing (Gendlin, 1981, 1984) assists the development of such awareness through enabling clients to develop a ‘‘felt-sense”’ (1984: 77) of aspects of themselves. Contacting such unknown aspects is facilitated, according to Mearns and Thorne (1997: 48), through focusing on “‘the edge of awareness”. Psychological growth is impeded without this inward attention to experiencing and its processing. Through this processing, an internal locus of evaluation develops. Living in the present involves attention to both the past and the present, including the life-enhancing people and events that individuals have previously encountered and that live on in their memory. The integration of past and current experiences often occurs when an event is encountered that is associated with a similar previous incident. An example of this phenomenon

was the aftermath

of the death of Diana, Princess of Wales, when

large numbers of people grieved publicly for her. Although the emotion may have been somewhat connected to her death, it is likely that much of the expressed grief derived from their own unexpressed feelings relating to a past death or loss. Repetitive story-telling may be either an indication that the hoped-for response has not been obtained from the listener or a sign of unfinished business. Some emotion experienced at the time of a significant event was not dealt with and remains with the individual many years later. These emotions can be either toxic or healthy. The recounting of stories holding positive affect can be a source of satisfaction and self-esteem. However, negative affect resulting from unfinished stories can sap energy. These stories can be distinguished from healthy recollections in that the latter are devoid of resentment, anger and guilt. In accounts of unfinished business, it is important to identify the particular feeling involved in terms of both its location and its expression in the body. In the case of older adults, the verbalization of emotion may precede its bodily identification. Once the feeling is worked through, individuals may continue to refer to the incident but without the emotional intensity of feeling with which it was previously associated. The psychological energy previously invested in the feeling becomes available to the person for more constructive use. When older adults consider the death of a peer, past, present and future come together to form a meaningful gestalt. In her research, the first author (O’Leary & Nieuwstraten, 2001b) found that a death in the family circle or

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in the nursing home was a trigger for therapeutic work for older persons. This trigger is usually accompanied by stories relating to the deceased person, which can often move older adults to contemplate their own deaths. Group members are encouraged to make “I’”’ statements when exploring their mortality. Paradoxically, through focusing on feelings associated with the boundaries of life and death that emerge in the present, the therapeutic work takes on a prospective quality in terms of moving towards acceptance of an inevitable event. A participant in the Cork Older Adult Intervention Project (O’Leary & Nieuwstraten, 1999, 2001a, 2001b) — an ongoing project with older adults, in which the authors are engaged — frequently used the phrase ‘“‘Press on redundantly” when exploring his thoughts and feelings around his own death. It emerged that he felt he would be forgotten once he died (O’Leary & Nieuwstraten, 2001la) and chose to express his present feelings relating to his own future death in this manner. Gestalt reminiscence therapists ignore neither the past nor the future in the lives of clients but rather work on both from the perspective of the present. Living in the present allows the exploration of ambiguity that often emerges when individuals are open to emerging experiences and circumstances. It also encourages the ability to respond to new challenges. Thus, the future is viewed with optimism. A further example of this present—future preparation is given in the following excerpt where Ruth has previously revealed to the group that she would like if her son visited her more frequently in the nursing home. 339

Ruth

But I’d like to see him...

343 344

Ruth Facilitator

and I miss that... And have you told him?

349 350

Facilitator

And have you to/d George that you'd like him to come and visit you . . . more often?

357 358 359 360 361 362 363 364 365 366 367

Ruth Facilitator Ruth

Norns And... can you say it to him. . .? (pause) Well, the next time he’ll come down, I’ll Sayiitiws 2 What will you say to him. . .? I'll just say, that I love him dearly, like all of them Mmmmmmm And eh... I think they’re the best in the world . Mmmmm And eh... I'd like to see him more often . . .

Facilitator Ruth Facilitator Ruth Facilitator Ruth

Gestalt reminiscence therapy 368 Mrs Sullivan 369 = Facilitator

Yes! Yes

370

That’s nice to know that

=Mrs Sullivan

55

Attending to the present allows the participant to express how she feels about the situation, as evidenced in lines 343 and 362, and to say what she wants from him (line 367) on his next visit. This rehearsal emerges as a

result of the interventions of the facilitator outlined in lines 344, 349/350, 358 and 361. The attentiveness of the audience for this rehearsal is illustrated in the spontaneous “‘yes’’, “‘yes’’ of both Mrs Sullivan and the facilitator. In the first author’s previous writings (1992: 69), she pointed out that rehearsal techniques were often used “‘so that clients may model reactions to experiences with which they have difficulty . . . new modes of action are put into practice through rehearsal. This provides the level of encouragement necessary to deal with the emotions which emerge. They then attempt the same in a less supportive situation outside therapy.” She pointed out that rehearsal ‘“‘can be particularly useful if the person is apprehensive about dealing with some situation in the future, such as going for a job interview or job promotion” (1992: 70). Thus, by using rehearsal in the present, Ruth was able to express to her son, on his next visit, her wish to

see him more often. Living fully in the present results in older adults attending to their own needs rather than responding solely to the needs of others. This process may require a re-examination of values and attitudes. Rigid adherence to beliefs can result in stagnation, while healthy growth is characterized by excitement, fascination and a willingness to move beyond responding in a reactive, habitual manner. This excitement emerges from the energy that accompanies fluid boundaries. If older adults are to develop psychologically up to the point of death, they need to possess a fluid and open attitude towards later life. This attitude allows them to uncover available choices, to take responsibility for how they wish to respond to the issues and circumstances

of their lives, and to choose

for themselves.

However,

for some

older people, there are a limited number of endeavours in which they are invited to participate, thus limiting the possibility of living in the present as fully as they might. Increasing inner support

The development of inner support involves becoming responsible for oneself, a central focus of the work of Perls (1969). In gestalt reminiscence therapy, clients are encouraged to move from a state of dependence on others to a state of being self-supporting in which they realize that they can do many things for themselves. The gestalt reminiscence group can be a safe

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haven in a world that can be fraught with loss of independence. This loss may be heightened in nursing home settings, as illustrated in a comment about residents by a carer who participated in an awareness raising group for carers in the Cork Older Adult Intervention Project.

50 Carer SI 32 53 54 Facilitator 55° Carer 56 Sif 58 SP 60

You leave your real personality outside. You come in here and you're a resident. It’s just the feeling that you can’t be your own person any more. You're part of a thing, a system — your individuality is gone. Does that happen straight away when you come in? Something dies in you when you come in that door and then it’s a gradual deterioration all the way down, until you feel yourself you are part of the system, fighting to keep your independence but after a while you just fall in and that’s the way you behave and you don’t even realize what’s after happening to you.

Participation in such awareness-raising groups by carers influences the quality of life and inner support of residents. By acknowledging the individuality of each older person, both carers and therapists are less likely to encourage dependence. This individuality is heightened when due respect is given to their stories. Positive support of older adults leads to their empowerment while unhealthy assistance is characterized by a lessening of their decision-making ability, their capacity to initiate new activities and their sense of personal contact. The importance of inner support is most apparent in its absence. Individuals low on this dimension look outwards to the environment for a sense of their own worth. The goal in gestalt reminiscence therapy is to facilitate an internal movement within older adults where responsibility for self begins to emerge. In this process, a sense of mastery emerges as individuals increasingly take charge of their own lives. By demonstrating trust in older adults, gestalt reminiscence therapists allow them to trust themselves and thus become empowered. This empowerment was apparent in the case of Ruth, who felt free to express much of her communication through song, thus displaying her high level of inner support. Empowerment can be distinguished from an unhealthy dependence, as was discovered

in the research of Hanson

and Lubin

(1986), who

found

an inverse relationship between self-support and dependence on others. Dependence on others is manifested in statements such as “Nobody cares about me”. In contrast, healthy older adults do not wait for others to recognize their needs but ask for what they want with the understanding that the potential respondent has the right to agree or disagree. Supporting oneself includes acceptance of both oneself and others and exists in tandem with interdependence and co-operation (O’Leary, 1996).

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In the nursing home context, the group can provide an important ancillary social support function, particularly if contact with family members is not regular. This support allows an expansion of personal boundaries to encompass a view of oneself as connected to other members through both emotional and social ties. In this manner, helplessness and dependency, which might be increased through institutionalization, can be partly counteracted. However, it is important that, at all times, older adults in nursing homes are invited but not required to.attend either groups or individual reminiscence sessions.

The role of therapists In gestalt reminiscence therapy, respect can be communicated in the very first session through empathic listening, which affirms the worth of individuals and their stories. Empathy has a supportive function in that it assists in the creation of a climate of perceived safety that allows older adults to delve deeper into their internal experiencing. This enables them both to contact and to express their feelings. Within gestalt reminiscence therapy, special attention is given to counsellor attitudes and client beliefs that may hinder progress. Counsellors may be fearful of the ageing process, hold the belief that problems in later life are solely due to either organic brain disease or general deterioration associated with old age, or experience an inability to deal with death and bereavement. It is imperative that such attitudes and beliefs be explored and challenged in counsellor training courses. Similarly, the beliefs held by some older adults may make it difficult for them to avail themselves of counselling support or may serve to block the counselling process; for example, the perception that attending counselling is synonymous with mental illness or cultural views positing that appropriate support for problem resolution resides in the family or with a higher power (O’Leary, 1990). Therapists seek to enhance contact at both intrapersonal and interpersonal levels. Contact within refers to internal organismic processing and experiencing. It is not uncommon for people to become flooded and to lose the ability to centre themselves when demands from the environment are excessive. The creation of time and space for internal work must be prioritized if development is to occur. This requires a decision on the part of older adults with respect to time. The use of time in spiritual development was illustrated by a 90-year-old in a nursing home when, irrespective of visitors, she insisted on maintaining her personal boundaries by specifying a definite time for God each day. She was aware of her own needs and made choices that were congruent with her values. This attention to her internal life was also evident in the group when her behavioural choices were grounded in her own organismic valuing process rather than being driven by the “wants” or “shoulds”’ of family, friends or nursing staff.

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The facilitation of good interpersonal contact requires the management of boundaries. At times, one member may interrupt another’s work. Although it is important to hear and respect the interjector’s input before returning to the original theme, it is also essential that the process of exploration with the working member not be disrupted unduly. In these cases, facilitators acknowledge and affirm the member’s contribution. They then bracket it off (Polster & Polster, 1973) and address it at another time. If such interjections occur early in group sessions, it is important that facilitators use this method so that group members become familiar with it. In work with older adults in nursing homes, it has been our experience that they are extremely keen to share their stories immediately at the commencement of the group and thus may interrupt frequently. Bracketing off ensures that all stories are heard in a non-threatening atmosphere in which self-disclosure can occur, thus enhancing interpersonal contact and cohesion within the group. Therapists encourage a participative style among group members. They seek to build bridges between the stories of participants. These bridges help to develop authentic contact and the evolution of a group identity. Stories or issues presented by two different individuals may appear initially to be unrelated, but by identifying a common theme, facilitators enable the work to move forward. They can encourage group members to talk directly to one another, thus furthering the development of interpersonal contact. The aim is to develop a supportive network of friendships within the group through authentic contact. Moreover, interaction between members of the group outside sessions can further expand their social and emotional worlds. Research

To date, research on gestalt reminiscence therapy has been conducted in nursing homes. Since such research is in an exploratory phase, qualitative methods have been employed. Three studies by O’Leary and Nieuwstraten (1999, 2001a, 2001b) have explored the themes of unfinished business, death and dying, and memories in gestalt reminiscence group-work. In the first study of seven older adults, O'Leary and Nieuwstraten (1999)

found that at the beginning of therapy, participants spoke of unfinished business in impersonal terms. During therapy, therapists assisted clients to personalize their stories from the past in order to allow the process of working through this unfinished business to begin. In the second study (2001b), the authors examined

the exploration of memories

by five older

adults and discovered that participants felt empowered through knowledge of their past and experienced increased self-esteem through recollection of their achievements. They also found that gestalt reminiscence therapy facilitated the identification of unfinished business. The final study

Gestalt reminiscence therapy

59

investigated the subject of death and dying with seven older adults in a gestalt reminiscence therapy group (2001la). Findings, some reminiscence based and some present centred supported the existence of Kubler-Ross’s (1973) stages of denial, depression and acceptance. In addition, the results

identified a fear of being forgotten. Coping mechanisms such as deflection, as well as the creative resources of song, prayer and humour, were used in helping older adults to discuss death. Overall, the studies supported the integrative nature of gestalt reminiscence therapy through both their use of gestalt therapy concepts and techniques and the focus on story, a feature of gestalt therapy but the central focus of reminiscence therapy. Further studies involving the themes of all three studies need to be undertaken so that saturation of data may be attained, thus strengthening the validity of emerging findings. Conclusion

Gestalt reminiscence therapy draws on a lifespan developmental model of the person in which ongoing personal growth is viewed as not only possible but also desirable. Within approaches to integration in psychotherapy, it falls into the classification of theoretical integration since it integrates gestalt and reminiscence therapies. Outlined previously by O’Leary and Barry (1998, 2000), it has obtained some research support from O’Leary and Nieuwstraten

(1999, 2001a, 2001b). The focus of gestalt reminiscence

therapy is on improving the quality of life of older adults through three goals, namely, raising self-esteem, living in the present, and balancing selfsupport and interdependence. The role of therapists involves the provision of empathy, the enhancement of intrapersonal and interpersonal contact, and the encouragement and management of boundaries and of participation among group members. To optimize their role, it is essential that they work through any ageist attitudes that they possess. References Bender, M., Bauckham, P., & Norris, A. (1999). The therapeutic process of reminiscence. London: Sage. Cumming, E., Dean, L.R., Newell, D.S., & McCaffrey, I. (1960). Disengagement: A tentative theory of aging. Sociometry, 22, 23-35. Cumming, E. & Henry, W.E. (1961). Growing old: The process of disengagement. New York: Basic Books. Derlega, V.J., Metts, S., Petronio, S., & Margulis, S.T. (1993). Self-disclosure. Newbury Park, CA: Sage. Gendlin, E. (1981). Focusing (2nd edn). New York: Bantam. Gendlin, E.T. (1984). The client’s client: The edge of awareness. In R.F. Levant & J.M. Shlien (eds), Client-centered therapy and the person-centered approach: New directions in theory, research, and practice (pp. 76-107). Westport, CT: Praeger.

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Hanson, P.G. & Lubin, B. (1986). Support systems: Understanding and using them effectively. Organisation Development Journal, 4(4), 59-66. Kovach,

C.R. (1990). Promise

and problems in reminiscence

research. Journal of

Gerontological Nursing, 16(4), 10-14. Kubler-Ross, E. (1973). On death and dying. London: Routledge. Mearns, D. & Thorne, B. (1997). Person-centred counselling in action. London: Sage. O’Leary,

E. (1990).

Cultural

differences

between

Ireland

and

the USA

in the

perception of friendship, the development of trust and problem coping behavior: A phenomenological investigation with implications for counseling. Cross Cultural Psychology Bulletin, 24, 9-12. O’Leary, E. (1992). Gestalt therapy: Theory, practice and research. London: Chapman & Hall. O’Leary, E. (1996). Counselling older adults: Perspectives, approaches and research. London: Chapman & Hall. O’Leary, E. & Barry, N. (1998). Reminiscence therapy with older adults. Journal of Social Work Practice, 12(2), 159-165. O'Leary, E. & Barry, N. (2000). Older adults. In C. Feltham & I. Horton (eds), Handbook of counselling and psychotherapy (pp. 642-648). London: Sage. O’Leary, E. & Nieuwstraten, I. (1999). Unfinished business in gestalt reminiscence therapy: A discourse analytic study. Counselling Psychology Quarterly, 12(4),

395-411. O’Leary, E. & Nieuwstraten, I. (2001a). Emerging psychological issues in talking about death and dying: A discourse analytic study. International Journal for the Advancement of Counselling, 23(3), 179-199. O'Leary, E. & Nieuwstraten, I. (2001b). The exploration of memories in gestalt reminiscence therapy. Counselling Psychology Quarterly, 14(2), 165—180. Perls, F.S. (1969). Ego, hunger and aggression: The beginning of gestalt therapy. New York: Random House. Polster, E. & Polster, M. (1973). Gestalt therapy integrated: Contours of therapy and practice. Oxford: Brunner/Mazel. Sarason, I.G., Sarason, B.R. & Pierce, G.R. (1990). Social support: The search for theory. Journal of Social & Clinical Psychology, 9(1), 133-147.

Chapter 6

Hypnoanalysis An integration of clinical hypnosis and psychodynamic therapy Peter J. Hawkins

Hypnosis and psychodynamic

therapy

The central concepts of psychodynamic psychotherapy are based on the broad principles of psychoanalytic theory. The therapy is often short-term and time-limited (Budman & Gurman, 1988; Strupp & Binder, 1984) and is intended to uncover and illuminate the origins of symptomatology linking the present to the past and behaviour to motivation. Psychopathology is understood as a product of repression and dissociation and therapy is designed both to identify the repressed dynamics and to allow clients to gain insight into formative experiences at physiological, affective and cognitive levels. Psychoanalytic perspectives refer specifically to Freudian principles and techniques, and therapy is generally long-term. However, many therapists (e.g. Balint, 1968; Davanloo, 1978; Malan, 1963; Sifneos, 1979) now employ

short-term dynamic therapy, which has been substantially influenced by developments in humanistic, phenomenological, transactional, and behavioural approaches. Nevertheless, in terms of their central propositions, all these therapies stay remarkably close to the theory propounded by Breuer and Freud (1895/1955). The most important dynamic concepts include:

the influence of the individual’s past on their current functioning the importance of the unconscious mind in determining how a person functions psychosomatically the repression of traumatic experiences the somatization (hysterical conversion) of repressed negative affect the unconscious dynamic resistance the development of ego defence mechanisms and coping strategies to deal with the repressed “dynamic”’. Freud was influenced by Charcot (Ellenberger, 1970) and, with Breuer, established the ideas of hypnotic regression and dynamic psychotherapy and published many case studies utilizing these methods. He describes his

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a

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a

ee

a

a

ee

method to access the unconscious and remove symptoms by direct suggestion as follows:

I decided to start from the assumption that my patients knew everything that was of any pathogenic significance and that it was only a question of obliging them to communicate it. Thus when I reached a point at which, after asking a patient some question such as: “How long have you had this symptom?’ or: ‘““What was its origin?”, I was met with the answer “‘I really don’t know’, I proceeded as follows: I

placed my hands on the patient’s forehead or took her head between my hands and said: “You will think of it under the pressure of my hand. At the moment at which I relax my pressure you will see something in front of you or something will come into your head. Catch hold of it. It will be what we are looking for. — Well, what have you seen or what has occurred to you?” (Breuer & Freud, 1895/1955: 110) In this process, Freud emphasized communication rather than suggestion. He used mild rituals of induction that evoked a special state of therapeutic communication which shifted the locus of control from the therapist to the inherent creativity of the client. Erickson (Erickson et al., 1976) built on these approaches by developing innovative ways to access and utilize the client’s own inner resources for problem-solving and healing, particularly the use of “the implied directive’ and other indirect suggestions (e.g. metaphors, stories, and double binds). The implied directive is a way of facilitating an intense state of internal learning or problem-solving. Rossi and Cheek (1988: 14) argued that ‘The induction and maintenance of a trance serve to provide a special psychological state in which clients can reassociate and reorganise their inner psychological complexities and utilise their own capacities in a manner in accord with their own experiential life’’. In hypnoanalysis, hypnosis and psychodynamic therapy are systematically integrated into a comprehensive and holistic way of working. The clinician utilizes hypnosis both to assist clients in uncovering the origins of their problems in their unconscious and to help them deal with their behavioural, emotional, cognitive and somatic consequences. A number of standard exploratory and uncovering techniques are available, e.g.:

ideodynamic questioning (Rossi & Cheek, 1988) affect/somatic bridge (Watkins, 1971, 1990) theatre visualization technique (Wolberg, 1964)

dream analysis (Jung, 1943/1966) ego state therapy (Watkins & Watkins, 1979) hypnotherapy (Rossi, 1996, 2002).

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These are fully discussed by Cheek and LeCron (1968), Crasilneck and Hall (1975), Karle and Boys (1987), Kroger (1977), and Heap and Aravind (2001).

Ideodynamic approaches psychotherapy

and dissociation in

Dynamic theories of psychotherapy argue that there is usually amnesia, relating to both the source of psychological problems and neurosis, and that it is necessary to gain insight into this repressed dynamic. Ideomotor behaviour, a phenomenon of the hypnotic trance, can be used as a procedure for uncovering unconscious material in a much shorter time than traditional psychoanalytical approaches. It is an excellent method to introduce early in the treatment process because it literally puts “‘control” in the hands of the client (Phillips & Frederick, 1995: 50). Ideomotor signalling is essentially a utilization approach that is particularly useful for uncovering repressed traumatic events and associated distressed feelings that relate to current psychological and psychosomatic problems (Cheek & LeCron, 1968; Erickson & Rossi, 1979; Rossi, 1996; Rossi & Cheek, 1988). By using ideodynamic approaches (which examine motor, sensory or physiological behaviours that are unconsciously motivated), the therapist, in collaboration with the client, can manage the level

of dissociation and consequently the degree of emotional distancing and associated catharsis (Hawkins, 1995). Ideodynamic finger signalling rapidly accesses state-bound information that may not be available to the client’s conscious verbal levels of functioning and consequently allows clients to reframe their problems psychosomatically. Because the levels of dissociation can be therapeutically managed by the collaboration of the therapist and client, the possibility of negative iatrogenic reactions (i.e. caused by medical or other interventions), such as the premature revivification of traumatic experiences, is considerably minimized. With recursive accessing and reviewing of experiences, at both cognitive and affective levels, clients (usually) arrive at a point in time when they indicate ideodynamically by finger signalling that their unconscious mind is able to allow them to be without their problem(s) at some time in the future. It is also recognized that such repetitive, recursive, and sequential reviewing of the original experience is often necessary in order to break through traumatic amnesia (Scheff, 1979). This method sets up very powerful expectancies for change to occur. Briere (1992) argued that getting in touch with feelings associated with past significant events, while avoiding an overwhelming revivification of emotion, facilitates a powerful psychosomatic reframing. This is often an important component of therapeutic interventions with survivors of child sexual abuse. A basic framework for using the ideodynamic finger signalling methods

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described above, for resolving psychological and psychosomatic problems, has been presented by Hawkins (1994).

The affect bridge Clients are first provided with appropriate ego-strengthening techniques. They are then requested to experience the situation in which the negative affect associated with the problem occurs and to allow that feeling to grow stronger and stronger. When they are fully experiencing the negative affect, while retaining an “anchor” to their positive resources, they can be asked: When was the first time you felt like that? . . . first thought. How old are you now?... Where are you?... What’s happening? ... Who else is there? Of course, the exact nature of the interventions will depend on the verbal and non-verbal behaviour of clients. Other methods of creating a “bridge” to earlier events associated with the elicited feelings include the use of suitable imagery, e.g. following a road over a bridge, counting backwards from the client’s current age, or the use of ideomotor responses. It is also possible to use a ‘“‘somatic bridge’? for physiological problems. For example, a client with psychogenic pain could be asked to Focus on your pain and, as you do that, will your unconscious mind let you know, when the first experience associated with this sensation occurred? At all times, it is important that therapists manage the levels of dissociation related to the prototypical events in order to control for any iatrogenic reactions. As well as “‘bridging”’ back in time to negative experiences, it is also possible for clients to “bridge” back to experiences before they had the problem or to times when they were dealing with it more effectively.

Ego-state therapy Ego-state therapy (Phillips & Frederick, 1995; Watkins & Watkins, 1986) is a psychodynamic approach used to resolve conflicts between various “ego states”. There are many ways to begin ego-state therapy. A simple method is to hypnotize the client, with a formal induction, progressive relaxation or imagery, and then state I'd like to talk to the part that is upset by what is going on, but if there is no such separate part, that’s all right. The latter intimation is to prevent the creation of a false ego state. The content is determined by the information received from the waking client. Watkins (1990: 238) described his approach as follows:

I often use an hallucinated room in which the hypnotised client sits on a couch while I sit on a chair and then have the client watch the door to see if “anyone” comes in. There is an implicit suggestion that “someone” may come in, but there is no demand to do so. An even less

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suggestive way is to ask the hypnotised client, “I wonder why Mary (name of the client) has been having those headaches lately?” Or to probe further “I wonder if anyone can tell me about the headaches (or any other symptom).”’ An ego state will often make itself known. Gibson and Heap (1991: 87) described a procedure for helping clients resolve traumatic and disturbing childhood memories using the concept of ego states, as follows: the client is regressed to any such incident and any abreaction is allowed to take place; the therapist then takes the client through a kind of psychodrama in fantasy in which it is suggested that the client’s adult ego state, possessed of all the resources, knowledge, and learning accumulated since that incident, goes back in time and provides the child ego state with all the reassurance,

comfort,

and resources

with

which to cope with and resolve that memory so that it no longer causes problems for the client.

Theatre visualization technique In this approach (Wolberg, 1964), clients are requested to imagine that they are visiting a theatre to see a play. The therapist “guides” them through the play (which is “related” to the aetiology and resolution of the problem) while allowing them space to “project” their own personal material (thoughts, feelings, sensations, interpretations, and solutions) that emerge spontaneously during the session. A particular client of mine presented with difficulties in relating to her father who was terminally ill in hospital. She was unable to “get close” to him either psychologically or physically, although she wanted to do this. In the “theatre technique’, she uncovered early material in which she discovered that she had been sexually abused by her father, and, although she denied it at first, she gradually came to accept

that this had occurred. After considerable therapy, she was able to forgive her father and visited him in hospital to tell him this.

Hypnotherapy Rossi (1996) has developed a permissive client-centred hypnotherapeutic approach that utilizes the clients’ own natural ultradian dynamics to help them access their own creative resources in their own problem-solving and healing. In hypnotherapeutic work, Rossi induces a permissive state of therapeutic hypnosis that “‘allows’’ clients to identify the sources and history of any emotional problem or symptom with consequent psychosomatic reframing. He argued that, in their efforts to explain their problems, clients review the state-dependent memories associated with their origin and their

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psychosomatic symptoms. This internal review often leads to a spontaneous cathartic reaction (in which stress hormones are released), which re-evokes and releases state-bound memories associated with the original trauma and stress. Rossi suggested that the activation of this primary arousal leads to activation of primary response genes which in turn leads to the formation of new proteins. These proteins facilitate the organization of new neural networks in the brain, a process referred to as neurogenesis (the insight stage). This usually leads to a spontaneous period of psychobiological relaxation and a time in which therapist and client can collaboratively develop a behavioural prescription that will facilitate the ongoing process of mind—body healing in the future.

Case study — One session of ideodynamic demonstration therapy The “‘client’’ was a 22-year-old female student with a problem concerning anxiety and irritability in her relationships with people closest to her. Ana volunteered to take part in a demonstration session given during a hypnosis course. Of course, the number of sessions required for brief therapy would normally be more than this. The task of the therapist was to facilitate the process of unconscious healing and problem resolution using hypnoanalytical/ideodynamic approaches. The initial interview covered the following areas: e = getting the client e asking questions approximate age own explanation e describing what therapist will do

to accept responsibility for the problem about the past, particularly with respect to the when the problem began and whether she had her or “story” concerning the cause of the problem kinds of things are about to happen (i.e. what the and what the client can be expected to do)

e

working with the Visual Analogue Scale (VAS)

e

dealing with any issues and anxieties relating to the client’s understanding of hypnosis and hypnoanalysis.

It was explained to Ana that the therapy was a collaborative process in which the therapist was there to assist her in finding inner resources and solutions to her problem. Questions were asked concerning the modulation of the problem, i.e. is the problem sometimes worse/better? It is useful to ask patients to imagine a time when the problem was better by using a VAS, i.e. When you are experiencing the problem now that it is much better (ask them to imagine the time when this occurred), tell me where the pointer rests on a 10-point scale somewhere between 0 and 10, where 10 is the most uncomfortable (distressful) and 0 the most comfortable and relaxing. They can also be asked to experience a time in their life when the symptoms were

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worse. This introduces them to the idea of regression, to the use of their imagination to recall experiences, and to the evaluation of these experiences. It provides therapists with a useful device to monitor the progress of therapy during the session or over the course of treatment. It also heightens patients’ sensitivity to their symptoms so that they can better appreciate those periods throughout the day when symptoms threaten to get worse — as well as just-noticeable therapeutic improvements that can motivate and reinforce their progress. Asking questions about the past indirectly suggested to Ana that early formative experiences might be important in understanding the cause of the problem (i.e. a psychodynamic explanation). It also strongly conveyed the idea that in the past she had found solutions to her problems and that she stll had

inner

resources

and

solutions.

As

stated

above,

Rossi

(1997)

suggested that clients review state-dependent memories related to the origin of their problems and psychosomatic symptoms when attempting to explain them. This initial unconscious review was deepened with further ideodynamic work. The therapist set up expectations in the client at both conscious and unconscious levels, which arguably increased the strength of therapeutic engagement and collaboration. By using the VAS, Ana learned that her problematic behaviours modulated and that she could affect this process both consciously and unconsciously. She was asked to rate the problem on a scale of 0-10. Her unconscious mind was also requested to allow her arm to float to the time when the problem was non-existent or less severe:

On a scale of 0 to 10 where 10 is the most severe, what is the intensity of your problem currently? . . . the worst it has ever been? . . . the most comfortable it has been?. . . Who is responsible for these changes? . . . and, when your unconscious mind has found a time in your life when the problem was much better, will your arm float to that time? [Ana’s right arm floats] . . . and, when you know that you still have these resources to deal with your problem, will your arm drift back downwards towards your leg? The last intervention is what Rossi calls “the basic accessing question”, where the implied directive is turned into a question (Rossi, 1996). Essentially, this use of the VAS allows the client to develop a sense of control. This example of ego-strengthening is an essential prerequisite for hypnoanalytic work and generally helps to avoid any iatrogenic reactions. Establishing ideodynamic signals The ideodynamic “‘yes” finger/arm signal was set up by utilizing what Ana had already achieved, i.e. to find a time in her life when she did not have the

problem or when the problem was less severe (cf. Hawkins,

1994).

