The SAGE Encyclopedia of Theory in Counseling and Psychotherapy (2 Volume Set) [1-2] 9781452274126

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The SAGE Encyclopedia of

Theory in Counseling and Psychotherapy

Editorial Board Editor Edward S. Neukrug Old Dominion University

Editoral Board Allen Bishop Pacifica Graduate Institute Nina W. Brown Old Dominion University Sarah P. Deaver Eastern Virginia Medical School David Donnelly University of Rochester Andre Marquis University of Rochester Rip McAdams The College of William and Mary Jane E. Myers University of North Carolina at Greensboro Suzan K. Thompson Military Integrative Therapies, LLC Richard E. Watts Sam Houston State University Jeffrey Zeig Milton H. Erickson Foundation

Managing Editor Kevin C. Snow Old Dominion University

Associate Editors Hannah B. Bayne Virginia Tech Cherée F. Hammond Eastern Mennonite University

The SAGE Encyclopedia of

Theory in Counseling and Psychotherapy

1 Edited by Edward S. Neukrug Old Dominion University

Copyright © 2015 by SAGE Publications, Inc.

FOR INFORMATION: SAGE Publications, Inc.

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.

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Developmental Editor: Carole Maurer Reference Systems Manager: Leticia Gutierrez Production Editor: David C. Felts Copy Editor: QuADS Prepress (P) Ltd. Typesetter: Hurix Systems Pvt. Ltd. Proofreader: Sally Jaskold Indexer: Joan Shapiro Cover Designer: Candice Harman Marketing Manager: Carmel Schrire

15 16 17 18 19 10 9 8 7 6 5 4 3 2 1

Contents Volume 1 List of Entries vii Reader’s Guide xi List of Theorists xvii About the Editor xxvii Contributors xxix Introduction xxxix Entries A B C D E

1 85 149 269 307

F G H I

399 449 483 529

Volume 2 List of Entries vii Reader’s Guide xi Entries J K L M N O P R

591 599 607 623 691 731 753 845

S T U V W Y Z

905 997 1021 1035 1043 1057 1063

Appendices Appendix A: Chronology 1067 Appendix B: Resource Guide—Journals and Professional Associations 1073 Appendix C: Bibliography 1083 Index 1161

List of Entries Accelerated Experiential Dynamic Psychotherapy Acceptance and Commitment Group Therapy Acceptance and Commitment Therapy Ackerman, Nathan Ackerman Relational Approach Activity-Based Group Psychotherapy Acupuncture and Acupressure Adler, Alfred Adlerian Group Therapy Adlerian Therapy Advanced Integrative Therapy Adventure-Based Therapy Alexander Technique Analytical Psychology Animal Assisted Therapy Applied Behavior Analysis Archetypal Psychotherapy Aromatherapy Art Therapy Assimilative Psychotherapy Integration Attachment Group Therapy Attachment Theory and Attachment Therapies Attachment-Focused Family Therapy Attack Therapy Autogenic Training Bandura, Albert Bateson, Gregory. See Palo Alto Group Beck, Aaron T. Behavior Modification Behavior Therapies: Overview Behavior Therapy Behavioral Activation Behavioral Group Therapy Berg, Insoo Kim. See de Shazer, Steve, and Insoo Kim Berg Bibliotherapy Biodynamic Psychology Bioenergetic Analysis Biofeedback

Biopsychosocial Model Body-Mind Centering® Body-Oriented Therapies: Overview BodyTalk Böszörményi-Nagy, Ivan Bowen, Murray Bowenian Therapy. See Multigenerational Family Therapy Brain Change Therapy Brainspotting Breathwork in Contemplative Psychotherapy Brief Solution-Based Group Therapy. See Focused Brief Group Therapy Brief Therapy Cautious, Dangerous, and/or Illegal Practices: Overview Cerebral Electric Stimulation Chaos Theory Characteranalytical Vegetotherapy Chess Therapy Classical Conditioning Classical Psychoanalytic Approaches: Overview Client-Centered Counseling. See Person-Centered Counseling Co-counseling. See Re-evaluation Counseling Cognitive Analytic Therapy Cognitive Enhancement Therapy Cognitive Processing Therapy Cognitive-Behavioral Family Therapy Cognitive-Behavioral Group Therapy Cognitive-Behavioral Therapies: Overview Cognitive-Behavioral Therapy Coherence Therapy Collaborative Therapy Common Factors in Therapy Communication Theory of Couples and Family Therapy. See Human Validation Process Model Communication/Validation Family Therapy. See Human Validation Process Model vii

viii

List of Entries

Complementary and Alternative Approaches: Overview Concentrative Movement Therapy Constructivist Therapies: Overview Constructivist Therapy Contemplative Psychotherapy Contemporary Psychodynamic-Based Therapies: Overview Contextual Therapy Conversion Therapy. See Sexual Orientation Change Efforts Core Energetics Core Process Psychotherapy Couple and Family Hypnotic Therapy Couples, Family, and Relational Models: Overview Creative Arts and Expressive Therapies: Overview Critical Incident Stress Management Cross-Cultural Counseling Theory Cyclical Psychodynamics Dance Movement Therapy Daseinsanalysis de Shazer, Steve, and Insoo Kim Berg Developmental Constructivism Developmental Counseling and Therapy: Theory and Brain-Based Practice Developmental Needs Meeting Strategy Dialectical Behavior Therapy Directive Therapy Drama Therapy Eclecticism Ecological Counseling Ecotherapy EcoWellness Ego Psychology Ego State Therapy Ego-Oriented Therapies: Overview Ellis, Albert EMDR. See Eye Movement Desensitization and Reprocessing Therapy Emotional Freedom Techniques Emotion-Focused Family Therapy Emotion-Focused Therapy Energy Psychology Erickson, Milton H. Erickson-Derived or -Influenced Theories: Overview Ericksonian Therapy Evidence-Based Psychotherapy

Existential Group Psychotherapy Existential Therapy Existential-Humanistic Therapies: Overview Experiential Family Therapy. See Symbolic Experiential Family Therapy Experiential Psychotherapy Exposure and Response Prevention Exposure Therapy Eye Movement Desensitization and Reprocessing Therapy Eye Movement Integration Therapy Family Constellation Therapy Feedback-Informed Treatment Feldenkrais Method Feminist Family Therapy Feminist Psychoanalytic Therapy Feminist Therapy Fisch, Richard. See Palo Alto Group Focused Brief Group Therapy Focusing-Oriented Therapy Foundational Therapies: Overview Frankl, Viktor Freud, Sigmund Freudian Psychoanalysis Fry, William. See Palo Alto Group Functional Analytic Group Therapy Functional Analytic Psychotherapy Gender Aware Therapy Gestalt Group Therapy Gestalt Therapy Glasser, William Gottman Method Couples Therapy Group Analysis Group Counseling and Psychotherapy Theories: Overview Growth Model. See Human Validation Process Model Guided Imagery Therapy Hakomi Therapy Haley, Jay Healing From The Body Level Up Healing Touch Heart Rate Variability HeartMath Hellerwork Herbal Medicine Holding Therapy Holotropic Breathwork Homeopathic Medicine and Counseling Horney, Karen

List of Entries

Human Validation Process Model Humanistic Psychoanalysis of Erich Fromm Humanistic-Experiential Model. See Human Validation Process Model Hypnotherapy Identity Renegotiation Counseling Imago Relationship Therapy Impact Therapy Improvisational Therapy Individual Psychology. See Adlerian Therapy Inner Child Therapy Integral Eye Movement Therapy Integral Psychotherapy Integrative Approaches: Overview Integrative Body Psychotherapy Integrative Family Therapy Integrative Forgiveness Psychotherapy Integrative Milieu Model Interaction Focused Therapy Internal Family Systems Model Interpersonal Group Therapy Interpersonal Integrative Group Therapy Interpersonal Psychoanalysis Interpersonal Psychotherapy Interpersonal Theory Intersubjective Group Psychotherapy Intersubjective-Systems Theory Jackson, Donald. See Palo Alto Group Jung, Carl Gustav Jungian Group Psychotherapy Jungian Therapy. See Analytical Psychology Kelly, George Kernberg, Otto Klein, Melanie Lacanian Group Therapy Lacanian Psychoanalysis Laing, R. D. See Phenomenological Therapy Lazarus, Arnold Linehan, Marsha Logotherapy and Existential Analysis Madanes, Cloe Mahler, Margaret Mahoney, Michael J. Maslow, Abraham Maslow’s Hierarchy of Needs May, Rollo Meditation Meichenbaum, Donald Mentalization-Based Treatment Metaphors of Movement Therapy

ix

Method of Levels Milan School of Systemic Family Therapy. See Systemic Family Therapy Miller, Jean Baker Miller, William R. Mind–Body Therapy. See Psychosocial Genomics Mindfulness Techniques Mindfulness-Based Cognitive Therapy Mindfulness-Based Stress Reduction Minuchin, Salvador Modern Analytic Group Therapy Morita Therapy Motivational Interviewing Movement Therapies. See Dance Movement Therapy; Yoga Movement Therapy Multigenerational Family Therapy Multimodal Therapy Multisystemic Therapy Multitheoretical Psychotherapy Music Therapy Narrative Family Therapy Narrative Therapy Nature-Guided Therapy Neo-Freudian Psychoanalysis Neurofeedback Neuro-Linguistic Programming Neurological and Psychophysiological Therapies: Overview Neuroprocessing Neuropsychoanalysis Non-Western Approaches Object Relations Theory O’Hanlon, Bill Operant Conditioning Orgonomy Ortho-Bionomy Other Therapies: Overview Palo Alto Group Parent–Child Interaction Therapy Pastoral Counseling Pavlov, Ivan Perls, Fritz Personal Construct Theory Person-Centered Counseling Phenomenological Therapy Play Therapy Poetry Therapy Positive Psychology Possibility Therapy Postural Integration

x

List of Entries

Prayer and Affirmations Primal Integration Primal Therapy Process Groups Process Therapy. See Human Validation Process Model Process-Oriented Psychology Processwork. See Process-Oriented Psychology Prolonged Exposure Therapy Provocative Therapy Psychedelic Therapy Psychoanalysis. See Freudian Psychoanalysis Psychodrama Psychodynamic Family Therapy Psychodynamic Group Psychotherapy Psychoeducational Groups Psychosocial Development, Theory of Psychosocial Genomics Psychosynthesis Pulsing Radix Rational Emotive Behavior Therapy Rational Living Therapy Reality Therapy Rebirthing Rebirthing-Breathwork Recovered Memory Therapy Re-evaluation Counseling Regression Therapy. See Primal Therapy Reich, Wilhelm Reichian Therapy. See Orgonomy Reiki Relational Group Psychotherapy Relational Psychoanalysis Relational-Cultural Theory Relationship Enhancement Therapy Reparative Therapy. See Sexual Orientation Change Efforts Response-Based Practice Rogers, Carl Rolfing Rollnick, Steve. See Miller, William R. Rubenfeld Synergy Satir, Virginia Schema Therapy Scream Therapy. See Primal Therapy Self Psychology Self-Help Groups Self-Relations Psychotherapy

Seligman, Martin Sensorimotor Psychotherapy Sexual Identity Therapy Sexual Minority Affirmative Therapy Sexual Orientation Change Efforts Shapiro, Francine Skinner, B. F. Social Cognitive Theory Solution-Focused Brief Family Therapy Solution-Focused Brief Therapy Somatic Experiencing Status Dynamic Psychotherapy StoryPlay Therapy Strategic Family Therapy Strategic Therapy Structural Family Therapy Sullivan, Harry Stack Support Groups. See Self-Help Groups Supportive Psychotherapy Symbolic Experiential Family Therapy Systematic Desensitization Systemic Constellations Systemic Family Therapy Systems-Centered Group Counseling Tavistock Group Training Approach Therapeutic Touch Training Groups Transactional Analysis Transformational Systemic Theory. See Human Validation Process Model Transpersonal Psychology: Overview Transtheoretical Model Trauma-Focused Cognitive-Behavioral Therapy Unified Theory Unified Therapy Unifying Nonlinear Dynamical Biopsychosocial Systems Approach Values Clarification Voice Dialogue Wellness Counseling Whitaker, Carl White, Michael Wilderness Therapy. See Adventure-Based Therapy Winnicott, Donald Writing Therapy Yalom, Irvin Yoga Movement Therapy Zimbardo, Philip George

Reader’s Guide The Reader’s Guide is provided to assist readers in locating articles on related topics. It classifies articles into twenty general topical categories: Behavior Therapies; Body-Oriented Therapies; Cautious, Dangerous, and/or Illegal Practices; Classical Psychoanalytic Approaches; Cognitive-Behavioral Therapies; Complementary and Alternative Approaches; Constructivist Therapies; Contemporary PsychodynamicBased Therapies; Couples, Family, and Relational Models; Creative Arts and Expressive Therapies; EgoOriented Therapies; Erickson-Derived or -Influenced Theories; Existential-Humanistic Therapies; Foundational Therapies; Group Counseling and Psychotherapy Theories; Integrative Approaches; Neurological and Psychophysiological Therapies; Other Therapies; Theorists; and Transpersonal Psychology. Entries may be listed under more than one topic. Behavior Therapies

Core Energetics Feldenkrais Method Hakomi Therapy Holotropic Breathwork Integrative Body Psychotherapy Orgonomy Ortho-Bionomy Postural Integration Primal Integration Primal Therapy Pulsing Radix Rolfing Rubenfeld Synergy Sensorimotor Psychotherapy Somatic Experiencing Yoga Movement Therapy

Acceptance and Commitment Therapy Applied Behavior Analysis Behavior Modification Behavior Therapies: Overview Behavior Therapy Behavioral Activation Classical Conditioning Dialectical Behavior Therapy Exposure and Response Prevention Exposure Therapy Functional Analytic Psychotherapy Multimodal Therapy Operant Conditioning Parent–Child Interaction Therapy Prolonged Exposure Therapy Social Cognitive Theory Systematic Desensitization

Cautious, Dangerous, and/or Illegal Practices

Body-Oriented Therapies

Attack Therapy Cautious, Dangerous, and/or Illegal Practices: Overview Holding Therapy Psychedelic Therapy Rebirthing Recovered Memory Therapy Sexual Orientation Change Efforts

Alexander Technique Biodynamic Psychology Bioenergetic Analysis Body-Mind Centering® Body-Oriented Therapies: Overview Characteranalytical Vegetotherapy Concentrative Movement Therapy

xi

xii

Reader’s Guide

Classical Psychoanalytic Approaches

Adlerian Therapy Analytical Psychology Classical Psychoanalytic Approaches: Overview Ego Psychology Freudian Psychoanalysis Interpersonal Theory Neo-Freudian Psychoanalysis Object Relations Theory Self Psychology Cognitive-Behavioral Therapies

Acceptance and Commitment Therapy Adlerian Therapy Cognitive Analytic Therapy Cognitive-Behavioral Therapies: Overview Cognitive-Behavioral Therapy Critical Incident Stress Management Dialectical Behavior Therapy Functional Analytic Psychotherapy Guided Imagery Therapy Impact Therapy Method of Levels Mindfulness-Based Cognitive Therapy Mindfulness-Based Stress Reduction Motivational Interviewing Multimodal Therapy Rational Emotive Behavior Therapy Rational Living Therapy Reality Therapy Schema Therapy Trauma-Focused Cognitive-Behavioral Therapy Complementary and Alternative Approaches

Acupuncture and Acupressure Advanced Integrative Therapy Alexander Technique Aromatherapy Autogenic Training BodyTalk Brainspotting BreathWork in Contemplative Psychotherapy Complementary and Alternative Approaches: Overview Contemplative Psychotherapy Ecotherapy Emotional Freedom Techniques Energy Psychology

Healing From The Body Level Up Healing Touch HeartMath Hellerwork Herbal Medicine Homeopathic Medicine and Counseling Integrative Forgiveness Psychotherapy Meditation Mindfulness Techniques Morita Therapy Non-Western Approaches Prayer and Affirmations Rebirthing-Breathwork Reiki Therapeutic Touch Constructivist Therapies

Coherence Therapy Collaborative Therapy Constructivist Therapies: Overview Constructivist Therapy Ericksonian Therapy Feminist Therapy Gender Aware Therapy Identity Renegotiation Counseling Narrative Therapy Personal Construct Theory Response-Based Practice Solution-Focused Brief Therapy Contemporary Psychodynamic-Based Therapies

Accelerated Experiential Dynamic Psychotherapy Archetypal Psychotherapy Attachment Theory and Attachment Therapies Contemporary Psychodynamic-Based Therapies: Overview Core Process Psychotherapy Cyclical Psychodynamics Emotion-Focused Therapy Feminist Psychoanalytic Therapy Holding Therapy Interpersonal Psychoanalysis Intersubjective-Systems Theory Lacanian Psychoanalysis Mentalization-Based Treatment Neuropsychoanalysis Psychosocial Development, Theory of

Reader’s Guide

Relational Psychoanalysis Self Psychology Couples, Family, and Relational Models

Ackerman Relational Approach Attachment-Focused Family Therapy Cognitive-Behavioral Family Therapy Couple and Family Hypnotic Therapy Couples, Family, and Relational Models: Overview Emotion-Focused Family Therapy Family Constellation Therapy Feminist Family Therapy Gottman Method Couples Therapy Human Validation Process Model Identity Renegotiation Counseling Imago Relationship Therapy Integrative Family Therapy Internal Family Systems Model Multigenerational Family Therapy Multisystemic Therapy Narrative Family Therapy Psychodynamic Family Therapy Relationship Enhancement Therapy Solution-Focused Brief Family Therapy Strategic Family Therapy Structural Family Therapy Symbolic Experiential Family Therapy Systemic Constellations Systemic Family Therapy Creative Arts and Expressive Therapies

Adventure-Based Therapy Animal Assisted Therapy Art Therapy Bibliotherapy Chess Therapy Creative Arts and Expressive Therapies: Overview Dance Movement Therapy Drama Therapy EcoWellness Impact Therapy Improvisational Therapy Music Therapy Nature-Guided Therapy Play Therapy Poetry Therapy Psychodrama Wellness Counseling Writing Therapy

Ego-Oriented Therapies

Adlerian Therapy Analytical Psychology Developmental Needs Meeting Strategy Ego Psychology Ego State Therapy Ego-Oriented Therapies: Overview Freudian Psychoanalysis Gestalt Therapy Inner Child Therapy Internal Family Systems Model Psychosocial Development, Theory of Transactional Analysis Voice Dialogue Erickson-Derived or -Influenced Theories

Brain Change Therapy Couple and Family Hypnotic Therapy Directive Therapy Ego State Therapy Erickson-Derived or -Influenced Theories: Overview Ericksonian Therapy Impact Therapy Improvisational Therapy Interaction Focused Therapy Metaphors of Movement Therapy Nature-Guided Therapy Neuro-Linguistic Programming Possibility Therapy Psychosocial Genomics Self-Relations Psychotherapy Solution-Focused Brief Therapy StoryPlay Therapy Strategic Therapy Existential-Humanistic Therapies

Daseinsanalysis Emotion-Focused Therapy Existential Therapy Existential-Humanistic Therapies: Overview Experiential Psychotherapy Focusing-Oriented Therapy Gestalt Therapy Humanistic Psychoanalysis of Erich Fromm Logotherapy and Existential Analysis Maslow’s Hierarchy of Needs Person-Centered Counseling

xiii

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Reader’s Guide

Phenomenological Therapy Positive Psychology Primal Integration Primal Therapy Process-Oriented Psychology Psychodrama Psychosynthesis Transactional Analysis Values Clarification

Modern Analytic Group Therapy Process Groups Psychodrama Psychodynamic Group Psychotherapy Psychoeducational Groups Relational Group Psychotherapy Self-Help Groups Systems-Centered Group Counseling Tavistock Group Training Approach Training Groups

Foundational Therapies

Adlerian Therapy Analytical Psychology Behavior Therapy Cognitive-Behavioral Therapy Constructivist Therapy Ericksonian Therapy Existential Therapy Feminist Therapy Foundational Therapies: Overview Freudian Psychoanalysis Gestalt Therapy Narrative Therapy Person-Centered Counseling Rational Emotive Behavior Therapy Reality Therapy Solution-Focused Brief Therapy Strategic Therapy Group Counseling and Psychotherapy Theories

Acceptance and Commitment Group Therapy Activity-Based Group Psychotherapy Adlerian Group Therapy Attachment Group Therapy Behavioral Group Therapy Cognitive-Behavioral Group Therapy Existential Group Psychotherapy Focused Brief Group Therapy Functional Analytic Group Therapy Gestalt Group Therapy Group Analysis Group Counseling and Psychotherapy Theories: Overview Interpersonal Group Therapy Interpersonal Integrative Group Therapy Intersubjective Group Psychotherapy Jungian Group Psychotherapy Lacanian Group Therapy

Integrative Approaches

Accelerated Experiential Dynamic Psychotherapy Assimilative Psychotherapy Integration Biopsychosocial Model Cognitive Analytic Therapy Common Factors in Therapy Contextual Therapy Cyclical Psychodynamics Developmental Constructivism Developmental Counseling and Therapy: Theory and Brain-Based Practice Eclecticism Emotion-Focused Therapy Evidence-Based Psychotherapy Eye Movement Desensitization and Reprocessing Therapy Integral Psychotherapy Integrative Approaches: Overview Integrative Milieu Model Integrative Forgiveness Psychotherapy Interpersonal Psychotherapy Multimodal Therapy Multitheoretical Psychotherapy Positive Psychology Transtheoretical Model Unified Theory Unified Therapy Unifying Nonlinear Dynamical Biopsychosocial Systems Approach Neurological and Psychophysiological Therapies

Autogenic Training Biofeedback Brain Change Therapy Cerebral Electric Stimulation Cognitive Enhancement Therapy

Reader’s Guide

Developmental Counseling and Therapy: Theory and Brain-Based Practice Eye Movement Desensitization and Reprocessing Therapy Eye Movement Integration Therapy Heart Rate Variability Hypnotherapy Integral Eye Movement Therapy Neurofeedback Neuro-Linguistic Programming Neurological and Psychophysiological Therapies: Overview Neuroprocessing Neuropsychoanalysis Other Therapies

Brief Therapy Chaos Theory Common Factors in Therapy Cross-Cultural Counseling Theory Ecological Counseling Evidence-Based Psychotherapy Feedback-Informed Treatment Metaphors of Movement Therapy Other Therapies: Overview Pastoral Counseling Provocative Therapy Re-Evaluation Counseling Relational-Cultural Theory Self-Relations Psychotherapy Sexual Identity Therapy Sexual Minority Affirmative Therapy Status Dynamic Psychotherapy Supportive Psychotherapy

Frankl, Viktor Freud, Sigmund Glasser, William Haley, Jay Horney, Karen Jung, Carl Gustav Kelly, George Kernberg, Otto Klein, Melanie Lazarus, Arnold Linehan, Marsha Madanes, Cloe Mahler, Margaret Mahoney, Michael J. Maslow, Abraham May, Rollo Meichenbaum, Donald Miller, Jean Baker Miller, William R. Minuchin, Salvador O’Hanlon, Bill Palo Alto Group Pavlov, Ivan Perls, Fritz Reich, Wilhelm Rogers, Carl Satir, Virginia Seligman, Martin Shapiro, Francine Skinner, B. F. Sullivan, Harry Stack Whitaker, Carl White, Michael Winnicott, Donald Yalom, Irvin Zimbardo, Philip George

Theorists

Ackerman, Nathan Adler, Alfred Bandura, Albert Beck, Aaron T. Böszörményi-Nagy, Ivan Bowen, Murray de Shazer, Steve, and Insoo Kim Berg Ellis, Albert Erickson, Milton H.

Transpersonal Psychology

Analytical Psychology Holotropic Breathwork Integral Psychotherapy Jung, Carl Gustav Maslow, Abraham Maslow’s Hierarchy of Needs Psychosynthesis Transpersonal Psychology: Overview

xv

List of Theorists* Theory/Approach

Theorist

Accelerated Experiential Dynamic Psychotherapy (AEDP) Acceptance and commitment therapy (ACT) Ackerman relational approach (ARA) Adaptive Information Processing (AIP) model Advanced Integrative Therapy (AIT) Adlerian Therapy Alexander technique All-quadrant, all-level (AQAL) model Alternative psychiatry Analytical music therapy (AMT) Analytical psychology Applied behavior analysis (ABA) Archetypal psychotherapy Aromatherapy Art therapy Authentic Movement Autogenic training BASIC I.D. formulation Behavioral therapy Biodynamic psychology (BP) Bioenergetic analysis Biophilia hypothesis Biopsychosocial model Body movement structural patterns Body psychotherapy Body-Mind Centering® Body-oriented therapies BodyTalk System

Diana Fosha Steven Hayes Nathan Ackerman Francine Shapiro Asha Clinton Alfred Adler Frederick Matthias Alexander Ken Wilber R. D. Laing Mary Priestly Carl Gustav Jung Ted Allyon and Jack Michael James Hillman Rene Gattefossé Margaret Naumburg Mary Whitehouse Johannes Heinrich Shultz Arnold A. Lazarus John B. Watson Gerda Boyesen Alexander Lowen and John Pierrakos E. O. Wilson George Engel Judith Aston Wilhelm Reich Bonnie Bainbridge Cohen Wilhelm Reich John Veltheim

*

The following attempts to match many of the theories in the encyclopedia with the theorist who developed the theory. In some cases, there are others who assisted in the development of the theory or are regularly known to be associated with the theory. Please do not consider this an exhaustive list, as is often the case, many individuals go into the development of a large portion of these theories.

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List of Theorists

Theory/Approach

Theorist

Bonny method of guided imagery and music (BMGIM) Bowenian family systems theory Brain Change Therapy Brainspotting Brief Therapy Broad-spectrum behavior therapy Characteranalytical Vegetotherapy Childhood developmental theory Choice theory Classical conditioning learning theory Clinical Pastoral Education Cognitive Analytic Therapy Cognitive processing therapy Cognitive therapy Cognitive-behavioral analysis system of psychotherapy Cognitive-behavioral family therapy

Helen Bonny Murray Bowen Carol Kershaw and Bill Wade David Grand Insoo Kim Berg and Steve de Shazer Arnold A. Lazarus Wilhelm Reich Jean Piaget William Glasser Ivan Petrovitch Pavlov Rev. Anton Boisen and Dr. Richard Cabot Anthony Ryle Patricia Resick and Monica Schnicke Aaron Beck James McCullough

Joseph Wolpe, Aaron Beck, Albert Ellis, Frank Dattilio, Donald Baucom, Norman Epstein, and others Cognitive-behavioral therapy (CBT) Aaron Beck, Albert Ellis, and Arnold A. Lazarus Coherence therapy (or depth-oriented brief therapy) Bruce Ecker and Laurel Hulley Cognitive psychology Jean Piaget Cohesion construct David Olson Collaborative family therapy William Madsen Collaborative therapy Harlene Anderson and Harold Goolishian Common factors approach Jerome Frank Communication theory Gregory Bateson, Don D. Jackson, John Weakland, Jay Haley, and William Fry Concentrative movement therapy Helmuth Stolze Concept of arousability Jeffry A. Gray Conjoint family therapy Don D. Jackson Contemplative psychotherapy Chogyam Trungpa Rinpoche Contextual therapy Ivan Böszörményi-Nagy Control (system) theory William Glasser and William T. Powers Core Process Psychotherapy Maura Sills Critical Incident Stress Management/Debriefing Jeffery Mitchell approach Culture-centered music therapy Brynjulf Stige Cyclical psychodynamics Paul L. Wachtel Dance movement therapy (DMT) Marian Chace and Mary Whitehouse

List of Theorists

Theory/Approach

Theorist

Daseinsanalysis Developmental constructivism Developmental counseling and therapy (DCT) Developmental Needs Meeting Strategy (DNMS) Developmental theory of separation-individuation Developmental transformations Dialectical behavior therapy (DBT) Dialogical self theory Differentiation concept Ecopsychology EcoWellness Ego state therapy Emotional freedom techniques Emotive Voice Dialogue Method Energy medicine Existential-humanistic theory

Medard Boss Michael Mahoney Allen Ivey Shirley Jean Schmidt Margaret Mahler David Read Johnson Marsha M. Linehan Hubert Hermans Murray Bowen Theodore Roszak Ryan F. Reese and Jane E. Myers John G. Watkins and Helen Watkins Gary Craig Sidra Stone and Hal Stone Donna Eden Viktor Frankl, Abraham Maslow, Rollo May, Carl Rogers, and others Martin Heidegger Rollo May Carl Whittaker Kurt Lewin Francine Shapiro

Existential phenomenology Existential psychotherapy Experiential family therapy Experiential group counseling Eye Movement Desensitization and Reprocessing (EMDR) Eye movement integration therapy Family constellation therapy Feldenkrais Method Feminist psychology Filial Therapy Fixed Role Therapy Focusing therapy Functional analytic psychotherapy (FAP) General systems theory Gestalt therapy “Good enough” mothering Gottman method couples therapy Group analysis or group analytic psychotherapy Group therapy Hakomi therapy (HT) Haley-Madanes model for strategic therapy Hayashi Reiki Ryoho Kenkyu kai

Connirae Andreas and Steve Andreas Bert Hellinger Moshé Feldenkrais Karen Horney Bernard Guerney and Louise Guerney George Kelly Eugene Gendlin Robert Kohlenberg and Mavis Tsai Karl Ludwig von Bertalanffy Fritz Perls and Laura Perls Donald Winnicott John Gottman S. H. Foulkes Kurt Lewin, Carl Rogers, and others Ronald S. Kurtz Jay Haley and Cloe Madanes Chujiro Hayashi

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List of Theorists

Theory/Approach

Theorist

Healing From The Body Level Up (HBLU) Healing Touch Hellerwork Structural Integration Hierarchy of needs Holding therapy Holotropic Breathwork Homeopathy Humanistic psychoanalysis Humanistic psychology Human validation process theory Hypnotherapy Identity Renegotiation Counseling Imago Model Imago Relationship Therapy Impact therapy Improvisational therapy Individual Psychology Inner child therapy Integral psychotherapy

Judith Swack Janet Mentgen Joseph Heller Abraham H. Maslow Robert Zaslow Stanislav Grof and Christina Grof Samuel Hahnemann Eric Fromm Abraham Maslow, Rollo May, and Carl Rogers Virginia Satir Milton H. Erickson Thomas W. Blume Harville Hendrix and Helen LaKelly Hunt Harville Hendrix Ed Jacobs Bradford Keeney Alfred Adler John Bradshaw Andre Marquis, Elliott Ingersoll, and Mark Forman Andre Marquis

Integral Taxonomy of Therapeutic Interventions (ITTI) Integral theory Integrative Behavioral Couple Therapy (IBCT) Integrative Body Psychotherapy Integrative five-phase model Integrative forgiveness psychotherapy Integrative interpersonal group therapy Integrative milieu model Integrative relational therapy Interactional therapy Interactive biblio/poetry therapy Internal family systems (IFS) model Interpersonal group counseling model Interpersonal group therapy Interpersonal learning feedback loop Interpersonal theory of human behavior Interpersonal psychotherapy (IPT) Intersubjective group psychotherapy Intersubjective recognition theory

Ken Wilber Neil Jacobson and Andrew Christensen Jack Lee Rosenberg and Beverly Kitaen Morse Renée Emunah Philip H. Friedman Harry Stack Sullivan Kevin McCready Paul Wachtel Jay Haley Sister Arleen Hynes and Mary Hynes-Berry Richard C. Schwartz Irvin Yalom Joseph Pratt Irving Yalom Harry Stack Sullivan Gerald Klerman and Myrna Weissman Jessica Benjamin Jessica Benjamin

List of Theorists

Theory/Approach

Theorist

Intersubjective-systems theory Intersubjectivity IS-Wel model of wellness Journal therapy Klein-Bion model Lacanian psychoanalysis Law of Similia Lifescript theory Logotherapy and existential analysis Mentalization-based treatment Metaphorical storytelling Method of Levels (MOL) Milan systemic family therapy

Robert D. Stolorow and George E. Atwood Robert Stolorow Jane E. Myers and Thomas J. Sweeney Katherine Adams Melanie Klein and Wilfred Bion Jacques Lacan Hippocrates Claude Steiner Viktor Frankl Anthony Bateman and Peter Fonagy Milton Erickson Timothy A. Carey Mara Selvini Palazzoli, Gianfranco Cecchin, Luigi Boscolo, and Giuliana Prata Ernest Rossi Zindal Segal Jon Kabat-Zinn Jeffery Mitchell Hyman Spotniz Hyman Spotnitz Shoma Morita William R. Miller and Stephen Rollnick Richard Fisch, John Weakland, and Paul Watzlawick Murray Bowen Arnold A. Lazarus Jeff Harris Derald Sue Scott W. Henggeler Ken Aigen E. Thayer Gaston Nathan Azrin Michael White and David Epston George W. Burns Richard Bandler and John Grinder Michael Thaut Paul Nordoff and Clive Robbins Melanie Klein, Ronald Fairbairn, and Donald Winnicott W. R. Bion

Mind–body healing Mindfulness-based cognitive therapy Mindfulness-based stress reduction Mitchell Model Modern analytic group psychotherapy Modern psychoanalysis Morita therapy Motivational interviewing MRI (Mental Research Institute) brief therapy Multigenerational family therapy Multimodal therapy (MMT) Multitheoretical psychotherapy (MTP) Multiple Dimensions of Cultural Competence Multisystemic therapy(MST) Music-centered music therapy Music therapy Mutual reinforcement and reciprocity Narrative family therapy Nature-Guided Therapy Neuro-linguistic programming (NLP) Neurological music therapy (NMT) Nordoff-Robbins music therapy (NRMT) Object relations theory Object relations theory of thinking

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List of Theorists

Theory/Approach

Theorist

Operant conditioning Orgonomy/Reichian therapy Ortho-Bionomy Parent–child interaction therapy (PCIT) Pastoral counseling

B. F. Skinner Wilhelm Reich Arthur Lincoln Pauls Sheila Eyberg Seward Hiltner, Carroll Wise, Paul Johnson, and Wayne Oates James Pennebaker Carl Rogers George Kelly Henry Murray Edmund Husserl Eugene Gendlin Marty Seligman and Philip George Zimbardo William “Bill” O’Hanlon Jack Painter Frank Lake and William Emerson Arthur Janov John Weakland and his colleagues, the Palo Alto Group Edgar Schein Leslie Greenberg and Robert Elliott Vittorio Guidano and Giovanni Liotti Arnold Mindell Edward Jacobsen Edna B. Foa Frank Farrelly Gerald Caplan Humphry Osmond and Abram Hoffer Sigmund Freud Melanie Klein Jacob Levy Moreno Carol Ryff Hal and Sidra Stone Roberto Assagioli Curtis Turchin Michael B. Frisch Charles Kelley Maxie C. Maultsby Albert Ellis Maxie C. Maultsby

Pennebaker Writing Paradigm Person/client-centered therapy/counseling Personal construct theory (PCT) Personology Phenomenological therapy Philosophy of the implicit (POI) Positive psychology or well-being theory Possibility Therapy Postural Integration Primal integration Primal therapy Problem resolution brief therapy Process consultations Process-experiential therapy Process-oriented cognitive therapy Process-oriented psychology (or Processwork) Progressive muscle relaxation Prolonged exposure therapy Provocative Therapy Psychiatric crisis intervention theory Psychedelic therapy Psychoanalysis (Freudian) Psychoanalytical play technique Psychodrama Psychological well-being theory Psychology of Selves theory Psychosynthesis Pulsing Quality-of-life therapy Radix Rational behavior therapy (RBT) Rational emotive behavior therapy (REBT) Rational emotive imagery

List of Theorists

xxiii

Theory/Approach

Theorist

Rational emotive therapy (RET) Rational Living Therapy Rational self-analysis Reality therapy Rebirthing-Breathwork Re-evaluation Counseling (RC) Reiki Relational psychoanalysis Relational-cultural theory (RCT) Relationship Enhancement therapy Release Therapy Receptive/Expressive/Symbolic model RESPECTFUL model Response-based practice (therapy) Role theory and role method Rolfing (Postural Release, Structural Integration) Rubenfeld Synergy Method (RSM) Schema therapy Self-determination theory Self Psychology Self-relations psychotherapy Sensorimotor psychotherapy Sequential analysis of verbal interaction (SAVI) Sexual identity therapy (SIT) Sexual orientation change efforts (SOCE) Social cognitive theory Social learning theory Solution-focused brief family therapy (SFBFT) Solution-focused brief therapy (SFBT) Solution-oriented therapy Somatic Experiencing Stages of change model

Albert Ellis Aldo R. Pucci Max Maultsby William Glasser Leonard Orr Harvey Jackins Mikao Usui Jay Greenberg and Stephen Mitchell Jean Baker Miller Bernard G. Guerney Jr. David Levy Nicholas Mazza Judy Daniels and Michael D’Andrea Allan Wade, Linda Coates, and Nick Todd Robert Landy Ida Rolf Ilana Rubenfeld Jeffrey Young Edward Deci and Richard Ryan Heinz Kohut Stephen Gilligan Pat Ogden Yvonne Agazarian and Anita Simon Warren Throckmorton and Mark Yarhouse Sandor Rado Albert Bandura Albert Bandura Steve de Shazer and Insoo Kim Berg Steve de Shazer and Insoo Kim Berg William “Bill” O’Hanlon Peter A. Levine James Prochaska, Carlo DiClemente, and John Norcross Peter Ossorio Cloe Madanes Joyce Mills Jay Haley Jay Haley and Cloe Madanes Donald Meichenbaum Donald Meichenbaum

Status dynamics Steps for Repentance method StoryPlay therapy Strategic Therapy Strategic Family Therapy Stress Inoculation Training (SIT) Stress inoculation therapy

xxiv

List of Theorists

Theory/Approach

Theorist

Structural Family Therapy Supportive psychotherapy

Salvadore Minuchin Kurt Eissler, Jerome Frank, and Herbert Schlesinger Carl Whitaker James Lawley and Penny Tompkins Joseph Wolfe Bert Hellinger Luigi Boscolo, Gianfranco Cecchin, Mara Selvini Palazzoli, and Giuliana Prata Yvonne Agazarian Wilfred Bion and Melanie Klein Toshishiro Eguchi Jean Watson Claude Shannon Alfred Korzybski John Bowlby Hans J. Eysenck

Symbolic experiential family therapy (SEFT) Symbolic Modeling Systematic desensitization Systemic constellation therapy Systemic family therapy Systems-centered therapy and training (SCT) Tavistock Group Training Approach Tenohira Ryoji Kenkyo Kai system Theoretical transpersonal caring model Theory of communication Theory of general semantics Theory of infant attachment Theory of physiological bases of extraversion and introversion Theory of power and knowledge Theory of psychosocial development Therapeutic letter-writing campaigns Therapeutic Touch Thought field therapy (TFT) Tomita Teate Ryoho system Training groups (T-groups) Transformative writing Transpersonal psychology Transference-focused psychotherapy (TFP) Transactional analysis Transcranial electric stimulation Transcranial magnetic stimulation Transference-focused psychotherapy (TFP) Transgenerational family therapy Transpersonal psychology Transtheoretical Model (TTM) Trauma-focused cognitive-behavioral therapy (TF-CBT) Trauma Treatment Model Tripartite model

Michael Foucault Erik H. Erikson Stephen Madigan Dolores Krieger and Dora Kunz Roger Callahan Kaji Tomita Kurt Lewin Sherry Reiter Stanislav Grof, Abraham Maslow, and Viktor Frankl Otto F. Kernberg Eric Berne P. A. Merton and H. B. Morton Anthony Barker Otto F. Kernberg Murray Bowen Ken Wilber James Prochaska and Carlo C. DiClemente Judy Cohen, Esther Deblinger, and Anthony Mannarino Shirley Jean Schmidt Derald Sue and David Sue

List of Theorists

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Theory/Approach

Theorist

Unified psychotherapy movement Utilization Unified theory Unified therapy Values clarification Vegetotherapy Voice Dialogue (method) Well-being interventions Wheel of Wellness Writing therapy (therapeutic writing) Z-process

Jeffrey Magnavita and Jack Anchin Milton Hyland Erickson Gregg Henriques David Allen Louis Raths, Sidney Simon, and Merrill Harmin Wilhelm Reich Hal and Sidra Stone Giovanni Fava and Michael B. Frisch Jane E. Myers and Thomas J. Sweeney Fred McKinney and Albert Ellis Robert Zaslow

To Carole, Ray, Howie, and Amy for your constant support and love

About the Editor Born and raised in New York City, Dr. Edward S. Neukrug obtained his B.A. in psychology from SUNY (State University of New York) Binghamton, his M.S. in counseling from Miami University of Ohio, and his doctorate in counselor education from the University of Cincinnati. He currently holds a number of credentials, including being a nationally certified counselor (NCC), licensed professional counselor (LPC), Human Services–Board Certified Practitioner (HS-BCP), and licensed psychologist. After teaching and directing a graduate program in counseling at Notre Dame College in New Hampshire, he accepted a position at Old Dominion University, in Norfolk, Virginia, where he currently is Professor of Counseling and Human Services and former chair of the Department of Educational Leadership and Counseling. In addition to teaching, Dr. Neukrug has worked as a substance abuse counselor, a counselor at a crisis center, an outpatient therapist at a mental health center, an associate school psychologist, a school counselor, and a private practice psychologist and licensed professional counselor. Dr. Neukrug has held a variety of positions in counseling and human services in local, regional, and national professional associations. In addition, he has received a number of grants and contracts with school systems and professional associations. He has received numerous honors and awards, including being designated a “University Professor” at Old Dominion University, in recognition of his teaching, research, and professional service. He has been a speaker on numerous radio and TV shows, including WBAI in New York City and National Public Radio, Virginia.

Dr. Neukrug has written more than 60 articles and chapters in books and has presented at dozens of conferences. In addition to this encyclopedia, he has published eight books: (1) Counseling Theory and Practice; (2) The World of the Counselor (fifth edition); (3) Experiencing the World of the Counselor: A Workbook for Counselor Educators and Students (fourth edition); (4) Theory, Practice and Trends in Human Services: An Introduction to an Emerging Profession (fifth edition); (5) Skills and Techniques for Human Service Professionals; (6) Skills and Tools for Today’s Counselors and Psychotherapists; (7) Essentials of Testing and Assessment for Counselors, Social Workers, and Psychologists (third edition); and (8) Brief Orientation to Counseling: Professional Identity, History, and Standards. He has also developed a DVD that illustrates the major theories of counseling and another that demonstrates important counseling skills and techniques. In addition to his books, Dr. Neukrug has been developing an interactive and animated website titled Great Therapists of the Twentieth Century (www.odu.edu/~eneukrug), where you can “meet” some of the major theorists of counseling and psychotherapy and learn more about them and their theories. He has also developed an interactive survey where you can identify your view of human nature and examine which school of therapy it is closest to (http://ww2.odu.edu/~eneukrug/ therapists/survey.html). Dr. Neukrug is married to Kristina Williams Neukrug. They have two children, Hannah and Emma.

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Contributors Amir Abbassi Texas A&M University–Commerce

Bonnie Bainbridge Cohen Founder of BMC

David Allen University of Tennessee Health Science Center

John Banmen University of British Columbia, Vancouver, British Columbia, Canada—Retired

Elizabeth Allison University College, London Jack C. Anchin University at Buffalo–SUNY Harlene Anderson Houston Galveston Institute Joel G. Anderson University of Virginia Margaret Andover Fordham University Connirae Andreas Private practice and consulting Steve Andreas Trainer/consultant Leslie Armeniox University of Hawaii Virginia Peace Arnold Rebirth International & Rebirthing NYC Lewis Aron New York University S. Dean Aslinia Texas A&M University–Commerce Andrew T. Austin Private practice Katherine Bacon University of Houston-Victoria Carrie Lynn Bailey Walden University, The College of William and Mary

Suzanne Barnard Duquesne University Sonja V. Batten U.S. Department of Veterans Affairs Central Office Alexander Batthyány University of Vienna Brent A. Bauer Mayo Clinic Scott Baum Society for Bioenergetic Analysis Hannah B. Bayne Virginia Tech Danie Beaulieu Académie Impact Leslie C. Bell Women’s Therapy Center, Berkeley Esther N. Benoit Walden University Anna A. Berardi George Fox University Christine Berger Old Dominion University Raymond Bergner Illinois State University Richard M. Billow Adelphi University Allen Bishop Pacifica Graduate Institute xxix

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Contributors

Daniel Bjork St. Mary’s University

Jorge Colapinto Minuchin Center for the Family

Thomas W. Blume Oakland University

Melinda H. Connor Langara College

Matthew Wardell Bonner Old Dominion University

Robert K. Conyne Seattle University and University of Cincinnati

Mary Kim Brewster Ackerman Institute for the Family

Ellen P. Cook University of Cincinnati

Sara K. Bridges The University of Memphis

John O. Cooper The Ohio State University

Annie Brook Certified BMC teacher

Joseph Coppin Pacifica Graduate Institute

Amanda A. Brookshear Old Dominion University

Gerald Corey California State University, Fullerton

Nina W. Brown Old Dominion University Laura Bruneau Adams State University Patricia A. Buchanan Private practice

Ann Weiser Cornell Focusing Resources Ashley Cosentino The Chicago School of Professional Psychology and Governors State University Stephen J. Costello Viktor Frankl Institute, Dublin

George W. Burns Cairnmillar Institute, Melbourne, Australia

Eleanor F. Counselman Harvard Medical School

Kay Bussey Macquarie University

Charles Crews Texas Tech University

John V. Caffaro California School of Professional Psychology

Sue Cutshall Mayo Clinic

Timothy A. Carey Flinders University

Heather D. Dahl Old Dominion University

Kristy L. Carlisle Old Dominion University

Jack Danielian Karen Horney Center

Robert M. Carlisle Old Dominion University

Victor Daniels Sonoma State University

Ann Casement Private practice

LaShauna M. Dean William Paterson University

Enrico Cazzaniga Centro Milanese di Terapiadella Famiglia

Sarah P. Deaver Eastern Virginia Medical School

Joseph V. Ciarrochi University of Western Sydney

Shannon Dermer Governors State University

Asha Clinton Advanced Integrative Therapy Institute

John Dewell Loyola University New Orleans

Contributors

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Annette Deyhle Institute of HeartMath

Janet Froeschle Texas Tech University

Stephen A. Diamond Loyola Marymount University

Paul A. Gabrinetti Pacifica Graduate Institute/C. G. Jung Institute

Gail Donaldson Union College

Susan P. Gantt Emory University School of Medicine

David Donnelly University of Rochester

Wangui Gathua University of Iowa

Kristin I. Douglas Murray State University

Brent B. Geary Milton F. Erickson Foundation

Anthony P. DuBose Behavioral Tech, LLC Catherine Ducommun-Nagy Drexel University Erika Dyck University of Saskatchewan Bruce Ecker Coherence Psychology Institute Roxanna Erickson Klein Milton H. Erickson Foundation Jose A. Fadul De La Salle–College of Saint Benilde David Feinstein Innersource Genovino Ferri Italian School of Reichian Analysis

Evan George BRIEF Stephen Gilligan Private practice H. L. Gillis Georgia College Barry G. Ginsberg The Center of Relationship Enhancement (CORE) Francesca G. Giordano The Family Institute at Northwestern University Macario Giraldo Washington School of Psychiatry Jacob W. Glazier University of West Georgia

Trey Fitch Troy University, Panama City

Brett K. Gleason Old Dominion University

Skye Fitzpatrick Ryerson University

Brian Gleason Institute of Core Energetics

Peter Fonagy University College, London

Dale C. Godby Group Analytic Practice of Dallas

Diana Fosha AEDP Institute

Emilie Godwin Virginia Commonwealth University

Victoria A. Foster The College of William and Mary

Kristopher M. Goodrich University of New Mexico

Philip H. Friedman Foundation for Well-Being

Charles F. Gressard The College of William and Mary

Michael B. Frisch Baylor University

Joshua Gross Florida State University

Patricia R. Frisch Private practice

Rebecca Hall Stanford University

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Contributors

Sean B. Hall University of Alabama at Birmingham

Earl Hopper Member, Institute of Group Analysis, London

Cherée F. Hammond Eastern Mennonite University

Michael F. Hoyt Independent practice

Terry D. Hargrave Fuller Theological Seminary

Mark A. Hubble International Center for Clinical Excellence

Jeff E. Harris Texas Women’s University

Daniel Hughes Quittie Glen Center for Mental Health

Jessica A. Headley The University of Akron

Ado Huygens International Federation of Daseinsanalysis

Justin Hecht University of California, San Francisco

Chris Iveson BRIEF

Katherine A. Heimsch Old Dominion University

Allen E. Ivey University of Massachusetts, Amherst

Stig Helweg-jørgensen Odense University Hospital, Southern Denmark

Tracy L. Jackson Virginia Beach City Public Schools

Gregg R. Henriques James Madison University

Ed Jacobs West Virginia University

Jessica S. Henry Ohio University

Sachin Jain Walden University

Jason Hepple Association for Cognitive Analytic Therapy

Marty Jencius Kent State University

Ruth Herman-Dunn Private practice and University of Washington

Catherine B. Jenni University of Montana

Timothy E. Heron The Ohio State University

Eric D. Jett Walden University

William L. Heward The Ohio State University

Debbie Joffe Ellis Independent practice

James F. Hill Rush University Medical Center and The Morita School of Japanese Psychology

Gregory J. Johanson Hakomi Educational Resources

Tara M. Hill Old Dominion University Lisa D. Hinz Saint Mary-of-the-Woods College Stefan G. Hofmann Boston University

Kaprea F. Johnson Old Dominion University Miranda Johnson-Parries Old Dominion University Jason S. Jordan Trevecca Nazarene University

Janice Miner Holden University of North Texas

J. Jozefowiez Université Lille Nord de France & Universidade do Minho

Jim Hopkins University College, London

Francis J. Kaklauskas Naropa University

Contributors

Hillary Keeney University of Louisiana

Kathleen Levingston Old Dominion University

David V. Keith SUNY Upstate Medical University

Kristopher Lichtanski Saybrook University

Nick Kemp Nick Kemp Training, LTD

Melissa Lindsay The Radix Institute

Carol J. Kershaw Brain Change International

Jessica LLoyd-Hazlett The College of William and Mary

Howard Kirschenbaum University of Rochester

Camillo Loriedo Sapienza University of Rome

Beverly Kitaen Morse IBP

Lisa Loustaunau Institute of Core Energetics

Keith Klostermann Medaille College

Marilyn Luber Private practice

Robert J. Kohlenberg University of Washington Marilena Komi European Association for Body Psychotherapy Kurt L. Kraus Shippensburg University of Pennsylvania Victoria E. Kress Youngstown State University Janice R. Kuo Ryerson University Mario A. Laborda Universidad de Chile Stephen R. Lankton Arizona State University

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Herman R. Lukow II Virginia Commonwealth University Rebecca R. MacNair-Semands University of North Carolina at Charlotte Cloe Madanes Robbins-Madanes Training Stephen Madigan Vancouver School for Narrative Therapy J. Maia University of York Andre Marquis University of Rochester Jennifer Marshall Troy University, Panama City

Richard Lawton Bodymind Integration

Christopher R. Martell University of Wisconsin–Milwaukee and Martell Behavioral Activation Research Co.

Arnold A. Lazarus The Lazarus Institute

J. Barry Mascari Kean University

Clifford N. Lazarus The Lazarus Institute

Cynthia H. Matthews New Horizons Center for Healing

Elsa Soto Leggett University of Houston-Victoria

Peggy L. Mayfield Private practice

Molyn Leszcz Mount Sinai Hospital

Rip McAdams The College of William and Mary

Peter A. Levine Developer

Rollin McCraty Institute of HeartMath

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Contributors

Angela R. McDonald University of North Carolina at Pembroke

Jason K. Neill Colorado Christian University

Melissa Kate McIntosh Pacifica Graduate Institute

Robert A. Neimeyer The University of Memphis

Dean McKay Fordham University

Edward S. Neukrug Old Dominion University

Narelle McKenzie The Radix Institute

Sarah Noble The University of Akron

Anne S. McKnight Bowen Center for the Study of the Family

Bill O’Hanlon Possibilities

Candace M. McLain Tait Colorado Christian University

Adele Logan O’Keefe Walden University

Donald Meichenbaum University of Waterloo

Leslie W. O’Ryan Western Illinois University–QC Campus

Sarah Meng Georgia Safe Schools Coalition

Marvarene Oliver Texas A&M University–Corpus Christi

Franklin Mesa University of Central Florida

Elizabeth A. Olson University of Colorado

Stanley B. Messer Rutgers University

Bill Owenby The University of Akron

Gonzalo Miguez State University of New York at Binghamton

Delila Owens The University of Akron

Scott D. Miller International Center for Clinical Excellence

Everett W. Painter Walters State Community College

Ana Mills Virginia Commonwealth University

Daniel M. Paredes North Carolina A&T State University

Joyce C. Mills StoryPlay Global LLC Jeffry Moe Old Dominion University Mary Molloy Gerda Boyesen International Institute of Biodynamic Psychology and Psychotherapy

Will Parfitt United Kingdom Council for Psychotherapy Rob Parker Private practice Stephen Parker Regent University

Jane E. Myers University of North Carolina at Greensboro

Agatha Parks-Savage Eastern Virginia Medical School

Nicki Nance Webster University Ocala

Jacqueline Ciccio Parsons University of Texas at San Antonio

Cheryl W. Neale-McFall West Chester University of Pennsylvania

Sandra Lee Paulsen Bainbridge Institute for Integrative Psychology

Sandra M. Neer University of Central Florida

Dale-Elizabeth Pehrsson Central Michigan University

Contributors

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Rebekah R. Pender Kean University

Kathleen Y. Ritter California State University, Bakersfield

Betsy Perluss Pacifica Graduate Institute

Thomas B. Roberts Innerchange Counseling, & Thomas Roberts, LLC

Teri Pichot Denver Center for Solution-Focused Brief Therapy

Christopher J. Rogers Retired chiropractor

Gina B. Polychronopoulos Old Dominion University Verl T. Pope Northern Kentucky University Felicia D. Pressley Shorter University James O. Prochaska University of Rhode Island and Pro-Change Behavior Systems Cassandra G. Pusateri Youngstown State University Jonathan D. Raskin State University of New York at New Paltz Harvey Ratner BRIEF Wendel A. Ray University of Louisiana at Monroe Nick Reed University of Hertfordshire Ryan F. Reese Oregon State University–Cascades Sherry Reiter Touro College, Hofstra University Robert W. Resnick Gestalt Associates Training, Los Angeles Richard J. Ricard Texas A&M University–Corpus Christi Robert Rice St. John Fisher College Alan Richardson International Association of Process-Oriented Psychology Frances Rinaldo International Primal Association

Jack Lee Rosenberg Integrative Body Psychotherapy Jim Ross The Radix Institute Ernest Lawrence Rossi Milton H. Erickson Institute of the California Central Coast Kathryn Lane Rossi Milton H. Erickson Institute of the California Central Coast John Rowan Private practice Shawn Rubin Saybrook University Lori A. Russell-Chapin Bradley University J. Scott Rutan Boston Institute for Psychotherapy Pepe Santana Private practice clinical psychologist Jane Saunderson Society of Teachers of the Alexander Technique Massimo Schinco Centro Milanese di Terapiadella Famiglia Shirley Jean Schmidt DNMS Institute, LLC Karin Schreiber-Willnow Concentrative Movement Therapy David Seelow Excelsior College and Rensselaer Polytechnic Institute Jason A. Seidel International Center for Clinical Excellence Xavier Serrano-Hortelano European Association for Body Psychotherapy

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Contributors

Laura R. Shannonhouse University of Maine

Suzan K. Thompson Old Dominion University

Francine Shapiro Mental Research Institute

Warren Throckmorton Grove City College

Meg Sharpe Member of the Institute of Group Analysis, London

Mavis Tsai Independent practice and University of Washington

Dan Short Private practice Jack D. Simons University of Missouri–St. Louis

Leah Tucker University of Louisiana at Monroe Mary Catherine Tucker Indiana State University

Kevin C. Snow Old Dominion University

Emmy van Deurzen Middlesex University and New School of Psychotherapy & Counseling

Sandro M. Sodano University at Buffalo–SUNY

Luc Vandenberghe Pontificia Universidade Catolica de Goias

Roger Solomon EMDR Institute

John Veltheim International BodyTalk Association

Lynn Somerstein Institute for Expressive Analysis

Paul L. Wachtel City College of NY and CUNY Graduate Center

Len Sperry Florida Atlantic University

Allan Wade Centre for Response-Based Practice

Shari Shamsavari St. Martin Private practice

J. William Wade Brain Change International

J. E. R. Staddon Duke University and the University of York

Naoko Wake Michigan State University

Penelope S. Starr-Karlin Institute of Contemporary Psychoanalysis, Los Angeles

Hollida Wakefield Private practice

Claude M. Steiner International Transactional Analysis Association

Beverly M. Walker University of Wollongong

Hans Steiner Stanford University

E. Scott Warren Warren Counseling Services

Julie A. Strentzsch St. Mary’s University

Jeffrey M. Warren University of North Carolina–Pembroke

Deborah C. Sturm James Madison University

Wanda Warren Wisdom Traditions Wellness

Jamie Sturm Boston University

Toby T. Watson Associated Psych Health Services

Tami Sullivan State University College of New York at Oswego

Richard E. Watts Sam Houston State University

Judith A. Swack Healing From The Body Level Up, Inc.

Jane M. Webber Kean University

Contributors

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Haim Weinberg The Professional School of Psychology, Sacramento, CA

Julia Woodman Scientific Research Group, Society of Teachers of the Alexander Technique

Marjorie E. Weishaar Brown University

Robert E. Wubbolding Center for Reality Therapy

Avrum Weiss Pine River Psychotherapy Training Institute

Danny Yeung AEDP Institute

Jana Whiddon Capella University

Miyoung Yoon Hammer Fuller Theological Seminary

Martyn Whittingham Catholic Health Partners

Carlos P. Zalaquett University of South Florida

Chinwé U. Williams Argosy University, Atlanta

Michael L. Zanders Texas Woman’s University

Nona Wilson St. Cloud State University

Elliot M. Zeisel Center for Group Studies

David A. Winter University of Hertfordshire

Barry J. Zimmerman Graduate Center of City University of New York

SAGE was founded in 1965 by Sara Miller McCune to support the dissemination of usable knowledge by publishing innovative and high-quality research and teaching content. Today, we publish more than 750 journals, including those of more than 300 learned societies, more than 800 new books per year, and a growing range of library products including archives, data, case studies, reports, conference highlights, and video. SAGE remains majority-owned by our founder, and after Sara’s lifetime will become owned by a charitable trust that secures our continued independence. Los Angeles | London | Washington DC | New Delhi | Singapore | Boston

Introduction The SAGE Encyclopedia of Theory in Counseling and Psychotherapy is the first encyclopedia of its kind. Since Sigmund Freud’s astonishing creation of psychoanalysis, the first comprehensive theory of counseling and psychotherapy, hundreds of other theoretical approaches to counseling and psychotherapy have been developed, and this encyclopedia provides an overview of the vast majority of them. An encyclopedia, by its very nature, gives a focused description of an important concept. These descriptions can often be used in helping understand a concept more clearly, in comparing concepts, in getting a thorough understanding of a number of related concepts, and more. Thus, this encyclopedia offers wide-ranging descriptions of most of the major theories of counseling and therapy, so that individuals can gain a quick grasp of them. However, to have a full understanding of this encyclopedia, we should first define what is meant by “theory of counseling and psychotherapy.”

What Is a Theory? Having a theory to drive a clinician’s understanding of personality and to be the undercarriage of one’s approach to conducting counseling and psychotherapy is critical. This is because theories are heuristic—they allow one to develop hypotheses about the theory, research the theory, change the theory based on what the research shows, and develop new and better theories. Many of the theories found in this encyclopedia have been researched and examined, and have changed over time. For instance, today, there are numerous iterations of what began as classical Freudian psychoanalytic theory. This is because Freud meticulously spelled out his theory, and using his model as a base, others were able to develop new theories that kept many of his core principles but also moved in

novel directions. Carl Rogers understood the importance of carefully explaining one’s theory when he encouraged others to research the core concepts of his approach, person-centered counseling. Thus, research on the use of empathy in counseling, one of his core concepts, has been conducted almost since the inception of his theory and continues into recent years, with numerous studies now indicating that it is one of the critical elements in all counseling relationships. Finally, showing the efficacy of an approach through research has been one of the hallmarks of the cognitive-behavioral approaches. The ability to match specific symptoms to cognitive-behavioral treatments has shown positive outcomes for a number of disorders and has bolstered the importance of using “evidence-based treatment” when working with individuals with specific mental disorders. The heuristic nature of theory has also rendered some theories useless. For instance, during the 19th century and the beginning of the 20th century, many believed in phrenology, or the “science” that “proved” that the size and shape of the cranium was predictive of personality. Although the encyclopedia does not include those theories that have been shown to be ineffective and are no longer practiced, it does include some approaches that have been shown to be harmful yet continue to be used. We included these approaches because it is important that the public knows about theories that are still around and should not be used as well as those theories that are still in use and can be potentially dangerous. Finally, many of the theories in the encyclopedia have not been thoroughly researched, sometimes because they are new, other times because the research has simply not been conducted. Only time will tell if they will be proven worthwhile. Keeping this in mind, as I reflect on the beginning stages of the mental health field 100 years ago and

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Introduction

realize how far we have come, I also wonder what the mental health field will look like 100 years from now. Which theories found in this encyclopedia will no longer be used in the years to come?

Counseling Versus Psychotherapy, Counselors Versus Psychotherapists, Clients Versus Patients Many in the mental health professions (human services, counseling, social work, psychology, and psychiatry) make a distinction between what some call counseling and others call psychotherapy. Counseling, they say, tends to be short-term, is often supportive and nurturing, deals mostly with what some call “surface issues,” tends to have more of a present or “here-and-now” focus, and is often educationally oriented and preventive. In contrast, psychotherapy, they assert, is long-term, concentrates largely on personality reconstruction and restoration, deals with issues that are out of one’s awareness or in one’s unconscious, and examines embedded, secretive, underlying issues in an attempt to heal an individual of neurotic or psychotic symptoms. Despite this clear distinction made by some, others in the mental health professions, including myself, do not distinguish the two terms so clearly. I, for instance, realize that most theory books do not make a distinction between counseling and psychotherapy, and that a clinician who uses a particular “theory” when conducting “counseling” has learned the same concepts that another clinician has learned who uses the same theory but suggests that he or she is conducting “psychotherapy.” Thus, I tend to be less inclined to view theories of counseling as something separate from theories of psychotherapy. Given my understanding of counseling and of psychotherapy, you can see why this encyclopedia is called “The SAGE Encyclopedia of Theories of Counseling and Psychotherapy.” Yet despite my insistence that any specific theory is no different whether you call it a theory of counseling or a theory of psychotherapy, I also realize that two clinicians trained in the same theory, using the same techniques, may practice it very differently. One ends up doing “counseling,” and the other ends up doing “psychotherapy.” The theory is the same, but something about the manner in which the clinician delivers the theory varies. Perhaps it

is the clinician’s willingness to take the client to a “deeper level” or the fact that the setting does not allow for long-term counseling and thus inhibits the clinician from practicing psychotherapy or that there are other, unknown factors that differentiate the manner in which a person practices his or her skills. So differences in the manner in which a clinician delivers a theory do exist, but the theory tends to remain the same—it is a constant. This encyclopedia offers you an overview of many, if not most, of the theories of counseling and psychotherapy that are used today, and even some that are rarely used. But keep in mind that some clinicians may deliver these theories quite differently. In a similar vein, some who conduct counseling or psychotherapy call themselves counselors, while others call themselves therapists, psychotherapists, psychologists, clinicians, or practitioners. Sometimes this difference has to do with their training and the credential the individual received (licensed psychologists call themselves “psychologists,” whereas licensed professional counselors tend to call themselves “counselors”). Sometimes, it has to do with how the practitioner views the manner in which he or she delivers services (some who call themselves “counselors” may see themselves conducting “counseling,” whereas others who call themselves “psychotherapists” see themselves conducting “psychotherapy”). When reading the entries, I would look beyond the term that is used to describe the practitioner and focus more on the description of the theory. Remember that regardless of what they call themselves, the theory is the same. Finally, you will find that throughout the encyclopedia a number of different words are used to describe the consumer of counseling and psychotherapy. When Freud developed psychoanalysis, being a physician and viewing the client from an objective viewpoint, he naturally used the word “patient.” In contrast, the existential-humanistic therapies that developed during the middle of the 20th century rebuffed this clinical objectification of the individual and thus moved to the use of the word “client,” Although the split between the analysts’ and the existential-humanists’ use of the words “patient and client,” respectively, has, to some degree, remained, many of the approaches you will find in the encyclopedia are comfortable with the

Introduction

use of either of these words, or even other words such as “customer” or “consumer.” For consistency, we decided to use the same word for each entry, whether it be “client,” “patient,” “consumer,” and so on. Usually, this was the word used most frequently by the author who wrote the entry. However, I would not jump to any conclusions about the theory based on whether the entry author used the word “client,” “patient,” or some other word. It may have simply been the training or preference of the author of the entry.

Identifying Theories for the Encyclopedia So how does one choose which theories to include in an encyclopedia such as this? My first thought was to be broad based. I decided that unless a theory had been shown by research to be worthless and was clearly no longer in use, it had an equal opportunity to be placed in the encyclopedia. So I did what seemed logical—I searched the web, I examined books on counseling theories, and I reviewed the theories-related journals. In the end, I identified close to 300 theories that are used in the delivery of mental health services. With my list at hand, I began to place the theories into logical categories. Having written a counseling theory text, I knew that many of the theories would historically fit under the following categories or schools: psychodynamic, behavioral, existential-humanistic, cognitive-behavioral, and postmodern. Psychodynamic theories include those theories that, to some degree, had their origins with Freud’s classical psychoanalytic approach. These theories tend to view personality formation as the product of early child-rearing patterns in combination with dynamic conscious and unconscious intrapsychic forces. Although originally developed during the second half of the 19th century, many of these original theories are still practiced, and other, modern variations have developed over time. Next, I placed theories under the behavioral school. To some degree, these theories were based on learning theory, which originated with Ivan Pavlov’s experiments with classical conditioning and B. F. Skinner’s research on operant conditioning at the beginning and into the middle of the 20th century. As their name implies, these theories focus mostly on changing behaviors. Although many modern behavioral approaches look dramatically

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different from the originally practiced theories, because they continue to focus mostly on changing behaviors, I kept them in this school. The existential-humanistic school made up the next group of theories. They mostly arose during the middle to second half of the 20th century and focused on the plight of the human condition. They stood in stark contrast to the determinism of the early psychoanalytic approaches and the systematic and methodical analysis of the early behavioral approaches. They stressed the individual’s development of self as the person encounters others throughout life, tended to be optimistic, and focused on the individual’s ability to change. Just past the midpoint of the century, a number of cognitive approaches arose and focused on how cognitions are conditioned and are the impetus for problematic feelings and behaviors. These approaches later developed into what has become known as the cognitive-behavioral school of therapy, as they broadened their focus to include changing cognitions and changing behaviors. In recent years, we began to see a new school of psychotherapy arise. Starting during the 1990s, the postmodernists provided an approach that stressed that one’s reality is the product or function of the language milieu one encounters through life, that those in positions of power are often responsible for the language that is used, that such language tends to oppress those who are not in power, and that individuals can reconstruct or reauthor their lives as they find new solutions to past problems or problem-dominated narratives. I took my theories and neatly placed them in my five classic schools: (1) psychodynamic, (2) behavioral, (3) existential-humanistic, (4) cognitivebehavioral, and (5) postmodern approaches. I quickly saw that many of the theories I had found were not accounted for—did not fit neatly into any of these five schools. For instance, I realized that there were many approaches that one might consider complementary or alternative—approaches not mainstream, used by a fair number of counselors and therapists, and of interest to many who were trying to find an approach that was a bit “off the beaten path.” These became known as the complementary and alternative theories. As I continued categorizing, I realized that there were a host of other approaches that were based on the early work of what some call the most interesting

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“master therapist” of all time—Milton H. Erickson. His distinctive, unusual, and sometimes-irreverent techniques were found to quickly “cure” people of their presenting problems. I thus added another category: Erickson-derived or -influenced theories. As I continued to try and neatly categorize the various theories, other headings quickly popped up, and soon I had added creative arts and expressive therapies, or therapies that use the creative and expressive arts to work with clients. I next added ego-oriented therapies, or approaches that de-emphasize instinctual drives and focus on the development of the individual’s ability to manage and deal with reality. Next, I saw that there were a number of transpersonal approaches, or theories that have a bit of the mystical and/or spiritual in their focus. Then, the recent influence of neuropsychology became evident, as some of the theories were clearly based on recent brain research. I also realized that some approaches integrated different theories, so I created a heading called integrative approaches. It also became evident to me that there were a number of unique ways of practicing group counseling and couple and family therapy—thus, two more categories evolved. The wise editors at Sage suggested that I pull together an editorial board. Having developed my tentative headings, I reached out to world-renowned individuals to examine what I had developed. These individuals provided me with some wonderful feedback. For instance, the psychodynamic heading became two separate headings: Classical Psychoanalytical Approaches and Contemporary Psychodynamic-Based Therapies. The postmodern therapies became Constructivist Therapies (though not all constructivist therapies are postmodern). The complementary and alternative therapies resulted in two headings: (1) Complementary and Alternative Approaches and (2) Body-Oriented Therapies. The neuropsychology approaches became Neurological and Psychophysiological Therapies, and couple and family therapy became Couples, Family, and Relational Models. And, of course, there were those theories that did not neatly fit into any one category. Those went in the Other Therapies category. As the encyclopedia evolved, I came to the conclusion that there were two other categories greatly needed. First, there were some therapies included in the encyclopedia that were or could be harmful and/or illegal, so I added a category called Cautious, Dangerous, and/or Illegal Practices.

Finally, I realized that some approaches were widely used by the vast majority of counselors and psychotherapists. Thus, I added a heading called Foundational Therapies to highlight these approaches. In the end, we had twenty headings to categorize the theories: Behavior Therapies Body-Oriented Therapies Cautious, Dangerous, and/or Illegal Practices Classical Psychoanalytical Approaches Cognitive-Behavioral Therapies Complementary and Alternative Approaches Constructivist Therapies Contemporary Psychodynamic-Based Therapies Couples, Family, and Relational Models Creative Arts and Expressive Therapies Ego-Oriented Therapies Erickson-Derived or -Influenced Theories Existential-Humanistic Therapies Foundational Therapies Group Counseling and Psychotherapy Theories Integrative Approaches Neurological and Psychophysiological Therapies Other Therapies Theorists Transpersonal Psychology Each of the headings, and their affiliated theories, can be found in the Reader’s Guide at the beginning of each volume. As you review the theories in the Reader’s Guide, you may observe that some are listed under more than one heading. This is because theories are not as discrete as my brain would like them to be. For instance, clearly Freudian Psychoanalysis belongs in the Classical Psychoanalysis section as well as the Foundational Therapy section. Thus, a theory may share elements of two schools (headings), or maybe even three or four schools. Undoubtedly,

Introduction

placing theories into the various categories was at times challenging, and in the end, you may dispute the placement of some of these theories. Every entry that describes a theory starts with a short definition of the theory, which summarizes its main points. It then offers historical influences that may have affected the theory’s development. Next, the entry describes the theoretical underpinnings that drove the theory, followed by the major concepts of the theory. The entry then provides examples of some of the theory’s more popular techniques and then offers a description of how the theory is applied—the therapeutic process. Each entry also lists other entries that inform the theory (under the “See also” section) and further readings that may be of interest to the reader.

Overview Entries and Biographies In addition to classifying the major theories into twenty categories or schools, I included an “overview” entry for each of the twenty categories or schools. These overview entries begin with a description of the categories or schools found in the Reader’s Guide, under which the various entries fall (e.g., “Freudian Psychoanalysis” falls within the school of Classical Psychoanalytical Approaches). The overview entries then provide the following for each of the categories or schools found in the Reader’s Guide: (a) historical context, (b) theoretical context, and (c) short descriptions of each theory listed under that category. They also include a “See also” list that identifies all entries and biographies from the Reader’s Guide that are related to the overview, as well as select further readings for that category. Finally, I decided to include about 40 select biographies, thinking that one could not have an encyclopedia of theories of counseling and psychotherapy without including some basic information about individuals like Sigmund Freud, B. F. Skinner, and Carl Rogers. These biographies focus more on the development of their theory, as opposed to lengthy background information about the individual theorist’s upbringing and personal life. These entries conclude with a “See also” list that identifies entries that are related to the individual and a list of further readings that may be of interest to the reader. Clearly, my list is subjective.

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There may well be those whom you think should be included who were not and those who were included whom you believe should be taken off the list. You may be right.

Identifying Individuals to Write the Theories Whenever possible, I recruited some of the most well-known authors on the specific theories to write the entries. These individuals were sometimes the originators of the theory or students and colleagues of the original theorist. Generally, I contacted these individuals directly by e-mail. If they informed me that they could not write the entry, they usually recommended other well-known colleagues with whom I could follow up. When these individuals could not be contacted, we found experts on the theory to write the entry, usually through professional listservs. Thus, you will find that all entries are written by individuals who are extremely knowledgeable about the subject matter. For consistency and clarity, I asked all entry writers to follow the same format for each theory written (Description, Historical Context, Theoretical Underpinnings, Major Concepts, Techniques, See also, and Further Readings).

How to Use the Encyclopedia You probably have an interest in understanding one or more specific theories when you decide to use this encyclopedia. If that is the case, you might want to go directly to the Index and look up the theory you are interested in. It is more than likely listed there. Then, you can read about that theory. The entry will include the “See also” list of other theories, overviews, or biographies that you can also read if you want to find out more about the theory and related materials. In addition to going directly to the Index, you can also find a theory in a couple of other ways. First, you can go directly to the Reader’s Guide, which lists the theories by category or school, as noted earlier. The Reader’s Guide can be found at the beginning of each volume. Second, an alphabetical list of all entries can also be found at the beginning of each volume. You can look through the list and identify any theories you might have an interest in reading about.

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If you want to know more about a whole class of theories (e.g., classical psychoanalytical, cognitive-behavioral, complementary and alternative, existential-humanistic), then you might want to start with the “overview” entry, as this will describe the category and give very brief descriptions of the various theories listed under that category. Then, you can pick and choose those theories you want to review in more depth. You can find the overview entries listed in the Reader’s Guide, the List of Entries, and the Index. As noted earlier, select biographies regarding a number of classic or iconic theorists are included in the encyclopedia and can be found under the Theorists category in the Reader’s Guide. Also, immediately following the Reader’s Guide, you will find a list of theories cross-referenced with the theorist who founded the theory. Thus, if you want some limited information about these theorists, you can read about them in the entry with which they are associated. Finally, if you have identified a specific theorist and want to see if he or she is included in the encyclopedia, you can see if he or she is listed in the List of Entries and/or the Index.

Acknowledgments Whom to acknowledge first? Clearly, I need to recognize those who, early on, I most irritated, when I felt like I had taken on more than I could handle. My wife, Kristina, and two lovely daughters, Hannah and Emma, put up with me all those nights that I sat at the computer and struggled to put this encyclopedia together. They stuck with me, continue to stick with me, and continue to love me. I love you too. I was handed a gift one day—Kevin Snow, a new doctoral student in our counselor education and supervision program, was assigned to me to assist me with the encyclopedia. Kevin had the humanities and philosophy background that I did not have. He was a natural editor and became the managing editor of the encyclopedia. I must admit that on more than a couple of occasions I said to Kevin, “Can you review this entry?” because I knew that he had the background and the ability to edit some entries that I simply could not understand. Kevin, you are the best!

I could not have finished this encyclopedia without the help of the editorial board. They examined the category headings I developed and suggested changes to them. They suggested additional theories that should be listed under the headings, and they recommended that I move some theories to other headings. They helped me find experts to write many of the entries, and on some occasions, they wrote the entries themselves. Those members of my esteemed editorial board include Allen Bishop from Pacifica Graduate Institute; Nina W. Brown from the Old Dominion University; Sarah P. Deaver from Eastern Virginia Medical School; David Donnelly from the University of Rochester; Andre Marquis also from the University of Rochester, Rip McAdams from The College of William and Mary; Jane E. Myers from the University of North Carolina at Greensboro; Suzan K. Thompson from Military Integrative Therapies, LLC; Richard E. Watts from Sam Houston State University; and Jeffrey Zeig from the Milton H. Erickson Foundation. As I was working on the encyclopedia, I realized that I needed some additional help to finish it, and I reached out to two colleagues, Drs. Hannah B. Bayne and Cherée F. Hammond. I had worked with Cherée when writing my counseling theory text and knew she would be a wonderful editor. And Hannah was one of my former, top doctoral students, and I knew she too could do the job. Thank you, Hannah and Cherée, for stepping up when I needed you. Finally, there are a number of individuals without whom this encyclopedia could not have been completed. Shamila Swamy, the copy editor, was skillful and masterful, and the encyclopedia is much stronger due to her wonderful ability, and that of her team from QuADS Prepress. Anna Villasenor, Reference Systems Coordinator, Sage Publications, was also incredible. Her assistance with all of the minutiae that needed to be addressed was remarkable, and always, she would respond quickly and with a kind and helpful attitude. Finally, Carole Maurer, Senior Development Editor at Sage Publications, was amazing. Her artfulness in massaging sentences and ensuring accuracy is quite remarkable. I have worked with developmental editors in the past, but never have I seen one as good as Carole.

A early training in psychoanalytic and psychodynamic therapies and her subsequent immersion in the short-term dynamic therapies are reflected in key aspects of the model. From there, what later became AEDP and the transformational theory of change was shaped by the need to develop a theoretical framework to explain the phenomenon of quantum change associated with experiential work. Attachment and mother–infant developmental research, as well as cutting-edge findings from brain science, informed further shifts away from both neutrality and relentless confrontation. As a result, AEDP features a therapeutic stance of explicit empathy, care, and compassion. It emphasizes experience instead of insight as the sought-for catalytic agent in the process and shifts attention from what is wrong to what is right and from pathology to healing. Until recently, the mental health field lacked concepts to capture the motivational strivings for psychological health that operate in psychotherapy patients. AEDP rectifies that bias toward pathology by harnessing innate healing capacities to build on our natural resilience. Transformance— that is, the hardwired motivation toward vitality, growth, healing, and self-righting—is a key concept. Neuroplasticity, or the ability of the brain to change neural pathways throughout life, is the neurobiological basis of transformance.

ACCELERATED EXPERIENTIAL DYNAMIC PSYCHOTHERAPY Accelerated Experiential Dynamic Psychotherapy (AEDP) is an integrative, nonpathologizing, attachment-, emotion-, and transformation-focused therapy model. AEDP assumes a healthy core within all people, emphasizes adaptive motivational strivings, works actively and explicitly to create the experience of safety in the therapeutic relationship, and stresses the importance of experiential work with adaptive and affective change processes. The central agent of change in AEDP is the experiential processing of bodily based emotional experiences, with the active help of a trusted other in the context of a therapeutic relationship that is experienced as safe, affirming, helpful, and emotionally engaged. The experiential processing of emotions has two aspects: The first involves the processing of previously unbearable emotional experiences, that is, emotions such as anger, fear, grief, or disgust, that are associated with traumatizing events. The second involves the equally rigorous experiential processing of the positive transformational affects and experiences, for example, self-compassion, joy, or gratitude, that emerge when the previously unbearable emotions are metabolized and integrated within self-experience.

Historical Context Theoretical Underpinnings

Since the publication of Diana Fosha’s The Transforming Power of Affect in 2000, AEDP has been emergent in its growth as a model. Fosha’s

Seamlessly integrating previously disparate theoretical constructs, AEDP’s conceptual framework 1

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Accelerated Experiential Dynamic Psychotherapy

reflects the influence of affective neuroscience, attachment and emotion theories and research, and transformational studies.

then dyadically regulated and processed. For example, in therapy, the counselor and the client might use regulated anger to assert healthy boundaries, or activate compassion to care for self and others.

Affective Neuroscience

Affective neuroscience has demonstrated the centrality of the right brain in regulating attachment and of subcortical structures in the somatic processing of emotions and self-experience. Dyadic affect regulation has been shown to be mediated through right brain communication between dyadic partners. It is accomplished through achieving a psychobiological state attunement involving gaze, play, vocal tones and rhythms, touch, visual imagery, and somatosensory experiences. Similarly, emotion and core self-experience have been shown to be both generated and mediated subcortically, making experiential techniques that engage felt sense experience and bodily sensation of paramount importance. Processing emotion and attachment requires this somatic, relational nonverbal lexicon, which is precisely what AEDP seeks to engage through its bottom-up focus on experience regulated through the therapeutic interaction. Attachment Theory and Developmental Research Into Moment-to-Moment Mother–Infant Interaction

Attachment theory and developmental research into moment-to-moment mother–infant interaction inform AEDP’s goal to establish a patient–therapist relationship as a secure base from which to explore aversive experiences. This is accomplished through the moment-to-moment coordination and regulation of affective states through psychobiological state attunement, where disruptions motivate repair and negative emotions are metabolized rapidly while relational connection is maintained. In simpler terms, AEDP seeks to help patients feel and deal while relating. Emotion Theory

Emotion theory emphasizes the fundamentally adaptive nature of emotions, conceptualized as complex, wired-in neurobiological programs with distinct arousal, appraisal, physiological patterns, and adaptive action tendencies. AEDP techniques aim for rapid access to adaptive core affects, which are

Transformational Studies

AEDP’s understanding of the dynamics of healing transformation is informed by multidisciplinary studies that document the nongradual, discontinuous, rapid, and mutative nature of change processes. This has led to an articulated phenomenological description of the transformational process.

Major Concepts Transformance as a motivational force is the counterpart of resistance (a contraction response fueled by dread and avoidance). Transformance is expansive, powered by hope, and marked by positive vitality affects. Therapeutic processes that are on the right track are accompanied by vitality affects (i.e., positive somatic-affective markers that are experienced not necessarily as happy feelings but rather as experiences that “feel right”). If explicitly and experientially focused on, these vitality affects bring more vitality and energy into the therapeutic process, adding fuel for the ongoing work (e.g., feeling empowered to voice an emotional truth). Whereas resistance results in stasis and deterioration, transformance underlies processes that result in resilience and flourishing. Along with transformance, a key construct in AEDP is the undoing of aloneness. Psychopathology is understood as resulting from the patient’s unwilled and unwanted aloneness in the face of overwhelming emotional experience. For healing to take place via the transformational processing of emotion, AEDP seeks to undo the patient’s aloneness in the face of what can seem to be an overwhelming emotional experience. This is achieved both through the AEDP’s therapeutic stance of acceptance, explicit empathy and affirmation, emotional engagement, and accompaniment and through the dyadic affective regulation of adaptive experiences of relatedness, emotion, arousal, and transformation. When core affective experiences are (a) supported and dyadically regulated from moment to moment, (b) experienced viscerally, and (c) worked through to completion, there is a release

Accelerated Experiential Dynamic Psychotherapy

of adaptive action tendencies and self-righting motivations that are hardwired in the patient’s mind and body, both of which are accompanied by positive affect. In turn, these positive affective experiences that are released as a result of processing the emotions associated with trauma and suffering to completion are themselves experientially addressed through metatherapeutic processing. Metatherapeutic processing is based on the discovery that the experiential processing of transformational experience is itself another transformational process, one that gives rise to upward spirals of positive affect, releasing energy and vitality.

Techniques Guided by the phenomenology of the transformational process, AEDP uses a fundamentally experiential methodology to work with all realms of experience: attachment, emotion, and/or transformation. While AEDP shares many techniques with other experiential approaches, given limited space, the focus here is on quintessentially AEDP techniques. These are all seen not only as processes to entrain but also, most important, as experiences to process. Transformance Detection and the Privileging of What Is New, Emergent, and Corrective

Transformance detection and the privileging of what is new, emergent, and corrective involves attention to and amplification of transformance manifestations, which include glimmers of resilience, strength, relatedness, evidence of new capacities, and the innate pull for the patient’s selfat-best to manifest itself. When there is a choice to be made between focusing on the repetitive patterns associated with negative affect or on new emergent adaptive experiences associated with positive affect, where the patient is taking a risk and experiencing something new, AEDP privileges the latter, experientially processing experiences of change for the better. For example, consider a patient who tends to be self-deprecating. If the therapist detects even a glimmer of self-empathy, the AEDP therapist will explicitly encourage the patient to notice that glimmer of self-empathy and experience it, and then, if possible, the therapist will work with the patient to experientially savor its felt sense in the body.

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Undoing Aloneness and the Dyadic Regulation of Affective Experiences

AEDP works to make sure the patient is not alone with overwhelming emotional experience by recruiting a “true other,” that is, a figure whom the patient experiences as deeply in his or her corner. Seeking to become experienced as a true other, the therapist goes “beyond mirroring,” actively demonstrating emotional engagement through explicit empathy, the use of the therapist’s own authentic affective experience and judicious self-disclosure, the willingness to help, and the explicitly stated desire to be there together with the patient to share and bear the emotional pain of trauma processing as well as the joys of healing. Explicit and Experiential Work With the Experience of Attachment

Explicit and experiential work with the experience of attachment is a hallmark AEDP technique, where attachment is not just a process but also an experience. This includes experiential work with receptive affective experiences where AEDP therapists explore whether the constituents of attachment (e.g., care, empathy, and concern) are being received and reflected in receptive experiences of feeling cared for, seen, or loved. Metatherapeutic Processing

Metatherapeutic processing is a quintessentially AEDP technique where experiences of transformation are experientially explored and processed as rigorously as any other affective change process. It is explicit and experiential work with the experience of transformation. For example, a patient is invited to somatically stay with and experience the joy of voicing a previously dissociated emotional truth and then is further encouraged to explore the felt sense of what happens as a result of having experienced the joy.

Therapeutic Process AEDP is an integrative, healing-oriented, and transformation-based model. Treatment can range from a single session to several years. In each session, including the first one, the therapist, through forming an affect-regulating attachment

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bond from the get-go, seeks to actively catalyze a self-righting psychobiological state transformation with the patient and, together with the patient, to process the healing changes that thus emerge. AEDP has articulated the transformational process as four state transformations that therapists seek to entrain, activate, and move through. Knowledge of the phenomenology of the transformational process allows therapists to know where they are and where they need to go, thus guiding their choice of interventions from moment to moment. State 1 is devoted to building safety, to working to bypass defenses, and to regulate inhibitory affects, such as anxiety, fear, and shame, so as to allow the focus to move from being in the head to being in the body. State 2 work is devoted to processing core affective experiences, including excluded emotions and self states. It is often characterized by an increasing swell of intrapsychic emotional experiences of grief, anger, fear, or relational feelings. The therapist encourages full experiencing and expression of the core affective experience until positive affects come to the fore, marking completion of the natural wave of emotion and the coming online of adaptive action tendencies. State 3 work is devoted to metaprocessing, that is, processing the positive transformational affects and experiences achieved in State 2, for instance, the joy of mastering previously feared emotional experience, the mourning of missed opportunities, and/or the gratitude experienced toward the therapist for midwifing the rebirthing of the self. State 4 involves work with the core state, which is characterized by calm, an expanded perspective, wisdom, a sense of wellbeing, flow, ease, vitality, and compassion toward self and others. Relationally, core state is characterized by emotional intimacy and is often experienced as an I–thou encounter between patient and therapist. AEDP’s therapeutic journey is marked by moving through the four states of the transformational process, a movement that, from moment to moment, is guided by the positive somatic-affective markers of the transformational process. In a relationship where the therapist is experienced as a true other, the true self of the patient emerges and with it the ability to construct an adaptive and authentic life story grounded in a profound sense

of coherence, and self- and other empathy, imbued with wisdom and meaning. Danny Yeung and Diana Fosha See also Ego State Therapy; Emotion-Focused Therapy; Focusing-Oriented Therapy; Internal Family Systems Model; Person-Centered Counseling; Positive Psychology; Sensorimotor Psychotherapy; Somatic Experiencing

Further Readings Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York, NY: Basic Books. Fosha, D., Paivio, S. C., Gleiser, K., & Ford, J. (2009). Experiential and emotion-focused therapy. In C. Courtois & J. D. Ford (Eds.), Complex traumatic stress disorders: An evidence-based clinician’s guide (pp. 286–311). New York, NY: Guilford Press. Fosha, D., Siegel, D. J., & Solomon, M. F. (Eds.). (2009). The healing power of emotion: Affective neuroscience, development and clinical practice. New York, NY: W.W. Norton. Fosha, D., & Yeung, D. (2006). AEDP exemplifies the seamless integration of emotional transformation and dyadic relatedness at work. In G. Stricker & J. Gold (Eds.), A casebook of integrative psychotherapy (pp. 165–184). Washington, DC: APA Press. Frederick, R. (2009). Living like you mean it: Use the wisdom and power of your emotions to get the life you really want. San Francisco, CA: Jossey-Bass. Lamagna, J. (2011). Of the self, by the self, and for the self: An intra-relational perspective on intra-psychic attunement and psychological change. Journal of Psychotherapy Integration, 21(3), 280–307. doi:10 .1037/a0025493 Lipton, B., & Fosha, D. (2011). Attachment as a transformative process in AEDP: Operationalizing the intersection of attachment theory and affective neuroscience. Journal of Psychotherapy Integration, 21(3), 253–279. doi:10.1037/a0025421 Prenn, N. (2011). Mind the gap: AEDP interventions translating attachment theory into clinical practice. Journal of Psychotherapy Integration, 21(3), 308–329. doi:10.1037/a0025491 Russell, E., & Fosha, D. (2008). Transformational affects and core state in AEDP: The emergence and consolidation of joy, hope, gratitude and confidence in the (solid goodness of the) self. Journal of Psychotherapy Integration, 18(2), 167–190. doi:10.1037/1053-0479.18.2.167

Acceptance and Commitment Group Therapy Tunnell, G. (2011). An attachment perspective on the first interview. In C. Silverstein (Ed.), The initial psychotherapy interview: A gay man seeks treatment. New York, NY: Elsevier Insight Books. (Recipient of the 2011 Distinguished Book Award from the American Psychological Association, Division 44)

ACCEPTANCE AND COMMITMENT GROUP THERAPY Acceptance and commitment therapy (ACT; pronounced like the word act) was developed in the late 1980s and is commonly grouped under the third wave of behavior therapy. ACT is rooted in the capacity for language: how we hear it, how we experience it, and how we fit it into our existing schema. This therapy incorporates mindfulness, awareness and acceptance, and values-based psychological flexibility. Unlike cognitive-behavioral therapy, which emphasizes modifying thoughts and behaviors that produce stress, ACT emphasizes accepting these stress-producing thoughts. This therapy is based on six primary core conditions, which focus on mindfulness and flexibility. ACT is used in a variety of delivery methods, including individual, group, workshop, and supervision sessions. In the context of group work, ACT has been used successfully with a variety of clients, within multiple settings, and for various mental health issues. Treatment length varies and can range from participation in a single, multiple-hour workshop, to group participation several times per week spanning a period of weeks or months.

Historical Context Originally called comprehensive distancing, ACT was developed by the psychologist Steven Hayes in the late 1980s; it emphasizes experiential change strategies and is a modern take on behavioral and cognitive therapy. Since then, ACT has been used by hundreds of programs, agencies, and organizations to assist in treatment programs for a variety of mental health issues. More than 50 efficacy trials have been studied in both the United States and other countries. ACT practice is guided by the Association of Contextual Behavioral

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Science, and it is also considered by the American Psychological Association to be an empirically validated treatment for specific areas of mental health and chronic pain. ACT has recently shown promising results in use with children, adolescents, and trainees. Over the past 10 years, ACT has been applied to a variety of group settings for diverse participants. Adults and adolescents, both males and females, have been a part of group interventions using applied ACT constructs. Specifically, ACT has been examined in the research as a group treatment method for participants with mental health issues (e.g., anxiety, depression, eating disorders, phobias, and borderline personality disorder), substance abuse issues (alcohol, drugs, and smoking), pain management problems (e.g., chronic pain, headache), work-related stress concerns (stress management), physical health diagnoses (e.g., diabetes, obesity, epilepsy, and stuttering), and stigmarelated social issues (e.g., mental health, sexual orientation). Studies examining ACT group therapy interventions specific to students (both secondary and postsecondary) focused on test anxiety, impulsivity, low self-esteem, phobias, gambling, anxiety, and depression. Generally speaking, the research results again showed ACT to be effective at helping students cope with worry and anxiety while demonstrating greater psychological flexibility and fewer negative thoughts. Recently, there has been an increased focus on the adoption of ACT constructs for use in field training supervision. In supervision, the supervisor models the experiential work and application of the six ACT core concepts for the trainee, who, in a parallel process, models them for the client. Specific techniques being used in the supervision setting include mindfulness exercises and the use of role-plays for the exploration of thoughts, feelings, and sensations related to the clinical situation.

Theoretical Underpinnings Stemming from cognitive and behavioral principles, ACT is heavily based on language, cognitions, and the actions and behaviors that stem from both linguistic and cognitive messages. In addition to cognitions and behaviors, ACT is rooted in relational frame theory, which states that as we grow, we learn

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Acceptance and Commitment Group Therapy

to respond to events, both internally and externally, based on their relation to another, previous event. This new event is then categorized into an existing schema or worldview and is perceived through a lens of prior experience. Relational frame theory suggests that this causes “inflexibility” because it is easier to assimilate knowledge into our existing schema than to adapt our worldview to accommodate new events. ACT helps individuals and groups master the difficult work of unraveling these collections of thoughts and language by understanding, noticing, and accepting the thoughts, feelings, and behaviors rather than by attempting to control or alter them. When a person is able to understand himself or herself through reflection, mindfulness, and the gathering of information, then psychological flexibility can ensue. ACT also incorporates aspects of postmodern theories, such as constructivism, narrative therapy, and feminist therapy. Overall, the fundamental notion of ACT is that psychological suffering stems from feeling overwhelmed by one’s cognitions and feelings because they are examined in a rigid manner or are avoided all together. These problems are represented in the acronym FEAR: Fusion with thoughts, Evaluation of experience, Avoidance of experience, Reason-giving for behavior. When faced with FEAR, one should ACT, or Accept reactions and live in the present, Choose a valued direction, and Take action.

ruminating over a troubling emotion or cognition. This can be done by repeating a statement over and over until its original, negative meaning and corresponding emotional reaction are lost and only the words are left. Being Present

Being present describes the process of focusing in the here-and-now, without getting wrapped up in the past or future. This allows for flexibility and congruency with one’s values. Self as Context

Self as context involves being fully aware of one’s experiences, thoughts, and language without attachment or investment, which may foster acceptance and flexibility. This can be achieved via mindfulness exercises, metaphor work, and experiential processes. Defining Valued Directions

Defining valued directions is a process whereby an individual learns to identify values that are salient and personally meaningful for oneself as a separate process from accepting the values that someone else dictates to be important (social compliance).

Major Concepts and Techniques Six core concepts linked to ACT that assist clients in developing psychological flexibility are (1) acceptance, (2) cognitive defusion, (3) being present, (4)  self as context, (5) defining valued directions, and (6) committed action.

Committed Action

Committed action involves being dedicated to one’s chosen values and living an authentic life through mindfulness, goal setting, role-plays, and experiential exercises. It is the culmination of the aforementioned constructs.

Acceptance

Acceptance involves being fully open to feeling and experiencing difficult emotions without resistance or defense. Although not an end in itself, acceptance helps foster the increase of valuesbased actions. Cognitive Defusion

Cognitive defusion assists in creating an emotional separation or distance when observing or

Therapeutic Process With varying degrees of success, ACT is proving to be a promising therapy for reducing factors related to feelings of stress, depression, anxiety, and pain management, while increasing feelings of selfefficacy, acceptance, and psychological flexibility overall. A review of the literature illustrates that of the 40-plus studies examined where ACT was utilized in a group setting, the majority of participants participated in 7 to 14 group sessions. Fewer

Acceptance and Commitment Therapy

studies (mostly related to work stress) utilized one or two multiple-hour workshops in which ACT core concepts and techniques were implemented. Therapists will typically conclude the last session with an examination of the overall progress of individuals in the group therapy. A check-in 3 to 6 months out is also common practice. Cheryl W. Neale-McFall See also Acceptance and Commitment Therapy; Behavior Therapy; Behavioral Activation; CognitiveBehavioral Therapy; Dialectical Behavior Therapy; Functional Analytic Psychotherapy; Mindfulness Techniques; Mindfulness-Based Cognitive Therapy; Skinner, B. F.

Further Readings Clarke, S., Kingston, J., Wilson, K. G., Bolderston, H., & Remington, B. (2012). Acceptance and commitment therapy for a heterogeneous group of treatmentresistant clients: A treatment development study. Cognitive and Behavioral Practice, 19, 560–572. doi:10.1016/j.cbpra.2012.03.001 Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behavior Research and Therapy, 44, 1–45. doi:10.1016/j.brat.2005 .06.006 Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. Oakland, CA: New Harbinger.

ACCEPTANCE AND COMMITMENT THERAPY Acceptance and commitment therapy, or ACT (pronounced as the word act, not as the letters a-c-t), is a contextual behavioral therapy designed to increase psychological flexibility, or the ability to contact the present moment and change or persist in behavior to serve valued ends. The ultimate goal of ACT is to help people live rich, full, and meaningful lives. ACT can be conducted in a variety of settings, including individual, group, couples, and family therapy, as well as in organizational, educational, and coaching contexts. Cutting across

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many types of presenting problems for children and adults, ACT has been empirically shown to improve functioning for individuals diagnosed with depression, anxiety disorders, substance use disorders, and chronic pain, as well as for behavioral targets, such as smoking cessation, diabetes management, and obesity reduction.

Historical Context ACT was developed in the 1980s and 1990s by the psychologists Steven Hayes, Kirk Strosahl, and Kelly Wilson, and their students and colleagues. Although the practical applications of ACT started to become widely known in the late 1990s, the therapeutic approach was an outgrowth of a line of research on a contemporary model for understanding human language and cognition begun by Hayes and other researchers at his lab at the University of Nevada, Reno, in the early 1980s. In 2006, the Association for Contextual Behavioral Science was formed in response to international interest in ACT and other contextual behavioral approaches that aim to reduce suffering and help humans thrive.

Theoretical Underpinnings ACT derives from the traditions of behavior analysis, behavior therapy, and cognitive-behavioral therapy, building on and moving beyond the psychologist B.F. Skinner’s analysis of verbal behavior. It also shares many assumptions and techniques with existential, humanistic, and Gestalt models of therapy. ACT approaches problems in living through a transdiagnostic framework that identifies the important role of language in human suffering. Language has an upside and a downside. On the upside, humans use language to transcend the physical world. For example, if someone says to you, “Don’t eat that meat; it is rancid,” you might react by showing disgust at the idea of the rancidity of the meat, without having to actually contact the meat in the physical world by eating it. You have experienced its aversiveness through words. To use another example, say you are told, “We need to plant now, or we will starve in winter.” The words let you imagine starvation, and you avoid it before it becomes a physical reality.

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The upside of language is also its downside. Words allow us not only to transcend the physical world but also to lose touch with it. We can become dominated by, or “fused” with, our ideas about life. Words let us worry about futures that may never take place, reexperience negative past events, and criticize ourselves even when there is no practical reason to do so. ACT suggests that individuals frequently begin to lose psychological flexibility as they make choices based on verbal rules and beliefs rather than experience. For example, they may come to believe, “Nobody will ever love me” and be so dominated by this belief that they fail to act when they have a genuine opportunity to form a loving relationship. Other potentially unhelpful judgments might include thoughts like “People are untrustworthy,” “I am not good enough,”“My life is hopeless,” and “I am weak.” ACT does not seek to directly challenge or refute unhelpful verbal content, as is common in other forms of cognitive-behavioral therapy. Rather, ACT uses mindfulness-based techniques to help people experience thoughts as passing events and recognize that words do not always need to direct actions (see “Defusion” in the following section). Thus, through ACT, people learn to open up to and notice their verbal content and not let it dominate their lives. ACT views one type of verbal content as particularly problematic, namely, those beliefs and judgments that encourage chronic experiential avoidance, or the tendency to avoid painful thoughts, feelings, memories, urges, or bodily sensations (i.e., “private events”). People often judge these events to be “bad” and develop beliefs about needing to control distress (e.g., “I mustn’t worry”). The downside of avoidance is that not only does it fail to reduce distress, but it also often increases it. Socially anxious clients may avoid people and become more socially anxious and depressed about their lives. Trauma survivors experiencing posttraumatic stress disorder often seek to avoid a painful memory and in doing so worsen their reexperiencing symptoms. People use alcohol to escape feelings of insecurity, and they can become increasingly isolated, lonely, and self-loathing. Obsessive clients may seek to avoid feelings of contamination and waste large amounts of time cleaning rather than living their lives.

Major Concepts The major concepts associated with ACT interventions can be described by six core processes, which promote psychological flexibility: (1) acceptance and willingness, (2) defusion, (3) contact with the present moment, (4) self and perspective taking, (5) values, and (6) committed action. Acceptance and Willingness

ACT helps people let go of unhelpful experiential avoidance strategies (acceptance) and willingly allow and make space for distressing private events that occur as a routine part of life. For example, people often fail to pursue loving relationships because they fear that they will get hurt. If they nevertheless value being in a loving relationship, ACT can help them pursue love and make mindful space for the difficult emotions that show up. Acceptance and willingness are not the same as resignation or tolerance and do not imply that one must simply accept the external circumstances of one’s life without trying to affect things that can be changed. Acceptance is a powerful choice, because it can eliminate wasteful attempts to control feelings and free up energy for vital activity. Defusion

ACT employs a variety of processes designed to help clients hold their thoughts and verbal rules more lightly, rather than treating them as if they are literal truth to be followed. Defusion exercises are different from cognitive disputation methods. Rather than seeking to dispute the content of a client’s cognitions or beliefs, defusion disrupts the usual functions of thoughts, so that they no longer have such a strong influence on behavior. For example, clients learn to experience the thought “I’ll never succeed” while pursuing goals that help them succeed. In a defused context, negative thoughts still occur but no longer have the same level of negative influence on actions. Contact With the Present Moment

Within the ACT model, problems in effective living are often tied to being overly focused on things that have happened in the past or fruitlessly concerned about what might or might not happen in the future.

Acceptance and Commitment Therapy

The client can lose touch with potential sources of reinforcement and joy in the present moment. Using a variety of mindfulness processes and exercises, the ACT therapist helps clients pay attention to the present moment, on purpose, with curiosity. Self and Perspective Taking

ACT shows clients that they are not defined by their thoughts, feelings, or histories and that there are alternate ways in which they can view themselves and their content. For example, clients can learn to view themselves as separate from their content (e.g., feelings, thoughts) and as the one who holds that content and therefore has no need to cling to it or fight it. They can experience what it is like to see themselves through the eyes of a kind friend and thereby develop self-compassion and improved ability to rebound from setbacks. They can learn to view things from other people’s perspectives and develop the capacity for empathy and genuine love. Values

All of the work of ACT depends on what is important to the individual client, that is, the client’s values. Client and therapist work together to identify personal values in areas such as relationships, employment, spirituality, and personal wellbeing, clarifying what is truly valued by that individual, not simply what is expected from society or family members. Committed Action

Once values have been identified, then processes such as acceptance and defusion are practiced in the service of value-consistent action. This process helps clients identify goals that reflect their values and to identify and plan for barriers and ways to rebound from setbacks. The ultimate goal of ACT is not to increase insight or positive feelings but to increase the extent to which clients engage in behaviors that make their lives richer and more meaningful and vital.

Techniques ACT is a theoretically driven approach that uses many techniques in the service of promoting

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psychological flexibility, but it is not defined by any specific techniques. Techniques that appear to be consistent with ACT can be used in quite ACT-inconsistent ways (e.g., mindfulness practice to avoid stress). ACT techniques are not identified by their form but by their purpose, that is, by the extent to which they promote each of the six core processes and psychological flexibility. The skillful ACT therapist may be found using analogies and metaphors to allow clients to have an intuitive, “picture-like” understanding of their experiences that does not require excessive verbalizing. For example, a client might be asked, “What if your struggle with anxiety is like struggling with quicksand: the more you struggle, the more you get stuck?” ACT frequently employs mindfulness exercises, experiential exercises, imaginal exercises, and writing, all in the service of practicing the six core processes described in the previous section. ACT also has components in common with approaches such as behavioral activation; the heart of ACT focuses on working with clients as they make and keep (or don’t keep) behavioral commitments in the service of their values. ACT therapists may teach basic social or life skills; however, the ACT therapist may also explore how problems like experiential avoidance may have gotten in the way of acquisition and execution of such skills. ACT therapists sometimes use common cognitive-behavioral techniques, but with the purpose of activating behavior rather than reducing distress. For example, an ACT therapist working with a client with anxiety or posttraumatic stress disorder may frequently use exposure exercises. However, in ACT, exposure is not focused on habituation and reduction of anxiety but on increasing behavioral flexibility in the presence of anxiety or traumatic reexperiencing. Distress is often reduced in ACT interventions, but this is presumed to be the indirect consequence of an increase in flexibility and valued living.

Therapeutic Process The therapeutic process in ACT is based on an assumption that therapist and client are on an equal footing—processes related to problems in living are common to all humans. This work is

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informed by a fundamental respect for the client’s values; only the client can know whether a certain behavior or choice is valued and workable. The therapist also assumes that the client is not broken or disordered, trusting that the client has what he or she needs to move forward and doesn’t need “fixing.” The ACT therapist seeks to be open and present with clients in their pain, instill hope, and help clients choose behavior by way of direct experience (rather than primarily through verbal rules). When practiced skillfully, the undefended and accepting therapeutic relationship itself serves as a model for how the client can learn to respond to his or her own thoughts, feelings, memories, and physical sensations, while moving forward in life. Sonja V. Batten and Joseph V. Ciarrochi See also Acceptance and Commitment Group Therapy; Behavior Therapy; Behavioral Activation; CognitiveBehavioral Therapy; Dialectical Behavior Therapy; Functional Analytic Psychotherapy; Mindfulness Techniques; Mindfulness-Based Cognitive Therapy

Further Readings Batten, S. V. (2011). Essentials of acceptance and commitment therapy. London, England: Sage. Ciarrochi, J., & Bailey, A. (2008). A CBTpractitioner’s guide to ACT: How to bridge the gap between cognitive behavioral therapy and acceptance and commitment therapy. Oakland, CA: New Harbinger. Hayes, S. C., Barnes-Holmes, D., & Wilson, K. G. (2012). Contextual behavioral science: Creating a science more adequate to the challenge of the human condition. Journal of Contextual Behavioral Science, 1, 1–16. doi:10.1016/j.jcbs.2012.09.004 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168. doi:10.1037/0022-006X.64.6.1152 Torneke, N. (2010). Learning RFT: An introduction to relational frame theory and its clinical application. Oakland, CA: New Harbinger.

Wilson, D. S., Hayes, S. C., Biglan, A., & Embry, D. D. (2014). Evolving the future: Toward a science of intentional change. Behavioral and Brain Sciences. Advance online publication. doi:10.1017/ S0140525X13001593

Website Association for Contextual Behavioral Science (ACBS): www.contextualscience.org

ACKERMAN, NATHAN Nathan Ackerman (1908–1971), one of the originators of family therapy, was born in Bessarabia in Eastern Europe and immigrated with his family to New York City in 1912. Ackerman was the first son in his family to survive infancy. Prior to his birth, three of his siblings died, each within a year of the other. From the beginning of his life, Ackerman was expected to fulfill the dreams of his merchant-class parents, who prioritized education and cultural pursuits and wanted their son to pursue a scholarly career. Ackerman possessed both the intellectual intensity and the facility required to invent and implement family therapy, one of the most widely used modalities of counseling and psychotherapy. Perhaps it was Ackerman’s family story of shifting fortune and tragedy that stimulated his decision to become a psychiatrist and focus his professional life on the health and well-being of families. After his arrival in New York, Ackerman’s father worked during the day and studied pharmacology at night and eventually opened his own drugstore. Ackerman’s mother cooked, sewed, and nurtured the family. During the Great Depression, however, mounting debts forced the closing of the family pharmacy; his siblings Gertrude and Bernard struggled in their marriages, and his youngest brother, Harry, suffered a mental breakdown. Ackerman survived two near-fatal illnesses that left him with a heart condition, mitral stenosis, and an unwavering conviction that he had been chosen to accomplish something special in his lifetime. Ackerman had little tolerance for authority. He is said to have talked his way into Columbia University by ignoring the existing quota for

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Jewish students and to have talked his way out of the Columbia University College of Physicians and Surgeons by dismissing the fact that he had failed a pediatrics exam. It is likely that his brother’s struggle with psychiatric illness, which began shortly after Ackerman graduated from medical school in 1933, had some effect on his decision to become a psychiatrist. Ackerman spent a year interning at Montefiore Hospital in New York and continued his residency in neuropsychiatry at the Menninger Clinic in Topeka, Kansas, from 1935 to 1936. He returned to New York in 1937 to become the medical director at Stony Lodge Hospital in Ossining and had his brother transferred there so that he could supervise his ongoing psychiatric care. While he is considered to be one of the founding fathers of family therapy, Ackerman was trained in psychoanalysis and retained an allegiance to psychoanalytic thinking throughout his life. Ackerman attended the New York Psychoanalytic Institute between 1937 and 1942. His training analyst was Clara Thompson, who with Erich Fromm, Harry Stack Sullivan, and others founded the William Alanson White Institute, a psychoanalytic training institute in New York City. Ackerman adhered to many psychoanalytic ideas, but he critiqued classical psychoanalytic practice for focusing exclusively on the internal life of the individual to the neglect of what he deemed important family and social contexts. While many of the early family therapists, such as Don Jackson and Gregory Bateson, were concentrating on what occurred between people, focusing on issues such as communication patterns and circular feedback, Ackerman concentrated on the internal life of the individual and the family. In 1937, Ackerman published his first article about the family, titled “The Family as a Social and Emotional Unit.” In this article, he laid down the themes that were to occupy him for the rest of his life; he described the family as a unit with a psychological and social life, and he emphasized how an individual’s childhood experiences in the family can leave profound and lasting impressions on him or her in later life. In subsequent articles on family theory, Ackerman developed the idea of interlocked reciprocity in family relationships and proposed that the unit of behavior to be observed in the treatment of children was not the child alone

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but the interaction of the child with family members. By the mid-1940s, Ackerman was seeing child patients and their families together in therapy. As early as 1954, Ackerman proposed that individual therapy should be subordinated to, at the very least, a psychosocial evaluation of the family as a whole. In 1955, Ackerman organized the first session on family diagnosis and treatment at a meeting of the American Orthopsychiatric Association attended by Murray Bowen, Don Jackson, and Lyman Wynn. Ackerman was instrumental in developing the family systems premise that if one person in the family has a problem, the entire family has a problem. He believed that families, like individuals, engage in defensive processes and repress and deny their motives, thoughts, and feelings, particularly those involving sex and aggression. Ackerman viewed the work of therapy as bringing the unconscious motives, impulses, and wishes of the family into the realm of conscious examination and discussion. In this way, he remained loyal to his psychoanalytic roots, although his idea of expanding the concept of psychiatric illness to include the family and his practice of seeing the family in its entirety were very much outside the realm of psychoanalysis. Ackerman viewed family treatment as a clinical interview with a group consisting of the family members who live together as well as relatives who fulfill a significant role in the family. He saw the psychological functioning of the individual as informed by the individual’s position and role in the family as well as by the history of the family as a whole. Ackerman believed that pathogenic conflict is passed down from one generation to the next, and he argued that an understanding of the family across three generations is required to grasp how the family and its members function in the hereand-now. He noted that it is rare to find a family in which only one member is emotionally disabled, and he regarded the symptom of one member of the family as a symptom of the “emotional warp” of the entire family. Ackerman regarded the family member who was referred for psychiatric help as either the scapegoat for the pathology of the family or a stand-in for a more critically disturbed member. He saw the complex interplay between an individual’s defenses against anxiety and the family’s defenses against conflict as leading to a host of

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psychological and behavioral disturbances, including avoidance or denial, emotional splitting in the family, quarrels, alienation, scapegoating, escape through drugs or alcohol, sexual acting out, reversal of parent–child roles, dilution or excessive tightening of the family organization, and a “thinning of the border” between the family and the outside community. It was in his clinical practice that Ackerman invented one of the first forms of family therapy. His approach to therapy was intended to shake up the defenses responsible for maintaining the problematic behaviors and pathogenic stasis in the family. Referencing his psychoanalytic training, he called his method “tickling the defenses.” He saw the therapist as the catalyst necessary to stimulate an active, spontaneous, and emotionally meaningful exchange that would challenge family members to relinquish their defenses and become more in touch with each other and themselves. Ackerman viewed the eliciting of candid disclosures, the confronting of evasion, and the establishing of connections between the conflicts in the family and the anxieties of individual members as the heart of the therapy process. This involved catching family members by surprise; interpreting body language; exposing discrepancies, rationalizations, and secrets; and negating the scapegoating of members of the family. It also involved empathizing with each person in deeply touching ways and offering the nurturance, acceptance, warmth, and emotional support that the family lacked but sorely needed. Ackerman’s contributions to the field of family therapy are extensive. While he did not establish a specific theory of family therapy, his clinical style influenced many family therapists who emerged out of the psychiatric establishment of the East Coast. He founded several institutions that remain central in the field today. In 1972, together with Don Jackson and Jay Haley of the Mental Research Institute, Ackerman started the first family therapy journal, Family Process. In 1957, he opened the Family Mental Health Clinic of Jewish and Family Services, and in 1960, he founded the Family Institute in New York City—later renamed the Ackerman Institute for the Family. He had the foresight to film many of his interviews and initiated the tradition of audiovisual documentation of clinical work, which remains a cornerstone in the training of family therapists. Perhaps his most important

legacy, however, is as a clinician and a teacher. He taught many of the leading clinicians and theoreticians in the field of family therapy, including Salvador Minuchin, Donald Block, and Peggy Papp, all of whom have acknowledged Ackerman’s brilliance, courage, and innovative spirit. Mary Kim Brewster See also Ackerman Relational Approach

Further Readings Ackerman, N. (1950). Anti-Semitism and emotional disorder. New York, NY: Harper. Ackerman, N. (1958). The psychodynamics of family life. New York, NY: Basic Books. Ackerman, N. (1966). Treating the troubled family. New York, NY: Basic Books. Block, D., & Simon, R. (1982). The strength of family therapy: Selected papers of Nathan W. Ackerman. New York, NY: Brunner Mazel.

ACKERMAN RELATIONAL APPROACH The Ackerman relational approach (ARA) is a relational-systemic approach to counseling and psychotherapy that focuses on helping families and couples find ways to understand, repair, or restructure the relationships that matter the most to them. Developed at the Ackerman Institute for the Family in New York City, the ARA is designed to strengthen and clarify relationships between members of a couple or family and to empower them to create relationships that are safe, nurturing, and supportive. The ARA is aimed at eliminating or reducing a symptom or problematic behavior, while simultaneously ameliorating the interpersonal relationships in the family or couple. This requires a process of therapy during which members of the family or couple are enlisted to address the presenting problem actively and collaboratively with each other and the therapist.

Historical Context The ARA was developed in the early 2000s by the faculty of the Ackerman Institute for the Family, led

Ackerman Relational Approach

by Marcia Sheinberg, Director of Training. The Ackerman Institute is a postgraduate training institute and a free-standing, nonprofit clinic that delivers family and couple psychotherapy services to people in New York City and the larger metropolitan area. The institute derives its name from Nathan Ackerman, who founded the training facility and is regarded as one of the founders of family therapy in the United States. Recognizing the need to provide therapists training at the institute with guidelines for conducting family or couple therapy, the faculty came together to articulate the theoretical foundations, principles, and core practices of the approach of the Ackerman Institute. The ARA emerged out of several years of discussion and debate about the theories and ideas that inform how family and couple therapy is practiced at the institute. Since the early 2000s, the ARA has provided therapists training at the institute with a multitheoretical framework and guidelines for interviewing, conceptualizing a case, and constructing interventions for families and couples. As such, the ARA has influenced the manner in which many family and couple therapists conduct clinical work. One of the first centers in the United States to focus on providing family therapy and training family therapists, the Ackerman Institute for the Family was initially known as the Family Institute. The institute was formed in the 1960s when a group of families, grateful for the therapy they had received by Ackerman, came together to establish a nonprofit center to support and expand his work in teaching and training. In addition to creating the training institute, Ackerman was experimenting with the new modality of family therapy. Rather than viewing family treatment as an adjunctive therapy to individual psychoanalysis, Ackerman saw family therapy as the primary therapeutic modality in the treatment of children. He published, taught, and even videotaped his new methods, initiating the tradition of audiovisual documentation of clinical work, which has become a cornerstone in the teaching and training of family therapists. Many of the approaches and techniques considered at the present time as fundamental procedures in the field of family therapy were developed and practiced by Ackerman during his years at the Family Institute. While many of the family therapy institutes being formed around this time in the United States

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had a distinctive conceptual core or an allegiance to a specific person, Ackerman was not interested in establishing a school or a theory of family therapy. From the beginning, Ackerman was dedicated to the invention and development of clinical innovations to address some of the more difficult problems facing families and couples. He was interested in introducing these techniques and approaches into the field of family therapy through teaching and training. Because of this emphasis, the Ackerman Institute for the Family evolved into a postgraduate center for therapists studying family and couple therapy rather than into a specific theoretical school of therapy. Ackerman’s approach to family therapy was singular and original. His clinical work reflected his paradigmatic change from psychoanalysis to systems theory. Because Ackerman’s clinical style was personal and idiosyncratic, modifications of his technique, as well as alternative approaches, were required to develop a model of family therapy that therapists training at the institute could learn, master, and implement. The responsibility of developing these techniques, and of modifying Ackerman’s approach, fell largely on the faculty associates whom Ackerman brought to the institute in the early years. Peggy Papp and Kitty La Perriere, among others, took on the challenge of developing and synthesizing the clinical methods and training approaches initiated by Ackerman. The multitheoretical, innovative, pragmatic, clinically focused, and dynamic process of creating and refining clinical technique and practice—the method that characterizes and defines the ARA— dates back to this time.

Theoretical Underpinnings The central idea that distinguishes the ARA and systemic approaches from other modalities of counseling and psychotherapy is the focus on the relational context. A fundamental assumption of this approach is the understanding that the problems of individuals exist within a broadly defined relational, cultural, and sociopolitical context. This idea represents a paradigmatic shift from models of psychotherapy that locate the problem “in” the individual. This alteration in perspective—from the individual to the individual in the relational context—began in the 1960s and was evident in the

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early work of Ackerman. Since then, family and couple therapists have taken a perspective on problem formation that views clinical difficulties as not solely existing “inside” a person but also occurring “between” people. This relational perspective is a bedrock theoretical assumption of the ARA. A core assumption of the ARA is that behavioral, psychological, or interpersonal problems are addressed more effectively and comprehensively when members of the family or couple work together toward addressing the problem. In this sense, an improvement in the quality of interpersonal relationships is viewed as central to helping an individual recover from a psychological or behavioral difficulty. For example, if a child presents with symptoms of anxiety related to difficulties with school performance, and the child’s parents are in distress and in conflict with one another, the therapist will intervene to help the parents come together to address the child’s problem in a calm and consistent manner. Improving the quality of the parenting is seen as a relational-systemic way of addressing the child’s individual difficulties. The ARA intends to help all members of the family or couple expand their capacities for empathy and understanding and, in doing so, open up opportunities for building connection, trust, and relational competence. The ARA is informed by many theories and clinical practices within the broad domain of couple and family therapy, as well as from developments in other fields such as anthropology, philosophy, and neurobiology, to name a few. Since its inception, members of the faculty and therapists training at the institute have been influenced by the theories, methods, and practices in the main of family and couple therapy. Because of this, the ARA is multitheoretical in orientation; attachment, behavioral, Bowenian, Milan systemic, narrative, strategic, structural, psychodynamic, and integrative models have been incorporated and assimilated into clinical practices at the institute. More specifically, the ARA integrates and expands on the contributions from scholar-practitioners of systems, narrative, social-constructionist, feminist, social justice, and attachment theories.

Major Concepts The ARA is guided by a core of major concepts. Therapists using the ARA endeavor to understand the relational meaning families and couples attach

to the presenting problem; view the experiences of the individual and couple/family within a relational context that includes the larger system, community, and broader society; and strive to make sensitivity to diversity, difference, and culture evident in the therapy. Importantly, the stance of the therapist using the ARA is collaborative and informed by feminist and social justice perspectives that prioritize equality and fairness. Focusing on Relational Meaning

Symptoms of distress are sometimes mitigated when the meaning of the presenting problem shifts from a misunderstanding of the person and the problem to an empathic understanding of the person and the problem. The therapist aims to understand the thoughts, feelings, and behaviors of the family/couple and individual, as well as the very specific meanings each person connects to the presenting problem. For example, a couple comes in for therapy with the presenting problem of a wife “withdrawing sexually” from her husband. The husband feels rejected and hurt and responds by becoming angry with his wife. When the therapist is able to link the wife’s sexual withdrawal temporally to the loss of an important member in her family, the husband becomes less defensive in his behavior and approaches his wife with greater concern and care. This change occurs as the meaning of the problem held by the husband shifts from feeling rejected to understanding his wife’s behavior in the context of her experience of loss. Change is seen to occur when the meaning attributed to a problem shifts, and the family/couple and individual are better able to mobilize resources to address the difficulties that bring them into therapy. Understanding the Relational Context

The relational context of the individual begins with the family or the couple. The ARA defines the family as any relational arrangement that expresses commitment to and caring for others. These include relationships with biological and nonbiological family members, functional kinships, same-sex partners, and gender-variant persons. In addition to the extended members of the family or couple, the relational context includes friends, peer groups, teachers, and other people who hold important positions in the life of the individual.

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It  also includes larger systems such as schools, health care facilities, religious communities, and social service agencies. The ARA acknowledges how ideas and premises form relational contexts for the family or couple. Beliefs and values—for example, the assumptions an individual, family, or couple hold about gender, sexuality, and power— are seen to shape and inform relational dynamics.

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endeavors to acknowledge the multiple perspectives that people bring to therapy without being simplistic, Pollyannaish, or reductionist; embraces the strengths and resilience of the family or couple and brings them forward in the therapy; aims to understand how experiences of the pasts are imbricated in relationships in the here-and-now; and uses a variety of systemic interventions to promote and maintain positive change in relationships.

Taking a Social Justice Perspective

The experiences of living within systems of oppression—conditions that sustain inequality and unfairness based on difference—can have deleterious effects on both the structure and the relational processes of a family or couple. The therapist using the ARA looks carefully into how experiences of oppression, including poverty, lack of access to medical care and educational facilities, as well as societal messages that stereotype individuals and convey inferiority, can be taken up into the interior of a family or couple and influence relational functioning. Engaging in Self-Reflection: Collaboration and Transparency

The therapist using the ARA takes care to work collaboratively with families and couples. The process of therapy is aimed to provide individuals with opportunities to regain control in their lives and make decisions that are in the best interest of themselves and their families. When the therapist collaborates around setting goals and is transparent about the process of the therapy, families and couples are more likely to “own” the therapy and take responsibility for the process of change. The stance of the ARA therapist is open and nonjudgmental. The therapist is engaged, throughout the therapy, in a process of self-reflection as to how experiences in his or her family of origin, relationships, culture, and social location influence, impede, or foster an understanding of the lived experiences of the family or couple.

Techniques The clinical focus or techniques of intervention may vary from session to session, according to the needs of the family or couple presenting for therapy. In general, the therapist using the ARA

Holding Multiple Perspectives

Each member of the family or couple holds a perspective on the presenting problem. Oftentimes, one person’s perspective will be vastly different from those held by others in the family or couple. When each person can begin to listen to and embrace other points of view, the need to deny the experiences of others in order to hold on to one’s own becomes unnecessary. The therapist works to help the family or couple redefine and expand their perspectives on the presenting problem by including the voices and multiple perspectives of the members of the family or couple, including children, in the therapy. Working From Strengths

The therapist using the ARA focuses on bringing forward the strengths and resources that are inherent in the family or couple. While bringing forth resilient responses is important, a therapy that focuses on deficits or pathology is seen to be detrimental in that it constrains the sense of optimism, flexibility, and hopefulness that is viewed as essential to initiating and sustaining change. Highlighting and amplifying strengths is viewed as necessary to provide a platform from which the family or couple can rebuild and restructure relationships in positive ways. “Going Up a Generation”

By “going up a generation,” the therapist works to identify, understand, and ultimately construct meaning regarding the ideas, premises, and patterns of interaction that are transmitted from one generation in the family to the next. The therapist endeavors to understand how experiences of the past may be imbricated in the present. Members of the family or couple are seen as attempting to

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either repair or repeat the relational patterns of prior generations, many of which are held out of the awareness of the individual. The therapist aims to identify and bring forward the intergenerational patterns that inform and influence relationships in the here-and-now. Systemic Interventions

Sculpting Sculpting is an experiential technique, expanded for use in couple and family therapy by Peggy Papp, in which the therapist asks members of the family to pantomime scenarios that depict problems or patterns of interaction in their relationships. Sculpting relies on visual and sensory communication rather than on verbal language and is intended to help families or couples explore emotions, longings, and conflicts within the realm of symbolic representation and metaphor. Decision Dialog The decision dialog is a technique developed by Marcia Sheinberg and Fiona True at the Ackerman Institute. Using this technique, the therapist has individual sessions with the child and links what is said to the family sessions with a “decision dialog” in which the child and the therapist converse and decide together what information should be shared with family members, why it should be shared, and by whom. This allows the child, who may feel constrained from speaking due to fears of making other members of the family upset or angry, to participate more fully in the therapy. Rituals Supporting a family or a couple in creating and maintaining rituals is a technique developed by Evan Imber-Black at the Ackerman Institute. Rituals such as coming together for holiday meals or simply greeting family members after they come home from school or work are essential aspects of couple and family life because they promote and heighten a felt sense of connection and belonging. Maintaining rituals is seen to be particularly important when a family or couple is experiencing an illness or a loss, because rituals provide family life with a sense of vitality and continuity while also highlighting change.

Homework Offering the family or couple a homework assignment in between therapy sessions is used to promote positive relational experiences and to reinforce change. Homework assignments are designed to be highly specific to the presenting problem and the therapeutic needs of the family or couple. For a family experiencing a recent loss, the therapist may suggest that the family prepare a meal together; for a couple caught up in escalating arguments, the therapist may ask the couple to refrain from discussing contentious topics outside the therapy sessions and plan an enjoyable activity together.

Therapeutic Process The ARA is a collaborative therapy that can last from a few sessions to many years depending on the expressed interest and needs of the individual family or couple. In general, members of the family or couple attend sessions together, although individual sessions are also used in an ongoing therapy. In the beginning, the therapist interviews members of the family or couple to obtain each person’s specific point of view on the presenting problem. The therapist aims to understand who in the family or couple is the most affected by the presenting problem, why it is happening now, and what efforts have been made in the past to address it. While listening and asking questions, the therapist also notices the strengths inherent in the family or couple; identifies the patterns of interaction around the problem; locates the problem within the context, lifecycle, and social location of the family or couple; and clarifies the premises, beliefs, values, and themes that have shaped the relational dynamics over time. The therapist uses this information to construct a systemic explanation of why the problem is happening at the current time. When the therapist has a complex and specific understanding of the problem and the meaning it carries for the family or couple, interventions are formulated to help each person address the problem. Systemic interventions that are used in the ARA include sculpting, suggesting a ritual, or offering a homework assignment, to name a few. Therapists at the institute are offered training in these systemic

Activity-Based Group Psychotherapy

interventions, many of which were developed at the Ackerman Institute over the past 50 years. The ARA focuses on helping families and couples find ways out of negative patterns of relating to one another into more positive ones. The therapist uses the ARA interviews to arrive at a specific understanding of the presenting problem and the meaning, or meanings, each person attaches to it. The therapist then works with the family or couple to repair or reconstruct the relationships so that members can more effectively come together to resolve their problems. The ARA regards clarifying and strengthening relationships as the core of therapy. Mary Kim Brewster See also Ackerman, Nathan; Couples, Family, and Relational Models: Overview

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communication, cooperation, problem solving, and trust; in addition, group members often view the activities as fun. Activity-based group psychotherapy focuses on actions as the therapeutic process. Therapists assess the group and the individuals within the group, select and match activities using either structured curriculum or spontaneous cocreation, and facilitate the discussion of the activity as a reflection on the group’s process. Activities allow the therapist and fellow group members to observe behavior in the here-and-now rather than as a report of what happened outside the group. In the belief that group members project their issues onto the novel activity, activity-based group psychotherapists believe that they are seeing through defense mechanisms as members work through their issues by participating in activities and then implementing insights gleaned from their actions, reflection, and group feedback.

Further Readings Ackerman, N. (1966). Treating the troubled family. New York, NY: Basic Books. Goldner, V., Penn, P., Sheinberg, M., & Walker, G. (1990). Love and violence: Gender paradoxes in volatile attachments. Family Process, 29, 343–364. doi:10.1111/j.1545-5300.1990.00343.x Papp, P. (1983). The process of change. New York, NY: Guilford Press. Papp, P., & Imber-Black, E. (1996). Family themes: Transmission and transformation. Family Process, 35, 5–20. doi:10.1111/j.1545–5300.1996.00005.x Sheinberg, M., & Fraenkel, P. (2001). The relational trauma of incest: A family-based approach to treatment. New York, NY: Guilford Press.

ACTIVITY-BASED GROUP PSYCHOTHERAPY Activity-based group psychotherapy is used to describe approaches that intentionally employ physical, social, and emotional group tasks as the primary focus of the psychotherapeutic process. Activities include but are not limited to play, games, movement, dance, art, music, physical challenges, and drama. Goals of activity-based group psychotherapy may be combinations of

Historical Context Two men who are considered the founders of modern-day group psychotherapy are Jacob Moreno and S. R. Slavson. Both engaged in what can be classified as activity-based group psychotherapy. Moreno combined overt action with group dynamics and spontaneity to create what became known as psychodrama. In psychodrama, the action of the protagonist within the context of a group is the psychotherapy. Many of the processes and techniques used in psychodrama are thought to have influenced Gestalt therapy, transactional analysis, Virginia Satir’s people making, and other forms of using action within group psychotherapy. Slavson began to use what he called activity therapy for groups of children because he found it difficult to engage school children in talking sessions. He found that many youth did not enter therapy willingly and often mistrusted or felt threatened by the therapist. Activities followed by discussion periods were found to be more productive.

Theoretical Underpinnings Many of the theoretical underpinnings of activitybased group psychotherapy can be traced to psychodrama in its use of overt action combined with

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Activity-Based Group Psychotherapy

group dynamics. Group participants are believed to project their unconscious selves onto novel activities, much like they might project their thoughts and feelings onto a Rorschach inkblot. Having this projection take place in the context of a group, where behaviors can be observed in the here-and-now, is fundamental to both the history of and current thinking about activity-based group psychotherapy. Kurt Lewin’s classic formula related to group dynamics states that behavior is a function of group members’ personal characteristics interacting with environmental factors (the group) is essential to understanding activity-based group psychotherapy. Lewin’s change process involves three stages: (1) “unfreezing”—often through the use of novel experiences—where defense mechanisms are bypassed, leading to (2) a stage where change could occur during an experience followed by (3) “freezing” for the change to become crystallized in the group member so he or she becomes comfortable with new insights. Lewin also coined the term action research that involves a circle of planning, action, and reflection. His work is a precursor to the experiential learning cycle that is mostly associated with David Kolb. The experiential learning cycle involves an action phase followed by reflection on the action and change occurring based on that reflection. This cycle, grounded in action research, is fundamental to activity-based group psychotherapy.

Major Concepts The major concepts associated with activity-based group psychotherapy are assessment, appropriate activities, the therapist as facilitator of the activities, and reflection, discussion, or processing of each activity. Assessment

Prior to a group meeting, the therapist needs to know about the people involved in the group and the context in which they are operating. Why is the group together? Is there a common diagnosis shared among its members? Is the context a residential treatment center, a private practice office, or community-based placement? Is the group composed of individuals who have prior history with

one another like a family? Is the group in a beginning, middle, or ending stage of therapy? In short, what does the therapist know about the group specifically and generically that can aid in the forming of treatment hypotheses that can be tested through action? Base of Activities

Having a base of appropriate activities to choose from is essential for a successful outcome. Activities can include, but are not limited to, games, free play, drama, music, art, or physical challenges. The therapist needs access to, knowledge of, and competence with activities that are relevant to the outcomes desired. Knowing the physical or psychological risk involved with an activity and how to minimize it is also imperative to the ethical use of activities in group psychotherapy. Activities can either be prescribed, as part of a curriculum to work with a particular issue or diagnoses, or spontaneously be cocreated with the group as issues are discussed or emerge. In both cases, the activity is the vehicle and the focus of therapy. For example, in an activity used with a substance abuse curriculum in a 12-step context, the therapist might wish to demonstrate the importance of each of the steps. One way this might occur is to have twelve 1-foot-square pieces of carpet to be used as “stepping stones.” The group is challenged to cross a 25-foot expanse. The rules might be that physical contact is maintained with each square at all times. If a group member loses physical contact with a carpet square, the square is “lost” for the duration of the activity. Discussion following the activity might center on the relative importance of a specific lost step and/or the importance of support from the group for successful completion of the activity or recovery from substance use issues. As an example of an activity emerging from a group issue, imagine that a group cannot focus on a common problem because some members are not engaged with the group. The leader might bring out a bandana and a 12-ounce plastic cup almost full of water and ask the group to balance the cup of water on the taut bandana. The group might be led on a short journey inside or outside the group room and challenged to complete the journey. The

Activity-Based Group Psychotherapy

success of pulling together to keep the water balanced as well as the consequences of the water spilling provide an opportunity to discuss the advantages of having a common goal and working together to achieve it. Many therapists involved in activity-based group psychotherapy consider the novelty of an activity as important. Novelty contributes to spontaneous reactions, catching the group off guard, which might allow for unique insights due to defense mechanisms being minimized. Many therapists believe that activities should match the group’s issues. In other words, if communication or support is an issue, the activity should require good communication or significant support within the group to achieve a successful outcome. Metaphorically, the structure of both the above examples parallels the groups’ issues: the first by the need to complete each of the 12 steps and to (ask for) support to maximize sobriety potential, the second by requiring a level of communication, focus, and cooperation. Facilitator of Activities

Most often in activity-based group psychotherapy, the therapist serves as a facilitator of the activity more than an interpreter or analyst of what is happening. In this approach, the therapist is much more the “guide on the side” rather than the “sage on the stage.” The competent activity-based psychotherapist is skilled at giving clear instructions for activities and is a keen observer of behavior during the activity for use in facilitating the discussions that follow. Reflection, Discussion, or Processing

Reflection, discussion, or processing of the activity is also a major concept. While some therapists may believe that the action speaks for itself and might be “ruined” by postactivity discussion, most of them believe that sharing insights and observations about the impact of an activity helps cement or “freeze” the changes observed. Through facilitating a reflective process, group members are able to consider how insights may be developed into concrete actions that can follow the therapy experience.

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Techniques Primary techniques of activity-based group psychotherapy include choosing an activity, presenting it to the group, and facilitating discussions after the activity. Choosing Activities

Choosing activities may be as simple as following a structured curriculum that is linked to a particular issue or tied to a particular stage in the treatment process. The 12-step activity noted under the “Major Concepts” section is an example of this. Otherwise, therapists rely on spontaneity in the moment and listen to the groups’ concerns. They let the choice of activity be dictated by the experience with particular activities and the ability to mold them to fit the nature of the group’s issues. The cup of water and bandana activity is an example of this approach. Presenting an Activity

Presenting an activity to the group may be as straightforward as giving the group instructions for the task at hand and providing any necessary props to conduct the activity. Sometimes, therapists provide a metaphorical introduction in the form of a story related to how the activity appears to fit the group’s issues. In other situations, particularly with resistant clients (often adolescents), a therapist may choose to paradoxically introduce the activity by challenging the group. Predicting behaviors the group is likely to engage in during the activity is one way this can be accomplished. For example, a therapist might introduce an activity by telling the group that the therapist does not expect them to be successful because the activity requires clear communication and the group has thus far been unable to exhibit clear communication in their previous work together. Sometimes, this type of introduction may compel the group members to paradoxically communicate quite clearly to one another and be successful with the activity in order to prove to the therapist that they can communicate. Success in the activity often motivates continued accomplishments that demand effect communication within the group. Facilitating a discussion about the activity may be free form or structured. One common format

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Acupuncture and Acupressure

for a structured discussion is borrowed from Gestalt therapy. The facilitator asks the group “what” happened, “so what” this means to the group, and finally “now what” we can do with that information as we move on after group activity to another activity. Other forms of discussion may involve scaling techniques where group members are asked to rate how impactful the activity was for them using a scale of 1 to 10, with 10 being the most impactful, and then discussing their rating. In any case, the facilitator’s role is to help the group and its members create meaningful insights from an activity and to develop action plans for future use.

Further Readings Baim, C., Burmeister, J., & Maciel, M. (Eds.). (2007). Psychodrama: Advances in theory and practice. Advancing theory in therapy. New York, NY: Routledge/Taylor & Francis Group. Gass, M. A., Gillis, H. L., & Russell, K. C. (2012). Adventure therapy: Theory, research, and practice. New York, NY: Routledge/Taylor & Francis Group. Nickerson, E. T., & O’Laughlin, K. (Eds.). (1982). Helping through action: Action-oriented therapies. Amherst, MA: Human Resource Development Press. Wiener, D. J., & Oxford, L. K. (Eds.). (2003). Action therapy with families and groups: Using creative arts improvisation in clinical practice. Washington, DC: American Psychological Association.

Therapeutic Process The therapeutic process of activity-based group psychotherapy involves assessing the context, selecting the activity, conducting the activity, and discussing the impact of the activity. Sometimes, activity-based group psychotherapists will begin their group process with a warm-up activity. Warming up can be a method of getting the group into a frame of mind to engage in psychotherapy, or it can be a method for allowing group issues to surface. Those who use the latter approach to a warm-up activity would be following Moreno’s psychodrama format, in which he would use a warm-up activity as a method for choosing the protagonists for the drama. Therapists who use activities to set a mood often find it helpful to use the same opening activity for each session to communicate that now is the time for therapy to begin. Sometimes, a therapist will also use a final brief activity as a method for bringing closure to a session. Colleagues who have worked in prisons, mental hospitals, or residential treatment centers have found using bookend activities to be productive. In general, the discussion that follows an activity attempts to relate where the clients are with what actions they want to take once they leave the group. The group process of these discussion sessions utilizes group members’ insights into their peer’s behavior in a manner similar to the interpersonal group process. H. L. Gillis See also Gestalt Therapy; Group Counseling and Psychotherapy Theories: Overview; Psychodrama; Satir, Virginia; Transactional Analysis

ACUPUNCTURE

AND

ACUPRESSURE

Acupuncture (the insertion of fine sterile needles at certain points to assist in healing) and acupressure (the use of energy meridians for treatment via the application of pressure at particular points) are two techniques in Traditional Chinese Medicine (TCM). Since the Han dynasty (206 BCE–220 CE), these techniques have been documented to positively treat psychiatric illness and mental-emotional behavioral issues. Presently, mental health practitioners are working in tandem with acupuncturists to provide acupressure techniques in counseling sessions throughout the United States and abroad. To understand acupuncture’s and acupressure’s use in emotional and behavioral health, this entry references the historical and modern applications, as well as the pathophysiology base, and explains the TCM paradigm of a holistic system of body, mind, emotions, and qi (the energy of the body that conducts changes to the human emotions, mind, and body). This entry provides an introduction to understanding acupuncture’s and acupressure’s ability to assist clients in their goals with counseling and psychology.

Historical Context Recorded application of acupuncture and acupressure and the use of energy meridian systems have their roots in the Yellow Emperor’s Classic of Internal Medicine, a discussion between Huang Di and his physician Qi Bo about the complete

Acupuncture and Acupressure

Chinese Medicine system of the time (Han Dynasty) and the basis of today’s acupuncture paradigm. The Five-Element Acupuncture system was introduced in England by J. R. Worsely after he returned from training in Taiwan, Singapore, and Korea in the 1950s. In 1956, he established the College of Traditional Acupuncture in the United Kingdom. Trainings based on Worsely’s interest in the Five-Element Acupuncture system continue to this day. Interest in acupuncture in the United States was heightened in the early 1970s after President Nixon made a historical visit to China in 1972 and after the first acupuncture school in the United States was established in 1975. As China opened its doors to the West in the 1970s, TCM and Classical Chinese Medicine became more available throughout the world. In 1982, the U.S. Department of Education recognized the Accreditation Commission for Acupuncture and Oriental Medicine as a specialized and professional accrediting agency for Acupuncture and Oriental Medicine colleges, and the National Certification Commission for Acupuncture and Oriental Medicine was established and continues to administer all national Acupuncture and Oriental Medicine examinations. Because of the increase in accredited programs, there were approximately 30,000 nationally certified acupuncturists working in the United States as of 2013. Just as surgery and pharmaceuticals are treatments in Western medicine that use surgical tools and biochemistry, respectively, for treatment, acupuncture is a modality within TCM that uses energy meridians for treatment. To perform acupuncture, counselors need to complete a 5-year Oriental Medicine certified program, sit for a National Board, and become licensed in the state of their practice; but to use acupressure in session, one only needs to understand the system of points and applications of pressure. A counselor can utilize acupressure in session and maintain referral relations with licensed acupuncturists, to whom the counselor can refer clients as needed for clients’ benefits.

Theoretical Underpinnings The health of one’s body relates closely to the health of one’s emotions. Acupuncture and acupressure are modalities in TCM documented as the eighth and sixth branches, respectively, of the

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TCM paradigm for overall physical, mental, and emotional health care. The eight branches are: 1. meditation; 2. exercise, including tai qi and qigong, posture, focus, and breath; 3. nutrition and food; 4. cosmology, the time cycles influential to the wellbeing of a person—for example, waking nightly at 3 a.m. is a sign of Liver Meridian (depression, anger, or exhaustion), because an increased area of qi travels through the liver at 3 a.m., affecting a depressed liver and waking a person from deep sleep; 5. environment, or the relationship of nature, climate, season, location, work space, and home to a person’s energetics, which assists in harmonizing the person’s emotions, behavior, and health—for example, a dark, damp, cold room can lead to depression; 6. bodywork, including acupressure techniques such as tuina or massage; 7. herbology, or TCM pharmacology; and 8. acupuncture.

To comprehend acupuncture and acupressure at a basic level, one needs to understand the paradigm of the meridian system and organ system in TCM. TCM takes into account the effect emotions have on the body and how the body affects emotions. The health of the emotional-mental system is highly referenced in TCM, and TCM does not see the mind separate from the body or the emotions separate from physiology. For example, a person with migraine often has problems focusing in life; a person with chronic pain can be depressed or angry, or when someone is angry, he or she can have increased pain. Acupuncture and acupressure can be designed to alleviate mental and emotional complaints.

Major Concepts A number of major concepts are central to acupuncture and acupressure: qi; the yin–yang balance; TCM diagnosis; excess, deficiency, and disharmony; shen, qi, and jing; acupuncture and acupressure; the differentiation into Five Elements and their correspondences; and the meridian system.

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Acupuncture and Acupressure

Qi

In the United States, the word qi has been simplified to mean “energy,” which works for a basic understanding of qi, but in TCM, the word carries a specific meaning. The premise is that humans have both electrical and biochemical communication throughout their form and expression. The meridians and qi create our human form, our biochemistry, and our nervous system’s electrical potential and expression. In TCM, the definition of qi captures both of the “energetic” principles of movement: the form and the function. Gui qi is the energy and function of digestion, liver qi is the health of the form and function of the liver. Qi is in the blood, the meridians, air, water, and food. The Yin–Yang Balance

The symbol of yin–yang is one circular boundary of a whole, enclosing two colors flowing into each other from a small tail to a large area; within each side the opposite color will be seen an inner circle, signifying that there is yang in yin, or yin in yang (see Figure 1). This symbol represents the interplay and balance of opposites, as seen in the 24-hour cycle of day and night. TCM Diagnosis

A TCM diagnosis is a perception of the balance within six paired organ systems and/or Five

Element Groups and/or meridians and/or Three Treasures and/or simply hot/cold, inner/outer, deficient/excessive, stuck/overactive, or yin/yang. A TCM diagnosis is a relationship audit of balance. This may seem confusing at first, but each system of balance is assessed in TCM to establish the plan of care using acupuncture and/or acupressure. Excess, Deficiency, and Disharmony

An acupuncturist and professionally trained acupressure practitioner use the concept of balance when diagnosing clients. For example, a client may have excess grief, which can lead to respiratory illness—a presentation that would be labeled an excess to be treated. However, the same client may not be sleeping, leading to a deficiency of the adrenals, and he or she may also be anxious, which acupuncture and acupressure practitioners consider a shen disturbance (see the following subsection). All three signs and symptoms can be treated in one acupuncture or acupressure session. Shen, Qi, and Jing

Shen, qi, and jing are historically called the Three Treasures. Shen is a term for the quality of all thought, intellect, and emotional balance within the cognitive arena. This term is frequently used in mental health TCM diagnoses. Qi is a term used for energetic form, function, movement, and strength. Qi can be excess, deficient, in disharmony, or stagnant in the client. Jing is the amount of health and vitality at birth. Jing can be enhanced by good food, a balanced life, and limited stress when practicing a quiet mind and focused exercises. If a healthy teenager has a good amount of jing and balanced shen, the eyes shine and the muscles are strong. A 95-year-old person could have bright shen, but jing may become deficient and exhausted from supplying life for 95 years. Acupuncture and Acupressure

Figure 1 Yin–Yang Symbol Source: By Gregory Maxwell, via Wikimedia Commons (public domain). Retrieved from http://commons.wikimedia .org/wiki/File%3AYin_yang.svg

As noted previously, acupuncture refers to the act of inserting fine sterile needles into acupuncture points, whereas acupressure refers to the

Acupuncture and Acupressure

application of pressure to an acupuncture point. Acupuncture and acupressure treatments use a “keyboard of acupuncture points” to adjust the excess, deficiency, or disharmony in and between the body and mind systems. Differentiation Into Five Elements and Their Correspondences

The Five Elements is a popular energy reference system used today that dates back to the Classical Chinese Medicine school of thought. The Five Elements are archetypal energies as described by the Classical Chinese culture of a cyclical and balancing interaction of physical, mental, and emotional correspondences. This school of thought provides diagnoses and treatments that sometimes differ from other TCM schools of thought. The Five Element correspondences include the meridians, paired organs, and predominate emotions. The following is a simplified list of the Five Elements and their respective correspondences: Fire—heart and small intestine; joy and excitement/ overwhelming Earth—spleen and stomach; thought, thinking, nurturing, and pensiveness Metal—lung and large intestine; boundaries, sorrow, and release Water—kidneys and bladder; fear, fright, strength, and energy Wood—liver and gallbladder; growth, anger, and depression

Meridians

Meridians are the pathways of qi. There are 12 main, 12 divergent, and eight extraordinary meridians, with approximately 400 points with bilateral representation. The traditional names of these meridians reference the yin–yang principle, but over the course of history, they have been simplified to Gallbladder Meridian or Stomach Meridian, reflecting the primary organ of the meridian. Original point names reference the usage of the point. An example is Shenshu (mind, emotions),

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which means Shen Master Point and is now often called Bladder 52. Shencang (mind or spirit storehouse) is a point used in energy psychology tapping and is used in TCM for cough, asthma, chest pain, and strengthening of the adrenals (energy) while calming the mind.

Techniques Acupuncture and acupressure techniques vary extensively in application and point formula rationale in Classical Chinese Medicine, Japanese acupuncture, and acupuncture as performed by MDs, DCs, and other health professionals. Point formula rationale assists in the decision making of which points to use during treatment. The diagnostic results and protocols are based on individual training. Differences in acupuncture techniques can be seen in the needle gauge, the depth of insertion, the manipulation of the needles, the formula of points, the diagnosis, the length of retaining the points, and the acupuncturist’s rapport with the client. It is important to understand the experience of the acupuncture modality, for client outcome can be  relative to  the rapport and specialization of the acupuncturist. An acupuncture session often includes an intake that examines all aspects of the client’s health and life: environment, family life, emotional state, mental and/or physical challenges, and desired outcome. The client’s pulse will be taken for attributes recognizable in diagnostic assessment. An assessment of the client’s tongue color, size, and coating allows the practitioner to evaluate excesses, deficiencies, and disharmony and to determine treatments. For example, a pale tongue denotes blood deficiencies often seen in anxiety disorders; therefore, protocols to restore the blood production often decrease anxiety. A more purple tongue will direct the practitioner to liver qi stagnation or blood stagnation due to a deficiency of qi, often seen in depression. The coating and size of the tongue provide additional information concerning the digestive system and the ability to hold mental clarity. Learning tongue diagnosis is beneficial to understanding TCM and can be utilized in mental health assessments.

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Adler, Alfred

An acupressure session is less complex. In an acupressure session, only the application of manual pressure to an acupuncture point is necessary, but adding breathing and focusing instructions can enhance the results.

See also Emotional Freedom Techniques; Energy Psychology; Herbal Medicine; Non-Western Approaches

Further Readings

Therapeutic Process When a client first starts an acupuncture session, he or she will have a complete history assessment. In concert with the practitioner, he or she will establish mental, emotional, and physical goals. This energy paradigm asserts that emotional distress can manifest behaviorally, systemically, neurologically, cognitively, and chemically. When acupuncture needles are inserted or gentle acupressure from a professional provider is given, the body relaxes. Acupressure results depend highly on the practitioner’s rapport with the client and the practitioner’s training. Acupuncture is not as limited by rapport. With stress being a main issue in activities today and with the amount of high sensory-level stimuli, an acupuncture or acupressure session can provide deregulation of the limbic system and decrease sympathetic arousal. An acupuncture session can last from 20 to 60 minutes. The length of acupuncture treatments depends on the diagnosis. A common complaint of anxiety from exhaustion or fright can be decreased or eliminated within one to three visits. Acupressure treatment often takes much longer than acupuncture treatment due to its weaker stimulus on the human system and the need for excellent rapport with the client. Acupuncture and acupressure treatments can assist in unblocking a depression, releasing energy from anger safely, and improving physical endurance for emotional challenges while increasing mental focus and improving sleep. Acupressure and/or acupuncture for grief can release emotional exhaustion with less stress and can support the body in processing the emotions with less fear. While treating the flexibility of emotions, behavior, or thought through a proper diagnosis, counselors can use an acupressure protocol of energy psychology, TCM, or the Five Element paradigms to quickly improve outcomes. Referral relationships between acupuncturists and counselors can be positive and educational for both professionals. Wanda Warren

Flaws, B., & Lake, J. M. (2001). Chinese medical psychiatry: A textbook and clinical manual. Boulder, CO: Blue Poppy Press. Hammer, L. I. (1990). Dragon rises, red bird flies: Psychology and Chinese medicine. New York, NY: Station Hill Press. Jarrett, L. S. (1998). Nourishing destiny. Stockbridge, MA: Spirit Path Press. Larre, C., Rochat de la Vallee, S. J., & Rochat de la Vallee, E. (1995). Rooted in spirit: The heart of Chinese medicine, a sinological interpretation of chapter eight of Huangdi Neijing Lingshu (S. Stang, Trans.). New York, NY: Station Hill Press. Maciocia, G. (2009). The psyche in Chinese medicine. Edinburgh, England: Churchill Livingstone. Ni, M. (1995). The yellow emperor’s classic of medicine: A new translation of the Neijing Suwen. Boston, MA: Shambhala.

ADLER, ALFRED Alfred Adler (1870–1937) developed a theory of personality and approach to counseling and psychotherapy that he called Individual (or Adlerian) Psychology. Although Adler was a colleague of Sigmund Freud’s in the Viennese Psychoanalytic Society (VPS) early in his career (1902–1911), his theory and approach to mental health evolved over time into an integration of cognitive, constructivist, existential-humanistic, systemic, and psychodynamic perspectives that focuses on prevention and education rather than merely remediation, mental health rather than mental illness, and client’s strengths, assets, and abilities rather than their weakness and disabilities. Adler was born in the village of Rudolfsheim, a suburb of Vienna, Austria, on February 7, 1870. He was the second of six children and had health problems most of his early life, including bouts with rickets, spasms of the glottis, and pneumonia. At the age of 3, his younger brother Rudolf died in his bed next to him. A year later, when he

Adler, Alfred

contracted pneumonia and became gravely ill, he  heard the physician telling his father that the young Adler was going to die. In addition to the numerous illnesses, Adler was twice run over in the streets. Adler’s strong awareness of death at an early age was a factor in his decision to become a physician. These issues of belonging, inferiority, weakness, compensation, and overcoming had a significant influence on the young Adler. He had poor eyesight and, due to his numerous physical ailments, was clumsy and uncoordinated as a child. He initially was a mediocre student. His mathematics teacher recommended to his father that Adler stop attending school and instead apprentice as a shoemaker. Adler’s father disagreed and encouraged the child to improve his academic skills. Subsequently, Adler became one of the best math students in the class. Encouragement became a key piece in Adler’s mature theory and practice. In 1895, Adler completed his medical degree and graduated from the University of Vienna with a specialization in ophthalmology. Given Adler’s theoretical views on compensation and striving to overcome real or perceived inferiorities, his specialization in ophthalmology could have been a compensation for poor eyesight. And his decision to pursue medicine may have been due to a desire to overcome or forestall death. Adler became interested in the rising socialist movement in Vienna. He began attending meetings and there met Raissa Timofeyewna Epstein. They married in 1897. Raissa was a staunch socialist and a feminist who continued her active interest in political affairs throughout their marriage. More of a humanist than a socialist, Adler was nonetheless very interested in and influenced by the social equality philosophy in socialism. Early in Adler’s work as a physician, he switched from ophthalmology to internal medicine. He noted that the diseases that many of his patients contracted originated in the social environments in which they lived and worked. The location of Adler’s practice in Vienna allowed him the opportunity to work with persons from middle and lower socioeconomic situations. Adler’s practice was also located near the local circus in Vienna, and he regularly treated the performers, who historically were called sideshow freaks. He was intrigued by the relationship between their

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physical abnormalities and their choice of vocation and how their bodies compensated for their abnormalities. In 1902, Freud invited Adler and three other colleagues to meet with him on a Wednesday evening to discuss psychoanalytic theory and therapy. This meeting resulted in regular Wednesday meetings and, ultimately, led to the formation of the VPS in 1908. Adler became president of the VPS and was coeditor of the journal it published. Adler began his association with Freud with many of his own ideas, which he worked hard to conceptualize within the language of Freud’s psychoanalysis; however, the longer he remained in VPS and the more he developed his own ideas, the more difficult it became for him to adhere to Freud’s expectation of psychoanalytic orthodoxy. In 1911, Freud could no longer tolerate Adler’s lack of adherence, and this resulted in Adler resigning his membership of VPS. Adler disagreed with Freud’s biologically oriented psychosexual theory, as well as his belief that social influences contributed very little to the origins of psychological disturbances. Adler’s holistic understanding was that social-psychological (familial and societal) influences were foundational to clients’ presenting problems; biological influences were included but were not given the place of primacy as in Freud’s theory. In addition, Adler emphasized “oppression” over “repression”; that is, he noted that societal oppression of women (later, he expanded this to all groups of people who experienced oppression) resulted in disturbance for both individuals— women and men—and society as a whole. Adler’s break with Freud was indicative of both the man and his theory development. Adler was an early feminist and an advocate for the poor and oppressed. The experiences of his childhood—both the difficult experiences and the enjoyment he found in being with other children—along with the socialist political beliefs and activities of his wife, Raissa, clearly influenced his theory development. Furthermore, Adler was a voracious reader, and his professional and literary influences were extremely diverse. In addition to Freud’s initial influence, Adler noted his indebtedness to the Bible, the Stoics, and great authors such as William Shakespeare, Johann Wolfgang von Goethe, and Fyodor Dostoyevsky. In particular, Adler acknowledged the following as influential

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in the development of his approach: Henri Bergson, Immanuel Kant, Karl Marx, Fredrich Nietzsche, and, most important, Hans Vaihinger. Shortly after breaking with Freud, Adler and his colleagues founded a new group titled The Society for Free Psychoanalytic Research. He later changed its name to The Society for Individual Psychology. Adler decided to call his theory Individual Psychology, based on the Latin meaning of individuum—“indivisible” or “holistic.” As noted earlier, Adler’s theory development was an evolving process. His development of Individual Psychology can be viewed as occurring in two periods: (1) prior to World War I and (2) after the war. Prior to World War I, Adler was a psychoanalyst and maintained a private practice as a psychiatrist. During the war, Adler served as a military physician and saw the horrors of war firsthand. Subsequent to war, Adler added gemeinschaftsgefuhl (“community feeling”/“social interest”) to his theory. He stated that war occurred because of insufficient community feeling/social interest and not because humans have a desire to destroy themselves (as Freud had suggested). World War I obviously had a profound impact on Adler because gemeinschaftsgefuhl became the cardinal tenet of his theory. The addition and subsequent development of this construct, which emphasizes the role of belonging, compassion, and contributing to the common good of humankind, initiated the second period of Adler’s work and theory development. It is in this later period of his work that Adler focused more on issues of social equality, prevention and education, mental health, and normal human development. In this period, Adler functioned more as a social and community psychologist, philosopher-educator, and counselor. From 1926 onward, Adler spent much of the time during the fall and winter months in the United States lecturing, conducting clinics, and in private practice. He held a visiting professor position at Columbia University and lectured at Harvard University and the City College of New York, among others. In 1932, Adler joined the faculty of Long Island College of Medicine (known today as SUNY Downstate College of Medicine) as Professor of Medical Psychology. As the Fascists came to power in Austria, he and Raissa moved permanently to the United States in 1935. That year also marked the founding of the International Journal

of Individual Psychology. Adler’s heavy schedule of teaching, writing and editing, lecturing, and giving demonstrations worldwide took a heavy toll. In 1937, while concerned with the fate of his daughter Vali, who had disappeared in Russia, Adler experienced chest pains during a lecture tour in Europe. The attending physician advised him to rest, but Adler ignored the advice and continued on with the tour. On May 28, 1937, in Aberdeen, Scotland, Adler suffered a heart attack and died while taking a walk prior to a scheduled lecture. Albert Ellis stated that Adler, even more so than Freud, was the true father of modern counseling and psychotherapy. Many scholars have noted that Adler’s ideas have permeated contemporary approaches to counseling and psychotherapy, typically using different nomenclature and without any recognition of Adler and his work. In sum, more has been borrowed, without acknowledgment, from Adler’s work than from any other author. Nevertheless, Adler’s psychology and approach to counseling continue to be an important theory and practice perspective. There are numerous Adlerian societies and associations throughout the world (e.g., North American Society for Adlerian Psychology), and several journals focused on the theory and practice of Adlerian psychology and counseling (e.g., Journal of Individual Psychology). Richard E. Watts See also Adlerian Group Therapy; Beck, Aaron T.; Classical Psychoanalytic Approaches: Overview; Cognitive-Behavioral Therapies: Overview; Constructivist Therapies: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Couples, Family, and Relational Models: Overview; Ellis, Albert; Frankl, Viktor; Freud, Sigmund; Kelly, George; Mahoney, Michael J.

Further Readings Carlson, J., Watts, R. E., & Maniacci, M. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association. Ellenberger, H. L. (1970). The discovery of the unconscious. New York, NY: Basic Books. Hoffman, E. (1994). The drive for self: Alfred Adler and the founding of individual psychology. Reading, MA: Addison-Wesley.

Adlerian Group Therapy Mosak, H. H., & Maniacci, M. (1999). A primer of Adlerian psychology. Philadelphia, PA: Accelerated Development/Taylor & Francis.

ADLERIAN GROUP THERAPY Adlerians believe that psychological issues are rooted in efforts to establish satisfying social interests. Groups provide the opportunity for individuals to openly discuss feelings of isolation and insecurity in a supportive setting. Feelings of inferiority can be challenged and mistaken notions addressed by feedback offered by the leader and the members. Group members challenge each other to remain focused on strengths and the ability to make behavioral and attitudinal changes in the present that reflect their values for future living. Adlerian group experiences foster members’ development of a more authentic and socially accurate perception of themselves and of others within their group as well as in their natural social environment. Members should be more socially oriented, personally integrated, and goal directed when the group ends. Group members often become aware that many of their problems and issues are related to their efforts to pursue social purposes.

Historical Context As an advocate of social justice and socially oriented change, Alfred Adler (1870–1937) initially introduced a group approach to increase the efficiency of psychotherapeutic intervention in child guidance centers in the early 1920s. Since that time, Adlerian therapists, most notably Rudolph Dreikurs, popularized the approach in the United States. Accordingly, Adlerian group work perspectives have contributed to a theoretical understanding of early vocational career choice, volunteerism and service commitment, and, in particular, school counseling. Today, Adlerian group work is flexible, pragmatic, and oriented toward impactful outcomes that address client discouragement and difficulties in living. Adlerians strive to take full advantage of each therapeutic moment, recognizing that future opportunities to interact with clients are limited

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and uncertain. This approach is integrative in spirit, and specific techniques employed during group work are considered subordinate to relevance and potential benefit to a clients’ particular situation.

Theoretical Underpinnings Adler rejected the Freudian notion of sexuality and instinctual drives as the primary motivational force for living. Instead, Adlerians emphasize that the psychosocial factors of ultimate importance to civilization are social feeling, concern for the community, and the need to associate and cooperate with people in three main life tasks: society, work, and love. Adler emphasized how the dynamics of interpersonal experiences, such as parent–child relationships, relate to purposeful engagement in socially adaptive life tasks. Adler’s Individual Psychology focuses on the importance of each person’s unique perspective on life. This phenomenological perspective recognizes that situational experiences and problems have different meanings for and effects on different people. Adler believed that life pursuits are aimed at purposeful ends characterized by growth and expansion. While Adlerians consider the past behavior patterns of individuals, these patterns are interpreted not as deterministic of the present and the future but as indicative of continuity of goals and pursuits. Therapeutic intervention is targeted at increasing awareness and providing curative feedback. Awareness may involve individuals understanding more clearly how values and life goals are related to core beliefs about overcoming insecurities. The awareness may foster insights into new choices and commitments for living. Adlerian group work recognizes individuals as creative, purposive, and self-determined in their strivings for growth. Adler’s teleological stance recognizes individual freedom and that people are best understood by looking ahead to what they are striving to accomplish, as opposed to determination of past experiences.

Major Concepts A number of major concepts constitute the basis of Adlerian group therapy. Some of these include feelings of inferiority and striving for superiority, style

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of life, social feeling, present-oriented focus, phenomenological stance, holism, and cultural sensitivity. Feelings of Inferiority and Striving for Superiority

Early-childhood experiences of helplessness and dependence support personal feelings of inferiority and insecurity. These feelings of inferiority motivate striving for superiority or efforts to master the environment by compensating for the feelings of inadequacy. Individual pursuit of a “perfect life” represents the major motivational force for developing strengths and resources for living. Individuals are often discouraged when they act on mistaken notions or faulty assumptions that increase distress. Individuals are viewed as self-determined and creative free thinkers interested in lives of meaning and purpose as they experience increased awareness of the validity of the beliefs and goals that actually underlie their actions. Style of Life

Style of life is the manner in which a person lives his or her life and is reflected in all of a person’s cognitions and behaviors. The style of life also is a reflection of how a person has responded to the early feelings of inferiority. One goal of Adlerian therapy is to have the client be able to adapt his or her unique attitudes and skills in a manner that is not unduly influenced by the early feelings of inferiority as he or she pursues his or her life goals in society, work, and love. This style of life incorporates strategies and personally held beliefs about achieving a prototypical good life that is free from insecurities and imperfections. Social Feeling

Social feeling is the core Adlerian concept that life’s significant tasks are situated in social environments. That is, life is about learning to negotiate and invest in the social milieu. Family atmosphere is perhaps the most fundamental social setting. The dynamics of birth order and family dynamics play a central role in early beliefs about the social world and one’s place in it. Groups provide opportunities for members to experience social feeling and as such are natural settings facilitating personal

growth. Therapeutic groups provide individual members with opportunities to self-challenge and receive feedback about assumptions related to discouraged feelings. Group experiences are expected to promote members’ growth in their ability to accept themselves and others. Present-Oriented Focus

Adlerians maintain a consistent present-oriented focus on beliefs that motivate goal-oriented strivings. For example, short-term, school-based groups incorporate psychoeducational skills training for teachers, parents, and children. Adlerians consider school-based behavioral issues as an indication of mistaken goals (e.g., desire for attention). Similarly, parent-training groups focus on helping parents gain awareness of how interactional and parenting behaviors affect the quality of their relationship with their children. Phenomenological Stance

Adlerian constructs include a phenomenological stance, which is concerned with the subjective nature by which people perceive the world. Individuals have a unique and personal perspective on their own life situation. Adlerian group experiences encourage individuals to interact with peers who may or may not share the same assumptions and yet find commonality in the group experience. In sharing experiences as they see them, members are exposed to different points of view that may foster growth in personal insight and awareness of their life situation. Holism

The Adlerian concept of holism emphasizes understanding the entire person (thoughts, feelings, actions) in the context of a number of socially embedded contexts. That is, individuals are multifaceted and function in different relationshiporiented roles. For example, persons in their daily lives function as parents, coworkers, bosses, children, husbands, and wives. Yet it is as an integrated individual that each person pursues the tasks of living. Adlerian groups afford members a reflection of real-life situations. Adlerian group leaders are interested in the interpersonal dynamics of group members (including the functional roles they adopt

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in-group) more than the intrapsychic dynamics characteristic of psychodynamic approaches. Social maneuvering within the group is diagnostic of beliefs (often faulty or mistaken) and underlying strategies for accomplishing the tasks of life. Individuals can experiment with interactions and receive feedback in a safe and structured social environment. In doing so, potential lessons for adaptive living outside the group may be learned.

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involves helping individuals to be courageous in actions for creating new patterns of behavior, developing strengths and resources, and, ultimately, developing a new style of life. Individuals are encouraged to act as if they were free of insecurity and emotional distress. By acting as if the desired conditions of living exist, individuals can experience the benefits and perhaps gain confidence for committing to action that is more adaptable to their life situation.

Cultural Sensitivity

Adlerian group work is especially applicable with diverse populations. Adlerians are keenly focused on how individuals adapt to living from culturally diverse points of view. Members’ phenomenological reflections on their cultural and contextual worldviews contribute to the dynamics of group interactions and provide individuals opportunities to experience a diversity of perspectives on their own situation.

Techniques Adlerians employ a number of assessment strategies to facilitate member growth of awareness. Early recollections are viewed as important indicators of individuals’ attitudes and beliefs in life. Reasoning that we remember events that have personal significance, members are asked to describe their earliest memories. Adlerians use early memories to get a clear sense of feelings of inferiority, mistaken notions, guiding goals in life, present attitudes, social interest, and possible future behavior. The question “How would your life be different if you didn’t have this problem?” is used to promote reflection on problematic life circumstances. Leader interventions and member feedback raise awareness perhaps by attacking faulty logic to highlight possible alternative perspectives and action choices that might improve the situation. Adlerians believe that individuals are responsible for the progress and changes in their lives. A supportive group environment encourages individuals to risk self-disclosure in a nonthreatening setting. Cooperative groups support feelings of trust, belonging, and nonjudgmental acceptance. Supportive feedback encourages members to courageously express their discouragement, and they recognize that they are not alone in a given predicament. Adlerians believe that encouragement

Therapeutic Process Adlerian group work involves the investigation and interpretation of how one’s understanding of one’s early life experiences motivates strategies for living in a structured group setting. Groups provide opportunities for members to practice interaction skills with others in a safe environment, with the goal of generalizing growth and awareness to their social situations in life. Adlerian groups have four distinct stages. The initial group session is concerned with establishing trust and maintaining cooperative and collaborative relationships among group members. Individuals are asked to commit to helping each other pursue growth by actively participating and providing thoughtful, authentic, and nonjudgmental feedback. They are also encouraged to risk disclosure. The second stage, analysis and assessment, is concerned with self-assessment and open exploration of one’s lifestyle and how it affects one’s pursuit of valued life tasks. The assessments involve using early memories, dreams, family constellations, and behavior in social settings to explore goals and values. Group members and leaders support this exploration by offering interpretations and summaries of the issues raised. Members may identify assets and strengths as well as possible mistaken notions and personal mythologies that influence their interaction with others in their particular life situation. The third stage, awareness and insight, is concerned with recognizing the value of focused reflection for behavior change. The group setting is effective in helping individuals gain awareness of mistaken goals and mistaken notions through leader interventions and member feedback offered as possible interpretations for client consideration. As individuals consider the relevance of the

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feedback in the group setting to their lives, subsequent group interactions provide an opportunity for verifying hypotheses related to current perceptions and actions in a given situation. Ultimately, individuals begin to understand and accept responsibility for creating and maintaining problematic behavior and to consider how they might be able to improve the situation. The fourth stage, reorientation and reeducation, is concerned with empowering individuals to rethink and challenge current beliefs and attitudes about life and ultimately commit to a new way of living. Individuals are encouraged to take risks and make changes based on their group experience. Individuals are empowered to act on their enhanced selfawareness and, when necessary, “catch themselves” by learning to identify the signals of problematic behavior or emotions. In doing so, individuals emerge from the therapeutic group process with a new and creative perspective for pursuing life goals. Richard J. Ricard See also Adler, Alfred; Adlerian Therapy; Group Counseling and Psychotherapy Theories: Overview

Further Readings Adler, A. (1958). What life should mean to you. New York, NY: Capricorn. (Original work published 1931) Carlson, J., Watts, R. E., & Maniacci, M. (2006). Alderian therapy: Theory and practice. Washington, DC: American Psychological Association. Mosak, H. H., & Dipietro, R. (2006). Early recollections: Interpretive method and application. New York, NY: Routledge. Mosak, H. H., & Maniacci, M. P. (1999). Primer of Adlerian psychology. New York, NY: Brunner/ Routledge. Sonstegard, M. A., & Bitter, J. R. (2004). Adlerian group counseling and therapy: Step by step. New York, NY: Brunner/Routledge.

ADLERIAN THERAPY Adlerian therapy, developed by Alfred Adler (1870–1937), is an encouragement-focused counseling approach that focuses on prevention and education rather than merely remediation, mental

health rather than mental illness, and clients’ strengths, assets, and abilities rather than their weakness and disabilities. Early in his career, Adler was a colleague of Sigmund Freud, but his theory and practice of counseling evolved over time into an integration of cognitive, constructivist, existential-humanistic, systemic, and psychodynamic perspectives. Consequently, it is difficult to situate Adlerian therapy in one theoretical category (e.g., psychodynamic, existential-humanistic, or cognitive). Scholars have suggested that Adler’s most important contribution may have been his influence on other theoretical approaches. Adler’s influence has been acknowledged by—or his vision traced to—neo-Freudian approaches, existential therapy, person-centered therapy, cognitive-behavioral therapies, reality therapy, family systems approaches, and, more recently, constructivist and social-constructionist (e.g., solution focused and narrative) therapies. A study of contemporary approaches to counseling and psychotherapy reveals that many of Adler’s ideas have appeared in these modern perspectives with different nomenclature and often without giving Adler the due credit. Albert Ellis did acknowledge Adler’s tremendous influence. He stated that Adler, more so than Freud, is the true father of modern psychotherapy.

Historical Context Adler was born in a suburb of Vienna, Austria. He attended public school in Vienna and then trained as a physician at the University of Vienna. Adler graduated with a specialization in ophthalmology and entered private practice. Shortly thereafter, he switched to general practice and then to neurology. In 1902, he was invited by Freud to join a Wednesday evening discussion group. This group later became the Vienna Psychoanalytic Society, and Adler served as its president and as coeditor for the journal it published. Between 1902 and 1911, Adler attempted to work within the boundaries of orthodox psychoanalysis as defined by Freud. However, Adler’s fundamental assumptions were different from Freud’s, and eventually the two reached a breaking point. Adler resigned from the society in 1911 and formed a new group that was originally named The Society for Free

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Psychoanalytic Research. He later renamed it The Society for Individual Psychology. After his break from Freud, and prior to and during World War I, Adler worked as a psychiatrist in private practice and rapidly expanded his version of psychoanalysis. During this time, however, his work focused on abnormal human behavior and seemed very psychoanalytic. During the war, Adler served as a military physician, and his experience of the war affected him profoundly. After the war, Adler was more interested in normal human behavior, and his approach to helping people became progressively more encouragement focused, with an emphasis on clients’ strengths and abilities. During this later period, Adler functioned less like a psychiatrist and more like a community and social psychologist, philosopher-educator, and counselor. In the main, contemporary Adlerian psychology and counseling are based on Adler’s postwar period (ca. 1920–1937) and subsequent developments by later Adlerians. Those who practice classical Adlerian therapy, however, base their work on Adler’s prewar theory and therapy.

Theoretical Underpinnings Individual Psychology, or Adlerian psychological theory, is often misunderstood as primarily focusing on individuals; however, Adler chose the name “Individual Psychology” (from the Latin, individuum, meaning “indivisible” or “holistic”) for his theoretical approach because he disdained reductionism. An integration of cognitive, constructivist, existential-humanistic, psychodynamic, and systemic perspectives, Adlerian theory is holistic, phenomenological, socially oriented, and teleological (goal directed) in its approach to understanding and working with people. According to Adlerian theory, humans are proactive and creative with regard to the development of their style of life (or lifestyle), the Adlerian nomenclature for personality. Because they are proactive and creative, humans concomitantly function like both playwrights and actors in constructing their own personalities within a socially embedded context. Thus, Adlerians believe that humans co-construct the realities to which they respond. Similar to other existential-humanistic perspectives, Adlerians affirm that the central human

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directionality is toward competence, completeness, or mastery, what Adler called striving for perfection or superiority. This is the individual’s creative and compensatory answer to the normal and universal beliefs that one is less than one should be and the accompanying feelings of insignificance and disempowerment (i. e., feelings of inferiority). This striving is the natural human desire to move from a perceived negative position to a perceived positive one. This striving occurs in a relational context and may occur in either a socially useful or a socially useless manner. How a person chooses to strive constitutes the Adlerian criterion for mental health: Healthy development follows the goal of  gemeinschaftsgefuhl, which is translated as “community feeling” or “social interest”; maladjustment is the consequence of pursuing narcissistic self-interest. According to the Adlerian perspective, when persons creatively respond with courage and community feeling or social interest to the challenges of life and feelings of inferiority, they are considered to be functioning well. When they avoid the tasks of living, or if they respond without community feeling or social interest, they are discouraged and may have what Adler called an inferiority complex. Persons with this complex are overly concerned with how others perceive them, more so than they are with finding solutions to problems. The superiority complex is a socially useless attempt to overcome an inferiority complex. Persons with an inferiority complex tend to be passive and withdrawing. Persons compensating for inferiority feelings by the superiority complex tend to be arrogant and boastful. In both cases, the persons are discouraged but responding to overwhelming feelings of inferiority in different ways.

Major Concepts Some of the major concepts associated with Individual Psychology include the style of life; gemeinschaftsgefuhl, or community feeling or social interest; striving for perfection or superiority; and discouragement. Style of Life

Style of life (or lifestyle), the Adlerian term for personality, is a cognitive blueprint or personal

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metanarrative containing a person’s unique and individually created convictions, goals, and personal beliefs for coping with the tasks and challenges of living. The style of life is uniquely created by each person, begins as a prototype in early childhood, and is progressively refined throughout life. The style of life organizes and simplifies coping with the world by the following functions: It assigns rules and values; it selects, predicts, and anticipates; its perceptions are guided by its own “private logic”; it selects what information it allows to enter, what it will attend to, what affects will be aroused, and what its response will be. Gemeinschaftsgefuhl

The cardinal tenet of Adlerian psychology is gemeinschaftsgefuhl, a German word typically translated as “community feeling” or “social interest.”Both community feeling and social interest are needed for a holistic understanding of gemeinschaftsgefuhl; that is, community feeling addresses the affective and motivational aspects and social interest the cognitive and behavioral ones. Thus, true community feeling (i.e., sense of belonging, empathy, caring, compassion, and acceptance of others) results in social interest (i.e., thoughts and behaviors that contribute to the common good, the good of the whole, at both micro- and macrosystemic levels); true social interest is motivated by community feeling. Striving for Perfection or Superiority

The central human directionality is toward competence or self-mastery, what Adler called striving for perfection or superiority. Adler’s understanding of “striving” evolved over time, and he used various words like completion, mastery, perfection, and superiority to describe how humans seek to move from the present situation, as observed and interpreted, to a better one, movement to a status that is superior to the present one. How one strives, and the manifest behaviors, are predicated on one’s community feeling or social interest. According to Adler’s mature theoretical formulation, striving for perfection means that one is striving toward greater competence, both for oneself and for the common good of humanity, a horizontal striving that is useful both for self and

for others, seeking to build both self- and otheresteem. In contrast, striving for superiority means to move in a self-centered manner, seeking to be superior to others; a vertical striving that primarily pursues personal gain without contribution to or consideration of others and the common good. Discouragement

Adlerians do not view clients as sick and in need of a cure. Rather, clients are viewed as discouraged, as lacking the courage to engage in the tasks of living. Adlerians affirm that early existential decisions about self and the world—decisions made within and in relation to the first sociological environment, the family—form the core convictions of a client’s style of life. Many of the early-formed convictions may have been useful for a child to belong to and survive in his or her early environment, but later they may prove no longer useful for productive living. Since Adlerians view clients as discouraged rather than sick, they thus view client symptoms from a proactive rather than a merely reactive perspective. Symptoms are selected and chosen because they are perceived as facilitating movement toward a desired goal. In other words, symptoms are not merely reactions to situations, but rather, they are attempted solutions.

Techniques As noted earlier, contemporary Adlerian counseling and psychotherapy are an integration of cognitive, constructivist, existential-humanistic, systemic, and psychodynamic perspectives. This integrative perspective allows counselors to be therapeutic chameleons in their work with clients. The beauty of the Adlerian approach to therapy is its flexibility; Adlerians can be theoretically consistent and technically eclectic. Adlerian therapy allows the counselor to do whatever is in the best interest of his or her client, rather than forcing the client—and his or her unique situation—into a narrow, inflexible framework; that is, it allows the therapist to be a therapeutic chameleon. That is not to say, however, that Adlerians have not created techniques of their own. Although not an exhaustive list, the following subsections note some of the most commonly used techniques developed by Adlerians,

Adlerian Therapy

including encouragement, style-of-life analysis, the question, hypothesis interpretation, acting as if, catching oneself, and the pushbutton technique. Encouragement

Encouragement is not merely a technique, but  rather it is a way of being with clients. Encouragement can be understood as the modeling of community feeling or social interest. Clients present for counseling because they are discouraged and, consequently, lack the confidence and “courage” to successfully engage in the tasks or problems of living. The process of encouragement helps build hope and the expectancy of success in clients. In addition to building a strong client– counselor relationship, Adlerians use encouragement throughout the counseling process to help clients create new patterns of behavior, develop more encouraging perceptions, and access resources and strengths. Adlerian counseling and psychotherapy are an encouragement-focused approach. Encouragement skills or techniques include the following: valuing clients as they are; demonstrating concern for clients through active listening, respect, and empathy; focusing on clients’ strengths, assets, and abilities, including identifying past successes, and communicating confidence in clients; helping clients generate perceptual alternatives for discouraging fictional beliefs and oppressive narratives; helping clients distinguish between what they do and who they are (deed vs. doer—the problem is the problem); focusing on clients’ efforts and progress; communicating affirmation and appreciation to clients; and assisting clients to see the humor in life. Style-of-Life Analysis

There are several different ways for counselors to conduct a style-of-life analysis. Some conduct the interview in the first session, while others take two or three sessions to complete it. Some interviewers utilize a standard format for the assessment, whereas others may collect the information more informally. However, Adlerian counselors typically include an interview that leads to a formulation or summary of the client’s style of life that is shared with the client. These interviews, based on clients’ memories of their family of

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origin, have many common subject areas that are explored. Interviewers ask about relationships with siblings and influence of parents. This gives the counselor information about the client’s perceived ordinal position (or psychological birth order), the family constellation (how each person related to the other), and the family atmosphere (the overarching “mood” of the family). Next, Adlerian counselors ask about the client’s childhood physical development, sexual development, social development, and school experience. Counselors also ask about clients’ local community and socioeconomic status to help determine their view of themselves and the family’s position in the larger world. The final phase of the interview is the collection of early-childhood recollections. Early memories are not coincidences; they are often projections. In large measure, what we selectively attend to from the past is reflective of what we believe and how we behave in the present and what we anticipate for the future. Each early recollection elicited by the counselor should be a single, specific incident preferably occurring before the age of 10 years. Interviewers collect anywhere from three to eight early memories. Having gathered all the aforementioned data, the counselor has all the information necessary to create tentative hypotheses about a client’s style of life—patterns of behavior, way of viewing themselves and the world around them, and so on—which are then presented to the client. The Question

In using the question technique, counselors ask a variation of the question that Adler developed: “How would your life be different if you no longer had this problem?” There are variations for dramatic or explanatory purposes. There are three possible responses to the question. One type of response indicates that the symptom is purely psychological in nature. The second type reflects the belief that the symptom is purely physical in nature (i. e., chronic pain, condition, or illness). The third type of response is a combination of the two. The question forces clients to think in terms of a new reality where they are no longer burdened by their presenting problem. As a result, either clients will be unable to hide what their symptom is doing for them (i.e., the usefulness or “purpose” of the

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behavior), or they will feel a sense of encouragement because they begin to understand that they have the resources and abilities to overcome the problem. Hypothesis Interpretation

The purpose of using hypothesis interpretation is to convey to the client that more than one explanation for the behavior exists and that the counselor wants to check out his or her own hunches to see if they are on the mark. When using this technique, phrasing is important. For example, after reviewing the style-of-life assessment, a counselor may start the interpretation process with “Could it be that . . . ?” or “Is it possible that . . . ?” Interpretations phrased in this way provide the client an opportunity to let the counselor know if he or she is on the right track. Acting As If

Using the “acting as if” technique, counselors ask clients to begin acting as if they were already the person they would like to be—for example, a confident individual. Counselors ask clients to pretend and emphasize that they are only acting. The counselor suggests a limited task, such as acting as if one had the courage to speak up for oneself. The expectation is that the client will successfully complete the task. If the task is unsuccessful, then the counselor explores with the client what kept him or her from having a successful experience. A more reflective approach, called “reflecting as if,” asks clients to take a “reflective” step back prior to stepping forward to act “as if.”This process encourages clients to reflect on how they would be different if they were acting “as if” they were the person they desire to be. By using reflective questions, counselors can help clients construct perceptual alternatives and consider alternative behaviors prior to engaging in “acting as if” tasks. Catching Oneself

This technique involves encouraging clients to catch themselves in the act of performing the presenting problem. Clients may initially catch themselves too late and fall into old patterns of

behavior. However, with practice, clients can learn to anticipate situations, recognize when their thoughts and perceptions are becoming selfdefeating, and take steps to modify their thinking and behavior. “Catching oneself” involves helping clients identify the signals or triggers associated with one’s problematic behavior or emotions. When the triggers are identified, clients can then make decisions that stop their symptoms from overwhelming them. The Pushbutton Technique

The purpose of this technique is to help clients become aware of their role in maintaining, or even creating, their unpleasant feelings. The pushbutton technique has three phases. In Phase 1, clients are asked to close their eyes and recall a very pleasant memory, a time when they felt happy, loved, successful, and so on. Clients are to re-create the image in their minds in as specific detail as possible and strongly focus on the positive feelings generated by the pleasant memory. In Phase 2, clients are asked to close their eyes and recall a very unpleasant memory, a time when they felt sad, unloved, unsuccessful, and so on. As in Phase 1, clients are to recall the memory in all its clarity and, this time, strongly focus on the unpleasant feelings created by the memory. In Phase 3, clients are asked to retrieve another very pleasant memory or return to the one used in Phase 1. Again, they are to recall the memory in specific detail and strongly focus on the positive feelings. After they have relived the pleasant memory and positive feelings, clients are instructed to open their eyes. They are then asked to share what they learned from the exercise. Clients usually make the connection between beliefs and feelings. If they fail to do so, then counselors help them understand that certain thoughts or images usually generate certain types of feelings.

Therapeutic Process Adlerian counseling and psychotherapy are commonly viewed as consisting of four phases. The first and most important phase is called relationship. The client–counselor relationship is described as cooperative, collaborative, optimistic, and respectful. Most Adlerians believe that success in

Advanced Integrative Therapy

the other phases of the counseling process— assessment of the client’s style of life, helping the client develop insight, and reorientation/ re-education/action—is predicated on the development and maintenance of a strong client–counselor relationship. The fundamental goal of Adlerian counseling and psychotherapy is to help clients change discouraging style-of-life convictions (similar to core schema or personal metanarrative), experience and assimilate new information (i.e., restructuring or restorying), and engage in behavior change consistent with the more encouraging perspectives. Thus, Adler was doing cognitive restructuring or helping clients restory their personal narratives decades prior to the cognitive revolution or the advent of postmodern therapies. The ultimate goal for Adlerians is the development and expansion of clients’ social interest or community feeling. Richard E. Watts See also Adler, Alfred; Adlerian Group Therapy; Classical Psychoanalytic Approaches: Overview; CognitiveBehavioral Therapies: Overview; Constructivist Therapies: Overview; Contemporary PsychodynamicBased Therapies: Overview; Couples, Family, and Relational Models: Overview; Existential-Humanistic Therapies: Overview

Further Readings Adler, A. (1956). The individual psychology of Alfred Adler (H. L. Ansbacher & R. R. Ansbacher, Eds.). New York, NY: Harper Torch books. Adler, A. (1979). Superiority and social interest (H. L. Ansbacher & R. R. Ansbacher, Eds.; 3rd ed.). New York, NY: W. W. Norton. Carlson, J., Watts, R. E., & Maniacci, M. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association. Dinkmeyer, D., Jr., & Sperry, L. (2000). Counseling and psychotherapy: An integrated, Individual Psychology approach (3rd ed.). Upper Saddle River, NJ: Merrill/ Prentice Hall. Mosak, H. H., & Maniacci, M. (1999). A primer of Adlerian psychology. Philadelphia, PA: Accelerated Development/Taylor & Francis. Oberst, U. E., & Stewart, A. E. (2003). Adlerian psychotherapy: An advanced approach to Individual Psychology. London, England: Brunner-Routledge.

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Sweeney, T. (2009). Adlerian counseling and psychotherapy: A practitioner’s approach (5th ed.). New York, NY: Routledge. Watts, R. E. (1996). Social interest and the core conditions: Could it be that Adler influenced Rogers? Journal of Humanistic Education and Development, 34, 165–170. doi:10.1002/j.2164-4683.1996 .tb00342.x Watts, R. E. (Ed.). (2003). Adlerian, cognitive, and constructivist psychotherapies: An integrative dialogue. New York, NY: Springer. Watts, R. E. (2003). Reflecting “as if”: An integrative process in couples counseling. Family Journal: Counseling and Therapy for Couples and Families, 11, 73–75. doi:10.1177/1066480702238817 Watts, R. E., & Carlson, J. (Eds.). (1999). Interventions and strategies in counseling and psychotherapy. New York, NY: Routledge. Watts, R. E., & Critelli, J. (1997). Roots of contemporary cognitive theories and the Individual Psychology of Alfred Adler: A review. Journal of Cognitive Psychotherapy, 11, 147–156. Watts, R. E., & Pietrzak, D. (2000). Adlerian “encouragement” and the therapeutic process of solution-focused brief therapy. Journal of Counseling & Development, 78, 442–447. doi:10.1002/j.1556-6676.2000.tb01927.x

ADVANCED INTEGRATIVE THERAPY Advanced Integrative Therapy (AIT) regards the fundamental cause of human suffering to be trauma, which can create psychological disorders, physical illnesses, and spiritual issues. AIT’s theoretical perspective integrates aspects of quantum mechanics, neuropsychology, and spiritual philosophy with energy psychology and psychodynamic theory, as well as attachment therapy, analytical psychology, trauma theory, cognitive-behavioral therapy, transpersonal psychology, and body-centered psychotherapy. Treating the many areas in which trauma affects people, it focuses on the whole person rather than the psyche. It utilizes the gentle energetic removal of the aftereffects of trauma and transforms the negative beliefs that trauma engenders. It also utilizes the reparative relationship between client and therapist, energetic treatment of the brain’s trauma-caused dysfunctions, and meditation to effect healing and transformation.

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Advanced Integrative Therapy

Historical Context Under the name Seemorg Matrix Work, AIT was developed by psychotherapist and social worker Asha Clinton in the late 1990s. Since the first AIT training in 1999, more than 1,800 clinicians in the United States, Canada, Great Britain, Germany, Greece, Denmark, Poland, Guatemala, El Salvador, Argentina, and Mexico have learned it. AIT is taught in 3-day seminars, two of which introduce its foundational elements. Its 13 advanced seminars focus on the theory and treatment of particular types of trauma symptoms, for example, personality disorders, anxiety disorders, and posttraumatic stress disorder. Research studies are in progress.

Theoretical Underpinnings AIT posits that everything in a person is interconnected; therefore, trauma can affect every aspect of our being—physical, psychological, intellectual, and spiritual. For treatment to be fully effective, according to AIT, it must be able to target all those aspects. Furthermore, Albert Einstein posited that everything consists of energy. This includes all posttraumatic symptoms (e.g., emotions and behavior). The focused removal of such symptoms, in the form of energy, provides quick, gentle relief.

Major Concepts AIT defines trauma as any occurrence that, when we think back to it or when it is triggered by some present event, evokes difficult emotions and/or physical symptoms or sensations and gives rise to negative beliefs, desires, fantasies, compulsions, and/or obsessions. Trauma also leads to depression, negativity, anxiety, hallucinations, delusions, addictions, and/or dissociation; blocks or distorts the development of positive qualities and spiritual connection; and fractures human wholeness. Childhood and adult trauma can affect an individual throughout life, but ancestral and cultural-historical trauma can also distort adult character, behavior, beliefs, emotions, expectations, achievement, and purpose. AIT consists of protocols for treating all these aspects. In AIT, the psyche is understood to consist of multiple layers, each of which can be adversely

affected by trauma. Deep within the unconscious lies the center, which provides guidance and connection to the Divine and also contains the personal archetypes. Akin to objects, each of these is a nexus of qualities that, when stimulated into activity by life experience—trauma included— can act within us autonomously. Although much of the damage that trauma creates occurs in the ego and its connection to the center, the most deep-seated trauma can damage the archetypes and the center itself, both of which may require treatment. AIT recognizes that trauma, especially in childhood, is often at the root of the difficulties that bring clients into therapy, and that what is happening in the present that deeply triggers them likely repeats what happened in childhood. When various types of traumas (e.g., abandonment) repeat in an individual’s life, they form traumatic patterns, which, to stop repeating, also require treatment. AIT utilizes 13 major energy centers, each of which is a center of physical, psychological, and spiritual energy and can also contain posttraumatic energy. AIT treatment removes posttraumatic energy from these centers.

Techniques Single-incident trauma treatment begins when the client chooses and remembers a traumatic memory and then gets in touch with the emotions and physical sensations attached to that memory as well as he or she can. Then, the client places his or her hands in turn on the 13 major energy centers while repeating at each of them a phrase that briefly describes the trauma or symptom being treated. This process conditions the body to drain the traumatic energy, limiting beliefs, posttraumatic physical sensations, and other symptoms until they are completely and lastingly gone. This technique treats dissociated as well as conscious emotion and sensation. Particular traumas tend to repeat and form traumatic patterns. To remove the symptoms not only of the original traumas but also of later ones that repeat their content (e.g., a series of abandonment traumas), AIT uses 3-Step Transformation. In the first step, the AIT therapist energetically treats the original traumatic incident, including the

Adventure-Based Therapy

emotions that arise from the trauma as well as the significant aspects of what happened. The second step energetically treats the traumatic repetitions and their aspects. These often include beliefs, emotions, behaviors, and physical symptoms. The final step breaks the energetic connection between the original trauma and the traumas that developed from it. Once the connection is treated, the original trauma stops repeating. Although AIT’s advanced seminars offer more powerful treatments, for example, for  obsessive-compulsive disorder, posttraumatic stress disorder, anxiety, and depression, 3-Step Transformation forms the basis of AIT treatment.

Therapeutic Process AIT begins with history taking, establishing a connection between client and therapist, and the client’s development of trust in the therapist. Treatment begins with a process that establishes cooperation between the client’s ego and center, weakens resistance to treatment, and provides diagnostic information. By analyzing and diagnosing the client, the therapist next discovers and treats the major themes (e.g., neglect, abuse) that require treatment. When the therapist deems it appropriate, he or she offers the client meditations to do at home as well as at work to redevelop qualities destroyed by the trauma, for example, strength or compassion. As a part of this general therapeutic process, AIT’s advanced seminars offer theoretical understanding and treatments for negative beliefs, negatively constellated personal archetypes, damaged character structures, and specific diagnoses. Adding depth and efficacy to the process, these are interpolated into the therapy where relevant. Asha Clinton See also Analytical Psychology; Attachment Theory and Attachment Therapies; Object Relations Theory; Transpersonal Psychology: Overview

Further Readings Clinton, A. (2002). Seemorg Matrix Work: The transpersonal psychotherapy. In Energy psychology in psychotherapy, a comprehensive sourcebook (pp. 93–115). New York, NY: W. W. Norton.

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Clinton, A. (2006). Seemorg Matrix Work: A new transpersonal psychotherapy. Journal of Transpersonal Psychology, 38(1), 95–116. Mollon, P. (2008). Psychoanalytic energy psychotherapy. London, England: Karnac Books.

ADVENTURE-BASED THERAPY Adventure-based therapy is a therapeutic approach that utilizes multiple activities for groups or individuals, typically in an outdoor setting. Activities within adventure-based therapy include, but are not limited to, ropes courses, cooperative group games, guided journaling, and outdoor pursuits. Although applied differently based on the setting, adventure-based therapy tends to be founded on solution-focused and humanistic theories, which stress self-reflection, the importance of experience in the change process, and action if change is to occur. Three common models seen in adventurebased therapy are (1) Kolb’s experiential learning cycle, (2) the double diamond model, and (3) the adventure-based counseling model. The approach has multiple goals, the most common being teambuilding through group cooperation, cognitive and behavioral change through experiential learning, and stress relief through journaling and solitude. Adventure-based therapy is most often used in working with children, adolescents, families, and therapeutic groups; however, the approach is growing in popularity within individual therapy and with adult clients. Wilderness therapy, a subcategory of adventure-based therapy, tends to have more of a focus toward experiencing nature and overcoming physical and mental challenges through hiking and primitive survival strategies than adventure-based therapy.

Historical Context Adventure-based therapy was popularized in the 1960s in North America, but its roots can be seen as far back as ancient times. In fact, nature being used as a tool for healing can be seen throughout the history of many religions. Adventure-based therapy as a therapeutic approach came to North America in multiple forms throughout the 20th  century. In the early 1900s, psychiatric

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Adventure-Based Therapy

hospital patients stayed in tents outside the hospital in an effort to increase patient health and wellness by allowing them out of the hospital to experience nature. In the 1930s, camping programs for troubled youth emerged with the main emphasis being to offer experiential learning and recreation in the outdoors. During the 1960s, Outward Bound started a popular school in Colorado with a focus on adventure as a therapeutic instrument. This program focused on many different client groups (e.g., adolescents, prisoners, sexual assault victims, and substance abusers) and is credited with the implementation of ropes courses as trust and cooperation exercises. Soon, other schools took notice of the effectiveness of Outward Bound’s model and began their own programs utilizing some of the same activities in an effort to increase self-esteem, cooperation, and team building among their students. Project Adventure, one such school, created many of the activities and games that are used by adventure-based therapy practitioners today. Adventure-based therapy has increased in popularity over time and continues to grow. Today, many counseling and psychotherapy graduate programs offer an emphasis on or certification in adventure-based therapy.

Theoretical Underpinnings Adventure-based therapy is often described as experiential learning through relationship building and reflection with hands-on activities such as ropes courses, obstacle courses, and journaling. Although most commonly associated with solutionfocused and humanistic approaches, the approach can fluctuate greatly depending on the program, goal, agency, and practitioner. This is why the concepts of Carl Rogers, who focused on the importance of self-awareness and self-reflection, and Milton Erikson and William Glasser, both of whom focused on the importance of “doing” or “acting” to make change, seem to be the basis of the many applications of adventure-based therapy.

Experiential Learning Cycle

In 1984, David A. Kolb, creator of the experiential learning cycle, suggested that the progress of experiential learning occurs within a cycle that includes (1) concrete experience, (2) reflective observation, (3) abstract conceptualization, and (4) active experimentation. Adventure-based therapy utilizes this model to emphasize problemsolving techniques and skills for clients by having clients reflect on their experiences after participating in hands-on activities. Double Diamond Model

During the 1990s, Christian Itin and Scott Bandoroff integrated Kolb’s experiential learning cycle with the solution-oriented ideas of Erikson to create the double diamond model. This model recognizes change and growth in both the client and the practitioner and consists of goal setting, tailoring (making the goal specific to the client), gift wrapping (presenting the goal in an appropriate and appeasing way to the client), and processing (receiving feedback regarding the goal from the client). Adventure-Based Counseling Model

Perhaps the most popular model in adventurebased therapy is the adventure-based counseling, or ABC, model. Developed by Project Adventure, this group-based model is driven by the following values: (1) Full Value Contract, in which the group decides on basic principles and values in an effort to create a supportive environment in which it is safe for an individual to expose his or her true thoughts and feelings; (2) The Adventure Wave, where a visual image is used to describe the three stages of adventure-based counseling: briefing, activity, and debriefing; and (3) Challenge by Choice, where every individual in the group reserves the right to opt out of an activity free from judgment or pressure from other group members and leaders.

Techniques Major Concepts The three major models of adventure-based therapy that drive the way this approach is used are the experiential learning cycle, the double diamond model, and the adventure-based counseling model.

Adventure-based therapy utilizes multiple techniques, some of which are drawn from other therapies and others that are specific to it. These techniques include, but are not limited to, ropes courses, climbing walls, psychodramas, family sculptures, and guided journaling.

Alexander Technique

Ropes Courses and Climbing Walls

Ropes courses and climbing walls are often used in adventure-based therapy to engage the group or individual in perceived psychological and physical risk. These activities are often used for teaching problem-solving skills and for team building. Psychodrama

When issues arise within the adventure-based course, psychodrama is sometimes applied as a method to have individuals within a group or a family act out dramatizations of assigned roles and self-representation. This technique allows individuals to express themselves to the group and tell their narrative. Family Sculptures

When families do adventure-based courses together, family sculpturing may be applied to help families gain insight about themselves. Family sculptures, originally developed by Virginia Satir, refers to an activity in which members of a family position themselves in ways that are representative of how they are in their family (e.g., a mother points critically at her children while they look away, and the father is scowling at his wife). Adventure-based practitioners often use this technique to enable individuals to represent past, current, or future family themes, allowing the individuals to give their narrative a visual form. Guided Journaling

Journaling one’s experiences, especially while in nature, is frequently utilized. Practitioners frequently ask their clients to participate in journaling exercises after experiencing various activities such as obstacle or ropes courses and team-building activities in an effort to have individuals reflect on their experiences, lives outside of therapy, or plans for the future.

Therapeutic Process Adventure-based therapy typically occurs in intense increments of 6 or more hours over a few days’ time. Adventure-based therapy is popular in a weekend retreat format but has begun to grow in the individual therapy realm and can also be used

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on a weekly therapeutic basis. Because the programs offering adventure-based therapy are oftentimes based in more rural areas, where nature is more easily accessible, the therapy tends to be used on trips or in a camping program. Adventurebased therapy is also commonly used by substance abuse rehabilitation programs. Depending on the program and therapy focus, adventure-based therapy can last anywhere from a single weekend to multiple weekly sessions. Brett K. Gleason See also Behavior Therapy; Erickson, Milton H.; Glasser, William; Rogers, Carl; Solution-Focused Brief Therapy

Further Readings Bandoroff, S., & Newes, S. (2004). Coming of age: The evolving field of adventure therapy. Boulder, CO: Association of Experiential Education. Hill, N. R. (2007). Wilderness therapy as a treatment modality for at-risk youth: A primer for mental health counselors. Journal of Mental Health Counseling, 29, 338–349. Newes, S. L. (2001). Future directions in adventure-based therapy research: Methodological considerations and design suggestions. Journal of Experiential Education, 24(2), 92–99. doi:10.1177/105382590102400206

ALEXANDER TECHNIQUE The Alexander technique (AT) is concerned with the use of the self: how we think, react, move, and coordinate ourselves in all activities of daily life. A practical way of working and learning self-help, the AT was developed by Frederick Matthias Alexander (1869–1955) as he sought to discover a solution for a recurrent voice problem. Early in his investigations, Alexander became convinced of the psychophysical unity of the self, rejecting the prevailing orthodoxy of mind–body dualism. His “holistic” model was relatively unusual at the time (late 19th century), but it is more readily accepted now. People are generally unaware of habits of excessive effort and tension that adversely affect their general functioning, particularly the postural and balance mechanisms. AT teachers do not set out to treat or cure specific physical or psychological

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Alexander Technique

problems but aim to show individuals how they can avoid habits that are unhelpful or potentially damaging. Reported therapeutic effects come about as a result of the re-educational process and a gradual improvement in overall functioning. The AT is taught through hands-on and spoken guidance from a trained teacher. It is predicated on the understanding that our thinking, habitual or otherwise, profoundly affects the way in which we carry out any activity. People come to be treated by the AT for diverse reasons, falling into three broad categories: first, and most commonly, they come for improving health and well-being, with specific reasons including back and other pain, poor posture, stress, depression, coping with chronic illness or disability, or assisting with pregnancy and childbirth; second, athletes, musicians, and actors use the AT to enhance performance and deal with stress; and third, those interested in self-development learn the AT to increase selfawareness and a sense of agency. A key strength of the AT is its applicability to all aspects of daily life.

Historical Context As a young man, Alexander was pursuing an acting career in Australia when he began to recurrently lose his voice. As no treatment brought lasting relief, he began a process of self-observation and experimentation that ultimately developed into what is now known as the Alexander technique. He began teaching others his technique, moved to the United Kingdom in 1904, and commenced training teachers in 1931. During his lifetime, he gained support from a number of prominent figures, including the educationalist and philosopher John Dewey, the Nobel Prize–winning scientists Sir Charles Sherrington and Professor Nikolaas Tinbergen, and the writer Aldous Huxley. Alexander outlined his ideas in four books published between 1910 and 1942. His work continues to develop and grow. Fritz Perls, developer of Gestalt therapy, and Moshé Feldenkrais, founder of the Feldenkrais Method, encountered Alexander’s work. Although their work developed differently, these three men shared the principle that a person must be considered as a psychophysical whole, whose integrated functioning could be improved by better sensory

awareness and preventing habits that get in the way. Ilana Rubenfeld developed her method, Rubenfeld Synergy, as a result of her experiences of the AT, the Feldenkrais Method, and Gestalt therapy. Furthermore, Alexander’s focus on the present, not on past experience, was a theme in common with these and other humanistic approaches, such as person-centered counseling and focusing.

Theoretical Underpinnings Alexander developed the AT through observation and self-experimentation. Endeavoring to solve his voice problem, he came to recognize that when speaking, he habitually created excessive tension, which affected not only his vocal mechanisms but the whole of his body. He realized that he had to learn not to react in his usual way to his intention to speak. Alexander found that the head–neck– back relationship was fundamental, and gradually, he devised a way to prevent his habitual interferences and allow his voice, breathing, and general psychophysical functioning to work more dynamically and freely. This investigative experience became the working process of his technique, which he realized could be applied to any activity to improve performance. In Alexander’s lifetime, several of his concepts received indirect validation from research on animal physiology, specifically the ideas of functioning as an integrated whole and the significance of the head–neck–back relationship. Parallels have also been drawn between the AT and ideomotor theory. Historically, only anecdotal evidence indicated the effectiveness of AT lessons for improving performance skills, breathing, repetitive strain injury, back pain, and other musculoskeletal issues, as well as for enhancing a general sense of well-being and agency. However, more recently, these reports have begun to be underpinned by research. AT training has been demonstrated to result in changes in movement coordination, with significant improvements observed in balance, postural regulation, and muscle tone adaptability. Randomized controlled trials have demonstrated significant long-term reductions in pain and incapacity in people with chronic back pain, as well as a sustained increased ability to carry out everyday activities in individuals with Parkinson’s disease.

Alexander Technique

Smaller clinical studies have shown significant improvements following AT lessons in respiratory function, stuttering, and chronic pain, as well as balance in elderly people. Anecdotal psychological and emotional effects of AT lessons include increased overall cheerfulness and resilience. The Parkinson’s disease randomized trial also showed significant, short-term improvements in depression scores for participants. Many of these benefits can be seen as indirect effects of improved overall functioning—for example, feeling less depressed when not so bodily “weighed down,” or more confident and positive as a sense of agency improves. Other psychological effects have been reported, such as the reemergence of blocked off emotions as chronic muscle tensions are released. Further effects include a decreased ability to hold onto defensive patterns, that is to say, maintain potentially outmoded reaction patterns that originally protected us from overwhelming or conflicting feelings, thus enabling more open and appropriate responses in the present. Moreover, increasing physical selfawareness may bring increased awareness of underlying anxieties. Clinical experience suggests that these effects are often dealt with by teacher and student as an integral part of lessons, although given the AT has no specific methodology for working with emotional processes, supplementary counseling or psychotherapy may sometimes be valuable.

Major Concepts AT teaching is guided by several defining principles: the mind–body as an indivisible unit, the force of habit, endgaining as a driving force, prevention of unwanted habitual reactions, directed thought, optimally coordinated movement, and faulty sensory appreciation. The Mind–Body as an Indivisible Unit

In Western culture, the mind/body split remains deeply entrenched; importance is attached to the thinking mind, while the physical self is often regarded as a property of the self. The AT recognizes the indivisibility of the mind and the physical self (psychophysical unity/embodied mind). All thoughts, beliefs, and preconceptions will play out

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in the physical self in, for example, the quality of movement, the degree of muscle tension, breathing, and posture. The Force of Habit

There is currently little recognition that the way in which individuals carry out their daily activities (i.e., sitting at a computer, walking, carrying, etc.) will have long-term consequences for their health and well-being. Contrast the natural freedom of movement and poise of many young children with that of the typical adult, whose habitual way of carrying out activity tends to put additional strain on the spine and joints. In AT lessons, people are taught how to prevent the habitual interferences with balance and movement coordination, thereby allowing a more natural response to occur. They learn how to gain more choice over how they respond to the world on physical, mental, and emotional levels. Endgaining as a Driving Force

Endgaining describes our predominant attitude of focusing on achieving a desired goal while paying little or no attention to how that goal is achieved. An example would be loading heavy shopping bags into the car while already thinking of driving off. With the AT, we learn how to recognize and lessen this attitude and become more present and mindful of how we achieve the goal. The resultant response or action will be more psychophysically integrated, and any movement is likely to be characterized by better balance and more fluidity. Prevention of Unwanted Habitual Reactions

Applying the AT involves a process of conscious prevention of unwanted habitual reactions. This involves deciding not to react to a stimulus (whether external or internal) in the usual unthinking, that is, habitual, manner. If the immediate response is not to react, one then has an opportunity to choose whether and how to respond—for example, having a choice over whether to respond to a phone ringing, or not reinforcing the stress response to being held up in heavy traffic. Developing this skill involves developing greater awareness of oneself in everyday life, such that unwanted habitual reactions can be diminished.

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Alexander Technique

Directed Thought

Applying the AT involves directing conscious awareness to the embodied self in relation to one’s surroundings. This process consists of framing and energizing conscious intentions known as directions. Directions are largely spatial in nature and aim to promote an enlivened postural support system and balanced, coordinated movement. The awareness of one’s embodied presence is integral to enhancing a sense of self and tends to lead to a calmer state of being. Optimally Coordinated Movement

Well-coordinated movement is characterized by a natural integrated dynamic relationship between a person’s head, neck, and back. This can often be observed in young children, in animals, and also in adults who have grown up in less Westernized cultures in which people spend less time being sedentary and performing repetitive tasks. Given the near-ubiquitous maladaptive response to living in this increasingly complex developed world, the natural relationship of the head–neck–back is interfered with in almost all activities (i.e., sitting, using a computer, etc.). As a result, there is a tendency toward compression of the spine. AT teachers employ guided movement to help reestablish the basic integrated movement pattern. Faulty Sensory Appreciation

In any activity, we are guided by our sense of what feels right, which tends to simply be our habitual way of carrying out that activity and may involve undue effort and tension. Sensory appreciation gradually improves during a series of AT lessons, enabling us to gauge with increasing accuracy what we are actually doing and so make more appropriate psychophysical responses, less constrained by long-standing habits.

Techniques The AT is an educational process and, as implied by its name, cannot be separated into discrete techniques. Teachers employ both gentle hands-on guidance and dialogue to engage the individual in a learning process that is both experiential and conceptual. The hands-on component of teaching involves light touch to guide movement and to

bring individuals’ awareness to certain aspects of themselves, for example, where they are tensing and holding. The teacher aims to facilitate for the student an experience of less interference and increasing freedom and support in movement. Dialogue is used to help develop understanding of the underlying AT principles and to explore preconceptions and habitual responses. The overall aim is to enable students to put the AT into practice in everyday life through increased selfawareness and applying the conscious processes. Facilitating experience through bodily touch is seen as crucial to the process of change, an assumption the AT has in common with some other approaches, such as body-oriented therapies and certain neurological and psychophysiological approaches. However, the AT use of touch differs from other approaches—for example, from that in body psychotherapy, where it is often used specifically to facilitate release of long-held emotions and recall of body memory. It also differs markedly from the use of touch in massage or osteopathic or chiropractic techniques. The addressing of beliefs and attitudes, and the offering of constructive cognitive strategies, is also seen as important in the change process. This assumption that cognition affects feelings and behavior, the central focus of cognitive approaches, is shared by the AT. Thus, the AT can be seen as both a bottom-up approach and a top-down approach. Teachers differ in the relative emphasis they put on experiential and conceptual learning. Teaching styles also vary according to the background of the teacher and the student’s needs.

Therapeutic Process The AT describes a teacher–student relationship, not therapist–client; the process is educational rather than overtly therapeutic. Teachers aim to embody good use and provide an accepting, constructive learning environment—offering relational qualities reminiscent of Carl Rogers’s core conditions (e.g., congruence, unconditional positive regard, and empathy). The AT is primarily taught on a one-to-one basis, with workshops and group work generally seen as supplementary. In addition to private teaching, the AT forms part of the syllabus in leading drama schools and music colleges. The number of lessons taken depends on the student’s needs and

Analytical Psychology

aims. A few may be helpful, but to learn to consistently apply the AT in daily life, a series of lessons over time is required. Worldwide, there are several professional associations of AT teachers, with the largest being the Society of Teachers of the Alexander Technique and its affiliated societies, through which training and professional standards are regulated. Typically, teacher training courses are 3 years, full-time. Jane Saunderson and Julia Woodman See also Body-Oriented Therapies: Overview; CognitiveBehavioral Therapies: Overview; Feldenkrais Method; Focusing-Oriented Therapy; Gestalt Therapy; Neurological and Psychophysiological Therapies: Overview; Person-Centered Counseling; Rubenfeld Synergy

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work with Sigmund Freud (1856–1939) and later out of Jung’s understanding of the nature of the unconscious and its relationship to human growth and development. In particular, Jung’s work differed from Freud’s in that Jung’s work greatly expanded understanding of the unconscious. For Jung, the unconscious included not only personal content but also inherited content. His research and clinical observations led to many contributions to our understanding of the development of an individual’s conscious capacity and ego, such as complexes, introversion and extraversion, persona, and shadow. Jung further explored the inherited or historical unconscious, which he later referred to as the collective unconscious, with its primordial archetypes; the development of the self out of the collective unconscious; human development throughout the lifespan; and the process of individuation.

Further Readings Alexander, F. M. (1985). The use of the self. London, England: Orion. (Original work published 1932) Alexander, F. M. (2004). Constructive conscious control of the individual. London, England: Mouritz. (Original work published 1923) deAlcantara, P. (1999). The Alexander technique: A skill for life. Marlborough, Wiltshire, England: Crowood Press. Gelb, M. J. (2004). Body learning: An introduction to the Alexander technique. London, England: Aurum Press. Jones, F. P. (1997). Freedom to change. London, England: Mouritz. Vineyard, M. (2007). How you stand, how you move, how you live. Cambridge, MA: Da Capo Press.

Websites American Society for the Alexander Technique (AmSAT): www.amsatonline.org Society of Teachers of the Alexander Technique (STAT): www.stat.org.uk

ANALYTICAL PSYCHOLOGY Analytical psychology is the name that the Swiss psychiatrist Carl Gustav Jung (1875–1961) gave to the set of discoveries and the school of psychology that he originated. The development of analytical psychology evolved out of Jung’s early

Historical Context Jung, whose father was a pastor in the Swiss reformed church, studied medicine at the University of Basil. In 1900, Jung began his psychiatric training at the Burgholzi Mental Hospital in Zurich, Switzerland, where he first began to examine the contents of his patients’ psychotic hallucinations and sought to find their meaning. His desire to understand the unconscious meaning of psychotic processes led him to his initial research with word association experiments. The word association studies probed the nature of the unconscious, as it related to psychological disturbances. Out of this research came his understanding of clusters of unconscious conflicts, which he referred to as complexes. Jung found that these complexes had a strong emotional and feelingoriented charge, or energy, and that they exerted considerable influence on an individual’s attitudes and behaviors. These studies attracted the attention of Jung’s eventual mentor, Freud. Jung became a close colleague of Freud, and in the early years of psychoanalysis he became one of the pioneers who applied Freud’s psychoanalytic method. Ultimately, Jung objected to Freud’s notion of an exclusively sexual unconscious because his own observations showed that not all the contents of the unconscious were sexual or exclusively a result of personal conflict; so he broke from Freud in 1913. Jung conceived the

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Analytical Psychology

term analytical psychology to describe his work and to differentiate it from Freud’s work. Many developments in psychology grew out of Jung’s research and clinical work. Although Jung agreed with Freud that the unconscious contained both unwanted and unresolved conflicts, he also saw that unrealized parts of personality were pressing to be discovered and realized in consciousness. Among his most interesting discoveries was that of the anima and the animus. The anima is the feminine counterpart in men, and the animus is the masculine counterpart in women. These capacities reside within the unconscious and foster a greater wholeness in an individual. In addition, as Jung came to understand the uniqueness of the individual personality, he demonstrated that introversion and extraversion are fundamental conscious attitudes that each individual is born with and that they are related to each individual’s unique self. Jung’s work was among the first to recognize human potential as evolving throughout the lifespan. This lifelong development is possible because of the collective unconscious that is part of our evolution. Jung observed that primal forces, which he referred to as archetypes, drive the collective unconscious. This observation of instinctual archetypal energies in the collective unconscious led him to postulate his foundational discovery that the self is the preeminent core of personality, which grows out of the collective unconscious and is the source of ongoing development. Jung declared the self to be a fundamental archetypal force in the collective unconscious that is present in every individual from the beginning of the individual’s life. Furthermore, Jung recognized that when an individual begins to interact with these deeper historical layers to the unconscious self, the individual’s life not only begins to develop but also a simultaneous experience of meaning and purpose begins to develop. Jung called the ongoing process of interaction between an individual’s conscious attitude (which he referred to as the ego) and the individual’s unconscious self over the lifespan individuation. Individuation is a process, not a specific goal. All of these foundational human experiences are incorporated into the psychotherapy work practiced by therapists and analysts who are trained in analytical psychology. Analytical psychology is practiced throughout the Western world and since

the 1990s has spread into the former Eastern Bloc countries and to the Far East into China and Southeast Asia. Analytical psychology has also had a strong influence in literature and the arts and continues to grow.

Theoretical Underpinnings In analytical psychology, the collective unconscious holds the primal archetypal forces and is the basis from which all human development proceeds. Jung’s observation of patients’ unconscious contents, dreams, and patterns of behavior led him to postulate that humans inherit an unconscious endowment through ancestral evolution in the same way that they have inherited other human characteristics. We carry with us the unconscious history of our predecessors. From this collective heritage, each of us receives our own unique self. This self is innate, exists from the beginning of our lives, and has personal manifestations that develop out of this inherited collective unconscious. Analytical psychology holds that the preeminent or preexistent archetypal self seeks to be realized throughout the lifespan. Analytical psychotherapists work with the issues that patients bring into psychotherapy and watch for the expressions of the self that may unconsciously show up through the conflict. For the self to be realized within an individual’s life, the individual needs to have a well-developed and capable conscious life. This conscious capacity is referred to as the ego. Ego consciousness and awareness are required for ongoing development, because it is through our ability to interact with other people; to realize our own needs, desires, and feelings; and to direct our efforts on our behalf for our outer and inner lives that we develop. Without well-functioning ego skills, life would be very difficult. Jung’s definition of ego is very different from the contemporary use of the word. In contemporary usage, ego is often associated with arrogance and self-importance; however, in Jung’s analytical psychology, ego capacity refers to a capacity for mastery in one’s endeavors, competence, and creative adaptation. Analytical psychology has identified two attitudes that are natural to an individual’s ego development: introversion and extraversion. These two attitude types are a natural part of a developing ego, and they refer to an individual’s relationship

Analytical Psychology

to people and events in the individual’s life. Introversion refers to an attitude of looking into one’s inner feelings and reality first and then to others’, whereas extraversion looks to the relationship with others first and then to one’s own inner feelings and reality. All individuals have the capacity for both attitudes; however, one attitude usually predominates over the other. These attitudes are part of the developing self and show themselves through the ego’s participation in life. Two other important constructs that are important in the practice of analytical psychology are the persona and the shadow. The term persona, derived from the Greek word to describe the various masks that actors wore during theatrical performances, is used to refer to the made-up way of being (mask) that an individual adopts but is not an honest representation of the individual’s self. The persona is often the result of familial or cultural conditioning that does not recognize an individual’s genuine self. The persona, as used in analytical psychology, is similar to the more recent concept of the false self proposed by Donald Winnicott (1896–1971). Although it is necessary for an individual to adopt certain culturally accepted behaviors to navigate everyday life, persona becomes problematic when it is used excessively, that is, to the point where the individual does not recognize that he or she is overusing it. Shadow is the term used to refer to the unconscious within an individual. The shadow is a uniquely analytic term for the unconscious, becoming a repository for all the unwanted and unrealized parts of a person. The persona and shadow are often seen as complementary in that the more an individual lives in the world of the persona, the more the person’s genuine self, or life potential, is hidden in the shadow. Conversely, the more one is aware of the unconscious issues and potentials that are in the shadow, the less one overuses the persona. Finally, analytical psychology recognizes that in each individual there exists a contrasexual aspect to the individual’s biological identity. In men, there is the anima, or feminine counterpart, and in women, there is the animus, which is the masculine counterpart. Each of these counterparts serves to facilitate development as an unconscious potential that helps develop a greater wholeness within each individual. Practitioners of analytical psychology seek to help their patients become conscious of their

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unconscious complexes and shadow issues, which can undermine conscious ego function and are often the products of unresolved conflicts stemming from familial or environmental circumstances. Complexes have a strong emotional or feeling charge and can interfere with an individual’s general life adaptation and ultimately the individual’s ability to realize the self’s need to become a conscious part of the individual’s life. When a complex has been triggered, an individual is usually either overwhelmed by it or spends a great deal of time on strategies to escape or avoid it. There can be as many different types of complexes as there are individuals. A few typical themes in complexes are  inferiority, abandonment, and superiority. Analytically orientated psychotherapists seek to make these complexes conscious so that their influence over an individual’s emotions and behavior can be moderated, allowing the individual to experience greater freedom of choice and an increased ability to recognize feelings and the needs of the self.

Major Concepts Although Jung’s theory is complex and one can identify dozens of important concepts discussed in his volumes of work, some of the ones that stand out include his definitions of the anima, the animus, archetypes, the collective unconscious, complexes, consciousness, extraversion, individuation, introversion, the persona, the personal unconscious, the self, and the shadow. Anima

The anima is the feminine counterpart within a man. It often serves to expand the development and wholeness of a man’s potential. Animus

The animus is the masculine counterpart within a woman. It often serves to expand the development and wholeness of a woman’s potential. Archetypes

Archetypes are the fundamental energetic forms that reside in the collective unconscious. These forms reside in the inherited unconscious, and their

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Analytical Psychology

expression can be seen manifesting uniquely across cultures and throughout the world. These forms carry a large amount of energy and exercise a strong influence in the unconscious. Examples of archetypes include, but are not limited to, the hero, the fool, the mother, and the father. Collective Unconscious

The collective unconscious is inherited in the same way that humans inherit other capacities or characteristics. The collective unconscious represents the shared accumulation of psychological capacities, potentials, and energies inherited from the history of all humans. Complexes

Complexes are the result of unresolved life struggles that have unifying themes, are highly charged, and reside within the personal unconscious. Complexes have a life of their own in the unconscious and often interrupt internal and external interactions. The unifying themes of complexes may be as diverse as the individuals who struggle with them. For instance, if an individual has had difficulties with authority as a result of unresolved family problems, then this may show itself in conflicts with authority of all types in that individual’s life. Consciousness

Consciousness is the focus of an individual’s general awareness and is usually referred to as ego consciousness. This is individually directed toward a person’s outward life and awareness and toward inner life, imagination, and needs. Well-developed ego consciousness is essential to life function and well-being. Extraversion

Extraversion is an inborn attitude of consciousness that is orientated to outer life as a way of adaptation. Individuation

Individuation is an ongoing life process and not a goal or place of arrival. Functionally, individuation is the ongoing interaction between consciousness

and the unconscious over the lifespan, which allows for the development of a unique and truly individual identity and life. Introversion

Introversion is an inborn attitude of consciousness that is orientated to the inner subjective life as a way of adaptation. Persona

The persona is the typical mask or face that one wears in the world. The persona includes certain social norms of adaptive behavior that are used in everyday interactions and allow an individual to navigate life’s typical and impersonal situations. The persona becomes problematic when it is used as a substitute for one’s more genuine self-expression. Personal Unconscious

The personal unconscious is where unresolved personal difficulties reside. These contents are seeking to be made conscious and may cause conflicts with ego consciousness when an individual is not willing or able to work with them. Self

The self represents the totality of the personality from which an individual grows and develops. The self includes inherent interests, aptitudes, and even physical capacities that make for a distinctive blending of individual preferences and directions. The self is a unique set of capacities that may manifest internally as an interest or curiosity and can be creatively lived out in numerous ways. In the practice of analytical psychology, the unique capacities of the self that are not recognized within one’s familial development can come to be recognized and valued as the distinctive qualities of an individual. Shadow

The shadow contains the unresolved conflicts and unrealized potential of the self and stands in contrast to the persona. The shadow represents the genuine qualities of the personality in struggles, such as with complexes, and in unrealized potential.

Analytical Psychology

Techniques The major contributions of analytical psychology in practice are less focused on technique and more focused on the understanding, novel realization, and development of an individual’s unique self than are those of other therapeutic modalities. That being said, analytical psychologists often use the following modalities in helping to foster this process: encountering the individual, dreams, amplification, active imagination, and creative techniques. Encountering the Individual

Although analytical psychology does not foster the methodological application of techniques as a therapeutic end unto itself or as a prescription for a particular manner of therapy interaction, it does seek to foster a genuine encounter between two people: the patient and the therapist. Both the patient and the therapist are affected in the interaction, which becomes an important source of understanding of the nature of the patient’s suffering for which the patient sought therapy. Analytical psychology views each patient as having unique needs and as seeking a unique path through the interactive work of therapy, so it is important for the therapist to understand each patient’s situation and needs. Dreams

Dreams are used in the course of analytical therapy to help identify the unconscious shadow that is causing distress and is attempting to find its way into consciousness. Personal conflicts and unrealized understandings are expressed in the contents, or stories, of dreams. Because dreams are not bound by the space and time parameters that govern conscious linear life, they can express impressions, experiences, and understandings drawn from a person’s diverse experiences in brief sequences. Mythological patterns and images along with metaphorical themes may also be discovered in dreams, revealing a new synthesis of a situation or collective themes that may be active within a patient’s life. Amplification

Amplification helps unlock the meaning of a particular dream image or phrase. Images conveyed by the unconscious through dreams hold

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unique meaning or symbolism for each dreamer, and amplification allows the dreamer to relate to that unique meaning. Images or phrases may be amplified or expanded as a result of the associations, mythological or literary references, and metaphorical stories that strike a meaningful resonance within the dreamer. Active Imagination

Active imagination refers to the direct encountering of dream images, objects of imagination, and symbols in waking life. It is a method for dreaming the dream onward and is usually used in the latter part of analytical treatment to help enable the patient to work more directly with his or her own unconscious. Creative Techniques

Analytical psychotherapists may use sand play, artistic expression, music, or other expressive modalities to help discover unconscious contents.

Therapeutic Process The psychotherapeutic practice of analytical psychology seeks to ultimately foster an ongoing interaction between a patient’s conscious ego and the self over the course of the patient’s life. Therapeutic contact in analytical psychotherapy may occur from once to multiple times per week, depending on the needs and desires of the patient. The process is interactive between the therapist and the patient, whereby the patient is accompanied on this analytical journey by a therapist who is experienced in the process of discovering the self. The focus of this interactive therapeutic work is initially the understanding of the patient’s historical context, allowing the patient to appreciate his or her own life in the context of personal history and current difficulties. Because the self often attempts to be realized through conflicts and struggles, another focus of analytical therapy is working out conflictual issues that may prevent the ego’s interaction with the self. These emotional and personal understandings allow a patient to grow into a relationship with the emergent self, which makes itself known in the interactions with the therapist, the patient’s everyday life circumstances, and dreams that

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Animal Assisted Therapy

amplify one’s life situation and point to deeper understandings of the unconscious. Such interaction can be a part of an individual’s growth and development over a lifetime. Ultimately, this inner and outer understanding is a process that an individual can gain from therapy and use over the course of his or her life. Paul A. Gabrinetti See also Classical Psychoanalytic Approaches: Overview; Freud, Sigmund; Jung, Carl Gustav; Winnicott, Donald

professional. While personal pets may be comforting to their owners and others, their therapeutic value is not, strictly speaking, AAT. Trained helping professionals intentionally use both directive and nondirective intervention strategies in the therapeutic process. In many populations, AAT has been shown to decrease depression and anxiety while increasing self-esteem and self-efficacy and has been found especially effective in working with neglected and/or abused children, oncology patients and individuals struggling with other medical conditions, and veterans coping with posttraumatic stress disorder.

Further Readings Bosnak, R. (1988). A little course in dreams. Boston, MA: Shambhala. Campbell, J. (Ed.). (1971). The portable Jung. New York, NY: Penguin. Edinger, E. F. (1992). Ego and archetype. Boston, MA: Shambhala. von Franz, M. L. (1975). C. G. Jung: His myth in our time. New York, NY: Putnam. Hannah, B. (2000). The inner journey: Lectures and essays on Jungian psychology. Toronto, Ontario, Canada: Inner City Books. Jung, C. G. (1977). The practice of psychotherapy. In The collected works of C. G. Jung (R. F. C. Hull, Trans.; Vol. 16). Princeton, NJ: Princeton University Press. Jung, C. G. (1977). Two essays on analytical psychology. In The collected works of C. G. Jung (Vol. 7). Princeton, NJ: Princeton University Press. Jung, C. G. (1989). Memories, dreams, reflections. New York, NY: Vintage Books. Singer, J. (1994). Boundaries of the soul. New York, NY: Anchor Books. Whitmont, E. C. (1969). The symbolic quest. Princeton, NJ: Princeton University Press.

ANIMAL ASSISTED THERAPY Animal assisted therapy (AAT) is a therapeutic modality that utilizes certified therapy animals (CTAs) as therapeutic agents in a process facilitated by trained helping professionals. Incorporating animals into therapy is argued to be ameliorative because clients have opportunities to give and receive affection. AAT is especially important for clients who may be impaired in their ability to create a therapeutic relationship with a human helping

Historical Context Human–animal bonds are strong and have been part of human development for thousands of years. In addition to domesticating several species for agricultural, transportation, and other service roles, over the centuries people have kept animals as companions, using them to fulfill emotional and social needs. The earliest reported forms of AAT occurred during the late 1700s, when small domestic animals were used to enhance the morale, socialization, and recovery of both psychological and medical patients in institutional settings. Since the advent of psychoanalysis, animals have also been used in individual therapy, with the child psychiatrist Boris Levinson championing their use in the 1960s. Not all animal species are well suited to AAT; it is primarily practiced with domesticated animals that have been selectively bred to interact well with humans. Most frequently, dogs, cats, and horses are used in AAT, but other animals including birds and dolphins have also been utilized.

Theoretical Underpinnings As there are many ways to conduct AAT, there is  also a broad range of theoretical justifications from which researchers have tried to explain its effectiveness. Calming Effect of Animals

Both evolutionary and learning theories are used to explain how animals reduce arousal and anxiety in people. According to the biophilia hypothesis, humans tend to gravitate toward the natural world

Animal Assisted Therapy

as there is an evolutionary advantage in maintaining productive interspecies partnerships. Alternatively, animals may interfere with the perception of anxiety-generating stimuli. For instance, when a client is facing an anxiety-inducing situation that needs to be discussed in therapy, the anxiety-reducing effect of the animal may increase the likelihood of the situation being discussed. Social Mediation

In the presence of animals, rapport is built faster between therapist and client, or even between strangers. CTAs may make the therapist seem less threatening, and they may also serve as a source of conversation. Attachment Theory

Much discussion has gone into the bonds of attachment formed by clients to CTAs. From this instinctual bond, the animal may serve as a transitional object to comfort the client until a therapeutic relationship develops. CTAs also provide much needed unconditional positive regard for clients, increasing their overall self-esteem and their likelihood of bonding with others.

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certain concepts are important to the broader understanding of AAT. Certified Therapy Animal

This legal category is similar in many ways to that of “service animals” such as seeing-eye dogs. Several organizations credential small domestic animals and horses as CTAs. Animals must be nonaggressive, social, friendly, confident, obedient, and predictable. They must be able to initiate contact, stay engaged with clients, respect personal boundaries, and cope with stress. Animal Assisted Activities

CTAs are often used by paraprofessionals and volunteers in various animal assisted activities. Credentialing bodies provide special training to CTA owners and trainers so that they become a working team. Animal assisted activities occur in many environments (e.g., hospitals, schools, and malls) and provide therapeutic benefit. Conversely, AAT is facilitated by trained helping professionals who use animals within the scope of their professional framework.

Techniques Social Cognitive Theories

Animals can provide immediate and honest feedback to social behaviors and may in turn influence cognitions. Training and caretaking of CTAs, especially dogs and horses, may foster client selfefficacy and personal agency by exposing a client to controllable situations where he or she can generate accomplishments through particular behaviors with the animal. Role Theory

By asking clients to take on specific roles (e.g., teacher or caretaker) with a CTA, the positive practices and traits associated with that role may become ingrained in clients’ behavior.

Major Concepts There is considerable variation in which type of helping professionals implement AAT and how they incorporate it into their practice. However,

There are varied nondirective and directive ways of implementing AAT in work with clients; the following approaches are most frequently employed. Nondirective Therapeutic Facilitation

Therapists may use CTAs as a means of building relationships with clients. In this case, the CTA is simply present during therapy, enabling therapists to foster feelings of trust and safety with clients. Directive Techniques

Talking to or About the Animal Therapists may ask clients to share their feelings with the animal, tell it their concerns, or make up stories involving it. Additionally, the spontaneous actions of the animal can be used to start a discussion, or the client–CTA connection may be directly commented on by the therapist.

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Physical Interaction and Training Clients can be encouraged to touch or play with the animal. Additionally, this interaction may take the form of conducting tricks or training the CTA.

mental health professionals. Journal of Creativity in Mental Health, 6(2), 90–104. doi:10.1080/15401383 .2011.579862 Van Fleet, R., & Faa-Thompson, T. (2010). A case for using animal-assisted play therapy. British Journal of Play Therapy, 10, 4–18.

Storytelling or Metaphorical Discussion Using the Animal Therapists may share information about the animal’s family or personal history or use stories of the animal as metaphors in the therapeutic process.

Therapeutic Process AAT is a versatile modality that can augment different therapeutic styles and environments. While some intervention strategies may be appropriate for brief therapy settings (e.g., nondirective techniques or physical interaction), many are more conducive to a longer term therapy over multiple sessions. Before implementing AAT, therapists must know their animal and be able to advocate for their well-being (e.g., watch for signs of animal stress, be able to reassure the animal with cues). Therapists are encouraged to learn the policies, procedures, liabilities, and benefits of utilizing a CTA in their therapeutic working context, and they should incorporate language into their informed consent so that clients are made aware of the potential risks and benefits of engaging in AAT. Using AAT in therapy may foster rapid connection and offer a therapeutic advantage when working with particular clients because it makes clinical use of the timeless bond between humans and animals. Laura R. Shannonhouse See also Attachment Theory and Attachment Therapies; Creative Arts and Expressive Therapies: Overview; Ecotherapy; Sensorimotor Psychotherapy; Social Cognitive Theory

Further Readings Chandler, C. (2005). Animal assisted therapy in counseling. New York, NY: Routledge. Fine, A. (Ed.). (2006). Handbook on animal-assisted therapy: Theoretical foundations and guidelines for practice (2nd ed.). San Diego, CA: Academic Press. O’Callaghan, D., & Chandler, C. (2011). An exploratory study of animal assisted interventions utilized by

APPLIED BEHAVIOR ANALYSIS Applied behavior analysis (ABA) is a scientific discipline devoted to understanding and to improving human behavior. While numerous social sciences and helping professions share similar aims, ABA’s focus, behavior change interventions, and evaluation methods distinguish it as a unique discipline. Applied behavior analysts select behaviors that improve the quality of people’s lives, alter environmental antecedents and/or consequences to change the target behavior(s), and employ methods of scientific inquiry (e.g., objective measurement, controlled experimentation) to seek functional relations between interventions and behavioral improvements. In short, ABA is a scientific approach for discovering environmental variables that reliably influence socially significant behavior and for developing a behavior change technology based on those discoveries. A significant part of ABA’s technology comprises strategies and tactics for effective therapy.

Historical Context At least five events serve as key historical markers for the development and evolution of ABA within the timeline of the history of counseling. These include B. F. Skinner’s pioneering empirical laboratory work; early field-based demonstrations of operant principles; clinical applications across a variety of situations, settings, and behaviors; the promotion of generalization and maintenance; and the advancement of functional behavior assessment (FBA). The empirical foundations for ABA began with B.  F. Skinner’s laboratory experiments in the 1930s demonstrating how consequences select and maintain behavior. Skinner showed that what had traditionally been considered “voluntary” or “willed” behavior could be understood as operant (i.e., learned)

Applied Behavior Analysis

behavior  by examining the relationship between a behavior and its consequences. Many historians trace the beginning of ABA, and hence its eventual application in therapeutic situations, to a 1959 article by Ted Ayllon and Jack Michael. Their article, titled “The Psychiatric Nurse as a Behavioral Engineer,” described how training hospital staff to use operant-based procedures (e.g., providing social attention for desired behavior, ignoring maladaptive behavior) produced remarkable reductions in the “persistent problem behavior” of psychiatric patients. In the late 1950s, Sidney Bijou transformed the Institute for Child Development at the University of Washington into a behaviorally based center investigating the application of Skinner’s ideas to the problems of children. In the early 1960s, a series of four studies designed by Montrose Wolf provided the original experimental demonstrations of the power of social attention as reinforcement for children’s behavior. Wolf taught nursery school teachers to use differential attention to reduce children’s crying and segregated play behavior and to increase their social, gross motor, and walking behaviors. Clinical applications of ABA expanded rapidly during the 1960s and 1970s. These early interventions occurred in natural settings (e.g., schools, treatment centers, and hospitals), addressed a range of behavioral issues (e.g., schizophrenia, autism, developmental disabilities, and brain injury), and entailed diverse tactics (e.g., modeling, parent and counselor training, positive and negative reinforcement, shaping, stimulus fading, and token economy systems). Clinical applications informed by ABA continued to advance based on the results of the early interventions. Contemporary counseling and therapy, influenced by behavior analysis, addressed additional behavioral concerns, including anxiety, aphasia, criminal behavior, delinquency prevention, depression, eating disorders, obesity, problems of aging, self-injurious behavior, and substance abuse. Acceptance and commitment therapy (ACT) and functional analytic psychotherapy (FAP) are two examples of formal psychotherapy approaches influenced by behavior analysis. ACT, founded by Steven Hayes, centers on the application of acceptance and mindfulness tactics. ACT therapists

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encourage clients to learn to accept their experiences, thoughts, and behaviors that cause personal problems and commit to a measured course of action. William Follette and Jordan Bonow describe the FAP model as in-session therapy. During FAP sessions, clients emit problem behaviors that are functionally the same as those they experience in their daily lives. FAP therapists use differential reinforcement to weaken the in-session dysfunctional behaviors and strengthen alternative behaviors. Some professionals criticized the early practice of ABA for its failure to demonstrate lasting behavior change after intervention. In a 1978 review of 270 ABA studies, Trevor Stokes and Don Baer concluded that the most common technique for promoting postintervention change was “train and hope.” In 120 of the studies, however, these authors found evidence of an “implicit technology” for promoting generalized outcomes, including aiming for natural contingencies of reinforcement, teaching multiple exemplars, programming common stimuli, training loosely, and programming in discriminable contingencies. Stokes and Baer’s review reminded applied behavior analysts that generalization and maintenance of behavior change is the gold standard for success and inspired a multilayered research agenda that continues today. Widespread recognition of ABA as a distinct discipline began with the publication of the Journal of Applied Behavior Analysis. While this journal, first published in 1968, remains the field’s flagship journal, peer-reviewed ABA research and practice papers are also published in other behavioral journals (e.g., Behavior Analysis in Practice, Behavioral Interventions, and Behavior Research and Therapy) and in select counseling and psychotherapy journals (e.g., Child & Family Behavior Therapy, Cognitive and Behavioral Practice, and Journal of Abnormal Child Psychology). Behavior analysis, and ABA in particular, has experienced tremendous growth in recent years. Founded in 1974 as an organization for theorists, basic and applied researchers, and practitioners, the Association for Behavior Analysis International has more than 20,000 members and affiliate members in 44 countries. In 1998, the Behavior Analyst Certification Board was founded to meet the increasing credentialing needs of qualified behavior analysts.

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Applied Behavior Analysis

As of 2014, the Behavior Analyst Certification Board had credentialed more than 14,000 behavior analysts, most of whom provide home- and center-based treatment for children with autism, help teachers prevent and reduce classroom behavior problems, and work in hospitals and clinics helping people learn more about ABA principles and tactics. Finally, the emergence of FBA as a systematic process for gathering information about the purpose and function of problem behavior adds to the historical context of ABA. The topography, or form, of a behavior often reveals little about the conditions that account for it. Two children cry, scream, and throw themselves on the floor: One does so because parental attention or access to toys usually follow; the other child has learned such behavior as a surefire way to postpone going to bed or taking a bath. The children’s tantrums may look the same, but positive reinforcement accounts for the former case, whereas negative reinforcement (escape from aversive task demands) accounts for the latter. Interventions based on FBA alter antecedent events that trigger the behavior (e.g., access to attention, providing choices), change the consequences for the problem behavior, and/or teach alternative behaviors that produce the same reinforcements that had been maintaining the problem behavior. Clinical research and practice have identified three types of FBA—indirect, descriptive, and experimental—each yielding varying degrees of precision and requiring different levels of time, resources, and expertise to conduct. Indirect FBA, the quickest and least time-consuming method, uses structured interviews, checklists, rating scales, or questionnaires to obtain information from persons familiar with the client in order to identify conditions or events in the natural environment that correlate with the problem behavior. Descriptive FBA entails direct observation of the problem behavior under naturally occurring conditions in an effort to determine the antecedent conditions or events that trigger the behavior and the consequences that maintain it. Antecedent– behavior–consequence recording is an often used option with descriptive FBA as it provides a descriptive and sequenced account of the antecedent conditions, the problem behavior, and the consequences as those events unfold.

The most intensive form of FBA entails an experimental protocol. A groundbreaking research program spearheaded by Brian Iwata and his students in the early 1980s showed that brief experimental comparisons of a client’s behavior under alternating conditions—alone, contingent on social attention, contingent on tangible items/activities, and as an escape from task demands—often identified behavioral function when other methods failed. While experimental analysis had been the primary method for discovering functional relations between behavior and its controlling variables in behavior analysis since the field’s inception, using FBA for pre-intervention analysis advanced clinical practice tremendously. Functionbased treatments have enabled children and adults to overcome aggression, chronic eating disorders, obsessive-compulsive behaviors, property destruction, and self-injurious behaviors that had been resistant to previous psychological interventions.

Theoretical Underpinnings During the early 20th century, a number of learning theories emerged that attempted to conceptually organize and practically explain the behavior of organisms. Edwin Guthrie’s contiguity theory, Edward Tolman’s sign-learning theory, and Clark Hall and B. F. Skinner’s reinforcement theories serve as influential examples. Skinner’s reinforcement theory and comprehensive philosophy of science—termed radical behaviorism—provided the foundation for the development of a new basic science, the experimental analysis of behavior (EAB). Radical behaviorists view all behavioral events, including private events such as thoughts and feelings, as actions for scientific study. Radical behaviorism does not restrict the science to events that can only be observed by more than one person. The defining feature of radical behaviorism is the recognition of private events. Skinner’s philosophy of radical behaviorism and the EAB provide the theoretical underpinnings of ABA.

Major Concepts ABA should be viewed in the context of the philosophical and basic research foundations from which it developed and with which it remains

Applied Behavior Analysis

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interrelated.ABA is the applied branch of behavior analysis, a natural science approach to understanding and changing behavior. Behaviorism and EAB are the philosophical and basic research domains of behavior analysis. Just as investigators and practitioners in other natural sciences (e.g., biology and physics) explain their subject matters, behavior analysts rely on physical processes and natural events to understand behavior. Metaphysical entities and hypothetical constructs (e.g., free will, memory storage, and retrieval mechanisms) have no role in a behavior-analytic account. In two classic papers, Donald Baer, Montrose Wolf, and Todd Risley (1968, 1987) defined seven characteristic criteria for ABA that have guided the field since its inception: applied, behavioral, analytic, technological, conceptually systematic, effective, and capable of generalized outcomes.

test. A dead person can “not hit others.” A more meaningful behavior would be “interact with others by sharing materials.” Second, the behavior must be measured directly. For example, direct observation and measurement of older depressed adults’ interactions with their peers during social functions would meet the behavioral criterion intended to increase adults’ prosocial interactions. However, data from sociograms, questionnaires, or interviews asking the participants’ opinions of how they are getting along with others would not. Such measures are at best proxies for the socially significant behavior changes sought. Third, the target behavior must be defined precisely so that accurate, reliable measurement of its frequency, duration, latency, topography, and/or magnitude can be made.

Applied

Analytic

The applied in ABA signifies the field’s focus on changing behaviors that improve people’s quality of life. Learning to read, to interact effectively with peers, and to play a musical instrument are obvious examples of behavior changes that meet the applied criterion. An intervention that turns a noncompliant, acting-out child into a quiet and passive one would fall short of the applied standard. A  more meaningful—and thus more applied— intervention would also increase the frequency with which the child emits desirable, alternative behaviors, such as complying with parental requests. Applied also means that the methods used to change behavior are practical and acceptable to those who use them, including the participants and significant others affected by them.

Measurement provides evidence of the existence, direction, and extent of behavior change, but measurement alone cannot reveal why the change occurred. Applied behavior analysts use a variety of analytic tactics commonly known as single-subject, single-case, or intrasubject experimental designs (e.g., reversal, multiple baseline, alternating treatments, and changing criterion) to pursue and identify what Baer called the “acid test proof” of an intervention’s effectiveness. Analysis has been achieved when a functional relation between the intervention and a reliable change in the targeted behavior has been demonstrated. In effect, the analyst is able to “turn on and turn off” the behavior change by systematically manipulating the intervention.

Behavioral

Technological

That ABA must be behavioral would seem selfevident, but this dimension entails three important criteria. First, an actual behavior must be targeted for change. Behavior is the interaction between an individual and his or her environment. Targeting the absence of responding, such as “not hitting others,” does not meet this criterion. Ogden Lindsley proposed the “dead man test” to check if an objective is truly behavioral. Any goal a dead person could achieve fails the

No matter how robust its effects in an experimental study, an intervention will be of little value if practitioners are unable to replicate it. A technological description of a clinical tactic derived from ABA specifies in clear language everything a therapist should do, and not do, under all likely conditions. Detailed and unambiguous procedural descriptions make treatments replicable and teachable. Without this criterion, it would be impossible to compile a validated compendium of clinical tactics.

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Applied Behavior Analysis

Conceptually Systematic

An ABA intervention is conceptually systematic when the procedures and the interpretations of how or why those procedures were effective are described in terms of the basic principle(s) from which the intervention was derived. The requirement to be conceptually systematic yields two important outcomes. First, relating behavior change procedures to basic principles enables practitioners to derive similar and potentially equally effective interventions from the same principle(s). Second, ABA’s conceptual system, embodied within its integrated principles and tactics that can be taught, distinguishes it from mere assortments of behavior change tricks with limited utility. Effective

To be considered effective, an ABA study must produce behavior changes that reach clinical or social significance. Statistical significance—the standard by which research in education and the social sciences is typically judged—plays no primary role in ABA. An investigation can yield statistically significant results but have limited social significance for the participants. For example, consider a therapeutic intervention that decreased a student’s profanity-laced outbursts from 30 instances per hour to 5. While this result might be statistically significant, it would be clinically insufficient. Five instances of swearing in class per hour is still too many. How much a given behavior must change to be considered socially significant is a practical question, one best answered by those directly affected by the intervention.

Techniques Effective and ethical use of ABA by counselors and psychotherapists requires a solid understanding of the basic principles of behavior and evidence-based behavior change tactics derived from those principles. A principle of behavior describes a functional relation between behavior and one or more controlling variables. Principles of behavior (e.g., reinforcement, punishment, extinction, and stimulus control) are empirical generalizations inferred from the results of hundreds of basic research studies in the EAB. Principles are general laws that explain how behavior works, how consequences select and strengthen behavior, how behavior comes under the control of antecedent stimuli, and how behavior is more or less likely to occur as a function of specific motivating operations. A behavior change tactic is a specific method for changing behavior derived from one or more basic principles of behavior. Research in ABA has shown each behavior change tactic to possess sufficient generality across individuals, settings, and/ or behaviors to warrant being codified and recommended to therapists. There are many behavior change tactics, each one derived from relatively few basic principles. Examples of behavior change tactics frequently used in therapeutic situations include contingent praise and attention, habit reversal, modeling, self-monitoring, and differential reinforcement. The principal techniques that counselors and psychologists have at their disposal for making functional and sustainable behavior changes include tactics such as extinction, imitation, positive reinforcement, shaping, social reinforcement, stimulus fading, stimulus and response prompts, time-out from positive reinforcement, and using tokens as conditioned reinforcers.

Capable of Generalized Outcomes

Behavior changes that vanish after treatment has ended, that fail to occur in relevant settings and situations beyond where the intervention was implemented, or that do not spread to relevant behaviors have limited impact on participants’ quality of life. Thus, a major focus of ABA is the experimental demonstration of strategies and tactics that reliably promote the generalization and maintenance of behavior change.

Therapeutic Process Regardless of the behavior change technique that is employed, counselors and psychologists using these techniques follow a process that involves the following phases: (1) baseline data are collected until a stable trend with respect to the target behavior of interest can be discerned; (2) an intervention is introduced; (3) data continue to be collected to evaluate the effects of the

Archetypal Psychotherapy

treatment(s); and (4) probes are taken to assess maintenance and generalization effects. Ultimately, therapeutic effectiveness is deemed to have occurred when the target behavior changes in a socially significant direction. The length of any clinical intervention depends on the initial level of the behavior, the therapist’s success in applying the most powerful but least intrusive treatment, and the therapist’s ability to obtain robust maintenance and generalization effects. Timothy E. Heron, John O. Cooper, and William L. Heward See also Acceptance and Commitment Therapy; Behavior Therapy; Functional Analytic Psychotherapy; Operant Conditioning; Skinner, B. F.

Further Readings Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Pearson. Follette, W. C., & Bonow, J. T. (2009). The challenge of understanding process in clinical behavior analysis: The case of functional analytic psychotherapy. The Behavior Analyst, 32, 135–148. Hayes, S. C., & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17, 289–303. Layng, T. V. J. (2009). The search for an effective clinical behavior analysis: The nonlinear thinking of Israel Goldiamond. The Behavior Analyst, 32, 163–184.

ARCHETYPAL PSYCHOTHERAPY Archetypal psychotherapy is one of the depth psychotherapies in the lineage of psychoanalysis and Jungian analytical psychology, all of which share a dialogical approach to engaging unconscious material. It is talk therapy in which the talk is operating at multiple levels, including the levels of the personal and collective unconscious. It is based on the theories of the post-Jungian field of archetypal psychology. This body of theory, which calls for a new understanding of the nature of the psyche itself and a new orientation to symptoms, has

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significant implications for the practice of psychotherapy, some of which are quite paradoxical in the context of mainstream suppositions about mental health.

Historical Context The field of archetypal psychology is largely based on the work of James Hillman (1926–2011), a Jungian analyst, trained at the C. G. Jung Institute in Zurich, Switzerland. Hillman’s core ideas about the nature of the psyche—for example, that it is real, that it is constituted of images, that it is necessarily symptomatic, that it is both personal and more than personal—can all be found in the writings of Jung and his followers. But Hillman reacted against a trend toward dogma and the development of a “priest class” of analysts that put them “in charge” of the psyche. He saw the proper domain of psychology to be more than the individual. It should also address the community, the culture, politics, the arts, and the environment. He strongly criticized psychotherapy aimed at strengthening the ego in favor of psychological work that was aimed at relativizing the ego—putting the ego into relationship with other aspects of the psyche.

Theoretical Underpinnings In Jungian psychology, the word archetype is used to describe an unconscious pattern, image, instinct, or idea that is universal and timeless and that appears in personal psyches through dreams, fantasies, and imagination. Everything can have its archetypal level of existence. Thus, though we all have personal mothers, there is also an archetypal Mother that gives shape and meaning to the actual experience of personal mothers. This idea has roots in Greek Platonic philosophy (e.g., Platonic ideal forms). That the title “archetypal psychology” begins with the word archetypal is often considered misleading because this is not a psychology about specific archetypes per se. Instead, the interest is in seeing the archetypal quality or dimension in all things. Hillman called this activity “soul making.” Some of Hillman’s followers expressed a preference for the title “imaginal psychology,” a more direct representation of Hillman’s focus on imagination

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Archetypal Psychotherapy

as the core process of the psyche. In fact, the work of Henry Corbin (1903–1978), a scholar of Sufi mysticism and Islamic studies, provided Hillman and his followers with the pivotal idea of an autonomous creative imagination that we participate with but do not author or control. Corbin’s idea of a mundus imaginalis fitted well into the Jungian positions that the psyche is real and autonomous rather than a production of the personal mind and that this more than human psyche is constituted of images. Therefore, psychological life is best understood as a continually creative act that unfolds through the processes of imagination.

Major Concepts In his seminal work Revisioning Psychology, Hillman introduces four key ideas that lead to suggestions for imaginal practice, including the practice of psychotherapy. These include personifying or imagining things, pathologizing or falling apart, psychologizing or seeing through, and dehumanizing or soul making. Personifying or Imagining Things

Personifying is a way of seeing that the world is alive and filled with presences that have their own subjectivity, worthy of being engaged as we might engage other human beings. It is not a new idea and is well understood by poets and other writers and artists. But it is an innovation to bring it into psychotherapy, which traditionally used a language of labels and processes that tend to deaden the objects of our attention. One example of this as a technique might be to use the words anger and compassion as subjective archetypal presences, as in the sentence “When Anger walked into the room, Compassion walked out.” Pathologizing or Falling Apart

Pathologizing or falling apart refers to the understanding that the psyche is, by nature, symptomatic. Therefore, the practice of psychotherapy needs to resist the impulse, in both patients and therapists, to immediately eliminate symptoms. Instead, it begins by making relationship to the symptom as a way of making deeper connection to

the psyche. Archetypal psychologists see symptoms as pointing to the soul, and here the terms psyche and soul are often used interchangeably. As a technique, or “move,” this might take the form of acknowledging our struggle to patiently bear the symptom and expressing curiosity about its qualities, its character, and its nature. Psychologizing or Seeing Through

Hillman criticized mainstream clinical psychology as impoverished in the realm of ideas, favoring a reductionist approach to its own language, bringing the language of the “talking cure” down to abstract concepts. Psychologizing reverses that trend by seeing through all experience to the ideas, images, myths, and metaphors that enrich our understanding. This would include the move of seeing through clinical practice as, itself, a metaphor or myth and therefore resisting the pull to take things such as diagnoses and treatment plans literally. For example, when treating a patient for panic disorder, the archetypal psychotherapist is less inclined to view the client as having a disorder. Instead, the therapist would, at least inwardly and metaphorically, recognize the presence of the Greek god Pan. In that sense, a Panic disorder is both an individual diagnosis and a visitation by an archetypal force. Dehumanizing or Soul Making

This practice emerges from a criticism of humanistic psychology and its tendency to separate humans from the larger ecology of which we are a part. Archetypal psychotherapy would include decentering the patient as an isolated symptomatic individual and expanding the context of therapy to include the community, the culture, and the world. This idea is somewhat comparable with other theories that extend the focus beyond the individual person (e.g., social psychology and family systems psychology); however, archetypal psychology takes this extension even further to include the nonhuman world in its definition of the psyche. The supposition here is that by remembering that the things of the world are alive and have their own soul, we can break through painful fantasies of isolation and find a deeper kind of remedy.

Aromatherapy

Techniques Archetypal psychotherapy relies less on specific techniques than on maintaining an attitude of openness to the psyche, personal and collective. Some techniques or “moves” are included in the “Major Concepts” section as examples of how the major concepts may play out in therapy. In summary, the techniques include the following: Sticking with the image—remembering that the psyche is constituted of images and that working with the images, dreams, and fantasies that are present in the symptom and in the therapy, is the primary mode of therapy Restoring a metaphorical sensibility—encouraging the patient to see the metaphorical level of his or her symptoms and letting go of the literal definitions that typify other clinical approaches

Therapeutic Process For archetypal psychotherapy, as with other depth-oriented psychotherapies, the practice is essentially therapeutic dialogue aimed at engaging the unconscious. The primary difference is one of attitude and intention. It is important that the archetypal psychotherapist be emotionally and psychologically available to host the images, narratives, and figures that show up in this kind of work. The underlying supposition of the reality of the psyche means that these things are also real, and attending to them is a necessary aspect of the therapy. Joseph Coppin See also Analytical Psychology; Ecotherapy; Freudian Psychoanalysis; Intersubjective-Systems Theory; Psychosynthesis

Further Readings Corbin, H. (1972). Mundus imaginalis or the imaginary and the imaginal. Spring Journal, 1–19. Hillman, J. (1975). Re-visioning psychology. New York, NY: Harper & Row. Hillman, J. (1983). Archetypal psychology: A brief account. Dallas, TX: Spring. Marlan, S. (Ed.). (2008). Archetypal psychologies. New Orleans, LA: Spring Journal Books.

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AROMATHERAPY Aromatherapy is the use of essential oils as possible therapy for various symptoms or conditions. Essential oils are the volatile and fragrant oils of plants (flowers, herbs, or trees). Those that are used for aromatherapy are extracted in natural ways, such as by distillation with steam and/or water, or by mechanically pressing the plants. Oils that are chemically processed are not considered true essential oils. Each type of oil has a different chemical composition, which affects how it smells, how it is absorbed, and how it is used in the body. Oils of the same variety of plant also can have different chemical compositions that vary by the  location of harvest. Aromatherapy is one of the fastest growing of all the complementary and integrative therapies and is often used as an adjunct to traditional approaches of counseling and psychotherapy.

Historical Context Fragrant plants, including flowers, herbs, and trees, have been used for thousands of years across many cultures. Methods of extracting oils from plants were first discovered during the Middle Ages. A French chemist named Rene Gattefossé is referred to as the “grandfather of aromatherapy” and was the first to use the term aromatherapy in his book published on the subject in 1937. During World War I, Gattefossé investigated the antibacterial and healing properties of essential oils for treating wounded soldiers. He continued to study the effects of essential oils on many different diseases and symptoms. In recent years, emphasis has shifted to the effects that aromatherapy might have on a broader range of symptoms. These include common problems such as nausea, insomnia, and fatigue, as well as an increasing focus on symptoms associated with mood, such as anxiety and depression. While public acceptance of aromatherapy has grown significantly, many clinicians remain skeptical, in part due to the limited regulatory oversight of the field. If no specific claims or indications are advanced for treatment, aromatherapy products do not need U.S. Food and Drug Administration approval. Today, there are no state laws or licensing

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Aromatherapy

requirements for aromatherapy practice. Licensed professionals such as counselors and therapists, massage therapists, and nurses often combine aromatherapy training with their practice.

It is not entirely clear how aromatherapy and essential oils work, but one prominent theory proposes that receptors in the nose may react to the aroma by sending chemical signals to the central nervous system and along the nerve pathways to the brain’s limbic system. These chemical signals then affect moods and emotions. Imaging studies have shown the effect of smelling oils on specific brain activities. After essential oils are inhaled, chemical markers or compounds can be found in the bloodstream. This suggests an effect on the body similar to that caused by a drug.

ingestion of oils. Ingested oils may be placed in a capsule or added to food or medicinal preparations. Indirect inhalation occurs when a patient breathes in essential oils by placing drops nearby or in a diffuser. Direct inhalation occurs when individual inhalers are used. Essential oils, diluted in carrier oils, may be used during a massage and applied to the skin. Essential oils also may be combined with bath salts or lotions and applied with dressings. Lavender is the most widely used essential oil, but research with other oils is needed to determine the relevant physiologic effects of essential oils for the treatment of psychiatric disorders. Some studies have found indirect inhalation of lavender to be potentially beneficial for decreasing agitation with dementia, treating symptoms of depression, reducing migraine pain and nausea, enhancing mood, and adjunctively treating mild insomnia.

Major Concepts

Therapeutic Process

Aromatherapy is used by patients for various conditions and symptoms. It is not a substitute for conventional medical care but may be used as an adjunctive therapy. Some oils have been studied for their effects on mood and emotions or immune responses. Oils can have either a calming or an energizing effect, depending on the oil used. Aromatherapy has been studied for use in the treatment of stress, anxiety, sleep, depression, agitation, migraine headaches, and other healthrelated conditions. Aromatherapy also has been used to increase sexual desire and improve general feelings of well-being. Studies have had mixed results. Some studies reported improvements in mood, anxiety, pain, nausea, and constipation, while others reported no effect. There is insufficient evidence to rate the effectiveness of aromatherapy for agitation, anxiety, depression, migraine headaches, promoting well-being, insomnia, nausea and vomiting, stress relief, pain, dementia, headache, fibromyalgia, relaxation, and increasing sexual desire.

Often, aromatherapy is used by counselors and other mental health professionals as an adjunct to more traditional counseling approaches. If used safely and correctly, and on the basis of relevant neuropharmacologic and limited clinical evidence, aromatherapy has potential in the field of counseling and psychiatry for mood, anxiety, insomnia, stress, and depressive symptoms.

Theoretical Underpinnings

Techniques Aromatherapy is used in various ways, including indirect inhalation, direct inhalation, application to the skin with or without massage, or orally by

Brent A. Bauer and Sue Cutshall See also Complementary and Alternative Approaches: Overview; Non-Western Approaches

Further Readings Edris, A. E. (2007). Pharmaceutical and therapeutic potentials of essential oils and their individual volatile constituents: A review. Phytotherapy Research, 21, 308–323. doi:10.1002/ptr.2072 Perry, N., & Perry, E. (2006). Aromatherapy in the management of psychiatric disorders: Clinical and neuropharmacological perspectives. CNS Drugs, 20, 257–280. doi:10.2165/00023210-200620040-00001 Woelk, H., & Schläfke, S. (2010). A multi-center, doubleblind, randomised study of the lavender oil preparation Silexan in comparison to Lorazepam for generalized anxiety disorder. Phytomedicine, 17, 94–99. doi:10.1016/j.phymed.2009.10.006

Art Therapy Yim, V. W., Ng, A. K., Tsang, H. W., & Leung, A. Y. (2009). A review on the effects of aromatherapy for patients with depressive symptoms. Journal of Alternative and Complementary Medicine, 15, 187–195. doi:10.1089/acm.2008.0333

ART THERAPY Art therapy is a human service profession in which art materials, the creative process, and a final art product are the vehicles for therapeutic interaction. Along with talking, creating some sort of art product is a focus of the therapy session. Personal awareness and growth take place as the patient interacts with art materials and learns something about himself or herself from the process of using them. An underlying assumption is that the processes that people use during the creation of images or sculpture mimic the patterns of thought, feeling, and action displayed in other aspects of their lives. Learning occurs through the creation of personal symbols or by linking to universal themes, by illustrating and thinking through problems, and via the release of tension and expression of emotion. Art therapy is often suggested for people who have difficulty expressing their emotions and/or verbalizing their thoughts. It is appropriate for a patient of any age, from young children through the elderly. Individuals, couples, families, and groups all have benefited from the power of therapeutic art making. Art therapy is one of the fastest growing allied health professions in the United States and has been applied across a wide variety of settings: churches, domestic violence shelters, eating disorder clinics, homeless shelters, inpatient mental and medical hospitals, outpatient counseling programs, prisons, private practice clinics, retirement communities, schools, substance abuse programs, and veterans administration hospitals. A master’s degree is required to become a registered art therapist. The prerequisites for graduate school include psychology classes and studio art classes demonstrating familiarity with a variety of art media. Art therapists appreciate the unique power of the creative process and the resulting art product in helping patients rapidly give voice to their concerns and demonstrate their strengths, sometimes before these factors are consciously known.

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Historical Context The field of art therapy began to take shape in the mid-20th century in both the United States and Great Britain. The influences were similar in both countries: the need to provide mental health services for returning World War II veterans, the increasing prevalence of psychoanalytically influenced treatment programs, and the changing nature of fine art. At that time, art was becoming less representative of what artists saw with their eyes and more liberally based on what artists felt and thought. For example, surrealist artists often depicted their wishes and dreams on their canvases. At the same time, in the field of psychology, there was a growing interest in the projective use of images in the assessment of patient concerns and personality traits. Procedures such as the Rorschach Ink Blot Test, the Thematic Apperception Test, and the House-Tree-Person Drawing assessment were widely used based on the belief that responses to images (either talking about them or drawing them) reflected projections of the artist’s internal world. Thus, everything that a patient produced or responded to was considered a self-portrait. The roots of art therapy were in self-projection and psychoanalysis, with many of the art therapy pioneers having undergone their own personal analyses. Margaret Naumburg, who regularly is referred to as the founding mother of art therapy, believed that drawings could be used in therapy as a type of pictorial free association. Rather than talk about what came into their minds, as they would in psychoanalysis, patients in art therapy painted or drew mental images. Naumburg was convinced that images created in art therapy provided access to unconscious material more rapidly and more deeply than spoken words.

Theoretical Underpinnings From its inception, art therapy was characterized by a fundamental controversy as to the underlying nature of its effectiveness. One section of art therapists promoted “art in therapy,” and the other main group of practitioners believed in “art as therapy.” Proponents of “art as therapy” proposed that the process of creating an artistic product was the healing mechanism. They explained that the necessary and sufficient conditions for therapeutic

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Art Therapy

change take place in an art therapy studio using art materials. They believed that the verbal processing of the experience or product was secondary to creating it and not necessary for achieving a therapeutic effect. On the other hand, for those who subscribed to the “art in therapy” view, the art was seen as a tool used in conjunction with another theoretical approach and therefore usually heavily dependent on verbal processing of the experience or of the resulting art image. For example, in psychoanalysis, drawn or painted images were used as a way to aid free association and to fuel the verbal analysis. The outcome of the controversy is that most art therapists agree that art functions therapeutically in both of these powerful ways as well as in many others. Art therapy has been conceptualized as operating through many different theoretical channels, including Jungian, Gestalt, humanistic, and cognitivebehavioral, to name a few. Each of these approaches to art therapy has in common that art is used as a tool to facilitate the therapeutic work according to the tenets of another theory—expanding it but not owning it. Thus, a cognitive-behavioral approach to art therapy would use image making to help promote cognitive restructuring or the creation of more rational views of a problematic situation or to increase the ability for cause-and-effect thinking. Jungian art therapy uses images to illustrate and integrate important parts of the self and to provide solutions to complexes. In Gestalt-oriented art therapy, the image can represent a part of the self that is later engaged in therapeutic dialogue. Art therapists coming from diverse theoretical backgrounds can sometimes believe that theirs is the only correct way to conceptualize and conduct therapy. In addition, the inclusion of numerous different theoretical models can fragment rather than unify the profession. Furthermore, the application of art making to various theories promotes the view of art therapy as an adjunctive treatment rather than as a potent, stand-alone therapy. The Expressive Therapies Continuum (ETC) is a theoretical model developed by art therapists to define and explain the many and various therapeutic uses of art expression. It can explain therapeutic experiences from all psychological theories and expressive therapies, and in its inclusiveness, it encourages respectful comprehension of the power of art therapy as a unique profession. The ETC is a

theoretical and practical tool that sets art therapists apart from others who use expressive activities or apply the use of art to another psychological theory. Developed more than 30 years ago, the ETC incorporates information from diverse forms of art therapy and art education, and psychological and neurological sources into a comprehensive theoretical structure that explains patient interactions with art media during expressive activities to process information and form images. The ETC includes three bipolar levels arranged in a hierarchical and developmental fashion to include all forms of creative expression, as demonstrated in Figure 1. The hierarchical nature of the theory means that the therapeutic actions of art making are conceptualized as occurring from simple to complex: from (at the bottom of Figure 1) simple movement and sensation, moving up through perceptual/emotional expression, to complex thought and multileveled symbol creation (at the top of Figure 1).This manner of viewing expressive experiences mirrors the development of information processing from infancy to adolescence. Infants take in information through first random and later purposeful movements, in concert with sensory feedback. Children use mental schema formation as one way to master their world and their emotional responses to it. Finally, with the development of more sophisticated thought processes, adolescents can generalize

Creative (Level)

Cognitive (Component)

Symbolic (Level) (Component)

Perceptual (Component)

Affective (Level) (Component)

Kinesthetic (Component)

Sensory (Level) (Component)

Figure 1 The Expressive Therapies Continuum Source: “Walking the Line Between Passion and Caution: Using the Expressive Therapies Continuum to Avoid Therapist Errors,” by L. D. Hinz, 2008, Art Therapy, 25(1), pp. 38–40. Reprinted with permission of the American Art Therapy Association.

Art Therapy

their knowledge to new situations and think in a complex manner that includes the use of metaphors and symbols. According to ETC theory, persons seeking therapy usually have a preferred way of processing information, which can be determined by watching how they use art materials and form images in the first few art therapy sessions when given free access to art materials and tasks. Patients with a kinesthetic/sensory preference use the art materials as facilitators of action or sensation, without much regard to the finished art product. Those who prefer the perceptual component, on the other hand, will be very invested in creating an image that is characterized by a precise focus on form. Form becomes less important when the affective component is preferred. In this case, fluid media like paint or chalk pastels in bright colors are used to express emotion. A cognitive preference can be shown through the use of words or art activities that contain many complicated steps or procedures. A  symbolic inclination can be seen through the use of complexly layered and metaphorical representations. These component functions take into account all of the ways in which art can be applied across various psychological theories.

Major Concepts Regardless of theoretical orientation, art therapists use art materials in their work and are concerned about providing a safe environment, nontoxic materials, and a maximally therapeutic experience. Maximizing the therapeutic nature of the experience means that art therapists understand media properties and the appropriateness of media choices with various patient populations. In addition to media properties, when conceptualizing art interventions, art therapists pay careful attention to task complexity, task structure, reflective distance, mediators, and boundaries. Media Properties

Art materials possess inherent qualities that affect the way they are perceived and the unique response they elicit in the user. Most frequently, art therapists reference a continuum of fluid to resistive media characteristics capable of evoking thought, behavior, and emotion. Media with a more inherent structure (wood, stone, and plasticine modeling

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material) are called resistive because they resist easy manipulation or modification. Working actively with resistive materials in art therapy is likely to promote a cognitive experience as patients think through how to achieve the product they want. Fluid media are easily altered, and thus more difficult to control, and using fluid media, such as chalk pastels or watercolor paint, is likely to arouse emotion and allow for its free-flowing expression. The fluid/resistive nature of media interacts with paper texture to modify the emotional/cognitive nature of the expression. Heavier paper and paper with a rough texture create a more resistive experience, whereas smooth paper, such as slippery finger paint paper, adds to the fluid nature of the experience. Task Complexity

The complexity of a task can roughly be equated to the number of steps necessary to complete it. A low-complexity task is one that requires only one instruction or one step to successful completion. In contrast, a high-complexity task requires multiple steps, and completion is more complicated and requires more conscious thought. Therefore, a highly complex task is likely to evoke a cognitive experience, whereas a low-complexity task has greater possibility to elicit emotion. Structure of Materials

Media with a solid composition, such as wood or mosaic tile, are called highly structured or boundary-determined media and are hypothesized to provide a safe, controlled, and nonthreatening art therapy experience. Materials with no inherent boundaries, such as watercolor paint, are quantity determined. The amount of the medium limits their use, and therefore, if an individual is responsive to the emotional qualities of a fluid medium, adding more of the medium would increase the emotional experience. In addition, paper size provides boundaries that add a limit-setting function: Larger paper allows for freer expression, whereas smaller paper can contain ideas or emotions.

Techniques The number of art therapy techniques is limited only by one’s imagination. Media properties, task

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instructions, and level of complexity can be combined in countless ways for various therapeutic reasons and results. The following is a list of a few common art therapy techniques accompanied by rationales for their use.

unpleasant experiences at different ages. Experiences are further identified with symbols in this complex activity that promotes a cognitive appraisal of the lifetime. Mandala Drawing

Clay Manipulation

The manipulation of clay through pounding, pushing, rolling, throwing, juggling, or any other movement facilitates the release of energy and tension. This energetic free expression can be an end in itself, or it could lead to the shaping of a form that takes on personal meaning.

Mandala drawings occur in a circular shape, typically starting at the center and extending to the outer edge. The drawing can include meaningful colors and shapes as well as personal symbols, or it can merely entail the coloring of a predrawn form. Research indicates that coloring in the circular mandala form reduces stress and anxiety.

Finger Painting

Finger painting is a sensual experience that stimulates the senses of sight and touch. Through sensory stimulation, one can potentially match an inner state with an outer state to create a sense of calm, focused attention. Changing-Point-of-View Drawings

Changing-point-of-view drawing requires that a patient create a picture of a current challenge. Subsequently, the patient draws an extreme closeup view of the original drawing, usually emphasizing one part of it. The final drawing is a bird’s eye view of the original creation, which puts it into a context. The combination of the three pictures helps the patient understand that his or her perception of a challenging situation greatly influences the experience of it. Four Primary Emotions Drawing

Four primary emotions drawing asks patients to represent the emotions happy, sad, angry, and afraid in four quarters of a paper. These side-byside representations can aid patients in beginning to identify and discriminate among their emotions. Lifeline Drawing

Lifeline drawings involve representing one’s life as a line from birth to the current time (or perhaps into an imagined future). The line dips below or rises above midline to represent pleasant and

Therapeutic Processes Art can be created in a session and/or assigned as homework to be completed outside the therapeutic hour. Usually, as the art therapist is getting to know the patient and his or her concerns, creation is reserved for the therapy hour. This reservation is a precaution against eliciting too much information or emotion, which might be unmanageable by the patient alone. Whether in a group or individual context, the art therapy session frequently begins with a checkin period, in which the concerns of the week or day are discussed and goals for the session determined. The art therapist might then suggest an art activity and media, or the patient might choose his or her own materials. The art therapist silently witnesses the patient’s creative process, noting how and where it began on the page, the colors used, the words spoken, the struggles with limits and boundaries (paper size, time allotted, etc.), and the challenges to coping skills. Coping skills can be assessed through how the patient deals with an unfamiliar medium or how he or she responds to mistakes. After image completion, the patient often is asked to describe the process of creating as it was experienced internally. The discussion of the creative process can mirror the patient’s typical way of facing other life challenges. For example, if a painting did not turn out as desired and was torn to pieces, this might mimic frustration and giving up in other circumstances. The patient also is encouraged to talk about how the image or object produced looks once it is completed. The art therapist might add what he or

Assimilative Psychotherapy Integration

she observed during the process as one way to extend the exploration. However, the art therapist does not “interpret” the product, believing that the patient is the foremost expert on his or her creation. Patient and art therapist work together to discover the significance and meaning of the product. At times, patients will be encouraged to respond to the original image with another image or “response piece,” or through dance, music, poetry, drama, or some other artistic means. The art therapist typically keeps the art while patients are in therapy, and at the conclusion of therapy, patients can review their work to note areas of change and personal growth. The result of art therapy is that patients can learn new and more positive ways to view themselves and their lives. Art therapy aids personal growth. Patients accrue skills and can use art methods to reduce stress, aid meditation, think through problems, or express their emotions. Lisa D. Hinz See also Dance Movement Therapy; Drama Therapy; Gestalt Therapy; Music Therapy; Poetry Therapy; Psychodrama; Writing Therapy

Further Readings Hinz, L. D. (2009). Expressive therapies continuum: A framework for using art in therapy. New York, NY: Routledege/Taylor & Francis Group. Kagin, S. L., & Lusebrink, V. B. (1978). The expressive therapies continuum. Art Psychotherapy, 5(4), 171–180. doi:10.1016/0090-9092(78)90031-5 Landgarten, H. B. (1981). Clinical art therapy: A comprehensive guide. New York, NY: Brunner/Mazel. Malchiodi, C. A. (1998). The art therapy sourcebook. Los Angeles, CA: Lowell House. McNiff, S. (2004). Art heals: How creativity cures the soul. Boston, MA: Shambhala. Moon, B. L., Huestis, R., & Reece, J. (1994). Introduction to art therapy: Faith in the product. Springfield, IL: Charles C Thomas. Moon, C. (2010). A history of materials and media in art therapy. In Materials and media in art therapy: Critical understandings of diverse artistic vocabularies (pp. 3–47). New York, NY: Routledge/Taylor & Francis Group. Naumburg, M. (1966). Dynamically oriented art therapy: Its principles and practice. New York, NY: Grune & Stratton.

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Rubin, J. A. (2010). Introduction to art therapy: Sources & resources (Rev. ed.). New York, NY: Routledge/Taylor & Francis Group. Wadeson, H. (2010). Art psychotherapy (2nd ed.). Hoboken, NJ: Wiley.

ASSIMILATIVE PSYCHOTHERAPY INTEGRATION Assimilative psychotherapy integration, or assimilative integration, is a mode of conducting psychotherapy or counseling in which a technique, concept, or perspective is incorporated into one’s home or preferred therapeutic approach from another form of therapy. One might, for example, incorporate systematic desensitization or social skills training— that is, cognitive-behavioral techniques—into a psychodynamic or person-centered therapy, or one could include in cognitive-behavioral therapy special attention to the therapeutic relationship as described in client-centered therapy. Assimilative integration is one of four major types of psychotherapy integration or eclecticism, the others being theoretical integration, common factors, and technical eclecticism. It recognizes that although most therapists are trained in, and practice from within, one theoretical model, as they gain experience they are likely to include features of another approach that have been demonstrated to help therapy progress more effectively and/or efficiently. In this way, therapists build on and, hence, modify the theoretical modality to which they have primary allegiance by integrating new methods.

Historical Context The broader historical context of assimilative integration is the history of psychotherapy integration itself. Sigmund Freud, for example, who established the field of psychotherapy in the late 19th and early 20th centuries, acknowledged that in certain cases of phobias and obsessions it might be necessary to actively encourage patients to face their fears, a decidedly behavioral approach. In the 1920s, Sandor Ferenczi went further in this regard and dubbed what he did “active therapy.” Moving forward to the late 1940s, one of the prominent early integrative theories was that of

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John Dollard and Neal Miller, who proposed integrating learning theory and psychoanalysis, which is an example of theoretical integration. Also in the 1940s, Franz Alexander proposed the concept of the “corrective emotional experience,” arguing that the patient improves by virtue of his or her relationship to the therapist. More specifically, it suggests that the patient can reexperience the original conflict situation in the presence of a benign and helpful person and thus learn to deal with it in a more positive manner. This was a precursor to the prominence of the therapeutic relationship as a common factor of change across all therapies. In the 1960s, technically eclectic models emerged in which the emphasis was on what worked, preferably as determined by empirical research, with less concern about theory. Most prominent were the approaches of Arnold Lazarus and Larry Beutler. While Lazarus combined a wide variety of different techniques in what he termed multimodal therapy, Beutler tried to determine the kinds of patients, therapists, and treatment variables that interacted to produce the best results. In the 1970s, Paul Wachtel wrote his influential book Psychoanalysis and Behavior Therapy: Towards an Integration, in which he proposed a theoretical model that justified behavioral interventions within a psychodynamic therapy, naming the result cyclical psychodynamics. It is widely considered the best example of a theoretical integration of behavioral and psychodynamic therapies. This and other volumes on integration argued that insight could follow from behavioral changes just as readily as insight could precede change. It was in the context of these approaches to integration that Stanley Messer proposed the concept of assimilative integration. It has been referred to as a middle ground between theoretical integration and technical eclecticism, as a mini theoretical integration, or as a way station to a fuller integration. It has the advantage of allowing therapists to practice within the comfort zone of their favored theoretical approach, even while broadening their repertoire to include techniques or perspectives from other modalities. In a survey of clinical psychologists, assimilative integration was found to be one of the most endorsed forms of integration or eclecticism. In another study, those identified as

experts in psychotherapy integration were asked to assess the extent to which they were influenced by psychodynamic, cognitive-behavioral, humanistic, and family systems theories. Three quarters indicated that only one was a salient influence, supporting a major claim of assimilative integration, namely, that practitioners tend to have a home base in one theory.

Theoretical Underpinnings Two major philosophical concepts drawn on in assimilative psychotherapy integration are (1) contextualism and (2) pluralism. The former can be contrasted with mechanism and the latter with organicism, as described by the philosopher Stephen Pepper. Contextualism

Within a contextualist view, an act or event is explained by demonstrating the relationship it bears to other events or acts that surround it. The object is not to integrate all the events in the field but to limit the explanation of that event or fact to the specific domain in question. For example, in psychotherapy, the case study or the field of psychobiography is contextualist in so far as the meaning of the events described comes from the context in which the life facts that are being considered or interpreted reside. Unlike the situation in a more mechanistic framework, which emphasizes individual, independent facts, parts, or events, in a contextualist worldview there is no separation of detail from context. One way to understand contextualism is to consider a sentence. It derives its meaning from the individual words it comprises, but the way in which we understand the meaning of the words within a sentence is determined by the meaning of the sentence as a whole. Similarly, a fact does not stand on its own but can only be evaluated and understood in relation to the larger theory or argument of which it is a part. At the same time, this larger structure is dependent on its individual parts. We move back and forth between the part and the whole, which constitutes the circle of understanding (or hermeneutic circle). As applied to a clinical situation, this implies that one cannot import a technique into one’s home therapy without noting

Assimilative Psychotherapy Integration

that it has been somewhat changed and has taken on a different meaning within its new clinical context. That is, it gets assimilated into the larger context of the home theory and therapy. One might then consider the way in which the home theory is altered, which is its accommodative aspect.

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should be grounded in observation and empirical evidence, there are a multitude of ways to construct valid theories, including by assimilating techniques or concepts into one’s home theory and therapy.

Major Concepts Organicism Versus Pluralism

The philosophical position known as organicism argues that in the world we encounter fragments of experience, such as the observations of a school of therapy, which may be contradicted by the observations of a different theory of therapy. However, lying beneath the seeming differences in these theories is a unity waiting to be discovered. In other words, the apparent contradictions were never really contradictions at all because they disappear once the integrated system of therapy is discovered. This unified system in which individual parts are united is said to be greater than the sum of its parts. This way of looking at the world is known as a modernist viewpoint, which sees the world and its biological, chemical, physical, and social features as discoverable; hence, one can, in principle, also discover the one true and correct therapy. In contrast to organicism, pluralism holds that one theory or model can never preclude an alternate, competing theory. This is because, according to pluralism, we do not discover what is in nature but, rather, invent our theories and conceptual categories and view reality through them. What follows is that there are, and always will be, multiple ways of conceptualizing and interpreting human experience. So, rather than viewing contradictions among theories as negative or a challenge to be overcome, pluralism sees them as a way of spurring on the creation of yet other ideas and theories. Such differences are not to be viewed as mere deviations from one accurate way of understanding or treating people but as expressions of the many ways in which human experience can be conceptualized and ameliorated. We will always have several theories of therapy because the way to the truth is via the confrontation and dialogue among them. Assimilative integration can be thought of as comprising a bridge between these two outlooks. Even while a theory of therapy, in accordance with the modernist view,

The major concepts in an assimilative therapy come largely from the home theory into which a  technique or concept is incorporated. For example, one major type of assimilative integration is assimilative psychodynamic therapy, as exemplified in the work of Messer and of George Stricker and Jerry Gold. In this approach, one would rely primarily on concepts from psychodynamic therapy, such as establishing what Freud referred to as rapport between patient and therapist; focusing on transference and countertransference; and being attentive to resistance and defenses.

Techniques In an assimilative psychodynamic therapy, many of the techniques flow from psychodynamic concepts and would be in the service of helping the patient achieve insight into his or her problems, especially insight that is deeply felt. This would include an enlarged awareness of internal conflict and interpersonal difficulties, including those that are unconscious. This comes about through the therapist reflecting on what the patient has been saying, clarifying the material, and, when the patient is ready, interpreting it. The therapist draws on the patient’s memories, fantasies, wishes, and dreams. Best is when patients themselves come to a new realization in the transference (the view patients have of the therapist, which stems from their childhood experience) or can connect what is happening in the transference to their current difficulties outside the therapy room and to what has transpired in their past. When things go well, this leads to a greater sense of freedom to act in accordance with one’s true self and a lessening of symptoms such as anxiety, depression, and somatic problems. However, there are times when insight is not enough or the therapy is moving along too slowly. At such junctures, the therapist will introduce and assimilate techniques from other therapies. These

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may include skill building based on the patient’s faulty learning history or behavioral deficits; cognitive techniques to challenge a patient’s irrational thoughts; and experiential techniques such as the two-chair exercise, in which a patient may take the role of her mother in one chair and herself in the other and engage in a dialogue to get in touch with her feelings and resolve a conflict. The therapist may give patients a relaxation tape, advise them on how to do meditation, or use systematic desensitization to help them gain better control over their anxiety.

Therapeutic Process Messer has reported an example of how he treated a young professional man who experienced anxiety bordering on panic in his work setting since graduating from law school. Although Messer conducted a largely psychodynamically oriented therapy to help the patient deal with his problematic relationship to a highly critical and demanding father, he found that the patient, nevertheless, was having trouble focusing on his work. In line with cognitive therapy, the therapist pointed out to the patient his selective negative focus on the most problematic aspects of his work, his magnification of them, and his catastrophizing about them. Together, they came up with other cognitive strategies to help the patient get through the day, such as reminding himself that he had succeeded in similar situations in the past—that is, he was expecting too much of himself as a novice professional and that he needn’t be predicting the future, namely, failing at his work. Because he tended to depend on his stance toward older men, the challenge was for him not to fall into that transference mode with the therapist and for Messer not to take up the countertransference role of the powerful, rescuing parent. This was subsequently analyzed by the cognitive interventions with good effect. This example illustrates an important principle of assimilative integration, namely, the necessity to note the impact of an imported technique or strategy on the relationship of the patient to the therapist and to the newly introduced therapy technique. In another example of assimilative psychodynamic integration, Stricker reports asking a patient to do homework, a behavioral technique, namely, to write a poem about her

therapeutic experience, which he then worked with much as he would with a dream. Most recently, William Gottdiener used an assimilative psychodynamic therapy for the treatment of people with a substance use disorder. Likewise, Louis Castonguay and colleagues have described a cognitive-behavioral assimilative integration that includes aspects of other therapies, such as facilitating emotional deepening from process-experiential therapy. Stanley B. Messer See also Common Factors in Therapy; Cyclical Psychodynamics; Freudian Psychoanalysis; Integrative Approaches: Overview

Further Readings Castonguay, L. G., Newman, M. G., Borkovec, T. D., Grosse Holtforth, M., & Maramba, G. G. (2005). Cognitive-behavioral assimilative integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 241–260). New York, NY: Oxford University Press. Gottdiener, W. H. (2013). Assimilative dynamic addiction psychotherapy. Journal of Psychotherapy Integration, 23, 39–48. doi:10.1037/a0030271 Lazarus, A. A., & Messer, S. B. (1991). Does chaos prevail? An exchange on technical eclecticism and assimilative integration. Journal of Psychotherapy Integration, 1, 143–158. Messer, S. B. (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. 130–165). New York, NY: Basic Books. Messer, S. B. (Ed.). (2001). Introduction to the special issue on assimilative integration. Journal of Psychotherapy Integration, 11, 1–54. doi:10.1023/A:1026619423048 Safran, J., & Messer, S. B. (1997). Psychotherapy integration: A postmodern critique. Clinical Psychology: Science and Practice, 4, 140–152. doi:10.1111/j.1468-2850.1997.tb00106.x Stricker, G. (2013). The process of assimilative psychodynamic integration. Psychotherapy, 50, 404–407. doi:10.1037/a0032719 Stricker, G., & Gold, J. (2005). Assimilative psychodynamic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 221–240). New York, NY: Oxford University Press.

Attachment Group Therapy

ATTACHMENT GROUP THERAPY Attachment group therapy is a form of group therapy based on attachment theory. It is a relational model that views interpersonal connection over the lifespan as a primary human drive, not something to be “worked through.” Although attachment theory is generally considered a type of psychodynamic theory, it is a theory about early learning and adaptation rather than repression and defense. Attachment group therapists use the group experience to explore attachment difficulties and develop more effective attachment behaviors.

Historical Context Attachment theory was developed by John Bowlby (1907–1990), a British psychoanalyst. Bowlby was born to an upper-class British family that conformed to the social mores of the era. Raised mainly by a nanny and sent off to boarding school at 7 years of age, he subsequently developed a theory that emphasized the importance of the bond between children and their primary caretakers. Bowlby was influenced by the work of Anna Freud, Dorothy Burlingham, and Rene Spitz, who worked with World War II wartime evacuees, refugees, and orphans and became interested in the effect of separation on children. A rebel in an era of Freudian drive theory, he felt that relational connection was a major component in human development and viewed attachment as a primary drive. While his supervisor, Melanie Klein, insisted that he explore the fantasies of his child patients, he wanted to observe mother–child interactions. (He was subsequently ostracized by the British Psychoanalytical Society.) Drawing from anthropological studies, he argued that mammal babies are biologically driven to seek attachment for survival purposes. He also studied the transmission of attachment patterns generationally. Bowlby’s student Mary Ainsworth conducted research to support his theories and identified three attachment styles found in children: (1) secure, (2) anxious insecure, and (3) avoidant insecure. Her colleague Mary Main later added a fourth category: (4) disorganized attachment. A protocol called the Strange Situation was developed to observe the attachment between a caregiver and a child.

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In the 1980s, attachment theory was expanded to include the psychology of adults and thus became a theory of lifelong development. Rather than perceiving independence as the pinnacle of maturity, attachment theory views interdependence and the capacity for healthy relationships that help regulate emotions as hallmarks of mental health. Adult attachment researchers such as Cindy Hazen, Mario Mikulincer, and Phillip Shaver found that the attachment styles observed in children are also found in adulthood. Their research has subsequently been refined to include the concepts of attachmentrelated anxiety (people high on this dimension worry about whether their partner is available, responsive, etc.) and attachment-related avoidance (people high on this dimension prefer not to rely on others or open up to them). Research on adult attachment patterns has continued to confirm the generational transmission of attachment patterns that Bowlby noted. Modern attachment theory has also been supported by recent findings in interpersonal neurobiology showing that the central nervous system of social mammals benefits from external stabilization and regulation via attachment relationships at all ages, not just in childhood.

Theoretical Underpinnings Early attachment experiences create internal models of self and others. If a child’s emotional needs are attended to enough of the time, then the child feels loved and therefore lovable. That child also learns to view his or her “significant others” as safe, dependable, and responsive. These models, created by thousands of interactions, become relationship expectations and produce interpersonal scripts. The earliest interpersonal learning occurs on the implicit level, which is nonverbal, formed by somatic experience and often out of conscious awareness. Implicit learning is much stronger than explicit learning. Explicit learning comes later and may or may not be congruent with what has been learned implicitly. While implicit learning begins at birth, the part of the brain that allows explicit learning does not come “online” until about the second birthday. Group therapy is an excellent treatment modality in which to learn about attachment. The early interpersonal lessons, absorbed on an implicit level, appear in the interactions with other members. Members demonstrate their models of self

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Attachment Group Therapy

and others in their behavior in a group, but they receive more attuned responses and are encouraged to challenge their old, often rigidly held, assumptions about how they must interact. While individual therapy is helpful to many people, it can be a place where relationship difficulties are talked about. In contrast, group therapy is a place where people have their difficulties and thus can learn experientially.

Mentalization

Mentalization is the capacity to reflect on one’s inner experience and that of another person at the same time. Mentalization allows one to have an emotional experience and name it without necessarily acting on it. The ability to mentalize develops from secure attachment experiences. Group as a Safe Haven and Secure Base

Major Concepts Attachment group therapy is based on attachment theory. The fundamental concepts of attachment theory relevant for group therapy are emotional regulation through attachment, mentalization, the safe haven and secure base, and how different attachment styles appear in a therapy group.

Group leaders who operate from an attachment theory model see the group as a safe haven and secure base. A safe haven provides comfort and security. A secure base makes exploration of emotions and of new interpersonal behaviors possible. An important aspect of the leader’s role is to maintain the group as a safe haven and secure base for its members.

Emotional Regulation via Attachment

Attachment strategies at any age reflect ways of processing and regulating emotion. These reactions and strategies reflect temperament and also are the mechanisms people use to survive difficult situations while growing up. When there is distress, the person seeks comfort and soothing from an attachment figure. When the need for regulation through connection is met through empathy, attunement, and soothing, the person is able to separate again. If not, there is a predictable and well-observed pattern of increased activity: angry protest, clinging, depression, despair, and ultimately detachment. What happens when there is no one consistently available who is able to provide adequate comfort and soothing—that is, no secure attachment figure? A chronic lack of a safe and secure attachment figure during childhood evokes and maintains automatic fight, flight, or freeze responses that limit information processing and constrict interactional responses. In other words, affect dysregulation occurs. There can be reduced self-caring and reduced caring for others, inhibited problem solving, and use of rigid strategies such as black-orwhite thinking and alternative methods of selfsoothing (e.g., overeating, substance abuse). This experience is what many group members bring to their work in group therapy. Group therapy is a place to discover and change the internal models of self and other, which are often automatic and out of awareness.

Attachment Strategies

Two major dysfunctional attachment strategies are (1) attachment-related anxiety and (2)  attachment-related avoidance. Anxiously attached members typically present with high emotionality and difficulty regulating overwhelming affect. The early implicit learning for them has been that they have to work hard to have their emotional needs met, with constant checking required to see if the attachment figure is available. They may experience panic attacks, depression, and chronic fears of abandonment. They may express emotions such as hurt, sadness, anxiety, and loss readily yet be very fearful of anger and conflict because of the perceived threat to a relationship. In a group, they may be quite attentive to other members and hypervigilant for signs of other members leaving the group (abandonment). They frequently seek comfort and reassurance from members and the leader. Avoidantly attached members are likely to present with difficulties in sustaining close relationships and/or meaningful work situations. They withdraw from closeness. They are underemotional and cannot describe their childhood in much detail. There is often a detached, bland, or dismissive quality to their relationships. A person with an avoidant attachment style may describe his or her childhood as “nice” or “fine” but be unable to elaborate on any affective qualities of

Attachment Group Therapy

their caretakers. Those with a more dismissive style may find it hard to see what other people really have to offer. The early implicit learning for them has been that their needs for secure attachment will not be met, and they have deactivated their needs accordingly.

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toward avoiding abandonment. Similarly, an avoidant person may have no idea of the way he or she deflects emotions and keeps people at a distance. The “hall of mirrors” that other group members provide is one way in which group therapy can be an effective modality for changing one’s relational style.

Techniques Attachment group therapists work with the individual members’ attachment styles, which are often out of conscious awareness. The leader must create a safe and secure environment for the emotional exploration, and strategies for doing so are described in this section. Working With Attachment Styles in a Group

For anxiously attached people, the group can be an excellent place to experience a consistent sense of emotional responsiveness, as the leaders and group members provide a nonjudgmental, caring, authentic, and consistent environment on which members can come to depend. Some members talk about the sense of belonging as the most curative factor in their group therapy experience. The consistency of the group’s regular meetings, the leader’s facilitative presence, and the weekly attendance of members can all create a new sense of security that offers dependability. Because anxiously attached people are hyperactivated, the work of therapy is to help them “down-regulate” and become less overwhelmed. For avoidantly attached members, the group offers a place to learn about the world of emotions, often by first listening to other members talk about their feelings. They may feel that they are hearing a new language. They also begin to learn about their own internal world, often initially through somatic experience. The work for them is to “up-regulate” their emotional self. They may struggle with the group commitment—feeling, “What does this group have to offer me?”—but further exploration can reveal the resistance to becoming attached to the group. It is important that the group therapist remember that the early attachment learning is implicit and often out of awareness. The learned attachment behavior is automatic and rapid. Thus, an anxiously attached person may not be aware of his or her frantic activity geared

Role of the Leader

Leaders maintain safety and security in a group in many ways. There should be a clear group agreement that all members understand before joining the group. Typical agreements include regular attendance, confidentiality, and agreement about the purpose and boundaries of the group. For example, many group therapists feel that outside socializing detracts from the effectiveness of the group. Irregular attendance can make a group feel very unsafe. Leaders maintain the group agreement, start and end the group on time (consistency), and serve as gatekeepers for new members. A leader who allows ongoing agreement violations without exploring them creates an unsafe environment.

Therapeutic Process As members experience increased safety in the group, they begin to access long-buried attachment longings. These may be buried under models of self such as “I don’t have strong feelings,” “I’m not worth caring about,” “I have to be perfect,” or “It’s my job to make sure everyone else is okay,” or under models of others such as “People aren’t really there for you” or “If you get too close, they’ll just find more faults.” Some of the changes members make in a group are in the area of affect regulation. Members learn that they can turn to the group for comfort and soothing, and eventually that knowledge is internalized. Members will sometimes say, “I carried the group in my pocket, and it helped me through a difficult experience.” Members who have been avoidant may say, “I was surprised to find that I missed the group while I was away.” They are feeling more, not less, and this is another important corrective emotional experience. As members learn to reflect on their own and others’ emotions, they develop better mentalization skills.

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Attachment Theory and Attachment Therapies

It is a rare group that does not have empathic failures. These can be on the part of the leader or the members. The rupture and the subsequent empathic repair process are an important aspect of attachment. No attachment figure is perfectly attuned. Estimates are that even the best mothers are correctly attuned only about 30% of the time: Donald Winnicott’s aptly named “good-enough” mother. But insecurely or avoidantly attached individuals have not experienced an attachment figure who is transparent about a misattunement and works to repair it. “Help me understand better . . . ” leads to healing. An important aspect of attachment theory is that secure attachment liberates. Thus, attachment theory is about both connection and separation. Just as the securely attached child feels free to explore the physical environment, group members who feel secure in the group are more likely to do their own psychological exploration. Bowlby felt that specific child-rearing practices were not nearly as important for a child’s development as the emotional climate of the home. The same is true of a group. A secure group is one where members feel encouraged to explore their inner worlds, their sense of personal agency, and their differences with each other and the leader. It is a place where the protest or conflict that is inevitable in any authentic relationship can be addressed and worked through without fear of abandonment or retaliation. Groups that provide experiential (implicit) learning, optimal arousal, and the experience of a safe haven and secure base will create a new attachment experience for the members that will ultimately lead to lasting personal change. Eleanor F. Counselman See also Attachment Theory and Attachment Therapies; Contemporary Psychodynamic-Based Therapies: Overview; Group Counseling and Psychotherapy Theories: Overview; Interpersonal Group Therapy; Psychodynamic Group Psychotherapy; Self Psychology

Further Readings Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. London, England: Routledge.

Flores, P. J. (2010). Group psychotherapy and neuroplasticity. International Journal of Group Psychotherapy, 60, 546–571. doi:10.1521/ ijgp.2010.60.4.546 Holmes, J. (2001). The search for the secure base: Attachment theory and psychotherapy. New York, NY: Routledge. Marmarosh, C. L., Markin, R. D., & Spiegel, E. B. (2013). Attachment in group psychotherapy. Washington, DC: American Psychological Association. Mikulincer, M., & Shaver, R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York, NY: Guilford Press. Wallin, D. J. (2007). Attachment in psychotherapy. New York, NY: Guilford Press.

ATTACHMENT THEORY AND ATTACHMENT THERAPIES Attachment theory was created by John Bowlby in the 1950s and later expanded by Mary Ainsworth and others. It is the prevailing theory for understanding early social development in children. Attachment theory is used to describe and explain the affectional bond that is formed between infants and their caregivers. Because infants are fragile at birth and need extended caregiving during infancy to survive, Bowlby believed that infants are born with an innate drive to form a unique bond with a parent to ensure survival. To enhance the emotional bonding between infant and caregiver, the infant forms an intense attachment with the caregiver, and the infant behaves (e.g., crying, eye contact, cooing) in ways that tend to elicit caretaking behaviors from the parent. In addition to ensuring physical survival, the quality of the attachment of the child to the parent influences the infant’s later development of emotional regulation, social skills, and parenting skills. The quality of attachment can be categorized as either secure or insecure. When a parent consistently and accurately attends to the needs of the child, the caretaker is said to be attuned to the child’s attachment needs, and this attunement assists in creating a secure attachment. About two thirds of the general population form secure attachments as children and thus grow up to become securely attached adults. The parent–child

Attachment Theory and Attachment Therapies

relationship becomes a model for expectations in other relationships; the quality of attachment to the parent is thought to predict the quality of romantic and other relationships later in life.

Historical Context Bowlby, a psychiatrist and psychoanalyst, believed that affectional bonds were essential to the survival of humans. Bowlby became interested in child development and how separation from caregivers affects children. His research and writings influenced psychology, education, child care, and parenting. Bowlby’s early research was influenced by the ethologist Konrad Lorenze, who studied instinctive behavior in animals and was known for studying imprinting in birds. Imprinting is a special kind of learning where young birds become socially bonded to the first moving object they see. Although human babies do not imprint, Bowlby believed that they form a lasting psychological connectedness (attachment) with early caregivers, usually mothers. Bowlby originally focused on maternal presence or deprivation and saw the father’s role as ambiguous. Later, he recognized that fathers are imperative as attachment figures. In particular, fathers seem to be important for enhancing the exploration part of a secure attachment. A father’s support of exploratory behaviors contributes to the child’s sense of safety during difficult tasks and increases the chance for the child to focus, follow his or her curiosity, and master new talents in an emotionally unhindered way. Ainsworth, a psychologist, expanded the influence of attachment theory by studying the quality of and individual differences in attachments. She studied differences in attachment patterns (styles) using an assessment technique called the Strange Situation Classification. The strange situation consisted of observing children 12 to 18 months old as (a) a mother leaves the room that is considered an unfamiliar environment, (b) the child is approached by a stranger, and (c) the mother returns, and the stranger leaves. During these stages, four behaviors were measured: (1)  separation anxiety, (2) the infant’s willingness to explore the environment, (3)  stranger anxiety, and (4)  reunion behavior. Separation anxiety is the distress that an infant

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displays when the caregiver leaves, stranger anxiety is the infant’s distress in response to the presence of a stranger, and reunion behavior is how the infant reacts when the caregiver returns. Ainsworth classified attachment based on three different styles: (1) secure, (2) insecure avoidant, and (3) insecure ambivalent. These three styles have been explored and expanded on by subsequent researchers. In the stranger situation, securely attached children were distressed when their mothers left the room, avoided the stranger when alone, were happy when the mother returned, and used the mother as a safe base from which to explore the environment. Ambivalently attached children were intensely distressed when the mother left, avoided the stranger and were fearful, approached the mother when she returned but avoided contact with her, and cried more and explored less than children with other types of attachment. Finally, children with avoidant attachments did not show distress when the mother left, were not distressed by the stranger’s presence, and showed little interest when the mother returned.