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Allow your unconscious mind to find a time in your life when you did not have the problem . . . or when the problem was not bothering you _.. when you had the resources to stay healthy; allow your unconscious to do this without any interference from your conscious mind . . . it can happen all by itself as it did just a short while ago . . . a finger may move first on your right hand... and you may be wondering which finger will move first . . . and you may be surprised when this happens ... sooner or later, or your hand and arm may become lighter and float effortlessly away from your leg [Ana’s right arm floats again]. The “‘no”’ finger signal was established by asking the unconscious to signal with a finger when it knows that it can say “no” to the problem: See yourself on a television screen with your problem. If you want, you can turn the sound down and have the picture in black and white... and, when you know that you can say no to the problem, then a finger may move on your other hand... and you may notice it first as a sensation in one of your fingers... which can change into movement . . or your left arm may float [a finger on Ana’s left hand lifted and then her arm floated]. Suggesting to clients that they see themselves on a television screen creates a dissociation that decreases the possibility of an abreaction. The level of dissociation can be increased by either suggesting to them that the picture can be black and white or even “‘blurred”’, or by turning down the sound. After the ideodynamic signals were established, Ana was requested to focus on her problem and her unconscious mind was then asked the following: When your unconscious mind knows that it is appropriate to work with this issue in your life, will your “‘yes’’ arm float? . . . Or, if it is not appropriate for you to do this work right now, will your “no” arm float?

Ana’s right arm lifted, indicating that her unconscious cooperate in the therapeutic work. The session continued:

was

ready to

When you know that you have the inner resources, will your unconscious mind indicate this [her right arm began to lift]... and, when you are ready to access all those memories, experiences, emotions, and sensations relating to your problem, will your hand continue to float upwards? [Ana’s hand floated higher] . . . and there is nothing you really need to know consciously unless it is appropriate for you to know right now . . . and you may learn more, if it is appropriate for

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you to know, from a dream when you are asleep tonight, or maybe tomorrow or the next day .. . and you may be wondering when this will happen. During this experience, Ana showed signs of distress. This internal review often leads to a spontaneous state of emotional arousal as state-bound memories are released (Rossi, 1996, 1997). I asked her As you are experiencing that feeling, how old are you? Ana replied that she was eight years old. I continued: You are eight years old... what is happening in your life right now? Just stay with whatever comes into your mind knowing that you only need to allow those memories that are appropriate to come into your conscious mind... and all other memories, emotional, somatic, and cognitive, can stay in your unconscious. And there may have been a good reason for this “problem” to have come into existence at this time in your life as a way of helping you. I noticed that Ana’s breathing had become very shallow, so I requested that she breathe more deeply and indicate to me where she was experiencing any tension in her body. Ana indicated that she was experiencing tension in her chest, and I applied fingertip pressure to the area as she exhaled. Permission to touch her, if appropriate, was sought earlier in the session. a little more sound as you exhale . . . just letting that happen quite naturally ... bringing those sounds or words up from your chest as you continue to breathe more deeply and effortlessly . . . How are you feeling right now? And, maybe you can find some important conscious or unconscious learnings from this experience that you can utilize in the future to solve the current problems as well as others . . . knowing that you have the healing resources to allow that to happen... And, as I count forwards from eight, you can allow yourself to progress from that age until you are 22 years old... and, when you are 22 years old, will your eyes open so that you can come back into this room knowing that some important internal changes and learnings have taken place? Appropriate touching of clients when they are in a “regressed and emotional state” provides them with an important positive communication about the “here and now’, i.e. that she is not really eight years old although part of her may be experiencing the memories of being younger. The client is essentially “‘divided’’, with part of her being eight (child) and another part being 22 (adult), thus allowing the process of re-evaluation to occur. Further ideodynamic questioning, including accessing and reviewing experiences

related to the problem,

was

carried

out until Ana

indicated

ideodynamically that she was able to go into the future without the problem(s). An exercise, that helped to verify and consolidate the experience for Ana, was then carried out:

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When your eyes close, will your unconscious mind review all of the learning experiences that you have had during the session? . . . and, when you unconsciously review all of these experiences, will a finger on your right hand move all by itself when each of these learnings is recognized? . . . and, when you have finished reviewing all of these experiences, then will your arm float up in recognition that the process is complete and you are ready to go into the future, sooner or later, without the problem? [Ana’s right arm floated] That is fine . . . and your arm can float to the date by which the problem will have been completely resolved and you can write this date with your unconscious mind .. .and you may choose to forget to remember this date. . . and, when you know that your unconscious can continue with this inner healing, will you find your feet moving first or will your arms stretch first as you awaken to discuss whatever is necessary? [The last “instruction” is a good example of a “therapeutic double bind” as well as an implication that there are important things to discuss.] Verifying the therapeutic learning experiences is valuable for both the therapist and the client. Ana was given feedback concerning her ideodynamic behaviours during the session, i.e. her finger movements, arm levitation and automatic date writing. She was told that this was a positive indication of the success of the therapeutic session and that the negative experiences could have positive effects in the longer term. I then suggested the following homework: When it is convenient, you can find a place in which you can relax and just look at your right hand and allow it to float up, just closing your eyes as this happens, and go to the time when your problem(s) have been resolved . . . experience yourself clearly at this time in the future and, when you feel good and confident that your inner work can allow this to happen, then rub your thumb and forefinger together and open your eyes. You can do this now. Ana has positive improve Before that she

e

learnt a powerful self-hypnotic approach that she can use in a and goal-directed way (Alman & Lambrou, 1992), not only to her relationships but also to apply to other problems. Ana left, a number of present-time techniques were used to ensure had reoriented to the present. These included:

describing the room describing how she would go home after the session suggesting to her to keep the present positive orientation and to let go of all the negative images that possibly come to mind asking what she was looking forward to later in the day.

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Eight months later, Ana reported that her hypnosis session had helped her to cope with both her relationships and other issues in her life. Conclusions

It is important to note that the therapist had a “working map” relating to the hypnotherapy session, although it should be emphasized that this was regarded only as a general and approximate guide, with creativity and utilization being important aspects of the developing therapy. The overall approach, hypnoanalysis, can be conceptualized as a form of short-term psychodynamic therapy where hypnosis was the facilitating modus operandi. The therapist helped to facilitate the process of the “‘unconscious search’’ for the “inner healer” and for the underlying repressed dynamic that was maintaining the symptom and preventing solutions. The clinical approach adopted was democratic and collaborative, involving both choice and self-determination. This view promulgates the idea that clients have the conscious and unconscious resources available to solve their problems but require assistance from a caring facilitator. It also implies that individuals participate in their own illness and ipso facto their own health through a combination of mental, physical, and emotional factors. The overall hypnotherapeutic approach was considerably influenced by the work of Erickson and Rossi (1979) and Rossi (1996, 2002), although it is important to recognize that the theories, practice, and research drawn from generic psychotherapy and hypnotherapy also made a significant contribution; for example, the importance of developing a trusting relationship and instilling a sense of hope and optimism. Hypnosis can provide considerable advantages to the therapist utilizing psychodynamic approaches. In this “hypnosis environment”, a number of important facilitative processes are utilized, in particular that of the unconscious search, where clients can access, review, and re-evaluate aetio-

logical experiences. These, along with the principles of the unconscious resource or “inner healer’, make hypnoanalysis a potentially very powerful short-term dynamic psychotherapy. With respect to psychotherapy integration, the hypnoanalytic approach discussed here approximates the criteria presented by Stricker and Gold (1996) and Stricker (2001) with respect to the common factors approach as well as to theoretical integration. It is clear that the approach adopted within the case study recognizes the importance of the major curative factors, e.g. the therapeutic alliance, emotional catharsis, cognitive restructuring and provision of new learning experiences. The theoretical structure is essentially based on contemporary psychodynamic theories, while freely using methods and interventions from other therapeutic systems (primarily Ericksonian but also cognitive behavioural, gestalt therapy, bioenergetics, and humanistic). It is, therefore, best described as an assimilative model of

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integration (Messer, 1992), although at first sight the approach may seem like an example of technical eclecticism. Arguably this latter conclusion cannot be supported because there is an ostensible binding theoretical approach. Although psychodynamic theories form the focus of the theoretical structure, new techniques, particularly hypnosis, are employed within this structure. Unlike traditional psychoanalysis, there is an emphasis on a humanistic/phenomenological constructivism based on the recognition that the client has the necessary healing resources. Hypnosis enables the client to work through dissociated experiences at an unconscious level without the need for the elaborate rituals of interpretation and analysis. On the basis of the therapist’s experience, rather than any specific research evidence, techniques were seamlessly introduced into the generic psychodynamic framework from cognitive behavioural and humanistic paradigms, with hypnosis providing a facilitative therapeutic context. As Stricker (2001: 4) comments, “With the seamless approach, the patient is not aware that integration is taking place, but rather feels a consistent approach 1s being maintained”’.

References Alman, B.M. & Lambrou, P. (1992). Self-hypnosis: The complete manual for health and self-change (2nd edn). New York: Brunner/Mazel. Balint, M. (1968). The basic fault: Therapeutic aspects of regression. London: Tavistock. Breuer, J. & Freud, S. (1955). Studies on hysteria. In J. Strachey (ed. and trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. II). New York: W.W. Norton. (Original work published 1895) Briere, J. (1992). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park, CA: Sage. Budman, S.H. & Gurman, A.S. (1988). Theory and practice of brief therapy. London: Hutchinson. Cheek, D.B. & LeCron, L.M. (1968). Clinical hypnotherapy. New York: Grune & Stratton. Crasilneck, H.B. & Hall, J.A. (1975). Clinical hypnosis: Principles and applications. New York: Grune & Stratton. Davanloo, H. (1978). Basic principles and techniques in short-term psychodynamic psychotherapy. New York: Spectrum. Ellenberger, H.F. (1970). The discovery of the unconscious: The history and evolution of dynamic psychiatry. New York: Basic Books. Erickson, M.H. & Rossi, E.L. (1979). Hypnotherapy: An exploratory casebook. New York: Irvington. Erickson, M.H., Rossi, E.L., & Rossi, S.I. (1976). Hypnotic realities. New York: Irvington. Gibson, H.B. & Heap, M. (1991). Hypnosis in therapy. Hove, UK: Lawrence Erlbaum.

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Hawkins, P.J. (1994). Ideodynamic signalling in psychodynamic psychotherapy. European Journal of Clinical Hypnosis, 2(1), 41-44. Hawkins, P.J. (1995). Catharsis in counselling psychology. Counselling Psychology Review, 10(2), 11-17. Heap, M. & Aravind, K.K. (2001). Hartland’s medical and dental hypnosis. Edinburgh: Churchill Livingstone. Jung, C. (1966). The synthetic or constructive method. In R. Hull (trans.), Collected works of Jung, Volume 7: Two essays on analytical psychology (2nd edn, pp. 80-— 89). New York: Pantheon. (Original work published 1943) Karle, H. & Boys, J.H. (1987). Hypnotherapy: A practical handbook. London: Free Association Books. Kroger, W.S. (1977). Clinical and experimental hypnosis in medicine, dentistry and psychology. Philadelphia: Lippincott. Malan, D. (1963). A study of brief psychotherapy. New York: Plenum. Messer, S. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In J.C. Norcross & M.R. Goldfried (eds), Handbook of psychotherapy integration (pp. 130-168). New York: Basic Books. Phillips, M. & Frederick, C. (1995). Healing the divided self: Clinical and Ericksonian hypnotherapy for post-traumatic and dissociative conditions. New York: W.W. Norton. Rossi, E.L. (1996). The symptom path to enlightenment. Palisades, CA: Palisades Gateway. Rossi, E. (1997). The symptom path to enlightenment: The psychobiology of Jung’s constructive method. Psychological Perspectives, 36, 68—84. Rossi, E.L. (2002). The psychobiology of gene expression. New York: W.W. Norton. Rossi, E. & Cheek, D.B. (1988). Mind—body therapy. New York: W.W. Norton. Scheff, T. (1979). Catharsis in healing, ritual, and drama. Berkeley: University of California Press. Sifneos, P.E. (1979). Short-term dynamic psychotherapy. New York: Plenum. Stricker, G. (2001). An introduction to psychotherapy integration. Psychiatric Times, 18(7). Retrieved January 25, 2004 from www.psychiatrictimes.com/

p010755.html Stricker, G. & Gold, J. (1996). Psychotherapy integration: An assimilative, psychodynamic approach. Clinical Psychology: Science and Practice, 3(1), 47-58. Strupp, H.H. & Binder, J.L. (1984). Psychotherapy in a new key: A guide to timelimited dynamic psychotherapy. New York: Basic Books. Watkins, H. & Watkins, J. (1979). The theory and practice of ego state therapy. In H. Grayson (ed.), Short term approaches to psychotherapy (pp. 176-220). New York: National Institute for the Psychotherapies & Human Sciences Press. Watkins, J.G. (1971). The affect bridge: A hypnoanalytical technique. /nternational Journal of Clinical and Experimental Hypnosis, 19, 21—27. Watkins, J.G. (1990). Watkins’ affect or somatic bridge. In D.C. Hammond (ed.), Handbook of hypnotic suggestions and metaphors (pp. 523-534). New York: Norton. Watkins, J.G. & Watkins, H.H. (1986). Hypnosis, multiple personality and ego states as altered states of consciousness. In B.B. Wolman & M. Ullman (eds), Handbook of states of consciousness (pp. 133-158). New York: Van Nostrand. Wolberg, L.R. (1964). Hypnoanalysis. New York: Grune & Stratton.

Chapter 7

Integrative psychotherapy of schizophrenic symptoms: Recent developments Joannis N. Nestoros

Let’s view at last the world through the eyes of the insane I will share with you my treasures of schizophrenia Lefteris Poulios, 1977!

Evolution of the concept of schizophrenia Schizophrenia has fascinated health professionals and ordinary people since the beginning of humankind (for an extensive review of the evolution of the concept, cf. Nestoros (1997a)). According to Herodotus (484—426 BCE), mental illness was the result of possession by the evil spirits or goddesses, Mania and Lyssa. Such views might account for the discovery of trephined (surgically drilled) skulls in archaeological excavations. Plato (428-348 BCE) conceptualized four kinds of madness: prophetic, telestic, poetic and erotic, while Hippocrates (460—355 BCE) suggested that mental disorders were caused by brain chemical imbalance of the bodily humours. Galen (CE 130-200) considered madness to be a disharmony between rational, irrational and lustful parts of the psyche. Morel (1860) introduced the term “dementia praecox”’, which was also adopted by Kraepelin (1913/1919/1971). Both believed that the disease had its onset in adolescence or early adulthood (praecox), with progressive deterioration of mental powers (dementia). Therefore, the defining feature of this disorder was its poor outcome. If the patient recovered, the diagnosis was considered incorrect. The term “‘schizophrenia’’ was coined by Eugene Bleuler in 1911; related terms included “hebephrenic” (Hecker,

1 We thank the poet Lefteris Poulios and Kedros Publishing Company of Athens, Greece for

permission to include excerpts from the poem entitled “Magnetic Mountain”.

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1870; as cited in Lehmann, 1980) ‘‘paranoid” (Sander, 1868; as cited in Lehmann, 1980) and “catatonic” (Kahlbaum, 1863; as cited in Lehmann,

1980). These terms were introduced long before 1911 (cf. Lehmann,

1980; Nestoros,

yet they are still in use

1997a).

To date, 18 different types of ‘“‘schizophrenia” have been described in the editions of the Jnternational classification of diseases (ICD) (World Health Organization, e.g. 1979) and the Diagnostic and statistical manuals of mental disorders by the American Psychiatric Association (e.g. DSM-IV, 1994). These are: “simple” (Diem, 1903; as cited in Lehmann, 1980), “oneiroid”’ (Mayer-Gross, 1923; as cited in Lehmann, 1980); “‘pseudoneurotic’”’ (Hoch & Polatin, 1949; as cited in Lehmann, 1980); “latent”? (World Health Organization, 1979) and 14 other types (cf. Lehmann, 1980; Nestoros, 1997a). Although these numerous types have been described in various

versions of the ICD and DSM, only five types are included in DSM-IV: (a) paranoid; (b) disorganized; (c) catatonic; (d) undifferentiated and (e) residual. To complicate matters further, disorganized speech, disorganized or catatonic behaviour, and flat or inappropriate affect (which, according to DSM-IV, constitute exclusion criteria for “paranoid” schizophrenia) often coexist with suspiciousness, delusions or frequent auditory hallucinations. Moreover, catatonic schizophrenic patients usually reveal that they experienced paranoid symptoms during their catatonic episode. However, the classification of psychotic symptoms into positive and negative (Andreasen, 1984a, 1984b; Kay et al., 1987) helps clarify certain issues, notwithstanding

the fact that the same individual always presents different psychopathological symptoms during the course of his or her illness. Positive psychotic symptoms,

such as hallucinations,

delusions, formative thought disorder,

bizarre behaviour and inappropriate affect are more prominent in the initial acute phase, whereas negative psychotic symptoms, such as flattened affect, avolition—apathy, anhedonia (a loss of the ability to enjoy things) and reduced

sociability, as well as attention

deficits, characterize

the chronic

phase. In that respect, “‘undifferentiated”’ schizophrenia does not differ from “paranoid” schizophrenia whose positive symptoms have been reduced by first-generation antipsychotic medications and replaced by negative symptoms (caused by the same medications). “Residual” means that most signs and symptoms have greatly subsided so it can apply to all other DSMIV schizophrenia subtypes. In summary, “paranoid” schizophrenia seems to be the main type, with the others being forms of the same disorder that present a different clinical picture due either to different severity (“disorganized” and “catatonic” representing very severe forms and “residual” a very mild form) or to change during the course of therapy. Another issue complicating our understanding of “schizophrenia” is that all positive and negative psychotic symptoms that occur in schizophrenic patients also appear in a great variety of other psychological disorders. For

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example, hallucinations and delusions occur in (a) manic and major depressive episodes; (b) Alzheimer’s disease and many other categories of brain damage; (c) intoxication combined with a variety of psychoactive agents (e.g. cocaine, amphetamines, ecstasy, marijuana, mescaline, LSD); (d) withdrawal from drugs such as alcohol and heroin; (e) reactions to extreme stress (e.g. combat situations); (f) medical conditions causing extreme changes in the equilibrium of the body (e.g. after long surgical procedures); (g) sensory deprivation, especially when used as punishment; (h) pellagra psychosis caused by vitamin B6 deficiency; and (1) temporal lobe epilepsy. Thus, it is proposed that schizophrenic symptoms are not the result of a certain illness but the manifestations of the individual’s reaction to extreme changes in his or her bio-psycho-social homeostasis. For example, a patient with electroencephalogram abnormalities may become psychotic not only if his or her brain electrical activity worsens abruptly, but also if his or her abnormal electrical activity is treated abruptly to become normal (Demers-Desrosiers et al., 1978). This observation corresponds with Selye’s (1950) definition of stress, which emphasizes that the amount of stress depends not so much on whether the situation is pleasant or unpleasant, or whether the change is towards “normality” or “‘abnormality”’’, but rather on the amount of energy the organism requires to adapt to the new internal or external environment.

Historical review of psychotherapy

in schizophrenia

A detailed historical review of psychotherapy in schizophrenia, covering psychoanalytic, humanistic/existential and behavioural perspectives, can be found in Nestoros (1997b). Although in the USA and many other parts of the world psychotherapy for schizophrenics was strongly criticized until recently (Nestoros, 1997b), this situation is rapidly changing for the better. In an international context, there have been some positive developments. Under the auspices of the Royal College of Psychiatrists, Martindale et al. (2000) edited an important textbook regarding the various psychological approaches and their effectiveness in psychosis, including chapters on cognitive approaches; family, group and psychosocial approaches; individual psychoanalytical psychotherapy; and early interventions using needadapted psychological treatment models. In 2001, both the Journal of Contemporary Psychotherapy (Moses, ed.) and the Clinical Psychology Review (Tarrier, ed.) devoted special issues to promising developments in psychotherapy with psychosis. The latter journal had previously published a review of cognitive behavioural therapy for psychosis (Haddock et al., 1998), an apparently favoured topic since three other important papers have been published since 2000 in other journals (Gould et al., 2001; Rector & Beck, 2001; Turkington & McKenna, 2003). Finally, the Journal of the American Academy of Psychoanalysis and

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Dynamic Psychiatry (Silver & Larsen, 2003) devoted a special issue to “The schizophrenic person and the benefits of the psychotherapies” as part of the response of clinicians and researchers to two meta-analyses that concluded that (a) “social skills training and cognitive remediation do not confer reliable benefits for patients with schizophrenia” (Pilling et a/., 2002a: 783) and (b) family intervention and cognitive behavioural therapy should be offered in certain cases yet both treatments “should be further investigated in large fields” (Pilling et al., 2002b: 31).

The present model What follows is an integrative model for the psychotherapy of individuals suffering from schizophrenic symptoms. Emphasis is mostly on the amelioration of extreme anxiety, suspiciousness, delusions and hallucinations which the author considers the cardinal schizophrenic symptoms. A detailed account of the origins and development of this model can be found elsewhere (Nestoros, i1997b). The approach contains an integration of psychodynamic and humanistic principles as well as pharmacotherapy. The integration of psychodynamic with humanistic/existential perspectives appears at first consideration impossible since the former emphasize unconscious processes, and the latter stress the power of conscious free will as a reaction to the pessimistic views of both early psychodynamic theory (supremacy of the id over the ego according to Freud (1927)) leading to intrapsychic determinism, and early behavioural (Skinner, 1971; Watson, 1924) approaches suggesting environmental determinism. This conflict 1s solved by viewing human beings as not necessarily exercising conscious free will unless they become aware of their potential to do so. Furthermore, this awareness of the freedom of choice over one’s behaviour, thoughts and feelings is a common goal cultivated by all modern psychotherapies. The model was influenced and shaped by the following parameters: (a) ancient and modern Greek philosophy, civilization and culture; (b) the author’s training in the ‘‘eclectic’”’ approach to psychotherapy and his personal psychotherapy with Lela C. Korenberg; (c) the international and multicultural atmosphere of McGill University where the author was trained; (d) the author’s research experience in clinical psychopharmacology with Lehman, Ban and Nair and in basic neuroscience with Krjevic; (e) Marmor’s academic lecture on “‘a unified science of psychotherapy” at the 1974 annual meeting of the Canadian Psychiatric Association and other research related to psychotherapy integration; and (f) over 30 years of clinical and research experience with ‘‘schizophrenic’”’ patients. The model’s basic hypotheses concerning the nature of “‘schizophrenic”’ experience are that: (a) it is a transient mental state which often becomes chronic because of iatrogenic, false personal and societal understanding of its true nature and absence of appropriate systematic treatment; (b) the vast

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majority of typical symptoms are easily explained as a result of extremely high levels of anxiety, fear or stress (i.e. hallucinations and delusions are misinterpretations of real internal or external stimuli; thought processes of the neocortex are disorganized by extreme activation of the emotional brain, i.e. the amygdala of the limbic system; emotional withdrawal is a defence mechanism to avoid worsening of the anxiety); (c) tranquillizing medication and/or anxiety-reducing psychotherapy have strong and permanent beneficial effects in reducing and even eliminating schizophrenic symptoms; (d) lack of understanding of the above can lead to vicious circles with both the suffering person, his or her family, mental health professionals and society in general becoming increasingly fearful of schizophrenic symptoms because of the prejudice and stigma associated with the concept of an incurable, lifelong, genetically determined illness of the brain; (e) the presence of biological factors in its aetiology does not preclude the usefulness of psychotherapy, since neurophysiological processes underlie all forms of normal and abnormal behaviour and psychotherapy can change brain function; (f) previous failures to remedy schizophrenic symptoms through psychotherapeutic methods and techniques probably reflect either a false model of understanding human nature and the “schizophrenic” experience and/or application of therapy with insufficient intensity or length. The principles of integrative psychotherapy for individuals with schizophrenic symptoms are as follows (cf. Nestoros, 1997b, 2001):

1. Schizophrenia is amenable

to psychotherapy

The first and by far the most important principle of the proposed model was formulated by Heraclitus (trans. 1931): If you do not expect it, you will not find the unexpected, as it is hard to be sought out and difficult. Positive results in the psychotherapy of individuals with schizophrenic symptoms can be accomplished only by clinicians who do not rule out the possibility that psychotherapy may have an effect on schizophrenic symptoms: there is no chance of success without this hope. A review of 67 empirical studies of psychotherapy with schizophrenics published between 1973 and 1996 (Nestoros, 1997b), which included all modes of therapy except for family interventions to decrease expressed negative emotion, revealed a universal agreement that psychotherapy was beneficial. Moreover, several more recent papers (e.g. Garety er al., 2000; Kanas, 2000) concurred with this finding.

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Thus, the first principle of this model, which was a theoretical philosophical principle in 1990 when it was first formulated, is today based on scientific evidence.

2. The integration of different approaches to the treatment of schizophrenia is possible and has many advantages over conventional one-sided approaches

The integration of different approaches to the treatment of schizophrenia is not only possible but absolutely necessary, since integration is the only way to combine the various biological (antipsychotic medication), psychological (individual psychotherapy, family therapy, group therapy) and societal/ cultural (interventions to remove the stigma of mental illness) perspectives. These perspectives are all useful but provide limited results when applied alone (Nestoros,

1997a, 1997b).

3. Schizophrenic symptoms are best understood as resulting from many different factors (biological, psychological, familial, social) according to the stress-diathesis vulnerability model

In the context of an understanding of the multidimensional aetiology of schizophrenia, the present approach proposes a multifactorial model of treatment addressing diverse targets. Factors that need to be addressed include anxiety reduction and the elevation of hope through supportive psychotherapy, increased socialization through social skills training, insight into mechanisms initiating or perpetuating symptoms through insightoriented therapy, the reduction of the family’s expressed emotion through family therapy, and alteration of the biological responses of the person to internal or external stimuli through antipsychotic medications.

4. Schizophrenic symptoms in themselves are not as bad as either the individual’s or society’s reactions to them The final manifestations of schizophrenia have very little to do with the true nature of schizophrenic symptoms and much more to do with societal factors. In this regard, the ideas of Szasz (1960) (that mental

illness is a

myth) and Scheff (1966) (that schizophrenia is not a disorder but a learned social role) and the works of Rosenhan (1973) (about “being sane in insane places”, p. 250) and Watzlawick (1981) are all very useful. In addition, the inadequacy of the currently available mental health services for individuals suffering from schizophrenic symptoms — the “non-system” of mental health care described by Stein er al. (1990) — also contributes deleteriously.

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5. Schizophrenic symptoms form a continuum with normal behaviour at one end As Laing (1967) eloquently argued, “normal” people often exhibit crazy behaviours. Certain conditions, such as sensory deprivation, torture and imprisonment, and certain psychoactive drugs can produce schizophrenic symptoms in normal individuals. 6. Paranoid schizophrenic symptoms are rapidly eliminated by reducing anxiety through anxiolytic medication or by other means That paranoid schizophrenic symptoms are associated with terror is well known. In 1958, Mednick postulated that anxiety was the central problem in schizophrenia. Moreover, in a series of studies (Nestoros, 1980; Beckmann & Haas, 1980; Nestoros et al., 1982, 1983; Lingjaerde, 1982), extremely high

doses of diazepam (at least ten times higher than the doses producing deep sleep or coma in normal and neurotic individuals) produced a dramatic decrease in the symptoms of patients diagnosed as paranoid schizophrenics within a few hours, with a complete disappearance of schizophrenic symptoms in many of them. A similar reduction of schizophrenic symptoms can be accomplished if therapists manage to make their patients feel absolutely calm by using various psychotherapeutic methods and techniques. Hallucinations are easily eliminated by a successful psychotherapy session; delusions are not eliminated but are significantly improved. 7. Individuals with schizophrenic symptoms are not 100% disturbed or “‘crazy”’; that is, they have a logical part that can collaborate with the psychotherapist Recent evidence (Amador & Strauss, 1993; Amador et al., 1993, 1994) on “awareness” or “insight” in psychosis suggests that insight into having a mental disorder is a complex phenomenon. It is influenced by culture, its component dimensions are continuous rather than dichotomous, and it is modality-specific and influenced by the previous exposure of patients to information regarding the nature of their illness.

8. Psychotherapy is a very complex process requiring special conditions

which, in the case of schizophrenia,

have to be

applied consistently over a long period of time

Complex neurophysiological experiments require a wide variety of factors and conditions for their success. Failure to obtain the desired psychotherapeutic effects should not be regarded as evidence that these effects are

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unobtainable; perhaps only one component was missing. It is also possible that no component was missing but that the efforts were not applied for long enough. Where a thousand efforts fail, a thousand efforts plus one may be successful.

9. The schizophrenic condition is often characterized by a state of increased potential

Schizophrenia is not only a disease but also a state of increased potential. Mahrer (2001), from an experiential perspective, offers some interesting suggestions as to how this increased potential can be mobilized to help patients to relieve their psychotic symptoms. Perhaps Mahrer’s most important contribution was that psychotic individuals understand that there is no real reason to be greatly afraid of their thoughts, emotions and memories. Moreover, they are taught an effective way to deal with their experiences.

Cultural aspects When the present author returned to Greece in 1982, the use of psychotherapy to treat individuals with schizophrenic symptoms was considered by most physicians — including many representatives of the academic establishment — to be sheer charlatanism. The most commonly expressed criticism was an axiom attributed to Hippocrates: Do not scratch healed wounds. The author had heard this aphorism from so many sources that he always accepted it as true. However, careful study of Hippocrates’ Aphorisms, both in the ancient Greek text and in the English translation (1931), revealed no such aphorism.