Theoretical Underpinnings Infants are born with attachment behaviors that are utilized to maintain closeness to caregivers, and later in life, similar behaviors are used to maintain closeness with significant others (attachment figures). If these strategies are successful, then a sense of security is created, and the infant feels secure to explore the world and explore relationships with others. To be an effective attachment figure, caregivers need to be attuned to the needs of the child. The caregiver should be available (maintain proximity) and responsive, especially in times of distress. In addition, attachment figures provide a safe haven of support and comfort in times of distress and provide a secure base from which the child can explore the world. In adulthood, the need to be soothed and feel safe is usually satisfied by a romantic partner; therefore, a sense of attachment security is created through interactions with significant others who are responsive to requests or bids for physical nearness/ closeness, available in times of need, and sensitive to the need for support and reassurance. Attachment bonds have four defining features: (1) proximity maintenance (wanting to be physically close to the attachment figure), (2) separation

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distress, (3) being a safe haven (retreating to caregiver when sensing danger or feeling anxious), and (4) providing a secure base (exploration of the world knowing that the attachment figure will protect the infant from danger). Attachment relationships evolve over the first 2 years of life and beyond, but most important, these early attachment relationships overlap with a time of significant neurological development of the brain in children. The relationship between parent and child and the environment parents create can influence the infant’s brain development and structure, which has lasting effects on the child. Approximately 65% of the U.S. populace is securely attached, about 20% have an avoidant attachment, and about 10% to 15% have ambivalent attachment. Later, researchers added another style of attachment, (5) disorganized, to describe attachment styles sometimes created by abusive caregivers. Securely attached children are confident that attachment figures are reliable and can meet their needs. This security encourages exploration of the world with the knowledge that the attachment figure can soothe them in times of distress. These children tend to become adults who enjoy being connected to others and trust that others can and will meet their emotional needs. Avoidantly attached children have had minimally close and emotionally expressive communication with their caregiver. They do not trust that people will be there for them during times of emotional distress. As they grow up, these children tend to be controlling of others and are distant from their own emotional needs. The yearning for interrelatedness is minimized and denied. For children who are ambivalently attached, the need for others is amplified rather than denied. The caregiver is sometimes attentive and at other times is not; the intermittent reinforcement creates an uncertainty about the relationship, so that the child becomes dependent on parental input for a sense of security even into the adult years. People with this type of attachment may become preoccupied with feelings of mistrust and rejection in adult relationships. Disorganized attachment results from frightening experiences with a caregiver. To cope with these experiences, the person may dissociate from experiences and/or feelings. People with this type of attachment have extreme difficulty regulating emotions and maintaining relationships, and they may have relationships characterized by fear.

The child’s first attachment with the primary caregiver provides the basis for an internal working model of understanding the self, relationships, and the world. Based on the internal working model, a person evaluates the following: (a) the trustworthiness of others, (b) one’s own value, and (c) the self as effective when socializing with others. Future relationships are guided by expectations based on the primary attachment and the resulting internal model. Although changes over time can influence the attachment status of a child, there is a strong continuity between infant attachment patterns, child and adolescent patterns, and adult attachment patterns. Changes in attachment status can occur in either direction (secure to insecure, insecure to secure). In fact, the term earned secure has been used to describe individuals who experience parents who are not attuned to their needs (therefore, one would expect an insecure attachment status) but form securely attached relationships with others. However, for the majority of individuals, the manner in which they learned to manage anxiety early on in life will continue unless their circumstances change or other experiences intervene.

Major Concepts Attachment theory proposes that affectional bonds are essential to the survival of humans. There are three defined subgroupings of attachment associations: (1) secure, (2) anxious avoidant, and (3) anxious resistant (or ambivalent). Attachment Style

Attachment is a deep, emotional bond between a caregiver and an infant formed based on the caregiver’s ability to make the child feel safe, secure, and protected. Based on whether people are securely or insecurely attached, they will tend to seek or not seek deep, emotional connections with others and will have differing levels of security or anxiety attached to those relationships. Secure Attachment A secure attachment is characterized by feelings of emotional intimacy, emotional security, and physical safety in relation to an attachment figure,

Attachment Theory and Attachment Therapies

especially when distressed. The securely attached person feels comfortable expressing distress and the need for comfort and has confidence that the attachment figure is attuned to his or her needs. Anxious-Avoidant Attachment Anxious-avoidant attachment is a type of insecure attachment where a person has learned not to depend on close relationships as a source of comfort and soothing in times of distress or as a source of consistent support and joy in times of nondistress. People with avoidant-attachment styles tend to undervalue the importance of relationships, withdraw in relationships, and are emotionally distant. Anxious-Resistant (Ambivalent) Attachment Anxious-resistant attachment is a type of insecure attachment characterized by having one’s need for feelings of safety and security inconsistently and unpredictably met by an attachment figure. In response to an inconsistently responsive attachment figure, a person may exaggerate distress in order to elicit caretaking behaviors from significant others. People with anxious-resistant styles may overvalue the importance of relationships and monitor them closely.

Techniques Attachment theory offers a plan for understanding and working with individuals and their relationships. Emotion is the heart of the attachment relationship. Attachment theory helps the therapist understand people’s key emotional needs and fears by using emotion to change. This is done by predicting the level of emotional responsiveness between individuals. The absence of responsive interactions determines the quality of future relationships, instead of focusing on conflict levels. Decreasing conflict is not the goal. Attachment theory tells clinicians and clients what to change and provides a direction, goal, and focus. Working With Different Attachment Types

When a person has an insecure attachment, there are three common strategies the person can  use to work through relationship distress: (1) anxiety, (2) avoidance, or (3) a combination of

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both (fearful avoidant). People who are anxious use attachment strategies that are likely to be persistent, clingy, and aggressive to feel secure. Avoidant people have a tough time believing that people are safe, trustworthy, accepting, receptive, and open. They often fear that if people really understood them they would not love them. Avoidant people view themselves as unlovable. Fearful-avoidant people desire to have close relationships, but they distance themselves when others come near. They are confused about relationships—they desire to have one but also worry about being rejected. Both anxious and avoidant clients make unclear, inconsistent statements about their past and often struggle to support those memories with concrete examples. Anxious clients have a hard time organizing their ideas to talk about them. Avoidant clients often clearly remember the past, but if their emotions and feelings are not addressed, they may struggle with having a close relationship out of fear of rejection from that attachment figure. No matter the strategy, each person has learned pattern behaviors that affect this or her relationships. Secure Base Exploration

The desire for humans to feel safe and securely connected to others is part of human nature. A  sense of connection with a person offers the client a secure base from which to handle life matters. The more confident the client is that people are there for him or her, the more the client can explore his or her internal and external worlds and adjust to new situations. Focusing on a secure base guides the counselor to validate the client’s desire for safety and encourages him or her to pay attention to creating a safe relationship. Softening

Softening is a technique used to help a hostile or critical individual access the “softer” emotions and be vulnerable enough with a partner to ask for attachment needs to be met. The goal is for both individuals to be attuned, engaged, and responsive to each other. The counselor works with the hostile partner to explore attachment fears and how to express those needs in a connecting way rather than in an aggressive, distancing,

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or critical way. The main component of this change event is that clients deepen their emotional experience. This is done by having clients reach, risk, share, and ask for needs to be met by another person. They must process this emotionally and in the moment rather than cognitively. Clients should face each other to heighten the impact and emotional connection.

Therapeutic Process Attachment theory offers a systemic viewpoint for understanding and intervening in problematic parental and adult relationships. Attachmentbased therapies are based on normalizing an individual’s need for emotional connection and his or her style of seeking attachment-enhancing behaviors from others to fulfill the attachment needs in significant relationships. The need for attachment and expression of emotion is at the core of adult relationships. When a person feels that his or her attachment is in jeopardy, attachment behaviors are triggered to protect the attachment bond. If the attachment behaviors are unsuccessful at obtaining the wanted response from the other person, then a set of expected responses begins, such as anxiety, avoidance, and withdrawal. Attachment injuries occur when an attachment figure is unavailable or unresponsive in times of distress. Based on one’s history of attachment relationships, an internal working model of attachment is created that includes expectations about responsiveness, how to elicit caretaking from others, whether attachment needs will be met, whether others are trustworthy or not, the importance of close relationships, and whether it is safe to express authentic feelings. Attachment-based counselors assess the attachment style and internal working model of insecurely attached clients and assist them in creating secure relationships. Attachment Injuries

Attachment injuries occur in both secure and insecure relationships, but they have a bigger impact in insecure relationships. Regardless of attachment style or internal working model, once attachment injuries occur, it is best to resolve them sooner rather than later. Sue Johnson created and

utilizes emotionally focused therapy to assess adult attachment patterns and help resolve attachment injuries. Repairing attachment injuries can be done by using a cycle of engagement and reconciliation. Judy Makinen and Johnson have developed a six-step model for resolving attachment injuries. This is done by identifying the attachment injury, reconnecting with the primary emotions of the injured party, reengaging with the partner, forgiving, and reconciling. Step 1: Use the emotional experience connected to the attachment injury, and define the incident’s outcome on relational trust. Step 2: Together with the counselors, the offending partner works on being receptive to the other’s weakness and takes responsibility for the damage. Taking responsibility is possible because of the importance of the relationship. Step 3: After the offending partner accepts responsibility, the injured person requests comfort and caring, which were not available during the time of the injury. They work together by changing what they did in the present. Step 4: The offending person replies to the request for comfort in a peaceful, warm way that calms the previously traumatic experience. Step 5: Once the offending person genuinely apologizes, the injured person identifies what is needed to bring closure to the event. Both partners learn how to respond differently to the situation. Step 6: The people involved begin revising their story. The new story outlines the attachment injury event that caused the damage of trust and emotional connection.

Client–Counselor Relationship

The key to the counselor–client relationship in attachment-based counseling is creating a safe, secure, attuned relationship. Once the client sees the counselor as a secure base, within the context of a therapeutic relationship, the client will feel safe enough to explore feelings of anxiety associated with significant relationships and explore how to successfully express and fulfill attachment needs of self and others. Patterns of hypervigilance

Attachment-Focused Family Therapy

and/or avoidance of attachment needs are explored, and the client practices expressing authentic emotions and attachment needs in a way that is likely to elicit caretaking behaviors from others rather than distancing. In addition, clients are taught to repair attachment injuries and accept the attachment needs of others. Ashley Cosentino and Shannon Dermer See also Attachment Group Therapy; Couples, Family, and Relational Models: Overview; Emotion-Focused Family Therapy; Emotion-Focused Therapy; Experiential Psychotherapy; Symbolic Experiential Family Therapy

Further Readings Ainsworth, M. D. (1989). Attachments beyond infancy. American Psychologist, 44,709–716. doi:10.1037/0003-066X.44.4.709 Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Oxford, England: Lawrence Erlbaum. Berlin, L. J., & Cassidy, J. (1999). Relations among relationship: Contributions from attachment theory and research. In J. Cassidy, & P. R. Shaver (Eds.), Handbook of attachment theory (pp. 688–712). New York, NY: Guilford Press. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York, NY: Basic Books. Bowlby, J. (2005). The making and breaking of affectional bonds. New York, NY: Routledge. Bretherton, I. (2010). Fathers in attachment theory and research: A review. Early Child Development and Care, 180(1/2), 9–23. doi:10.1080/03004430903414661 Dunham, S., Dermer, S., & Carlson, J. (2011). Poisonous parenting: Toxicrelationships between parents and their adult children. New York, NY: Routledge. Grossmann, K., Grossmann, K. E., Kindler, H., & Zimmermann, P. (2008). A wider view of attachment and exploration: The influence of mothers and fathers on the development of psychological security from infancy to young adulthood. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed., pp. 857–879). New York, NY: Guilford Press. Johnson, S. (2007). A new era for couple therapy: Theory, research, and practice in concert. Journal of Systemic Therapies, 26(4), 5–16. doi:10.1521/ jsyt.2007.26.4.5

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Lieberman, A. F., & Pawl, J. H. (1988). Clinical applications of attachment theory. In J. Belsky & T. Nexworski (Eds.), Clinical implications of attachment (pp. 327–351). Hillsdale, NJ: Lawrence Erlbaum. Lowenstein, L. F. (2010). Attachment theory and parental alienation. Journal of Divorce & Remarriage, 51(3), 157–168. doi:10.1080/10502551003597808 Newland, L. A., & Coyl, D. D. (2010). Fathers’ role as attachment figures: An interview with Sir Richard Bowlby. Early Child Development and Care, 180(1/2), 25–32. doi:10.1080/03004430903414679 Peluso, P. R., Peluso, J. P., White, J. F., & Kern, R. M. (2004). A comparison of attachment theory and individual psychology: A review of the literature. Journal of Counseling & Development, 82(2), 139–145. doi:10.1002/j.1556-6678.2004.tb00295.x Waters, E., & Cummings, E. (2000). A secure base from which to explore close relationships. Child Development, 71(1), 164–172. doi:10.1111/14678624.00130

ATTACHMENT-FOCUSED FAMILY THERAPY Attachment-focused family therapy (AFFT), developed by Daniel Hughes, is a relationship-centered model of family treatment whose goal is to facilitate the relationships between parents and their children, using the theories and research of attachment and intersubjectivity as its guide. AFFT models itself on the reciprocal, contingent interactions that characterize the relationship between parent and infant or young child. The initiatives and responses of therapist, parent, and child create a reciprocal dialogue that has both affective and reflective components. The dialogue communicates acceptance, not evaluation, and generates an open and engaged attitude common to a person who is safe, rather than that of someone who is defensive. Within this dialogue, affective states are being coregulated, new meanings of relationships and events are being cocreated, and more coherent narratives are developed for both parent and child.

Historical Context In the late 1980s, Hughes strived to find a treatment modality that would be more successful in

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assisting abused and neglected children to both resolve their traumatic history and develop safe and meaningful relationships with nonabusive caregivers, especially foster and adoptive parents. The children’s oppositional, withdrawn, angry, and/or hyperactive behaviors seemed resistant to his interventions as well as the excellent care that the children were receiving in their new homes. In an effort to understand the difficulties that the children had, he began studying attachment theory and research. He concluded that the children manifested patterns of behavior that were often characteristic of insecure attachments, especially attachment disorganization, a research classification of children that is associated with psychopathology as they age. For the next several years, Hughes developed the key principles of his treatment model, using attachment theory as its organizing feature. He read the works of John Bowlby and subsequent attachment theorists and researchers. He also used the principles of intersubjectivity, which he learned from Daniel Stern and Colwyn Trevarthen, to become better engaged with these children. Hughes brought in many features from his trainings, including the unconditional acceptance and empathy advocated by Carl Rogers, the utilization theory of Milton Erickson, the strategic interventions of many family therapists, and the organizing principles of developmental pathology from psychodynamic theorists. Hughes was also influenced by emerging findings of neuropsychology. Throughout the 1990s, Hughes developed his core treatment model while focusing on abused and neglected children being cared for by foster or adoptive parents. He called this treatment Dyadic Developmental Psychotherapy, which it continues to be known as for this population of clients. Between 2000 and 2005, he began to apply this model to the general population of children and families, resulting in two books and a workbook on attachment-focused family therapy and attachment-focused parenting.

Theoretical Underpinnings The central motivation for an infant’s attachment strivings is to create physical and psychological safety. Parents facilitate attachment through sensitive, contingent responses to the young child’s expressions of distress, providing comfort and

support while meeting the child’s felt needs. The infant’s sense of safety is established and protected by the infant’s moment-to-moment relationship with his or her parents. Within AFFT, the core treatment assumption is that either a stress in the attachment relationship is undermining the child’s sense of safety or the attachment relationship is not being utilized well to facilitate the child’s resolution of whatever difficulties the child is facing. These same attachment principles are used to ensure safety within treatment. At the same time, these contingent, nonverbal interactions that the child has with his or her parents enable the child to develop a sense of who he or she is, who the caregivers are, and the meaning of events in his or her world. Stern and Trevarthen call this process intersubjectivty. Because a central function of therapy is to assist the child (and parent) in developing a sense of self that is coherent, comprehensive, and integrated, the therapist uses this same process to create such new meanings within therapy.

Major Concepts A few of the central concepts of AAFT include coherent autobiographical narratives, coregulation of affect, and cocreation of meaning. Coherent Autobiographical Narratives

Relying on attachment theory and on intersubjectivity, the central organizing goal of AFFT is to assist family members in developing coherent narratives for the meaning of self and other and the nature of their relationships. When attachment patterns do not provide relational patterns that generate safety and new meanings for the child, the child is at risk of manifesting difficulties in developing a coherent autobiographical narrative. Events that lead to unresolved conflicts, shame, and dysregulating affective states are often not integrated into a coherent narrative. The therapeutic dialogue facilitates both safety and new meanings so that both parent and child are able to more successfully develop more coherent narratives. Coregulation of Affect

When attachment patterns do not develop safety, there is risk that the child will not be able to

Attachment-Focused Family Therapy

develop his or her emotional regulation skills. Much as parents do with infants, the therapist strives to coregulate the emotions of the child (or parent) by matching the affective expression of those emotions. The therapist does so through matching the voice prosody (intensity, rhythms, latencies) as well as the facial expressions that convey the child’s emotion, without necessarily experiencing the emotion itself. Thus, when the child is angry and is expressing it through greater intensity and more rapid cadence in his or her voice, the therapist uses a similar intensity and cadence, which often enables the child to remain regulated and able to remain focused on the theme being explored.

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honesty, willingness to face vulnerabilities, and other related aspects of the person, fostering the parent’s and child’s ability to experience these same features in themselves and each other. As is the case in the parent–infant intersubjective relationship, many of the positive experiences of the therapist are communicated nonverbally—through facial expressions, voice prosody, gestures, and posture. The therapist also actively uses the three components of intersubjectivity (attunement, joint attention, and complimentary intentions) to maintain the engagement in the dialogue, while deepening the child’s and parent’s experiences of each other, as they discover each other’s strengths and the positive qualities in their relationship that they might strive for.

Cocreation of Meaning

Many stressed children (and their parents) frequently have difficulty reflecting on the meaning of events and often interpret these events with negative assumptions or with anxiety as a result of uncertainty about their meanings. Within the therapeutic dialogue, the therapist facilitates the ability of the child and the parent to suspend such negative assumptions and judgments, to remain regulated emotionally, and then to be open to exploring new meanings for the events. This facilitates reflective functioning, which the child and the parent are able to utilize when they are faced with further conflicts, uncertainties, and differing wishes in the future.

Techniques AFTF therapists strive to take an intersubjective stance, provide skills within a PACE (playfulness, acceptance, curiosity, and empathy) framework, and use talking-for and talking-about techniques when working with families.

PACE

In facilitating a relationship that generates safety and new learning, the therapist maintains an attitude characterized by PACE. This attitude generates an open and engaged dialogue that minimizes defensiveness. Playfulness at times may be expressed with laughter and animation; at other times, it is shown as a quiet confidence and openness to whatever is explored, including stressful themes. Acceptance conveys the attitude that the person’s thoughts, feelings, wishes, and memories are always explored with openness and without evaluation. Curiosity conveys a nonjudgmental, deep interest that facilitates the individual’s and family’s readiness to reflect on and explore their inner lives. Empathy conveys to the parent and the child that the therapist is emotionally present and supportive when they face difficult experiences. By the therapist conveying PACE for the child’s experience, the parent is assisted to develop a similar attitude toward his or her child. Talking For and Talking About

An Intersubjective Stance

The therapist takes an intersubjective—as opposed to a neutral—stance throughout the course of therapy. The therapist conveys his or her own experience of the experiences and behaviors expressed by the parent and the child during the session. The therapist conveys his or her experience of the strengths and positive meanings of the client’s actions, discovering courage, persistence,

When the child (or at times the parent) has difficulty finding the words to describe an aspect of his or her inner life, the therapist takes the lead and speaks for the child, guessing what the child might be thinking, feeling, or wishing. This guess is always tentative, with the child deciding whether it is accurate and whether it needs to be explored further. This enables the dialogue to continue at a deeper, more open, and more vulnerable degree.

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Periodically, the therapist speaks about the child or parent to the other. This facilitates reflective functioning and often generates the deepening of the experience of the child or parent, now influenced by the therapist’s experience.

Therapeutic Process With AFFT, the therapist assumes the responsibility of ensuring that the ongoing dialogue is safe, intersubjective, and intentional. As a result, the therapist often takes the lead in the dialogue (a directive stance), while at the same time following the parent’s or child’s response to the lead or willingly allowing a member of the family to take the lead when the components of the therapeutic dialogue are present (a nondirective stance). The therapist has one or more sessions with the parents alone prior to having joint sessions with the parents and child. In this way, the therapist ensures safety for the parent first, so that together the parents and therapist are able to ensure safety for the child. AFFT has two phases. First, the therapist meets with the parents to establish an alliance with them so that they experience safety within the session. Then, joint sessions begin where the therapist and parents establish safety for the child. Within these phases, the therapist has an affective–reflective dialogue, attempts an integration of nondirective and directive skills, and assists the family in developing new individual and family narratives. Affective–Reflective Dialogue

The communications within the session that tend to be the most therapeutic are those that contain both affective and reflective components and that are conveyed with a varied, modulated voice rather than through rational monotones. Such communication is intersubjective—the experiences of all influence it—and it is characterized by PACE. This dialogue is similar to that utilized in storytelling and is central in facilitating an open and engaged—not defensive—state of mind. Such dialogue conveys an openness, without judgment, to the experience of the other so that the other is encouraged to share and go deeper into the events of his or her life without becoming defensive. Within the context of the dialogue that creates safety and new meanings, past or current stress or conflicts within the family are explored. The

momentum of the dialogue enables the more stressful themes to be explored and integrated in a manner similar to, and within the context of, the exploration of the more routine themes. The intersubjective stance of the therapist conveys confidence and PACE, which enables the child’s and parent’s emotional state to remain regulated and new meanings of the difficult events to be developed. Integration of Nondirective and Directive Skills

It is the therapist’s responsibility to ensure that the flow of the dialogue about all aspects of the family’s individual and shared lives is continuous, within an integrated theme of joint discovery, without conditional judgments and evaluations. Initially, the therapist often leads the discussion, though he or she is quick to follow the family member’s response to this lead, changing it often if necessary to attain safety and engagement with each family member. As the family members develop this skill in being able to create safety for each other, and so being able to openly explore their joint experiences with PACE, the therapist adopts an increasingly nondirective stance. Development of Individual and Family Narratives

The course of the treatment sessions involves the development of coherent narratives for the events in the lives of the parent and child. The therapist establishes a safe conversation in which both the parent and the child are led to understand each other’s experience without judgment, so that these experiences can be organized into a coherent narrative that provides safety and new meanings for the strengths and vulnerabilities of their joint lives. AFFT might be brief, in which only a few themes are brought into the narrative, or it might be more extensive, where a more comprehensive development of the narratives is sought. Daniel Hughes See also Accelerated Experiential Dynamic Psychotherapy; Emotion-Focused Therapy; Ericksonian Therapy; Experiential Psychotherapy; Internal Family Systems Model; Narrative Family Therapy; Person-Centered Counseling

Attack Therapy

Further Readings Casswell, G., Golding, K. S., Grant, E., Hudson, J., & Tower, P. (in press). Dyadic developmental practice (DDP): A framework for therapeutic intervention and parenting. Child & Family Clinical Psychology Review, No. 2. Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 6, 263–278. doi:10.1080/14616 730412331281539 Hughes, D. (2006). Building the bonds of attachment (2nd ed.). Northvale, NJ: Jason Aronson. Hughes, D. (2007). Attachment-focused family therapy. New York, NY: W. W. Norton. Hughes, D. (2009). Attachment-focused parenting. New York, NY: W. W. Norton. Hughes, D. (2009). The communication of emotions and the growth of autonomy and intimacy within family therapy. In D. Fosha, D. J. Siegel, & M. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development, and clinical practice (pp. 280–303). New York, NY: W. W. Norton. Hughes, D. (2011). Attachment-focused family therapy workbook. New York, NY: W. W. Norton.

ATTACK THERAPY Attack therapy is an approach of treatment that emphasizes confrontation of the client in an effort to address dysfunctional behaviors and low selfesteem. This approach concentrates on providing negative feedback to the client as a motivation to change and has been used in a small number of substance abuse and adolescent treatment facilities. Also known as confrontational therapy or ventilation treatment, this method of therapy is used to assist the client or group to address problematic behavior that may be hindering therapeutic progress. This approach uses verbal abuse, humiliation and shame, denouncing, and demoralizing techniques by the therapist toward the client or group members. Although controversial and potentially dangerous for some clients, it has been shown to be somewhat effective within limited settings.

Historical Context Attack therapy was an outgrowth of what had been called ventilation treatment, a counseling approach

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developed in the mid-20th century, whereby confrontation between the therapist and the client was encouraged in an effort to remove the client’s defenses and to have the client look more clearly at himself or herself. Similarly, attack therapy focuses on having the therapist, or other group members, use verbal attacks to confront the client’s current way of living in the world. Designed to break down defenses, this highly emotional process evokes strong feelings, and clients can often be found crying or becoming extremely angry. One of the first places to use this form of therapy was Synanon, a drug and alcohol residential treatment center. Individuals who went through treatment at Synanon could expect verbal confrontation and even other forms of humiliation, such as having one’s head shaved, all in an attempt to break down defenses. Other places that have been reported to use a similar type of approach are Scared Straight, where juveniles with problematic behaviors meet with and are verbally challenged by convicts, and boot camps, where juveniles are taken to secluded places for extended periods of time, confronted, and pushed to live a healthier life. In general, this form of therapy has been used with persons who have exhibited oppositional behaviors and/or are abusing substances. This approach to counseling can be dangerous to clients and, in some cases, has led to psychological disorders and harm to clients, including the death of some who have participated in boot camps.

Theoretical Underpinnings Attack therapy assumes that behavioral patterns are developed and perpetuated by defense mechanisms that the individual uses to protect the individual’s fragile self-esteem. The basis of this approach, therefore, is to break down the client’s defenses and to help him or her build a new selfimage based on a new behavioral repertoire. Thus, this approach can be seen as an integration of psychodynamic theory, in that it assumes that defense mechanisms are developed through some type of complex unconscious process, and behavior therapy, in that it believes that once defenses are broken down, new behaviors can be adopted and a new self-image developed. Behavior therapy and behavior modification are predominantly utilized for clients exhibiting self-destructing behavior. Furthermore, attack therapy can be seen as therapeutic coaching and training of the client.

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Attack Therapy

This form of behavior therapy allows the client to evaluate his or her current living situation and change the negative to positive.

down the client’s defenses so that new, healthier ways of thinking and behaving can be adopted. Synanon Game

Major Concepts Three major concepts integral to attack therapy are (1) defenses, (2) confrontation, and (3) behavior modification. Defenses

Defenses refers to the manner in which the client protects his or her ego from being hurt. Sometimes, defenses can support maladaptive behaviors in an effort to protect a fragile ego. Some common defense mechanisms include repression, regression, intellectualization, and rationalization. Confrontation

In the context of attack therapy, confrontation is seen as the mechanism that is used to break down defenses in an effort to help develop a new ego and new, more functional behaviors. Behavior Modification

From an attack therapy perspective, clients are encouraged to, and sometimes bullied to, change their behaviors. New, healthier behaviors are heavily encouraged by the therapist and, if in a group setting, by group members.

Techniques Three common techniques that are used in attack therapy are (1) confrontation, (2) the Synanon Game, and (3) the hot seat. Confrontation

Confrontation is the process in which clients are faced with their faulty ideas and maladaptive behaviors and challenged to change them. Clients may be yelled at, asked to comply with a series of rigid rules, verbally humiliated, ridiculed, and told that they must conform if they are to become healthy. Noncompliance is met with increased confrontation. The goal of confrontation is to tear

Developed by Synanon, the Synanon Game is a technique that has each group member confront other group members’ faulty behaviors. Discussion about negative past behaviors, and their consequences, is encouraged, and the development of new positive behaviors is promoted. Hot Seat

The term hot seat is used to identify the individual who in a group is targeted to discuss his or her problems. When an individual is in the hot seat, he or she is expected to be truthful, to let down his or her defenses, and to be open to suggestions by the therapist and by other group members. If this is found not to be the case, the therapist and other group members will generally confront the individual until he or she opens up.

Therapeutic Process Attack therapy can be one session long, last for a few sessions, or be numerous sessions that extend over a number of weeks, depending on the depth of the issues surrounding the problematic behavior. Sessions may be a combination of individual and group treatment. For instance, in Scared Straight programs, adolescents meet with convicts once for a few hours, and the adolescents’ dysfunctional behaviors are confronted as they view their potential future in prison. In contrast, sessions for individuals in substance abuse treatment are typically four to six per week, for at least 4 weeks, and are a combination of individual and group therapy. An intake process, sometimes conducted during the beginning sessions, is used to provide a historical review of the client’s life. These sessions are important to formalize the therapeutic relationship as well as to provide important information regarding the client’s behavioral pattern. Furthermore, the intake process supplies the foundations of the evidence for the attack therapy approach. Felicia D. Pressley

Autogenic Training See also Behavior Therapy; Cautious, Dangerous, and/or Illegal Practices: Overview; Operant Conditioning

Further Readings Juedes, J., & Barton, W. (2002). Fringe psychology of the 1960s in breakthrough/momentus training. Retrieved from http://www.empirenet.com/~messiah7/ brk_fringepsych.htm Reverse Engineering Organized Stalking. (2013, February). Attack therapy. Retrieved from www .redecomposition.wordpress.com/2013/02/01/ attack-therapy/ Treatment4addiction.com. (2011). Treating addiction through attack therapy. Retrieved from www .treatment4addiction.com/treatment/types/ attack-therapy White, W., & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12–30.

AUTOGENIC TRAINING Autogenic training (AT; autogenic translates to “from within”) is a type of psychophysiological relaxation technique. AT can be considered a selfhypnosis technique that incorporates the use of self-directed exercises to create mental and physical relaxation. It incorporates the daily practice of specific mental recitations and physical relaxation techniques. AT has been researched for use with physical and psychological disorders and for selfgrowth and positive life adjustment. The research on AT has shown its effectiveness as an adjunct intervention to traditional interventions for insomnia, mild to moderate depression, anxiety, irritable bowel syndrome, fibromyalgia, and many other conditions. While AT is taught in the United States, it is taught and practiced predominantly in European countries.

Historical Context AT was developed in 1932 by Johannes H. Shultz, a German neurologist and psychotherapist, who recognized the importance of concepts within clinical hypnosis, neurology, and meditation and yoga practices from the Indian culture.

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He incorporated concepts from each of these areas to develop AT. Shultz was particularly curious about the effects of hypnotherapy but was sensitive to some of its adverse effects, particularly dependence on the hypnotherapist. Through his studies, he became convinced that he could train people to practice self-induced hypnotic suggestions to improve their physical and psychological health. Shultz documented the use of AT on various types of people for the purposes of enhancing creativity, decreasing stress levels, promoting self-growth, and reducing symptoms of many physical and mental disorders. Shultz used AT as a preventive measure with healthy individuals and as a treatment for the clinical population. Shultz conducted AT in group settings, which have been noted as one of the earliest uses of group interventions. Later, in the 1960s, Wolfgang Luthe, a student of Shultz, began publishing more detailed information about AT. From 1969 to 1970, Luthe wrote comprehensive descriptions of the facets of AT, including comprehensive procedural, clinical, and research details, making AT available in English-speaking countries.

Theoretical Underpinnings AT is considered a mind–body approach to health and wellness, as Shultz was a strong believer in the healing powers of the body. It is a psychophysiological form of therapy whereby an individual can use passive concentration, selfcontrol, and self-regulation to achieve an outcome. AT is a means by which a person can minimize autonomic arousal and return to a state of homeostasis. Its underpinnings are diverse, having roots in neurology, behaviorism, meditation, and yoga. The foundational concept is that people can control their physical and psychological responses, especially during times of stress. The practice of AT can bring about changes to major systems of the body, including the cardiovascular, respiratory, muscular, endocrine, digestive, and nervous systems. Chronic stress has a negative impact on these bodily systems, and through the practice of AT, the systems come into balance, or homeostasis, and can engage in optimal functioning.

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Major Concepts The major concepts of AT are rooted in physiology, behaviorism, and meditation. In the area of physiology are the processes of the stress response and the relaxation response. The stress response is the term coined to encompass the physical and mental processes that occur when people are in perceived stressful situations. In short, many of the brain’s activities, such as the ability to concentrate, make decisions, and store and access memories, can be compromised due to stress. On a physical level, the stress response can keep the body in a state of arousal, exhausting certain systems of the body, like the autonomic nervous system. On the other hand, the relaxation response can encourage autonomic nervous system functions, which aid in the regenerative process of the body. The notion that people have the ability to regulate these two systems in a psychophysiological way, used in AT, comes from the behavioral perspective. In essence, a person’s response to a perceived stressful situation can be conditioned and learned. This speaks to the heart of classical conditioning, which is the learning or conditioning that takes place when a conditioned stimulus is paired with an unconditioned stimulus. The concept of meditation that is inherent in AT is the notion of passive concentration. Passive concentration is when an individual is focused in the moment on the experience rather than on the outcome of the experience.

Techniques The techniques in AT include six standard mental visualizations or formulas that create specific sensations that correspond to these six areas of the body: (1) muscles, (2) circulation, (3) breath, (4) heart, (5) abdomen, and (6) head. The visualizations purposefully begin with a focus on the body’s musculature because it is the most easily accessed and influenced by conscious intentions, according to AT theory. The mental visualizations take about 10 to 15 minutes to complete with a client. The therapist repeats each visualization step in sequence several times and encourages the client to imagine personally meaningful images to enhance the visualizations. Between each of the visualizations, the therapist encourages the client to experience a sense of calmness and breath

awareness. The practice is done while in a comfortable position, either sitting or in a supine position, with closed eyes. Lying down on one’s back is a preferred physical position because it promotes physical relaxation, and closing the eyes creates a state of sensory withdrawal whereby a person’s attention can be turned inward to focus on inner experiences. After several weeks of practice, the client can fully sense the visualizations on a physical level. The visualization categories are listed below, with an example of each one: 1. The heaviness experience—“My right arm is heavy.” 2. The warmth experience—“My arm is very warm.” 3. Regulation of breathing—“My breathing is calm and steady.” 4. Regulation of the heart—“My heart is beating quietly and strongly.” 5. Regulation of the visceral organs—“My abdomen is warm and soft.” 6. Regulation of the head—“My forehead is cool and relaxed.”

After the six standard mental formulas are mastered, upper-level AT can be implemented. The exercises are structured and are similar in process to the six standard formulas. The process begins with the practice of the six formulas, with the client achieving the autogenic state within 1 minute of beginning each of the formulas. Then, the therapist teaches a series of seven exercises that move from more concrete and simplistic toward greater abstraction and imagery. The imagery begins with a focus on colors and objects, then moves to visions such as a bridge or an opened door, and then to physical movement like walking or running. Each visualization step becomes more complex and utilizes deeper metaphorical meaning. This movement toward more abstract visualizations triggers emotional responses that are deemed therapeutic.

Therapeutic Process AT is taught by trained professionals such as physicians, psychologists, psychiatrists, or counselors.

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In the initial sessions, the skilled professional introduces the concepts and process of AT while assessing the client’s current mental and physical state and needs. The professional creates a supportive environment and encourages a sense of self-control throughout the process. The visualizations are taught over several weeks, with a new visualization introduced each week. The techniques are initially taught in a face-to-face individual or group setting once a week for several weeks. The exercises are designed to be practiced at home on a daily basis in an environment that is free from distraction. Mastery of the visualizations takes many weeks; but with adherence and practice, the desired effects can occur. Until the visualizations have been mastered, the trained professional should monitor the person’s progress and reinforce the need for a structured and consistent daily home practice. The client should be encouraged to maintain a journal of experiences throughout the process. This journaling can inform the professional as to the person’s successes and areas of challenge. While AT is eventually practiced individually, the support of a skilled professional maximizes the outcomes. Jana Whiddon See also Biofeedback; Classical Conditioning; Hypnotherapy; Meditation; Mindfulness Techniques

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Further Readings Krampen, G. (1999). Long-term evaluation of the effectiveness of additional autogenic training in the psychotherapy of depressive disorders. European Psychologist, 4(1), 11–18. doi:10.1027//10169040.4.1.11 Linden, W. (1990). Autogenic training: A clinical guide. New York, NY: Guilford Press. Manzoni, G., Pagnini, F., Castelnuovo, G., & Molinari, E. (2008). Relaxation training for anxiety: A ten-years systematic review with meta-analysis. BMC Psychiatry, 8(41), 1–12. doi:10.1186/1471-244X-8-41 Sadigh, M., & Montero, R. (2001). Autogenic training: A mind-body approach to the treatment of fibromyalgia and chronic pain syndrome. New York, NY: Hawthorne Medical Press. Shinozaki, M., Kanazawa, M., Kano, M., Endo, Y., Nakaya, N., Hongo, M., & Fukudo, S. (2010). Effect of autogenic training on general improvement in patients with irritable bowel syndrome: A randomized controlled trial. Applied Psychophysical Biofeedback, 35, 189–198. doi:10.1007/s10484-009-9125-y Stetter, F., & Kupper, S. (2002). Autogenic training: A meta-analysis of clinical outcome studies. Applied Psychophysiology and Biofeedback, 27(1), 45–98. doi:10.1023/A:1014576505223 Yurdakul, L., Holttum, S., & Bowden, A. (2009). Perceived changes associated with autogenic training for anxiety: A grounded theory study. Psychology and Psychotherapy: Theory, Research, & Practice, 82, 403–419. doi:10.1348/147608309X444749

B social and familial causes of aggression with his doctoral student Richard Walters. They found that children whose parents modeled aggressive attitudes and punitive modes of social control in the family showed greater aggression toward their classmates in school. To test a hypothesis of vicarious learning of aggression along with a contrasting Freudian hypothesis based on catharsis, Bandura and two doctoral students, Dorrie and Sheila Ross, conducted experiments using the now classic inflated Bobo doll. According to a catharsis hypothesis, children’s identification with a modeled aggressor vicariously diminishes their aggressive drives and reduces their aggressive behavior. These researchers found that young children who viewed an aggressive model attack the Bobo doll in novel ways displayed higher levels of aggression than those in a no-model control group. These findings conflicted with the catharsis hypothesis. Exposure to an aggressive model increased aggression rather than decreased it. Furthermore, the children readily learned novel forms of aggression vicariously without performing them behaviorally or receiving rewards for imitation. These outcomes conflicted with instrumental conditioning views of social learning. This evidence that witnessing vicarious violence increased children’s aggression attracted the attention of U.S. congressional committees that were investigating the impact of televised violence on children’s aggression during the 1960s. Bandura’s first comprehensive description of his theory was presented in a 1977 book titled Social Learning Theory. It depicted human functioning

BANDURA, ALBERT Albert Bandura (1925– ), a pioneering theorist of social cognitive therapeutic interventions leading to development of personal agency, is cited widely by counselors and psychotherapists. His social learning theory, later known as social cognitive theory, evolved from an initial interest in social models’ impact on children’s aggression, to modeled interventions for phobias, to enhancing patients’ selfefficacy beliefs and use of self-regulatory processes. Bandura was born on December 4, 1925, in a rural hamlet in northern Alberta, Canada. He was the only son in a family of six children of Ukrainian and Polish heritage. His early educational experiences were conducted in an eight-room school with only two high school teachers and few instructional resources. This often led to a reversal of teacher and student roles, and Bandura and his classmates had to develop their own academic skills, which they accomplished with considerable success. Defying conventional expectations, all members of his self-study group attained collegiate degrees. Bandura achieved recognition as an undergraduate at the University of British Columbia by receiving the Bolocan Award in Psychology, the first of many honors in his storied career. These formative educational experiences led to his view of learning and adaptive functioning as a social and self-directed process. After completing his doctorate at the University of Iowa, Bandura accepted a faculty appointment at Stanford University, where he began to study the 85

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triadically—involving reciprocal interactions between (1) personal (cognitive-affective), (2) behavioral, and (3) environmental components. People are both producers and products of their environments, and the effects of cognitive processes on behavior are also bidirectional. This formulation could explain not only observers’ reactions to social models in the environment but also observers’ cognitive beliefs and preventive behavior designed to regulate their exposure to models. In a 1986 text, Bandura extended his theory to cover emerging research on self-efficacy beliefs and self-regulatory processes. Self-efficacy involved individuals’ prospective judgments of their capabilities to perform at certain levels, such as to solve a specific math problem. Self-efficacy was assessed using taskspecific rating scales, which made them sensitive to variations in task difficulty and to the effects of therapeutic interventions. These dynamic item properties differentiated self-efficacy measures from trait measures of self-confidence and led to the former’s widespread predictive power. Bandura identified three self-regulatory subfunctions: (1) self-observation, (2) self-evaluation, and (3) self-reactions. For example, overweight persons could observe and record their weight daily, set goals, and self-evaluate their progress toward them, and then self-react by altering their diet or levels of exercise. Because of Bandura’s increasing focus on these cognitive and self-regulatory issues and because diverse researchers had also labeled their theories as “social learning,” Bandura renamed his theory as “social cognitive.” In 1997, Bandura published a book that greatly expanded the role of self-efficacy in social cognitive theory. Research on these beliefs had extended into diverse fields of functioning, such as education, health, clinical problems, athletics, and social and political change. Clearly, self-efficacy theory could be adapted successfully to a wide variety of areas. He also studied self-efficacy beliefs as they operate in social systems, such as schools, medical clinics, and athletic teams. This collective efficacy referred to a group’s shared beliefs about members’ combined capabilities to achieve certain goals. This measure could be used to identify problematic groups as well as specific practices that undermine a staff’s collective efficacy, such as poor coaching practices. Bandura also described the four sources of self-efficacy information: (1) vicarious experience, (2) enactive mastery experience,

(3) verbal persuasion, and (4) influences from physiological and affective states. For example, a therapeutic intervention for test-anxious students might involve watching a skilled model demonstrate and verbally encourage students to emulate a test preparation strategy and gradually enacting the strategy on their own. The strategy could comprise affective and cognitive components, such as relaxation and memorization. In a 2006 journal article, Bandura placed research on self-efficacy beliefs and self-regulation in a broader social cognitive framework, which he labeled “human agency.” This construct refers to personal efforts to control one’s functioning and life circumstances, and its core properties are (a)  intentions, (b) forethought, (c) self-reactions, and (d) self-reflection. Bandura cautioned that agentic intentions are not vague inclinations to act, but instead, they concern specific action plans and strategies for carrying out those plans. A graduate student experiencing serious procrastination problems in writing her thesis might self-record the number of words written during each session. The second core property of an agent, forethought, refers to goals and the anticipated outcomes of prospective actions to guide and motivate goal attainment. The graduate student could set daily goals for word production and plan to monitor changes in output. The third core property, selfreactions, refers to one’s ability to construct appropriate courses of action and to motivate and self-regulate their execution. The graduate student could motivate herself by engaging in rewarding activities when 50% of her daily word goal is achieved. The fourth core property, self-reflection, refers to one’s skill in self-examining one’s functioning. This includes self-reflecting on one’s personal efficacy, the effectiveness of one’s thoughts and actions, the ultimate meaning of one’s pursuits, and one’s corrective adjustments—if necessary. The graduate student might discover that her writing production was higher at the library than at home and could decide to reduce potential distractions from her home or to write exclusively at the library. Bandura’s social cognitive theory has had a major impact on clinical applications. Social modeling, self-regulation, and agentic self-beliefs are widely used to prevent and modify varied types of psychological disorders. Bandura and two doctoral students, Edward Blanchard and Bruni Ritter, developed

Beck, Aaron T.

a highly effective participant modeling approach in which patients observed a skilled model approach and handle the feared threat, followed by enactive efforts to imitate the model in graduated steps. In contrast to a no-treatment control group and a desensitization alternative treatment group, the participant modeling group was more effective in reducing lifelong fears and terrifying nightmares. After the intervention, the participants expressed their gratitude for curing their phobias. They reported another important outcome: a profound sense that they can exercise greater control over their lives. This outcome Bandura would later measure formally using self-efficacy scales. A 2002 survey ranked Bandura as the most widely cited living psychologist. In addition to the application of his social cognitive theory in psychology, it is widely cited in adjacent fields, such as health, medicine, education, athletics, and communication. In a book he is completing, he extends social cognitive theory to the exercise of moral agency. Among his many awards, he was elected president of the American Psychological Association, and he received its highest research award for Distinguished Contributions. He also received the William James Award, the highest research award of the American Psychological Society, and the E. L. Thorndike Award for his contributions in education. He was given Distinguished Contribution awards by the Clinical Psychology Division of the American Psychological Association, the International Society for Research on Aggression, and the Society of Behavioral Medicine. He has been elected to the American Academy of Arts and Sciences and the Institute of Medicine of the National Academy of Sciences. He is the recipient of a Guggenheim Fellowship and 20 honorary degrees from American and foreign universities. Barry J. Zimmerman See also Behavior Modification; Cognitive-Behavioral Therapy; Mahoney, Michael J.; Meichenbaum, Donald; Social Cognitive Theory

Further Readings Bandura, A. (1973). Aggression: A social learning analysis. Englewood Cliffs, NJ: Prentice Hall.

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Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood, NJ: Prentice Hall. Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H. Freeman. Bandura, A. (2006). Toward a psychology of human agency. Perspectives on Psychological Science, 1, 164–180. doi:10.1111/j.1745-6916.2006.00011.x

BATESON, GREGORY See Palo Alto Group

BECK, AARON T. As the founder of cognitive therapy, Aaron Temkin Beck (1921– ) has shaped the way psychologists and counselors understand psychological disorders and their treatment. Beck’s work, including a comprehensive theory of psychological functioning based on how people process information, the use of empirical research to substantiate his theory, and the development of a therapy consistent with his theory, contributed to a major shift in how mental health professionals view psychological functioning and behavior change. In addition, Beck’s cognitive therapy included the client in the active process of change in a different manner from preceding therapies. Beck was born in 1921 in Providence, Rhode Island, the youngest child of Russian immigrants who revered education and community involvement. Two of their children died in childhood, and the loss of their only daughter in the influenza epidemic of 1919 plunged Beck’s mother into a deep depression. As a consequence of these losses as well as an accident and the resulting life-threatening illness that almost killed Beck, Beck’s mother became overprotective of her youngest son. Beck attributes his fears—including those of abandonment, suffocation, and health anxiety—to his childhood illnesses and to his mother’s anxiety. His illness also set him back in school, and consequently, he believed that he was inept and stupid. With the help

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of his brothers, he studied hard and skipped ahead in school. He believes that the idea that he was being put down by others mobilized him to excel in school. Beck worked his way through Brown University with a series of part-time jobs, including being a door-to-door salesman. He had a wide range of interests in college, taking courses in all fields except accounting, while majoring in English and political science. This exemplifies the intellectual curiosity that would serve him well in creating cognitive therapy. He went on to medical school at Yale School of Medicine. He entered psychiatry by circumstance during his neurology residency, for there was a shortage of psychiatrists where he was training and he was required to do a rotation in psychiatry. He was exposed to psychoanalysis in medical school and during his residency and subsequent fellowship but was resistant to its formulations, finding them far-fetched and lacking in scientific foundation. He thinks he was also rebellious due to being the youngest in his family. Still, he was curious and kept trying to embrace the psychoanalytic model. Beck completed training in psychoanalysis without really being convinced about psychoanalytic theory. Thus, he decided to be scientific about his understanding of psychoanalysis through research. In an attempt to substantiate Sigmund Freud’s theory that depression was anger turned toward the self, Beck studied the dreams of depressed patients. Rather than finding themes of anger and hostility, however, he found the dreams to be characterized by loss. Further experiments by Beck that compared depressed and nondepressed persons indicated that depressed people distorted reality by adopting negative views of themselves. Observations of depressed patients in his private practice also revealed that they had a train of thought quite apart from what they were reporting. This parallel line of thinking or internal monologue was full of “automatic thoughts” that were immediate, plausible, and negatively biased. This negative cognitive bias was found to affect the patients’ mood and behavior. This discovery of the conscious role of cognition in psychological distress was groundbreaking. As Beck developed his theory further, he incorporated deeper levels of cognition, such as conditional beliefs and assumptions, and schemas, or the

organizing principles for a person’s view of himself or herself and other people. In practice, schemas are treated as core beliefs that are part of the foundation of personality. While elaborating and substantiating his theoretical model, Beck invented a therapy for treating psychological disorders that works directly with cognitions, from the level of automatic thoughts to the deepest level of schemas. In cognitive therapy, clients are taught to examine their negative thoughts and test them logically and through behavioral experiments. Unlike other cognitivebehavioral therapies based on challenging a person’s negative thoughts, cognitive therapy worked through the empirical testing of beliefs rather than by either the substitution of coping thoughts provided by the therapist or a philosophical debate of irrational thoughts. Cognitive therapy was of shorter duration than psychoanalysis and was found to be as effective as medication in the treatment of depression. It was found to be superior to medication in reducing the relapse or recurrence of depression. The demonstrated success of cognitive therapy provided empirical support for the emerging cognitivebehavioral therapies in psychology. Beck started developing cognitive therapy in the 1960s, a time of great change in psychiatry and psychology. The two dominant schools of psychotherapy at the time were (1) behavior modification, which focused on environmental contingencies or conditioning, and (2) psychoanalysis, based on unconscious drives and motivations. As some behaviorists were returning to a consideration of the client’s internal world, some psychoanalysts were looking for tools and techniques to help their clients. Cognitive therapy addressed both of these needs. Beck’s work, with its empirical tests of theory and therapy, seemed to appeal more to academic psychologists trained in experimental research than to psychiatrists, who were still dominated by the consensus of senior clinicians. Thus, cognitive therapy moved into mainstream psychology as mainstream psychiatry was moving into biological causes and an emphasis on pharmacotherapy. Indeed, Beck’s initial reception was most favorable among psychologists who were also developing their own cognitive models of psychotherapy.

Beck, Aaron T.

Since the 1960s, there has been a merging of cognitive and behavioral formulations in psychotherapy. Initially, however, many behaviorists opposed the work of Beck and others, notably Albert Ellis and Donald Meichenbaum, for being too focused on mental activities. Alternatively, some found cognitive approaches unnecessary, for thoughts were seen as a form of behavior. Indeed, by the mid-1970s, the acceptability of cognitive therapies was hotly debated among members of behavior therapy’s premier professional organization, the Association for the Advancement of Behavior Therapy. After years of consideration, in  2005, the organization changed its name to the  Association for Behavioral and Cognitive Therapies. Psychoanalysis objected to cognitive therapy for its seemingly superficial treatment of psychopathology. Cognitive therapy placed the emphasis on present experience rather than on early-childhood recollections and on conscious or preconscious thought rather than on the unconscious. In addition, the short-term nature of cognitive therapy seemed inadequate for lasting change. Finally, psychoanalysts viewed the apparent lack of attention to the therapy relationship as another shortcoming, for it is the agent of change in psychoanalysis. Beck’s research demonstrating the effectiveness of cognitive therapy across a range of disorders won over critics and established a new standard in psychotherapy research. He codified what went on in therapy and thus challenged others to do the same. In addition, he used clinical populations, such as hospitalized patients rather than college student volunteers, in his research, thus making his findings more pertinent to clinical disorders. As Beck’s research grew beyond the treatment of depression to include anxiety disorders, eating disorders, schizophrenia, substance abuse, bipolar disorder, suicide, and personality disorders, the applicability of cognitive therapy expanded. Beck’s impact on counseling and psychotherapy is significant. His research into the roles of beliefs and assumptions in psychiatric disturbances changed the way psychopathology is viewed. His change of the therapy relationship to one of collaboration made psychotherapy transparent and made the client an active participant in designing behavioral experiments to test beliefs. A goal of cognitive therapy is to teach the client to become

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his or her own therapist. In this way, Beck has influenced the self-help movement. Additionally, the demonstration of the effectiveness of cognitive therapy as a short-term therapy has had implications for health care policy. In terms of research, Beck developed classification systems for disorders, most notably suicidal behavior, as well as tests to assess the severity of symptoms of depression, anxiety, and other syndromes. He has employed rigorous tests of the effectiveness of cognitive therapy and is unique in studying clinical populations that were previously excluded from research studies because they carried dual diagnoses or were of high suicide risk. Such studies further demonstrate the robustness of cognitive therapy. Currently, cognitive therapy is practiced worldwide. The American Psychological Association reported cognitive therapy to be the leading psychotherapy practiced by clinical psychologists in the United States in 2012. The Accreditation Council for Graduate Medical Education requires psychiatry residency programs to train residents in cognitivebehavioral therapy. More than 100 empirical studies support the cognitive theoretical formulation of depression and other disorders. Beck himself has published more than 21 books and 540 articles. His work has been translated into more than a dozen languages. In Europe, some health systems recommend the use of cognitive therapy in treating a number of disorders. Research in cognitive therapy has been conducted in many countries, primarily in industrialized economies. Beck is currently University Professor Emeritus of Psychiatry at the University of Pennsylvania. He remains active in research and writing. Among Beck’s awards are the American Psychological Association Lifetime Achievement Award in 2007, the American Psychiatric Association Distinguished Service Award in 2008, and the Albert Lasker Clinical Medical Research Award in 2006, the highest U.S. scientific honor in biomedical research. Marjorie E. Weishaar See also Behavior Therapy; Cognitive-Behavioral Therapies: Overview; Cognitive-Behavioral Therapy; Ellis, Albert; Meichenbaum, Donald

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Further Readings Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: New American Library. Beck, A. T. (1991). Cognitive therapy: A 30-year retrospective. American Psychologist, 46, 368–375. doi:10.1037//0003-066X.46.4.368 Beck, A. T. (2005). The current state of cognitive therapy. Archives of General Psychiatry, 62, 953–959. doi:10.1001/archpsyc.62.9.953 Beck, A. T., Freeman, A., Davis, D., & Associates. (2004). Cognitive therapy of personality disorders (2nd ed.). New York, NY: Guilford Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press. Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York, NY: Guilford Press. Weishaar, M. E. (1993). Aaron T. Beck. London, England: Sage.

BEHAVIOR MODIFICATION Behavior modification involves analyzing behavior and developing procedures to modify or change behavior. To measure change, behavior must be observable and measurable. Observable behavior can be measured in terms of frequency, duration, or intensity; changes in these parameters are used to assess the efficacy of behavior modification procedures. Behavioral excesses or deficits are usually the targets for behavior modification. A behavioral excess is typically objectionable, and the goal is to decrease the frequency, duration, or intensity of the behavior. An example of a behavioral excess may be  self-injurious behavior (e.g., head banging). A behavioral deficit is more likely to be a favorable behavior for which behavior modification is used to increase the frequency, duration, or intensity of the behavior. Examples of behavioral deficits may be lack of eye contact or speech in social situations.

Historical Context Behavior modification is based on behavioral principles that have been studied in laboratory settings since the early 1900s. Edward Thorndike (1874–1949)

described the law of effect when he observed that behavior that had a favorable effect on the environment was likely to be repeated. Ivan Pavlov (1849–1936) demonstrated that behavior could be conditioned by training dogs to salivate to a sound by pairing food and the sound repeatedly. He called this a conditioned reflex. John B. Watson (1878–1958) coined the term behaviorism when he described a stimulus–response paradigm in which environmental events (stimuli) elicited behavioral responses. B. F. Skinner (1904–1990) described operant conditioning, in which the consequence of behavior was shown to control the likelihood of future behavior. These early scientists laid the foundation for behavior modification in working with animals and, later, humans. Behavior modification research with humans began in the 1950s.

Theoretical Underpinnings As stated above, behaviors are specific, mostly observable actions that may be measured on multiple dimensions (e.g., frequency, duration, intensity, latency). Behavior is also lawful, meaning that it is influenced by environmental events. The environmental events maintaining a behavior, once understood, may be manipulated to alter the behavior. To modify a behavior, an emphasis is placed on current environmental events that are functionally related to the behavior. Past learning experiences do affect current behavior; however, they are de-emphasized by behavior analysts because only current environmental influences can be changed. Furthermore, underlying causes of behavior are not examined because they cannot be proven and their functional relationship with a behavior is mostly hypothetical.

Major Concepts Functional Analysis

Before behavior modification techniques can be used, a functional analysis of the behavior must be completed. When conducting a functional analysis, the clinician or behavior analyst tries to identify causal links between the behavior and the environment. The analyst must gather information about the antecedents and consequences of the behavior to be targeted. Antecedents are the events

Behavior Modification

that take place before the target behavior occurs, and consequences are the events that occur after the target behavior occurs. This type of functional assessment helps the analyst understand why the behavior is occurring. Methods of Assessment

Development of a behavior modification program should include indirect and direct methods of assessment. Indirect methods include behavioral interviews and questionnaires. The interview should be conducted with the target individual (if possible) as well as other individuals who know the target person. The main goal of the interview is to determine the problem behavior as well as the antecedents and consequences of the behavior. Questions should be phrased to elicit specific information that is observable and measurable. For example, “When/where does the behavior usually occur?” is an example of a standard interview question to determine the antecedents of the behavior. “What happens immediately after the behavior occurs?” may be asked to determine the consequences of the behavior. Direct observation typically occurs in the environment in which the behavior occurs (e.g., home, school). The observer records the antecedents and consequences of the behavior so that these parameters can be adjusted. Reinforcement and Punishment

One of the most effective and widely used techniques for increasing a behavior is positive reinforcement. Positive reinforcement occurs when behavior is followed by the presentation of a stimulus (reinforcer) that results in the strengthening of the behavior. Commonly used reinforcers include food, social reinforcers such as attention or praise from another person, money, or tokens. Tokens are often traded for primary reinforcers such as food or secondary reinforcers such as money. Negative reinforcement involves strengthening a behavior by removing an unpleasant stimulus after the behavior occurs. Escape and avoidance behaviors, broadly, are maintained by negative reinforcement. Escape involves performing a behavior to terminate an unpleasant stimulus. For example, the bothersome buzz of an alarm begins, and a nearby individual is motivated to perform some

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behavior (e.g., buckle his or her seat belt in an automobile) to end the unpleasant sound. In this case, buckling the seat belt before the alarm begins is avoidance because the unpleasant stimulus is prevented from occurring at all. A procedure in which the consequence reduces the strength of the preceding behavior is called punishment. Similar to reinforcement, punishment may be either positive or negative. Positive punishment consists of introducing an aversive stimulus following a behavior, and negative punishment is the removal of a reinforcing stimulus after a behavior. Both methods result in a decrease in the frequency, intensity, or duration of the behavior they follow. Schedule of Reinforcement

Rules that guide the delivery of reinforcers for a behavior make up the schedule of reinforcement (SOR); schedules may be categorized as continuous or intermittent. In a continuous SOR, the target behavior is reinforced every time it occurs. This technique is used primarily to encourage quick acquisition of the desired behavior. An intermittent SOR is then applied to produce long-term maintenance of a behavior. During an intermittent SOR, the target behavior is only sometimes reinforced. Intermittent schedules are further divided into ratio and interval schedules. Reinforcement is delivered after a predetermined number of occurrences of the behavior in a ratio schedule and after an interval of time has passed in an interval schedule. Furthermore, intermittent schedules may be either fixed or variable. Reinforcement is delivered consistently after a specific number of occurrences of a behavior or a specific duration of time has passed in a fixed schedule. In a variable schedule, reinforcement does not occur consistently. Instead, it is delivered after a certain number of occurrences of the behavior (ratio) on average or after the first instance of the behavior after a defined duration of time (interval) on average. Variable ratio schedules have been demonstrated to be the most effective in maintaining a behavior in the long term. Operant Conditioning

Operant conditioning is the process of behavior modification in which behavior is influenced by its consequences. When the consequence of a behavior

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strengthens the behavior (i.e., increases the frequency, duration, or intensity), reinforcement has occurred. Consequences that reduce the strength of a behavior (i.e., decrease the frequency, duration, or intensity) are termed punishment. During behavior modification interventions, reinforcement and punishment may be manipulated to increase desirable behavior or decrease undesirable behavior. Classical Conditioning

Classical conditioning (also called respondent conditioning or Pavlovian conditioning) is the process of learning automatic, bodily responses to a neutral stimulus. Without any prior learning or experience, humans respond to unconditioned stimuli (e.g., food in the mouth or a puff of air in the eye) automatically (by salivation and blinking, respectively). These reflexive behaviors are termed unconditioned responses because they are innate bodily reflexes in nearly all humans. Classical conditioning occurs when a previously neutral stimulus, a stimulus that does not produce an unconditioned response, such as a ringing bell, is repeatedly paired with an unconditioned stimulus that produces an unconditioned response. After repeated pairing, the neutral stimulus becomes a conditioned stimulus in that it is able to elicit the reflexive behavior (now called the conditioned response).

Techniques

Behavioral Chains

A complex behavior that consists of multiple steps in a specific sequence may be taught using behavioral chains (BC). Each behavior in a BC provides a cue for the next behavior, and the final behavior provides a reinforcer. For instance, tying the laces of a shoe requires several individual behaviors in a specific sequence. Each behavior cues the next step (e.g., grab one lace in each hand, bring the laces together, place the tip of one lace under the other, etc.). BCs may be forward (first to last step) or backward (last to first step). Backward chaining is advantageous in some situations. The final step is taught first; therefore, reinforcement is delivered sooner. This technique is helpful when working with children with special needs, who may not be able to learn all of the steps needed to complete a task. An adult or therapist completes the first steps, allowing the child to complete the final step and receive a reward. Steps are then added (in a backward manner) until the child completes the task from start to finish. Token Economy

A token economy, generally used in group or residential settings, is a method commonly used to reinforce specific behaviors. The target behavior is reinforced with tokens (often a tangible or visible stimulus that has an assigned value), and the tokens may later be exchanged for other, preferred reinforcers.

Shaping

Shaping is an appropriate procedure to implement when the goal of a behavioral intervention is to develop a new behavior. It is defined as the  differential reinforcement of successive approximations to a target behavior. Differential reinforcement is an application of operant conditioning in which only one specific behavior in a specific situation is reinforced and all others are not. Successive approximations are behaviors that are successively similar to the target behavior. In practice, a behavior is broken into smaller steps. An individual’s behavior is reinforced at each step, but prior steps are not reinforced, to encourage approximations toward the final target behavior.

Response Cost

An application of punishment, response cost is the loss of a specified amount of a reinforcer contingent on the occurrence of a problem behavior (e.g., loss of three tokens for cursing). Time-Out

Time-out is the removal of an individual from a situation in which his or her problem behavior is reinforced. The individual should be placed in a location where all reinforcement for the undesired behavior is removed. Time-out is consistent with negative punishment and is a form of response cost.

Behavior Therapies: Overview

Behavioral Skills Training

Various useful skills can be taught using behavioral skills training (BST). BST procedures typically include specific instructions for how the target skill is performed as well as modeling of the skill by an instructor. The trainee then rehearses the target skill, and the instructor may provide corrective feedback or praise. BST is also effective when delivered to multiple trainees in a group.

Therapeutic Process All behavior modification paradigms begin with a thorough functional assessment of current behaviors in the settings in which behavioral change is desired. Caregivers are asked to report behavioral observations in child cases, or self-monitoring may be used. Patterns of antecedents and reinforcement are identified to determine how current undesired behaviors are elicited and maintained. Next, a behavioral intervention is designed in which the target behavior is reinforced and all other behaviors are not reinforced and/or punished. It is important that the counselor or therapist identify appropriate reinforcers for the individual (and punishers, if  implemented) and reinforcers that vary in magnitude—simple, quick reinforcers should be available as well as larger reinforcers that require greater displays of the target behavior. Behavioral observations/self-monitoring should continue throughout the intervention to monitor effectiveness. Changes may then be implemented as needed to achieve the desired outcome. Effective counselors and therapists realize that even when behavior change occurs, older patterns may reappear and that follow-up and repeat interventions are sometimes necessary if change is to be permanent. Sandra M. Neer and Franklin Mesa See also Behavior Therapy; Classical Conditioning; Functional Analytic Psychotherapy; Operant Conditioning; Pavlov, Ivan; Skinner, B. F.; Systematic Desensitization

Further Readings Fraser, M. W., Galinsky, M. J., Smokowski, P. R., Day, S. H., Terzian, M. A., Rose, R. A., & Guo, S. (2005). Social information-processing skills training to promote social competence and prevent aggressive behavior in the third grades. Journal of Consulting

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and Clinical Psychology, 76, 1045–1055. doi:10.1037/0022-006X.73.6.1045 Kazdin, A. E. (2013). Behavior modification in applied settings. Long Grove, IL: Waveland Press. Kurtz, M. W., & Mueser, K. T. (2008). A meta-analysis of controlled research on social skills training for schizophrenia. Journal of Consulting and Clinical Psychology, 76, 491–504. doi:10.1037/0022006X.76.3.491 Matson, J. L. (Ed). (2012). Functional assessment for challenging behavior. New York, NY: Springer. Miltenberger, R. G. (2012). Behavior modification: Principles and procedures. Belmont, CA: Thompson Wadsworth. O’Connor, M. J., Frankel, F., Paley, B., Schonfeld, A. M., Carpenter, E., Laugeson, E. A., & Marquardt, R. (2006). A controlled social skills training for children with fetal alcohol spectrum disorders. Journal of Consulting and Clinical Psychology, 74, 639–648. doi:10.1037/0022-006X.74.4.639

BEHAVIOR THERAPIES: OVERVIEW Behavior therapy is an umbrella term used to identify a broad array of therapeutic techniques that have in common at least a partial basis in the classical conditioning learning theory of Ivan Pavlov, the operant learning of E. L. Thorndike and B. F. Skinner, or both. While the focus on internal cognitive or emotional events may vary as a function of the specific behavioral therapy being considered, commonalities include the reliance on objective and observable data to monitor therapy fidelity and effectiveness and a conceptual reliance on changed behavior as the outcome focus of treatment. Within this framework, these approaches to therapy can range from the complete reliance of applied behavior analysis on  environmental manipulation and rejection of mentalistic interpretation (which is in stark contrast with humanistic, insight, or existential theoretical approaches) to blended techniques that incorporate aspects of cognitive or insight therapy while also maintaining aspects of their behavioral roots.

Historical Context The concept of behavior therapy was, in part, an outgrowth and adaptation of the Pavlovian or classical conditioning and behaviorist laboratory

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studies of learning, as well as of the work of defectors from the ranks of clinical psychology and psychiatry. In the aftermath of the Second World War, psychoanalysis became the dominant approach to psychotherapy in the United States and many Western countries. Not all practitioners were satisfied with the results of Freudian and neo-Freudian psychoanalysis, however. In England in the early 1950s, for example, Hans Eysenk published pointed criticisms regarding the lack of observable benefit from psychoanalysis and argued for an empirically based treatment approach. Some practitioners also found the results of psychoanalytic therapy wanting. Among those who searched for a more effective approach was Joseph Wolpe, a South African physician and psychoanalyst. After the war, he engaged in laboratory studies in which he created and then eliminated phobias in cats, utilizing the principles of classical conditioning. He then applied the process, which he termed desensitization, to humans in treating phobias and other psychological disorders. At the same time, Skinner and his then doctoral student Ogden Lindsley published Studies in Behavior Therapy in 1954, arguably the first published use of the term behavior therapy. In the late 1950s and early 1960s, a number of individuals, having graduated from schools of experimental psychology (often students of Skinner or his students), began to apply what they had learned to institutionalized populations with intellectual disabilities or mental illness, utilizing the singlesubject designs they had learned in the laboratory. In the process, they developed a broad array of well-defined procedures for behavior change and therapy, which is generally reflected in current applied behavior analysis. Another thread can be traced to Albert Bandura, who graduated from the University of Iowa while Kenneth Spence was department chair. Spence and his colleague Clark Hull achieved national prominence in their attempt to explore and explain motivation as a mathematical formula involving a number of different variables. While he did not subscribe to Spence and Hull’s efforts to quantify motivation, Bandura did build on their concept of multiple variables influencing and motivating behavior and published significant research on the

impact of modeling on child learning and behavior. Bandura went on to develop a theory of personality where the individual’s perception of self (or  self-efficacy), the environment, and the individual’s behavior worked together to influence one another, which he termed reciprocal determinism. This concept continues to be a significant conceptual basis for many forms of behavior therapy today. Over time, these threads of research, scholarship, and treatment have been developed, embellished, combined, and/or modified by additional practitioners, often reading and commenting on and borrowing from one another’s work. While each can be seen as distinct, and often practitioners will disavow any but their own conceptual orthodoxy, there are obvious overlaps and common foundations for the various categories of thought represented in behavior therapy. These different but related understandings of behavior are ultimately responsible for the breadth, diversity, and focus of behavior therapy as it is currently practiced.

Theoretical Context Behavior therapy has at least part of its foundation in the field of physiology (through classical conditioning) and the empiricist worldview representative of the British and American positivists. This positivist viewpoint holds that there is an objective reality, which can be explored and investigated through the rigorous application of scientific methods to the study of human action, as applied here. According to this paradigm, there can be found through objective, replicable inquiry a universal truth underlying human behavior, which can be illuminated through observation, hypothesis testing, experimentation, and replication, resulting in falsifiable hypotheses and theories of human behavior. Behavior therapies are, in a fundamental way, an outgrowth of the learning theory research first conducted in universities and college laboratories and applied to human behavior. Two approaches to learning predominate: (1) classical conditioning (also referred to as respondent conditioning or Pavlovian conditioning) and (2) operant conditioning.

Behavior Therapies: Overview

A significant third thread in behavior therapies is the concept of cognitive-behavioral theory, as proposed by Bandura. Harkening back to William James’s and Edward Tolman’s functionalism, Bandura and others have extended the concepts of learning to include cognitive events. These three theories, together with the work of those who have built related therapeutic approaches, form a philosophical foundation from which behavior therapies can be considered as a whole. Classical Conditioning

A significant portion of behavioral therapies are grounded in the work of the Nobel laureate in medicine Ivan Pavlov (1849–1936) on classical conditioning. Many forms of behavior therapy incorporate the associative processes involved in the acquisition of a situation or event as a conditioned stimulus (CS), through repeated pairings with an existing CS or an unconditioned stimulus (UCS) over trials. This is often followed by generalization of that relationship to other similar stimuli. In some cases, such as in conditioned taste aversion, the relationship can be formed extremely quickly. This is an application of the research conducted by John Garcia in the 1970s, whereby taste aversion could be demonstrated as occurring after one learning trial in which the CS and UCS were separated temporally. This body of work has since been recognized as significantly altering our conceptualization of classical conditioning and also expanding our understanding of the parameters that act as individual and species-specific characteristics that support (or suppress) the potential of a stimulus to become a CS. This variant of classical conditioning is currently represented in taste aversion therapy used in the treatment of individuals chemically dependent on alcohol by administering disulfram, a compound that, when alcohol is introduced into the person’s system, results in strong nausea and vomiting within minutes. A more controversial example of aversion therapy is represented in Stanley Kubrik’s 1971 movie A Clockwork Orange. At the same time, at the core of therapeutic approaches such as exposure and response prevention and systematic desensitization is the process of classical extinction, where a CS is

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repeatedly presented in the absence of an UCS or having an associated response prevented, resulting in gradual reduction and virtual elimination of the conditioned response. Operant Conditioning

Operant conditioning is a term adopted by Skinner to describe the process by which an organism learns, thereby changing, increasing, or decreasing voluntary behaviors as a result of the outcomes resulting from that behavior in a given context or environment. In earlier work, Thorndike hypothesized his law of effect—that is, the concept that an action or behavior can be stamped in, or increased, when followed by desirable consequences or stamped out when followed by undesirable ones. In Skinner’s conceptualization of operant conditioning, the probability of a specific behavior being exhibited by an individual in the future increases when stimuli in the environment have been paired with reinforcing consequences in the past. In a similar manner, the future probability of a particular behavior would decrease if the consequences were punishing when exhibited in the past. With his emphasis on objective experimental methods and data recording, as well as exploration of the differential effects of schedules of reinforcement on behavior, Skinner’s impact on behavior therapies has been profound and enduring. Cognitive-Behavioral Theory

At a time when psychology in the United States was dominated by behavioral theory, Bandura proposed an understanding of behavior that included cognitive concepts reminiscent of the functionalism of James and reflecting the inference of internal cognitive intervening variables in behaviorism espoused by Tolman. Bandura’s enduring research legacy in demonstrating the power of modeling and learning in the absence of reinforcement, along with his expansion into selfefficacy as an internal mediating variable in understanding human actions, has made his approach a significant foundational component of many behavioral therapies. Together, classical and operant conditioning and cognitive-behavioral theory form a basic

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conceptual framework that, either in whole or in part, forms the basis for the specific therapeutic approaches that are detailed below.

Short Descriptions of Behavior Therapies Acceptance and Commitment Therapy

Combining cognitive components of cognitive therapy with values clarification–fueled behavioral activation, acceptance and commitment therapy has been used in a variety of therapeutic approaches (e.g., individual, group, and seminar) to assist individuals in becoming self-aware, in accepting their experiences and emotions without reliving them, and in developing functional choices based on identifying what the individual perceives as values and valued outcomes. Applied Behavior Analysis

Applied behavior analysis employs the rigorous empirical assessment of the contextual cues and consequent outcomes that affect the probability of an individual’s behaviors. In addressing an existing behavior, applied behavior analysis provides for forming hypotheses regarding which types of functions the behavior serves for that individual in that setting and systematically altering those antecedents and consequences to obtain outcomes that are addressing those functions while being validated by social desirability. Applied behavior analysis is not a specific technique but, rather, a set of techniques that are objectively described and replicable and avoid reliance on mentalistic terms or constructs. Behavior Modification

Behavior modification is based on the principles of operant conditioning. Behavior modification serves three broad functions: (1) to increase socially desirable behaviors that are currently not as prevalent as would be appropriate; (2) to decrease behaviors that are problematic in their intensity, frequency, or duration, or by their occurrence; and (3) to teach new skills that will assist the individual in functioning independently. Behavior Therapy

Broadly, behavior therapy is an umbrella term used to characterize a number of therapeutic

approaches anchored at least in part on operant and/or classical conditioning, or social learning theory. Behavioral Activation

Developed as a treatment for depression, behavioral activation posits that mood change can best be obtained by reinforcing individuals for engaging in activities that are assessed as desirable by that person, thereby increasing his or her opportunities to experience the naturally occurring reinforcement available in the environment. Recently, this approach has demonstrated effectiveness in working with aged populations and with individuals with dementia. Classical Conditioning

Also referred to as Pavlovian or respondent conditioning, classical conditioning describes the process by which a previously neutral stimulus becomes a CS—that is, acquires the capacity to evoke a conditioned response from the individual through repeated pairings of the neutral stimulus with an UCS or a different previously used CS. Dialectical Behavior Therapy

Dialectical behavior therapy is a multipronged therapeutic approach employing behavioral, cognitive therapeutic approaches and mindfulness training in combined individual and group therapy. Dialectical behavior therapy, sometimes combined with residential and pharmacological treatment, has been shown to have positive impact when working with individuals diagnosed with borderline personality disorder, a group who had been extremely resistive to treatment using other counseling approaches. Exposure and Response Prevention

Based on the principles of classical extinction and cognitive-behavioral therapy, exposure and response prevention utilizes a variety of settings (e.g., in vivo, virtual reality, and simulation) to expose an individual to anxiety-producing stimuli and situations, while preventing the individual from engaging in otherwise problematic rituals in a controlled environment. By allowing the individual to experience the anxiety-evoking stimulus

Behavior Therapies: Overview

without being able to engage in his or her ritual response, the individual’s conditioned anxiety undergoes an extinction process because no real harm or injury occurs. This process serves to weaken the conditioned fear response to that stimulus. Exposure Therapy

Similar to exposure and response prevention, exposure therapy is employed to treat anxiety disorders through repeated presentation of the fearevoking stimulus. In the absence of harm, the fear associated with the stimulus decreases over trials. Functional Analytic Psychotherapy

A relatively recent addition to behavior therapies, functional analytic psychotherapy utilizes many of the principles of applied behavior analysis, such as a focus on the current behaviors and behavioral history of the individual, as well as assessment of the environmental antecedents and consequences maintaining the current behavior. This is combined with a willingness to borrow from other therapeutic traditions and adopt hypotheses regarding internal mentalistic events, such as thoughts and beliefs, if doing so leads to effective intervention. Multimodal Therapy

Based on the work of Arnold Lazarus, multimodal therapy is based on the idea that personality is multidimensional. Multimodal therapy proponents assert that it is essential to treat the several aspects of a person—biological, psychological, and social—to achieve optimal functioning or performance. Operant Conditioning

Operant conditioning refers to any of a variety of techniques having their origin in the work of Skinner and his followers where the behavior of the individual is seen as being maintained by its consequences. Parent–Child Interaction Therapy

Parent–child interaction therapy grew out of a university-based treatment of parent–child

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interactions in guided or coached interactions between parents and their child. Treating parents and children together acknowledged the relevance of these interactions in the development and treatment of problem behaviors. Parents are provided with real-time guidance in effective reinforcement and appropriate ignoring of attention-based misbehaviors, and praise for using behaviorally sound parenting. Prolonged Exposure Therapy

A variant of cognitive-behavioral therapy and classical conditioning, prolonged exposure therapy has been used successfully in the treatment of posttraumatic stress disorder from a variety of sources. Social Cognitive Theory

An extension of Bandura’s social learning theory, social cognitive theory includes a conceptual focus on the three aspects of Bandura’s reciprocal determinism (i.e., self-efficacy or belief, the environment, and behavior) as essential components of effective behavioral treatment. Systematic Desensitization

Combined with relaxation training, systematic desensitization employs the gradual introduction of fear-producing stimuli in a least-to-most progression while practicing incompatible relaxation techniques. Systematic desensitization has been effectively used to reduce anxiety reactions in specific phobias in a wide variety of settings and populations. David Donnelly See also Acceptance and Commitment Therapy; Applied Behavior Analysis; Bandura, Albert; Behavior Modification; Behavior Therapy; Behavioral Activation; Classical Conditioning; CognitiveBehavioral Therapies: Overview; Dialectical Behavior Therapy; Exposure and Response Prevention; Exposure Therapy; Functional Analytic Psychotherapy; Lazarus, Arnold; Linehan, Marsha; Multimodal Therapy; Operant Conditioning; Parent–Child Interaction Therapy; Pavlov, Ivan; Prolonged Exposure Therapy; Skinner, B. F.; Social Cognitive Theory; Systematic Desensitization

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Further Readings Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91–97. doi:10.1901/jaba.1968.1-91 Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall. Lazarus, A. A. (1971). Behavior therapy and beyond. New York, NY: McGraw-Hill. Skinner, B. F. (1974). About behaviorism. New York, NY: Knopf.

BEHAVIOR THERAPY Behavior therapy is a broad approach to treatment that relies on principles derived from two major theories: (1) classical conditioning and (2) operant conditioning. These two theories have led to a wide range of interventions that have been applied to psychological and emotional problems.

with no positive reactions will be less likely to occur in the future (extinction or desensitization). Punishment in operant conditioning takes place in two ways. One, negative punishment, occurs when a behavior leads to the removal of a positive stimulus. The other, positive punishment, occurs when a behavior leads to the application of an aversive stimulus. In operant conditioning, punishment is generally considered only for stopping specific behaviors and is not used as a long-term learning procedure. Classical conditioning and operant conditioning have their roots in research involving animal behavior. Collectively, these two techniques are referred to as learning theory. The emergence of learning theory was in part to develop methods of objectively demonstrating behavior change principles. These principles were derived from single-case experimental designs, in animals and humans, and were then further validated in larger experiments.

Theoretical Underpinnings Historical Context Classical conditioning and operant conditioning were derived from basic experimental research. Classical conditioning, on the one hand, resulted from research showing that environmental stimuli (e.g., a specific sound) when paired with elicitors of specific automatic responses (e.g., salivation due to exposure to food sources) would also elicit the same response. Once conditioned, these responses could be eliminated if the stimulus (e.g., a specific sound) was presented with no stimuli that elicit an automatic response. This process has been called extinction and, sometimes, habituation. While the literature often uses these terms interchangeably, they are distinct concepts, as discussed in the section “Major Concepts.” Operant conditioning, also derived from basic experimental work, suggests that when individuals exhibit a response that is paired with established positive feedback (e.g., food, praise), that response will be more likely to occur in the future (positive reinforcement). Likewise, a response that leads to the termination of something unpleasant will also be more likely to occur in the future (negative reinforcement). However, responses that are paired

Behavior therapy is based primarily on the principles of classical and operant conditioning. In classical conditioning, a neutral stimulus is paired with an unconditioned stimulus; the unconditioned stimulus produces a specific response (unconditioned response) without prior training. Following repeated pairings of the neutral stimulus and the unconditioned stimulus, the previously neutral stimulus becomes a conditioned stimulus when presented on its own because it elicits the response (now a conditioned response) even without the presence of the unconditioned stimulus. Although classical conditioning is discussed in detail elsewhere in this encyclopedia, two additional aspects are important to note because of their impact on behavior therapy. Classical conditioning explains conditioned inhibition, where a neutral stimulus is conditioned to indicate the absence of an unconditioned stimulus. In addition, reciprocal inhibition is the process by which a competing state is used to extinguish an undesirable response. For example, relaxation training may be used to aid in the extinction of an anxiety response. Operant conditioning explains how consequences lead to changes in behavior. An individual’s behavior is followed by an outcome. This

Behavior Therapy

outcome may reinforce the behavior by making it more likely that the behavior will be performed again, or it may lead to a decrease in the response rate (punishment). Reinforcers and punishers can be positive or negative. If a stimulus is produced, it is positive; if a stimulus is eliminated or prevented from occurring, it is negative. A thorough review of operant conditioning is beyond the scope of this entry, but again, two additional aspects are important to note because of their application to behavior therapy. Negative reinforcement, whereby the removal or prevention of an aversive stimulus makes it more likely that a behavior will be repeated, explains many escape and avoidance behaviors that can be addressed with behavior therapy. In addition, differential reinforcement of other behavior is a training paradigm whereby a competing or more acceptable behavior than the target behavior also leads to an appetitive stimulus (e.g., food or other desirable stimuli), thereby increasing the probability that this new behavior will be repeated.

Major Concepts A few of the major concepts that underlie behavior therapy are extinction, stimulus control, differential reinforcement of other behavior, the role of cognition, and observational learning. Extinction

One of the most important concepts in behavior therapy, extinction can be traced to its theoretical underpinnings in classical and operant conditioning. Extinction involves the withholding of either the unconditioned stimulus or the reinforcing stimulus. When the stimulus is withheld, the rate of response decreases, and the response may be eliminated altogether. A common phenomenon during extinction is an extinction burst. This is a temporary increase in the target behavior, or the occurrence of novel behaviors, early in the extinction process, which will generally remit if the stimulus continues to be withheld. Spontaneous recovery may also be seen during extinction; this is the return of the originally conditioned response if the stimulus is presented. In spontaneous recovery, although the behavior returns, it generally does not occur at the same frequency as before

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extinction. Extinction is different from habituation because while extinction is a loss of a learned behavior over repeated trials, habituation is a decrease in a natural response to a stimulus over repeated trials. Stimulus Control

A behavior is under stimulus control when there is an increased likelihood that the behavior will be performed when a specific stimulus is present. This stimulus, called a discriminative stimulus, may be a specific situation, circumstance, or person. Stimulus control is often determined with a functional assessment, and it can be used to modify behavior (antecedent control). Functional assessment, discussed in more detail in the section “Techniques,” is a process whereby the target behaviors are carefully evaluated for the conditions that are reinforcing them (i.e., maintain or increase them) as well as for the environmental conditions that may promote them (i.e., discriminative stimuli). For example, if a client usually drinks in a specific bar, the bar may serve as a discriminative stimulus. If the client refrains from going to that bar, the client may be less likely to engage in the target behavior of drinking. Differential Reinforcement of Other Behavior

Differential reinforcement of other behavior is a type of operant conditioning paradigm used in changing behavior. Simply put, reinforcement is withheld in the presence of a target behavior, but the reinforcement is instead administered when another behavior is performed. There are several variations, including differential reinforcement of alternative behavior, incompatible behavior, or low rates of responding. For differential reinforcement of alternative behavior, reinforcement is provided when the client engages in a more adaptive or preferred behavior. For incompatible behaviors, reinforcement is provided only when a client engages in a behavior that is incompatible with the target behavior, such as sitting at a desk when the target behavior is getting up without teacher permission. For differential reinforcement of low rates of responding, reinforcement is provided if the client engages in the behavior fewer than an agreed-on maximum number of times.

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The Role of Cognition

In behavior therapy, the therapist and the client aim to define the cognition as specifically as possible. There are a number of ways in which cognitions may be interpreted in behavior therapy. Cognitive behavior can be considered as a conditioned stimulus, as it may be associated with an unpleasant conditioned response; as a motivating operation, which influences the strength of reinforcers or punishers; or as a reinforcer or punisher itself, if it follows another behavior and increases or decreases the likelihood that the behavior will be repeated. Cognitive interventions may include behavioral features such as self-instructional training, where clients are taught specific self-statements to function as discriminative stimuli, increasing the likelihood of engaging in the desired behavior when the self-instruction is used. Observational Learning

Based in social learning theory, observational learning, or modeling, posits that behavior does not have to be learned through direct reinforcement. Instead, observing another individual receive consequences for behavior, such as reinforcement or punishment, may in turn lead to behavioral change. That is, by observing a behavior and its outcome, the observer may in turn exhibit (if the observed behavior was reinforced) or inhibit (if the observed behavior was punished) new behavior. For example, after observing someone engage in a behavior and then receiving praise, the observer is more likely to engage in the behavior that was just observed.

Techniques There are literally dozens of different kinds of behavioral techniques; however, some have become more typically used in clinical practice, such as functional behavioral assessment, relaxation training, assertiveness training, token economy, time-out and response cost, habit rehearsal, exposure therapy, and behavioral activation. Functional Behavioral Assessment

Functional behavioral assessment is a key component of behavior therapy. Grounded in operant

conditioning principles, functional behavioral assessment allows for an investigation of the factors that increase, decrease, and maintain behavior. Although there are several methods of functional behavioral assessment, most include an assessment of the antecedents and consequences of target behavior. Functional analysis specifically involves the direct manipulation of these variables to investigate their role in a target behavior. Relaxation Training

Relaxation training strategies are used to decrease physiological arousal associated with fear and anxiety, which may be a conditioned response to specific stimuli. As relaxation procedures produce physiological sensations opposite to those experienced during fear and anxiety, they are incompatible with each other, and the client is prevented from experiencing the previously learned conditioned response. Assertiveness Training

Assertiveness training uses operant conditioning to change social behavior. Clients are taught specific skills for interacting with others, and these new social skills are reinforced by desired responses from the social environment. Token Economy

In a token economy, desired target behaviors are reinforced on a specified schedule by a token. The token is later exchanged for a desired reinforcer, such as a toy or computer time. The token itself is not inherently reinforcing but becomes a secondary reinforcer through its association with the desired reinforcer for which it is exchanged. Time-Out and Response Cost

Time-out and response cost are two techniques based on operant conditioning that are used to decrease problem behaviors. In time-out, a technique commonly used with children, an individual is removed from access to positive reinforcement following engagement in a target behavior. Because the behavior is now no longer being reinforced, engagement in the behavior will decrease. Response

Behavior Therapy

cost is a negative punishment procedure that relies on the removal of a reinforcer to decrease the likelihood of engaging in a target behavior. Paying a speeding ticket is an example of response cost: The individual receiving the ticket must pay a fine, which is loss of a reinforcer (i.e., money), as a consequence of speeding. Habit Reversal

Habit reversal procedures may be used for repetitive behaviors that are automatically reinforced and often occur without conscious intent. The main components of habit reversal are awareness training, when the client becomes more aware of the behavior and its triggers, and competing response training, when the client learns to engage in a behavior that is incompatible with the target behavior. Motivation for changing the behavior and social support for doing so are also significant components of the technique. For example, highlighting the importance of completing an exercise regime in light of stated treatment goals and facilitating the role of significant others by having them support incremental success in the client improve outcomes when applying habit reversal. Exposure

Exposure is a procedure that is designed to reduce avoidance behaviors. Most commonly, exposure is used for fear reduction, such as that associated with phobias, panic, and obsessivecompulsive symptoms. A related procedure, but less commonly used in contemporary behavior therapy, is systematic desensitization. This procedure involves first training the client in progressive muscle relaxation. Once this is established, the client is guided in a series of images associated with the feared objects, and when anxiety is experienced, then relaxation is applied. While exposure operates on the principle of extinction, systematic desensitization operates on the basis of a competing response—that is, anxiety and relaxation cannot exist together simultaneously. In both exposure and systematic desensitization, treatment begins with the development of a hierarchy. This hierarchy arranges feared situations or stimuli from least to most anxiety producing. Treatment typically begins with the items on the

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hierarchy that the client determines would be most easily approached as part of therapy. Exposure to the stimuli can be either live (also called in vivo) or in imagery. For example, in treatment for fear of spiders, in vivo exposure involves coming in closer and closer contact with actual spiders, whereas in imagery, the therapist develops scenes that involve spiders for the client to imagine. In many instances, during in vivo exposure, the therapist will engage in additional imagery with the client. This process of pairing in vivo exposure with imagery is considered a means for increasing the effectiveness of the intervention. Behavioral Activation

Behavioral activation is a specific type of behavioral therapy that may be used alone or in conjunction with other techniques. Originally developed to treat depression, behavioral activation relies on operant conditioning to modify behavior and increase available reinforcers. Using specific guidelines, pleasure and mastery activities are scheduled with the client. These activities are carefully selected to be appropriately challenging yet achievable and to provide external reinforcement (e.g., social) and/or intrinsic reinforcement (e.g., pleasure, achievement). Per operant conditioning, engaging in activities that will lead to an appetitive reinforcer will increase the likelihood that the activity will be engaged in again, leading to more positive reinforcement. Behavioral activation was formerly referred to as pleasant events scheduling. This term was discarded when it was found that despite the fact that clients were practicing activities that would eventually be beneficial in their lives, many clients did not find the activities pleasant (e.g., due to diminished enjoyment during depression).

Therapeutic Process Behavior therapy focuses on changing behaviors by understanding and modifying the antecedents and consequences maintaining the behavior. Reduction in clinical symptoms is attained through behavior change. Behavior therapy focuses on behavior in the present, although it is acknowledged that a wide range of factors that cannot be objectively verified likely contributed to the development and

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maintenance of the target behaviors. Behavior therapy is typically short-term, and for most psychological conditions, treatment lasts for between 16 and 20 sessions. Specific sessions are typically driven by an agenda, defined in collaboration between the therapist and the client. For example, in ongoing therapy, the session starts with the client reporting on progress made in the past week, the therapist inquires about areas that are still problematic but for which goals may be set for the session to accomplish, and then specific betweensession activities are developed to foster further progress toward the overall goals of therapy. Modern behavior therapy is part of a larger movement referred to as empirically supported practice. In this broad approach to therapy, scientifically derived methods are applied to presenting psychological problems. Therapy then is considered a fully collaborative experience between therapist and client, and goals for treatment outcome may be adjusted in the course of treatment. That is, as some goals are met, clients come to understand that other unrecognized problems can also be addressed, and new goals are therefore formulated. Dean McKay and Margaret Andover See also Applied Behavior Analysis; Behavioral Activation; Biofeedback; Classical Conditioning; Cognitive-Behavioral Therapy; Exposure Therapy; Operant Conditioning; Pavlov, Ivan; Prolonged Exposure Therapy; Skinner, B. F.; Social Cognitive Theory; Systematic Desensitization

Further Readings Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety: Principles and practice. New York, NY: Guilford Press. Alberti, R., & Alberti, M. (2008). Your perfect right (9th ed.). New York, NY: Impact. Barlow, D. H., & Hersen, M. (1984). Single case experimental designs. New York, NY: Pergamon. Goldfried, M. R., & Davison, G. C. (1994). Clinical behavior therapy. New York, NY: Wiley. Kazdin, A. E. (1978). History of behavior modification. Baltimore, MD: University Park Press. Martell, C. R., Dmidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. New York, NY: Guilford Press.

O’Donohue, W., & Krasner, L. (1995). Theories of behavior therapy. Washington, DC: American Psychological Association Press. O’Donohue, W., & Lilienfeld, S. O. (2013). Case studies in clinical psychological science. New York, NY: Oxford University Press. Richard, D. C. S., & Lauterbach, D. L. (2007). Handbook of exposure therapies. Amsterdam, Netherlands: Academic Press.

BEHAVIORAL ACTIVATION Behavioral activation is a treatment for depression that evolved out of behavioral approaches in the 1970s and 1980s and from a component analysis of cognitive therapy performed by Neil Jacobson and colleagues in the 1990s. Behavioral theory posits that people get depressed because their lives have become less rewarding due to a loss or an increase in stress. While it is normal to experience sadness with such events, depression can occur when people respond to negative events by withdrawing or disengaging from life in some way. This type of withdrawal (e.g., interacting with friends less or avoiding issues that should be confronted) can maintain and sometimes exacerbate depression. A downward spiral then occurs whereby one withdraws when life is punishing, the rewards of engaging in positive activities are not reaped, and continued depression and withdrawal result. Behavioral activation seeks to resolve this vicious cycle by using a specific technique called guided activation, which helps people solve problems and reengage with the rewarding aspects of life.

Historical Context The roots of behavioral activation stem from the work of Charles Ferster, Peter Lewinsohn, and Aaron Beck, the founder of cognitive therapy. Behavioral activation evolved out of Lewinsohn’s pleasant events schedule, which is a self-report inventory of commonly rewarding events. As a stand-alone therapy, behavioral activation came into being when Jacobson and colleagues performed a component analysis of cognitive therapy to see how the behavioral activation component of cognitive therapy would stand relative to full

Behavioral Activation

cognitive therapy. After the behavioral activation component was found to be comparable with cognitive therapy, a more fully articulated version that included the ideas of the early behavioral pioneers was used for a full-scale randomized controlled trial launched in the late 1990s.This version was then compared with cognitive therapy and with antidepressant medication to determine the robustness of behavioral activation relative to gold standards. Behavioral activation performed as well or better than cognitive therapy or antidepressant medication, even for severe depression. Today, behavioral activation has broad empirical support with diverse populations and through a variety of delivery methods such as teletherapy, videoconferencing, and computerized applications.

Theoretical Underpinnings The antecedents of behavioral activation can be traced to the 1970s, when Ferster, a behaviorist, posited that depression occurs when a person increasingly disengages from his or her environment because it has become less rewarding or more negative in some way. For example, say a person calls a friend in the hope that this will be enjoyable. If the friend is unavailable, doesn’t return the call, or gives some indication of a lack of desire to interact, then the behavior of calling this friend goes unrewarded. The caller may withdraw to some degree, thereby decreasing the likelihood of positive interaction. Another theorist with a major contribution to the development of behavioral activation is Lewinsohn. Similar to Ferster, Lewinsohn wrote that a rewarding life depends on the number of reinforcing life events, how much reinforcement is available, and how much is required of the individual to obtain reinforcement. Lewinsohn developed the pleasant events schedule, in which individuals choose from a list of potentially enjoyable activities and then schedule them into their week to diminish depression. Lewinsohn’s approach remained the predominant behavioral treatment for depression during the 1980s and into the early 1990s. Beck utilized a behavioral component in his development of cognitive therapy by asking depressed individuals to engage in “behavioral experiments” and schedule pleasant events in order to challenge depressogenic beliefs. The

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behavioral aspects of Beck’s therapy were borrowed from Lewinsohn and others, but it is Beck’s version of behavioral activation that has developed into today’s stand-alone behavioral treatment for depression known as behavioral activation.

Major Concepts An understanding of behavioral activation requires clear definitions of the following: behavior, contingency, behavioral context, reinforcement, and avoidance. Behavior

In behavioral models starting with B. F. Skinner and radical behaviorism, behavior is defined as both public and private responses, including overt actions and spoken and unspoken thoughts. Behavior can be both discreet events and broader patterns, such as the behavior associated with interpersonal conflict. Contingency

A contingency is the consequence associated with a particular behavior or behavioral pattern. Behavioral Context

Behavioral context refers to the unique relationship between the setting in which a behavior occurs and the consequences that follow that behavior. Understanding context is critical to understanding what change is needed to increase rewards. Reinforcement

Reinforcement occurs when a consequence increases the likelihood that a behavior will recur. For example, while praise is commonly thought of as reinforcing, unless the behavior being praised increases, praise has not reinforced the behavior and therefore is not reinforcing. Avoidance

Behavior that moves one farther away from goals is a primary target for change in behavioral activation and can be viewed as avoidance.

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Behavioral Activation

Avoidance occurs in ways obvious (e.g., staying in bed) and subtle (e.g., distracting oneself from a negative but necessary emotion).

Techniques Some of the more useful techniques in behavioral activation are orienting, activity and mood monitoring, behavioral analysis, activity structuring and scheduling, and assignment and review of homework. Orienting

Orienting is the strategy of describing for the client the concepts and structure of treatment. At the beginning of treatment, the client is oriented to the behavioral activation model and structure. Agenda setting at the beginning of each session is an example of orienting that occurs throughout treatment. Activity and Mood Monitoring

The strategy of activity and mood monitoring is used to understand the links between what the client does and how the client subsequently feels. An activity log is the most common monitoring tool, but other methods may be used to discover behavioral “antidepressants.” Behavioral Analysis

This assessment technique is used to understand activity–mood links or any other contextual responses related to mood.

Therapeutic Process Behavioral activation treatment can be viewed in three stages and can occur within 20 sessions but may require more stages or sessions depending on the existence of comorbid conditions. The initial task is to understand the client’s unique history as it relates to the current depressive episode and his or her responses to life events that may have maintained or exacerbated the depression. Validating the pain of losses and the normal urge to withdraw is very important at this stage and throughout treatment. The behavioral activation model is then discussed in conjunction with the client’s story, and an individual case conceptualization is developed collaboratively. Behaviors to increase (because they may alleviate depression) and behaviors to decrease (because they maintain depression) are generated by therapist and client. The bulk of behavioral activation treatment consists of the client self-monitoring activity and mood relationships to understand how avoidant coping responses keep the client stuck in depression. Problem solving ensues to deal with difficulties that were previously too challenging to confront. Homework (e.g., activity scheduling) is collaboratively developed to bring the client back into contact with reinforcers and life goals. Completion of behavioral activation treatment is near when the client has clarity on what “antidepressant” behaviors will afford him or her a more rewarding life, individualized triggers for relapse have been identified (potential losses or new stressors), and new coping strategies have been developed. Ruth Herman-Dunn and Christopher R. Martell

Activity Structuring and Scheduling

Based on assessment of avoidance and potential rewards, activity structuring and scheduling, the most common form of homework, is used with the goal of increasing contact with potential reinforcers and solving life problems. Assignment and Review of Homework

The behavioral activation therapist checks on assigned homework and assesses what is and isn’t working. New homework is assigned based on the assessment and on articulated treatment goals.

See also Beck, Aaron T.; Behavior Therapies: Overview; Cognitive-Behavioral Therapies: Overview; CognitiveBehavioral Therapy

Further Readings Addis, M. E., & Martell, C. R. (2004). Overcoming depression one step at a time: The new behavioral treatment to getting your life back. Oakland, CA: New Harbinger. Dimidjian, S., Barrera, M., Jr., Martell, C., Muñoz, R. F., & Lewinsohn, P. M. (2011). The origins and current status of behavioral activation treatments for depression.

Behavioral Group Therapy Annual Review of Clinical Psychology, 7, 1–38. doi:10.1146/annurev-clinpsy-032210-104535 Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M., . . . Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658–670. doi:10.1037/0022-006X.74.4.658 Dimidjian, S., Martell, C. R., Herman-Dunn, R., & Hubley, S. (2014). Behavioral activation for depression. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (5th ed., pp. 353–393). New York, NY: Guilford Press. Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. New York, NY: Guilford Press.

BEHAVIORAL GROUP THERAPY Behavioral group therapy was founded on the idea that human behavior is learned. Thus, maladaptive behaviors can be replaced by new, socially appropriate behaviors. Behavioral therapy groups incorporate classical behavioral therapy treatment principles rooted in classical conditioning, operant conditioning, and modeling and apply them in a group setting with the aim of encouraging group members to make positive behavioral changes. Behavioral group therapists focus on teaching, modeling, and applying scientific ways of thinking to group therapy.

Historical Perspective Behavioral therapy emerged during the 1950s and 1960s as an alternative to psychoanalytic treatment approaches. John B. Watson, widely considered the founder of behavioral therapy, emphasized the application of scientific principles to psychology. In a behavioral therapy approach, assessment and evaluation procedures are used to address and monitor behaviors that are targeted for change. Although classical behavioral approaches applied mostly operant and classical conditioning paradigms, during the latter part of the 20th century, modeling and other social learning techniques were

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increasingly integrated into behavioral therapy. In recent years, a focus on how cognitions affect behaviors has been increasingly integrated into traditional behavior therapy approaches. As group therapy became more popular during the 1970s, behavioral therapists began to form behavioral therapy groups, and it was common to find behavioral therapy groups that focused on behavioral issues such as weight loss, assertiveness training, and anger management. Today, it is rare to find behavioral therapy groups that have a strictly behavioral focus, with most being hybrids of cognitive and behavioral therapy (i.e., cognitivebehavioral therapy).

Theoretical Underpinnings Because behavioral therapy is rooted in the behavioral principles of classical conditioning, operant conditioning, and modeling or social learning, behavioral group therapists reject the idea that mental health issues and daily difficulties are the result of disease, drives, or vague constructs such as psychosexual development. Thus, they do not concern themselves with why or how problems develop; they care more about the current factors that influence and maintain the problem. In group settings, therapists do not emphasize a group member’s childhood or past but instead focus on current functioning and how it can be changed. Insight is not a critical aspect of behavioral group therapy. Instead, behavioral group therapists believe that with behavior change, people will begin to feel better, which ultimately promotes long-term health and continued behavioral successes. Behavioral group therapy is an active, directive approach that emphasizes group members’ learning of new behaviors, targeting specific behaviors for change. It is founded on the idea that if consequences or rewards are punishing or reinforcing—in and out of the group sessions— then maladaptive behaviors will shift, ultimately correcting the clients’ presenting issues. Relatedly, behavioral group therapies are based on the following assumptions: (a) each group member has an identifiable problem that is related to behavior, (b) there is always an opportunity for new behaviors to be learned, and (c) behavioral changes can

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Behavioral Group Therapy

be assessed, measured, and massaged so that group members can achieve their goals. Groups provide a unique setting for group members to model and imitate their peers’ adaptive behaviors and practice new skills. Today, behavioral group therapies are commonly accepted as effective treatments for a wide range of behavioral health needs, including disruptive child and adolescent behavior, intimate partner abuse, irrational fears and phobias, depressive and anxiety disorders, obsessive-compulsive behaviors, as well as medical issues such as obesity, chronic pain, epilepsy, and cardiovascular disease. Behavioral group therapy can also help group members develop skills that can be modeled by others, be practiced in and out of the group setting, and enhance group members’ ability to fully function. Examples include assertiveness training groups, relationship enhancement skill groups, and social skills groups.

Behavioral group therapy involves the use of dozens of techniques. The following subsections highlight just a few of the more common techniques used in behavioral group therapy.

and extinction are three of the concepts typically associated with operant conditioning. Reinforcements are used to increase the likelihood that a behavior will reoccur, while punishments are used to decrease the occurrence of a behavior. Negative reinforcement involves strengthening a behavior by removing an aversive stimulus (e.g., a child can get up from the dinner table [aversive stimulus] after she eats three bites of her vegetables [behavior]). Positive reinforcement involves adding a stimulus to make it more likely that a behavior will occur (e.g., reinforcing another group member’s behaviors by having each group member tell the individual group member what a good job he or she did). Punishment can be either negative or positive, depending on the nature of the consequence. Positive punishment involves adding an aversive stimulus (e.g., physical punishment, a scolding) after a behavior occurs to decrease the likelihood that the behavior will occur again in the future. For example, if a child exhibits disruptive behavior in the group, a counselor expressing disapproval of the behavior would be a form of positive punishment. Negative punishment involves removing a desirable stimulus following a behavior to reduce the likelihood that the behavior will occur again in the future. Because punishment can lead to feelings of anger in the person being punished, it should be doled out carefully and judiciously. Extinction is the process of extinguishing a behavior by no longer reinforcing it. For example, group members ignore attention-seeking disruptive behaviors by a fellow group member until the disruptive behavior eventually ceases. Clients in group therapy can be taught these concepts, which they can then apply to their experiences in and outside the group to effect the desired change. For instance, a client who wants to lose weight can be positively reinforced by other members of the therapy group when he or she loses a few pounds; outside the group, the client can develop methods of positively reinforcing healthy eating behaviors.

Operant Conditioning Techniques

Social Skills Training

The techniques involved in operant conditioning are designed to generate consequences in response to behavior. Reinforcement, punishment,

The central aim of social skills training is to facilitate and improve an individual’s ability to communicate and interact with others. Behaviorists

Major Concepts Behavioral group therapy hinges on concepts related to classical conditioning, operant conditioning, and social learning theory. Classical conditioning involves forming an association between stimuli that have an identified relationship to modify behavior. Operant conditioning focuses on increasing or decreasing the frequency of a particular behavior through reinforcement and punishment. Social learning theory relates to the idea that people learn in a social context and through imitation and observation. Techniques used in behavioral group therapies are derived from these behavioral approaches.

Techniques

Behavioral Group Therapy

contend that because social skills are learned behaviors, they can be improved on through operant conditioning and modeling techniques (e.g., role-playing). It is believed that if group members correct their maladaptive behaviors in practice situations, they will then be able to apply the new skills in real-world settings. In group settings, therapists may assign group members to role-play in different situations. To help group members learn new ways of behaving, they may also invite group members to demonstrate what they would say or how they would respond in various situations. Relaxation Training

Many clients enter therapy with stressor difficulties in managing life demands. Relaxation techniques are often taught to group members as a form of stress management or as a way to help them manage fear and anxiety. Relaxation training is founded on the idea that an individual cannot be anxious and relaxed at the same time. Relaxation training (e.g., the gradual tensing and then relaxing of major muscle groups, enhanced breathing skills) can help clients learn to become relaxed both generally and during times when it is needed. Relaxation training can be done as a stand-alone intervention or in conjunction with, or as a foundation for, other interventions such as anger management or systematic desensitization. Systematic Desensitization

Systematic desensitization is grounded in classical conditioning principles and is used in groups to decrease fears, traumas, anxieties, and phobias. When using systematic desensitization, group members are first taught relaxation exercises and coping strategies. Next, group members identify a hierarchy of situations from least to most fearful. Group members are then prompted to imagine anxiety-producing situations, beginning with the least fearful one in the hierarchy, then moving up to the most fearful, all the while applying the learned relaxation exercises. The goal of the systematic desensitization process is for group members to use relaxation and coping strategies to gradually extinguish anxietyproducing fears. Such treatment traditionally

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begins with visualization procedures, practiced in the group setting, and then gradually progresses to real-life situations. Self-Management Programs

Self-management programs involve group therapists sharing their knowledge of behavior therapy principles with group members with the aim of helping group members develop their ability to live in a focused, self-directed fashion, independent of therapy. These programs typically focus on teaching group members the following: how to select realistic goals, how to translate goals into target behaviors, how to make a plan for change, and how to self-monitor and evaluate their actions.

Therapeutic Process Before a client enters behavioral group therapy, the group therapist assesses the client to determine which target behaviors the client wants to change and evaluates the client’s physiological, cognitive, behavioral, and affective responses to the triggering stimuli and the consequences of those responses. The therapist considers the factors that may contribute to maladaptive behaviors and the techniques that may be most effective in addressing the client’s needs. Based on these evaluations, the client, in collaboration with the group therapist and group members, identifies behavior change goals. In addition, the group as a whole may develop a separate set of observable therapeutic aims. These goals and the accompanying behavior changes become the focus of the group process. Because groups provide a unique opportunity for clients to interact with others and practice new behaviors in a safe, controlled environment, therapists encourage clients to practice skills in the group setting. Clients may be asked to role-play within the group, with the intention being to eventually transfer these skills to the real-world setting. Group therapists may also assign homework so that members can practice the newly learned skills and behaviors outside the group. Between sessions, clients track and monitor their behaviors and apply newly learned skills and behaviors. To do so effectively, it is important that group members are motivated to change and are committed to group therapy.

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Bibliotherapy

Behavioral group therapy tends to be of shorter duration than more traditional psychodynamic or existential-humanistic approaches. However, it is not unusual for some groups to last a few months or even up to a year. Other groups may last for a short period of time but may periodically meet again to check on progress.

deep emotions, gain insight, develop solutions, and experience vicarious cultural immersion. Bibliotherapy is widely employed among mental health and educational practitioners to augment therapy.

Victoria E. Kress and Jessica S. Henry

Bibliotherapy has deep historical roots. Indeed, in ancient Greece, the inscription over the library door at Thebes reads, “The Healing Place of the Soul.”The etymology of bibliotherapy is Greek, from biblion (“book”) and therapeia (“healing”). During the 19th century, its practice spread to the United States, offering a source of entertainment and knowledge for patients in hospitals. In 1916, Presbyterian minister Samuel Crothers coined the term bibliotherapy to describe the use of literature when counseling those with mental illness. As the practice flourished, bibliotherapy spread to various mental health and medical settings, schools, and public libraries. Bibliotherapy now includes self-help books, the media, and audiovisual materials.

See also Cognitive-Behavioral Group Therapy; Dialectical Behavior Therapy; Rational Emotive Behavior Therapy

Further Readings Bandura, A. (1969). Principles of behavioral modification. New York, NY: Holt, Rinehart, & Winston. Hays, P. A., & Iwamasa, G. W. (Eds.). (2006). Culturally responsive cognitive-behavioral therapy: Assessment, practice, and supervision. Washington, DC: American Psychological Association. Long, S., Hollander, M., & Kazaoka, K. (1988). Six group therapies: Behavior therapy group. New York, NY: Plenum Press. O’Donohue, W. T., & Fisher, J. E. (Eds.). (2009). Cognitive behavior therapy: Applying empirically supported techniques in your practice. Hoboken, NJ: Wiley. Wilson, G. T. (2010). Behavior therapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 235–273). Belmont, CA: Brooks/Cole.

BERG, INSOO KIM See de Shazer, Steve, and Insoo Kim Berg

BIBLIOTHERAPY As books influence the way we think about our world, it makes sense that reading can have a profound impact on a single reader. Bibliotherapy, or reading for therapeutic or educational purposes, is also known as reading therapy, literatherapy, therapeutic reading, and self-help reading. Grounded in psychodynamic theory, bibliotherapy allows readers to experience connection, feel

Historical Context

Theoretical Underpinnings Bibliotherapy is psychodynamically grounded. In  1950, Caroline Shrodes built on this foundation, suggesting that readers move through three phases. First, clients identify with the characters, plots, or information. As a result, readers experience catharsis, or emotional release. Finally, readers develop insight, or understand their unique thoughts, feelings, and behaviors. Subsequent authors have proposed a potential fourth stage, universalization, or the recognition that others have similar issues. Additionally, the reading process mirrors other therapeutic factors of group therapy, including instilling hope and self-understanding. A final proposed stage, projection, allows readers to consider the future and provides a framework for readers to piece together experiences.

Major Concepts Bibliotherapy is considered moderately effective for a variety of issues. Advantages include reasonable cost and access. Authors have asserted various

Bibliotherapy

types of bibliotherapy, including clinical bibliotherapy, for use with clients with significant issues; developmental bibliotherapy, which focuses on well-being; self-help bibliotherapy, which utilizes nonfiction work about various issues; and creative/ imaginative bibliotherapy, which uses fiction, poetry, and creative writing to improve mental wellness. Regardless of type, readers develop a relationship with the book, which allows them to change in some way as a result of reading. Outcomes include increased understanding of self or others, the discovery that others have similar problems, development of solutions, behavioral changes, increased emotional expression, relief from distress, and a better developed self-concept. Bibliotherapy allows readers to work through painful feelings from an emotionally safe place, acts as a therapeutic container for these emotions, and clears a path for clients and counselors to discuss presenting concerns. Bibliotherapy is effective with children, adolescents, and adults in most settings (e.g., educational, medical, and correctional). Therapeutic reading groups are also popular.

Techniques Although the act of reading provides advantages, bibliotherapy advocates emphasize the actual discussion about the reading process. If a book is prescribed in counseling, counselors should monitor readers’ reactions. Counselors who understand clients and the books read can promote client growth and enhance the therapeutic alliance. Bibliotherapy can be used throughout various stages of counseling, including the opening phases, in which counselors and clients establish rapport, as well as later stages when clients may put their insights into action. The process begins with identifying the readers’ concerns and issues. Counselors need to select materials with or for readers, requiring counselors to review the reading materials. Perfect matches may not exist, so counselors look for materials with content similar enough to client issues to foster identification. Maximizing connections between readers and the reading material is key for success. Counselors select materials to meet the readers’ unique developmental needs, interests, reading ability, and relevant experiences. Practical considerations

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include subject, format, length, language, text, illustrations, cultural context, and cost.

Therapeutic Process Once materials are read in or out of session, counselors shift toward the readers’ experience, following up on insights gained from the process. Four steps in this process are (1) recognition, having readers experience a sense of connection to the material; (2) examination, having readers look at issues in the material and feelings evoked through this process; (3) juxtaposition, gaining insight through interactive discussion with counselors regarding the reading process; and (4) self-application, integrating the insights gained from the process. The discussion should focus on situations or characters and how readers make sense of their experience as well as their choices. This creates a safe venue to consider new possibilities. Essentially, readers “walk in the shoes” of another through the reading process. Questions that counselors may ask clients include the following: Are you like any of the characters or people in the book? What is your favorite part? How would you change how the story or situation ended? Readers may be challenged to retell stories or situations, focusing on incidents and their feelings about this information. Readers explore the consequences of actions made by characters and develop alternative solutions for these characters. Overall, readers are encouraged to make comparisons between their lives and the material. Counselors may follow up with creative interventions, such as creative writing, art, or drama-based interventions. Empirical studies have focused on self-help reading material, and subsequently, the impact of fictional, imaginative literature on readers is less understood. Overall, research confirms that the benefits of reading are maximized when thinking and feeling dimensions are intensified through identification with the reading material. While bibliotherapy is a popular adjunct, more research is needed. Laura Bruneau and Dale-Elizabeth Pehrsson See also Art Therapy; Drama Therapy; Poetry Therapy; Writing Therapy

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Further Readings Hynes, A. M., & Hynes-Berry, M. (1986). Bibliotherapy: The interactive process: A handbook. Boulder, CO: Westview Press. Jack, S. J., & Ronan, K. R. (2008). Bibliotherapy: Practice and research. School Psychology International, 29, 161–182. doi:10.1177/0143034308090058 Pardeck, J. T. (1998). Using books in clinical social work practice: A guide to bibliotherapy. New York, NY: Hawthorne Press. Pehrsson, D.-E., & McMillen, P. (2010). A national survey of bibliotherapy preparation and practices for professional counselors. Journal of Creativity in Mental Health, 5, 412–425. doi:10.1080/15401383.20 10.527807

BIODYNAMIC PSYCHOLOGY Biodynamic psychology (BP) recognizes the direct relationship between mind and body. It is based on understanding the movement of life energy in the body (bio means “life,” dynamic means “movement”). BP uses psychological and physical methods including psychotherapy, specialized massage techniques, and bodywork to liberate trapped energy and dislodge trapped fluids in the tissues of the client’s body. This enables natural biological processes to complete psychological and emotional healing and restores homeostasis and organic equilibrium. Biodynamic treatments can be crucial in healing from the effects of trauma howsoever caused and can be helpful as a short-term or ongoing mind–body intervention that promotes health, reduces symptoms, and improves quality of life.

Historical Context BP was established in Europe in the 1950s by the Norwegian clinical psychologist Gerda Boyesen (1922–2005). A clinical psychologist and physiotherapist, Boyesen underwent psychoanalysis and vegetotherapy (a specialized form of bodywork) over several years with Ola Raknes (1887–1975), who trained at the Berlin Psychoanalytic Institute, and with Wilhelm Reich, MD, in Norway. BP is rooted in psychoanalytic and related concepts. During her work in psychiatric hospitals as a clinical psychologist, Boyesen noticed that some

patients had audible peristalsis sounds during talking sessions when they expressed emotion or feeling about a psychological or emotional event. When these sounds happened, patients reported feeling relief and sometimes reported that this physical experience brought insights and helped clear their minds. During her work as a physiotherapist, Boyesen began to notice that these same sounds came in response to physiotherapy treatment. She realized that those patients who had such sounds during a session improved more quickly and thoroughly than those who did not. She hypothesized that there was a hitherto unknown biological mechanism, which she called “vegetative discharge,” whereby the emotional affects and the biochemical effects of disturbance or trauma, could be resolved, dissolved, and then discharged via this mechanism in the body. She adapted a normal medical stethoscope with a long lead (so that she could walk around the treatment table), placed the stethoscope on the lower abdomen of the client, and began to listen more carefully to the peristaltic sounds. She referred to the sounds arising from the vegetative discharge mechanism as “psychoperistalsis” to differentiate between these sounds and the normal peristalsis sounds of digestion. She first developed a range of specialized biodynamic massage methods to find the organic “key” to activate the psycho-peristaltic sounds. This indicated that the “vegetative discharge” function was restored and optimized. She later developed specialized biodynamic psychotherapy and psychodynamic approaches to create the supportive environment to facilitate the activation of this innate healing mechanism in the client. Throughout her life, she developed her concepts and methods, now known as BP, and developed training schools and clinics in Europe and worldwide. Recent research—both longitudinal studies and randomized control trials—has proved the effectiveness of the biodynamic approach for healing from the effects of trauma.

Theoretical Underpinnings In addition to psychoanalytic, humanistic, cognitive, integrative, functional, and esoteric approaches, Reich’s theories are fundamental in BP. They include his understanding of the cosmic laws, especially that energy attracts fluid; the four-beat formula that is

Biodynamic Psychology

related to the stages of the sexual cycle; his concept of orgone energy, which is composed of biological energy and cosmic energy; character formation; contactlessness; understanding libido as a lifeenhancing flow, which includes sexuality but is not confined to it; and the theory of cosmic superimposition. In a healthy person, the bioenergy is naturally aligned to the universal—cosmic—energy as a basis for healthy, mature living and satisfying work and social relationships.

Major Concepts Some major concepts of BP include the biodynamic environment, holding, armoring, tissue armor, survival mechanisms, zone of firing, primary personality, and recuperation and integration. Biodynamic Environment

The biodynamic environment is the conscious creation of a safe and structured, nonjudgmental space that affirms each person, supports honest self-expression, and facilitates self-discovery and reintegration of mind and body. Holding

In an individual or group BP session, the therapeutic space is “held,” which means that the therapeutic setting and relationship are attuned to and ready to support the client in his or her expression of feelings or thoughts. In a bodywork session, the biodynamic psychotherapist can hold and support a muscle or joint to enable energy or fluid trapped in there to be liberated. Armoring

The human organism is capable of repressing painful emotions and conflicts by chronic contraction of the diaphragm and by muscular tension. Armoring keeps the emotional and physical energy encapsulated or stuck. Biodynamic massage and bodywork techniques release armoring and its related encapsulation by unraveling muscular defenses. Tissue Armor

Tissue armor refers to the concentration of metabolic residues in the body, such as lactic acid

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or adrenaline. This fluid encapsulation can be released by gradually undoing the muscular defenses, enabling the body to use its healthy biological mechanisms to complete the emotional and bodily cycles that were interrupted, thereby emptying or releasing the fluids that were stored in the tissues at the time of the original uncompleted cycle, or trauma or shock. Survival Mechanisms

Survival mechanisms refer to the fight-or-flight (mobilization) or freeze (immobilization) mechanisms. When temporary survival mechanisms are interrupted, an individual can either remain alert and hypervigilant, in a chronic state of sympathetic nervous system excitement, or feel paralyzed, lethargic, and depleted. BP helps restore the healthy functioning that is disturbed by these innate survival mechanisms. Zone of Firing

In therapeutic expression, it is important to build up enough energy to create a healthy charge in order to bring the trapped impulse safely through the encapsulation of muscular and psychological defenses to the “zone of firing.” This allows the liberation of formerly trapped energy and the release of formerly trapped fluids for elimination and leads to the downward movement of resolution and relaxation through activation of the parasympathetic system. Primary Personality

Primary personality is the BP concept that speaks to our natural spontaneous self—that is, who we are rather than who we have had to become in an effort to protect ourselves for any reason. The nonspontaneous, defensive self is known as the “secondary personality.” Recuperation and Integration

Following the expression of emotions, or following any kind of working through on the physical, mental, or emotional level, time is given for the establishment and operation of the vegetative discharge function, which ensures recuperation, integration, normalization, and return to homoeostasis.

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Techniques Within the field of BP, the following biodynamic techniques, which can be applied in individual sessions or used in groups, have been developed: biodynamic psychotherapy, biodynamic massage, deep draining, and vegetotherapy. Biodynamic Psychotherapy

Biodynamic psychotherapy is a noncritical and nonjudgmental approach. The client is invited to bring all symptoms, hopes, dreams, resistances, avoidances, memories, and feelings to the sessions and to talk things through in an atmosphere of welcome and safety. Biodynamic Massage

Biodynamic massage is the name given to the range of specialized massage methods used in the treatment and relief of many physical, nervous, and psychological conditions. Deep Draining

Deep draining, otherwise known as psychopostural treatment, is a systematic and structured massage treatment aimed at loosening tension on the skeletal and respiratory muscles or in specific segments of the body. The aim of the treatment is to dissolve muscle armor and release the encapsulation of energy, thus making the client’s emotional energy available first as sensations and later as feelings that can then be worked with using BP methods. Vegetotherapy

Vegetotherapy involves specialized bodywork techniques and breathwork to liberate the vegetative or autonomic nervous system response as an  aid to restoring homoeostasis and health. Vegetotherapy works with impulses from within and with the seven segments of the body: pelvis, abdomen, diaphragm, chest, throat, jaw, and ocular.

Therapeutic Process BP typically lasts between 3 and 12 months of weekly or fortnightly sessions and can be longer term if needed. Each client completes an in-depth

Client Information Record, which includes a detailed medical history and lifestyle and background information. There is an initial consultation between the client and the therapist to discuss and mutually agree on workable outcomes and to establish clear terms for working together. The therapeutic process commences with the establishment of the vegetative discharge capacity and progresses on through stages of restoring selfregulation, honest self-expression, building resilience, and transforming anger, depression, stress, or anxiety into a capacity for positive living and relationships. As the therapy progresses and life energy is liberated, the needs and goals of therapy can change. Time, appreciation, respect, and attention are given to understanding these transformational shifts and ensuring that all aspects are integrated. Mary Molloy See also Body-Oriented Therapies: Overview; Characteranalytical Vegetotherapy; Integrative Body Psychotherapy; Neurological and Psychophysiological Therapies: Overview; Orgonomy; Reich, Wilhelm

Further Readings Boyesen, G., & Boyesen, M. L. (1974). Psycho-peristalsis: The abdominal discharge of nervous tension. Energy & Character: The Journal of Biosynthesis, 5(1), 5–16. Nunneley, P. (2000). The biodynamic philosophy and treatment of psychosomatic conditions (Vols. 1–2). Bern, Switzerland: Peter Lang. Saint-Arnault, D. M., Molloy, M., & O’Halloran, S. (2012). The use of psychodrama in biodynamic psychotherapy: Case examples from a domestic violence healing workshop. International Journal of Family Studies, XVII, 111–118. Saint-Arnault, D. M., Molloy, M., O’Halloran, S., & Bell, G. (2013). “You made your bed, now you can lie in it”: The biodynamic understanding of healing the social mechanisms keeping women in abusive relationships. In C.Arcidiacono, I. Testoni, & A. Groterath (Eds.), Daphne and the centaurs: Overcoming gender based violence (pp. 93–103). Leverkusen, Germany: Budrich. Southwell, C. (1988). The Gerda Boyesen method: Biodynamic therapy. In J. Rowan & W. Dryden (Eds.), Innovative therapy in Britain (pp. 179–201). London, England: Open University Press.

Bioenergetic Analysis

BIOENERGETIC ANALYSIS Bioenergetic analysis is a psychodynamic psychotherapy that works with somatic (body), psychic, emotional, and interpersonal phenomena as part of a unitary whole. A therapist in this approach practices psychotherapy with a theory base and a repertoire of techniques that permit interventions to be made in each dimension—body, mind, and relationship. These interventions are made with a sophisticated understanding of body organization (including anatomy, physiology, and morphology) and of psychological processes (the formation of personality, emotion, and cognition), and the application of modern theories of self and relationship formation.

Historical Context The modern form of bioenergetic analysis developed out of the elaborations of psychoanalytic theory proposed by Wilhelm Reich, a student of Sigmund Freud. Reich, who emigrated to the United States in 1939, investigated the complex relationship between personality organization and somatic organization. This study led one of his students in New York, Alexander Lowen, to modernize Reich’s ideas into a comprehensive method for correlating various developmental thrusts— separation and individuation dynamics, the emergence of self-structures, relationship patterns, and the development of self- and other representations, among others—with patterns of somatic organization. Examples of these somatic patterns include muscular tension systems, for example, chronic contractions or flaccidity of the musculature and habitual body postures that correspond to psychological positions, attitudes, interactional styles, and cognitive patterns. Together these organizations cohere into a character structure that while uniquely individual shows the effects of the dynamics present in each of these dimensions. Reich took ideas inherent in psychoanalysis as propounded by Freud, such as self-determination and consciousness of self as an instrumental and responsible being, and added to them the insight that when people are in possession of their sexual selves, they have a tool for self-awareness and for self-expression that is inalienable, cannot be taken

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away by authorities, and is external to the self or even those internalized as part of the self. This is a view of psychotherapy as a revolutionary activity. It views psychotherapy as a method of self-definition, of raising consciousness, and, where necessary, of liberation from oppressive external and internal forces. Pleasure is seen, in modern bioenergetic analysis, as the capacity for connection with the benevolence in the universe. When people have a visceral, developed, and experienced sense of that connection, it is hard to dominate their consciousness and tell them what reality is, what things mean, and whether their personal experience is valid. Bioenergetic analysis, originally developed in the United States, is now practiced in many countries around the world. Most practitioners belong to local, geographically based societies and to the International Institute for Bioenergetic Analysis.

Major Concepts Modern bioenergetic analysis is a developmental theory of the embodied self. People are seen as having a thrust to maturation that has physical, psychic, emotional, cognitive, interpersonal, and social dimensions. When the thrust to grow and develop along any of these dimensions is disrupted or impinged on in ways that an individual cannot manage successfully, the person develops psychological and somatic defensive operations to protect the self from further harm. Included in that protective defensive system are mechanisms to constrain self-expression, so that one does not express feelings or reactions that will result in continued reactions from others that cause the harm being inflicted. The impingement on development, or the harm being inflicted, can vary in strength and severity from the inevitable vicissitudes of everyday life, which all of us have to encounter and develop effective methods to manage, to massive soul-, mind-, and body-destroying abuses. In the theory of modern bioenergetic analysis, a person’s system of defenses is organized as a holistic interlocking system that is referred to as character organization. This defense system not only protects against the assault from other people in the environment but also conceals from others and from oneself the emotional and psychological reactions to the assault. Character

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structure is a durable, ongoing personality organization in which these defenses are habitual and reflexive and, to a large degree, at least before psychotherapeutic intervention, arise out of awareness. The structures that make up character organization exist on somatic, psychological, and cognitive dimensions. For example, someone who has been profoundly and chronically terrified early in life and has withdrawn into a frozen selfprotective space will show a body that is deeply contracted, with very limited capacity for expansion—in breathing, in mood, and in contact with others. That person will also have difficulty being flexible—physically, psychically, and interpersonally—and when encountering strong emotional or interpersonal stimulation, will be inclined to withdraw or feel overwhelmed. It is a principle of bioenergetic analysis that human beings, being as adaptable and inherently flexible as we are, can grow around an underlying character organization. And so a bioenergetic therapist must learn to look at underlying structures and patterns beneath surface appearances. This includes an experiential and theoretical understanding of body processes such as breathing, vitality, flexibility, expansion and contraction, musculoskeletal and neuromuscular functioning and their relationship to energetic processes, and psychological and emotional functioning. The patterns of a person’s character organization may become apparent in the therapy process, enabling both patient and therapist to observe them in action and begin to soften the habitual reactions and defensive maneuvers on a physical, psychological, and interpersonal level. Because each person’s personality and character organization is unique and individual, the work of therapy can never be done exactly the same way across patients. It is the art of the therapist to respond to the unique and specific realities presented by the individual patient.

Techniques One of the central principles of modern bioenergetic analysis is that the underlying content of any organized pattern in each of these dimensions can be accessed through the recruitment of intense emotional experience. Intense, here, is a relative term referring to the strength of subjective experience

within the range of tolerance and usefulness for the individual. Strongly experienced and expressed emotion is not seen as a primitive event or as a cathartic discharge of built-up charge or energy. Rather, the experience and expression of strongly felt emotion in a grounded, contained, and relational manner is understood to be a method for accessing and developing a tolerance for deep emotional life. It is a tenet of the belief system in modern bioenergetic analysis that the experience and expression of powerful and meaningful emotion is a means of knowing reality, and living one’s personal reality, and that the expression of deeply and strongly felt emotion is a skill that with practice and refinement becomes a sophisticated tool for communication with oneself and with others. The techniques in bioenergetic analysis support this view of emotion and self-representation. Much of what goes on in bioenergetic therapy, allowing for the stylistic differences between therapists, looks like what transpires in any psychodynamic psychotherapy. Bioenergetic therapists strive to create a therapeutic alliance with a patient that will act as a supportive medium for the establishment of an attachment that will withstand the arousal and expression of painful and difficult feelings. Both the patient and the therapist participate in the construction of the relationship that will carry the therapeutic process forward. Bioenergetic therapists use techniques derived from an eclectic selection of theoretical systems to make interventions that support people in becoming more self-determining, more autonomous, more open and available for contact, more alive, and more skilled at following their own process to meaning and pleasure. In addition to those therapeutic technical skills, bioenergetic therapists are constantly attentive to corresponding physical processes that can be addressed in a technical way to advance the therapeutic project the individual patient brings. These technical perspectives allow for the use of breathing patterns; positions that strain muscular holding patterns beyond their usual capacity to hold rigidity; contact, including touch, that can act to bring awareness to a part of the body, to support, to open holding patterns, or to help build boundaries; and expressive movement, by the patient alone or along with the therapist or members of a therapy group. The philosophy of

Biofeedback

technique in bioenergetic analysis allows and supports creative, attuned, empathically derived interventions.

Therapeutic Process Bioenergetic therapists maintain an ongoing interest in and discussion of developments in theory and research. This includes new ways of understanding the development of personality and self, as well as self in relationship; the contribution of neurosciences in illuminating the degree to which human beings are evolutionarily adapted for attachment and empathic attunement to each other; and the investigation of the nature and healing properties of the therapeutic relationship. Recently, psychological and emotional trauma has swung back into the foreground of study and discourse about the causal elements in human suffering. Such study has highlighted the importance of understanding the ways in which trauma has an enduring effect on basic body processes. Although newly in focus, trauma plays a central role in the theories that first gave rise to the bioenergetic approach as conceived by Lowen and as derived from the work of Reich and Freud. Bioenergetic therapists approach the therapeutic relationship from a number of perspectives. Generally agreed on is the concept that the therapeutic process is a laboratory for the exploration of the forming, deforming, and injurious effects of relationships. The patterns of relationship to self and others that emerge from early formative experiences are repeated in the therapeutic relationship and can be examined and modified in a relationship that does not require the usual constraints and inhibitions of conventional social relationships. Many bioenergetic therapists subscribe to the ideas derived from feminist theory that relationships can be egalitarian and cocreated. That is, the therapist and the patient together create a unique and specific relationship, an intersubjective one, between two subjects, with the aim of creating a living space in which the patient can be real, authentic, and self-expressive to the extent and as fully as she or he wishes and is able. Bioenergetic therapists bring to this vision of relationship a set of interventional skills that allow for a wide range of physical and emotional expression and a tolerance for strongly felt and strongly expressed emotion. This

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treatment philosophy is coupled with a strong conviction about the healing properties of relationships and a strong belief in the calling in each of us to seek meaning in life and connect with and experience pleasure through relationships with one another and the environment in all its dimensions. Scott Baum See also Integrative Body Psychotherapy; Orgonomy Psychodrama; Sensorimotor Psychotherapy; Therapeutic Touch

Further Readings Baum, S., Guze, V., Hall, D., Madden, A., Panvini, R., Rhoads, E., . . . Tuccillo, E. (2011). Modern bioenergetics: An integrative approach to psychotherapy. New York, NY: New York Society for Bioenergetic Analysis. Cockburn, G. (2013). “Seeing what is so simply present”: Learning to be a bioenergetic therapist. Bioenergetic Analysis, 23, 75–100. Helfaer, P. (2011). Foundations of bioenergetic analysis. In V. Heinrich-Clauer (Ed.), Handbook of bioenergetic analysis (pp. 21–34). Giessen, Germany: PsychosocialVerlag. Johnson, S. (1994). Character styles. New York, NY: W.W. Norton. Keleman, S. (1985). Emotional anatomy. Berkeley, CA: Center Press. Lowen, A. (1975). Bioenergetics. New York, NY: Coward, McCann, and Geoghegan. Tuccillo, E. (2013). Somatopsychic unconscious processes and their involvement in chronic relational trauma. Bioenergetic Analysis, 23, 17–62.

BIOFEEDBACK Biofeedback is a psychophysiological selfregulation therapeutic training approach used to help involuntary biological functions become more voluntary. Electronic instruments with small sensors pick up signals associated with functions in the body such as heart rate, respiration, blood pressure, electrodermal activity, electrical activity of the muscles, peripheral skin temperature, and so on. Feedback from the sensor is presented to the individual in a visual, auditory, or other sensory manner. Once feedback is received, the client is

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then guided or coached through ways to modify and control internal functions. This information can then be used to help the client know what necessary adjustments need to be made to improve overall health and functioning. Ideally, the body becomes its own feedback device, so individuals start feeling subtle changes within their bodies and make adjustments on their own without needing instrumentation or a biofeedback therapist to guide them. Biofeedback has been used to help decrease symptoms associated with stress, generalized anxiety, panic attacks, test anxiety, difficulty relaxing, disrupted sleep, attention deficit disorders, depression, pelvic muscle dysfunction and incontinence issues, headaches, temporomandibular joint dysfunction, phantom limb pain, and chronic pain—although this is not a complete list. Biofeedback has also been used to  treat physical rehabilitation conditions such as repetitive motion injuries, strokes, speech disorders, incontinence, and epilepsy. In addition, biofeedback has been used to improve peak performance by musicians, astronauts, and athletes.

Historical Context Psychophysiological training was evident in the early 1900s through the training approaches of Edward Jacobsen’s progressive muscle relaxation and Johannes Schultz’s autogenic training. Although these approaches did not use formal biofeedback equipment as part of their training, they involved instructional aspects that helped increase awareness and calm the mind as well as the body. These approaches are still employed today. In the 1960s, clinical biofeedback using electronic instrumentation came to the forefront, and by the late 1960s, the first biofeedback professional association was established (then called the Biofeedback Research Society and  now called the Association for Applied Psychophysiology and Biofeedback). Since then, interest in particular areas of biofeedback has grown, such as surface electromyography (sEMG), heart rate variability, neurofeedback, and incontinence. The Biofeedback Certification Institute of America (now called Biofeedback Certification International Alliance) is the credentialing association that has set forth professional standards for clinicians and offers certifications in the areas of biofeedback, neurofeedback, and pelvic muscle dysfunction.

Theoretical Underpinnings Commonly accepted premises in biofeedback include the following: • The mind and body are connected. • Our minds and bodies function better when health is addressed from a holistic perspective. • Increased awareness helps us better understand internal psychophysiological functions. • Feedback received from the body using instrumentation and/or sensors gives feedback on particular biological functions. • Using feedback and increased awareness, individuals can learn to adjust and/or control both the mind and the body; this in turn can help improve wellness and functioning. • Depending on the training needs of the individual receiving biofeedback, biofeedback therapists serve in various roles as coach, trainer, mentor, or counselor. • Over time, there is no longer a need for a biofeedback therapist or the use of instrumentation because individuals have increased their awareness enough that their bodies become their own feedback device.

Major Concepts Major concepts in the field of biofeedback include autonomic nervous system, electrodermal response, heart rate variability, peak performance, mind– body connection, neurofeedback, peripheral skin temperature training, psychophysiology, respiration rate, self-regulation, and sEMG. Autonomic Nervous System

The autonomic nervous system (ANS) controls biological functions that happen on their own (e.g., heart rate, respiration) and consists of the sympathetic and parasympathetic branches. Most autonomic functions are typically seen as involuntary. ANS functioning becomes important to biofeedback in two main ways: 1. Through increased awareness, feedback, and biofeedback training, individuals can have a greater degree of control over the involuntary functions of the body.

Biofeedback

2. The ANS is thought to be associated with the body’s fight-or-flight response. In biofeedback, ANS arousal contributes to increased stress and anxiety. Learning to decrease ANS arousal can improve overall psychophysiological functioning.

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Mind–Body Connection

In biofeedback, there is a strong belief that the mind and body are connected. One influences the other. For those who are spiritually minded, it is expanded to be called the mind–body–spirit connection.

Electrodermal Response

Neurofeedback

Electrodermal response (EDR) refers to the electrical response from eccrine sweat gland activity in the hands. EDR is an indirect measure of stress in that elevated EDR activity is often associated with increased stress levels. Biofeedback devices for EDR provide slightly different kinds of feedback. Some measure skin conductance, some measure skin resistance, and others measure skin potential. A common electrodermal biofeedback device is the galvanic skin response. EDR training is often used to assist with anxiety, stress, and pain management.

Neurofeedback is a specialized branch of biofeedback that focuses on receiving feedback from brainwaves in the body. Various sensors are placed on key points on the head that pick up electroencephalographic waves. The client then learns how to manipulate the feedback to achieve improved psychophysiological functioning. Neurofeedback has been used to treat individuals with attention deficit disorders, anxiety and depression, epilepsy, autism spectrum disorders, insomnia, and stressrelated disorders. It has also been effective in enhancing peak performance.

Heart Rate Variability

Peripheral Skin Temperature Training

The heartbeat is made of PQRST waves. Heart rate variability (HRV) refers to the variations in the heartbeat, specifically variations between the beat-to-beat or peak-to-peak intervals, which are referred to as R-R intervals. HRV measures these fluctuations. During training, individuals receive feedback on their HRV and learn to increase HRV amplitude. HRV feedback has been used for stress management, peak performance training, asthma, anxiety, depression, pain management, cardiopulmonary diseases, and chronic illnesses.

Peripheral skin temperature relates to vasodilation and vasoconstriction in the periphery. A sensor, called a thermistor, is attached to the back of a finger or a toe. This sensor measures peripheral skin temperature, which is seen as an indirect measure of stress. Using biofeedback readings from the thermistor coupled with autogenic training, visual imagery, or other approaches, individuals can train themselves to increase or decrease their peripheral skin temperature at will. Peripheral skin temperature training is often used in biofeedback-assisted relaxation training, pain management (particularly for the treatment of various types of headaches), hypertension, and Raynaud’s disease.

Peak Performance

Peak performance pertains to functioning at an optimal best. Biofeedback training for peak performance has been used to decrease performance anxiety and increase one’s ability to perform at one’s best. Biofeedback training typically focuses on enhancing mental alertness, emotional stability, and relaxation skills and improving confidence, endurance, and physical health. Peak performance training has been used to assist athletes, musicians and other performance artists, students, and public speakers/presenters.

Psychophysiology

Psychophysiology refers to a field of study as well as the interconnections and relationship between the mind and body. Respiration Rate

Respiration rate refers to the number of breaths per minute. In general, high respiration rates have been correlated with increased stress levels and

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anxiety. Respiration training is often called breathwork training. A pneumograph (a respiratory strain gauge) is placed around an individual’s chest or belly and gives feedback on respiration rate. Individuals are trained in abdominal breathing or belly breathing. Respiration rate biofeedback training has been used for stress, anxiety, panic attacks, test anxiety, depression, pain management, chronic illness, hypertension, asthma, cardiopulmonary diseases, and peak performance training. Self-Regulation

Self-regulation in biofeedback refers to one’s ability to regulate or manage psychophysiological responses in the mind and body. Slowly, individuals integrate the skills learned into everyday life. As they do so, they are able to decrease, manage, or alleviate symptoms without the need for a biofeedback therapist or biofeedback equipment; their body becomes their own feedback device.

Techniques Techniques used in biofeedback vary depending on treatment needs. Many of the techniques are related to equipment and feedback received. Some biofeedback equipment has games to assist with training. Many of the equipment-related techniques have been described above; additional techniques such as psychoeducation, deep breathing, progressive muscle relaxation, imagery, and autogenic training are discussed in this section. Biofeedback therapists tend to use some, but not all, of the techniques noted in this entry. Psychoeducation

Psychoeducation is a process of educating clients about the biofeedback concepts, mind–body awareness, training approaches, and specific skills. Deep Breathing

Surface Electromyography

In sEMG biofeedback training, sensors, called electrodes, are placed over the belly of a muscle (or a group of muscles) and pick up the electrical activity of the muscle. The electrical activity is typically recorded in a raw data or graph format. These data (i.e., feedback) can then be used to help with training purposes and treatment goals. sEMG is commonly used in biofeedback-assisted relaxation training as well as for pain management and musculoskeletal and neuromuscular rehabilitation training. In biofeedback-assisted relaxation training, sEMG sensor placements often include a frontalis, temporalis, upper-trapezius, or wrist-to-wrist placement. The goal is to decrease sEMG electrical activity because elevated sEMG activity is seen as an indirect measure of stress. In biofeedback training used for pain management or rehabilitation, sEMG sensor placements vary. A dynamic assessment is often conducted using multiple groups of muscles with multiple electrode placements at one time. Depending on treatment needs, sEMG biofeedback training goals for pain management or for rehabilitation purposes may include working on increasing electrical activity at times and decreasing it at other times.

Clients learn how to breathe from the diaphragm versus using intercostal and accessory breathing muscles. Progressive Muscle Relaxation

Progressive muscle relaxation is the process of tensing, holding, and relaxing muscles. This is usually done one muscle group at a time. As the muscles relax, they tend to go into a more relaxed state than before they were tensed. Passive progressive muscle relaxation often includes tensing muscles to various intensities. This process can assist with discerning subtle tension levels in the body. Imagery

Imagery is a technique wherein the mind is used to visualize soothing images that aid relaxation and/or enhance peak performance. Autogenic Training

Autogenic training is a sequential self-hypnosis process where relaxing phrases are repeated to oneself.

Biopsychosocial Model

Therapeutic Process Biofeedback training sessions are typically 45 minutes to 1 hour in length. The number of biofeedback sessions recommended depends on treatment needs. Standard biofeedback training (such as biofeedback-assisted relaxation training) consists of 6 to 12 sessions, although some individuals see benefits after only 2 or 3 sessions. Neurofeedback, a specific biofeedback approach, is a longer process and can take 40 or 50 sessions. The initial intake biofeedback session includes gathering background information, providing psychoeducation on biofeedback, giving a biofeedback demonstration, establishing baseline levels, and creating treatment goals. If biofeedback-assisted relaxation training is a goal, then a stress test and a relaxation demonstration are also conducted. If the individual comes in for pain management or rehabilitation, sEMG readings will often be measured through a dynamic assessment from more than one muscle grouping. Symmetry may also be assessed. Homework is an essential part of the biofeedback training process and aids in increasing awareness, helping clients to begin using the body as its own feedback device, providing symptom relief, and integrating skills into everyday life. Although specific goals for a client are based on treatment needs, common overall goals include the following: • Increasing awareness of the mind–body connection • Using biofeedback equipment and training to increase the client’s ability to make involuntary functions more voluntary • Improving, managing, or eliminating problematic symptoms and suggesting specific steps to reach those goals • Creating a specific treatment plan with goals to reevaluate treatment needs after several sessions, work toward tapering treatment, maintain the skills learned, and decrease (or eliminate) symptomology, leading to eventual self-regulation.

Kristin I. Douglas See also Autogenic Training; Behavior Modification; Cognitive-Behavioral Therapy; Heart Rate Variability; Neurofeedback

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Further Readings Benson, H. (1975). The relaxation response. New York, NY: HarperCollins. Chandler, C., Bodenhamer-Davis, E., Holden, J. M., Evenson, T., & Bratoon, S. (2001). Enhancing personal wellness in counselor trainees using biofeedback: An exploratory study. Applied Psychophysiology and Biofeedback, 26(1), 1–7. doi:10.1023/A:1009548719340 Green, E. (1969). Feedback technique for deep relaxation. Psychophysiology, 6(3), 371–377. doi:10.1111/j.1469-8986.1969.tb02915.x Kasman, G. S., Cram, J. R., & Wolf, S. L. (1998). Clinical applications in surface electromyography: Chronic musculoskeletal pain. Gaitherburg, MD: Aspen. Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology and Biofeedback, 25(3), 177–191. Lehrer, P. M., Woolfolk, R. L., & Sime, W. E. (Eds.). (2007). Principles and practice of stress management (3rd ed.). New York, NY: Guilford Press. Moss, D., McGrady, A., Davies, T. C., & Wickramasekera, I. (2003). Handbook of mind-body medicine for primary care. Thousand Oaks, CA: Sage. Peper, E., Tylova, H., Gibney, K. H., Harvey, R. A., & Combatalade, D. (2009). Biofeedback mastery: An experiential teaching and self-training manual. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback. Schwartz, M. S., & Andrasik, F. (Eds.). (2005). Biofeedback: A practitioner’s guide (3rd ed.). New York, NY: Guilford Press. Thompson, M., & Thompson, L. (2003). The biofeedback book: An introduction to basic concepts in applied psychophysiology. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

BIOPSYCHOSOCIAL MODEL The biopsychosocial model takes a general systems approach to understanding disease, coping, and treatment. The model, introduced by the psychiatrist George Engel in the late 1970s, expanded the dominant paradigm of the medical field beyond an exclusive focus on biological components to include the effects of psychological and social

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influences on a patient’s experience. The model thus broadens the scope for health providers to acknowledge the interplay of dynamics that may affect the expression of disease, coping methods, adherence to treatment, and recovery. These factors can include social support systems, cultural factors, patient cognitions, lifestyle, social class, and many other diverse influences. Although the biopsychosocial model was developed in a medical context, its holistic approach to patients has also provided a useful model for counseling professionals, emphasizing the need for treatment that is responsive to mind and body considerations. The model additionally provides a context for crossdisciplinary collaboration among health care professionals to enhance treatment along multiple dimensions.

Historical Context Disease and illness have, historically, been viewed through multiple lenses, including possession by spirits, punishment for wrongful acts, the imbalance of elements within the body’s system, and a variety of other interpretations. In response to the rise of scientific empiricism, which emphasized the scientific method, Western medicine also began to transition to a model that favored the observable, scientific study of medical conditions. Also known as the biomedical model, this approach emphasized diagnosis and identification of standard treatments. Physicians were trained in quickly and accurately identifying the medical problem, and  treatments were selected according to what had been proven effective based on established research. Disease thus became viewed through the categorization of symptoms, and medical interviews focused on matching symptoms and objective tests of body systems to diagnose and treat the patient. This biomedical model was, and continues to be, the driving model of Western medicine. However, though the focus on disease provides a useful means to categorize patients and streamline treatment based on the common physiology of a diagnosis, it is not as sensitive to other processes that may exert influence on each patient’s unique experience. In the late 1970s, Engel, a young physician, published an article that called for an expanded scope of the biomedical approach. Engel, who had

attended college at age 16 and completed medical school as a physiologist and internist, was not originally a proponent of changing the dominant discourse in medicine. His studies and research in his early career valued an objective and scientific approach to patients, and he scoffed at mentors and colleagues who were beginning to question the biomedical model in favor of acknowledging the role of psychosomatic conditions (or psychological factors affecting medical symptoms). However, as he continued his practice and observed the impact of bedside manner and listening to the patient, Engel began to realize that he could no longer ignore the impact of nonbiological factors on illness and on the recovery process. He sought out training in psychotherapy and began seeing a psychotherapist himself, both of which further convinced him of the necessity to include psychological factors in the approach to health and wellbeing. He also observed the importance of family and social factors to the recovery process, realizing that social influences had an unavoidable impact on treatment. The culmination of these experiences resulted in the publication of Engel’s article in 1977, which called for a revolutionary change to the medical system and proposed his biopsychosocial approach. Engel’s work was met with mixed reactions. Some criticized his ideas as being overly ambiguous and philosophical. In addition, though his concept of addressing biological, psychological, and social aspects became popular in the medical field as a whole, in day-to-day practice there was a sense of paying lip service to Engel’s ideas while continuing business as usual based on the biomedical model. Since the publication of his first article, however, subsequent research by Engel and others has gone further in delineating ways to implement the approach, and other studies have shown positive effects of integrating the biopsychosocial approach in treatment.

Theoretical Underpinnings In discussing what the biopsychosocial model is, it can be helpful to begin with what it isn’t; namely, its purpose was to provide a shift from the biomedical model. As highlighted previously, the biomedical model has for a long time been the dominant perspective for health care. Biomedicine is based on the

Biopsychosocial Model

concept that there is a normal level of functioning for the human body and that disease or illness represents a change from normality that can be explained through natural causes or conditions. In other words, there is a way to identify and intervene in what causes the disease and thus cure it. In the biomedical tradition, the cause is physical, or biological, in nature. Through this lens, even behavioral symptoms are treated as results of biological causes. Depression, for example, would be approached as a condition of the brain and would be treated based on our current understanding of brain chemistry. The biomedical model would not, in its purist form, also assess for external factors such as unemployment, grief or bereavement, diet and exercise, or lack of social support. Engel felt, however, that these additional factors had, perhaps, just as much (if not more) influence on the manifestation, diagnosis, and treatment of the condition as the biological factors. For example, Engel noted that an individual might have a predisposition to diabetes or schizophrenia, yet each illness may not fully manifest until triggered by some other factor. Symptoms of schizophrenia may not appear until triggered by a particularly stressful life event or trauma. Diabetes may not be fully present until a lifestyle change reduces activity or alters diet. In either case, the biochemistry was present all along but the psychosocial elements interacted to produce the symptoms. The biopsychosocial model therefore follows a systems perspective in understanding disease. General systems theory, conceptualized by the biologist Ludwig von Bertalanffy (1901–1972), is based on the idea that nothing exists in isolation and that full understanding requires integration of multiple parts. Systems theory, as applied to the medical field, acknowledges influences from the molecular level all the way up to the larger community in which a person resides. Within this systemic perspective, the cause and experience of an individual’s disease may be affected by biological causes, the individual’s own behavior or beliefs, as well as influences from the family or cultural group. Instead of reducing symptoms to one underlying cause, the biopsychosocial model encourages a more expansive focus on how contributions to disease or illness are interrelated. Treatment is therefore based on targeting multiple levels, and this requires an understanding of the entire system: biological, psychological, and social.

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Discussion to this point has centered on the application of the biopsychosocial approach in medical practice. However, mental health providers are increasingly finding opportunities to work alongside or in consultation with physicians to treat clients who have biological factors that significantly affect psychological and social functioning. As such, the biopsychosocial model offers a means of collaboration between providers, as well as a perspective through which to view a client holistically. Thyroid issues, for example, can alter mood and lead to diagnoses of depression or anxiety. Lyme’s disease has been associated with a variety of psychological conditions, such as depression, anxiety, psychotic features, memory loss, attention deficit disorder, obsessive-compulsive disorder, and others. In addition, the diagnosis of a chronic condition can have a tremendous impact on a client’s mood, coping styles, and interpersonal relationships. Therefore, the biopsychosocial perspective is also relevant as an approach within mental health treatment.

Major Concepts The essential concepts of the biopsychosocial approach primarily serve as reminders of where to direct clinical attention in order to address the dimensions of a client’s condition. These concepts include biological, psychological, and social aspects, as well as the importance of a facilitative relationship between the client and the provider. Biological Aspects

The body is a complex interaction of sophisticated systems that can affect mental and physical functioning. Blood flow, organ function, gastrointestinal processes, the nervous system, and genetics all contribute to an individual’s overall health and level of functioning. Changes at the molecular or cellular level can have a profound impact on other body systems. Individuals with a chronic or terminal illness must manage physiological symptoms and treatment side effects on a daily basis. Also, as discussed previously, brain chemistry and the impact of certain diseases can produce effects consistent with mental diagnoses. The body’s processes, then, are important to consider in an overall assessment of functioning.

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Psychological Aspects

Integration

A person’s own internal reality can have a significant impact on disease. Personal beliefs about illness can affect how a person responds to a diagnosis as well as how the person follows through on treatment. Coping strategies, including thoughts and feelings about one’s condition, have been shown to affect the severity of an illness, with individuals who feel hopeless and powerless experiencing more severe symptoms than those who maintain more positive perspectives. The impact of trauma on an individual can produce profound and far-reaching changes in areas of psychological well-being, physical symptoms, sleep, and social functioning. Psychological factors can also have an impact on whether a person is even aware of his or her illness, as well as the person’s motivation to adhere to treatment recommendations.

Each of the previous concepts can contribute significantly to both the development and the treatment of a condition; therefore, integration of all of these areas is a key feature of the biopsychosocial model. Although this integration can provide a more comprehensive assessment and treatment plan, it also requires a great deal of attention and knowledge on the part of the provider. Counselors must be knowledgeable of the biological components affecting their clients’ well-being, while physicians must be aware of the psychological and social factors. The knowledge of when and where to refer a client for additional support is also an important part of integrated care and requires cross-disciplinary relationships.

Social Aspects

It is also important to remember that individuals do not exist in a vacuum. On a broader scale, cultural norms and societal expectations can contribute to health or illness significantly. One’s culture provides values such as whether it is acceptable to seek treatment for a problem or whether the condition is seen as the person’s own doing. Other cultural standards may involve rejection of medication, reliance on communal rather than medical or psychological support, or emphasis on physical symptoms rather than addressing psychological factors. Cultural and social factors can have an impact on a person’s diet, exercise, religious practices, and other behaviors. Social connections with others can also be important in regulating health or coping with illness. Studies have shown that the existence of strong social supports can speed up recovery and contribute to longer life expectancies. Individuals with strong social support often show better adherence to treatment because family and friends are motivators during the process. In contrast, individuals newly diagnosed with a chronic condition may experience turmoil within family or other social systems as others struggle to adapt to the condition and any role changes that may result.

Quality of the Relationship

Awareness of the multiple components affecting a client’s condition and knowledge of how to modify treatment based on these factors are necessary but not sufficient to ensure implementation of the biopsychosocial model. An additional key factor, the quality of the relationship between the physician and the patient, was stressed by Engel and has been reinforced by research as a pivotal ingredient in both patient satisfaction and success of treatment. Patients who feel as though their physician understands and cares for them tend to follow through with treatment goals and express greater satisfaction than patients who do not feel this connection. Similar results and implications have also been highlighted in mental health research. Listening to the client, understanding the client’s perspective and barriers to treatment, and communicating so that the client feels understood can all strengthen relationship quality.

Techniques The biopsychosocial approach is more of a model than a theory, thus, it provides a conceptualization of where to place clinical attention rather than support of specific techniques. However, there are general processes that are important to consider in the implementation of the model. The following points demonstrate the various tasks involved in incorporating the biopsychosocial model in treatment. For

Biopsychosocial Model

the purpose of this section, medical and mental health provider designations are used interchangeably, as the biopsychosocial model encourages comprehensive assessment and treatment across professional roles.

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seen as the expert on his or her own experience, and thus the assessment can be a collaborative process of discovery. Forming Treatment Considerations

Hearing the Client’s Story

First and foremost, clinicians must be able to hear the client’s story and explore relevant biopsychosocial factors. Some research has shown that physicians wait an average of 15 seconds before interrupting a patient and directing the interview. This can discourage patients from providing their own account of their experience, or they may leave out important details. The biopsychosocial model stresses the need to understand how the client interprets what is happening to him or her, as well as explore perspectives regarding other variables that may be relevant. Open and closed questions, reflections and paraphrases, and summary statements can all be useful as listening techniques. Establishing a Relationship

As previously mentioned, a strong therapeutic relationship is needed within this model. Relationships are formed as a client begins to trust that the provider has the client’s best interests in mind, and as the client feels fully understood. This understanding can develop by accurately responding to the client’s story, acknowledging barriers, and establishing a collaborative stance toward treatment. Acknowledging Relevant Factors

Another important skill involves having knowledge of various biological, psychological, and social factors and assessing how each may be interacting within a client’s experience. This may mean becoming more knowledgeable about the experience of dealing with chronic conditions, the side effects of medications, cultural norms, common medical and psychological approaches, and other related considerations. The ability to complete a full assessment of related factors and their impact on the client is essential. It is important to keep in mind during this process that the client is

Assuming that the relationship has been formed and a full assessment of factors has been completed, the next essential skill is to form and implement a reasonable treatment plan. Successful treatment will incorporate client strengths and resources and take into account any perceived barriers or limitations. Within the biopsychosocial model, treatment may be designed to address multiple dimensions of the client’s experience. A depressed client, for example, may have a treatment plan consisting of medication, regular exercise, cognitive-behavioral counseling, and goals targeting increased social engagement. It is also important that the client views the treatment plan as realistic and achievable. A client with diabetes may understand the need for regular exercise and healthy meals but may be restricted by work schedules and family diet. In this case, these factors should be acknowledged as part of the treatment plan, assessing reasonable ways to incorporate changes. This client could commit to walking during her or his lunch hour, for example, or offering to prepare a meal at home each week that meets her or his dietary needs. As an initial goal, this may be more reasonable than a full integration of significant life changes. Finally, treatment can also include collaboration between providers. Following integrated care or other collaborative models, clinicians involved in the client’s care should ensure that treatment goals are mutual and that all are working for the good of the client as a whole. Communication between providers can be useful, especially in ensuring understanding of the various biological, psychological, and social elements of the client’s condition.

Therapeutic Process Because of the multidimensional nature of the biopsychosocial model, the therapeutic process can also consist of multiple entities and varied approaches. As previously discussed, the assessment

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process is an essential part of this approach, both the initial assessment and the continued evaluation of progress toward treatment. The model also encourages practitioners to draw on multiple resources and utilize different approaches and techniques in order to meet the needs of the client. In addition, during the course of treatment, some priorities may be more relevant at different times. In other words, medical care may be more prevalent in the initial diagnosis and treatment of a disease, but counseling may become more pivotal as an individual learns to cope with the impacts of a diagnosis. The therapeutic process can thus be a long-term relationship in the case of chronic conditions or a  brief approach to assist a client in developing lifestyle changes or coping strategies. Hannah B. Bayne See also Behavior Modification; Biofeedback; Brain Change Therapy; Cognitive-Behavioral Therapy; Integrative Approaches: Overview; Motivational Interviewing; Neuropsychoanalysis

Further Readings Bayne, H., Neukrug, E., Hays, D., & Britton, B. (2013). A comprehensive model for optimizing empathy in person-centered care. Patient Education and Counseling, 93, 209–215. doi:10.1016/j.pec.2013.05.016 Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. doi:10.1126/science.847460 Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535–544. Engel, G. L. (1996). From biomedical to biopsychosocial: Being scientific in the human domain. Families, Systems, and Health, 14, 425–433. doi:10.1037/h0089973 Fava, G. A., & Sonino, N. (2008). The biopsychosocial model thirty years later. Psychotherapy and Psychosomatics, 77, 1–2. doi:10.1159/000110052 Frankel, R. M., Quill, T. E., & McDaniel, S. H. (Eds.). (2003). The biopsychosocial approach: Past, present, future. Rochester, NY: University of Rochester Press. Garcia-Toro, M., & Aguirre, I. (2007). Biopsychosocial model in depression revisited. Medical Hypotheses, 68, 683–691. doi:10.1016/j.mehy.2006.02.049 Neukrug, E., Britton, B., & Crews, C. (2013). Common health-related concerns of men and their implications for counselors. Journal of Counseling and Development, 91, 390–397. doi:10.1002/j.1556-6676.2013.00109.x

Pies, R. W. (1994). Clinical manual of psychiatric diagnosis and treatment: A biopsychosocial approach. Washington, DC: American Psychiatric Press. Smith, T. W., & Nicassio, P. M. (Eds.). (1995). Psychological practice: Clinical application of the biopsychosocial model. In Managing chronic illness: A biopsychosocial perspective (pp. 1–31). Washington, DC: American Psychological Association. Sperry, L. (2006). Biopsychosocial aspects of some common chronic illnesses. In L. Sperry (Ed.), Psychological treatment of chronic illness: The biopsychosocial therapy approach (pp. 41–64). Washington, DC: American Psychological Association. Sperry, L. (2006). Biopsychosocial therapy: Assessment and case conceptualization. In L. Sperry (Ed.), Psychological treatment of chronic illness: The biopsychosocial therapy approach (pp. 115–139). Washington, DC: American Psychological Association. Wood, B. L. (2012). Biopsychosocial. In L. L’Abate (Ed.), Paradigms in theory construction (pp. 169–186). New York, NY: Springer. doi:10.1007/978-1-46140914-4_9

BODY-MIND CENTERING® Body-Mind Centering® (BMCSSM) is a unique embodiment awareness practice and approach developed by Bonnie Bainbridge Cohen in the late 20th century. Its application is vast, from psychological selfawareness, to healing arts, to performance arts. BMC is a psychoeducational approach that is movement and touch oriented. It promotes an emotional and cognitive awakening. BMC engages awareness by working with perceptual experience, through both various body systems and movement experiences. The senses, such as touch, taste, and smell, and also balance, vision, proprioception, and tactile sensitivity govern perceptions, which drive social emotional meaning making. BMC interventions can support psychological change, as practitioners help clients develop awareness of their senses and perceptions and find strength in difficulties. BMC practitioners support a client’s natural instincts of resiliency, thus helping them experience physical comfort and emotional ease. BMC blends the Western sciences of anatomy, neurophysiology, and somatic practices with Eastern principles of awareness and movement to foster body–mind integration and neurological

Body-Mind Centering®

clarity and organization. BMC attunes clients’ perceptions in inner and outer attention and intention and increases their ability to be embodied.

Historical Context Bainbridge Cohen, a movement artist, researcher, educator, and therapist, developed BMC throughout her life and founded the School for Body-Mind Centering in 1973. Bainbridge Cohen’s kinesthetic sensitivity and ability to transmit living anatomy principles has melded movement arts with the science of exploration and discovery. Her vast movement background includes dance, dance therapy, yoga, martial arts, voice, and visual arts. She is also an occupational therapist, trained as a neurodevelopmental therapist, and has studied cranial sacral and visceral therapy, as well as many other therapeutic modalities. Today, BMC influences the manner in which movement educators, hands-on practitioners, developmental therapists, and psychotherapists meet their clients, allowing advanced participation in consciousness and health through greater embodied awareness and skill. There are licensed training programs in North and South America, Asia, and Europe, and graduates in 32 countries on five continents.

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Major Concepts When individuals are guided toward a more developmentally supported body, they can resolve emotional and physical distress. Attention to living systems, cells, and tissues and basic awareness are key components of BMC. Movement is how organisms stay healthy and resilient and how the brain stays flexible and informed. Movement perception extends to very refined levels as clients are guided using touch or movement explorations. These levels include the major body systems (e.g., organs, muscles, bones, nerves, cells, and fluids) and infant developmental pathways. Such work can bring cellular relief of stress and emotional blockages and can lead to ease and well-being. Body Systems

Each body system manifests different aspects of consciousness. The discovery of these intricacies allows clients to know themselves more fully and to repattern ineffective habits. In BMC, all the body systems are studied using movement, touch, and spatial planes and in relationship to bodybased development, embryological development, and relational-emotional development. As a result of this, clients develop an inner “knowing” based on direct experience.

Theoretical Underpinnings BMC builds a foundation of consciousness, movement inquiry, and well-being. Practitioners learn a finely tuned perceptual awareness that includes listening to cells and tissues. Cells communicate with other cells; tissues have vibration and feeling qualities that create and inform different states of consciousness. The skeletal system provides a framework and alignment for movement of the body and mind. Organs provide a sense of self, of internal processing; endocrine glands engage crystallization and organization of chaos. Fluids support flow and ease. Nerves record, communicate, and integrate all systems into a unified whole. Every individual has a unique developmental process, and BMC practitioners recognize and design treatments that facilitate each individual to discover his or her own uniqueness. Distinguishing physicality and consciousness of body tissues provides integrative ease and greater emotional stability, clarity, and creativity.

Developmental Movement

BMC practitioners teach parents how to support their infants’ development in relationship to gravity, with regard to movement through space, and in connection with others. By educating parents on  basic neuro-cellular patterns, including primitive reflexes, righting reactions, and equilibrium responses, BMC practitioners provide them with movement knowledge and language, as well as perceptual and psychological abilities that facilitate social integration and repatterning of behavior.

Techniques BMC practitioners are trained in methods based in dialogue and body reeducation. The techniques utilized are best understood by knowing how

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practitioners are trained. BMC training includes a dialogue method that happens in four ways: 1. Hands-on listening to a client’s tissues: Practitioners have a strong understanding of anatomy, both through touch and in movement. BMC calls this “living anatomy.” 2. Movement observation dialogue: Practitioners observe what a client’s body shows through expression or containment, such as a large gesture, holding one’s breath, or whether energy, such as excitement, anger, or grief, is allowed to travel through the body system or is limited to only one body area. 3. Use of the client’s movement intelligence and reeducation based on developmental movement knowledge: Practitioners learn the prenatal embryological movement gestures of development and the infant developmental patterns utilized by babies in learning to crawl and then to stand. Such knowledge gives practitioners a skill set to understand and meet the body–mind of clients in a relational and reeducative manner. 4. Development of a “feltsense” and an energetic perceptual sense of the different body systems, so treatment can meet the “mind” of the body system: This helps clients develop self-awareness and relational awareness as they become increasingly in touch with their different body systems.

Therapeutic Process BMC sessions are 30 to 60 minutes in length. A practitioner will inquire about the need for the session—whether injury related, emotional, or developmental—and treat the client following the client’s lead, using the practitioner skills outlined in the previous section. In addition to sessions, BMC practitioners may also share the BMC method in class format or longer workshop formats. Annie Brook and Bonnie Bainbridge Cohen See also Body-Oriented Therapies: Overview; Complementary and Alternative Approaches: Overview; Mindfulness Techniques; Non-Western Approaches; Yoga Movement Therapy

Further Readings Bainbridge Cohen, B. (2012). Sensing, feeling, and action: The experiential anatomy of Body-Mind Centering®. Northampton, MA: Contact Quarterly Books. Brook, A. (2000). Contact improvisation and body-mind centering: A manual for teaching and learning movement. Boulder, CO: Smart Body Books. Brook, A. (2001). From conception to crawling: Foundations for developmental movement. Boulder, CO: Smart Body Books. Brook, A. (2014). Birth’s hidden legacy: Vol. 1. How surprising beliefs from infancy limit adult and child behavior. Boulder, CO: Smart Body Books. Brook, A. (2014b). Birth’s hidden legacy: Vol. 2. Treat earliest origins of shock and attachment trauma in adults, children, and infants. Boulder, CO: Smart Body Books. Miller, G. W., Ethridge, P., & Morgan, K. T. (2011). Exploring Body-Mind Centering®: An anthology of experience and method. Berkeley, CA: North Atlantic Books.

BODY-ORIENTED THERAPIES: OVERVIEW Body-oriented therapies place more emphasis on the body–mind interconnection than most other psychotherapeutic approaches. While the majority of psychotherapy approaches are verbal and many are cognitively focused, body-oriented therapies are holistic, concentrating on both the body and the mind. Body-oriented psychotherapies are generally experiential, here-and-now, and somatic approaches that rely on the body’s innate wisdom and processes to resolve difficulties. Body symptoms are seen as creative messages of emotional and psychological pain or indications of patterns of responses to distress or trauma. Bodyoriented therapies tend to work within the concept of somatic memory: The body itself stores memories and feelings outside the conscious mind. Body symptoms and expression mirror emotional and psychological issues. Thus, changes facilitated in the body will affect emotions and beliefs. A client’s movement, within the context of body-oriented therapies, starts from within the body, and when strengthened through the therapy,

Body-Oriented Therapies: Overview

it becomes more extrinsic, dynamic, and functional. Therapy in this modality is intended to help clients work out what is trying to happen and allow its fuller expression by supporting the client’s process toward becoming more flexible and open to new experiences. Focused attention is brought to the body and its symptoms or experiences. The client is encouraged to identify more closely with his or her body and learn to respect its needs. Each of the approaches places varying value on the role of “surrender”— allowing the body to lead the healing process, integrating it more fully into the body–mind connection.

Historical Context Influenced by Sigmund Freud (1856–1939), Wilhelm Reich (1897–1957) primarily laid the historical groundwork for these forms of therapy. Others who were instrumental in shaping bodyoriented therapies include Carl Jung (1875–1961) and Fritz Perls (1883–1970), the cofounder of Gestalt therapy. Reich, in the 1920s and early 1930s, explored and developed his style of therapy, first focusing on habitual patterns, which individuals use to defend themselves against perceived external and internal threats. His emphasis remained on the body and energetic forces at the same time the existentialhumanistic theories began to take hold. Reich became a controversial figure due to a variety of societal forces as well as his own reduced interest in psychotherapy in the traditional sense. Reich’s work birthed a variety of body-oriented therapies that developed in the 1960s and 1970s, including Alexander Lowen’s bioenergetic analysis, or bioenergetics, and various primal therapies. Beginning in the 1970s and 1980s, body-focused therapies have been combined with neuroscience and applied to resolving stress and trauma.

Theoretical Underpinnings While there is no one theory in body-oriented approaches, an underlying assumption is that the body is what unifies the emotional and psychological aspects of human functioning: It embodies emotional and mental, social and spiritual experiences. Most body-oriented therapies emphasize

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body-based experiences in human development. Some of these therapies draw on concepts of attachment, nonverbal and body memory systems, affect regulation, and, more recently, neuroscience. The purpose is an attempt to describe processes that are beyond cognitive—those that are embedded in the body—and therefore emphasize the part that the body plays in influencing the mind and behaviors.

Short Descriptions of Body-Oriented Therapies Alexander Technique

This approach focuses on gentle hands-on guidance by the practitioner and movement by the client as a way to help the client understand that habits of thinking affect posture, coordination, and how the client expresses himself or herself in order to relieve pain and tension. Biodynamic Psychology

Biodynamic psychology centers on the direct relationship of the brain and gut, assisting the body with “digesting” experiences through specific protocols that move and restore energy to the mind and body. Bioenergetic Analysis

Also known as bioenergetics, this approach maintains that pain in the body is a symptom of repressed emotions, desires, and experiences. Through breathing, focused and exaggerated movement, verbal processing, and other emotional release methods, the client is restored to a natural state of well-being. Body-Mind Centering®

This educational approach explores, through guided imagery, touch, and movement, the client’s perceptions and body awareness to promote cognitive and emotional integration. Characteranalytical Vegetotherapy

The first of Wilhelm Reich’s body psychotherapy styles, characteranalytical vegetotherapy means

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“therapy of the vegetative nervous system,” which is now called the autonomic nervous system. It mediates the involuntary aspects of how we embody experiences. Concentrative Movement Therapy

Concentrative movement therapy is an approach used primarily with psychosomatic illnesses to bring awareness to body sensations and to their symbolic expression and meaning.

thereby increasing a client’s sense of self, wellbeing, and his or her soul’s journey. Orgonomy

Also known as Reichian therapy, this somatic approach focuses on ways a client’s character adapts to experiences and distorts the flow of life energy and the expression of the client’s authentic self. Ortho-Bionomy

Core Energetics

This body-oriented approach assumes that experiences block vital energy from naturally flowing from its core through the client’s body, mind, and emotions as well as spirit. Interventions reestablish disrupted energy flow and increase conscious awareness and expression.

As with most forms of body-oriented therapies, ortho-bionomy assumes that the body has the ability to heal itself. This particular therapy includes comfortable positioning, gentle movements, and compressions that stimulate reflexes to support the  body’s natural movement toward ease and balance.

Feldenkrais Method

Postural Integration

Based on movement and self-observation, this approach helps clients become aware of habitual movement patterns that may be the basis for psychological and physical pain and teaches clients new ways of moving to increase mental awareness and somatic health.

This approach uses bodywork, deep tissue massage, and other process-oriented techniques to reintegrate memories as well as restructure the client’s ability to access and express emotions.

Hakomi Therapy

Hakomi therapy is a process and experiential approach that applies mindfulness and nonviolence principles to raise the client’s awareness of the body–mind connection.

Primal Integration

Primal integration is a depth-oriented approach that relies on regression and subsequent exploration of what has been experienced in early life and aims to assist clients with developing new patterns of insight, behavior, and self-expression. Primal Therapy

Holotropic Breathwork

A form of primal therapy, this therapy borrows from Reich’s original bodywork techniques and focuses on deep breathing within a group context, where participants breathe in a circular and rhythmic process and aim to access a “nonordinary” transpersonal state.

This approach is founded on the concept that the body remembers and stores traumatic events from birth onward. In very intensive sessions, defenses are broken down so that clients can release the memories and repattern their experiences. Pulsing

Integrative Body Psychotherapy

This approach emphasizes the unity of body and mind and integrates transpersonal and bodywork to release energy related to bodily blocks,

This somatic and educational approach uses gentle rocking, cradling, and movement to promote relaxation, increased mobility, and emotional release in the client.

BodyTalk

Radix

Radix is an approach that synthesizes Reichian techniques and humanistic methods to work with the client’s life energy toward releasing blocked emotions in order to heal and find deeper meaning in life. Rolfing

Rolfing is a therapeutic approach that uses deep tissue manipulation to restore the body to its natural alignment.

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Concentrative Movement Therapy; Core Energetics; Feldenkrais Method; Hakomi Therapy; Holotropic Breathwork; Integrative Body Psychotherapy; Orgonomy; Ortho-Bionomy; Postural Integration; Primal Integration; Primal Therapy; Pulsing; Radix; Rolfing; Rubenfeld Synergy; Sensorimotor Psychotherapy; Somatic Experiencing; Yoga Movement Therapy See also (Theorists) Freud, Sigmund; Jung, Carl Gustav; Perls, Fritz; Reich, Wilhelm

Further Readings

Rubenfeld Synergy

This method integrates gentle touch, movement, and talking to access emotions and memories locked in the client’s body in order to relieve stress, anxiety, and depression. Sensorimotor Psychotherapy

Sensorimotor psychotherapy is an experiential approach that focuses on increasing clients’ awareness of the connection between their bodies and psychological issues to treat trauma. Somatic Experiencing

Developed specifically for dissolving the physiological, emotional, and psychological effects of trauma, this therapy is based on the belief that the body innately has the potential and capacity to heal itself. Symptoms are a direct result of body memory and blocked emotion, a kind of frozen or residual energy that has not been discharged as it normally would be. Bringing awareness to breathing and other body functions allows the client’s body to slowly release the embodied memory of events. Yoga Movement Therapy

This approach is founded on the concept that body and mind are integrated and emotional or psychological healing, therefore, must incorporate movement and body awareness. Suzan K. Thompson See also (Theories) Alexander Technique; Biodynamic Psychology; Bioenergetic Analysis; Body-Mind Centering®; Characteranalytical Vegetotherapy;

Lowen, A. (1994). Bioenergetics. New York, NY: Penguin. Totton, N. (2003). Body psychotherapy: An introduction. Philadelphia, PA: Open University Press. Van der Kolk, B. A., McFarlane, A. C., & Wisaeth, L. (1996). Traumatic stress: The effects of overwhelming experience on mind, body and society. New York, NY: Guilford Press.

BODYTALK The BodyTalk System concerns understanding the psychology of the body and the influence it has on health. Generally, a BodyTalk session is facilitated by a trained practitioner in a clinical setting where specific health, relationship, and behavioral issues or a general sense of improved quality of life can be addressed. The BodyTalk System is designed to standalone or to be complementary to other healthcare systems and allows any healthcare practitioner to use his or her existing knowledge, methods and techniques in a more holistic manner.

Historical Context The BodyTalk System was developed by Dr. John Veltheim in the mid-1990s. His own state of health was compromised despite being a leader in the healthcare field, working with both Eastern and Western methods. He eventually found a simple technique that did correct his condition. He (and Esther Veltheim) saw this breakthrough as a new priority in his life and proceeded to investigate the techniques and principles involved. The core features of the BodyTalk System make it accessible to lay persons, healers, medical

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professionals, and experts in any field who wish to approach their work in a more holistic manner to achieve greater overall success. The system has been taught around the world and used in a variety of ways.

Theoretical Underpinnings The BodyTalk System is a consciousness-based approach to WholeHealthCare™ that treats the well-being of an individual as a reflection of his or her whole life in all of its complexity, which includes other individuals and environmental factors. The psychology of the body is a language that tells an unheard story. The practitioner interacts with that level of communication to facilitate a shift in the client’s awareness or consciousness toward aspects of the inner psyche or outer life that may be rejected or resisted. As the client’s awareness changes, conflict in all of its manifestations reveals its healing nature. Optimal health and the permanency of well-being are established holistically, transcending the limitations of symptoms and circumstances.

and history are all drawn on to establish a personalized approach. BodyTalk practitioners are trained to be expert listeners, which allows them to be excellent communicators. In other words, they have the skills to identify the unique details of the health story and bring awareness to their clients so that their clients’ bodies can self-heal. The skill they use to identify the whole story is structured intuition. Structured Intuition

Structured intuition is a fusion of left-brain knowledge (accumulated from learning and experience) and right-brain intuition. The left brain is only as powerful as the wealth of knowledge it can access. Many people think of intuition as unreliable, perhaps because they may not understand it. Everyone has intuition; the problem is in our ability to understand it through our filters (which of course includes our conditioning about life, our beliefs about what is possible and what is not, what is appropriate and what is not, etc.). The BodyTalk practitioner is trained how to access and utilize intuition in a structured manner.

Major Concepts The concepts behind this system are influenced by a variety of approaches and theories, including consciousness-based systems, energy medicine, dynamic systems theory, Advaita Vedanta, psychology, and more. Major concepts include WholeHealthcare, structured intuition, and biofeedback. WholeHealthcare

BodyTalk understands the profound influence our psychology has on our health. Instead of focusing on symptoms, BodyTalk finds the underlying causes of illness by addressing the whole person and the individual’s whole story. Health challenges arise for a variety of reasons. When a practitioner is trained to look at the whole person—emotional, physical, and environmental influences—the true underlying causes of dis-ease can be revealed. Every choice and every experience has contributed to the current state of health. Each scar, laugh line, and injury has a unique story and a history. WholeHealthcare takes into consideration the whole story. Lifestyle, genetics,

Biofeedback

Combined with structured intuition, the practitioner also utilizes biofeedback, which provides an outlet for the intuition. In other words, biofeedback helps to physically translate what we are listening to. The biofeedback process provides the practitioner with yes-or-no answers to a specific set of questions from the BodyTalk protocol chart. This chart contains a systematic list of all of the BodyTalk balancing options.

Techniques The practitioner observes the unfolding of a formula based on the unique details of the client (his or her whole story), structured intuition, and biofeedback. These formulas are devised using the BodyTalk protocol chart, which essentially provides the practitioner with the techniques necessary to restore balance to the client. The techniques are then implemented in a variety of simple and noninvasive ways that may, or may not, include physical touch or verbal explanation.

Böszörményi-Nagy, Ivan

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Protocol

Further Readings

The protocol is a set of specific balancing options (from basic organ-balancing techniques, to options for addressing energy systems, to emotional releasing, etc.) that are utilized by the practitioner to identify the unique details of the client’s health story, which when implemented will help restore balance.

Oschamn, J. L. (2000). Energy medicine: The scientific basis. Oxford, England: Churchill Livingstone. Oschman, J. L. (2003). Energy medicine in therapeutics and human performance. Edinburgh, England: Butterworth-Heinemann. Veltheim, E. (2001). Who am I?: The seeker’s guide to nowhere. Sarasota, FL: PaRama. Veltheim, J. (2013). The science and philosophy of BodyTalk: Healthcare designed by your body. Sarasota, FL: PaRama.

Formulation

The result of the use of the protocol to determine health imbalances is the unfolding of an energic formula that will reveal the nature of the shift that facilitates coming into consciousness. This energic matrix will superimpose on the energy blueprint (biofield) of the client. The energic changes profoundly affect the structure of the cells, which, in turn, changes the physiology of the body as well as induces strong improvements in the communication and synchronization within the whole ecology of the client.

Therapeutic Process The BodyTalk System can be used as a stand-alone ongoing process of self-introspection and personal growth in the sense of unraveling false, destructive perceptions, beliefs, and tendencies. It is often used in conjunction with other therapies to provide a holistic basis for the overall treatment. Clients typically fill out an intake form and discuss their reasons for the session with the practitioner. Clients usually lie on a massage table, face up and fully clothed. The practitioner may sit or stand at their side, where they then use structure intuition and biofeedback to interact with the clients to determine the unique details of their health story that are holding them in dis-ease. The practitioner will then implement the balancing options that were revealed during the session, ideally allowing for a shift in consciousness to occur. Session duration and frequency vary greatly and are often determined by the BodyTalk protocol itself. John Veltheim See also Acupuncture and Acupressure; CognitiveBehavioral Therapy; Emotion-Focused Therapy; Gestalt Therapy; Jung, Carl Gustav

BÖSZÖRMÉNYI-NAGY, IVAN Ivan Böszörményi-Nagy (1920–2007) was a Hungarian American psychiatrist who is recognized as one of the pioneers of family therapy and the founder of contextual therapy, an approach whose premises are relevant not only for family therapy but also for couple and individual therapy. His book Invisible Loyalties introduced the theme of family loyalty into family therapy literature. In Hungary, he is known as Böszörményi-Nagy, Ívan. In the professional literature, he is often mentioned simply as Ivan Nagy, but these names do not represent his correct professional name: Ivan Böszörményi-Nagy. Born in Budapest, where he completed his education, Böszörményi-Nagy was a fully trained psychiatrist when he arrived in the United States as a political refugee in 1950. Atypical for a psychiatrist, he also pursued advanced studies in biochemistry and physics, hoping to engage in a search for the biological determinants of schizophrenia. He spent the first 6 years of his life in the United States as a biochemistry researcher at the University of Illinois in Chicago. He did groundbreaking studies on the glucose metabolism of patients with schizophrenia, and his work has retained some value for modern researchers. When he returned to clinical work, he retained a scientific attitude. To build up his approach, he relied on direct clinical observation, not on broad intellectual speculations. He and his team were among the first to use a one-way mirror to observe family interviews and to use audiotaping and, later, videotaping to record these sessions. Most of his

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discoveries were made through the microanalysis of such taped therapy sessions. He also used this material extensively in his teaching. Most of Böszörményi-Nagy’s career was spent in the Philadelphia area. It started at Eastern Pennsylvania Psychiatric Institute in Philadelphia, where he worked from 1957 to 1980, first as the director of a research unit on schizophrenia and later as the director of its Family Psychiatry Division. A great part of his academic career was spent at Hahnemann University, where he founded a Master of Family Therapy program in the late 1970s. This program was later transferred to Drexel University, from which he retired in 1999 as an emeritus professor. In addition, he was also very involved in training local and international professionals through his own organization, the Institute for Contextual Growth, which is still in existence today. He taught extensively abroad, mostly in Europe, where he toured annually for almost 30 years. He was the recipient of many professional awards. Significantly, he received an honorary doctorate from the University of Bern, Switzerland. In Hungary, he received the presidential gold medal acknowledging those who made special contributions to the country. Along with the pioneers of the family therapy movement, Böszörményi-Nagy contributed to a major shift of paradigm in the understanding of the origins of mental health and illnesses. This move was marked by a shift from an individual/psychological model of causalities to a supra-individual model informed by general systems theory and cybernetics. In contrast with most of his systemically oriented colleagues, he insisted on retaining a place for individual determinants of behaviors in his model of family therapy. The most drastic shift occurred when these pioneers started to abandon individual therapy. This exposed them to a significant degree of rejection by a psychiatric establishment that was still massively influenced by psychoanalysis. To overcome the isolation, they reached out to each other. Böszörményi-Nagy and his team organized one of the earliest conferences on family therapy, leading to the publication of Intensive Family Therapy, one of the earliest books on the subject. He also played an important role in the development of family therapy as an organized movement. One of Böszörményi-Nagy’s main contributions to the field of psychotherapy comes from his

understanding that people measure relationships in terms of justice and expect fairness and loyalty in their close relationships. Following the writings of the philosopher Martin Buber, he proposed the term relational ethics to describe this crucial determinant of relationships. While therapists have known that people attach great importance to issues of justice, he is the only one who has built an entire therapy approach addressing the relational and multigenerational impact of injustices. Böszörményi-Nagy believes that his interest in justice did not come from the simple fact that he was born into a family of judges and lawyers. Instead, he credits this interest to the direct influence of his father, a man who showed a deep commitment to social justice and a judge who was always trying to understand the human predicament of the people who presented before him. This became the blueprint for a strategy that is at the core of contextual therapy, multidirected partiality, which is discussed later in this entry. Another of Böszörményi-Nagy’s major contributions is the result of his discovery that family loyalty serves as one of the principal sources of cohesion in the family system. He developed an entire corpus of knowledge about the clinical manifestations of family loyalties, showing that family loyalty can become a source of individual and relational pathology when it results in loyalty conflicts, split loyalties, or indirect and invisible loyalties. By now, these notions have penetrated the fields of family therapy and psychotherapy so deeply that most therapists are not aware of their origin. Today, this results in a vast discrepancy between the relatively modest number of therapists who identify themselves as direct followers of Böszörményi-Nagy and the enormous number of people all over the world who have been clearly influenced by his work but would not identify themselves as contextual therapists. What is less known is that Böszörményi-Nagy proposed a “dialectic theory of the personality,” which is based on the premises of existential philosophy. In this perspective, the Self cannot exist outside of a relationship with an Other, which serves as its necessary counterpart. He described the inherent dependence of the Self on the Other to exist as a Self as an “ontic dependence.” In this view, individual autonomy becomes a paradoxical notion because it can only be achieved within a

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relationship. This theory leads to a new perspective on family loyalty. While family loyalties are generally perceived as an obstacle to individuation, in this perspective, loyalty can become a source of individual autonomy exactly because it creates a link between people. In an effort to take into account all the different elements that play a role in relationships, Böszörményi-Nagy has proposed an integrative model of therapy. In its current formulation, contextual therapy is organized around the description of five dimensions of relational reality: (1) the dimension of facts, including sociohistorical and biological determinants; (2) the dimension of individual psychology; (3) the dimension of systems and transactions; (4) the dimension of relational ethics; and, last, (5) the ontic dimension. Contextual therapists are required to understand that pathology can stem from any of these dimensions and that each of them also contains specific therapeutic resources, but their main therapeutic activity is exerted in the dimension of relational ethics. Contextual therapists believe that fairness and trustworthiness are the key ingredients of successful relationships and that, conversely, injustices and mistrust can become a source of pathology that can affect families over several generations. The most lasting effect of injustices comes from what Böszörményi-Nagy calls “destructive entitlement.” He describes that people who have been wronged and cannot obtain redress from the wrongdoers can be drawn to seek redress from people who are in no way responsible for their predicaments, which is very unfair. This process can damage family relationships over several generations. Contextual therapists see a solution in what is called “the earning of constructive entitlement.” Long before neuroscientists and other researchers became interested in the benefits of altruism, Böszörményi-Nagy had shown that clients who could show generosity toward others experience an increase in self-worth, an increased inner freedom, and even an increase in physical well-being. He describes this gain as “constructive entitlement.” If people who have accumulated destructive entitlement can discover that they can gain from showing fairness to others, it will be easier for them to let go of claims that have become destructive to relationships. This becomes the main source of therapeutic optimism.

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To reach this moment, contextual therapists use a specific strategy: multidirected partiality. Therapists need to offer their attention to each one of the persons involved in a relationship, making their best effort to try to understand each person’s unique predicament. At the same time, they need to maintain an all-inclusive attitude, a determination to eventually offer a similar partiality to all the other participants in the relationship. In the process, each one of the participants meets the fairness of the therapist, and as a consequence, each becomes a little more likely to show fairness to others and to earn constructive entitlement. The goal of contextual therapy is similar to the goal of all psychotherapies: a decrease of individual and relational pathology and an increase in personal satisfaction. In addition, it includes a mandate for posterity, an understanding that the main beneficiaries of the therapeutic endeavor need to be the next generations. Catherine Ducommun-Nagy See also Ackerman, Nathan; Bowen, Murray; Contextual Therapy; Palo Alto Group; Satir, Virginia; Whitaker, Carl

Further Readings Böszörményi-Nagy, I., & Framo, J. (Eds.). (1985). Intensive family therapy: Theoretical and practical aspects. New-York, NY: Brunner/Mazel. (Original work published 1965) Böszörményi-Nagy, I., & Krasner, B. (1986). Between give and take: A clinical guide to contextual therapy. New York, NY: Brunner/Mazel. Böszörményi-Nagy, I., & Spark, G. (1984). Invisible loyalties. New York, NY: Brunner/Mazel. (Original work published 1973) Ducommun-Nagy, C. (2002). Contextual therapy. In F. Kaslow (Ed.), Comprehensive handbook of psychotherapy (Vol. 3, pp. 463–487). New York, NY: Willey.

BOWEN, MURRAY The psychiatrist Murray Bowen (1913–1990) focused his professional studies on observing the interactions of the family and formulating a theory

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of the family as a system. He believed that the social interactions of the human family could best be understood in the context of the human’s evolutionary heritage. His work remains the foundation of Bowen theory. Bowen’s early work as a psychiatrist led him to the observation that the family was an interactive social unit in which all the family members played a part in creating a symptomatic individual. This went against the grain of the mental health community at the time. In the 1950s, when he was developing his ideas on the family system, Freudian theories described a symptom, whether neurotic or psychotic, as an outcome of intrapsychic conflicts (i.e., within the individual). Bowen, born on January 31, 1913, was the oldest of five children of Maggie and Jess Bowen. The Bowen family ran a funeral parlor in Waverly, Tennessee. He grew up close to nature, helping his family with their farm outside town and observing the natural rhythms of farm life. He received a B.S. from the University of Tennessee and an M.D. from the University of Tennessee Medical School in Memphis in 1937. After several internships, he served active duty in the army in the United States and Europe between 1941 and 1946. Although he was initially interested in becoming a surgeon, his interaction with soldiers during World War II spurred his shift to psychiatry. From 1946 to 1954, he worked as a fellow and staff member in psychiatry and personal psychoanalysis at the Menninger Foundation in Topeka, Kansas. While at the Menninger Foundation, Bowen began a lifelong interest in the emotions and behavior in families. He observed that patients with schizophrenia had a uniquely intense relationship with their mothers, to the point of regressing in reaction to parental visits to the psychiatric institution. Realizing how intertwined the emotional life of the patient was with his or her family, Bowen labeled the relationship process between an individual with schizophrenia and the individual’s mother as “symbiotic.” In 1954, Bowen obtained a grant to further study individuals with schizophrenia and their families in an inpatient ward at the National Institute of Mental Health campus in Bethesda, Maryland. The Family Study Project initially admitted mother–daughter dyads to a special residential

unit. Later, when it became apparent that family members important to the mother were also involved in the problem, fathers and siblings were also admitted. From the five years of research (1954–1959) of the Family Study Project, several significant findings were produced. Bowen believed through his clinical observations that the family could be conceptualized as an emotional unit. This concept was based on his clinical research of how family interactions affected members emotionally and physically. In addition, he developed a new method of working with families, termed family psychotherapy, which derived from that concept. If the therapist worked from the basis that the family was an emotional unit, then the traditional therapeutic relationship was altered. Although schooled in the techniques of transference and countertransference, Bowen believed that a more effective clinical relationship with a family was one of emotional objectivity and detachment. After leaving the National Institute of Mental Health, Bowen became a faculty member in the Department of Psychiatry at Georgetown University Medical Center, where he continued to develop theoretical concepts about the family. He was part-time professor and chair of the Division of Family and Social Psychiatry at the Medical College of Virginia from 1964 to 1978. While at the college, he pioneered the use of closed-circuit television for clinical sessions as a teaching tool for psychiatrists and clinicians interested in the application of family systems theory to clinical work. He created the family diagram to visually capture the facts of a relationship system over three or more generations. Figure 1 is an example of a family diagram. In 1975, he founded and directed the Georgetown Family Center, which became the Bowen Center for the Study of the Family in 2000. This center continues his legacy by offering training for mental health professionals, clergy, and organizational professionals; publishing a journal; and organizing conferences to promote the development of the theory. In Bowen’s approach, theory, rather than techniques, guided therapy. In the years of research and clinical observations, Bowen developed a family systems theory with eight concepts: (1) differentiation of self, (2) triangles, (3) nuclear family emotional

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Some items to consider including on a genogram are: birth date, death date, educational level and focus, health issues, place of residence, and occupation. The above, partial genogram, gives just a few examples of these and is based on a genogram created in 2015.

Marriage Divorce Miscarriage

Figure 1 Example of a Family Diagram

system, (4) family projection process, (5) multigenerational transmission process, (6) emotional cutoff, (7)  sibling position, and (8) societal emotional process. Differentiation of self describes the functioning of an individual based on the degree of self he or she is able to maintain in the face of emotional pressures to conform by a family or other important groups. The basic building blocks of self are inborn, but an individual’s family relationships during childhood and adolescence establish the individual’s lifelong level of differentiation of self. The degree of an individual’s differentiation of self determines his or her ability to think, act, and choose in emotionally charged interactions. Those with poorly differentiated selves depend heavily on the acceptance and approval of others or pressure others to conform to their expectations. Those with well-differentiated selves realize their dependence on others but can distinguish what they think about the facts of a situation

in the face of conflict, criticism, and rejection by others. Every society has people who vary in a range of levels of differentiation, with those who depend more intensely on the help and approval of others being more vulnerable to periods of heightened anxiety in the family, which contributes to their having more symptoms and relationship problems. In the triangle concept, the triangle refers to a three-person relationship, which is the basic building block and smallest stable unit of an emotional system. A two-person system is unstable in that it tolerates little tension before one or the other will involve a third person. If the tension is too high for one triangle to contain, one of the parties will involve a fourth, spreading the tension to interlocking triangles. Triangles have many different configurations. A common example is when two are in an alliance, with the third on the outside. In the family projection process, for example, parents may agree that the child is the problem.

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Nuclear family emotional system describes four basic relationship patterns that govern how problems develop in a family. Families vary in what relationship pattern they engage in—some utilize all the patterns, some react mainly with one. Clinical problems or symptoms develop during periods of prolonged family tension. The higher the tension, the greater is the chance that symptoms will be severe and that several people will be symptomatic. The four relationship patterns are as follows: 1. Marital conflict: Anxiety is externalized into the marital relationship, with each spouse blaming and trying to control the other. 2. Dysfunction in one spouse: One spouse pressures the other to act in a certain way, and the other accommodates, ultimately ending up with anxiety fueling the development of a psychiatric, medical, or social symptom in the adaptive spouse. 3. Impairment of children: The spouses focus anxiously on one or more children, with each child increasingly being tuned into their worry, making him or her vulnerable to acting out or internalizing family tensions and impairing his or her school achievement, social relationships, and health. 4. Emotional distance: People distance themselves from one another to reduce tension but thereby risk becoming isolated from important others.

The family projection process involves the way parents transmit their anxiety onto a child. In the parental triangle with a child, the process follows three steps: (1) the parents focus on the child out of fear that something is wrong with the child, (2)  the parents interpret the child’s behavior as confirming the fear, and (3) the parents treat the child as if something is really wrong with the child. The child can cooperate by acting in a way that is in tandem with the parents’ fears. The multigenerational transmission process occurs when emotional processes are transmitted from one generation to another. Bowen believed that the level of differentiation was transmitted across generations and that one child could grow

up more compromised by the family projection process and more dependent on the parents than others in the family. In addition, families replicate patterns of mental, physical, or social problems across generations. Emotional cutoff occurs when a family member manages intense relationship problems by severing contact with the family. Such individuals are propelled by a sensitivity to and denial of the importance of family relationships. By severing contact, these individuals believe that they are resolving the difficulties in one relationship only to find that they invest intensely in other relationships, such as children, which then becomes problematic. Bowen recognized the impact of sibling position, or birth order, as an important factor in an individual’s functioning in the family. He incorporated the original research of the psychologist Walter Toman on sibling position but qualified the outcome by recognizing that the emotional process in the family often altered the profile of a particular position. For example, an oldest son is often a leader, but he can become nonfunctioning if the projection process in the family is focused on him. The societal emotional process, the last and least developed of Bowen’s eight concepts, describes how the theory could be applied to societies as well. Thus, Bowen thought that the diminishment of the earth’s resources, shrinking frontiers, and population explosion contributed to heightened anxiety and decreasing flexibility in societal interactions, which can have an impact on family functioning. Bowen believed that understanding and applying these concepts in one’s own life was critical if a clinician were to be effective. Theory guided therapy rather than therapy relying on techniques for change. Although Bowen died in October 1990, his ideas have a lasting legacy in the fields of mental health, the clergy, and business, particularly for his focus on the professional managing his or her reactions in the reciprocal interactions of a relationship system. Anne S. McKnight See also Couples, Family, and Relational Models: Overview; Multigenerational Family Therapy

Brain Change Therapy

Further Readings Bowen, M. (1976). Theory in the practice of psychotherapy. In P. J. Guerin (Ed.), Family therapy: Theory and practice (pp. 42–90). New York, NY: Gardner Press. Bowen, M. (1978). Family therapy in clinical practice. New York, NY: Jason Aronson. Bowen, M., & Kerr, M. (1988). Family evaluation. New York, NY: W. W. Norton. Gilbert, R. (1992). Extraordinary relationships. Minneapolis, MN: Chronimed.

Website Bowen Center for the Study of the Family: www .thebowencenter.org

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Historical Context Brain Change Therapy was developed by the clinicians Carol Kershaw and Bill Wade, who after 30 years of practice researched the following questions: “What is the common denominator among all of the most successful approaches in psychotherapy?” and “How does neuroscience inform psychotherapy in practical applications for interventions?” Brain Change Therapy developed from their work in biofeedback and neurofeedback, Ericksonian hypnosis and psychotherapy, family therapy, cognitive-behavioral therapy, treating athletes and performers for the high-performance mind, and studies in attachment. The authors discovered that all of their brain change concepts were supported by the neuroscience research.

Theoretical Underpinnings

BOWENIAN THERAPY See Multigenerational Family Therapy

BRAIN CHANGE THERAPY Brain Change Therapy is an integration of Ericksonian hypnosis, neuroscience, meditation, and the principles of biofeedback and neurofeedback. This therapeutic treatment focuses on shifting neurocircuitry and targets several identified emotional circuits. These include rage/anger, fear/anxiety, panic/grief or distress, care/nurture, play, lust/sexual, and seeking or curiosity/ desire. It is particularly suited to treating posttraumatic stress disorder by eliminating the emotional charge to past events and reconsolidating memory so that it is no longer troubling. It utilizes clinical hypnosis and neuro-repatterning, teaching clients how to turn on and off certain brain circuits, and brain technologies to eliminate symptoms and train toward the optimal mind. The approach has been successful in treating war veterans, adults suffering from early abuse, athletes, performers, and children who have difficulty adjusting to life stress.

Brain Change Therapy focuses on the concepts that with training people can control their own psychoneurophysiology and that flexibility in mental state change is key to brain/mind health and life success. Mental state change refers to the capacity to shift the mind from one emotional state to another and to shift the brain from one neural pattern to another. The ability to keep arousal levels at midrange under stress reflects the flexibility in mental state change. Brain science suggests that people who can hold their attention in a positive mental state for extended periods of time are the happiest and most successful. All learning and behavior are state specific. What a person learns in one state of arousal is remembered best in that state of arousal. When a person is either overaroused or underaroused, it is difficult for that individual to remember the information and skills necessary to perform some task. Those tasks may include being a good parent or spouse, adjusting to work, or some specialized skill such as music, remembering lines in a play, or an athletic endeavor. Past a certain level of arousal, thoughts and behaviors follow, rather than precede, feelings or brain states. Any experience lays a neural pathway in the brain that can be easily triggered throughout a lifetime. These pathways form from early familyof-origin learning, life experience, and mental states and behaviors that are conditioned over

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time. The neural pathways never disappear and activate throughout a lifetime. The result is that old beliefs and behaviors turn on unconsciously under certain circumstances, and without active brain/mind training, clients notice the same troubling problems at different developmental ages. These troubling patterns keep clients from developing states of optimal functioning and may result from underlying trauma that is still active at the unconscious level. After trauma, the sympathetic nervous system activates with the smallest stimulus and results in waves of anxiety and depression. The waves are actual electrical frequencies firing out of synchrony, and clients have difficulty managing their mental states. After a trauma, anxiety, panic, overreaction to noise, and difficulty sleeping can plague a person for years. Life events are perceived through this hyperaroused filter, and reactivity becomes unbridled. Brain Change Therapy uses Strategic Neurocoaching™, a process where individuals intentionally use tools to practice states of stability and flexibility. The process turns emotional neural circuits on and off and transforms negative ideas that block goal achievement. By learning to shift brain states to more productive ones, practicing those states, and creating an environment that reinforces the high-performance mind, profound change occurs. In addition, these processes help balance life by clearing frantic activity and making time for self-growth activities such as meditation, which restores equanimity and evolves awareness into self-compassion. These processes activate mental states and slower healing brain frequencies. As soon as the brain recognizes its creation of a satisfying calm state, it begins to remain there longer. With certain mental exercises, the brain is then engaged in a continuous optimization process.

Major Concepts Brain Change Therapy uses brain/mind/state change as the focus of treatment and is based in neuroscience discoveries that reveal that change is lasting when it focuses on neural circuitry. The overarching concept is that when a person is stuck in a negative belief and subsequent negative behaviors, it is because the “stuckness” is attached to a level of arousal. Unless the arousal is changed, the

negative belief is impossible to change. The memory of arousal around an issue re-creates in present time the same level of arousal that blocks change. There are three broad therapeutic modalities through which the clinician can assist the client in changing the brain’s neural patterning and shifting attention from negative to positive states. Brain Change Therapy makes directed use of all three. These are (1) the preconscious, (2) the conscious, and (3) brain technology. Preconscious work entails the use of clinical hypnosis to help clients change mental states and access their internal resourceful experiences of confidence, courage, and security. Identifying the client’s previous experiences where the emotional resource was learned and reviewing it until the individual reexperiences the resource in present time accomplish this work. Conscious work uses the client’s ability to change the focus of attention. By doing so, certain brain circuits can be encouraged to fire. For example, a gentle focus on relaxing body tension allows for the activation of a mental state of creativity in problem solving. Brain technology involves the use of biofeedback and neurofeedback to manage states of arousal and encourage healthy psychophysiological functioning. By conditioning the “zone” state so that it is easily accessible even under stress, the client can shift into the focused and alert but relaxed state of mind. In this calm mental state, people learn about amazing abilities. However, mental strategies based on biofeedback principles can condition the zone state without expensive systems. The process can lead to developing the optimal mind and psychological coherence. High brain coherence—symmetrical firing across both hemispheres, from activating steady states—leads to higher consciousness experiences and what we call psychological coherence. Possibilities open up, and the client experiences being in charge of the mind and accomplishing goals and dreams.

Techniques There are a number of techniques Brain Change Therapy uses. First, the major assessment tool is the quantitative electroencephalograph, which measures brain function before and after treatment and

Brain Change Therapy

clearly shows whether an individual develops the optimal mind or whole-brain state—that is, whether the brain is firing in a synchronous fashion after intervention. There are seven tools that Brain Change Therapy incorporates to achieve the wholebrain state: (1) developing the state of empowerment to expand perceived possibilities; (2) activating motivation for change; (3) bilateral stimulation with the tapping or tossing of an object, sound, or dual inductions; (4) future pace questions; (5) neurorepatterning and neuro-tuning; (6) nonthinking; and (7) deep-state transformation. Developing the State of Empowerment to Expand Perceived Possibilities

This tool is used to teach clients about their abilities of which they are unaware. For example, warming the hands, slowing the heart rate, or lowering the blood pressure with changing mental states and slower breathing accomplishes this goal. The implied suggestion with this tool is that if a person can accomplish this, what else is possible? Activating Motivation for Change

Strategies that move people toward pleasure and away from pain activate motivation. When the clinician can help the client develop a compelling future, put off pleasure for a while, and attach a strong emotion to that future’s outcome, the client keeps motivation activated. When the client begins to think about the new future, the brain begins to rewire itself and consider the “new and improved” self.

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the brain to see possibilities in the direction of this future. Examples might include “What would you need to do professionally and personally by the end of a year to accomplish what you desire?”and “What would your perfect life look like?” Neuro-Repatterning and Neuro-Tuning

With practice, clients can learn to turn off anger by switching to the neural circuit of curiosity. Panic can be switched off by turning on love and nurture, unless the client is over a threshold of arousal where it is impossible to calm the mind. With practice, on first noticing the panic feeling, the client can learn to completely turn it off. The neural circuit of play and humor can also turn off a circuit of fear. By practicing the “target mental state” for an event or activity, a person conditions the mind/brain to positively shift attention, thus tuning the brain to the desired focus. Nonthinking

Nonthinking is the default state of the mind when a person daydreams or is quiet. When the mind relaxes and gently thinks about pleasant things without criticism, the process regenerates creativity and problem solving. Nonthinking results in lowered stress levels and an increase in imagination. When the clinician suggests this activity as a homework assignment, clients become more intent to create relaxation, stop self-criticism, and notice that their power of putting ideas together in novel ways improves.

Bilateral Stimulation

The brain has a built-in mechanism to resolve trauma through bilateral stimulation by drumming, walking, tapping on either side of the body, or listening to bilateral sounds or voices, as in hypnotic dual inductions. The process replicates the rapid eye movement during sleep, which reconsolidates memory and removes the emotional charge from an event. Future Pace Questions

Questions that stimulate a person’s imagination about the best possible future begin to condition

Deep-State Transformation

In this process, a client is guided to the deepest state above sleep and allowed to hover there for 20 minutes. If the goal is resolving trauma, safety and security states are first practiced. Then, the clinician guides the client back to the traumatic event to view it from a safe adult perspective. The deep state causes the brain to release a family of endocannabanoids that have healing properties with regard to negative memories. By changing the level of arousal to a profoundly deep state, shift in beliefs, perspectives, and possibilities occur.

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Brainspotting

Therapeutic Process There are nine simple steps in the Brain Change Therapy Process: 1. Acknowledge the client’s presenting state and the issues driving it. Creating a therapeutic relationship is essential to all good forms of therapy. When clients feel heard and understood, it is possible to move from a hopeless state to a hopeful state. 2. Define the problem as solvable. 3. Identify the target state (the mental state the client prefers to act from). This can include courage, persistence, making a commitment to a goal, or facing fears. 4. Assist the client in changing states and moving toward the target state. The clinician assists the client in experiencing the target state by using one of the seven tools. 5. Condition and reinforce the new state by discussing it and having the client begin to notice when it is experienced. 6. Establish the new state as a means of resolving the underlying issues. 7. Assist the client in creating workable solutions as they emerge from changing states and behaviors. 8. Support the client in taking action. The clinician suggests that the client notice when thinking and perceptions begin to change. 9. Link the action into the client’s social context. The clinician encourages the client to practice the target state and accompanying behaviors in a community.

Carol J. Kershaw and J. William Wade See also Cognitive-Behavioral Therapy; Ericksonian Therapy; Hypnotherapy; Solution-Focused Brief Therapy

Further Readings Begley, S. (2007). Train your mind, change your brain: How a new science reveals our extraordinary potential to transform ourselves. New York, NY: Ballantine Books.

Erickson, M., & Rossi, E. (2009). The February man: Evolving consciousness and identity in hypnotherapy. New York, NY: Routledge. Goleman, D. (2013). Focus: The hidden driver of excellence. New York, NY: Bloomsbury. Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. London, England: Oxford University Press.

BRAINSPOTTING Brainspotting (BSP) is a relational and brainbased approach that helps clients resolve a variety of concerns related to stress, anxiety, or trauma, especially when traditional talk therapy is not effective. BSP also provides rapid resolution of traumatic symptoms so that clients need not reexperience traumatic events, which often results in retraumatization. Instead, the counselor leads the process using the client’s eye movements, fixed-eye position, and breathing, often without verbalization of the distressing content.

Historical Context David Grand, a clinical social worker and Eye Movement Desensitization and Reprocessing (EMDR) practitioner, developed an advanced model called natural flow EMDR. Observing that assumptions, which were often not questioned, became part of the belief system of many clinical models, Grand established a “no assumptions” phenomenology. He worked with clients having sports, athletic, and artistic performance issues and began developing BSP in 2003 after he discovered that the eyes of a figure skater held the key to her performance block. As the client held that spot in her vision, traumatic memory poured out, and she was able to perform a previously impossible movement. Lisa Schwarz, practitioner and trainer, added the resource model to BSP for use with overwhelmed or dissociative clients who need to begin the process slowly in a calm spot. Several thousand clinicians throughout the world have been trained in BSP and use it as a stand-alone treatment or with other approaches.

Brainspotting

Theoretical Underpinnings BSP is an integrative model that focuses on dual relational and neurobiological attunement, similar to EMDR and Somatic Experiencing. BSP holds no relationship to any counseling theory or worldview, and the brain and body are seen as one entity. The BSP foundational concept posits that traumatic memory and pain can be accessed from the field of vision to the brainspot where the memory is stored. When the proper circumstances are set, a brain with trauma will heal itself. Brainspots hold the experiential or sensory parts of the event in the noncognitive and nonverbal parts of the brain. The brain continually scans itself for memories and experiences that are out of place, attempting to store them in their proper location. Sensory integration of the left and right hemispheres takes place through techniques that provide bilateral stimulation of the brain, including the use of music and sounds. Once the encapsulated traumatic memory is unfrozen from its location, the client is free to process and resolve the memory so that it is stored and integrated by using the body’s natural healing abilities.

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avoid an abreaction. The counselor helps identify the place in the body where the client feels calmest and most grounded. Subjective Units of Distress

The Subjective Units of Distress Scale (SUDS) measures a client’s current level of distress related to a complaint on a scale of 0, indicating no distress, to 10, indicating extreme distress. The counselor uses the SUDS to assess the impact of the intervention by regularly checking with the client.

Techniques The major techniques of BSP include activation, eye fixation, and squeezing the lemon. Activation

The counselor guides the client in intensifying the inner experience by focusing on the problem or traumatic memory to raise the level of intensity. Eye Fixation

Major Concepts

The incorporation of bilateral sounds and music alternating from ear to ear helps clients use their inner experience in the process of BSP treatment.

The client is guided to where the emotional or sensory distress is strongest and fixates on the eye position (outside window). Once the position is identified, the counselor asks the client to continue to increase the intensity of the distress by focusing on the problem or situation until the SUD is highest. Clients can also locate the brainspot on their own by scanning their visual field while identifying the area where the greatest feeling of distress occurs (inside window).

Brainspot

Squeezing the Lemon

The brainspot is the position in the client’s field of vision that correlates with the place in the brain holding the emotionally charged material. By focusing on the brainspot, parts of the brain that contain distressing memories are accessed for processing.

After the SUD is significantly reduced, the client is encouraged to bring up the traumatic memory and re-elevate the SUD. If the SUD is elevated, processing (“squeezing the lemon”) is continued until the traumatic memory is no longer distressing and no “drops” remain.

Major concepts of BSP include bilateral sound, the brainspot, the resource spot, and subjective units of distress. Bilateral Sound

Resource Spot

The resource spot is the starting position for clients who are overwhelmed, severely distressed, or dissociative to better tolerate processing and

Therapeutic Process After developing a safe, supportive relationship, the counselor asks the client to visualize a distressing

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memory and guides the client to locate the brainspot. The counselor is simultaneously attuned to both the client in the relationship and the slightest body or eye movement. The client focuses on the spot and holds the feeling in place while processing the memory internally until it resolves itself. The SUDS is used throughout the process to measure progress, and “squeezing the lemon” continues until the memory is no longer distressing and the SUD is at or near 0. J. Barry Mascari and Jane M. Webber See also Eye Movement Desensitization and Reprocessing Therapy; Meditation; Mindfulness Techniques; Somatic Experiencing

Further Readings Grand, D. (1999). Defining and redefining EMDR. New York, NY: Biolateral Books. Grand, D. (2001). Emotional healing at warp speed: The power of EMDR. New York, NY: Harmony Books. Grand, D. (2013). Brainspotting: The revolutionary new therapy for rapid and effective change. Lewisville, CO: Sounds True. Scaer, R. (2005). The trauma spectrum: Hidden wounds and human resiliency. New York, NY: W. W. Norton.

BREATHWORK IN CONTEMPLATIVE PSYCHOTHERAPY Breathwork is a meditation technique used by contemplative psychotherapists that involves becoming aware of one’s breath and using it to develop self-awareness, or mindfulness, to enhance personal development and clinical exploration. Contemplative psychotherapists incorporate Western psychology with Eastern spiritual practices in their work with clients. Because the breath can be controlled both automatically and consciously, it is seen as a bridge between mind and body, according to ancient Buddhist and Yoga teachings. Contemporary research also affirms the efficacy of breathwork in psychotherapy. Through breathwork, clients learn to develop their particular, individual breath, which brings them closer to their true, or primordial, self.

Historical Context Focusing on the breath is an ancient practice of many Eastern wisdom traditions. It is called pranayama by yogis, tummo by Tibetan Tantrists, and anapanasati by Buddhists. The Chinese spiritual practices of T’ai Chi and Qigong also consciously use the breath. Yogic and Tibetan breathing techniques change the breath to bring about certain physiological, spiritual, and psychological changes. Anapanasati, the classic Buddhist technique, does not involve deliberately changing the breath; however, the term means “mindfulness of breathing” or “conscious breathing.” Nevertheless, observing the breath often permits the breath to become longer, deeper, and more relaxed. Based on Buddhist practices, which include meditation and breathwork, as well as philosophy and psychology, Chogyam Trungpa Rinpoche (1939–1987) developed the theory of contemplative psychotherapy at Naropa University in Colorado. Starting in the 1970s as part of the human potential movement, breathwork was increasingly used by Western psychologists as a therapy tool. Today, many contemplative psychotherapists employ a variety of breath modalities. Breathwork helps clients access the deepest parts of the mind and brain, enhancing psychotherapeutic treatment.

Theoretical Underpinnings People are born breathing from the diaphragm. Anyone who has watched an infant, dressed only in a diaper and lying on its back, can see the process very clearly. To inhale, the infant’s belly goes out, the ribs expand, and the collarbone goes up. To exhale the reverse happens: The infant’s collarbone goes down, the ribs go in, and the belly goes in. An observer can actually see the diaphragm move. Many people lose their natural breath and its rhythm as they age. People also often hold the breath when stressed. According to contemplative psychotherapy, the breath reflects our emotions. Through breathwork, people find the original diaphragmatic breath, leading them to the core of their being or their original selves. Using anapanasati, or natural diaphragmatic breathing, a person can still his or her mind, create a feeling of peace and spaciousness, and provide a perspective from which to experience and investigate

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thoughts, feelings, time, and space in the moment as the person becomes less reactive to life. With this technique, changing the breath can change one’s emotional state, which is especially helpful for people who are feeling stressed or anxious.

Major Concepts Breathwork psychotherapists operate from several major concepts that guide their work to help clients become more self-aware, including anapanasati, observing the breath, the true self, and mindfulness. Anapanasati

Anapanasati is the process of observing the breath without trying to change it. Observing the Breath

Observing the breath, an intimate experience, leads clients inward toward meditation and closer to the true self. As clients find their individual breath, they find their true self. True Self

The true self expresses an individual’s inner nature of goodness and wisdom, an unwrapping of life experiences that encompasses one’s identity. Mindfulness

Mindfulness is a deep honesty about and acceptance of the present, or experience in the moment. To be mindful is to be right here, right now, receptive to what arises but not caught in the experience.

Techniques Contemplative psychotherapists use several specific techniques in their work: breathwork, anapanasati, pranayama, and the psychotherapeutic use of breathwork. Breathwork

Breathwork, itself, is a primary technique used in this therapeutic approach. Breathwork is a

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way to learn to be aware of the breath, to become centered and present, and to enter the meditative state. Breathwork begins with good posture; the client sits in a chair, toward the edge, and on the tailbone, so that the spine stretches upward and the chin is slightly tucked. Good posture ensures the lungs’ ability to inflate properly. The client’s eyes may be partly open, and the client is asked to notice the air flowing in and out of the nostrils. This simple noticing may continue, or, alternatively, the therapist can ask the client to change the breath, making it longer and slower, perhaps pausing between inhales and exhales. There are many different ways to change the breath, which can cause psychological, spiritual, and physiological changes in the client. Anapanasati

In anapanasati, practitioners do not change the breath but rather follow the teachings of the Buddha and simply remain aware of the breath. The experience is one of “being breathed” rather than breathing. Each inhale and exhale together forms one round; one technique is to count each round up to the number 10. Once the number 10 is reached, another round begins, starting from 1. Pranayama

There are many varieties of pranayama, which means to extend one’s breath. A basic breath type taught to clients is to notice the pause between the bottom and the top of the breath (exhaling and inhaling, respectively) and to gradually lengthen this natural pause, or suspension. Psychotherapeutic Use of Breathwork

Both the client and the therapist can benefit from the use of breathwork, which is often accompanied by feelings of relaxation and positive energy. Breathwork stimulates endorphin production and causes the heart and respiration rates to become synchronous, producing feelings of calm and centering. These feelings that follow the use of the techniques allow for a deeper exploration of the client’s emotional life and inner world.

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Therapeutic Process The contemplative psychotherapist is trained in both psychology and mindfulness practices, grounded in the belief that meditation helps people draw closer to their true selves. Both therapist and client employ meditative techniques as part of their inner search and intimate therapeutic relationship. Breathwork and talk therapy together construct a positive synergy that can be beneficial to personal development for the client. Lynn Somerstein See also Body-Mind Centering®; Contemplative Psychotherapy; Mindfulness-Based Stress Reduction; Neurological and Psychophysiological Therapies: Overview

Further Readings Carter, J., Gerbarg, P. L., Brown, R. P., Ware, R. S., D’Ambrosio, C., Anand, L., . . . Katzman, M. A. (2013). Multi-component yoga breath program for Vietnam veteran post traumatic stress disorder: Randomized controlled trial. Journal of Traumatic Stress Disorders & Treatment, 2(3), 1–10. doi:10.4172/2324-8947.1000108 Easwaran, E. (2007). The Dhammapada: Introduced and translated by Eknath Easwaran. Tomales, CA: Nilgiri Press. Loizzo, J. (2000). Meditation and psychotherapy: Stress, allostasis and enriched learning. In P. Muskin (Ed.), Complementary and alternative medicine and psychiatry (pp. 147–198). Washington, DC: American Psychiatric Press. Van der Kolk, B. A. (1996). The body keeps the score: Approaches to the psychobiology of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 214–241). New York, NY: Guilford Press. Zucker, T. L., Samuelson, K. W., Muench, F., Greenberg, M. A., & Gevirtz, R. N. (2009). The effects of respiratory sinus arrhythmia biofeedback on heart rate variability and posttraumatic stress disorder symptoms: A pilot study. Applied Psychophysiology and Biofeedback, 34, 135–143. doi:10.1007/s10484-009-9085-2

BRIEF SOLUTION-BASED GROUP THERAPY See Focused Brief Group Therapy

BRIEF THERAPY Brief therapy is a term that refers to various intervention approaches that endeavor to get from Point A (the problem that led to therapy) to Point B (the resolution that ends therapy) via a direct, parsimonious, and efficient route. Brief therapy may be defined succinctly as time-sensitive treatment to relieve psychological distress and/or promote growth or as the development of a collaborative alliance and an emphasis on patient strengths in the service of an efficient attainment of cocreated goals. Synonymous with brief therapy is the phrase planned short-term therapy. Another closely related term is time-limited therapy, which explicitly emphasizes the temporal boundaries of the treatment. The approach is intended to be quick and helpful, without anything extraneous and without one more session than necessary. Brevity and shortness are watchwords signaling efficiency, the contrast being the more intentionally protracted or open-ended course of traditional long-term (often psychodynamic) therapy. Most brief therapy is de facto brief, by design or default, meaning a few sessions, over weeks to months. Abundant research shows that the average length of therapy is three to eight sessions and the modal or most common length of treatment is only one session. Brief therapy is used generically to indicate any time-sensitive, goal-directed, efficiency-focused intervention strategy (and could thus include brief psychodynamic therapy, brief behavior therapy, brief family therapy, etc.). It is sometimes also used to refer particularly to the therapy approaches— such as those developed at the Mental Research Institute in Palo Alto, California, and the Brief Family Therapy Center in Milwaukee, Wisconsin— of practitioners influenced by the pioneering strategic hypnotherapy work of Milton H. Erickson (1901–1980).

Brief Therapy

Historical Context It could be said that the father of psychoanalysis, Sigmund Freud (1856–1939), was also the father of brief therapy in that some of his early cases lasted only a single session to a few months— although these cases were brief more by default or necessity than by design or intent. Psychoanalysis was also a research instrument, and treatment focused on transference, resistance, and unconscious material became longer and longer. World War II spurred interest in approaches that would help soldiers reduce symptoms more quickly and return to function either in combat zones or in civilian life—harbingers of what today are called “reality factors” and “accountability.” By the early 1950s, various theorists were exploring what could be done using psychodynamic principles in more active, focused, and shorter treatments. Others were exploring different theories and developing different approaches, such as cognitivebehavioral therapy, Gestalt therapy, transactional analysis, and family therapy. The Mental Research Institute was founded in 1959, and its Brief Therapy Center was soon established and developing strategic interactional therapy. In 1973, Jay Haley published Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. At around the same time, Paul Watzlawick, John Weakland, and Richard Fisch published Change: Principles of Problem Formation and Problem Resolution. During the mid-1980s, Steve de Shazer, who studied at the Mental Research Institute and had met Erickson, established the Brief Family Therapy Center and developed what he called solution-focused brief therapy. In 1988, a conference titled “Brief Therapy: Myths, Methods, and Metaphors” was held in San Francisco, California, with several thousand mental health professionals attending; several such conferences have been held since. Forms of managed mental health care, driven by cost containment, further supported the push for briefer (read cheaper) treatments—sometimes with dubious ethical and practical problems, such as undertreatment of some patients. Leading brief therapy practitioners spoke out strongly against the conflation of brief therapy and managed care. As they noted, brief therapy predated managed

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care. Although brief therapy principles such as having clear goals, spending more time looking forward than backward, and emphasizing patient strengths and resources might help make therapy more effective and cost-efficient, brief therapy was developed to more quickly achieve good clinical outcomes and help patients improve their quality of life and not primarily to cut costs or save money for insurance companies.

Theoretical Underpinnings Planned or intentional brief therapy is predicated on the belief and expectation that change can occur in the moment, particularly if theoretical ability, practical skill, and interest in efficacy are brought to bear. The work is not superficial or simply technique oriented; it is precise and beneficial, often yielding enduring long-term benefits as well as more immediate gains. Indeed, brief therapists recognize that what really counts is what happens after the session and thus will need to see its impact (outcome: change and durability) before assessing the “goodness” or effectiveness of a session. In addition to meaning “efficient” and “to the point,” brief therapy is also used sometimes to refer particularly to interventions based on certain theoretical principles (generally social constructionist), not on the number of sessions or length of treatment. The goal of brief therapy is not a reworking of the patient’s personality but, rather, the efficient resolution of the problem that has led the person to seek consultation. Directly or indirectly, these approaches involve a wide variety of creative methods that operate at the level of cybernetics and hermeneutics, strategies and language games, all more or less intended to influence how patients recursively interact and construe (or “story”) their experience. The brief therapist helps the patient develop new perspectives and access and use strengths to achieve specific goals. A symptom is an attempted solution to a problem that does not work or that engenders unwanted results. More of the same (behavior, outlook, defense, etc.) does not produce change. As the old saying goes, “It you don’t change directions, you’ll wind up where you’re heading!” Whether it is

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conceptualized as an intrapsychic compromise between an impulse and an anxiety, a “game people play,” or a self-perpetuating maladaptive interpersonal pattern, effective therapy involves breaking such a pattern, doing something different that results in new ways of thinking and being—which resolves the presenting problem and sometimes can have ripple effects that influence other aspects of the patient’s total lifestyle. Novelty may come by seeing oneself and one’s situation differently, by practicing a new way of transacting with others, by  experiencing unacknowledged feelings, or by utilizing strengths and abilities that were previously overlooked or are newly learned. Whatever the means, the brief therapist looks for ways to start or amplify the patient’s movement in the desired direction as soon as possible.

Major Concepts The brief therapist’s primary effort is directed to help the patient recognize options in the present that can result in enhanced coping, new learning, growth, and other beneficial changes. By entering the patient’s worldview, brief therapists have the advantage of being culturally sensitive—which is  important both for efficiently joining with patients and helping them to better use their various resources as well as for the broader social imperative of appreciating, embracing, and celebrating cultural diversity. The most frequently cited generic components of brief therapy are as follows: 1. A rapid and generally positive working alliance between therapist and patient 2. Focality, the clear specification of achievable treatment results, with keen respect accorded to the patient’s stated goals 3. A clear definition of patient and therapist responsibilities, with a relatively high level of therapist activity and patient participation 4. Emphasis on the patient’s strengths, competencies, resources, and adaptive capacities 5. Expectation of change, the belief that with skillful facilitation improvement is within the patient’s (immediate) grasp 6. Here-and-now (and next) orientation, the primary focus being on current functioning and

patterns in thinking, feeling, and behaving—and their alternatives 7. Time sensitivity, making the most of each session as well as the idea of intermittent treatment replacing the notion of a one-and-forall definitive “cure”

Techniques The innovative work of Erickson is especially difficult to summarize because it is individualistically based on the talents of particular patients and therapists—a situation that also makes systematic research quite problematic. For Erickson, the basic problem was not so much one of pathology or defect but of rigidity, the idea that people get “stuck” by failing to use a range of skills, competencies, and learnings that they have (perhaps unconsciously) but are not applying. Utilization, making constructive use of whatever the patient brings to the office (beliefs, behaviors, understandings, interests, and motivations), is thus primary. Various interventions are designed to put people in touch with their latent or overlooked abilities for the purpose of activating and transforming both inner worlds of experience as well as outer worlds of behavior and social community. The following are some of Erickson’s key methods: Hypnosis: Induction of trance and the use of multilevel communication to help patients focus and defocus their attention and to allow them to be more accepting of therapeutic suggestions and directives Storytelling and metaphor: Using imagery and enchantment to capture the ear of the listener and structure experience and convey meanings Therapeutic double-binds: Creating situations that require patients to think and act differently Time distortion: Expanding or contracting subjective time to allow more enjoyment or reduce discomfort, respectively, as well as providing pauses during which patients could choose healthier ways of responding Homework and directives: Giving behavioral assignments that lead patients to new experiences and meanings, as well as placing the patient under the control of the therapist Ordeal therapy: Motivating someone to give up a symptom by requiring increasingly onerous activities before doing the symptom

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The theorists-practitioners at the Mental Research Institute focused not on putative individual psychopathology but on identifying and modifying the interpersonal situation that requires or maintains a problem or symptom. They developed the concept that the attempted solution actually perpetuates the problem (as when an erstwhile romantic partner tries to draw the object of affection closer by pointing out his or her flaws or when an insomniac tries to force himself or herself to go to sleep). Reframing thus involves interventions that change the meaning or context of behavior by offering an alternative conceptual and/or emotional setting or viewpoint in relation to which a situation is experienced and thus placing it in another frame that fits the “facts” of the same concrete situation equally well or even better, thereby changing its entire meaning. The intention is to produce second-order change (not just less of the same), a shift in the rules that govern the system’s organization and patterns of interaction. Using symptom prescription and paradoxical intention, patients are sometimes taught to bring on (and thus tolerate and overcome) anxiety and depression and to have arguments when they are not mad (to learn that they have control and to reduce the partner’s assumptions and automatic response), and hesitant patients are urged to “go slow” and refrain from rushing toward a desired behavior. de Shazer (and his partner, Insoo Kim Berg, and others) at the Brief Family Therapy Center became interested in solution formation, when the problem is not a problem. They offered the “Basic Rules” of solution-focused therapy:

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Skeleton key question: Between now and the next time we meet, please notice so that you can describe it to me what you were doing differently when the problem did not occur. Exception question: What is different about those times when the problem does not happen? Efficacy (agency) question: How did you do that? What were you doing differently? Endurance (coping) question: Given the terrible situation, how come things aren’t worse? How have you managed to cope as well as you have? Scaling question: On a scale from 1 to 10, with 1 being none and 10 being total, what number would you give your current level of [hope, motivation, progress]? What will tell you that your level has gone up by one number?

Therapeutic Process The goal of brief therapy, regardless of the specific theoretical approach or technical method, is to help the patient resolve a problem, get “unstuck,” and move on. Techniques are specific, integrated, pragmatic, and as eclectic as needed. Treatment is focused, the therapist appropriately active, and the patient responsible for making changes. Each session is valuable, and therapy ends as soon as possible. Good outcome, not good process, is most valued. More is not better; better is better. The patient carries on and can return to treatment as needed. Michael F. Hoyt

If it ain’t broke, don’t fix it. Once you know what works, do more of it. If it doesn’t work, don’t do it again; do something different.

They vitiated the concept of resistance by developing different ways of cooperating depending on whether the patient is relating as a customer, a complainant, or a visitor. They also developed a series of questions to direct attention (“solution focus”) toward desired outcomes and helpful resources: Miracle question: Suppose tonight, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?

See also de Shazer, Steve, and Insoo Kim Berg; Erickson, Milton H.; Haley, Jay; Hypnotherapy; SolutionFocused Brief Therapy

Further Readings Battino, R. (2006). Expectation: The very brief therapy book. Norwalk, CT: Crown House. Bloom, B. L. (1992). Planned short-term psychotherapy: A clinical handbook. Boston, MA: Allyn & Bacon. Erickson, M. H. (1980). Collected papers (4 vols.; E. L. Rossi, Ed.). New York, NY: Irvington. Fisch, R., Ray, W. A., & Schlanger, K. (Eds.). (2010). Focused problem resolution: Selected papers of the MRI Brief Therapy Center. Phoenix, AZ: Zeig, Tucker & Theisen.

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Haley, J. (1973). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York, NY: W. W. Norton. Hoyt, M. F. (2000). Some stories are better than others: Doing what works in brief therapy and managed care. Philadelphia, PA: Brunner/Mazel. Hoyt, M. F. (2009). Brief psychotherapies: Principles and practices. Phoenix, AZ: Zeig, Tucker & Theisen. Hoyt, M. F., & Talmon, M. (Eds.). (2014). Capturing the moment: Single-session therapy and walk-in services. Bethel, CT: Crown House. Ratner, H., George, E., & Iveson, C. (2012). Solution focused brief therapy: 100 key points and techniques. New York, NY: Routledge. de Shazer, S. (1985). Keys to solution in brief therapy. New York, NY: W. W. Norton.

Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York, NY: W. W. Norton. Zeig, J. K., & Gilligan, S. G. (Eds.). (1990). Brief therapy: Myths, methods, and metaphors. New York, NY: Brunner/Mazel.

Websites BRIEF (formerly the Brief Therapy Practice): www.brief .org.uk European Brief Therapy Association: www.ebta.nu Mental Research Institute: www.mri.org The Milton H. Erickson Foundation: www .ericksonfoundation.org

C treatment. Paralleling the rise of psychedelic therapy is attack therapy. As experimentation of different forms of treatment became popular during the 1960s, some therapists believed that extreme confrontation and humiliation of clients, especially those struggling with addictions, would break down defenses and help clients work on unresolved issues. Following the heyday of the use of hypnosis and, later, psychoanalysis during the first part of the 20th century, with their focus on the unconscious, there was a widespread belief by some that early traumatic memories could be repressed and distorted by the unconscious and result in pathology later in life. To some degree, rebirthing and recovered memory therapy grew out of this belief, in the 1970s and 1990s, respectively. SOCE, such as reparative or conversion therapy, has the longest history, dating back at least to the 19th century, when hypnosis was used to change “unwanted” impulses, such as attraction toward same-sex individuals. Over the years, a variety of “techniques” were used to change a person’s attraction to same-sex individuals, including castration and lobotomy. In the latter part of the 20th century, a number of approaches arose that attempted to assist individuals with same-sex attractions in eliminating or refraining from acting on those urges. However, these approaches have had limited if any success and, indeed, have been found to be harmful to many individuals who have undergone such treatment. Today, most of the approaches listed in this category have strict warnings against their use, are banned, or are illegal. For instance, attack therapy

CAUTIOUS, DANGEROUS, AND/OR ILLEGAL PRACTICES: OVERVIEW Any psychotherapeutic approach should be performed cautiously, which is why throughout the United States psychotherapy cannot be practiced unless one is highly trained and licensed. However, certain approaches have been shown to be particularly harmful to clients and, if used at all, need to be conducted in controlled settings by highly trained therapists. Some approaches have been shown to be so harmful to clients that they have been deemed unethical by professional associations and illegal in some areas of the country. Although they have little in common with one another theoretically, attack therapy, psychedelic therapy, rebirthing, recovered memory therapy, and sexual orientation change efforts (SOCE) have all shown cause to be listed under the category of cautious, dangerous, and/or illegal practices.

Historical Context Despite the fact that their histories are rather distinct, the approaches in this category of cautious, dangerous, and/or illegal practices all arose in the mid- to late 20th century. Psychedelic therapy, as one might surmise, was fueled by the discovery of LSD in 1938 and its later popularization during the 1960s. Intrigued by the potential “mind-expanding” properties of LSD and other hallucinogens, some believed that the use of such drugs could expedite 149

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has been shown in numerous studies to have deleterious effects on some clients and is rarely used today. Rebirthing and recovered memory therapy are not scientifically based and have been shown to cause harm, and even death, in some of those who partake in it. Psychedelic therapy has left some with long-term psychological damage and has shown little ability at offering a standardized treatment. Finally, because homosexuality and other sexual orientation differences today are seen as normal and positive parts of human sexuality, and because evidence exists that shows that individuals who undergo SOCE are often psychologically damaged, all of the major mental health professions have established policy statements cautioning against or outright banning its use. In addition, many states have deemed its use to be illegal.

Theoretical Underpinnings Although attack therapy, rebirthing, recovered memory therapy, and psychedelic therapy all have an underlying belief that one must somehow uncover hidden aspects of self, they have little in common with one another theoretically. However, one common thread of these approaches is that they all can cause harm to the client or others and, therefore, should either be used cautiously or not used at all. Although research suggests that between 3% and 10% of clients become worse after any therapy, other research indicates that select therapies, such as the ones discussed in this entry, may have particularly large percentages of clients reacting negatively to treatment. Scott O. Lilienfeld suggests that harm can come in many forms, such as relatively large client dropout rates; harm to friends or relatives, such as when clients falsely accuse a friend or relative of abuse; an increase in negative symptoms; the appearance of new symptoms; or even physical harm or suicide. With all the major mental health professions including a statement in their ethics code regarding the importance of using only empirically sound approaches, or obtaining informed consent when not using such practices, it is important that all helping professionals know of the potential risk of any treatment. Although many approaches may cause some harm in small numbers of clients, Lilienfeld suggests that there are three levels of potential harm,

with Level 1 including those approaches that probably will cause harm in a number of clients. Under this model, the author’s list includes therapies such as attack therapy, rebirthing, and recovered memory therapy, and although he does not specifically mention psychedelic therapy or SOCE, these therapies seem to also fit into this category.

Short Descriptions of Cautious, Dangerous, and/or Illegal Practices The following therapies have been found to cause harm in some or many clients who have been exposed to them. Please see the individual entries in this encyclopedia for further information about their theory and the harmful effects they may have induced. Attack Therapy

Often used in a group setting with those who abuse substances, this approach uses intense forms of confrontation between the therapist and a client, or between group members and a client, to break down defenses, humiliate the client, and ultimately push the client toward change. Shown to have deleterious effects for a large percentage of clients who participate, the approach is rarely used today. Holding Therapy

An approach loosely based on attachment theory, this therapy uses physical holding, cognitive restructuring (e.g., strong advice giving), and other techniques to assist aggressive children and children with autism in developing new, healthier attachment styles and in decreasing aggression. Holding therapy has led to unanticipated psychological damage and death in some children. Psychedelic Therapy

This therapy relies on LSD, or other hallucinogenic or entheogenic drugs, to enhance the psychotherapeutic experience. Reaction to the experience can vary dramatically by client and has been shown to be interpreted differently by therapists, making standardization of the approach difficult. Today, it is practiced almost exclusively in a controlled, experimental setting.

Cerebral Electric Stimulation

Rebirthing

Based on the idea that rage from birth trauma can be repressed, this approach has parents or therapists wrap children in blankets and hold them tightly or sit on them to reemulate the birth process. A number of children have been hurt or killed in this process, and no controlled studies have been conducted to support its efficacy.

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Lilienfeld, S. O., Fowler, K. A., Lohr, J. M., & Lynn, S. J. (2005). Pseudoscience, nonscience, and nonsense in clinical psychology: Dangers and remedies. In R. H. Wright & N. A. Cummings (Eds.), Destructive trends in mental health: The well-intentioned path to harm (pp. 187–218). New York, NY: Routledge.

CEREBRAL ELECTRIC STIMULATION Recovered Memory Therapy

This therapy assumes that traumatic childhood events can be hidden from consciousness yet still affect an individual’s psychic world and cause severe psychological disturbance. This approach encourages the reemergence of traumatic memories assumed to have been lost through amnesia; however, it has been found that such remembrances are often false memories. In addition to potential psychological damage, recovered memory therapy has resulted in false accusations of abuse against individuals. Sexual Orientation Change Efforts

These approaches, which attempt to suppress or change one’s sexual orientation or behavior, have been deemed unethical by professional associations because they pathologize one’s sexual identity and often leave individuals psychologically damaged. These approaches are illegal in many parts of the United States. Edward S. Neukrug See also Attachment Theory and Attachment Therapies; Attack Therapy; Holding Therapy; Psychedelic Therapy; Rebirthing; Recovered Memory Therapy; Sexual Orientation Change Efforts

Further Readings Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716. doi:10.1146/annurev.psych.52.1.685 Lambert, M. J., & Miller, M. J. (2001). Helping prospective patients avoid harmful psychotherapies. Journal of Contemporary Psychology, 46, 386–388. Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53–70. doi:10.1111/j.1745-6916.2007.00029.x

Cerebral electric stimulation (CES) consists of noninvasive techniques in which varying levels of electricity are passed across the scalp of an individual using at least one electrode to treat a variety of health-related issues. The tremendous technological advances of the past 100 years have greatly influenced the ways mental health practitioners use electric stimulation. Styles and use of CES differ based on electric dosage as well as electrode placement. While CES is most commonly used for chronic pain, anxiety, and depression, increased research is examining the practicality of this practice in the treatment of other mental and physical health issues.

Historical Context The use of electricity as a form of medical treatment has a long history in medical literature. Early Greek literature includes discussions of “electric fish” to address chronic pain, epilepsy, and other ailments that early physicians could not treat with traditional remedies. In 1902, the use of what would be termed electromedicine reemerged when two French doctors experimented with lowintensity electrical currents across the scalp, which they called electrosleep. However, this research was not published until 1914 by Louise Robinovitch. Over the next 60 years, Russia and Europe dominated research in this field. In 1963, the United States began to see an increased use of electrosleep, and although research discovered that sleep did not  in fact occur, there was a state of relaxation resulting from its effects. In the early 1900s, a parallel form of CES— called electroanesthesia or electronarcosis—was also researched. In contrast to electrosleep, electroanesthesia used high-frequency stimulation as a way to induce anesthesia without the use of

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chemicals. Electroanesthesia began to lose ground as a treatment as a number of side effects were discovered, including “fading,” or the loss of the anesthetic effect over time during surgery. Therefore, to keep a patient anesthetized, it became necessary to increase the frequency stimulation, which then led to other unpleasant side effects. There are a number of problems that hinder a clear understanding of CES. First, the literature is littered with varying terms that can be confusing. Second, these terms are often associated with dosage level and electrode placement recommendations given by regulatory agencies. As continued analysis and technological advances led to changes in treatment protocols and to increasingly complex dosage protocols, the federal government used these changes to define the varying types of CES. The most notable agency to regulate CES is the U.S. Food and Drug Agency (FDA). In 1977, after review by the FDA, cerebral electric therapy and its derivatives were granted FDA approval as a Class III device for the treatment of anxiety, depression, and insomnia. According to the FDA, these devices consist of a microprocessor and electrodes used to pass the current across the head. In essence, a modern CES is delivered via a small device that has a set of controls allowing the user to manipulate microcurrent levels and intensities.

Theoretical Underpinnings It is unclear at this time how CES works. One theory discusses CES affecting the thalamic system, limbic system, and reticular activating system as well as regulating the brain’s electroencephalogram signature. The electroencephalogram brain waves recognized in current research include delta, theta, alpha, beta, and gamma. The brain wave most associated with CES is the alpha wave. This wave is associated with a calm and relaxed state and, when induced, is correlated with reduced stress hormone levels and mood stabilization. Because the brain functions using combinations of electricity and neurochemicals, it makes sense that small shifts in the electrical signals can help the brain regain a balanced state. Another potential theory behind the effectiveness of CES describes the use of electrical stimulation increasing one’s pain threshold, along with reducing anxiety and depressive symptoms below

clinical levels. Additionally, it is possible that CES increases the parasympathetic nervous system response by activating the vagus nerve. Although researchers do not know how CES works, they do know that the human brain is quite complex, and it is likely that research to understand the impact of CES on the brain will continue for the foreseeable future.

Major Concepts While full understanding of CES is yet to come, it is important to understand how the various forms of CES (e.g., electrosleep, electroconvulsive therapy, cranial electrotherapy stimulation, and transcranial electric stimulation) differ based on their physical waveform, the dosage of electric stimulation, the length of time of electric stimulation, and their electrode placement. Ultimately, it is important to understand how each of these early and later forms of CES differ in protocol, dosage, and process, as these factors provide the definition for each type of device. Electrosleep

Electrosleep uses a 2- to 25-milliamps (mA) monophasic square wave that pulses at 100 cycles per second (cps) for 0.3 to 0.5 milliseconds (ms). The average time for therapeutic relief per session is 20 to 60 minutes (min), with electrode placement occurring over the eyes and the mastoid bone. Electroconvulsive Therapy

Electroconvulsive therapy uses an 800-mA monophasic square wave or biphasic sine wave for 1 to 6 seconds (s). Electrode placement can occur either bilaterally or unilaterally at the scalp. Cranial Electrotherapy Stimulation

Cranial electrotherapy stimulation was originally called cranial electrostimulation therapy in 1966. It used a 0.1- to 0.5-mA monophasic or biphasic square wave with a pulse frequency of 30 to 100 hertz (Hz) and a pulse width of 1 to 2 ms. Electrode placement occurred over the eyes and the mastoid bone, as in electrosleep. In 1978, cranial electrostimulation therapy was renamed cranial

Cerebral Electric Stimulation

electrotherapy stimulation. Cranial electrotherapy stimulation uses a 15/500/15,000-Hz stimulation square wave, which is typically biphasic but can also be monophasic. The electric stimulation occurs in 50-ms bursts, with a 16.7-ms off period. Electrode placement is also moved to either the ears or the forehead. Treatment time typically lasts from 20 to 60 min. Transcranial Electric Stimulation

Transcranial electric stimulation uses 150 to 1,840 volts and lasts between 13 and 48 ms. The monophasic stimulation occurs every 1 to 3 s. Electrodes can be placed in multiple configurations. A bifocal configuration includes two electrodes placed over the identified treatment area of the scalp. A unifocal configuration can include from 2 to 13 electrodes placed around the scalp and a single electrode placed on top of the head.

Techniques There are a number of CES techniques currently available for the treatment of a multitude of mental health issues. The most common ones are electroconvulsive therapy, transcranial electric stimulation, transcranial magnetic stimulation, and cranial electrotherapy stimulation. An early form of CES is electroconvulsive therapy, or electroshock therapy, developed around 1933. The use of electroconvulsive therapy was popularized in the 1960s and 1970s as a nondrug treatment for severe depression and psychosis. The FDA approved electroconvulsive therapy as a treatment for depression in 1976, 1 year prior to its approval of cranial electrostimulation therapy, also known as cranial electrotherapy stimulation. As the FDA approval of both electroconvulsive therapy and cranial electrostimulation therapy happened within an approximate 1-year time frame, these terms are often used interchangeably, despite major differences between the two. The use of electroconvulsive therapy has been cyclical due to past adverse events associated with the practice. Recent technological advances, however, have allowed for changes in electroconvulsive therapy protocols, which are allowing psychiatrists to now consider electroconvulsive therapy as a potentially safe practice. While they both provide noninvasive

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electrical stimulation to the brain, the purpose of the dosage and the results vary considerably: Electroconvulsive therapy is a high-voltage repetitive current designed to induce seizure activity in the brain, while cranial electrotherapy stimulation uses a low-dosage microcurrent to induce a relaxed state. Transcranial electric stimulation, developed by P. A. Merton and H. B. Morton in 1980, is applied by stimulating the motor cortex areas of the brain. One problem with transcranial electric stimulation is the high pain levels associated with activated pain fibers in the scalp. Using magnets, Anthony Barker in 1985 developed transcranial magnetic stimulation, which also activated the motor cortex areas of the brain but with little or no pain. Transcranial magnetic stimulation is unique in that it can stimulate or inhibit regions of the brain, allowing for functional mapping of the cortex. Because transcranial magnetic stimulation can temporarily inhibit brain function when paired with positron emission topography or functional magnetic resonance imaging, it allows researchers to access brain function by the millisecond. While single transcranial magnetic stimulation pulses do not change brain function, rapid transcranial magnetic stimulation (rTMS) has produced results that last after the stimulation period. Research has shown promise in a number of areas, most notably in improving mood disorders. In 2008, the FDA approved the use of rTMS to treat depression. While it works similarly to electroconvulsive therapy, it has two distinct advantages: rTMS does require anesthesia and has fewer side effects. Another form of CES known as cranial electrotherapy stimulation, which uses a small handheld device, is FDA approved to reduce anxiety, depression, and insomnia. Cranial electrotherapy is marketed today under a variety of names, such as Alpha-Stim, CES ultra, and Fisher Wallace. Using a random waveform generator, which prevents the brain from needing ever-increasing doses of treatment, it is believed that the use of cranial electrotherapy stimulation increases activity in some neurological systems while deactivating others. These shifts are called neuromodulation, and it is believed that such stimulation creates changes in nerve cells that then change the electric and chemical activity in the brain stem.

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Cerebral Electric Stimulation

Transcutaneous electrical nerve stimulation is another treatment often confused with CES yet is not considered a CES device. Transcutaneous electrical nerve stimulation current is not passed across the scalp and therefore does not meet the definition for CES. Additionally, transcutaneous electrical nerve stimulation differs in how the voltage level is controlled. Individuals using transcutaneous electrical nerve stimulation report tolerance to initial settings, but long-term or continued usage often requires increasing the treatment dosage to reduce pain.

Therapeutic Process Most notably, the therapeutic process for the majority of CES requires treatment intervention to take place in the office of a doctor, often a psychiatrist. Electroconvulsive therapy continues to require a general anesthetic and, based on client evaluation, may be performed on either an inpatient or an outpatient basis. Treatment typically happens two to three times a week for about 4 weeks. This form of therapy is generally successful when other forms of treatment for depression fail. Transcranial magnetic stimulation requires passing a large magnet across the scalp. While this CES therapy does not require anesthesia, it does require knowledge of where to place the magnetic wand against the scalp, as well as knowledge regarding correct dosing. Magnetic stimulation is increased until the client’s fingers or hands twitch, which is known as the motor threshold. The magnetic dosage can be adjusted as needed during each session. Treatment typically happens 5 to 6 days a week for approximately 6 weeks. Transcranial magnetic stimulation is primarily used for depression without psychosis. Although cerebral electrotherapy stimulation can take place in a doctor’s office, it is not a requisite for treatment. Cranial electrotherapy stimulation is currently the only CES device that can be used on clients by licensed mental health workers (e.g., Licensed Professional Counselors, Licensed Clinical Mental Health Workers, and Licensed Marriage and Family Therapists), and it does not require a medical license. While cerebral electrotherapy stimulation requires a prescription, this form of CES can be used in the comfort of an individual’s home. Cranial electrotherapy stimulation

has a number of benefits. The ratio of cost to benefit is generally low. Cranial electrotherapy stimulation has minimal side effects, and the current average cost of 1 year’s worth of treatment is $3.27 per session. Additionally, the low cost allows this technique to be paired with other forms of therapy such as neurofeedback, biofeedback, and traditional talk therapy in the clinician’s office. Researchers are rapidly embracing forms of CES to address mental health issues in ways that are noninvasive and cost-effective. Human brains are complicated and delicate organs that use a combination of electrical and chemical processes to drive biological processes. Both electrical and chemical solutions have been explored over the past century, with chemicals often the option of choice for both doctors and their clients. The increased understanding of technology during the past decade has increased the research on using noninvasive, nondrug options that provide both temporary and lasting treatment. In addition to the original research on anxiety, depression, insomnia, and chronic pain, researchers are exploring other ways in which CES can benefit both physical and mental health. Current research includes expansion into addressing posttraumatic stress disorder, addiction, attention defict disorder, traumatic brain injury, Parkinson’s disease, as well as many others. Julie A. Strentzsch See also Bioenergetic Analysis; Biofeedback; Integrative Forgiveness Psychotherapy; Mindfulness-Based Stress Reduction; Neurofeedback; Somatic Experiencing

Further Readings Guleyupoglu, B., Schestatsky, P., Edwards, D., Fregni, F., & Bikson, M. (2013). Classification of methods in transcranial Electric Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations. Journal of Neuroscience, 219, 297–311. doi:10.1016/j.jneumeth.2013.07.016 Hallet, M. (2000). Transcranial magnetic stimulation and the human brain. Nature, 406, 147–150. doi:10.1038/35018000 Kirsch, D. L. (2002). The science behind cranial electrotherapy stimulation (2nd ed.). Edmonton, Alberta, Canada: Medical Scope.

Chaos Theory Kirsch, D. L., & Gilula, M. F. (2007). CES in the treatment of anxiety disorders: A review and metaanalysis of cranial electrotherapy stimulation (CES) in the treatment of anxiety disorders. Practical Pain Management, 7(4), 33–41. Krisch, D. L., & Nichols, F. (2013).Cranial electrotherapy stimulation for treatment of anxiety, depression, and insomnia. Psychiatric Clinical, 36, 169–176. doi:10.1016/j.psc.2013.01.006

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eventually chaotic. In 1934, the biologist Ludwig von Bertalanffy asserted his view of all living organisms as a system that adapts to the environment and occurs at various ecological levels. Combined, these discoveries support the importance of small changes in social systems and how adaptation and transformation occur.

Theoretical Underpinnings

Chaos theory suggests that a small change in initial conditions can create unpredictable outcomes over time. This simplistic definition is commonly known as the butterfly effect. Its genesis comes from mathematical and physics theory and is gaining popularity in the social sciences. Chaos theory explores how change does not occur in a smooth linear path but progresses irregularly and irreversibly over time while increasing in organization and complexity. Change can become unstable and compounds until it appears disordered. Within the apparent disorder, organization will occur that is transformative. Researchers, family therapists, career counselors, and psychologists were among the first to use chaos theory to better understand how individuals, families, and groups adapt and transform to meet environmental pressures.

Chaos theory combines psychology and physics to explain individuals and their relationships. The interactions within a person and between people that form relationships are seen as a physicist might see a planetary system in motion. The hallmark of chaos theory is sensitivity to initial conditions. A system progresses from a starting point along a nonlinear trajectory where it modulates inputs and outputs to adapt, transforming from one state to another. It adapts to meet changing environmental demands by learning and becoming more complex as it reflects on prior interactions. Chaos theory emphasizes an organismic view that systems learn continuously, creating irreversible transformation within the system. As the system’s rate of transformation increases, it moves toward the edge of chaos, where it can become overwhelmed. Past the edge of chaos, a system appears chaotic but is reorganizing itself within the apparent disorder. A therapist can assist the system to reorganize and maintain a healthy level of transformation.

Historical Context

Major Concepts

In 1963, while attempting to replicate a weather system forecast, Edward Lorenz, who became known as the father of chaos theory, entered seemingly insignificantly rounded numbers into a linear model, which created an unpredictable difference in the outcome. Lorenz’s discovery that a small change in initial conditions can have a significant impact on later outcomes was popularized with sayings such as “If a butterfly flapped its wings in Brazil, a year later there could be a tornado in Texas.” Lorenz’s discovery and its application to the social sciences have been supported by other historical findings. In the 1880s, the physicist Henri Poincare disputed Isaac Newton’s clockwork deterministic prediction of the relationship between two planetary bodies in motion by showing that by adding a third body to the system, it became complex, unpredictable, and

Because of chaos theory’s wide range of application, it is associated with numerous concepts. The more notable and widely accepted concepts are sensitivity to initial conditions, fractals, bifurcations, attractors, self organization, and iteration.

CHAOS THEORY

Sensitivity to Initial Conditions

The smallest change in initial conditions can have drastic, disproportional, and improbable effects. This is better known as the butterfly effect. Fractals

Fractals are geometrical structures that form patterns in nature. Fractals replicate themselves, forming layers of similar shapes or patterns of interactions.

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Chaos Theory

Patterns of interactions include thoughts, feelings, and behaviors that are observed at different levels, such as within an individual, a family, or a social system. Bifurcation

A bifurcation is a division into two parts. It occurs at a critical point when normal functioning of a system becomes overwhelmed by environmental demands, and the system can no longer maintain its current organization and splits. Attractor

An attractor exerts force on a system like gravity would affect a pendulum. A system may move within the boundaries of the attractor but will not repeat any one position. Attractors govern the movements of systems and affect their functioning. Self Organization

Living organisms have the ability to adapt to their environment by creating order from apparent chaos. Organisms can become overwhelmed to the extent that they move past the edge of chaos, becoming chaotic, and then reorganize into a more complex adaptive form to meet the demands of the environment. Iteration

Iteration is a process in which new information is repeatedly reflected on to create exponential growth. It is an indication of the irreversible experiences where a person self reflects and grows exponentially so that the whole is more than the sum of the parts.

Techniques Chaos theory does not have a widely accepted unique therapeutic modality. Therapeutic techniques focus on resolving conflict by focusing on communication to facilitate change and self organization. Communication

Communication is a critical component of the system’s change process. It serves to regulate and facilitate accurate expressions and avoid miscues or double binds that can be harmful to relationships.

Group Therapy

Chaos theory is used to find patterns of interactions among participants. Patterns of group interactions associated with dysfunction can be interrupted or exacerbated to foster self organization into a more adaptive pattern. Mapping

Mapping is similar to ecological maps and genograms, which can encourage client insight by organizing relationships between people, thoughts, behaviors, and feelings to foster reflection and adaptation. Narratives

Chaos theory restories or reframes planned and unplanned life transitions as opportunities to reorganize, become more complex, and achieve a more desirable state. Systemic Family Therapy

Systemic family therapy focuses on the relationships within the family system. The family is assisted in identifying the interactions within a person and between family members that contribute to family dysfunction by working with the whole family unit.

Therapeutic Process Chaos theory suggests that therapy usually begins when the system is overwhelmed and is approaching a critical point or is in a chaotic state. Systems are seen on a stagnant to chaotic continuum. It suggests that change is an ongoing process affected by internal and external attractors. The therapist acts as an attractor that establishes boundaries, regulates interactions, and appropriately energizes or stabilizes the system to facilitate adaptive self organization. The goal is to increase the system’s complexity to meet changing environmental demands and optimize its adaptability to maximize biopsychosocial functioning. Therapy provides space and support for the individual’s own self-organizational processes. Jason S. Jordan

Characteranalytical Vegetotherapy See also Attachment-Focused Family Therapy; Biopsychosocial Model; Ecological Counseling; Narrative Therapy; Palo Alto Group; Positive Psychology; Systemic Family Therapy

Further Readings Bütz, M. R., Chamberlain, L. L., & McCown, W. G. (1997). Strange attractors: Chaos, complexity, and the art of family therapy. New York, NY: Wiley. Gleick, J. (2008). Chaos: Making a new science. New York, NY: Penguin Books. Guastello, S. J., Koopmans, M., & Pincus, D. (Eds.). (2011). Chaos and complexity in psychology: The theory of nonlinear dynamical systems. New York, NY: Cambridge University Press. Miller, J. H., & Page, S. E. (2007).Complex adaptive systems: An introduction to computational models of social life. Princeton, NJ: Princeton University Press.

CHARACTERANALYTICAL VEGETOTHERAPY The term characteranalytical vegetotherapy was coined by Wilhelm Reich (1897–1957) in 1935 in Oslo, Norway, and describes his method for the practice of psychoanalysis. He introduced significant modifications to both the concept of setting and the clinical tools used. These would subsequently form the basis for the so-called body-oriented psychotherapies. Characteranalytical vegetotherapy is based on psychodynamic theory and introduces the corporeity of the patient as a third element in the psychotherapeutic setting. The patient’s body, however, takes on diagnostic value, with information obtained from the “language of the body” (the word character means etymologically “incised mark,” incised marks from the object relations in the seven corresponding bodily areas, or “levels”), and it represents a therapeutic guideline. The sense organs give access to the psychic functions and, together with the analysis of the characterological traits of the patient, provide insights that, then, suggest possible corrective experiences. All of this occurs in the psychotherapeutic setting and in the context of the most appropriate intersubjective relationship.

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Historical Context Reich became interested in sexology in the 1920s, near the end of his studies on neuropsychiatry in Vienna, Austria. He was fascinated by Sigmund Freud, and his approach to psychoanalysis was channeled in that direction from a very young age. He was also influenced by the ideas of the vitalist philosopher Henry Bergson, by the theory of Karl Marx, and by several other cultural and scientific contributions of that time. These included the connection between emotions and the movement of the body (Elsa Gindler and Elsa Linderberg), the relaxation techniques of Edmund Jacobson and Johannes Heinrich Shultz, and the medical investigations on the autonomous (vegetative) nervous system carried out by A. Muller and his team from Leipzig University. Muller’s results helped Reich understand the influence of psychism and the “affects,” or “moods,” in many pathological disorders, later leading to further development of psychosomatic medicine. Reich joined the psychoanalytical circle of Vienna, but after a few years he moved to Berlin, attracted by the political and social movements that were starting there, before Adolf Hitler became predominant. These events put the psychoanalytical fraternity in a very delicate position. They felt uncomfortable about Reich’s radical political beliefs, which led to Reich’s expulsion from the newly created International Psychoanalytic Association. Persecuted by the Nazis, Reich was given shelter by a group of Norwegian psychoanalysts, including Ola Raknes and Nic Waal. He settled in Oslo from 1935 to 1939, where he developed his own contribution to psychoanalysis, which would later be called characteranalytical vegetotherapy. The term would be changed to characteranalytical orgonotherapy while he was in the United States, where he had emigrated in 1939, when the war moved to northern Europe. Reich, unlike Freud, did not include a detailed description of his clinical approach in his writings. After his death, different interpretations of his theories appeared, with numerous people claiming to continue his work and others who took some aspects of his clinical approach and developed new techniques such as Rolfing, bio-respiration, and the primal cry.

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Decades ago, the European Association for Body Psychotherapy was founded, representing the various approaches that arose from Reich’s work, including bioenergetic analysis, biosynthesis, the biodynamic approach, somatotherapy, and others, in addition to characteranalytical vegetotherapy. Characteranalytical vegetotherapy continued its own development and evolution due to the contribution of collaborators and direct disciples of Reich. A few years before his death in 1975, Ola Raknes sponsored the creation of the first training institute, called the Scuola Europea Di Orgonoterapia, or S.E.Or. (European School of Orgonotherapy), whose president was the Italian neuropsychiatrist Federico Navarro (1924–2002), Raknes’s student and collaborator. Navarro’s work in creating a system of clinical methodology was completed with the contribution of his students and colleagues, such as Jean Loic Albina in France and Genovino Ferri in Italy. Ferri has integrated characteranalytical vegetotherapy with analysis of the character of the relationship, defining the relationship as being ‘‘the third complex living system’’ that is born from the dialogue between the analyst’s and the patient’s traits. Other contributors include Markus Valimaki in Finland, Clorinda Lubrano in Greece, Bjorn Blummenthal in Norway, and Xavier Serrano-Hortelano in Spain. Serrano-Hortelano has created a differential structural diagnostic method, which permits the application of the methodology according to the structure of the patient (neurotic-adaptive, borderline, or psychotic-mimetic), as well as a focused, psychosocial method known as “brief characteranalytical psychotherapy.” Today, there are training institutes for characteranalytical vegetotherapy in France, Norway, Finland, Italy, Greece, Spain, Brazil, Chile, and Mexico. Characteranalytical vegetotherapy has been recognized as a scientific modality by the European Association for Psychotherapy.

Theoretical Underpinnings The clinical aim is for the patient to recover the identity of his or her Ego, which has been stifled by psychic or somatic defense mechanisms established during a childhood filled with deficiencies and repressions that have limited the growing-up process. For this reason, it is necessary for the patient

to recover the ability to feel pleasure and to restore the energetic pulsation, regulating the organism and restoring psychosomatic health. To achieve all this, the patient must reach a balance in the autonomous (vegetative) nervous system, through analysis and disassembling the character, which is defined as the muscular armor of the Ego (the mind–body functional identity). In his work The Function of Orgasm, published in 1927, Reich wrote that by relaxing the chronic character attitudes, we obtain reactions in the vegetative nervous system. He stated that we also liberate not only the character attitudes but also the corresponding muscular attitudes. In this way, part of the work is moved from the psychical and characterological field to the immediate disassembling of the muscular armor. Reich considered a neurosis to be not only the expression of a disturbance in the psychic balance but also, in a much deeper, well-justified sense, the expression of a chronic disturbance in vegetative equilibrium and natural mobility. From this perspective, the psychic structure is, therefore, a determinate biophysical structure. In the characteranalytical vegetotherapy setting, which has been influenced by Sandor Ferenczi, the psychotherapist adopts a more active role by placing himself or herself next to, instead of behind, the patient, which he or she does without abandoning his or her neutral position. The psychotherapist also introduces into the analytical dynamic the importance of the spontaneous attitudes and some corporal aspects of the patient, such as the patient’s manner of breathing or muscular rigidities. The psychotherapist thus is able to promptly intervene as required, such as through application of pressure or focused massage. Reich states that it is surprising to see how the decomposition of a muscular contraction not only liberates vegetative energy but also reproduces in the memory the situation in which the repression of the impulse took place. He says that every muscular contraction contains the story and the meaning of its original creation. He sensed that there are very different ways of organizing the body’s defensive mechanisms and thus conceived the therapeutic relationship to be a dynamic process. He was a pioneer in the description of “borderline” pathology, of the segmental defensive “armoring” of the neurotic personality,

Characteranalytical Vegetotherapy

and of the perceptual-optical split of the psychotic. He gave great importance to the development of negative transference as the first, necessary step to achieve real, positive transference.

Major Concepts Most of the major concepts were delineated in the “Theoretical Underpinnings” section and include recovering the identity of one’s Ego, which has been stifled by psychic or somatic defense mechanisms; the relationship between character attitudes and muscular responses; reaching balance in the autonomous (vegetative) nervous system, through analysis and disassembling the character; and the importance of focused massage or the application of pressure in releasing tensions.

Techniques Characteranalytical vegetotherapy was specifically systematized by Raknes and Navarro and related to the seven corporeal levels identified by Reich: (1) eyes, ears, and nose; (2) mouth; (3) neck; (4) chest and arms; (5) diaphragm; (6) abdomen; and (7) pelvis and legs. Navarro assembled Reich’s principal techniques, which he named “actings,” and introduced additional techniques, outlining criteria for correct use (e.g., time, rhythm, and direction) and developing a clinical methodology. Characternalytical vegetotherapy acts on the autonomous (vegetative) nervous system, the muscular system, the neuroendocrine system, and the energetic pulsation—direct expressions of emotional, affective, and instinctive life. It tends toward rebalancing these systems. It induces neuro-vegetative phenomena and emotions, which represent expressions in the language of the body that are essential for understanding character aspects. Verbalization of the sensations, the emotions, and the associations produced, as well as interpreting significant relationships with the partial objects of the respective evolutive phases of the life story of the patient represent successive steps in this methodology. Being Attuned to the Language of the Body

Particularly, the language of the body is the most significant message in the Reichian psychotherapeutic setting. It accompanies all the other

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data on “how” the person is expressing himself or herself: from dreams to lapsus, from symbols to metaphors, from imaginary life to liberating fantasies, and from the type of thought itself to the characterological trait that sustains it. Actings

Characteranalytical vegetotherapy investigates the body in its significant psychic expression through exercises, called actings, which act on the seven bodily levels. These are specifically selected and performed successively by the patient, who will experience psycho-affective evolution. The actings reproduce natural ontogenetic movements that occur at the respective corporeal levels that prevail during the evolutionary phases. The actings bring back the “how” of the partial object relations as they were incised in the corporeal level of the Self at that time and phase, but they also provide insights. They therefore suggest the possibility of a new object relationship in the present. Actings connect the “there-and-then” with the “here-and-now,” the depth with the surface, the unconscious with the conscious, implicit memory with explicit memory, informing, forming, and reforming the mind. They increase cognition and feeling, determining a higher intelligence of the mind. During the performance of the actings of vegetotherapy, we give priority to “the feeling” instead of “the thinking,” and therefore we respect the organization of the evolution of the human being. An analytic therapeutic project aims at giving the person the capacity to manage his or her defensive armor and characterological combination.

Therapeutic Process From his essay on masochism, in 1927, which was later included in Character Analysis, Reich begins the integration of character analysis with vegetotherapy on a clinical level. He initially facilitates the emergence of analytical material (insights) by pointing out the ways the patients present themselves in the session (e.g., tone of voice; gestures such as crossing legs, looking away, or blushing), as well as more permanent attitudes (e.g., compulsive, masochistic, phallic, or hysterical). He also focused on chronic muscular rigidities (i.e., of the neck, chest, pelvis)

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Chess Therapy

that influence body posture and its internal functioning, establishing a tendency to contraction and anxiety (predominance of the “sympathetic” part of the vegetative nervous system) with consequent bioenergetic and psychosomatic imbalance. On specific occasions, he stimulated the output of the voice, increased the depth of speaking, modified the way of looking, even sometimes suggesting silence, to provoke emotions in the patient that were related to fears (even unconscious fears), sadness, or anger. By dismantling the defense mechanisms and the stratified, segmented stiffness of such defensive armor, a more global involuntary experience arising from the progress of the therapeutic process could then be added. One such experience is the “orgasm reflex”—a slight, involuntary movement of the whole body when a patient, lying on the couch, achieves the capacity to breathe fully and relax chronic muscular tensions. Reich considered these to be objective signs of progress toward achieving clinical goals, while underlining that making the defenses and the armor more flexible or mobile is a very delicate process, given that they are part of the identity of the patient. For this reason, and notwithstanding other considerations, careful, consecutive steps should be followed in relaxing the seven functionally related corporeal segments in a cephalo-caudal (head to foot) direction. In characteranalytical vegetotherapy, interventions usually focus from the first level (i.e., eye, ears, and nose) to the seventh level (i.e., pelvis and legs) of the body, bearing in mind that all levels are interrelated and that partial interventions are not effective. At the same time, it is necessary to integrate the emotional experience through an analytical elaboration of the patient–therapist relationship. Genovino Ferri, Marilena Komi, and Xavier Serrano-Hortelano See also Body-Oriented Therapies: Overview; Object Relations Theory; Orgonomy; Reich, Wilhelm

Further Readings Ferri, G., & Cimini, G. (2012). Psicopatologia e Carattere, L’Analisi Reichiana: La psicoanalisi nel corpo ed il corpo in psicoanalisi [Psychopathology and character, Reichian analysis: Psychoanalysis in the body and the body in psychoanalysis]. Rome, Italy: Alpes Editore.

Navarro, F. (1989). La Somatopsicodinámica [Somatopsychodynamics]. Valencia, Spain: Publicaciones Orgón. Navarro, F. (1989). La vegetoterapia caracteroanalítica [Characteranalytical vegetotherapy]. Revista Somathotherapies et Somatologie Strasbourg. Navarro, F. (1991). Caratterologia post-reichiana [PostReichian characterology]. Palermo, Italy: Nuova Ipsa Editore. Reich, W. (Ed.). (1972).Character analysis. Rangeley, ME: Wilhelm Reich Trust Fund. (Original work published 1933) Reich, W. (2007). The function of the orgasm. New York, NY: Farrar, Straus & Giroux. (Original work published 1927) Serrano, X. (2011). Profundizando en el diván reichiano: La Vegetoterapia en la psicoterapia caracteroanalítica [More deeply on the Reichian couch: Vegetotherapy in characteranalytical psychotherapy]. Madrid, Spain: Edit. Biblioteca Nueva.

CHESS THERAPY Chess therapy is a form of creative therapy or recreational therapy. It endeavors to use chess games between the therapist and the client to form better rapport between them for the purpose of confirmatory or alternate diagnosis and toward the goal of problem solving or achieving higher levels of functioning. This approach, of course, limits itself to therapists and clients who play chess and are familiar with the rules and peculiarities of the game. Early on, practitioners of various theoretical backgrounds and persuasions have incorporated chess games in their sessions to gain better rapport with the client, to diagnose client personality and help the client develop selfawareness and insight regarding his or her temperament, and to teach social experience, which necessitates abiding by rules and taking into consideration the acts of the opponent in the game. In chess, intense interpersonal relations are possible in a brief period, and using chess therapy as an approach with a child who has Landau-Kleffner syndrome has been shown to be effective. It has been used by the Barnes-Jewish Hospital Siteman Cancer Center with its patients and by a growing number of chess-playing clinicians and counselors in general.

Chess Therapy

Historical Context The earliest published case of chess therapy was in 1945 by Joan Fleming and Samuel Strong. They recounted an isolated, adolescent schizoid who showed improvement after he became interested in chess. They described how chess provided an outlet for his aggressive impulses in a nonretaliatory manner and discussed how a game enables a patient to exert some conscious control over his feelings and thus learn to master them to a limited extent. In recent years, the use of tactics and strategies in chess games as life metaphors to help clients think better was employed by the school counselors Roumen Bezergianov and Fernando Moreno, the social worker Rick Kennedy, and the clergyman Angelo Subida. With the advent of online chess games and automated games analysis, this approach has received both positive and negative peer reviews from various practitioners.

Theoretical Underpinnings The theoretical foundations of chess therapy vary from one school of thought to another. In psychoanalytic theory, chess games are considered wish fulfillment, and an important part of wish fulfillment is the result of repressed desires—desires that can scare us so much that our games may turn into a series of defeats. In Jungian psychology, chess imagery is part of a universal symbolic language. Chess games are an open pathway toward our true thoughts, emotions, and actions. In our chess games, we are able to somehow see our aggressive impulses and desires. Chess games are a way of compensating for our shortcomings in our life. For instance, if a person is unable to stand up to his superior, he or she may safely lash out at a chess piece in a game. Thus, chess games offer some sort of satisfaction that may be more socially acceptable. In Gestalt therapy, chess games may contain most of what we need to know about the causes of our psychological troubles and can tell us why we are as we are—say, someone for adventure, an underachieving worker, or an impulsive buyer— and they can also show us the remedy for our disorder. The unconscious, through chess games, is not concerned merely with putting right the things that have gone wrong in us; chess games aim at our well-being in the fullest sense. The goal in our chess games is our complete personal victory or

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development in defeats, the creative unfolding of the potentialities that are contained in the analysis of the games that we have played, whether we won, lost, or managed a draw. We seek to fill our emotional voids so that we can become a unified whole. Thus, a person’s game may reflect the rejected, disowned parts of the self. A chess piece, tactic, or strategy in a game represents an aspect of oneself. In this sense, chess imagery is not part of a universal symbolic language because each chess game is unique to the individual who played it. On the other hand, the behaviorist underpinnings take account of reinforcing desired behavior in most social games. A game of chess is a social experience that necessitates abiding by rules and taking into consideration the thoughts and acts of another person. Chess therapy has also been used in behavior modification, as classical conditioning suggests that if exposure to potentially panic-inducing situations (e.g., losing a valuable piece or having a bad position) becomes continually paired with a calm mood, the panic-inducing situations will eventually become habituated to or experienced calmly by the client.

Major Concepts Chess concepts are used in chess therapy, and the major ones include tactics and strategy, and sacrifice. Tactics and Strategy

In chess, a tactic refers to a sequence of moves that limits the opponent’s options and may result in tangible gain. Tactics are contrasted with strategy, in which advantages take longer to be realized and the opponent is less constrained in responding. Some tactics include pinning, where if a chess piece moves, it leaves another piece vulnerable; forking, where a chess piece makes two or more attacks simultaneously; and offering a sacrifice. Sacrifice

In chess, a sacrifice is a special tactic whereby one gives up a piece in the hope of gaining tactical or positional compensation in other forms. A sacrifice can also be a deliberate exchange of a chess piece of higher value for an opponent’s piece of lower value.

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Sacrifices in chess games are metaphors of sacrifices in real life. Players try to hold on to their own pieces; thus, offering a sacrifice can come as an unpleasant surprise to one’s opponent, causing the opponent to calculate whether or not the sacrifice is sound and whether to accept it.

Techniques With chess therapy, techniques are intimately related to the stages of therapy. In the order they are conducted, they include casual chess games for gathering initial information, chess education, emotion impulse training, a discussion of life metaphors in chess, and playing as an individual and as a member of a team. Casual Chess Games

Casual chess games refer to the process whereby a therapist plays one to three casual games with the client while inquiring about the client’s problem and/or subsequent situations that causes distress. Chess Education

Chess education involves the process of educating clients about the psychological theories behind the board game and the goals of chess therapy, to increase their awareness of the psychological gains they can make through playing chess. Emotion Impulse Training

Players often start to panic as soon as their opponent starts attacking a valuable piece. Clients can come to understand that it is very human to become frantic and illogical when one’s chances are slipping away in a match and that such a reaction often results in negative intrapersonal or interpersonal functioning. Through emotion impulse training, the therapist teaches a client how to reduce physiological arousal through implementing slow, rhythmic breathing and concentration.

philosophy of life based on how they manage their games. Such awareness can help clients maintain a sense of calm and control. Playing as an Individual and as a Member of a Team

In playing as an individual, the therapist observes the client’s play with the white pieces and with the black pieces. The client is asked to try to maintain a sense of calm while playing, and a scale may be used to monitor the amount of distress he or she is experiencing. The client is asked to play several games with selected opponents and later recall the games in detail and the lessons learned in each game. This helps the client work on impulse control. Later, the client is asked to join a team of his or her choice and play as a member of that team. In this process, the client can work on interpersonal skills.

Therapeutic Process As employed at times by Jose Fadul and Reynaldo Canlas, and as in solution-focused brief therapy, chess therapy may take only one or two sessions. However, as employed by Fleming and Strong, Moreno, Kennedy, and Subida, it typically lasts for about five to nine sessions. Early sessions involve assessing the client’s temperament while at play, and a discussion of metaphors. The next sessions involve exposing the client’s playing style in handling white or black pieces, which can be followed up with games with other clients to affirm the findings of the therapy. This is followed by sessions that focus on the use of software for analysis, playing under time pressure, and playing as a member of a team. Therapists conclude the therapy with a final session that examines the progress made in therapy. Jose A. Fadul See also Creative Arts and Expressive Therapies: Overview; Freudian Psychoanalysis; Gestalt Therapy; Play Therapy; Solution-Focused Brief Therapy

Life Metaphors in Chess

Further Readings

Life metaphors in chess are taken up with clients and compared with their values in life. In a systemic manner, clients can slowly define their

Berzergianov, R. (2011). Character education with chess: Useful ideas for parents, teachers, and therapists. Amazon Digital Services. Retrieved from www.amazon.com

Classical Conditioning Fadul, J., & Canlas, R. (2009). Chess therapy. Raleigh, NC: Lulu Press. Moreno, F. J. (2001). Teaching life skills through chess: A guide to educators and counselors. Baltimore, MD: American Literary Press. Reider, N. (1945). Observations on the use of chess in the therapy of an adolescent boy. Psychoanalytic Quarterly, 14, 562.

CLASSICAL CONDITIONING Classical (or Pavlovian) conditioning is a process through which animals learn relationships between stimuli present in their environment. It is crucial to adaptive behavior and survival because it allows the prediction of rewarding, harmful, or neutral events (i.e., outcomes) on the basis of others that preceded them (i.e., cues). If the outcome has a biological meaning, the animal will exhibit overt anticipatory responses in the presence of the cue, which can be behavioral, cognitive, or emotional in nature. Classical conditioning can also lead to the development of inappropriate or prejudicial behaviors that are implicated in many psychological disorders, such as drug addictions, anxiety disorders, phobias, and relapse from therapy.

Historical Context Ivan Petrovitch Pavlov (1849–1936) pioneered the scientific study of classical conditioning. Initially a physiologist of digestion (for which he won the Nobel Prize in Physiology or Medicine in 1904), he later reoriented his work toward the study of conditioned reflexes. In his famous experiments on dogs, he paired an initially neutral stimulus (NS; e.g., tone) with an unconditioned stimulus (US; e.g., food). The food has a biological meaning for the dog and therefore produces an unconditioned response (UR; e.g., salivation), whereas the tone does not. After several pairings with the food, the tone becomes a conditioned stimulus (CS), which triggers a conditioned response (CR). That is, the tone becomes a stimulus that predicts the occurrence of the food, as witnessed by the fact that in its presence the animal exhibits anticipatory responses (e.g., salivation). Pavlov was interested in studying the CR as a tool to understand brain functioning. The early American psychologists found Pavlov’s findings

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fundamentally important but put the emphasis on the analysis of behavior and on the specific conditions required to produce conditioning. Pavlov believed that conditioning establishes a connection between brain centers representing the CS and US. Thus, whenever the CS was presented, the US center would be indirectly activated through its connection with the CS center, therefore eliciting the CR/UR. A stimulus–stimulus association (CS-US) would be created through conditioning, allowing the animal to anticipate the occurrence of the US in the presence of the CS and to adjust its behavior accordingly. In the 1970s, the modern view of classical conditioning emerged. Following the discovery of new phenomena (e.g., blocking) and the proposal of new models (e.g., the Rescorla-Wagner model), classical conditioning was no longer considered as the mere creation of stimulus–response links between CSs and URs but, instead, as a sophisticated prediction process by which animals learn the “causal structure of the environment.” As a consequence, less emphasis was put on the CR, now viewed as a simple index of learning, and more on the role of predictions and cognitive processes. Another important landmark in the history of classical conditioning is J. B. Watson and his assistant Rosalie Rayner’s controversial “Little Albert” experiment, conducted in the late 1910s. In this experiment, Watson and Rayner experimentally conditioned an emotional fear response in a 9-month-old baby by pairing a loud noise (US) that frightened him (UR) with a small furry animal (CS; e.g., a rat). The baby “Albert,” who initially expressed no fear of furry objects or animals, after conditioning started exhibiting a fear response (e.g., crying) in the presence of, for instance, a rabbit. Although appalling from an ethical point of view by today’s standards, this study opened the door to research on the role of classical conditioning in psychopathology, notably anxiety disorders.

Theoretical Underpinnings Classical conditioning is an empirical phenomenon and, as such, is not tied to any particular theory, though there are various theoretical accounts of it. The most influential is the one

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proposed by Robert Rescorla and Alan Wagner in 1972. It proposes that, through conditioning, a CS-US association is created and that its strength, representing the level of expectation of the US in the presence of the CS, changes whenever the subject is surprised, that is, when what he or she expects does not match what he or she gets. For instance, if in the presence of a tone (CS), a dog anticipates receiving food (US) and indeed gets it, the strength of the association between tone and food remains the same. However, if the animal does not receive the food, it will be surprised: It would have overpredicted the amount of food following the CS. As a consequence, the strength of the CS-US association is decreased: Next time, the animal will anticipate a smaller amount of food after the US. The same way, if it receives more food than usual, it will again be surprised, but this time, it would have underpredicted the amount of food following the CS. As a consequence, the strength of the CS-US association is increased: Next time, the animal will anticipate a larger amount of food. Hence, according to the Rescorla-Wagner model, whenever an animal is surprised, it changes its expectation to reduce its level of surprise (error correction learning). These principles are illustrated in several phenomena. For instance, in blocking, an NS (e.g., light) is paired with the US (e.g., food). Later, once the animal has learned to associate the light with the food, another NS (e.g., tone) is paired with the food in the presence of the light. Although the tone has been paired with the food, it fails to trigger a CR (i.e., salivation). According to the Rescorla-Wagner model, as the food is fully predicted by the light, the subject is not surprised, hence the associative strength between the tone and the food remains null. Another example is overexpectation, in which the simultaneous presentation of two previously established CSs A and B (e.g., a tone and a light) with the same US (e.g., a shock) used to condition them leads to a decreased expectation of the US in the presence of each CS. According to the Rescorla-Wagner model, each CS presented alone fully predicts the US, but when presented together, their predictions sum and the subject expects a US twice as intense. As this fails to happen, it leads to a decrease in the associative strengths of both stimuli.

Major Concepts Two concepts associated with classical conditioning are conditions for learning and the effect of learning on behavior.

Conditions for Learning

Besides perceptual factors (e.g., CS and US saliences), several variables play a critical role in determining whether the subject learns to expect the US in the presence of the CS, notably the number of CS-US pairings and the temporal contiguity between CS and US, that is, the time between CS and US onset. Usually, the more CS-US pairings, the more likely the subject will anticipate the US in the presence of the CS. The same way, the closer in time the US onset is to the CS onset (down to a certain interval) the more likely the subject will perceive a link between them. Nonetheless, the critical variable seems to be the ratio between the US-US interval and the CS duration (C/Tratio): The bigger this ratio is, the better the conditioning. Quantitatively, there are huge discrepancies in the way these variables affect different learning situations. In taste aversion learning, where the subject associates a taste with symptoms of food poisoning, conditioning takes place after just one or two pairings, whereas eye blink conditioning, where a CS signals a puff of air to the eye, requires hundreds. The optimal CS-US interval for eye blink conditioning is measured in milliseconds, while it is measured in hours for taste aversion learning. This makes sense from an evolutionary point of view. If an animal were not able to detect predictors of danger (e.g., poison) after a few trials, he might not live to survive another encounter: Only fast learners were able to pass their genes to the next generation. The same way, predictors of an impact to the eye precede the impact by a few milliseconds, while ingestion of a contaminated food precedes food poisoning by several hours. Animals that are able to restrict their focus to only the most essential predictors would have had an advantage over animals considering all preceding stimuli. These are examples of biological constraints on learning, where prior knowledge about the learning situation is introduced in the learning process during evolution to make it more efficient and specific. Another way evolution interferes with

Classical Conditioning

learning is by predisposing organisms to learn specific CS-US associations (preparedness). For instance, a rat easily associates a new flavor with symptoms of food poisoning but not with an electric shock. Finally, the informational value of the CS regarding the prediction of the US is critical. Conditioning is a function of the difference between the probability of the US given that the CS was presented and the probability of the US given that the CS was not presented. For example, if every time you eat at Restaurant A you feel sick, and that only happens at that place, you will certainly expect to feel sick whenever you eat there. That is to say, if the probability of the US (feeling sick) in the presence of the CS (Restaurant A) is higher than the probability of the US in the absence of the CS (e.g., eating in another restaurant), the CS will become an excitator, in the presence of which the subject anticipates the occurrence of the US. On the other hand, if you feel sick in every other restaurant you eat but not in Restaurant A (i.e., the probability of the US in the presence of the CS is lower than the probability of the US in the absence of the CS), you will expect not to feel sick when you eat in Restaurant A; the CS will become an inhibitor, in the presence of which the subject anticipates the nonoccurrence of the US. Excitators and inhibitors act in opposite directions. Hence, if presented together, the positive and negative expectations of the US triggered by the excitator and the inhibitor cancel each other out. The Effect of Learning on Behavior

Animals will associate stimuli as long as the conditions for learning described above are met, though learning will remain behaviorally silent if the two stimuli are neutral. The predicted stimulus does not need to have a biological meaning for learning to occur, only for learning to be expressed, that is to say, for the CS to trigger a CR. The CR is not equal to the UR: In many situations, the recorded CR differs from the UR and sometimes is even opposite to it. The UR to morphine is an increase in the pain threshold, whereas the CR to a morphine-predicting CS is a decrease in the pain threshold. Moreover, by using a single behavior as an indicator of learning, most studies fail to grasp the full complexity of the CR, whose

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components are not only behavioral but also cognitive (e.g., changes in reaction time and attention, greater likelihood to engage in behavior rewarded by the US), emotional (e.g., emotions triggered by the CS), and physiological (e.g., arousal, change in the pain threshold, release of stress hormones). An animal exposed to a tone CS paired with an electric shock will not only display defensive behavioral responses (e.g., freezing in rats) triggered by the CS but will also pay more attention to the stimulus. At the same time, various autonomous and endocrinal responses will increase the level of arousal of the organism while reducing its pain threshold. Reaction time to the predicted US will decrease, making it easier to detect. Similarly, human participants will report fear, anxiety, and dislike of a CS predicting an unpleasant US. All in all, CRs are automatic adaptive anticipatory reactions, part of the genetic endowment of the organism, emitted in anticipation of a US because they help the animal cope with and/or process the US. Several variables will determine the nature of the CR, notably the US, the CS (CRs are tuned to specific stimuli), and the CS-US interval (a response might be adaptive if the US is imminent but maladaptive otherwise, and vice versa).

Techniques One of the main successes of classical conditioning has been the development of specific techniques used in psychotherapy to treat pathological behavior implicated in phobias, obsessive-compulsive disorder, and similar anxiety disorders. The idea is that anxiety and phobia are CRs triggered by CSs predicting aversive USs. Thus, the patient avoids the fear-inducing CS, which in most cases leads to adaptive behavior, allowing the subject to avoid dangerous or stressful situations or to prepare for them. However, in some cases, behavior will degenerate into pathological conducts, especially if the initial CS-US pairing is accidental, which is always a risk given that, for evolutionary reasons, aversive conditioning occurs very quickly. The plausibility of this analysis is strengthened by the fact that, at the neural level, fear conditioning is centered on a subcortical nucleus, the amygdala, which controls emotional reactions to stimuli. This may explain the irrational aspect of fears and phobias.

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Therefore, some learned CS-US associations are maladaptive and lead to the development of inappropriate or pathological behavior that should be extinguished. Extinction (the name of both a procedure and the process involved in it) is done by presenting the CS alone, that is, not followed by the US. Because the patient naturally avoids the CS, extinction does not occur easily in the patient environment. In therapy, the patient is confronted with the fear-inducing stimulus (CS) using a technique named exposure therapy, which kicks off the extinction process by gradually exposing the patient to the stimulus in a supportive and controlled context. Although extremely efficient, exposure therapies are limited by the fact that extinction is context sensitive: If the CS-US association is acquired in Context A (e.g., the everyday life of the patient) but extinguished in Context B (e.g., the therapy clinic), the CR will reappear outside of Context B. In the absence of obvious external stimuli, very subtle cues, such as the internal state of the subject or even the presence or absence of the US, will acquire contextual control over behavior. This general phenomenon, also demonstrated in nonhuman animals, is called renewal. Along with several other phenomena (e.g., spontaneous recovery: reappearance of extinguished CRs if the CS is presented again a long time after extinction; reinstatement: reappearance of extinguished CRs due to the experience of one or more US-only presentations after extinction; and rapid reacquisition: relearning following extinction is faster than the original learning), it shows that extinction is not the unlearning of the previously acquired excitatory CS-US association but the learning of a new, context-sensitive inhibitory CS-US association, in which case both will cancel out. Given the right circumstances, the excitatory CS-US association will reappear. Recent data on the neural basis of fear extinction seem to confirm this analysis: Fear conditioning involves the reinforcement of synaptic connections between the sensory cortices and thalamus and the amygdala; fear extinction does not weaken those synapses but instead relies on active inhibition of the amygdala by the prefrontal cortex. Recovery phenomena are a major source of relapse, not only in exposure therapy but also in any therapy or intervention relying explicitly or implicitly on extinction. For instance, drug-predicting CSs

will, among other things, trigger craving and drugseeking behavior. During rehab, these CSs will undergo extinction, but once the patient returns to his or her everyday environment, they might trigger the craving or drug-seeking CRs again through renewal, spontaneous recovery, reinstatement, or rapid reacquisition, hence increasing the chances that the patient relapses. Due to its important clinical implications, considerable research has been devoted to finding ways to suppress or reduce renewal. Methods such as counterconditioning (the CS is not merely extinguished by being presented without the US, it is also associated with another rewarding US; for instance, the patient can be taught to relax in the presence of the anxiety-triggering CS, a technique known as systemic desensitization), deep extinction (extinction continues well beyond the disappearance of the CR), or extinction in multiple contexts have been explored. The efficiency of various drugs has also been assessed, notably NMDA-receptor agonists such as D-cycloserine. Promising new lines of research are trying to chemically perturb the molecular mechanisms underlying the strengthening of CS-US associations in order to erase the excitatory CS-US link altogether.

Therapeutic Process Therapies based on classical conditioning exploit the natural ability of the brain to detect statistical regularities between stimuli and to adjust to them. In a Pavlovian analysis, pathological behavior and emotions are conceptualized as CRs triggered by a CS associated with a meaningful US. Treatment involves breaking the CS-US association, usually through the use of techniques involving extinction. This is notably the case of exposure therapy, an evidenced-based approach for the treatment of several anxiety disorders (e.g., phobias, panic disorder, social anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder) that is recognized by the American Psychological Association. Various forms of exposure therapy exist, depending on whether or not the therapist chooses to expose the patient to the actual anxiety-triggering stimulus (in vivo exposure therapy), in an all-or-none fashion (flooding) or more gradually (graded exposure

Classical Psychoanalytic Approaches: Overview

therapy) or not at all (through either imagining of the fearful stimulus—imaginal exposure—or the use of virtual reality—virtual reality exposure). Relaxation and cognitive restructuring (which challenges the irrational, maladaptive, and unrealistic beliefs the patient might have about his or her fear) can be used as adjunct to the therapy. The therapist must be careful to avoid the development of any safety behavior in the patient (e.g., beliefs such as “If the session takes place in this room, I will be ok”) to avoid overcontextualization of fear extinction. J. Maia and J. Jozefowiez See also Applied Behavior Analysis; Behavior Modification; Operant Conditioning; Pavlov, Ivan

Further Readings Bouton, M. E. (2006). Learning and behavior: A contemporary synthesis. Sunderland, MA: Sinauer. Escorbar, M., & Miller, R. R. (2004). A review of the empirical laws of basic learning in Pavlovian conditioning. International Journal of Comparative Psychology, 17, 279–303. Quirk, G. J., & Mueller, D. (2008). Neural mechanisms of extinction learning and retrieval. Neuropsychopharmacology, 33, 56–72. doi:10.1038/ sj.npp.1301555 Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is. American Psychologist, 43, 151–160. doi:10.1037/0003-066X.43.3.151 Schanks, D. R. (2007). Associationism and cognition: Human contingency at 25. Quarterly Journal of Experimental Psychology, 60, 291–309. doi:10.1080/17470210601000581

CLASSICAL PSYCHOANALYTIC APPROACHES: OVERVIEW Classical psychoanalytic psychotherapies are firstgeneration evolutions of the original Freudian paradigm. They were elaborated in the first 60 years of psychoanalytic writing. The psychotherapist was a dispassionate surgeon of the mind who would present a blank screen to his or her patients. Onto this screen, the patient would “transfer” his or her painful early object relations. The therapist’s

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evenly suspended attention would allow him or her to gain access to the patient’s unconscious conflicts as expressed through dreams, free associations, and somatic experience. The evolution of the classical approach has produced a more focused concentration on countertransference as a method of both understanding the patient’s internal world and formulating effective interventions. Throughout the early years of classical thinking, insight and interpretation have remained core to the therapeutic action of analysis. More recently, the presence of a sustaining, empathic “new object” related to but not identical with an “interpreting” object has become a focus of psychoanalytic interest.

Historical Context During its first 125 years, psychoanalytic theorizing has traversed many roads, with major shifts occurring on important fronts. The early emphasis on a physiodynamic foundation by Sigmund Freud (1856–1939), the founder of psychoanalysis, has yielded to a more psychodynamic orientation. Freud’s introduction of the Oedipus complex as etiologic in neurosis helped shift the focus away from sexual trauma. Freud’s metapsychological constructs privileging intrapsychic processes have also yielded in time to more field-related interpersonal perspectives. Freud initially viewed transference and countertransference as blocks to effective treatment, but after experience, he endorsed both as central to psychoanalytic cure. Finally, classical theory shifted from a firmly patricentric orientation to a more matricentric perspective ushered in by the child analysts who focused on the mother–child interaction during the pre-oedipal period of development. Freud’s early predictions, codified in his brief book The Project for a Scientific Psychology (1894), have come to fruition in today’s cutting-edge research, which evidences a return to establishing the biological bases of psychological and emotional development.

Theoretical Context The major philosophical foundations of psychoanalysis can be found in determinism, associational psychology, and the primacy of unconscious processes. These trends are codified in Freud’s

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basic topographical, structural, economic, and dynamic metapsychologies—along with the basic rule of psychoanalysis, free association. Classical theory in psychoanalysis has evolved in significant ways as a product of its internal history. However, the external history of the first 125 years has had a major impact as well. Models of the physical world have been added to the early Newtonian understandings, and the evolution of quantum theory has helped promote a more solidly based overarching field theory approach in every discipline. In addition, the feminist movement has played a major role in the transformation of psychoanalytic theory from its solid masculine bias to a more feminine perspective. A major issue that has emerged during these early years, which requires thoughtful reflection in every analyst, is whether we should provide a binocular vision of human experience that includes both intrapsychic and relational/field constructs or whether we should look through only one lens. The image of binoculars seems appropriate for this debate inasmuch as it is only by looking through both lenses that we can appreciate the true depth of the experience we are examining. Finally, the evolution of classical theory has led to far more reliance on the information gained from the therapist’s countertransference as a source of understanding and interpreting the patient’s internal world. Classical theory began with a focus on the internal world as a complex interaction of drives and defenses. The early structural and dynamic metapsychologies focused on the conflict and defense paradigm. For Freud, the psyche was governed by two principles: (1) the pleasure principle, attendant to instinctual life, and (2) the reality principle, governing the ego’s adjustments to reality. The internal world was conceived as a set of complex forces in dynamic tension. Neurotic illness resulted from conflict between the three agencies of the mind (id, ego, and superego) and represented a compromise formation. Freud and his early followers expanded their initial findings on hysteria as being the result of repressed and unexpressed affects related to sexual trauma to eventually include the etiological importance of unconscious complexes, most important the Oedipus complex, as a way to understand neurotic disturbance. This significant shift in early theorizing moved psychoanalysis to a psychodynamic discipline.

Recent research by Jeffrey Masson and others, however, suggests that Freud’s early abandonment of the sexual trauma etiology was premature and looked away from a significant social problem. Psychotherapeutic technique during this early period experimented with hypnosis but eventually settled on free association (the basic rule) as the most useful way to access unconscious processes. With the publication of The Interpretation of Dreams in 1901, the importance of dreams as wish fulfillments and as the “royal road” to the unconscious was established. Freud dictated that the analyst should listen to his or her patient with “evenly suspended attention” and situate himself or herself equidistant from the three psychological structures (id, ego, and superego). The goal of treatment in this paradigm is to have each of the structures achieve a balanced libidinization, so that the id can provide drive and motivation; the ego, planning and delay; and the superego, appropriate levels of guiding guilt. Freud was reluctant to take seriously the evidence of unconscious erotic elements, which were evident in Josef Breuer’s treatment of Anna O., but finally, he accepted the important role of transference in accessing a patient’s conflicts. His attitude toward countertransference exhibited the same change of heart. In his first attention to the topic, he was firm in discussing how it placed a limit on the therapist’s capacity to grasp the patient’s internal world. A few years later, he described the therapist’s countertransference as a valuable tool in “decoding” the patient’s unconscious communications. This switch in attitude predicted the eventual acceptance by British object relations therapists of countertransference as “the patient’s creation in the therapist’s mind.” Freud’s capacity to make mid-course corrections in his theorizing was clearly one of his strengths. Freud’s early followers did find much to debate on during these early years, and several “left the fold” to pursue their own specific perspectives. Sandor Ferenczi, who today is considered an early spokesperson for contemporary relational approaches, departed from Freud over the issue of psychoanalytic technique. Freud’s early prescriptions for technique focused on abstinence in the face of the patient’s infantile wishes. Abstinence, it was believed, would lead to remembering the early traumas and provide the opportunity for working through the affective

Classical Psychoanalytic Approaches: Overview

storms of early conflict within a new context. However, for Ferenczi, abstinence was tantamount to retraumatization; thus, he pushed for a more relaxed technique that allowed for gratification of early needs (this often included physical gratification). Ferenczi felt that this was a more empathic and heartfelt approach. Freud continued to criticize Ferenczi and, in a personal letter, suggested to Ferenczi that perhaps in the future he will say, “Maybe after all I should have halted in my technique of motherly affection before the kiss.” Carl Jung and Freud were originally very closely aligned and supportive of each other. Together, they came to the United States in 1911 to present the Psychoanalytic Lectures at Clark University. These two iconic figures, however, had a falling out over Jung’s contentions that the libido is more than just sexual energy and is utilized in multifarious ways. Jung also refuted Freud’s recently published work on infant sexuality. Jung’s capacity to follow his own internal process led to a psychology embedded in mythological tradition, transpersonal experience, and the topic of religion. Today, Jung’s school is designated by the terms analytic psychology or depth psychology. His focus on concepts such as archetype, the collective unconscious, and complexes provides a significantly broader listening perspective that includes both personal and transpersonal levels. Jung also is noted for his movement away from Freud’s view that dreams are disguised unconscious contents to viewing the dream as an accurate depiction of undeveloped aspects of the psyche. Alfred Adler was originally a member of Freud’s inner circle, which met regularly during the first decade of the 20th century. His major areas of disagreement with Freud centered on his move away from the Oedipus complex and Freud’s strict biological determinism. His unique areas of interest included organ inferiority, the will to power, and sibling rivalry. His school of Individual Psychology helped inaugurate the move from biological reductionism to a more socio-psychoanalytic approach. Object relations theorists departed from Freud’s early writings by shifting the theory of motivation underlying human development from the pleasure principle to one in which children seek another mind that they can use as an auxiliary mind as they grow to master their impulses and affects. The work of Melanie Klein, Wilfred Bion, Ronald

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Fairbairn, and Donald Winnicott helped establish the richness of this paradigm. A major shift inaugurated by the object relations therapists was that of looking at early-childhood experience in relationship to primary objects. Freud did not treat children; thus, his developmental theories of infant sexuality and psychosexual development relied heavily on reconstruction from adult treatments. Object relations therapists focused on the treatment of children and the observation of childhood development. Margaret Mahler’s developmental theory of separation-individuation stands out in this regard. Implied in this shift is a clear move from the Freudian patricentric model of psychoanalysis to a more dyadic, mother–child, or matricentric, approach. These ideas were expanded by Anna Freud and ego psychologists as well. This shift also laid the foundation for today’s contemporary relational models and treatments relying more heavily on provision than on deprivation. The introduction of classical Freudian theory in the United States in 1911 brought to the forefront ideas about the unconscious, fantasy, infantile sexuality, and dream work, and it quickly surpassed behaviorally oriented psychology in popularity. Two active forces came to bear on the new discipline: (1) American psychologists who were steeped in Wundtian experimental paradigms attempted unsuccessfully to disprove the major findings of psychoanalysis through experimentation and (2) the American Medical Association was able to take over psychoanalysis as a medical specialty and limit training to physicians. The days of lay analysis, endorsed by Freud, were over. The medical model aligned well with the unfolding ego psychology emphasis, which emphasized ego adaptation over id psychology. The strict limitations on those who could be trained began the slow decline of psychoanalysis in the United States, which was only rescued when in the 1980s, four psychologists, backed by the American Psychological Association, successfully sued the American Psychoanalytic Association to make it allow other mental health professionals to obtain training. Ego psychology has found its strongest adherents in the United States after establishing itself in Vienna and then London. This perspective was given a large boost by the work of Anna Freud, in particular her publication of The Ego and the Mechanisms of Defense in 1936, which illuminated the basic ways

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Classical Psychoanalytic Approaches: Overview

in which the ego protects itself against internal and external threats. Ego psychologists focused on the development of the ego and its role in the individual’s adaptation to the environment. This perspective shifted the focus away from the id and drives, which characterized the Freudian paradigm, and is often criticized as not being “deep.” Ego psychologists, like Otto Kernberg, argue against the concept of a primary destructive instinct. Erik Erikson was a major contributor to this perspective with his 1950 book Childhood and Society, in which he discussed the psychosocial crisis each human must traverse during his or her development. The neo-Freudian perspective is brought forth in the writings of Karen Horney, Erich Fromm, and Harry Stack Sullivan. These analysts were determined to steer psychoanalysis away from the biological and patricentric theories of Freud and introduce society as a major component in the development of neurotic illness. Perhaps the least well received of Freud’s theorizing was his explanation of women’s psychosexual development. Freud even went so far as declaring that he had no answer to this mystery. Horney, in particular, attacked Freud’s concept of penis envy and his misogynistic theory of female development. She introduced concepts such as basic anxiety and basic hostility to describe the experiences of growing up in a failing cultural milieu. In addition, she characterized the “feminine type” as an adaptation and internalization of a maledominated culture. Horney suggested a theory of primary femininity, which contradicted Freud’s paradigm of the woman as a failed man who struggled without the benefit of a robust superego. Fromm’s many books were primarily addressed to the general public and helped bridge psychoanalysis with the popular culture. His Marxist pedigree underwrote his prolific writings on the dangers of capitalism and the power of the socioeconomic state to derail authentic development and lead to what he referred to as the “pathology of normalcy.” His numerous and accessible writings include The Art of Loving and The Anatomy of Destructiveness. One of his final publications, To Have or to Be?, articulated the costs of living a life of having or accumulating versus a life of being and productively and lovingly engaging life. Sullivan was a major theorist to promulgate the neo-Freudian emphasis on societal factors in development and neurosis. His interpersonal psychiatry

focused on the establishment of “self systems,” which are in the service of achieving security and avoiding anxiety. He eschewed the oedipal bases of neurosis for a more interpersonally generated pattern that leads to “parataxic distortions” of current experiences with objects. Clearly, the ego psychologists and object relations theorists were moving psychoanalysis into a more relational paradigm with a focus on earlier developmental events. Working originally from an ego psychological perspective, Heinz Kohut engaged the topics of empathy and narcissism and reintroduced the concept of the Self to psychoanalytic metapsychology in his Self Psychology. His postulates relating to the narcissistic line of development helped introduce a more deficit-based approach to psychoanalysis. Core concepts such as the Self Object and the Self helped define his theory and distinguished it from ego psychology. This, in turn, helped further the movement from the intrapsychic to the interpersonal. In addition, Kohut’s prescriptions for treatment moved from pure deprivation and abstinence to provision. His approach also helped expand the concept of transference to include a strong developmental element. With this in hand, therapists have been encouraged to provide the requisite psychological structures and experiences that the patient was not given during his or her developmental years. Modern-day analysts are called on now more than ever to determine when a patient’s needs must be gratified versus when it is important to hold to the rule of abstinence. The classical concepts, which have gained wide acceptance during the first 125 years of theory building, include the centrality of unconscious processes in the development of emotional illness, the focus on psychic reality rather than objective reality, the importance of the psychoanalytic treatment frame, and the centrality of transference interpretation.