Twenty-three years later, the situation has reversed. It is not uncommon for mental health professionals to support psychotherapy for schizophrenia. In Greece nowadays, many established neurologists—psychiatrists employ one or two young psychology graduates with no postgraduate training. The psychiatrist prescribes antipsychotic medication and monitors pharmacotherapy. It is not uncommon for psychotic patients to attend two individual psychotherapy sessions per week and a parallel group session. The main problem is that often the psychologists employed have little or no training in this difficult task, and no supervision. There are plans to create a Greek chapter of the International Society for the Psychotherapy of the Schizophrenias and other Psychoses (ISPS), which will hopefully remedy the above problems. In 2001, the Superior Court of Lamia in Greece ordered the release from prison of a person diagnosed as “schizophrenic” until the day of his court hearing so that his psychotherapy sessions could be continued.

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Research is under way to investigate the psychotherapeutic elements in ancient and modern Greek culture and to revive modern Amphiaraia (Nestoros, 2000). These are envisioned as diagnostic, therapeutic and research centres located in parts of Greece characterized by special natural beauty of the landscape, temperate climate, sunshine (known to exert antidepressant effects), therapeutic architecture and an integrative psychotherapeutic approach. Discussion

The above model has been rigorously tested since 1994 in a number of process and outcome studies at the University of Crete. The data were mostly derived from audiotaped or videotaped individual and family sessions of clients who meet DSM-IV diagnostic criteria for schizophrenia, paranoid type or schizoaffective disorder. For every new client, a series of psychometric evaluations was carried out at baseline and at various stages of treatment (cf. Nestoros, 1997a, 1997b).

In many studies the client’s psychopathology and session satisfaction were assessed immediately before and after the session with a series of scales. The relationships of clients exhibiting schizophrenic symptoms with their parents and other important relatives were assessed at baseline and at various stages of treatment. As to the psychotherapeutic process, the transcripts of many “good” and “‘bad”’ sessions were analysed in various ways. The results of these studies have been presented in scientific meetings (one of them received the David Feinsilver Award at the 13th International Symposium for the Psychological Treatments of Schizophrenias and other psychoses; Zgantzouri & Nestoros, 2000) and one of the papers has been published (Kalaitzaki & Nestoros, 2003). It is proposed that schizophrenia does not constitute a specific “mental disorder” with specific aetiology, evolutionary course and treatment. Rather, there are individuals who exhibit “schizophrenic symptoms” or, more specifically, a certain constellation of “positive” and/or ‘“‘negative”’ psychotic symptoms with considerable individual differences in aetiology, evolution in time and appropriate therapy. In the context of this view, the author’s research attempts to clarify how specific positive or negative psychotic symptoms appear, evolve and worsen or improve in specific individuals who are characterized by a certain genetic background, neurophysiological development and psychological adaptation processes. ‘The psychotherapy of individuals with schizophrenic symptoms presents a good model to study psychotherapy in general because of the wealth of information available today about the role of various biological, psychological, social and cultural factors” (Nestoros, 1997a: 635). For example, adopted children whose biological parents met diagnostic criteria for schizophrenia displayed an increased incidence of schizophrenic symptoms only when they

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were raised by a family whose functioning had been rated as disturbed (Tienari et al., 1994). Thus, what is inherited is not necessarily a vulnerability to psychosis, but may be even something positive — for example, increased sensitivity to environmental stimuli — which in the appropriate family environment may even create a gifted individual. According to Lehmann (1975: 891), ‘tall schizophrenics are, at least originally, more sensitive than the average person. It is likely that this increased sensitivity and heightened responsiveness to sensory and emotional stimulation, is present in schizophrenics from an early age, possibly from birth.” The proposed model has significant similarities to, but also differences from, other integrative approaches to schizophrenia (Alanen et al., 2000; Brenner et al., 1994; Kanas, 2000). It shares Karon’s (2001) emphasis on

fear as an aetiological factor for schizophrenic symptoms and on iatrogenic myths (cf. Nestoros, 1993, 1997b). However, unlike Karon, the present author supports the careful use of newer psychotropic medications. The present model is not psychoanalytic in origin. Many conceptualizations regarding aetiology and therapeutic intervention, as presented by Karon (2001) and Silver (2001), are quite similar to those employed by the author. However, the presented approach employs, when appropriate, cognitive, behavioural and humanistic/existential principles, as well as pharmacotherapy and marital, family and group therapy. As regards the understanding of schizophrenic symptoms, probably the distinguishing element of the integrative model proposed here is its emphasis on extreme stress due to severe changes in the individual’s bio-psychosocial homeostasis. The neurophysiological basis of this effect of extreme stress may be increased dopaminergic, noradrenergic and serotoninergic neurotransmission and/or a reduction in GABAergic neurotransmission due to: (a) genetic predisposition; (b) aberrations during pre- and post-natal brain development; (c) cocaine or other substance abuse; (d) childhood environmental trauma that creates false perceptions of the outside world as threatening to the person; (e) learned fear responses through conditioning or social or cognitive learnings; (f) unconscious conflicts; (g) existential dilemmas; (h) impossible work or societal conditions (unemployment, poverty, war), or (i) or any combination of the above external or internal stimuli that causes fear, anxiety, or stress.

Finally, an integrative explanation to delusion formation is offered to explain in evolutionary terms why humans, when extremely threatened, misinterpret stimuli from their external and/or internal environment (Nestoros, 1997b, 2001). For the vastly greater part of the time Homo sapiens has been present on earth (two and a half million years), our species survived through hunting and gathering, and we still have the biological responses of the hunter as exemplified by our “fight—flight” response to danger. It is plausible to suggest that our ancestors survived to supply us with their genes only because they became suspicious to the point of

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paranoia when frightened. Thus, every accidental external stimulus was interpreted as relevant and dangerous to the organism. The sound created by a broken twig in the woods was considered significant for survival. From an evolutionary point of view, it makes sense that our ancestors considered external stimuli as directly related to themselves and interpreted these phenomena as potentially created by their enemies. In other words, those of our ancestors who were not suspicious when frightened and did not develop the (often wrong) impression that all accidental external stimuli had a special significance and purpose that was directly related to them (ideas of reference and persecution) were more likely to be killed by wild animals or their fellow humans.

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Loeb Classical Library, LCL 150 (pp. 449-509). Cambridge, MA: Harvard University Press. Hippocrates (1931). Aphorisms (trans. W.H.S. Jones). In G.P. Goold (ed.), The Loeb Classical Library, LCL 150 (pp. 98-221). Cambridge, MA: Harvard University Press. Kalaitzaki, A.E. & Nestoros, J.N. (2003). The Greek version of the revised Person’s

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Kraepalin, E. (1913/1919/1971). Dementia praecox and paraphrenia (trans. R.M. Barclay, 1919). Huntington, NY: Robert E. Krieger. Laing, R.D. (1967). The politics of experience. New York: Ballantine. Lehmann, H.E. (1975). Schizophrenia: Clinical features. In A.M. Freedman, HI. Kaplan, & B.J. Sadock (eds), Comprehensive Textbook of Psychiatry I (pp. 890— 923). Baltimore, MD: Williams & Wilkins. Lehmann, H.E. (1980). Schizophrenia: History. In H.I. Kaplan, A.M. Freedman, & B.J. Sadock (eds), Comprehensive textbook of psychiatryl III — Vol. 2. Baltimore, MD: Williams & Wilkins. Lingjaerde, O. (1982). Effect of benzodiazepine derivative estazolam in patients with auditory hallucinations. A multicentre double-blind, cross-over study. Acta Psychiatrica Scandinavica, 65, 339-354.

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3-67.

86 aNestoros ig baled ty She

Maer atchlage eta ln

AOS EI Tos oe

Nestoros, J.N. (1980). Benzodiazepines in schizophrenia: A need for reassessment. International Pharmacopsychiatry, 15, 171-179. Nestoros, J.N. (1993). In the world of psychosis: Eric’s odyssey and other cases. Athens, Greece: Ellinika Grammata. Nestoros, J.N. (1997a). A model of training in the methodology of individual psychotherapy research: The case of schizophrenia as a paradigm. In P-J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice and research (pp. 633-681). Athens, Greece: Ellinika Grammata. Nestoros, J.N. (1997b). Integrative psychotherapy of individuals with schizophrenic symptoms. In P.J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice and research (pp. 321-363). Athens, Greece: Ellinika Grammata. Nestoros, J.N. (2000). Modern “amphiaraia” in the Greek periphery. In G. Thill (ed.), Sustainable development in the islands and the roles of research and higher education (Vol. 2, pp. 159-165). Namur, Belgium: Coordination scientifique de

PRELUDE. Nestoros, J.N. (2001). Synthetiki psychotherapy: An integrative psychotherapy for individuals with schizophrenic symptoms. Journal of Contemporary Psychotherapy, 31(1), 51-S9. Nestoros, J.N., Nair, N.P.V., Pulman, J.R., & Schwartz, G. (1983). High doses of

diazepam improve neuroleptic-resistant chronic schizophrenic patients. Psychopharmacology, $1, 42—47. Nestoros, J.N., Suranyi-Cadotte, B.E., Spees, R.C., Schwartz, G., & Nair, N.P.V. (1982). Diazepam in high doses is effective in schizophrenia. Progress in NeuroPsychopharmacology & Biological Psychiatry, 6, 513-516. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Martindale, B., Orbach, G., & Morgan, C. (2002a). Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. Psychological Medicine, 32(5), 783-791. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J.. Orbach, G., & Morgan, C. (2002b). Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behavior therapy. Psychological Medicine,

32(5), 763-82. Poulios, L. (1977). The naked orator. Athens: Kedros. Rector, N.A. & Beck, A.T. (2001). Cognitive behavioral therapy for schizophrenia:

An empirical review. Journal of Nervous and Mental Disease, 189, 278-287. Rosenhan, D.I. (1973). On being sane in insane places. Science, 179, 250-258. Scheff, T.G. (1966). Being mentally ill: A sociological theory. Chicago: Aldine. Selye, H. (1950). The physiology and pathology of exposure to stress. Montreal, Canada: Acta Medical Publishers. Silver, A.-L.S. (2001). Psychoanalysis and psychosis: Trends and developments. Journal of Contemporary Psychotherapy, 31(1), 21-30. Silver, A.-L.S. & Larsen, T.K. (eds) (2003). The schizophrenic person and the benefits of the psychotherapies — Seeking a PORT in the storm. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31(1) (special issue). Skinner, B.F. (1971). Beyond freedom and dignity. New Y ork: Knopf. Stein, L.I., Diamond, R.J., & Factor, R.M. (1990). A system approach to the care of

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persons with schizophrenia. In M.I. Herz, S.J. Keith, & J.P. Docherty (eds), Handbook of schizophrenia: Vol. 4: Psychosocial treatment of schizophrenia (pp. 213-246). Amsterdam: Elsevier. Szasz, T.M. (1960). The myth of mental illness. American Psychologist, 15, 113-118.

Tarrier, N. (ed.) (2001). Special issue on psychosis. Clinical Psychology Review, 21(8) (special issue). Tienari, P., Wynne, L.C., Moring, J., Lahti, I., Naarala, M., Sorri, A., Wahlberg, K.E., Saarento, O., Seitamaa, M., Kaleva, M., & Laksy, K. (1994). The Finnish adoptive family study of schizophrenia: Implications for family research. British Journal of Psychiatry, 164 (suppl. 23), 20-26. Turkington, D. & McKenna, P.J. (2003). Is cognitive-behavioral therapy a worth-

while treatment for psychosis? British Journal of Psychiatry, 182, 477-479. Watson, J.B. (1924). Behaviorism.

New York: Norton.

Watzlawick, P. (1981). Patterns of psychotic communication. In Y. Winkin (ed.), La nouvelle communication. Paris: Editions du Seuil. World Health Organization (1979). International classification of diseases (9th edn). Geneva: WHO. Zgantzouri, K.A. & Nestoros, J.N. (2000). Psychotherapy process research in schizophrenia paranoid type: The investigation of delusion formation through the evaluation of insession events. Acta Psychiatrica Scandinavica, 102(404), suppl.,

8-9.

Chapter 8

Multimodal stress therapy An integrative approach Patrizia Collard

This chapter describes multimodal stress therapy, which integrates multimodal therapy with stress management techniques. In particular, the use of multimodal stress therapy in early intervention for substance misuse is examined. Stress as the cause of substance misuse is discussed and a case study of multimodal stress therapy in action is presented.

Aetiology of substance

misuse

in relation to stress

management

There is a general consensus that alcohol and nicotine appear to be among the best ‘“‘quick fixes’? for an immediate reduction of stress symptoms. For example, Sher (1986) argued that a relationship exists between alcohol consumption and a decrease in stress responses. Of course, this anecdotal assumption is not sufficient to prove a link between the use of alcohol and drugs and stress reactions. However, research by Conger (1956) found that the tension relief associated with alcohol intake reinforced the drinking response. Stress, of course, is not the only factor linked to the misuse of substances.

For example, Bandura (1969) proposed, from a social-learning-theory standpoint, a developmental framework regarding alcohol use and misuse which assumes that all drinking behaviour is governed by principles of learning, cognition and reinforcement. Thus, misuse may derive from habituation, co-action and/or a biological predisposition. Nevertheless, in many cases of misuse, there 1s an expectation that the chosen substance will achieve a reduction of stress and associated discomfort. Misuse is likely to occur under conditions that overwhelm effective coping ability and reduce individuals’ perception of efficacy (George, 1990). Stress reduction methods appear most effective among those who misuse substances specifically to manage stress and anxiety. The first goal of multimodal stress therapy is recovery, which may be achieved through either abstinence or controlled intake, while the second goal is for clients to

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achieve a better quality of life through the teaching of general stress coping skills and self-control skills.

Definitions Stress

Stress has been defined as “the psychological, physiological and behavioural response of individuals when they perceive a lack of equilibrium between the demands placed upon them and their ability to meet those demands

which, over a period of time, leads to ill health’ (Palmer,

1992:

39). Lazarus and Folkman (in Palmer et al., 2003) described stress simply as an imbalance between demands and resources. A distinction must be made between external stressors and internal ones. Although some external stressors are often not within the control of individuals, they can learn how to cope with them. Internal ones (e.g. perfectionism, lack of interpersonal and time management skills) can be worked on in stress management.

Stress management Stress management is a systematic approach to the prevention or reduction of stress. It does not consist merely of the teaching of various forms of relaxation or meditation: these techniques may certainly form part of stress management, but they are by no means its central core. Many inexperienced practitioners without the necessary training employ such strategies in the erroneous belief that they constitute stress management. Psychotherapists need to be aware of the possible pitfalls and contraindications of certain techniques. There is, therefore, a great need for increased awareness, training and empirical evaluation in this field. Stress management is first and foremost a psycho-educational approach that helps people to pinpoint, interpret and deal with their personal stressors. However, it can also be considered a form of therapy (stress counselling/coaching), which concentrates more on relief of stress symptoms. Most stress counsellors tend to use an array of techniques. In order to be effective and time-efficient, it is important to have a systematic assessment procedure and treatment plan. One such form of treatment is provided by multimodal therapy, which can be successfully applied to stress management in the field of substance misuse (cf. Palmer & Dryden, 1995). Palmer and Woolfe (2000) state that our Zeitgeist is defined by the postmodernist tendency to move away from purist approaches in all fields of human endeavour. The tendency in the field of psychotherapy is to distance oneself from the belief that one particular therapeutic approach is superior to any

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other. Furthermore, our understanding of the multidimensional aspects of human personality and the complex dynamics that shape it have revolutionized psychotherapy (Dumont & Corsini, 2000) and stress management. Thus, integration is on the rise.

Multimodal misuse

therapy and its relation to substance

Origins of multimodal therapy

Lazarus (1973), the founder of multimodal therapy (MMT), emphasized the need for systematic technical eclecticism as a basis for therapy, where the therapist not only is guided by one preferred theory (in this instance Bandura’s (1986) social and cognitive learning theory) but also incorporates techniques from other orientations. These techniques are chosen for their effectiveness in practice without necessarily accepting theoretical principles that underlie them. Lazarus (1956) considered psychological as well as biological dysfunction as a possible cause for addiction, and pointed out that it is not psychological sensitivity alone that makes people dependent but rather their inability to cope with environmental stress. He saw the psychology of alcoholism as embracing a pattern of conditioning and habit formation: “The individual in stress situations makes a number of different responses, one of which might be the consumption of alcohol, which affords him temporary relief. Repetition . . . eventually leads to a conditioned response between stress and consumption of alcohol . . . This may soon occasion feelings of guilt... which in turn adds to the already mounting stress. This ‘self-perpetuated stress’ precipitates further drinking” (p. 3). Lazarus argued that this vicious cycle must be broken at several strategic points, and emphasized a “broad-spectrum” orientation which then evolved into his “multimodal” position (Dryden, 1991). Lazarus (1965) stipulated five treatment areas, namely, the patient’s physical problems, the breaking of compulsive habits, interpersonal needs within the patient’s social network, psychotherapeutic interventions, and co-therapy with the patient’s partner (where applicable). These areas eventually developed into seven specific modalities called BASIC ID, a concept that now forms the bedrock of multimodal therapy. BASIC ID

The human personality can be divided into seven distinct, interactive modalities, outlined in Table 8.1. This principle is the foundation of assessment and treatment in MMT.

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Table 8.1 The seven modalities of human personality (BASIC ID)

Behaviour Affect Sensation Imagery Cognition interpersonal Drugs/biology

Actions Emotions and feelings Sensory experiences (relating to taste, touch, pain, etc.) Fantasies, daydreaming, thinking in pictures Ability to think and analyse, beliefs The social being in relation to others Health and physiology

The acronym BASIC ID derives from the first letter of each modality. People have tendencies to favour some modalities over others. Some work more with thoughts in the form of words (cognition) while others work more with thinking in pictures (imagery). Thus, it is very important, for the selection of appropriate interventions, that the therapist and client be aware of the client’s BASIC ID. Matching the correct interventions with the individual’s needs is one of the great challenges in practising multimodal therapy. Despite its great breadth, MMT is brief, highly focused and problem-solving in its approach. Whenever possible, empirically supported treatment methods are applied. Therapeutic limitations Three limitations are now examined briefly in relation to MMT:

thresholds,

social learning and missing information, and interpersonal deficits and poor self-acceptance. Thresholds

Tolerance viduals

thresholds

to tolerate

differ from person to person. negative

stimuli,

such

The ability of indi-

as pain, frustration

or stress,

varies. Within boundaries, however, it is possible to teach clients to stretch their thresholds and abilities. This type of therapy requires determination and motivation on the client’s part as much as an ability and inclination to follow a programme outline. It is demanding and time-consuming for both parties, and therapists have to be fairly skilled in a wide array of interventions in order to design the most appropriate programme for each client. Social learning and missing information Bandura’s work (1986) shows how much of human behaviour is the result

of learning processes. His research particularly highlights the importance of observation and imitation in producing and maintaining behaviours. Thus, social learning influences the development of personality in numerous ways.

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Throughout life, people learn both helpful and harmful ways of thinking and behaving. MMT seeks to uncover maladaptive habits and unhelpful associations as well as pre-conscious beliefs and perceptions of self-efficacy (e.g. “I can only socialise if Idrink”’) (Bandura, 1986). In addition, people often lack necessary information (e.g. safe drinking levels) and coping skills to deal with life’s demands. Interpersonal deficits and poor self-acceptance

Many people experience unhealthy interpersonal relationships. These may stem from both deficits in the interpersonal modality and unrealistic expectations in the cognitive modality (e.g. “I must always be loved or treated fairly by others’’). Problems in this area can lead to low selfacceptance. If individuals fail in an area of life, they may think of themselves as complete failures rather than accepting shortcomings as a lack of skills that can be improved. In summary, these three types of limitations constitute challenges to therapeutic work with clients but can be successfully dealt with using the multimodal approach. MMT can be applied to stress management. The following sections link stress to developments within the seven modalities in substance misuse.

Responses to stress within the BASIC ID The responses that can be expected in clients requesting stress counselling or stress management are listed in Table 8.2 (Palmer & Dryden, 1995: 11). These responses are particularly evident in those whose stressful life-events have led them to substance misuse. The BASIC ID channels the various symptoms under modality headings so that clients may be assessed and treated in a systematic and unique fashion.

Practice

Some general points

Multimodal stress therapy can be seen as a holistic approach that deals with all aspects of the person rather than focusing on one particular problem or modality. Palmer & Dryden (1995) pointed out that the modalities can be seen as linked together to produce an affective response. Furthermore, the drugs/biology modality is involved with each link in the chain through stress hormones and other chemicals. As clients are usually troubled by

a

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Table 8.2 Responses to stress within the BASIC ID ae ni ENS BT ks i Spe SR Behaviour Addiction (to substances/behaviours) Avoidance Sieep disturbance Affect (emotions)

Sensations

Imagery (seeing oneself as)

Cognition

Interpersonai

Drugs/biology (physiological state)

ss

Ce

Withdrawal from relationships Anxiety/depression Anger Guilt Morbid jealousy Suicidal tendencies Palpitations Nausea Pain Dizziness Sexual dysfunction Alone Losing control Failing Being humiliated or embarrassed “Must” beliefs (“Il must perform well . . .”) “Life is awful, unbearable” Low frustration tolerance (LFT) Perfectionism Black-and-white outlook on life Labelling, e.g. “I failed the exam, therefore | am a failure” Passive/aggressive Unassertive Lack of friends Martyr-like behaviour Substance misuse Digestive disorders Allergies High blood pressure Chronic fatigue Low immune response

numerous problems, treatment endeavours to assess and address them all (or most of them) in order to reach their stated goals. As will be seen later,

there are a large number of possible interventions from which counsellors can select those most appropriate for specific clients. Within the multimodal framework, rigidity is avoided. Outcome goals are listed for each of the modalities where change seems advantageous. Overcoming misuse of substances may thus be one goal among many and may receive reduced attention within this approach in comparison to other substance misuse treatment models. This in itself may contribute to better outcome results. Stephen Palmer, a leading stress management consultant, reported (personal communication, April 1999) that clients had overcome dependency by improving their skills in various modalities without the

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labels “addiction” or “dependency” ever being used. By increasing their general coping skills they reduced or stopped their substance misuse. Multimodal

assessment

The initial interview is intended to establish rapport with the client, to assess presenting problems and to consider possible forms of intervention. At this stage, therapists are merely collecting information, particularly in cases of organic or psychiatric disorders or in those outside their range of competence.

Therapists work as facilitators and educators but most of the work has to be done by clients. A comprehensive multimodal life history inventory (MLHI) is presented to clients, which they take home to complete. On its return, therapists can compare their personal notes with the MLHI and create a persona! BASIC ID based on this information for each client. The initial session and the MLHI help therapists to choose the kind of therapeutic style to which clients might best adhere.

Modality profile Therapists then draw up a modality profile. This is a BASIC ID chart that lists the problems and the proposed interventions within each modality. With instruction, it is usually possible to ask clients to draw up their own modality profile. To obtain a more objective evaluation, a comparison between the two profiles can be made. Possible contradictions and suggested interventions can then be discussed. The ability to present techniques in ways that are acceptable to clients is a core skill for multimodal stress counselling (Palmer & Dryden, 1995).

An example of a modality profile: ‘‘Sophie’’ Sophie presented with general stress and anxiety symptoms and was heavily dependent on painkillers. She tended to use them preventatively in order to avoid potential pain and discomfort. Sophie’s modality profile is outlined in Table 8.3. Selection of interventions

A number of interventions were suggested to Sophie. The main selection criterion for any technique was empirical research evidence of its validity. Nelson-Jones

(1995: 339) claimed

that such data are available for using

these techniques to treat, inter alia, “bulimia nervosa, compulsive rituals, social skills deficits, bipolar depression, schizophrenic delusions, focal phobias, tics, habit disorders, pain management, hyperventilation, panic

Multimodal stress therapy Table 8.3 Sophie’s modality profile ren mre re Modality Problem

Behaviour

Affect

Sensation

imagery

Cognition

Interpersonal

Drugs/biology

ee

e Avoids women e Procrastination e Lack of concentration, sleep disturbances e Anxiety e Depression © Guilt e Anger e Flushes e Dizziness e Tension (head) e Women rejecting her e Being told off by mother as a little girl e Perfectionism e Irrational beliefs e Self/other damnation e Low frustration tolerance (LFT) e Unassertive with women e Mother-conflict e Lack of female friends e Headaches e Sleep disturbance e Overuse of painkillers (initially 100 per week) e Stomach problems e Skin rashes e Lack of exercise

ee ee ee Pe Proposed intervention

eee

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2

e Role-playing and cognitive restructuring e Burns’s prescription for procrastinators* ¢ Relaxation; tape and imagery work e e e e e e e e e

Relaxation, colour visualization Coping imagery, physical exercise Dispute irrational beliefs Self-calming statements Positive imagery Relaxation Exercise imagery and thought stopping Mastery image

e e e e

Bibliotherapy Disputing irrational beliefs Cognitive restructuring Positive reinforcement; self-monitoring

e e e e e e

Assertiveness training Intimacy training Disputing irrational beliefs Stop using car and walk Exercise bike Relaxation Stability zones Extending LFT Time projection imagery

e © @

Burns’s prescription for procrastinators (Burns, 1990) includes a number of elements, such as (1) performing a cost—benefit analysis; (2) assessing advantages and disadvantages of starting today; (3) making plans, attaching specific time; (4) making it easy; (5) eliminating distorted thinking; (6) giving oneself credit for each solid accomplishment. Mastery images help clients to picture themselves completing tasks perfectly in order to overcome irrational thoughts of failure, rejection or helplessness.

disorders, autism, enuresis, vaginismus and other sexual dysfunctions and a

variety of stress-related disorders’. Secondly, the techniques were selected because of Sophie’s personal preference. Through conversation and the MLHI, I was able to investigate the client’s preferred modalities and ways of working. She struck me as a very intelligent woman who liked to use cognitive skills frequently. Many of her problems could be traced back to certain irrational beliefs that needed restructuring. Thus, cognitive interventions were deemed most appropriate. Careful consideration was given to answers to the MLHI questions: “What do you think therapy is about?’’, ‘““How long do you think it should last?”’,

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and “What personal qualities should the ideal therapist possess?” (NelsonJones, 1995). Sophie had a preference for the therapist to possess understanding, empathy, intelligence, humour and warmth. My experience of therapy with Sophie was used to put the interventions described below into a practical perspective. In order to preserve confidentiality, the client’s name and some intervention details were changed. Behavioural

interventions

Palmer and Dryden (1995) held that, in order to use behavioural techniques as effectively as possible, the following guidelines should be followed:

e e e e e

Make sure clients understand the nature of the intervention and how it will benefit them Take a note of the desired outcome targets and record gradual improvement Encourage clients to practise the technique regularly Use positive reinforcement and rewards Encourage clients to use additional coping strategies, e.g. relaxation, to enable them to complete the behavioural task.

Of course, there exists a multitude of behavioural interventions. Those that

I have found useful in the treatment of stress and substance misuse through reducing anxiety levels are now described. Systematic exposure encourages clients to expose themselves to the feared situation and to accept the anxiety. By staying with it, their anxiety level will gradually decrease. In behaviour rehearsals, therapists and clients act out difficult situations with the goal of teaching clients what to do in a feared interpersonal encounter. Fixed role therapy enables clients to make their constructs about life and themselves more flexible; for example, they do not have to remain shy for the rest of their lives simply because they have been shy heretofore. In stimulus control, individuals recognize that unhealthy behaviours may increase in the presence of certain stimuli. This intervention helps clients to reduce unhealthy behaviours by adhering to previously defined limitations upon which they themselves decide. Positive reinforcement involves the use of praise, recognition and encouragement by therapists. In recording and self-monitoring, clients are encouraged to record everything they do in order to change a certain behaviour. This will show them how they have progressed and help them to overcome lapses. Time management helps clients learn how to prioritize, become more methodical and avoid procrastination. In Sophie’s case, she was encouraged to monitor herself regularly and report back weekly on how she was getting on with various interventions. She was taught how to avoid procrastination. She learned to prioritize the

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activities that were important to her and that she liked doing, and to spend less time on those that were less important to her but that she felt she ought to be undertaking. This intervention complemented the cognitive intervention of giving up irrational beliefs such as: “It is selfish to do things that you enjoy doing (such as going to study in the library)”. She was also encouraged to reward herself on successful completion of tasks, and I reinforced her self-acceptance by acknowledging her efforts and achievements. Affect interventions

Lazarus has argued that one cannot change affective reactions without using methods derived from the other six modalities (Palmer & Dryden, 1995). Therefore, affective interventions incorporate techniques that influence behaviour, cognitions, senses, images, interpersonal relations and biological functioning. These interventions are now described. Anger expression enables clients to own and express their anger and may require behavioural rehearsal (e.g. how to express one’s anger in an assertive way, while acknowledging other people’s feelings). In anxiety management

training,

a number

of techniques

such as relaxation,

goal-rehearsal

and coping imagery are used. In coping imagery, clients imagine anxietyprovoking situations and immediately follow this with relaxing images. Using this technique in real life helps clients to cope in stressful situations. Feeling identification aims at recognizing significant feelings that might be unclear or misdirected (Nelson-Jones,

1995).

Sophie was taught how to manage her anger more effectively through the use of self-calming statements. This technique was particularly important when she was dealing with her mother. Because of a lack of affection and refusal to listen on her mother’s part, Sophie often felt very frustrated and angry with her. This resulted in a rather strained relationship where civilized conversation was perceived to be impossible. We dealt with this not only on a cognitive level but also by applying self-calming statements. This helped to reduce Sophie’s intake of painkillers significantly, especially on days when her mother was due to visit. Sensation

interventions

These interventions aim at alleviating physiological stress symptoms. They represent the antithesis of the stress response (Palmer & Dryden, 1995) and are a main resource for clients who might previously have misused substances in order to cope with life’s stressful events. Two such interventions are hypnosis and relaxation training. Hypnosis is used in conjunction with ego-strengthening techniques to reduce tension and reinforce new helpful beliefs. These new beliefs are formed through cognitive interventions and

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replace some of the old irrational ones. Relaxation training decreases the activity of the sympathetic nervous system (which produces adrenalin, cortisol and other stress hormones in response to stressors) and increases the activity of the parasympathetic nervous system (which preserves energy levels and aids relaxation). Multimodal relaxation techniques teach clients to breathe calmly and to gently relax all their body parts, followed by the use of positive images, sensations and colour visualizations. I mainly used relaxation training with Sophie, as she had expressed a dislike and distrust of hypnosis. She chose the image of an old oak-panelled room as her favourite place of relaxation and the colours pink and blue for the visualization exercise. Although she initially found relaxing very difficult, she subsequently moved into a state of deep relaxation and could only be woken up with difficulty. She had not been aware how powerful positive images could increase physical, mental and spiritual well-being, and found a new strength in this intervention. Imagery interventions Negative images, more often than events, tend to be responsible for people becoming stressed and anxious. Flashbacks from the past projected into the future can lead people to believe that nothing will ever change, that others will always treat them badly or that they will always fail. Clients are often able to conjure up negative images and they need to learn how to replace those with new, more helpful ones. Thus, initial training in being able to evoke natural or positive images might be necessary to stimulate a client’s imagery modality. Four different kinds of imagery may be identified. Aversive imagery involves clients associating an unpleasant image with the behaviour they are trying to reduce. Coping imagery consists of clients learning to imagine themselves coping with a difficult situation — not necessarily always succeeding but coping with it nevertheless. They imagine themselves as strong and powerful people who are able to overcome their urges. Positive imagery encourages clients to replace negative images with positive, calming scenes. Time-projection imagery can help clients to work through past events and see themselves as their new selves. They imagine some dreadful event in the past and then remember how they felt a few months later and how they feel about it now. This teaches them that negative events can be transient and can be coped with successfully. Sophie took part in various imagery interventions such as imagery for coping with women (including her mother), when they professed racist beliefs — beliefs that Sophie felt a desire to challenge. She learned a positive imagery intervention (candle and colours) which helped her to become calm and block out negative images. Through a mastery intervention, she could see herself as a caring mother who was also able to enjoy studying for her

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degree. The time-projecting image showed her what it would and will be like to be more emotionally balanced, to be in less pain and to have female friends to support her.

Cognitive interventions People’s negative thoughts and beliefs are very often triggers for their stress response.

Unrealistic expectations, such as absolute ‘“‘musts’’, contribute to

people’s emotional disorders. The aim of cognitive interventions is therefore to help people change their irrational (unhelpful) beliefs into more realistic (helpful) ones. A number of such interventions are now outlined. Bibliotherapy encourages clients to read useful self-help books or articles. Ellis’ A~B-C-—D-—E paradigm shows clients how the A (activating event) is interpreted by B (beliefs), which then leads to C (consequences) that may be negative. These irrational beliefs need to be D (disputed) which will result in the E (effect) of diminishing the negative consequences. Disputing irrational beliefs involves clients’ receiving a list of common cognitive distortions (e.g. Burns, 1990) and learning how to “untwist” their thinking. Thought blocking can help clients to stop unwanted, intrusive thoughts, e.g. cravings. In order to eradicate them as quickly as possible before one acts on them, clients are instructed to see a “STOP” sign. Ideally, the thought should then be replaced with a positive one to prevent it from intruding again. LFT-expansion involves working on low frustration tolerance (LFT), which can lead people to seek immediate relief. When clients are encouraged to experience the frustrating situation a little longer, they can eventually arrive at a situation where discomfort is no longer intolerable. Sophie felt most comfortable working in the cognitive modality, and made a fervent effort to untwist her thinking. She succeeded both in becoming less perfectionist and less guilty and in attaining more realistic expectations of herself and others. Thought stopping proved useful when she attempted to enter friendships with females. Thoughts such as “Women have never accepted me, and they won’t now’, which used to get in her way, were reduced.

Interpersonal interventions

These types of intervention are educational ones where therapists teach clients useful interpersonal skills. Three are now outlined. Communication training involves training clients to receive and send communication, e.g. eye, body, verbal and voice messages. In social skills and assertiveness training, four specific assertive responses can be offered to the client to practise: “learn to say no”, “express and own one’s own feelings”, “ask for help” and “learn to communicate”. Friendship and intimacy training tends to overlap with the other two.

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Sophie presented a real need to improve her skills in this area. Cognitively, she worked on replacing her “must” for female companions to “preferences”. She needed to accept that it was better to look for a few good friends rather than one outstanding one. She also had to learn about complementarity, as she had mainly sought friends among women with whom she had very little in common. Drugs/biological interventions Drugs/biological interventions mainly seek to improve physiological symptoms. Therapists need to inform themselves of both relevant health issues and prescribed and non-prescribed drugs. If in any doubt about clients’ presenting symptoms, therapists should refer to medical practitioners and exchange notes with them (with the agreement of clients). Within this modality, therapists have the opportunity to investigate clients’ use/misuse of substances such as coffee, nicotine, alcohol and drugs. Clients are then encouraged to take responsibility for their health. Three methods of doing so are exercise, stability zones and rituals. Exercise can improve one’s mental health and self-acceptance by releasing aggression in a safe way. Stability zones can be thought of as physical areas, belongings or objects of which a person may be fond and that may promote feelings of well-being. Rituals are activities that are regularly performed in order to achieve relaxation (e.g. having a regular cup of tea, playing Scrabble, meeting friends, enjoying a relaxing bath). Sophie decided that joining a gym was not for her. However, she stopped using the car for collecting the children from school and started using her exercise bike when watching TV. She reintroduced rituals such as going window-shopping and visiting the local library to study. She decided to work on her LFT towards physical discomfort and accepted that not every headache needed immediate attention. Firstly, she tried relaxation exercises when she felt early symptoms. If that did not work, she bargained with herself to wait another half hour before taking a tablet and rewarded herself for her endurance. While waiting, she refused to look at her watch and engaged in an activity that she enjoyed to take her mind off the pain. More often than not, she did not need to take a painkiller at the end of the half hour. Overall evaluation of treatment outcome

After 12 therapy sessions, Sophie decided that she had regained control of her life and stopped regular therapy, although she still comes for booster sessions on occasion. Her intake of painkillers was greatly reduced from up to 100 tablets a week to approximately 40 per month. She has stopped using them to

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prevent pain and only takes them now when other methods of pain control have failed. Headaches and other discomfort generally occur less frequently, mainly at times of PMT. Consequently, her stomach is in a much healthier condition and her sleep has improved. Her relationship with her mother is less stressful and the notion of female friends has changed from an absolute must to a preference. Sophie appears more joyful and energetic. She has enrolled to do various diplomas and is very much looking forward to this challenge.

Conclusion Multimodal stress therapy can be used very successfully to treat stressrelated substance misuse. Clients are assessed and treated within a holistic model through intervention in seven distinct yet strongly linked and interdependent modalities. The approach generally tends to avoid dealing with substance misuse directly, preferring to overcome the numerous obstacles that might contribute to it. Because of space limitations, only the main techniques of multimodal stress therapy are outlined here. A comprehensive summary of other techniques can be found in Palmer and Woolfe (2000). Multimodal stress therapy offers a systematic and comprehensive framework to ensure that significant issues for the client’s recovery are less likely to be overlooked (Nelson-Jones, 1995) and efficient and effective treatment can be achieved. It is brief but highly focused; in short this therapy “cuts to the chase without cutting corners” (Whipple, 2000: 144).

References Bandura, A. (1969). Principles of behaviour modification. New York: Holt, Rinehart & Winston. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Burns, D.D. (1990). The feeling good handbook. New York: Plume. Conger, J.J. (1956). Reinforcement theory and the dynamics of alcoholism. Quarterly Journal of Studies on Alcohol, 17, 296-305. Dryden, W. (ed.) (1991). The essential Arnold Lazarus. London: Whurr. Dumont, F. & Corsini, R.J. (eds) (2000). Six therapists and one client. London: Free Association Books. George, R.L. (1990). Counselling the chemically dependent: Theory and practice. Boston: Allyn and Bacon. Lazarus, A.A. (1956). A psychological approach to alcoholism. South: African Medical Journal, 30, 707-710.

Lazarus, A.A. (1965). Towards the understanding and effective alcoholism. South African Medical Journal, 39, 736-741.

treatment

of

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Collard

Lazarus, A.A. (1973). Multimodal

behavior therapy: Treating the “BASIC

ID”.

Journal of Nervous & Mental Disease, 156(6), 404-411.

Nelson-Jones, R. (1995). The theory and practice of counselling psychology (2nd ed. ). London: Cassell. Palmer, S. (1992). Stress management:

A course reader. London: Centre for Stress Management. Palmer, S., Cooper, C., & Thomas, K. (2003). Creating a balance: Managing stress. London: British Library. Palmer, S. & Dryden, W. (1995). Counselling for stress problems. London: Sage. Palmer, S. & Woolfe, R. (eds) (2000). Integrative and eclectic counselling and psychotherapy. London: Sage. Sher, K.J. (1986). Stress response dampening. In H.T. Blane & K.E. Leonard (eds), Psychological theories of drinking and alcoholism (pp. 227-271). New York: Guilford Press. Whipple, A.G. (2000). Multimodal therapy: Arnold Lazarus. In F. Dumont & R.J. Corsini (eds), Six therapists and one client (2nd edn, pp. 145—174). London: Free Association Books.

Part Il

Professional and clinical integrations and special populations

Chapter 9

The integrating collaboration of a psychologist with a psychiatrist Joannis N. Nestoros, Konstantia A. Zgantzouri and Nikitas E. Polemikos

Collaboration among health professionals was defined by Lorenz et al. (1999: 402) as both an attitude and an interpersonal process. Such collaboration embodies cooperation and a spirit of working together as a team with a flexible hierarchy in order for professionals — with divergent educational backgrounds, training, expertise and special talents — to provide high-quality, comprehensive and efficient care to their patients. Karl and Will Menninger, the founders of systemic family therapy, believed that effective treatment could be provided not only by physicians but also by many other mental health professionals (Menninger, 1998). Interdisciplinary collaboration in mental health services has recently flourished, mostly due to the changes that have taken place during the past 50 years in the delivery of such services. These include the focus on smaller, locally based settings rather than on larger traditional psychiatric hospitals; the development of psychiatric wards in general hospitals; the assignment of significant roles to new mental health professionals such as community psychiatric nurses, clinical psychologists, social workers and liaison psychiatrists; developments in psychiatric knowledge that have led to the acceptance of the value of a multidisciplinary team approach in providing mental

health

services

(Kingdon,

1992;

Milgrom

et al., 2001);

and

the

development of new eclectic and integrative models of treatment for the severely mentally ill that combine different therapeutic modalities (such as individual and family psychotherapy and pharmacotherapy) with the therapeutic factors (e.g. the therapeutic relationship) common to all psychotherapies (Hawkins & Nestoros, Nestoros & Vallianatou, 1990/1996).

1997; Nestoros,

1993,

1997a,

1997b;

In recent times, interdisciplinary collaboration has been emphasized as an essential component in the provision of mental health services as the overlap between biomedical, psychological, familial and social problems for most of the patients exhibiting symptoms of severe mental illness has been recognized. This widespread collaboration has significant advantages for practice but is also the cause of some significant difficulties, which hinder its beneficial characteristics. A brief review of these issues is provided in this

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ee chapter, together with a case study that focuses on the collaboration between a psychologist and a psychiatrist in order to offer the patient the best possible modality of integrative treatment.

The advantages and disadvantages of interprofessional collaboration in mental health Collaboration and teamwork in mental health services vary depending on how much professionals like working together. Some mental health professionals enjoy working together while others prefer more independence and working alone. Although teamwork depends mostly on the personal preferences of these professionals, in recent decades the necessity for interdisciplinary collaboration has been emphasized, since it offers many advantages for the collaborating professionals, the patient’s welfare, significant others in the patient’s life, the mental health delivery system and society in general. Moreover, relevant models of treatment have been proposed, such as the Therapeutic Contracting Program presented by Levendusky and his colleagues (Heinssen et al., 1995; Levendusky et al., 1983; Levendusky & Swett, 1979), the team approach and milieu therapy at the Menninger Hospital (Menninger, 1998) and the integrated human services delivery model for First Nation communities (Boone et al., 1997). Lorenz et al. (1999) stated that the key ingredients for the development of an effective interdisciplinary collaboration among mental health professionals are: a good working relationship, 1.e. the establishment of a relationship between the members of the team which should be based on their clinical responsibility and mutual respect; a common purpose, i.e. to work together to achieve the specific goals of therapy and to promote the patient’s health and overall bio-psychosocial welfare; sharing of the same paradigm, or the recognition of professional autonomy, 1.e. the approval of differences existing between the collaborators and the limits of their therapeutic expertise; effective communication, i.e. the avoidance of misunderstandings between team members; /ocation of services offered to the patients, i.e. whether they are co-located and the professionals practise together or whether they practise separately and independently of each other; and, finally, the business arrangement, i.e. issues such as the payment for services and the patient’s health insurance coverage. The process of interdisciplinary collaboration itself extends and deepens the knowledge and boundaries of professionals from different disciplines, by giving them the opportunity to use the specialists’ knowledge of all the encounters. It also (a) provides them with a deeper understanding of their roles in therapy and breaks down stereotypes, (b) expands the training element of each collaborative encounter through the exchange of thoughts and ideas, (c) allows them to share in practice and explore a variety of potential solutions to the problem at hand, (d) combines resources and

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effective strategies of work in a more holistic fashion, (e) provides the opportunity to offer and receive support and to use the alliance for the therapeutic benefit of clients, and (f) shares responsibility for the patients and their families. As a result, the professionals, through their involvement in this collaboration, develop greater awareness and more sophisticated thinking about mental illness. These collaborations are viewed as team endeavours and provide better and more effective mental health services (Boone et al., 1997; Huxley & Oliver, 1993; Imhof er al., 1998; Kingdon, 1992; Lorenz et al., 1999; Menninger, 1998; Milgrom & Burrows, 2001; Roberts & Priest, 1997).

Despite the emphasis on collaborative practice among mental health professionals, little research has focused on the role each professional plays in a multidisciplinary team. Slade er al. (1995) studied the roles of the members of multidisciplinary mental health teams, namely psychiatrists, clinical psychologists, psychiatric nurses, social workers and occupational therapists, in one Australian and two Indian mental health centres. The researchers focused primarily on the professionals’ leadership and management skills as well as conflict resolution and therapeutic abili-

ties. Results showed

that these skills were mostly associated with the

professionals’ training (psychiatrists seeming better equipped in these skills) and were more developed in staff working in community settings. Another study (Rubinstein, 1994), investigating cooperation patterns among Israeli psychiatrists, psychologists and social workers, found higher cooperation levels in mental health clinics than in other mental health sites, in trainees than in experts, in women than in men, and in psycho- . logists and social workers than in psychiatrists (a fact that was attributed to their training). Leadership issues need to be addressed among the members of a multidisciplinary mental health team, and the roles of the professions in a multidisciplinary setting need to be clarified and differentiated (Slade ef al., 1995). Slade and his colleagues stated that a debate was taking place internationally on leadership in the clinical team: the US Group for the Advancement of Psychiatry emphasized the leadership position of psychiatrists for the provision of better mental health services to the patients, while the other mental health professionals addressed the issue of increased leadership in their own roles. Recent scientific literature (Kingdon, 1992; Milgrom & Burrows, 2001) has focused mostly on the benefits for clients of the collaboration between mental health professionals. Emphasis has been given to the provision of a comprehensive biopsychosocial treatment modality that integrates many perspectives and is organized around (a) the clients’ needs and stages of treatment; (b) the opportunity to investigate a variety of potential solutions to the problems of clients; (c) the collaborative development of a care plan among the members of the therapeutic team and clients; (d) the use —

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in addition to the techniques of counselling and psychotherapy — of pharmacotherapy and other forms of treatment when they are needed; and (e) the opportunity for more than one mental health professional to monitor and respond to the developments of the treatment procedure in an accurate and integrative fashion. Although interdisciplinary collaboration has been proposed as a therapeutic component of much importance for the welfare of clients, certain issues may hinder its execution. These include (a) differences in the frames of reference and goal heterogeneity between different professions; (b) role stereotypes, role conflicts and problematic communication or misunderstanding between professionals; (c) group pressure towards conformity among its members or towards group maintenance rather than towards the task and the benefit of patients; (d) distress caused by the distinctive projection of clients and their relatives’ negative feelings onto one member of the therapeutic team, which may influence professional interactions, causing the singled-out member to feel professionally and individually undervalued (Boone et a/., 1997: Gustafsson et al., 1979; Imhof et al., 1998;

Kingdon, 1992; Roberts & Priest, 1997).

Collaboration between a psychologist and a psychiatrist: An example of the integration of perspectives Goldberg (in Birley, 1987) argued that professionals who work only in the environment of their own profession are likely to believe that if individuals cannot be helped by their own “brand of intervention’, they cannot be helped at all: therefore, they can be discharged to suffer on their own. In this chapter, the benefits of collaboration between a psychologist and a psychiatrist are presented, and discussed through a case study. A young man exhibiting both positive and negative psychotic symptoms was treated with psychotherapy and pharmacotherapy by a psychologist (NP) and a psychiatrist (JN). Both therapists are clinicians who are also involved in academic research. The combined integrative treatment of the same patient by these mental health professionals created the opportunity for elucidation of the advantages and limitations of each professional perspective, while at the same time giving the patient the opportunity to receive the best possible integrative modality of treatment.

The case of Erophilos Erophilos is a 32-year-old man. He lives on a Greek island and works during the summer as a bartender in the family’s hotel. Erophilos is the

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older of the two children in his family. He has a 30-year-old brother who left Greece to study physics. After receiving his PhD in the USA, his brother emigrated to Germany where he continues to live and work. Erophilos’ father is now 78 years old. After studying chemistry, he established a small perfume industry, which in recent years has been unable to compete profitably with larger firms. He does not smoke, abstains from alcohol and is a vegetarian. He is very thin and short in stature. As a person, he is aloof and avoids social contact. In their smal! community, he

has the reputation of being a peaceful person who enjoys painting. As a father, he was not greatly involved in his children’s upbringing, being emotionally distant and never giving advice or help in problem-solving. Erophilos’ mother, 57 years old, is 21 years younger than her husband. In contrast to her husband, she is tall, full of energy and a very sociable woman who does not hesitate to take initiative and responsibility. She controls the family both at home and in their business. Erophilos was never a good student but he managed to finish the Lyceum because of intensive tutoring by his mother. Afterwards he went to England in order to learn English, but stayed for only a few months since he was homesick. Throughout his life he has been heavily engaged in physical exercise and athletics such as karate, weight-lifting, surfing and jogging. Physically, as a result of many years of vigorous exercise, he looks very masculine and athletic. For an extensive period, he took a great variety of vitamins and dietary supplements. Although he exercises a lot, he also smokes heavily and drinks up to six cups of coffee a day. Although he is efficient as a bartender, when he is anxious he is not punctual in his working hours. This anxiety usually arises when he is suspicious due to misinterpretation of the behaviour of certain clients. His mother usually covers his duties in such circumstances. When he was 17 years old, Erophilos, at his mother’s insistence, asked for psychological help. The presenting problem was related to ejaculation during masturbation. Erophilos reported that when he was 14 years old, his mother saw him masturbating and she told him to stop it because it was “‘a bad thing’. His mother, when asked by the psychologist (NP), did not confirm this incident. The psychologist tried to help Erophilos to exculpate himself by giving him some practical advice to deal with the problem and to reduce his guilty feelings. During four psychotherapy sessions, he was assured that he did not have any organic problems. As a result, Erophilos felt relieved and his guilty feelings were minimized. He also considered the practical advice given by the psychologist to be very effective. Six years later, Erophilos — prompted by his mother — again sought psychological help. The presenting problem was his interpersonal relationships: he misinterpreted the intentions of other people and reacted aggressively even to his friends. On one occasion, he had a fight with his karate master which was related to Erophilos’ flirting with his teacher’s

110 Nestoros, Zgantzouri and Polemikos Oe Ee ee a a

girlfriend. In that fight, Erophilos ended up with a broken leg. According to Erophilos, he started the fight “half jokingly and half seriously”. In this second series of sessions, it became clear to the psychologist that Erophilos had started to exhibit severe psychological problems. He presented with both persecutory delusions and ideas of reference (he believed that people at the bar were staring at him while “their eyes turned red”’). At night before falling asleep, he put a knife under his pillow. He also kept all the kitchen knives locked in his room because he was afraid that his father was planning to hurt him. According to the psychologist, the patient was likely to benefit from a collaborative treatment combining psychotherapy and medication. Therefore, he informed Erophilos and his mother that medication might be helpful. The psychologist referred Erophilos for medication evaluation to a prescribing psychiatrist (JN) with whom he (the psychologist) already had a mutually respectful working relationship and shared philosophies of treatment (Polemikos et al., 2000).

Erophilos and his mother were not opposed to considering the initiation of medication as a complement to his ongoing psychotherapy. He visited the psychiatrist and received medical treatment that was effective and beneficial in eradicating his auditory hallucinations, persecutory delusions, loosening of associations, bizarre thinking and inability to trust his psychologist. All of the above enabled the psychologist to continue with the psychotherapeutic process. The fact that the prescribing psychiatrist was also an experienced psychotherapist, who had proposed an integrative psychotherapy model for .the treatment of psychotic symptoms (Nestoros, 1993, 1997a, 1997b), had a profound impact not only on their relationship but also on Erophilos’ willingness to accept medical treatment and to continue his psychotherapy. Due to his positive feelings towards the prescribing psychiatrist and the psychotherapist, he was also persuaded to continue his psychotherapy sessions even when his symptoms decreased due to medical treatment. From time to time, in order for the client’s working relationship with the mental health professionals to become more beneficial and to promote his well-being, his feelings about visiting the psychologist and the psychiatrist, transference and countertransference considerations, confidentiality issues in his relationship with each of them, as well as any risk considerations of medication received, were explored. In one of his psychotherapy sessions with the psychologist, Erophilos reported that during the fifteenth month of his military service (which he had undertaken after the beginning of his psychotherapy) he had had a nervous breakdown, with an outbreak of crying without reason. This event did not impede his completion of military service, since his military superiors understood his problems and released him from most of his duties.

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Erophilos also reported that, during a trip with his father to an island, he could not sleep at night because he was afraid that his father was planning to attack him as he slept. However, he said that he had a very good relationship with his mother, with whom he discussed even his sexual and erotic problems. He did not confide in his father, although he described him as a very calm and peaceful person who could not hurt even an ant. These facts led the psychologist to believe that Erophilos’ fears of being hurt by his father probably revealed a castration anxiety as a consequence of an unresolved Oedipus complex. Erophilos had a lot of interpersonal problems, not only with men but also with women. He became irritated with some people and he talked about his problems even to acquaintances. Although he is a handsome man and has a good sense of humour when he feels good, he sometimes misinterprets others’ behaviours, becomes disappointed when his friends are not what he expected them to be and then ends those friendships. Sexuality for Erophilos was a crucial issue which bothered him a lot. He overreacted to homosexuality-related issues, and it seemed that he had developed a latent homophobia which was revealed in his overreaction to certain issues. When the word “‘gay’” was mentioned, he became very nervous. Erophilos also reported that many times when he was windsurfing, he became dizzy and heard women’s voices uttering sexual content. He believed that these voices were also heard by other people who were windsurfing and he felt embarrassed. When the voices became stronger, he felt compelled to stop windsurfing and to rest in his car or go home and sleep in order for his symptoms to disappear. When these voices sometimes made him doubt his sexual identity, he would get out of the water and panic and put his hands on his genitals to reassure himself that he was a man and did not have female genitals. The psychologist believed that this description undoubtedly revealed castration anxiety. For a long period of time, Erophilos had an obsession that he had started fires because he threw a cigarette through the car window five years previously. He also had a paranoid reaction when he saw trucks loaded with wood for the construction of buildings: he thought that they wanted to crucify him because he was someone special, the Messiah. He did not share

these delusions of grandeur with his parents because he was afraid that they would punish him in revenge for the trouble he was causing them.

Cultural aspects Since the behaviour of every person is always influenced by cultural as well as biological and psychological perspectives, mental health professionals need to focus on the cultural dimensions of illness behaviour. These include how patients or their families perceive, conceptualize and present their problems, how they seek help and what kinds of healing systems are

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Zgantzouri

and Polemikos

available and utilized within each cultural setting. In some societies, including Greece, mental disorders still carry a substantial stigma with the result that seeing a mental health professional is to be avoided. Therefore, beyond being clinically competent, clinicians need to possess qualities that enable them to sharpen cultural sensitivity, acquire cultural knowledge, enhance cultural empathy, adjust to culture-relevant relations and interaction, and establish an ability for cultural guidance (Tseng, 2003; Tseng & Streltzer, 2001; Yutrzenka, 1995).

Although cultural factors and attitudes towards schizophrenia do not directly affect its manifestation or frequency, they influence people’s beliefs and understanding of the disorder and mould their reaction towards it. The attitudes of mental health professionals in Greece towards the treatment of schizophrenia remain controversial because of the historically limited effectiveness of its treatment and its poor prognosis. Most mental health professionals in Greece believe that schizophrenia is an incurable illness that we do not and cannot understand,

while some

others, based on the

combination of an optimistic attitude regarding their ability to understand and influence patients’ behaviour and of present scientific knowledge in the fields of aetiology, psychopathology, psychotherapy, pharmacotherapy and neurosciences regarding psychotic symptoms, believe schizophrenia to be curable. Obviously these attitudes greatly influence the nature and provision of mental health services, the patient’s illness behaviour and therapeutic outcome, and practitioners’ interprofessional collaboration. As far as interprofessional collaboration is concerned, in the case of Erophilos, the psychiatrist and psychologist shared a view of schizophrenia as a curable disorder. Based on the principle that the integration of different approaches to the treatment of schizophrenia is possible and has many advantages over conventional one-sided approaches (Nestoros, 1997b), they utilized pharmacotherapy and psychotherapy in a complementary way. The two mental health professionals respected each other’s work and shared the belief that both pharmacotherapy and psychotherapy were crucial and necessary for the client’s recovery. Thus, they both encouraged Erophilos to continue the two treatments simultaneously. Finally, the two specialists communicated often and treated each other as equals in hierarchy, giving equal attention and value to their client’s psychotherapy and pharmacotherapy. Discussion

In the case study presented above, the psychologist and the prescribing psychiatrist were characterized by clarity in their professional roles and clearly defined expectations of each other as they shared basic principles about the nature and treatment of mental illness (Hawkins & Nestoros, 1997;

Nestoros,

1997a,

1997b;

Polemikos,

1997).

Both

are

founding

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members of the European Institute of Psychotherapy, which emphasizes an integrative understanding of mental illness and provides training in the application of the integrative psychotherapy model in its treatment (Polemikos ef a/., 2000). The shared view of mental illness seems to be the

key element for the provision of effective cooperation for the client’s benefit, while at the same time functioning to maintain balance among mental health professionals as far as the issues of professional identity, therapeutic capabilities and use of specific interventions are concerned. As a consequence of the collaboration detailed above, the client became a more active agent in the treatment procedure; that is, he was more inclined to follow therapists’ recommendations, mostly due to the establishment of an effective therapeutic alliance that allowed him to be an equal partner in the treatment process, have better compliance with pharmacotherapy and complete both his pharmacotherapy and psychotherapy treatments. Moreover, because of his personal investment in the treatment process, the client maintained most of his health-related behaviours, minimizing or lessening the length of time spent in treatment as well as the associated costs. At present, Erophilos is symptom-free most of the time, receiving very small amounts of antipsychotic medication (which has no side-effects) prescribed by the treating psychiatrist and having occasional psychotherapy sessions with his psychologist during periods of exceptional stress. Both therapists feel that Erophilos would probably have needed higher doses of antipsychotic medication and repeated hospitalizations had he not been given the opportunity to have combined psychotherapy and pharmacotherapy from a psychologist and a psychiatrist working harmoniously together. References Birley, J.L.T. (1987). Psychiatrists and psychologists: Working together for planning services in the post-Griffiths era. Psychiatric Bulletin of the Royal College of Psychiatrists, 11, 210-211.

Boone, M., Minore, B., Katt, M., & Kinch, P. (1997). Strength through sharing: Interdisciplinary teamwork in providing health and social services to northern native communities. Canadian Journal of Community, 16(2), 15—28. Gustafsson, L.H., Lagerberg, D., Larsson, B., & Sundelin, C. (1979). Collaboration

in practice: Experience from a multidisciplinary research project on child abuse and neglect. Acta Paediatrica Scandinavica, suppl. 275, 126-131. Hawkins, P.J. & Nestoros, J.N. (1997). Beyond the dogmas of conventional psychotherapy: The integration movement. In P.J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 23-95). Athens, Greece: Ellinika Grammata. Heinssen,

R.K.,

Levendusky,

P.G., & Hunter,

R.H.

(1995). Client

as colleague.

Therapeutic contracting with the seriously mentally ill. American Psychologist, 50(7), 522-532.

114. Nestoros, Zgantzouri and Polemikos la sche inet lem rt eR SONS SEIS WN

Rg

BS

Huxley, P. & Oliver, J. (1993). Mental health policy in practice: Lessons from the all

Wales strategy mental illness. International Journal of Social Psychiatry, 39(3), 177-189.

Imhof, J.E., Altman,

R., & Katz, J.L. (1998). The relationship between psycho-

therapist and prescribing psychiatrist. Some considerations. American Journal of Psychotherapy, 52(3), 261-272. Kingdon, D.G. (1992). Interprofessional collaboration in mental health. Journal of Interprofessional Care, 6(2), 141-147.

Levendusky, P.G., Berglas, S., Dooley, C.P., & Landau, R.J. (1983). Therapeutic contract program: A preliminary report on a behavioral alternative to the token economy. Behavior Research & Therapy, 21, 137-142. Levendusky, P.G. & Swett, C. (1979). Inpatient contracting: A behavioral treatment approach to chronic pain. In D.J. Osborne, M.M. Gruneberg, & J.R. Eiser (eds), Research in psychology and medicine (Vol. 1, pp. 49-52). New York: Academic Press. Lorenz, A.D., Mauksch, L.B., & Gawinski, B.A. (1999). Models of collaboration. Primary Care, 26(2), 401—410.