Short Descriptions of Classical Psychoanalytic Therapies Adlerian Therapy

This breakaway from Freudian theory further reduced the role of biological determinism and the Oedipus complex. Adler focused on the client’s strengths, striving for perfection or superiority, and compensation for feelings of inferiority.

Classical Psychoanalytic Approaches: Overview

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Analytical Psychology

Object Relations Theory

This approach focuses on the processes of individuation and transformation and expands the metapsychological underpinnings of theory to include concepts such as the collective unconscious, archetype, and complex. Carl Jung’s typologies of thinking, feeling, sensation, and intuition have gained considerable notoriety and complement his concept of introversion and extroversion.

This approach focuses on the building up of an internal world through projection and introjection. The basic premise is that the individual is motivated to seek a relationship with another mind rather than simple drive reduction. Internal objects serve as templates for interacting with the object world. Successful treatment involves stable whole-self and object representations. Self Psychology

Ego Psychology

This uniquely American brand of psychoanalysis centers on analyzing the ego and its defenses and capacities for adaptation. This approach also de-emphasized the id psychology of Freud and moved more toward a psychosocial perspective on development.

Kohut’s Self Psychology established a paradigm emphasizing deficit rather than conflict psychology. The role of Self Objects in enabling the establishment of a cohesive nuclear self through a failureand-repair paradigm is core to this approach. A cohesive nuclear self results from a successful line of narcissistic development. Allen Bishop

Freudian Psychoanalysis

This approach has a conflict and defense paradigm that focuses on the interaction of the id, ego, and superego in regulating an internal world driven by drives and defenses. It uses interpretation of resistance and the transference relationship to understand defenses, with the goal being to balance libidinization of the psychological structures (id, ego, and superego). Interpersonal theory, under the guidance of Harry Stack Sullivan—interpersonal psychiatry (theory)—emerged in conjunction with the neoFreudian perspective. Focusing on the importance of early object relations and our social environment in creating a sense of safety, this approach helped continue the move from intrapsychic to relational approaches in psychoanalysis. In addition, it helped de-emphasize the classical Freudian genetic model and substituted it with a more here-and-now focus on the causes of behavior. Neo-Freudian Theory

This theory is characterized by a focus on sociocultural variables in normal development and neurotic illness. Problems arise when an individual identifies with a “sick” society. There is a de-emphasis of biological determinism.

See also Adler, Alfred; Adlerian Therapy; Analytical Psychology; Ego Psychology; Freud, Sigmund; Freudian Psychoanalysis; Horney, Karen; Interpersonal Theory; Intersubjective-Systems Theory; Jung, Carl Gustav; Kernberg, Otto; Klein, Melanie; Lacanian Psychoanalysis; Neo-Freudian Psychoanalysis; Neuropsychoanalysis; Object Relations Theory; Reich, Wilhelm; Relational Psychoanalysis; Self Psychology; Sullivan, Harry Stack; Winnicott, Donald

Further Readings Brenner, C. (1973). Elementary text in psychoanalysis. New York, NY: International Universities Press. Guntrip, H. (1964). Personality structure and human interaction. New York, NY: International Universities Press. Mackinnon, R., Michels, R., & Buckley, P. (2006). The psychiatric interview in clinical practice (2nd ed.). Washington, DC: American Psychiatric. Moore, B., & Fine, B. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press. Segal, H. (1973). The work of Melanie Klein. London, England: Karnac Books. Singer, E. (1965). Key concepts in psychotherapy. New York, NY: Basic Books. Sulloway, F. (1979). Freud, biologist of the mind. New York, NY: Basic Books.

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Cognitive Analytic Therapy

CLIENT-CENTERED COUNSELING See Person-Centered Counseling

CO-COUNSELING See Re-evaluation Counseling

COGNITIVE ANALYTIC THERAPY Cognitive Analytic Therapy (CAT) is a time-limited integrative psychotherapy developed in the United Kingdom by Anthony Ryle (1927– ) during the 1980s and designed to be an in-depth and affordable approach, originally developed for the United Kingdom’s National Health Service (NHS). CAT initially integrated aspects of psychodynamic psychotherapy and personal construct/cognitive psychology to provide a collaborative method of working with clients and a relational model of personality development and psychopathology where the self is socially formed and evolves throughout the life span in its continuing dialogue with others. CAT focuses on what the client brings to the therapy, and the therapist’s ideas are shared explicitly with the client in the form of letters and maps. CAT is centrally concerned with establishing and maintaining a respectful and creative therapy relationship.

Historical Context Ryle studied medicine at Oxford University, qualifying in 1946. His father, the surgeon John Ryle, was the first chair of the Institute of Social Medicine at Oxford and was formative in establishing social medicine as a discipline that gave central importance to the social context of illness. In 1948, the NHS was founded in the United Kingdom, establishing a comprehensive public health service that is accountable to the public and free to all at the point of delivery. Ryle began his career in general practice (as a family doctor) and, with a developing interest in his patients’ often

untreated emotional and psychological problems, moved on to become director of a university health service and then consultant psychotherapist at St. Thomas’ Hospital in London. His central concern in developing CAT was to provide an approach that could be delivered affordably to a wide range of clients, in keeping with the principles of the NHS. Ryle realized the importance of social context and childhood development in the way psychological problems are constructed but differed with the predominant psychoanalytic models of the time concerning the length of treatment required, the emphasis on unconscious process, and the use of the objective analytic stance. He felt the need to derive a metatheory with a language and therapeutic method that restated some psychoanalytic ideas in more cognitive terms that could be shared with the client and whereby therapeutic change could be accelerated. He was influenced in this by developments in cognitive psychology and personal construct theory, as well as by observational studies of infant development. CAT is based on a set of flexibly applied principles that carefully focus on the differing needs of clients. Adherence to the CAT model can be measured effectively using a tool called C-CAT. The evolving evidence base for CAT shows it to be popular with clients and therapists and effective with clients who have experienced abuse, neglect, or trauma, or have personality disorders, eating disorders, addictions, or other complex presentations including self-harm and risk to others. CAT is now established worldwide with national associations in Finland, Ireland, Australia, Greece, Spain, Italy, and India. CAT has been called an “integration project” and continues to evolve its theory and practice as it encounters new social and cultural contexts around the world.

Theoretical Underpinnings CAT was named in 1984 and, as its name implies, sought to use psychoanalytic concepts, particularly ideas from object relations theorists like Ronald Fairbairn, Harry Guntrip, Donald Winnicott, and Thomas Ogden, and restate them in more cognitive terms that could be more accessible to clients and therapists. Early articles by Ryle explicitly restate psychoanalytic concepts

Cognitive Analytic Therapy

such as transference and countertransference and projective identification in CAT terms. The developing CAT theory moved away from psychoanalytic drive theories and the concept of unconscious process in favor of a more relational and dialogic explanation of thoughts, feelings, and behavior. Ryle was concerned with finding out why clients failed to change dysfunctional patterns of behavior and realized that the therapist needed to get alongside the client’s understanding of his or her own world and the characters within it and to agree on explicit aims for the therapy with the client at the outset. Ryle was much influenced by the personal construct theory of George Kelly, and early in his research, he used Kelly’s repertory grids, which are tools to identify the manner in which individuals understand their experiences. He was also concerned with establishing a collaborative and respectful meaning-making relationship with the client in the therapy setting, where the client and the therapist are seen to have different but equally valued viewpoints and where developing insights are openly shared in the form of letters and drawings. This humanistic positioning of the therapist was influenced by the work of James Mann and Jerome Frank. Later, under the influence of a Finnish psychologist, Mikael Leiman, CAT theory and practice integrated ideas from Russian philosophy and psychology. Most important was the work of Lev Vygotsky, who put forward a fundamentally social understanding of how self-to-other processes become self-to-self processes as human beings learn from caregivers and peers within their “zone of proximal development.” This theoretical approach has been supported by observational studies of infant development, notably the work of Colwyn Trevarthen, Daniel Stern, and Vasu Reddy. Another Russian influence has been Mikhail Bakhtin’s “dialogism.” The model of the self in CAT has now become firmly dialogic, with an acknowledgment of the potential for continued growth throughout the life span in an ongoing authoring of the self as the person dialogues with others, including the therapist. The dialogic self is never finalized, is always a work in progress, and is embedded inextricably in the historical, cultural, and social context of the client and the client–therapist relationship.

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Major Concepts In CAT, four major concepts are the dialogic self, the procedural sequence model (PSM), reciprocal roles, and the multiple self states model (MSSM). Dialogic Self

In CAT, the self is seen to develop in the social and relational context of the child’s upbringing as the child engages in dialogue (question and response) with caregivers, siblings, and peers. Patterns of relating to others are later internalized to form the basis of self-care and internal dialogue. The dialogic self is always contextual and evolving in an attempt to author itself in light of the responses of others. Procedural Sequence Model

The PSM was the first stage in the development of the CAT model and was concerned with the factors affecting stability and change in thoughts, feelings, and behaviors. It is a model of aimdirected action where learned relational assumptions about the self are used to select actions based on an appraisal of the predicted consequences. When action is taken, the consequences are used by individuals to confirm or revise their aims and underlying assumptions. At its simplest, the PSM describes a cycle of aim, belief, action, and consequence. Early research showed there to be three general categories of procedures: traps, dilemmas, and snags. Traps In traps, negative assumptions about the self in relation to others are confirmed by the actions chosen and enacted (e.g., “As I feel depressed, I avoid others for fear of not coping in company. Over time, this compounds my feelings of loneliness and low self-esteem”). Dilemmas With dilemmas, it seems as though choices about relating to the self and others are polarized, offering only extreme alternatives (e.g., “It’s as if I either bottle everything up or explode with feelings and make a mess”).

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Reformulation

Snags Snags refer to situations where good things are avoided because of the expected consequences (e.g., “It seems as if it is dangerous to cherish something as I expect it to be taken away and destroyed”). Reciprocal Roles

Reciprocal roles describe the two poles of a relationship pattern and are a shorthand way of describing each relationship an individual seeks to find or elicit in others. For example, a male child exposed to a violent father may grow up thinking that there are only two ways to be a man in the world: as either a submissive victim or a powerful attacker. The following would represent the reciprocal role: attacking/powerful in relation to attacked/submissive/humiliated. The description and mapping of reciprocal roles in CAT is an important way of looking at the patterns that are being enacted in the client’s life and in the therapy relationship. Multiple Self States Model

The MSSM describes how some clients make rapid transitions between often contrasting self states (containing reciprocal roles) and may have limited ability to hold on to an overview of the self states that they often visit and draw others into. This is a prominent feature of borderline personality disorder and in clients who have experienced severe abuse and neglect. An example is a pattern of idealization and admiration switching to disillusion and angry attack and feelings of rejection toward the same person. In a CAT session, self states are mapped out visually on paper using words and images, so the client can begin to recognize and then revise the patterns of relating that are problematic to the client and to others.

Techniques In addition to the taking of an open, empathic, and collaborative stance in relation to the client, some specific techniques in CAT include reformulation, sequential diagrammatic reformulation (“maps”), rupture repair model, and good-bye letters.

Early on in CAT therapy, the therapist writes and reads out a “reformulation letter” to the client. The reformulation is an empathic retelling of the client’s story and ends with a description of the agreed target problems of the therapy and the reciprocalrole procedures that underlie the problems. The therapist tries to anticipate the likely reenactment of these patterns in the relationship between the client and the therapist, which may hinder therapeutic engagement or change. The reformulation is a collaborative tool, subject to dialogue and revision, and provides evidence that the therapist is alongside and “doing with” the client. Sequential Diagrammatic Reformulation

As therapy progresses, prose descriptions evolve into visual maps incorporating the reciprocal-role procedures, the self states, and the transitions between them. Mapping is an active and shared process that can be part of each therapy session. As the therapy moves forward, maps can evolve, and partial maps can be assimilated into each other to provide an overview or “observing-eye” position, with the aim of finding “exits” and “getting off the map” altogether. Rupture Repair Model

CAT research suggests that good outcomes are related to the repair of potential therapeutic ruptures, and the CAT description of reciprocal roles that are being reenacted in the therapy relationship is a key technique for CAT therapists and supervisors. Good-Bye Letters

At the end of the therapy, the therapist and the client read out and exchange good-bye letters describing how they see the therapy and suggesting ways for the client to move forward in the future, find exits, and avoid or overcome the anticipated setbacks and obstacles. Other Techniques

Other techniques commonly used in a CAT therapy include the psychotherapy file (a questionnaire listing common traps, dilemmas, snags, and self states), the

Cognitive Enhancement Therapy

personality structure questionnaire (a measure of the degree of structural dissociation experienced by the client), and creative or narrative-based tools such as “no-send letters,” drawings, and paintings.

Therapeutic Process Individual CAT involves an hour-long weekly session, typically for 16 to 24 weeks, with one or more follow-up appointments. Each CAT session is a process of exploration of the individual client and the client–therapist relationship, where the therapist seeks to take an open, collaborative, and creative position alongside and “doing with” the client, while taking care to identify, name, and attempt to learn from and repair any potential therapeutic ruptures. CAT is being increasingly used in client groups that last from 2 to 18 months and as a way of helping teams understand how dysfunctional relational patterns, derived from clients they work with, may be played out among professionals in health and social care settings. Jason Hepple See also Cognitive-Behavioral Therapies: Overview; Freudian Psychoanalysis; Object Relations Theory; Personal Construct Theory

Further Readings Clarke, S., Thomas P., & James, K. (2013). Cognitive analytic therapy for personality disorder: Randomized controlled trial. British Journal of Psychiatry, 203, 129–134. doi:10.1192/bjp.bp.112.108670 Hepple, J. (2012). Cognitive analytic therapy in a group. Reflections on a dialogic approach. British Journal of Psychotherapy, 28(4), 474–495. doi:10.1111/j.1752-0118.2012.01312.x McCormick, E. (2012). Change for the better: Self help through practical psychotherapy (4th ed.).Thousand Oaks, CA: Sage. Ryle, A. (1997). Cognitive analytic therapy and borderline personality disorder. The model and the method. Chichester, England: Wiley. Ryle, A., & Kerr, I. B. (2002). Introducing cognitive analytic therapy: Principles and practice. Chichester, England: Wiley. Ryle, A., Kellett, S., Hepple, J., & Simmonds, R. (2014). Cognitive analytic therapy (CAT) at thirty. Advances in Psychiatric Treatment. Manuscript submitted for publication.

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COGNITIVE ENHANCEMENT THERAPY Cognitive enhancement therapy encompasses specific physical and psychological practices for improving an individual’s ability to perceive and act on perceptions regarding the self and the world. The therapy utilizes the modalities of biofeedback, art therapy, and autogenic breathing, and its purpose is to connect the inner (psychological) and the outer (physical, including the body) worlds of the individual in order to promote the development of a healthy self-concept that permits optimum functioning in society.

Historical Context Addressing the need to improve our abilities to perceive ourselves and the world around us as we function within that world has long been a topic of philosophy and an important part of psychology since its inception with the work of Wilhelm Wundt, who, in 1837, proclaimed “an alliance” between the two sciences of physiology and psychology. In the 1990s, approaching human concerns from the viewpoint that the mind and the body do not operate separately led Shari Shamsavari St. Martin to develop a set of therapeutic criteria that integrates the psychological and physiological necessities of children to enhance the developmental process—a therapeutic approach that St. Martin continues to develop and refine more than 20 years later. The therapeutic criteria include art therapy, autogenic breathing, and somatic education— disciplines that can help children in particular to “see” kinesthetically (through autogenic breathing and visually by creating images) how they are behaving. By accessing psychological and physiological information consciously, children can improve their conduct as well as address their ongoing needs. Today, cognitive enhancement therapy is used in schools and in private practice to address behavioral issues in children (and adults) through the use of art therapy techniques and biofeedback. Recently, the project Alcanzando Ninos en Las Fronteras (Reaching Children at the U.S./Mexico Border) was developed by St.  Martin and is supported by the federal governments of both the United States and Mexico to address the needs of children and their families

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through the techniques of art therapy, biofeedback, autogenic breathing, somatic education, and rehabilitation.

Theoretical Underpinnings The well-known cognitive developmentalist Jean Piaget suggested that as soon as a child is born, his or her sensory and emotional systems begin working together. Children’s felt experiences begin immediately to shape both their sensory and emotional growth, and by 3 years of age, children begin telling themselves stories to make sense of their experiences and surroundings. Children who experience insecurities that go unresolved (due to adverse life circumstances) are less able to tell themselves positive stories or to imagine or anticipate a positive future. For many of these children, the result is lack of success in school and home life, susceptibility to negative influences including drug addiction and criminal behavior, and an impoverished sense of self and personal potential. Often, children who experience such negative results are treated with medication that may eliminate or reduce the problem behaviors temporarily—that is, when the medication is stopped, the problem behaviors return and the children may feel less in control of themselves and less able to respond appropriately to their surroundings. Through the use of a combination of biofeedback, somatic exercises, autogenic breathing, and art therapy interventions, children can instead learn that they have within themselves the capacity to alter their behavior and express their needs in a constructive manner.

Major Concepts Reconciling the inner and outer worlds of the individual to help the individual trust his or her core psychological and physical nature and develop the capacity to deal with life situations is the basis of cognitive enhancement therapy. This form of therapy utilizes the integrated disciplines of art therapy, biofeedback, autogenic breathing, and somatic exercises to help clients achieve this reconciliation and broaden their sense of self. The inner, psychological world is explored and interpreted through projective art therapy practices with the help of the therapist, and the information derived is supported by the objective measurement of the individual’s

physiological activity through biofeedback. The individual can see how thoughts and feelings affect the physical being, and vice versa. The Conscious and the Unconscious Mind

According to the psychiatrist Carl Jung, the conscious and unconscious minds need to unite in order to create a new third dimension, which he called the transcendent function. Cognitive enhancement is obtained at the point when this unification occurs. For example, when a shift occurs in the emotions of a child to a positive state of being and a feeling of renewal, the child is motivated to function better in society. The conscious and unconscious minds can be expressed through physical and mental practices that allow a deeper connection between the two parts. When there are substantial gaps in cognitive stimulation and affection during the early stages of a child’s life due to negative influences such as poverty or lack of parental educational involvement, problems may arise. The combination of art therapy and biofeedback is synergistically powerful. When doing art therapy, children express the truths of their lives and psyches (souls) directly. Through their imagery, their actual lived experience becomes more evident to the therapist: The visual image (picture) is worth a thousand words. At the same time, biofeedback captures and graphs the client’s physical bodily functions: heart rate, temperature, sweat gland activity, muscle activity, and brain waves. Biofeedback provides vital information about how a person’s mind and body are functioning together. Interventions that reveal this integration of body and mind are powerful tools to help health practitioners understand more completely how a patient or client is functioning psychologically and emotionally as well as physically. Taken together, both processes provide a direct “mirroring back” of the patient’s or client’s actual lived experience: Art therapy reflects the subjective, psychological reality, while biofeedback reflects the objective, physical reality. The imagery created during art therapy emerges naturally from within a person: It portrays— makes visible—the person’s emotionally experienced story from the inside out. And biofeedback makes visible the functioning of the physical mind

Cognitive Enhancement Therapy

and body. Together, both approaches provide significant feedback: Art therapy elicits imagery that describes the subjective quality of the individual’s life, including his or her psychological health and some unconscious physical symptoms, while biofeedback provides a quantitative measurement of the body’s functioning in the same time period. In this work with children, the practitioner seeks to help each child become individually more self-aware. This aligns with Sigmund Freud’s (1856–1939) principle of making conscious that which is unconscious. Freud believed that studying the experience of the unconscious was a science in itself and that probing the unconscious mind was a scientific process. Welcoming the imaginal world of children helps them experience, see, and appreciate themselves; supporting children through training and mentoring can increase children’s self-acceptance and self-esteem, which is important for their future mental health and social well-being, helping them become resilient when exposed to trauma.

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image making and art processes, and biofeedback takes the invisible physical states of the person and makes them visible through graphic recording. Autogenic Breathing

Autogenic breathing is used as a relaxation technique to promote a sense of calmness and is taught as a tool for self-regulation of physical and psychological states. It involves performing diaphragmatic breathing through the nose, inflating the lungs and extending the stomach, then exhaling from the bottom of the lungs, and bringing the stomach inward, like inflating and deflating a balloon. This is done for 3 minutes and repeated after a pause until the individual can do it naturally and without effort. Autogenic breathing has the effect of balancing the oxygen–carbon dioxide ratio in the individual’s respiratory system and promotes a feeling of calmness. Somatic Exercises

Art Therapy

Art therapy has ancient roots, from the time of the cavemen who drew pictures of animals and scenes on rocks recounting their stories and leaving imprints or recordings of their culture. Today, images serve as recordings of events remembered by individuals that can be understood through clinical interpretations. Image making has the ability to establish a different way of heuristic communication between teacher and student, patient and doctor, or individual and community. The arts are a silent language that can communicate to the observer what is actually occurring for the artist, as well as what has occurred in the artist’s past. In cognitive enhancement therapy, art therapy serves as a diagnostic technique and as a means of cultivating a client’s enhanced sense of self. Biofeedback

Biofeedback involves recording an individual’s internal physical activities so that they can be observed in real time and reviewed later by the individual as well as by the biofeedback practitioner. In essence, both art therapy and biofeedback perform similar functions: Art therapy makes invisible psychological events visible by way of

Physical exercises that focus on the awareness of increasingly subtle physiological states are taught to refine the individual’s sense of his or her body and how it functions and to promote efficient movement through deliberate actions. Performing deliberate exercises that allow free and unrestrained movement serves to retrain the brain away from functioning in a way that reinforces acquired maladaptive habits. This occurs by shifting brain activity from the portions of the nervous system responsible for involuntary or automatic movement, such as the spinal cord, to the parts that are subject to conscious control.

Techniques The ultimate goal of cognitive enhancement through psychological and physiological practices is to address the whole person and provide an approach to psychological and physical conditions that integrates the human capacity for image making with the capacity to heal. Biofeedback Assessment

Baseline measures are taken for temperature (Temp), electrodermal activity (EDA), muscle activity in the forehead (EMG1), and muscle activity in

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the back of the neck (EMG2), as well as cardiac rhythm at rest, with moderate movement, and with exercise (running). The client is seated comfortably, and sensors are applied at the fingers, the forehead, and the back of the neck. These sensors report physiological activity to a biofeedback instrument that translates the activity into graphs and charts displayed in real time on a screen and recorded for later review. The client’s data are then analyzed according to norms to determine whether the levels of activity are problematic. Neurofeedback Assessment

A neurological assessment of the brain is conducted in which the individual, in a procedure known as electroencephalogram, is measured for brain wave activity in the alpha, beta, theta, and delta ranges. Each range is associated with a specific state of consciousness (generally, alpha is a relaxed, somewhat dreamy state; beta is focused and goal oriented; theta is deeply relaxed; and delta is deep sleep). When the measurements are disproportionate, the individual may experience difficulty responding to stimuli in an appropriate fashion. Art Therapy Assessment

Clients engage in a projective art therapy activity, the House-Tree-Person test, which is a pencil drawing process to gather information on the client’s psychological, physical, and emotional development. This test is followed by a series of free drawings to gain a sense of the client’s level of functioning or nonfunctioning in his or her world. The House-Tree-Person test is again conducted after intervention as a means of assessing change in the client’s self-image. Analysis of Other Environmental Factors

External factors include the client’s environment (e.g., school for a child) and family dynamics; individual subjective factors include the client’s own feelings and behaviors as well as the use of any medications or drugs prescribed for prior symptoms. The therapist notes any factors of the client’s background that may be related to the presenting complaint and considers this information

when conducting the art therapy interventions and during conversation with the client. An analysis of the hair of the client is also sometimes done to determine possible nutritional needs that are not being met or the presence of toxins. A quantity of 1.0 gram of hair is tested to determine the presence of trace minerals or lead. Somatic Exercises

Depending on the client’s individual needs, specific somatic exercises and autogenic breathing techniques are demonstrated and recommended to reinforce the client’s physical self-awareness and confidence in his or her ability to influence personal well-being.

Therapeutic Process At the first meeting, the therapist conducts a baseline biofeedback evaluation and administers the House-Tree-Person art therapy projective test to gain information about the client’s self-concept and perception of his or her environment. Subsequent meetings involve conversation with the client, the use of various art therapy interventions and free drawing to allow the client to express inner perceptions and beliefs for which he or she may not have words or that may not be consciously available, and biofeedback measurement to demonstrate the link between mind and body and encourage the development of self-regulation skills (e.g., the ability to reduce electroencephalogram activity in alpha and increase it in beta to promote concentration). These modalities are interspersed with somatic exercises and autogenic breathing. The duration of treatment to promote cognitive enhancement through the means described herein varies according to the needs and availability of the clients, but generally, it takes place over a period of several weeks or months. Ten sessions is sometimes sufficient to permit a demonstrable improvement in a client’s ability to self-regulate physiological activity and to reflect improvement in self-concept and social interaction. Shari Shamsavari St. Martin See also Autogenic Training; Body-Mind Centering®; Feldenkrais Method; Guided Imagery Therapy; Psychodynamic Family Therapy

Cognitive Processing Therapy

Further Readings Benson, H., & Klipper, M. (1975). The relaxation response. New York, NY: HarperCollins. Buck, J. N. (1948). The H-T-P technique: A qualitative and quantitative scoring manual. Journal of Clinical Psychology, 4, 317–396. doi:10.1002/1097-4679(194810)4:43.0.CO;2-6 Criswell, E. (1995). Biofeedback and somatics. Novato, CA: Freeperson Press. Naumburg, M. (1950). An introduction to art therapy: Studies of the “free” art expression of behavior problem children and adolescents as a means of diagnosis and therapy. New York, NY: Teachers College Press. St. Martin, S. (2011). Symptoms, stories, and the evolving child. Guadalajara, Jalisco, Mexico: Ediciones de La Noche. St. Martin, S. (2012). Symptoms, stories, and the evolving child: Using art therapy and biofeedback with children, Part I. Somatics Magazine-Journal of the Mind/Body Arts and Sciences, 16(4), 50–51. St. Martin, S. (2013). Alcanzando Ninos en las Fronteras [Reaching children along the U.S./Mexico border]: A program for disadvantaged children. Biofeedback, 41(2), 66–70. doi:10.5298/1081-5937-41.2.01 St. Martin, S. (2013). Symptoms, stories, and the evolving child: Using art therapy and biofeedback with children, Part II. Somatics Magazine-Journal of the Mind/Body Arts and Sciences, 17(1), 36–40.

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Kathleen Chard has joined Resick and Schnicke in further developing CPT, expanding it to include treatment of a variety of traumas. Furthermore, CPT has been adopted as a treatment for military and veteran populations who are diagnosed with PTSD. Currently, CPT is used by the U.S. Department of Veterans Affairs as a treatment protocol specifically for PTSD, with a military and veteran population–specific CPT treatment manual.

Theoretical Underpinnings CPT is an adapted treatment model using socialcognitive theory approaches in a manualized treatment format. In CPT, the emphasis of treatment is on how the client has constructed the trauma in his or her mind and what the client can do to take control of his or her life. When a traumatic event occurs, the person develops escape and avoidance behaviors and, more important, develops a fearcentric approach to stimuli. The shattering of his or her just-world belief, or the notion that a person’s actions always result in fair consequences, is a major tenet of CPT. When a traumatic event occurs and a person’s just-world belief is shattered, a person may overassimilate or overaccommodate to his or her beliefs in an effort to adjust to the trauma. This can result in extreme views or feelings to overcompensate for safety.

COGNITIVE PROCESSING THERAPY Major Concepts Cognitive Processing Therapy (CPT) is a treatment approach focusing on reducing symptoms related to posttraumatic stress disorder (PTSD). Used by counselors when treating someone with a diagnosis of PTSD, it is a 12-session treatment approach that attempts to address themes of PTSD such as trust, control, and safety. An evidence-based practice initially developed for use with PTSD and sexual abuse victims, it is now used by counselors in a variety of settings. CPT has been shown to have greater improvement in reducing the symptomology of PTSD than other PTSD treatments.

Major concepts in CPT include a variety of social cognitive theory and cognitive-behavioral therapy tenets, including accommodation, assimilation, overaccommodation, and PTSD. Accommodation

Accommodation is the incorporation of new information into a person’s existing cognitive framework so that it results in a new way of understanding the world. Assimilation

Historical Context CPT was first developed in the early 1990s by Patricia Resick and Monica Schnicke as a treatment for sexual assault victims. Since the initial research,

Assimilation refers to the incorporation of information into a person’s existing cognitive framework so that it matches the beliefs of the person prior to the traumatic event.

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Overaccommodation

Overaccommodation is the extreme altering of beliefs in an effort to feel safe and in control. Posttraumatic Stress Disorder

PTSD is a disorder that occurs from a traumatic event or extreme stressor that results in debilitating symptoms such as intrusion, avoidance, negative changes in cognitions and/or moods, and changes in arousal and reactivity.

Techniques In CPT, techniques are used throughout the 12-session model in a structured manner according to the CPT manual. Techniques used include the trauma impact statement, Socratic questioning, stuck points, identification of thoughts and feelings, and specific topic sessions on safety, trust, power/control, esteem, and intimacy. Trauma Impact Statement

Occurring near the beginning of treatment, this is when the client is asked to either write or discuss a detailed statement that addresses why he or she believes the traumatic event happened and how it has changed his or her worldview. Socratic Questioning

Socratic questioning refers to questions that are asked in a manner that stimulates the client’s understanding of the traumatic event and increase awareness of the client’s reaction to the event. They are often used to challenge assimilation and overaccommodation beliefs that have developed from the traumatic event. Stuck Points

Stuck points are distorted beliefs that occur as a result of the traumatic event and are the result of assimilation and overaccommodation. Such points result in negative mood and dysfunctional behavior. Identification of Thoughts and Feelings

This is the psychoeducational process of helping the client identify his or her thoughts and how they

affect feelings and behaviors. For instance, clients might use the ABC worksheet, which demonstrates that it is not the activating event (A) that is responsible for the consequential (C) negative feelings and dysfunctional behaviors but the belief (B) about the event. Specific Topic Sessions

In the final sessions, themes are introduced that are typically seen as issues that arise for clients in treatment. Safety, trust, power and control, selfesteem, and intimacy are discussed from the point of view of the person in treatment and how the person views others.

Therapeutic Process Typically, CPT is a 12-session treatment modality that begins with a written or verbal trauma impact statement that the client reads or speaks out aloud. The first 5 sessions involve Socratic questioning to challenge distorted beliefs that the client has developed from the trauma. In the final 7 sessions, cognitive therapy interventions are used to develop skills in specific areas that may have been affected by the traumatic event. Heather D. Dahl See also Cognitive-Behavioral Therapy; Eye Movement Desensitization and Reprocessing Therapy; Prolonged Exposure Therapy; Trauma-Focused CognitiveBehavioral Therapy

Further Readings Ahrens, J., & Rexford, L. (2002). Cognitive processing therapy for incarcerated adolescents PTSD. Journal of Aggression, Maltreatment & Trauma, 6, 201–216. doi:10.1300/J146v06n01_10 Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of child sexual abuse. Journal of Child Sexual Abuse, 15, 87–103. doi:10.1037/0022-006X.73.5.965 House, A. S. (2006). Increasing the usability of cognitive processing therapy for survivors of child sexual abuse. Journal of Child Sexual Abuse, 15, 87–103. doi:10.1300/J070v15n01_05 Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related

Cognitive-Behavioral Family Therapy posttraumatic stress disorder. Journal of Counseling and Clinical Psychology, 74, 898–907. doi:10.1037/ 0022-006X.74.5.898 Resick, P., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Counseling and Clinical psychology, 5, 148–156. doi:10.1037//0022-006X.60.5.748

COGNITIVE-BEHAVIORAL FAMILY THERAPY Cognitive-behavioral family therapy (CBFT) has its roots in both cognitive and behavioral approaches to counseling theory, drawing on the work of Joseph Wolpe, Aaron Beck, Albert Ellis, Frank Dattilio, Donald Baucom, Norman Epstein, and others. This approach focuses on the interplay between behavior, cognition, and interaction patterns between and among family members.

Historical Context CBFT, while a fairly new treatment approach, is based on concepts whose importance has been recognized throughout history. Building on the work of behavioral and cognitive-behavioral theorists, family therapists began to integrate cognitivebehavioral theory and techniques into their approach in the 1970s. The origins of this approach can be traced back to early pioneers in behavioral theory, such as B. F Skinner, whose seminal work examining operant conditioning informed therapists of the significance of rewards and punishments in reinforcing individual behavior. Beck and Ellis, leading cognitive theorists, examined how cognitions influenced individuals and their relationships. Ellis recognized that unrealistic patterns of expectations between partners affected relational conflict; he developed rational emotive behavior therapy as a method to help individuals identify these irrational cognitions and restructure them into more realistic and constructive beliefs. Numerous family theorists (including Richard Stuart, Gerald Patterson, Donald Meichenbaum, Neil Jacobson, John Gottman, Norman Epstein, Frank Datillio, and Donald Baucom) then built on these two foundational theories, combining them to formulate behavioral family therapy and CBFT approaches.

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Initial behavioral family therapy approaches relied heavily on operant conditioning principles and included behavioral parent training, the use of role rehearsal and modeling, and contingency contracting to shape the behavioral responses of family members. As therapists began to consider the influences of internal processes such as attitudes, thoughts, and feelings along with behavioral theory and a systems perspective, modern-day CBFT approaches were born.

Theoretical Underpinnings Initially seen as incongruent with the systemic focus on circular causality, cognitive and behavioral approaches were largely dismissed by family clinicians. Over time, several shifts have occurred in the perception of cognitivebehavioral approaches to interpersonal therapies. The work of Beck, Dattilio, Baucom, and Epstein has helped support the mutually influential constructs of cognition, emotion, and interpersonal interaction. Recognizing the way in which these factors reciprocally influence each other has helped bridge cognitive-behavioral approaches with systems theory. CBFT emphasizes the role of perception and interpretation of events and interpersonal transactions as they relate to behavioral responses. Heavily influenced by both behavioral and cognitive theories, this model attempts to explore how distorted thought patterns influence behaviors and interpersonal relationships. CBFT draws from Ellis’s work, which examined the ABCs of behavior: activating events, beliefs, and consequences. Ellis suggested that the event itself does not lead to the subsequent behavior; rather, one’s beliefs about events or interpersonal exchanges influence patterns of interaction. Similarly, in CBFT, unproductive assumptions or beliefs about self, others, and family can lead to behavioral consequences that are undesirable. In keeping with its historical roots, CBFT is a model that relies on frequent assessment, including a baseline assessment of behavior to determine which problems will be the focus of treatment. As with other cognitive-behavioral approaches, empirical evaluation is highly valued, leading to a significant amount of research that demonstrates the effectiveness of cognitive-behavioral approaches, particularly with couples.

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Major Concepts A number of principles, most of which are basic to cognitive and behavioral therapy, are critical to this approach to family therapy and include operant conditioning, family schema, automatic thoughts, cognitive schema or core beliefs, cognitive restructuring, irrational or distorted thinking, and Premack’s principle. Operant Conditioning

Based on the work of Skinner, operant conditioning is a form of learning that describes how reinforcement and punishment are used to modify behaviors. Both positive and negative forms of punishment and reinforcement exist. Positive reinforcement (+) is the addition of stimuli that leads to an increase in desired behavior. Negative reinforcement (−) is the removal of stimuli that leads to an increase in a desired behavior. Positive punishment applies an unpleasant consequence following an undesired behavior. Negative punishment removes a pleasant or desired condition following an undesired behavior.

expectations, and attributions about our world and our relationships. These thoughts can lead to problematic interpersonal exchanges and are often the focus of therapeutic intervention. Cognitive Schema or Core Beliefs

A person’s schema, sometime called core belief, represents the floor plan or blueprint of an individual’s cognitive system. A schema of “I’m not worthwhile” will affect a person’s automatic thoughts with resulting thoughts such as “I can’t finish this project” or “I really fail as a parent.” Automatic thoughts affect the individual’s behaviors, feelings, and physiological responses. Negative schemas result in negative automatic thoughts, and positive ones result in positive automatic thoughts. Cognitive Restructuring

Cognitive restructuring is the process of helping to change a person’s cognitive schema and associated automatic thoughts. This process ultimately helps shift one’s perceptions, beliefs, and expectations by examining automatic thoughts and schema.

Family Schema

Irrational or Distorted Thinking

Perhaps one of the most important concepts used in conceptualizing how individuals and families perceive their roles and expectations is the concept of a schema. Schemas represent our core assumptions about how the world operates and serve as a way of organizing our thought processes. Schemas about family are based on our experiences as family members, our personal history, societal and cultural beliefs about family, and other relevant cultural and contextual influences. Family schemas organize and structure interaction among family members. These schemas can be problematic when they include unrealistic or unproductive assumptions that constrict how family members engage with each other.

Cognitive therapists have often focused on how irrational or distorted thinking can affect the individual and the family. Beliefs such as “I must be loved by everyone in the world” or black-and-white thinking can result in difficulties in relationships.

Automatic Thoughts

Automatic thoughts are fleeting thoughts that we have of which we are not usually aware. However, with some focused attention, we can easily become aware of them. Automatic thoughts are reflexive and steeped in the cultural and contextual structure provided by schemas. They include beliefs,

Premack’s Principle

Used to help guide behavior modification interventions, Premack’s principle suggests that more desirable activities can motivate individuals to get through less desirable activities. Thus, positive or pleasant tasks are contingent on the completion of less desirable tasks. A father might ask his daughter to clean her room before she is able to go outside to play with friends. In this example, the desirable activity (playing with friends) is contingent on the less desirable activity (cleaning the room).

Techniques Cognitive-behavioral family therapists generally begin with a focus on the family, not the individual, as the root of the problem behaviors, with a

Cognitive-Behavioral Family Therapy

goal of teaching families how to think and behave in mutually beneficial and less conflictual ways. Cognitive and behavioral techniques are also used with individuals as needed. Education, communication skills training, problem-solving skill building, contracting, homework, behavioral parent training, and cognitive and behavioral techniques are outlined here. Education

Building on the basic principles outlined earlier, cognitive-behavioral therapists employ education strategies to foster understanding among family members about how relationships function and the role of each member within that system. Therapists may provide coaching to assist individuals in employing these new strategies and to provide them with opportunities to practice and build new skills. Communication Skills Training

Effective communication is related to positive functioning in couples and families. Within the context of CBFT, communication skills training is used to help increase positive and productive interactions between and among family members. This training may include modeling, role-playing, and coaching. Problem-Solving Skill Building

A couple’s or family’s ability to navigate conflict largely depends on its problem-solving skill repertoire. Therapists working from this model actively coach and educate family members about effective problem-solving strategies through modeling, instruction, positive reinforcement, and reciprocity. Contracting

Contracting refers to a straightforward approach in which a formal agreement or contract is negotiated. This contract specifies behaviors and reinforcements for each family member involved, with the goal of reducing negative interactions and increasing positive, mutually rewarding, and cooperative behavior. These contracts stipulate rewards for certain behaviors and generally outline the expectations of when specific behaviors should occur.

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Homework

The therapist may assign a number of different homework exercises to the family to facilitate the integration of various principles focused on during the sessions. These may include various activities such as contracting, behavioral task assignments, self-monitoring, bibliotherapy, and cognitive restructuring. Behavioral Parent Training

Generally focused on issues of child management within a family, the therapist provides a number of programs and intervention efforts aimed at assisting the parents in applying behavioral skills to guide their children through problematic issues such as bed-wetting, temper tantrums, disobedience, aggressive behavior, hyperactivity, or other unwanted behaviors. Parents are provided information and practice in behavioral parenting techniques, such as positive reinforcement, shaping, and extinction, that are grounded in operant conditioning and classical conditioning principles. Parents are instructed in and guided through the processes of determining baseline behaviors, conducting a functional analysis of those behaviors, and charting when the behaviors occur. Then, specific procedures, such as the use of time-outs, or token economies, are developed to assist the parents in diminishing those unwanted behaviors. Thereafter, the therapist conducts a functional analysis of the interactions between family members to further inform the strategies used to address those problem behaviors. Functional Family Therapy

After an initial assessment stage in which the therapist determines the functions of various behavior patterns employed by various family members, the therapist works to change the focus of the family from an individualistic, blaming outlook to one of shared responsibility for family behavior problems. Employing an eclectic process, general systems, behavioral, and cognitive interventions are applied to address and modify attitudes, cognitions, expectations, and reactions within the family system. This approach facilitates the reinforcement of new behaviors and patterns of interaction.

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Conjoint Sex Therapy

Cognitive-behavioral techniques are applied to alleviating sexual dysfunction within a relational and interpersonal context. Cognitive restructuring, behavioral skills, communication skills, and sex education may be employed to assist the couple in working through interpersonal conflict as well as overcoming negative feelings and images regarding the sexual experiences of each partner. Cognitive Techniques

Two main cognitive techniques are (1) cognitive restructuring, which has to do with changing schema or core beliefs, and (2) disputing irrational beliefs or distorted thinking. Both are done with the intent of improving the relationships in the family. Individuals who have healthier thinking relate better to one another. In addition, therapists may help families examine their family schema and help restructure that blueprint that affects the behavior of the family. Other cognitive techniques geared toward specific individuals in the family may be used as needed. Behavioral Techniques

There are literally hundreds of behavioral techniques, based on operant conditioning and other behavioral paradigms, that can be used with individuals, couples, and families. Some of the more popular ones include behavior modification, contingency contracts, positive reinforcements, shaping, systematic desensitization, extinction, modeling, and role-playing.

Therapeutic Process To influence dysfunctional or unproductive behavior, one must explore the patterns of cognition that influence these behaviors. Cognitivebehavioral family therapists work to increase positive or functional behaviors and their accompanying cognitions, and to decrease those behaviors and cognitions that are unproductive or limiting. Clinicians may work with clients to build problem-solving and communication skills, helping to build on the base of strategies and skills that family members can use when encountering current and future challenges. Cognitive-behavioral

family therapists are active in coaching and educating their clients, using specific cognitive and behavioral techniques to move clients toward stated goals. Baseline Assessment

Initially, therapeutic work involves baseline assessment to determine how the family is functioning at the onset of counseling. Individuals and family interaction patterns are assessed. Assessment is framed in behavioral terms. Functional Analysis

The therapist might also perform a functional analysis of the identified presenting problem to address the underlying cognitive assumptions and consequences of the behavior or interaction patterns. The therapist works with the client’s family to identify irrational beliefs and family schema. Once identified, emphasis is placed on shifting automatic thoughts and irrational beliefs to more productive assumptions. Techniques such as modeling, thought stopping, and contracting may be used to help challenge these unproductive assumptions. As irrational beliefs are challenged and the client and the therapist settle into counseling, the therapist also works with the client family to create reinforcing behaviors, building in rewards and contingencies to help support the client in working toward the goals. Charting may be used as a way to track behaviors and monitor progress. Because CBFT is a highly collaborative therapeutic approach, the therapist is likely to enlist the client’s help in maintaining work done during the session through the use of homework assignments. Cognitive and behavioral therapies are often time limited, and CBFT is no exception. As the therapeutic relationship comes to an end, families revisit their therapeutic goals. The therapeutic process generally ends when the undesired or unproductive behaviors have been greatly reduced or extinguished. Esther N. Benoit and Carrie Lynn Bailey See also Behavior Therapies: Overview; CognitiveBehavioral Therapies: Overview; Evidence-Based Psychotherapy; Gottman Method Couples Therapy; Operant Conditioning

Cognitive-Behavioral Group Therapy

Further Readings Baucom, D. H., & Epstein, N. (2013). Cognitive-behavioral marital therapy. London, England: Routledge. Dattilio, F. M. (2001). Cognitive-behavior family therapy: Contemporary myths and misconceptions. Contemporary Family Therapy, 23(1), 3–18. doi:10.1023/A:1007807214545 Dattilio, F. M. (2009). Cognitive-behavioral therapy with couples and families: A comprehensive guide for clinicians. New York, NY: Guilford Press. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Friedberg, R. D. (2006). A cognitive-behavioral approach to family therapy. Journal of Contemporary Psychotherapy, 36(4), 159–165. doi:10.1007/s10879-006-9020-2 Graham, P., & Reynolds, S. (Eds.). (2013). Cognitive behaviour therapy for children and families. Cambridge, England: Cambridge University Press. Schwebel, A. I., & Fine, M. A. (1992). Cognitive-behavioral family therapy. Journal of Family Psychotherapy, 3(1), 73–91. doi:10.1300/j085V03N01_04

COGNITIVE-BEHAVIORAL GROUP THERAPY Cognitive-behavioral group therapy (CBGT) is a counseling intervention that uses the foundations and methods of cognitive-behavioral therapy in the group counseling context. Its purpose is to help individuals change how they perceive and experience their environment and develop new response patterns to social and environmental factors. CBGT utilizes group process as a safe “classroom,” where clients can experience stimuli, behaviors, and consequences with the counselor as a guide. This allows clients to practice new behaviors and receive direct and immediate feedback from other group members, a transaction that can assist them in choosing more effective ways of interacting with their environment and social network outside the group.

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The modern use of the term cognitive-behavioral therapy is imprecise as it is a term associated with certain historical figures, yet it also represents a family of therapeutic approaches that has its roots with several theorists. Some of these historical roots are Edward Thorndike (1874–1949), who postulated that behavior could be changed through a process he called behavior modification. B. F. Skinner (1904–1990) built on Thorndike’s work, demonstrating that behavior could be changed through a process he referred to as operant conditioning. Both Skinner and Thorndike emphasized that change could be realized in clients or subjects by exposing them to a specific set of experiences that would condition them to display expected, observable behaviors. Neither attempted to modify what the clients or subjects were thinking. Aaron Beck (1921– ), the founder of cognitive therapy, applied the concept of thought to the change process, asserting that counselors need to identify problems in clients’ thought patterns and help them find more effective ways to think. It is only through such modifications, Beck believed, that clients’ behaviors and perceptions can change. Albert Ellis (1913–2007), the father of a school of cognitive therapy known as rational emotive behavioral therapy (REBT), also emphasized the role of undesirable emotions as both an antecedent and an outcome of ineffective or, in his terms, “irrational” thinking. He maintained that irrational thinking leads to negative or “maladaptive” behaviors. Consistent with Beck and Ellis, Arnold Lazarus (1932–2013) developed an approach that he referred to as multimodal therapy, which incorporates concepts of behavior, affect, sensation, imagery, cognition, relationships, and biology into the therapeutic process. All of these therapeutic approaches have at their foundation the basic idea that problematic behaviors and emotional reactions are the expected outcomes of how individuals think. These theorists assert that developing more effective ways to think leads to the development of desirable changes in behavior.

Historical Context Cognitive-behavioral therapy intertwines with a variety of historical conceptualizations of therapeutic change, the most obvious concepts being cognitive understanding and behavioral change.

Theoretical Underpinnings CBGT seeks to address a variety of mental health issues by applying cognitive and behavioral techniques within a group setting. Developed separately

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by Beck and Ellis, cognitive approaches assume that core beliefs affect the development of one’s thinking, behaviors, feelings, and physiological responses. Thus, if the therapist can help the client identify his or her negative core beliefs (called irrational thinking by Ellis), then the client can begin the process of changing his or her belief system and ultimately behave differently and feel better. Often, emotional retraining and behavioral changes are suggested to reinforce the changing of core beliefs. Therapists who use a cognitive-behavioral approach also generally use a number of techniques that are rooted in operant conditioning, classical conditioning, and social learning or modeling. These approaches assume that one’s negative behaviors become conditioned through these learning modalities. Thus, if a therapist can apply a behavioral analysis of the client’s current ways of acting in an effort to discover which dysfunctional behaviors have become conditioned or learned, then these behaviors can be extinguished and new, more functional behaviors can become conditioned. Finally, the application of cognitive and behavioral approaches can be strengthened through their use in a group setting. A group allows individuals to gain feedback from other individuals, and these individuals can also be important in reinforcing new ways of thinking and acting. Using basic group counseling techniques can lead to group cohesiveness, which in and of itself can be a powerful reinforcer of new behaviors learned within the group setting.

greater level of skill on the part of the counselors to manage the group development process effectively. If facilitated effectively, therapy groups can, over time, foster a facilitative environment that allows group members to exchange therapeutic feedback and provide a safe environment in which to practice new social behaviors. Eligibility for Group

Counselors routinely form cognitive-behavioral therapy groups with individuals who experience the same or similar problems, such as anxiety. The counselor screens each prospective member for appropriateness for the group, using appropriate psychological instruments to assess his or her willingness to participate and the degree of dysfunction to determine whether the potential member “fits” into the particular group. Assessment

Typically, an assessment of the client’s ways of thinking and acting is conducted near the beginning of the group process. This allows the counselor to determine the specificity of the problems and to develop cognitive and behavioral techniques that can combat the problems at hand. Sometimes called a functional cognitive and behavioral analysis, such an assessment can be conducted verbally, by the counselor, and/or through a series of psychological assessment instruments. Goal Setting

Major Concepts Major concepts associated with CBGT include group therapy, eligibility for group, assessment, and goal setting.

Once an assessment is completed, the counselor can begin to develop appropriate cognitive and behavioral techniques to address the problems at hand. Usually, older, maladaptive ways of thinking and acting are extinguished, and new, more functional ways of thinking and acting are applied.

Group Therapy

Group therapy is not a theory of counseling; instead, it is a modality, a way of providing counseling services. In group therapy, one or, occasionally, two counselors work with several clients; typically, there are between 5 and 12 clients per group. Because there are multiple clients, the complexity of the relationships increases exponentially as the size of the group increases. This requires a

Techniques A number of traditional group counseling skills are used in CBGT so that the group process can take hold. This allows for increased cohesiveness in the group. As the group solidifies and appropriate assessment takes place, a number of cognitive and behavioral techniques can be applied.

Cognitive-Behavioral Group Therapy

Group Counseling Skills

Traditional group counseling skills include paraphrasing, which helps ensure that the client has been heard correctly; linking, which brings together clients who have similar stories and helps build cohesiveness; summarization, which pulls together various themes that have been discussed; posing questions, which are used to help explore a client’s situation and can be particularly helpful in the assessment process; pointing out conflicts, such as highlighting times when clients’ thoughts, feelings, and behaviors may not be incongruent; support and challenge, which can be used to gently confront clients to change while ensuring that they feel as if they are supported by the counselor; and immediacy, which is when the counselor understands what is going on with a client in the “hereand-now” and then effectively uses that information to facilitate a greater understanding in the client as to how one might change. Traditional group counseling skills help increase client insight, build group cohesiveness, identify problematic thinking and behaviors, and develop goals for treatment. Such skills are used by the counselor but are often also applied by other group members as they increasingly view the counselor applying the skills and model the counselor’s behaviors. Cognitive and Behavioral Skills

In addition to the traditional group counseling skills, there are a number of cognitive and behavioral skills that are used within this type of group setting. Cognitive Skills Some cognitive-behavioral therapists have clients examine their automatic thoughts within the group setting. Such thoughts are affected by core beliefs. A core belief such as “I am not worthwhile” will lead to negative automatic thoughts (“I can never make this relationship work”). Ultimately, clients need to both work on their automatic thoughts and eventually resolve their core beliefs. Other cognitive therapists examine how one’s “irrational beliefs” affect one’s feelings and behaviors. This ABC model assumes that it is not the

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activating event (A) that leads to consequences (C) but the belief (B) about the event. In this model, irrational beliefs lead to dysfunctional behaviors and negative feelings, while rational beliefs lead to functional behaviors and reasonable feelings. Thus, the individual who does poorly on an exam and catastrophizes may say, “I am going to flunk out of school and end up in a do-nothing job.” Such catastrophizing often leads to anxiety and depression. The job of the therapist is to help the client understand that the irrational belief leads to the negative feelings and to help the client learn how to dispute the irrational belief with a rational belief (“I didn’t do as well as I liked on this exam, but I know it’s not the end of the world and I can try harder the next time”). Behavioral Techniques There are many different types of behavioral techniques that can be applied in cognitive-behavioral therapy. These techniques, which are all based on operant conditioning, classical conditioning, or modeling, can supplement cognitive techniques or may be used on their own to help change identified dysfunctional behaviors. A few common techniques include relaxation exercises, systematic desensitization, modeling, flooding and implosion techniques, prolonged exposure therapy, stimulus control, self-management techniques, and operant conditioning techniques.

Therapeutic Process Once groups are formed and begin functioning, CBGT group leaders expect their groups to develop over time. This means that group members’ interactions will increase in frequency and honesty as members get to know each other. As a greater level of trust develops, group members will display behaviors from outside the group within the group process. Thus, the maladaptive behaviors and the precipitating factors related to their problems would be observed in the group. This allows both counselors and group members to see, assess, and intervene with the cognitions and behaviors leading to members’ issues in an immediate way. This process also helps members learn to receive feedback and enables them to practice different behaviors within a protected environment.

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At times, the problematic behaviors demonstrated during group sessions prove even more problematic than the original presenting issues. This apparent worsening of a problem is to be expected in the short-term because as members use their time in group to “try on” and “try out” various new behaviors, they receive immediate feedback as to their effectiveness. Such processes can be challenging (thus, the apparent worsening of the underlying issue), but the experimentation and feedback can assist members not only in choosing the behaviors that would work the best in their lives but also in establishing realistic and measurable goals for the implementation of those personal behaviors both inside and outside of the group. Throughout the group process, each client can be reassessed to determine the level of the maladaptive behavior and the progress toward individual clients’ goals. The counselor may use both standardized and informal clinical assessments to determine the progress of each client. This, in turn, can be used to determine counseling effectiveness, readily contributing to what is known as data-driven, evidence-based practice. A primary emphasis of CBGT is the concept that clients use the group process to gain “experience.” Clients are exposed to and encouraged to participate in exercises in which they practice responding to situations differently. As new ways of responding are practiced, each is processed by the counselor and the other group members, and then, each client can choose which pattern of behavior would be the most functional in any given situation. This allows the client to cognitively choose the behavioral response to an antecedent to lead to the most effective consequence. Furthermore, because the counselor can observe and assess the new behaviors, the effectiveness of counseling improves. Verl T. Pope See also Beck, Aaron T.; Behavior Therapy; Behavioral Group Therapy; Cognitive-Behavioral Therapies: Overview; Cognitive-Behavioral Therapy; Ellis, Albert; Rational Emotive Behavior Therapy; Skinner, B. F.

Further Readings Beck, A. T. (1979). Cognitive therapy and the emotional disorders. New York, NY: Plume.

Brown, N. W. (2013). Creative activities for group therapy. New York, NY: Routledge. Ellis, A. (2001). Overcoming destructive beliefs, feelings, and behaviors: New directions for rational emotive behavior therapy. Amherst, NY: Prometheus Books. Frankl, V. (1984). Man’s search for meaning. New York, NY: Washington Square Press. Kline, W. B. (2003). Interactive group counseling and therapy. Upper Saddle River, NJ: Merrill Prentice Hall. Lazarus, A. A. (1989). The practice of multimodal therapy. Baltimore, MD: Johns Hopkins University Press. Skinner, B. F. (1953). Science and human behavior. New York, NY: Free Press. Sperry, L. (2006). Cognitive behavior therapy of DSMIV-TR personality disorders (2nd ed.). New York, NY: Taylor & Francis. Wuthrich, V. M., & Rapee, R. M. (2013). Randomised controlled trial of group cognitive behavioural therapy for comorbid anxiety and depression in older adults. Behaviour Research and Therapy, 51, 779–786. doi:10.1016/j.brat.2013.09.002

COGNITIVE-BEHAVIORAL THERAPIES: OVERVIEW Cognitive-behavioral therapy (CBT) is a form of counseling and psychotherapy that focuses on changing maladaptive behaviors, emotions, and thoughts. The name refers to behavior therapy (BT), cognitive therapy (CT), and to therapies that are based on a combination of basic behavioral and cognitive principles and research. Many therapists working with individuals dealing with anxiety and depression use a combination of cognitive and behavioral therapy. Unlike other approaches that focus on insight, such as the psychoanalytic psychotherapy and existential-humanistic approaches, CBT is “problem focused” and “action oriented.” This means that CBT addresses the specific problems of clients and provides them with specific strategies for dealing with those problems. CBT can be used with adults, adolescents, and children. It is thought to be effective for the treatment of a variety of psychological conditions, including mood disorders, anxiety disorders, personality disorders, eating disorders, substance disorders, stress disorders, attention-deficit/hyperactivity

Cognitive-Behavioral Therapies: Overview

disorder, psychotic disorders, and some medical conditions, including chronic pain and fibromyalgia. CBT can be utilized in individual, family, couple, and group settings. It can be delivered via treatment manuals and has been adapted for selfhelp applications. Currently, CBT is the most commonly practiced therapy approach in North America. Cognitive-behavioral therapy is usually time limited, which means that treatment can be completed in 6 to 20 one-hour sessions.

Historical Context CBT is the integration of cognitively oriented therapies with behavior modification. The term cognitive-behavior modification was first used by the psychologist Donald Meichenbaum (1940– ) in his 1977 book Cognitive-Behavior Modification: An Integrative Approach. Afterward, the term cognitive-behavioral therapy emerged and became commonplace among therapists, clients, researchers, and the media. This integration of two seemingly different perspectives and treatment approaches began in the late 1970s. Historically, the distinctions among cognitive-behavioral therapies concern what type of responding (cognition or behavior) is targeted to change behavior, emotions, or relationships. The behaviorally oriented approaches primarily conceptualized these problems in terms of modifying overt behavior or its environmental context. In contrast, the cognitively oriented approaches primarily conceptualized these problems in terms of changing cognitions. As the field of CBT has evolved over the past four decades, these two perspectives and treatment approaches have evolved and merged, with less time devoted to differentiating cognition from behavior. Both approaches focus on treatment targets that will increase client functioning and well-being as well as reduce client vulnerability to the presenting symptoms or concern. Behavioral Orientation

CBT had its roots in the BT of the 1950s. BT focused on observable behavior and its modification in the present, in sharp contrast to the psychoanalytic method of Sigmund Freud (1856–1939), which focused on unconscious processes and their roots in the past. Traditional BT was developed by

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researchers and therapists who were critical of the prevailing psychoanalytic treatment methods. BT drew on various behavioral theories and research, including the classical conditioning principles of Ivan Pavlov (1849–1936), the operant conditioning research of B. F. Skinner (1904–1990), and the first applications of behavioral principles to therapy by Joseph Wolpe (1915–1997). Pavlov became famous for experiments in which dogs were trained to salivate at the sound of a bell. Skinner pioneered the concept of operant conditioning, in which behavior is modified by changing the response it elicits. Wolpe was successful in applying both classical and operant conditioning to phobias and other anxiety disorders with systematic desensitization and assertiveness training. By the 1970s, BT had achieved considerable success as a treatment approach, even though it was largely focused on treating anxiety symptoms. Since the 1980s, many therapists have begun to use CBT to change clients’ maladaptive behavior involved in a wider array of mental disorders, including depression and psychosis. Cognitive Orientation

The cognitive therapies arose as a response to the perceived shortcomings of BT and the psychoanalytic and psychodynamic therapies. Some of the pioneers in the development of the cognitive therapies had originally been trained in psychoanalysis. These included Albert Ellis (1913–2007), the developer of REBT, and Aaron T. Beck (1921– ), the developer of CT. Others had training in BT and other approaches, like schema therapy (ST), which was developed by Jeffrey Young (1950– ). The focus of basic science research in the 1970s, called the “cognitive revolution,” served as a turning point in the rapid evolution, acceptance, and legitimacy of the cognitively oriented therapies. The historical roots of the cognitively oriented therapies have been identified in various ancient philosophical traditions, particularly Stoicism. For example, both Ellis and Beck cite the influence of the Stoic philosophers. One of these, Epictetus, wrote in The Enchiridion, “Men are disturbed not by things, but the view which they take of them.” Other influences on the cognitive therapies include Alfred Adler (1870–1937), who said, “I am convinced that a person’s behavior springs from

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his ideas” (Ansbacher, 1956, p. 182). Adler developed Individual Psychology, in which the cognitive orientation is central to his description of lifestyle convictions, which include schemas about self and others. These self–other schemas are now prominent in various CBT approaches, and both Ellis and Beck acknowledge Adler’s influence on their thinking. The evolution of CBT can be understood in terms of what has been called the “three waves” of BT. First Wave The first wave emphasized traditional BT, which focused on replacing problematic behaviors with constructive ones through classical conditioning and reinforcement techniques. Traditional BT was a technical, problem-focused, present-centered approach that was markedly different from psychoanalysis, individual-centered therapy, and similar approaches of that era that emphasized the therapeutic relationship and the feelings and inner world of the individual. Second Wave The second wave involved the incorporation of the cognitive therapies that focused on modifying problematic feelings and behaviors by changing the thoughts that cause and perpetuate them. Within the mental health professions, the incorporation of cognitive and behavioral therapies in the 1970s was not initially a cordial or conflictfree union, but today, most cognitive therapists incorporate key behavioral interventions, while most behavior therapists recognize the role of individuals’ beliefs about the consequences of their behaviors The fact that both were problemfocused and scientifically based therapies has helped foster this union and resulted in CBT becoming the most commonly practiced treatment method in the United States since the late 1980s.

treatment tends to be more experiential and indirect and utilizes techniques such as mindfulness, dialectics, acceptance, values, and spirituality in fostering a more holistic approach to cognitive and behavioral change. More specifically, thirdwave approaches are characterized by downplaying problem solving and emphasizing awareness and nonreactivity. Unlike first- and second-wave approaches, third-wave approaches emphasize second-order change—that is, basic change in structure and/or function—and are based on contextual assumptions including the primacy of the therapeutic relationship. Representative approaches include acceptance and commitment therapy, developed by Steven Hayes (1948– ); dialectical behavior therapy (DBT), developed by Marsha Linehan (1943– ); the cognitivebehavioral analysis system of psychotherapy, developed by James McCullough (1942– ); and mindfulness-based cognitive therapy, developed by Zindal Segal (1956– ).

Theoretical Context While there are several approaches to CBT, all share a number of commonalities, with some research suggesting that the following characteristics are common to all CBT approaches. Cognition and Behavior Emphasis

A basic premise of CBT is that emotions and behavior are influenced by cognitions and thinking. Because most emotional and behavioral reactions are learned, the goal of therapy is to help clients unlearn unwanted responses and learn new ways of responding. The process begins with assessing maladaptive thoughts and behaviors. Then, these thoughts and behaviors are challenged and modified so that clients can gain control over problems previously believed to be insurmountable. Present and Future Focus

Third Wave The third wave involved the reformulation of conventional CBT approaches that were based on a modernist paradigm or perspective. In contrast, third-wave approaches tend to be more influenced by the postmodern perspective. Accordingly,

Unlike other approaches that focus on the past, CBT focuses on the impact of clients’ present maladaptive thoughts and behaviors on their current and future functioning. In addition, skills learned in therapy are designed to promote more effective future functioning.

Cognitive-Behavioral Therapies: Overview

Directive

CBT is a directive approach in which therapists direct the treatment process. They do this by setting an agenda, deciding and planning what will be discussed prior to the session, and then actively directing the discussion of specific topics and tasks. Cognitive-behavioral therapists also actively work to engage clients in the treatment process and in these decisions. Skill Focus

Cognitive-behavioral therapists teach clients the necessary skills for coping more effectively with problematic situations. Dealing directly with skill deficits and excesses is essential for clients to achieve and maintain treatment gains. Psychoeducational

Cognitive-behavioral therapists explicitly discuss the rationale for treatment and the specific techniques utilized. They may provide clients with specific information such as books, articles, or handouts. The purpose is to orient clients to the treatment process, to increase clients’ confidence in treatment, and to enhance their ability to cope with problematic situations. Homework

Homework and between-session activities are a central feature of CBT. Such activities provide clients the opportunity to practice skills learned in sessions and transfer gains made in therapy to everyday life. These activities can also foster and maintain symptom reduction.

Short Descriptions of the CognitiveBehavioral Therapies Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a form of BT that assists individuals to increase their acceptance of difficult and painful experiences and to increase their commitment to action that can improve and enrich their lives. Instead of reducing symptoms, the goal of ACT is to learn how to accept and detach from them. When acceptance occurs, symptom reduction is a by-product. ACT treatment

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uses mindfulness and other interventions to develop psychological flexibility and to clarify and foster values-based living. Instead of attempting to directly change or stop unwanted thoughts or feelings, ACT focuses on developing a mindful relationship with those experiences to free individuals to make them more receptive to taking action that is life-giving. Adlerian Therapy

In Adlerian therapy, clients explore how early memories, especially early memories related to feelings of inferiority, affected their private logic (similar to one’s cognitive schema), resulting in a style of life that is reflective of this private logic. Adlerians help clients understand and ultimately change their private logic. New, more functional private logic results in a new style of life and more realistic goals that are in line with their natural talents and abilities. Cognitive Analytic Therapy

Cognitive Analytic Therapy integrates psychodynamic and construct/cognitive therapy in a relational model that looks at how the self develops and evolves through time as the individual is in dialogue with others. Cognitive analytic therapy is particularly focused on how dysfunctional patterns of relating may be enacted in the therapeutic relationship and how that relationship can help the client construct a new way of being that evolves through conversations with the therapist. Cognitive-Behavioral Therapy

CBT, which has the same name as this overarching category, emphasizes cognitive processing in emotion and behavior and views personality as shaped by core schemas. Presenting problems and symptoms are understood to result from maladaptive core schemas and beliefs. The focus of treatment is to become aware of limiting automatic thoughts, confront faulty beliefs with contradictory evidence, and develop more adaptive beliefs and behaviors. Critical Incident Stress Management

Critical incident stress management is an approach used to prepare, respond, and cope with disasters and crises and to help alleviate the

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impact of such incidents. The approach focuses on helping to lessen crisis through preparation and education; offering on-site support when a crisis does occur; offering one-on-one, group, and family support; and providing follow-up services. It can be viewed as a cognitive-behavioral approach due to its focus on how mediating thoughts can induce stress and because it has a goal-oriented process. Dialectical Behavior Therapy

DBT is less cognitive than traditional CBT because DBT assumes that cognitions are less important than affect regulation. The core strategies in DBT are validation and problem solving. Attempts to facilitate change are surrounded by interventions that validate the client’s behavior and responses in relation to the client’s current life situation. Problem solving focuses on the establishment of necessary skills. Functional Analytic Psychotherapy

Functional analytic psychotherapy uses awareness, courage, and therapeutic love in the therapeutic relationship as a mechanism for change as the therapist responds in the here-and-now to client issues and improvements. Within this type of relationship, client history and client change are viewed from a behavioral perspective and often combined with other types of cognitive-behavioral approaches, such as CBT. Guided Imagery Therapy

Guided imagery therapy uses the client’s imagination and creativity to gain insight that can be used in the therapeutic process. Several forms of imagery can be practiced, and these can focus on specific goals of therapy. Impact Therapy

Impact therapy is an active, multisensory, and creative approach to counseling that uses props, experiential activities, metaphors, and more to focus the session and stimulate the client in an effort to make abstract concepts more concrete. Impact therapy assumes that multiple sensory modalities increase interest in counseling, strengthen the

therapeutic bond, and increase the ability of the client to work on issues and make progress toward goals. Methods of Levels

Rather than focusing directly on symptoms, Methods of Levels integrates cognitive and experiential therapies in that it develops a conversation with the client in an effort to understand the client’s distress and develop new perspectives on the client’s perceptions of the world. Ultimately, clients are encouraged to reorganize their perceptual field. Mindfulness-Based Cognitive Therapy

Mindfulness-based cognitive therapy is an adjunctive (extra) or stand-alone form of treatment that emphasizes changing one’s awareness of, and relation to, thoughts rather than changing thought content. It fosters a detached attitude toward negative thinking and provides the skills to prevent escalation of negative thinking at times of potential relapse. Clients engage in various formal meditation practices designed to increase momentby-moment nonjudgmental awareness of internal sensations, thoughts, and feelings. Mindfulness-Based Stress Reduction

An 8-week structured group process, the mindfulness-based stress reduction approach to counseling was originally used to treat those with chronic pain, cancer, and other physical ailments but has been expanded to treat depression and anxiety and other symptoms. It uses mindfulness techniques, such as meditation, focused attention, and breathing techniques, to assist clients in working on their presenting issue. Motivational Interviewing

A client-centered and goal-driven approach, motivational interviewing seeks to understand clients’ resistance to change and their motivation for change. Theorizing that clients tend to teeter between resistance and wanting to change, counselors use empathy and a nonadversarial caring approach, with other gently prodding techniques, to gingerly motivate clients and move them toward their goals.

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Multimodal Therapy

Schema Therapy

Multimodal therapy uses the BASIC I.D. (behavior, affect, sensation, imagery, cognition, interpersonal relationships and biological processes [sometimes “drugs”]), to understand those areas in client treatment that need to be addressed. After the counselor assesses these areas, the counselor uses a wide range of tactics and strategies to assist the client toward his or her goals.

ST is a derivation of CT, originally developed for use with personality-disordered clients who failed to respond adequately to CT. It is a broad, integrative model that shares some commonalities with object relations therapy, experiential therapy, DBT, interpersonal therapy, as well as CT. The basic goals of ST are the following: (a) to identify early maladaptive schemas, (b) to validate the client’s unmet emotional needs, (c) to change maladaptive schemas to more functional ones, (d) to promote more functional life patterns and coping styles, and (e) to provide an environment for learning adaptive skills.

Rational Emotive Behavior Therapy

In REBT, problems and symptoms are considered to be the result of self-defeating thought processes. These thought processes include self- and otherdeprecation, catastrophizing, overgeneralizing, and personalizing. The goal of REBT is to change irrational beliefs and self-defeating thought processes into rational beliefs and adaptive thought processes. The focus of treatment is to identify and change the irrational beliefs that underlie disturbed feelings and self-defeating behavior through various cognitive restructuring methods, particularly disputation. Rational Living Therapy

Rational living therapy helps clients achieve insight into their irrational and negative thinking and dysfunctional behaviors and has clients do an accurate assessment of their attributes and abilities (the “four As”) while helping clients work toward their desired goals. Rational self-counseling skills are taught, and homework assignments are frequently used to augment treatment. Reality Therapy

Reality therapy assumes that behavior is based on internal motivation and examines how five needs are the origins of such motivation (e.g., [1] survival of self-preservation, [2] love and belonging, [3] power or inner control, [4] freedom or independence, and [5] fun or enjoyment). Making the assumption that such needs are sometimes obtained in dysfunctional ways (e.g., the need to be loved may be addressed through the use of drugs), reality therapists believe that through finding new ways of acting and thinking, a client can better meet his or her needs and change what reality therapists call his or her total behavior (how the client acts, thinks, and feels and his or her physiological responses).

Trauma-Focused Cognitive-Behavioral Therapy

Trauma-focused cognitive-behavioral therapy is an integration of humanistic and CBT treatment strategies that helps children and parents deal with the emotional and behavioral impact of a severe trauma in their lives. It combines sensitive, humanistic relationship-building skills with traditional cognitive-behavioral techniques to help children and parents manage and resolve the impact of trauma in their lives. Len Sperry See also Acceptance and Commitment Therapy; Adler, Alfred; Adlerian Therapy; Bandura, Albert; Beck, Aaron T.; Cognitive Analytic Therapy; CognitiveBehavioral Therapy; Critical Incident Stress Management; Dialectical Behavior Therapy; Ellis, Albert; Functional Analytic Psychotherapy; Glasser, William; Guided Imagery Therapy; Impact Therapy; Lazarus, Arnold; Linehan, Marsha; Mahoney, Michael J.; Meichenbaum, Donald; Methods of Levels; Miller, William R.; Mindfulness-Based Cognitive Therapy; Mindfulness-Based Stress Reduction; Motivational Interviewing; Multimodal Therapy; Pavlov, Ivan; Rational Emotive Behavior Therapy; Rational Living Therapy; Reality Therapy; Schema Therapy; Shapiro, Francine; Skinner, B. F.

Further Readings Ansbacher, H. L. (1956). The individual psychology of Alfred Adler: A systematic presentation in selections from his writings. New York, NY: Basic Books. Beck, A. (1967). Cognitive therapy and the emotional disorders. New York, NY: International Universities Press.

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Beck, J. S. (2010). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press. Blagys, M., & Hilsenroth, M. (2002). Distinctive activities of cognitive-behavioral therapy: A review of the comparative psychotherapy process literature. Clinical Psychology Review, 22, 671–706. doi:10.1016/S0272-7358(01)00117-9 Crane, R. (2009). Mindfulness-based cognitive therapy. New York, NY: Routledge. Craske, M. G. (2010). Cognitive-behavioral therapy. Washington, DC: American Psychological Association. Ellis, A., & MacLaren, C. (2005). Rational emotive behavior therapy: A therapist’s guide (2nd ed.). Atascadero, CA: Impact. Hayes, S. C., Strosahl, K., & Wilson, K. (2003). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press. Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. McCullough, J. P. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy. New York, NY: Guilford Press. Miller, A. L., Rathus, J., & Linehan, M. (2007). Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford Press. Segal, Z. V., Williams, J., & Teasdale, J. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). New York, NY: Guilford Press. Sperry, L. (2015). Cognitive behavior therapy of DSM-5 personality disorders (3rd ed.). New York, NY: Routledge. Wolpe, J. (1990). The practice of behavior therapy (4th ed.). New York, NY: Pergamon Press. Young, J. E., Klosko, J., & Weishaar, M. (2003). Schema therapy: A practitioner’s guide. New York, NY: Guilford Press.

COGNITIVE-BEHAVIORAL THERAPY Cognitive-behavioral therapy (CBT) is the merging of behavioral and cognitive therapies that mostly focuses on working with the client in the present. Although there are many approaches to CBT, there tend to be some common features. For example, CBT is generally a directive approach to psychotherapy that helps clients to challenge their problematic thoughts and to change the behaviors

associated with those thoughts. In addition, most approaches to CBT are structured and time limited and include some type of homework where the client can practice the cognitive and behavioral strategies learned in the therapeutic setting. This entry focuses mostly on CBT as defined by Aaron Beck, one of the early founders of this approach.

Historical Context The first approach to CBT to achieve widespread recognition was rational emotive therapy, originated by Albert Ellis in the mid-1950s. Ellis developed his approach in reaction to his disliking of the inefficient nature of psychoanalysis. Ellis believed that how we act and how we feel are the result of irrational thinking, and he proposed a number of typical irrational thoughts that people tend to have that will lead to dysfunctional ways of being in the world (e.g., the need to be loved by everyone on the planet, the idea that we must rely on others for our happiness, etc.). His approach was widely used in the latter part of the 20th century and continues to be used today. Not too soon after Ellis developed his approach, during the early1960s, Aaron Beck developed a similar approach he called cognitive therapy. Initially applying his approach to those with depression, Beck’s ideas eventually spread to a whole range of other diagnostic categories. Beck stayed away from the use of the word irrational and instead suggested that core beliefs and deep schemas, or embedded ways by which we tend to view the world, lead to dysfunctional behaviors and negative feelings. His approach was outlined in a classic series of articles published in the 1960s. Beck’s early writings focused primarily on pathology in information processing styles in clients with depression or anxiety, but he also incorporated behavioral methods to prevent feelings of helplessness. After the work of Ellis and Beck, a number of others developed related theories that became widely used. For instance, Max Maultsby developed rational emotive imagery, rational self-analysis, and the five criteria for rational behavior, which included an emphasis on client rational selfcounseling skills and therapeutic homework. Another example is Donald Meichenbaum, who developed stress inoculation therapy, an attempt to

Cognitive-Behavioral Therapy

integrate the research on the roles of cognitive and affective factors in coping processes with the emerging technology of cognitive-behavioral modification. More recently, CBT has been influenced by new theories and associated assessment, treatment, and prevention technologies that highlight psychological acceptance and mindfulness. One of the most prominent examples is Marsha Linehan’s dialectical behavior therapy (DBT), which incorporated CBT with mindfulness and balancing acceptance with change. DBT was originally developed by Linehan for clients with borderline personality disorder and related parasuicidal behaviors. It has since been modified for use with other populations, including those with substance abuse and depression. Today, CBT comes in many shapes and forms and has become a dominant force in psychotherapy in much of the world. This is largely due to the increased focus on evidence-based practice and related demands for accountability in the delivery of mental health services. Throughout its history, CBT has been committed to a scientific perspective to the study of psychopathology and its treatment. Hundreds of studies have evaluated various cognitive-behavioral theories of psychopathology, and hundreds more have assessed the efficacy of CBT interventions.

Theoretical Underpinnings CBT is applied in many different ways today, and all CBT approaches have in common a focus on the cognitive and behavioral aspects of the person. Psychotherapists who use CBT believe that people learn by observing and imitating, as well as through reinforcement. From this theoretical perspective, dysfunction can generally be linked back to childhood experiences, though the approach itself focuses on the here-and-now. In some ways, all CBT approaches attempt to challenge and modify the client’s thinking process and behaviors in an effort to assuage dysfunctional ways of living in the world. CBT posits a two-way relationship between cognition and behavior in which cognitive processes can influence behavior, and behavioral change can influence cognitions. Because cognition and behavior are so closely linked, psychotherapists can opt to intervene at either the cognitive or

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the behavioral level, using practical methods of interrupting the cycle and encouraging more adaptive responses.

Major Concepts Cognitive Concepts

Three major levels of cognition that are often identified in the practice of CBT include (1) full consciousness, (2) automatic thoughts, and (3) schema. Full consciousness is defined as a state of full awareness and optimized judgment. In contrast, automatic thoughts are cognitions that flow rapidly in the stream of everyday thinking and may not be carefully examined for correctness or rationality. Usually out of consciousness, they are readily accessible once a person is made aware of them. Everyone has automatic thoughts, but in the case of pathology such as obsessive-compulsive disorder (OCD) or generalized anxiety disorder, these cognitions are often full of errors in logic. These are called cognitive distortions and include distorted thinking such as overgeneralization, allor-nothing thinking, mind reading, fortune telling, and discounting the positive, to name a few. For example, someone with OCD might overestimate the risk involved with refusing to engage in a compulsion such as hand washing or checking. Likewise, in generalized anxiety disorder, people might underestimate their ability to cope with a potential threat. For example, someone might choose to avoid holiday shopping altogether because she or he fears how she or he will manage the crowds and parking. The final and deepest level of cognition defined by CBT is schemas, sometimes called core beliefs. These are a client’s fundamental rules or templates for processing information. Types of schemas include person schemas, event schemas, role schemas, and self schemas. Person schemas are schema about the attributes (skills, values, abilities) of a particular individual. Event schemas, or cognitive scripts, are processes, practices, or ways in which we typically approach tasks and problems. Role schemas contain sets of role expectations or how we expect a person in a certain role to behave. Last, self schemas are generalizations about oneself taken from current and past experiences.

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It is important to note that CBT does not say that all negative or painful emotions are bad. Emotions such as fear, anger, and sadness can be very appropriate and even useful. Fear can tell us there is danger, and motivate us to protect ourselves. Anger can inform us that our rights are being violated, and we need to take action to assert our rights. Sadness can be the result of losing something or someone important to us and can indicate that we need to take the time to grieve. When working with clients, it is important to distinguish between adaptive and maladaptive emotions. Negative and painful emotions can be adaptive if they are based on accurate thinking and guide an appropriate response. Maladaptive emotions are driven by distorted thinking and cause unnecessary suffering. Behavioral Concepts

It is natural to avoid things that are painful or difficult. Up to a point, avoidance is understandable and effective, but it can become problematic if it becomes the primary method for dealing with difficult life circumstances. Unfortunately, these “safety behaviors” tend to maintain problems rather than deal with them. In behavioral therapy, psychotherapists help clients strategically change behaviors that they typically exhibit in response to schemas and their resulting automatic thoughts and dysfunctional behaviors. At the same time, behaviors that are likely to improve a client’s overall well-being are increased. Such behaviors challenge the natural avoidance behaviors that have been developed to maintain the individual’s “safety.” In the case of OCD, challenging natural avoidance behaviors might involve “saying no to OCD” or doing the opposite of what you typically would do in response to an intrusive thought. The term for this technique in CBT is exposure and response prevention and is covered in greater detail in the next section. Likewise, in the case of depression, a practitioner using CBT might assign activities to help a client focus on positive goals or accomplishments. This often involves doing things for oneself that one might not otherwise do while in a depressed state. In either case, the goal is to change behavior by bringing schemas that result in dysfunctional behaviors into conscious awareness.

Techniques CBT involves the use of a wide variety of techniques to help people change their cognitions and behavior. Psychotherapists select techniques based on their ongoing assessment of the client and his or her problems, as well as their specific goals. There is no one technique in CBT that is right for everyone. Cognitive Techniques

Cognitive techniques are techniques used in CBT to help clients challenge problematic patterns of thinking. The following techniques are among the most common cognitive techniques used in practice. Use of Questions The use of questions, an important and frequently used cognitive technique, encourages the client to break through rigid patterns of dysfunctional thinking and to see new perspectives. Socratic questioning involves inquisitive questions that gently challenge the client and guide him or her to become actively involved in finding answers. Socratic questions are often used for the following reasons: 1. Clarification (e.g., “What do you mean when you say . . . ?”) 2. Probing assumptions and evidence (e.g., “How can you verify or disprove that assumption?”) 3. Questioning viewpoints and perspectives (e.g., “Who benefits from this . . . ?”) 4. Analyzing implications and consequences (e.g., “How come . . . is important?”) 5. Summarizing and synthesizing (e.g., “What are your reactions to the evidence that we looked at?”)

When used skillfully, Socratic questioning can help clients engage in the process of guided discovery. Guided discovery involves a series of questions that help clients reflect on the way they process information. Through this process of answering questions, clients can explore alternative ways to think and behave. One useful analogy for guided discovery is that of going to an optician for an eye test. The optician will initially have patients look through several

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lenses while removing or replacing some of them. Then, through a process of trial and error, patients begin to see more clearly.

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viewpoint using objective evidence. If the client is unable to substantiate the beliefs, then the therapist points out the error in that client’s thinking.

Journaling Often used at the beginning phase of therapy, clients are asked to make notes of their automatic thoughts that occur in stressful situations and to identify emotions associated with these thoughts. As the client gains knowledge and experience with CBT, the journal can be used to help identify cognitive errors embedded in one’s automatic thoughts, generate rational alternatives, and chart the outcome of making these changes. Cognitive Restructuring Cognitive restructuring refers to the process of replacing cognitive distortions with thoughts that are more accurate and useful. Cognitive restructuring has two basic steps: (1) identifying the thoughts or beliefs that are influencing the disturbing emotion and (2) evaluating them for their accuracy and usefulness using logic and evidence and, if warranted, modifying or replacing the thoughts with ones that are more accurate and useful. CBT emphasizes that this is best done as a collaborative process in which the client is assisted in taking the lead as much as possible. As a result, the psychotherapist refrains from assuming that the client’s thoughts are distorted. Instead, the psychotherapist attempts to guide clients with questions that help them make discoveries on their own.

Guided Imagery Guided imagery refers to the use of vivid or figurative language to help clients relax, meditate, gain confidence, improve mood, gain understanding, and improve future personal performance and development. Guided imagery is considered to be more effective when the person performing it is already in a relaxed state. When using guided imagery, the psychotherapist helps clients find a situation, location, or state of being that can be imagined and called on to help achieve therapeutic outcomes either within or outside of the therapy room. Imagery-Based Exposure One version of imagery-based exposure involves bringing to mind a recent memory that provoked strong, negative emotions. This also involves labeling the emotions and thoughts experienced during the memory and what behavioral urges were present. Imagery-based exposure can help make intrusive or painful memories less likely to trigger rumination. Psychotherapists use this technique with caution, after ensuring that the client has the coping skills necessary to deal with the negative emotions being evinced. Behavioral Techniques

Cognitive Rehearsal In cognitive rehearsal, the psychotherapist and the client work collaboratively to find ways to resolve a specific problem by “rehearsing” the situation when this problem is most likely to occur. For example, a client might use her imagination to think about having a positive interaction or experience with her new in-laws. She would then, with the therapist’s help, mentally rehearse the steps needed to achieve this outcome. Validity Testing With validity testing, the psychotherapist challenges the validity of a client’s beliefs or thoughts, allowing the client to defend his or her

In CBT, behavioral interventions typically follow the establishment of a therapeutic relationship. Then, behavioral techniques are implemented to reinforce what is being learned from a cognitive perspective. Some of the most commonly used behavioral techniques are listed and described in the following subsections. Activity and Pleasant Event Scheduling Activity and pleasant event scheduling are commonly used to help depressed clients reverse problems with low energy. They involve obtaining a baseline of activities during a day or week, rating activities on the degree of mastery or pleasure, and then collaboratively designing changes that will

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reactivate the client, stimulate a greater sense of enjoyment in life, or change patterns of social isolation or procrastination. Graded Task Assignments In graded task assignments, problems are broken down into parts and a stepwise management plan is developed. Graded task assignments are used to assist clients in coping with situations that seem especially challenging or overwhelming. Abdominal Breathing Abdominal breathing refers to the act of breathing by contracting the diaphragm and expanding the abdomen. Abdominal breathing is widely considered to be the most effective way to breathe to reduce stress. With the emergence of new technology, abdominal breathing is sometimes paired with biofeedback to help reinforce clients’ efforts to self-regulate. Exposure and Response Prevention Exposure and response prevention is the process of strategically exposing a client to a feared stimulus (e.g., dirt) and supporting her or him in avoiding typical behaviors performed in response to that feared stimulus (e.g., washing hands). This is considered to be one of the most effective behavioral techniques. Exposure protocols can be either rapid or gradual. Typically, a hierarchy of exposure experiences is developed, with sequential increases in the degree of anxiety provoked. Clients are encouraged to expose themselves gradually to these stimuli until the anxiety response dissipates and they gain a greater sense of control and mastery. Progressive relaxation and abdominal breathing exercises may also be used to reduce levels of autonomic arousal and support the exposure protocol. Cognitive rehearsal is often used to prepare for exposure and response prevention. Writing in a Journal Also called a “thought record,” clients write down their thoughts so that they can analyze them, often with a psychotherapist. This gives clients a chance to reflect on their thinking after an incident, when they are not reacting out of fear or anger. For this reason, journaling can be used to help with both behavioral and cognitive outcomes.

Systematic Positive Reinforcement Systematic positive reinforcement is a behavioral technique in which a psychotherapist encourages a client to reward positive or adaptive behaviors with something pleasant. This technique also works because it involves withholding a chosen reinforcement in response to maladaptive behavior. Homework Homework is an assignment or “mission” given to clients by psychotherapists to support progress between therapy sessions. Homework assignments might include reading or practicing coping skills learned in therapy (e.g., abdominal breathing). Flooding The process of flooding involves exposing people to fear-evoking stimuli intensely and rapidly. During flooding, clients are prevented from escaping or avoiding the feared stimulus. Modeling Modeling uses role-play to teach appropriate ways to respond to difficult situations. With this technique, the client uses the psychotherapist as a model to solve problems in her or his life.

Therapeutic Process CBT is goal oriented and characterized by a highly collaborative relationship in which the psychotherapist and the client work together to identify maladaptive cognitions and behavior, test their validity, and make revisions where needed. A principal goal of this collaborative process is to help clients effectively define problems and gain skills in managing these problems in the future. As in other effective psychotherapies, CBT also relies on the nonspecific elements of the therapeutic relationship, such as rapport, genuineness, understanding, and empathy. CBT for mental disorders such as uncomplicated depression or anxiety disorders can typically be completed in a range of 5 to 20 sessions. More complicated cases involving severe or chronic mental illness may require more than 20 sessions. “Booster sessions” are often used after therapy is completed to help limit the likelihood of relapse.

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CBT can also be implemented effectively in group settings, as with the skills training groups used in DBT. CBT sessions are structured to increase the efficiency of treatment. Sessions begin with a functional assessment leading to the establishment of realistic goals. Homework assignments are used to extend the client’s efforts beyond the confines of the psychotherapy context. Homework also helps structure therapy by serving as a recurrent agenda item that links one session with the next. Psychoeducation is another key feature of CBT. Skilled psychotherapists who use CBT have extensive knowledge of readings and other educational aids specific to their area of expertise. Typically, clients are asked to read self-help books, pamphlets, or handouts during the beginning phases of therapy. Workbooks can also be used for specific problems. More recently, computer-assisted CBT tools are gaining popularity, as they offer opportunities for clients to better track their progress and practice skills interactively using technology. Robert Rice See also Beck, Aaron T.; Behavior Therapies: Overview; Cognitive-Behavioral Therapies: Overview; Ellis, Albert; Linehan, Marsha; Meichenbaum, Donald

Further Readings Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Wiley. Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M., & Westbrook, D. (Eds.). (2004). Oxford guide to behavioural experiments in cognitive therapy. Oxford, England: Oxford University Press. Brewin, C. R. (1989). Cognitive change processes in psychotherapy. Psychological Review, 96, 379–394. doi:10.1037//0033-295X.96.3.379 Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientific foundations of cognitive theory and therapy of depression. New York, NY: Wiley. Harvey, A. G., Watkins, E. R., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford, England: Oxford University Press. Hollon, S. D., & Beck, A. T. (2003). Cognitive and cognitive-behavioral therapies. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and

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behavior change (5th ed., pp. 447–492). New York, NY: Wiley. Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Counseling and Clinical Psychology, 72, 31–40. doi:10.1037/0022-006X.72.1.31 Padesky, C. A. (1994). Schema change processes in cognitive therapy. Clinical Psychology & Psychotherapy, 1, 267–278. doi:10.1002/cpp.5640010502 Power, M. J., & Dalgleish, T. (1997). Cognition and emotion: From order to disorder. Hove, England: Psychology Press. Riskind, J. H. (2005). Cognitive mechanisms in generalized anxiety disorder: A second generation of theoretical perspectives. Cognitive Therapy and Research, 29, 1–5. doi:10.1007/s10608-005-1644-0 Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression. New York, NY: Guilford Press.

COHERENCE THERAPY Coherence therapy is a focused, experiential methodology that guides deep resolution of the core emotional themes that maintain a client’s presenting problems and symptoms. Applicable with individuals, couples, and families, it is a systematic application of what is known about emotional learning and unlearning. The coherence therapy approach consists of bringing the implicit emotional learnings underlying and generating a given problem or symptom into explicit awareness and then guiding the innate process of memory reconsolidation to unlearn and dissolve that material. This process ends symptom production at its emotional and neural roots. Coherence therapy is a system of transformational change, as distinct from incremental change, and is applicable to all the acquired, unwanted patterns of behavior, mood, emotion, thought, and somatization arising from the persistence of implicit emotional learning and memory.

Historical Context Developed initially from 1986 to 1994 by the psychotherapists Bruce Ecker and Laurel Hulley, the method was first known as depth-oriented brief therapy, the title of their 1995 book. Ecker and

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Hulley had been influenced by various understandings of symptom production, most notably constructivism, humanistic-existential frameworks, family systems theory, and the Jungian view of the unconscious as coherent. More important, however, was their own observation of occasional “profound change events” in therapy sessions, resulting in abrupt, transformational change and an enduring end of symptoms. From among thousands of therapy sessions, they closely studied those sessions that produced such breakthroughs, identified a sequence of experiences that preceded those shifts, and then designed a clinical methodology focused on facilitating that sequence from the start of therapy. Independently, neuroscientists in 2004 identified the same sequence as being the brain’s requirement for launching the process of memory reconsolidation, which destabilizes the synapses storing a specific emotional learning, allowing erasure of the learning through rewriting the synaptic encoding with new learning. These discoveries were then incorporated into the metapsychology of coherence therapy, as described in the 2012 volume, Unlocking the Emotional Brain.

Theoretical Underpinnings In coherence therapy, any symptom, or unwanted behavior, emotion, mood, thought or somatic distress, is understood as being generated by specific emotional learnings held in implicit memory, outside of conscious awareness. Symptoms that are not based in learning, such as autism spectrum conditions or depression due to hypothyroidism, are unsuitable for coherence therapy. However, the large majority of symptoms presented in therapy arise from the contents of implicit emotional memory, acquired through learning. Through experiential methods, the underlying implicit learning responsible for a given symptom can be retrieved into direct awareness, revealing its content, usually in a small number of sessions. The revealed material always is found to be both adaptive and coherent: It consists of a set of personal constructs in modular form—a schema or mental model or set of core beliefs—that is, knowledge of one’s vulnerability to a particular suffering, how that suffering comes about, and how to avoid it. Such schemas and models are infused with emotion and urgency, and they manifest in various

phenomenological forms, such as ego states, complexes, attachment patterns, projections, and traumatic memories. When the revealed material underlying a given symptom is thoroughly felt, cognized, and verbalized, it becomes apparent that the symptom is itself a fully coherent feature of the schema. Coherence therapy subscribes to the constructivist view that all knowledge is formed by the individual’s active processes of meaning making or construing, that this learning through construing is usually not conscious, and that the individual experiences and responds to the version of reality he or she has construed. Based on both the neuroscience of implicit memory and humanistic psychology, coherence therapy does not subscribe to pathologizing views of the persistence of symptom-generating schemas and core beliefs as “maladaptive” or “pathogenic.” Rather, such persistence is understood as the emotional memory system functioning as it was developed to do in the course of evolution. Evolution, however, has also provided for the permanent dissolution of such schemas. To that end, coherence therapy guides the sequence of experiences that induces the brain’s innate process of memory reconsolidation. The methodology is based entirely on the clinical observation that a given symptom is observed to cease as soon as there no longer exists any emotional learning in which the symptom is in some way necessary as part of how the individual strives to avoid suffering and have safety and well-being.

Major Concepts Major concepts include symptom coherence, symptom-requiring schema, retrieval, agency, transformational change through memory reconsolidation, and juxtaposition experience. These concepts define key aspects of the phenomenology of symptom production by implicit emotional learnings, and how such learnings are accessed and thoroughly unlearned. Symptom Coherence

Symptom coherence is the view that a symptom occurs entirely because it is compellingly necessary according to nonconscious, adaptive emotional learnings or schemas and that the symptom ceases

Coherence Therapy

to occur with the unlearning and dissolution of all symptom-requiring schemas, with no other symptom-stopping measures needed. Symptom-Requiring Schema

A symptom-requiring schema is a module of acquired knowings in an implicit (tacit, nonconscious) state. It consists of interlinked personal constructs, including attributions of meaning, models of causation, if–then sequences, elements of perceptual, emotional and somatic memory, and the emotions arising from these components. A given symptom is produced as part of a response that is compellingly necessary according to the underlying schemas. A symptom-requiring schema is sometimes referred to as the emotional truth of the symptom or as the person’s prosymptom position. Retrieval

Retrieval is the guided experiential process in which a symptom-requiring schema is shifted from being implicit (nonconscious) knowledge into being explicit knowledge that is directly experienced emotionally and conceptually. The person experiences the emotional knowledge inside the schema, while verbalizing that knowledge in detail. Retrieval unfolds through two processes: (1) discovery, the initial finding and bringing to awareness of a symptom-requiring schema, and (2) integration, the stabilizing of the schema in mindful, daily awareness of it, changing one’s conscious narratives and model of oneself accordingly. The discovery process tends to be efficient and swift due to utilizing the symptom’s coherence (emotional necessity) as a compass, but it proceeds in “small enough steps” to avoid undue distress. An example of the verbalization of a retrieved, previously nonconscious schema maintaining pervasive underachieving is this: I am responsible for all of my father’s emotions. If I’m successful, Dad will sink into feeling he’s a failure by comparison and start drinking again, and it will be my fault, and Mom will blame me. That’s terrifying, so I’ve got to stay away from any success. Agency

Prior to retrieval of a symptom’s underlying schema, the symptom seems to happen with a mysterious power and life of its own and to be

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irrational, completely undesirable, and a personal defect. After retrieval, the individual is lucidly aware of the coherent emotional necessity of producing the symptom as part of how he or she responds to a present or anticipated suffering. With this awareness comes an experience of agency in relation to the symptom—a felt sense of producing the symptom as part of a purposeful striving for safety and well-being. The experience of agency dispels the negative, pathologizing meanings that the symptom had prior to retrieval. Transformational Change Through Memory Reconsolidation

Each learned schema maintaining a given symptom is unlearned and dissolved through the process of memory reconsolidation. This is a transformational change, which is defined and confirmed by verifiable markers: A long-occurring emotional reaction no longer occurs in response to the cues that formerly triggered it, the symptoms generated by that reaction also no longer occur, and these changes persist effortlessly and permanently. Coherence therapy avoids use of techniques of counteractive change, which build up preferred states, behaviors, and resources without dissolving the symptom-requiring schemas, yielding incremental change that is unstable, requires ongoing effort to maintain, and is prone to relapse. In transformational change through memory reconsolidation, new learning replaces and eliminates the problematic target learning, whereas counteractive change creates a new learning that merely competes against the target learning (as in extinction protocols). Juxtaposition Experience

A juxtaposition experience is what brings about transformational change in coherence therapy. It is the subjective accessing of both a symptomrequiring schema and, simultaneously in the same field of awareness, some other decisive, experiential knowing that is sharply contradictory and disconfirming of the schema’s unquestioned expectations of how the world functions. Each side of this juxtaposition feels emotionally real, yet both cannot possibly be true. Coherence therapy provides various ways of finding the contradictory

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knowledge. The guiding of a juxtaposition experience and its repetition a few times creates an experiential disconfirmation of the symptom-requiring schema. This is the core process of change in the final, transformation phase of coherence therapy, and it embodies the entire process of schema erasure through memory reconsolidation as identified in neuroscience research (where the juxtaposition is termed a mismatch experience or prediction error experience).

Techniques Coherence therapy was developed with a number of simple, experiential techniques. Of these, symptom deprivation, sentence completion, and overt statement are described below; information on others can be found in the Further Readings. Coherence therapy is not defined in terms of specific techniques, however. It is defined as the symptom coherence model of symptom production combined with the clinical methodology of experientially retrieving symptom-requiring schemas and unlearning and dissolving them through juxtaposition experiences (i.e., through memory reconsolidation). Coherence therapy is openended with regard to techniques, a wide range of which can facilitate the methodology effectively. Symptom Deprivation

A symptom’s underlying schema and coherent emotional necessity may often be found by guiding an imaginal experience of being without the symptom in the very circumstance in which it normally occurs. Any unwelcome, uncomfortable effects and distress that develop are fully drawn into awareness. The distress that occurs without the presence of the symptom is an indication of the implicit knowledge being avoided by having the symptom. Sentence Completion

As adapted for use in coherence therapy, this projective technique provides an opportunity for explicit expression of a suppressed, implicit, and symptom-necessitating schema. The therapist designs the first words of a sentence to clearly imply completion by symptom-necessitating knowledge. The stem is spoken aloud by the client,

who has been instructed to simply allow the sentence to complete itself, without prethinking or consciously choosing the ending. This is repeated with the same stem until no new endings arise. For example, for a problem of underachieving, the stem could be “If Mom and Dad see me being successful . . . ” Overt Statement

Overt statements create an emotionally rich, direct experience of a symptom-necessitating schema, as distinct from a merely cognitive discussion of the schema. The subjective inhabiting of the schema is induced by an overt statement’s style of phrasing, termed limbic language: a present tense I-statement spoken with utterly candid, vivid naming of personal knowledge of a suffering, of what one feels when suffering it, and of what is necessary for avoiding it. An example is the verbalized schema under the previous subsection “Retrieval.”

Therapeutic Process Coherence therapy begins with eliciting the client’s descriptions of the unwanted patterns (symptoms), and on that basis the retrieval work begins, often in the first session. The number of sessions required for retrieval depends on the number, complexity, and emotional intensity of the underlying schemas maintaining the symptoms. Two sessions are often sufficient for a single schema of moderate intensity, whereas for severe complex attachment trauma, several dozen sessions may be required to retrieve all schemas thoroughly. As the content of a given schema becomes explicit, the process of finding vivid contradictory knowledge begins and can require from one to several sessions. As soon as contradictory knowledge is found, the therapist guides a juxtaposition experience, which takes about 5 minutes, with a few repetitions over the next 10 or 15 minutes. Checking for schema erasure is done in subsequent sessions by examining both real and imaginal encounters with situations known to trigger the schema. The total number of sessions is sometimes as low as 2; more typically, it is 8 to 12 and may extend to 60 or more in some cases of severe childhood abuse and complex attachment trauma. Sara K. Bridges and Bruce Ecker

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See also Constructivist Therapies: Overview; Ego State Therapy; Existential-Humanistic Therapies: Overview; Foundational Therapies: Overview; Integrative Approaches: Overview; Neurological and Psychophysiological Therapies: Overview

knowledge, expertise, and resources to produce outcomes fitting to the uniqueness of the client and his or her novel circumstances.

Further Readings

The roots of collaborative therapy trace back to multiple impact therapy (MIT), which originated in the 1950s in the psychiatry department at the University of Texas Medical Branch in Galveston, Texas. MIT was a family therapy approach designed to work with children (and their families) for whom other treatments had been unsuccessful. Collaborative therapy maintains the emphasis that MIT placed on the significance of the client’s voice and expertise in his or her own life and the assumption that if the client can become a partner in therapy, more energy and creativity are released for the therapeutic task and the results of therapy are more individually tailored and sustainable compared with expert-driven ones. Collaborative therapy thus developed by Harlene Anderson and Harold Goolishian in the early 1980s entails a reflexive process of theory, practice, and client feedback. First called collaborative language systems, later collaborative therapy, and currently collaborative dialogue therapy, Anderson applies the approach to disciplines and practices such as education, research, organizations, and leadership.

Bridges, S. K. (2015). Coherence therapy: The roots of problems and the transformation of old solutions. In H. E. A. Tinsley, S. H. Lease, & N. S. Giffin Wiersma (Eds.), Contemporary theory and practice of counseling and psychotherapy. Thousand Oaks, CA: Sage. Ecker, B., & Hulley, L. (1996). Depth oriented brief therapy. San Francisco, CA: Jossey-Bass. Ecker, B., & Hulley, L. (2011). Coherence therapy practice manual and training guide. Oakland, CA: Coherence Psychology Institute. Retrieved from http://www .coherencetherapy.org/resources/manual.htm Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. New York, NY: Routledge. Ecker, B., Ticic, R., & Hulley, L. (2013). Unlocking the emotional brain: Is memory reconsolidation the key to transformation? Psychotherapy Networker, 37, 18–25, 46–47.

COLLABORATIVE THERAPY Collaborative therapy is among those therapies referred to as dialogical, conversational, narrative, postmodern, and social constructionism that are informed by assumptions of postmodern and hermeneutic philosophies, and dialogue and social construction theories. Parallel to these therapies, the collaborative relationship and dialogical conversation of this approach decentralize the therapist, shift the therapist from a hierarchical strategist position to one of mutual inquirer, and encourage a natural rather than predesigned transformational process. The therapy system is considered a conversational partnership that relies on the expertise that client and therapist bring, and therefore, the system becomes less hierarchical and dualistic as compared with expert–nonexpert topdown systems. The process of the approach helps the client access, develop, and use his or her local

Historical Context

Theoretical Underpinnings Collaborative therapy is based in the discourses of postmodern and hermeneutic philosophies and social construction and dialogue theories that pose an alternative view of conventional knowledge and language as representational, as proposed, for example, in the writings of Mikhail Bahktin, Jacques Derrida, Hans-George Gadamer, Kenneth Gergen, Jean François Lyotard, John Shotter, Lev Vygotsky, and Ludwig Wittgenstein. More specifically, this alternative view is distinct from the dominant essentialist view in the social sciences of knowledge as fundamental, definitive, fixed, or discovered and language as an inborn grammatical structure and representational. Instead, these authors each uniquely propose that knowledge and language are interactive interpretive processes and products of social discourse and are therefore generative and intrinsically transforming. All

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participants in a collaborative-dialogue, for instance, contribute to the construction and sustainability of the product of the dialogue. These alternative discourses inform three major perspective-orienting assumptions that invite the therapist to maintain skepticism, avoid generalization, and privilege local knowledge: 1. Maintain skepticism: The invitation to the therapist is to hold a critical and questioning attitude toward institutionalized knowledge: inherited dominant discourses, metanarratives, and universal truths that mostly are unwittingly taken for granted and perpetuated. 2. Avoid generalization: The invitation to the therapist is to beware of the risks when dominant discourses, metanarratives, and universal truths are generalized and applied across peoples, cultures, situations, or problems. The risk is reverting to preconceived judgments such as theoretical scripts and predetermined rules that produce categories and types of people, problems, and solutions that can interfere with the therapist’s learning about each person and the therapist’s uniqueness from the person himself or herself. 3. Privilege local knowledge: The invitation to the therapist is to appreciate and to work with the local knowledge that is formulated within a community of persons who have firsthand experience and unique understandings of their lives, constructing outcomes that are relevant, pragmatic, and sustainable.

Major Concepts The orienting assumptions of collaborative therapy inform a philosophical stance: the therapist’s way of being “with”—talking, thinking, acting, and responding with the client. In addition to the major concepts discussed under “Theoretical Underpinnings,” detailed in this section are seven interrelated characteristics that serve as action-guiding sensitivities for engendering the potential for collaborative dialogue between the therapist and the client. Mutual Inquiry

Mutual inquiry is a joint activity in which the client and the therapist co-explore the client’s reason for seeking therapy. Taking a learning position,

the therapist listens and responds from a genuinely curious position to best understand the client’s perspective. A therapist’s responses keep close to the client’s language, checking-out through comments, questions, and so on, whether the therapist has understood what the client wants the therapist to understand, and pausing for listening and reflecting spaces. In this dialogic search, meanings and understandings are continually interpreted, clarified, revised, and created between the therapist and the client. It is through this dialogic search that newness in meanings and understandings emerge that are critical to generating possibilities for fresh perspectives, feelings, emotions, expressions, and actions. The therapist’s participation in the conversation is toward encouraging the mutual inquiry process, not toward steering the conversation. Relational Expertise

Both the client and the therapist bring expertise to the therapy and in their joint action create possibilities that neither could have done alone. The therapist’s focus on the client’s expertise (local knowledge) calls attention to the client’s wealth of know-how on his or her life and cautions the therapist not to value or privilege his or her own knowing over the client’s. Not-Knowing

Not-knowing refers to how a therapist thinks about the construction of knowledge and the intent, manner, and timing with which his or her knowledge is introduced. Emphasis is on knowing with instead of knowing about the client, knowing the client’s circumstances and preferred outcome better than the client. The therapist offers his or her knowledge as food for thought and dialogue, as alternative ways to continue to talk about what is being addressed and what previously might have been difficult to speak of. Being Public

The therapist’s private thoughts (professionally, personally, theoretically, or experientially) influence how the therapist listens, hears, and responds. The therapist is open and generous with his or her thoughts, making them visible or public. Being public is a way of proposing possible topics to

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talk about, finding ways to talk about them, and minimizing the risk of the therapist’s inner talk collapsing into a monologue or conversational breakdown. Uncertainty

There is uncertainty in the unfolding, direction, and destiny of conversations when the client and the therapist coordinate their actions. When a therapist is not guided by prestructured maps or questions, he or she must trust the vagueness and remain open to the surprises that accompany it when the paths, detours, and final destinations vary from client to client and situation to situation. Mutually Transforming

The therapy encounter is a withness process in which each person is influenced by the other(s). Both the client and the therapist are at risk for change. Everyday Ordinary Life

The therapist views therapy as one kind of life event; although it takes place inside a particular context and agenda, it can resemble the way people naturally interact and talk in everyday life as they search for a way to move forward with their lives. Also, the therapist views people positively and believes in their capacity for resilience and desire for healthy relationships and life qualities. Importantly, the therapist is careful of the constraints of deficit discourses that can impose judgmental labels and limits to possibilities.

Techniques Collaborative therapy is not formulaic. The therapist does not employ a set of replicable techniques or prestructured steps. Instead, perspective-orienting assumptions and action-guiding sensitivities shape the therapist’s philosophical stance, inviting and encouraging shared engagement and joint action with the client. Although the therapist’s stance has identifiable characteristics, because each client is considered a unique person who presents with a unique circumstance and because each session is considered unique as well, the expression of the characteristics is distinct to each therapist, client,

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and session. The stance spontaneously invites and promotes spaces and processes for conversations and relationships that are individually tailored for each client, in which both client and therapist maximize the possibility to connect and collaborate toward constructing an outcome specific to that client. The client and the therapist walk side by side; the therapist does not steer or unilaterally determine the problem definition, the goal, and the paths toward the goal.

Therapeutic Process Because the client and the therapist walk side by side determining the path together, therapy becomes briefer than most other therapies. Collaborative therapists do not think in terms of number of sessions. At the end of each session, the client and the therapist decide together if they will meet again and when and who should be included in the next session. As a partner in therapy, the client develops a sense of participating, belonging, and owning and sharing responsibility for the therapy and its outcome. Hence, because the client participates in the creation of outcomes and has a sense of ownership, outcomes are more sustainable than when they are created by the therapist. Harlene Anderson See also Focused Brief Group Therapy; Narrative Family Therapy; Narrative Therapy; Solution-Focused Brief Family Therapy; Solution-Focused Brief Therapy

Further Readings Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy. New York, NY: Basic Books. Anderson, H., & Gehart, D. (Eds.). (2007). Collaborative therapy: Relationships and conversations that make a difference. New York, NY: Taylor & Francis Group. Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems: Preliminary and evolving ideas about the implications for clinical theory. Family Process, 27(4), 371–393. doi:10.1111/j.1545-5300.1988.00371.x Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee & K. Gergen (Eds.), Social construction and the therapeutic process (pp. 25–39). Newbury Park, CA: Sage.

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Common Factors in Therapy

COMMON FACTORS

IN

THERAPY

Common factors are a core group of ingredients shared by all forms of counseling and psychotherapy regardless of the specific theories or procedures that constitute and differentiate various treatment approaches. While specific interventions may be targeted at specific psychological problems, a large body of evidence shows that the individual components and technical operations derived from specific theoretical approaches account for insubstantial amounts of outcome variance when measuring treatment effectiveness. The same body of research demonstrates that the commonly occurring elements in all methods, including the client’s experience of the relationship, the creation of hope and expectancy, the structure and focus, and the qualities of the therapist, are responsible for a much larger proportion of outcome variance.

Historical Context In 1936, Saul Rosenzweig first drew attention to the idea of common factors. Based on his observation that very different methods of psychotherapy based on utterly different theories were often similarly capable of success for a given problem, he suggested that the effectiveness of different treatment approaches had more to do with a shared group of pan-theoretical factors than with the alleged ingredients in the theories and methods popular in his day. Later, the psychiatrist Jerome Frank placed the common factors in a broader, cross-cultural context. He asserted that they were responsible for the effectiveness of not only psychotherapy but all forms of healing, including much of medicine and drug therapies and the religio-magical rituals found in nonindustrialized societies. Frank’s work stood virtually alone until the 1980s and 1990s, when research and discourse significantly expanded on the subject. At that time, broad agreement existed regarding the key role of common factors in psychotherapy, but there was little consensus regarding what these common factors were. In 1992, the researcher Michael Lambert proposed four shared therapeutic ingredients— (1) extratherapeutic factors, (2) common (relationship) factors, (3) expectancy or placebo effects, and (4) specific techniques—as the principal elements

that account for improvement in clients. Although not derived from a strict statistical analysis, he wrote that they embodied what empirical studies suggested about psychotherapy outcome. Inspired by Lambert’s work, the psychologists and practitioners Scott Miller, Mark Hubble, and Barry Duncan proposed the first framework for using the common factors to bridge the differences between the various schools of psychotherapy and directly apply them in routine clinical work. Research by these groups has focused especially on the contribution of the client’s perception of the quality of the working relationship between therapist and client as perhaps the most significant common factor affecting clinical outcomes. From the late 1990s onward, the strongest empirical evidence in support of the common factors has been published by Bruce Wampold and colleagues. Using metaanalysis, Wampold’s group provided evidence against the belief that specific elements of treatments were responsible for the outcomes of specific psychological disorders, and they also provided evidence for a core group of common therapeutic ingredients.

Theoretical Underpinnings The common factors are a hypothetical construct like intelligence or ability, indirectly measurable through consensually agreed-on methods and not by direct observation. Because the common factors are (by definition) common to all methods, they cannot be distilled into a specific method, reduced to a set of techniques, and administered to a client. Rather, they can be considered the vehicle through which specific therapeutic behaviors are enacted or the context in which therapists engage in a particular therapeutic process. Much like “raw materials” in nature, the common factors exist in an unprocessed or minimally processed state and must be used or acted on to create a product or structure. The eventual form a treatment assumes depends entirely on the materials available, the skills of the artisan (in this case, the therapist), and, most important, the desires and preferences of the end user (the client).The role and degree of influence of any one specific therapeutic factor (e.g., behavioral extinction, catharsis, finger movements in Eye Movement Desensitization and Reprocessing) depend on the

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context—specifically, who is involved, what takes place between the participants, when and where the interaction occurs, and ultimately from whose point of view these matters are considered. In short, the common factors account for why treatment works despite the existence of differing treatments for similar problems. On the other hand, they do not provide a specific protocol or formulary for how to conduct therapy.

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Demoralization

Demoralization is the psychological state of mind, posited by Jerome Frank, that is shared by all who present for psychotherapy. As such, successful treatment is less about eliminating symptoms than about addressing experiences of helplessness, hopelessness, and confusion. Engagement

Major Concepts The following sections highlight some of the major concepts in understanding the common factors in the therapeutic relationship: allegiance, contextual model, core conditions, demoralization, engagement, extratherapeutic or client factors, the healing setting, the medical model, model and technique, rationale, relationship factors, specific factors, and therapist factors. Allegiance

Allegiance refers to the roles a therapist’s or researcher’s belief in and commitment to a given therapeutic approach play in the outcome of treatment. Empirical evidence shows them to be far more influential than the methods used. They contrast with placebo, in which a client’s belief influences the outcome more than the specific ingredients in the treatment. Contextual Model

The common factors model is a metamodel accounting for how the common factors operate in successful psychotherapy. In contrast to the medical model, it proposes that treatment outcome depends on contextual variables, such as the characteristics of the therapist and the client, the quality of their relational bond, the meaning each attributes to the process, and the setting in which therapy takes place.

Engagement refers to the quality of the client’s participation in treatment. Research shows it to be the most important determinant of outcome. Extratherapeutic or Client Factors

An extratherapeutic or client factor is a common factor encompassing all factors that are independent of the treatment and that influence improvement, including unexplained, uncontrolled, or unrecognized influences on outcome and the client’s premorbid functioning, motivation, existing social support network, and strengths. Healing Setting

Referring to the physical and interpersonal context in which treatment occurs, the healing setting includes the client’s experience of safety to express feelings, thoughts, and behaviors usually concealed or avoided and the client’s relationship with a person or professional whose position and deportment inspire confidence and heighten the expectation of success. Medical Model

The medical model is the traditional assumption that the effectiveness of treatment results from the application of a standardized and specific procedure (or procedures) containing ingredients remedial to the condition being treated. Model and Technique

Core Conditions

The core conditions are three common factors, first proposed by the psychologist Carl Rogers, considered essential for all successful counseling and psychotherapy. They include unconditional positive regard, empathy, and congruence.

The concept of model and technique involves common factors encompassing the nature and structure of treatment in general. All treatment models establish a set of premises, strategies, and rituals and procedures (techniques) believed to mitigate or cure a particular psychological problem.

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Rationale

Further Readings

A rationale is a conceptual scheme that explains a person’s problems or symptoms and prescribes a set of healing rituals for resolving them.

Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins University Press. Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association. Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 143–198). New York, NY: Wiley. Miller, S. D., Hubble, M. A., & Duncan, B. L. (1997). Escape from Babel: Toward a unifying language for psychotherapy practice. New York, NY: W. W. Norton. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy: “At last the Dodo said, ‘Everybody has won and all must have prizes’.” American Journal of Orthopsychiatry, 6, 412–415. doi:10.1111/j.1939-0025.1936.tb05248.x Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum.

Relationship Factors

A relationship factor is a common factor consisting of the emotional bond between the client and the therapist, their agreement regarding the goals and tasks (i.e., the means to reach the goals) of treatment, and the fit of the entire process with client preferences or point of view. Specific Factors

Specific factors are the particular ingredients of the models or procedures in psychotherapy believed by proponents of the medical model to be remedial to the problem or disorder being treated. Therapist Factors

Long considered the “forgotten” common factor, the therapist factor includes the person of the therapist: who the therapist is, what he or she believes, and how the therapist behaves in the therapy. The impact of such qualities on outcome exceeds the contribution of the relationship and has been shown to be as much as nine times greater than effects of the specific treatment used.

Therapeutic Process By definition, the common factors are inherent in all treatment approaches. For this reason, the primary utility of the common factors is not prescribing a singular or invariant therapeutic process but helping practitioners keep in mind what matters most when creating the conditions for a successful psychotherapy. Any and all methods will be more effective when delivered by a therapist who attends to the relationship, seeks consensus, respects the client’s point of view, inspires hope and confidence, and provides a compelling rationale and set of healing rituals. Scott D. Miller, Jason A. Seidel, and Mark A. Hubble See also Evidenced-Based Psychotherapy; Feedback-Informed Treatment; Person-Centered Counseling; Rogers, Carl

COMMUNICATION THEORY OF COUPLES AND FAMILY THERAPY See Human Validation Process Model

COMMUNICATION/VALIDATION FAMILY THERAPY See Human Validation Process Model

COMPLEMENTARY AND ALTERNATIVE APPROACHES: OVERVIEW Complementary and alternative approaches to counseling include a wide array of treatment modalities that aim to create wellness in mind,

Complementary and Alternative Approaches: Overview

body, and spirit. The National Center for Complementary and Alternative Medicine (NCCAM), which is a division of the U.S. National Institutes of Health, has been studying these approaches and their effects on physical, mental, and emotional wellness since 1998. NCCAM defines complementary therapies as treatments that are used along with conventional treatments, whereas alternative therapies are typically used in place of traditional Western approaches. NCCAM also uses two terms to discuss these therapies: (1) complementary and alternative medicine (CAM) and (2) complementary health approaches. NCCAM categorizes CAM into two categories: (1) natural products and (2) mind and body practices. Natural products include herbs and supplements. Mind and body practices include acupuncture, meditation, massage, energy healing, and manipulative therapies such as chiropractic, among others. Research completed by NCCAM in 2007 found that the most commonly used therapies in the United States include herbs and supplements, deep diaphragmatic breathing, meditation, chiropractic, massage, yoga, diet-based therapies (nutrition), progressive relaxation, guided imagery, and homeopathy. According to NCCAM, as of 2007, approximately 38% of adults over 18 years of age in the United States used complementary health approaches. For the purposes of counseling, it is important to better understand the mental health implications and possible benefits of these complementary approaches.

Historical Context From a Western health perspective, complementary approaches are considered emerging treatments that exist alongside traditional conventional modalities. However, many of these approaches have existed in Eastern countries, such as China and India, for thousands of years. Before the rise of Western medicine, these cultures sought to prevent and treat illness by using methods found within their cultural and philosophical systems. Eastern Approaches to Wellness

Prior to the predominance of the Western medical model in the mid-19th century, it was common in most cultures to consider treating any sort of physical or emotional challenge within the paradigm of a holistic mind–body–spirit system. Most

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people used a combination of intuition, natural remedies, and shamanic practices to attempt to address health problems. China has Traditional Chinese Medicine (TCM), and India has a health system called Ayurveda; both systems have been in place for more than 2,000 years. TCM was the dominant form of health promotion in China and is still in practice today. TCM includes subtle energy healing through techniques such as acupuncture, use of herbal medicines, and practices that integrate mind–body–spirit based on movement and breath, such as T’ai Chi and qigong. Ayurveda, in India, is a holistic wellness system that assesses individual types, called doshas, and prescribes a variety of natural therapies to balance each dosha. Other cultures have their own healing systems, but these two seem to be the largest and most well-known. Eastern healing methods emphasize a phenomenon called chi, which is considered to be an animating and dynamic life force energy not visible to the eye. Many cultures understand this subtle energy and have used it in their healing practices. TCM, as well as other forms of energy healing, is based on this understanding, so a brief explanation of subtle energy is necessary. The three main components of chi, or subtle energy, are chakras, meridians, and the biofield. Chakras are considered to be wheels of energy that are located in seven major centers of the body along the spine. Meridians are lines that carry subtle energy throughout the body; they are used in acupuncture and energy medicine. The biofield, also known as the aura, is a large field of energy that penetrates and surrounds the body and extends outward several feet from the physical body. Holistic approaches to wellness are multimodal and value healing and health as a balanced interconnectedness where the mind, body, and spirit operate in a dynamic flow of power. Holism implies that all aspects of human nature, physical and nonphysical, are in deep communication. Eastern health traditions have historically seen the human experience as whole and dynamic, where any attempt to separate out the parts is illogical and can ultimately be harmful. Western Approaches to Wellness

Western medicine arose gradually between the 16th and 19th centuries with the mechanical understanding of the body as a machine that can

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be definitively studied and fixed. This health paradigm shift occurred after a variety of philosophical explorations and scientific discoveries that emerged around the time of the Renaissance and extended through the Industrial Revolution. Reason and science were prized above faith, intuition, and holism. An important reason for this shift came from the philosopher René Descartes and the concept of dualism. Mind and body, once taken as united, were free to be studied and addressed as unique phenomena. Suddenly, exploration of the body led to the development of surgery and innovative understandings and treatments for biologically based ailments. However, with the rise of sophisticated Western medicine also came a steady increase in other health challenges, such as heart disease, diabetes, cancer, depression, anxiety, and other health problems that persist despite narrow and specifically targeted Western approaches. Currently, these are considered lifestyle diseases, and some now believe that the treatments call for a return to holistic and multimodal approaches. Our current Western culture is stressful, and chronic stress may be one of the variables that contribute to these lifestyle problems. The most cited reasons for CAM use are back pain, other chronic pain, and psychosomatic problems that have no specific recommended treatment. A full picture of the reasons why people seek CAM is not yet known, but it is speculated that additional reasons include a need for a solid relationship and partnership with health practitioners, a desire for more personal responsibility around health promotion, a congruence of treatment values, and frustration with the lack of relief from existing allopathic models.

Theoretical Underpinnings Complementary approaches have taken considerable time to demonstrate their relevance to the Western scientific community. Rigorous research on CAM has been conducted in the medical fields for the past 30 years, but CAM research in counselor education has been minimal to date. However, clinical reports and research effects indicate that complementary approaches are becoming used more often and with results that affect our understanding of wellness and counselor education. In addition, these approaches are

relevant to counseling due to the value that the field of counseling places on wellness and holistic health promotion and prevention of illness. Taking a multimodal approach to mental health and wellness may create more efficient outcomes for clients, address varied holistic needs within the individual, and save money for both individuals and institutions. Although the theory behind complementary and alternative approaches was discussed in the “Historical Context” section, it should be emphasized that because of the many complementary and alternative approaches that are practiced, there are a number of other philosophical assumptions that underlie the approaches—too many to discuss in this entry. With the emphasis on evidence-based practices in Western medicine, it is not surprising that CAM has grown as a research topic in the past 20 years and many hospitals and universities have explored the research and clinical applications of these complementary health approaches. These institutions include Harvard University, Duke University, Yale University, University of Maryland, the Mayo Clinic, the Scripps Center for Integrative Medicine, and the University of Arizona. These institutions offer clinical treatments, conduct empirical research, and offer courses to their medical students designed to integrate complementary and alternative approaches into their medical education.

Short Descriptions of Complementary and Alternative Approaches Acupuncture and Acupressure

Acupuncture is a treatment based on the TCM energy model. It primarily utilizes subtle energy pathways that run throughout the body and addresses physical and emotional challenges. Extremely fine needles are inserted into specific energy centers to balance the chi and allow the energy meridians to flow properly. Acupressure is a form of acupuncture that uses seeds or finger pressure instead of needles to stimulate the energy points. Acupressure is becoming more utilized in substance abuse treatment centers to manage substance cravings and prevent relapse. Research is beginning to show that acupuncture is effective in reducing pain and managing anxiety.

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Advanced Integrative Therapy

Brainspotting

This is an integrative form of psychotherapy, founded by Asha Clinton in the late 1990s, that blends energy psychology techniques with analytical psychology and attachment healing techniques. It is intended for complex and stubborn psychological disorders such as posttraumatic stress disorder and personality disorders. It is designed to integrate the fractured self and address disorders at the causal, not symptomatic, level.

Developed by David Grand in 2003, brainspotting is a psychotherapy technique that uses specific eye positions (“brainspots”) to focus and release emotional trauma. The process is guided and works on the cognitive, affective, and somatic levels.

Alexander Technique

The Alexander technique teaches individuals how to become more mindful of their bodies for optimal functioning. A primary assumption is that we do not engage the movements of our body efficiently, and these movements are compromised due to stored tension in the body. Raising awareness of the movement and posture of the body in everyday experiences can lead to increased freedom and ease. Aromatherapy

Aromatherapy is a modality that utilizes essential oils to heal various ailments. The oils are inhaled or applied topically, and the effects come from various combinations of oils or specific oils for specific health challenges. Research is developing, but so far aromatherapy seems to aid in reducing stress, anxiety, depression, and chronic pain.

Breathwork in Contemplative Psychotherapy

A key component of contemplative psychotherapy is the focus on the breath as the central integrator of mind, body, and spirit. Therapy sessions and homework aim to teach clients how to become mindful of their breath to reduce bodily tension and emotional stress and to connect to the true self beyond the ego. Contemplative Psychotherapy

Along with the influence of mindfulness on counseling, there has been interest in a form of psychotherapy that integrates contemplative practices such as meditation with traditional Western approaches to psychotherapy. This approach evolved as a theory from dialogue between various psychologists and the Tibetan Buddhist teacher Chogyam Trungpa Rinpoche primarily during the1970s. It uses mindfulness practices to connect with the innate goodness and compassion that everyone possesses. Additional theorists in this area include Tara Brach, Rick Hanson, and Mark Epstein. Ecotherapy

Autogenic Training

Autogenic training is a relaxation technique developed by Johannes Heinrich Schulz in 1932. It uses the power of the mind and visualization to restore balance between the sympathetic and parasympathetic nervous systems in the body. BodyTalk

This is a holistic system based on TCM and bioenergetic psychology that operates on the assumption that the body knows best how to heal. The process uses applied kinesiology to assess where the body–mind system needs to heal. It focuses on the brain and uses acupressure “tapping” to restore balance to the system.

Ecotherapy is a general term for the movement in the fields of counseling and psychology to include and integrate the natural world into wellness and health promotion. In some cases, this can be as simply spending time in nature; it can also be recommended as an active participation in the natural world for holistic wellness through activities such as gardening or horseback riding. Preliminary research suggests that spending time in nature decreases symptoms of anxiety, depression, and attention-deficit/hyperactivity disorder. Emotional Freedom Techniques

Emotional freedom techniques is an energy healing method that uses acupressure points in

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combination with affirmations targeted toward healing a client’s specific problem. Its development is attributed to Gary Craig in the 1990s. Specific points on the hands, face, and torso are “tapped” with the fingers to stimulate the acupressure points. Preliminary research indicates that emotional freedom techniques may be effective in treating trauma. The advantage of this modality is that it is simple, can be learned, and is a self-help treatment. Energy Psychology

Energy psychology includes the use of acupressure points and meridian-based techniques in psychotherapy to address psychological issues. Techniques in this area include emotional freedom techniques (tapping), thought field therapy, and Donna Eden’s energy medicine. The clinical psychologist David Feinstein has recently conducted and compiled research in this area. Healing From The Body Level Up

Developed by Judith Swack in the late 20th century, this holistic psychotherapy system integrates a variety of techniques to heal the mind, body, and spirit. It uses components from neurolinguistic programming, energy healing, Reiki, and applied kinesiology, among others. Healing Touch

Healing Touch was created by Janet Mentgen in 1990. It is a biofield energy healing therapy that uses gentle touch to influence the client’s biofield to reduce stress and induce overall integration of the client’s body, mind, and spirit. It is a heartcentered practice that uses the healing relationship along with the client’s energy field for healing.

targets the muscles and fascia, or connective tissue. The assumption in this approach is that stress and tension build up in the fascia, so this healing method targets those areas to release stress. Herbal Medicine

Herbal treatments have been used as medicine in cultures around the world for thousands of years. Modern Western attention has focused on herbal treatments that come from TCM or Ayurveda. Research is growing on how herbal supplements can address a variety of physical and psychological challenges, and preliminary data indicate that they can be effective in treating depression and anxiety disorders. Homeopathic Medicine and Counseling

Homeopathy is a treatment concept created by Samuel Hahnemann in the 19th century and utilizes the principle that “like cures like.” Based on the idea that a small amount of a substance influences the immune system, specific diluted substances are given to individuals with health problems to reduce the overall problem. Integrative Forgiveness Psychotherapy

Developed by Philip H. Friedman, this approach suggests that unforgiveness of grievances, judgment, and attack thoughts toward self and others lead to intrapersonal and interpersonal problems and that the major focus of therapy should be on forgiving self and others by becoming in touch with one’s inner spirit, higher power, or higher intuition.

HeartMath

Meditation

HeartMath is an institute and a field of study that embraces the influence of the heart on emotional wellness and overall health. It utilizes biofeedback techniques to assess and understand the power of the heart to induce coherence, or a balance between body, mind, and emotions.

Meditation is a term that encompasses a wide variety of methods to center one’s awareness and integrate mind, body, and spirit. Typically, it is a practice where one sits in stillness and tries to quiet the mind. Some types of meditation focus on a mantra, some focus on the detached observation of thoughts to develop an awareness of presence, and some utilize guided imagery. The effects of each method include stress reduction, greater inner peace, and improved ability to respond to the challenges of life.

Hellerwork

This approach addresses the whole human system—mind, body, and spirit—but primarily

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Mindfulness Techniques

Rebirthing-Breathwork

Mindfulness is a term that has been embraced by Western practitioners but originated in Eastern traditions. It is an aspect of Buddhism that encourages people to embrace the present moment. Various meditative practices lead to greater mindfulness, where mind, body, and spirit are better integrated. One of the most utilized and researched has been mindfulness-based stress reduction, created by Jon Kabat-Zinn in 1979. Another approach is mindfulness-based cognitive therapy for depression, which focuses on preventing future depressive episodes by utilizing mindfulness techniques. It has been used for a variety of health challenges, such as cancer and living with chronic pain.

This approach is attributed to Leonard Orr’s work in the 1960s and 1970s and involves specific breathing techniques designed to release unconscious tension and pain. Some of the techniques access aspects of consciousness reaching as far back as birth to relieve emotional birth trauma, as well as other forms of trauma. Individuals report a release of emotions or physical sensations that returns them to a state of clarity and balance.

Morita Therapy

This therapy was developed by the Japanese psychiatrist Shoma Morita in 1919 to address “neurosis.” Its philosophical assumptions are that symptoms should not be actively forced to reduce or dissolve but that acceptance leads to a natural resolution of the problem. This approach contains aspects of Zen Buddhism whereby a person suffering from emotional or mental disorders undergoes a four-stage process. The goal of this process is for the client to fully immerse himself or herself with total acceptance into the phobias or issues as a means to transcend the disorders. Non-Western Approaches

Outside of the epistemology of Western approaches to counseling, non-Western approaches are often based on the indigenous cultures of many Asian, African, South American, and Pacific Islander countries. Having a worldview that is different from theories based on Western approaches, these methods may augment or replace traditional Western approaches. Prayer and Affirmations

Prayer has been embraced in many cultures for millennia to call on the transcendent or a Higher Power to assist in healing and wellness. Although the types of prayer and affirmations can vary dramatically, they have been related to a variety of positive client outcomes, such as substance abuse recovery, stress reduction, pain management, and having a positive attitude.

Reiki

Reiki is a biofield energy healing practice of Japanese origin, established by Mikao Usui in the early 1900s. It is a gentle healing process in which hands are laid on or just above various parts of the body to heal body, mind, and spirit. It has become widely used in hospitals and hospices as a means of stress and pain reduction and palliative care. Pamela Miles is a Reiki master who has written widely describing Reiki and its benefits for the Western health care system. Therapeutic Touch

Therapeutic touch is also a biofield energy healing therapy and is similar in process to Reiki. It was created in the United States in the 1970s by the nursing professor Dolores Krieger and the healer Dora Kunz. It has been used primarily in the nursing field, with effects similar to those of Reiki. It also utilizes a gentle laying on of hands in the healing process, although some of its techniques do not require touching by the counselor. Christine Berger See also Acupuncture and Acupressure; Advanced Integrative Therapy; Alexander Technique, Aromatherapy; Autogenic Training; BodyTalk; Brainspotting; Breathwork in Contemplative Psychotherapy; Ecotherapy; Emotional Freedom Techniques; Energy Psychology; Healing From The Body Level Up; Healing Touch; HeartMath; Hellerwork; Herbal Medicine; Homeopathic Medicine and Counseling; Integrative Body Psychotherapy; Meditation; Mindfulness Techniques; Morita Therapy; Non-Western Approaches; Prayer and Affirmations; Rebirthing-Breathwork; Reiki; Therapeutic Touch

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Further Readings Feinstein, D., Eden, D., & Craig, G. (2005). The promise of energy psychology: Revolutionary tools for dramatic personal change. New York, NY: Penguin. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness (Rev. ed.). New York, NY: Bantam. Lake, J. (2007). Textbook of integrative mental health care. New York, NY: Thieme Medical. Miles, P. (2006). Reiki: A comprehensive guide. New York, NY: Penguin. Shannon, S. (2002). Handbook of complementary and alternative therapies in mental health. San Diego, CA: Academic Press.

CONCENTRATIVE MOVEMENT THERAPY Concentrative movement therapy (CMT) focuses on the awareness and expression of body sensations for clients with a wide range of mental illnesses. Based on psychodynamic therapy, this approach uses sensory motor body experience and symbolization of inner processes by CMT objects, postures, or words. The purpose is to evoke emotions to understand the psychological meaning of body symptoms, which some believe are expressions of childhood or actual conflicts. CMT is used in individual therapy in outpatient settings but is used primarily in group therapy for psychosomatic illnesses (physical diseases or conditions influenced by mental stress) and in psychiatric hospitals. Evidence has shown this approach to be especially helpful for inpatient clients with neurotic disorders, psychosomatic illness, or personality disorders. It is common in the health care system of Germany and Austria, where it is called Konzentrative Bewegungstherapie, or KBT.

Historical Context CMT was developed during the mid-1950s by Helmuth Stolze, a psychoanalyst working in Munich, Germany. Its roots go back to the early 1920s, to the gymnastic work of Elsa Gindler in Berlin, Germany. She developed the concept of sensory awareness, in both rest and motion, using

movement for self-discovery and inner experience development. CMT has spread throughout Germany and Austria and is most often used in inpatient group psychotherapy with multiprofessional teams. It was further developed by practitioners like Christine Gräff. Since 1975, a training program of the German Association of CMT (Deutscher Arbeitskreis für Konzentrative Bewegungstherapie e.V., or DAKBT) sets standards for CMT training. The European Association of CMT (Europäischer Arbeitskreis für Konzentrative Bewegungstherapie, or EAKBT) overseas the national CMT associations of five other European countries, using standards similar to those of the German association. CMT works with the body image, that is, the subconscious frame of meaning of movements, body sensations, and emotions. Mind and brain research of the past decade has shown the importance of the body in psychotherapy, and CMT has shown evidence of its usefulness with clients experiencing neurotic and psychosomatic disorders. Recently, the approach has been expanded for use with clients suffering traumatic experiences.

Theoretical Underpinnings CMT therapy focuses on body perception, body experience, and movement expression. A central treatment element is the use of the “CMT offer,” where clients are invited to become aware of their perceptions while they are moving. CMT therapists develop this offer based on (bodily) countertransference, or their awareness of feelings toward the client. The therapists make the offer based on their “movement interpretation” of the current therapy event. The clients react with “free movement association” (analogous to the psychoanalytical “free association”). In concentrative moving and acting, clients realize their feelings and may remember old movement and communication patterns that are inscribed in body memory. According to CMT, unresolved or unconscious life events are stored in the body memory. These “embodied experiences” emerge in the therapeutic situation and are integrated into therapy by nonverbal symbolization and verbalization in the therapeutic dialogue. Following this step, the client may experiment with new behaviors in movement or posture.

Concentrative Movement Therapy

Major Concepts A number of concepts related to psychodynamic and humanistic theory are used in CMT. Major concepts include body image; connection of movement, perception, thinking, and acting; space to experience and space to reflect; and contact.

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intensity and character of a touch. Being touched by the therapist or group members can change old patterns of anxiety or withdrawal and can give comfort. Now the client can feel that a gentle hand on her or his shoulder is caring and sheltering.

Techniques Body Image

Body image is a construct for the inner representation of the physical and psychological self. It is not fixed but depends on experiences in relationships, including body schema, body self, body fantasy, and body concept. By listening to the body, those unconscious aspects can become conscious for therapists and their clients. Connection of Movement, Perception, Thinking, and Acting

CMT works with the connection between movement and perception, on the one hand, and thinking and acting, on the other. In CMT, the process of change can be initiated by moving, perceiving, acting, or thinking. Space to Experience and Space to Reflect

CMT divides the therapeutic session into an experience space and a reflecting space. In the first part, clients are allowed to behave freely, like a playing child. In the second part, clients and therapists develop an understanding of what has happened and interpret the actions based on the clients’ biography or the group interaction. Contact

Physical contact, or touching, is a useful tool of CMT. When a person is a young child, touching helps him or her establish physical boundaries and define himself or herself as being different from others. Sometimes clients suffer from too much touching (abuse) or too little touching (neglect). Touching CMT objects, such as balls or stones, helps clients to develop their own sense of tactition. For example, clients realize by gently touching their own hand that touch does not need to be painful or against their will (as in former times) and that they have control with regard to the

CMT therapists apply techniques based on the need of clients. Techniques include concentrative sensing and movement, working with CMT objects, play, and body dialogue. Concentrative Sensing and Movement

Concentrative sensing and movement is the process whereby clients become aware of their body sensations and therapists learn nonverbal information about the clients’ problems. CMT Objects

Using CMT objects helps clients differentiate their sensory perception and gives them opportunities to symbolize their conflicts or traumas without words. Objects help a client come into contact with others or to establish a border between oneself and others. Play

Clients who were neglected or suppressed in early childhood often did not have the opportunity to play. Donald Winicott described how important play is for the development of children’s creativity. He called the realm of playing “transition space,” a space of fantasy between the outer and inner worlds. CMT offers can be seen as an invitation to establish this transition space in therapy. Clients are invited to play with CMT objects or with the group members. Playing is acting guided by the unconscious instead of the conscious mind. The new experience of playfulness is integrated into positive memory. Body Dialogue

Unconscious movements regulate the dialogue with others. In CMT, this body dialogue is made conscious by awareness. New ways to regulate

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distance and closeness are explored. For example, a client who has realized that she always had neglected her body perception—she came too close to others and was hurt by their rejection—now uses her bodily sensations to keep a comfortable distance from others. Another client who presented himself as grim in the CMT group discovered that he was trying to protect himself from the anger of others but instead provoked anger and rejection by his behavior. With awareness, he now experiences the approach of other group members to be friendly and not harmful and learns to trust others and himself.

Therapeutic Process CMT takes 40 sessions on average; however, it can range from 5 to 300 sessions. Inpatient group therapies take 5 to 10 weeks (10–20 sessions). Early sessions focus on creating a good therapeutic alliance and the teaching of concentrative sensing. In further sessions, old dysfunctional patterns in movement and behavior appear; intra- and interpersonal conflicts emerge, and the body-oriented approach is used to understand them. In the second half of treatment, new movement patterns are explored and repeated. New solutions are found by body awareness and contact with other group members, and conflicts can be resolved. In the final session, separation and farewell are experienced with the body and mind. Karin Schreiber-Willnow See also Body-Oriented Therapies: Overview; Dance Movement Therapy; Yoga Movement Therapy

Further Readings Schreiber-Willnow, K. (2000). The body and self experience grid in clinical concentrative movement therapy (CMT). In J. W. Scheer (Ed.), The person in society: Challenges to a constructivist theory (pp. 317–327). Gießen, Germany: Psychosozial-Verlag. Schreiber-Willnow, K., & Seidler, K.-P. (2013). Therapy goals and treatment results in body psychotherapy: Experience with the concentrative movement therapy evaluation form. Body, Movement and Dance in Psychotherapy, 8, 254–269. doi:10.1080/17432979.2013.834847 Seidler, K.-P., & Schreiber-Willnow, K. (2004). Concentrative movement therapy as body-oriented psychotherapy for inpatients with different body

experience. Psychotherapy Research, 14, 378–387. doi:10.1093/ptr/kph031 Stolze, H. (1983). Concentrative movement therapy: The work after Elsa Grinder. The Charlotte Selver Foundation Bulletin, 11, 9–15.

CONSTRUCTIVIST THERAPIES: OVERVIEW Constructivist therapies focus on how people construct meaningful ways of understanding themselves and the world, which they use to guide their lives. Constructivist therapists assume that what each person knows is not a reproduction of the world as it is but a humanly invented interpretation. In constructivist theory, the meaningful understandings people rely on to make sense of events are products of their internal processes rather than direct reflections of an outside world. While the outside world may trigger people’s meaning-making processes, it is those processes, rather than the world alone, that determine how they understand and experience events. Thus, from a constructivist perspective, people never know the world directly, but only indirectly via their constructed understandings of it. Effective therapy involves helping clients loosen the taken-forgranted constructions that lock them into existing patterns and then entertain new ways of meaningfully construing circumstances. Constructivist counselors work collaboratively with clients to examine client constructions of self, relationships, and the world—including their origins in personal experience, interpersonal relationships, and social discourses. Constructivist therapies often involve experimenting with new ways of construing circumstances and encouraging clients to test alternative constructions in the course of everyday life. Constructivist ideas can be found in personal construct psychology, radical constructivism, social constructionism, narrative therapy, and some forms of feminist therapy.

Historical Context Constructivist theories emerged from a variety of philosophical influences. The ancient Sophist philosophers emphasized that truth is a function of

Constructivist Therapies: Overview

belief and that persuasive discourse influences what people take as true—a view common to today’s social constructionism. Another early influence comes from the philosophical Skeptics, who saw all arguments as having pros and cons; different views can be useful under different circumstances and dogmatic adherence to any one view is to be avoided. Seeing ideas as tools whose utility depends on circumstances was most fully developed in the late 19th and early 20th centuries by pragmatist philosophers such as John Dewey, William James, and Charles Sanders Peirce. Pragmatism, like the later constructivist theories, stresses the viability of humanly devised knowledge; if it is useful and functional in a given context, then knowledge can be seen as true under those particular circumstances. The idea that people invent meanings also can be found in other preconstructivist philosophy. In the early 1700s, the Italian philosopher Giambattista Vico argued that what people come to regard as truth is something they themselves invent. This idea was echoed two centuries later in Hans Vaihinger’s Philosophy of As If, which maintained that all knowledge consists of explanatory fictions created by people (an idea that influenced Alfred Adler as well as later constructivist theorists). Vico and Vaihinger therefore advanced the idea that people play a role in constructing knowledge. Another important premise of constructivism— that how people construct knowledge is constrained and shaped by their biological and psychological structures—can be found in Immanuel Kant’s 18th-century rationalism. Kant contended that people organize sensory information according to innate categories of thought. Thus, the structure of the knower is as important as the known in shaping knowledge. Similar ideas are found more recently in the 20th century in Alfred Korzybski’s theory of general semantics, which holds that what people know is constrained by the organization of their nervous systems. This idea is at the heart of radical constructivism’s notion of structure determinism. Korzybski also held that to develop knowledge, people must rely on mental abstraction. All constructivist approaches presume that people use abstraction in devising constructed understandings; personal construct psychology, especially, emphasizes the use of abstraction in the creation of personal constructs.

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Within psychology, the work of the Swiss developmental psychologist Jean Piaget on cognitive development during the 20th century has greatly influenced radical constructivist theories. According to the radical constructivist Ernst von Glasersfeld, Piaget has typically been misunderstood in the English-speaking world as seeing cognitive development as akin to having one’s understandings increasingly match the world as it is. However, Piagetian concepts like assimilation (incorporating new information into existing ways of comprehending) and accommodation (revising existing understandings when they fail to work) are both rooted in the assumption that human understanding is personal and private; it does not provide people with unmediated reality contact. Such a view is what makes Piaget’s ideas constructivist. George Kelly’s 1955 personal construct psychology can be viewed as perhaps the first constructivist theory of personality and psychotherapy—and in many respects, the most comprehensive. Kelly’s work has often been classified as an early cognitive theory. However, while personal construct psychology, like the early cognitive theories of the 1950s, moved away from the dominant behaviorism of the era and instead began to reintroduce the study of mental processes to psychology, Kelly himself was reluctant to have his work considered cognitive because he saw many of the early cognitive theories as too narrowly focused on logical thinking. For Kelly, construing is broader than thinking; it encompasses all meaning-making processes— both those commonly called “thinking” and those referred to as “feeling.”

Theoretical Context Constructivist approaches to psychotherapy grow out of several theories, all of which share the view that people construct understandings rather than know the world directly. Three of the main theoretical perspectives are personal construct psychology, radical constructivism, and social constructionism. Personal Construct Psychology

Kelly’s personal construct psychology assumes that people devise bipolar constructs, which are dimensions of meaning through which events are

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construed. Constructs are bipolar because each consists of something and its perceived opposite. This means that every person construes the world in a unique way using constructs of his or her own creation. In psychotherapy, therapists endeavor to map and comprehend client constructs. Personal construct psychology employs the person-as-scientist metaphor, in which clients are seen as agentive individuals who actively test their constructs in the course of daily life; ideally, they revise constructs that do not work well, but sometimes they cling to constructs despite evidence suggesting that their constructs are in need of revision. When people get locked into ways of construing, personal construct psychology therapists often engage in Fixed Role Therapy, in which the client is asked to play the role of someone else for a 2-week period. This allows the client to experiment with new ways of construing. Personal construct psychology tends to see construing as private and personal and in this regard shows a close kinship with radical constructivism. Radical Constructivism

Radical constructivism, associated with thinkers such as von Glasersfeld and Humberto Maturana, holds that people are closed information systems, only in touch with their own processes. Information never gets in or out; what is outside merely triggers changes inside, with the person devising internal representations as a result. To von Glasersfeld, the purpose of knowledge is not representational but adaptive. People do not passively take in the world as is. Rather, they actively construct internal representations as a means to survive. Maturana’s structure determinism, which states that the knowledge an organism constructs is constrained by its anatomical structure, is consistent with this view. The world’s influence on how people understand things is far less than the influence of their own internal makeup, which organizes experience in meaningful ways. In therapy, the therapist recognizes that the best he or she can do is attempt to disrupt the client’s usual ways of construing. Even if the therapist is successful in doing so, how the client reorganizes understandings in response to such disruption cannot be dictated by the therapist; it is always a product of the client’s internal meaning-making processes. Like personal

construct psychology, radical constructivism emphasizes construing as a personal and private process. Social Constructionism

Social constructionists such as Kenneth Gergen agree with constructivists that what people know is a human creation. However, they disagree with the emphasis on private knowledge, instead seeing meaning making as an inherently social and relational endeavor. People collectively develop discourses or narratives—shared ways of talking, communicating, and living. These discourses influence how people understand themselves and what they take for granted as real. Therapy often involves exposing people to alternative discourses or helping them to challenge or revise dominant discourses. Social discourses about proper gender roles, for instance, might be challenged within a social constructionist therapeutic frame. Epistemological Versus Hermeneutic Constructivism

A helpful way of differentiating constructivist theories is to categorize them as either epistemological or hermeneutic varieties. Those theories identifiable as exemplifying epistemological constructivism accept the existence of an external reality but maintain that people only know it indirectly via their constructions of it. By contrast, constructivist theories that do not see reality as independent from the observer and instead contend that the knower and the known mutually influence and shape one another are best classified as forms of hermeneutic constructivism. Both epistemological and hermeneutic constructivism maintain a strong distinction between what is known and any hypothesized world beyond what is known. This is what makes them constructivist and different from limited realism, which posits a real world that can potentially be known—albeit often imperfectly. Integrative Model

Another way of thinking about constructivist theories is by looking at what they have in common and posing an integrative model. Such a model draws from personal construct psychology,

Constructivist Therapies: Overview

radical constructivism, and social constructionism in offering a metaframework for constructivist theory. An integrative constructivism offers four main premises helpful for therapists looking to work from a constructivist perspective. The first premise is that people are informationally closed systems, only in touch with their own processes. This premise pulls heavily from radical constructivism and personal construct psychology in seeing human meanings as ultimately personal and private creations. In therapy, it is critical to grasp the individual client’s personally meaningful constructions. The second premise is that people are active meaning makers. This holds that people are not simply passive respondents who take in the world as it is. Rather, they are agentive and active organizers of their perceptual experience, who devise unique understandings that guide their lives and influence how they understand the world. Constructivist therapists attempt to understand client constructions and treat clients as able to actively engage in the process of examining and revising them. The third premise is that people are inherently social beings. This premise integrates insights from social constructionism and its emphasis on meaning making as a collaborative undertaking. It posits that the personal and the social aspects of meaning construction are two sides of the same coin. Although constructions are personal and private, people regularly construe how other people construe the world. When they do this in a manner that others deem accurate, then a sense of “shared” construing occurs that allows for social coordination through the experience of social discourses and communal narratives. Constructivist therapists readily attend to the ways in which individual construing is influenced by this sort of social process. The fourth premise is that people construe both ontologically and epistemologically. Such a premise counters criticisms of constructivism as an “anything goes” form of relativism. Ontological construing occurs whenever people presume that their constructions represent the external world. Most construing is ontological in that the constructions people devise are taken as reflections of an external reality. That is, most of the time people do not treat their constructions as invented understandings unique to them. Instead, they treat them

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as the way the world is. Epistemological construing occurs whenever people pause to examine the constructed origins of their understandings. Their constructions, which were previously seen as reflections of the real, are suddenly treated as humanly devised creations. When construing epistemologically, people are able to examine, critique, and revise their constructions. Constructivist therapists acknowledge that clients construe both ontologically and epistemologically, and they utilize these two modes of construing when working with clients. While construing is inevitably relative to time, place, and context, it is never “anything goes” because when construing ontologically, what “goes” is constrained by both one’s structure and one’s ontological constructions of the real.