Menninger, R.W. (1998). The therapeutic environment and team approach at the Menninger hospital. Psychiatry & Clinical Neurosciences, 52 (suppl.), S173—S176. Milgrom, J. & Burrows, G.B. (eds) (2001). Psychology and psychiatry. Integrating medical practice. Chichester, UK: Wiley. Milgrom, J., Burrows, G.B., & Schwartz, S. (2001). The future of psychology and psychiatry in the medical centre. In J. Milgrom & G.B. Burrows (eds), Psychology and psychiatry: Integrating medical practice (pp. 297-331). Chichester, UK: Wiley. Nestoros, J.N. (1993). Ston kosmo tis psychosis: I Odysseia tou Eric kai alles periptoses (In the world of psychosis: Eric’s odyssey and other cases). Athens, Greece: Ellinika Grammata. Nestoros, J.N. (1997a). A model of training in the methodology of individual psychotherapy research: The case of schizophrenia as a paradigm. In PJ. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 633-681). Athens, Greece: Ellinika Grammata. Nestoros, J. N (1997b). Integrative psychotherapy of individuals with schizophrenic symptoms. In P.J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 321-363). Athens, Greece: Ellinika Grammata. Nestoros, J.N. & Vallianatou, N.G. (1990/1996). Synthetiki psychotherapia (Integrative psychotherapy). Athens, Greece: Ellinika Grammata. Polemikos, N. (1997). Psychotherapy with children. In P.J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 287-320). Athens, Greece: Ellinika Grammata. Polemikos, N., Zgantzouri, K.A. & Nestoros, J.N. (2000). The role of the European Institute of Psychotherapy in research and training in Rhodes and Crete. In G. Thill (ed.), Sustainable development in the islands and the roles of research and higher education (Vol. 2, pp. 189-195). Namur, Belgium: Coordination Scientifique de PRELUDE. Roberts, P. & Priest, H. (1997). Achieving interprofessional working in mental health. Nursing Standard, 12(2), 39-41.

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Rubinstein, G. (1994). Cooperation patterns of Israeli mental health practitioners. Journal of Social Psychology, 134(3), 275-285. Slade, M., Rosen, A., & Shankar, R. (1995). Multidisciplinary mental health teams. International Journal of Social Psychiatry, 41(3), 180-189. Tseng, W.S. (2003). Clinician’s guide to cultural psychiatry. Boston: Academic Press. Tseng, W.S. & Streltzer, J. (2001). Integration and conclusion. In W.S. Tseng & J. Streltzer (eds), Culture and psychotherapy. A guide for clinical practice (pp. 265— 278). Washington, DC: American Psychiatric Press. Yutrzenka, B.A. (1995). Making a case for training in ethnic and cultural diversity in increasing treatment efficacy. Journal of Consulting and Clinical Psychology, 63(2), 197-206.

Chapter 10

Some practical issues in working integratively with children and parents Nikitas E. Polemikos and Christina F. Papaeliou

The past century has witnessed enormous advances in the treatment of children’s psychological disorders. The age at which children are assessed and treated has steadily decreased. Numerous studies (Cassidy, 1994; Cicchetti et al., 1995; Dobson & Kendall, 1993; Fletcher-Janzen & Reynolds, 2003; Garmezy et al., 1984; Kendall, 2000; Lombroso et al., 1994; Szatmari et al., 1993; Thomas & Chess, 1977; Wamboldt & Wamboldt, 2000; Whit-

taker, 1976) have thoroughly investigated the aetiology of childhood disorders and a great number of diverse psychotherapy strategies (Ellinwood & Raskin, 1993; Gurman & Kniskern, 1991; Hibbs & Jensen, 1996; Johnson et al., 1986; Kazdin, 1996; Kazdin et al., 1990: Kendall, 1991; Kratochwill

& Morris,

1991; Meichenbaum,

1977; O’Connor,

1991; Vargas & Koss-

Chioino, 1992; Zilbach, 1989) have been developed that claim to be success-

ful in treating children’s problems. Various treatment approaches conceptualize children’s problems differently, and these diverse views lead to very different avenues of intervention. However, recently emphasis has been put on the use of integrative or combined approaches for treating children’s psychological or behavioural difficulties. It is reported that more than 70% of clinicians who work with children identify their approach as eclectic (Kazdin et al., 1990). Integrative psychotherapy, according to Kazdin (1996), refers to the use of two or more interventions each of which can stand on its own as a treatment strategy. This view reflects the technical eclectic approach to integration. Much of integrative psychotherapy is based mainly on two assumptions: (a) there are potentially common threads that seem to run through different treatment approaches (Norcross & Goldfried, 1992; Zeig & Munion, 1990); (b) there are specific variables in each treatment approach that may be particularly effective in working with certain types of problem (Garfield, 1995). These points are particularly important when one considers child psychopathology and treatment. A child’s psychopathological condition is usually multivariant and characterized by the coexistence of two or more different disorders (comorbidity), which may be the result of epigenesis, i.e. certain problems emerge as a consequence of the primary symptoms of another

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disorder (Kakouros ef a/., 2004). Thus, an eclectic approach to child psychopathology may be more effective than any particular treatment method. Nevertheless, eclecticism should not consist of the haphazard combination of elements of different approaches. Rather, the therapist should thoroughly assess the child’s difficulties and carefully select specific treatment methods based on their known effectiveness for particular problems. This chapter discusses in a general manner how specific factors from different treatment methods may be utilized in combination with certain crucial variables in child psychotherapy. This integrative approach includes elements from psychoanalysis and cognitive-behavioural, client-centred and family treatments.

The role of parents in child psychotherapy The significance of parents’ role in child psychotherapy is now universally acknowledged and strongly supported by family and cognitive-behavioural treatments. Child psychopathology may be determined by variables operating in the larger family system of which the children are a part, while the parents’ perceptions and feelings about their children’s behaviour determine to a considerable extent how they will react (Gurman & Kniskern, 1991; Meichenbaum, 1977). Thus, in order for the treatment to be successful, the therapeutic framework should not be limited to the clinical sessions; rather, it should include the active participation of parents and teachers in all stages of the planning and application of the intervention programme (Gurman & Kniskern, 1991; Zilbach, 1989). As Dodds (1987: 83) noted, “The child does not live in isolation and therefore cannot be most efficiently treated in isolation”’.

The cooperation of the therapist with the parents becomes necessary for a variety of reasons. Parents may be a rich source of information about the developmental course and medical background of their children and may assist in assessing problems and identifying optimal solutions (Kratochwill & Morris,

1991). Moreover,

any developmental factors, are strongly of their relationship children’s problems, 1996; Brown,

it is argued that, the course and outcome

of

disorder, even those caused by inborn or biological affected by the parents’ own personalities, the quality with their children, and their attitudes towards their the treatment and the role of the therapist (Armstrong,

1995; Conrad,

1975; Glass & Wegar, 2000; Hartmann,

1996).

Thus, parents are an integral part of the problem and any solution lies within the family. In family sessions relating to a particular client, certain aspects of the quality of family relations, such as the attitude of parents towards their child, the behaviour of children in the elicitation of particular

behaviours in their parents, the tone of the parents’ relationship or the role of siblings in the dynamics of the family, are likely to emerge (Zilbach, 1989).

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Parents may experience intense negative feelings about their child’s referral to the therapist, especially by agents other than themselves, e.g. teachers or a paediatrician. Even if parents consent to the referral, they may fear that psychotherapy will reveal problems within the family. Moreover, they may feel guilty about or responsible for their child’s problems. In this case, any suggestion that they should modify their behaviour may be perceived as blame. The therapist should help them to deal with their guilt, emphasizing that they could not anticipate what would happen and that they did not deliberately set out to produce this problem (Dodds, 1987; Reisman & Ribordy, 1993; Tsiantis, 1989). Difficulties in the. parent—child—therapist relationship may also arise from parents’ feelings towards their child or the therapist. They may unconsciously be angry with the child because they feel he/she is responsible for family problems including the financial burden of treatment. Moreover, parents may have ambivalent feelings towards the success of the therapist in what they have failed to do and become jealous. In the worst case scenario, parents may be distressed by signs of improvement, seeing this progress as proof of their own inadequacies. They may develop resentment and anger if they believe that the therapist has allied him/herself with their child against them. Moreover, parents who need psychological help may feel jealous of the exclusive attention that their offspring receives in the therapeutic relationship (Dodds,

1987; Reisman & Ribordy, 1993).

It is of great importance that therapists become aware of all feelings parents may have towards them and vice versa. They should not automatically assume that a child who needs psychotherapy comes from a dysfunctional family and that the parents are uncooperative (Polemikos, 1997; Tsiantis, 1989). Parents’ roles in child psychotherapy will now be clarified as we consider specific problems in this process.

First visit

Parents often experience difficulties with what to tell their children when they decide to take them to a therapist. What parents say to them prior to the first visit is very important as it is a strong indication of the nature of the parent-child relationship and has a potential impact on the child— therapist relationship. It is not unusual for parents to mislead their children or not to prepare them for the meeting. As a result “the session gets off to an awkward start with parents confronting their incompetence or dishonesty” (Chasin, 1989: 18). In order to establish trust in the relationship, parents need to tell the truth about the visit to the office/clinic (Group for the Advancement

of Psychiatry,

1982),

for example,

‘““We

are

worried

because you [always fight with other children at school], so we will visit a

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specialist who does not use needles, but helps children by talking and playing with them’’, Sometimes, the therapist’s first attempt to bring children into the therapy room may provoke extreme separation anxiety. Their level of fear and how they deal with it reveals much about their relationship with their parents and about their personality structure (Reisman & Ribordy, 1993). This information should be used in the assessment. As Dodds (1987: 51) noted, “Assessment does not begin in the playroom: it begins as soon as the child and parent are first observed’’. If children refuse to follow therapists into the playroom, therapists may invite the mother either to enter or to take a seat near the door, asking her politely to sit quietly and allow the interaction to begin at the child’s own pace (O’Connor, 1991). On the first visit, it is advisable that therapists tell children what they know about the presenting problem and even ask for their opinion of it. Very rarely do children bring up the referral issue. On the one hand, delay in talking about a psychologically important topic produces much tension, which may in turn negatively influence the child—therapist relationship. On the other hand, telling children what therapists know helps to set the stage for open communication, since therapists model openness early in the relationship. Children are not self-referred to therapists, so it cannot be assumed that

they will collaborate. Moreover, as cognitive behavioural approaches predict, children may have distorted perceptions of themselves, which may obstruct

their

social

functioning

(Kendall,

1991;

Meichenbaum,

1977).

Thus, the main purpose during the first visit should be to motivate a child to cooperate voluntarily as well as to establish and maintain a continuous mutual interaction (MacDonald,

1986; Melton & Ehrenreich, 1992). Client-

centred treatments strongly emphasize that the first step in this direction can be achieved by clearly conveying to children the message that they are unconditionally accepted in this context despite any difficulties (Ellinwood & Raskin, 1993). Therapists need to avoid asking questions such as “How old are you?”, ““What school do you go to?’’, “What grade are you in?” or closed questions that can be answered by “‘yes” or “no” or other single words such as “Do you have many friends?’”’. Rather, open questions that have a great potential for extensive and informative answers should be asked, such as “What do you like to do for fun with your friends?” Moreover, therapists should discuss topics that interest the child and with which he/she is able to cope by acting normally and employing a combination of play and talk, especially with young children.

Confidentiality Absolute privacy and consideration are proper treatment, and psychotherapists

non-negotiable conditions for are responsible for ensuring

120 il

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andi

glen pate enBe Be PB i Se

confidentiality. Lack of confidentiality may render therapy less effective or negatively affect it (American Psychiatric Association, 1994; DeKraai Sales, 1991; MacDonald, 1986; Melton & Ehrenreich, 1992).

Confidentiality, however, and serious dilemmas. The utter privacy at all costs” someone’s life is in danger;

&

is a very complex issue with many parameters axiom “‘The therapist must protect the client’s has certain limitations. This is the case when for example, when the client threatens suicide or

murder, when he/she is a drug abuser, or when a child is neglected or abused in any way. In these situations, therapists should inform clients of

the limits of confidentiality. Some information about assessment and the techniques applied in therapy should be given to parents (and teachers or trainers in cases of children seen in a training clinic) in order to facilitate the progress of the intervention programme. Parental permission should be obtained before therapists reveal any information concerning children to others (DeKraai & Sales, 1991; Johnson et al., 1986; Sandoval & Irvin, 1990).

Children are referred to therapists by their parents, who are also responsible for paying the fees. Thus, parents have some legitimate claim to be informed about assessment and progress and difficulties arising during the course of psychotherapy. Nevertheless, any information should be conveyed with discretion and tact and therapists should continuously assess how parents use it (Cooper & Wanerman,

1977).

The issue of confidentiality should be dealt with differently depending on whether clients are young children or adolescents. Young children are more dependent on their parents; adolescents seek more independence and privacy, and therapists should help them attain this. Unlike adolescents, children’s cognition depends heavily on concrete events and they trust action rather than words. This means that the limitations of confidentiality would be better explained to young children as the occasion for revealing information arises (Johnson ef al., 1986; McCabe,

1996; O’Connor,

1991).

In any case, therapists must inform children and ask for their permission — if possible — before revealing any information regarding the content of therapy. Children must be reassured that no information will be disclosed to parents or teachers without letting them know in advance, and that neither will receive any details of the sessions. On the other hand, it is the right of children to reveal the content of the therapy sessions. If parents or teachers inform therapists about an incident with a child (e.g. truancy), therapists should disclose this information and let the child decide whether he/she wants to discuss it (McCabe,

1996; Robitscher,

1973).

Parents may exercise pressure on children to talk about the content of therapy sessions. This kind of parental behaviour may be the result of simple curiosity, protectiveness, or insecurity because of a feeling of loss of control. Therapists should not advise children against giving their parents information about the therapeutic sessions because this may cause

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conflict between the parties. Rather, children should be helped to understand the desire of parents to know something about the progress of the therapy.

Honesty

and

discretion

between

children

and

therapists

are

essential in order for children to feel secure enough to open up intra-psychic areas for exploration and change (Reisman & Ribordy, 1993). Gifts

There are occasions when children may offer a present to therapists. This present might be something made by children, such as a painting, or an expensive item bought by their parents. Should these presents be accepted? In everyday life, the giving and accepting of gifts are regarded as expressions of affection. However, there is a crucial difference between a therapeutic and an ordinary relationship: unlike the latter, the former is not meant to meet the psychological needs of each participant. Any relationship developing during the therapeutic process should aim at satisfying the needs of clients. Therefore, therapists need to detect the influence that offering or receiving a gift may have on clients, and act for their benefit (Dodds, 1987). In addition, they should try to identify the motives of children and determine why presents are offered. Therapists are generally advised to accept graciously and gratefully gifts offered spontaneously by children. A refusal will most probably hurt them, particularly if they made the present. On the other hand, if the offer of the present was the initiative not of the child but of the parents, it is best to

express appreciation for the gesture and decline (Reisman & Ribordy, 1993). The display of gifts may show to children that they are highly valued, since it gives tangible indications of their acceptance and appreciation. Such genuine acceptance may contribute to the replacement of distorted perceptions about the self and to an improvement of self-esteem and emotional well-being. As cognitive-behavioural and client-centred treatments claim, self-esteem is a necessary precondition for the development of the capacity for personal growth and adaptive functioning (Ellinwood & Raskin, 1993; Kendall, 1991). However, therapists need to be aware that gift displays carry the risk of fostering competition and rivalry among children and may stimulate unwelcome complications, such as a particular child producing a plethora of presents. Therapists may also offer gifts to children — in fact, certain treatment approaches, such as cognitive-behavioural therapy, consider gift giving by therapists to be a necessary part of the intervention programme, which functions as reinforcement in the attempt to change the behaviour of children (Kendall, 1991). In any case, gifts should be of small monetary value and preferably consumable and relevant to the aims of the programme (e.g. a coloured pencil may be offered to a child following an intervention programme for learning disorders).

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Fee payment In private practice with adults as well as with children, it is tempting for both clients and therapists to deny the existence of fees. Such a denial helps clients to gain a feeling of self-importance, while therapists may feel quite noble (Reisman & Ribordy, 1993). However, it is a common view within various treatment approaches that fees may help clients to realize that a therapeutic relationship is a professional one and gain a greater understanding of the importance of the process. The fees, and an acceptable schedule of payment, should be agreed with the parents by the end of the first meeting. Failure to pay may arise from legitimate reasons such as loss of employment or unexpected expenses. In this case, the optimal solution is usually a rearrangement of the payment schedule. However, failure of fee payment may represent a dissatisfaction with the service provided, anger with therapists, or the parents’ desire to have contact with therapists. In this case, it is advisable that a meeting be arranged to address the problem. Even if children have little understanding of fees, they should be informed that their parents will be paying for the services of therapists. Some may want to hasten their treatment to relieve their parents of this financial burden while others will see the cost as a way of punishing (Reisman & Ribordy, 1993).

Termination

The particular problems of termination will vary with type of clients, length and type of treatments, and the kind of relationships that have developed between therapists and clients. The length of therapy ranges from a few weeks in behavioural approaches to many years in psychoanalytic approaches (Garfield, 1995). As therapy progresses towards completion, two simple but important questions are raised. How do therapists know it is time to terminate an intervention programme? When and how should therapists let children and parents know? Ideally, termination should take place when the goals that were set at the beginning have been attained. Strong indications that intervention programmes are completed include alleviation or even elimination of symptoms, achievement of greater self-confidence and independence, establishment of desired behaviours such as improved social and academic functioning, and better organized and constructive play activities. Children may sense these improvements and ask therapists directly if it is necessary to continue a programme. However, this rarely occurs because neither the reason for referral nor improvements in their behaviour are often obvious to them. Furthermore, children may not be able to verbalize what is going on for them. It is the responsibility of therapists to detect

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signs in their behaviour that the therapy has attained a satisfactory level of success, to explore their feelings about bringing the programme to an end, to inform both children and parents about the prospect of termination, and to help children to deal with this new phase of their relationship (Group for the Advancement of Psychiatry, 1982; MacDonald, 1986; Melton & Ehrenreich,

1992).

At the termination stage, children, parents and therapists experience a mixture of feelings that will probably be more intense in the last meeting. Children may feel independent, proud and optimistic because they have achieved confidence and a capacity to deal with life problems. Nevertheless, feelings of sadness and disappointment may also arise for the loss of a “significant other’. Despite being ready to cope with life problems independently, they (or even their parents) may siill experience anxiety and worry, which may make them doubt the decision to terminate the therapy. Therapists should encourage clients to unburden themselves of these concerns by showing willingness to receive the release of strong affect in an accepting and understanding manner. Such emotional release is particularly favoured in psychoanalytic approaches and, in many instances, appears to be relieving for clients, thus facilitating their improvement (Garfield, 1995). On the other hand, therapists may experience guilt due to the awareness that more could have been achieved and that goals have not been attained. However, therapists need to handle their feelings and help both of the other parties to cope with theirs. Moreover, throughout the programme, and especially in the last meeting, therapists need to reassure children (and parents) continuously that they are able to handle dilemmas and misgivings, thus enabling children to feel strong and competent. Therapists should offer continued interest and availability, especially in cases of emergency. After the completion of an intervention programme, therapists have a responsibility to themselves, to the children, and to the parents to assess what has been accomplished. This evaluation usually takes place in the last session. Parents often spontaneously assess the psychotherapy by reporting some gains and positive feelings about the experience. In some cases, however, they may perceive only a few constructive changes compared to those that have actually occurred. In this case, therapists should help parents to avoid discouragement and find something positive and meaningful arising from their sessions. Sometimes intervention programmes have to be terminated prematurely, for a variety of reasons. In cases where the family has to move town, there is usually enough time before separation for a few more sessions to be devoted to helping children understand the reasons for termination and to working out some of the accompanying feelings. It is more difficult to deal with unexpected termination caused by the serious illness of children, or when parents suddenly remove their child from the programme before its completion. The latter decision may be the result of parents feeling that

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they are losing control of their children or that the whole endeavour is in vain. It may also be due to financial or time constraints. Unexpected termination can cause distress. Therapists should attempt to have at least one final session or contact children by phone or mail explaining the real reasons for termination and expressing positive wishes for the future.

Cultural aspects of child psychotherapy Cultural beliefs and values are reflected in parent-child interactions, longterm socialization goals, thoughts about illness and disability, and roles and expectations of family members and professionals (Keller et al., 2003; Rodriguez

& Olswang,

2003; Vargas

& Koss-Chioino,

1992).

In Greek

society, socialization goals include obedience and respect but children are simultaneously praised for being unique and remarkable. Education is considered very important, and academic success is highly valued (Georgas, 1999; Katakis,

1976). Moreover, in Greek culture one can observe gender-

related differences in adults’ expectations and attitudes towards children’s behaviour. Higher degrees of activity and aggression are more acceptable in boys, while girls are expected to be more tolerant and emotional (Maniadaki et al., 2004).

Thus far, the effect of Greek cultural values and practices on child psychotherapy has not been studied systematically. However, we may attempt some inferences based on clinical experience. No more than two decades ago, parents reacted to their children being referred to a psychotherapist with shame and fear. Psychological or behavioural problems were strongly regarded as akin to insanity or mental retardation, so parents preferred to hide such problems, hoping that difficulties would eventually be overcome. Even when parents decided to seek help, they took every precaution to avoid gossip (Polemikos, 1997). During the past decade, the situation has changed and parents are now more willing to deal with problems that may obstruct the academic progress of their children. An increase has been observed in referrals to public and private clinics for difficulties in reading or writing (Kakouros et al., 1996). It is worth noting that parents often ignore the diagnoses made by specialists and label these problems as “dyslexia”. Probably due to the etymology of the word, parents perceive “dyslexia” as a very specific language problem which is not related to any other behavioural or psychiatric difficulty and can be treated in a few sessions with simple exercises. Given the increasingly multicultural nature of many societies, including Greece, clinicians should be aware of cultural differences and try to adapt to their clients’ beliefs and values. In this way, professionals can provide valid screening, assessment, intervention, consultation, and family support, and the effectiveness of therapy services can be maximized (Lieberman, 1989; Lynch & Hanson, 1998).

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Conclusion

The planning of an intervention programme consists of the careful assessment of the child’s condition which aims to differentiate, define and measure behaviours, cognitive abilities and emotional reactions that are of concern. Any specific disorder is usually defined by general laws that apply to broad groups of individuals. However, every child is different and the expression, course and outcome of a particular disorder depend on factors related to that individual. Parents contribute to the process of their child’s psychotherapy through being honest with their children about the visit to the therapist, sharing information with therapists which may assist assessment and problem solution, and through their involvement in family sessions relating to their child. The normative and idiosyncratic factors related to disorders guide clinicians to integrate the knowledge of different therapeutic methods in new ways so as to make them applicable to particular problems. In this way, it is closely allied to Lazarus’ (1995) conception of eclecticism. Clinicians who follow this integrative approach try both to relate problems to particular stages of psychosexual development and to examine ego defence mechanisms (a psychodynamic orientation). At the same time, by creating a nonthreatening situation, by accepting completely everything patients say and by expressing a warm and accepting attitude, therapists enable children to explore their unconscious feelings and to bring them into awareness. In the safety of the therapeutic relationship, threatening feelings are assimilated into the self-structure in an actualizing fashion (a client-centred approach). The incorporation of the cognitive-behavioural approach in the therapeutic process is apparent when, for example, clinicians praise and reward patients for their academic progress or when clinicians explain to children about a phobic situation and train them in relaxation techniques. Moreover, clinicians should take account of the abovementioned factors in order to formulate a therapeutic framework that may involve parent and teacher participation.

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of ADHD: Proposal of a theoretical model. Poster presentation at the 18th Biennial Meeting of the International Society for Study of Behavioral Development, Ghent, Belgium. McCabe, M.A. (1996). Involving children and adolescents in medical decision making: Developmental and clinical considerations. Journal of Pediatric Psychology, 21, 505-516. Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum. Melton, G.B. & Ehrenreich, N.S. (1992). Ethical and legal issues in mental health services for children. In C.E. Walker & M.C. Roberts (eds), Handbook of clinical child psychology (pp. 1035-1055). New York: Wiley. Norcross, J.C. & Goldfried, M.R. (eds) (1992). Handbook of psychotherapy integration. New York: Basic Books. O’Connor, K.J. (1991). The play therapy primer: An integration of theories and techniques. New York: Wiley. Polemikos, N.E. (1997). Psychotherapy with children. In P.J. Hawkins & J.N.

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Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 287-320). Athens, Greece: Ellinika Grammata. Reisman, J.M. & Ribordy, S. (1993). Principles of psychotherapy with children (2nd edn). New York: Lexington Books. Robitscher, J. (1973). Child psychiatry and the law. In S.L. Copel (ed.), Behavior pathology of childhood and adolescence (2nd edn) (pp. 422-438). New York: Basic Books. Rodriguez, B. & Olswang, L. (2003). Mexican-American and Anglo-American mothers’ beliefs and values about child rearing, education, and language impairment. American Journal of Speech-Language Pathology, 12, 452-462. Sandoval,

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Mazel. Tsiantis, J. (1989). Syghrona themata pedopsychiatricis. Vol. 3. Therapeutici prosegisi (Modern topics in child psychiatry. Vol. 3. Therapeutic approach). Athens, Greece: Castaniotis. Vargas, L.A. & Koss-Chioino, J.D. (eds) (1992). Working with culture: Psychotherapeutic interventions with ethnic minority children and adolescents. San Francisco: Jossey-Bass. Wamboldt, M.Z. & Wamboldt, F.S. (2000). Role of the family in the onset and outcome of childhood disorders: Selected research findings. Journal of the American Academy of Child & Adolescent Psychiatry, 3910), 1212-1219. Whittaker, J.K. (1976). Causes of childhood disorders. Social Work, 21(2), 91-96. Zeig, J.K.

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Chapter 11

Psychosocial interventions in families with an ill member Possibilities and experiences José Navarro Gongora

The field of psychosocial interventions in dealing with medical problems has seen both theoretical and technical integration of approaches (individual, group, family/couple and network), the choice depending primarily on the phase of the illness. Group approaches (groups of individuals, couples, or families) can be used not only to educate about the disease at its beginning but also to review coping strategies in the chronic phase. The network approach can be used during periods of crisis, while individual and family/couple approaches can be used at any stage, especially during the acute and terminal stages of illness. At times, a corabination of approaches can be used.

Objectives and strategies of intervention Strategy varies according to whether therapists are confronted with an acute or a chronic problem. Generally, the goals of intervention are (1) the adaptation to or resolution of illness-related psychosocial needs; (2) the revision of illness coping strategies in the sense of “‘putting the illness in its place’ (Gonzalez et al., 1987: 35); (3) the creation of a network

of social

relations offering long-term support; and (4) the development of self-help groups to offer long-term services. A mental health expert is rarely consulted in the chronic phase of the illness. By this time, stable mechanisms of adaptation are already in place and the affected people might feel no need for psychological help (Pollin & Baird Kanaan,

1995; Rolland,

1994).

Types of intervention The intervention of mental health experts can take place in three major forums: (a) medical settings, (b) self-help associations, and (c) mental health services. Each of these will now be discussed.

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Be

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SS

SSS

eS

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Interventions in medical settings

The goals of these interventions are twofold: (1) to provide information regarding the psychosocial problems patients and their families might experience as a consequence of the disease, and (2) to help medical personnel to take account of psychosocial components for both patients and families. Two kinds of processes may be distinguished: (1) interventions with inpatients and their families, and (2) sensitization of medical professionals to psychosocial needs. Interventions with inpatients and their families

The presence of a mental health professional is desirable whenever the physician reveals a life-threatening or seriously disabling diagnosis to a family. This professional can translate the medical information into psychosocial terms, help the patient and family to understand what plans, priorities, and habits they need to modify, prepare them for those changes and normalize their reactions. Usually this procedure is completed in one session. The items included in the protocol for the first visit are shown in Table 11.1. The information given may trigger a considerable crisis that makes it difficult for patients to understand what is being explained. Thus, a second meeting may be recommended. Crucially, the crisis state makes patients and their families more open to information. The most important intervention occurs at this moment of diagnosis and, if carried out correctly, can make others unnecessary. Therefore, this information is very likely to condition their future management of the illness. Scripts of hope or hopelessness, of control or lack of control, may develop. They also relate either to patient care or forbidding normative tasks that will deeply condition the relationships between those who outlive the patient. This is illustrated in the following case:! Luis, 42 years old, consults the Family Medical Programme of the University of Salamanca because ‘the does not know if he must tell his father that his mother is in the terminal phase of cancer”. He considers the subject now because his mother has begun to refuse to go out or to do domestic chores due to lack of strength. His father interprets it as laziness and a lack of love, and discord has erupted between husband and wife. Luis’ approach to the programme has occurred after a

considerable medical pilgrimage in which his mother consulted many doctors. During the visit to the final doctor, his mother, father and Luis

1 The case related is a real case but certain information has been changed to preserve the anonymity of the people involved.

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Table 11.1 Information protocol to be followed when the diagnosis is given

1 Ask patients with whom they wish to receive the diagnosis. 2 Inform them of the gravity of the problem (‘you have a very serious problem, you will have to fight very hard”). Additional information should be given as required. Ask directly whether or not they want more information. Give the diagnosis and prognosis in terms of the illness’ possible evolution and the maintenance of hope. Explain the diagnostic procedures to be used. Reveal treatments, primary and secondary effects, maintenance and crisis medication. Encourage participation of patients and their families in the treatment (e.g. in the case of rehabilitation, which programmes can be applied at home). Explain complementary methods of treatment, e.g. psychological treatment of pain by relaxation or by self-hypnosis, guided imagery, meditation, massage, rehabilitation. Attention should be paid to the spiritual needs of the patient. Explore the psychosocial repercussions of all the medical information: the impact on personal and family life, emotions and expected effects (to be given by the mental health expert). Refer them for a second meeting and, if necessary, to self-help groups. If possible and appropriate, define the treatment limits patients wish to have.

awaited the results of various analyses in a room packed with patients and relatives. Eventually, the physician came from his office and, pointing at Luis, said, “You, come

in!”’, after which the doctor con-

firmed the mother’s cancer diagnosis. During this crisis, the doctor gives several messages: the parents, for some

reason, cannot know the diagnosis; the son must take charge of

the “secret” and consequently the illness. This information creates a script of hiding the seriousness of the cancer from the parents and the assumption of responsibilities that gravely interfere with the normative illness-related tasks. As the terminal phase approaches, Luis may not bid farewell to his mother, nor may he help her efficiently in the revision of her life. Luis’

mother,

who

notices

her deterioration

and realizes

that the

hour of her death draws near, cannot talk about her feelings and finds that her husband does not know anything and that Luis plays down the seriousness of the situation. She does not have any support when she needs it most. She cannot say goodbye to her husband. For his part, the husband will not have the opportunity to share fully these last moments with his wife nor to bid her farewell. Ultimately, the mother has a heart attack in the presence of her husband and of Luis, and the father does not know what to do. It is Luis who, true to the script, attends to the mother and catches her last words, thus shaping his future relationship with his father, who, in the last few moments of his spouse’s life, played the secondary role awarded to him at the beginning of the illness.