Short Descriptions of Constructivist Therapies Coherence Therapy

Coherence therapy focuses on the underlying, unconscious constructions that are at the core of emotional difficulties. By simply helping clients become aware of these out-of-awareness constructions (as opposed to actively countering them), their emotional impact is reduced or eliminated. Collaborative Therapy

This approach incorporates ideas from social constructionism and postmodernism. The client and the counselor are viewed as collaborators, which serves to minimize power differentials and allows them to work together to harness client resources. Constructivist Therapy

A variety of therapies go by this name, including most of the other therapies listed in this section. All share an emphasis on helping people examine and revise existing ways of understanding so that new possibilities for living emerge. Ericksonian Therapy

Ericksonian approaches are rooted in the work of the renowned psychotherapist Milton H. Erickson. Often closely tied to Erickson’s work

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using hypnosis, Ericksonian therapy techniques sometimes rely on indirect suggestion. Paradoxical and other indirect suggestions often result in shifts in client meanings.

dysfunctions in the person are often restoried as external entities, which often influence the client but can be resisted. Personal Construct Theory

Feminist Therapy

Feminist therapy is a broad approach, and not all feminist therapies are consistent with constructivism. Those that are tend to see dominant narratives as often rooted in unexamined power and privilege; for many feminist therapists, the personal is inevitably tied to the political and requires attention not just to individual meanings but to larger social meanings as well. Feminist therapists often work collaboratively with clients to help them deconstruct dominant discourses about gender and other important issues impeding their growth and development. Gender Aware Therapy

Gender aware therapy is sometimes also called gender sensitive therapy. It is rooted in feminist therapy but explicitly expands its focus to include helping both men and women to examine and revise discourses about gender that interfere with psychological adjustment. Identity Renegotiation Counseling

Identity Renegotiation Counseling builds on the social constructionist notion of the multiphrenic self, in which people are seen as not having a singular and stable self that cuts across situations but a series of different relational identities that vary across situations and relationships. Identity Renegotiation Counseling helps people map and renegotiate their various identities within the specific contexts in which they function and relate to others. Narrative Therapy

In narrative therapy, the underlying social discourses (i.e., narratives) that constrain a person’s sense of self and possibility are examined. Therapy emphasizes restorying, in which accepted internalized narratives rooted in relational discourses are challenged and retold in new ways. In narrative therapy, problems that are seen as internal

Kelly’s personal construct theory focuses on helping clients map and revise their bipolar construct dimensions. It often involves helping clients to elicit and examine their personal constructs. Construct elicitation is achieved by a variety of specific assessment methods (including versions of the Repertory Grid Test, first introduced by Kelly himself). However, personal construct therapy is not tied to a particular technique and often employs therapeutic strategies from other approaches. The one specific therapy technique it does espouse is Fixed Role Therapy, in which clients experiment with new ways of construing through role-playing someone different from themselves for a given period of time. Response-Based Practice

Response-based practice focuses on analyzing and revising social discourses in coming up with ways to respond to the challenging situations clients face, especially those where violence is involved. Its social constructionist roots are evident in its tendency to challenge dominant social discourses that perpetuate violence and oppression. Solution-Focused Brief Therapy

This approach focuses on helping clients identify solutions to problems rather than spending time on understanding their underlying origins. Solutions are often rooted within the ways people meaningfully understand and relate to others, yet they often have not been made explicit. Solutions are sought that fit within clients’ meaningful ways of understanding themselves and how they ideally wish to live. Jonathan D. Raskin See also Adler, Alfred; Coherence Therapy; Collaborative Therapy; Constructivist Therapy; de Shazer, Steve, and Insoo Kim Berg; Erickson, Milton H.; Ericksonian Therapy; Feminist Therapy; Gender Aware Therapy; Identity Renegotiation Counseling; Kelly, George; Mahoney, Michael J.; Meichenbaum, Donald;

Constructivist Therapy Narrative Therapy; O’Hanlon, Bill; Palo Alto Group; Personal Construct Theory; Response-Based Practice; Solution-Focused Brief Therapy; White, Michael

Further Readings Chiari, G., & Nuzzo, M. L. (1996). Psychological constructivisms: A metatheoretical differentiation. Journal of Constructivist Psychology, 9, 163–184. doi:10.1080/10720539608404663 Efran, J. S., Lukens, M. D., & Lukens, R. J. (1990). Language, structure, and change: Frameworks of meaning in psychotherapy. New York, NY: W. W. Norton. Glasersfeld, E. von. (1995). Radical constructivism: A way of knowing and learning. London, England: Falmer Press. Kelly, G. A. (1991). The psychology of personal constructs (2 vols.). London, England: Routledge. McNamee, S., & Gergen, K. J. (Eds.). (1992). Therapy as social construction. London, England: Sage. Neimeyer, R. A. (2009). Constructivist psychotherapy: Distinctive features. London, England: Routledge. Raskin, J. D., & Bridges, S. K. (Eds.). (2008). Studies in meaning 3: Constructivist psychotherapy in the real world. New York, NY: Pace University Press. Raskin, J. D., Bridges, S. K., & Kahn. J. S. (Eds.). (2014). Studies in meaning 5: Perturbing the status quo in constructivist psychology. New York, NY: Pace University Press. Winter, D. A., & Viney, L. L. (Eds.). (2005). Personal construct psychotherapy: Advances in theory, practice and research. London, England: Whurr.

CONSTRUCTIVIST THERAPY Constructivist therapy is not a single approach but rather refers to a family of therapies that share the assumption that people actively construct their worlds, with the implication that therapy involves the reconstruction of aspects of the person’s worldview, or more fundamentally of the person’s process of meaning making. The therapies concerned differ in features such as the extent to which they consider a real world to be accessible, or even to exist at all, beyond people’s constructions of it; their emphasis on the individual’s, or on social, constructions; and the particular techniques that they use. In addition to full-blown

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constructivist therapies, constructivist trends are also now apparent in most mainstream therapeutic approaches.

Historical Context Philosophical Roots

Constructivist views date back at least to the early Greek philosophers, such as Gorgias, who in the 5th century BCE questioned whether anything exists and, if it does, whether it can be known, and Epictetus, who in the 2nd century CE asserted that people respond not to “things” but to the view that they take of these. However, constructivism is generally regarded as having its roots in the 17th and 18th centuries, in the writings of the Italian historian Giambattista Vico and, subsequently, the German philosopher Immanuel Kant, both of whom emphasized how people actively structure their experiences. At around the same time, the Irish philosopher George Berkeley was arguing that objects do not exist beyond people’s perceptions of them. In the following two centuries, among the influential thinkers in this tradition were another German philosopher, Hans Vaihinger, and the Polish originator of the system of general semantics, Alfred Korzybski. Vaihinger’s philosophy of “as if” considered that the structuring of people’s experience is by the use of “workable fictions,” while Korzybski distinguished people’s linguistic “maps” of their experience from the “territories” of their worlds. Links have also been noted between constructivism and pragmatism, developed by American philosophers such as John Dewey at the end of the 19th century; pragmatism questions any distinction between knowledge and action. Another related philosophical movement is phenomenology, with its concern with the structure of consciousness, as expounded by the Moravian Edmund Husserl early in the 20th century and extended as hermeneutics by the German Martin Heidegger as well as by the French philosopher Maurice Merleau-Ponty, with his emphasis on the role of the body in knowing the world. Of particular relevance to the approach that has been termed social constructionism is a school of thought that focuses on the role of language in constructing the world. This was stressed by the British philosopher Jeremy Bentham at the end of

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the 18th century and emphasized by the sociologists Peter Berger and Thomas Luckmann (Austrian and Slovenian, respectively) nearly two centuries later in their exposition of the social construction of reality. Such emphases are in contrast with constructivism’s focus on the individual’s construction of his or her world. Other contributions to constructivism have come from the fields of cybernetics and biology. The German philosopher Ernst von Glasersfeld and the Austrian physicist Heinz von Foerster were both cyberneticists writing toward the end of the 20th century. von Glasersfeld put forward a “radical constructivism” that asserted that it is only when one’s constructions fail that the real world becomes apparent, while von Foerster delineated a second-order cybernetics that differed from firstorder cybernetics in that the observer is part of the system that is being described, affecting and being affected by it. In the 1970s, the Chilean biologists Humberto Maturana and Francisco Varela also proposed a radical constructivist view of living systems as autonomous and generating their own organization. Psychological Applications

Within psychology, one of the earliest examples of an approach that was essentially constructivist was the Swiss developmental psychologist Jean Piaget’s exposition of the processes of assimilation and accommodation that children go through in developing constructions of their worlds. This has been used by the American psychologist and counselor Allen Ivey as the basis of a constructivist therapeutic approach termed developmental therapy. In the field of memory, the British experimental psychologist Fredric Bartlett also emphasized that remembering is an active process of reconstruction rather than a veridical recall of events. However, most relevant to the present entry is the work of the American clinical psychologist George Kelly, who in 1955 developed a whole new psychology of personal constructs and associated methods of clinical assessment and psychotherapy. This was the first thoroughgoing constructivist approach to therapy, and this entry will return to it later. In the late 20th century, the social constructionist perspective was taken up by the American psychologists Kenneth Gergen, who elaborated a

relational view of the self, and Jerome Bruner, who in his later work focused on the narrative construction of reality, viewing storytelling as central to knowing. Social constructionism has transformed systemic therapies, as in the work of the American family therapists Harlene Anderson and Harry Goolishian, with their view of the therapist as a “conversation manager.” However, it is not only systemic therapy but virtually every psychological theory and therapy that has been influenced by constructivism since the latter part of the 20th century. For example, as in the writings of the American analyst Donald Spence, psychoanalysis is now often seen as only being able to uncover the narrative truth, and not the historical truth, of a client’s life. Several therapists who originally practiced within the cognitive-behavioral tradition, such as the American psychologists Michael Mahoney and Donald Meichenbaum and the Italian psychiatrists Vittorio Guidano and Giovanni Liotti, also developed constructivist approaches to therapy. More generally, a constructivist turn can be seen in some of the third-wave developments of cognitive-behavioral therapy, such as those that incorporate mindfulness techniques, based on a Buddhist view of the self and reality as constructions. In the field of humanistic therapy, the process-experiential therapy developed by the Canadian psychologist Leslie Greenberg and his American colleague Robert Elliott is essentially constructivist in its concern with “selfhood processes” that are constantly evolving and provisional and its view of people as “multivocal.”

Theoretical Underpinnings As should now be apparent, constructivism is a metatheory that embraces several different theories and approaches. Unsurprisingly, it is itself open to different constructions, and distinctions have been made between different types of constructivism. One such distinction is that between trivial and radical constructivism, differentiating approaches that see the person as merely constructing representations of the real world from those in which the person is viewed as organizing, and adapting to, his or her world. Some of the former approaches have been regarded as not being constructivist at all but instead as varieties of limited realism, in which it is assumed that reality can be accessed

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directly. Another distinction, between epistemological and hermeneutic constructivism, differentiates approaches that acknowledge the existence of a real world, knowable only through one’s constructions of it, from those in which that world is viewed to be dependent on its observers and their “languaging” of it.

Major Concepts There are differences in the concepts used in the various constructivist approaches, but this section focuses on the principal ones and on those most relevant to constructivist therapies.

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encompass a person’s constructions of reality and ways of responding to these constructions. Of particular interest to them are the client’s positions with regard to his or her symptoms. These consist of a conscious antisymptom position, concerned with the disadvantages of the symptom or problem, and an unconscious prosymptom position, concerned with its advantages. The notion of position is also used by the Dutch personality theorist Hubert Hermans, whose dialogical self theory views the self as consisting of different “I-positions” that are in dialogical relationships with one another. Autopoiesis

Personal Constructs

As described by Kelly, personal constructs are bipolar discriminations between the elements of one’s world (e.g., constructivist vs. realist), and they are organized into a hierarchical system. On the basis of this system, people anticipate their worlds, making predictions that may or may not be validated by subsequent events. If invalidated, a person will normally revise his or her construct system, but psychological disorder is characterized by clinging to a particular construction of events regardless of invalidation. People are most likely to be threatened by the prospect of change in the core aspects of their construct systems—those that are the most central to their identities. Personal Meaning Organizations

Guidano and Liotti considered that people’s attachment processes lead them to develop characteristic personal meaning organizations that form the basis of their knowledge of the self and the world. While the personal meaning organization generally increases in complexity through a dialectical tension between processes of maintenance and change, particular inflexible patterns of closure of personal meaning organization are thought to characterize different clinical problems. Positions

The American psychotherapists Bruce Ecker and Laurel Hulley, who devised coherence therapy, use a concept of positions, which essentially

Maturana and Varela used the term autopoiesis to refer to an autonomous, self-maintaining system. Such a system and its environment exist in a state of “structural coupling,” in which each leads to “perturbations,” and consequent change, in the other. Storying

In narrative approaches, people are regarded as “storying” their experiences, and as described by the social workers and family therapists Michael White in Australia and David Epston in New Zealand, therapy from this perspective aims to enable clients to “reauthor” their lives, perhaps freeing them from dominant stories of their families or cultures that have previously subjugated them.

Techniques Constructivist therapies tend to be technically eclectic, using a range of techniques, some borrowed from other therapeutic approaches, that are selected to facilitate particular types of reconstruing. The mode of action of these techniques is therefore likely to be viewed in constructivist terms rather than in the terms of the particular theory from which they were derived. For example, twochair work, which has its roots in Gestalt therapy, may be used in some constructivist therapies, such as personal construct psychotherapy and coherence therapy, as a way of facilitating the integration of conflictual self constructions. However, the

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focus in this section is on techniques that are specifically constructivist in their derivation and that may be used either in therapy sessions or as between-session homework assignments. Techniques to Increase Awareness of the Self as a Construer

Several constructivist techniques may be used to increase an individual’s awareness of his or her constructions, and at a more superordinate level of the self as a construer of reality. These methods also allow the therapist to gain a glimpse of the world through the client’s eyes and, thus, to provide a focus for therapy. Various such techniques have been derived from personal construct theory. In one of these, the self-characterization, the person is asked to write an autobiographical character sketch as if it were written by a sympathetic friend. A more elaborate technique is the repertory grid, in which the person rates or ranks various elements of his or her experience (typically aspects of the self and significant others) in terms of personal constructs, which are usually elicited from the person by asking him or her to compare and contrast the elements. Numerous computer software packages are available to analyze repertory grids, deriving indices of both the content and the structure of the individual’s construct system. Another personal construct technique, laddering, is designed to elicit superordinate constructs by asking a person which pole of one of his or her constructs the person would prefer to be described by and why, and repeating this process with every new construct thus elicited. Variations on some of these personal construct techniques have been developed, for example, by the British clinical psychologist Harry Procter, to help families and couples explore their shared ways of viewing the world as well as the more personal constructions of individual members of the family or couple. In Guidano and Liotti’s process-oriented cognitive therapy, self-observation is facilitated by means such as the moviola technique, in which the client “zooms” in on and out of certain scenes from his or her life and is encouraged to view these events from both objective and subjective viewpoints. A more literal method of self-observation is mirror time, devised by Michael Mahoney, in which the person is asked to spend a period of time of

self-reflection in front of a mirror, perhaps then writing some observations on this experience. Self-reflection is also an aim of Hermans’s selfconfrontation method, which involves eliciting significant events from a person’s past, present, and future and rating these on a list of affect terms, thus enabling the person to develop a “metaposition” as an author of their various I-positions. In coherence therapy, there is a focus on one particular aspect of the self, the symptom, and radical inquiry aims to elucidate the client’s prosymptom position by means such as asking “experiential questions” that help the client to access previously unconscious aspects of his or her view of the world from a symptom-free perspective. Narrative therapies help people become aware of the dominant narratives in their lives, in particular those that are problem saturated. This is achieved by asking curious questions and externalizing the client’s problem by using a client-generated metaphor (e.g., depression as a “black fog”) to describe it. In this way, the problem is detached from the client, who is thus enabled to see that he or she is not the problem. Techniques Facilitating Experimentation and Reconstruction

In constructivist therapies, experimentation with new behavior is often seen as going hand in hand with, or promoting, reconstruing. One way of encouraging experimentation is role-playing, such as the method of casual enactment employed in personal construct psychotherapy, in which the client and the therapist briefly enact situations involving interactions with significant or hypothetical figures. A more formal approach is Fixed Role Therapy, in which the therapist writes a sketch of a hypothetical person who is somewhat different from, but not the opposite of, the client. The client is then asked to “become” this person for 2 weeks, during which time there are frequent rehearsals of the role with the therapist but at the end of which the client’s old self is invited to return and may or may not choose to take on some aspects of the new role. Experimentation may be facilitated by the use of metaphor, as by viewing therapy as the development of coalitions between members of the person’s “community of selves,” a notion developed

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by the British personal construct psychologist Miller Mair, or as their “dialogical self,” as described by Hermans and his Italian psychiatrist colleague Giancarlo DiMaggio. Although tending to be more directive than most constructivist therapies, neuro-linguistic psychotherapy, developed from the work of the Americans Richard Bandler and John Grinder, psychologist and linguist, respectively, shares a focus on the client’s view of the world and its reconstruction. To this end, it may use trance, for example, to encourage the anchoring of some resourceful state with particular problematic situations. Somewhat similar to Guidano and Liotti’s moviola technique, the client may also be asked to picture himself or herself watching some past traumatic event on a screen, and then to change the modalities of the picture, such as its brightness or size, or to invite the more resourceful present self to join the younger self in the picture.

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regarding the optimal therapeutic relationship as one that offers the client a secure base from which he or she can explore and experiment. This exploration may include a focus on the therapeutic relationship itself. The effectiveness of this process is reflected in a growing evidence base with a wide range of clients accumulating for constructivist therapies, both those, such as personal construct psychotherapy, that have been derived from explicitly constructivist theories, and those, such as processexperiential therapy, that have developed within other traditions. David A. Winter and Robert A. Neimeyer See also Coherence Therapy; Kelly, George; Mahoney, Michael J.; Narrative Family Therapy; Narrative Therapy; Personal Construct Theory; Postmodern Constructivist Therapies: Overview; White, Michael

Further Readings

Therapeutic Process The process of constructivist therapies involves a delicate balance of encouraging the client to experiment with new ways of viewing the world while at the same time being concerned to preserve the integrity of his or her construct system. Thus, the therapist will take care that aspects of this system are not dismantled until viable alternatives are available and that therapy does not involve a fundamental challenge to the client’s core constructs. In other words, the therapist selects interventions that are ecologically sound. Unlike some of the more rationalist approaches, the therapist does not try to lead the client toward a particular view of events but simply attempts to help the client discover that alternative views are possible and that the client need not be trapped in particular ways of construing. The approach is therefore one that is invitational rather than prescriptive. It is also, in Kelly’s words, “credulous,” taking the client’s view of the world at face value while “suspending” the therapist’s own constructions. The type of therapeutic relationship that best facilitates this process is a collaborative one, which some constructivist therapists, such as Kelly, Guidano, and Liotti, have likened to that between a research supervisor and his or her client. Guidano and Liotti also draw on attachment theory in

Chiari, G., & Nuzzo, M. L. (2010). Constructivist psychotherapy: A narrative hermeneutic approach. Hove, England: Routledge. Ecker, B., & Hulley, L. (1996). Depth-oriented brief therapy. San Francisco, CA: Jossey-Bass. Guidano, V. F. (1987). Complexity of the self: A developmental approach to psychopathology and therapy. New York, NY: Guilford Press. Hermans, H. J. M., & Dimaggio, G. (Eds.). (2004). The dialogical self in psychotherapy. Hove, England: Brunner-Routledge. Kelly, G. A. (1955). The psychology of personal constructs. New York, NY: W. W. Norton. Neimeyer, R. A. (2009). Constructivist psychotherapy. Hove, England: Routledge. Neimeyer, R. A., & Mahoney, M. J. (1995). Constructivism in psychotherapy. Washington, DC: American Psychological Association. Raskin, J. D. (2002). Constructivism in psychology: Personal construct psychology, radical constructivism, and social constructionism. In J. D. Raskin & S. K. Bridges (Eds.), Studies in meaning: Exploring constructivist psychology (pp. 1–25). New York, NY: Pace University Press. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton. Winter, D. A., & Viney, L. L. (Eds.). (2005). Personal construct psychotherapy: Advances in theory, practice, and research. London, England: Whurr.

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Contemplative Psychotherapy

CONTEMPLATIVE PSYCHOTHERAPY Contemplative psychotherapy is a therapeutic approach based in Tibetan Buddhist philosophy, more specifically the Kagu and Nyingma schools, and Buddhist psychology married with key features of Western psychotherapy. This therapeutic approach embraces the notion that each individual client has a basic incorruptible nature that features openness, clarity, and compassion. It is the aim of the contemplative therapist not to change clients but to help them connect and reflect this inner nature.

Historical Context Western psychology and therapy experienced three different points of contact with Buddhist philosophy, frequently described as Buddhist psychology because Buddhist literature includes an extensive study of the nature of the mind. Sigmund Freud (1856–1939) first came into contact with Buddhism and meditation but was critical of it. However, Karen Horney (1885–1952), Carl Jung (1875– 1961), and Eric Fromm (1900–1980) each expressed an interest in Buddhist philosophy and wrote on the topic. In 1979, Jon Kabat-Zinn (1944– ) began a second wave of Buddhist influence on counseling with the establishment of the Stress Reduction Clinic and with it the influence of Buddhist thought on cognitive approaches to counseling. Then, a Tibetan Rinpoche, Chogyam Trungpa (1939–1987), established the third wave of Buddhist influence in Western therapy with the development of contemplative psychotherapy. Trungpa ultimately established the Naropa institute in Boulder, which to this day offers graduate studies in contemplative psychotherapy.

unduly distressed or excited by them. Clarity, on the other hand, refers to the capacity to see things as they are without getting lost in the past or too caught up in what might happen in the future. A central feature of clarity is an absence of judgment that might otherwise lead a person to be emotionally tied to what is experienced as good or to resist what is perceived as bad. Finally, contemplative psychotherapists believe that a disposition of compassion will naturally arise once greater spaciousness and clarity have been achieved. In contemplative psychotherapy, sanity and insanity have definitions that contrast with those used in contemporary Western psychology. While Western definitions generally revolve around reality-testing capacities, the contemplative psychotherapy definition of insanity refers to behavior that would physically or emotionally hurt the individual or those around the individual. Consequently, aggressive behaviors, verbal or physical, are considered a form of insanity. The origins of mental health concerns in adulthood are thought to arise from two primary sources in childhood and one process more likely to begin in adulthood or adolescence. The first is an environment in which aggression or strong aversion is present in the child’s world. A second source of mental illness that might arise from childhood is the unskillful relational interactions of parents or teachers with the child. The third source of mental health difficulty arises out of attempts to manage misperceptions about reality and is explored in more detail in what is known as the “Six Realms,” which is discussed in more detail in the next section.

Major Concepts Several key concepts distinguish contemplative psychotherapy, some of which pertain to the client’s experience and some that apply to the therapist.

Theoretical Underpinnings Contemplative psychotherapists embrace the notion that at each individual’s core is an essential and incorruptible sanity. This essential goodness and sanity is also described as Buddha Nature. Buddha Nature comprises three key traits: (1) spaciousness, (2) clarity, and (3) compassion. Spaciousness refers to the capacity to hold and experience a broad range of emotional experiences without becoming

Ego in Contemplative Psychotherapy

Ego has different meanings and different psychodynamic roots in Western and Buddhist psychologies. Western psychology views a strong ego as essential to psychological functioning and central to navigating difficult emotional contexts. The ego in Buddhist psychology, however, is believed to be a construct rooted in insecurity

Contemplative Psychotherapy

about our humanness and nurtured by the fear of the truth of impermanence. Ego in the contemplative context would be better described as an ongoing mental activity that creates an illusion of structured and relatively unchanging consistency. The Four Noble Truths

Foundational to Buddhist philosophy and fundamental to Buddhist psychology are the Four Noble Truths. Each of us is subject to the experiences of loss, illness, and aging, and this fact points to the first of these truths: the inevitability of pain. The second truth is that it is our resistance to pain and our unwillingness to accept our lives as they are that causes suffering, not the painful events themselves. The third truth promises that there is a way to relieve suffering, while the fourth truth offers that the course of the relief of suffering is the Eightfold Path. Existential Versus Neurotic Suffering

Two major categories of suffering are considered in contemplative psychotherapy: (1) existential suffering and (2) neurotic suffering. Existential suffering is suffering that is related to what are known as the Three Marks of Existence: (1) pain, (2) the truth of impermanence, and (3) clinging to one’s ego or sense of self. The first of the three marks refers to the same suffering as is discussed in the Four Noble Truths. Existential suffering emerges from resistance to the inevitability of pain in one’s life, such as loss and illness; from denying that everything is impermanent; and by clinging to the belief in a consistent and stable ego. This existential suffering is not thought of as unhealthy suffering. In contrast, neurotic suffering describes a variety of psychological states that emerge from cognitive distortions and result in negative and unhelpful behavioral patterns and ways of being in the world. These cognitive distortions are referred to as the Six Realms. Each of the realms represents a particular distortion and associated response. The Six Realms

The first three of the realms are known as the Lower Realms and include the Hell Realm, the Hungry Ghost Realm, and the Animal Realm. The

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Hell Realm features the belief that the world is an ugly place and is associated with strong feelings of powerlessness and victimization. A person existing in the Hell Realm tends to experience depression and anxiety. In contrast, the Hungry Ghost Realm describes a state of mind in which a person hungers for the chance to be seen and recognized by others. Persons in this state see the world as filled with vast riches and opportunities for fame, riches, and attention, which they cannot hope to attain. People experiencing the world in this way typically struggle with very poor self-esteem. The Animal Realm represents a psychological state in which the world is experienced as overwhelming and difficult to understand or control. People experiencing this neurotic way of responding sometimes work to shut the world out and may have a tendency toward autism or schizoid personality, for example, or may work to try to control the world, sometimes developing obsessive-compulsive disorders. The Higher Realms include the God Realm, the Jealous God Realm, and the Human Realm. The God Realm describes a state in which individuals are aloof to the events of the world, almost as if they were above earthly concerns. These individuals respond with hedonism, sometimes substance abuse, excesses of various kinds, and, occasionally, narcissistic personality disorders. The Jealous God Realm reflects the state of mind of individuals who experience the world as competitive. These individuals feel as if they need to be on the defensive at all times. These individuals may develop paranoid ideation and even paranoid schizophrenia. The Human Realm response to the world is to work constantly to seek out pleasure and to avoid all suffering. Compassionate Hospitality

Compassionate hospitality refers to the disposition of compassion and unconditional welcoming with which the therapist meets each client. Contemplative psychotherapists believe that persons with mental health concerns tend to be very sensitive and are thought to be fairly accurate about the emotional climate. It is thought that these individuals can easily sense rejection from the therapist, and consequently, it is important that the therapist be both compassionate toward and welcoming to each client.

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Exchange

Exchange refers to the direct and immediate experiencing of the client’s own experiencing by the therapist. However, this experiencing is one that is highly nuanced as it is unfiltered by the therapist’s expectations, preferences, or evaluations. An example of exchange might be a therapist’s inexplicable but accurate shared feeling of deep sadness on meeting a client for the first time without having heard the client’s story of grieving and thus not having had the opportunity to intellectually judge the story to be a negative or sad experience. Ongoing Meditation Practice

To cultivate a very deep and enduring compassion, contemplative psychotherapists must maintain an ongoing meditation practice. However, many contemplative psychotherapists never mention or recommend meditation to their clients, unlike therapists who make use of mindfulness-based therapies that incorporate meditation directly into the therapy. Contemplative therapists are encouraged to engage two stages of meditation practice. The first stage is the taming of the mind; the second stage is to understand the nature of one’s own mind.

Techniques Contemplative psychotherapists make use of few techniques, most of which share similarities with other mindfulness-based therapies. However, contemplative psychotherapists share an appreciation for diversity from one client to the next, which they recognize requires the use of a diverse range of techniques. Therapists are encouraged to develop their own styles of counseling through the vessel of their own authentic experiencing and creativity. Working With Mindlessness and Cultivating Mindfulness

Contemplative therapists work to help clients cultivate mindfulness. Mindfulness is the capacity for present-moment awareness with an absence of judgment. Clients are always encouraged to develop this skill through loving kindness directed

both at the self and at others. At the same time, contemplative psychotherapists also work with habits that are based in mindlessness. For instance, a therapist may encourage his or her client to become very curious, though not judgmental, about a habit of overeating. The therapist might ask, “What sensations signal that it is time to eat?” “What do you experience as you are eating?” “How do you know when to stop eating one thing and begin eating another?” “What signals or sensations do you experience that let you know it is time to stop eating?” The purpose of these questions is not to educate or point out anything; rather, the purpose is to become mindful of the thoughts, feelings, and physical sensations that accompany the experience of overeating and to become curious about each aspect. Looking for Disguised Sanity

Therapists trained in this model are encouraged to look for sanity where it might be disguised as insane behavior or thought. For instance, grandiose ideas about saving others from some threat are viewed as an expression of compassion. The desire to express compassion for others then becomes the focus of the work, rather than challenging or dismantling the belief. Clean, Uncluttered Space

It is believed that the therapist’s office space should be very tidy and welcoming. Clients are often encouraged to clean and de-clutter their homes and workspaces. It is thought that the area in which people work and live is a metaphor for the mind and that a cluttered space facilitates cluttered thinking.

Therapeutic Process Contemplative psychotherapy can be described as a relationally oriented therapeutic approach. In this work, the therapist strives to develop a strong relationship with the client in which a deep and authentic trust is developed. Within the context of this relationship, the client examines the ways in which he or she is clinging to things that are impermanent or to aspects of the ego, or in some other way resisting experiencing the world as it is.

Contemporary Psychodynamic-Based Therapies: Overview

A pivotal moment in the therapeutic process happens when clients realize that their own clinging and delusion about impermanence have been the source of their suffering. This realization often brings strong feelings of what the psychologist Karen Wegela describes as “disgust” and marks a point of both vulnerability and opportunity for the client. This moment in therapy is thought to be one that evidences the client’s own sanity as he or she recognizes his or her own capacity to experience the world as it is. Cherée F. Hammond See also Acceptance and Commitment Therapy; Mindfulness Techniques; Mindfulness-Based Cognitive Therapy; Mindfulness-Based Stress Reduction

Further Readings Kaklauskas, F. J., Nimanheminda, S., Hoffman, L., & Jack, M. S. (2008). Brilliant sanity: Buddhist approaches to psychotherapy. Colorado Springs, CO: University of the Rockies Press. Trungpa, C., & Goleman, D. (2005). The sanity we are born with: A Buddhist approach to psychology. Boston, MA: Shambala. Wegela, K. (2010). The courage to be present: Buddhism, psychotherapy, and the awakening of natural wisdom. Boston, MA: Shambala. Wegela, K., & Richio, D. (2010). What really helps: Using mindfulness and compassionate presence to help, support and encourage others. Boston, MA: Shambala.

CONTEMPORARY PSYCHODYNAMICBASED THERAPIES: OVERVIEW Contemporary psychodynamic-based therapies are the descendants of the first psychological model of human development and the first model for the practice of psychotherapy: psychoanalysis. Psychoanalytical theory has had a sweeping and profound influence. As the genesis of psychotherapy, virtually every other form of therapy that has followed can be seen as an extension of, modification to, or reaction against psychodynamic principles. Moreover, in ways that no other psychological theory has achieved, psychodynamic thought has interacted with the broader culture; it has been

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integrated into numerous academic fields, particularly the arts and humanities, and into popular culture itself. Despite such pervasiveness, some scholars believe that psychodynamic psychotherapy is a frequently misunderstood approach. It often either is described in dense, highly specialized terminology, understood only by those with significant training, or is depicted in a superficial, stereotypical fashion that distorts and frequently mocks it. To address this dichotomy, a plainlanguage introduction to the core concepts of psychodynamic thought is offered herein.

Historical Context Contemporary psychodynamic theory and practice are rooted in psychoanalysis, which was developed by Sigmund Freud approximately 125 years ago. The significant influences that informed Freud’s life and work, however, extend even further back in time. Freud was born in 1856 in Freiberg, Moravia. Then located in the Austrian Empire, the region is now part of the Czech Republic. He lived, worked, and developed his ideas in the context of momentous intellectual advances, cultural contradictions, and political conflicts. His own interests and education were remarkably broad in scope. The way in which his life and work were affected by wideranging influences has been studied and written about extensively elsewhere. Some important influences on his work are Charles Darwin’s theory of evolution; Hermann Helmholtz’s theory of the conservation of energy; the Romantic era philosophies and German idealism; the writings of Johann Wolfgang von Goethe, Arthur Schopenhauer, and Friedrich Nietzsche; a life-long love of the works of William Shakespeare; the conflicting values of the Victorian era; Judaism and anti-Semitism; and the destruction caused by World War I. A significant part of Freud’s genius was his ability to harness the strengths of two very different traditions—(1) the objectivity of science and (2) the subjectivity of philosophy—and then apply those strengths to the study of human experience. Following his medical training in 1881, Freud developed his ideas and methods in Vienna. By 1905, he had published several major works on psychoanalysis, and in 1909, was invited to the United States to speak. In the early years of psychoanalysis in the United States, at least two

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factors greatly influenced its subsequent development: (1) there was concern within the medical community about medicine’s scientific respectability and lack of standardized training and (2) Freud was increasingly concerned about the misuse of his methods. As a result, the American medical community carefully controlled analytic training, limiting such training to the province of medical schools and independent training institutes. As psychoanalysis was taking hold in the United States, Freud continued to develop and refine his ideas. Following his death in 1939, his students and collaborators extended psychodynamic theory and practice. Since then, psychodynamic approaches have grown far beyond Freud’s initial theories, but other models also took hold, including behavioral therapy, person-centered therapy, cognitive therapies, and systems approaches. All those models were, like psychoanalysis before them, shaped by and reflective of the social, cultural, political, and intellectual contexts in which they arose. Similarly, psychoanalysis was also influenced by such factors and by the emerging alternative approaches to psychotherapy. The civil rights and feminist movements of the 1960s raised pressing questions about power and authority; the multicultural movement beginning in the 1980s required new attention to issues of identity, particularly the role of race, ethnicity, gender, sexual orientation, religion, and physical abilities. Contemporary psychodynamic approaches reflect sensitivity and attention to these issues. Currently, the context calls for evidence-based treatments in psychotherapy, which, in many circles, has become synonymous with cognitivebehavioral therapy. An oft-repeated accusation is that psychodynamic models lack empirical support and are no longer relevant. While some within the psychoanalytic community have eschewed research, others are leading the way to bring attention to the substantial empirical evidence supporting psychodynamic psychotherapy and to demonstrate that much of what is “supported” empirically in other approaches are the psychodynamic elements that those models have incorporated.

Theoretical Underpinnings The theoretical underpinnings of contemporary psychoanalytic therapies reach back to Freud’s early work, but they have also moved far from his

initial ideas. Many of his early ideas have been rejected outright by contemporary practitioners. While Freud’s early structural model (id, ego, and superego) is still used to introduce people to psychoanalytic concepts, contemporary practice makes virtually no use of it. Following Freud’s structural model and stages of psychosexual development, ego psychologists such as Heinz Hartman, Eric Erikson, and Anna Freud brought attention to the important ego functions that allow people to adapt to their environments and develop coherent identities. Margaret Mahler and Donald Winnicott each made major contributions to the understanding of mother–infant relationships. The resulting object relations branch of psychoanalytic therapy emphasizes the basic human need to be connected and the importance of unconscious internalized relationships. Unlike the ego psychological model, which was primarily interested in defense structures, or the drive psychological model, which emphasized the unconscious instinctual drives of the id, object relationists focused their attention on the nature of the individual’s attachment to others as a reflection of early parent–child attachment. They emphasized the actualities of that early environment, outside of the infant/child’s inner psychology. The Self Psychologists, most notably Heinz Kohut, stress the need for empathic understanding throughout life and how early, healthy narcissism (strong self-esteem) develops as a result of empathy received from caregivers. This line of development demonstrates the movement from a one-person conflict model to a two-person relational model in psychoanalytic theory. Contemporary psychodynamic therapies are strongly influenced by attachment theory and research, particularly the work of John Bowlby. Additionally, they are increasingly intersecting with neuroscience and cognitive research and are being reshaped by questions regarding power, authority, and multiculturalism. Evolving over a rich course of approximately 125 years of theory, practice, and research, contemporary psychodynamic theories and their corresponding therapeutic practices can differ significantly from one another and from the original psychoanalytic model from which they all arose. There are, however, common features that unite them. Nancy McWilliams, Jonathan Shedler, and Matthew Blagys and Mark Hilsenroth have identified such common

Contemporary Psychodynamic-Based Therapies: Overview

features, including the following: (a) the significance of unconscious mental content and processes, (b) the resulting complexity of subjective experience, (c) the inherent defenses against honest self-knowledge, (d) the benefits and freedom that arise from such self-knowledge, (e) the significance of parent–child relationships, (f) transference and countertransference, and (g) attention to the counseling relationship. Importance of the Unconscious

The importance of the unconscious is perhaps the cardinal feature of psychodynamic-based theories. The models center on recognizing that psychological material and processes exist in varying degrees of consciousness—fully accessible to conscious awareness, outside of conscious awareness, or partially in and partially out. The extent to which material can be accessed consciously is related to the degree to which it is psychologically threatening: the less threatening, the more accessible, and the more threatening, the less accessible. Of particular interest to psychodynamic practitioners is unconscious psychological material, because it represents aspects of the self that have been disavowed—cut off from conscious awareness. Such material is kept from conscious awareness because it is somehow incompatible with present values. Complexity of Subjective Experience

What makes unconscious material so significant is that it does not simply rest inert or outside of awareness but rather exerts considerable influence on the conscious aspects of experience. That is, although unconscious material is barred from conscious awareness, it pushes for expression, and it can guide conscious experience in sometimes puzzling and problematic ways. Thus, unconscious material is active and alive within the mind, even while outside of conscious awareness; this is the “dynamic” aspect of psychodynamic models. Psychodynamic therapies seek to understand unconscious material—the expectations, motives, desires, and fears that shape people’s lives but that lie outside the bounds of conscious choice. Because unconscious material, by definition, lies outside of conscious awareness, one cannot rely solely on conscious processes for self-understanding. Unconscious

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material is accessed through associative processes— that is, by encouraging free discussion of whatever comes to mind. This may sound simple, but even as one is invited to speak freely, and consciously agrees to do so, resistance to unconscious material arises in the form of psychological defenses. Defenses Against Self-Knowledge

The idea of psychological defenses (e.g., denial, repression, regression, or projection) is another hallmark of psychoanalytical theory and practice. Defenses not only censor psychological material, but they are themselves outside of conscious awareness. That is, a person does not consciously choose defense mechanisms. Although others may find a person’s defensive strategies frustrating, unpleasant, or even destructive, for the person, defenses are a form of self-protection or self-preservation. Benefits of Self-Knowledge

Achieving greater access to unconscious material (i.e., acknowledging the truth about oneself to oneself) is believed to result in substantial benefit because it allows for the possibility of conscious choice, which in turn affords a kind of personal freedom not otherwise available. Quite importantly, then, the goal of contemporary psychodynamic therapies is not simply freedom from psychological symptoms but the freedom to be more fully oneself and to consciously engage in one’s life. Parent–Child Relationships

Parent–child relationships and early-life experiences play a significant role in psychodynamic theory and practice. They are seen as formative, shaping the development of personality and providing a template for future experiences and relationships. Not surprisingly, it is believed that the past exerts influence on subsequent experiences largely unconsciously, often manifesting itself in transference. Transference and Countertransference

Transference is a process by which people react to new situations and new relationships as if they were previous situations and relationships. For example, a client might respond to the counselor in

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ways she would to her mother, not solely because the counselor is in reality similar to her mother. She is believed to do so because she brings to the helping relationship unconscious expectations, carried forward from her earlier relationship with a primary caretaker. Transference is also a defense against remembering and thus serves, through repetition, as a protection from reexperiencing painful or unpleasant memories. In psychodynamic therapy, considerable attention is given to recognizing and working through the client’s transference reactions to the counselor. However, transference is confined neither to the client nor to the counseling relationship; rather, transference is ubiquitous in human experience. The counselor also experiences transference (referred to as countertransference), and all human relationships are influenced by transference. Transference reactions can range from extremely positive to extremely negative, either easing the formation of new emotional bonds or hindering them. Its potential to become problematic is increased when it remains an active force outside of conscious awareness.

seeks to foster natural healing capacities in the context of an emotionally safe and supportive relationship. Archetypal Psychotherapy

Archetypal psychotherapy, initiated in the 1970s by James Hillman, is a post-Jungian approach that emphasizes myth, fantasy, and image. The model seeks to understand and value the existential unfolding of the psyche—or the “soul”—and challenges many mainstream notions of mental health. Attachment Theory and Attachment Therapies

Attachment-based therapies are grounded in attachment theory, which examines the early emotional bonds between infants and caregivers. Mary Ainsworth identified three attachment styles: (1) secure, (2) insecure-avoidant, and (3) insecureresistant. Attachment therapies emphasize how such early attachment patterns are internalized and repeated in adult relationships. Core Process Psychotherapy

The Counseling Relationship

Relationships are central in psychodynamic theory and practice. They are seen as the foundations for health and well-being, with early relationships setting the stage for later relationships and with most client difficulties understood as arising from relational concerns. The therapeutic relationship itself, then, is of central importance. It is the primary route by which the client’s relational difficulties are assessed, understood, and worked through.

Short Descriptions of Contemporary Psychodynamic-Based Therapies Accelerated Experiential Dynamic Psychotherapy

Accelerated experiential dynamic psychotherapy maintains that intense emotional experiences are an inescapable part of being alive and that people have a natural capacity to heal and adapt. When intense emotions are painful and relationships fail to support adaptive responses, people may resort to problematic defenses. This approach

Core Process Psychotherapy (CPP) is a mindfulness-based theory combining Buddhist and psychodynamic concepts. CPP emphasizes the transformative power of awareness and of relationships, extending the one-person process of mindfulness into a two-person process of therapy. Very little has been written about CPP and its effectiveness. Cyclical Psychodynamics

Cyclical psychodynamics is an integrated approach that examines how relationships with others, behaviors, unconscious motivations, and conflicts are all reciprocally determining. The approach values contextual factors (external events) as well as internal states. Internal states may lead to behaviors that create reactions that, in turn, support or alter internal states. Emotion-Focused Therapy

Emotion-focused therapy is an empirically validated brief treatment approach. Emotion-focused therapy seeks to help people reclaim disowned

Contemporary Psychodynamic-Based Therapies: Overview

experiences as a crucial first step toward change. The emphasis is on accepting, expressing, regulating, and then, if needed, changing emotion. Emotional intelligence and secure relationships are central goals. Feminist Psychoanalytic Therapy

Whether aligned with classical or relational psychoanalytical thought, feminist psychoanalytic therapy critically considers how gender dynamics affect psychic structures, which are then reinforced by relational patterns. The model emphasizes the role of gender in parent–child relations and the development of identity, as well as the ongoing affects of sexism and gender inequality. Holding Therapy

Holding therapy (HT) is an intervention first used on children with autism; one or more therapists restrain the child and maintain eye contact, with the goal of inducing anger or rage. The assumption is that “releasing” blocked anger will foster attachment. HT is highly controversial. Death and injury have resulted. Sometimes identified as part of attachment therapy (AT), HT and AT are not the same as the ATs discussed in association with attachment theory. Interpersonal Psychoanalysis

Interpersonal psychoanalysis is based on the work of Harry Stack Sullivan, who maintained that the patient’s internalized view of self and the world can be understood by examining personal relationships. The analytic process then becomes centered on the relationship between the analyst and the patient and what it reveals about the patient’s inner world. Intersubjective-Systems Theory

Intersubjective-systems theory is a contemporary relational perspective. Much of intersubjective-systems theory is based in philosophy and argues that analysts must examine their beliefs about the mind and about their clients. The approach maintains that the mind is not an isolated entity and that clients are not separate objects to be fixed.

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Lacanian Psychoanalysis

Lacanian psychoanalysis derives from Jacques Lacan’s poststructuralist revisioning of Freudian concepts. Lacan emphasized language and deconstructing the illusions of a unified psychic life. Drawing from philosophy, structural linguistics, anthropology, logic, and mathematics, he developed key Freudian insights relevant both to the centrality of speech and to language in analysis. Mentalization-Based Treatment

Mentalization-based treatment is a form of psychodynamic therapy developed for those with borderline personality disorder. Mentalization is an ability to observe and interpret one’s own state of mind as well as imagine that of other people. This approach seeks to help patients develop that skill and use it, especially during times of stress. Neuropsychoanalysis

Neuropsychoanalysis brings together two different fields of study, both related to brain functioning: (1) neuroscience, which focuses on the biology of the brain, and (2) psychoanalysis, which examines the subjective experience of the mind. Neuropsychoanalysis draws on philosophy, neuroscience, psychoanalysis, psychiatry, and psychology, and it seeks an understanding of how neurological processes are turned into psychological processes. Theory of Psychosocial Development

Erik Erikson’s theory of psychosocial development is the most widely known and details eight stages of development from birth to death, through which all people should pass. As they do, they face, and ideally master, a psychosocial challenge. Other notable figures include Arthur Chickering and Linda Reisser, James Marcia, Otto Rank, and Karen Horney. Relational Psychoanalysis

Relational psychoanalysis is a relatively new, but influential, form of psychoanalysis, which places primary importance on the role of relationships, both real and imagined. It is closely linked to

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social constructivism and brings together theoretical concepts from interpersonal psychotherapy (Harry Stack Sullivan) and British object relations. Self Psychology

Self Psychology, initiated by Heinz Kohut, represented a challenge to the classical drive and defense perspectives offered by Freud and the object relations theorists. It shifted attention from internal conflicts to unmet or disrupted developmental needs. Key concepts include self objects, optimal frustration, idealization, and twinship needs. It set the stage for the current interest in relational and intersubjective approaches to psychoanalytic psychotherapy. Nona Wilson See also Accelerated Experiential Dynamic Psychotherapy; Archetypal Psychotherapy; Attachment Group Therapy; Core Process Psychotherapy; Cyclical Psychodynamics; Emotion-Focused Therapy; Feminist Psychoanalytic Therapy; Freud, Sigmund; Holding Therapy; Horney, Karen; Interpersonal Psychoanalysis; Intersubjective-Systems Theory; Jung, Carl Gustav; Kernberg, Otto; Klein, Melanie; Lacanian Psychoanalysis; Mahler, Margaret; MentalizationBased Treatment; Neuropsychoanalysis; Psychosocial Development, Theory of; Relational Psychoanalysis; Self Psychology; Sullivan, Harry Stack; Winnicott, Donald

Further Readings Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive activities of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7, 167–188. doi:10.1093/ clipsy.7.2.167 Cabaniss, D. L., Cherry, S., Douglas, C. J., & Schwartz, A. R. (2011). Psychodynamic psychotherapy: A clinical manual. Hoboken, NJ: Wiley-Blackwell. Frederickson, J. (1999). Psychodynamic psychotherapy: Learning to listen from multiple perspectives. New York, NY: Routledge. Luepnitz, D. (2002). Schopenhauer’s porcupines: Intimacy and its dilemmas. New York, NY: Basic Books. Maroda, K. J. (2010). Psychodynamic techniques: Working with emotion in the therapeutic relationship. New York, NY: Guilford Press.

McWilliams, N. (1999). Psychoanalytic case formulation. New York, NY: Guilford Press. McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York, NY: Guilford Press. McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: Guilford Press. Shedler, J. (2006). That was then, this is now: An introduction to contemporary psychodynamic therapy. Retrieved from http://www.jonathanshedler.com/PDFs/ Shedler%20%282006%29%20That%20was%20 then,%20this%20is%20now%20R9.pdf Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. doi:10.1037/a0018378 Shedler, J. (2010). Getting to know me. Scientific American, 52–57. doi:10.1038/ scientificamericanmind1110-52 Thompson, M. J., & Cotlove, C. (2005). The therapeutic process: A clinical introduction to psychodynamic psychotherapy. Washington, DC: Jason Aronson.

CONTEXTUAL THERAPY Primarily developed by the late psychiatrist Ivan Böszörményi-Nagy (1920–2007), contextual therapy is an integrative approach that combines concepts and techniques from several systemically based counseling theories that address different dimensions of relationships. Applying family-oforigin therapy, contextual therapists help clients understand the systemic patterns, obligations, entitlements, and loyalties that developed in important family relationships and how these issues have affected the development of each person in the family system. The therapist then shares insight about how those patterns, both constructive and destructive, are repeated. Contextual therapy is also psychodynamic in nature as it is insight oriented and identifies the therapeutic relationship as a primary nexus for change. As clients become more aware of their issues and are fully understood by their therapist, they can use the insight to make constructive choices about their relationships and actions. The primary contribution of the approach has been the focus on the essential component of justice for the development of trustworthiness in relationships. The assumption is that regardless

Contextual Therapy

of the consequences, people are motivated to pursue what they perceive to be their just entitlements. Thus, when clients’ perceived entitlements are acknowledged or fulfilled in therapy, resulting in an experience of justice, they are better situated to explore and gain insight about the root of their entitlements and subsequent actions. Such insight reduces the likelihood of destructive actions and creates an opportunity for greater trustworthiness—the fundamental component of an effective therapeutic relationship as well as the primary healing factor in individual and family dysfunction.

Historical Context Böszörményi-Nagy was a Hungarian-born psychiatrist who immigrated to the United States in 1950. Although his early work focused on the biomedical impacts in psychiatry, he gained recognition and influence through working with families at the Eastern Psychiatric Institute. He was one of the first to recognize the impact of family dynamics on individual behavior and became a founder of the family therapy movement. Deeply influenced by the existential philosopher/theologian Martin Buber (1878–1965), as well as the British school of object relations theory, Böszörményi-Nagy developed a working understanding of how significant relationships shaped individual personality and behavior. In the early 1970s, he collaborated with Geraldine Spark and developed ideas concerning justice, loyalty, and trustworthiness as motivating factors in personality and behavior. By the late 1970s and early 1980s, his collaboration with Barbara Krasner produced the coherent and integrative theory they called contextual therapy. Böszörményi-Nagy, Krasner, and Spark all worked to teach and expand the approach to address diverse clinical issues, but the hallmark of the approach is its continued relevance to working with individual and family dysfunctional behavior such as abuse, trauma, and repetitive violations. The approach is novel in that the therapist seeks partiality to every member of the relationship in an effort to convey that every person is entitled to a trustworthy understanding of his or her position. By the standards of today, it would be seen as a long-term, insight-based approach necessitating

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weekly sessions for many months. Prominent additions to contextual therapy have been made by Catherine Ducommun-Nagy, Peter Goldenthal, and Terry Hargrave.

Theoretical Underpinnings A primary tenet of contextual therapy is that all of life plays out in a relational context that is multidimensional. Although each dimension is distinct, the dimensions are interconnected, interdependent parts that make up a whole reality. Traditional contextual therapy identified four dimensions of relational reality, namely, (1) facts, (2) individual psychology, (3) systemic interactions, and (4) relational ethics. In the past decade, Ducommun-Nagy developed a fifth dimension, referred to as the ontic dimension. Facts

Facts are empirical factors such as genetic input, physical health, historical background, and events in a person’s life cycle. Facts are variables that cannot be altered and, at the same time, affect relationships. For instance, being diabetic, growing up in a single-parent home, or coming from a lower socioeconomic group will influence a person’s perspective on relating to others. Contextual therapists understand these biomedical and sociological factors as influences that play into the perspectives and actions of individuals and family members. Individual Psychology

Based on experiences and interactions within relationships, individuals internalize the subjective psychological integration of identity and develop an understanding about the purpose of relationships. These internal ideas then become the basis of emotional reactions, defense mechanisms, personality characteristics, beliefs about relationships, motivations, and cognitive styles. For instance, if a person’s primary caregivers were unresponsive or unreliable, the individual may develop a belief that relationships are generally unsafe and, therefore, should be avoided. Although current individual psychology tends to draw from attachment theory, the early contextual therapists developed this dimension with object relations theory in mind.

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Family or Systemic Interactions

All relationships involve transaction patterns. Patterns are created and perpetuated within relationships, and it is within these interaction patterns that power alignments, hierarchies, roles, and beliefs about relationships are defined. Therefore, if an individual grows up in a family where gender equality is valued, the person will be more likely to give and take equally when making decisions with another person. This dimension is heavily influenced by the early family therapy tradition concerning patterns and roles greatly affecting one’s perspective of relationships. Relational Ethics

This dimension is Böszörményi-Nagy’s unique contribution to the field of family therapy. Relational ethics is the subjective balance of justice that determines relational trustworthiness. In any relationship, there is an expected balance of what a person is obligated to give and what a person is entitled to receive. When there is a balance of giveand-take over time, the person tends to believe that the balance will continue in future interactions. This belief about continued balance in the relational give-and-take is the essence of trustworthiness. Trustworthiness allows individuals to concentrate on giving because they trust that the other will give according to their needs. Relationship dysfunction develops when the relational ethic is violated. For example, if a woman consistently gave fidelity, love, nurturance, and physical and monetary means to her spouse and her spouse gave nothing or very little in return, the woman would likely feel distrustful of the spouse. She may be motivated to end the relationship or stop giving. She might take aggressive action toward her spouse, such as physical or emotional abuse. These reactions resulting from the inability to trust in relationships and feeling unfulfilled with one’s just entitlement is called destructive entitlement. Destructive entitlement usually develops into long-standing patterns of violations in families and is seen in this theory as the primary root of individual and family dysfunction. Relational ethics is the primary dimension that creates an individual’s structure for relational dynamics. As such, the therapeutic relationship is

the first place where attempts to stabilize destructive entitlement with trustworthy actions are made. As clients feel heard and understood by the contextual therapist and their entitlements are appreciated, clients feel a sense of trustworthiness and are less likely to act destructively. The contextual therapist then seeks to expand this understanding and empathy to relational partners and family members so that mutual trustworthiness and giving are rekindled. As trustworthiness and giving grows among relational members, destructive entitlement and dysfunction becomes less and less likely. Although Böszörményi-Nagy began exploring the fifth dimension of relational reality in the 1990s, it was not until the early 2000s that Ducommun-Nagy more fully developed this dimension, called the ontic dimension. This dimension is based on the notion that individuals cannot know themselves apart from a relationship with another person, and thus, the dialectic nature of relationships is essential for self-knowledge and human thriving. Individuals know themselves visà-vis who they are not and based on their prescribed meanings of their relationship roles. Some in the field see this dimension as the existential aspect of a relational reality that exists in the other four dimensions, while others see it as the therapeutic process or dialogue between the therapist and the client.

Major Concepts Contextual therapists are first driven by their desire to give hearing and understanding to the client’s ledger, history, and story in a way that produces understanding and insight. Dialogue

Dialogue includes communication, intention, and behavior. Both relational partners intend to be balanced in mutuality of giving and receiving based on the principle of justice and a desire to produce the resource of trustworthiness. Destructive Entitlement

Destructive entitlement refers to beliefs held or actions taken that are self-justifying attempts to gain balance in a relationship where imbalance

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has occurred. Usually based in retribution, destructive entitlement is mostly directed at innocent parties who were not originally responsible for the imbalance or violation in the ledger of give-and-take.

acknowledging efforts, and accountability, contextual therapists increase trustworthiness as individuals feel heard, acknowledged, and understood. Next, individuals give the same partiality to one another in constructive dialogue.

Legacy

Working Up and Working Down

Legacy is the accumulated history of all interactions across dimensions that are left to an individual as a result of intergenerational relationships. It most often relates to the accumulated history of how a family has dealt with obligations and entitlements in either a balanced way, producing justice and trust, or an imbalanced way, producing destructive entitlement and violation.

The contextual therapist creates empathy within an individual by relating his or her concerns, imbalances, or injustices to the preceding or following generation. For instance, an individual who experienced abuse as a child may be able to relate to the feelings of the parent’s abuse as a child.

Revolving Slate

A revolving slate is a legacy issue in the relational ledger of obligations and entitlements where an individual feels the effects of injustices or imbalances from previous generations. Invisible Loyalty

Invisible loyalty describes an unconscious attempt by an individual to destructively balance the relational ledger. For instance, a husband who was dominated by his mother and was unable to confront the issue successfully overly controls or passively regards his spouse in an effort to balance the past relationship.

Techniques Contextual therapists help relational members develop insight and understanding and then initiate trustworthy behavior through mutual dialogue and effective giving. Multidirected Partiality

Multidirected partiality is the most important technique in contextual therapy. Therapists are not neutral. Rather, they are partial to each relational member and his or her concerns, efforts, history, and relational story. Contextual therapists usually sequentially side with each person in the relational reality. Using the tools of empathy, crediting,

Forgiveness and Exoneration

Forgiveness and exoneration involve lifting the load of culpability off a person responsible for a relational violation. The contextual therapist works with the victim to gain insight about interaction sequences where the relational and psychological pain is perpetuated. Then, through the use of circular questioning, the therapist helps the client develop new responses to yield a different interaction sequence. The contextual therapist also facilitates the victim’s understanding of the actions and past of the violator. The therapist is partial to the development, limitations, and pain of the violator and helps the victim realize his or her own destructive coping, thereby making human connection between the victim and the violator. This connection creates a new possibility for the victim to seek and receive trustworthy and nurturing behavior from the violator.

Therapeutic Process Contextual therapy most often is an approach that entails many sessions lasting several months to years. Throughout the process, the therapist takes the position of understanding the dynamics of the four dimensions and the effects of the past on the person’s relational ledger issues. Whether the therapy is with an individual or the family, the therapist is partial to the story of all relational parties, and when trust is built sufficiently, he or she works to connect relational members in balanced and trustworthy dialogue. Most important, as relational members give to one another, they

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increasingly move away from destructive actions and relational dysfunction. Terry D. Hargrave and Miyoung Yoon Hammer See also Attachment Theory and Attachment Therapies; Böszörményi-Nagy, Ivan; Existential Therapy; Family Constellation Therapy; Integrative Family Therapy; Multigenerational Family Therapy; Narrative Therapy; Object Relations Theory; Person-Centered Counseling

Further Readings Böszörmény-Nagy, I., & Krasner, B. (1986). Between give and take: A clinical guide to contextual therapy. New York, NY: Brunner/Mazel. Böszörmény-Nagy, I., & Spark, G. (1984). Invisible loyalties. New York, NY: Brunner/Mazel. Ducommun-Nagy, C. (2002). Contextual therapy. In F. Kaslow, R. Massey, & S. Massey (Eds.), Comprehensive handbook of psychotherapy: Vol. 3. Interpersonal/humanistic/existential (pp. 463–488). New York, NY: Wiley. Goldenthal, P. (1996). Doing contextual therapy: An integrated model for working with individuals, couples and families. New York, NY: W. W. Norton. Hargrave, T. D. (1994). Families and forgiveness: Healing wounds in the intergenerational family. New York, NY: Brunner/Mazel. Hargrave, T. D., & Pfitzer, F. (2003). The new contextual therapy: Guiding the power of give and take. New York, NY: Routledge. Hibbs, B. J. (2009). Try to see it my way: Being fair in love and marriage. New York, NY: Avery.

CONVERSION THERAPY See Sexual Orientation Change Efforts

CORE ENERGETICS Core Energetics is a body-oriented psychotherapy that draws from developmental, evolutionary, and character theory. This approach posits the unity of human energy and consciousness and views each individual as having a center of energetic wholeness (the Core), whose vital energy is meant to inform and flow freely through the body, emotions, mind,

will, and spirit. Core Energetics interventions restore energy flow that has been disrupted through the experience of developmental deficits that engender protective responses within the personality, known as character defenses, and within the body as energy blocks. Various techniques are used to liberate energy from constricted regions of the body, making suppressed material available to consciousness. The result is an expansion of clients’ capacity to express and contain emotion and use their energy toward creative rather than defensive purposes.

Historical Context Core Energetics emerged from the Reichian tradition of body-centered psychotherapy. Alexander Lowen and John Pierrakos cofounded bioenergetic analysis, and in 1978, Pierrakos founded the Institute for Core Energetics. Pierrakos maintained that a spiritual dimension was a crucial but missing component of Reichian and bioenergetic theories of body-centered psychology. During the 1970s, Pierrakos incorporated the lectures of the spiritual medium Eva Broch (whom he married) into his clinical perspective. These lectures, called The Pathwork, became an integral aspect of Core Energetics with their emphasis on psychospiritual development. Pierrakos asserted that we not only seek to heal from historical emotional injuries but also strive to reach our highest potential. Thus, he came to refer to Core Energetics as an “evolutionary process” rather than a therapy. As such, Core Energetics is both a body-centered approach and a transpersonal model.

Theoretical Underpinnings Character theory posits that as children we develop adaptations related to our early familial environment. These adaptations are not only fixed ideas about the world and others (images) but also structured in the body as muscular and fascial tensions (blocks) that alter the body’s growth and shape. Analysis of physical character informs the therapist of the deficits to primary needs (e.g., safety, loving touch, nourishment, and autonomy) at key developmental periods. Core Energetics recognizes five major character structures, each recognizable by its pattern of blocks, which repress the frustration, pain, and memory of early circumstances. However, these blocks also decrease the ability to experience

Core Energetics

pleasure and affect all aspects of personality, including emotional repertoire, experience of embodiment, behavior, and cognition. Transpersonal theory in Core Energetics views each character as having particular core qualities, which emerge as energy is freed and consciousness grows. The work evolves over four stages: (1) recognizing the idealized or defensive components of the personality (Mask); (2) identifying and taking responsibility for destructive and separative components of the personality (Lower Self) to transform them; (3) opening the heart to free expression of authenticity and creativity (Higher Self); and (4) in the final stage (Life Plan), clients bringing gifts as their unique contribution to the world from a deep knowing of themselves as an integral part and expression of the whole of life. Core Energetics also builds on other treatment modalities and theories, including developmental psychoanalytic theory, object relations, attachment theory, and self psychology.

Major Concepts Several Core Energetics concepts are consistent with Reichian theory and bioenergetic analysis, and some are particular to the Pierrakos model. The fundamental concepts include armoring, charge and discharge, character structures, grounding, and higher self, lower self, and mask. Armoring

Armoring is the process by which the human body adapts to protect itself from pain and the restrictions and frustrations to the spontaneous movement of energy and emotion that children are born with. Not only the mind but also the body’s muscles, tissues, and organs learn to adapt to the surrounding environment. Armoring results from a constriction of energy in the seven main segments of the body: (1) ocular, (2) oral, (3) cervical, (4) thoracic, (5) diaphragmatic, (6) abdominal, and (7) pelvic. The result of armoring is that both mind and body develop limited and habitual patterns of responding to the outer world. Charge and Discharge

The principle of charge and discharge is based on the ongoing condition of tension buildup and

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tension release, excitation and relaxation, sympathetic arousal and parasympathetic rest. Evident in orgasm and multiple life processes, recent research in trauma work validates the body’s basic need to discharge the energy to release trauma. Character Structure

During the formative years, the human body– mind forms in response to familial conditions. Ongoing experiences of danger, rejection, neglect, invasion, overcontrol, betrayal, and conditional love form one of five primary character structures: (1) schizoid, (2) oral, (3) masochist, (4) psychopath, and (5) rigid. Grounding

Being grounded means containing energy in the body and remaining present to sensation, feelings, and awareness of self in relation to one’s surroundings and to others. Higher Self, Lower Self, and Mask

Three layers of personality characterize the human body–mind. The higher self expresses the universal qualities of love, empathy, generosity, and wisdom, as well as each person’s unique core qualities, such as intelligence, integrity, or charisma. The lower self is the destructive aspect of the self and includes the impulse to be cruel, humiliating, or punishing. The mask is the social self, which hides both lower and higher self energy and exiles unwanted emotions and vulnerabilities.

Techniques In Core Energetics, use of techniques is determined by several factors, including client ego strength, the strength of the therapeutic alliance, the client’s character structure, and the ability of the client to tolerate and contain energy. Psychoeducation

Psychoeducation involves educating clients about the theory behind Core Energetics, the use of physical interventions, and the concepts of mask, lower self, and higher self.

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Body and Energy Reading

In body and energy reading, information is garnered through observation and discussion of the client’s body. Grounding

Grounding is a technique whereby postural and stance adjustments, breath, and awareness are used to support greater connection to sensations in the body and to feelings, and to enhance mindfulness of the present moment. Breath Techniques

Breathing retraining through various breath techniques supports the release of chronic tensions in the body that inhibit physical and emotional spontaneity. Active Expressive Techniques

Active expressive techniques are used to support the flow of energy to regions of the body where energy is needed and to bring consciousness to disowned feelings. These techniques are targeted to activate (charge) and support the release (discharge) of chronic muscular and emotional holding. Hands-On and Soft Techniques

Hands-on techniques are used with prior consent, caution, and clarity of purpose to bring awareness to regions of holding in the body, to encourage the release of energy in blocked areas, or to lend support to areas of the body. Soft techniques include gentle movement, mindfulness, and work with the chakra system. Embodied Relational Dynamics

Core Energetics goes beyond identifying transferential and countertransferential enactments that emerge in the relationship with the therapist by supporting the expression of emotions and energy evoked by these experiences.

Therapeutic Process In early Core Energetics sessions, a therapeutic alliance is forged. This includes identifying the client’s

primary concerns, introducing simple techniques to support mindfulness and body awareness, and grounding and physical interventions. The work serves to dismantle clients’ character armor while at the same time supporting healthy ego strength and trust in the spontaneous movements of the Core. As the process continues, clients see how their mask generates unsatisfying relationships, and energy work exposes the impulses that originate in the lower self. Clients begin to experience the reserve of untapped energy previously held in the unconscious lower self, which, when exposed and owned, becomes transformed into higher self creative energy. This increase of energy and consciousness is brought to bear on life issues as clients become selfempowered as agents of their own transformation. Core Energetics can be used for limited and specific issues wherein the work takes place over the course of several months or as a longer program of healing, empowerment, and self-development. Lisa Loustaunau and Brian Gleason See also Attachment Theory and Attachment Therapies; Bioenergetic Analysis; Body-Oriented Therapies: Overview; Orgonomy; Self Psychology

Further Readings Black, S. (2004). A way of life: Core Energetics. Lincoln, NE: iUniverse. Gleason, B. (2001). Mortal spirit: A theory of spiritualsomatic evolution. Lincoln, NE: Writers Club Press. Pierrakos, J. (1987). Core Energetics: Developing the capacity to love and heal. Mendocino, CA: LifeRythmn. Pierrakos, J. (2001). Eros, love & sexuality. Mendocino, CA: LifeRhythm.

CORE PROCESS PSYCHOTHERAPY Core Process Psychotherapy (CPP) is a mindfulness-based counseling theory that combines Buddhist teachings with traditional and alternative psychotherapeutic techniques. CPP is a contemplative therapy in which awareness itself is considered a curative process to relieve clients of suffering that has occurred throughout the life span, including pre- and perinatal experiences. The “Core” component of CPP suggests that all humans

Core Process Psychotherapy

possess the innate tendency toward health, the tools to heal themselves, and the ability to create a true state of being. The “Process” component is an act of awakening the senses and orienting to the present time through several largely experiential techniques. Although very little has been written about CPP and its effectiveness, proponents of the theory assert that its techniques are accessible to a wide audience and that long-lasting change can be produced.

Historical Context In 1982, Maura Sills, a former Theravada Buddhist nun and occupational therapist originally from Edinburgh, Scotland, founded CPP. Then, in 1984, Maura and her partner, Franklyn Sills, founded the Karuna Institute in Devon, England, to teach CPP and mindfulness practices to others. More recently, in January 2013, CPP became a full master’s degree program, in partnership with Middlesex University of London, and accredited by the British Association for Counselling & Psychotherapy. The Karuna Institute also offers introductory weekend trainings and a postgraduate certification in CPP. There are currently 179 CPP practitioners registered with the United Kingdom Council for Psychotherapy, who practice almost exclusively in Great Britain.

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or a special space created between mother and infant, was evidence of the need for humans to create relational bonds. As incorporated in CPP, the counseling relationship is intended to connect deeply with the client’s need to be interrelated and seeks to re-create the sacred holding environment so that healing can occur in the most nurturing of spaces. CPP also incorporates pre- and perinatal psychology theories, such as those proposed by Frank Lake and William R. Emerson. Birth psychology theories propose that all experiences that occur in the womb and during birth—including traumas— are stored and remembered by the body. Birth traumas can affect later interpersonal relationships, bonding, emotionality, and personality. CPP proposes that these formative experiences can be brought to awareness and the traumas can be resolved especially through the creation of a strong therapeutic bond. Finally, elements of holotropic breathwork are incorporated into CPP. Stanislav Grof proposed that intensified breathing, or hyperventilation, typically performed in a group setting and combined with other bodywork techniques, can encourage the body’s natural tendency toward healing. The breathing technique evokes suppressed feelings—perhaps even stored since birth— that can then be explored by the client and the counselor during sessions of CPP.

Theoretical Underpinnings A significant theoretical foundation of CPP is the Buddhist tradition, although CPP does not inherently teach religion. Specifically, CPP borrows from Buddhism the teaching that human suffering can be ended through a process of self-enlightenment. Strategies toward enlightenment, including defining a shared sense of being, are utilized in CPP counseling sessions. The CPP training programs and the Karuna Institute are open to people of all or no faiths. The object relations model, especially as defined by W. R. D. Fairbairn and Donald Winnicott, is another key component of CPP. Differing slightly from Sigmund Freud, who believed that babies identified people as “objects” that served to satisfy natural drives, Fairbairn stated that babies identified with caretakers to gain satisfaction from the relationship itself. Winnicott specified that the holding environment,

Major Concepts CPP has several major concepts relevant to the method, including holism, natural healing tendency, and kindness. Holism

The mind, body, spirit, and emotions are connected and inseparable. The CPP therapist must treat the individual as a whole person to resolve mental and physical issues. Therefore, a mindfulness activity might relieve a headache, and a breathing technique might decrease anxiety. Natural Healing Tendency

To relieve suffering, one must bring into awareness the body’s natural tendency to heal. The body will send messages through emotions, sensations,

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and energies to identify areas of pain. Additionally, every layer of experience can be transformed with innate tools such as self-listening, self-love, and self-compassion. Kindness

CPP is an individualized process that requires one to respond to one’s own unique, physical, emotional, and spiritual needs without judgment. Showing kindness to oneself by engaging in nurturing activities and respecting the path to holistic health will facilitate healing.

Techniques A combination of techniques is used in CPP, including forming a collaborative relationship, addressing transference and countertransference, and utilizing various mind–body awareness activities. Collaborative Relationship

It is essential to the effectiveness of CPP that both the counselor and the client are deeply affected by the counseling relationship. The holding environment provides a safe space for healing to take place on multiple levels of being. Transference and Countertransference

By addressing both comfort and discomfort in the counseling relationship, the client identifies past challenges, traumas, and unresolved issues from other relationships that may affect current functioning. Mind–Body Awareness Activities

Techniques used to encourage awareness may include self-listening, visualizations, breathing exercises, meditation, art or creative writing activities, and even gentle touching between the counselor and the client. Techniques will vary based on the client’s preferences and self-expressed needs.

Therapeutic Process The CPP counselor is responsible for providing a calm, safe, confidential, and collaborative environment for the client; he or she then facilitates and

“holds” the emotional space while the client engages in a process of becoming aware of his or her whole self, including body sensations, emotions, thoughts, and energies. The client will learn, through a unique combination of mindfulness techniques, to connect his or her current state of being with past life choices and experiences. The client will verbalize his or her experiences of the here-and-now to the counselor, but as opposed to other talk therapies, the client’s self-actualizations do not require interpretation. Healing occurs through a realization, reevaluation, and re-storying of the past to fit the client’s immediate sense of being. The counseling relationship is critical to CPP as Buddhist traditions emphasize that there is no discreteness between individuals, in this case the client and the counselor; therefore, transference and countertransference are considered to be essential tools of the theory, and the healing process is a shared experience. Six initial CPP sessions are recommended for new clients to determine a goodness of fit in the counseling relationship. Each session is typically one hour long. A traditional course of CPP sessions lasts approximately one year or more but varies by client. CPP therapists acknowledge that individual awareness may take varying lengths of time and that producing satisfactory life change is a subjective process. Katherine A. Heimsch See also Breath Work in Contemplative Psychotherapy; Object Relations Theory

Further Readings Karuna Institute. (2013). Core process psychotherapy. Retrieved from http://www.karuna-institute.co.uk/ core-process-psychotherapy.html Sills, F. (2008). Being and becoming: Psychodynamics, Buddhism, and the origins of selfhood. Berkeley, CA: North Atlantic Books. Sills, M., & Lown, J. (2008). The field of subliminal mind and the nature of being. European Journal of Psychotherapy & Counselling, 10, 71–80. doi:10.1080/13642530701869318 Watson, G., Batchelor, S., & Claxton, G. (Eds.). (2000). The psychology of awakening: Buddhism, science, and our day-to-day lives. York Beach, ME: Samuel Wiser.

Couple and Family Hypnotic Therapy

COUPLE AND FAMILY HYPNOTIC THERAPY Couple and family hypnotic therapy is a form of psychotherapy that includes the use of hypnosis, both directly and indirectly, on couples, families, and individuals. In this approach, the hypnotic induction is simultaneously applied to the entire family system, and the utilization of the trance state shared by different family members is considered an important part of the treatment.

Historical Context The techniques and theoretical background of hypnosis, used within many psychotherapy techniques since the late 1800s, have had a strong influence on family therapy from the beginning. Family therapy was first popularized in the 1940s, and soon after, hypnotic techniques began to be applied by several important theorists. Ericksonian hypnosis, first developed in the early 1960s, in particular, has a number of aspects in common with the family therapy principles that have bridged family therapy and hypnosis. Although Milton Erickson frequently interviewed and hypnotized individuals together with their families, a formal use of hypnosis with families officially did not begin until the late 1970s. In the 1970s, Gunther Schmidt utilized the Ericksonian approach to hypnosis and psychotherapy, combining it with the family therapy of the Helm Stierlin group in Heidelberg, Germany. The approach used by Schmidt is mostly indirect and inspired by a constructivist view. In 1983, Michele Ritterman, after studying with both Salvador Minuchin and Erickson, was the first to write a book on the use of hypnosis and family therapy. She elaborated on the concept and applied a structural approach for working with hypnotized families. Couple and family hypnosis therapy continues to be used today.

Theoretical Underpinnings The process of hypnotic treatment in family therapy is based on the fact that families (through stories, lullabies, fairy tales, and other communication

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modes) provide a common context for early hypnotic learning experiences. Many family therapists have observed the tendency of families to spontaneously induce a trance and have inferred that this ability to induce and develop a trance is specifically aimed to activate their personal and relational resources. However, the theoretical perspective that underlies the hypnotic approach with families and couples is not a causative or linear model but rather a circular and evolving process that develops within a systemic perspective. When a systemic perspective is applied to the conjoint family trance, the usual observed hypnotic phenomena in the individual setting activate a number of specific responses in the family interaction. As in individual hypnosis, overlooking the presence of hypnotic phenomena can seriously damage the therapeutic results, compromising the opportunity to obtain desired change. Aligning with Gregory Bateson’s view of the family system being organized like a mind, under hypnosis a family tends to overcome, if only temporarily, internal conflicts, permitting therapy to work better and making deeper resources available. Systemic hypnotic phenomena tend to improve family internal relationships as well as the family’s relationship with the therapist. A favorable therapeutic context is then established as soon as the family goes through a conjoint experience of trance. Several key theoretical concepts underlying couple and family hypnotic therapy are discussed in the following subsections. Reduction of Spontaneous Interactive Exchanges

As soon as the family trance develops, the number of interactive exchanges within the system progressively decreases, which meaningfully modifies the interpersonal consequences of family interactions. This is similar to the effect of the reduction of initiatives that individuals in trance typically develop. Slower Interaction Rhythm

As well as reduced exchanges, interactive exchanges are performed slower by family members during a family trance. This phenomenon, together

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with the previous one, explains why automatic interaction in the family tends to disappear when the systemic trance develops. Synchronism

Under hypnosis, the family system develops a number of synchronic behaviors, or isomorphic positions, such as movements, gestures, or postural shifts that are immediately reproduced by others in a chain of simultaneous activities.

therapy, Jurgen Ruesh and Bateson noticed that the more spontaneous and healthy a relationship, the more the relationship aspect of communication recedes into the background. Conversely, sick relationships are characterized by a constant struggle about the nature of the relationship, with the content aspect of communication becoming less and less important. A hypnotic induction of the entire family system results in reduced attention to the relationship level of communication. Increased Attention to Content

Conjoint Activity and an Increased Sense of Togetherness

Pragmatic coincidences, behavioral synchronisms, and emotional attunement tend to increase the sense of togetherness in this therapy. Families that have shared a hypnotic experience demonstrate a greater ability to work as a team and to perform conjointly. Reduced Reactivity to Family Members

Most dysfunctional families and couples demonstrate a prompt reactivity to each other’s statements. An intense emotional involvement produces a quick response that is often pronounced before the other’s phrase is completed. When reactivity is so immediate, family communications are full of overlapping statements and interruptions. The simple induction of trance makes this typically dysfunctional pattern disappear. Increased Attention to the Individual

Despite the presence of other family members, systemic hypnosis allows each individual to focus more on his or her inner self. The attention to other family members gradually tends to be reduced, and an internal search for meanings and explanations occurs. In this way, interpersonal boundaries are enforced, and individual autonomy receives support.

Family hypnotic induction offers the ability to pay close attention to communication content. A trance state allows any single family member to more easily hear and understand the meaning conveyed by others, regardless of who is presenting a personal point of view. By contrast, when family relationships are dysfunctional, the content is considered secondary to the person who is presenting it, and any specific message is accepted or refused only because it was presented by a certain family member. Increased Responsivity to the Therapist

The development of a trance makes the subject more responsive to the therapist’s suggestions. Erickson attributed this relevant change in subject responsivity to a peculiar form of attention defined as attentive responsiveness. When trance induction is applied to the family system, a shared responsivity to the therapist occurs. The usual ability to oppose and resist that many families exhibit when they are faced with the therapist’s tasks and prescriptions becomes surprisingly frail and is substituted with an unexpected inclination of compliance.

Major Concepts Several concepts inform the work of couple and family hypnotherapists. These share and reinforce the common historical and theoretical underpinnings of hypnosis and systemic family therapy.

Reduced Attention to Family Relationships

When a dysfunctional member responds to another, he or she is mostly responding to the relationship level. Since the early years of family

Hypnotic Induction

The simple hypnotic induction of putting individuals into a trance (without specific suggestions)

Couple and Family Hypnotic Therapy

tends to remove some of the obstacles to correct family functioning. Conjoint hypnotic experience can obtain some important changes in the interactive behavior of the couple or the family. After being induced in a trance, a hypnotic subject has decreased muscular tension, reduced anxiety, and increased responsivity to the therapist. Entering a different state of consciousness can influence both family members and their relationships. Induction Phenomena

The induction is able to induce not only interactional changes in a family but also individual hypnotic phenomena in its members, which can be used to achieve the desired change in the family relationship. These phenomena include anesthesia, analgesia, time distortion, age regression, dissociation, amnesia, and recall of hidden memories. Inclusion of All Family Members

Working with families and couples, the therapist is aware of the family system’s complexity and includes in the interview, as well as in the interventions, all family members. The therapist activates family resistance and homeostasis by paying little attention to or ignoring one or more participants. Interconnected Meanings

An individual response in a family is intended as a system’s response. This means that the family members in hypnosis will continue to produce interconnected meanings, even if only one member is producing them. If a family member describes during the family trance that he or she was imagining traveling alone, his or her description can be seen not only as an individual expression of personal autonomy but also as giving permission to the other family members listening to the person to be less enmeshed.

Techniques Specific direct and indirect techniques are required to activate family resources and to induce a deep and meaningful change in the most rigid family

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patterns. Frequently considered as therapeutic techniques, particularly with families, induction techniques are described separately here. Induction Techniques

Focusing on the Patient A powerful hypnotic technique for families is describing the patient and his or her symptoms or giving to him or her specific suggestions and requesting the family to focus on his or her behavior during the session. This technique utilizes the natural family tendency to pay intense attention to the patient and is particularly useful when the family places a strong emphasis on the identified patient role, which habitually happens with patients with psychosomatic disorders, anorexia nervosa, and substance abuse. Repeating the Family History Using the Family’s Language This technique requires intense attention on the part of the therapist during the initial interviews with the family. Repeating the family history works well with past-oriented families, like depressive families and couples. If the therapist repeats the history using the family language (i.e., the same words, phrases, or metaphors), the therapeutic alliance will be strongly reinforced. Acknowledging and Repeating Each Person’s Point of View With this form of induction, the individuality of each family member is supported through the emphasis given to each member’s point of view. This technique is indicated for an immediate indirect approach designed to change families with too intense involvement. Therapeutic Techniques

Explaining the Family Problems and Solutions With a Story Families tend to be sensitive to the therapist’s stories, so this approach is useful to allow each family member to take from the story a different meaning. If the therapist uses it in the induction phase, he or she can also use the same story immediately to suggest therapeutic change or in a later

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therapy phase to reconnect to the story seeded in the initial sessions. Stories can also be tailored to fit with a wide variety of families. Hypnotically Generating Fantasies The therapist asks the family members to activate their fantasies and present them one after the other during the hypnotic experience. The therapist can then use the material coming out of each one’s fantasy to interpret it, like interpreting a dream, or make comments to reframe similarities and differences. Taking an Imaginary Trip Every family member is invited during the hypnotic trance to experience an imaginary trip and to listen to one another’s trips. The therapist may suggest personal trips or collective family trips or else leave to each member the choice of the persons who can participate in each member’s trip. Setting interpersonal boundaries is usually the goal of this technique. Listening to Other Family Members in Silence In families where overlapping and interruption create fragmentary conversations, listening in silence allows more reciprocal attention and respect.

Therapeutic Process The systemic hypnotic therapy with families and couples initiates with a general interview to investigate the social aspects of the family, which includes each individual’s work, each individual’s personal passion, and each individual’s description of the family history. The interview focuses on collecting resources for later therapy phases rather than just collecting problems or complaints. An exploration of the symptoms and problems as well as the therapeutic goals is then made so that the therapy can be oriented toward specific solutions in accordance with the family requests. The initial phase usually requires one to three sessions to complete. Differing from individual treatment, couples and families often indicate varying or even conflicting objectives to be reached by therapy. In this case, a negotiation process to establish shared goals is needed, requiring additional sessions to complete this process.

Before proceeding with the induction, the therapist creates a hypnotic context that will facilitate the participation of the family members in the common experience of trance. Explaining what hypnosis is like and clarifying misconceptions about hypnotic trance are commonly included in this part of the therapy. Then family members are invited to give their consent to participate in the family hypnotic experience. They are also informed of the option to remain outside it, participating in the session without entering the trance or going back and forth. At this point, the therapist uses one of the induction techniques to achieve the trance. According to the Ericksonian philosophy of utilization, all the material derived from the initial part of the therapy is utilized to reach the therapeutic goals agreed on with the couple or family. Resources, symptoms, hypnotic interactive changes, and hypnotic phenomena observed in the induction phase can all be utilized to obtain change and to overcome family dysfunctional patterns. Specific techniques can be used to tailor the therapeutic interventions to the family interaction style, including usage of the family or individual resistance. The conclusion phase takes place when the therapeutic objectives begin to be reached. Individual satisfaction is considered a sign of successful treatment when it is shared by all the family members and when it is accompanied by the disappearance of the dysfunctional family behaviors. Camillo Loriedo See also Constructivist Therapy; Couples, Family, and Relational Models: Overview; Ericksonian Therapy; Hypnotherapy; Structural Family Therapy

Further Readings Loriedo, C. (2008). Systemic trances: Using hypnosis in family therapy. American Association for Marriage and Family Therapy, Family Therapy Magazine, 7(4), 27–30. Loriedo, C., & Torti, M. C. (2010). Systemic hypnosis with depressed individuals and their families. International Journal of Clinical and Experimental Hypnosis, 58(2), 222–246. doi:10.1080/00207140903523277 Ritterman, M. (1983). Using hypnosis in family therapy. San Francisco, CA: Jossey-Bass.

Couples, Family, and Relational Models: Overview

COUPLES, FAMILY, AND RELATIONAL MODELS: OVERVIEW The couples, family, and relational models of counseling present a general shift in thinking about the causes and solutions to human problems. Whereas most individual or intrapsychic counseling theories view both the origin and the solution to problems as occurring within the individual person (i.e., the individual psyche), the couples, family, and relational models assume an interpersonal perspective in which problems and their solutions are viewed as occurring and being resolved through the interactions of individuals within their immediate social environments. Family interactions are of particular importance because they are seen as the model for the relationships that individual family members have in most other contexts of their lives. From a couples, family, and relational counseling perspective, problems are viewed as circular rather than linear in nature; that is, the cause of a problem cannot be traced back to a single source, but rather, problems arise and are seen as being maintained through the mutual and reciprocal contributions of relating individuals who each are contributors to the problem. Similarly, solutions to problems are not seen as resting with one individual but, instead, may require changes in all individuals within the social system where the problem is occurring. Social system and especially family system interactions are, therefore, the primary target of intervention in the couples, family, and relational models of counseling. Couples, family, and relational counselors work to join and become a part of their clients’ families or other primary social systems, sometimes using their own influence as a member of the system to promote relational change.

Historical Context The practice of couples, family, and relational counseling (hereafter referred to in this section as simply “couples and family counseling”) was almost nonexistent prior to the 1940s. The preeminence of Sigmund Freud’s (1856–1939) intrapsychic drive theory along with a pervasive American value on rugged individualism resulted in a view of human problems as originating within the individual and as being best resolved through

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individual hard work and change. One early exception to this view was demonstrated by the physicians Abraham and Hannah Stone, who in 1929 opened the Marriage Consultation Center in New York, where they worked with married couples around family planning as a route to improving women’s health. However, it was not until the 1940s that attention to family dynamics began to emerge as a route to understanding individual mental health. Expanded interest and the need for clinical assistance to families were sparked substantially by the stressors placed on families during and after World War II. Changing gender roles, increased rates of divorce, and new educational and employment opportunities for women created challenges for families and set the stage for couples and family counseling to emerge as a profession during the next decade. The 1950s have been called the genesis of couples and family counseling. In 1956, the British anthropologist Gregory Bateson proposed that schizophrenia may have relational origins, pointing to the “double bind” that is experienced when children receive contradictory parental demands that result in inevitable failure regardless of their response. Bateson postulated that to avoid frustration and punishment, these children may come to approach all relationships with suspicion and confusion and in the case of schizophrenia may withdraw from the world of relationships altogether. Although controversial among clinicians, the double bind hypothesis was groundbreaking in directing researchers and clinicians to look beyond the individual in understanding and working with psychopathology. By the late 1950s, the stage was set for couples and family counseling to progress from being merely an interesting idea to becoming a reality, thanks in part to the American psychiatrist Nathan Ackerman, whose publication of The Psychodynamics of Family Life in 1958 called on the world of psychiatry to give up its entrenched intrapsychic views of human dysfunction in favor of exploring family dynamics and using them in the treatment process. The decade of the 1960s was an era of rapid growth of couples and family counseling as a profession. Initially, almost all of the innovation of the period occurred at the Mental Research Institute (MRI) in Palo Alto, California. MRI (also called the Palo Alto Group) was founded by the American psychiatrist Don Jackson in 1959 as a center for

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couples and family counseling research and training. It was the place where many of couples and family therapies’ leading figures came to work, including Salvadore Minuchin, Jay Haley, Cloe Madanes, and Virginia Satir. Fostering a climate of almost unparalleled experimentalism, MRI sparked the birth of some of the major couples and family counseling frameworks. Several other developments indicated that the field of couples and family counseling was gathering momentum. In 1961, Ackerman founded the Family Institute in New York, bringing family counseling to both the east and west coasts. Then, in 1962, The Family Journal was founded and became the first professional journal dedicated to couples and family counseling. Attracted by the creative work at MRI, the Italian psychiatrist Mara Selvini-Palazzoli formed the Institute for Family Studies in Milan, Italy, marking the first development of couples and family counseling outside the United States. As the 1960s came to a close, the roots of couples and family counseling as a major helping profession had taken a firm hold. Bateson’s cybernetic concept of family function largely shaped the development of couples and family counseling in the 1970s. Bateson postulated that families maintain stability through self-regulating feedback systems (i.e., cybernetic systems) that must be understood to effect family change. His cybernetic formulation laid the intellectual foundation for some of the major couples and family counseling models that continue to guide the field today, including Minuchin’s structural family therapy, Murray Bowen’s transgenerational family therapy, and Carl Whittaker’s experiential family therapy. The decade of the 1970s was also a period of critical evaluation and continued organization of couples and family counseling as a profession. Feminist critique challenged family counselors to examine their values and to confront sexist views that could be detrimental to helping female family members feel empowered. The major organizational milestone of the decade was the founding and growth of the American Association for Marriage and Family Therapy (AAMFT) in 1971. The formation of the AAMFT national organization along with the publication in 1975 of its associated professional journal, the Journal of Marital and Family Therapy, effectively established couples and family counseling as a major helping discipline.

Professionalization and internationalization best describe the events occurring in couples and family counseling during the 1980s, which have also been referred to as the golden age of family therapy. Before the end of the decade, there were multiple international organizations dedicated to couples and family counseling and two dozen professional journals in the United States and abroad. Most notable among the organizations founded during this period were the International Association of Marriage and Family Counselors, the International Family Therapy Association, and the Division of Family Psychology of the American Psychological Association. Along with the establishment of more than 300 training institutes in the United States, there were many new models of couples and family counseling, and while all relied on systems theory, most of them were related to the individual perspectives of their founders. Consequently, the 1980s ended with a proliferation of competing models and rival schools of couples and family counseling, which necessarily began to merge during the coming decades. During the 1990s, social constructionist philosophy began to confront the theoretical certainties of some accepted couples and family counseling models and to press for clients to have greater control of the counseling process. Several new constructionist models were introduced (e.g., solutionoriented brief family therapy, narrative family therapy) that rejected a “one-size-fits-all” view of counseling in favor of a view of the counselor and family as coauthors of the change process. The 1990s saw a rapid increase in state licensure of couples and family counselors, with regulations calling for university training in a broad spectrum of treatment modalities and professional issues. As a result, most of the free-standing institutes that offered exclusive training in narrowly defined specialties gave way to university-based programs. By the end of the decade, the Council for Accreditation of Counseling and Related Educational Programs had designated Marriage and Family Counseling as a formal counseling specialty with comprehensive professional training standards. In addition, managed care, developed by insurance companies to control health care costs, had brought about further regulation governing treatment eligibility, treatment frequency, and length of treatment in couples and family counseling practice.

Couples, Family, and Relational Models: Overview

During the 21st century, the profession of couples and family counseling has continued to evolve. To fully understand the diversity of experiences of contemporary families, couples and family counselors have found it necessary to pay greater attention to family ecology—that is, to the influences of the social systems within which families reside on their problems and responses to treatment. In addition, today’s couples and family counselors are being called on to inform their practice with relevant research. Emphasis seems to be shifting away from proving the effectiveness of the various clinical models toward determining what practices, regardless of the clinical model they come from, lead to the most positive outcomes. A final hallmark of 21st-century couples and family counseling practice (to date) has been an effort to identify core competencies that clearly delineate the professional identity of anyone claiming the title of couples and family counselor. Although this effort is a work in progress, it is hoped that developing a unified professional identity for couples and family counseling professionals will ultimately help clarify their range of competencies for their consumers, thus giving consumers a clearer sense of whom best to approach for help with their problems.

Theoretical Underpinnings Despite the wide variety in therapeutic processes and techniques among the different theoretical models of couples, family, and relational counseling, almost all models to some degree encompass the perspectives of general systems theory and cybernetics. First proposed by the Austrian biologist Ludwig von Bertalanffy in the 1920s and adopted by family counselors in the 1940s, general systems theory offers a set of assumptions about how family systems maintain stability by means of organization and rules, circular causality, homeostasis, subsystems, and boundaries. As noted above, cybernetics refers to the means by which family systems use self-regulating feedback loops to maintain balance and constancy. Organization and Rules

The concepts of organization and rules are central to understanding how systems operate. A system represents a set of separate units that relate to

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one another in a stable and predictable way, and it is the rules governing the nature of those relationships that provide stability and predictability. Family systems, like all systems, are organized around sets of rules and metarules (rules for making rules) that determine how family members relate to one another and differentiate one system from another. Couples, family, and relational counselors contend that it is impossible to fully understand a system by examining only its individual members. Rather, systems can only be understood by examining the enduring patterns of relationships among members that define the family’s unique relational structure. Circular Causality

In the physical sciences, there is utility in showing one thing to be the direct cause of another. For couples, family, and relational counselors, however, this linear or “billiard ball” model of causality is not useful. Within a family, one member’s actions affect all other members’ actions, which, in turn, affect the original member’s actions, in an ongoing reciprocal or circular fashion such that any search for a single (linear) cause of a problem becomes pointless. From a family systems perspective, working with only one member of a conflicting party is likely to be ineffective. It is only by examining the circular interactions among all conflicting parties that the cause of the conflict can be fully understood and resolution effectively achieved. Homeostasis

Homeostasis refers to a system’s self-regulating efforts to resist change in order to maintain stability. To an extent, homeostasis is necessary to the integrity or constancy of the system; however, it can also serve negatively to prevent systems from adapting to new environmental conditions when adaptation is needed. In poorly functioning family systems, demands for even modest changes may be met with strong homeostatic resistance, whereas well-functioning families are more likely to achieve change without forfeiting stability. For couples, family, and relational counselors, homeostasis is seen as a normal and anticipated protective mechanism for family systems; the goal of counseling is

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often a reconfiguration of the family’s homeostasis so that the family can function in a healthier manner. Subsystems

Subsystems are sets of stable relationships within a larger system that carry out specific tasks necessary to the function of the larger system. In family systems, the most enduring subsystems are the spousal, parental, and sibling subsystems, each making a unique contribution to the family. The spousal subsystem provides models of closeness and intimacy, the parental subsystem offers direction and nurturance to children, and the sibling subsystem provides children with their first lessons in social interaction with peers. Typically, there are numerous additional subsystems in any family, with family members belonging to more than one subsystem. For couples, family, and relational counselors, understanding the subsystems of the family is central to understanding and assisting in the family’s function and dysfunction.

intended path. From a cybernetic perspective, constancy in the direction of the moving body is maintained through frequent corrective changes sent to the body through these feedback loops. In applying cybernetic principles to families, Bateson suggested that families maintained constancy through selfregulating systems for issuing corrective feedback to errant members. Although direct attention to cybernetics varies among different couples and family counseling models, the notion that an individual cannot be fully understood outside of his or her cybernetic system remains foundational to a family systems perspective.

Short Descriptions of Couples, Family, and Relational Models Ackerman Relational Approach

The Ackerman relational approach places a lack of coordination, or complementarity, among family members’ roles at the forefront of family problems. The goal of the model is to address role conflict and confusion by attending to both the conscious and unconscious processes that support them.

Boundaries

Boundaries are the rules of engagement that separate an individual, a subsystem, or a system from its outside surroundings. They help ensure the integrity of a system and its subsystems by defining their exact membership, functions, and relationships to others. In families, the permeability of boundaries is seen to be more important than their number or composition. Effective, or clear, boundaries are those that are permeable, or open, enough to allow for interaction and coordination with others and yet impermeable, or closed, enough to ensure the integrity of the individual, subsystem, or system they define. The clarity of family boundaries relates directly to the ability of a family system to adapt effectively to changes in its environment.

Attachment-Focused Family Therapy

Based on attachment theory and intersubjectivity, this approach to family treatment has the therapist provide a safe and trusting relationship with parents and children, with the focus being to develop new individual and family narratives. In this process, the therapist uses affective-reflective dialogue and integrates nondirective and directive skills. Cognitive-Behavioral Family Therapy

This approach focuses on the use of the principles of behavioral modification and is designed to change the interactional patterns of family members as well as restructure the distorted beliefs and perceptions that develop as a result of faulty interaction.

Cybernetics

Cybernetics is a term coined in 1948 by the mathematician Norbert Weiner that referred to a process by which a moving body such as a ship or missile could be maintained on a steady course through corrective messages, or feedback loops, enacted whenever the body diverted from its

Couple and Family Hypnotic Therapy

After establishing negotiated goals with families, this approach to couples and family treatment uses family hypnotic induction techniques to achieve agreed-on goals. Therapy is successful when each member involved in treatment is satisfied with his

Couples, Family, and Relational Models: Overview

or her achieved goals and there is reduction or elimination of dysfunctional behaviors. Emotion-Focused Family Therapy

Emotion-focused family therapy proposes that deep-seated emotions around early attachments can underlie negative interaction patterns in current relationships. Activating these emotions in therapy can bring them into awareness and help clients change the problematic emotional states affecting their relationships. Family Constellation Therapy

This approach uses spatial placement of multiple participants to re-create an extended family system (i.e., “constellation”) in therapy. Its aim is to reveal a previously unrecognized systemic dynamic that spans multiple generations in a given family and to resolve the damaging effects of that dynamic. Feminist Family Therapy

Feminist family therapy seeks to identify and address the ways in which gender inequality along with other types of oppression such as race, class, culture, and sexual orientation lead to unfair distributions of power and authority that negatively shape the lives of family members. Gottman Method Couples Therapy

This approach combines therapeutic interventions with scientifically founded couples exercises to help clients develop the tools necessary to remove the natural walls and defenses that hinder and prohibit effective communication and bonding. Human Validation Process Model

This approach emphasizes collaboration between the therapist and the family to achieve wellness. Clear rules for communication and positive self-esteem among family members are seen as essential to a functional family system. Identity Renegotiation Counseling

Starting with the assumption that clients have multiple identities that are constantly changing

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and vying for dominance, identity renegotiation counseling focuses on reducing identity conflicts. In this process, which is usually fewer than 15 sessions, couples and families learn the complexity of their individual and family narratives and take an active role in understanding and ultimately changing their relational identities. Imago Relationship Therapy

This approach assists couples in unveiling their unconscious components (the imago) that determine their choice of mate. Its goals are to give couples the tools to relate to each other and themselves in a positive and caring way and to reveal the emotional pathway formed in childhood that led them to their current situation. Internal Family Systems Model

The internal family systems model proposes that the internal system of the mind is subdivided into an indeterminate number of subpersonalities, or parts, and that systems theory can be used to understand and reorganize these subpersonalities so that there is balance and harmony. Integrative Family Therapy

This approach brings together various theoretical perspectives and procedural techniques to bear on specific family problems and dynamics that are relevant to a given family. The therapist determines whether a particular process or technique is relevant for a particular family and clinical situation. Multigenerational Family Therapy

Multigenerational family therapy posits that chronic anxiety in families is passed from generation to generation and results in excessive emotionality in decision making. The goal is to reduce anxiety by facilitating awareness of how the emotional system functions. Multisystemic Therapy

A home-based family counseling model, this approach has been used to treat youth with antisocial behaviors. The approach is based on finding fit (understanding antisocial behaviors in their

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context), emphasizing the positive, increasing individual and family responsibility, being present and action oriented, targeting issues from multiple systems that affect the problem, ensuring developmentally accurate interventions, making continuous effort toward goals, evaluating the process, and having treatment be generalizable to other family problems. Narrative Family Therapy

Narrative family therapy asserts that families frequently construct self-defeating narratives about their lives and inadequate explanations for why they cannot change. Its goal is to help families rewrite their narratives to include the possibility of a more positive future outcome. Psychodynamic Family Therapy

This approach integrates classical Freudian psychoanalytic theory’s interest in the unconscious aspects of individual personality development and function with an interest in the social context, and especially the family context, in which individual and relational dysfunction develops. Relationship Enhancement Therapy

Relationship enhancement therapy seeks to focus on the learning and generalizing of specific interpersonal skills in an effort to improve individual, couple, and family well-being. This is partially done through the development of a secure emotional atmosphere, which allows for the learning of new skills that can be applied to multiple issues. Solution-Focused Brief Family Therapy

This approach suggests that families come to therapy when efforts to solve problems have only served to perpetuate the problems they were intended to solve. The goal is to help the family generate alternative solutions that have not been available to them before. Strategic Family Therapy

This approach posits that family struggles result from covert power struggles among family members. The family therapist “strategically” uses his

or her own influence to interrupt the interactional processes that support and maintain the power struggles. Structural Family Therapy

Structural family therapy shifts the emphasis of treatment from the individual presenting the problem to the reorganization of family transactional patterns or “structures” that are supporting the problem. Systemic Family Therapy

Systemic family therapy, also known as the Milan Approach, suggests that problems arise when family members engage in symptom-causing dynamics to control other members. Through the use of questions that help provide insight and understanding, former, rigid ways of understanding self, and the self’s related systems, are abandoned. Then, through a variety of techniques including prescriptions, rituals, and reframing, new, healthier ways of experiencing self and others are developed. Symbolic Experiential Family Therapy

This approach seeks to help individual family members feel more fulfilled and self-actualized by building levels of intimacy and cooperation within the family unit. Its goal is to help family members learn to communicate with one another and respect one another’s unique needs. Systemic Constellations

Systemic constellations therapy suggests that problems arise when family members engage in symptom-causing dynamics that are the result of transgenerational issues that get played out unconsciously within families. It attempts to expose these issues and assist clients in gaining insight into their behaviors as they visualize new images of health and move toward change. Rip McAdams See also Ackerman, Nathan; Ackerman Relational Approach; Attachment-Focused Family Therapy; Böszörményi-Nagy, Ivan; Bowen, Murray; Cognitive-Behavioral Family Therapy; Couple and Family Hypnotic Therapy; Couples, Family, and Relational Models: Overview; Emotion-Focused

Creative Arts and Expressive Therapies: Overview Family Therapy; Family Constellation Therapy; Feminist Family Therapy; Gottman Method Couples Therapy; Haley, Jay; Human Validation Process Model; Identity Renegotiation Counseling; Imago Relationship Therapy; Integrative Family Therapy; Internal Family Systems Model; Madanes, Cloe; Multigenerational Family Therapy; Multisystemic Therapy; Narrative Family Therapy; Palo Alto Group; Psychodynamic Family Therapy; Relationship Enhancement Therapy; Satir, Virginia; Solution-Focused Brief Family Therapy; Strategic Family Therapy; Structural Family Therapy; Symbolic Experiential Family Therapy; Systemic Constellations; Systemic Family Therapy

Further Readings Gladding, S. T. (2011). Family therapy: History, theory, and practice (5th ed.). Boston, MA: Pearson Education. Goldenberg, H., & Goldenberg, I. (2013). Family therapy: An overview (8th ed.). Belmont, CA: Brooks/Cole. Nichols, M. P. (2012). Family therapy concepts and methods (10th ed.). Boston, MA: Pearson Education.

CREATIVE ARTS AND EXPRESSIVE THERAPIES: OVERVIEW Creative arts and expressive therapies include a broad range of therapeutic approaches based on the premise that internal conflicts, tensions, and problems can be manifested externally through artistic or bodily means or through exposure to environments or activities that are different from our usual daily routines. In the United States, creative arts therapies include those disciplines that are under the umbrella of the National Coalition of Creative Arts Therapies Associations: art therapy, dance movement therapy, poetry therapy, psychodrama, drama therapy, and music therapy. Other expressive therapies in this section include adventure-based therapy, animal assisted therapy, bibliotherapy, chess therapy, EcoWellness, impact therapy, improvisational therapy, nature-guided therapy, wellness therapy, and writing therapy.

Historical Context For eons, humans have used artistic means such as dance, music, and art for self-expression, communication, well-being, and healing; thus, many of the creative arts and expressive therapies claim ancient

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roots. Indeed, even the use of chess in therapy has been attributed to a physician in 9th-century Baghdad. In modern times, some creative arts and expressive therapies emerged simultaneously in Europe and the United States. This may be attributed to the predominance of psychoanalytic theory and practice in the mid-20th century in Western societies, including their emphasis on Sigmund Freud’s (1856–1939) concepts of the unconscious and psychic determination. Emanating from these basic Freudian concepts, many creative arts therapies were fundamentally based on the idea that the creative process and product reflect the internal, sometimes unconscious, experience of the patient or client. Furthermore, in concert with early-20thcentury interest in child development, creative arts therapies also emerged as approaches effective in working with children who lacked the verbal skills necessary to talk about their experiences in a therapeutic context. In the aftermath of World Wars I and II, creative arts and expressive approaches to healing grew in credibility through their use with traumatized veterans and “troubled youth,” who responded well to creative, expressive, and nature-based experiences. Soon, creative arts and expressive therapies professional membership associations began to emerge, along with codes of ethics, education standards, research, scope of practice documents, and credentialing. Although most of the approaches described in this entry are adjunctive to traditional talk therapy, some creative arts therapists, by virtue of their professions’ rigorous educational standards, ethical codes, and defined scope of practice, are able to engage in independent practice through licensure by state regulatory boards.

Theoretical Underpinnings Wellness in and of itself is an overarching holistic paradigm for the field of counseling and development. Based on Adlerian principles, wellness is defined as body, mind, and spirit combined into a balanced life. Counselors using a wellness approach embrace a health model rather than the medical model, which emphasizes diagnosis leading to treatment. Theoretically, EcoWellness, a contemporary variation of wellness therapy, is based on the empirically supported notion that viewing nature and being in natural surroundings have multiple

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positive effects on health. On the other hand, nature-guided therapy and adventure-based therapy seem to fall under the broad concept of ecopsychology, a new psychological approach that conceptualizes humans as functioning within the context of natural surroundings. Proponents of nature-guided therapy implement solution-focused and sensory nature-based experiences in counseling. Adventurebased therapy is based on experiential education that integrates cognitive therapy, rational emotive behavior therapy, reality therapy, Gestalt therapy, solution-focused therapy, and humanistic approaches to outdoor group experiences that contain some perceived or actual physical risk. Another expressive therapy approach that relies on multiple theoretical underpinnings is impact therapy, which combines rational emotive behavior therapy, transactional analysis, and Gestalt techniques along with the use of props to provide the client with a multisensory experience that leads to insight and change. Bibliotherapy is a broad term that includes those expressive approaches based on the belief that reading is intrinsically healing. It incorporates the psychodynamic concepts of identification (with characters in the literature being read), catharsis through reflection and processing with the therapist, and insight leading to change. One form of bibliotherapy is poetry therapy, which capitalizes on the lyricism, use of metaphor, and rhythm characteristic of poems as catalysts for the desired client outcomes of identification, catharsis, and insight. Often used in conjunction with bibliotherapy, writing therapy is largely based on the research of James Pennebaker, who developed a protocol for clients to write about their traumatic experiences. Encouraging results from extensive research on the protocol led to the theory—not entirely supported empirically— that the psychodynamic concept of abreaction—the process of discharging pent-up emotions and discussing their meaning—is responsible for the positive outcomes of expressive writing. Interestingly, animal assisted therapy, chess therapy, and improvisational therapy are theoretically based on relationship dynamics. In the case of animal assisted therapy, the bond that develops is between the client and a trained therapy animal; with chess therapy, the relationship occurs between the therapist and the patient. Additional theories underlying chess therapy include the notion that the chess game itself represents the Freudian

concept of wish fulfillment and the Jungian concept of archetypal symbolism. In contrast to animal assisted therapy and chess therapy, improvisational therapy is focused on allowing the therapist and the client to spontaneously interact, in a creative and nonprescriptive manner, with the focus on examining how past relational patterns are repeated and how new patterns can be experimented with and lead to healthier behaviors. Several psychotherapy theories underlie the creative arts and expressive therapies and play therapy. Originally growing out of psychoanalysis, the fields of art therapy, dance movement therapy, drama therapy, psychodrama, poetry therapy, and music therapy have evolved through research and practice into a variety of theoretical directions. For example, art therapists may embrace a number of psychological development and psychotherapy approaches from psychodynamic to narrative, but the underlying theoretical constructs that direct art therapy practice are the Expressive Therapies Continuum, which suggests that creative expression comes in a variety of forms (e.g., sensory/kinesthetic, perceptual/affective, cognitive/symbolic) and the premise that focused art making promotes self-reflection. Likewise with play therapy: It originally emanated from the work of Anna Freud and Melanie Klein, yet contemporary play therapists are largely person centered and embrace a number of different theoretical models in their work. Dance movement therapy was one of the first disciplines to embrace the importance of the interrelationship of mind, body, and feelings. Psychodrama, with its emphasis on reenactment and catharsis, emanated from improvisational theater, psychoanalysis, and group therapy. Drama therapy draws from psychology, theater, psychoanalysis, and child development theories. Music therapy, initially based on psychoanalytic theory, has been widely researched regarding the physiological response to music and has broadened from its original roots.

Short Descriptions of Creative Arts and Expressive Therapies Adventure-Based Therapy

This approach utilizes multiple activities, usually outdoors, for groups or individuals. Activities such as ropes courses or cooperative games are used to facilitate team building, change through experiential learning, and stress reduction.

Creative Arts and Expressive Therapies: Overview

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Animal Assisted Therapy

EcoWellness

Facilitated by trained helping professionals, this modality employs certified therapy animals to provide opportunities for giving and receiving affection to decrease depression and anxiety and to increase self-esteem, particularly in neglected or abused children, medically ill persons, and veterans with posttraumatic stress disorder.

When an EcoWellness approach to counseling or psychotherapy is applied, a human–nature connection is created that facilitates the client’s positive sense of self, spiritual well-being, and connection to others. Impact Therapy

Art therapy entails focused art making within the therapeutic relationship of the art therapist and the client. It is based on the premise that the approaches clients take to create art pieces, and the art pieces themselves, reflect clients’ thoughts, feelings, and behaviors.

This approach uses a variety of prompts to create a multisensory experience for the client in an effort to assist him or her in gaining insight and understanding of the issue at hand. Examples of prompts include toy hammers, a whiteboard, pictures, and experiential activities, any of which can be used to deepen the counseling experience after the client and the counselor have agreed on mutual goals.

Bibliotherapy

Improvisational Therapy

This approach, widely implemented by a variety of mental health and educational professionals, involves reading for therapeutic or educational purposes. The practice of bibliotherapy facilitates readers in gaining emotional connection, problemsolving skills, and insight.

Rooted in cybernetics and systems theory, improvisational therapy looks at circular patterns of behavior; examines how client behaviors, within sessions, reflect past ways of interaction and communication; and allows the client to experiment with new, creative forms of behaviors. Within this process, therapists can also be spontaneous as they attempt to move the client toward change.

Art Therapy

Chess Therapy

Chess therapy is based on the theory that playing chess facilitates intense interpersonal relationships in a short period of time. In this approach, when chess is played between the client and the therapist, rapport is developed, allowing for accurate diagnosis and successful treatment, leading to client insight.

Music Therapy

Music therapists utilize four main methods called (1) improvisation, (2) recreative, (3) composition, and (4) receptive to facilitate music experiences that foster change and growth within clients.

Dance Movement Therapy

Nature-Guided Therapy

Professional dance movement therapists emphasize client movement as crucial in assessment and intervention to address and integrate the emotional, social, cognitive, and physical aspects of client functioning.

Conducted with self or with others (e.g., couples and families), this systemic approach to therapy has clients get in touch with their sensory experiences relative to their environment (e.g., nature and others involved), encourages clients to become more mindful of self and their surroundings, and helps clients connect with nature and with others as they enhance their sense of well-being.

Drama Therapy

Using drama, sometimes called theater techniques, this experiential approach to therapy uses techniques such as improvisation and performance to facilitate self-learning, personal growth, and insight and to work toward therapeutic goals.

Play Therapy

Therapists and counselors trained in play therapy integrate play, including music, games,

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costumes, toys, and the like, into treatment sessions with children of ages 3 to 11 years. Through play therapy, youngsters can resolve problems, master difficult feelings, and change maladaptive behaviors. Poetry Therapy

In poetry therapy, language, stories, and symbols are catalysts for psychological health and well-being. A trained facilitator uses carefully selected poems or other literature to stimulate emotional responses, which can be discussed by clients. Psychodrama

Psychodrama is a therapeutic modality that facilitates recognition in clients of how a past interaction influences current distress. Through reenactment guided by the psychodramatist, the client learns how to overcome the effects of the past event on current functioning. Wellness Therapy

Wellness therapy or counseling is the process of helping a client become aware of the meaning of wellness and of how one’s thoughts, feelings, and behaviors have either positive or negative effects on one’s own wellness. Writing Therapy

This modality involves the therapist facilitating the client’s expression of thoughts and feelings through the act of writing. It is often used as an adjunct to traditional verbal therapy. Sarah P. Deaver See also Adventure-Based Therapy; Animal Assisted Therapy; Art Therapy; Bibliotherapy; Chess Therapy; Dance Movement Therapy; Drama Therapy; EcoWellness; Impact Therapy; Improvisational Therapy; Music Therapy; Nature-Guided Therapy; Play Therapy; Poetry Therapy; Psychodrama; Wellness Counseling; Writing Therapy

Further Readings Davis, W., Gfeller, K., & Thaut, M. (Eds.). (2008). An introduction to music therapy: Theory and practice

(3rd ed.). Silver Spring, MD: American Music Therapy Association. Gass, M., Gillis, H. L., & Russell, K. (2012). Adventure therapy: Theory, research, and practice. New York, NY: Taylor & Francis. Johnson, D. R., & Enumah, R. (2009). Current approaches to drama therapy. Springfield, IL: Charles C Thomas. Knill, P., Levine, E., & Levine, S. (2004). Principles and practice of expressive arts therapies: Toward a therapeutic aesthetic. Philadelphia, PA: Jessica Kingsley. Landreth, G. (2002). Play therapy: The art of relationship. New York, NY: Taylor & Francis. Mazza, N. (2003). Poetry therapy: Theory and practice. New York, NY: Brunner-Routledge. Rubin, J. (2010). Introduction to art therapy: Sources and resources. New York, NY: Taylor & Francis.

CRITICAL INCIDENT STRESS MANAGEMENT Crisis-related interventions consist of three phases: (1) information, (2) training, and (3) support. Critical Incident Stress Management (CISM) follows this model and is designed to provide a framework for organizations, communities, and other groups to plan, prepare, respond to, and cope with the impact of disasters and crises. The goals of CISM are to mitigate the psychological impact of critical incidents and facilitate psychological closure. CISM techniques and components can be customized to address the particular needs of the specific affected group requiring the intervention. In addition, the approach provides for precrisis planning and education, on-scene support, and postcrisis specific interventions such as follow-up screening for referral.

Historical Context During the American Civil War (1861–1865), the first systemic efforts toward mitigating the negative psychological effects of trauma exposure, such as combat stress (now referred to as posttraumatic stress disorder) experienced by soldiers, were initiated. In the mid-1970s, the CISM approach was developed by Jeffery Mitchell. CISM is defined as a comprehensive, integrative,

Critical Incident Stress Management

multicomponent crisis intervention system that spans all aspects of a critical incident, from preparation for to response to a traumatic event. It was initially developed to assist emergency personnel after exposure to traumatic experiences. The purpose of current-day practice of CISM is to prevent the negative psychological effects the first responders, survivors, witnesses, and community may experience as a result of a crisis or disaster. Specifically, the CISM approach (a) mitigates the impact of a traumatic event; (b) facilitates recovery; (c) restores individuals, groups, and organizations to adaptive functioning; and (d) identifies people who may need additional support services. It is known as a form of psychological or emotional first aid. In its early days, CISM was referred to as Critical Incident Stress Debriefing (CISD) or the Mitchell Model. This was a misnomer, as debriefing is only one component of the approach. Additionally, utilizing the CISD component alone is inadequate and does not completely embrace the comprehensiveness of the full approach. Consequently, use of the approach has evolved to include the integrated seven-component system and the standards of practice for many organizations and communities.

Theoretical Underpinnings The foundation of CISM can be traced to emergency service provision and group psychological debriefing techniques. CISM is not a substitute for mental health treatment but a series of interventions combined to assist people who have been affected by a traumatic event. Mitchell was influenced by four major theoretical traditions in the development of the system: (1) crisis intervention, (2) group psychotherapy, (3) community psychology, and (4) peer support. CISM is also influenced by the works of Irvin Yalom focusing on group therapy, Gerald Caplan’s theory of psychiatric crisis intervention, Eric Lindemann’s observations on grief and loss responses, and Howard Parad’s models of crisis prevention and interventions.

Major Concepts The CISM program includes seven core components. These interventions are described in the following subsections.

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Precrisis Preparation and Education

During the precrisis preparation and education component, CISM team members participate in specialized training focusing on overall incident and impact assessment skills, strategic planning, and helping skills for crisis management. In addition to specialized training, the team develops and provides information and education on stress, physiological and emotional responses to traumatic events, and coping and other self-care techniques to members of the community prior to a critical incident. On-Scene Support Services

During the crisis event, support services are managed by peer volunteers of the CISM committee. This involves crisis management briefings for first responders, survivors, witnesses, and community members. Town meetings are used to provide crisis event information to large groups. In addition, CISM team members provide information and consultation to incident command staff. On-scene demobilization during the crisis event is offered and involves providing basic needs (e.g., nourishment and rest), information regarding traumatic stress and coping skills, and emotional and psychological support prior to first responders being released to off-duty status. A specific location is arranged for demobilization services, which are provided by specially trained CISM team members. Defusing

The process of defusing is provided for small groups during or immediately after a traumatic event. Defusing is a three-phase structured discussion facilitated by at least two CISM team members and includes the introduction phase, exploration phase, and information phase. The purpose of defusing is to reduce acute stress reactions and promote effective coping. In addition, the defusing process provides CISM team members opportunities to assess and triage group members for assistance with acute symptom management. Critical Incident Stress Debriefing

CISD is a component of the larger CISM process. Using CISD in isolation is not recommended because it is designed to be an integral part of the

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whole CISM approach. CISD is typically provided a few days to a few weeks after the crisis event, and the purpose is to mitigate the psychological impact of the critical incident, accelerate the recovery process, assess the need for follow-up and referral, and provide a sense of closure. The CISD is typically conducted by a mental health professional with the assistance of three to five specifically trained peer CISM team members. The CISD group process consists of seven steps; it begins at a cognitive level by having participants briefly describe the event, discussing thoughts and perceptions, and continues to an affective process that includes a discussion about natural reactions and feelings experienced. It then moves back to a cognitively based approach that focuses on teaching and closure. The seven phases are (1) introduction, (2) fact phase, (3) thought phase, (4) reaction phase, (5) symptoms phase, (6) teaching phase, and (7) reentry phase.

incident. Thus, support services in the form of precrisis education and postcrisis support are provided by CISM team members. Follow-Up Services

Acute trauma symptoms requiring additional psychological support and interventions may occur both during and after the critical incidents. During follow-up one-on-one sessions, referral information regarding possible professional support is provided.

Techniques CISM involves the use of a number of basic counseling techniques such as active listening, empathy, group therapy skills, and the ability to accurately assess psychological and emotional conditions to provide referrals to appropriate resources to aid individuals experiencing a crisis event.

One-On-One Crisis Interventions

Throughout the crisis event, specially trained peers or mental health CISM team members provide one-on-one interventions and psychological support to first responders, survivors, witnesses, and community members. The purpose of these individual meetings is to provide crisis interventions, mitigate acute stress reactions, and facilitate access to other interventions provided by the CISM team. These meetings can be initiated by CISM team members, at the suggestion of other involved individuals, or by the first responders, survivors, witnesses, or community as needed. Family Support Services and Organizational Support and Consultation

Support services are offered by the CISM team to assist family members and organizations with their own reactions to and long-term impacts of the traumatic event. People in relationship with those directly involved in the critical incident have their own emotional and psychological responses to the event. Additionally, following the crisis, those families and organizations can be affected by the long-term consequences experienced by the first responders, survivors, witnesses, or community members directly involved in the

Therapeutic Process The CISM program involves comprehensive planning for all phases of a crisis or disaster. Planning includes CISM team members at all levels of the organization from the administration to the direct service workers. However, the support provided directly to those involved in the incident is facilitated by specially trained peer-level team members. These one-on-one, small- and large-group defusings and debriefings, and the demobilization processes may be guided, cofacilitated, and/or supported by trained clinicians. All interventions are based on the cognitive to affective loop, moving from discussion of thoughts, to reactions and emotions, to education and closure. Tara M. Hill See also Cognitive-Behavioral Therapies: Overview; Group Counseling and Psychotherapy Theories: Overview; Psychoeducational Groups; Self-Help Groups; Training Groups

Further Readings International Critical Incident Stress Foundation. (2010). Home page. Retrieved from www.icisf.org

Cross-Cultural Counseling Theory Mitchell, J. T., & Everly, G. S. (2000). Critical incident stress management and critical incident debriefings: Evolutions, effects and outcomes. New York, NY. Cambridge University Press. Mitchell, J. T., & Everly, G. S. (2001). The basic critical incident stress management course: Basic group crisis intervention (3rd ed.). Ellicott City, MD: ICISF. Mitchell, J. T., & Everly, G. S. (2001). Critical incident stress debriefing: An operations manual for CISD, defusing and other group crisis intervention services (3rd ed.). Ellicott City, MD: Chevron. Müller-Leonhardt, A., Mitchell, S. G., Vogt, J., & Schürmann, T. (2014). Critical incident stress management (CISM) in complex systems: Cultural adaptation and safety impacts in healthcare. Accident Analysis and Prevention, 68, 172–180. doi:10.1016/ j.aap.2013.12.018

CROSS-CULTURAL COUNSELING THEORY Cross-cultural counseling theory assumes that all counseling interactions involve cultural and class factors and that a person’s worldview is affected by his or her belief systems, values, lifestyles, customs, traditions, and all other important identifiers that the person finds salient. Although all helping relationships are cross-cultural, some are more affected by differences in worldview, such as when a white counselor is working with a person of color. The focus on cross-cultural counseling dates back to the early part of the 20th century but began to become more prevalent in the late 1900s and into the current century. Sometimes called multicultural counseling or transcultural counseling, cross-cultural counseling has become an important focus of all counseling relationships today. While definitions of cross-cultural counseling vary, the major underpinning of cross-cultural theory generally includes the following: The counselor should have an awareness of personal biases that may affect the counseling relationship, the counselor should seek knowledge about clients and persons who are assumed to be culturally different, and the counselor should be ever vigilant about proactively addressing skill deficits when working with clients who are assumed to be culturally different.

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Historical Context Cross-cultural counseling can be traced back to 1920, when Emory S. Bogardus, one of the first persons to establish a sociology department at an American university (the University of Southern California), developed a scale to measure feelings toward ethnic groups. After World War II, individuals of various minorities in the United States began to feel acute frustration over the treatment meted out to them despite their service to the country. Minority service members who had been recognized for their fortitude and commitment found that they were once again subjected to unequal treatment, and women, who were called on to fill stereotypically male roles during the war, found themselves back in the traditional female, often submissive, roles they had held earlier. During the 1950s, the civil rights movement began to gain momentum, opening opportunities for equal education and sparking interest in multicultural research. At this time, scholars became increasingly interested in how culture—the system of behaviors and values transmitted through social contact of a group of connected individuals—influenced counseling, and a consensus was developed on the importance of counselors refraining from forcing their values on their clients. Social change relative to lessening inequities became more prevalent, and groups such as African Americans, Mexican Americans, women, and Native Americans were making strides toward equality. In 1972, the Association for Non-White Concerns (ANWC) (now the Association of Multicultural Counseling and Development [AMCD]) was formed to address the needs and concerns of nonwhite clients. In 1978, the professor of counseling psychology Derald Sue proposed several characteristics that signified a competent counselor, including the ability of the counselor to recognize his or her own beliefs and how they might differ from those of the client, an awareness that counseling theories are differentially affected as a function of the client’s culture, an understanding that sociopolitical forces have influenced culturally unique groups, the ability to understand and accept the client’s worldview, and the ability to incorporate skills and interventions based on the cultural factors influencing the client. Meanwhile, through repeated efforts, ANWC

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became established as a division of the American Personnel and Guidance Association (APGA; now the American Counseling Association [ACA]). The mission of ANWC at the time was to bring awareness to diversity-related concerns in society and counseling. Moving forward, the counseling profession celebrates diversity in both practice and research and is focused on creating an atmosphere of fairness, equity, and equality for all throughout all systems that may affect an individual’s life. During the late 1970s and into the 1980s, as AMCD became more established, it began to develop cross-cultural counseling competencies and advocated for a focus on social and cultural issues in accreditation standards. At around the same time, the American Psychological Association’s Division of Counseling Psychology helped develop such standards and competencies by publishing a position paper, Cross-Cultural Counseling Competencies, and developing Guidelines for Providers of Psychological Services to Ethnic and Culturally Diverse Populations. Then, in 1992, 31 cross-cultural competencies were simultaneously published in the Journal of Counseling and Development and the Journal of the Association for Multicultural Counseling and Development. These competencies were intended to be standards for curriculum training of mental health professionals and focused on knowledge, attitudes and beliefs, and skills in three main areas: (1) counselor awareness of his or her own cultural values and biases, (2) counselor awareness of the client’s worldview, and (3) culturally appropriate intervention strategies. Although the need and value had been expressed in the field of psychology as early as 1982, it was not until 2001 that Derald Sue developed the Multiple Dimensions of Cultural Competence, which addressed many of the same issues as the multicultural counseling competencies. Reasons for the delay in the presentation and implementation of cultural competency guidelines in the field of psychology included the lack of a clear definition of cultural competence, the lack of a group or organization to focus and develop its complex dimensions, a belief that psychological theories are universal and thus transferrable across cultures, and a pervasive monoculturalistic viewpoint. As the view of culture and the complexity of the needs of those being served were realized, psychologists

moved toward social advocacy as part of multicultural competence as a way to influence social change. While reputed to focus on working with individuals within the context of their societal and immediate environmental systems— commonly referred to as the person-in-environment perspective—social workers were only formally charged with an ethical mandate to be culturally competent in 1996, when the policy statement “Cultural Competence in the Social Work Profession” was adopted by the National Association of Social Workers (NASW) Delegate Assembly. This statement was later published in Social Work Speaks: NASW Policy Statements and the NASW Code of Ethics. Social work emphasizes a heightened awareness of how clients relate to the world as a product of their culture and how they interact and function as part of the larger society. The code of ethics also requires, as part of the mission of the social work profession, that social workers work to end injustice in the form of discrimination, oppression, and so on, through social justice advocacy on the part of the client and the society. Today, multiculturalism is considered the “fourth force” in counseling (the other three being psychodynamic, behavioral, and humanistic movements), and standards in the fields of counseling, social work, and psychology all address the importance of cultural competence. And, in recent years, professional associations have increasingly stressed the importance of advocacy—a subset of multicultural counseling. Purported by some to be the “fifth force” in counseling, advocacy seems to be an up-and-coming wave of the future in working with clients.

Theoretical Underpinnings Cross-cultural counseling stresses the importance of establishing rapport, being attentive to clients’ presenting and underlining concerns, and understanding how the environment affects people’s behaviors, actions, and feelings. Given these basics, it is also clear that some clients are affected by the social and cultural context more than others. Thus, counselors will generally pay greater attention to those groups that have been historically oppressed, such as people of color; individuals with disabilities; gays, lesbians, bisexuals, and transgender individuals; older persons; and women.

Cross-Cultural Counseling Theory

To help understand the concerns of others, a number of models have been developed. For instance, Judy Daniels and Michael D’Andrea developed the RESPECTFUL model, which stresses the importance of knowing the client’s religious and spiritual identity, economic class, sexual identity, psychological development, ethnic and racial identity, chronological or developmental concerns, traumas that have been faced, family background, unique physical characteristics, and location and language. The existential model as well as the tripartite model developed by Derald Sue and his son David Sue focus on understanding the client’s uniqueness and group affiliation, as well as the universal responses that all people have. In addition to the above models, a number of developmental models have been formed to help counselors understand how individuals establish a racial identity. These models tend to move from little awareness of one’s race or ethnic identity to an increasing sense of identification with one’s ethnic and cultural background and, if the higher stages are reached, to an ability to understand, respect, and value a variety of cultures and ethnic backgrounds. As noted earlier, one of the most important models that is now driving efforts toward understanding diversity within the counseling relationship is the multicultural counseling competencies. These competencies stress the importance of having appropriate attitudes and beliefs, knowledge, and skills in three areas: (1)  the counselor’s awareness of the client’s worldview, (2) the counselor’s awareness of his or her own cultural values and biases, and (3) the counselor’s ability at using culturally appropriate intervention strategies. This model has been operationalized to assist counselors in understanding how best to work with clients. Other paradigms that drive cross-cultural counseling include the fact that it takes on a postmodern perspective in the sense that it assumes that reality is developed as a function of social interaction and the language used by individuals in dialogue with one another. This perspective assumes that there is no “right or wrong” when it comes to cross-cultural differences but a sense that each person, and each culture, has a different take on reality. With this as its base, it assumes the following:

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1. The importance of embracing cultural pluralism 2. The importance of teaching the value of diversity 3. Understanding how issues of equity, cultural democracy, and social justice are affected by society 4. The importance of acquiring the attitudes, knowledges, and skills necessary to communicate and be effective with people from varying backgrounds 5. Understanding that cross-cultural counseling goes beyond race to include things such as ethnicity, class, gender identification, sexual orientation, nation of origin, skills, disability status, geographic origin, country of origin, citizenship status, and so on 6. The importance of accepting and celebrating diversity 7. The importance of respecting and valuing other approaches to helping, including Eastern and Western approaches

Being aware of one’s own cultural values and biases requires counselors to examine their biases and the potential impact that these biases have on their psychological processes. It also requires sensitivity to others and the ability to be comfortable with the differences between themselves and others. Such counselors recognize the limits of their competency and will (a) seek consultation, (b) seek further training or education, (c) refer the client to more qualified individuals or resources, or (d) engage in a combination of these. When a counselor has honed his or her ability to relate to a client based on that client’s worldview, the counselor is willing to set aside his or her own beliefs and attitudes about particular racial and cultural groups and accept the perspectives of culturally different clients in a nonjudgmental manner. To gain comfort and familiarity with working with diverse populations, a multiculturally competent counselor will become involved in a multicultural life outside of client sessions. This involvement may extend to community events, neighborhood groups, social and political functions, celebrations, developing friendships, and so on.

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Major Concepts

Techniques

This entry has already highlighted a number of major concepts important to the multicultural counseling process, including the RESPECTFUL model, the tripartite model, the existential model, the multicultural counseling competencies, and racial identity models. Other words and concepts that are important to an understanding of multicultural counseling follow.

Basic to any cross-cultural counseling relationship is acceptance, empathy, and unconditional regard— qualities suggested in the person-centered counseling relationship and techniques used by most counselors today. Beyond these qualities, crosscultural counseling assumes that the counselor may embrace any of a variety of counseling theories and techniques. However, he or she does it with the awareness that some models and techniques have been traditionally Western based and biased toward certain clients’ cultures. When this is the case, the counselor must make adjustments to the approach to eliminate bias. In addition, it is critical that counselors eliminate, as best they can, any of their own biases and prejudices so that they can apply appropriate techniques to working with clients. If counselor bias and prejudice result in misdiagnosis, then techniques and treatment plans will be misapplied. Derald Sue suggests that the techniques used can be affected by four conditions within the counseling process:

Acculturation versus assimilation is the difference between adopting and converting. Acculturation is the process of adopting the culture and social norms of another group. Assimilation is the process that occurs when an individual begins to, in an effort to become part of or adopt another culture, lose or subjugate the characteristics of his or her own culture. It is possible for an individual to adopt features of the new culture without losing or negating the individual’s original culture. Developing cultural pluralistic philosophy is an ethical course of action. Because culture permeates all aspects of life, including belief systems, values, problem-solving methods, and decision-making processes, an effective cross-cultural counselor must develop the ability to accept the multiple perspectives and cultures that create each client’s unique worldview. Ethnic identity is rooted in social construction and relates to a group’s social and cultural heritage. Ethnicity differs from race. For example, a person may identify as black racially and Hispanic ethnically (e.g., some people from Panama, Cuba, and Dominican Republic may identify in this manner); likewise, a person can identify as white racially and Hispanic ethnically (e.g., some people from Spain may identify in this manner). Etic versus emic approaches identify the way counselors and other social scientists conceptualize their view of counseling work. An etic approach is universal in that it looks for principles that are common in helping relationships that transcend cultures. Emic focuses on the study of individual and specific cultures and how best to work with individuals within those cultures.

1. Appropriate process, appropriate goals: The counseling process is consistent with the client’s values and life experiences. 2. Appropriate process, inappropriate goals: The strategy is compatible with the client’s values, but the goals may be impractical or questionable. 3. Inappropriate process, appropriate goals: The strategy is at odds with the client’s value system, despite the ability to address the client’s goals. 4. Inappropriate process, inappropriate goals: The strategy violates the client’s value system and the results are not those desired by the client.

It is important to note that Conditions 3 and 4 often result in an antagonistic relationship that prompts early termination.

Therapeutic Process Cross-cultural counseling is an approach to counseling that is flexible, sensitive, and attentive to clients’ unique needs. Counselors utilizing this

Cyclical Psychodynamics

approach use this perspective as a lens when working with all clients; however, they still might ascribe to a specific theoretical counseling approach. Key to the therapeutic process is the counselor–client relationship. Three elements must be present within this relationship: The first quality that the counselor must possess is credibility, meaning that the client must view the counselor as believable and entitled to confidence. The second quality, expertness, means that the client must view the counselor as well-informed and the counselor must be willing to gain expertise utilizing independent research, cultural informants, and the client. The third quality is trustworthiness, which is key and understood as how the client perceives the counselor’s decision making and assertions. In addition, the counselor must validate client concerns, maintain a nonjudgmental demeanor, be comfortable with issues related to culture, and manage bias and prejudices. There is no one way of doing cross-cultural counseling. However, if the counselor has knowledge of self and knowledge of others and can apply theory and techniques appropriately, he or she is more likely to have a successful cross-counseling therapeutic relationship. Kaprea F. Johnson and Miranda Johnson-Parries See also Constructivist Therapy; Existential Therapy; Existential-Humanistic Therapies: Overview; Feminist Therapy; Gender Aware Therapy; Person-Centered Counseling; Sexual Identity Therapy; Sexual Minority Affirmative Therapy; Sexual Orientation Change Efforts

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Fukuyama, M. A. (1990). Taking a universal approach to multicultural counseling. Counselor Education and Supervision, 30(1), 6–17. doi:10.1002/j.1556-6978.1990.tb01174.x Lee, C. C. (1994). Pioneers of multicultural counseling: A conversation with Clemmont E. Vontress. Journal of Multicultural Counseling and Development, 22(2), 66–78. doi:10.1002/j.2161-1912.1994.tb00245.x Patterson, C. H. (1996). Multicultural counseling: From diversity to universality. Journal of Counseling & Development, 74(3), 227–231. doi:10.1002/j.1556-6676.1996.tb01856.x Sue, D. W. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10, 42–52. doi:10.1177/0011000082102008 Sue, D. W. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), 790–821. doi:10.1177/0011000001296002 Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70, 477–486. doi:10.1002/j.1556-6676.1992.tb01642.x Vera, E. M., & Speight, S. L. (2003). Multicultural competence, social justice, and counseling psychology: Expanding our roles. The Counseling Psychologist, 31(3), 253–272. doi:10.1177/0011000002250634 Vontress, C. E. (2009). A conceptual approach to counseling across cultures. In C. C. Lee, D. A. Burnhill, A. L. Butler, C. P. Hipolito-Delgado, M. Humphrey, O. Munoz, & H. Shin (Eds.), Elements of culture in counseling (pp. 57–76). Columbus, OH: Pearson.

CYCLICAL PSYCHODYNAMICS Further Readings Arredondo-Dowd, P. M., & Gonsalves, J. (1980). Preparing culturally effective counselors. Personnel and Guidance Journal, 58(10), 657–661. doi:10.1002/j.2164-4918.1980.tb00351.x Association for Multicultural Counseling and Development. (n.d.). Cross cultural competencies. Retrieved from http://www.counseling.org/docs/ competencies/cross-cultural_competencies_and_ objectives.pdf?sfvrsn=3 Collins, S., & Arthur, N. (2010). Culture-infused counseling: A model for developing multicultural competence. Counseling Psychology Quarterly, 23(2), 217–233. doi:10.1080/09515071003798212

Cyclical psychodynamics is an approach that examines how people’s thoughts, feelings, desires, perceptions, and so forth (one’s “internal state”) lead to actions in the world that in turn create life circumstances and reactions from people that modify or maintain that internal state. Whereas traditional psychodynamic approaches looked predominantly at one’s internal state as the locus of causation, and early behavior therapists predominantly emphasized external events, this approach views both as crucial in the development of personality. Treatment, therefore, is focused on both and how they tend to feed into each other.

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Contextual factors, such as the patterns of family interactions, are also viewed as playing a critical role in shaping internal states and overt behavior. When one examines behavior and experience from this broad lens, it becomes apparent that inner and outer influences reciprocally shape each other, and it is the repeated cycles of inner–outer–inner–outer occurrences in personality development that give cyclical psychodynamics its name.

Historical Context Originated by Paul L. Wachtel, the original focus of cyclical psychodynamics was to enable researchers and clinicians to understand how the seemingly incompatible assumptions of psychodynamic and behavioral therapists could be reconciled. Originally trained as a psychoanalyst, Wachtel noticed the impressive evidence for the effectiveness of behavior therapy and wondered if the strengths of both approaches could be combined to create an even more effective and comprehensive form of therapy. But a great obstacle existed—the strong conviction by therapists of both orientations that the two approaches were fundamentally incompatible. As Wachtel began to immerse himself in the theory and practice of behavior therapy and in the research on which it was founded, he became increasingly convinced that it offered clinical methods that were helpful to people and that those methods usefully complemented those of the psychoanalytic tradition. He made contact with some of the leading behavior therapists of that period and studied their work intensively. As he began to introduce their methods into his practice, he found that patients responded well; often the behavioral methods either amplified the changes brought about by psychoanalytic methods or helped break deadlocks and points of clinical stasis. At the same time, he found that the use of these methods did not undermine or fundamentally alter his ability to employ the central psychoanalytic contributions that had guided his work, such as exploring the patient’s conflicted feelings and inclinations; illuminating and bringing to light wishes, thoughts, and feelings that had been rendered unconscious or only dimly in awareness because of anxiety, guilt, and shame; and attending to the patient’s feelings and perceptions in the

session itself, especially toward the therapist— what psychoanalysts call transference. Over time, the theory and practice further evolved in response to new developments in the field and to attention to still other theoretical orientations. One of the earliest additional perspectives incorporated into the cyclical psychodynamic perspective was that of family therapy. Since family therapists also conceptualize psychological causality largely in terms of repetitive circular patterns, it was not long before it became clear that there were important convergences between family systems thinking and cyclical psychodynamics— not only in their shared emphasis on circularity but also in their attention to understanding people in context and their readiness to intervene in problematic patterns via active interventions and not just interpretations. In 1986, together with his wife, Ellen Wachtel, who had trained at the Ackerman Institute for the Family after getting her Ph.D. and was a teacher and practitioner of couples therapy and systemic work with children and their families, Wachtel wrote Family Dynamics in Individual Psychotherapy, a book that spelled out integrative convergences between individual and systemic perspectives in theory and therapy. Around the same time, as behavior therapy evolved into cognitive-behavioral therapy, cyclical psychodynamics selectively incorporated elements of this new development. The constructivist version of cognitive therapy proved much more compatible than the rationalist. The latter’s emphasis on demonstrating that the person’s difficulties were caused by irrational assumptions and its linear emphasis on thoughts as the shaper of feelings, without an equally strong emphasis on the reverse causal sequence, did not fit well with the cyclical psychodynamic emphasis on the reciprocal causal links between thoughts, feelings, and actions or its view that one must accept and validate the way the person experiences the world before one can effectively promote any deep kind of change. In contrast, both constructivist cognitive therapy and “third-wave” cognitive-behavioral approaches such as dialectical behavior therapy and acceptance and commitment therapy were attentive to affect and to the dialectical relationship between validation and the promotion of change, and so were more readily integrated into the evolving viewpoint of cyclical psychodynamics.

Cyclical Psychodynamics

Theoretical Underpinnings Cyclical psychodynamics is a theoretical perspective developed to enable researchers and clinicians to understand how the seeming incompatibility between the assumptions of psychodynamic theory and behavioral theory could be understood as the consequence of each approach attending primarily to half of what is a larger circular pattern of causation: Depending on what part of the circle one is paying attention to, it can look like one’s internal state is the fundamental bedrock of personality or that external events and circumstances are fundamental, since they can be shown to lead to thoughts, feelings, and behavior in a predictable pattern. However, when examined with a broader lens, it becomes apparent that neither is primary. Rather, the person’s internal state (thoughts, feelings, desires, perceptions, etc.) leads to actions in the world that in turn create life circumstances and reactions from people that modify or maintain that internal state. The starting point of the description (whether in the internal state or in the actions and reactions in the world) is arbitrary, as development is cyclical and causal sequences are reciprocal.

Major Concepts Cyclical psychodynamics draws on many theoretical perspectives, but of particular importance are the relational version of psychodynamic thought, the role that attachment plays in development, understanding of how vicious cycles affect the development and dynamics of personality, and a view of development as a continuous process. Psychodynamic and Relational Understanding of the Individual

The psychodynamic foundations of cyclical psychodynamic theory are rooted in the relational branch of psychoanalytic thought, an integration of the interpersonal, object relations, and self psychology perspectives. The relational point of view intersects with the broader cyclical psychodynamic perspective in highlighting how personality evolves in the context of a complex relational matrix and in its emphasis on constructivism and on diverse and multiple self states rather than an archaeological model in which certain experiences are merely defensive facades that hide truer and deeper layers. The person is seen as characterized by a

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wide range of ways of feeling, behaving, and seeing oneself and others, with different aspects of this complex and differentiated selfhood being brought to the fore in different contexts. Attachment and Development

The cyclical psychodynamic perspective pays considerable attention to phenomena of attachment and the ways in which people learn early in life to be more comfortable with aspects of their experience of self that receive affirmation and attunement from their primary attachment figures. These shaping experiences need not be a matter of overt prohibition or disapproval by the attachment figure. When certain ways of behaving or the expression of certain feelings are not met with the kind of attuned responsiveness that other aspects of the person’s repertoire receive, they tend to drop out or be pushed aside. As they are marginalized, and thus do not participate as fully in the further evolution of the person’s way of being in the world, the person is less likely to have the kinds of experiences that enable him or her to learn how to express those feelings comfortably or effectively. Thus, whether it be anger, affection, sexuality, the expression of pleasure or satisfaction with what one has accomplished, or any of the myriad other ways of being fully human, individuals learn to refine their expression and make them work in their lives only when they have had countless experiences that, through trial and error, teach them to express them in ways that suit the relational context in which they find themselves. When people have been deprived of such opportunities because they have cast aside certain feelings, rarely expressing them or even being fully aware of them, it is not enough for the therapist to point them out and make patients conscious; they must be helped to fully appropriate these feelings into their repertoire of behaviors, to incorporate them into their way of experiencing themselves and being with others. This may take a good deal of relearning and practice, often with implicit guidance, structuring, support, and modeling from the therapist. Vicious and Virtuous Circles and the Recruiting of “Accomplices”

Central to the point of view of cyclical psychodynamic theory is an emphasis on the ways in which personality patterns are maintained over

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time by vicious and virtuous circles, in which the feedback resulting from established patterns of behavior and experience frequently results in the strengthening of those very patterns, whether they be adaptive (virtuous circles) or maladaptive and ultimately self-defeating (vicious circles). In this process, a major dynamic is the (usually unconscious and often unintended) recruitment of other people as accomplices in the maintenance of the pattern. Attention to accomplices, to the ways in which other people inadvertently participate in maintaining the ongoing pattern, is a central feature of the cyclical psychodynamic point of view. Personality is seen not as a simple matter of “internalizing” past experiences and then carrying them around within us. Rather, the self is understood as a contextual self; cyclical psychodynamics attends to the same kinds of complex, conflicted, and nuanced understandings of motivation, behavior, and subjective experience as other psychodynamic theories, but it looks at these phenomena in context, attending to the ways in which our behavior and experience may vary from one context to another and to the ways in which, however irrational they may appear, they can be seen to make sense if they are understood in relation to the context in which they are manifested. Development as a Continuous Process

Cyclical psychodynamics views development as a continuous process, not a matter of fixations and arrests, even when there is apparent continuity between patterns in adulthood and childhood. The patient’s problems may have originated in the past but can only be effectively understood and worked with if there is an understanding of how they continue to be perpetuated in the repeated experiences of the present.

Techniques Psychotherapy practiced from the theoretical perspective of cyclical psychodynamics can assume many forms, as befits an integrative theory that draws from a range of orientations. Thus, it is difficult to highlight techniques that all therapists might use. However, the most common application of this approach is the integrative relational therapy developed by Wachtel, rooted in a relational psychoanalytic mode of practice

but incorporating ideas and interventions from a broad range of perspectives. It is briefly described under “Therapeutic Process.”

Therapeutic Process When using the integrative relational approach deriving from cyclical psychodynamics, the therapist engages in an exchange with the patient that is designed to foster the therapeutic alliance and to illuminate the patient’s way of interacting with others. Much attention is paid to the actual relational experiences in the room, but the patient’s experiences in his daily life are also closely examined, because the key accomplices in maintaining the patient’s problematic patterns are those in his daily life and the changes ultimately sought reside there as well. The process of illumination and promotion of change incorporates both what psychoanalytic therapists call interpretation and what behavioral therapists call exposure. The patient is helped not just to understand his or her thoughts and feelings more deeply but also to directly experience what he or she has previously warded off, thereby overcoming anxiety about his or her subjective inclinations in much the same fashion that anxiety regarding external circumstances is overcome in more behavioral therapies. Approaching interpretation with an eye toward exposure also serves to ensure that the process of therapy is not limited to the cognitive realm but is deeply emotional and tied to changes in the overt patterns of interaction in the patient’s life. The therapy aims to build on and illuminate the patient’s strengths, not just focus on pathology, and it does so in part through careful attention to the variability in the patient’s behavior and experience, the ways he or she can be different in different relational contexts. In this way, changes in overt behavior lead to different feedback patterns from others, generating virtuous circles that replace the vicious circles of feedback that have been at the heart of the problem; and changes in thoughts, behavior, and affect reciprocally amplify each other, enabling previously warded off potentials for acting and experiencing to be reappropriated as part of a recursive process of inner and outer change. Paul L. Wachtel

Cyclical Psychodynamics See also Attachment Theory and Attachment Therapies; Behavior Therapy; Cognitive-Behavioral Therapy; Constructivist Therapies: Overview; Exposure Therapy; Freudian Psychoanalysis; Interpersonal Theory; Object Relations Theory; Relational Psychoanalysis; Self Psychology

Further Readings Gold, J., & Stricker, G. (Eds.). (2006). Case studies in psychotherapy integration. Washington, DC: American Psychological Association. Mitchell, S. A. (1988). Relational concepts in psychoanalysis. Cambridge, MA: Harvard University Press.

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Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration. New York, NY: Oxford University Press. Wachtel, E. F., & Wachtel, P. L. (1986). Family dynamics in individual psychotherapy. New York, NY: Guilford Press. Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. New York, NY: Guilford Press. Wachtel, P. L. (2011). Inside the session: What really happens in psychotherapy? Washington, DC: American Psychological Association. Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when (2nd ed.). New York, NY: Guilford Press.

D had extraordinary success fostering communication and promoting interaction with these patients through her nonverbal and developmental approach. In terms of modern neuroscience, it is likely that Chace was engaging the patients’ mirror neurons in combination with interpersonal resonance and other factors to cocreate visual and rhythmic synchrony and kinesthetic empathy. Chace’s work developed into one of the primary approaches in DMT, and many pioneering, firstgeneration dance movement therapists studied directly with her. Whitehouse developed a practice called Authentic Movement, which uses a form of moving from the inside out to make use of active imagination and bring the unconscious into awareness. The process is often done with the eyes closed to facilitate inner awareness, authenticity, and connection with the body and is grounded in the relationship between a mover and a witness. These states and processes are believed to be transformative in and of themselves. This approach served to drive DMT in the direction of transformative processes. Authentic Movement is widely used by dance movement therapists, who incorporate it into their work. The second generation of dance movement therapists formally integrated psychodynamic theories into the practice of DMT. Concepts such as unconscious processes, transference, countertransference, and defense mechanisms were introduced by dance movement therapists with experience or training in these theories. As DMT developed, it was expanded to integrate human development

DANCE MOVEMENT THERAPY Dance movement therapy (DMT) is a traditional form of counseling or psychotherapy that uses movement as the primary medium for interaction, assessment, and intervention to further the emotional, cognitive, physical, and social integration of individuals. DMT represents an important development in counseling and psychotherapy because it was among the first theoretical approaches to integrate the philosophy of the body–mind relationship into treatment of psychological disorders.

Historical Context DMT is rooted in the rich history of dance as a cultural activity used by most societies for thousands of years for celebration, healing, storytelling, mourning, and even preparation for war. In the 1960s, DMT was formalized as a profession, and the American Dance Therapy Association (ADTA) was formed. The ADTA continues to serve as a membership organization to further the growth of the profession. Early pioneers in DMT drew from their experiences in modern dance as a creative vehicle for expression and authenticity. Two pioneers who helped shape and define the profession were Marian Chace and Mary Whitehouse. Chace began working at St. Elizabeth’s Hospital in Washington, DC, in 1942, where she worked with patients who were receiving minimal treatment at a time when antipsychotic and other psychotropic medications were not available. Chace 269

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theories and other psychological theories, such as object relations, constructivist, Gestalt, family systems, cognitive-behavioral, humanistic, and feminist theories. Dance movement therapists today are educated and trained in the application of a variety of developmental and psychological theories and approaches. The ADTA was founded in 1966 as an organization to support the emerging profession of DMT. It is the only U.S. organization dedicated to the profession of DMT. The ADTA advocates nationally and internationally for the development and expansion of DMT training and services and stimulates communication among dance movement therapists through the social media, publication of the American Journal of Dance Therapy and the ADTA newsletter, and hosting an annual conference for continuing education in DMT. Historically, DMT has been recognized by the U.S. government as an important treatment modality. It is classified by the Federal Civil Service as a creative arts therapy. DMT was included in resolutions to implement the 1975 Education for All Handicapped Children Act (PL 194-42), amended several times and later renamed the Individuals with Disabilities Education Act. In 1992, it was included and defined in the 1992 Older Americans Act reauthorization amendments (PL 102-375). In 1993, the Office of Alternative Medicine of the National Institutes of Health awarded one of its first exploratory research grants to investigate DMT for those with medical illnesses. Also in 1993, a Title IV grant from the Administration on Aging, Department of Health and Human Services, was provided to support research on DMT with older individuals who have diminished neurological capacity due to aging or trauma. Findings suggested that DMT improved the functional abilities of the participants on a number of variables: balance, rhythmic discrimination, mood, social interaction, and increased energy level. In 1996, DMT was recognized by the Health Care Financing Administration of the Department of Health and Human Services as a covered element of a partial hospitalization program in Medicare facilities. At the state level, many dance movement therapists have become licensed as counselors, psychologists, and social workers. Several states, including New York and Pennsylvania, have created licenses for DMT as a creative arts therapy.

Today, DMT is an accepted form of therapy, as evidenced by the fact that there is a credentialing board, a recommended curriculum, a professional association (ADTA), and a code of ethics.

Theoretical Underpinnings DMT is based on the empirically supported premise that the body, mind, and spirit are interconnected and integration of mind, body, and spirit supports healthy functioning. Body movement is the core component of dance; it provides the means of assessment and the mode of intervention for DMT. Dance movement therapists work with people of all ages, races, and ethnicities as individuals or in couples, families, and groups. They also work in a wide variety of settings, including mental health, rehabilitation, medical, educational, and forensic settings, and in nursing homes, private practice, day care centers, and health promotion or wellness programs. DMT treatment, education, and training opportunities are available in the United States and 36 countries, including Argentina, Great Britain, China, Germany, Greece, India, Israel, Italy, Japan, Korea, Mexico, Norway, Philippines, Spain, and Thailand. Clients receiving DMT have a wide range of mental and physical abilities. DMT is effective for individuals with developmental, medical, social, physical, and psychological impairments. DMT can be an effective treatment for those who struggle with barriers to expression, relationships, and self-acceptance, as well as a vehicle for personal growth, behavioral change, and insight. It can be used as a primary or adjunctive treatment and is often used creatively and constructively when provided as part of a team approach. DMT should be distinguished from dance education and dance for recreation or enjoyment. While DMT may incorporate both of these elements, its primary focus is psychotherapeutic. The major theoretical orientations in DMT are the Chace approach, Integrated Development, and Authentic Movement. Chace Approach

Chace incorporated the use of mirroring, attunement, and rhythmic body action combined with both verbal and nonverbal communication to facilitate patients’ increased expression, interaction,

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formation of a more realistic body image, relaxation, and enjoyment. Through using movement, Chace reduced the isolation of individual patients and provided a context to engage in relationships and establish trust. Her leadership style involved reflecting individuals’ movements, or mirroring, while communicating acceptance and respect, and joining them in movement. She then worked with patients to explore, expand, or clarify communications. This approach has been called empathic reflection, and it is a means of both assessment and intervention within the process of DMT. The Chace approach can be used with patients with a wide variety of concerns and disorders. It can be used with individuals or groups. If patients are primarily nonverbal, the interaction can be nonverbal and supported by music, props, and the therapist’s verbal comments. If patients are able to integrate verbal and nonverbal communication, Chacian groups can easily incorporate symbols, metaphor, and rituals, such as closing rituals. Integrated Development

Developmental DMT is another widely used approach that draws from psychodynamic, Jungian, ego psychology, and relational models. A solid understanding of movement and body development in the individual in relationships, groups, and family systems across the life span is a foundation for the approach. This approach is primarily influenced by the work of Erik Erikson, Judith Kestenberg, Anna Freud, Margaret Mahler, Jean Baker Miller, and Donald Winnicott. Dance movement therapists observe developmental phases in body movement and use movement to assist patients with working through conflicts, delays, and blocks. This approach is most frequently used with individuals or families. This work often involves creating a holding environment, a safe, supportive place where parents and children can interact and share experiences. Props such as balls, pillows, parachutes, scarves, blocks, and tunnels may be used to provide support and focus. Interventions will vary based on the developmental level of the patient and the treatment goals. Developmental sequencing may be implemented, and developmental transitions should be supported. It may be important to focus on boundaries, control, and containment along with expression, communication, and relational skills.

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Working through unresolved developmental issues is the primary goal of this approach. Authentic Movement

Many dance movement therapists incorporate Whitehouse’s Authentic Movement into their work. The process involves a mover, a witness, and a safe container for the work. The mover works with eyes closed in the presence of a witness, who maintains the integrity and safety of the space. The mover attunes inwardly to impulses or desires to move and responds. The mover’s body becomes a container wherein the unconscious can become conscious and the conscious awareness can be used to see oneself more clearly. The witness maintains an awareness of his or her personal responses to the mover, noting that they may be interpretations, projections, or evaluations. These responses are shared as personal responses experienced while internalizing the mover’s movement. The Authentic Movement approach often incorporates metaphor and dream states. Janet Adler taught, refined, and developed Authentic Movement for many years, and her work informed the continued development of Authentic Movement as a transformational practice.

Major Concepts Two major ways in which DMT is utilized are (1) by conducting an assessment and (2) as an intervention tool. Assessment

An essential part of the DMT process is movement observation, analysis, and interpretation. Nonverbal communication is difficult to describe clearly and communicate to other professionals. Several assessment systems and tools have been developed to describe movement. These include Laban movement analysis, Kestenberg Movement Profile, Espenak’s movement diagnostic tests, and differential diagnosis dance/movement assessments, which include Davis’s Movement Psychodiagnostic Inventory and Kalish-Weiss’s Body Movement Scale for Autistic and Other Atypical Children. Dance movement therapists study one or more of these systems and tools to

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become competent in observing and analyzing thousands of nonverbal parameters that may emerge as part of a diagnostic assessment and treatment. These tools are also used as instruments in research on DMT. Intervention

DMT can provide an alternative form of expression and interaction for those who feel limited by traditional verbal therapy because they do not have adequate language abilities for the process, find words inadequate for the process, find themselves hiding behind words, or prefer a more embodied, action-oriented approach. For example, dance movement therapists have had success working with infants who have not developed formal language, toddlers participating in painful treatments for cancer, and children on the autism spectrum, which is characterized by delayed and/or impaired communication. DMT can be used effectively to address preverbal memories and trauma and/or abuse when painful or frightening memories manifest in the body. Similarly, it can be useful when individuals are developing the ability to stand up for themselves. Becoming empowered involves more than learning the words to say; it must be accompanied by the appropriate posture and movement qualities that are fully integrated. In addition, DMT has been effective in treating eating disorders and body image issues. Moreover, DMT can be an ideal approach for adults who have excellent verbal skills but have difficulty translating awareness and insight into action. These are just a few of the many examples of the effectiveness of DMT. A substantial amount of research has been conducted on the effectiveness of DMT with various populations. Meta-analyses have indicated that DMT is as or more effective than verbal psychotherapies.

Techniques DMT is more process oriented than technique driven. DMT can be directive or nondirective. Directive dance movement therapists often use structured experiential exercises or activities that are movement based. Nondirective dance movement therapists typically choreograph or create interventions as part of the group process. For

example, a directive therapist might provide a parachute game structure to focus on planning and impulse control with adolescents, or a movement choir activity to focus on synchrony and cohesion. A nondirective therapist might allow individuals in a group to demonstrate movements that reflect how they are feeling and use their contributions to create a metaphor for the group experience based on the thematic content that emerges from the group. Thus, a group may be involved in a moving metaphor, regression in the service of the ego, or moving the content of dreams. The therapist chooses interventions that are appropriate, based on movement that is observed at the beginning of the session and movement that emerges as part of the process. Often, participants become involved in the cocreative process and contribute their own ideas and suggestions. Whether directive or nondirective, in DMT body movement as the core component of dance is focused on, and it simultaneously provides the means of assessment and the mode of intervention for DMT. DMT is focused on expressive, communicative, and adaptive behaviors as they emerge within the therapeutic relationship. Movement introduced as an intervention may be dance based or rooted in creative/expressive or improvisational movement. Rhythm and music may be used to support the movement; rhythm has a primary function of establishing synchrony and uniting groups to create community and cohesion. Music takes on the role of a prop to provide a structure or framework from which the group can draw; however, music is not necessary, and many dance movement therapists use no music in their work. Relaxation exercises and movement meditation can easily be integrated into DMT. Additional props may be used to support a quality or sequence of movement until the individual or group has mastered the quality or sequence and the prop is no longer needed. Props include soft balls, pillows, fabric, scarves, blocks, hoops, parachutes, and balloons.

Therapeutic Process DMT sessions have a clear beginning, middle, and end. A safe container for the work is established, and if needed, rules are established for the session. Although there are no documented negative

Daseinsanalysis

effects of DMT, safety is a primary concern, and measures must be taken to avoid injuries, whether physical or psychological. The beginning phase includes a warm-up so that the body is ready to do more intensive or variable work. The working phase may include directive or nondirective activities that are based on the patients’ needs and goals, as well as the therapist’s training and skills. The ending of the session should be clearly established. The phases of a session have also been described as preparation, incubation, illumination, and evaluation. Within the session, it is important to assist participants with smooth transitions; in most cases, the movement activity should flow smoothly, without abrupt starts and stops. Rhythmic and visual synchrony can be used to promote flow and transitions. The therapist uses summarization as part of closure and may use movement to help participants become centered, grounded, and focused on the present prior to leaving the session. Verbal processing can be used when appropriate, and in some cases, homework may be given. Therapists also provide feedback related to progress and goals. Like many body-based experiences, DMT is challenging to describe and is best understood by participating in or observing sessions. Dance movement therapists continue to develop the profession and are especially interested in multicultural applications and developments in neuroscience that may explain what, until now, has been remarkably successful yet difficult to explain. Leslie Armeniox See also Analytical Psychology; Creative Arts and Expressive Therapies: Overview; Ego Psychology; Integrative Body Psychotherapy; Mahler, Margaret; Object Relations Theory; Winnicott, Donald

Further Readings Chace, M., Sandel, S. L., Chaiklin, S., & Lohn, A. (1993). Foundations of dance/movement therapy: The life and work of Marian Chace. Columbia, MD: Marian Chace Memorial Fund of the American Dance Therapy Association. Lewin, J. L. N. (1998). Dance therapy notebook. Columbia, MD: Marian Chace Memorial Fund of the American Dance Therapy Association.

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Payne, H. (1992). Dance movement therapy: Theory and practice. New York, NY: Routledge. Totora, S. (2006). The dancing dialogue. Baltimore, MD: Paul H. Brooks.

DASEINSANALYSIS Daseinsanalysis is a mode of psychotherapy that is phenomenologico-hermeneutical and ontologicoanthropological. The dominant natural-scientific model of psychology tries to objectify and explain human existence in terms of postulated forces behind human phenomena, but Daseinsanalysis respects and reveres the human phenomenon as such, as that which shows itself from itself. Human existence, studied as a phenomenon, shows itself as Dasein (“being-there”): always already in the world with others, a being whose being is always capable of being open to itself and the world. The Daseinsanalyst and Daseinsanalysand engage in a shared quest to explore and to enhance the openness to the world of one of them, but the ground of this quest is the primordial fellow-human relationship between the two of them, and so the quest may be radically revealing and transforming for both.

Historical Context At the beginning of the 20th century, several thinkers dared to express their fear that the power of natural science would overshadow and even crush the fundamental dimension of psychotherapy, which is grounded in the question “What does it mean to be a human being?” On the basis of Martin Heidegger’s 1927 book Being and Time, the psychiatrist Ludwig Binswanger (1881–1966) showed that the natural-scientific way of thinking fails to account for human experience and behavior and misses the specific nature of human existing. He adapted Heidegger’s Daseinsanalytik as what he called Daseinsanalyse (“Daseinsanalysis”), a descriptive phenomenology of the worlds of his patients. Medard Boss (1903–1990), a Swiss psychiatrist and psychotherapist, collaborated with Heidegger himself, who conducted the Zollikon seminars (1959–1969) in Boss’s home. Together, they pioneered Daseinsanalysis as the fundamental

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theory and practice of Daseinsanalytic therapy. In 1971, Boss’s colleague Gion Condrau (1919–2006) cofounded and directed the Daseinsanalytic Institute for Psychotherapy and Psychosomatics. Daseinsanalysis continues to be practiced today, and many adherents to this approach now belong to the International Federation of Daseinsanalytic Psychotherapy.

Theoretical Underpinnings Guided by the phenomenological insight of Edmund Husserl that whatever “is” will show itself in itself, Daseinsanalysis as a hermeneutic phenomenology focuses on phenomena as the way a patient’s being-in-the-world comes into presence. The foundation and core of Daseinsanalytic therapy is the relationship between the Daseinsanalyst and the Daseinsanalysand. The point of departure of a Daseinsanalytic understanding is to be open to the existing of the human being. Existing here does not refer merely to the indifferent availability of entities, even sentient ones, but rather to the particular way of being of human beings as worldrelated being-there (Dasein).

Major Concepts Major concepts in Daseinsanalysis include Dasein, or “being-in-the world,” truths as disclosedness, phenomena, and freedom. This section examines each of these in turn. Dasein (Being-in-the-World)

Dasein is a common German word that Heidegger used in a special sense to describe human beings. He maintained that human beings are not enclosed subjects placed in the world like other entities. Rather, they are always already in the world as openness (being-in-the-world). Daseinsanalysis is a shared endeavor to free the client, as far as possible, from obstacles to this openness, so that he or she may live more truly, in the sense of truth as unconcealedness.

concealment of Being. Dasein approaches entities through its disclosedness (Erschlossenheit), a being open to Being, an openness that is characterized by disposedness (Befindlichkeit), understanding (Verstehen), and language (Sprache). Phenomena

Daseinsanalysis starts and finishes with respectful attention to phenomena, understood as what shows itself from itself. There is no recourse to hypothetical forces behind the phenomena. All modalities of human experience are approached in this way, so that dreams and hallucinations, for example, are treated as they arise as important phenomena that reveal directly truths of the analysand’s being-in-the-world, without needing interpretation as symbols, signs, or symptoms of something behind the phenomena. Freedom

Freedom in Daseinsanalysis refers primordially not to the freedom of the human being as a subject in relation to objects or, of course, as an object himself or herself. Rather, it is understood in Daseinsanalysis as the freedom of Dasein to respond in resoluteness (Entschlossenheit) to the call of conscience or in serenity (Gelassenheit) to the invitation or gift of the event-of-Being (Ereignis).

Techniques Daseinsanalysis—in accordance with its roots— does not resort to “tools” or “techniques.” Rather, as a clinical practice, it focuses on fundamental issues such as being attuned, authentic togetherness, coming into presence, and paths to openness and understanding. These words have to be grasped not as concepts or formulae but as embodying the thinking that arises from phenomenological “seeing.” Hence, for example, there is no “technique” of “dream interpretation” in Daseinsanalysis. Dreaming is understood as a phenomenon, like any other modality of the analysand’s experience: a direct revelation of his or her world, speaking for itself.

Truth as Disclosedness

Truth is understood in Daseinsanalysis in the Ancient Greek sense of aletheia, the interplay between unconcealment (Un-verborgenheit) and

Therapeutic Process With its basic understanding of human being, Daseinsanalysis is able to address all forms of mental

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and psychosomatic suffering, provided the analysand is ready and willing to face, with the analyst’s support, the crises of his or her existence. The hindrances to the analysand’s possibilities of human relating manifest themselves in neurotic, psychosomatic, and psychotic disturbances. The analysand has the task of letting himself or herself into the “space” of the unfolding therapeutic relationship to mature further. Daseinsanalysis aims to facilitate the free opening of the analysand’s Dasein to being in the world with others in response to the invitation of Being. At stake are the patient’s being or nonbeing, life and death, and openness to fellow humans (Mitwelt) and the nonhuman environment (Umwelt). Daseinsanalysis understands mental and psychosomatic suffering as ways of restricted and unfree relating to Mitwelt and Umwelt. In Daseinsanalysis, mental symptoms have meaning, the illumination of which leads the patient to himself or herself and to the understanding of his or her suffering. The task of the Daseinsanalyst is • to gain insight into the lived and embodied ways of bearing the possibilities of being (existentialia) given to each person as constitutive for his or her existence and • to respond in serenity (Gelassenheit) to the Dasein’s implicit quest, accompanying him or her on the journey as new possibilities for relatedness unfold

Ado Huygens See also Existential Group Psychotherapy; Existential Therapy; Existential-Humanistic Therapies: Overview; Frankl, Viktor; Logotherapy and Existential Analysis; Maslow, Abraham; May, Rollo

Further Readings Boss, M. (1979). Existential foundations of medicine and psychology. New York, NY: Jason Aronson. Condrau, G. (1998). Martin Heidegger’s impact on psychotherapy. New York, NY: Mosaic. Heidegger, M. (1927). Being and time. New York, NY: Harper & Row.

Website International Federation of Daseinsanalysis: www.i-f-da.org

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Steve de Shazer (1940–2005) and his wife and colleague, Insoo Kim Berg (1934–2007), developed the therapeutic approach known as SolutionFocused Brief Therapy (SFBT). de Shazer referred to Berg as a gifted clinician and stated that his life work was spent attempting to document what Berg was doing during client sessions that was instrumental in assisting in client change. Berg in turn referred to de Shazer as a “creative genius” and greatly admired his way of viewing clients and the change process. Their reciprocal admiration energized their work as well as demonstrated to solution-focused professionals that the SFBT model could be effectively used by a wide range of professionals who embodied different personality characteristics. Born and raised in Milwaukee, Wisconsin, de Shazer was the son of an opera singer mother and an electrical engineer father. His interests ranged from reading philosophy in original German and French to sports, cooking, taking long daily walks, and playing the saxophone on the jazz circuit. He became interested in Asian thought initially as a way to better understand his wife’s heritage; however, he later discovered a personal interest in Eastern religions, Eastern philosophies, and Eastern Orthodox churches. de Shazer obtained an M.S.S.W. degree from the University of Wisconsin, Milwaukee, and he was often described by his friends as a man of few words who was comfortable sitting in silence. This same minimalist style was seen in his work with therapy clients as he effectively built rapport and sent messages of compassion, all with a genuine head nod, purposeful silence, and solution-focused questions that were carefully worded and succinct. Born and raised in South Korea, Berg studied at Ewha Women’s University in Seoul before moving to the United States in 1957. While expectations from her family were that she would follow her family’s profession and become a pharmacist, she changed her major to social work and earned her M.S.S.W. from the University of Wisconsin, Milwaukee. She respectfully challenged traditional therapeutic approaches, building rapport through a gentle demeanor and quiet persistence, and made

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political inroads with skeptical organizations that used a problem-focused approach rather than a solution-focused approach. She used solutionfocused principles not only with clients but also with professionals and organizations. She was known to sit down for lunch beside line staff at agencies for which she consulted, believing that she would learn the most about the agency’s clients and what worked by engaging in conversations with the staff. The SFBT therapeutic approach developed by de Shazer and Berg was influenced by several factors. de Shazer credited the work of the anthropologist Gregory Bateson, the psychiatrist Don Jackson, and the psychotherapists Jay Haley and John Weakland for early elements of the foundation of SFBT. Through their work, Bateson and colleagues challenged the then common way of viewing schizophrenia as residing within the person and began to view it within the context of interactions within the family unit. The key element of their work on which de Shazer, Berg, and their colleagues later expounded was the idea of focusing on describing what was occurring between clients and those within their environment, rather than speculating about what was occurring inside each client as a person. Bateson and his colleagues’ work was the basis for general systems theory, which resulted in a number of key ideas, including wholeness (a change in one part of the system will influence the entire system), equi-finality (the end state of a system can be reached from differing paths), nonsummativity (the whole of the system is different from the sum of its parts), multifinality (similar initial states may lead to differing end states), nonlinearity, and circular causality. Meanwhile, during the 1960s in Palo Alto, California, Jackson, Weakland, Haley, and the later psychotherapist Paul Watzlawick and psychiatrist Richard Fisch established the Mental Research Institute (MRI), where de Shazer later studied. MRI, and the brief therapy model developed at MRI, greatly influenced de Shazer, as Weakland became his mentor and friend. In addition, during his time at MRI, de Shazer met Berg, and they formed a personal and professional partnership. The work of Weakland, Haley, and others at MRI was greatly informed by the psychiatrist

Milton Erickson. Erickson’s focus was on clients’ current and desired future rather than on insight, the past, or pathology. Erickson, who was known as a strategist, would sometimes prescribe outlandish between-session tasks to his clients, which were paradoxical and often resulted in significant, positive change. He sought to help clients behave differently, believing that, in turn, they would become more satisfied with their lives and begin to think differently. All of these influences were brought to MRI and can be seen in the therapeutic approach that de Shazer and Berg developed. Another factor that shaped the development of de Shazer’s and Berg’s therapeutic approach was the movement within family therapy toward brief family therapy. Although family therapy initially required a long treatment time frame, over time it became evident that treatment could be completed within a shorter amount of time. This trend was supported by a body of research that demonstrates that regardless of the model of therapy used, more than 80% of clients remain in therapy for less than 10 sessions, with most staying in therapy for 4 to 6 sessions. Weakland, Fisch, and Watzlawick integrated this concept of a 10-session limit into their work at MRI, calling it problem-focused brief therapy. During the 1970s, de Shazer and Berg brought the problem-focused brief therapy they learned at MRI to the Brief Family Therapy Center in Milwaukee. In addition, they brought with them a different way of viewing clients and problems. They believed that clients wanted to cooperate with therapists, and they viewed problems as behaviors that were accidently being maintained by the client’s failed attempts at finding solutions. After using this model for approximately 10 years, their focus shifted from solving problems to better understanding what clients’ lives would be like once the problems were resolved. In addition, they became increasingly curious as to what clients were doing during times in which the problems were less severe or even nonexistent. They began to de-emphasize therapists’ strategic interventions and sought the wisdom and effective actions of clients. In 1986, de Shazer, Berg, Eve Lipchik, Elam Nunnally, Alex Molnar, Wallace Gingerich, and Michele Weiner-Davis published an article on this model, which they called SFBT.

de Shazer, Steve, and Insoo Kim Berg

This model developed gradually over time and was continually refined through careful observation of client sessions and by continually asking themselves and their clients what was working. de Shazer and Berg’s team made use of a teaching tool, the one-way window: Berg would work with clients in front of the window, while de Shazer and their colleagues would observe the sessions from behind. Initially, the team behind the window took a more passive role by discussing observations after the session and using a phone to call in suggestions as needed. One day, the therapist in front of the window disagreed with the suggestion and took a break during the session to discuss the disagreement with the rest of the team in order to determine a plan for the rest of the session. This consultation break was so helpful that it later became part of the normal routine in SFBT. This spirit of collaboration and valuing of both colleagues and clients was central to the model of SFBT. de Shazer viewed SFBT as something that would likely remain small, believing that only a few professionals would ever see the value of this different way of working. Berg, who was more optimistic, focused on emphasizing client strengths that are naturally discovered through the solution-focused process, as a way to join with problem-focused professionals since this was a commonality with other, more accepted models. Although many counseling and therapy professionals expressed interest in de Shazer and Berg’s approach, there initially was strong criticism of SFBT, particularly in the United States within the substance misuse treatment community. Many within the field viewed the profound respect for clients and clients’ expertise that de Shezar and Berg advocated as heresy and something that would fuel the “denial” that was seen as symptomatic in this client population. In addition, some misinterpreted the fewer number of sessions required in this model of treatment as a way of rationing care; others viewed SFBT mistakenly as a model that could not address what they believed were the “deeper issues” within clients. At times, some addiction professionals openly challenged SFBT and its developers. Not one for confrontation, extended discussion, or political compromise, de Shazer shifted his professional focus to Europe, where audiences were

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more receptive to his innovative ideas. He later partnered with the physician Luc Isebaert in Belgium and conducted groundbreaking research on the application of SFBT with those struggling with substance misuse. Berg also traveled regularly throughout the United States, Europe, Asia, South America, and Canada to provide workshops and training on SFBT as well as deliver keynote speeches at international conferences. Berg consulted with community-based agencies and was instrumental in enlightening mental health treatment programs and organizations on SFBT. She believed that providing a demonstration of this model was oftentimes the most effective way of teaching it, and consequently her work with clients is memorialized in numerous videos and audiotapes. Active participants in many professional groups, both de Shazer and Berg were instrumental in founding the European Brief Therapy Association, and they later cofounded the North American Solution-Focused Brief Therapy Association. de Shazer’s focus in the latter organization was on developing the Research Committee, whose objectives were to increase the credibility of the model, to emphasize a partnership with the psychologist Janet Bavelas in her work in microanalysis and language, and to incorporate students and new professionals into the field. As prolific writers, de Shazer and Berg have authored or coauthored numerous articles and books, many explaining the solution-focused approach with a wide array of client populations. In de Shazer’s later years, he was influenced by the writings of Ludwig Wittgenstein, an Austrian schoolteacher and philosopher who thought about ethics, language, and reality. de Shazer integrated Wittgenstein’s work throughout the book More Than Miracles: The State of the Art of SolutionFocused Brief Therapy, which was published posthumously in 2007. This blending of SFBT with minimalist philosophy typified de Shazer’s thinking and way of understanding the world, while Berg is remembered for her warm and expressive interactive style. Teri Pichot See also Erickson, Milton H.; Palo Alto Group; Solution-Focused Brief Therapy

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Further Readings Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. (1956). Toward a theory of schizophrenia. Behavioral Science, 1, 251–264. doi:10.1037/11302-016 Berg, I. K. (1994). Family based services: A solutionfocused approach. New York, NY: W. W. Norton. Berg, I. K. (1995). Solution-focused brief therapy with substance abusers. In A. Washton (Ed.), Psychotherapy and substance abuse: A practitioner’s handbook (pp. 223–242). New York, NY: Guilford Press. Berg, I. K., & Dolan, Y. (2001). Tales of solutions: A collection of hope-inspiring stories. New York, NY: W. W. Norton. Berg, I. K., & Gallagher, D. (1991). Solution focused brief treatment with adolescent substance abusers. In T. C. Todd & M. D. Selekman (Eds.), Family therapy approaches with adolescent substance abusers (pp. 93–111). Needham Heights, MA: Allyn & Bacon. Berg, I. K., & Miller, S. D. (1992). Working with the problem drinker: A solution-focused approach. New York, NY: W. W. Norton. Berg, I. K., & Reuss, N. H. (1998). Solutions step by step: A substance abuse treatment manual. New York, NY: W. W. Norton. Berg, I. K., & Steiner, T. (2003). Children’s solution work. New York, NY: W. W. Norton. de Shazer, S. (1982). Patterns of brief family therapy. New York, NY: Guilford Press. de Shazer, S. (1984). The death of resistance. Family Process, 23, 79–93. doi:10.1111/j.1545-5300.1984.00011.x de Shazer, S. (1985). Keys to solution in brief therapy. New York, NY: W. W. Norton. de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York, NY: W. W. Norton. de Shazer, S. (1991). Putting difference to work. New York, NY: W. W. Norton. de Shazer, S. (1994). Words were originally magic. New York, NY: W. W. Norton. de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W., & Weiner-Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 25, 207–221. doi:10.1111/j.1545-5300.1986.00207.x de Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E., & Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy. New York, NY: Haworth Press. de Shazer, S., & Isebaert, L. (2003). The Bruges model: A solution-focused approach to problem drinking. Journal of Family Psychotherapy, 14(4), 43–52. doi:10.1300/J085v14n04_04

DEVELOPMENTAL CONSTRUCTIVISM Developmental constructivism is an integrative approach to the theory and practice of counseling that Michael Mahoney began developing in the 1980s. Although developmental constructivism shares some of the distinguishing features of other forms of constructivism—such as emphasizing how humans (intersubjectively) construct knowledge rather than (objectively) discover “the truth” existing “out there”—it is unique in many other ways, such as its emphasis on the complex, nonlinear dynamics involved in human change processes, its interdisciplinarity, and the breadth of its integration of a wide diversity of counseling theories and their practical application. Emphasizing humans’ active construction of their sense of self and the world, the pervasive nature of organizing (structuring) processes is central to developmental constructivism.

Historical Context Constructivism—broadly conceived—has been a philosophical perspective for millennia. Some of the earliest proponents of constructivism include the Buddha, who emphasized the active role that our mental processes play in the construction and maintenance of our experience of self and reality. Lao Tzu and Heraclitus both posited that opposites not only coexist but mutually define each other. Although constructivist developments from the 18th, 19th, and 20th centuries include a wide array of individuals—from Giambattista Vico, Immanuel Kant, and Hans Vaihinger to Frederic Bartlett, Johann Herbart, Jean Piaget, and George Kelly—only a few of their contributions can be mentioned here. Kant posited that we do not have direct knowledge of the nature of reality; rather than know the noumenon (reality as it is “in itself”), we experience phenomena (reality as perceived) as a function of our mind’s categories, which filter, organize, and interpret experience. Piaget studied the qualitatively different ways in which people construct their perceptions and knowledge as they develop from young children into adults; the process of self-organization is significant to their perception of an organized world. Kelly’s personal construct theory emphasized the self-organization of personality; the

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rigidity or flexibility of a person’s constructs (organizing processes) was central to how his psychotherapeutic system conceived of, and intervened with, clients. Throughout the second half of the 20th century, sundry expressions of constructivism emerged, not only in psychology, mental health, and related disciplines but also in diverse fields such as art, architecture, education, and economics. With regard to counseling and psychotherapy, constructivism has been expressed within many traditions, from cognitive-behavioral and existential-humanistic to psychoanalytic and integral. Mahoney’s developmental constructivism incorporates aspects of each of these traditions.

Theoretical Underpinnings Mahoney clearly stated that his developmental constructivism was a form of “critical constructivism.” Some of the key tenets of critical constructivism include the following: (a) although the external world exists independently of humans, knowledge is always a function of human construction and is never complete or final; (b) knowledge cannot be separated from the activities of the knower; (c) the person is viewed as a “coconstructor” or “cocreator” of personal realities; (d) the centrality of multiple methodologies, interpretation, and the role of emotional processes in the knowledge quest; and (e) the necessity of understanding the complex interactions of multiple systems rather than reducing complexity to a single dynamic. The last point highlights the relevance of dynamic systems theories, chaos theory, and other studies of complexity to counseling and other human change processes. Like integral counseling, developmental constructivism is a metatheoretical approach to psychotherapy integration and unification that is sufficiently comprehensive and dialectical to unite principles and processes within the apparent dualities that have traditionally plagued counseling and psychology. Mahoney began his career within the behavioral tradition and eventually made pioneering contributions to the cognitive revolution. Although he never lost sight of the importance of cognitive-behavioral and other “empirical” perspectives—such as biology and neuroscience—his later developmental constructivism emphasized empathic attunement

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to the client’s phenomenological experience, idiographic—in contrast to nomothetic— assessment, intersubjectivity, and emotion-focused work. Thus, even though developmental constructivism is a comprehensive and balanced approach to psychotherapy integration, it is more resonant with existential-humanistic, intersubjective, and even transpersonal/“higher potential” psychologies than it is with traditional cognitive-behavioral and other “objectivist” perspectives. The key principles with which developmental constructivism accomplishes this integration are described in the next section.

Major Concepts In addition to his pioneering Constructive Psychotherapy, Mahoney is also widely known for his 1991 magnum opus Human Change Processes, arguably one of the most monumental contributions to counseling and psychotherapy in many decades. Mahoney distilled his developmental constructivism into five principal themes regarding human experience and development, and four “core ordering processes.” The five basic themes are (1) active agency, (2) order/organization, (3) self/identity, (4) social-symbolic processes, and (5) dynamic dialectical life span development. Human Change Processes

Human change processes are nonlinear— neither cumulative nor continuous, they usually involve gradual “baby steps” that are punctuated by sporadic regressions or larger leaps forward. Oscillations—such as expanding–contracting, opening–closing, engaging–disengaging—are also pervasive in human development. Because novelty and disorder are essential for development, developmental processes involve periods of perturbation and disruption in functioning and experience; this disorder may or may not become problematic. Under conditions of novelty or developmental challenge that produce disorder and disorganization, a person may become maladaptively rigid or adaptively flexible. If the novelty is insufficient, the person may stagnate; if the challenge exceeds a person’s capacities, the individual may “break down” into excessive disorder. Ideally, novel disruptions are optimally challenging to one’s developmental capacities, resulting in a “breakthrough”

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transformation. Resistance to change is the norm—particularly if too much is changing too quickly; such resistance is a form of self-protection and should be empathically worked with, not against. Attentional skills are paramount, and new insights must be actively practiced. As such, rituals and other experiments in living can function to promote and elaborate valued experiences. Relationships characterized by strong affective bonds, safety, and intimacy are especially potent crucibles for personal change. Likewise, a host of spiritual—not necessarily religious—practices appear to be significant in their potentials for personal transformation. Because compassion and care are essential to life, they are essential to counseling. Active Agency Human experience is a function of continuous and fundamentally anticipatory activity. In other words, we are active participants and creators of our lives, not mere passive pawns. Importantly, simply “paying attention” is a profoundly important act of agency (activity does not need to be externally observable). The practice of various attentional skills is often helpful to clients, ideally when engaged regularly and paired with behavioral action. Order/Organization Human agency is fundamentally devoted to ordering processes (the organization and patterning of experience) that are largely emotional in nature; they are primarily nonconscious, and they constitute the essence of meaning making. Emotions are not only critical in directing our attention; they also shape our perceptions, organize our memory, and motivate adaptive action. Developmental constructivism views emotions not as unhealthy, bad, or dangerous but, rather, that the pervasive denial or avoidance of them is usually detrimental to health. Although challenges to our ordering systems are phenomenologically disruptive and disorganizing, they are essential to learning and development. Self/Identity The organization of experience is essentially recursive or self-referent, which results in a phenomenological sense of personal identity or selfhood as

the center of our psychological universe. One’s sense of self is usually linked with one’s sense of reality, and one’s relationships to one’s self are indicative of life quality. Importantly, this self is a process, or verb—not a noun; moreover, it is not isolated or separate. In other words, the self is a coherent yet fluid perspective from which we experience life, and it emerges from and changes predominantly in emotional relationships with others. Social-Symbolic Processes Social-symbolic processes are pervasive influences on how we obtain and maintain order and meaning. We are embedded within webs of relationships and other social discourse practices that are mediated by language and other symbol systems. Although the Western notion of self usually implies individuality, selfhood (as well as meaning) emerges only within (intersubjective) relationships; as such, we are as much “embedduals,” as Robert Kegan describes, as we are individuals. Dynamic Dialectical Life Span Development Humans can potentially develop throughout the entire course of their lives. Development always involves the tensions of contrasts (e.g., good/bad, possible/impossible, approach/avoid, me/not me, us/the, and able/unable), and these seldom remain static. In developmental processes, oscillations between opening (expanding) and closing (contracting) are common. Extreme contraction is a natural response to overwhelming challenges to our current organizational processes, and periods of disorganization are usually required in the reorganization and integration involved in healthy human development. Core Ordering Processes

Core ordering processes (COPs) are deeply abstract and nonconscious processes that are central to our psychological experiencing and meaning making. When a person changes in important, long-lasting ways, what changes most are his or her COPs. However, being so central to our experience, COPs tend to be rather stable and difficult to change. The four COPs, which are not completely separate from each other, are (1) reality, (2) value, (3) self, and (4) power. Reality refers to a person’s worldview—an

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individual’s perceptions and constructions along dimensions such as real–unreal, meaningful– meaningless, and possible–impossible. Value refers to valuing processes—constructing emotional judgments (which require assigning a valence— positive or negative) along dimensions such as good–bad, approach–avoid, and right–wrong. Self refers to that with which one identifies, constructed along dimensions such as me–not me, body–world, and us–them. Power refers to a sense of control and agency, constructed along dimensions such as engaged–disengaged, hopeful– hopeless, and in–out of control. Many other major concepts within developmental constructivism fit more appropriately under the remaining two sections.

Techniques Although Mahoney wrote at length about techniques, created original techniques, and even did research on them, he also cautioned about the “tyranny of technique.” For him, meticulously performed techniques will not be effective if the counselor does not understand the deeper structure from which the specific intervention derives. Thus, he emphasized processes of change rather than specific strategies. For example, relaxing is a process that can be accomplished with many different specific strategies, from progressive muscle relaxation and autogenic training to meditation and yoga. Reflecting a dialectically balanced approach, nothing was more central to Mahoney than compassion and caring; at the same time, he emphasized homework—collaboratively designed experiments in living—as central to clients’ change processes. In Mahoney’s 2003 book Constructive Psychotherapy, six chapters are devoted to specific techniques, ranging from basic centering skills and problem-solving strategies to pattern-level interventions and process-level exploration (the structure of those chapters will make more sense after reading the “Therapeutic Process” section of this entry). In four chapters, Mahoney describes many dozens of behavioral, cognitive, analytic, humanistic, constructivist, and spiritual/transpersonal strategies for change, all of which he integrated in his developmental constructivism. The fifth and sixth chapters, addressing specific techniques, describe

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two interventions that Mahoney created—stream of consciousness and mirror time, both of which are process-level strategies. Constructive Psychotherapy also includes 14 appendices, most of which focus on specific techniques; three that are briefly described here are compassion and caring, mirror time, and constructive recommendations for counselors. Compassion and Caring

Compassion and caring may not be techniques per se, but they form the heart of developmental constructivism. Having procedural competence and understanding the best available research are important, but they are not nearly as effective in the absence of compassion and care. Mirror Time

Mahoney believed that self-relationships (including but not limited to self-esteem and selfconcept) are critical to one’s quality of life, and mirror time was perhaps his favorite method to assess and assist in clients’ self-relationships. Clients are invited to look into a mirror without doing the usual cosmetic activities. They begin by taking a few deep breaths and setting positive intentions; they are then encouraged to connect with themselves compassionately. In the course of the next 10 minutes, they are to look into their face and eyes; to periodically close their eyes and observe any sensations or emotions in their body; to periodically relax with deep breaths and remember to be gentle with themselves; to open their eyes and notice where their attention is drawn and what they think, feel, or otherwise notice; to periodically return their gaze to their eyes; and to alternate between closing their eyes (inviting themselves to relax and be gentle with themselves) and opening them (inviting themselves to notice what they are aware of). If and as they are comfortable doing so, they are invited to verbally share as they are experiencing this exercise, and this material is processed. Constructive Recommendations for Counselors

Mahoney encouraged counselors to prepare for each session with some form of centering technique or private reflection. He cautioned against

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presuming to understand clients too quickly, rather than honoring each individual’s uniqueness, including the person’s capacities and pace of change. Developmental constructivism is an experiential approach; thus, clients are encouraged (not required) to actually feel their emotions rather than merely talk about them. It follows that Diana Fosha’s construct of “affective competence” is a prerequisite to this type of counseling. If you, as a counselor, become emotionally overwhelmed, recenter yourself with any balancing skill that helps you. Your clients’ safety is paramount, but also challenge your clients’ growing edges with individually tailored explorations and experiments (discomfort is not the same thing as being unsafe). Finally, teach self-care, encourage forgiveness, and emphasize clients’ ability to experience compassion for themselves and others.

Therapeutic Process Developmental constructivism involves an approach that is developmentally tailored to each client; thus, there is no single therapeutic process that applies across all cases. That being said, there are some general principles. Mahoney’s overarching goal was to serve his clients’ immediate and future developmental needs and well-being; this requires a deep understanding of the client as a person—his or her experiences, strengths, weaknesses, and self-perceptions; how the client has been hurt and helped in the past; what the client believes is possible; his or her worldview, sense of self, and emotional life; and what provides meaning to his or her life. The first interactions with a client are important. Mahoney viewed the intake session as a mutual exploration of compatibility, and he attuned to the client with his whole body (e.g., mind, emotions, sensations, and other internal reactions, etc.), paying as much attention to clients’ nonverbal communications as to what they say. He assessed clients ideographically, and his intake assessment form is included as an appendix in his Constructive Psychotherapy. In general, Mahoney would begin his sessions by being present and making contact with the client. He would then assess the client’s current situation and collaboratively establish an agenda for the session. His continued attunement to the client’s cycles of experiencing helped him balance the

comfort and challenge he offered. He would assist clients in practicing various techniques or exercises pertinent to their struggles and process their experience of those exercises. He would offer affirmations, alternative perspectives, and usually homework (experiments in living) and end the session with presence and good will. Like compassion and caring, collaboration and action are foundational to developmental constructivism. Collaboration entails an egalitarian (nonauthoritarian) relationship—a “working together”; action emphasizes the importance of what people actually do in their daily lives, which is usually more significant than their intentions. Also central to developmental constructivism are affirmation and hope. Affirmation does not entail an unwavering support of, or cheerleading, whatever the client reports; rather, it capitalizes on clients’ strengths and offers encouragement while not minimizing the problems and consequences of their current patterns. One of the responsibilities of a counselor is to promote clients’ hope, but hope is not mere wishing for something positive. For Mahoney, hope is fundamentally about actively engaging in life and trusting that—in the midst of suffering and pain—things can be different. Developmental constructivism does not recommend a one-size-fits-all approach. Sensitive attunement is required to know what a given client needs most at any given moment. Developmental constructivism suggests thinking in terms of two fundamental and interrelated dimensions: opening–closing and comforting– challenging. When a person is excessively closed, he or she is cut off from certain forms of exchanges with his or her world. When a person is excessively open, the person may exceed his or her capacity to metabolize what he or she is receiving. Constructive change requires openness to novelty, but not too much too quickly; it is the counselor’s responsibility to help the client balance his or her cycles of opening and closing. Likewise, good counseling involves a balance of comfort and challenge; that balance differs from client to client, and even with the same client at different points in his or her life. The challenge that Mahoney referred to was not aggressive but progressive—inviting the client to explore and experiment and communicating trust in the client’s capacities and possibilities.

Developmental Counseling and Therapy: Theory and Brain-Based Practice

Mahoney found it useful to think of counseling as addressing three interwoven domains: problems, patterns, and processes. Many, if not most, clients seek counseling to solve specific problems; in attending to this therapeutic focus, Mahoney drew on many behavioral and cognitive interventions. However, specific problems usually derive from patterns; they rarely exist in isolation. Facilitating clients’ understanding of their patterns involves an integration of experiential work (hereand-now, emotion focused) and cognitive work (understanding, analyzing). Some of Mahoney’s preferred strategies for pattern work include unsent letters, personal journaling, life review exercises, bibliotherapy, and narrative reconstructions. The focus or level of work that Mahoney believed held the most potential for significant, enduring change was process work. Although process-level work is the most challenging for counselors (and clients), all problems and patterns are expressions of the client’s processes—dynamics and experiences at a level below, above, or between words. Process work is necessarily done in the living, immediate moment; far from abstract discussions or superficial tinkering, this form of deep, experiential work explores the client’s core ordering processes as they are emerging in the here-and-now of the session. Precisely because this type of work can be so powerful, it can also be risky; thus, counselors should invite clients to this type of work only when clients are ready for it (i.e., they are proficient in centering skills with which they can regulate themselves and regain psychological balance and coherence). A common theme of process work is facilitating clients’ nonjudgmental “looking inward” to observe the physical, emotional, mental, and spiritual processes that produce their moment-to-moment experience. Some of the strategies that Mahoney drew on in process work include embodiment exercises (ranging from strength training to yoga, dance, music, referrals for massage, and petting/ playing with pets), dreamwork, mirror time, stream of consciousness, and various forms of meditation. Andre Marquis See also Accelerated Experiential Dynamic Psychotherapy; Emotion-Focused Therapy; Existential-Humanistic Therapies: Overview; Integral Psychotherapy; Integrative Approaches: Overview; Intersubjective-Systems Theory; Meditation; Personal Construct Theory

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Further Readings Fall, K., Holden, J. M., & Marquis, A. (Eds.). (2010). Constructivist approaches. In Theoretical models of counseling and psychotherapy (2nd ed., pp. 347–386). New York, NY: Routledge. Mahoney, M. J. (1974). Cognition and behavior modification. Cambridge, MA: Ballinger. Mahoney, M. J. (1991). Human change processes: The scientific foundations of psychotherapy. New York, NY: Basic Books. Mahoney, M. J. (2000). Behaviorism, cognitivism, and constructivism: Reflections on persons and patterns in my intellectual development. In M. R. Goldfried (Ed.), How therapists change personal and professional reflections (pp. 183–200). Washington, DC: American Psychological Association. Mahoney, M. J. (2003). Constructive psychotherapy: A practical guide. New York, NY: Guilford Press. Mahoney, M. J. (2005). Suffering, philosophy, and psychotherapy. Journal of Psychotherapy Integration, 15, 337–352. doi:10.1080/07351692209349018 Mahoney, M. J., & Marquis, A. (2002). Integral constructivism and dynamic systems in psychotherapy processes. Psychoanalytic Inquiry, 22(5), 794–813. doi:10.1037/1053-0479.15.3.337 Marquis, A. (2008). Michael J. Mahoney: A constructive heart and the heart of constructivism. Constructivism in the Human Sciences, 12(1), 119–141. Marquis, A., Warren, E. S., & Arnkoff, D. B. (2009). Michael J. Mahoney: A retrospective. Journal of Psychotherapy Integration, 19, 402–418. doi:10.1037/ a0017971 Neimeyer, R. A., & Mahoney, M. J. (Eds.). (1996). Constructivism in psychotherapy. Washington, DC: American Psychological Association.

DEVELOPMENTAL COUNSELING AND THERAPY: THEORY AND BRAINBASED PRACTICE Developmental counseling and therapy (DCT) is an integrated theory of assessment and treatment based on five central concepts: (1) the coconstructive nature of relationships and knowledge, (2) the adaptation of Piagetian cognitive stages, (3) the cultural character of the counseling relationship, (4) the neuroscientific foundation of counseling interventions, and (5) the classification of therapies to match the treatment to the client.

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DCT recognizes the value and capacity of various therapeutic treatments in changing the cognitive/ emotional styles of clients and uses careful assessment to match these treatments to clients’ cognitive/emotional styles. DCT also believes that clients play an active role in discovering solutions to their issues.

Historical Context DCT was developed by Allen Ivey, and the basic tenets of the theory were published in his 1986 book Developmental Therapy: Theory Into Practice. Since its inception, Ivey has written extensively about DCT and its relation to multicultural concepts and neuroscientific findings. Key authors who have contributed to the development of DCT are Óscar Gonçalves, Jane Myers, Thomas Sweeney, Sandra Rigazio-Digilio, and Carlos Zalaquett. The theory has been applied to a wide variety of contexts, such as counseling adults, children, and families; addictions treatment; dream and metaphoric work; and spirituality. Recent applications of DCT in Australia, Japan, Korea, India, and Turkey demonstrate its international reach.

Theoretical Underpinnings DCT is notable for its theoretical integration of different philosophical, psychological, and intellectual traditions. These include ancient philosophy (e.g., Plato, Ibn Sı-na-), Piagetian theory, family theories, existential-humanistic theories, developmental theories, multicultural theories, and neuroscience findings. It also draws from Jacques Lacan, Sigmund Freud’s disciple in France, who emphasized unconscious processing from what we now call a multicultural perspective. This means a philosophy of connection with the past, present, and future of not only the client but also society. DCT sees behavior as philosophy in action. Behavior can be understood using the philosophies reviewed, and DCT integrates these different intellectual traditions to explain clients’ behaviors. More specifically, from the Piagetian tradition, DCT seeks to understand the developmental level of a client and work with the client based on the client’s developmental stage. In addition, brain functions are related to specific stages, so the DCT therapist takes into account how the brain may be “firing” as a function of stage levels and creates

interventions to support the client yet challenge the client to use other stages. From the existentialhumanistic frame, DCT seeks to “hold” the client in a manner that will build the optimal relationship. Thus, humanistic counseling skills, such as microskills, are applied to the counseling relationships. This allows the client to feel safe in the relationship and offers opportunities for growth and change—a safe client can “hear” subtle challenges to growth. Finally, from the psychodynamic, family, and multicultural perspectives, DCT seeks to understand the client from a systemic perspective— systemic in the sense that the past affects the present and can influence the future and that the family and the broader community, as well as society, can and do affect how the individual views the world. This complex web is all taken into account in DCT, especially in light of how the client may unconsciously be responding to this involved and complicated system.

Key Concepts The following concepts are central to DCT. These terms and definitions explicate the theory and describe the foundation of DCT’s therapeutic work. Reformulating Client Problems

DCT therapists question the individualistic problem-focused interventions of most previous forms of psychotherapy, as these emphasize the client while minimizing context. Albert Ellis, the well-known author of rational emotive behavioral theory, originally argued strongly against DCT’s multicultural emphasis but then read Ivey’s writings and came to the conclusion that his own work and that of other theoreticians had failed to give sufficient attention to the multicultural and social context. Instead of placing blame and responsibility for the resolution of a client’s issues almost solely on the individual client, DCT focuses on the person and his or her social context in search of collaborative solutions. Topics and Key Words

In psychotherapy, many clients stay focused on a single topic to the exclusion of other issues, or they change topics subtly or abruptly in an effort

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to avoid negative feelings or stressful issues. DCT therapists help clients stay on the topic or observe topic changes to gain a better understanding of clients’ concerns. They also focus on key words or images clients use to describe themselves and their life situations, as these often represent the overall constructs by which clients organize and make sense of their world. By attending to these topics and words, therapists gain a better understanding of the clients’ worldviews, which they can use to guide counseling work.

2. Concrete cognitive/emotional style: Clients with this style may have only a vague sense of the emotions underlying their concerns. They often express emotions outwardly and can name and describe them concretely. They are unlikely to recognize obvious emotions in others unless clearly manifested verbally and nonverbally. Cognitively, these clients focus predominantly on factual descriptions of concrete details of situations or issues from their own perspective. There is limited perspective taking and minimal emphasis on evaluation or analysis.

The Cognitive/Emotional Abstraction Ladder

3. Abstract formal-operational cognitive/emotional style: Clients presenting with this style are more abstract and reflect on emotions from a greater cognitive distance. These clients can describe repeating patterns of thought, behavior, and affect in the self (or others) that occur across situations and can engage in analysis and understanding of situations. They are able to organize situations and thoughts in highly abstract ways to articulate a new and more complex understanding of the situation. These clients demonstrate awareness of the complexity of feelings and are able to separate self from feelings and reflect on them. Formal-operational clients may be effective at seeing repetitive patterns of emotion, but they may also have difficulty being concrete and specific. They may not experience emotion in a sensorimotor style.

Central to DCT is assessing client cognitive/ emotional style and then matching therapeutic interventions to the unique client. Through electroencephalogram (EEG) study, Richard Lane found that different areas of the brain fire as a function of talk from different cognitive/emotional levels. Client communication styles can be viewed as representing a continuum between concrete and abstract. In DCT, this concept is referred to as the cognitive/emotional abstraction ladder. DCT therapists who can identify their clients’ communication and experiencing style may be able to use the same style to facilitate the exploration of thoughts and feelings in the here-and-now. Therapists may also intentionally mismatch clients’ style to help clients explore other possible styles for dealing with their cognitive and emotional experiences. Drawing from Piaget’s work, DCT recognizes the following four cognitive/emotional styles along this continuum: 1. Sensorimotor cognitive/emotional style: Clients presenting with this style are predominantly in their emotions. They experience emotions rather than naming them or reflecting on them. Their body is fully involved. They are dominated by sensory stimuli and affect, with very minimal distinction between sensory input, cognition, and emotions. The positive aspect of this style is the individual’s access to the real and immediate experiences of being sad, mad, glad, or scared in the moment. The negative side is that clients may be overwhelmed by too much emotion. Here, we see the centrality of our brain’s perceptual systems and the activation of thought and action from the limbic system.

4. Abstract dialectic/systemic cognitive/emotional style: Clients using this style are very effective at analyzing their emotions, and their emotionality will change with the context. Clients may exhibit a more analytical and multiperspective view of emotionality, which can move them even farther away from direct, here-and-now experiencing. This style tends to be theoretical, and emotions are analyzed more than experienced. DCT therapists may ask questions that lead to multistyle processing of clients’ emotional experience. DCT therapists assert that cognitive/emotional developmental style is the key component to understanding and facilitating change, but they do not view anyone of these four cognitive developmental orientations as better or more desirable than another. Rather, healthy development is conceptualized as continuous mastery of life tasks, which promotes competency in all four of these

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orientations. Ideally, people should have access to a variety of well-integrated cognitive structures and be flexible and adaptable enough to shift into whichever cognitive structure is likely to work best under a given set of circumstances. Horizontal and Vertical Development

According to DCT, at any given time, people have a predominant cognitive/emotional style in operation. Goals of treatment are to help clients gain more awareness of and flexibility in their cognitive/emotional style, use all four styles to develop multiple perspectives on their issues, and develop solutions for their issues that are relevant to their developmental and environmental needs. DCT promotes both horizontal and vertical development. Horizontal development involves working with clients’ preferred cognitive/emotional style to facilitate communication and better understanding of their presenting issues. This enriched understanding can lead to an effective resolution of clients’ concerns. Vertical development helps clients shift their style and draw on all four of the cognitive/emotional styles to facilitate the use of varied perspectives and alternative ways of thinking, feeling, and acting on their issues. Cognitive and Emotional Blocks

Clients may be unable to experience a particular event or circumstance in one or more of the cognitive/emotional styles described earlier. This difficulty may represent a developmental block. For example, clients with a sensorimotor block may be unable to experience and deal appropriately with feelings or may be overwhelmed or immobilized by them. Clients with a concrete block may have difficulties linking cause and effect. Neuroscience and Stress Management

Advances in the field of neuroscience have demonstrated brain plasticity, the capacity of the brain to create new neurons. Psychotherapy changes the way clients think, feel, and behave, and also the structure of their brain. Therapy can add new and permanent neural connections and even change memories. Stress can injure the body and mind and

destroy neurons. DCT sees therapy as a vehicle to promote neurogenesis and manage stress. Developmental Classification of Therapeutic Theories

DCT conceptualizes some therapeutic theories as focusing on structuring the environment for the client (e.g., behavior therapy, relaxation training), some as providing concrete trainings (e.g., assertiveness training, rational emotive behavior therapy), some as focusing on formal operations (e.g., Rogerian therapy, psychodynamic therapy), and some on systems of operation (e.g., feminist therapy, multicultural counseling). DCT therapists use the interventions from these different theories that best meet the client’s cognitive/emotional style.

Techniques There are a wide variety of techniques that are used with DCT. First, the therapist performs a DCT assessment of a person’s cognitive developmental style. In addition, the therapist will likely conduct a positive asset search, a personal strength inventory, and a cultural/gender/family strength inventory. The therapy will also look for positive exceptions, apply microskills, use empathy and focus on wellness, and provide an egalitarian and strengths-based relationship. DCT Assessment

Assessment of a client’s cognitive developmental orientations can be accomplished by carefully listening to the client’s verbal and nonverbal communications, by using an assessment interview, or by using formal instruments. DCT therapists use specific questions to elicit a client’s general cognitive/emotional style during an assessment interview. It should be noted, however, that client styles will vary with the topic and the emotional issues concerned. Standard Cognitive-Developmental Interview

The Standard Cognitive-Developmental Interview is an instrument that can be used to identify clients’ cognitive/emotional style and developmental blocks. The structured sequence of

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questions also provides the foundation for designing treatment plans for clients. Positive Asset Search

DCT therapists constantly search for strengths and positive resources while listening to their clients. These observations may be shared with the clients, without minimizing the seriousness of the situation or being overly optimistic. Clients usually change based on what they can do, not on what they cannot do. DCT therapists develop a list of strengths and assets with a client and later draw from this list for resolution of concerns and problems. Personal Strength Inventory

Many clients tend to talk about their problems and what they are unable to do, especially when beginning psychotherapy. This puts them “off balance.” It can be beneficial to shift clients toward a positive orientation by helping them center and empower themselves through a strength inventory and focusing on what they are doing well. Therapists may spend time identifying some of the positive experiences and strengths that the client either has now or has had in the past, and may ask some or all of the following questions: (a) Could you tell me a story about a success you have had sometime in the past? I’d like to hear the concrete details. (b) Tell me about a time in the past when someone supported you and what he or she did. (c) What are your current available support systems? (d) What are some things you have been proud of in the past? Now? (e) What do you do well or others say you do well? Cultural/Gender/Family Strength Inventory

Many diverse clients will have a collectivist orientation, so it can be crucial to look at a client’s living context for positive strengths. Examples of helpful questions that a therapist can ask include the following: (a) Taking your ethnic/racial/spiritual history into consideration, can you identify some positive strengths, visual images, and experiences that you have now or have had in the past? (b) Can you recall a friend or acquaintance of your own gender who represents some type of hero in

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the way he or she dealt with adversity? What did that person do? Can you develop an image of her or him? (c) We all have family strengths despite frequent family concerns. For example, some people talk about a special uncle or aunt, or an older person who was helpful. Could you tell me concretely about a person like that and what she or he means or meant to you? Positive Exceptions

Searching for times when the problem doesn’t occur is often useful. This approach is common in brief, solution-focused therapy counseling. With this information, the therapist can determine what is being done right and encourage more of the same. Questions that focus on the exceptions can also lead to an exploration of positive assets: (a) When is the problem or concern absent or a little less difficult? Please give me an example of one of those times. (b) Few problems happen all the time. Could you tell me about a time when it didn’t happen? That may give us an idea for a solution. (c) What is different about this example from the usual? How did the more positive result occur? How is that different from the way you usually handle the concern? Microskills

DCT therapists use culturally sensitive microskills for attending to clients and effecting change. These microskills are communication skill units that help therapists interact more intentionally and effectively in counseling. Basic listening skills are central to relationship building and include attending, observing, questioning, encouraging, paraphrasing, summarizing, and reflecting feelings. Culturally sensitive influencing skills help clients explore personal and interpersonal issues, conflicts, or ambivalences and include confrontation, focusing, reflection of meaning, interpretation/reframing, self-disclosure, feedback, logical consequences, and psychoeducation. Empathy and Wellness

DCT therapists listen intentionally to clients’ stories to establish an empathic relationship, understand the clients’ world, and help alleviate

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clients’ stress. Based on the empathic relationship, DCT therapists work collaboratively with their clients and use interventions such as those previously mentioned to enable clients to experience emotions and feelings more appropriately, think more constructively, use strengths and resources, focus on wellness, and put agreed-on changes into action. Egalitarian and Strengths-Based Relationship

DCT therapists aspire to establish an egalitarian and strengths-based psychotherapeutic relationship; they work with clients, not on clients, to foster a respectful relationship, establish communication that matches clients’ preferred style, develop mutually agreed-on goals, and determine the best treatment plan. DCT therapists work with the severely distressed, those facing adjustment to new or challenging circumstances, and those engaged in efforts to better themselves. DCT therapists do not emphasize pathology or normality concepts; instead, they conceptualize clients’ behaviors or symptoms as developmental blocks or delays that often represent a logical response to clients’ developmental history and environmental circumstances.

Therapeutic Process An initial step in DCT is assessment of a client’s cognitive orientations and issues. During this step, it is important for the DCT therapist to intentionally assess the developmental level of the client and pull from interventions that match that level. After the assessment, the DCT model provides a paradigm for planning and implementing interventions to effectively address those issues. For example, clients functioning in the sensorimotor cognitive/ emotional style will benefit from interventions such as guided imagery, meditation, relaxation training, and Gestalt therapy. Clients functioning within the abstract formal-operational cognitive/ emotional style will benefit from dream analysis, person-centered therapy, rational emotive behavior therapies, and narrative therapy. DCT places a strong emphasis on understanding the client in context and adapting treatment to that client. DCT offers a useful paradigm for planning and implementing appropriate interventions to promote change and growth. This makes DCT

well suited for use with a variety of issues and with clients from diverse cultural backgrounds. To be effective, DCT therapists need to be skilled in assessment of cognitive/emotional styles and be able to function in all four styles. Also, they need to be accomplished in a broad range of treatment systems and strategies so that they can implement the treatments that match the client’s cognitive/ emotional style. Carlos P. Zalaquett and Allen E. Ivey See also Existential Group Psychotherapy; Existential Therapy; Existential-Humanistic Therapies: Overview; Gestalt Therapy; Interpersonal Group Therapy; Process Groups; Symbolic Experiential Family Therapy

Further Readings Ivey, A. (2000). Developmental therapy: Theory into practice. North Amherst, MA: Microtraining Associates. (Original work published 1986) Ivey, A., Ivey, M., Myers, J., & Sweeney, T. (2005). Developmental counseling and therapy: Promoting wellness over the lifespan. North Amherst, MA: Lahaska. Zalaquett, C. P., Chatters, S. J., & Ivey, A. E. (2013). Psychotherapy integration: Using a diversity-sensitive developmental model in the initial interview. Journal of Contemporary Psychotherapy, 43, 53–62. doi:10.1007/s10879-012-9224-6 Zalaquett, C. P., Fuerth, K. M., Stein, C., Ivey, A. E., & Ivey, M. B. (2008). Reframing the DSM-IV-TR from a multicultural/social justice perspective. Journal of Counseling & Development, 86, 364–371. doi:10.1002/j.1556-6678.2008.tb00521.x

DEVELOPMENTAL NEEDS MEETING STRATEGY The Developmental Needs Meeting Strategy (DNMS) is a comprehensive, gentle, strengthsbased, client-centered, ego state therapy that treats adults wounded in childhood. It helps heal attachment wounds that originate with parental rejection, neglect, and enmeshment and trauma wounds that come from verbal, physical, and sexual abuse. Parts of self can get stuck in childhood when attachment needs and safety needs are not met

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well. The DNMS guides the Resources part of self to help wounded parts get unstuck from the past, by meeting those unmet needs now. As wounded parts heal, unwanted behaviors, beliefs, and emotions diminish. The DNMS has helped treat a wide variety of presenting problems from anxiety and depression to personality disorders and dissociative disorders.

Historical Context Shirley Jean Schmidt began developing the DNMS in 2000. She had been using the Trauma Treatment Model—a three-stage approach for treating clients traumatized in childhood. The model is based on the popular assumption that unresolved traumatic events from the past (e.g., childhood sexual abuse) are at the root of unwanted behaviors, beliefs, and emotions and that trauma desensitization is key to adaptive resolution. But she observed that many of her wounded clients did not have “traumas” to desensitize. Rather, many were stuck in the past because of attachment wounds from an absence of emotional connection, loving attunement, or validation. Because the trauma model was not designed to address this, she changed her focus from trauma desensitization to remediating unmet developmental needs. She discovered that remediating unmet needs could repair attachment wounds from rejection, neglect, and enmeshment and could heal trauma wounds. Old trauma memories would gently desensitize as each associated need got met. Schmidt has been writing about her protocols and teaching them to therapists since 2002.

Theoretical Underpinnings The DNMS is informed by ego state theory, inner child therapy, self-reparenting therapy, developmental psychology, attachment theory, Eye Movement Desensitization and Reprocessing (EMDR) therapy, and the science of mirror neurons. The DNMS assumes that we all have parts of self. Healthy parts of self form in response to positive, affirming relationships with people who are loving and attuned. They live in the present; feel and manage the full range of emotions; hold positive beliefs about self and world; engage in appropriate, desirable behaviors; and have an adaptive point of view. Wounded parts of self form in

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response to traumas and to negative, wounding relationships with people who are abusive, neglectful, rejecting, and enmeshing. They live in the past; are stuck in painful emotions; hold negative, irrational beliefs about self and the world; engage in unwanted or inappropriate behaviors; and have a maladaptive point of view. Parts of self relate to each other much like family members do. They can communicate with support or with hostility. They can work with each other or against each other. They can have competing agendas, which can lead to internal conflicts. The DNMS endeavors to help heal individual wounded parts and heal the relationships between parts. Healing happens when neural integration is facilitated by protocols that get healthy parts of self to communicate love and support to wounded parts. Protocols incorporate alternating bilateral stimulation (made popular by EMDR), which also facilitates neural integration.

Major Concepts To understand DNMS, a number of concepts are highlighted, including developmental needs, wounded parts stuck in the past, Resources part of self, reactive parts, maladaptive introjects, getting triggered in adulthood, and healing by meeting needs. Developmental Needs

Abraham Maslow theorized a hierarchy of human needs. The first four tiers consist of developmental needs that children need parents to meet. They are (1) basic physiological needs (food, water, air, sleep, etc.), (2) safety needs (protection from danger), (3) belongingness needs (love, attachment, attunement, etc.), and (4) esteem needs (to be respected and appreciated). Wounded Parts Are Stuck in the Past

The DNMS model assumes that the degree to which developmental needs were not adequately met is the degree to which a client may be stuck in childhood. That means a person may go from feeling adult-like in one moment to suddenly feeling like a sad, angry, or fearful child.

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Resources Part of Self

Getting Triggered in Adulthood

Three healthy parts of self are mobilized: (1) a Nurturing Adult Self, (2) a Protective Adult Self, and (3) a Spiritual Core Self. These three Resources, together as a team, form a Healing Circle. Wounded parts will get their needs met by the Resources, inside the Healing Circle.

Stressful events in adulthood can trigger maladaptive introjects, which then trigger reactive parts. For example, when Jennifer’s boss corrected her harshly, she suddenly felt overwhelmed, powerless, and childlike. A mother-introject message, “If you’re not perfect you’re despicable,” played back and activated a reactive part believing, “If I’m not perfect I’m despicable.”

Reactive Parts

Reactive parts are wounded parts of self that hold negative beliefs like “I’ll never be good enough,” “I’m powerless to protect myself,” and “I’m unlovable.” They are formed in reaction to significantly wounding people, like abusive or rejecting parents. They stay stuck in the past, reacting to the maladaptive introjects that mimic those wounding people. Maladaptive Introjects

Mirror neurons record our encounters with others—for better or worse. Recorded messages from significant encounters get saved and can play back over and over. In adulthood, maladaptive introjects are parts of self that form when mirror neurons record especially wounding encounters. They play back wounding messages, like “You’ll never be good enough,” “You’re powerless to protect yourself,” and “You’re unlovable.” This can create the illusion that the original wounding experience is still happening and relevant right now—even if it stopped happening years ago. The DNMS conceptualizes introjection a little differently from other therapy models. It posits that when an unkind person is significantly wounding, a recording of the encounter, and the wounding message, gets stuck to an innocent part of self like a costume. From that point on, that part wearing the costume does not like it, want it, or need it but cannot take it off. When the costume plays back that recorded message, it is directed to the reactive parts of self, evoking internal conflict. The wounding message is not spoken or endorsed by the part wearing it; in fact, that part has a completely opposite point of view but no way to express it. The disturbing message feels real and threatening enough to the reactive parts now to keep them stuck in the past.

Healing by Meeting Needs

Maladaptive introjects and reactive parts can get completely unstuck from the past when the Resources join with them to meet all their emotional needs (e.g., love, protection, validation, nurturing), process through all their painful emotions (e.g., fear, anger, and grief), and form an emotional bond. This brings these parts out of their painful past and fully into the present. After healing, when Jennifer’s boss harshly corrects her, she effortlessly responds from her most adult self. No wounded parts get triggered. Healing by meeting needs helps in two ways: (1) as wounded parts completely heal, they come in to the present with confidence and self-worth— integrated with the most adult self—and (2) the associated painful memories completely desensitize.

Techniques The process starts with connecting clients to a team of Resources. A problem behavior, belief, or emotion is selected for processing. Reactive parts and introjects connected to the problem are identified, and a series of interventions for helping get them unstuck begins. Once complete, another problem is selected for processing, and the series of interventions is repeated. Resource Development Protocol

Brief guided meditations are used to connect clients to an inner Resource team. The meditations to connect clients to their Nurturing Adult Self and Protective Adult Self are grounded in real, personal experiences of being a competent caregiver of a child, pet, plant, patient, and so on. The meditation

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to connect to a Spiritual Core Self is anchored by a personal peak spiritual experience—a transcendent experience from prayer, meditation, yoga, a near-death moment, or walks in nature. Most clients can readily recall a peak spiritual experience. Target Selection

Problems are selected for targeting based on a client’s therapy goals. Very wounded clients (e.g., those with personality disorders, eating disorders, and dissociative disorders) who have trouble finding a starting point, may opt to process with the DNMS Attachment Needs Ladder—a special questionnaire that lists the negative beliefs clients might hold if their attachment needs were not met well. Beliefs are categorized into four themes and listed in order of importance: Rung 1 lists beliefs about existence (e.g., “I shouldn’t exist”); Rung 2 lists beliefs about physical, sexual, and emotional safety (e.g., “Everyone is out to physically hurt me”); Rung 3 lists beliefs about sense of self (e.g., “I don’t matter”); and Rung 4 lists beliefs about relationships with others (e.g., “People will inevitably reject me”).

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her or his pocket, which feels very good. This typically takes 10 to 20 minutes to complete. A checkin with reactive parts reveals that they feel much less reactive and stuck. Associated unwanted behaviors, beliefs, and emotions begin to diminish. This is repeated for all the introjects connected to the targeted problem or rung. Needs Meeting Protocol

Needs meeting is done with the reactive parts and introjects connected to the targeted problem. They are invited, along with their pocketed costumes, into the Healing Circle. In 20 steps, the Resources meet all their emotional needs, help them process through painful emotions, and establish a loving, supportive bond. Needs get met in six different ways, until the wounded parts are completely unstuck, the painful experiences are no longer disturbing to recall, the wounding messages are no longer upsetting, and the pocketed costumes are completely gone. This protocol takes roughly 1 to 3 hours. Once complete, clients report that those old messages, and the memories attached to them, are no longer triggering.

Reactive Parts Are Invited Forward

Overcoming Processing Blocks Techniques

Reactive parts holding negative beliefs about a targeted problem, or a single Attachment Needs Ladder Rung, are invited forward. They are welcomed and invited to look and see who wounded them. When the reactive part gets a mental picture of a wounding person (the maladaptive introject costume), the therapist helps the reactive part reveal the entire wounding introject message.

The DNMS model includes dozens of effective techniques for understanding and respectfully clearing blocks. All were designed with the assumption that the parts interrupting processing are trying to solve a problem or manage an internal threat.

Switching the Dominance Protocol

This protocol starts with the therapist speaking with the innocent part wearing the (dominant) costume—validating that she or he is different from the costume. A series of steps teaches the part that the costume is just an old recording, not real life. As the part begins to understand that it is a harmless recording, the costume gets smaller. It eventually loses all its animation and becomes small enough to pocket. At the end of this protocol, this part (now dominant) puts the costume in

Therapeutic Process The DNMS is a comprehensive, strengths-based, client-centered approach. It is very gentle and ego strengthening. Clients can get trauma memory resolution without the usual emotionally taxing abreactions common to desensitization protocols. While the DNMS is not brief therapy, it can help some clients resolve deep issues in much less time than talk therapy. Very wounded clients may first need to build rapport with their therapist. They may have blocks to connecting to the Resources that could take weeks to clear. Healthier clients can connect to the Resources right away. Once the

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Resources are mobilized, clients are invited to select a problem to work on. The wounded parts connected to a targeted problem are invited to connect to the Resources. Through a series of steps, the Resources help them become completely unstuck. Once work on a selected problem is complete, clients typically report noticeable benefits. A  new problem is then selected, and these steps are repeated. Clients cycle through these steps as often as they need to until their therapy goals are met. Typically, DNMS therapy takes months to years. It can help clients across the dissociation continuum—but the more dissociated clients typically need more time in treatment. Most report noticeable benefits within a few sessions. Shirley Jean Schmidt See also Attachment Theory and Attachment Therapies; Developmental Counseling and Therapy: Theory and Brain-Based Practice; Ego State Therapy; Eye Movement Desensitization and Reprocessing Therapy; Inner Child Therapy; Person-Centered Counseling; Psychosocial Development, Theory of

Further Readings Gallese, V., Eagle, M. E., & Migone, P. (2007). Intentional attunement: Mirror neurons and the neural underpinnings of interpersonal relations. Journal of the American Psychoanalytic Association, 55, 131–176. doi:10.1177/00030651070550010601 Illsley-Clarke, J., & Dawson, C. (1998). Growing up again: Parenting ourselves, parenting our children (2nd ed.). Center City, MN: Hazelden Information Education. Maslow, A. H. (1968). Toward a psychology of being. New York, NY: Wiley. Schmidt, S. J. (2004). Developmental needs meeting strategy: A new treatment approach applied to dissociative identity disorder. Journal of Trauma & Dissociation, 5(4), 55–78. doi:10.1300/J229v05n04_04 Schmidt, S. J. (2009). The developmental needs meeting strategy: An ego state therapy for healing adults with childhood trauma and attachment wounds. San Antonio, TX: DNMS Institute. Schmidt, S. J., & Hernandez, A. (2007). The developmental needs meeting strategy: Eight case studies. Traumatology, 13, 27–48. doi:10.1177/1534765607299913 Watkins, J. G., & Watkins, H. H. (1997). Ego states: Theory and therapy. New York, NY: W. W. Norton.

DIALECTICAL BEHAVIOR THERAPY Dialectical behavior therapy (DBT) is a treatment that was originally developed for highly suicidal individuals who did not benefit from standard treatments, but later, it evolved into a treatment for complex, multidiagnostic individuals with borderline personality disorder (BPD). DBT is based on change-based principles derived from behavioral science, acceptance-based principles derived from Zen and contemplative practice, and dialectical philosophy. Standard DBT is comprehensive, involving four modes: (1) individual therapy, (2) skills training, (3) 24-hour phone consultation, and (4) DBT consultation team meetings for therapists. Ancillary treatments (e.g., pharmacotherapy and case management) are also part of the comprehensive model.

Historical Context The development of DBT began in the 1970s with the psychologist Marsha Linehan. Linehan completed her graduate training in experimental-personality psychology followed by a clinical internship on suicide prevention and a postdoctoral fellowship in behavior modification. Linehan’s therapeutic training, therefore, was heavily based in social behaviorism and classic principles of standard behavior therapy. Following the completion of her training, Linehan, self-described as a “missionary person,” was motivated to alleviate emotional suffering among those miserable enough to consider suicide. At that time, there was no standard treatment for suicidal behavior. Furthermore, national funding institutions emphasized treatments targeting specific diagnostic groups (e.g., BPD) rather than collections of problematic behaviors (e.g., suicidal behavior). Thus, Linehan chose to focus on BPD because individuals with this diagnosis commonly exhibited chronically suicidal behavior. Initially, Linehan drew from her therapeutic training and attempted to apply traditional principles of behavior therapy to the treatment of suicidal behavior. However, after implementing change-oriented strategies, such as contingency management and skills training, Linehan quickly learned that such a change-heavy, solutionfocused treatment was ineffective with this group.

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Individuals with BPD exhibited high sensitivity to rejection and criticism and experienced the heavy change focus in Linehan’s treatment as invalidating. Consequently, clients did not learn or collaborate with the therapist, and they withdrew from therapy, shut down, or became defensive, which sometimes included verbal attacks. Linehan knew that she needed to try something different, so she radically altered her approach from one of change to one of acceptance. Linehan had previously spent 3 months at Shasta Abbey, a Zen monastery, and 3 months in Germany studying under a Benedictine monk who is also a Zen master (Willigis Jäger, OSB [Ko-un Roshi]). Thus, she drew heavily on these teachings and on Zen philosophy to apply mindfulness and acceptance-based techniques in therapy. This was a radical departure from her previous approach, as validation, support, and empathy for the client were now emphasized. However, once again, this approach was also ultimately ineffective. While clients may have felt understood, the lack of focus on change led clients to feel that the therapist ignored their extreme level of suffering. Clients experienced extreme arousal, as well as hopelessness and occasional rage at the therapist. Put simply, clients reported needing help to change, and empathy alone was insufficient. The failure of these two polarized approaches led Linehan to consider a balance of acceptance and change as the basis of successful treatment. Indeed, Linehan discovered that integrating acceptance and change were the critical ingredients in facilitating progress in therapy. Much like two individuals sitting on opposing ends of a teetertotter adjusting their placements to create balance and movement, Linehan conceptualized movement in therapy as a constant balance of opposing “truths.” Part of this balance required teaching the client to tolerate and accept one set of problems while problem solving another set of problems. Without acceptance of one’s problems or behaviors, little could be done to change them. Emphasizing the balance of acceptance and change led Linehan to consider dialectical principles, espoused by the German philosopher Georg Wilhelm Friedrich Hegel, as the theoretical anchor for treatment. A dialectical worldview purports that everything is composed of opposing polarities and forces. Although the two polarities oppose

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each other, both contain degrees of validity and truth. When a synthesis is formed between the two polarities (e.g., acceptance and change), the individual is able to move forward. With the discovery of dialectics, the last piece of the puzzle fell into place; this overarching dialectical balance led to success in the treatment of BPD, and it came to form the backbone of DBT.

Theoretical Underpinnings The biosocial model is the theoretical framework underpinning DBT. Within this model, emotion dysregulation is the essence of BPD and accounts for the behaviors associated with the disorder (e.g., self-harm, suicidality, anger outbursts). Emotion dysregulation is theoretically conceptualized to consist of two primary components. The first involves a biological vulnerability to emotion dysregulation (e.g., higher sensitivity and/or intensity of emotional responding and slower emotional recovery), and the second includes difficulties regulating emotional responses (i.e., difficulties altering emotional experiences and intensity, either volitionally or automatically). The biosocial model suggests that emotion dysregulation, and subsequently BPD, arises from a transaction between a child who is biologically vulnerable to emotion dysregulation and an invalidating early environment. Early in development, the reciprocal influence between these two entities results in a child who becomes increasingly emotionally dysregulated and eventually develops BPD. An invalidating environment pervasively negates or dismisses an individual’s behavior (thoughts, emotions, or actions) independent of the actual validity of the behavior; it arbitrarily communicates to the individual that his or her behavior is inaccurate or inappropriate and, therefore, is characterized by unpredictability and uncertainty. An invalidating environment might respond erratically or inappropriately to the child’s expressions of his or her private experiences (e.g., emotions, thoughts, and sensations) such that the child never learns how to accurately identify or label his or her own experiences. Such an environment might also intermittently reinforce a child’s emotional escalation and, therefore, result in a child who oscillates between extreme emotional inhibition and intense emotional displays. Finally, this environment may

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also oversimplify the ease of problem solving. Consequently, the child never learns to tolerate distress and develops perfectionistic expectations for high emotional control and effective problem solving. Based on this conceptualization, DBT teaches individuals with BPD the skills necessary to effectively and simultaneously accept, validate, and regulate their emotional experiences.

Major Concepts Some of the major points to consider in the understanding of DBT include BPD, suicide and selfharm behaviors, dialectics, and mindfulness. Borderline Personality Disorder

BPD is a severe and complex disorder characterized by a pervasive pattern of instability in emotions, interpersonal relationships, sense of self, and impulsivity. At least five of the nine Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-5) criteria need to be met to receive a BPD diagnosis: (1) frantic efforts to avoid abandonment, (2) instability in interpersonal relationships, (3) identity disturbance, (4) impulsivity, (5) suicidal behaviors, (6) emotional instability, (7) chronic feelings of emptiness, (8) inappropriate or intense anger, and (9) stress-related paranoid ideation or dissociation.

A dialectical worldview also assumes that change and movement are inherent in all systems and that change is transactional and, therefore, nonlinear in nature. This is in part because the interplay of forces is presumed to reciprocally influence each unit in the relationship and the whole that they define. There is no one unit that causes change in all others without also being affected itself. Stasis and stability are the exception rather than the norm or ideal. Truth is neither absolute nor relative but instead reflects a constant evolution. Finally, it is important to note that a dialectical worldview emphasizes a complex interplay between two opposing forces (i.e., thesis and antithesis). A synthesis between these two oppositional units does not dilute the truth of either side. Rather, two seemingly opposed units can hold truth and combine to reveal a new understanding that reflects the interplay of both parts at their full intensity (i.e., a synthesis). For example, the primary dialectic underpinning DBT is between acceptance and change. Both aspects of this dialectic are true: Clients must accept themselves as they are, and clients must change. The “synthesis” of these two opposed truths does not necessarily reflect the average “score” of acceptance and change, but rather, it is a continuous ebb and flow between these positions. Mindfulness

Suicide and Self-Harm Behaviors

The vast majority (i.e., approximately 84%) of individuals with BPD engage in self-harm behaviors, and approximately 10% die by suicide. Thus, the reduction of suicide and self-harm behaviors constitutes the highest behavioral target in DBT. Dialectics

Dialectics is a way of understanding and relating to the world. DBT is nested within a dialectical worldview heavily influenced by Hegel’s writings. A dialectical worldview is relational in nature, such that units of any given system are defined solely in relation to other units that constitute that system. From this perspective, all entities are rendered by their changing relationship to other entities; the independent units of a whole by themselves are meaningless.

Mindfulness originated from Eastern contemplative practices and, in DBT, is primarily based on Zen practice. Mindfulness is similar to other contemplative and meditation practices and consists of attending to and observing the present moment without trying to change it; it refers to being awake and responding to “what is” using a nonjudgmental and accepting stance. Thus, mindfulness entails opening oneself to reality just as it is and subsequently engaging or becoming one with reality using skillful means. In DBT, mindfulness is taught as the foundational skill underpinning the other DBT skills.

Techniques The techniques employed in DBT reflect a dialectical balance of acceptance strategies and change strategies and include validation, behavioral chain

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analysis, skills training, exposure, contingency management, and cognitive modification. The therapist’s role is to assess the client’s moment-tomoment behaviors and mindfully respond with the therapeutic technique that will best lead the client toward his or her goals. Validation

Validation, the primary acceptance strategy in DBT, refers to communicating to the client that his or her behavior makes sense or is meaningful or justifiable in some way. There are six levels of validation in DBT. Level 1 refers to simply being present to the client and exhibiting unbiased listening and observing. Level 2 is an accurate reflection of the client’s verbal communication and meaning. At Level 3, the therapist “speaks the unspoken” and articulates the client’s unverbalized emotions, thoughts, or behaviors. This level of validation reflects a tacit intimacy between the client and the therapist such that the therapist can effectively “mind read” the client’s thoughts and emotions. Level 4 communicates that the client’s emotions, thoughts, or behaviors are valid in terms of his or her learning history or biological dysfunction. The biosocial theory, described earlier, is an example of Level 4 validation. In contrast, Level 5 communicates that the client’s emotions, thoughts, or behaviors are valid in terms of the present context or normative functioning (e.g., “It’s perfectly normal to be anxious meeting your partner’s parents”). Finally, Level 6 is the highest level of validation and refers to the therapist exhibiting “radical genuineness” toward the client. This concept shares the basic tenets of Carl Rogers’s person-centered therapy such that the therapist validates the client as a whole, accepting and responding to him or her without judgment. The therapist responds to the client with genuineness, rather than through arbitrary rules, and treats the client as an equal. Behavioral (Chain) Analysis

Behavioral, or chain, analysis is the primary assessment strategy employed in DBT. The behavioral analysis is a detailed, moment-to-moment analysis of the client’s thoughts, emotions, and actions that preceded and followed a problem behavior. The first step in the behavioral analysis entails clearly identifying the client’s problem

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behavior (e.g., self-harm). Next, the therapist aims to identify the prompting event or situational factor that triggered the problem behavior (e.g., fight with mother). Factors that render the individual vulnerable to the prompting event (e.g., vulnerability factors) might also be identified. Vulnerability factors might include environmental factors (e.g., recently receiving bad news) and/or dispositional states (e.g., being irritable) that give the prompting event greater “power.” Once the prompting event and vulnerability factors are identified, the therapist employs a chronological, moment-to-moment assessment approach by curiously inquiring about specific “links” (e.g., emotions, thoughts, or behaviors) between the prompting event and the problem behavior. Finally, the therapist identifies the consequences of the problem behavior (e.g., feeling relief) that are likely to maintain or increase the recurrence of the problem behavior. Throughout or after completion of the chain analysis, the therapist assists the client with generating alternative behaviors or solutions along the behavior chain to decrease the likelihood of the problem behavior occurring again. Skills Training

DBT is based on a skills deficit model, which assumes that individuals with BPD do not have the skills necessary to reach their behavioral goals. Thus, DBT aims to help individuals acquire, strengthen, and generalize the relevant skills to their everyday environments. DBT skills training typically occurs in a group format over a 1-year period. The skills are taught cyclically and are divided into four modules: (1) mindfulness, (2) interpersonal effectiveness, (3) emotion regulation, and (4) distress tolerance. The mindfulness skills represent the acceptance side of the dialectic and involve teaching individuals how to observe and be present in the current moment without judgment of, or attachment to, the moment’s experience (e.g., thoughts, sensations, urges). Mindfulness teaches clients to be aware of and accept the world as it is, and not as it should be, and to respond to each moment effectively. The interpersonal effectiveness skills have to do with teaching individuals how to apply interpersonal and problem-solving skills to obtain their goals in interpersonal contexts. Individuals are taught how to maximize the probability of obtaining their goal

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while, simultaneously, not damaging their relationships or self-respect. Emotion regulation skills teach clients to actively modify or change their emotions in the service of meeting a long-term goal. These skills teach clients how to make themselves less vulnerable to experiencing intense emotions, as well as how to change their experience of emotional suffering through mindful experiencing and acting opposite to the way they feel. Finally, distress tolerance skills consist of a blend of acceptance skills, which teach clients how to accept the reality of their difficult situation, and change skills, which teach an individual how to survive a crisis without making it worse. Exposure

Exposure is based on the rationale that an individual’s avoidance of emotions causes more suffering than the emotion itself. Exposure in DBT is implemented both formally and informally. Formal exposure entails a structured and systematic repeated application of exposing a client to an avoided cue to decrease anxiety. Formal exposure is typically applied during a discrete period of treatment. In contrast to formal exposure, informal exposure is weaved intermittently throughout therapy and is used to target any problematic emotion. Informal exposure entails exposing the client to the cue eliciting the problem emotion (e.g., shame, anger, sadness) for a briefer period than that used in formal exposure. Contingency Management

Contingency management entails the mindful and systematic application of operant principles to shape the client’s behaviors in the service of reaching the desired goals. From this perspective, an individual’s behavioral repertoire is largely a result of the individual’s learning history. Thus, principles of reinforcement and punishment are applied such that skillful behaviors (e.g., being mindful of emotions) are more likely to occur and unskillful or dysfunctional behaviors (e.g., self-harm) are less likely to occur. To increase or strengthen a skillful behavior, the therapist might add a reinforcer or remove something aversive. To weaken a dysfunctional behavior, the therapist might withhold a reinforcer or maintain an aversive consequence. Finally, to suppress an undesirable behavior, the

therapist might add an aversive consequence or remove a positive one with benevolent care. Cognitive Modification

DBT employs two types of cognitive modification procedures: (1) contingency clarification and (2) cognitive restructuring. Contingency clarification refers to highlighting to the client the relationship between his or her behavior and the environment, including others’ responses. The idea is that becoming aware of the outcomes of one’s behavior increases the likelihood of engaging in skillful behavior. The purpose of cognitive restructuring is to help the client change both the way the client thinks as well as the content of the thoughts. The therapist might challenge the client’s rigid or extreme ways of thinking and encourage more dialectical thinking. A variety of strategies used in standard cognitive therapies are used to change the content of the thought. For instance, the therapist might challenge the client to develop experiments to test the clients’ beliefs and/or examine whether the beliefs are logically consistent.

Therapeutic Process There are four stages of treatment in standard DBT, as well as a pretreatment stage. In the pretreatment phase (typically four sessions), the therapist collaborates with the client to decide whether they are willing to work with each other, to identify specific behavioral goals for therapy (e.g., reduction of suicidal behavior), and to obtain commitment to treatment. Once commitment is obtained, the client enters Stage 1, where the overall goal is to achieve behavioral stability and control. Within this overarching goal, therapy targets for Stage 1 are organized hierarchically such that decreasing life-threatening behavior (e.g., suicide and selfharm behaviors) is the highest target. This means that, when it is present, decreasing this behavior takes precedence to working on other behaviors. Decreasing therapy-interfering behaviors (e.g., showing up late, noncompliance) is the next highest target, followed by decreasing quality of life– interfering behaviors (e.g., depression, finding housing). Throughout Stage 1 of DBT, behavioral skills are taught, strengthened, and generalized. Stage 2 of DBT focuses on “quiet desperation” in which disorders of moderate severity, such as

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posttraumatic stress disorder and mood disorders, are addressed. The overall goal of this stage is for the client to be able to experience emotions without the secondary experience of extreme anguish and suffering. Stage 3 focuses on “problems in living” and aims to help the client address other outstanding psychological disorders or problems that may interfere with “ordinary” happiness. Standard treatment manuals for other disorders may be applied, with the ultimate goal of decreasing mildseverity mood and anxiety disorders and increasing overall quality of life. Finally, Stage 4 is predicated on helping the client decrease outstanding feelings of emptiness and incompleteness. Goals for this stage include expanding one’s awareness of one’s self in relation to others and the world and obtaining spiritual fulfillment. Janice R. Kuo and Skye Fitzpatrick See also Applied Behavior Analysis; Behavior Therapy; Cognitive-Behavioral Therapy; Exposure Therapy; Linehan, Marsha; Mindfulness Techniques; Operant Conditioning; Prolonged Exposure Therapy

Further Readings Brown, M. Z. (2006). Linehan’s theory of suicidal behavior: Theory, research, and dialectical behavior therapy. In T. T. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 91–117). Washington, DC: American Psychological Association. Harned, M. S., Banawan, S. F., & Lynch, T. R. (2006). Dialectical behavior therapy: An emotion-focused treatment for borderline personality disorder. Journal of Contemporary Psychotherapy, 36, 67–75. doi:10.1007/s10879-006-9009-x Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York, NY: Guilford Press. Koerner, K., & Linehan, M. M. (2002). Dialectical behavior therapy for borderline personality disorder. In S. Hofmann & M. Tompson (Eds.), Treating chronic and severe mental disorders: A handbook of empirically supported interventions (pp. 317–342). New York, NY: Guilford Press. Linehan, M. M. (1987). Dialectical behavior therapy for borderline personality disorder: Theory and method. Bulletin of the Menninger Clinic, 51, 261–276. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

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Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1997). Validation and psychotherapy. In A. Bohart & L. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 353–392). Washington, DC: American Psychological Association. Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 64, 459–480. doi:10.1002/jclp.20243 Rizvi, S. L., Welch, S., & Dimidjian, S. (2009). Mindfulness and borderline personality disorder. In D. Fabrizio (Ed.), Clinical handbook of mindfulness (pp. 245–257). New York, NY: Springer Science + Business Media. Robins, C. J., Schmidt, H., & Linehan, M. M. (2004). Dialectical behavior therapy: Synthesizing radical acceptance with skillful means. In S. Hayes, V. Follette, & M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioural tradition (pp. 30–44). New York, NY: Guilford Press.

DIRECTIVE THERAPY Directive therapy and counseling is based on a systems model for the identification and modification of etiologic factors in behavioral maladjustment. Rather than focusing on psychodynamics or individual insight, the intent of directive therapy is to change behavioral interactions within a family or organizational system. In this model, the therapist designs or selects a task or directive to solve the identified problem; thus, the therapist assumes full responsibility for the success or failure of treatment. In contrast to nondirective and collaborative approaches, directive therapy and counseling is typically conducted without explanation, requiring the client to trust the therapist as an expert who determines the method of intervention and the structure of the therapeutic relationship.

Historical Context Directive therapy is closely connected to the beginnings of strategic family therapy. The newly formed models of family therapy, which began developing in the 1950s, represent the confluence of two

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important influences: (1) the cybernetic systems theories of Gregory Bateson and (2) the case work of Milton H. Erickson. In the 1940s, Bateson extended cybernetics and systems theory to the social/behavioral sciences. In 1953, Bateson teamed with John Weakland, Jay Haley, Don D. Jackson, and William Fry to conduct a series of research projects based on Bertrand Russell and Alfred North Whitehead’s theory of logical types. In 1954, Bateson received a grant from the Macy Foundation to study schizophrenia and was then joined by Jackson. The newly formed group focused their research on the communication patterns of people diagnosed with schizophrenia to determine the origin of the symptoms. They examined the nature of human communication processes, context, and paradox. Five years later, Jackson established the Mental Research Institute (MRI), where he was joined by Virginia Satir and Jules Riskin, and later by Paul Watzlawick, Jay Haley, and John Weakland. This group would become one of the most creative teams of research/ practitioners in the field of marriage and family therapy. It was the writing and research of these individuals that framed family therapy as a distinct discipline. Within this context, various members of the MRI group created the strategic approach to therapy. In 1967, Haley left MRI to join Salvador Minuchin and Braulio Montalvo in a 10-year collaboration at the Philadelphia Child Guidance Clinic. Having studied under three of the most influential pioneers in the evolution of family therapy (i.e., Bateson, Erickson, and Minuchin), Haley combined their ideas to create strategic problem-solving therapy. Although Haley’s technique was most heavily influenced by Erickson’s modern approach to hypnosis, Haley did not accept Erickson’s insistence that the individual should be viewed as the basic unit of change. In keeping with the systems theories of Bateson, Haley insisted on treating the family as the basic unit of change. Like Minuchin and other structuralists, Haley believed that the symptoms or presenting problem should be addressed in treatment and that symptoms and problems are reflective of the underlying family structure. In 1976, Haley moved to Washington, DC, and with Cloè Madanes founded the Family Therapy Institute, which became the major training force behind the Haley-Madanes model for strategic therapy.

During the same time, the MRI team, also known as the Palo Alto Group, continued to develop its own version of strategic/directive therapy, including starting one of the first formal training programs in family therapy. In 1967, the Brief Therapy Center opened under the leadership of Jackson. Jackson was revered by his colleagues for his clinical wisdom and his ability to instantly accurately assess the problems and history of a family after viewing a video with just 2 minutes of interaction. Unfortunately, in 1968, at the age of 48, Jackson died by his own hand. Shaken by this tragedy, but not discouraged, Watzlawick emerged as the intellectual force that would lead the development of the second arm of strategic therapy. At the newly formed treatment center, the goal of therapy was to directly address the presenting complaint rather than to interpret the interactions to the family or to explore the past. In this model, the therapist first assesses the cycle of problematic interactions and then interrupts the cycle by using either straightforward or paradoxical directives. In contrast to Haley’s work, the theoretical orientation that emerged at MRI had its own set of premises about the nature of change and the role of the therapist. Shortly after, a third arm of strategic therapy began to develop in Europe under the leadership of Mara Selvini Palazzoli. In 1967, Palazzoli broke from the original Milan group and formed the Center for Family Studies with Luigi Boscolo, Gianfranco Cecchin, and Giuliana Prata. After reading the work of Bateson, Palazzoli abandoned her formal training in psychoanalysis and embraced the newly emerging family systems approach to therapy. After having read Haley’s 1959 article “The Family of the Schizophrenic: A Model System,” the research team decided to use a similar methodology to study systems interactions in families of anorexic clients, within the context of treatment. Initially, Watzlawick was invited to serve as a consultant to the group. In 1981, the Milan group published its work with families of anorexics, which led to international recognition for the team’s contributions to family therapy and strategic or directive forms of intervention.

Theoretical Underpinnings All forms of directive therapy have in common an original grounding in cybernetic theory. The word cybernetics comes from the Greek word for

Directive Therapy

“government” and was defined by Norbert Wiener, in 1948, as the scientific study of control and communication in animals and machines. Cybernetics is essentially concerned with how regulatory systems are controlled by feedback loops. When applied to families, cybernetic theory suggests that if communication patterns among family members are altered, all the members within the family system will begin to think, feel, and behave differently. Before directive therapy, the prevailing theoretical assumption in psychotherapy was that psychological symptoms stem from hidden psychological dynamics. Thus, “curing” the problem required that clients gain conscious insight into the unconscious impulses governing their behavior, which was a slow, arduous process that could take years. By contrast, Erickson demonstrated that therapy can be focused directly on the specific symptoms and problems presented by the client. Erickson believed that people had the ability to solve their own problems if they could be induced to try new behaviors. Using case studies, Erickson demonstrated that the process of change could be brief and that the client’s own natural resistance to change could, paradoxically, be used to bring about change. Because the newly emerging social cybernetic theory was more interested in altering patterns of interaction than in developing causal explanations for problems, it proved to be a good fit for conceptualizing Erickson’s radically different approach to therapy.

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First-Order Change/Second-Order Change

When family patterns of interaction are altered at the behavioral level only, it is considered a firstorder change. By contrast, a second-order change represents changes in the family rules or underlying beliefs that govern the family members’ behavior. For example, a father may consider a child’s playful affection a sign of poor discipline. A therapist trained in the MRI model would attempt a second-order change by reframing the child’s behavior as a sign of good mental health and as an indication that the parent has given the child happiness that he might have wished for during his own childhood. Hierarchical Arrangement

In contrast to the more neutral approach of the MRI and Milan groups, Haley and Madanes believe that symptoms stem from a faulty organization within the family and that the function of the symptom is to maintain the system’s structure and state of homeostasis. The hierarchical arrangement within the family becomes a crucial point or intervention. Haley believed that an individual is as disturbed as the number of malfunctioning hierarchies within which he or she is embedded. Madanes added the concept of incongruous hierarchies, which are created when children use symptoms to try and change their parents. Logical Connotation

Major Concepts Important major concepts in directive therapy include positive feedback loop, first-order change/ second-order change, hierarchical arrangement, and logical connotation. Positive Feedback Loop

The MRI group argues that families make commonsense but misguided attempts to solve their problems. These solutions fail because the selection of a solution, as well as its implementation, is governed by the same set of system rules that created the initial problem. When these attempts go awry, a positive feedback loop is created that makes the problem worse. The job of the therapist is to identify the feedback loop, expose the rules governing it, and change the loop and rules.

Logical connotation states that there is no need to frame symptomatic behaviors as useful or necessary to the family but, rather, the behavior has become familiar and habits are hard to break. The symptom is neither good nor bad; it is merely understandable given the context in which it developed.

Techniques Techniques in directive therapy include paradox and symptom prescription, therapeutic double bind, reframing, and rituals. Paradox and Symptom Prescription

A paradox is a contradiction. Accordingly, interventions involving the use of paradox are

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based on the expectation that families experiencing symptoms or communication problems are in most cases resistant to change. To counter this resistance, the therapist can forbid family members from changing, insist that change occur slowly, or ask the family to change in ways that seem to run counter to their desired goals. It is the family’s unification and rebellion against the therapist that then achieve the objectives of therapy. The use of resistance to promote change by applying specific strategies is a defining characteristic of strategic therapy. Therapeutic Double Bind

A therapeutic double bind promotes progress no matter how the family responds. For example, if a member of the family was to announce in therapy that he or she has nothing to say, then the therapist could instruct that person to say nothing during the course of therapy. Instead, he or she is to merely listen to everyone’s opinions and think about what can be learned from them. This creates an opportunity for helpful rebellion, if he or she begins to share opinions, or useful compliance, if the hour is spent listening.

odd days, they are false. On the seventh day, the family is to act spontaneously. This is one of many ways to introduce change into the system.

Therapeutic Process Directive therapy provides change through direction or metaphor. A trusting relationship is established, including empathy, concern, and encouragement. Then, the opportunity for providing a straightforward directive is created. Focus is given to symptoms in the present, and the social context, without insight or interpretation. The therapist tells clients what to do and then waits while the clients determine what to do with the directive. Clients’ abilities, strengths, and resources are necessary for resolution of their problems. Directives are carried out outside the session. Directives incorporate what to do, give advice, and coach clients. Dan Short, Elsa Soto Leggett, and Katherine Bacon See also Erickson, Milton H.; Eriksonian Therapy; Haley, Jay; Solution-Focused Brief Family Therapy; SolutionFocused Brief Therapy; Strategic Family Therapy

Reframing

Reframing is the use of language to give new meaning to an existing set of circumstances. It is a reinterpretation of events that may lead to behavioral change (first-order change) or a change in beliefs that govern the family (second-order change). Rituals

Rituals are interventions that require the family to either exaggerate or violate family rules. For example, rather than responding with fear or criticism to the child who makes suicidal comments, the family might be told to stay home from work and stay home from school any day there are suicidal gestures and spend that day practicing a family hug, with the child in the middle. Another example is the odd day/even day ritual. Typically, the therapist will give a directive that on even days the existing set of family beliefs are true. Then on

Further Readings Amini, R. L., & Woolley, S. R. (2011). First-session competency: The brief strategic therapy scale-1. Journal of Marital & Family Therapy, 37(2), 209–222. doi:10.1111/j.1752-0606.2010.00201.x Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy: Conversations in theory and practice. New York, NY: Basic Books. Ceballos, P. L., & Bratton, S. C. (2010). Empowering Latino families: Effects of a culturally responsive intervention for low-income immigrant Latino parents on children’s behaviors and parental stress. Psychology in the Schools, 47(8), 761–775. doi:10.1002/ pits.20502 Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, T., & Trepper, T. S. (2012). From Ericksonian roots to postmodern futures: Part I. Finding postmodernism. Journal of Systemic Therapies, 31(4), 63–76. doi:10.1521/ jsyt.2012.31.4.63 Chenail, R. J., St. George, S., Wulff, D., Duffy, M., Scott, K. W., & Tomm, K. (2012). Clients’ relational

Drama Therapy conceptions of co-joint couple and family therapy quality: A grounded formal theory. Journal of Marital & Family Therapy, 38(1), 241–264. doi:10.1111/j.1752-0606.2011.00246.x Frojan-Parga, M. X., Calero-Elvira, A., & MontanoFidalgo, M. (2009). Analysis of the therapist’s verbal behavior during cognitive restructuring debates: A case study. Psychotherapy Research, 19(1), 30–41. doi:10.1080/10503300802326046 Haley, J. (1987). Problem-solving therapy. San Francisco, CA: Jossey-Bass. Haley, J., & Richeport-Haley, M. (2007). Directive family therapy. Binghamton, NY: Haworth Press. Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York, NY: W. W. Norton. Zeig, J. K., & Munion, W. M., (1999). Milton H. Erickson. Thousand Oaks, CA: Sage.

DRAMA THERAPY Drama therapy (DT) is the intentional and systematic use of theater techniques to facilitate personal growth, promote health, and achieve therapeutic goals. DT is a form of action psychotherapy wherein individuals take on roles for therapeutic purposes. DT, along with other creative arts therapies, represents an important development in counseling and psychotherapy because it was one of the first approaches to intentionally integrating creative arts and process into treatment.

Historical Context DT is rooted in the rich history of drama as a cultural activity used by most societies for thousands of years for healing, storytelling, ritual, and celebration. Aristotle was one of the first to acknowledge the connection between drama and social healing, and he coined the term catharsis. DT was profoundly influenced by experimental approaches to theater, group dynamics, role-playing, and psychology in the 1960s, and it emerged as a creative arts therapy in the 1970s, when the North American Drama Therapy Association (NADTA) was formed. NADTA continues to serve as a member association to advocate for the profession, and

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it upholds requirements that must be met to qualify as a registered and board-certified drama therapist. DT should be distinguished from psychodrama, which was developed by Jacob Moreno in the early part of the 20th century. Both DT and psychodrama were developed for therapeutic purposes. Two different forms of DT developed in the United Kingdom and the United States. In the United Kingdom, Peter Slade coined dramatherapy in the 1950s, which developed out of his educational work with children. Sue Jennings expanded the field and extended its scope, while Marion Lindkvist founded a training organization in London called Sesame. In the United States, Eleanor Irwin, David Read Johnson, and Gertrud Schattner played important roles in the development and organization of the profession of DT. Others, such as Robert Landy, were integral to the development of training programs. Today, DT is an accepted form of therapy, as evidenced by the fact that there are credentialing standards, a recommended curriculum, a code of ethics, a peer-reviewed journal, and a professional association (NADTA). Drama therapists work with individuals and groups of all ages in a wide variety of settings, including mental health facilities, schools, medical settings, private practice, substance abuse treatment centers, correctional facilities, after-school programs, shelters, group homes, nursing homes, medical schools, training organizations, nursing homes, and theaters. Goals for DT include behavioral change, emotional and physical integration, skill building, and personal growth.

Theoretical Underpinnings Dramatic activity is a natural part of our existence and seen in the play of children, teaching, theater, ritual, prayer, and the service of healing. Shamanic healers have used drama, chanting, and dance for thousands of years in many diverse cultures. The theoretical foundation of DT represents a confluence of principles in drama, theater, psychology, psychotherapy, anthropology, play, and creative processes. DT is active and experiential and provides a context for participants to tell their stories, solve problems, express feelings, develop empathy,

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or achieve catharsis. Through drama, both the depth and the breadth of inner experience can be actively explored. Drama also provides a structure for enhancing interpersonal relationship skills. Participants can explore a repertoire of roles to build strengths and explore identity. Developmentally, drama begins when an infant first becomes aware of the body. William James described this as the “I” and “me”; in psychodynamic terms, this dynamic describes the observing ego. Drama therapists acknowledge this awareness of the body as a separate entity as “actor” and “role” or as “actor” and “observer.”

Major Concepts A few of the major concepts that drive the application of DT include models of DT, assessment in DT, DT as an alternative treatment modality, DT with children, DT with addictive disorders, and using DT in other ways. Models

Three models that have been used in the application of DT are (1) role theory and role method, (2) the integrative five-phase model, and (3) the developmental transformations model. Role Theory and Role Method Developed by Landy, role theory and role method draw from the theater and a taxonomy of roles that can be found in Western dramatic literature, from Greek to contemporary drama. According to Landy, the aim of DT is to find a balance between contradictory roles and to learn to live with the ambivalence related to those roles. An example of this would be finding a balance between the roles of victim and survivor. Steps in the role methods include invoking the role, naming the role, playing the role, exploring the relationships between roles, reflection on role-play, relating the fictional role to real life, integrating roles, and social modeling. The Integrative Five-Phase Model Renée Emunah developed a model of treatment based in phases that incorporates role theory and psychodrama. According to Emunah, the model is

based in humanistic psychology, especially in the work of Carl Rogers and Abraham Maslow. Phase 1 is dramatic play, a foundation for the other phases. Dramatic play is improvisational and may include dramatic activities and theater games. Phase 2 is scene work wherein participants develop sustained dramatic scenes using roles and characters. Clients may reflect on their experiences, and the audience (observers) also have an opportunity to share feedback and observations. Role-play is the focus in Phase 3, when the participants apply the notion that drama is rehearsal for life. They may examine specific problems in life or prepare for upcoming events. Phase 3 includes role reversals, to play the roles of significant others. Phase 4 is called culminating enactment and indicates a shift from behavior to  awareness of deeper issues or concerns. This phase operates more along the lines of psychodrama, allowing for introspection and exploration. The final phase is dramatic ritual and concerns closure. This approach is a group process approach; thus, it is important to validate each member’s contributions and the level of intimacy and trust achieved by the group. Developmental Transformations David Read Johnson developed this approach and defined it as embodied encounters in the playspace. Developmental transformations is an improvisational approach; participants interact dramatically within a space defined as a playspace and one that is dramatic in that it is separated from everyday life. After the client begins to play, the therapist joins in and the process of play is used to remove any psychic structures that may inhibit or otherwise create barriers to being. Spontaneity and flow are critical to the process, and the basic premise is that healing takes place within the enactment. Assessment in Drama Therapy

Role-playing and improvisation can be used for psychological assessment. Moreno’s Spontaneity Test was developed in 1946. Later, in the 1970s, Johnson developed the Diagnostic Role-Playing Test. Eleanor Irwin used a “Puppet Interview,” applying psychoanalytic theory to DT assessment.

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Landy developed the Tell-a-Story and Role Profiles, both based in a role theory framework. The Tell-a-Story assesses an individual’s ability to invoke roles within a narrative structure, explore their meanings, and relate the fictional roles to the person’s life roles. The process involves inventing a narrative and conveying the story, verbally, nonverbally, or both. The assessor then processes the experience with the client by asking questions about the characters and themes in the story. The Role Profiles assessment is a card sort involving 70 cards that contain the name of a role, such as “sister,” “outcast,” “wise person,” “warrior,” or “child.” The client is asked to sort the cards into four categories as quickly as possible. The four categories are (1) “I am this,” (2) “I am not this,” (3) “I am not sure if I am this,” and (4) “I want to be this.” A series of questions follows the card sort so that the assessor can gauge the client’s ability to evoke and attribute meaning to the roles. Landy’s tools are also used as instruments in research on DT; further research is needed to continue developing applications in treatment. Alternative Treatment Modality

DT can provide an alternative form of expression and interaction for those who feel limited by traditional verbal therapy or prefer a more embodied, action-oriented approach. DT interventions can take many forms depending on individual and group needs, skill and ability levels, interests, and therapeutic goals, and they are limited only by the imagination. Processes and techniques may include improvisation, theater games, storytelling, and enactment. Many drama therapists make use of text, performance, or ritual to enrich the therapeutic and creative process. Drama Therapy With Children

Some specific benefits likely to be achieved in DT with children include reducing feelings of isolation, developing new coping skills and patterns, broadening the range of expression of feelings, experiencing improved self-esteem and self-worth, increasing the sense of play and spontaneity, and developing relationships. According to Erik Erikson and other theorists, play allows children to gain mastery over conflicts and anxieties. DT

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provides a developmentally appropriate means of processing events with children and adolescents for whom verbal methods alone may be insufficient. It taps into their natural propensity toward action and utilizes it to engage children in play as a means of safely exploring issues and painful feelings. Because the drama therapist is willing to meet the child where the child is, be it angry, frustrated, or refusing to talk, and because DT accesses the imagination, it is a safer, familiar method for young people. This is particularly true for those who have a hard time trusting or connecting with adults or who might otherwise struggle in therapy. Drama Therapy and Treatment of Addiction

DT promotes an environment in which clients in treatment for addiction can openly express emotions, explore a drug-free future, develop communication skills, make personal connections, and practice honesty. Because it is action oriented, DT allows clients to act out negative behaviors, such as drug seeking, and consider their harmful impact in a more concrete way than traditional treatment approaches, without consequences. Clients are urged not to rationalize or deny addiction; rather, through the dramatic process, they are challenged to face their issues directly and truthfully. Through DT, clients have the opportunity to practice new skills, such as refusing drugs, and to imagine and take on new roles, such as a sober self. In addition, techniques such as role-play and improvisation offer clients a fresh perspective on their behaviors, choices, and relationships. Clients explore and develop their innate strengths through theatrical techniques that offer the distance necessary to consider their addiction (and resulting issues) without feeling overwhelmed. Other Treatment Issues

DT can be an ideal approach for adults who have excellent verbal skills but have difficulty translating awareness and insight into action. It can be used effectively to address preverbal memories and trauma and/or abuse when painful or frightening memories manifest in the body. Similarly, it can be useful when individuals are

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developing the ability to stand up for themselves. Becoming empowered involves more than learning the words to say; it must be accompanied by the appropriate posture and movement qualities that are fully integrated. In addition, DT has been effective in the treatment of older adults by focusing on cognitive and communication skills, increasing physical activity and creativity, and strengthening community. For higher functioning groups, a drama therapist may apply sociodrama techniques, guiding participants to create enactments that will help them develop ways to cope with stress, solve problems, or rehearse social skills. Research conducted on the effectiveness of DT with various populations showed that DT was successful in resolution of trauma, recovery from abuse, and management of symptoms in palliative care settings. DT has been helpful when used to augment cognitive-behavioral group therapy, particularly with offenders, and it has helped reduce anger in offenders with psychological disorders. Research also showed DT to be effective in behavior management programs, including wilderness programs for adolescents. DT has been successful in reducing symptoms of social anxiety in children and in teaching social skills and how to deal with shyness, adjust to transitions, and cope with bullying. DT also has a significant record of success when used in addiction treatment.

Techniques DT is more process oriented than technique driven, focusing on the evolving creative process and content within a structure or context. The population, setting, and goals for the client determine the approach within DT. Some drama therapists prefer a more structured approach, using experiential exercises or activities that utilize game structures, scripts, and/or props. For example, in an educational setting, the therapist could provide a script, the cast of characters, a topic, and inherent conflict and allow students to take on the roles, using puppets to play out the scene, and collaborate on the resolution of the conflict. Others may prefer a more nondirective approach, creating a space for the drama to occur and allowing the actors to take on roles and improvise. The drama therapist

intervenes as needed to guide and shape the process while maintaining focus and safety for the individual or group. Techniques in DT are primarily projective and focus on the creative process, fantasy, imagination, and hypothetical situations. To accomplish this, DT therapists employ protagonists who work within a fictional framework and playspace, taking on roles of people or things different from themselves; work with imaginary stories and sometimes directly with dramatic texts; and incorporate psychodrama concepts as part of their approach. Some specific techniques are role-play, storytelling, scripts, life scripts, improvisation, enactment, mask making, externalization, narradrama, performance, and sociodrama. Metaphor and symbolism may be integrated into the process. Props are often used to support the process; these include costumes (hats, glasses, masks, fabric, etc.), puppets, and masks.

Therapeutic Process Drama is the core component of DT, and its content can provide both a means of assessment and a mode of intervention for DT. DT is focused on expressive, communicative, and adaptive behaviors as they evolve within the therapeutic process. The process usually includes a warm-up, a main activity, and a closing. It is important to create a safe space or stage for the work and to clearly transition into the space and out of it when the session is concluded. Body movement and creative exercises can be used as warm-up activities. Once the foundational structure and relationship are established, appropriate techniques and props can be introduced for the main activity. This working phase includes activities and structured experiences based on the clients’ needs and goals as well as the therapist’s training and skills. It is essential to close the session and assist the clients with transition and endings. Rituals, such as bows and good-bye poems or songs, may be used for closing sessions. When appropriate, drama therapists include verbal processing of sessions. Although there are no documented negative effects of DT, care should be taken to minimize physical and psychological risks and injuries.

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Due to its creative nature and experiential basis, DT can be challenging to describe. It is best understood by participating in or observing sessions. Drama therapists are continuing to develop the profession and inform others about the efficacy and value of DT in treatment settings. Leslie Armeniox See also Creative Arts and Expressive Therapies: Overview; Integrative Body Psychotherapy; Play Therapy; Psychodrama

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Further Readings Jennings, S. (1997). Drama therapy with families, groups, and individuals: Waiting in the wings. London, England: Kingsley. Johnson, D. R., & Emunah, R. (2009). Current approaches in drama therapy (Vol. 2). Springfield, IL: Charles C Thomas. Jones, P. (2007). Drama as therapy: Vol. 1. Theory, practice, and research. New York, NY: Routledge. Moreno, J. L. (1946). Psychodrama. New York, NY: Beacon House.

E been engaged in a debate over the “best” way to bring about personality change. For decades, mental health professionals resisted any form of eclecticism, often to the point of denying the validity of alternative theories and ignoring effective methods from other theoretical schools. The early history of counseling and psychotherapy is marked by theoretical wars, with representatives from each of the major theories claiming to have the absolute truth. At the present time, writers in the field of psychotherapy integration emphasize that each theory represents a different vantage point from which to look at human behavior, yet no one theory has the total truth. Because there is no “correct” theoretical approach, practitioners are advised to search for an approach that fits who they are and to think in terms of working toward an integrated approach that addresses thinking, feeling, and behaving. To develop this kind of integration, clinicians need to be thoroughly grounded in a number of theories, open to the idea that these theories can be unified in some ways, and willing to continually test their hypotheses to determine how well they are working. Since the early 1980s, psychotherapy integration has evolved into a major way of thinking about psychotherapy practice. Integration is now an established and respected movement that is based on combining the best of differing theoretical orientations so that more complete therapeutic approaches can be articulated and more efficient treatments developed. There are professional organizations devoted to this development. One of these is the Society for the Exploration of Psychotherapy Integration, formed in 1983, which is

ECLECTICISM A large number of therapists identify themselves as “eclectic.” Although different terms are sometimes used—eclecticism, integration, convergence, and rapprochement—the goals are very similar: to enhance the efficiency and applicability of psychotherapy. In the mental health professions, there is a decided preference for the term integrative over eclectic. Psychotherapy integration is best characterized by attempts to look beyond and across the confines of single-school approaches to see what can be learned from other perspectives and how clients can benefit from a variety of ways of conducting therapy. An integrative perspective rests on the assumption that different clients require different methods, yet this blending of concepts and methods needs to be done systematically. At its worst, eclectic practice consists of haphazardly picking techniques without an overall theoretical rationale. This pulling of techniques from many sources without a sound rationale results in syncretistic confusion. If practitioners merely pick and choose according to their whims, their work will reflect a lack of knowledge. John Norcross, a key figure in psychotherapy integration, claims that a haphazard eclecticism is mainly an outgrowth of pet techniques, inadequate training, and an arbitrary blend of methods.

Historical Context John Norcross and Larry Beutler, key figures in the field of integrative psychotherapy, maintain that since Sigmund Freud’s era, practitioners have 307

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an international organization whose members are professionals working toward the development of therapeutic approaches that transcend single theoretical orientations. Today, the majority of psychotherapists do not subscribe to a particular therapeutic school as a basis for their practice; rather, they base their work on some form of integration.

Theoretical Underpinnings One reason for the movement toward psychotherapy integration is the recognition that no single theory is comprehensive enough to account for the complexities of human behavior, especially when the range of client types and their specific problems are taken into consideration. Thus, many writers in the field maintain that effective clinical practice requires a flexible and integrative perspective. To be effective, psychotherapy must be flexibly tailored to the unique needs and contexts of the individual client. Some even suggest that using an identical therapy relationship style and treatment method for all clients is inappropriate and may be ineffective and perhaps unethical. In an integrative approach, diverse theories and techniques are combined to contribute to an effective framework for clinical practice. At its best, integrative counseling is a creative synthesis of contributions from diverse theoretical orientations that fit a therapist’s unique personality and style. An eclectic theoretical perspective is not a rigid set of structures that prescribes, step by step, what and how therapists should function. Rather, an eclectic orientation provides a general framework that enables practitioners to make sense of the many facets of the therapy process, providing a map that gives direction to what therapists do and say.

Major Concepts The psychology scholar George Stricker identifies four common pathways to psychotherapy integration: (1) technical integration, (2) theoretical integration, (3) assimilative integration, and (4) the common factors approach. Technical integration tends to focus on differences, uses techniques drawn from many approaches, and is based on a systematic selection of techniques. This path calls

for using techniques from different schools without necessarily subscribing to the theoretical positions that spawned them. Arnold Lazarus, a pioneer in clinical behavior therapy and the founder of multimodal therapy, espouses technical (or systematic) eclecticism, which is more commonly referred to as technical integration. Multimodal therapists borrow from many other therapy systems, using techniques that have been demonstrated to be effective in dealing with specific problems. In contrast, theoretical integration is a conceptual or theoretical creation that goes beyond blending techniques. This path creates a conceptual framework that synthesizes the best of two or more theoretical approaches to produce an outcome richer than that of a single theory. Theoretical integration is the most complex, sophisticated, and difficult of all types of integration because it requires bringing together concepts from disparate approaches. This approach to integration emphasizes integrating the underlying theories of therapy along with techniques from each. A third pathway to integration is assimilative integration, which is grounded in a particular school of psychotherapy, along with an openness to selectively incorporating practices from other therapeutic approaches. Assimilative integration combines the advantages of a single coherent theoretical system with the flexibility of a variety of interventions from multiple systems. Researchers such as Michael Lambert, John Norcross, and Bruce Wampold conclude that a fourth pathway, called the common factors approach, can be a basis for psychotherapy integration. Some of these common factors include empathic listening, developing a working alliance, providing an opportunity for catharsis, practicing new behaviors, positive expectations of clients, and understanding interpersonal and intrapersonal dynamics. Among the approaches to psychotherapy integration, the common factors approach has the strongest empirical support. Wampold has done numerous reviews of psychotherapy research, and he reports that no specific form of treatment has been proven to be clearly superior to another. Rather, the common factors that are part of all theoretical orientations—such as the therapist’s ability to form an alliance with the client—are critical to therapeutic outcomes. For a more indepth treatment of common factors, see Barry

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Duncan, Scott Miller, Bruce Wampold, and Mark Hubble’s book The Heart and Soul of Change: Delivering What Works in Therapy.

Techniques Clearly, whether a clinician uses technical integration, theoretical integration, assimilative integration, or the common factors approach will affect the kinds of techniques he or she uses. However, regardless of what theoretical model clinicians work from, they must decide what techniques, procedures, or intervention methods to utilize, when to use them, and with which clients. For counseling to be effective, it is necessary to utilize techniques in a manner that is consistent with clients’ values, worldview, life experiences, and cultural background. Although it is unwise to stereotype clients because of their cultural heritage, it is useful to assess how the cultural context has a bearing on their problems. Some techniques may be contraindicated because of clients’ socialization. Thus, how clients respond to certain techniques is a critical barometer in judging the effectiveness of these techniques. Whatever techniques therapists employ, it is essential to keep the needs of a client in mind. Some clients relate best to cognitive techniques, others to techniques designed to change behavior, and still others to techniques aimed at eliciting emotional material. In addition, the same client, depending on the stage of his or her therapy, can profit from participating in many of these different techniques. Therapists need to adapt their techniques, as well as their relationship style, to fit the needs of the individual client rather than attempting to fit the client to their techniques. Lazarus has written about relationships of choice, as well as choosing appropriate techniques. Therapists need to assume an active role in blending a flexible repertoire of relationship styles with a wide range of techniques as a way to enhance therapeutic outcomes. In short, relationships of choice are at least as important as techniques of choice. The techniques that practitioners will use can best be determined by their assessment of the client, which is why it is important to integrate assessment with treatment. Once a practitioner knows what a client’s target problems and goals

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are, the next step is to design specific techniques that can be effective with that client. If clients do not respond to a particular technique, then the therapist has the task of adjusting the therapy accordingly. Tailoring techniques to what is going on with a client during a therapy session is a large part of what an integrative therapist does. From an integrative perspective, the ideal is to adapt techniques in a unique way in working with each client throughout the duration of the therapy process. In essence, it is a matter of creating a new therapy approach with each client.

Therapeutic Process Lambert’s review of psychotherapy research makes it clear that the similarities rather than the differences among models account for the effectiveness of psychotherapy and that various treatment approaches achieve roughly equivalent results. Reviews of comparative outcome studies reveal the same general conclusion: There is relative equivalence among the various therapeutic approaches. In fact, interpersonal, social, and affective factors common across therapeutic orientations may be more critical than adherence to a particular approach or applying specific techniques when it comes to facilitating therapeutic gains. Relative to process, one might say that based on the integrative approach chosen, the therapeutic process might vary considerably. However, what is more critical are the interpersonal, social, and affective factors that are used in this process. One common factor critical to the therapeutic process is the therapist’s ability at establishing and maintaining a collaborative and strong therapeutic alliance with the client. The therapist’s ability to be present during the therapy hour and to connect with the client is of paramount importance, for it is the relationship that heals, not merely implementing techniques. Other research shows that therapeutic approaches are equally effective when administered by therapists who believe in them and when they are accepted by the client. Finally, of all the factors contributing to the therapeutic process, the client is the most important variable in determining the outcome of treatment. The client’s own resources and life situation (e.g., internal support,

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social support, environmental circumstances, etc.) and readiness for counseling are critical to positive client outcomes. Duncan, Miller, Wampold, and Hubble emphasize the importance of enlisting the client’s active participation in the therapeutic venture. Monitoring outcome and adjusting accordingly on the basis of feedback from the client should become routine practice. What is of central importance is to systematically gather and use formal client feedback to inform, guide, and evaluate treatment. One can see that the therapeutic process is affected by many aspects of treatment, including the therapeutic relationship, the therapeutic style employed, the client’s own resources, and environmental factors. All of these factors contribute to the success of psychotherapy and must be taken into account in the treatment process. Clearly, becoming an integrative practitioner entails an ongoing process more than arriving at a final destination. Developing an integrative perspective is a lifelong endeavor that is refined with clinical experience, reflection, reading, and discourse with colleagues. Gerald Corey See also Assimilative Psychotherapy Integration; Common Factors in Therapy; Integrative Approaches: Overview; Multimodal Therapy; Multitheoretical Psychotherapy

Further Readings Corey, G. (2013). The art of integrative counseling (3rd ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association. Lazarus, A. A. (1995). Different types of eclecticism and integration: Let’s be aware of the dangers. Journal of Psychotherapy Integration, 5(1), 27–39. Lazarus, A. A. (1996). The utility and futility of combining treatments in psychotherapy. Clinical Psychology: Science and Practice, 3(1), 59–68. doi:10.1111/j.1468–2850.1996.tb00058.x Lazarus, A. A. (1997). Brief but comprehensive psychotherapy: The multimodal way. New York, NY: Springer. Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York, NY: Oxford University Press.

Norcross, J. C., & Beutler, L. E. (2014). Integrative psychotherapies. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (10th ed., pp. 499–532). Belmont, CA: Brooks/Cole, Cengage Learning. Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration (2nd ed.). New York, NY: Oxford University Press. Norcross, J. C., & Lambert, M. J. (2011). Evidence-based therapy relationships. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidencebased responsiveness (2nd ed., pp. 3–21). New York, NY: Oxford University Press. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 423–430). New York, NY: Oxford University Press. Norcross, J. C., & Wampold, B. E. (2011). What works for whom: Tailoring psychotherapy to the person. Journal of Clinical Psychology, 67(2), 127–132. doi:10.1002/jclp.20764 Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical analysis (8th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Stricker, G. (2010). Psychotherapy integration. Washington, DC: American Psychological Association. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum. Wampold, B. E. (2010). The basics of psychotherapy: An introduction to theory and practice. Washington, DC: American Psychological Association.

ECOLOGICAL COUNSELING The ecological counseling perspective can help counselors narrow down the large number of potentially helpful counseling tools into a smaller number applicable across clients and life situations. It is not a unique theory per se but an integrative framework that suggests common principles across counseling approaches and creative ways to facilitate change with individuals, groups, and communities. The ecological perspective sees human life as an ecology featuring a thinking organism interdependent with the contexts (or environments) surrounding him or her. Who we are as individuals depends on how we are

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connected with the world around us and how we perceive and understand these connections. Facilitating healthy synergistic interactions is the concern of the ecological counseling perspective.

Historical Context Since the time of Sigmund Freud (1856–1939), intervention models have been concerned mostly with personal causes of psychic distress. Despite the overarching focus on the individual, the helping professions have also always understood human behavior as grounded in the contexts in which people live. The importance of person– environment interaction is apparent in the evolution of human services—for example, early social workers worked within communities to help the poor, college student counselors transformed campuses to meet students’ needs, and family therapists saw the interaction of family members as critical to the development of problems within individuals and within the family. The increasing awareness of sociocultural diversity underscores the urgency of situating clients’ concerns in the world around them.

Theoretical Underpinnings The fundamental idea of the ecological perspective— that human behavior must be understood as the outcome of an individual’s interaction with his or her environment—is commonly attributed to Kurt Lewin’s seminal work early in the 20th century. Since then, experts have elaborated this statement into fundamental building blocks for psychological theory and research. Karl Ludwig von Bertalanffy, the Austrian-born biologist, developed general systems theory to explain the complex interaction of systems. His theory was eventually applied to the understanding of human systems. Urie Bronfenbrenner, a 20th-century American psychologist, is revered for his elegant model specifying the interrelated contexts comprising human lives. Bronfenbrenner showed that simple explanations for behavior often are not very accurate. We need professional language that can describe the complex, often surprising, interactions among the variables constituting everyday life. Although Bronfenbrenner’s work was exciting, practical applications were not his forte. However, others have elaborated the implications of ecological

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thinking for changing people’s lives. The perspective described here represents one synthesis of a recent and diverse body of literature. This synthesis specifies ideas and processes commonly accepted across counseling approaches. Mental health professionals can use this perspective to compare how different theories might explain similar ideas (e.g., the importance of personal characteristics) and change processes using them.

Major Concepts Four basic propositions provide the conceptual foundation for the ecological perspective: (1) behavior is personal, (2) behavior is contextual, (3) behavior is interactional, and (4) behavior is meaningful. Each proposition interacts with the other three, as shown in the following subsections. Behavior Is Personal

Behavior is influenced by unique individual characteristics: for example, genetic determinants, knowledge and skills learned from past experiences, and personal identity. How these characteristics actually manifest in a life depends on their interaction with the life circumstances. Consider the example of exceptional musical talent shared by two siblings. One sibling becomes a professional musician, the other a banker. Whether a personal potential transforms into a life role can depend on its interaction with other factors for expression and development: for example, personal motivation, support of a mentor, or the family’s financial circumstances. How people perceive and understand who they are as individuals will determine what they become over time. A person may never develop personal aptitude unless he or she is aware of it and is encouraged by others. Some personal characteristics (e.g., ability to nurture others) may also require time and life experience to flourish. In the ecological perspective, we value the uniqueness of every person, and we appreciate how this uniqueness offers possibilities for change. In the course of a lifetime—or with the help of a counselor—people learn the necessary tools for translating personal possibilities into life roles. Counselors can be very helpful in enabling clients to develop an array of tools appropriate to their

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needs. For instance, counselors can help clients with their career decision making, social skills, and communication skills. In recent years, counselors have begun to understand diversity (e.g., race or ethnicity) as the product of person–environment interaction and how people make sense of their interactions with others. For example, facial features are “personal” characteristics; however, the use of this facial feature as a marker of race (e.g., dark skin means “black” or “African American”) reflects how the broader sociocultural context categorizes and values certain groups of people over others. This recognition of diversity as an interactional process reminds counselors that how people perceive, create, enact, and internalize distinctions among themselves is far more complicated than at first glance. Behavior Is Contextual

The ecology of human life is constantly shaped by the features of the world in which the human organism is situated. These contexts (or environments) of a person’s life vary dramatically. They can be human (e.g., family living in one household) or physical (e.g., geography), proximal (close) or distal, and shared or idiosyncratic. The importance of a context can vary over time or across people. For some individuals, certain features of their life contexts carry weighty significance (e.g., a woman perceives that sexism impedes her career advancement, whereas a female colleague may insist that no such sexism exists). Experienced counselors know that a person’s perceptions of life contexts are crucial to explore. Building on Bronfenbrenner’s ecological work, life contexts are commonly portrayed as a series of concentric circles (subsystems) with the individual at the center. The contexts that are closest and most important in a person’s everyday life constitute the microsystem, containing family and other important relationships and physical sites experienced in everyday life. Subsequent rings represent less immediate but still influential systems of life contexts: groups, organizations, neighborhood and community, and broader social systems (e.g., media, the government). The broadest and least direct system of contexts is the macrosystem, containing abstract sociocultural “blueprints”

organizing and regulating human behavior (e.g., “Western” vs. “Eastern” cultures). Interactions with the world experienced in everyday life (e.g., friendships) tend to be most psychologically meaningful to people, although broader and more abstract contexts encompass, and therefore influence, the more proximal ones (e.g., cultural mores regarding how friends should interact). Behavior Is Interactional

Persons and contexts create human lives together. People participate in their own lifelong development by how they engage in bidirectional, dynamic interactions within their multiple life contexts. Over time, people’s life choices set the stage for future interactions, although some change is generally possible. Influenced by the combination of personal and contextual features experienced over time, each person must develop coping skills for managing the challenges of everyday life. People with a repertoire of coping skills appropriate for the type and magnitude of their life challenges are said to be resilient. Resilience is often relative. A person’s coping skills that are remarkably effective in one context may be less helpful in another. A combination of otherwise manageable stressors (one chronic illness plus one troubled teen plus one job lost . . . ) may also tax the resources of generally resilient people. Because the interactions characterizing human problems are so complex, even problems with straightforward origins can be complicated over time by personal or contextual interactions that modify or maintain them. When a problem is viewed as interactional, the counselor and the client can identify which features are most amenable—or meaningful—to change. Behavior Is Meaningful

This fourth proposition adds a level of complexity to human ecological interactions that is unique among living organisms: We perceive, define, understand, and predict life experiences. This meaning making allows us to communicate about, make sense of, and have some power in life. Language organizes our thinking processes and

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transmits our understandings; we evaluate what we think, do, and experience. Meaning making involves both content and process. The content refers to the system of sounds and signs people use to communicate using language and the specific words and constructs each person favors to explain his or her experiences to self and others. Process differences refer to distinctions such as emotional intelligence, abstract thinking capacities, or faith development. Process capacities can be based on personal aptitudes or can be learned. People depend on their broader life meanings, often including spiritual or religious traditions, to give their lives coherence and trustworthiness. Certain traumatic life events (e.g., the death of a child) can destroy a person’s fundamental life meanings; recovery then requires a rebuilding process far exceeding ordinary coping processes. Integrating such a loss into one’s life requires the grieving person to evolve new meanings for life that acknowledge one’s ultimate helplessness to control certain life events and to allow for the possibility of reaffirming life with hope despite heartbreak.

Techniques What makes counseling “ecological” depends not on using a designated collection of techniques but on using techniques already familiar to counselors with an ecological sensibility. Ecologically oriented counselors see behavioral patterns targeted as problematic to be caused and maintained by complex interactional chains over time. Counselors and clients consider how to interrupt these chains to introduce a more satisfying way to live. Strategies are selected to seek the most efficient and effective changes. Counseling techniques emphasize the development of strengths and resources wherever possible. This framing (meaning making) helps empower clients rather than focusing on their presumed deficits. Ecological counselors recognize that direct service is only one possible form of intervention. Direct service counseling might include suggesting how clients could change their environments (e.g., minimizing substance abuse recidivism by changing friendships and social sites). Ecologically oriented counselors also engage in other interventions, such

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as collaboration and referral, program development, prevention, and social justice–oriented counseling. This perspective recognizes the counseling profession’s ethical mandate to address the systemic conditions (e.g., economic inequities, biased attitudes) that perpetuate differential access to opportunities and resources.

Therapeutic Process In ecologically oriented counseling, clients develop an understanding of themselves interacting with their life situations, using personally meaningful ideas that empower them to take action. An essential process skill is the ability to understand the client’s world as he or she experiences it (ecological empathy). Counselors and clients work collaboratively to define what is possible and meaningful to change and what resources might be used. The steps of the ecological change process typically involve the following features. Using the client’s expertise regarding his or her own life and the counselor’s professional expertise, the counselor and the client first situate the problem within the client’s broad life ecology by elaborating relevant interactions, strengths that the client currently possesses (e.g., supportive relationships or skills in obtaining resources), and roadblocks the client perceives have prevented successful resolution thus far. Then, correspondence among resources and challenges implicit within the present ecology can be explored, along with meanings (self, others, life in general) at the heart of the client’s concerns. Following this exploration, it is possible to specify goals that are meaningful, plausible, and feasible to the client: What changes in the client, life contexts, interaction, and/or meaning making could help resolve the client’s concerns? It is empowering for the client to discuss how to use the present resources effectively, how to develop appropriate resources where needed, and how changes can help the client cope more effectively in the future as well. The ecological perspective was elaborated through years of discussions among practicing counselors about what they do and why. This perspective proposes a common language for discussing counseling across theoretical distinctions, and it reminds counselors about interventions sometimes overlooked in everyday practice settings. For example, counselors focused only on assigning

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diagnostic categories may not think ecologically and may fail to explore systemic opportunities to change the clients’ present and future life conditions. Finally, counselors can strengthen their work by building relationships with community resources such as faith-based communities, recreational programs, and schools. Counselors who can think ecologically are equipped to think about implementing changes at the individual, group, institutional, or broader systemic levels, including social justice interventions. Ellen P. Cook See also Brief Therapy; Common Factors in Therapy; Contextual Therapy; Eclecticism; Narrative Therapy; Positive Psychology; Wellness Counseling

Further Readings Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 515–531. doi:10.1037/0003066X.32.7.513 Conyne, R. K., & Cook, E. P. (Eds.). (2004). Ecological counseling: An innovative approach to conceptualizing person-environment interaction. Alexandria, VA: American Counseling Association. Cook, E. P. (2012). Understanding people in context: The ecological perspective in counseling. Alexandria, VA: American Counseling Association. Moen, P., Elder, G. H., Jr., & Luscher, K. (Eds.). (1995). Examining lives in context: Perspectives on the ecology of human development. Washington, DC: American Psychological Association. Prilleltensky, I., & Prilleltensky, O. (2006). Promoting well-being: Linking personal, organizational, and community change. Hoboken, NJ: Wiley. Shallcross, L. (2013). Building a more complete client picture. Counseling Today, 55(10), 30–39. Walsh, W. B., Craik, K. H., & Price, R. H. (Eds.). (2000). Person–environment psychology: New directions and perspectives. Mahwah, NJ: Lawrence Erlbaum.

ECOTHERAPY Ecotherapy is an emerging field of psychotherapy that expands beyond the traditional human-centered treatment modalities to include the human–nature

relationship. Ecotherapy is based on the theoretical orientation of ecopsychology, a relatively new field that recognizes that human health and identity are integrally linked to the health and sustainability of the earth. Ecopsychology maintains that environmental problems and psychological disease are a result of our alienation from the natural world; and thus, one of the goals of ecopsycology is to heal this fundamental split by increasing consciousness of our inherent connection with nature. Ecopsychology takes a holistic approach, addressing the physical, psychological, and spiritual conditions of both the human and the nonhuman world.

Historical Context The human ecologist Paul Shepard (1925–1996) was perhaps the first social scientist to make the connection between mental illness and human detachment from the natural environment in the early 1980s. Then, in the early 1990s, a new, more politically focused environmental psychology emerged. It was during this time that a group of concerned psychologists and scholars began to hold informal gatherings in the San Francisco Bay Area to address psychology’s response to environmental crises, such as global warming and species extinction. From these gatherings, ecopsychology was birthed—the term coined by the cultural historian Theodore Roszak (1933–2011). Three years later, Roszak, along with coeditors Mary Gomes and Allen Kanner, published a collection of papers by influential psychologists and environmental activists that attracted a wider audience and began to establish the field of ecopsychology within the academic community. In 1996, Howard Clinebell introduced the term ecotherapy as an approach to healing and growth supported by positive interactions with the natural environment. Nearly 15 years later, Linda Buzzell and Craig Chalquist brought more attention to the field through the publication of their edited book Ecotherapy: Healing With Nature in Mind. There is currently debate between first- and second-generation ecopsychologists about whether ecopsychology is a science, a philosophy, or a spiritual practice, and whether or not it should strive for acceptance within mainstream psychology or retain its politically radical edge. Ecopsychology has traditionally been an interdisciplinary project,

Ecotherapy

influenced by a wide range of disciplines, including transpersonal psychology, depth psychology, deep ecology, systems theory, religious studies, environmental studies, and the humanities.

Theoretical Underpinnings Most first-generation ecopsychologists adhere to the principle of an ecological unconscious that has been largely repressed by industrial and modern society, resulting in collective madness and environmental destruction. Similar to Carl Jung’s notion of the collective unconscious, the ecological unconscious includes our evolutionary and archetypal inheritance, which binds us to the earth.

Major Concepts Ecotherapy is a relatively new approach to psychotherapy that takes into account the vital role of nature and the human–nature relationship. This involves shifting from an egocentric to an ecocentric perspective, practicing psychotherapy as if the whole world mattered, recognizing the grief and trauma caused by environmental destruction, and encouraging nature connection practices. Shifting From an Egocentric to an Ecocentric Perspective

Ecotherapists reject the modern mechanistic view of the universe, which perceives the world as a lifeless, but well-functioning, machine, and reimagine a world that is ensouled, animate, and fueled by its own life-giving spirit. Within therapy, this involves practices such as active imagination that encourages dialogue between the individual and the psyche, or soul, of the nonhuman realm. Practicing Psychotherapy as if the Whole World Mattered

Unlike most psychotherapeutic models, which focus primarily on the individual, ecotherapy extends beyond the consulting room, always keeping in mind the direct link between psychological and environmental health. Depression, anxiety, and other symptoms, for instance, are viewed within the context of the environmental crisis.

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Recognizing Grief and Trauma Caused by Environmental Destruction

Drawing from systems theory, ecotherapy views grief and trauma caused by environmental destruction as inseparable from other forms of loss and trauma. Global warming, species extinction, loss of place, and other environmental disorders are respected as immediate concerns to be addressed within psychotherapy. Encouraging Nature Connection Practices

There is a wealth of empirical research that supports the healing capacity of nature. Nature connection practices include, but are not limited to, horticultural therapy, animal assisted therapy, adventure therapy, and wilderness rites of passage.

Techniques Ecotherapy does not adhere to any specific techniques per se but rather involves taking a philosophical stance of reciprocity and interdependence between the client and the larger environmental context. It is by holding this stance that transformation and healing come about as the client’s perception shifts from one of self-contained isolation to that of being a vital participant within a meaningful cosmos. Nevertheless, there are various practices and methods that some ecotherapists employ. Bringing Nature Into the Consulting Room

As part of the intake session, ecotherapists might include nature-related questions to assess a client’s previous and current relationship with nature. For instance, the psychotherapist might ask clients to talk about their early experiences in nature and how these experiences may have influenced their childhood development. Taking Therapy Outdoors

Ecotherapists commonly meet with clients in an outdoor setting. When meeting outdoors, nature becomes an essential piece of the therapeutic process.

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Nature-Based Assignments

Nature-based assignments take place between sessions and include directives such as spending time in a special place, devising rituals for oneself in a natural setting, and mindfulness practices in nature.

Hasbach, P. (2012). Ecotherapy. In P. Kahn & P. Hasbach (Eds.), Ecopsychology: Science, totems, and the technological species (pp. 115–139). Cambridge, MA: MIT Press. Roszak, T., Gnomes, M., & Kanner, A. (Eds.). (1995). Ecopsychology: Restoring the earth, healing the mind. San Francisco, CA: Sierra Club Books.

Use of Ritual in Nature

Ritual and symbolic acts are often used as a way of moving beyond rational thinking and touching on the unconscious aspects of the human–nature connection. For instance, by speaking and listening to a symbolic “wound” found in nature, such as a fallen tree or a hole in the ground, one can gain access to the depth and feeling of one’s personal wounds, further developing a sense of reciprocity between oneself and nature.

Therapeutic Process Ecotherapy begins with taking a philosophical stance that surpasses the modern belief that humans are superior to other life forms and repositions humans within the larger community of all beings. Ecotherapy does not adopt a clinical model of diagnosis and treatment; rather, it functions on the premise that by becoming conscious of one’s inherent connection with nature, a psychic shift takes place that brings about a greater sense of intimacy with self, others, and nature. Ecotherapy is concerned not with alleviating symptoms but with facilitating wholeness. Thus, ecotherapy is a noninvasive form of therapy that relies on the nonjudgmental, accepting, and genuine attitude of the therapist. Betsy Perluss See also Adventure-Based Therapy; Analytical Psychology; Animal Assisted Therapy; Archetypal Psychotherapy; EcoWellness; Nature-Guided Therapy; Transpersonal Psychology: Overview

Further Readings Buzzell, L., & Chalquist, C. (Eds.). (2009). Ecotherapy: Healing with nature in mind. San Francisco, CA: Sierra Club Books. Clinebell, H. (1996). Ecotherapy: Healing ourselves, healing the earth. Minneapolis, MN: Fortress Press.

ECOWELLNESS EcoWellness is a sense of appreciation, respect for, and awe of nature, resulting in feelings of connectedness with the natural environment and holistic wellness. EcoWellness theory includes seven empirically determined dimensions, which provide a foundation for the intentional application of nature in counseling, called EcoWellness counseling. Nature is conceptualized in EcoWellness as a positive, direct or indirect, and purposeful engagement with a nonhuman entity. Such definitions might include positive interactions with a  domesticated animal, watching a sunset on a beach, and indirectly experiencing nature via a mindfulness meditation where the participant visualizes his or her favorite natural landscape. EcoWellness counseling is empirically and theoretically based (i.e., ecopsychology, biophilia, place attachment theory, attention restoration theory, and stress reduction theory). It is also based on the Indivisible Self Model of Wellness and a plethora of multidisciplinary research. EcoWellness counseling differs from other helping paradigms incorporating nature into professional helping in that its underlying constructs are research based and nature connections are considered in the context of holistic wellness and diagnostic assessment. EcoWellness counseling is a complementary rather than a solitary pathway to healing and wellness, which is in contrast to some nature-based modalities (i.e., applied ecopsychology, often called ecotherapy) that view connecting with nature as the ultimate solution to reducing psychopathology and achieving mental health and wellness. Counseling and psychotherapy might occur indoors or outdoors, and a client’s connection with nature is addressed in the context of the client’s presenting problems.

EcoWellness

Historical Context EcoWellness theory highlights the importance of human–nature connections on human health and wellness. The theory developed out of several nature theories that focus on how humans have become increasingly disconnected from the natural environment. In 1992, Theodore Roszak, a pioneer of ecopsychology, observed the growing disconnection between humans and the natural environment and argued that an absence of understanding and connecting with nature leads to the experience of psychopathology. E. O. Wilson, who originally defined the biophilia hypothesis in 1984, suggested that humans evolved and adapted to be in connection with nature. Both theorists attracted mainstream attention for their focus on environmental sustainability, and a host of academic inquiry and nonacademic literature has resulted. While both theories have brought international attention to environmental issues, neither theory has proven testable so far. EcoWellness counseling was developed in 2012 by Ryan F. Reese and Jane E. Myers to provide a specific method for incorporating nature into professional counseling to help professional counselors and researchers more effectively assess and integrate nature in traditional counseling settings.

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spend time in or with nature. Despite the multidisciplinary research, wellness models in counseling and other related fields (i.e., public health) have yet to integrate the natural environment as an integral link to human wellness. With ecopsychology and biophilia not readily testable, attention restoration theory, stress reduction theory, and place attachment theory have all been used to ground the multidisciplinary nature of research findings. Within attention restoration theory, focusing on a natural landscape requires little cognitive effort relative to the more complex cognitive processing that occurs throughout a typical workday (i.e., focusing on a computer screen for 8 hours). This attentional shift resulting from spending time in or with the natural environment can help a client feel mentally restored. Researchers focused on stress reduction theory have found that nature enhances aspects of wellness and mood through reductions in various physiological measures (i.e., heart rate, blood pressure, and skin conductance). Place attachment theorists have found that the more connected one feels to a special “place” in nature, the more prone one is to experiencing different aspects of wellness, both for oneself and on behalf of the natural environment. Taken together, these theories and their supporting qualitative and quantitative research provide a strong theoretical and empirical foundation for EcoWellness.

Theoretical Underpinnings EcoWellness is based in multidisciplinary nature theory and holistic wellness models in professional counseling. Professional counseling, as opposed to psychology or social work, is distinguished from the other helping professions given its distinct focus on human holistic wellness. The Indivisible Self Model of Wellness is a highly evidence-based model of wellness in the counseling profession; it is an ecological model, in which a client’s wellness is tied to his or her contextual environment. Over the past several decades, a variety of research studies outside the helping professions have pointed to the positive effects of nature on wellness. For example, having a view of nature from one’s home, hospital room, or place of work reduces stress, increases focus and productivity, and enhances life satisfaction. Research has also shown that people feel closer to other people, the natural environment, and their conception of a higher power when they

Major Concepts The major concepts of EcoWellness are based in multidisciplinary research and theory, and the seven domains of EcoWellness are identified in the Reese EcoWellness Inventory. The domains of EcoWellness include the following: (1) physical access, (2) sensory access, (3) connection, (4) protection, (5) preservation, (6) spirituality, and (7) community connectedness. Physical Access

Physical access is defined in EcoWellness as living, working, socializing, or recreating in places and/or with species that the client considers nature. Through EcoWellness counseling, clients have the ability to physically access nature at their discretion. Clients are able to develop a positive conception of nature through accessing nature, form

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positive relationships with nature, and experience the positive and reinforcing benefits of spending time in or with nature.

consider taking care of or safeguarding nature as a means to bolster self-efficacy, feelings of security and safety, feeling connected with other people, and experiences of autonomy.

Sensory Access

Sensory access is defined in EcoWellness counseling as feeling a sense of closeness to nature through one’s senses, even when lacking immediate physical access. It includes a client’s accessing aspects of nature through the sense of touch, smell, sight, or hearing. For example, counselors might integrate nature on a television screen or introduce aromatherapy as a means to enhance client mood.

Spirituality

Spirituality is a common aspect of EcoWellness. When in or with nature, the counselor can help a client focus on experiencing an inner peace connection with the client’s conception of a higher power or life-guiding beliefs. Such an experience might occur when the client experiences a sense of being secluded or away from his or her typical environment.

Connection

Connection is defined in EcoWellness as the client’s experience of pleasant cognitions (including memories) and emotions while reflecting on his or her relationship with nature. This aspect of EcoWellness includes helping the client identify a special place (or places) in nature that elicits positive emotions and cognitions and/or having at least one activity in or with nature that the client incorporates into his or her sense of self. The more a client identifies with nature or feels connected with it, the more the client will spend time in or with nature and thus experience the wellness benefits of natural environments. Protection

Protection is based on the biophilic sense of humans having adapted or evolved in natural environments. Protection is defined in EcoWellness as incorporating elements of nature into a client’s lifestyle that can be of benefit to one’s survival and taking precautions in nature that would promote one’s survival when in the presence of or near species or natural elements that can bring harm to the individual. In essence, the more self-efficacious and comfortable the client feels in or with nature during counseling, the more he or she might experience the wellness benefits of spending time with the natural. Preservation

Preservation is defined in EcoWellness as taking action related to an environmental cause (e.g., recycling). Counselors can encourage clients to

Community Connectedness

Community connectedness is defined in EcoWellness as a greater sense of interconnectedness with the human and nonhuman community through contact with nature. It is marked by compassionate and generous acts toward others when exposed to nature.

Techniques EcoWellness can be a stand-alone approach where the counselor and the client work toward enhancing the seven dimensions of EcoWellness, or the approach can complement other traditional counseling modalities. EcoWellness assessment, psychoeducation, the use of metaphor, and homework are a few techniques that can be utilized when implementing an EcoWellness approach. EcoWellness Assessment

EcoWellness assessment by a counselor includes an exploration of the seven dimensions of EcoWellness with a client. Questions are asked in addition to traditional counseling assessment and within the context of the client’s presenting concerns. Example questions might include the following: • How often do you spend time in or with what you consider nature? • What is your view out your window at work like, if you have one? From home?

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• Would you characterize your connection with nature as positive or negative? Why? • How well could you fend for yourself on a camping trip? Could you build a fire? • Is there an environmental issue that you feel passionately about? If so, which one? • How would you describe your spirituality? How do you experience this when in nature? • To what extent do you spend time in nature with others? What kinds of things do you do?

Psychoeducation

Psychoeducation is an important aspect of EcoWellness, especially at the beginning of the counseling relationship. Many clients do not realize that spending a few hours a week at a park or on a trail can reduce stress and enhance wellness. Educating parents and guardians in particular can be helpful for parents in making activity decisions for their children. Metaphor

The use of the nature metaphor is one of the primary interventions in applying EcoWellness. For example, asking a client to find an aspect of the natural environment as a means to open a counseling session can help the client access deeper issues more quickly. The metaphor can go to the heart of the client’s presenting concerns and can be revisited throughout the counseling process in later sessions. Homework

Homework is an important component of EcoWellness. Counselors can help clients plan safe and appropriate homework assignments in nature. For example, a client wishing to deepen his or her connection with nature to enhance overall well-being may be uncertain of where to go and what to do in nature. Providing a client with specific instructions of where to go and what tasks to perform can be helpful and less overwhelming for a client who has spent little time in and around natural environments.

therapeutic processes. For example, EcoWellness can complement both humanistic and cognitively oriented treatments, depending on the client’s presenting problems and the counselor’s preferences. The first several sessions are spent indoors and may feel like traditional counseling sessions. The counselor gains a holistic picture of the client’s presenting issues, develops a therapeutic alliance, contextualizes presenting issues in specific regard to the client’s connection with nature, and determines whether the client wishes to include EcoWellness into treatment interventions. Assessing the seven components of EcoWellness provides a baseline for treatment. Sharing nature research handouts and directing clients to sources where they can learn how nature can enhance wellness is an emphasis early in treatment. Helping clients and their families create culturally relevant ways of connecting with nature to address presenting concerns can be helpful, especially for clients who want to deepen their connection with nature but lack the experience or understanding of how to do so. Later, after the client determines which aspects of EcoWellness he or she would like to expand, sessions include interventions that take place inside the office or outside. While the counselor can recommend specific nature activities, interventions are client driven and are in clear alignment with the client’s presenting concerns and objectives. Homework is a common component of the approach, including aspects of relaxation, mindfulness and meditation, exposure, and interpersonal interaction in or with nature. The counselor should check in frequently with the client as to the perceived effectiveness of counseling, and counseling concludes with the client revisiting how his or her connections with nature have shifted and how such transformations have affected his or her perceived level of growth. Ryan F. Reese See also Adventure-Based Therapy; Ecotherapy; NatureGuided Therapy

Further Readings

Therapeutic Process EcoWellness concepts and practices can be integrated into traditional counseling assessment and

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Kaplan, R., & Kaplan, S. (1989). The experience of nature: A psychological perspective. Cambridge, England: Cambridge University Press.