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Subsequent to diagnostic meetings, patients may be invited to participate in a multi-family information group. In these groups, patients recently diagnosed as having the same condition, as well as their relatives, receive information about the medical problems and the treatment they will receive. The impact of the illness on their lives and their compliance with treatment are explored. They have the opportunity to raise any points that they wish to discuss. This open educational group experience enables a family to raise an issue that another may not be able to, thus breaking through fears and aiding intra-family communication. The group format helps patients and their families to acknowledge that others are experiencing the same difficulties and that there are people who understand their situation. This format is especially recommended when working with chronic illnesses. According to McFarlane et al. (1995), the risk of developing mental disorders is reduced if information is offered during the first year and social support is offered from the second year onwards. This group session need not exceed one interview; it is advisable that a physician and a mental health expert conduct it together. The meeting ends with a recommendation that patients and their families enrol] in appropriate self-help associations. From the perspective of medical personnel, the group involves a considerable saving in time since these personnel are less often interrupted by patients and families seeking information. Conducting this type of educational group presents no great technical difficulty. What is needed is considerable knowledge about the psychosocial demands that the illness imposes on the patient and his or her family. (This does not hold for terminally ill patients who require an individualized approach). Sometimes, following individual and group meetings, it may be necessary to refer individual patients and their families for psychological help. In Table 11.2 a series of risk criteria are proposed, any one of which indicates the need for referral. Sensitization of medical professionals to psychosocial needs In the decision-making process concerning patients, mental health professionals may work in a collaborative programme with medical personnel. Accurate observations by mental health experts enhance the likelihood of their knowledge being accepted and integrated by medical professionals. The purpose of the programme is twofold: (1) to attend to the psychosocial needs of patients and their families, and (2) to sensitize medical professionals to those needs. Caplan and Caplan (1993) described this sensitizing

process as involving several steps. Once a need for attention in mental health is detected, the first step is for the centre to request the cooperation of a mental health professional. If demand is great and the experience of cooperation is mutually satisfactory, then occasional contact with the

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Table 11.2 Risk factors suggesting that patients (and their families) be referred to brief therapy (adapted from Pollin & Baird Kanaan, 1995)

1 2 3 4 5 6 7 8 9 10 11 12

Serious long-term medical condition. Suppressed or agitated affect. Suicidal ideation. Inadequate cognitive assimilation of the illness (failure to seek information or make necessary decisions). Inappropriate behaviour in respect of health care needs. Inadequate communication with medical caregivers. Limited social support. Difficult living arrangements. Limited financial/other practical resources. Limited knowledge of/ability to use community resources. Family, individual and illness turning points. Other serious problems in the family.

mental health service is expanded and professionals are invited to collaborate on a regular basis. Their work involves two elements: (a) attention to patients.and families affected by illness-related crises, and (b) participation in decision-making through adding their psychosocial contributions. The level of sensitivity of medical personnel to the psychosocial aspects of illness largely depends on the appreciation and respect they have for the work of mental health experts. Over time, one hopes that medical professionals will indirectly integrate psychosocial care skills into their repertoire through a process of sensitization. Formal training is not needed and it is not expected that nurses or doctors act as psychologists. Adding a duty to a professional under great work pressure is usually a guarantee of failure. The sensitization relies on occasionally observing psychologists at work, listening to their opinions in clinical meetings and learning from consultations with psychologists concerning individual patients. Additional information can be given in specialized courses. Interventions in self-help associations In the case of a prolonged chronic phase, the duty of mental health professionals is to inform and refer patients and their families to self-help associations,

which, in many

Western

countries, can guarantee

long-term

professional help. Medical services are becoming increasingly oriented towards intervention in acute situations, while chronically ill patients tend to be neglected. Interventions in self-help associations seek to provide (1) medical and psychosocial information about the disease and (2) long-term social support for patients and their families. The programmes developed depend on

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resources, the politics of the association and the degree of specialization of the professionals involved. The voluntary character of these associations raises uncertainty over their continuity. A further problem is the level of expertise of the volunteers, which can range from low to high. Self-help association programmes will now be discussed under the headings: (1) interventions with a low professional profile, and (2) interventions with a high professional profile.

Interventions with a low professional profile Interventions with a low professional profile include support groups and psychosocial programmes. Research evidence has indicated that information and social support can be protective in chronic illnesses. McFarlane et al. (1995), for example, found this to be the case in people with schizophrenia, with information-giving protecting against emotional problems during the first year of the illness and social support being protective from the second year onwards. These researchers offered social support using a multiple family group format that specifically addressed coping skills. The participants were also encouraged to help each other outside the sessions. Moreover, the authors stated that a superficial contact was enough for the positive effect of social support to appear. This was confirmed by Steinglass (1998) in his work with alcoholics. On the basis of research data (Buckman,

1992; McFarlane

et al., 1995)

from patients with severe chronic conditions, the following sequence of interventions is suggested: At the onset of illness, mental health professionals should work in a psycho-educational fashion, informing patients about the likely psychosocial consequences of their illness and how they can comply with treatment. Once the chronic phase is reached, they should inform patients about the stressors they have to face and how to cope with them. Long-term help, centred on the reconstruction of their social network, must be provided, preferably through referring them to self-help groups. Implementing this sequence requires integrated interventions (focusing on psycho-educational objectives and the revision of coping strategies) by highly qualified professionals in a limited timeframe with continuous open support groups (which seek to reduce social isolation). Support groups serve the purpose of providing long-term social, emotional and functional support to the family. The formulae for intervention can vary in complexity. At a low level, group members are simply encouraged to discuss an open (not necessarily illness-related) theme with no interpretation being given. At a more complex level, group sessions can convey information about coping strategies and mutual help behaviour. An example of the first formula is the hothouse meeting group. The leader focuses on two goals, the survival of the group through time (a “group of

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reference”) and the participation of all group members. Membership is open and the duration of the experience is unlimited. When the group work involves learning coping strategies, sharing emotions and constructing a group of reference, a higher professional profile is needed. Groups are usually open (changing membership) and meet on a weekly basis. Ideaily, meetings are held outside hospital or mental health contexts, preferably in self-help associations, in order to increase the possibility of continued help and to emphasize the psychosocial rather than the medical aspects of the illness. In order to avoid social stigmatization, a low

professional profile support group run by a self-help association is preferable to a high-profile group run by a mental health institution. It is critical to avoid labelling these groups as “therapeutic”, implying either that the families have some kind of “mental” disorder or are coping poorly and need psychological help. The goal of psychosocial programmes is to help patients and families with emotional needs. Normally, volunteers without professional training can provide these programmes, which offer services that depend on human resources, the organization’s politics and the specific psychosocial demands of the illness. Respite programmes for primary caregivers are an example. A second example is that of a programme named “pairing” in which a veteran patient describes the medical tests and treatments, in his or her own language, to a recently diagnosed patient. The veteran also constitutes a living proof that the illness can be survived. “Tell them a story” is a third example of such a programme, and is based on story-telling to hospitalized children. This programme provides them with diversion and helps them to maintain contact with school. Although psychosocial in nature, these programmes also have an obvious psychological impact. Interventions with a high professional profile

Such interventions include psychoeducational workshops, family therapy for medical patients, psychosocial rehabilitation, turning point groups and collaboration or consultation programmes. Each of these will now be discussed. In psychoeducational workshops (medical and psychosocial information), some programmes teach patients and their families relevant skills for the management

of specific behaviours.

Thus,

families

of older adults who

suffer from dementia discuss rules of conduct at home and rehabilitation programmes,

while those with dementia

are shown

how

to face reality.

Programmes looking at coping strategies require a high qualification. The content can be defined at each interview, depending on the number of such

strategies to be considered. However, the more structured the experience, the easier the programme is to run.

136 Gongora ee SS SSS ee a eee e

ee

Table 11.3 Family therapy for medically ill patients 1 2 3.

4 5

6

Definition of working techniques and conditions. Creation of rapport. Problem(s) assessment: e history of the patient’s illness, other illnesses of both the patient and his/her family e definition of the problem according to the patient (and/or family) e the location of problems in medical services, in family/social network, and/or in the patient (Navarro Gongora, 2004). The contract. Problem solution: e normalization e the expression of feelings and fears e systems of respite ® negotiation of compatibility between everyone's life plans and caring for the ill person putting the illness in its place control of the illness connecting the family with systems of social support maintenance of hope. The possibility of future contacts.

The aim of the family therapy for medical patients approach is to help patients and their families with emerging illness-related problems. It is applied especially during acute crises and during the transition stages of illness or developmental transitions in the lives of either the patients or their families. The phases involved in this intervention are outlined in Table 11.3. The following is an example of such an intervention. Javier, 25, has recently been diagnosed with a hereditary neurological condition that has seriously affected his mobility. His depression is understandable: his personal and professional prospects have been severely reduced. He informs us that he is satisfied with the information that he has received: his diagnosis was precise. However, he has not been given a concrete idea of his prognosis. He spends his time trying to monitor his developing progressive condition: he tests his ability to go up the stairs, to walk, to flex his muscles. Certain professional projects depend on his autonomy. We talk about the degree of uncertainty of his illness — perhaps the doctor could shed some light on the subject? Is he prepared for this information? Is he prepared to cope with the possibility that the doctor might not be able to reduce his uncertainty? This last issue is more painful. We propose a private or joint meeting with his neurologist and he chooses a joint meeting. One week later, the neurologist shows him the results of his tests: the illness is progressing but very slowly. If it continues at this pace, his confinement to a wheelchair will not be for many years. It is also possible

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that the progression will stop. Although the information has had its impact, Javier seems relieved and his anxiety appears to be more tolerable. In a later interview, we explore the patient—illness subsystem. The illness was untimely: Javier was studying for some examinations that, if passed, might have meant moving to another city. Now, he will have to abandon them and remain close to his parents. He also discards the possibility of having a partner, believing that having children who might inherit his condition would be irresponsible. He is adamant: he does not wish to expose himself to possible rejection. Only two or three of his most intimate friends are aware of his problem. He does not wish to go out with other friends since he would have to give embarrassing explanations. He feels ashamed and afraid of their reactions. He expects uneasy confusion and the playing down of his condition. However, he accepts that the illness does not stop him from having friends. Finally, we address his professional life. He rejects the idea of applying for one of the quota of positions reserved for the disabled, but he thinks over the idea of opening up a private consultancy with various colleagues. The illness forces him to change his professional aspirations but it is not the end of his professional life. When we look at the family subsystem, the picture widens. The mother also suffers from the illness but in such a minute form that it is unnoticeable. The father, a biologist, had a stroke months ago from which he is recovering but has sunk into a deep depression. A sibling suffers from the same condition: in his case, the illness evolved so quickly that, in the space of a few months, he ended up in a wheelchair, after which he did not leave the house for a year. Eventually he adapted perfectly: he has friends, goes out and works. Javier, then, has at his disposal various models of coping. However, he has a very serious clash with his parents: he blames them for their irresponsibility which has led to such disastrous consequences. We propose that when the time is right he could talk with them and find out why they did what they did. He does not seem very keen and chooses not to do so for the moment. He claims that all it would achieve would be to make his mother cry. Nonetheless, he is very resentful. After three interviews, we finish with the understanding that he will return for a review in six months. Gonzalez et al.’s (1987) programme of psychosocial rehabilitation of the chronically ill and its development by Steinglass (1998) aim at creating a space in which to discuss attitudes, feelings and coping patterns while sharing perspectives and strategies with other families. It is based on a multiple family group procedure (six or eight families, minimum of four)

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with eight highly structured meetings that include three components: education, family problems and affection. The patient attends all the meetings and families who refuse to include their ill members are excluded from the programme. Chronic physically and mentally ill patients are not mixed. Ideally, a group should be heterogeneous regarding illnesses but homogeneous in terms of the gravity of the condition. This programme is not appropriate for terminally ill patients, who present a very different problem profile. An interview format named ‘“‘a group within a group” is used in which two subgroups are created, one internal and one external. For 25 minutes, a problem is discussed under the direction of a therapist with the external group listening but unable to intervene. Once the time is up, the external group discusses the same subject moderated by a second therapist during a further 25 minutes. The internal group listens but cannot interrupt. This format breaks the control systems of communication that families habitually use and thereby facilitates talking about difficult illness subjects. The educational component is unfurled in the first three interviews in that families are educated about the stress generated by the chronic condition. The following three interviews are dedicated to the “family problem” component, which addresses illness coping strategies. In this case, the internal group is made up of one family. A relevant family issue (perhaps a habit, plan or priority) that has been affected by the illness is discussed in an attempt to find its meaning for the family as well as alternative formulae for managing the situation. The metaphors used to organize the discussion are: keeping the illness in its place, finding the family resources, and preserving family priorities. | The two final sessions are dedicated to the affective component. The goals are to examine the impact that the chronic illness has on the family’s emotional life and to evaluate alternative styles of emotional response. In the seventh interview, the internal group is composed of members freely chosen by each family. They discuss their families’ emotional styles and how these influence or are influenced by the presence of a chronic illness. In the eighth interview, a general discussion about the relationships between the illness and the family’s emotional experience is conducted, various alternatives for feeling management are assessed, and the feelings provoked by the end of the group are discussed. Gonzalez et al.’s (1987) programme demands therapeutic skills regarding the conducting of groups as well as profound knowledge concerning the impact of illness on a family, which ordinary mental health professionals do not usually possess unless they are specifically trained. Turning point groups may be created ex-profeso at points of transition in the illness, the family or the person. The objectives are at least twofold: to inform about new issues arising from the life change and to develop

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formulae for adjustment to the new realities, e.g. following an adequate diet and administering insulin in diabetes. The experience accumulated in self-help groups allows professionals to offer other medical and mental health professionals collaboration or consultation programmes related to the usual psychosocial problems of ill people and their families. Consultations can also be about the creation of programmes or about issues that present themselves once the programme is up and running (Caplan & Caplan, 1993). This kind of consultation work requires considerable professional development and complexity, and can be offered only when the self-help association has reached a very high level of maturity. Interventions in mental health settings

The first objective of this type of intervention is to provide help in crisis situations and consultation for hospitals and self-help associations. With respect to intervention in critical situations, knowledge about the characteristic effects produced by the presence of an ill member in a family is recommended. Professionals must also bear in mind that most of the time they cannot totally solve the emotional problems associated with the crisis, as these will remain as long as the medical condition exists. The second objective is to develop programmes for the treatment of the psychosocial repercussions of the illness on patients and their families. For those working in mental health settings, having a high degree of specialization in medical problems depends on the particular sensitivity of mental health professionals and their willingness to include physically ill patients in their work. Given optimal conditions, they can begin to see ill patients (and their families) with psychosocial difficulties in a collaborative partnership with hospitals and self-help associations, perhaps later moving on to collaborate in the development of psychosocial programmes with them. At times, the role of the mental health service shifts to assisting the creation of such self-help associations, supervising them at the beginning and letting them function autonomously later on. Conclusions

Approaching the field of medical problems from a psychosocial perspective allows a double integration, i.e. an integration of theories and an integration of techniques. The integration of theories includes the individual level (e.g. personality traits and coping strategies), the family level (systems theory with an emphasis on structural and lifestyle aspects), and an organisational level (e.g. communicational and collaborative aspects). A psychosocial perspective of disease provides a framework within which these three levels relate. In keeping with this framework, the technical integration also

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operates at a three-system level: the individual level (e.g. communicating information both in general and when requested at acute moments), the group level (individuals, families and couples, including reviewing coping strategies in the chronic phase of the illness), and the network level (which

includes professionals and can be used in crisis intervention). References Buckman,

R. (1992). How to break bad news. London:

Pan.

Caplan, G. & Caplan, R.B. (1993). Mental health consultation and collaboration. San Francisco: Jossey-Bass.

Gonzalez,

S., Steinglass, P., & Reiss, D. (1987). Family centered interventions for

people with chronic disabilities. Washington, DC: George Washington University. McFarlane,

W.R., Link, B., Dushay, R., Marchal, J., & Crilly, J. (1995). Psycho-

educational multiple family groups: Four-year relapse outcome in schizophrenia. Family Process, 34(2), 127-144. Navarro Gongora, J. (2004). Enfermedad y familia: Manual de intervenci6on psicosocial, Barcelona: Paidos. Pollin, I. & Baird Kanaan, S. (1995). Medical crisis counselling: Short-term therapy

for long-term illness. New York: Norton. Rolland, J.S. (1994). Families, illness and disability. New York: Basic Books.

Steinglass, P. (1998). Multiple family discussion groups for patients with chronic medical illness. Families, Systems and Health, 16(1—2), 55—70.

Chapter 12

Ameliorating interrelating within families of psychotic persons: An integrative approach Argyroula E. Kalaitzaki and Joannis N. Nestoros

The approach introduced here is a new Greek psychotherapy integration, called synthetiki psychotherapy, from the Greek word synthesis. Although initially based on individual therapy, it has gradually embodied principles from the relating theory of Birtchnell (1993/1996) (for detecting and assessing interpersonal relating) and is applied integratively to the families of persons with psychotic symptoms. In what follows, we shall briefly present the Greek psychotherapy model and introduce the relating theory whose principles were incorporated into it. We shall then describe the integrative application of individual and family approaches in ameliorating dysfunctional interrelating patterns within families of persons with psychotic symptoms. Lastly, cultural differences in interpersonal relating and psychotherapy will be presented.

Synthetiki psychotherapy The Greek approach to psychotherapy integration was developed by the second author (Nestoros, 1997; Nestoros & Vallianatou, 1990/1996) as a result of both his extensive clinical experience with psychotic patients and related research. Outpatient treatment is usually lengthy because of the enduring disability of persons with psychotic symptoms. More than 200 individuals have already been treated, the majority being either patients who were suffering their first acute psychotic episode or chronically ill patients resistant to previous treatments. The theoretical framework and principles of the model for understanding personality, psychopathology and psychotherapy, together with its applications to psychotic patients, have been published elsewhere (e.g. Nestoros, 1993, 1997, 2001) as well as in Chapter 7 of this book. Synthetiki psychotherapy encompasses many integrative features (Hawkins & Nestoros, 1997) but it also differs from other approaches to psychotherapy integration in many respects. The model was formulated in a way that does not conflict with any other scientific approach to psychotherapy (for example, it integrates psychodynamic with humanistic/

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existential approaches and it suggests that biological and learning theories are not necessarily in conflict with other theories). Another distinguishing characteristic of the model is the proposal of a neurophysiological model of anxiety, which highlights the role of extreme anxiety in the genesis of schizophrenic symptoms (Nestoros ef al., 1983). The model also suggests that the wise and proper combination of pharmacotherapy with psychotherapy (Nestoros, 1997), other treatments (e.g. music and dance therapy), or

dialectic

reasoning

(Nestoros,

2000),

is most

beneficial

in treating

psychosis. The emphasis on clients’ abilities and competence to find solutions to their problems within themselves offers a more optimistic conceptualization of both the prognosis and the outcome of psychosis than is traditionally applied. The incorporation of certain philosophical and ethical principles from ancient and modern Greek philosophy and civilisation (Katakis & Nestoros, 2000), combined with contemporary neuroscience, also differentiates the model from other integrative approaches. Moreover, synthetiki psychotherapy continuously adopts new trends, concepts and research findings from other theories and sciences for the improvement, enrichment, and expansion of its theoretical and clinical framework.

Synthetiki psychotherapy was initially applied solely to patients and was occasionally combined with family and/or marital therapy. The involvement of the family in the therapy of clients was dictated by a series of theoretical assumptions, research findings and clinically based evidence. The model views schizophrenia as being due to, among other things, maladaptive personality development, primarily identified within interactive relationships with others. In addition, it acknowledges research findings indicating the predictive role of families’ expressed emotion in psychotic relapse (e.g. Linszen et al., 1997) and the harmful effect that schizophrenic symptoms may exert on the family (e.g. Provencher, 1997). Having also recognized both the detrimental role that the family may play in the schizophrenic symptoms of clients (see Angelo’s case in Nestoros,

1993) and the burdensome

effect

that schizophrenic symptoms may have on a family member’s psychological condition (Nestoros ef al., 1999), the need to include the family in the planning and implementation of both research and therapy emerged.

Integrating the relating theory of Birtchnell Synthetiki psychotherapy has recently incorporated the relating theory of Birtchnell (1993/1996, 1997, 1999) into its theoretical base and clinical practice (Kalaitzaki & Nestoros, 2002) so as to advance understanding and assessment of and intervention in, maladaptive interrelating within the families of persons with psychotic symptoms. The relating theory proposes that relating style can be classified and measured within a biaxial model comprising the four poles (upper neutral, lower neutral, neutral distant and neutral close) of two intersecting axes. The four positions arranged between

Integrating individual and family therapy

143

the four main poles (upper close, upper distant, lower close and lower distant) represent the intermediate aspects of human relating and, together with the poles themselves, give rise to the interpersonal octagon on which relating can be graphically depicted (Birtchnell, 1993/1996). For each of the eight octants, the characteristics of both positive and negative relating have been fully described (Birtchnell, 1993/1996, 2002), and summary definitions of each are provided in Figure 12.1 in two separate octagons (the axes around which the octagon is constructed are not depicted in the figure). No position is considered preferable to any other. Closeness gives people the advantage of involvement, intimacy and cooperation, while distance affords personal space and privacy. Upperness offers the advantages of leading, guiding and advising, whilst lowerness provides those of seeking direction, guidance and advice. When people relate competently, comfortably and confidently in every position of an octagon, this is called positive relating. Relating that falls short of this competence is called negative relating. This is in accordance with Benjamin’s (1996) view that the distinction between adaptive and maladaptive interpersonal behaviour is qualitative and not quantitative. People who relate positively in all eight ways are termed “‘versatile’ and are unlikely to have interpersonal difficulties. People who seek psychotherapy tend to relate negatively in one or more of the eight ways. The need to initially assess a person’s negative relating resulted in the Greek translation of the revised Person’s Relating to Others Questionnaire (PROQ2-GR) (Kalaitzaki & Nestoros, 2003a), a 96-item self-report questionnaire based on relating theory (Birtchnell,

1997; Birtchnell & Evans,

2004). A further set of four questionnaires was constructed (the Couple’s Relating to Each Other Questionnaires; CREOQ) to measure the interrelating of two partners (i.e. relating and being related to) within the octagon (Birtchnell,

1997;

Kalaitzaki

& Nestoros,

2000).

The

assessment

of the

interrelating within a family of four (two parents and two children) required the development of a set of 16 questionnaires (the Family Members’ Interrelating Questionnaires; FMIQ) (Kalaitzaki et al., 1999). Each questionnaire is composed of eight 12-item scales representing the eight segments of the octagon. Two questionnaires (the self-rating and the other-rating) are required for the assessment of every person’s dysfunctional relating in a dyad. Each person’s scores consist of both qualitative (aspects of negative relating) and quantitative (extent of negative relating) measurements and are represented as shaded areas in the eight segments of an octagon.

The application of individual and family therapy approaches in ameliorating negative interrelating Unlike conventional psychotherapeutic models, in which clinicians focus primarily on clients’ medication and therapy, disregarding family

144

Kalaitzaki

and Nescomas UN Leading, advising, acquiring skills and competencies, striving for

UD

ND

uc

Setting limits and

achievement &

Rescuing, helping,

imposing laws, controlling, punishing

advancement

protecting, looking after, forgiving, showing the way

Setting up personal boundaries, needing space/privacy, being original, establishin - cere ae

Intimacy, interaction, involvement, Brrinienione 5 5 sharing, cooperating

Reliving upon elying Upon, being loyal/lawabiding and

Seeking direction,

respectful

guidance and

advice, being suggestible, expressing gratitude

LD

NC

Being soothed and ‘ Sie Tae pas 8

ae

eee Lc

LN UN

Bullying, dominating, selfassertion, boasting

UD Explaation

Intrusiveness,

rey an

possessiveness,

es 4

ND

uc

:

need of attention

y

and admiration

Avoidance, rejection, fear

; Fear of separation

of intrusion or

and of being abandoned, sag clinging

invasion,

aa suspiciousness

Compliance, obedience,

timidity, withdrawal

Submission, need for approval, search

NC

Fear of rejection and disapproval

for acceptance, LD

shunning

Lc

responsibility

LN

Figure 12.1 The octagon: examples of positive (top) and negative (bottom) relating for each octant. C, close; D, distant; U, upper; L, lower; N, neutral. Based on Birtchnell (1994); the descriptors for each category are expanded.

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involvement, the present model can be applied to individuals, couples or families. Upon clients’ request, therapists may initiate individual or family therapy. At any time, therapists and/or any family member may seek changes in the therapy format relating to recently arisen problems, symptom exacerbations, deterioration in relationships or other issues. For example, with the aim of disrupting the recurrence of restricted and ingrained negative relating patterns in a two-way interplay, therapists may decide to invite family members to individual psychotherapy sessions, meet separately with one or more family members at any point of the therapy or use family therapy work focusing in depth on one member who contributes most to the presenting problems. They can also involve all members in family meetings. The number and order of individual and family sessions depend entirely on the judgement of therapists. A brief description of the combined intervention is presented to individuals and their families, emphasizing the therapists’ goals and techniques to improve clients’ and their families’ negative interrelating behaviours. Selecting treatment format and setting the goals Frequently, therapy commences with individual sessions. From the beginning, the therapist determines the degree and extent of the contribution of families to the symptoms and difficulties of clients. When problems cannot be principally attributed to the family, clients remain the primary focus of the therapy, but when the family contributes to the onset and/or course of clients’ illness (e.g. well-established dysfunctional familial interrelating patterns suppress or prohibit improvement of clients or the family resists change in clients), the family needs to change together with the patient. Specifically, therapists try to detect whether clients and/or certain family members lack relating competencies. They observe how clients relate to them, which indicates how they relate to others. Through their narratives of various relating circumstances, therapists try to understand both how clients relate to others and how others relate to them. Frequently, no matter what problems clients bring to therapy, their essential nature is interpersonal, involving a number of specified others. If therapists discover that problems occur because clients relate negatively with people outside the family, as is the case in non-versatile clients, these clients become the priority in therapy. Within the individual context, therapists aim at transforming negative relating in clients into positive, while separate sessions with the family aim at providing them with the strategies to resist the negative relating imposed by clients (Birtchnell, 1999). Moreover, individual sessions with clients focus on their presenting symptomatology and aim at producing symptom relief and reducing clients’ fears and anxieties. Therapists also help them to replace negative selffulfilling prophecies and dysfunctional schemata with rational thoughts

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and realistic values about life, and enable them to acquire mental balance, well-being, and increased self-confidence. Furthermore, individual sessions

seek to gather detailed information about clients’ problems and dysfunctional behaviour and to assess in depth their strengths and problems. Irregular sessions with parents and/or the whole family facilitate therapists’ understanding and explicit diagnosis of symptoms of clients and the cause of their difficulties, and further assist in formulating a successful treatment plan. Notifying family members about the course of treatment and ensuring their collaboration in planning and implementing significant life changes for clients are also important targets. Moreover, therapists inform the family about certain actions they have to undertake to expedite the progress of clients in treatment, and train them in strategies for dealing with symptom fluctuation. Concurrently, therapists provide the family with emotional support and a rational and optimistic outlook on personality and psychopathology. If problems arise because of limitations in the relating of clients with certain family members, and/or one or more pairs of family members lack versatile competencies, the family is prompted to engage in therapy (Birtchnell, 1993/1996, 1999). In cases where the negative relating of clients involves versatile family members, clients remain the constant focus of therapists with the concurrent support of the other family members. The goal is to fortify family members against negative relating by others and/or clients, and to train them to cope with the noxious effect that maladaptive relating may have on them. Conversely, when there are non-versatile relaters apart from the client, who are willing to change their dysfunctional relating patterns towards each other and/or towards the client, both individual and family therapy sessions are required. Sessions with non-versatile individuals aim at improving their negative relating while, within the family context, therapists focus directly and observe in vivo the interrelationships of family members. Determining each person’s exact relating style is vital, as some combinations are worse than others (Birtchnell, 1999). For example, when both persons desire closeness,

they sustain an intimate relationship, when they are of insufficient ‘“‘lowerness’’, they both strive for upper relating (e.g. guiding), and when they are limited to lower relating, they both demand that the other take the lead. Family sessions also provide therapists with the opportunity to intervene straightforwardly in the disturbed interrelationships of specific pairs of negative relaters and enable them to distribute their focus and efforts equally between non-versatile persons. The family context is considered advantageous, as it is believed that dysfunctional interrelating can more easily be resolved in the presence of family members with whom interpersonal problems are likely to occur. Moreover, individual resistance is usually reduced,

when problems are identified as residing in the family rather than exclusively in the individual. Certainly, as more pairs of persons are involved in the

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interrelating (e.g. a family of four), the intervention requires much more effort and is more difficult than with one or two persons. If non-versatile family relaters are reluctant to engage in therapy, the minimum goal championed by therapists is to make them appreciate and respect each other, and the maximum anticipated is to persuade them to benefit in full from the therapy. Certainly, the ultimate target of therapy is the full integration of the family of clients into the psychotherapeutic process, thus establishing a therapist—client—family alliance while simultaneously concentrating on the therapist—client relationship (Atwook, 1990). Ameliorating negative relating and/or interrelating

For modifying clients’ negative relating and/or their families’ negative interrelating, principles and techniques from relating theory (e.g. detection and amelioration of relating deficiencies) and synthetiki psychotherapy are effectively combined and employed. Therapists assist individuals to recognize their negative relating tendencies and to discover how they learned them. During the course of therapy, to increase awareness therapists make references to past experiences, explore childhood interpersonal patterns and underline maladaptive interrelating (Birtchnell, 1999; Nestoros,

1997).

Once the decision about relinquishing negative relating has been made, the training of non-versatile persons is the next step in therapy. In order to teach people to acquire positive relating patterns and to vary their relating in the way they desire and in keeping with the demands of others and/or situations (Birtchnell, 1999), therapists make suggestions and explain how each person might behave positively. It has also been found (Kalaitzaki & Nestoros, 2003b) that, within the families of persons with psychotic symptoms, the relating of clients to other family members is determined not only by the way that members actually relate to clients, but also by clients’ and family members’ subjective views about each other’s relating. Therefore, the way that a male client relates to his father is influenced by (a) his father’s actual relating to him, (b) the client’s view of how his father relates to him, and (c) his father’s view of his son’s relating to him. In acknowledging persons’ specific interrelating incompetencies and the factors that influence interrelating in dyadic transactions (i.e. objective and subjective relating), therapists make certain disclosures and suggestions to both parties in a dyad and assist them to adopt positive relating forms, which may result in the discontinuation of the maladaptive interrelating patterns between them. To accomplish this, therapists need to be positive and versatile relaters so that others can imitate and identify with them (Hawkins & Nestoros, 1997). When negative interactions between family members have ceased or been attenuated, and positive relating patterns have been learned, they must be practised. In a family therapy context, the individual and other family

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members rehearse, practise, and test, in the presence of persons with whom they relate, these newly acquired relating competencies, learned skills, and strategies for safeguarding themselves from the negative relating of others (Birtchnell, 1999). This ensures that skills are consolidated. For instance, when a negatively close person relates with a negatively distant one, the persistent attempts of the close person to attain more proximity coerce the distant person into more distance, and the efforts of the distant person to preserve his/her independence force the close person into making more desperate attempts to obtain intimacy. Therapists increase the distant person’s awareness of his/her incompetence in allowing more closeness, and of the close person’s fear of rejection. They then explain that both persons have to change their relating behaviour in order that the vicious circle may be interrupted. Finally, they teach the distant person positive forms of closeness and the close person positive forms of distance, which, in turn, they will practise alone and in the presence of each other (Birtchnell, 1999). During the process of change, therapists support individuals and increase their hope and faith in the outcome of therapy (Hawkins & Nestoros,

1997).

Relevant research has resulted in additional guidelines for use in therapy. Kalaitzaki and Nestoros (2003c) found that (a) psychotic patients recognize and admit more negative relating tendencies towards their parents than their parents admit towards them, and (b) psychotic individuals more easily accept blame for their negative relating with their parents, while the parents tend to attribute negative relating to their children rather than to themselves. Based on these results, the intervention aims at both alleviating the excessive guilt and blame of patients and enhancing family members’ insight and acceptance of responsibility for their interrelating behaviours. The usefulness of the relating and interrelating questionnaires Administering FMIQ)

the appropriate

questionnaire(s)

facilitates and/or confirms

(the PROQ2

and/or

both therapists’ understanding

the

of their

clients’ relating and/or the interrelating difficulties of families. Therapists explore a person’s predominant areas of relating difficulties by examining the distribution of the shading area across the octants, and the family’s interrelating inadequacies by comparing the shading of the octagons between a pair of relaters. The disclosure of the octagons (after familiarizing family members with their meaning and their graphic representations) may constitute the starting point for therapy. Usually people are fascinated with the information that the octagons may reveal, and are then highly motivated to engage in therapy. At specified intervals over the course of therapy, therapists re-administer the questionnaires to clients and/or their families to discover whether the

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intended modifications have actually occurred. Therefore, the questionnaires can be utilized as a means to conduct and carry on therapy. Through frequently monitoring the areas and degree of negative interrelating, therapists provide individuals with feedback about improvements or failures, thus enabling them to rectify their negative relating. At the end of therapy, a measure of the overall change is also obtained. If intervention is not entirely successful, therapists modify their strategies and/or devise new techniques directed towards specific relating difficulties that need further attention (Birtchnell,

1999).

Cultural differences

The culture in which we are raised shapes all aspects of our lives and of our personalities, including behavioural and relating patterns (Kateri ef al., 2002). Research findings have repeatedly demonstrated that interpersonal relating depends on the culture in which it appears (e.g. Fuligni, 1998). Therefore, even though the expressed emotion is readily recognizable among diverse ethnic groups, there are striking cross-cultural variations in its form, expression and frequency (Jenkins, 1991). The findings of a study reporting on a Greek sample’s general relating to others (Kalaitzaki & Nestoros, 2003a) were compared with those of an English sample (Birtchnell & Evans, 2004). It was demonstrated that Greeks relate more negatively than English people. Greek women, in general, relate more negatively and are more negatively close than Greek men. English men are more distant than English women. In both countries, women relate more negatively close. Although there are some areas of divergence the study concluded that Greeks relate similarly to English people. Due to cultural differences, the necessity to provide diversified interventions has emerged (Kateri et a/., 2002). Nevertheless, traditional treatment

approaches tend to overlook cultural variables, thus creating gaps in service areas ranging from understanding to assessment and care provision. In order to be able to meet the needs of diverse patient populations, psychotherapists must adapt treatment delivery to reflect awareness of, sensitivity to and respect for cultural diversity, and attain skills and capacities to work with different patterns of human thought and behaviour. A culturally oriented assessment, which recognizes differences and treats them carefully within their cultural background, is of paramount importance (Kateri ef al., 2002). In Greece, which has recently become culturally diverse, mental health professionals also need to incorporate strategies that are based on culture and validate the strengths of patients and their families into their treatment planning and practice intervention. The development of a set of congruent behaviours, attitudes and policies will enable them to become competent in providing effective and high-quality mental health care services in various cross-cultural situations.

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Discussion

Despite the proliferation of integrative research in a wide spectrum of disorders, very few researchers have focused their interest on family dynamics and interpersonal conceptualizations, and even fewer have explicitly explored interrelating within families of persons with psychotic symptoms. The integrative model presented here is combined with the relating theory of Birtchnell (1993/1996). Within this context, interrelating between persons with psychotic symptoms and their families is meaningfully described and assessed. By assimilating relating theory into the framework and clinical practice of an integrative psychotherapy model (Messer, 2001), the integration of the person within their context and in relation to their interpersonal/ family environment is achieved (Fergus & Reid, 2001).

The present model recommends alternating a series of individual sessions with the client with a series of family sessions with other family members, as is deemed appropriate. Thus, an intertwined combination of intrapsychic and interpersonal factors and the coordination of symptomatic and interpersonal emphases are achieved. This combination is more advantageous than conventional unilateral approaches for the understanding of both the disorder and interpersonal interactions (Gold, 2001; Nestoros,

1997; Omer,

1993). Nowadays, many researchers assert that the optimal therapeutic approach for psychosis and other disorders is the integration of individual and family treatment (Allen, 2001; Feldman & Powell, 1992; Pinsof, 1983).

However, to the authors’ knowledge, only attempts to integrate concepts and techniques from individual therapy into family or couple therapy have been reported (Fraenkel & Pinsof, 2001; Heitler, 2001; Nichols, 2001). The proposed model for psychotic outpatients primarily emphasizes the therapist—client relationship, and concurrently maintains an alliance with the client’s family. Individual therapy remains the predominant treatment format and is complemented by family sessions as necessary. Nonetheless, this is not a mere incorporation of family sessions into the model’s individual framework, nor a sequential combination of the two formats; rather the two formats are applied in an interlaced and interchangeable manner as clinical practice steers and research findings dictate. Synthetiki psychotherapy, of its origin and its nature, is a model that implements and maintains a successful research-to-practice integration, addressing the need for practitioners to embrace and apply research findings in their professional practice (Lampropoulos ef al., 2002). Both the introduction of relating theory into the present model and the integration of individual and family therapy formats were research-driven, as the proposer of the model (the second author) is both a clinician and a researcher. Thus, the model persistently conducts research relevant to its practice and utilizes existing literature and the multitude of other empirical

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evidence derived from clinical research in identifying and applying the appropriate strategies to the treatment of identified patients and their families. The model also carries out process and outcome evaluations to assess the effectiveness of its interventions, resulting in further modification and enrichment. To recapitulate, synthetiki psychotherapy is a model that continually evolves, incorporating both research findings and clinical experience. Hitherto, the model has repeatedly proved to be extremely successful in ameliorating schizophrenic symptoms. Its recent development includes the integration of the family of the person with psychotic symptoms, and their complex interrelations, into practice and research (applying the relating theory), while the individual remains the constant focus. The integrative intervention at both the intrapersonal and interpersonal levels has already demonstrated the model’s effectiveness in both diminishing psychopathology and rectifying negative interrelating within families of persons with psychotic symptoms. Henceforth, through continuing to merge innovative knowledge and research findings, the model promises new theoretical advances and practical approaches in integrative intervention that will enhance its therapeutic effectiveness, validate its therapeutic leverage and expand its field of application.

References Allen, D.M. (2001). Integrating individual and family systems psychotherapy to treat borderline personality disorder. Journal of Psychotherapy Integration, 11(3), 313-331. Atwook, N. (1990). Integrating individual and family treatment for outpatients vulnerable to psychosis. American Journal of Psychotherapy, 44(2), 247-255. Benjamin, L.S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd edn). New York: Guilford Press. Birtchnell, J. (1993/1996). How humans relate: A new interpersonal theory. Hove, UK: Psychology Press. Birtchnell, J. (1994). The interpersonal octagon: An alternative to the interpersonal circle. Human

Relations, 47, 518, 524.

Birtchnell, J. (1997). Attachment in an interpersonal context. British Journal of Medical Psychology, 70, 265-279. Birtchnell, J. (1999). Relating in psychotherapy: The application of a new theory. Westport, CT: Praeger.

Birtchnell, J. (2002). Psychotherapy and the interpersonal octagon. Psychology & Psychotherapy. Theory, Research & Practice, 75(3), 349-363. Birtchnell, J. & Evans, C. (2004). The Person’s Relating to Others Questionnaire (PROQ2). Personality and Individual Differences, 36, 125-140. Feldman, L.B. & Powell, S.L. (1992). Integrating therapeutic modalities. In J.C. Norcross and M.R. Goldfried (eds), Handbook of psychotherapy integration (pp. 503-532). New York: Basic Books.

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Fergus, K.D. & Reid, D.W. (2001). The couple’s mutual identity and reflexivity: A systemic-constructivist approach to the integration of persons and systems. Journal of Psychotherapy Integration, 11(3), 385-410. Fraenkel, P. & Pinsof, W. (2001). Teaching family therapy-centered integration: Assimilation and beyond. Journal of Psychotherapy Integration, 11(1), 59-86. Fuligni, A.J. (1998). Authority, autonomy, and parent—adolescent conflict and cohesion: A study of adolescents from Mexican, Chinese, Filipino, and European backgrounds. Developmental Psychology, 34(4), 782-792. Gold, J. (2001). Psyche and system: On progress in the integration of individual psychotherapy and family psychotherapy. Journal of Psychotherapy Integration, 11(3), 285-288. Hawkins, P.J. & Nestoros, J.N (1997). Beyond the dogmas of conventional psychotherapy: The integration movement. In P.J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 23-95). Athens, Greece: Ellinika Grammata. Heitler, S. (2001). Combined individual/marital therapy: A conflict resolution framework and ethical considerations. Journal of Psychotherapy Integration, 11(3), 349-383. Jenkins, J.H. (1991). Anthropology, expressed emotion, and schizophrenia. Ethos, 19(4), 387-431. Kalaitzaki,

A.E.

& Nestoros,

J.N.

(2000).

Measuring

changes

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relating during integrative psychotherapy. Acta Psychiatrica Scandinavica, suppl., 404(102), 36-37. Kalaitzaki, A.E. & Nestoros, J.N. (2002). O1 endooikogeneiakes sxeseis atomon me

psychosika symptomata: Perigrafi kai aksiologisi basi tis theories tou diaprosopikou oktagonou. [The intrafamilial relating of persons with psychotic symptoms: Description and evaluation based on the theory of the interpersonal octagon]. In N. Polemikos, M. Kaila, & F. Kalavasis (eds), Ekpaideutiki, oikogeneieaki kai politiki psychopathologia [Educational, familial and political psychopathology] (Vol. II, pp. 140-163). Athens, Greece: Atrapos Publications. Kalaitzaki,

A.E.

& Nestoros,

J.N.

(2003a).

The

Greek

version

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Person’s Relating to Others Questionnaire (PROQ2): Psychometric properties and factor structure. Psychology and Psychotherapy: Theory, Research and Practice, 76, 301=3 14.

Kalaitzaki, A.E. & Nestoros, J.N. (2003b). Investigating the interpersonal factors that determine interrelating of persons with psychotic symptoms engaged in psychotherapy with their parents. Paper presented at the 14th International Symposium for the Treatment of Schizophrenia and Other Psychoses, Melbourne, Australia. Kalaitzaki, A.E. & Nestoros, J.N. (2003c). Individual integrative psychotherapy in persons with psychotic symptoms facilitates understanding and acceptance of responsibility for negative interrelating within the family. Paper presented at the 14th International Symposium for the Treatment of Schizophrenia and Other Psychoses, Melbourne, Australia. Kalaitzaki, A.E., Nestoros, J.N., & Birtchnell, J. (1999). Formulation of hypotheses for the evaluation of intrafamilial relating. Paper presented at the 30th Annual Meeting of the Society for Psychotherapy Research, Braga, Portugal. Katakis, K.G. & Nestoros, J.N. (2000). Greek philosophy and psychotherapy. In G. Thill (ed.), Sustainable development in the islands and the roles of research and

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higher education (Vol. 2, pp. 117-123). Namur, Belgium: Coordination Scientifique de PRELUDE. Kateri, E., Pourkos, M., & Nestoros, J.N. (2002). Politismos kai psychopathologia: Sinepagoges ton politismikon diaforon gia tin psychologiki gnosi kai tin psychotherapeutiki proseggisi [Culture and psychopathology: Implications of cultural differences for psychological knowledge and the psychotherapeutic approach]. In N. Polemikos, M. Kaila, & F. Kalavasis (eds), Ekpaideutiki, oikogeneieaki kai politiki psychopathologia [Educational, familial and _political psychopathology] (Vol. I, pp. 366-388). Athens, Greece: Atrapos Publications. Lampropoulos, G.K., Spengler, P.M., Dixon, D.N., & Nicholas, D.R. (2002). How psychotherapy integration can complement the scientist—practitioner model. Journal of Clinical Psychology, 58(10), 1227-1240. Linszen, D.H., Digemans, P.M., Nugter, M.A., van der Dose, A.J., Scholte, W.F., & Lenior, M.A. (1997). Patient attributes and expressed emotion as risk factors

for psychotic relapse. Schizophrenia Bulletin, 23(1), 119-130. Messer, S. (2001). Introduction to the special issue on assimilative integration. Journal of Psychotherapy Integration, 11(1), 1—4. Nestoros,

J.N.

(1993).

Ston

kosmo

tis psychosis:

I Odysseia

tou

Eric

kai alles

periptoses [In the world of psychosis: Eric’s odyssey and other cases]. Athens, Greece: Ellinika Grammata. Nestoros, -J.N. (1997). Integrative psychotherapy of individuals with schizophrenic symptoms. In P.J. Hawkins & J.N. Nestoros (eds), Psychotherapy: New perspectives on theory, practice, and research (pp. 321-363). Athens, Greece: Ellinika Grammata. Nestoros, J.N. (2000). Modern “amphiaraia” in the Greek periphery. In G. Thill (ed.), Sustainable development in the islands and the roles of research and higher education (Vol. 2, pp. 159-165). Namur, Belgium: Coordination Scientifique de PRELUDE. Nestoros, J.N. (2001). Synthetiki psychotherapy: An integrative psychotherapy for individuals with schizophrenic symptoms. Journal of Contemporary Psychotherapy, 31(1), 51-59. Nestoros, J.N., Kalaitzaki, A.E., & Zgantzouri, K.A. (1999). Antimetopisi atomon

me schizophrenica symptomata me to Synthetiko Modelo Psychotherapias: Erevnitiki proseggisi [The treatment of individuals with schizophrenic symptoms with the Integrative Psychotherapy Model: A research approach]. In S. Papastamou, S. Kanellaki, A. Mantoglou, S. Samartzi, & N. Christakis (eds), H psychologia sto stavrodromi ton epistimon tou anthropou kai tis koinonias [Psychology in the crossroads of humanistic and social sciences] (pp. 357-374). Athens, Greece: Kastaniotis Publications. Nestoros, J.N., Nair, N.P.V., Pulman, J.R., & Schwartz, G. (1983). High doses of diazepam improve neuroleptic-resistant chronic schizophrenic patients. Psychopharmacology, 81, 42—47. Nestoros, J.N. & Vallianatou, N.G. (1990/1996). Synthetiki psychotherapia [Integrative psychotherapy]. Athens, Greece: Ellinika Grammata. Nichols, W.C. (2001). Integrative family therapy. Journal of Psychotherapy Integra-

tion, 11(3), 289-312. Omer, H. (1993). The

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oriented perspectives in therapy, American Journal of Psychotherapy, 47(2), 283-295. Pinsof, W.M. (1983). Integrative problem-centered therapy: Toward the synthesis of family and individual psychotherapies. Journal of Marital and Family Therapy, 9, 19-35. Provencher, H.L. (1997): Positive and negative symptom behaviors and caregiver burden in the relatives of persons with schizophrenia. Schizophrenia Research, 26(1), 71-80.

Chapter 13

Breathing and awareness The integrating mechanisms of cognitivebehavioural gestalt therapy in working with cardiac patients Eleanor O’Leary

Cognitive-behavioural

gestalt therapy

Cognitive-behavioural gestalt therapy is based on the philosophical underpinnings of a humanistic framework (cf. Chapter 3) and is an integration of gestalt therapy as outlined by Perls eg a/. (1951) and Polster and Polster (1973) and cognitive-behavioural therapy as described in the works of Beck (1976) and Ellis (2001). While the former focuses on awareness, affect, contact and responsibility, the latter aims at altering particular patterns of irrational or debilitating thoughts or behaviours through examination of clients’ beliefs and biases. The value of drawing on the strengths of each approach when working with cardiac patients was first outlined by O’ Leary and Barry (1998b). Both focus on the current issues of clients and the immediate factors influencing them. Indeed, Perls (1969) acknowledged that a contribution of the behavioural tradition lay in its emphasis on observing the present. Recent writings in both traditions reflect a movement towards integration. Bates (1993) maintained that cognitive-behavioural therapy endeavours to strike a balance between showing compassion for the client and encouraging accountability. The former is achieved through empathic responding and genuineness while the latter occurs through the development of awareness. Both of these emphases have long been associated with gestalt therapy, which maintains that an authentic therapist—client relationship and the development of responsibility for oneself are essential in promoting growth. A recent trend towards the integration of cognitive-behavioural and humanistic perspectives may be identified in the work of a number of researchers. Bennett-Levy et al. (2003) explored the potential benefits for cognitive therapists of engaging in personal development, which has traditionally been considered a core element of training for gestalt therapists. According to these authors, such work supported the development of “personal artistry” (p. 143) in cognitive therapists. The importance of the role of contact in therapy was outlined by Polster and Polster (1973), while

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Waddington (2002) noted that the previous ten years had seen an increased interest in the relationship in cognitive therapy literature. Being presentcentred and aware, two of the cornerstones of gestalt therapy, have more recently been integrated into the cognitive approach through the introduction of the concept of mindfulness (Segal et al., 2002), defined by Kabat-Zinn (1994: 4) as “paying attention in a particular way: on purpose, in the present moment, and non-judgementally”’. Thoresen (1992: x) pointed out that ‘‘one of the most significant qualities of gestalt therapy, distinguishing it from other perspectives, lies in the recognition of how behaviour, affect and emotions and thoughts are experienced together in specific situations”. Some of these dimensions have been alluded to by O’Leary & Barry (1998a, 2000). In a similar vein, Beckham (1996) spoke of a homeostatic system consisting of many different components of a person’s life, with reciprocal feedback loops that maintain processes between these components. If one of the elements is changed, the other elements are also affected. Such integration is evident in the writing of Polster (1995), who saw action, which is highly valued by behavioural therapists, as being as essential to one’s definition and understanding of self as are awareness and contact. Cognitive-behavioural gestalt therapy can be used in a group or individual format and has been found by the author to be particularly useful in working with cardiac patients. In this context, therapists facilitate clients to work through a range of emotions such as anxiety, depression, and anger/ hostility. Clients are also provided with relevant cardiac information that can support the identification of areas to target for behavioural change (e.g. dietary and lifestyle matters). In terms of cognitive change, participants are encouraged to develop adaptive thinking patterns in relation to their health and their own self-care. The remainder of the chapter focuses on two particular aspects of cognitive-behavioural gestalt therapy, namely, breathing and awareness.

Breathing and feelings Relaxation and desensitization techniques have been widely applied by cognitive-behavioural therapists, especially in the treatment of various forms of anxiety. In the gestalt therapy tradition, focus on the breath is viewed as a supportive device that allows individuals to pay attention to their internal processing and organismic experiencing. Polster and Polster (1973) identified attention to breathing as central when the focus is on the

mobilization of support. In cognitive-behavioural gestalt therapy, the voluntary and involuntary aspects of breathing are explored and awareness of its control dimension developed. Breathing also assists in the development of relaxation, since it both gives and controls energy.

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Natural breathing has an even rhythm with equal amounts of breath being exhaled or inhaled. In the process of respiration, inhalation provides oxygen for the red blood cells while exhalation expels waste products such as carbon dioxide. Studying the pattern of inhalation/exhalation can inform therapists of the use of psychological energy: exhalation reflects movement outwards to the environment while inhalation indicates movement inwards. Asking clients to reflect on their breathing patterns usually enables them to identify whether or not the inhalation/exhalation process is even. Attention to breathing can identify the balance of self-support and environmental support from which individuals operate. In the author’s experience, good inhalation reflects a self-supporting attitude to life where individuals allow themselves

to take nourishment

from the environment,

while short breaths usually imply insufficient nurturance. Inhalation and exhalation mirror an ongoing process of contact with and withdrawal from the outside world, reflecting the inclusion of both internal needs and outside influences. In a group session with cardiac patients, the use of exercises focused on deepening inhalation and exhilation, allowing them to slow down not just their breathing but the whole rhythm of their lives. The exercise is particularly appropriate for future use in stressful situations and gives cardiac patients a valuable self-supporting tool in dealing with health issues. This progressive breathing exercise is akin to Jacobson’s (1929) progressive relaxation training in that its aim is to achieve a relaxation response in individuals. Anxiety may manifest itself in shallow breathing. Perls et a/. (1951: 128) defined anxiety as “the experience of breathing difficulty during any blocked excitement. It is the experience of trying to get more air into lungs immobilized by muscular constriction of the thoracic cage.” Since anxious people are not able to deal with excitement and block it through restricting their breathing, they can recover full breathing through the use of relaxation techniques. Shallow breathing usually indicates blocked emotion. The language of feeling is often missing in cardiac patients, who will respond “grand” or “‘fine’’ when asked how they are. They can be assisted to develop a vocabulary of feelings that contains words such as happy, sad, vulnerable, angry and fearful. By attending to both breathing and body sensation, facilitators can help cardiac patients to identify feelings that have not been allowed into awareness. The following method for identifying and expressing emotion was outlined by O’Leary (1992). Clients are asked (a) to locate a reported feeling or sensation within their bodies, (b) to give it an outline, (c) to describe its size, colour or texture, (d) to describe or name the feeling, and (e) to give it a voice by speaking as it. Hence, there is a close association between

breathing, body sensation and feelings.

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In a group where one of the cardiac patients began to cry after participating in a breathing exercise, the facilitator asked him whether he was aware of what was happening. His response was “‘Don’t mind me, I tend to cry”. This dismissal of emotion cloaked the fact that two experiences in his past were causing his tears, namely, tuberculosis and boarding school. The following passage illustrates the struggle that a cardiac patient, John, experiences in connecting the emotion of love with its bodily concomitants. Subsequent to an exercise in breathing, the group were invited to consider the emotion of love. 255 256 257 258 259

Fac John Fac John Fac

260 261 262 263 264 265 266 267 268 269 270 271 272 273 274

John Fac John Fac John Fac John Fac John Fac John Fac John Fac John

Where do you feel /ove? [What?] [Love. I mean if you were feeling love[ [ [for somebody where would you . .. where do you feel it in your

body? Ask the question again there (group erupts into laughter) Are you sure you [can hear]... [ (laughter continues with overlapping speech) [Where do you feel love? Love? Love. Yeah, yeah I suppose you feel it like... in the [ [Where do you feel? [the mind I suppose. You feel it in your mind? Yeah, I suppose, I dunno. So you think love? I suppose so And where do you feel it when you think if? (very low) Where do I feel it when I think it . . . (takes a deep breath)...

275 277 278 279 280

Fac John Fac John

I dunno is it here . . . ( pointing at his chest) In your chest is it? ’Tis I suppose Right. Where do you feel it. . . Well I'd have to say I feel love in my heart

[ denotes overlapping speech

The passage illustrates how participation in a breathing exercise assisted John in identifying feeling in his chest. Awareness of bodily sensations that accompany feelings and their location in the body can, in my clinical experience, provide signals of physical areas that need attention and care and may provide useful early warning signs of a possible future ailment.

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While relaxation techniques are usually associated with behavioural therapy, visualization or fantasy work forms an important part of gestalt therapy. In cognitive behavioural gestalt therapy, the two approaches are integrated. In the sessions discussed herein, the facilitator reflects this integration through associating breathing with imagery. Participants are invited to relax through breathing and are then asked to visualize a light way out in space, which gradually comes closer to them until it is behind their foreheads. They are requested to give the light a colour and to imagine that this colour illuminates the word ‘‘relax’’. This word illuminated by the particular colour is referred to as each person’s relaxed sign. At this point, group members are asked to imagine the colour spreading throughout their bodies. In working with cardiac patients in a cognitive-behavioural gestalt group, evidence that this process was internalized was provided when one group participant referred to his relaxed sign. Furthermore, participants were able to get in touch with a feeling of relaxation by contacting the colour. Thus, both physical and mental relaxation were attained. The prerequisite of relaxed breathing is a conducive environment. Factors that need to be considered include the environmental and the bodily. With respect to the environment, quietness, a comfortable temperature and ventilation need to be established. A grounded body is acquired by having an erect spine and placing one’s feet firmly on the ground. To accomplish a feeling of physical comfort, individuals need to be encouraged to move their bodies around until it is attained. If they notice any area that is tense, they are invited to relax either by changing position or by moving their bodies until the tension disappears. Cardiac participants in cognitivebehavioural gestalt groups frequently come to an awareness of the benefit of good environmental conditions for breathing. Examples of such awareness on the part of two of them, Eoin and Shane, are outlined in the following

excerpts. 574 Dio 576 577 578

Eoin fac Eoin Fac Eoin

580 581

Fac Eoin

996 Shane 997 998 999 1000

I had what I’d call a good week. No complaints Did you do your breathing? Oh yes. That was most important And...how... I always do them when I’m alone... I can concentrate a lot better Yes. And do you think it has helped you? Oh God it has... Immensely...

Im delighted ... I’m the happiest .. . I was even reading it this morning there again. . . I was sitting down . .. no one in the house... I was doing my breathing and everything, peace of mind and calm. . . (7 second pause) No... I

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1001 1002 1003

really enjoyed it... And I’m very grateful to .. . everyone here because they actually helped me... yknow...

“Peace of mind” was frequently referred to by participants as something that they discovered in the group context and deeply valued. One participant, Donncha, mentioned how he had succeeded in obtaining peace of mind through a combination of reading, breathing exercises and walking. Another, Eddie, stated that an important aspect of peace of mind for him was relaxation, while a third, Jerry, noted how he spent the time waiting for the bus engaged in conversation with others at the bus stop rather than worrying about when it would arrive. In this respect, he stated: “The point I am getting at is that I was at ease”. He described it thus: “There was no tension in it... no worries... no nothing . . . I was doing my breathing and everything . . . peace of mind and calm.” This comment is particularly interesting since it illustrates both the freedom from tension in the body and the freedom from anxiety in the mind. Peace of mind was thus accompanied by a lessening of anxiety and a feeling of ease. Breathing is particularly important for those who suffer from cardiac disease. In the author’s experience, a particular difficulty for this group is in convincing themselves of their need for relaxation, as is illustrated in the following excerpt. 882 883

Fac Robert

Yeah Ahm...

884 885 886 887

Fac Robert

Yes you do Ihave to make time for it... as simple as that now like Hmmmmm

Fac

I have to make time for it

The struggle to relax for this particular cardiac patient is evident in the above passage. Since relaxation is frequently difficult for these patients, they need to develop the ability to breathe well and fully.

Breathing and stress Breathing and the development of relaxation is an important antidote to experiences of stress in the lives of cardiac patients as is apparent in the following excerpt in which Kevin speaks of stress. 17

Kevin

And ...1knew.

.. that stress was bad for

18

me because I was after getting all the

19

leaflets and

Breathing and awareness

20 21 22 23 24

Fac Kevin

27 Kevin 28 29 30 Fac 31 Kevin d2AFac 33.

Kevin

34

161

Eheh Heart disease and everything, yet... But now... like, the breathing, if... [2 seconds] four months ago someone said to me, like “Just sit back and breathe”... you know... I wouldn’t have believed them in the first place and I would’ve said that’s like for hippies, or, you know, these weird groups Mmmmmmm that are into this meditation, like Mmmmmm But, 1 find that brilliant, the breathing,

you know. . .

Returning to the theme of relaxation, Kevin notes: 117. 118

Kevin Fac

I didn’t... know how to relax: that was it Mmmmm

119

Kevin

And... even though I probably thought I was

120

relaxeG . ; -

Kevin has made progress in that his breathing has helped him to control his stress and become more relaxed. However, his speech on the audiotape is still extremely rapid and his words are difficult to understand because of their hurried and “blurred” delivery, indicating that he still has some way to go on his road to recovery. Since time urgency was originally viewed as a feature of the Type A personality of cardiac patients as outlined by Friedman and Rosenman (1974), a possible interpretation of his behaviour is that he is time urgent even in the area of relaxation. This underpins the notion that Type A personalities may actually have a better chance than others of making a recovery: they approach the therapeutic interventions and the exercises they are given (in this instance deep breathing and relaxation) with their usual vigour. One of the best testimonies of what cognitive-behavioural gestalt therapy can achieve is the following excerpt by Martin, a cardiac group participant:

I didn’t blow it .. . And I would say ’tis the breathing . . . helps me. It calms me down . . It’s amazing you could live so long with yourself and didn’t know part of you was there . . . that never got out... it’s lovely to have a group you can talk with and get on with. You don't have to pretend anything . . . You can be yourself you know. To me that’s great .. . because you can get bogged down in problems . . . To

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me that’s great. And the exercises I found great . . . the breathing and that kind of thing... I found good . . . I’ve been through a few bad years and I can relax now.

The meaning of awareness The humanistic framework, in which cognitive-behavioural gestalt therapy is embedded, emphasizes attention to the whole person. Both feelings (an intrinsic part of the work in gestalt therapy) and thought patterns (a focus of the cognitive-behavioural approach) are considered. Since society primarily rewards cognitive expertise, due attention needs to be given to the affective dimension of human experience. As thoughts are often articulated more readily than affect, some individuals are unable to identify feelings unless their thoughts are respected, as was pointed out in Chapter 2. The words used, the emotions experienced and the construction of thought are unique to each person and provide an avenue into greater understanding of the individual’s phenomenological world. Awareness is an integrative concept that can be defined as consisting of cognitive, affective, bodily and behavioural processes. Awareness is dynamic and, once established, usually continues to develop over time. It can be distinguished from introspection and insight, which occur at a cognitive level only. Definitions of these terms illustrate this point. Introspection, as viewed by James (1890), involves a subject—object split and is evidenced in such expressions as “I deceived myself’. Awareness, on the other hand, involves an integration of subject and object. Insight is usually related to meaning only, as was pointed out by Polster (1995), who viewed it as bringing together disjointed experiences through imbuing their seemingly loose associations with meaning, while Corey (1985: 278) described awareness as “‘the process of recognizing what we are thinking about and what we are feeling, sensing and doing”.

Awareness, experiencing and processing Awareness allows individuals to enter into their organismic experiencing and internal processing, which are central in cognitive-behavioural gestalt therapy and consist of both thoughts and behaviours (central to cognitivebehavioural therapy) and feelings and bodily experiencing (a focus of gestalt therapy). The processing of emotions, thoughts, bodily experiencing and behaviours is dynamic, resulting in moment-to-moment change in the internal world of the person, which is affected by the altering circumstances in the external world. Emotions and thoughts emerge in the context of this person—environment field. When dealing with specific issues that cardiac patients encounter in their environments, cognitive-behavioural gestalt

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therapists may ask: What are the behavioural aspects of this problem? What thoughts and feelings occur? What are the bodily sensations? In this manner, these key dimensions are identified and expressed. Patients can be invited to list different approaches to the problem and to consider the advantages and disadvantages of these alternatives in assisting them to find a solution. The raising of awareness thus leads to resolution. Change may be viewed along a continuum of awareness—action. Healthy action in this context can be defined as reflected-upon behaviour. Awareness is necessary to ensure that new learning does not remain solely at the cognitive level. Such learning may result in repeated insight without any consequent action. Individuals who possess insight and neglect to engage in behaviour change may find that their bodies are taut due to the build-up of blocked energy (Polster, 1995). The awareness of a specific action by an individual may provide a springboard for change. Insight may signal a particular behaviour that is causing difficulty, but a marker alone is rarely sufficient for a positive outcome. Awareness involves the processing of a behaviour as a precursor to its assimilation. Behaviours upon which the individual has not reflected can absorb energy and consume time. Many of these behaviours have emerged in the person’s life from childhood, when certain actions resulted in the approval of powerful others such as parents and teachers. The more conditional the approval, the less opportunity individuals had to discover what they wanted for themselves. With awareness and assimilation comes a prioritizing of the actions that are most important for health. Without awareness, change cannot occur in such areas as faulty thinking patterns ensuing from irrational assumptions and generalizations. Working through generalizations often involves identifying their source. This was evidenced in one group where a patient, James, was reluctant to obtain feedback from others. Exploration of this reluctance resulted in the naming of an unpleasant experience in the past, in which he overheard himself being described as autocratic. The possibility of change was created by accessing feelings that still related to this incident. When asked how he felt about the particular episode, he stated that he felt annoyed. This identification allowed the subsequent working through of the annoyance. As Goulding and Goulding (1979: 175) observed, “Clients who do not say goodbye keep a part of their energy locked in yesterdays”’. Both the internalization of awareness and the opportunity to practise new thought patterns and behaviours that have been identified as beneficial are facilitated through “Shomework’’. Cognitive-behavioural therapists have emphasized the importance of set exercises in helping clients to achieve their goals in a systematic fashion (Ellis & Whiteley, 1979). The homework of cognitive-behavioural gestalt therapy allows awareness and learnings acquired by individuals in the sessions to be transferred to their everyday lives.

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Becoming aware of how they feel is an important step in cardiac patients becoming responsible for themselves. Once awareness of an emotion connected with some incident in the past or present has been identified, it can

be expressed and completed. It is important that clients acknowledge the feelings and evaluate the thoughts that the experience evokes. Facilitators need to link feelings and story by considering such aspects as “angry with whom?”’, “afraid of whom?” and “loved by whom?” The purpose is to enable clients to move from the recounting of the story of a significant occurrence to its re-experiencing. This allows the completion of previously unfinished feelings through confrontation in the present of important people, images and experiences from the past thus leading to therapeutic change (Polster, 1995). Although emotion is of very short duration, energy attached to unfin-

ished emotion is held in the muscles and does not allow the individual to breathe (Reich, 1969). Stored anger manifests itself behaviourally as aggression and attitudinally as hostility. Fear may be manifested in a raised shoulder that has become rigid, or tense stomach muscles. Watching a fearful cat graphically displays body reactions associated with fear. In anger, the shoulder and neck muscles may be tightened, the jaws clamped together and teeth ground, often resulting in headaches. In sadness, the throat may be contracted and the chin and facial muscles tightened. These muscular tensions can develop when feelings are not appropriately expressed. Expression of the held emotion results in a release of this muscular holding, thus allowing individuals to breathe freely. Alternatively, therapists can enable clients to view the proper use of breathing as a coping skill in dealing with muscular holding. Attending to feelings allows cardiac patients to check whether they are over- or under-extended. In most cases, the problem lies in an overextension. Over-involvement in a job requires a large outflow of energy. Cardiac patients need to be able to tap into awareness so that they can evaluate how they are doing at any particular point in their lives. Awareness allows the differentiation of unhealthy from healthy behaviour. In many cases, the more automatic the behaviour, the more likely it is to be unhealthy, since such behaviour usually involves reacting to the demands of the environment without reflection. Conclusion

As the name implies, cognitive-behavioural gestalt therapy is an integration of cognitive-behavioural and gestalt therapy approaches. Cognitive and emotional awareness enables clients to move beyond “faulty” thinking patterns that have guided behaviour in the past. It allows individuals to set priorities and take responsibility in relation to their health, to identify both healthy and unhealthy behaviours, and to enhance the former and modify

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the latter. Shallow breathing can signify blocked feelings while enhanced breathing can reduce stress and result in peace of mind. References Bates, A. (1993). Cognitive-behaviour therapy. In Boyne, E. (ed.), Psychotherapy in Ireland (pp. 149-182). Dublin: Columbia Press. Beck, A.T. (1976). Cognitive therapy and the emotional disorders. Oxford: International Universities Press. Beckham, E.E. (1990). Psychotherapy of depression research at a crossroads: Directions for the 1990s. Clinical Psychology Review, 10(2), 207-228. Bennett-Levy, J., Lee, N., Travers, K., Pohlman, S. & Hamernik, E. (2003). Cognitive therapy from the inside: Enhancing therapist skills through practising what we preach. Behavioural and Cognitive Psychotherapy, 31, 143-158. Corey, G. (1985). Theory and practice of group counselling (2nd edn). Monterey, CA: Brooks/Cole. Ellis, A. (2001). The rise of cognitive behavior therapy. In W.T O’Donohue & D.A. Henderson (eds), 4 history of the behavioral therapies: Founders’ personal histories

(pp. 183-194). Reno, NV: Context Press. Ellis, A. & Whiteley, J.M. (eds) (1979). Theoretical and empirical foundations of rational-emotive therapy. Pacific Grove, CA: Brooks/Cole. Friedman, M. & Rosenman, R.H. (1974). Type A behavior and your heart. New York: Knopf. Goulding, M. & Goulding, R. (1979). Changing lives through redecision therapy. New York: Brunner/Mazel. Jacobson, E. (1929). Progressive relaxation. Chicago: University of Chicago Press. James, W. (1890). Principles of psychology. New York: Holt, Rinehart & Winston. Kabat-Zinn, J. (1994) Wherever you go there you are: Mindfulness meditation for everyday life. New York: Hyperion. O'Leary, E. (1992). Gestalt therapy: Theory, practice and research. London: Chapman & Hall. O'Leary, E. & Barry, N. (1998a). Reminiscence therapy with older adults. Journal of Social Work Practice, 12(2), 159-165. O’Leary, E. & Barry, N. (1998b). Gestalt cognitive-behavioural therapy. Paper presented at the International Conference on Groups, Health and Disease, Stanford University, CA. O’Leary, E. & Barry, N. (2000). Older adults. In C. Feltham & I. Horton (eds), Handbook of counselling and psychotherapy (pp. 642-648). London: Sage. Perls, F.S. (1969). Gestalt therapy verbatim. Toronto, Canada: Bantam. Perls, F.S., Hefferline, R.F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York: Julian Press. Polster, E. (1995). A population of selves: A therapeutic exploration of personal diversity. San Francisco: Jossey-Bass. Polster, E. & Polster, M. (1973). Gestalt therapy integrated. New York: Random House. Reich, W. (1969). Character analysis (Tr. T. Wolfe). London: Vision Press.

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Segal, Z., Williams, M., & Teasdale, J. (2002) Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press. Thoresen, C.E. (1992). Foreword. In E. O’Leary, Gestalt therapy: Theory, practice and research (pp. ix—x1). London: Chapman & Hall. Waddington, L. (2002). The therapy relationship in cognitive therapy: A review. Behavioural & Cognitive Psychotherapy, 30(2), 179-192.

Chapter 14

Integrating the personal and professional development of therapists Eleanor O’Leary and Geraldine Sheedy

O chestnut tree, great rooted blossomer, Are you the leaf, the blossom or the bole? O body swayed to music, O brightening glance, How can we know the dancer from the dance? W.B. Yeats, “Among School Children”

Yeats’s image of the dancer being merged with the dance is very apt when we consider the person of the therapist in the therapeutic encounter. Who the therapist is plays an important role in the process and cannot be separated from it. In fact, the being of the therapist is probably one of the most essential factors in the therapeutic relationship. It is important, therefore, that therapists become aware of themselves and explore their internal

world

in order

to discover

their own

strengths,

limitations

and

areas of potential development. As early as the fifth century BC, Socrates claimed that ““The unexamined life is not worth living’ (Johns, 1996); in the last century, Freud (1937) stressed that only through self-reflection can therapists obtain the ideal qualification for their profession. The founder of gestalt therapy, Fritz Perls, set a good example in this regard when, following the advice of Karen Horney, he undertook analysis with Wilhelm Reich during 1931 and 1932. Perls’s (1969) account of Horney’s words to him, ““The only analyst that I think could get through to you would be Wilhelm Reich’, is both colourful and humble. Yet the most significant feature of this report was that Perls was open to his own personal development, thus setting a precedent for future generations of gestalt therapists. In ancient Rome, the inscription over the temple of Apollo read “Know thyself”. For many centuries, insight was the desired goal. Such insight or cognitive awareness is part of all personal growth and development initiatives. But what is personal development?

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Personal development The term “personal development” has come to have a multitude of meanings, which reflect the goals and interests of the individuals involved. Waters (1996) outlined four different approaches: the psychosocial, which emphasizes growth in both the intrapersonal and interpersonal dimensions of the individual, as is the case in many lifeskills initiatives; the psychoneurological, which construes learning as the discovery and control of the capabilities of the brain, as is found in NLP (neurolinguistic programming); the psychophysiological, which stresses mind—body relationships; and the psychospiritual, which focuses on the intrapersonal and transpersonal, as in psychosynthesis. All of these approaches have insight or cognitive awareness as one of the desired outcomes. However, cognitive awareness remains an intellectual exercise unless it leads to behavioural change. In the last century, writings in the psychotherapeutic field expanded the concept of awareness beyond insight (e.g. Perls et al/., 1951; Polster & Polster, 1973). Insight is important insofar as it illuminates heretofore unknown aspects of oneself at the cognitive level. In this chapter, we define awareness as consisting of four dimensions of the person: cognitive, bodily/ sensational, emotional, and behavioural.

For internal integration to occur,

these dimensions need to be in alignment with one another. Otherwise individuals are pulled between conflicting demands. Thus, true awareness is holistic in nature. Awareness emerges through attention to internal processing and is limited only to the extent that individuals do not attend to this processing, which is continually evolving, dynamic, ever changing and ever new. Its contents are owned and assimilated into ongoing experiencing, thus leading to internal change. The more individuals attend to it, the richer is their experience. The first step in personal growth is to become familiar, through internal processing of one’s own internal life, with ongoing physical sensations, feelings, thoughts and behaviours that are occurring at a particular moment. Usually one of these internal dimensions changes from one moment to the next, thus supplying the individual with valuable information. Through processing, individuals can keep abreast of all the elements that constitute their emotional, social, cognitive, physical, and spiritual lives. Personal growth requires time, focus and attention in an ongoing manner. Even awareness of sensations is not immediate. In this regard, Polster and Polster (1973: 213) stated that “Identifying basic sensations is no easy task. If the gap could be closed between basic sensations and more complex behaviour, there would probably be fewer instances of incongruent or out of touch behaviour”. Thus, a single female therapist who loves to dance may experience frustration on social occasions where

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her body yearns to move onto the floor when the norm is to wait to be asked by a male before doing so. By undertaking personal growth and development work, she can gain the internal freedom to respond to her body, which is clearly telling her that she wants to dance. However, the benefits of her awareness reach beyond herself in that she can understand better how clients can be bound by social expectation and can recognize the struggle involved in gaining the freedom that they need for themselves. Of particular importance to the professional development of therapists is the completion of their unfinished emotional business which, if not resolved, may lead to an inability to deal with similar issues in their clients. One example is that of therapists who are experiencing unresolved grief. If a theme of loss emerges in clients’ stories, they may avoid exploring it or they may become overly emotional and involved. These responses arise out of their own unfinished business. Unless therapists deal with them, they will be unable to work effectively. Another example is therapists who were terrified as children of an angry parent. This fear may remain an unresolved issue for them, with the result that they are unable to work with anger in clients. The relationship between the personal growth of therapists and that of clients was discussed in two papers (Spurling & Dryden; Norcross & Guy) published in 1989. Spurling and Dryden held that psychotherapy is a personal journey towards health on the part of therapists, and that it is this drive that is healing for the client. They further suggested that if therapists turn a blind eye to aspects of themselves, clients may copy this behaviour. In a similar vein, Norcross and Guy argued that psychotherapy outcomes are inextricably linked with personal development, and warned of the danger of working as therapists without undergoing personal analysis. Supervision plays a crucial role in identifying and becoming aware of any unfinished business that may be hindering progress. Its recognition can allow therapists to work through it in their own therapy. It is our belief that significant personal development is more likely to be achieved in a group setting than in individual work. While clients who are not self-supporting may need the womb-like safety that is characteristic of individual therapy, optimally functioning therapists are self-supporting. They will have explored issues of trust in themselves and others during training and will be free to benefit from the feedback of others in personal development groups that explore intrapersonal, interpersonal and/or group issues. The Johari window (Table 14.1), devised by Luft and Ingram (1955), provides an excellent map in which to illustrate the benefits of personal development in a group context. As outlined in Table 14.1, the window is

divided into four sections, A, B, C and D, with each part referring to aspects of individuals that are either known or unknown to themselves or

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Dee

ee

Table 14.1 Johari window Known to others Known to self

A

OPEN Unknown

Unknown to others

to self

B

AREA

HIDDEN

Ss

BLIND AREA

AREA

D

UNKNOWN

AREA

Source: Luft and Ingram (1955).

others. Area A, ‘“‘the open area’’, is what is acknowledged by both themselves and others. Area B, “‘the hidden area’, includes what they know about themselves but do not reveal to others. Area C, “the blind area’,

refers to aspects of themselves that others know but remain unknown to themselves. Finally, Area D, “the unknown area’, includes aspects of themselves that are unknown to both themselves and others. During personal development groups, participants come to learn more about those aspects of themselves that were previously outside their awareness but became known to them either through feedback from others (Area C) or through involvement in new and novel experiences within the group (Area D). Trained therapists can profit from involvement in a personal development group where each of the above four areas can be explored. Such involvement with peers can be of particular benefit since, due to the training and experience of group members, valuable feedback regarding themselves can be obtained. Thus, participation in personal development groups increases the authenticity of therapists.

Integration of the personal and professional development of therapists Due to the nature of therapeutic work, the journey to wholeness is part of the process of being a therapist. Personal exploration and development are integral parts of this journey. Rogers (1961) devised the term “‘congruence”’ to describe the ability of therapists to be themselves, considering it a core condition of his approach, while the first author has referred to this same ability as “authenticity” in person-centred gestalt therapy (cf. Chapter 3). Crouch (1997) suggested that a certain level of self-awareness and selfacceptance is necessary before one can be truly genuine. Shakespeare emphasized the role of the self in the lives of individuals in Act I, Scene III of Hamlet, when Polonius says to his son, Laertes: This above all: to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man.

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The attainment of this quality usually occurs through engagement in personal growth and development. Personal development allows therapists to explore and clarify their own values, enabling them to be more authentic with clients. As humans, therapists inevitably struggle with negative feelings, misperceptions and conflicts. Their authenticity is enhanced when they identify, explore and express these as part of themselves. Psychotherapists who do not consider therapy a prerequisite to being a therapist are, according to Norcross and Guy (1989), those who report not having had personal therapy themselves. Kottler (1993) commented on the hypocrisy displayed by many therapists who are convinced that therapy is for others but not for themselves. He drew attention to a study carried out by Deutsch (1985) that indicated hesitation on the part of many therapists to seek therapy due to a belief that asking for help indicated weakness or failure. Yet this is the very activity in which clients engage. Being vulnerable can take tremendous strength. It involves being open to experiences and working through their associated feelings without acting them out, suppressing them or rejecting them. By being open in this manner, individuals come to discover what is real. Becoming vulnerable takes time and needs to be experienced in order for the process to be trusted. Therapy can be very effective when clients are given a space to feel their fragility and its intrinsic power. For this to happen, it is important that therapists have enough confidence to allow clients to be in a vulnerable place. It is vital, therefore, that they welcome and explore their own frailty and are themselves cognizant of situations that bring them into contact with it. This experienced vulnerability will allow them to deal with its manifestation in clients who, in time, can discover their own inherent strength and power. We hold that personal development should be an ongoing endeavour of all practising professional therapists. Supervision does not substitute for this activity since, in supervision, the identification rather than the working through of personal issues occurs. Norcross and Guy (1989) maintained that self-therapy both sensitizes therapists to the needs of their clients, since they have direct experience of the process involved, and increases therapists’ comprehension of intrapersonal and interpersonal dynamics. Personal development is a prerequisite of empathy. The first author (O’Leary, 1982) described empathy as the sensing by therapists of the experiencing and feelings of clients as if they were their own without loss of their own separateness. In order to establish and maintain this separateness, it is important that therapists have previously explored their own feelings. Spurling and Dryden (1989) maintained that really entering someone else’s skin presupposes having already been there in some sense. Although therapists may not have had experiences similar to those of their clients,

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cnn

inReales

nial Retin acetate he Fi et wlRee

eS

through the use of visualization and its accompanying thoughts, feelings and bodily experiencing, they can effectively prepare themselves for their future work. For example, the visualization of one’s own death can be helpful for future work with dying or terminally ill individuals. Enhanced attention to, and awareness of, their bodies by therapists can lead to deeper understanding and greater progress in therapy. The more they consider their own bodies, the more aware they will be of the nonverbal behaviour of clients. A common error is to forget themselves and to focus only on clients. It is important, therefore, that they remain connected to their own sensing in the therapeutic relationship and maintain their identities as separate beings. What therapists experience at a somatic level can bring empathy to a deeper level, since empathy is communicated as effectively through the overt recognition of non-verbal as of verbal behaviour (O’Leary, 1993). It is our opinion that if bodily experiencing remains unacknowledged by therapists, the consequence may be that their interventions include only verbal content. Thus, it is important for them to engage in their own bodywork and become as aware as possible of their own somatic being. The first author (O’Leary, 1992: 147) has described how an awareness of the gestalt concept of foreground/background enables therapists to attune themselves to the inner experiencing of the client: “in empathy, the awareness of the phenomenal world of the other is figure, the central item of concern in the relationship, while the realisation of difference with the other is background”’. Yet, for those who have not undertaken personal development, an awareness of difference may be missing. In his definition of empathy, Rogers (1951) listed the ability of therapists to assume the internal frame of reference of clients as one of its characteristics, and suggested that there are limits to their engagement in the therapeutic relationship. Recognition of these limits depends to a certain extent on the degree to which therapists are free to experience the present moment without the distractions of either unfinished business from the past or present or anxiety concerning the future. The importance of personal development for trainees received attention in 1996 from both Corey and Johns. Corey (1996: 19) stated that ‘‘Personal therapy can be instrumental then in healing the healer. If student counselors are not actively involved in the pursuit of healing their own psychological wounds, they will probably have considerable difficulty entering the world of a client. As counselors we can take our clients no further than we have been willing to go in our life.”” Johns (1996) argued that purposeful personal development is the most essential element of counsellor training since it is inextricably linked to professional development, and that neither type of development is possible without awareness. These two authors thus echoed Bloomfield’s (1989) assertion that it is not what we do but how we are that

is most important in therapy.

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Cultural aspects Personal awareness is necessary if therapists are to engage in cross-cultural initiatives. In a study of 32 cross-cultural counsellors, Fitzgerald and O’Leary (1990) found that the most frequently mentioned barriers were cultural differences, value differences and language difficulties, while openmindedness and tolerance of difference were the qualities most frequently deemed beneficial. Engaging in personal growth work and having lived in the culture beforehand were considered to be the next most important preparations, and of equal value. In order to connect with clients, therapists need to be able to understand their world, however

different it is from their own.

To achieve this, they

must be open to and value learning from others. They need to relinquish any notion that their cultural belief system is in any way superior, and any expectation that clients should conform to it. In order to facilitate clients to embrace their own cultural values and beliefs, it is important that therapists have done this in their own personal work. Two prevailing views of self exist, depending on the culture within which one lives (Markus & Cross, 1990). One places emphasis on separateness and ego development; the other stresses connectedness and the belief that human beings are all one at a spiritual level. When one is working in a culture in which people have a different view of self to that of therapists, it is important to be aware of these distinct outlooks. Previous involvement in their own personal development and its exploration allows therapists both to identify what their underlying view of self is and to engage with clients who possess a different perspective. Being a therapist does not automatically preclude an individual from being biased or prejudiced. In working with clients from other races or cultures, therapists need to recognize any internalized racism they themselves may hold. Only by questioning and exploring their own cultural values, beliefs and concepts and by identifying how these impact their behaviour and attitudes can they become aware of their biases and prejudices. In this way, if they notice similar behaviour in clients, they can be open to exploring these attitudes. Stereotypes of clients (e.g. “All Tibetans are spiritual’) can hinder psychotherapeutic work. Therapists need to look beyond the stereotype and be aware of any preconceived notions they may project. This is particularly necessary in order to understand clients who come from marginalized minorities. Consider, for example, clients for whom tradition and strong family ties are of great importance. Therapists who believe in independence from family and see separation from it as vital may deem such clients to be emmeshed within their family and regard it as unhealthy. Unless therapists are conscious of their biases, values and belief systems, these attitudes may render therapy ineffective or harmful. However, if repression of a particular

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O’Leary and Sheedy

gender or minority is part of a culture, therapists should explore what their feelings are around the existence of such repression and the possibility of working with such clients in the future. Not all clients come to therapy with an acceptance of the customs of their particular culture. For example, when facilitating personal development groups in East Africa, the first author found that some educated females

felt themselves trapped by the tribal system of arranged marriages. Awareness of the existence of this custom in her own country two generations previously, and in some farming communities up to one generation, was of great benefit in working with these participants even though the emphasis in Ireland had been within a class rather than a tribal structure. We hold that culture-bound life experiences, class-bound values and language variables shape the individual identity and worldview of individuals. These differ across ethnic and racial groups. The major therapeutic schools have largely been developed by middle- and upper-class Europeans and Americans and have not taken these differences into account. In a European context, where people from non-European countries and cultures constitute a growing proportion of the population, there is a need on the part of therapists for a combination of sensitivity to cultural differences and acknowledgement of the common threads that unite people. It is important that therapists attend to these cultural factors in their own personal and professional development in order to experience clients’ subjective worldviews. Therapists need to explore attitudes that may never be encountered in their own everyday lives. These “hidden depths” can be discovered through internal processing and can also be enhanced, especially if their ownership occurs in a group context where feedback from others is possible. Conclusion

Through ongoing internal processing, therapists come to clarify their awareness of themselves, thus enhancing their own therapeutic practice. The development of this personal awareness is a lifelong endeavour. When therapists have engaged in personal development work, they can better understand the issues of clients and show greater empathy and congruence. Optimal personal development occurs in a group context since individuals are able to receive feedback from a number of others and thus expand their self-awareness. Their personal journeys allow therapists to integrate their personal and professional selves, just as Yeats’s dancer and dance become one. References Bloomfield, I. (1989). Through therapy to self. In W. Dryden & L. Spurling (eds), On becoming a psychotherapist (pp. 33-52). New York: Tavistock/Routledge.

Therapists’ personal and professional development

175

Corey, G. (1996). Theory and practice of counseling and psychotherapy (Sth edn). Pacific Grove, CA: Brooks/Cole. Crouch, A. (1997). Inside counselling. Becoming and being a professional counsellor. London: Sage. Deutsch, C.J. (1985). A survey of therapists’ personal problems and treatment. Professional Psychology: Research and Practice, 16(2), 305-315. Fitzgerald, K. & O'Leary, E. (1990). Cross-cultural counselling: Counsellors’ views on barriers, benefits, personal qualities and necessary preparation. Irish Journal of Psychology, 11(3), 238-248. Freud, S. (1937). Analysis terminable and interminable. In J. Strachey (ed.), Complete psychological works of Sigmund Freud (1964). London: Hogarth Press. Johns, H. (1996). Personal development in counsellor training. London:

Cassell.

Kottler, J.A. (1993). On being a therapist. San Francisco: Jossey-Bass. Luft, J. & Ingram, H. (1955). The Johari Window. A graphical model for interpersonal relations. Western Training Laboratory: University of California, Los Angeles. Markus,

H. & Cross, S. (1990). The interpersonal self. In L.A. Penin (ed.), Hand-

book of personality: Theory and research, (pp. 576-608). New York: Guilford Press. Norcross, J.C. & Guy, J.D. (1989). Ten therapists: The process of becoming and being. In W. Dryden & L. Spurling (eds), On becoming a psychotherapist (pp. 215-239). New York: Tavistock/Routledge. O'Leary, E. (1982). The psychology of counselling. Cork: Cork University Press. O'Leary, E. (1992). Gestalt therapy: Theory, practice and research. London: Chapman & Hall. O'Leary, E. (1993). Empathy in the person centred and gestalt approaches. British Gestalt Journal, 2, 111-115. Perls, F.S. (1969). In and out of the garbage pail. Lafayette, CA: Real People Press. Perls, F.S., Hefferline, R., & Goodman,

P. (1951). Gestalt therapy: Excitement and growth in the personality. New York: Delta. Polster, E. & Polster, M. (1973). Gestalt therapy integrated. New York: Vintage Books. Rogers, C. (1951). Client-centered therapy. Boston: Houghton Mifflin. Rogers, C. (1961). On becoming a person. London: Constable. Spurling, L. & Dryden, W. (1989). The self and the therapeutic domain. In W. Dryden & L. Spurling (eds), On becoming a psychotherapist (pp. 191-214). New York: Tavistock/Routledge. Waters, M. (1996). The element dictionary of personal development. Shaftesbury, UK: Element Books. Yeats, W.B. (1928/1989). Among School Children. In A.N. Jeffares (ed.), Yeats’s poems (pp. 323-325). London: Macmillan.

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therapist-client relationship 147, 150, 155 therapist-client-family alliance 147 thought patterns 162, 163 thoughts 17, 18, 26, 28, 34, 40, 41, 54, 69; 77, Sl; 91, 95, 99,. 106, 124,145, 155, 156, 162, 163, 164, 168, 172, 185, 187, 188 thought stopping 95, 99 time management 89, 96—7 time projection imagery 95, 98—9 tone 26, 33, 117 thames On2oc7. LOT at 72195. 1962197" 199, 200, 201, 210 transactional 61 transformations 38, 43, 45 treatment modality 107 trust 27529, 30,56, 71, 110, 118, 120, 169; 171, 199.200 Zseng: WS. 112 Type A 161, 164 ultradian dynamics 65

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58, 164, 169, 172 unfinished business 32, 35, 50, 52, 53,

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