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Kuo, F. E. (2010). Parks and other green environments: Essential components of a healthy human habitat. Ashburn, VA: National Recreation and Park Association. Retrieved from http://www .nrpa.org/uploadedFiles/nrpa.org/Publications_ and_Research/Research/Papers/MingKuo-ResearchPaper.pdf Louv, R. (2012). The nature principle: Human restoration and the end of nature-deficit disorder. Chapel Hill, NC: Algonquin Books. Myers, J. E., & Sweeney, T. J. (2008). Wellness counseling: The evidence base for practice. Journal of Counseling & Development, 86, 482–493. doi:10.1002/j.1556-6678 .2008.tb00536.x Reese, R. F. (2013). EcoWellness: Construction and validation of the Reese EcoWellness Inventory (Doctoral dissertation). University of North Carolina, Greensboro (Proquest, UMI Dissertations Publishing, 3568902). Retrieved from http://proxy.lib.odu.edu/ login?url=http://search.proquest.com/docview/142526 8211?accountid=12967 Reese, R. F., & Myers, J. E. (2012). EcoWellness: The missing factor in holistic wellness models. Journal of Counseling & Development, 90(4), 400–406. doi:10.1002/j.1556-6676.2012.00050.x Roszak, T. (1992). The voice of the earth: An exploration of ecopsychology. Grand Rapids, MI: Phanes Press. Wilson, E. O. (1984). Biophilia. Cambridge, MA: Harvard University Press.

EGO PSYCHOLOGY Ego psychology was developed from the notion that personality cannot be solely defined as the dynamic interaction of sexual and aggressive drives with the conscious and unconscious minds, as Sigmund Freud (1856–1939) had suggested. Instead, ego psychology adherents focus on the ego as a major force in development and view the ego as serving several functions, including reality testing, the development of tolerance, the overseeing of defenses and coping capabilities, the development of judgment, and the managing of affect and impulse control. In addition, in contrast to Freud, who stated that personality developed through the psychosexual stages that encompass the first 5 or 6 years of life, ego psychology suggests that development occurs over the life span.

Historical Context Following the emergence of classical psychoanalysis during the early part of the 20th century, other treatment modalities that focused less on instincts and the unconscious and more on a socially driven model of personality development arose. One of these broad approaches was ego psychology, which is considered a derivative of classical psychoanalytical theory. Many ego psychologists, neoFreudians, and individuals who studied traditional Freudian orthodoxy developed new, yet related theories. They began to build on and diverge from classical psychoanalytical concepts such as the psychosexual stages and the Freudian conflict model, in which a person develops a compromise formation, which suggests that the psyche compromises between the sexual and aggressive impulses of the id and the external demands of reality as overseen by the ego. The early neo-Freudian ego theorists, including Alfred Adler, Karen Horney, and Erik Erikson, began to develop their own theories regarding the development of a person’s unique personality and the causes of personality abnormalities. For instance, Adler and Horney downplayed the notion that personality development was driven by sexual and aggressive forces of the id. While Freud believed that people were motivated by libido energy, which was housed in the id and made up of Eros (“life”) and Thanatos (“death”) instincts, Adler and Horney believed that childhood personality development was more influenced by social tensions. Adler, who endured an extended illness as a child, was a testament to this social and individualized concept that a person’s behavior can be driven by efforts to conquer feelings of inferiority. Hence, his wellknown term inferiority complex was a prominent aspect of his theoretical underpinning. Horney believed that anxiety experienced early in life was a result of one’s helplessness and dependency on one’s parents. Considered one of the founders of feminist psychology, Horney also suggested that the differences between men and women could be traced to cultural and societal values, as opposed to inherent biologically based drives. Erikson contributed to ego psychology through his proposition of the psychosocial (vs. psychosexual) life stages. He believed that an

Ego Psychology

individual develops in relation to his or her social world over the entire life span. Ironically, one of the primary contributors to ego psychology was Freud’s daughter Anna Freud. In a time when psychoanalysis required substantial time and financial commitment due to its focus on the unconscious id and related repressed material, Anna Freud proposed a more direct investigation of the conscious ego and how it was predisposed to manage the id through a variety of defense mechanisms. She expanded on the psychosexual stages and related concepts by suggesting that one’s maturation does not solely depend on the id but also relies on mastery toward independence in the conscious world, as mediated by the ego. She also suggested that defense mechanisms reflect maturation and survival rather than maladaptation, as previously thought. For example, the defense mechanism altruism is viewed as being helpful to avoid feelings of helplessness. Although ego psychology reached prominence during the early and middle parts of the 20th century, there continue to be many therapists who practice similar therapies today using the basic concepts developed by the early ego psychoanalysts.

Theoretical Underpinnings Classical psychoanalysis centered on the pleasure principle, which is the force that drives the id and is the basis for drive theory. Through the id, a person’s drive is not the result of conscious thought but of unconscious desire and necessity. According to psychoanalytical theory, the id is the site from which the ego and superego develop and psychopathology originates. The id, called the primary process by psychoanalysts, along with the ego and superego, constitute the personality structure. Conflicts between each structure of the personality can result in conflict energy, subsequently causing neurotic, moral, or realistic anxiety in individuals. Freud believed that to deal with strong unconscious id forces and the resultant conflicts with the ego and superego, people develop defense mechanisms to prevent them from becoming overwhelmed or imprisoned by sexual and aggressive instincts. These defense mechanisms, mediated and deployed by the ego, afford individuals the ability to self-regulate in times of distress.

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In contrast to classical psychoanalysis, ego psychology speculates that the id was not solely in control of a person’s needs or the only source of energy for a person. Rather, individuals are believed to possess separate inborn ego processes. These processes contain energy separate from that of the id—energy related to one’s memory, perception, thoughts, and motor coordination. These ego processes are known as the personality “executive,” and each one operates on the reality principle (i.e., acting in accordance with reality or what is really going on) to gratify the id’s impulses and needs. Freud concluded that anxiety was the result of conflicts between the impulse to satisfy the needs of the id and the importance of maintaining civility in the world. Defense mechanisms are developed as a response to a person’s internal conflict (id’s need) and a realistic expectation (society rules) to cope (defense mechanism) in a civilized manner. While the id focuses on needs in an impulsive and sometimes demanding manner, the ego processes strive to adapt, master, and learn from the environment in an effort to meet one’s needs. Impulse control is known as one of the early tasks of ego development. Another task is ego mastery, which involves effectiveness, competency, coordination, and the development of skill sets. Ego strength refers to the manner in which a person manages his or her stressors in the environment. It consists of traits such as confidence and self-esteem. In general, ego psychology adheres to the concept that a person is born with the skills to survive in and adapt to the environment—skills mediated by the ego. Once the  environment becomes difficult to negotiate, issues arise due to conflict between internal needs and external limitations and requirements. If an individual does not develop ego functions, such as  judgment, reasoning, and perception, then psychopathology develops.

Major Concepts Ego psychology encompasses a set of theoretical concepts that reflect a shift in focus from psychoanalytical notions of the id (drives) to the functioning of the ego. An understanding of ego psychology starts with basic knowledge of the ego, ego functions, defenses, ego mastery and adaption, and object relations.

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The Ego

Ego development results from an individual’s attempts to meet basic needs, identify with others, learn, master developmental tasks, effectively solve problems, and develop successful coping mechanisms. The ego functions to help individuals operate in a logical, clear, and organized manner. The ego is our concept of who we are or the creation of our own reality. In contrast to Freud’s understanding of the ego, ego psychologists tend to view the ego as having innate abilities to adapt to the environment and regulate the id through the development of defense mechanisms. Ego Functions

Ego functions are the means that enable an individual to adapt to his or her environment. Some elements of ego functioning include degree of insight, degree of self-esteem and acceptance, degree of selfdirectedness, degree of empathy for others, degree of moral development, and degree of meaning making and purpose in one’s life. They serve as a measure of ego strength or a composite picture of the internal psychological equipment or capacities that an individual brings to his or her interactions. The strength of an individual’s ego functions can be situation specific and varied, ranging from “strong” to “impaired.” Psychopathology is more likely seen in individuals who have an overall impairment in ego functions. Defenses

Defenses are the unconscious mechanisms that protect an individual from experiencing impairing anxiety or threat in fear-provoking situations. Defense mechanisms are common to all individuals and are used to distort the reality of an event to some degree. It is the role of the practitioner to assess whether a client’s defenses are adaptive or maladaptive. Common defense mechanisms include repression, denial, reaction formation, displacement, reversal, inhibition, identification with the aggressor, asceticism, intellectualization, regression, sublimation, projection, projective identification, internalization, introjection, compensation, and splitting. Under extreme stress or illness, the ego’s defenses may fail, resulting in detrimental anxiety and the deterioration of ego functioning. This can cause the personality to become fragmented and chaotic, much like a psychotic episode. Ego

psychologists, thus, focus on understanding how the ego keeps things out of consciousness through the use of defenses. Ego Mastery and Adaption

Effectance is the ego’s independent energy, which motivates an individual to gain pleasure by acting on, manipulating, and exploring the environment. The ego strives for competence and mastery over the environment. Thus, motivating individuals to become more competent will result in feelings of effectance and ego strength. Ego psychology also proposes the following human adaptation capabilities: (a) individuals can change external reality to suit themselves, (b) individuals can change themselves to comply with the demands of reality, and (c) individuals can search for an environment that might best suit their psychological potential. Object Relations

Objects in ego psychology describe significant persons or things that are the target or “object” of an individual’s drives or feelings. This could be a person, place, or physical item in which an individual directs his or her emotional energy. Object relations are believed to be an important function of the ego. In adulthood, individuals relate to others based largely on internalized significant persons (i.e., objects) incorporated into the psyche during childhood. Repeated subjective and significant experiences with others thus shape one’s perceptions and also fantasies of how persons behave toward one’s self, how one should respond to others, and what one can expect interpersonally from patterns in the larger world. Object relations theory acknowledges that an individual’s emotional frame of reference was developed and takes root in early-childhood attachments, primarily to his or her mother and other significant caretakers. In ego psychology, objects are therefore reflected in the quality of an individual’s interpersonal relationships and reflect the past relationships that shape his or her current interactions.

Techniques Ego psychology emphasizes that no individual is perfectly adapted to his or her environment. The primary goal is adaptive functioning by focusing

Ego Psychology

on current behavior. Overall, ego psychology is interested in the structuralization of the ego. When ego functioning is disrupted, there are interventions and techniques that the therapist can use. Ego-modifying techniques focus on changing basic personality patterns or structures. Ego psychology techniques typically include an exploration of the individual’s past. Furthermore, “issues” within a person are considered developmental failures rather than oedipal conflict issues. When a client enters therapy, there are ego-supportive techniques that a therapist can use. The following subsections review some classical interventions.

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helping the client understand that love was never lost. Love still exists and can be displayed through other living relatives. Sustaining

This technique follows the premise that clients have not reached positive object constancy, or an internalized positive image of a parent who allows the child, and later adult, to be a separate strong individual. Therefore, therapy is focused on identifying the factors or traits of the previously desired needs from past relationships that are now sought in present relationships. The therapists are mindful of identifying past, present, and current external factors that existed that may have prevented such object constancy from occurring.

Another group of techniques are classified as sustaining techniques. These techniques are known for encouraging the client to continue discussion and disclosure of concerns in his or her life. The first of these techniques is known as sympathetic listening. The counselor, from a nonjudgmental stance, attempts to listen to the client and provide an environment of “being heard.” The second type of sustaining technique is known as reassurance. Through reassurance, the counselor attempts to instill a feeling of comfort through the belief that circumstantial stressors are temporary, thus reducing current emotional distress. The next technique is known as encouragement, where the counselor attempts to identify inspiration within the client and his or her circumstance in order to prevail over the client’s concerns. Further sustaining techniques include the therapist’s providing suggestions to the client, eliciting the client’s subjective and objective feelings, reflecting on the client’s current situations and relationships, and reflecting on defense mechanisms and their impact or utilization. This reflection can assist in solidifying the current state of mind with a statement of the client’s truth for the current situation. The final sustaining techniques include more intensive and deeper therapeutic processing. These types of techniques can include confronting and interpreting maladaptive, ego-syntonic behavior and exploring the underlying reasons for it. The exploration of the influence of past relationships on current behavior is important. Once rapport and trust are established and insight developed, both the client and the therapist can begin more extensive work into the structuralization of the client’s ego.

Helping With Differentiation

Social Learning

Differentiation is the client’s ability to differentiate one skill into multiple subsets. For example, when a client no longer experiences the love of a mother due to the mother’s death, the feeling of love is not completely lost. The therapist assists by

Ego psychology is interested in the development of an individual within his or her environment, especially the individual’s social or relational realm. One technique utilized by ego psychologists is known as modeling. There are three basic types

Internalization

Internalization involves the integration of others’ values, beliefs, and ways of being into one’s own character. Usually, internalization occurs in early childhood as the child introjects (takes in) his or her parents’ attitudes and behaviors. Naturally, children with dysfunctional parents will tend to internalize the dysfunctional behaviors of their parents, and when difficulties arise, these children, and later as adults, will re-create previous relationship patterns—in this case, dysfunctional ones. The therapist’s intervention is to identify these patterns and assist the client in developing more independent and strengths-based functioning. Locating the Good Object

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of modeling: overt, symbolic, and covert. Overt modeling is known as live modeling, where one or more individuals behave in the manner from which others are to learn and re-create. Symbolic modeling involves identifying the target behavior through video or audio representation of the target behavior. Covert modeling is where the client imagines the target behavior and the successful completion of such behavior within his or her mind. The goal of modeling is to identify the target behavior, assist the client through one or more of the three types of modeling, and implement the outcome of each attempt at changing the behavior. Role-Playing

Role-playing can be considered either a step beyond modeling or a technique in itself. This technique is considered when the client needs to combine modeling, insight, and reflection for a deeper understanding of his or her previous or current behaviors and the goals in mind. Typically, there are three stages: (1) warm-up, or introduction to the intervention; (2) enactment, where feedback is provided and/or exemplified; and (3) reenactment, where feedback is considered and the role-play is re-created for utilization. This technique begins with simple scenes and over time transitions into more complex areas of the client’s concerns. Supporting the Ego

One of the main functions of ego psychology is to raise the ego to a higher level of functioning. The therapist does this by assisting the client in recognizing past, dysfunctional patterns of behavior and helping the client develop new, functional patterns; by supporting yet challenging the client to gain insight into his or her defense mechanism; and by providing a safe environment where the client can discuss issues and find new, more adaptive ways of being in the world that builds a higher self-concept. As this process evolves, the client moves from needing the therapist’s reassurance to realizing that he or she can function on his or her own—gaining greater autonomy in functional and positive ways. Dream Analysis

Ego psychology utilizes dreams as another avenue to ego development. Dreams, according to Freud, can have manifest or latent meanings.

Manifested meaning is the surface meaning of a dream, whereas latent meaning is the hidden, coded meaning of the dream—hidden for the protection of the individual’s psyche. Through dream interpretation, the client and the therapist can discuss both manifest and latent meanings, as each can be utilized for conscious processing and application to ego development and sustainability. Helping to Verbalize Versus Acting Out

The therapist utilizes this technique to assist the client in developing communication with himself or herself and others. The client learns how to communicate needs, desires, fears, and dislikes to himself or herself, the therapist, and others without behaviorally acting on such needs or fears. Such internal processing is a step toward self-control and developmental maturity.

Therapeutic Process Fundamental to ego-centered therapy are biopsychosocial assessments, facilitating the counselor–client relationship and building client strengths. The biopsychosocial approach is a holistic approach that examines a client’s psychological, social, cultural, biological, and environmental worlds. This approach demonstrates that issues are interrelated, allows the therapist to make a critical analysis of client behavior, and leads to more accurate case conceptualization and treatment planning than an approach that focuses only on one or two aspects of the client’s world. Following the biopsychosocial assessment, the therapeutic process moves toward collaboratively setting goals with the client. Goals should be specific, measurable, achievable, and realistic and should have a clear and established time frame (SMART). To illustrate, a client may express a goal of increasing his or her positive self-concept. For instance, one SMART goal could be daily positive self-affirmations or journaling. Such a goal challenges past dysfunctional behaviors based on internalized patterns resulting from interaction with significant others and helps develop healthier ways of living in the world. As therapy continues, the therapist attempts to understand the client from the client’s phenomenological perspective, or frame of reference, and

Ego State Therapy

works toward having a positive therapeutic working alliance. Concurrently, the therapist tries to understand how the client’s childhood experiences have influenced the client’s current level of functioning and ego development. The therapist pays particular attention to ego functions, such as the client’s sense of the world and of self, how thought processes affect choices, how defenses mold behaviors, the client’s ability to make a sound judgment, and the client’s ability to be autonomous. The final stage in the therapeutic process is the termination phase, which is a process that occurs over time and involves an increase in the client’s ego functioning, the attainment of agreed-on goals, and increased autonomy of the client as the client develops a healthier ego. Delila Owens, Bill Owenby, and Sarah Noble See also Existential Group Psychotherapy; ExistentialHumanistic Therapies: Overview; Interpersonal Group Therapy; Process Groups

Further Readings Bellak, L., Hurvich, M., & Gediman, H. (1973). Ego functions in schizophrenics, neurotics and normals. New York, NY: Wiley. Gelso, C. J., & Woodhouse, S. (2003). Toward a positive psychotherapy: Focus on human strength. In B. W. Walsh (Ed.), Counseling psychology and optimal human functioning (pp. 171–197). Mahwah, NJ: Lawrence Erlbaum. Goldstein, E. G. (1984). Ego psychology and social work practice. New York, NY: Free Press. Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical analysis. Belmont, CA: Cengage Learning. Rapaport, D. (1958). The theory of ego autonomy: A generalization. Bulletin of the Menninger Clinic, 22, 13–35. Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications and theory. Boston, MA: Houghton Mifflin. Sharf, R. S. (2012). Theories of psychotherapy and counseling. Belmont, CA: Brooks/Cole. White, R. W. (1963). Ego and reality in psychoanalytic theory: A proposal regarding ego energies. New York, NY: International Universities Press. White, R. W. (1963). Motivation reconsidered: The concept of competence (pp. 33–59). Glenview, IL: Scott, Foresman.

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EGO STATE THERAPY Ego state therapy was developed by John G. Watkins and Helen Watkins as a method for giving voice to disowned, conflicted, or dissociated aspects of self, also called ego states, to resolve inner conflicts between disparate parts of self, resolve psychological disturbances, and improve the functioning of an individual’s self system or personality. Ego state therapy is consistent with the goals of psychoanalytical treatment, but it is more expeditious because it directly accesses deep psychodynamic structures and enables the relatively direct resolution of symptoms.

Historical Context Pierre Janet (1859–1947) used the term dissociation when discussing parts of the personality that were split off. Based on some of his ideas, the term ego state was first introduced by Paul Federn (1871–1950) as part of his theory of ego psychology. Ego states are historically based in the context of Freudian psychodynamic psychology in which John Watkins was a pioneer, innovator, and teacher. Watkins and Watkins taught extensively about ego state therapy between the 1970s and the 1990s and showed how the concepts could be used in hypnosis. Ego state therapy became important in the field of Eye Movement Desensitization and Reprocessing (EMDR) as it became clear that conducting EMDR without doing ego state work for highly dissociative clients could increase their risk of retraumatization. Ego state therapy is able to access parts of self that can accelerate EMDR processing or parts of self that can obstruct this process.

Theoretical Underpinnings Theoretically, ego state therapy is based on psychodynamic principles. Federn, having been a student of Sigmund Freud, distinguished himself from other psychoanalysts and ego psychologists with his articulation of ego states, but he never developed a therapy based on ego states. Rather, the early emphasis was on the analysis of what ego states were activated at a given moment. Watkins and Watkins articulated a therapy in which hypnosis is used to access internal dynamics and conflicts by deliberately adding either subjectivity or objectivity

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to ego states to accomplish specific therapeutic goals. In ego state therapy, the defense of dissociation is more prominent than that of repression, because ego states are understood to be disowned and dissociated when their contents become unbearable to other parts of self. Resolving these internal conflicts is a key goal of the therapy.

Major Concepts An ego state is a subsystem of behavior, characteristic emotion, and experience associated with a psychological function, separated from other ego states by a boundary that is more or less permeable. A human personality is a self system that comprises a number of ego states that are variously in or out of awareness in response to external or internal stimuli. Ego and Object Awareness

When an ego state is imbued with significant ego awareness (also called ego energy or ego cathexis), it is said to be executive, active, and present in the here-and-now. Ego awareness is indicated when the state is associated with the pronoun I or we, as in, “I am afraid,” when a fearful ego state is fully forward and executive. When an ego state is in ego awareness, all other states are in object awareness or out of awareness. Awareness can shift to another ego state, causing that state to be in ego awareness, and the previously executive state then may be in object awareness or out of awareness. Ego states that are executive can also be called present or copresent, meaning present in the office or sitting in the chair. Also, when ego states are executive, they may be said to be looking through the eyes. Ego State Boundaries

Ego state boundaries can be more or less permeable, depending on how necessary for psychological functioning or survival it is to keep some information and experience sequestered from other aspects of self. Minor conflicts between states (e.g., “Part of me wants to live in the city, and part of me wants to live in the country”) may allow shared awareness among states of one another’s motivations and preferences. However, major irreconcilable conflicts between states

(e.g., “Daddy loves me; Daddy rapes me”) may be intolerable to know throughout the personality, and so the two poles of that insolvable dilemma may be disparately held, or dissociated. In the “Daddy loves me; Daddy rapes me” example, one part of the child’s self maintains the belief of being loved, which optimizes functioning or even survival in daily life, and other parts, behind an amnesia barrier, hold the agony, the shame, the rage, and so on, associated with the knowledge and experience that the child is being molested. The presence of amnesia barriers indicates that impermeable boundaries are necessary for functioning and/or survival to resolve the insolvable conflicts. Dissociative Continuum

John Watkins developed the concept of the dissociative continuum to express the graduated nature of permeability of boundaries. On the left of the continuum is a self system with highly permeable boundaries, in which no amnesia is present in an integrated personality. Such a personality still has ego states because learning is organized by function, when neurons that repeatedly fire become associated. On the extreme right end of the continuum is dissociative identity disorder, formerly called multiple personality disorder, which is replete with amnesia barriers that sequester intolerable experience out of awareness. In the middle of the continuum, moving from left to right, we see shades of gray, such as ego state conflicts, posttraumatic stress disorder, and lesser degrees of dissociative disorders with no or less amnesia than at the far right.

Techniques Some of the techniques central to ego state therapy include those described in the following subsections, which can be conducted within or outside of formal hypnotic procedures. In this discussion, the example of severe child abuse is used for clarity and simplicity, but ego state disorders can occur for a range of reasons beyond child abuse. Accessing Ego States

Accessing ego states is accomplished by various means, ranging from speaking to each ego state directly (adding ego awareness) or speaking

Ego State Therapy

through an ego state about other ego states (which are then in object awareness). Some practitioners have one ego state do all of the interviewing and interventions with the other ego states, so that one ego state stays executive. In the Watkins approach, however, it is understood that adding ego energy to disowned states is a deep and profound intervention, giving “air time” to forgotten aspects of self, which is in itself relieving as ego states under pressure are thus decompressed. Hypnotic accessing is sometimes auditory only, whereby the client reports what he or she hears as other ego states answer. In the Dissociative Table Technique, the part of self that is executive glances into a conference room in the mind’s eye and passes along not only what it hears but also what it sees, which adds important information not provided by auditory accessing alone. Finally, in some clients, co-consciousness is not present among parts of self early in treatment. For those clients, initially, switching between ego states in which one after another part is serially executive is possible. Such clients are typically highly dissociative.

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the abuse was warranted because the child was unimportant and somehow to blame and the perpetrator was important and deserving to abuse his or her power, the client’s symptoms can only be resolved when the conflict between those states is resolved (though typically many such conflicts and other matters must be resolved for full symptom remission). Resolving these conflicts can sometimes happen by psychoeducation, but often, it requires the addition of ego or object energy. Adding ego energy increases the client’s access to parts of self, and adding object energy increases his or her understanding and compassion toward parts of self for their various perspectives. The addition of either ego or object energy enables the resolution of double binds inherent in the situation of being a helpless abused child with no way to stop the abuse. Introjects

Each ego state is treated with appreciation, respect, and curiosity because it is there for some functional reason, even if that reason is not immediately apparent or even if it is ultimately maladaptive. The more dissociative a client is on the continuum, the more critical it is for the therapist to ensure that each ego state is aware that it is part of the client (not having its own physical body) and that it is oriented to the present date, location, and circumstances. Many clients have parts that are high functioning and completely oriented and other parts that believe themselves to have separate bodies. Such ego states may be disoriented in time, may be living in a past decade, and/or may believe that child abuse is currently happening now even though the perpetration may have stopped years ago. Some disoriented ego states function to preserve the attachment to the aggressor for survival purposes.

An extremely important and often overlooked matter in working with internal conflicts, treatment noncompliance, therapeutic ruptures, and other problems in therapy is the matter of introjects of parents or perpetrators. Introjects are internal likenesses of external people. Children invariably introject their parents or key caretakers. If those adults are loving, the introjects are also loving. If the child is abused by parents or others, the introjects of those parents or others will be malignant, perpetrating internal havoc on other aspects of self even in the absence of the actual external perpetrator. Often, such introjects believe themselves to be, and other ego states believe them to be, the external others, not aspects of the client. Orienting and appreciating the survival function of introjects, and  educating and mediating between the selfidentified and introject parts of self, are integral to symptom reduction and recovery. Persistent attachment to the perpetrator’s point of view is evidence of the need to work with the introject of the perpetrator using an ego state maneuver. It is essential that much of this work occur before trauma metabolizing is attempted.

Identifying and Resolving Internal Conflicts

Metabolizing Trauma

If one part of self holds the painful knowledge, emotions, and sensations of having been abused and another part has the function of agreeing that

Watkins and Watkins used hypnotically induced abreactions to metabolize unresolved traumatic memories. In this method, memories are vigorously

Orienting and Appreciating Ego States

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and energetically enacted to release and integrate dissociated (unremembered) experiences. John Watkins described using therapeutic resonance to enable abreactive work by resourcing the client with the therapist’s energy so that the client can tolerate the pain of the work in hypnotic trauma processing. In lieu of hypnosis, contemporary practitioners often use EMDR to efficiently metabolize trauma and process it to an adaptive resolution. With nondissociative clients, a single traumatic memory can often be metabolized in an extended trauma-processing session. With highly dissociative or complex trauma clients, the processing of trauma is best conducted in fractions, paced over time.

more commonly employed. Working with ego states, the Dissociative Table Technique is also often used for direct and deep structural access. Ego state therapy is used to activate ego states to accomplish specific therapeutic goals. A conditioned response closure procedure is important for any session that has used ego state therapy to ensure safety. Ego state maneuvers, stabilization, containment, and resourcing strategies are conducted at length before trauma processing for clients with significant ego state conflicts. Sandra Lee Paulsen See also Erickson, Milton H.; Eye Movement Desensitization and Reprocessing Therapy

Therapeutic Resonance

Therapeutic resonance goes beyond simple therapeutic empathy because in resonance, as described by John Watkins, the therapist adds considerable gusto to the processing of trauma to strengthen the client’s capacity to process beyond what he or she could manage with only his or her own resources. He gives the example of hypnotically abreacting a World War II combat veteran’s memory of a Nazi soldier climbing into his foxhole; Watkins adds energy to the client’s strength by shouting, “Let’s get the bastard!” Contemporary therapists use other methods to either reduce the size of the material to abreact in one sitting (e.g., by fractionation) or increase client capacity (e.g., by resourcing, grounding, or realignment of supportive ego states proximal to the ego state that is executive during the processing). Integration of States

A typical goal of treatment is the integration of ego states with elimination of amnesia, if present, and resolution of conflicts. The goal is not elimination of states, because having states that serve adaptive functions in a smooth functioning system of states is a normal phenomenon in human experience.

Therapeutic Process Historically, in ego state therapy, formal trance induction was used, but in contemporary treatment, the Ericksonian therapy of implicit suggestion is

Further Readings Emmerson, G. (2007). Ego state therapy. Bethel, CT: Crown House. Forgash, C., & Copeley, M. (2007). Healing the heart of trauma with EMDR and ego state therapy. New York, NY: Springer. Fraser, G. A. (1991). The dissociative table technique: A strategy for working with ego states in dissociative disorders and ego-state therapy. Dissociation, 4(1), 205–213. doi:10.1300/J229v04n04_02 Lanius, U., Paulsen, S. L., & Corrigan, F. (2014). Neurobiology and treatment of traumatic dissociation: Toward an embodied self. New York, NY: Springer. Paulsen, S. L. (2009). Looking through the eyes of trauma and dissociation: An illustrated guide for EMDR therapists and clients. Charleston, SC: Booksurge. Phillips, M., & Frederick, C. (1995). Healing the divided self: Clinical and Ericksonian hypnotherapy for posttraumatic and dissociative conditions. New York, NY: W. W. Norton. Watkins, J. G., & Watkins, H. H. (1997). Ego-states: Theory and therapy. New York, NY: W. W. Norton.

EGO-ORIENTED THERAPIES: OVERVIEW Ego-oriented therapies originally derived from the work of Sigmund Freud (1856–1939), the founder of psychoanalysis. In some cases, ego-oriented therapies are extensions of Freud’s theories, whereas in other cases, ego-oriented theorists rejected or

Ego-Oriented Therapies: Overview

reinterpreted Freud’s ideas within their own frameworks. Indeed, many of the founders of ego-oriented therapeutic approaches, such as Carl Gustav Jung and Fritz Perls, were colleagues of Freud or were originally trained in psychoanalysis. Freud suggested that there was a structure of personality that included the id, ego, and superego, and he emphasized the importance of the id in determining personality. He noted how the libido, or inherent life and death forces (e.g., sex and aggression), are housed in the id and affect the personality in unconscious ways. The ego, through the development of defense mechanisms, places restraints on such forces. In contrast, ego-oriented therapies de-emphasized the id as a driving force in determining personality and focused on the ego as the main, unconscious motivator in the development of personality. Whereas Freud suggested that the id impinges on the person and that the ego had to manage the life and death forces of the id if the person was to live in a civilized world, ego-oriented therapists downplay these forces as shaping behavior. Various egooriented therapies view other drives as affecting the person but always see the ego, both unconsciously and consciously, as being the main focus of attention in therapy. Because the ego is both unconscious and conscious, in contrast to the stark unconsciousness of the id, it is more controllable, and therapists can focus on helping clients understand their ego and manage its functions. Ego-oriented therapists seek to educate clients on how their ego is composed of a number of separate parts and how conflicts between the parts get played out in the world. Helping clients learn to distinguish their parts of self and how to manage them can lead to improved functionality, greater self-awareness, and the holistic integration of self. Concepts from ego-oriented therapy have found their way into popular culture, including concepts such as the parts of self, the inner child, and games playing by people, among other important psychological terms. Despite having roots in the oldest version of psychotherapy, many ego-oriented therapies continue to evolve and have significant influence on the practices of modern psychotherapy.

Historical Context Freud first developed the concept of the ego and his id-ego-superego model of personality around 1911 but wrote about it most prominently in his

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1920 essay “Beyond the Pleasure Principle” and in his 1923 essay “The Ego and the Id.” Freud borrowed aspects of his model from Georg Groddeck, a physician interested in psychosomatic medicine. Groddeck coined the term id, or “the it,” which is that part of the self concerned with instinctual drives. The ego, known as “the I” was originally conceived of as a person’s sense of self. While Freud’s id-ego-superego model of personality, eventually called the structural model, proved influential within his circle of followers, many early theorists disagreed with his emphasis on the id and, instead, placed emphasis on the ego and its different functions as primary within psychotherapy. Paul Federn, a psychoanalyst and devotee of Freud, moved beyond Freud’s ideas in the 1920s to focus on ego states, or parts of self, as being the most important feature of personality. Federn saw the self (e.g., personality) as being composed of many different parts, and this instrumental idea led other theorists to develop related ego-oriented therapy approaches. Freud’s idea that there exist unconscious parts of the self hidden away from the daily awareness of an individual, and thus potentially causing problematic thoughts, feelings, and behaviors, had an impact on many of his early followers. Following Freud’s lead, other theorists expanded on his concept of ego psychology, including his daughter Anna Freud, an influential psychoanalyst in her own right. Other influential psychotherapists to expand on Freud’s idea of the id-ego-superego model of personality include Heinz Hartman, Erik Erikson, and David Rappaport. These theorists added their own ideas to shape psychological theory and therapy around the now commonly accepted idea that individuals are made up of various parts that can contribute to their health or dysfunction, depending on the awareness, acceptance, and integration of these parts. While some theorists extended their theories from Freud’s ideas, others took Freud’s ideas about ego in wholly new directions according to their own theories. For example, Jung, initially a colleague and collaborator of Freud, broke away to develop his own approach to therapy in 1913, called analytical psychology. Jung drew from Freud’s concept of the personal unconscious existing within individuals to develop the idea of the collective unconscious, which is composed of

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universal archetypes inherited, or shared, by all people. Others followed by transforming Freud’s structural model and integrating additional aspects of psychoanalysis with their own ideas, such as  Gestalt therapy, developed by Fritz and Laura Perls in the 1940s and 1950s. Gestalt therapy retained the idea of a person being made up of different parts, discussed as polarities, with a major goal of therapy being to integrate these disparate parts into a whole. This holistic union of the disconnected parts of self became a component of ego-oriented therapies such as Voice Dialogue and ego state therapy, which would emerge in the latter part of the 20th century. While the popularity of ego-oriented therapies declined during the 1970s, these approaches and the ideas stemming from them, such as the importance of viewing a person as a holistic being composed of various parts needing attention, continue to have an influence. Whether in psychotherapy, self-help, or related modern therapeutic approaches, the concept of ego states, or parts of self, continues to shape how individuals define their identity and is frequently a focus of clinical work for many practicing therapists.

Theoretical Context Ego-oriented therapies utilize several key Freudian concepts; however, not all of the classical psychoanalytical terminology is incorporated into these approaches. The most important concepts in egooriented therapies are the ego and the ego state (i.e., parts of self) or some variation on the concept of divided parts of an individual’s identity. Other important concepts used in many of these theories include the unconscious, defense mechanisms, dissociation, and the influence of past traumas. Ego

Ego-oriented therapies, including classical Freudian psychoanalysis, recognize that the human personality comprises several parts rather than being a single entity. In Freudian theory, the ego is the realistic self or the self that mediates between the instinctual drives of the id and the morality of the superego. The ego is the part of the human personality that is responsible for behavior and is influenced by its interaction with the external

worlds. The original term was translated from the German as “the I” but was Latinized to ego in English language texts by Freud’s translator, the psychoanalyst James Strachey. Ego-oriented therapies focus on the interplay of various ego functions, or ego states, and how they influence thinking, feeling, and behavior. These ego states are formed as a person grows and are shaped by interactions with the world as one develops. Ego States

Freud’s id-ego-superego model of personality saw an individual as comprising several parts of self: the id (i.e., the instinctual self), the ego (i.e., the realistic, mediating self), and the superego (i.e., the moral self). These parts interacted with one another to form one’s mental life and to make up the whole self, or personality. Whereas Freud placed emphasis on the id as the most important concept in determining personality within his model, ego-oriented therapists instead emphasize the various ego states, or parts of self, as most essential in human personality and the most manageable to treat in therapy. In other words, an individual’s personality is made of different parts of self, or aspects, called ego states. An ego state is an unconscious part of the self that is developed enough for it to be named once the individual becomes aware of it—such as one’s child self or paternal self. In ego-oriented therapies, these separate parts of self and how they function internally or play out in the world externally become the focus of therapy. Dysfunction in ego states may lead to problem thinking, feeling, and behaving—leading in extreme cases to multiple personalities. Ego state theorists use various names for these ego states, including the inner child in inner child therapy; the parent, adult, and child in transactional analysis; and polarities of self (e.g., adult vs. child) in Gestalt therapy. Regardless of the names given to the parts of self, ego-oriented therapies work with clients’ ego states to address the conflicts between them, to encourage their disclosure, or to integrate them into a more unified personality. Unconscious and Conscious Aspects of Self

The unconscious represents the hidden aspects of the self that affect a person’s life without their awareness. Unconscious aspects at work in a

Ego-Oriented Therapies: Overview

person’s life include memory, emotion, basic mental routines, habits, motivations, and desires. Anything that occurs automatically or is undetected by the aware, or conscious, mind resides in the unconscious. By contrast, ego-oriented therapists help clients become aware (i.e., conscious) of parts of self and related unconscious components that normally remain hidden from their conscious mind, such as phobias, attachment issues from childhood, repressed impulses, and other hidden aspects of the person that can contribute to problem thinking, feeling, and behaving. For example, an ego-oriented therapist might help a client become aware of his or her inner child and teach the client how to cope with childhood trauma that continues to affect the client negatively as an adult or to connect to a repressed part of the self that wants to be free and help the client integrate this part into a healthier, holistic personality. Defense Mechanisms

Defense mechanisms develop to protect or hide certain ego states, such as the child in transactional analysis, from clients’ conscious and can hinder the integration of a holistic personality as an adult. Defense mechanisms are created by the individual unconsciously as protective factors to defend against harm, generally developing in early childhood, or to hide negative impulses of the self. As individuals mature, defense mechanisms often remain in place, but where once they were protective, they often are a cause of dysfunction in the adult self. Defense mechanisms (e.g., rationalization, denial, repression, and intellectualization) can be brought into the conscious and examined for their effectiveness by the self as healthy or unhealthy strategies for coping. Dissociation

Dissociation is a disconnection from ego states that lead to dysfunction in life, internally and externally, and is a significant defense mechanism in some ego-oriented therapies. Dissociation occurs due to ego states, and problems connected with dysfunctional aspects of those states, such as emotional pain, remaining hidden or disconnected in the unconscious. By becoming aware of

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the dysfunctional or painful parts of the self and drawing them into the conscious mind, an individual can learn to recognize how the parts of self interact with one another and identify their connections (e.g., they can re-associate the connections and integrate them into a healthier, holistic self). Past Trauma

While Freud placed significant emphasis on past events that occurred to his clients, many egooriented therapies (e.g., developmental needs meeting strategy, inner child therapy, and internal family systems model) also emphasize the past, in particular childhood trauma, as a component needing focused attention in therapy. Whether arising in concepts such as the inner child or in the simple recognition of the influence early pain and trauma can have on people, these therapeutic approaches assist clients in moving beyond or through their past to become healthier individuals.

Short Descriptions of Ego-Oriented Therapies Adlerian Therapy

Alfred Adler was a colleague of Freud and is considered an originator of psychotherapy; however, he broke away early from Freud to develop his own psychodynamic approach to therapy. Adler was one of the earliest theorists to emphasize different parts of self and to promote the idea of holism, as well as emphasizing birth order and personality types in his therapeutic approach. Analytical Psychology

This therapeutic approach, also called Jungian therapy, was developed by Jung following his earlier work with Freud. Analytical psychology expands on the idea of the unconscious to include the collective conscious, or the inherited, historical conscious. Jung’s approach to therapy has been highly influential and contributed concepts such as archetypes, individuation, human life span development, and introversion and extraversion, among other important contributions, to the field of psychology.

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Developmental Needs Meeting Strategy

Gestalt Therapy

This approach helps clients heal from emotional, physical, and sexual trauma, frequently occurring in childhood, by employing a caring, strengths-based, global, client-focused approach to treatment. This therapy helps clients address lingering unmet attachment needs from childhood caused by trauma and helps them move beyond the past by helping them meet their attachment needs in the present.

Developed by Fritz and Laura Perls, this existential and experiential therapy approach focuses on the hereand-now of human experience, encourages the holistic integration of all aspects of a person (defined as polarities), and emphasizes the relationship between client and therapist within therapy. This therapy, born as a reshaping of Freud’s ideas, incorporates a diverse range of ideas, theories, and philosophies and has become a major influence on psychotherapy since its creation.

Ego Psychology

Inner Child Therapy

Ego psychology represents a large number of psychotherapeutic approaches and theories influenced by Freud’s notion of the ego, or “the I,” and these focus on the various functions of the ego, including reality testing, defense mechanism management, and impulse control, among others. Theories extending from Freud’s ideas under the banner of ego psychology include those formulated by his daughter Anna Freud and influential psychotherapists such as Alfred Adler, Karen Horney, and Erik Erikson.

Based on the idea that clients develop psychological disturbances due to unresolved childhood issues, this therapy helps clients to deeply explore their past trauma as children and to heal from these wounds by integrating the inner child’s needs with the needs of the adult client.

Ego State Therapy

Ego state therapy helps clients connect to the different parts of themselves, their ego states, which are dissociated, conflicted, or disconnected. Through a therapeutic approach that is more direct than classical psychoanalysis, this therapy helps clients settle internal conflicts and psychological disruptions between disjointed parts of the self or within one’s personality. Freudian Psychoanalysis

Freud developed his influential approach to therapy based on his ideas of the id, ego, and superego; the importance of defense mechanisms; the unconscious; and the internal drives that guide human behavior, among other deeply influential therapeutic concepts. After first researching hysteria and hypnosis, Freud eventually developed the talking cure and created the foundations from which modern therapy has evolved, in acceptance or rejection of his original ideas. Freud’s approaches to therapy and concepts have been applied in many other fields, including linguistics, literary and film criticism, and the study of culture.

Internal Family Systems Model

The internal family systems model aims to effect healing from individual, couple, and family trauma through using an integrative systems approach with ideas from Freudian therapy, such as ego states, and connected concepts from transactional analysis and psychosynthesis. This approach utilizes a variety of imaging techniques and enactments to help clients explore their different internal parts and to incorporate these subpersonalities into a harmonious collaboration of self. Psychosocial Theory and Development

Erik Erikson, like Freud, developed his theory around stages of development; but whereas Freud emphasized the id within personality, Erikson emphasized ego identity. Ego identity can be described as one’s conscious awareness of self created through interactions with the external world. Mastery of stages within Erikson’s psychosocial theory leads to ego strength, but poor management of a stage leads to a sense of inadequacy in the person. Erikson’s conception of the ego was as a creative, flexible structure that maintained one’s hold on identity. Transactional Analysis

Developed by Eric Berne, this therapy and theory of personality is rooted in the interplay

Ellis, Albert

between three distinct aspects of the ego: parent, adult, and child. Individuals transact, or engage, with these different ego states within their interpersonal relationships, often leading to dysfunctional behaviors, known as games people play, and therapy works to redress these dysfunctional behaviors toward well-being.

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Schwartz, R. C. (1995). Internal family systems therapy. New York, NY: Guilford Press. Stone, H., & Stone, S. L. (1989). Embracing our selves: The Voice Dialogue manual. Novato, CA: New World Library. Watkins, J. G., & Watkins, H. H. (1997). Ego oriented: Theory and therapy. New York, NY: W. W. Norton.

Voice Dialogue

This therapeutic approach recognizes that persons are made up of many parts and helps clients recognize and integrate the parts of themselves they had been rejecting. Through education and therapy, clients learn to distinguish the different parts of their self, to recognize how these parts may be causing them problems in life, and to develop greater self-awareness in life. Kevin C. Snow See also Adler, Alfred; Adlerian Therapy; Analytical Psychology; Developmental Needs Meeting Strategy; Ego State Therapy; Freud, Sigmund; Freudian Psychoanalysis; Gestalt Therapy; Inner Child Therapy; Internal Family Systems Model; Jung, Carl Gustav; Perls, Fritz; Psychosocial Development, Theory of; Reich, Wilhelm; Transactional Analysis; Voice Dialogue

Further Readings Ansbacker, H. L., & Ansbacher, R. R. (Eds.). (1956). The individual psychology of Alfred Adler: A systematic presentation in selections from his writings. New York, NY: Basic Books. Aziz, R. (1990). C. G. Jung’s psychology of religion and synchronicity. Albany: State University of New York Press. Berne, E. (1961). Transactional analysis in psychotherapy: A systematic individual and social psychiatry. New York, NY: Grove Press. Erikson, E. H. (1959). Identity and the life cycle. New York, NY: International Universities Press. Freud, S., & Strachey, J. (1970). An outline of psychoanalysis. New York, NY: W. W. Norton. Missildine, W. (1963). Your inner child of the past. New York, NY: Simon & Schuster. Perls, F. (1969). In and out the garbage pail. Lafayette, CA: Real People Press. Schmidt, S. J. (2009). The developmental needs meeting strategy: An ego oriented therapy for healing adults with childhood trauma and attachment wounds. San Antonio, TX: DNMS Institute.

ELLIS, ALBERT Widely known as the major founder of the cognitive-behavioral approach to counseling, Albert Ellis (1913–2007) developed what eventually became known as rational emotive behavior therapy (REBT). Born in Pittsburg, Pennsylvania, Ellis moved as a young child with his family to New York City. Although he suffered from various illnesses as a child, his parents rarely visited him at the hospital as his father was often away on business trips and his mother was occupied with his two younger siblings and other activities. Feeling neglected, Ellis looked for things to occupy himself, and he could often be found reading books from the hospital library, chatting with fellow patients, imagining what he would do when he grew up, creating games he and his fellow patients could play, and more. He later called this behavior “cognitive distraction,” and it eventually became one of the components of REBT and other cognitive approaches. Ellis was a voracious reader, often reading the early and modern-day philosophers and the work of popular psychologists. Not surprisingly, his classmates gave him the nickname “Encyclopedia.” At the age of 19, Ellis decided he wanted to cure himself of the debilitating shyness he had toward women. Keeping in mind John B. Watson’s idea of “in-vivo desensitization,” he gave himself the task of spending each lunchtime, during the month of August, sitting on a bench at the Bronx Botanical Gardens and forcing himself to talk with every woman who sat next to him. During that month, he spoke with a least 100 women and asked one out on a date. Finding that he survived the month with nothing dreadful happening, he eventually integrated trying new and often difficult or even embarrassing behaviors to overcome fears, guilt, or shame into his REBT approach.

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With the Great Depression taking its toll on his family and society, in his young adulthood, Ellis decided that it was prudent to earn a degree in business. At the same time, he continued his voracious reading, began to write hundreds of essays and manuscripts, and became interested in reading and writing about love, relationships, and sexuality. This resulted in numerous people coming to talk with him about their relationship and sexual problems. Knowing that he had taught himself to overcome and change his emotional upsets and difficulties, and realizing that he had a natural talent for helping people, he eventually enrolled in a doctoral program in clinical psychology at Columbia University. Like most clinical psychologists of the time, he studied psychoanalysis but quickly began to question this widely used approach. He soon noticed that although many clients felt better after talking about their past, they weren’t getting better; that is, they were not taking responsibility for creating their emotions and were not finding ways to change unhealthy emotions into healthy ones. He also questioned the new nondirective approaches, such as client-centered counseling, whose approach was far from the deductive reasoning style that he embraced when investigating the faulty thinking that was resulting in unhealthy emotions. In part, because of Ellis’s interest in scientific understanding, his passionate belief in civil rights, his conviction that it was unethical to judge people for their lifestyles, and his interest in human sexuality, in the early 1950s, he became the founder and first president of the Society for the Scientific Study of Sex as well as the first American editor of the International Journal of Sexology. He could often be found supporting equal rights for women, gay rights, and interracial relationships, and he was even involved in the American Association for Nude Recreation’s successful lawsuit to send sexually explicit magazines through the mail, which was decided by the Supreme Court in 1958. In his 20s, as the result of an on-again/off-again relationship and the resulting despair he felt, Ellis realized that it was not the rejection by his woman friend that caused his despair but his belief that the woman should love him as much as he loved her. The negating of this kind of absolutist thinking eventually became a major part of his therapy. As Ellis developed a private practice, he increasingly

realized that his clients had developed irrational beliefs that drove their behaviors and were the source of the unhealthy emotions from which they suffered. He also observed that even after they identified their irrational beliefs, many still had a tendency to maintain them. This led him to develop, in clear understandable terms, what was then called rational therapy, which focused on teaching others how to change their self-defeating, irrational beliefs into healthy, rational ones. He taught that people construct their emotions from the way they think, that it was not the circumstance that creates a person’s emotional destinies but one’s perception of the circumstance. It was then that he formulated his ABC Approach for Changing Disturbing Emotions, which later became known as the ABCDE approach. In the ABCDE approach, A refers to the activating event or adversity (the event that occurs prior to the interceding thoughts); B refers to one’s belief about the event (irrational beliefs lead to unhealthy consequences); C refers to the consequences (negative emotions or destructive behaviors result from irrational beliefs); D stands for the disputation of the irrational thoughts, which is done logically, realistically, and pragmatically; and E stands for effective new philosophies. Here, new rational beliefs are clearly expressed, with the intention of repeating them in one’s mind over and over again. At this stage, additional cognitive, behavioral, and emotional tasks are used to reinforce and help maintain the healthier emotions and behaviors. After publicly presenting his theory to his peers at the annual American Psychological Association (APA) convention in Chicago, Illinois, in 1956, Ellis was challenged and severely criticized by traditional psychoanalysts for what they described as his rational and simplistic approach. He was also challenged by some existential humanists who believed that he did not place enough emphasis on the client–therapist relationship, and they accused him of showing lack of empathy when working with clients. Although some of his critics could not see beyond his firm and directive tone and others did not like his humor and at times colorful vocabulary, his supporters recognized that fueling his manner was his genuine and fervent desire to help people suffer less and enjoy life more. Ellis became a great promoter of his theory. One of his first books on his approach, How to Live

Emotional Freedom Techniques

With a Neurotic, was published in 1957, and he established his institute for rational living, called the Albert Ellis Institute, in New York City 2 years later. Here, he created his famous weekly “Friday Night Workshop,” where he would demonstrate his approach. He traveled the world teaching REBT to practitioners in the healing professions and to the general public. He was a prolific writer, with more than 85 published books and more than 1,500 published articles, and his new approach to psychotherapy became one of the most popular approaches practiced. Over the years, Ellis continued to refine his approach and changed its name to rational emotive therapy (RET) and then in 1993 to REBT. Ellis worked solidly, 7 days a week, until succumbing to severe pneumonia in 2006 at the age of 92. However, even following his illness and despite being in hospital and rehab for most of his remaining 15 months, he continued to help students, colleagues, writers, and others who visited him. Considered one of the most influential therapists of all time, Ellis was conferred the APA’s Distinguished Professional Contribution award in 1985. At the APA’s annual convention in 2013, he was posthumously awarded the APA’s Award for Outstanding Lifetime Contributions to Psychology. He was also bestowed one of five Living Legend awards by the American Counseling Association in 2004. Today, many of the essential principles of REBT can be seen in most forms of cognitivebehavioral therapy that have arisen over the years. The popularity of these is mostly due to the groundbreaking, enlightening, pioneering, and tireless work of Ellis. Edward S. Neukrug and Debbie Joffe Ellis See also Beck, Aaron T.; Classical Psychoanalytic Approaches: Overview; Cognitive-Behavioral Therapies: Overview; Cognitive-Behavioral Therapy; ExistentialHumanistic Therapies: Overview; Meichenbaum, Donald

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critical appraisal of the theory and therapy of Albert Ellis (pp. 199–235). New York, NY: Academic Press. Ellis, A. (2004). Rational emotive behavior therapy: It works for me, it can work for you. Amherst, NY: Prometheus Books. Ellis, A. (2005). The myth of self esteem. Amherst, NY: Prometheus Books. Ellis, A. (with Ellis, D. J.). (2010). All out! An autobiography. Amherst, NY: Prometheus Books. Ellis, A. (n.d.). REBT by Albert Ellis, Ph.D.: 12 irrational ideas that cause and sustain neurosis. Retrieved from http://www.rebt.ws/REBT%20explained.htm Ellis, A., & Ellis, D. J. (2011). Rational emotive behavior therapy. Washington, DC: American Psychological Association. Ellis, A., & Harper, R. A. (1975). A new guide to rational living. North Hollywood, CA: Wilshire. Ellis, A., & MacLaren, C. (2005). Rational emotive behavior therapy: A therapist’s guide (2nd ed.). Atascadero, CA: Impact.

EMDR See Eye Movement Desensitization and Reprocessing Therapy

EMOTIONAL FREEDOM TECHNIQUES Emotional freedom techniques (EFT) is a meridian-based therapy that helps people by altering “blocked energy.” Blocked energy is conceptualized as the intersection of physiological symptoms and cognition. Physical manifestations of blocked energy can include anxiety, panic attacks, posttraumatic stress disorder, childhood trauma, and phobias.

Historical Context Further Readings Ellis, A. (1957). How to live with a neurotic. New York, NY: Crown. Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Lyle Stuart. Ellis, A. (1989). Comments on my critics. In M. E. Bernard & R. DiGiuseppe (Eds.), Inside rational-emotive therapy: A

EFT is one type of body-centered therapy (BCT). Such approaches challenge the belief in dualism that the body and the mind are separate entities, functioning independently. Body-centered therapies date to Sigmund Freud (1856–1939), who was the first psychotherapist to suggest that ego states functioning is directly related to one’s bodily sensations

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and bodily impulses. Freud initially believed that touch, including massage, was an effective strategy for healing a client but later retracted that belief due to concerns about sexual transference. Later body-centered therapists challenged his notion that the mind and the body are separate entities and became increasingly comfortable with the use of touch as a therapeutic modality. Wilhelm Reich, often considered the founder of body psychotherapy, believed that the body and the mind interacted and “mirrored” each other. Reich saw character as a bodily expression of “psychological conflict” caused by outside societal influences and was one of the first to study the physical processes of muscle contractions held throughout the body, calling it “armoring.” EFT was developed by Gary Craig and others during the latter part of the 20th century. EFT draws from Reich’s ideas around bodywork and acupressure and examines how the body can manifest a variety of issues, anxieties, and phobias.

Theoretical Underpinnings For centuries, people have been looking to their external environment, as well as to their “inner selves,” to define what, in the end, constitutes the “human core.” EFT is just one of many theoretical models looking to map the innermost existence of people. In the study of body-centered and somatic therapies, there is a fine distinction between what is felt somatically by the body and what is expressed outwardly through movement of the body. Feelings of unrest, anxiety, unexpressed emotions, phobias, fear of death, and buried traumas are all issues that are addressed through EFT. EFT suggests that the body and the mind are one interrelated system and that healing occurs when the body–mind interface is cohesive as a unit. It is believed that one’s best memories as well as one’s most traumatic memories are preserved deep in the body’s memory, not just in mental memory. By using the body’s remembered sensations from past experience, the unconscious can be reached.

Major Concepts Three major concepts associated with EFT are BCT, meridians, and acupoints. Each of these is discussed in turn.

Body-Centered Therapy

EFT is a type of BCT that is an outgrowth of nontraditional psychology or alternative counseling. BCT is a branch within psychotherapy with a fundamental belief that the body and the mind work together and must be focused on equally in therapy for successful change to take place. It is a holistic approach to psychotherapy, meaning mind and body are integrated. Central to BCT is the notion that our core beliefs become embodied and that we must experience our pain directly through our bodies if we are to achieve mental health. Meridians

Meridians are rooted in Chinese medicine and are based in the belief that there is life energy, called qi, that flows through a path in the body. There are 12 principal meridians, which are sometimes accessed in bodywork, such as acupressure, acupuncture, and EFT. Acupoints

Acupoints, or acupuncture points, are located along the meridians and places along the meridian that when touched or stimulated can bring a sense of balance or calm to the client.

Techniques In EFT, the therapist plays an active role in the therapeutic process, which may include touching the client, making movements with the client, breathing exercises, and sensory awareness. EFT releases blocked energy from the body by physically “tapping” on acupoints on meridians on the body. Although an EFT specialist, or a therapist trained in EFT, will initially do the tapping, tapping can eventually be self-administered once a client learns his or her meridian crossover points. Clients are taught to “tap” their meridian points in a specific order with a set-up phrase and learn how to rate their symptoms on a scale of 1 to 10. After tapping, clients reassess their symptoms to see if the blocked energy has been released or lessoned. Once this blocked energy is released, there is symptomatic relief. EFT is used by therapists to help people overcome phobias, anxiety, and even emotions that have been blocked in their bodies for

Emotion-Focused Family Therapy

years. Ultimately, counselors who practice bodycentered therapies, like EFT, report that clients often make dramatic improvements after their sessions.

Therapeutic Process When clients first enter EFT, they present to therapists with a variety of physical and emotional symptoms, such as anxiety, depression, or posttraumatic stress disorder. The role of the therapist is not to treat individual symptoms but to bring together the emotional and physical “wholeness” of the client. Slowly, clients move deeper, viscerally, into themselves, physically and emotionally. Eventually, clients self-report feeling calm in the face of emotional storms, physical and emotional awareness in their daily lives, a cathartic release of paralyzing emotions, and even great peace with death. Ultimately, counselors who practice EFT and other BCTs often report that clients make dramatic improvements after the therapy sessions. Continued research and publications will help bring forth more creditability to the power and benefit this therapy can bring to its clients. Sachin Jain See also Acupuncture and Acupressure; Body-Oriented Therapies: Overview; Coherence Therapy; Complementary and Alternative Approaches: Overview; Energy Psychology; Non-Western Approaches; Reich, Wilhelm

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Totton, N. (2002). Foreign bodies: Recovering the history of body psychotherapy. In T. Staunton (Ed.), Body psychotherapy (pp. 7–26). New York, NY: Taylor & Francis.

EMOTION-FOCUSED FAMILY THERAPY Emotion-focused family therapy is an attachmentoriented approach to family counseling that is designed to promote the development of secure emotional bonds, also called attachments, among family members. According to emotion-focused family therapists, connection to others through safe and nurturing relationships is considered to be a fundamental human need. The main objective of this approach is to create or restore emotional connections among family members so that each family member, and the family as a unit, can experience well-being and emotional growth in the context of securely attached relationships. Emotion-focused family therapy can be used with a variety of types of families, including nuclear families, blended families, and single-parent families. It has been shown to be effective in working with clients who present with communication problems, discipline and behavior problems, eating disorders, depression, and other concerns. Regardless of the presenting problem, the emotion-focused family therapist works to address individual problems and pathologies, as they are considered to be the result of unmet attachment needs that can be resolved through healing the family relationships.

Further Readings Eiden, B. (1999). The history of body psychotherapy: An overview. Counseling News—The Voice of Counseling Training, 12, 15–21. Manning, J. (2007). The use of meridian-based therapy for anxiety and phobias. Australian Journal of Clinical Hypnotherapy & Hypnosis, 28(2), 45–50. Roy, D. M. (2003). Body-centered counseling and psychotherapy. In D. Capuzzi & D. R. Gross (Eds.), Counseling and psychotherapy: Theories and interventions (3rd ed., pp. 387–414). Upper Saddle River, NJ: Merrill Prentice Hall. Staunton, T. (Ed.). (2002). Body psychotherapy: Advancing theory in therapy. New York, NY: Taylor & Francis.

Historical Context With the popularization of family counseling during the 1950s, there came a shift in focus from intrapsychic functioning to interpersonal dynamics. Rather than viewing problems as being within the person, family therapists, using systems theory, began conceptualizing problems and opportunities for interventions as located within the patterns of interactions and relationships among family members. By the 1970s, more distinct models of family counseling had developed, each model characterized by unique intervention methods and characterizations of pathology. Drawing on the tenets of

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attachment theory and focusing on emotional healing in intimate relationships, emotion-focused family therapy and emotion-focused therapy, as practiced with individuals, emerged into prominence in the 1980s. The popularity of emotionfocused therapeutic work contrasted with the increasingly popular emphasis on cognitions and behavior change and also coincided with the emerging exploration of adult attachment patterns rooted in the early work of John Bowlby and Mary Ainsworth on attachment patterns in children. Other notable emotion-focused therapy proponents since the 1980s include Sue Johnson, working with couples; John Byng-Hall, working on conceptualizing family systems; Les Greenberg; Jeremy Safran; and Laura Rice.

Theoretical Underpinnings Emotion-focused family therapy relies heavily on attachment theory to explain distress in families and individuals. The premise of attachment theory is that from an early age, individuals have an intense need or drive for close, stable, and dependable relationships with other people. Relationships with caregivers formed in early childhood affect emotional regulation because in early childhood the ability to emotionally self-regulate is forming. If children experience shame, fear, and vulnerability when expressing emotional needs, then protective and often dysfunctional secondary emotions develop that interfere with emotional expression. These emotional patterns can continue into adult relationships with friends, romantic partners, and one’s own children, interfering with future abilities to form healthy attachments to others. Bowlby, a  prominent attachment theorist, believed that work with parents was critical to improving the circumstances of children. As a specific approach to working with families, emotion-focused family therapy is concerned with cycles, patterns, boundaries, and the interconnectedness of members within the family system. Systems theory considers the family unit as a whole that is greater than the sum of its parts, and emotion-focused family therapists are concerned with the ability of the whole system to meet the emotional needs of each member of the system. Systems theorists hold that whenever a change occurs within the system, even at the individual

member level, the entire system changes. For this reason, emotion-focused family therapists are able to work on family issues and accomplish goals even without all family members present. An essential element of therapeutic relationships within emotion-focused family therapy is the existential-humanistic theory of Carl Rogers. Just as Rogers emphasized the unconditional positive regard necessary to develop conditions that promote positive growth and change, emotion-focused family therapists rely on creating therapeutic relationships that emphasize collaboration, trust, and respect to create a supportive therapeutic environment. Consistent with systems theory, attachment theory, and existential-humanistic theory, the model can be practiced with whole family groups or subgroups, such as a parental unit or one parent and one child, provided the therapeutic relationship creates the necessary conditions for a trusting safe environment that permits emotional exploration.

Major Concepts Emotion-focused family therapy is a model of family counseling that engages participants, or clients, around their need to connect with others. Some of the important concepts in this process include attachment, primary and secondary emotional responses, and relationship cycles. Attachment

In emotion-focused family therapy, therapeutic change is achieved by focusing on attachments and unmet emotional needs. All problems are characterized as attachment dilemmas, and the emotion-focused family therapist’s first task is to frame the family’s presenting problem as such. When conflicts occur in relationships, there is usually a perceived lack of accessibility to or responsiveness from an attachment figure, such as a spouse, partner, or parent. Primary attachment needs include a fundamental desire to be connected to others, emotional accessibility of loved ones, and emotional responsiveness of attachment figures. For example, a family that presents to counseling with a withdrawn and isolated adolescent child comes to understand that the primary

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issue facing the adolescent is a relational need to retain connection to parents while also experiencing increased independence and autonomy. The family therapist assesses the attachment style of the family as a whole and the individuals within it and validates each individual’s experience until the family members are able to assume this role for one another. A functional family is considered to be one in which all members’ attachment needs can be met.

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communication, emotion-focused family therapists address the fact that the negative cycle is an attempt to have the unmet attachment need of security and acceptance met. Only after the attachment need is addressed can the cycle be broken. A  positive cycle would be one of closeness and caring, wherein a family member who experiences distress reaches out to another family member, who in turn comforts and supports the distressed family member, thereby strengthening the attachment bond.

Primary and Secondary Emotional Responses

Emotion-focused family therapists believe that individuals have primary emotions. Primary emotions are fundamental emotions felt immediately in response to events. Primary emotions may include anger, sadness, or fear. In some individuals, primary emotions are masked by less functional secondary emotions like guilt or shame about the original primary emotion. Families seeking therapy are likely to be stuck in unproductive patterns of emotional expression. These families are likely to be more rigid and to exhibit greater insecurity and more overall negative affect. The work of the emotion-focused family therapist is to explore the emotions underlying dysfunctional emotional responses such as withdrawal, pursuing, and blame. Most likely, a primary emotional response of fear, hurt, or anger is underlying the secondary dysfunctional emotional responses. The emotionfocused family therapist explores the patterns that create and reinforce these interactions by connecting specific behaviors to emotional needs. The emotion-focused family therapist then works with family members to restructure these interactions so that family members deal more directly with primary emotional responses. Relationship Cycles

Drawing on systems theory, emotion-focused family therapists look for repeating cycles of interactions in family relationships. The pursue– withdraw cycle is a common dynamic wherein one family member pursues another family member and then that family member withdraws and the cycle repeats. This pattern becomes destructive to the family relationship as a safe and secure place for its members. Prior to teaching new skills in

Techniques An emotion-focused family therapist will employ a variety of techniques to achieve the goal of improved attachment and emotional expression. Emotion-focused family therapists are directive, especially in the early phases of treatment, when it is necessary to disrupt negative patterns of interaction. At later stages of treatment, after the notion of the family as a base for secure attachment is established, the therapist helps the family construct new meanings about their family relationships. Thus, the techniques employed by emotion-focused family therapists are determined by the phase of treatment. Processing, Accepting, and Soothing Emotions

Initially, the emotion-focused family therapist brings forth a discussion of unmet emotional needs among family members. The family therapist begins the emotional work by observing family members interact around an initial conflict, such as an adolescent’s drug use, and noting both primary and secondary emotions. The therapist then validates each family member’s perspective and highlights attachment needs, intentionally softening the family’s perspective about the conflict. This is very directive and active work on the part of the therapist, who may direct family members to speak directly to the therapist or to one another. Eventually, this ability to process, accept, and soothe emotions is transferred to the family members, who become increasingly able to care for the emotional needs of one another. Individuals within families increase their willingness to self-disclose their own emotional needs that were previously clouded over with blame, criticism, and anger

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because they have learned to trust and feel safe in their attachments through emotion-focused family therapy. When family members learn that they have not met their loved ones’ emotional needs, they respond with comfort and caring rather than defensiveness. Parenting Skills Training

Emotion-focused family therapy is ideal for circumstances that call forth more intensive work than merely parent education; however, teaching parenting skills, especially with regard to teaching parents how to teach their children to regulate emotion and communicate needs effectively, is essential. In fact, the emotion-focused family therapist may work with parents and their children outside the family therapy session and teach parents how to respond empathically to their children’s emotions. The emotion-focused family therapist also models desired parenting behaviors in session. A belief of emotion-focused family therapy is that parenting skills are ineffective if underlying attachment issues are not also addressed, so teaching parenting skills alone is considered insufficient. Reframing Problems

The emotion-focused family therapist works with the family members to develop a new perspective that reframes problems as being related to unmet emotional and/or relational needs rather than as merely disobedience or the common beliefs of “bad parents” and “bad children.” A  child acting out with disruptive behavior is viewed as a child in need of a more securely attached relationship with his or her parents. The parents effectively shape the child’s behavior through the power of their relationship with their child, not through punishment, coercion, or reinforcement, so strengthening the emotional bonds between parent and child is important. In the context of a securely attached relationship, the child is presumed to gravitate toward socially acceptable behavior to the extent developmentally possible. As therapy progresses, the family member becomes more involved in reframing problems and constructing a positive narrative for family life.

Therapeutic Process Family relationships can be intimate sources of healing or a volatile place of painful vulnerability. Because of the emphasis on emotions and family relationships during emotion-focused family therapy, it is important for families to be fully informed of the possibility for emotional intensity during and after sessions. Emotional catharsis is not useful in and of itself, but emotional expression is seen as a pathway to understanding underlying attachment needs. Emotion-focused family therapists direct families in a specific orientation toward increasing secure attachments and emotional healing. The family therapist’s relationship with the family is a critical element in the success of this approach, and family therapists must be certain to validate the perspective of all family members. Slowly, the emotion-focused family therapist helps each family member, and the family as a whole, understand how his or her unmet emotional needs have affected the family and helps the family provide a more secure and safe atmosphere. As family members wean themselves off counseling sessions, they continue to maintain the newly established secure attachments through ongoing positive family rituals so that all the family members experience reliable and positive intimate exchanges. An example of a family ritual that would create a reliable positive exchange would be a family movie night. The emotion-focused family therapist is interested in understanding past emotional attachments to better address present issues. The ultimate goal is to work through past attachments issues so that present relationships can be depended on for future needs. Angela R. McDonald See also Attachment Theory and Attachment Therapies; Couples, Families, and Relational Models: Overview; Emotion-Focused Therapy; Experiential Psychotherapy; Rogers, Carl

Further Readings Efron, D., & Bradley, B. (2007). Emotionally focused therapy and emotionally focused family therapy: A challenge/opportunity for systemic and post-systemic

Emotion-Focused Therapy therapists. Journal of Systemic Therapies, 26(4), 1–4. doi:10.1521%2Fjsyt.2007.26.4.1 Furrow, J., & Palmer, G. (2007). EFFT and blended families: Building bonds from the inside out. Journal of Systemic Therapies, 26(4), 44–58. doi:10.1521%2Fjsyt.2007.26.4.44 Hill, J., Fonagy, P., Safier, E., & Sargent, J. (2003). The ecology of attachment in the family. Family Process, 42, 205–221. doi:10.1111%2Fj.1545– 5300.2003.42202.x Pistole, M. C., & Arricale, F. (2003). Understanding attachment: Beliefs about conflict. Journal of Counseling & Development, 81, 318–328. doi:10.1002%2Fj.1556-6678.2003.tb00259.x

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designed for the treatment of depression, but it continues to grow in the scope of its applicability. Emotion-focused therapy is now an empirically supported treatment with demonstrated effectiveness in numerous applications. For example, emotion-focused therapy has been evaluated and found to result in positive outcomes in the treatment of anxiety, intimate partner violence, eating disorders, and trauma, in addition to its original purpose as a treatment of depression. Emotion-focused therapy is used with individuals, groups, couples, and families and in multiple cultural contexts. Empirical studies have indicated that as a result of emotionfocused therapy, clients report fewer symptoms of psychological distress and reduced interpersonal problems.

EMOTION-FOCUSED THERAPY Theoretical Underpinnings Emotion-focused therapy is an empirically validated brief treatment approach to counseling and psychotherapy. As implicated in the title of this therapy, emotion is considered to be of primary importance and is seen as an organizer of inner experiences and interpersonal relationships. Whereas cognitive and behavioral therapies conceptualize many of the difficulties addressed in counseling as being the result of a lack of skills or faulty assumptive cognitive frameworks, emotionfocused therapy addresses levels of emotional awareness and emotional regulation in resolving life difficulties. The model presumes that the human experience includes universal emotions that cut across cultural groups. These emotions include excitement, joy, anguish, contempt, anger, and fear. A primary goal of emotion-focused treatment is to help participants access and process emotions to construct new ways of being and make meaning of their world.

Historical Context Emotion-focused therapy was first developed in the 1980s and continues to be promoted as a model of counseling capable of producing empirically supported positive outcomes. A primary founder of this model is Les Greenberg. Other important contributors to this approach include Jeremy Safran, Susan Johnson, Laura Rice, and Robert Elliott. The approach was originally

Although a relatively newer treatment model, emotion-focused therapy is grounded in several established theories, primarily the existentialhumanistic therapies. Considered a processexperiential therapy, this model integrates the client-centered approach with Gestalt and experiential techniques in a systematic way. Emotionfocused therapy proposes that improving the awareness and regulation of emotion can result in improved psychological functioning and overall well-being. Thus, the focus of treatment is on establishing a working alliance that will facilitate healing and then prompting resolution of specific emotional tasks. The working alliance as an agent of therapeutic change is valued and, in this approach, is egalitarian and influenced by Carl Rogers’s person-centered approach. To attain a higher level of emotional arousal, considered necessary for the  emotional tasks, experiential activities are employed. For example, several of the techniques used for the working through of emotional tasks are focused on the here-and-now of Gestalt therapy. Attachment theory is another important theoretical underpinning to emotion-focused therapy. As John Bowlby proposed with attachment theory, emotion-focused therapy suggests that all humans experience a need for connection with significant others across the life span. Individuals internalize emotional experiences with these significant others and sometimes need assistance processing these emotional experiences through treatment.

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Emotion-focused counselors seek to establish strong therapeutic relationships during the initial session, and as the therapeutic relationship grows and strengthens, clients increasingly trust emotionfocused counselors to assist them in processing their emotions. Experiential activities assist counselors in helping clients connect with emotions, and emotional experiences are processed and connected to significant attachment figures. It is assumed that once negative emotional experiences are explored and processed, more positive emotional experiences can occur. In addition to processing emotional experiences, emotion-focused counselors also rely on constructivist theory to guide the work that takes place after emotional experiencing. They assist clients in putting the emotional experience into words and constructing new narratives to make meaning of their experiences.

emotion-focused therapy, clients are encouraged to express the full range of their feelings (positive and negative; passive and active), label their feelings as their own, assign responsibility appropriately to others who have caused hurt or emotional pain, and focus on their own emotional needs. Secondary Emotions

Secondary emotions are emotional responses to primary emotions. For example, an individual might feel the secondary emotion of anger at the primary feeling of vulnerability. The individual then creates an emotional experience that overemphasizes the secondary emotion while overlooking or negating the primary emotion. Emotion Schemes

Because therapeutic change is achieved by focusing on emotion, in emotion-focused therapy, the major concepts mostly relate to emotional experience and include the concepts of primary adaptive emotions, secondary emotions, emotional scheme, and maladaptive emotion schemes.

Individuals remember experiences that evoke emotional responses at the physiological, perceptual, cognitive, and action levels. These remembered emotional responses, called emotional memories or emotion schemes, help individuals interpret new information and new environments based on past experiences. Emotion schemes are the target for therapeutic intervention in emotionfocused therapy.

Primary Adaptive Emotions

Maladaptive Emotion Schemes

Emotion-focused counselors believe that emotions assist individuals in information processing, in constructing the self, and in making sense of the environment. According to emotion-focused therapy, all persons have primary biologically adaptive emotions, which are related to their immediate, direct responses to events. If these primary adaptive emotions are blocked, then emotions are unresolved and interfere with future abilities to process new emotions. For example, if a person experiences shame as a child when experiencing vulnerable feelings such as loss, then this same person is likely to have difficulty processing similarly vulnerable feelings in adulthood. The shameful vulnerable feelings would be masked by other secondary emotions, as described below. Processing these primary unresolved emotions in therapy can lead to positive transformation and new learning of emotional regulation. In therapeutic relationships using

Psychological and interpersonal distress is understood to be the result of maladaptive emotion schemes. Maladaptive emotion schemes result from previous experiences of criticism, humiliation, or shame in social relationships. Such feelings may resurface in present experiences when triggered by negative emotional reactions to current events. Replacing a maladaptive emotional state with a new emotion that is adaptive is a positive transformative experience. A goal of emotion-focused therapy is to provide transformative, or corrective, emotional experiences. For example, in the safety of counseling, maladaptive secondary emotion schemes of anger and contempt might be replaced with the primary emotion of sadness and the corrective new emotion of compassion. Through emotion-focused counseling, constriction and rigidity of emotions are replaced with expansiveness and flexibility of emotions.

Major Concepts

Emotion-Focused Therapy

Techniques The primary tasks of the emotion-focused counselor are to develop a strong therapeutic relationship or working alliance and to facilitate emotional processing work. Emotion-focused therapy counselors use a client-centered counseling approach to establish the working alliance but will move into more active work with emotions after the relationship has been built. The specific techniques used to facilitate emotional work are briefly described. Therapeutic Relationship/Working Alliance

Emotion-focused therapy counselors consider their work to be effective when it is done in an environment of empathy, genuineness, and respect, just as Rogers proposed for person-centered counseling. An emotion-focused counselor conveys sincere interest in the client’s world and in caring for the self of the client. The trusting relationship provides a secure base from which the client can explore attachment issues.

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a second self that is an inner critic and judges the original feeling may interrupt the original feeling. The emotion-focused therapy counselor uses this technique to achieve integration and resolution of the conflict. Each part of the self is explored with attention to the emotional needs of each. Empty-Chair Work Empty-chair work is used when a client expresses unfinished business related to someone else with whom the client has an attachment, such as a parent or lover. The goal of the empty-chair work is to provide an opportunity for the client to engage in a dialogue to resolve the unfinished business. The client will speak to the empty chair as if the object of attachment were present, and then, with support from the emotion-focused therapy counselor, also speak from the point of view of the attachment object. Both positive and negative emotions are encouraged to be expressed from both points of view. Focusing

Emotional Work Techniques

Emotion-focused therapy counselors use several different experiential techniques to help evoke and process emotion. It is considered critical that clients feel empowered to share their current and past emotional experiences in a nonjudgmental setting. Through emotion-focused therapy, maladaptive emotion schemes are resolved and replaced with new emotions. The emotional work techniques facilitate clients’ ability to access primary emotions that are being impeded from expression by maladaptive secondary emotion schemes. Emotionfocused counselors believe that the primary emotion must be experienced to be healed. Once the primary emotion is accessed and experienced, it transforms the maladaptive scheme and a new emotional state is achieved. Old memories are then experienced in the present to achieve emotional healing. To activate emotions, experiential Gestalt techniques are sometimes used. Two-Chair Work Two-chair work is used when a client expresses a conflict between two experienced emotions. The self of the client is described as feeling one way, but

The focusing technique is used to encourage a client to experience an emotion. When an emotionfocused counselor observes that a client has moved away from an emotion, he or she will prompt the client to stay with the emotion and to approach the emotion with curiosity. The emotion-focused therapy counselor then guides the client to note the affective, cognitive, and physiological experiences of focusing on the emotion. Affirming Empathic Validation

When emotion-focused therapy counselors observe clients to be experiencing feelings of vulnerability, fragility, insecurity, or shame, they use empathic validation to support, validate, and normalize clients’ emotional experiences. Developing New Narratives

Emotion-focused therapy counselors abide by the tenet that while thinking changes thoughts, only feelings can change basic emotions. Therefore, for clients to develop new narratives and meanings associated with basic emotions, they must access the feelings they seek to change. Reexperiencing

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painful emotional states and emotional catharsis are insufficient to produce positive change. The emotion-focused therapy counselor helps guide the client beyond merely experiencing the painful feelings again and actually helps the client access more adaptive new feelings that will take the place of the painful feelings. The client creates a new meaning around the old emotion, and this shift moves the client in a positive direction. The emotion-focused therapy counselor helps the client access old emotions and replace them with new emotions. This process of arousing painful emotions and replacing them with new, more positive attachment-seeking emotions is transformative. Clients actively construct new narratives and ascribe new meanings to previously difficult emotional states.

Therapeutic Process Emotion-focused therapy is a process-directive approach. The role of the counselor includes assessing the client’s process for intervention markers. Intervention markers are specific periods of time that call for specific interventions. For example, when a counselor observes a client to be experiencing vulnerability while experiencing emotions in session, the specific intervention of affirming empathic validation is employed to bring the client into emotional awareness. Understanding pacing, timing, and the therapeutic change process helps counselors understand how to intervene most effectively. Emotion-focused therapy counselors create a working therapeutic alliance, then evoke and explore emotion. Clients work with their counselors to correct maladaptive emotional responses, especially turning passive feelings such as hopelessness into active responses. The act of experiencing feelings and replacing negative feelings with positive feelings provides corrective experiences. This approach works by helping clients gain awareness of emotions, increase the range of emotional expression, and improve emotional regulation and reflection in the context of a positive therapeutic relationship. New narratives may be formed that disrupt the maladaptive emotional schemes of the past and increase opportunities for positive emotional experiencing in closer, more attached relationships. Angela R. McDonald

See also Attachment Theory and Attachment Therapies; Emotion-Focused Family Therapy; ExistentialHumanistic Therapies: Overview; Experiential Psychotherapy; Gestalt Therapy; Person-Centered Counseling

Further Readings Greenberg, L. S. (2004). Emotion-focused therapy. Clinical Psychology & Psychotherapy, 11, 3–16. doi:10.1002/cpp.388 Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The moment by moment process. New York, NY: Guilford Press. MacLeod, R., Elliott, R., & Rodgers, B. (2012). Processexperiential/emotion-focused therapy for social anxiety: A hermeneutic single case efficacy design. Psychotherapy Research, 22, 67–81. doi:10.1080/1050 3307.2011.626805 Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2007). Case studies in emotion-focused treatment of depression: A comparison of good and poor outcome. Washington, DC: American Psychological Association.

ENERGY PSYCHOLOGY Energy psychology is an approach to psychotherapy and self-help that combines conventional psychological procedures with techniques adapted from ancient healing and spiritual traditions such as meditation, yoga, and acupuncture. It is distinguished for its ability to—with unusual speed and precision—produce changes in the brain chemistry that underlies a wide range of psychological problems and goals. Studies have shown it to be effective in treating anxiety, depression, posttraumatic stress disorder, physical pain, and weight control as well as in helping heal physical illnesses and optimize the performances of athletes and others striving for their personal best.

Historical Context The origins of thought field therapy (TFT), the initial formulation of energy psychology, trace back to 1979, when a clinical psychologist named Roger Callahan was baffled after a year of unsuccessfully treating a young mother of two for a

Energy Psychology

phobia that kept her from being able to carry out even the most basic activities if they involved water or getting near water. Working with Callahan in his home office, she reported feeling nauseous during one of their sessions simply because she knew his swimming pool was nearby. Callahan had done some study of the physiological effects of tapping on certain acupuncture points (acupoints) and decided that there was nothing to lose in trying the method with his client. He asked her to tap a few times on a point that is directly beneath the eye, choosing an acupoint on the stomach meridian because she was feeling nauseous. This also happens to be a point that in acupuncture is associated with obsessive fear and worry. After several seconds of tapping, the woman exclaimed, “It’s gone!” and made a beeline for the pool—bending down to splash water on her face. She experienced no fear and later that day further tested her apparent cure by driving to the ocean during a rainstorm and wading in up to her waist. She remained completely free of fear. Trying to make sense of what had happened, Callahan began having other patients tap on various acupuncture points during their therapy sessions. The procedure seemed to markedly accelerate their progress. Callahan developed a set of treatment formulas that he found to be effective with a wide range of ailments. Within a few years, he was teaching his new method to other psychotherapists. By 2000, more than 30 variations of TFT or related energy psychotherapy approaches had emerged, each with its own name, procedures, and explanatory frameworks. Fred Gallo, a clinical psychologist, gave the name “energy psychology” to this aggregation of related methods in 1998 with his first edition of a book by that name. One of Callahan’s early students, Gary Craig, felt that Callahan’s original approach had the essential elements for rapid, beneficial clinical outcomes but could be streamlined and put into the hands of anyone, not just psychotherapists. He called this synthesis the emotional freedom techniques, or EFT. By the time of Craig’s retirement in January 2010, more than 1.2 million people had downloaded his EFT Manual, 30,000 to 40,000 more were downloading it each month, and EFT had become not only the most popular form of energy psychology but probably the most widely practiced psychological self-help approach in

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history, with more than half a million people registering for the fifth annual online World Tapping Summit in May 2013. The psychotherapy field was slow to embrace energy psychology for several reasons: (a) initial claims of its effectiveness were made publicly and with much fanfare before research was available to support them, (b) its methods (e.g., tapping on various areas of the skin) were unlike psychotherapy, and (c) it borrowed unfamiliar concepts from other cultures to attempt to explain why it worked. By 2012, however, more than 50 articles had been published in peer-reviewed journals showing that TFT and EFT were effective for a variety of disorders and psychological goals, and scientifically grounded explanations for this effectiveness were being proposed. Today, the Association for Comprehensive Energy Psychology, a professional membership organization founded in 1999, identifies three aspects of the human energy system typically addressed by energy psychology practitioners: (1)  the acupuncture points (and related energy pathways called meridians), used in Traditional Chinese Medicine; (2) the chakras, found in ancient yogic texts and practices; and (3) the human biofield. The biofield has been measured using a variety of scientific instruments and is referred to in at least 97 cultures and healing systems, often translated into English as “aura.” The protocols that are used most frequently by energy psychology practitioners combine tapping on acupoints with mental and verbal procedures. Two of these approaches, TFT and EFT, have the strongest research support and are the focus of this entry.

Theoretical Underpinnings Two keys for understanding how energy psychology can help people overcome posttraumatic stress disorder and other serious disorders are (1) the neurological effects of stimulating acupoints and (2) the way the brain processes information. A great deal has been learned in recent years about the effects of stimulating specific acupoints. For instance, an extensive research program at Harvard Medical School on the functions of acupoints demonstrated that certain points when stimulated send electrochemical signals to the brain that reduce emotional arousal.

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When a client brings to mind a painful memory that is at the root of psychological dysfunction or brings to mind an incident from his or her current life that triggers emotions that interfere with happiness or effective functioning, the brain’s emotional center, the limbic system, goes into arousal. Simultaneously tapping on selected acupoints sends signals that reduce such arousal. So the brain receives conflicting signals during an energy psychology session. When the signals produced by tapping are repeated while the disturbing thought remains activated, the electrochemical signals from the physical intervention (tapping) eventually dominate. The person is able to access the disturbing thought without being flooded with the discomforting emotions that often lead to maladaptive behavior. This contradiction between the way the brain had been responding to the disturbing thought and the new response also causes a deeper shift based on the way the brain processes information. Experiences initially, within seconds, become consolidated into what is called working memory and then, within minutes to hours, into short-term memory. This process involves the synthesis of proteins that form the pathways (synapses) among neurons. Over time, these memories and learnings are further consolidated with other memories and learnings into neural networks that guide people’s lives. When a memory or learning is based on trauma or other difficult experiences, however, this orderly progression may be disrupted. The memory or learning may instead be isolated in what is known as implicit memory, outside conscious awareness yet causing emotional reactions and behaviors that are inappropriately imposed onto current situations. These implicit memories and learnings may be the source of a range of psychological difficulties, and they have been notoriously difficult to change, even for psychotherapists. Despite the stubborn tenacity of these deep emotional learnings, nature has also established a mechanism for updating existing learnings with new ones. After an emotional memory has been brought to mind, the memory can, for a brief period, be integrated (“reconsolidated”) in a new way. If, during this “reconsolidation window,” a second vivid experience is introduced that contradicts what the reactivated memory expects or

predicts about how the world functions, the original learning will be revised or completely eliminated. In energy psychology sessions, the problematic memory or learning is mentally activated; the tapping reduces the stress response, which creates an experience that counters the expectation that there will be an emotional charge to the memory or old learning; and the memory or learning without the emotional charge becomes the “new normal.” These subtle changes allow the person to navigate through previously difficult territory with new levels of competency and mental focus, often leading to profound shifts in conditioned responses, life choices, and sense of well-being.

Techniques Energy psychology practitioners may be aligned with a wide range of theoretical and philosophical orientations, from psychodynamic to behavioral, to cognitive, to humanistic. In practice, however, they share a number of guiding principles. These include a client-centered framework, formulating the client’s concerns so that energy psychology can be applied, addressing the client’s unrecognized objections to meeting personal treatment goals, assessing progress frequently, shifting the focus as new aspects of the problem emerge, and a proclivity toward completely resolving the issue. Implementing a Client-Centered Framework

In identifying how to focus a session, energy psychology practitioners listen carefully to how their clients define the problems they wish to address. While the specific areas of focus may change as the work moves forward and as the dialogue between client and counselor deepens, the client shapes the direction of the work. This feature also allows energy psychology to be applied on a self-help basis. Formulating Client Concerns So That Energy Psychology Can Be Applied

Acupoint tapping is generally paired with verbal statements or mental images about a problem, memory, or goal. For it to be effective, the statement or image must be specific (e.g., rather than focusing on an issue such as low self-esteem, an

Energy Psychology

incident where the client experienced low selfesteem might be the target of the tapping) and must evoke emotional material that is subjectively meaningful to the client. Addressing the Client’s Unrecognized Objections to Meeting Treatment Goals

Often, when people identify areas of their lives that they wish to change, the reason why change has not yet occurred is that a part of them is afraid of such change, feels undeserving of it, or has other internal objections to the very goals that are bringing them into treatment. Energy psychology counselors help clients identify these internal objections and use energy techniques to resolve them so that the work can continue without these “psychological reversals” sabotaging the client’s treatment. Assessing Progress Frequently

Because acupoint tapping can quickly shift the emotional landscape of the problem being presented, the client is frequently invited to reassess the internal sense of distress about it. This process, which may be done as often as every few minutes, involves a mindful internal focusing and provides direction for the next part of the session. For instance, if the client reports that the subjective units of distress, or SUD, rating (0–10) has gone down from 9 to 5 after a few rounds of tapping, the therapist might ask how the client knows it is still at 5. If the answer is “Well, my heart isn’t beating as quickly, but I still have a tightness in my throat,” the next round of tapping might focus on that tightness. Shifting the Focus as New Aspects of the Problem Emerge

As the SUD rating goes down, new aspects of the problem often reveal themselves. For instance, if the client is focusing on anxiety about driving following an automobile accident, and the SUD rating is reduced to 4 but won’t go down further, an aspect of the problem that has not been a focus of the treatment may need to be addressed. This may be a sensory aspect that reveals itself while taking the SUD rating, such as “When I think of the accident now, the screeching of the tires is overwhelming,”

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and that becomes the focus of the next round of tapping. Aspects that are preventing further progress may also reveal themselves in the client’s dreams, in insights between sessions, or in discussions with the counselor. These may tie into earlier experiences that are related to the current problem, such as the person recalling a previously forgotten incident of having witnessed a car accident at 4 years of age, which was emotionally activated by the more recent mishap. Often, these aspects involve childhood incidents with the person’s parents or peers, so even with an initial focus on everyday problems, the work may quickly go very deep. The metaphor of “peeling the layers of an onion” is frequently used to describe this process. Resolving the Issue Completely

Because acupoint tapping is so quick and effective in changing internal emotions and understanding, practitioners usually do not feel the work is complete until the client has no remaining subjective distress around the original issue. In fact, it is common to challenge the results by having the client bring to mind an even more proactive situation than the initial problem. If the client’s goal was to reduce self-judgment about playing the piano, the challenge might involve imagining giving a performance to a larger and more critical group than the person has ever before encountered. The treatment is considered complete only when the new learnings and responses have been installed into the client’s back-home situation.

Therapeutic Process In 2002, 27 of the field’s pioneers and leaders— advocates of a divergent range of energy psychology approaches—were invited to address the following question: Can you reach a consensus on the methods and principles an experienced clinician new to energy psychology should master before introducing energy psychology into his or her clinical practice? Differences existed on dozens of theoretical and procedural issues, but common denominators were identified leading to basic consensual guidelines. All the approaches shared two essential elements: (1) a psychological difficulty or a desired psychological change was vividly brought to mind while (2) a simple physical intervention

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was performed that purportedly affected the body’s “energies” or “energy fields.” The techniques within energy psychology can vary substantially depending on the practitioner’s style and theoretical orientation, but as long as these two essential elements are present, the reported advantages of unusual speed and precision in changing the brain chemistry that underlies a wide range of psychological problems appear to occur. David Feinstein See also Acupuncture and Acupressure; Body-Oriented Therapies: Overview; Coherence Therapy; Emotional Freedom Techniques; Exposure Therapy; Non-Western Approaches; Person-Centered Counseling; Reich, Wilhelm

Further Readings Church, D. (2013). The EFT manual (3rd ed.). Santa Rosa, CA: Energy Psychology Press. Eden, D. (2008). Energy medicine (Rev. ed.). New York, NY: Tarcher/Penguin. Feinstein, D. (2012). Acupoint stimulation in treating psychological disorders: Evidence of efficacy. Review of General Psychology, 16, 364–380. doi:10.1037/ a0028602 Feinstein, D. (2012). What does energy have to do with energy psychology? Energy Psychology: Theory, Research, and Treatment, 4(2), 59–80. Feinstein, D., Eden, D., & Craig, G. (2005). The promise of energy psychology: Revolutionary tools for dramatic personal change. New York, NY: Tarcher/Penguin. Gallo, F. P. (2004). Energy psychology: Explorations at the interface of energy, cognition, behavior, and health (2nd ed.). Boca Raton, FL: CRC Press. Ortner, N. (2013). The tapping solution. Carlsbad, CA: Hay House.

Website Association for Comprehensive Energy Psychology: www .energypsych.org

ERICKSON, MILTON H. Milton H. Erickson (1901–1980) was an American psychiatrist who introduced numerous innovations in perspective and technique to the fields of

psychotherapy and clinical hypnosis. Although many of his methods were considered radical at the time, they have now become integrated into mainstream practice. Erickson was versed in psychoanalytical theory, as was the tradition in American psychiatry in the 1930s and 1940s. Throughout these two decades, he corresponded with and consulted with a number of eminent analysts, but his writings reflected a gradual shift in orientation from exploration of internal dynamics to a focus on symptom resolution. Erickson also emphasized the garnering of patient strengths in therapy rather than searching for historical causes of patients’ psychopathology. These practices represented a significant departure from conventional psychotherapeutic therapy and led Jay Haley to later describe Erickson as the first “strategic” therapist. Erickson’s interest in hypnosis was fostered before his formal psychiatric training. During his recovery from polio at age 17, he became interested in the power of suggestion, having largely rehabilitated himself by imagining motor activity in his paralyzed muscles and incrementally reactivating movement in them. The success he realized from experiencing responsiveness to his own internal suggestions led him to study formal hypnosis. As an undergraduate student at the University of Wisconsin, he took a course on hypnosis conducted by Clark Hull, the well-known American psychologist, and thereafter began experimental investigations into the nature and dynamics of hypnosis. He continued his research during his medical training and in his early professional appointments. Erickson’s first article on hypnosis was published in The Journal of Abnormal and Social Psychology in 1932. Hypnosis was in some disrepute during Erickson’s early career. Sigmund Freud (1856– 1939) had rejected the approach in favor of free association and other psychoanalytical techniques. In addition, hypnosis was widely associated with mesmerism, which was in almost universal disfavor in the professional community. Also, stage hypnosis was a popular form of entertainment that cast hypnosis in a false, “magical” light. However, Erickson persistently emphasized hypnosis as naturalistic, able to elicit the innate resources that most people possess, such as focusing, altering awareness, and relaxing. In his professional writing,

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he  advocated hypnosis as useful in a variety of medical, psychotherapeutic, and dental contexts. Erickson’s approach to hypnosis is often characterized as permissive, naturalistic, and/or indirect. Although Erickson could be quite imperative in his therapy, he also realized the value of an adaptive alternative that can minimize resistance to the direct commands that are traditionally employed in hypnosis. For example, he introduced the use of permissive verbs (e.g., “You can close your eyes”) to facilitate subjects’ acceptance of the therapist’s suggestions. Erickson also developed “indirection,” an anecdotal technique in therapy through which therapeutic messages are conveyed within factual stories or metaphorical narratives. Commonly termed multilevel communication, the story occupies the attention of the patient while therapeutic suggestions are simultaneously embedded within. In this way, hypnosis can be “tailored” to the individual subject. A direct approach can be employed with patients who readily accept commands. Indirection is useful when patients prefer a less authoritarian context for hypnosis. Erickson posited that by narrating a personal experience, giving an account of success by another patient, or other forms of storytelling, patients can derive meanings for themselves that are personally pertinent. This is often a better tactic than directly telling a person what to do. In the 1950s, Erickson and several colleagues founded Seminars in Hypnosis, through which they presented workshops for physicians and psychologists across the United States. Their teachings focused on hypnosis as a therapeutic relationship between the hypnotist and the patient, which countered two prevailing attitudes about hypnosis. One view was that the hypnotic process depended on a powerful, demanding hypnotist who commanded subjects into a trance and directly suggested changes. Alternately, experimental psychology viewed hypnosis as correlated with the measureable trait of hypnotizability, which influences the extent to which people can experience trance. Erickson disagreed with both of these positions and accentuated social dynamics including cooperation as a central variable in hypnosis. In this context, the hypnotist and the patient work together to achieve therapeutic outcomes. In 1957, Erickson and several of his associates founded the American Society of Clinical Hypnosis,

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an organization still in existence today. For the first 10 years, Erickson served as the editor of the association’s American Journal of Clinical Hypnosis. The journal published articles from numerous professionals who employed hypnosis in a vast array of contexts, and the society also sponsored workshops. Erickson’s concept of utilization is founded in his view of a benign, resourceful unconscious mind. He believed that behavior has an underlying positive intent. The emphasis in Ericksonian therapy is to discover and utilize the resources the patient possesses. Such resources can be derived from the patient’s experiential background, family and social contexts, aptitudes and talents, and a host of other variables. Erickson was one of the first to extend therapy into patients’ lives. He used homework assignments liberally, instructing patients to gain experiences and understanding in situations outside the consulting room. Erickson did not seek to uncover personal deficiencies in his patients. The Ericksonian approach is future oriented, striving to stimulate patients to learn skills that can be useful in problem resolution and achievement of personal goals. Erickson introduced new roles for both the patient and the therapist; each is active in therapy, doing much more than talking and analyzing. Although he did not propose a theory of personality, Erickson was keenly aware of human developmental processes. He believed that one of the central purposes of psychotherapy is to assist patients in accomplishing transitions throughout their lives. A number of patients consulted with Erickson intermittently over the many years he was in practice. Erickson used brief therapy in a targeted manner that focused on ways in which developmental obstacles could be overcome. The way in which Erickson transcended personal limitations in his own life provided him with supreme confidence in the inherent resourcefulness that people possess to effect change and grow. Erickson was color-blind and also overcame dyslexia to become adept in both the spoken and the written word. His therapy was designed to similarly find avenues of success for patients despite their limitations. In 1939, at the suggestion of Abraham Maslow, the eminent anthropologist Margaret Mead contacted Erickson. Eventually, she visited and consulted

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with him. This began a lifelong friendship between Mead and Erickson and his wife, Elizabeth, and also facilitated the association and friendship with Mead’s husband, Gregory Bateson (Mead and Bateson divorced in 1950). Bateson corresponded extensively with Erickson, particularly during the 1950s, when he and colleagues of the Palo Alto Group were studying communication patterns in families of schizophrenic individuals. Bateson introduced two of the researchers, John Weakland and Jay Haley, to Erickson, and they visited him in Phoenix, Arizona, on numerous occasions. Weakland was a member of the original staff of the Mental Research Institute that applied Erickson’s therapeutic methods in one of the first brief therapy clinics. Haley was primarily responsible for bringing Erickson and his work to the attention of the broader psychotherapeutic community by publishing Advanced Techniques of Hypnosis and Therapy: Selected Papers of Milton H. Erickson, M.D. in 1967 and Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. in 1973. Over the span of 50 years, Erickson had three careers: researcher, teacher, and clinician. In 1948, shortly after moving to Arizona from Michigan, Erickson established a private practice. He set up an office in his home because he had residual symptoms of polio, severe allergies, and other medical restrictions. For approximately 20 years, he traveled and taught extensively, published numerous professional articles, and maintained a busy psychiatric practice. In the 1970s, Erickson was confined to a wheelchair due to post-polio syndrome, and he suffered severe pain and other infirmities. However, beginning around 1974, he conducted almost daily teaching seminars in his home for professionals and students from around the world. Erickson also participated in the 1979 founding of the Milton H. Erickson Foundation and served as one of the original board of directors. The foundation, located in Phoenix, continues to this day to promote and advance his contributions. Erickson died on March 25, 1980. Erickson’s work exerted widespread influence in clinical hypnosis and psychotherapy. He is generally credited with being the first brief therapy clinician. Ericksonian therapy is now a commonly practiced approach in counseling and psychotherapy, and Ericksonian approaches in hypnosis are well-known and utilized around the world. In

addition to Haley’s strategic therapy and interactional therapy, developed at the Mental Research Institute, Erickson’s techniques are found in solution-focused therapy, a number of family therapy systems, and a wide variety of other therapies. Erickson coauthored five widely read books and published more than 140 scholarly articles. Numerous texts have been written about Erickson’s methods. Training in Ericksonian therapy is conducted throughout the world, and more than 140 institutes on all the inhabited continents exist to further his work. In the 20th century, Erickson developed his techniques and views in an often skeptical and unaccepting environment, but his methods continue to be generative in today’s world. Brent B. Geary See also Ericksonian Therapy; Haley, Jay; Palo Alto Group; Solution-Focused Brief Therapy; Strategic Family Therapy; Strategic Therapy

Further Readings Erickson, M. H., Rossi, E. L., & Rossi, S. I. (1976). Hypnotic realities. New York, NY: Irvington. Geary, B. B., & Zeig, J. K. (Eds.). (2002). The handbook of Ericksonian psychotherapy. Phoenix, AZ: Milton H. Erickson Foundation Press. Haley, J. (1993). Jay Haley on Milton H. Erickson. New York, NY: Brunner Mazel. Zeig, J. K. (1985). Experiencing Erickson. New York, NY: Brunner Mazel.

ERICKSON-DERIVED OR -INFLUENCED THEORIES: OVERVIEW To appreciate the depth of foundation supporting the many emerging psychotherapies inspired by Milton H. Erickson, M.D. (1901–1980), and how these contrast with other contemporary therapies, it is necessary to step back from the myopic view of post-Freudian thought and consider principles and practices that have withstood the test of time. Thus, this entry first examines the historical roots of hypnosis, which was foundational to Erickson’s understanding of the change process and which he

Erickson-Derived or -Influenced Theories: Overview

modified in his use with clients. It then goes on to discuss Erickson’s use of pragmatism, constructivism, holism, and paradox in his work with clients.

Historical Context Because Erickson’s approach to healing was deeply rooted in the practice of hypnosis, any therapy influenced by Erickson is best understood against the backdrop of the history of hypnosis, which is intertwined with the history of healing and medicine. While the demarcated use of hypnosis for psychological problems is a more recent development, the elicitation of hypnotic phenomena is associated with history’s greatest healers. The earliest record of medical hypnosis dates to 2600 BCE with Wong Tai, the father of Chinese medicine. He taught a method of healing that involved passing hands over a patient’s body while speaking words of curing. Ancient Hindu and Egyptian writings describe the use of “temple sleep” for religious and medicinal purposes; however, it was in Classical Greece that people sought to invoke Hypnos, the god of sleep, who was thought to bring healing and prophetic dreams. From this tradition, in 400 BCE, the Greek physician Asclepiades devised a formal hypnotic procedure in which he stroked his patients’ hands, leading them into sleeplike states. They were then left to sleep and dream in a healing room, which he called abaton. Later, Hippocrates, the father of Western medicine, more precisely defined hypnosis as a means of accessing the body’s natural ability to correct itself and grow healthy. He believed that “the natural healing force within each one of us is the greatest force in getting well” and that, “the affliction suffered by the body, the soul sees quite well with the eyes shut.” Plato recognized the profound implications of Hippocrates’s approach to medicine, pointing out that Hippocrates treated the body as a whole rather than as a collection of parts. The next pivotal figure in the history of medicine is the Persian physician Avicenna (Ibn Sina in Farsi). He wrote The Canon of Medicine (1025), one of the most widely read books in the history of medicine. It is in the 11th Book of Healing that Avicenna made the first recorded distinction between sleep and hypnosis, referring to hypnosis as al-Wahm alAmil, “the pleasant dreamy imagination.” Avicenna

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not only made use of psychological techniques for physical healing, such as confusion, shock, and therapeutic ordeals, but he also recognized that with hypnosis one could create the conditions that lead to the acceptance of a new reality orientation. Five hundred years later, the connection between imagination and healing was further elaborated by the Swiss physician Paracelsus (1493–1541). Now recognized as the father of modern psychiatry, Paracelsus was not only the first European physician to advocate for the humane treatment of the mentally ill, seeing them as “brothers ensnared in a treatable malady” rather than creatures possessed by evil spirits, he also recognized that imagination played a pivotal role in healing. He emphasized that a patient’s beliefs and will were able to affect health and that all cures involved some degree of imagination. For this reason, he stressed the importance of suggestion, using signs and amulets to help form mental images, which then translated into profound physical cures. He was also the first physician to theorize an unconscious aspect to cognition (About Illnesses, 1567). In this regard, Paracelsus anticipated by nearly 500 years the modern expectancy-based theory of hypnosis, including the conscious and unconscious dimensions. Although most historical accounts mistakenly credit Franz Anton Mesmer (1734–1815) with the discovery of hypnosis, Mesmer did revolutionize the provision of health care as one of the first European physicians to advocate low-cost health care and traveling medical clinics. In 1784, a French Royal Commission appointed by Louis XVI studied Mesmer’s theory of magnetic fluid under the light of scientific investigation. This is considered the first well-designed and published psychological experiment. The conclusion of this team of investigators was that it was the use of imagination that achieved physical healing, rather than a special magnetic fluid, as believed by Mesmer. Other important advances in the history of hypnosis were made by John Elliotson (1791–1868), who was the first to promote the use of hypnosis as a surgical anesthesia. Later, James Esdaile (1808–1859) discovered that by using a “mesmeric coma” the death rate in surgery dropped from 95% to 5%. Using hypnosis to reduce fear and pain, Esdaile was able to alter the patient’s

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physiological response to surgery. The significance of this finding was made more apparent when Jean-Martin Charcot (1825–1893) documented the curative effects of hypnosis for hysteria, a disorder that had previously been assumed to have physiological origins. This important discovery gave birth to the modern practice of psychosomatic medicine. Now regarded as “the founder of modern neurology,” Charcot is also credited with the discovery that psychological states can produce lasting physiological consequences. The modern study of hypnosis as a form of suggestive therapeutics began when James Braid (1795–1860) recognized that after staring at his lancet case, his patients would accept suggestions aimed at a cure. In 1853, he replaced the concept of magnetism with “hypnotism.” After further study, Braid came to the conclusion that hypnosis is really a fixation of attention on a single idea, rather than actual sleep. Ambroise-August Liebeault (1884) convincingly argued that cures could be achieved with suggestion alone, but the notion of mystical sleep remained popular, so the namesake of the Greek god of sleep remains in use to this day. Having studied hypnosis under Charcot, Josef Breuer (1842–1925) found that during hypnosis some patients would spontaneously recall past events, and after talking about these memories in a state of heightened emotional arousal, their hysterical symptoms would subsequently disappear. He called this his “talking cure,” which was later renamed by Sigmund Freud as “abreaction therapy.” Working together, Breuer and Freud came to the conclusion that a deeper, unseen level of consciousness could determine an individual’s conscious conduct. Then, in a dramatic turn of events, Freud dismissed hypnosis as a way of merely “suggesting away” symptoms rather than eliminating their cause. Contrary to its long history of success, Freud insisted that the use of hypnosis would inevitably result in symptom substitution. Breaking from the traditions of the day, the French pharmacist Émile Coué (1857–1926) promoted the idea of autosuggestion, or self-hypnosis. Known for his discovery of the placebo effect and as the “father of self-help,” Coué taught that hypnosis is something that individuals participate in rather than something that is done to them by a hypnotist. He believed that imagination played a

central role in solving problems. He gave hope to his clients by praising each remedy’s efficacy, often leaving a small positive note with the medication. He is the originator of the phrase “Day by day, in every way, I am getting better and better,” and contrary to Freud’s emphasis on conscious insight, Coué argued that curing some of our troubles requires a change in our unconscious imagination. He also found that eye closure was not necessary for hypnotic suggestion to be effective and that self-suggestion could decrease dependence on doctors. When applauded for his healing, Coué reportedly retorted, “I have never cured anyone in my life. All I do is show people how they can cure themselves.” One of the most talented premodern practitioners of hypnosis was Pierre Janet (1859–1947), a French psychologist, neurologist, and lead protégé of Charcot. Janet’s contributions to hypnosis were vast, including extended hypnosis (using the passage of time as a suggestion for healing without the use of specific suggestions), utilizing the temporary absence of symptoms during hypnosis (e.g., letting anorexic patients eat and drink), giving symptomoriented suggestions, identifying fixed ideas that were operating at subconscious levels (by using dissociative techniques such as “automatic writing” and “automatic talking”), and the practice of introducing new ideas to the unconscious as a curative measure. In a seminal conference paper (1896), Janet described the subconscious transmission of the clinician’s ideas to the patient and the dramatic results in terms of dependency and indirect hypnotic suggestion—a phenomenon that 100 years later was discovered to occur across all social contexts and came to be known as the Pygmalion effect. Janet also convincingly argued for designing individualized treatment strategies and treating patients as individuals. From these discoveries, achieved by some of the most brilliant practitioners in the history of medicine, Erickson began to craft his approach to healing. Looking beyond the pop psychology of his day, Erickson used experimentation and his exceptional powers of observation to further his knowledge of how to help individuals. As the “father of modern hypnosis,” Erickson demonstrated that the artifacts of tradition, such as eye closure, formal trance induction, and direct suggestion, are not needed for hypnosis to be effective. Operating

Erickson-Derived or -Influenced Theories: Overview

outside the limitations of contemporary talk therapy, Erickson demonstrated how verbal and nonverbal techniques, including metaphor, symbol, gesture, and innuendo, as well as symbolic and experiential events, including shock, confusion, imagined experience and physical ordeals, can be used to promote healing and growth. Any attempt to parcel Erickson’s therapy into hypnotic versus nonhypnotic work is futile. Hypnosis is the approach that Erickson fathered—something so elemental to healing that its practice and principles permeated all other aspects of his work. Similar to how children of a genius father often exemplify one or two characteristics of his total personality, the therapies inspired by Erickson embody one or two aspects of his numerous contributions to the modern practice of hypnosis.

Theoretical Underpinnings Ericksonian-influenced therapies are a uniquely diverse group of approaches that represent an endless variety of techniques and treatment milieus. This group of therapies are united not so much by philosophical doctrine as by the fact that they were inspired by the pioneering casework of Erickson. Because Erickson had a preference for experimentation and ideological flexibility, versus orthodoxy and protocol, it seems appropriate that the continually evolving class of Ericksonianinfluenced therapies continues to defy distinct lines of classification. While any number of ideologies can be projected onto Erickson’s casework, and used to structure future teaching and training, the following sets of ideas come closest to positioning this approach relative to a larger philosophical discourse. Pragmatism

Above all else, therapy inspired by Erickson is pragmatic. True to the philosophy of pragmatism, Erickson did not embrace conscious thought or any intellectual construct as a mirror of reality. Like William James (a pragmatist philosopher, psychologist, and hypnotist), Erickson sought to evoke thought (both conscious and unconscious) as a tool for prediction, action, and problem solving. In this regard, strategy is a key tool of the pragmatist, optimizing chances for success by readily accepting

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what is, while maximizing progress through resourcefulness and divergent problem solving. Strategically speaking, having the greatest number of options available maximizes the chances of accomplishing one’s goals, thus the classic axiom in Ericksonian therapy: “Use whatever works.” Of course, this can result in controversial practices that others consider unorthodox or dangerous, regardless of the positive outcomes achieved. From the intellectual background of pragmatism, Erickson developed the specialized strategy of utilization, which is reflected in another axiom: “Use whatever the client brings to therapy.” Within the context of therapy, utilization is founded on the premise that each person already has the intellectual and behavioral tools needed to achieve success in therapy. Thus, it is the job of the therapist to recognize these tools and use them to achieve some desirable end. This concept is considered to be Erickson’s greatest contribution to psychotherapy. Constructivism

Constructivism is based on the premise that all people learn most effectively through experience. Typically, a constructivist approach to psychotherapy emphasizes the importance of human relationships for well-being and development. Thus, a healthy supportive relationship between the client and the therapist is considered to be a core healing experience. More specific to the work of Erickson, and the hypnotists who came before him, is the experience of a new reality orientation that is created through the use of suggestion and imagination. For Erickson, the central activity of therapy is the process of constructing new possibilities by working within an individual’s repertoire of experience and the individual’s belief system. This is an approach to learning known as scaffolding, in which new knowledge is introduced by building on existing knowledge or experience. This open process demands collaboration and ideodynamic treatment, rather than the use of protocol or manualized treatment. In this approach, all interactions are tailored to the needs of the individual seeking help. Erickson went to great lengths to see the world from the client’s point of view. His general strategy was to help each individual construct his or her own goals and

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solutions, rather than imposing an outside theory of how to attain personal well-being. Self-organizing change is another subcomponent of constructivism, which maintains that the client is the best person to determine the course of his or her recovery. This philosophical position is reminiscent of Hippocrates’s recognition of the patient as the primary healing force. It is a principle of healing that is antithetical to a medical model in which the patient becomes a target for interventions by powerful exogenous agents. To act as a catalyst for self-organizing change, Erickson developed the techniques of permissive suggestion, open-ended direction, and hypnotic strategies for evoking the creative imagination. Symptom elimination often occurred, but that was not the primary objective. Erickson viewed problems as a process of learning, in which symptoms played an important role in developing the ability to exercise free will. To this end, he developed techniques that allowed a person to change the intensity, frequency, or location of a symptom; to keep some of the symptom; or to end its use. Erickson insisted that therapy should be permissive and maintain the highest respect for a person’s capacity for innate healing and self-determination. This ideology is expressed differently in each of the therapy approaches discussed in the “Short Descriptions of Ericksonian-Derived or -Influenced Therapies” section. For example, the Ericksonian approach embraces a dynamic dualism in which the unconscious mind and conscious mind possess different resources and serve different functions. During therapy, hypnotic techniques are used to bridge the gap between the part of the mind that needs answers and the part that holds those answers. In Haley’s strategic family therapy, psychodynamics are set aside in favor of systems dynamics. In this approach, strategic directives are used to uncover resources within the family, as family members become “healers of one another.” The main point is that it is this solicitation of selfdetermination, and thus self-organizing change, that characterizes not only Erickson’s casework but also any closely related theory of healing. Holism

First expressed by Hippocrates, the philosophy of a unified and interconnected mind and

body is a foundational principle that continues to permeate the use of modern hypnosis and modern holistic approaches to healing. More than a recognition of the link between a person’s state of mind and his or her state of health, holism rejects the atomistic or reductionist tendencies associated with formal systems of classification (i.e., diagnosis) and mechanistic rituals (i.e., treatment protocols). It is the humanistic perception that everything is interconnected and ecologically interdependent. Thus, in therapy, it is not just the client who is persuaded by the therapist, but both are equally dependent and vulnerable to influence. Since Charcot, most have come to agree that psychological states are connected to physical states, such that a change of mind will produce physiological consequences. However, Erickson took this ecological principle further, demonstrating that thoughts and behaviors are interconnected, as are family members and members of society, and a change in one small place can lead to changes throughout the system. Referred to by some as the domino effect, this idea is seen in therapies that incorporate pattern interruption or the use of elaboration and paradox. Paradox

The role of paradox in philosophy and mathematics has been to expose errors in definitions, leading to new axioms and improved logic. In Erickson’s work, both paradox and confusion are used as catalysts for the acquisition of new ideas and beliefs, which otherwise remain suppressed by habit or by a rigid mind-set. Erickson’s therapy often demonstrated that things are not always as they seem. For example, a chronically depressed individual may be surprised to learn that he has forgotten to be depressed after being instructed to practice his depression daily. The very nature of the change process, as inspired by Erickson, is presumably paradoxical because it begins with absolute acceptance of everything the client is thinking, doing, and experiencing. Naturally, when asked to summarize his theoretical position, Erickson suggested a paradoxical philosophy of change in which there are no preconceived notions of how change must occur.

Erickson-Derived or -Influenced Theories: Overview

Short Descriptions of Ericksonian-Derived or -Influenced Theories

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activities, pictures, metaphors, and other multisensory techniques to stimulate new awareness.

Brain Change Therapy

Brain change therapy integrates principles from hypnosis, biofeedback, meditation, and brain technology while seeking to help clients learn to achieve positive, resourceful mind states. Couple and Family Hypnotic Therapy

After establishing negotiated goals with families, this approach to couples and family treatment uses family hypnotic induction techniques to achieve the agreed-on goals. Therapy is successful when each member involved in treatment is satisfied with his or her achieved goals and there is reduction or elimination of dysfunctional behaviors.

Improvisational Therapy

Improvisational therapy seeks to use creativity, imagination, and playfulness to create a resourceful experience for the client. There are no established clinical methods, strategic protocols, diagnostic instruments, or interpretive frameworks to dictate how the therapy ought to be conducted. Interactional Therapy

In keeping with communication and systems theory, this approach examines how individuals behave in systems and works with individuals, couples, and families to achieve identified goals. Generally, change is evoked through direct behavioral prescriptions, paradoxical interventions, and positive connotations (reframing).

Directive Therapy

Directive therapy facilitates the strategic use of behavioral assignments to interrupt cognitive, emotional, and behavioral patterns, while also utilizing natural resistance to change. Ego State Therapy

This psychodynamic approach explores the internal conflicts existing beneath conscious awareness. This is achieved using either hypnosis or other methods designed to quickly access and integrate dissociated parts of self.

Metaphors of Movement Therapy

This approach uses metaphor to creatively define problem situations and to enable clients to use their imagination to generate solutions. Nature-Guided Therapy

Nature-guided therapy employs ecopsychology research on how contact with nature can have therapeutic benefits. Its interventions seek to increase the client’s connection to nature. Neuro-Linguistic Programming

Ericksonian Therapy

Ericksonian therapy embraces any style of intervention that can be ethically employed in service of the client’s goals and objectives. An atmosphere of permissiveness and acceptance is used to paradoxically activate a self-defined process of growth and change.

Neuro-linguistic programming facilitates a change in the structure of the client’s conscious and unconscious experience by employing imagery, movement, and auditory changes in the scope of experience, and it examines how that scope of experience is categorized to rapidly change the client’s emotional response to it.

Impact Therapy

Possibility Therapy

Impact therapy facilitates creative processes using visual and tangible props, such as signs, chairs, or a whiteboard, as well as movement, experiential

Possibility therapy uses the principles of acknowledgment and possibility to resolve the client’s problems in the present or future.

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Psychosocial Genomics

Psychosocial genomics utilizes the natural fourstage creative cycle for facilitating gene expression and brain plasticity to optimize problem solving in everyday life, as well as the resolution of stressrelated psychosomatic issues with a variety of cognitive-behavioral techniques. Self-Relations Therapy

Self-relations therapy seeks to activate a person’s creative consciousness that can be utilized in all aspects of his or her life. The therapist explores the harmonious and balanced conversations between the client’s multiple parts of self. Solution-Focused Brief Therapy

Solution-focused brief therapy begins with the identification of a specific problem and proceeds by identifying exceptions to the problem and the times when the problem was less severe or absent. It is strength based and hope oriented and elicits the imagination, while drawing attention to underutilized resources within the established repertoire of behavior. StoryPlay Therapy

This approach creatively uses interactive play, metaphor, and exercises in creativity to address problems caused by trauma and loss. Strategic Therapy

Strategic therapy uses strategic tasks assigned by the therapist to resolve the client’s presenting problem. The therapy focuses on the social context of human dilemmas and the potential for growth and healing within closely connected interpersonal systems. Dan Short See also Brain Change Therapy; de Shazer, Steve, and Insoo Kim Berg; Directive Therapy; Ego State Therapy; Erickson, Milton H.; Ericksonian Therapy; Feedback-Informed Treatment; Haley, Jay; Impact Therapy; Improvisational Therapy; Madanes, Cloe; Metaphors of Movement Therapy; Minuchin, Salvador; Nature-Guided Therapy; Neuro-Linguistic

Programming; O’Hanlon, Bill; Palo Alto Group; Possibility Therapy; Psychosocial Genomics; Satir, Virginia; Self-Relations Psychotherapy; SolutionFocused Brief Therapy; Strategic Therapy; Whitaker, Carl; White, Michael

Further Readings Haley, J. (1993). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York, NY: W. W. Norton. (Original work published 1973) Short, D., Erickson, B. A., & Erickson-Klein, R. (2012). Hope and resiliency: Understanding the therapeutic strategies of Milton H. Erickson, M.D. Norwalk, CT: Crown House. (Original work published 2005) Zeig, J. K. (2014). Teaching seminar with Milton H. Erickson. New York, NY: Taylor & Francis. (Original work published 1980)

ERICKSONIAN THERAPY Ericksonian therapy is broadly classified as any goal-oriented, problem-solving endeavor grounded in methodology inspired by the teachings and casework of Milton H. Erickson (1901–1980). It is a perspective on learning, healing, and growth that fosters flexibility in an ongoing, adaptive way. The core of Ericksonian influence is the very permissiveness that paradoxically makes it difficult to define. While the roles of clinician and client remain distinct, neither is constricted by orthodoxy or protocol; rather, each is free to explore any ethical direction or possibility elicited through the process of therapeutic discovery.

Historical Context Erickson is considered the architect of innovations in psychotherapy that parallel those of Sigmund Freud (1856–1939). Whereas Freud is known as the father of modern theories of psychotherapy, Erickson is considered a landmark pioneer in the practical techniques of intervention and change. This pioneering spirit and willingness to take risks is part of his life story. Born in a dirt-floor log cabin in a silver-mining town in Nevada, 5-yearold Erickson moved with his family to a farm in Lowell, Wisconsin. The journey began with a trip

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east in a covered wagon, an irony that Erickson used to illustrate moving forward by doing things in a backward fashion. Farm life provided Erickson with many opportunities for problem solving for everyday necessities, patiently waiting for crops to grow, and for carefully observing the processes of nature. These qualities—pragmatism, patience, and close attention—are evident in the practice of Ericksonian therapy. Tales of accepting hardship, overcoming adversity, accomplishing substantial work in increments, as well as using leverage for change became a standard part of his teaching techniques and are now used by therapists around the world. At 17 years of age, Erickson was stricken by poliomyelitis. While lying in bed paralyzed and fading in and out of consciousness, Erickson overheard the doctor advising his mother, “The boy will be dead by morning.” This statement had a profound effect on Erickson and yielded a powerful emotional response. He did not believe anyone had the right to say this to any mother, let alone his mother. In a state of defiance, Erickson found sufficient physical energy to not only survive the night but survive the illness as well. The polio virus affected his entire body, and for a while his only voluntary control was over his eyelids. Erickson recalled this time as one of intense awareness— awareness of his own limitations and of his surroundings. He used the months of tedious rehabilitation to learn about the interplay between mind and body, and during this period of confinement, he became astutely aware of the patterns of behavior of those around him, such as recognizing who was coming by the sound of the footsteps and anticipating their emotional state prior to actually seeing them. To complete his recovery, Erickson embarked on a 6-week canoe trip down the Mississippi River and back upstream. He was barely able to stand without crutches, incapable of portaging the route unassisted, and had minimal financial resources. Rather than asking for assistance directly, Erickson found that he could stimulate the curiosity of others and evoke unsolicited offers of help. Many nights, he “earned” his supper by telling stories to fishermen along the river. The practice of indirect suggestion and evoking resources as well as storytelling remain prominent features of the Ericksonian approach.

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After earning an M.D. and M.A. in psychology, Erickson took a series of positions in state hospitals working with seriously mentally ill patients. It was within the institutional setting that Erickson recognized the importance of humor and hope. He found ways to benevolently confront patients with their own symptoms by either watching them performed by others or having the patient intentionally perform the symptom behavior. This created a more detached perspective, which served as a springboard for additional therapeutic progress. A prolific writer, Erickson’s contributions to the professional literature were ongoing; he became known for his ideas and work—ideas and practices that were considered revolutionary by some and alarming by others. After moving to Arizona in 1948 and starting a private practice, his reputation grew both nationally and internationally, and other professionals sought to learn from him. Despite debility from the severe aftereffects of polio and his increasing age, Erickson continued teaching up to the time of his death in 1980, leaving a broad influence on the field that has continued to thrive over the subsequent decades.

Theoretical Underpinnings Self-Organizing Change

Erickson viewed the human organism as a complex, ever-changing, organized collection of intellectual, emotional, and biological processes, which have both conscious and unconscious dimensions. He taught that all humans possess impressive selforganizing, adaptive abilities that should be evoked and brought into service in therapy. He believed that change can and does take place on an unconscious level. This deep form of healing and growth involves unseen processes of reorganization, re-association, and adaptation. Ericksonian interventions are often targeted to the realignment and reorganization of preexistent internal resources, an awakening of previously unknown capabilities. Erickson encouraged his patients to “trust the unconscious mind.” This suggestion helps clients rediscover intuitive knowledge and engage parts of the mind that cannot be consciously understood.

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Theory of Mind

While the concept of an unconscious mind, capable of independent perceptions, attitudes, memories, emotion, and even reason, is shared by psychodynamic practitioners, there are diametrically opposing ideas about the role of the unconscious in healthy living. In contrast to the Freudian unconscious, Erickson viewed the unconscious mind as a vital resource, a reservoir of life experiences in which one’s experiential knowledge is stored and available to facilitate adaptation to ongoing needs. Erickson described the nature of the unconscious as benevolent and protective of an individual’s conscious personality. While working with a single individual, Erickson would address two psychological systems: “You are sitting here in front of me with your conscious mind and your unconscious mind.” Of these two, the unconscious mind is assumed to have greater access to memory and a greater capacity for processing internal and external stimuli. In this way, the unconscious mind has awareness of needs and experiences that are unknown to the conscious mind. Therefore, in Ericksonian therapy, addressing needs on an unconscious level is paramount, while problem resolution may or may not be needed on the conscious level. Problem-Solving Orientation

Erickson believed that human beings are purposeful organisms oriented toward survival and growth, with an innate need for mastery of internal and external life experiences. This results in a striving to overcome obstacles and challenges while drawing from organic knowledge and a lifetime of learning. Erickson believed that people are naturally altruistic and thrive while helping others and contributing to society at large. Thus, enduring health occurs through expanding self-awareness, the cultivation of interpersonal relations, meaningful labor, exposure to novelty, and continued learning. Individualization of Treatment

Erickson viewed the individualization of treatment as an imperative and objected to protocols of how therapy should proceed. Instead, Erickson emphasized the importance of

observation and flexibility as he used the immediate knowledge of the client to guide intervention, rather than theoretical knowledge derived from a diagnosis. Ericksonian practitioners recognize the importance of assessment not only during the initial visit but also throughout the duration of the therapy. However, the goal of assessment is not to arrive at a diagnosis but rather to collect as much information as possible about the unique needs, resources, and perspectives each person brings to therapy. While the first priority is to learn the client’s conceptualization of needs as expressed with language, it is assumed that explicit knowledge provides an incomplete picture. Observations of unconscious processes such as implicit logic and unconscious emotion are made by studying innuendos, patterns of behavior, and nonverbal expression. This information is used to formulate a carefully tailored approach to therapy. Collaborative Partnership

In Erickson’s approach, the relationship revolves around cooperation and can be described as reciprocal and self-reinforcing. Here, the therapeutic relationship exists for the sake of meeting the client’s needs. During this cooperative endeavor, the therapist accepts and encourages the client’s attempts to direct and influence the therapy process. In turn, the client is more open to the influence of therapy. Nonlinear Paradigm of Change

For Erickson, cause and effect were seldom linear. Rather, transformation is viewed as a paradoxical process that begins with absolute acceptance of clients. Erickson explained that sometimes you must go backward to move forward. For example, you can show a person how to be normal by acting crazy. Or sometimes, relapse is required for progress.

Major Concepts The following key concepts are therapeutic principles that underlie all Ericksonian techniques and are therefore essential to the process of conducting Ericksonian therapy.

Ericksonian Therapy

Utilization

The concept of utilization is considered by many to be Erickson’s key contribution to psychotherapy. Simply put, utilization is a psychotherapeutic strategy that engages circumstances, habits, beliefs, perceptions, attitudes, symptoms, or resistances in service of problem resolution. The general idea is that one uses everything at hand. An example of utilization with a client who is refusing to talk during therapy is the statement “As you sit there in silence, you will find that a lot of important thoughts come to mind, thoughts that are not easy to think about but that deserve your full attention.” This is utilization of behavior and of the total situation for the good of the client. Destabilization

Erickson believed that learning new patterns of thought and behavior required a period of destabilization during which conditioned responses are denied expression. New, more adaptive patterns of thought and behavior come about as the unconscious mind reorganizes with new associations and perspectives. Often referred to as the confusion technique, destabilization temporarily destabilizes conscious tracking by disrupting orientation to time, place, person, movement, or the meaning of events. An example of the latter, with someone who insists that therapy cannot help, is the question “Are you certain you have not already made progress without knowing it? You are confidently insisting that you have not become more assertive?” These questions disrupt the normal train of thought, thereby creating space for new ideas, new ways of viewing one’s self and future possibilities. Suggestion

Ericksonian approaches integrate an assortment of therapeutic suggestions ranging from strongly directive, to exceedingly permissive, to obtusely indirect. Hypnosis and hypnotic suggestion were so woven into Erickson’s communications that, at times, his students could not distinguish whether he was or was not performing hypnosis. Similarly, contemporary Ericksonian practitioners communicate from beginning to end of the therapeutic encounter suggestions such as “Change is possible,” “Help is available,” “The resources you need

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are inside you,” “You can do more than you realize,” “Change can occur without conscious effort,” and “You can continue to progress even after you leave therapy.” Although there are an unlimited number of ways in which suggestion can be embedded within communication, common Ericksonian approaches include indirect, metaphorical, and permissive suggestion. Of these three, permissive suggestion best exemplifies the principle of self-organizing change. An example of a permissive suggestion, offered to a client who is reluctant to share information, is the statement “You can tell me only what you are ready to reveal, and you can keep secret the things that are not important to your therapy.” This type of statement covers all possibilities, soliciting a response but without dictating what that response must be. Reorientation

As stated by Erickson, all of psychotherapy involves some form of reorientation. It can occur as a change in perspective, such as when a person develops new attitudes or beliefs; a change in frame of reference, such as when a person gains new life experiences or has new information; or a change in central nervous system activity, such as when intense anger is aroused, relaxation is induced, or pent-up tears are released. Then, there are also changes in key situational factors, such as when a person decides to get a new job, get married, or go back to school, which can stimulate a reorientation in all the domains listed above. Whereas many therapeutic approaches emphasize a reorientation in emotional experiencing or cognitive processing, Ericksonian practitioners often employ experiential, physical, or situational activities to achieve reorientation across numerous domains at both conscious and unconscious levels. Most famously, Erickson invited his patients and students alike to climb to the top of a nearby mountain to gain a broader perspective and reorient to life events.

Techniques In Ericksonian therapy, cognition, emotion, and behavior are not divided and singled out for intervention. Rather, changes that facilitate growth in

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any domain of experiencing are viewed as possible catalysts for continued development across all domains. Any experience by which the client can achieve new learning is potentially an important psychological intervention. Learning and forming new associations occur at different levels, many of which exist outside conscious awareness. Therefore, therapeutic communication is conducted on multiple levels, some intended for conscious processing and some intended for unconscious processing. Hypnosis

While the use of hypnosis is not synonymous with Ericksonian approaches, there is a close association. Clinicians often use formal and informal hypnosis to precipitate a shift in consciousness. This is in keeping with Erickson’s belief that hypnosis offers an avenue to deliver suggestions and to evoke internal resources. At times, the trance induction itself may be used to catapult a client into a state of destabilization and provoke internal reorientation.

statement “You can understand this concept now or remain confused and achieve deeper insight later” both validates freedom of choice and creates an expectation of progress regardless of the response. When only one of the two options is explicitly stated, and the implicit alternative is subsequently chosen by the client, then a form of unconscious commitment is activated—for example, “I don’t know when you will begin to notice that change is beginning to take place. You may have made a lot of progress and didn’t even notice it yet.” The alternative option, which was not mentioned, is that the client can choose to have immediate conscious awareness of progress. Seeding and Presupposition

Shock and therapeutic ordeals are experiential events that alter the prevailing subjective reality. Shock may be used to either stimulate an emotional response or defuse problematic emotional states. Erickson sometimes used brazen confrontational language to paradoxically bring about a lowering of defenses and a willingness to discuss troubling realities. In a typical therapeutic ordeal, an assignment is given in which an uncomfortable task the client has deliberately avoided is paired with unintentional symptom occurrence. For example, a person who is frightened of the dentist may be given the task of sitting in a dentist’s office, with nothing to do, until the fear is diminished. Thus, deliberate and nondeliberate actions become pitted against one another.

Techniques such as seeding and presupposition are used to stimulate awareness of future possibilities while avoiding overwhelming clients with memories or ideas that are emotionally intolerable. Seeding can be used for purposes of desensitization or as a form of priming. For example, when seeking to help a woman who is in denial about her husband’s diagnosis of terminal cancer, the therapist might ask the client about a favorite trip she took with her husband, how enjoyable it was, and how she is certain to hold on to those good feelings for a lifetime. The therapist can then ask if she was sad when the trip had to come to an end and what she did to get over the sadness. In this way, the client is exposed to the larger reality in a metaphorical way and engaged in adaptive thinking that will serve her at a future point in time. Presuppositions also introduce ideas that summon a future orientation in time. For instance, asking a client what she will do when she is healed interjects an implicit presupposition that healing will occur. The purpose of using a form of communication that points to a meaning beyond the stated words is to stimulate unconscious reasoning and/or mediate implicit emotions and attitudes.

Double Bind

Linking

The double bind technique employs a dichotomy in which either of two options represents progress. This technique obscures the possibility of negative outcomes by linking therapeutic progress to actions in either direction. For example, the

Linking is a form of suggestion in which new ideas are tied to existing behaviors or internal associations. For example, the therapist might say, “Each time that you come to therapy, you will notice that the therapy gets easier and easier and

Emotional Impact

Ericksonian Therapy

that you are gradually increasing the amount of progress that you make.” The client has already established his ability to come to the office, so the therapist simply links coming to therapy with making progress. Reframing

Reframing is a technique used to reorient the client to the emotional meaning given to a particular event. It is a change in perspective in which the same sets of facts find new meaning by changing the contextual background against which they are interpreted. For example, a rabbit seems small and insignificant when standing next to an elephant but large and powerful when standing next to a fly. Similarly, a client can feel wretched and inferior due to his depression until the therapist points out that he is one of the most highly functioning depressed individuals he has seen. Furthermore, the therapist can point out how in a single session the client did at least two if not three sessions’ worth of work. This reframe gives the client a new positive perspective on his depression and increases hope, the antidote to depression. Symptom Prescription and Pattern Interruption

Essentially a technique of paradox, symptom prescription is an instruction for the client to intentionally perform some part of the symptom complex. Because most clients have been consciously trying to inhibit the behavior, this reversal creates an automatic disruption in patterns of behavior. For example, an anxious client might be told, “You need to keep some small part of your worry so that you are able to act carefully when needed. Before reducing your overall anxiety, we should have you spend at least one or two weeks practicing the useful type of worry.” Once the client starts to wonder if she has worried enough during the week, the underlying belief that she is unable to stop worrying is transformed.

Therapeutic Process Similar to a Zen koan, Erickson’s ideas for therapy can be summed up as theory based on the premise that a theory of psychotherapy is not needed. Without the doctrine of a formal theory, there are

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no limits from which to distinguish proper or improper process. Instead, practitioners are admonished to have a willingness to use whatever works. Or on the flipside, “If what you are doing is not working, then try something different.” The standard by which progress is measured is subjective and established by the client relative to his or her personal goals. Dan Short and Roxanna Erickson Klein See also Erickson-Derived or -Influenced Theories: Overview; Hypnotherapy; Integrative Forgiveness Psychotherapy; Neuro-Linguistic Programming; Palo Alto Group; Solution-Focused Brief Therapy; Strategic Therapy

Further Readings Erickson, M. H., & Rossi, E. L. (1979). Hypnotherapy: An exploratory casebook. New York, NY: Irvington. Erickson, M. H., & Rossi, E. L. (1981). Experiencing hypnosis. New York, NY: Irvington. Erickson, M. H., Rossi, E. L., & Rossi, S. I. (1976). Hypnotic realities. New York, NY: Irvington. Haley, J. (1993). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, MD. New York, NY: W. W. Norton. (Original work published 1973) Haley, J. (Ed.). (1985). Conversations with Milton H. Erickson, MD: Vol. 1. Changing individuals. New York, NY: W. W. Norton. Haley, J. (Ed.). (1985). Conversations with Milton H. Erickson, MD: Vol. 2. Changing couples. Harrisburg, PA: Triangle Press. Haley, J. (Ed.). (1985). Conversations with Milton H. Erickson, MD: Vol. 3. Changing children and families. New York, NY: W. W. Norton. Havens, R. A. (2005). The wisdom of Milton H Erickson: The complete volume. Wilshire, England: Crown House. Lankton, S. R., Lankton, C. H., & Erickson, M. H. (1986). Enchantment and intervention in family therapy: Training in Ericksonian approaches. Wilshire, England: Crown House. Rosen, S. (Ed.). (2010). My voice will go with you: The teaching tales of Milton H. Erickson. New York, NY: W. W. Norton. Rossi, E. L., Erickson-Klein, R., & Rossi, K. (2010). The collected works of Milton H. Erickson, M.D. (10 vols.). Phoenix, AZ: Milton H. Erickson Foundation Press.

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Short, D., Erickson, B. A., & Erickson-Klein, R. (2005). Hope and resiliency: Understanding the psychotherapeutic strategies of Milton H. Erickson. Trowbridge, Wilshire: Crown House. Zeig, J. K. (1985). Experiencing Erickson: An introduction to the man and his work. New York, NY: Brunner/Mazel. Zeig, J. K. (Ed.). (2013). Teaching seminar with Milton H. Erickson [Google eBook]. New York, NY: Routledge. (Original work published 1985)

EVIDENCE-BASED PSYCHOTHERAPY Evidence-based psychotherapy is a psychological treatment that is supported by controlled research with a particular population and is shown to be efficacious in comparison with no treatment or another intervention. Most of these treatments are brief, manualized treatments and are evaluated with randomized controlled trials (RCTs), where subjects are randomized to either the treatment group or the no treatment or other intervention group. The majority of treatments identified as evidence based are cognitive-behavioral therapies (CBTs) and behavior therapies (BTs), as opposed to psychodynamic and humanistic therapies. Therefore, much of the controversy surrounding evidence-based psychotherapies is related to differences in therapeutic orientation and the scientific approach to psychotherapy.

Historical Context Evidence-based psychotherapy became a focus of the psychological community in the 1990s amid increasing interest in evidence-based medicine and changes in health insurance policies, and to counteract claims that pharmacological treatments were always more effective than psychotherapy. The American Psychological Association (APA) began to take an active role in the dialogue surrounding evidence-based treatments, creating guidelines for research on interventions as well as a task force dedicated to defining and disseminating empirically supported treatments. In 1993, the Division of Clinical Psychology (Division 12) of the APA created a Task Force on Promotion and Dissemination of Psychological

Procedures. The goal of the task force was to identify efficacious treatments for particular disorders based on current evidence and to make recommendations on more effective ways to disseminate these approaches. Although the initial list of treatments summarized by the task force was not the product of an exhaustive review of the literature, the list provided initial documentation of the current status of psychosocial treatment. Using strict methodological criteria, the task force then classified treatments into “well-established treatments” and “probably efficacious treatments.” A treatment was classified as well established if either one of the following two criteria were met: (1) at least two experimental clinical trials, conducted by different investigators, demonstrated the efficacy of the treatment (i.e., the treatment must have been either equivalent to an already established treatment or superior to psychological placebo, a pill placebo, or another treatment) or (2) a series of single case studies demonstrated the efficacy of the treatment. These single case studies must have used adequate experimental designs and must have compared the intervention with other treatments. The intervention also must have been described in treatment manuals, and characteristics of the patient samples must have been clearly delineated. Initially, the task force identified 18 “empirically validated” (later termed “empirically supported”) treatments. Subsequently, a number of individual researchers and task forces continued to examine evidence-based therapies for children, couples, and families as well as people with chronic pain and the elderly. The Division 12 criteria for identifying a treatment as empirically supported became a subject of controversy because most of the treatments on the list were short-term CBTs or BTs, to the exclusion of psychodynamically oriented treatments. Moreover, critics challenged the generalizability of these empirically supported treatments to clients with comorbid disorders or those with differing cultural, racial, and ethnic backgrounds. Proponents of evidence-based psychotherapy responded to this criticism by pointing out that meta-analytic studies demonstrated that RCTs are generalizable to patients seen in naturalistic settings. The controversy surrounding empirically supported treatments continues to this day. Members

Evidence-Based Psychotherapy

of APA Division 29 (Psychotherapy) took issue with the decision rules of what qualified as evidence of treatment efficacy, arguing that the role of the therapist, therapeutic relationship, and patient characteristics in the success or failure of treatments had been disregarded. In response, they created a task force to look into evidence-based therapy relationships. Leaders from this task force later formed the Task Force on Empirically Based Principles of Therapeutic Change, with the goal of determining common factors that made therapy effective, in the hope of enabling clinicians to use these general principles in practice. However, given the difficulties in assessing common factors and the relatively weak empirical support for the contribution of these factors to treatment outcome, the Division 29 task force had limited impact. In 2005, the APA Presidential Task Force on Evidence-Based Practice made a formal position statement that the best available research—which is not limited to controlled trial research—should be integrated with the expertise of the clinician and the patient’s culture, preferences, and characteristics. Division 12’s Task Force, which became a standing committee in 1999, continues to update the list  of empirically supported treatments, which is available online.

Theoretical Underpinnings First formulated in 1949 at the Boulder Conference on Graduate Education in Clinical Psychology in Boulder, Colorado, the APA set forth specific training guidelines for clinical doctoral programs. These guidelines have become known as the Boulder model (also referred as the scientist practitioner model). According to the Boulder model, clinical doctoral programs should train students to become scientist-practitioners who make empirically based and theory-driven health care decisions. In the same spirit were the efforts by the Division 12 Task Force. Thus, the idea that clinical practice should be based on a solid foundation of research far predated the evidence-based psychotherapy movement.

Major Concepts When developing the guidelines for treatment research, the APA task force emphasized two overarching conditions. First, studies must demonstrate

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treatment efficacy—that the treatment works as well or better than another intervention or is superior to a placebo condition, and second, it must establish clinical utility, or the usefulness of the intervention in a clinical setting. In defining the criteria that would allow treatments to be identified as empirically validated, the Division 12 Task Force largely favored studies that measured efficacy, the way in which interventions work in a controlled setting, rather than effectiveness, or real-world applicability. These criteria determine whether an empirically supported treatment is considered “well established” or “probably efficacious.” Treatment Efficacy

Guidelines for evaluating treatment efficacy answer the question of how well the treatment works. To be found efficacious, a treatment must be shown to work in comparison with either no treatment or a different form of intervention, with the latter being a more rigorous test of efficacy than the former. The evaluation of a treatment should be viewed in the context of methodologically sound, relevant literature and should take into account the appropriateness of the match between treatment and patient. In addition, expected outcomes of the treatment should be stated before the study is conducted. Clinical Utility

Clinical utility (also referred to as effectiveness) takes into account the generalizability of the treatment to various populations, based on age; gender; cultural, racial, or ethnic background; disorder severity; and comorbidity. Guidelines should account for differences in therapist skill and experience, interactions between the therapist and patient characteristics, the treatment setting, and variations in treatment delivery. Clinical utility also looks at feasibility, such as the treatment’s acceptability to the patient, possible negative outcomes of treatment, and clinician training. Well-Established Treatments

Empirically supported treatments are designated as well established in two instances: (1) if there are at least two RCTs showing that the treatment in

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question is better than a pharmacological intervention, psychological placebo, or another intervention, or it is shown to be equivalent to an already established treatment or (2) if more than nine single-case design experiments that used good experimental design and compared the treatment with another intervention (e.g., placebo) demonstrate efficacy. In addition, all experiments need to be  conducted with a manual, at least two separate investigations must have demonstrated the effects of the treatment, and patient population characteristics must be clearly delineated. Probably Efficacious Treatments

A treatment is deemed probably efficacious in three instances: (1) if there are two experiments showing that the results of the treatment were statistically superior to those of a wait list control group, (2) if one or more experiments meet all the criteria for a well-established treatment except for the criteria that effects need to be shown by two different investigators, or (3) if a group of three or more single-case design experiments otherwise meet the criteria of well-established treatments.

Techniques Behavior Therapy

BT refers to a family of treatments that include empirically based techniques to modify maladaptive behaviors (broadly defined) that serve to maintain psychological problems. Modern BT often includes techniques targeting maladaptive thinking, emotional responses, and interpersonal styles. Similarly, modern cognitive therapy incorporates techniques that target avoidance behaviors and other maladaptive responses to stimuli. Cognitive-Behavioral Therapy

CBT refers to a family of interventions. It also refers to a general scientific approach to psychological disorders. The core cognitive model states that cognitions causally (but not unidirectionally) influence emotions and behaviors. It is assumed that dysfunctional thoughts and cognitive distortions contribute to the maintenance of psychological problems. Thus, the model builds on the fact that emotions are strongly, and causally, influenced

by the perception of events or situations. This view is in contrast to that of early behaviorists who rejected the notion that cognitions can cause emotions and behaviors. However, modern psychotherapy integrates cognitive and behavior techniques that have become the treatment approach that is now known as CBT.

Therapeutic Process As evidence-based psychotherapies are largely shortterm behavioral therapies or CBTs, the therapeutic process involves a manualized treatment in which the number of sessions and the content for each session are explicitly outlined. Treatment most likely addresses a specific disorder, and the therapist guides the patient through the steps of the treatment. One elementary technique of BT is exposure therapy, in which patients are exposed to fear or other distress-inducing situations or objects to provide them with an opportunity to respond to their distress in more adaptive ways. Exposure therapy is often used to treat anxiety disorders, but it is also used in a range of other disorders ranging from addictive to self-injurious behaviors. Exposure therapy is generally brief and is easily manualized and studied in RCTs. There are numerous forms of CBTs, aimed at specific disorders or to treat broader issues. As noted earlier, CBT is highly represented in empirically supported therapies as it is a form of therapy in which the therapist needs to be empathic and directive. Although CBT is often conducted in conjunction with a treatment manual, it requires a considerable level of skills to conduct the treatment effectively. However, these skills are different from the so-called common factors that are difficult to quantify and train. Instead, the skill set in CBT can be effectively trained, measured, and implemented (e.g., Socratic questioning, reflective listening). Stefan G. Hofmann and Jamie Sturm See also Behavior Therapy; Cognitive-Behavioral Therapy; Exposure Therapy

Further Readings American Psychological Association. (2002). Criteria for evaluating treatment guidelines. American Psychologist, 57, 1052–1059. doi:10.1037//0003-066X.57.12.1052

Existential Group Psychotherapy American Psychological Association. (2006). Evidencebased practice in psychology. American Psychologist, 61, 271–278. Retrieved from http://www.apa.org/ practice/resources/evidence/[apa.org] Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Cristoph, P., . . . Woody, S. R. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51(1), 3–16. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716. Hofmann, S. G., Asmundson, G. J., & Beck, A. T. (2013). The science of cognitive therapy. Behavior Therapy, 44, 199–212. doi:10.1016/j.beth.2009.01.007 Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York, NY: Oxford University Press.

Website Society of Clinical Psychology, American Psychological Association, Division 12. Website on ResearchSupported Psychological Treatments: http://www .psychologicaltreatments.org

EXISTENTIAL GROUP PSYCHOTHERAPY Existential group psychotherapy shares much in common with other dynamic, relational, and humanistic approaches to group psychotherapy but emphasizes work that addresses anxieties generated by inescapable conditions of ordinary human existence. Generally, existential factors are woven into the fabric of group psychotherapy, though existential group approaches are also used as a stand-alone model.

Historical Context Existential group psychotherapy arises out of existential philosophy, which prioritizes an individual’s experience in creating meaning and taking personal responsibility for self-determination. Key contributors to existential thought include Martin Buber, Paul Tillich, and Søren Kierkegaard, who challenged traditional religious dogma as a guide to living life and offered more nuanced, some say complex, positions on religious thought.

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In addition, other philosophers, such as Martin Heidegger, Friedrich Nietzsche, and Jean-Paul Sartre, developed their thinking from more secular perspectives. Viktor Frankl developed a model of psychotherapy called logotherapy, emerging from his experience in Nazi concentration camps during the Holocaust in the 1940s. He believed that what determined a person’s survival in the face of unrelenting brutality was the attitude with which the person approached his or her existence when all personal control has been stripped away. More recently, these perspectives have been integrated into group therapies for patients facing extreme situations in life, such as cancer, HIV/AIDS, and other terminal illnesses, as well as those facing other limits in life such as aging or imprisonment. Evaluation of existentially informed group therapy of medically ill patients has consistently produced significant findings. Although patient anxiety may rise initially in the face of discussions of existential themes, the ultimate result often is improvement in the individual’s quality of life and reduction of emotional distress even in the face of advancing medical illness.

Theoretical Underpinnings Irvin Yalom, a contemporary leader within the existential psychotherapy and existential group psychotherapy movement, describes existential psychotherapy as a dynamic approach to therapy that centers on the individual’s existence and related core concerns. Existential therapeutic factors represent important components of group psychotherapy. Alongside cohesion, universality, interpersonal learning, and self-understanding, the existential group psychotherapist also emphasizes therapeutic factors such as the recognition that (a) life is often unfair and bad things happen to good people; (b) there is ultimately no escape from existential challenges including personal mortality and the death of loved ones; (c) though one builds a relational world, no matter how close one becomes with others, a fundamental aloneness persists that one must bear; (d) hoping for others to remove this aloneness is a recipe for inauthentic, unfulfilling relationships; (e) building on this awareness one can develop the capacity to live life in a more honest, authentic, and fully

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engaged fashion, taking full personal responsibility for one’s choices and actions. Rather than fleeing these anxieties through maladaptive behaviors or relationships, the existential approach emphasizes engagement in the presence of meaningful group support. Existential group psychotherapy centers on the interplay of four key themes. The first is how to live life meaningfully in the face of the reality of death. The second is recognizing one’s fundamental freedom to set a course and choose a path in life. This confronts the individual with the anxiety of potentially falling short of living life in a way that reflects one’s fundamental being, challenging passivity, inaction, and “nonbeing.” The third theme is focusing on pursuing what Buber refers to  as I–Thou relationships, genuine, authentic, respectful, and mutual relationships, as opposed to I–It relationships, in which the relationship is exploited and participants devalued. Finally, the fourth theme is focusing on making meaning in life and one’s personal responsibility to do so.

Major Concepts Recognizing that the aim of existential group psychotherapy is to facilitate the group members’ choosing to live their lives in a thoughtful, selfinformed fashion, treatment has to balance confrontation around these core anxieties with adequate support to keep members engaged and not overwhelmed. Responses to existential concerns are uncovered through the joint work in the group rather than offered or provided by the therapist. Patients develop the capacity to tolerate anxiety through direct emotional experience and engagement, rather than simply seeking solace. As noted, psychological difficulties emerge not from internal conflict regarding drives and instincts but rather from existential conflict about avoidance of or engagement with life as it unfolds. For example, choosing Path A in one’s life means closing the door to Path B and overcoming the fear that blocks choosing any path for fear of foreclosing another. The group leader in this model, in addition to fostering an environment that is cohesive, safe, and trusting, is generally more of a participant-observer recognizing that he or she is no more immune to these existential anxieties than the members of the

group are. Hence, the therapist engages as an informed fellow traveler and not as a wise, aloof sage.

Techniques Existential group therapy employs key techniques in the group process, including the development of a safe, confidential, and warm atmosphere; emphasizing the here-and-now and respecting the process; focusing on existential core issues; and providing support for those facing mortal illness. Developing a Safe, Confidential, and Warm Atmosphere

The key features that define any effective group therapy are equally important in existential group psychotherapy. Patients entering a group go through a process of selection ensuring that their goals align with the focus of the group. They are properly prepared to understand how the group works and given instruction on how to manage the initial anxiety that might deter participation. The group is constructed and led in a way that fosters cohesion with regard to warmth, trust, safety, confidentiality, and a commitment to honor the work and self-disclosure of each member of the group. The group leader aims to have the group members experience emotion and then reflect on that experience as a way to maximize learning. All therapy groups follow typical and predictable stages of development that involve the initial forming together as a group and then dealing with issues of power and authority before entering a working phase. Endings are particularly important in existential group therapy because the ending is a limit that must be confronted and addressed. Emphasizing the Here-and-Now and Respecting the Process

The group leader will pay attention to group process, trying to answer the following questions: Why is this happening in this way at this particular moment in time? What are the contributions of the group as a whole; what contributions are made as a group leader? What are the contributions of the group members? What do the interactions in the group illuminate? The existential

Existential Group Psychotherapy

group psychotherapist, much like the interpersonal group psychotherapist, will emphasize work in the here-and-now because of its greater authenticity and presence. The therapist will facilitate interaction, recognizing that every member of the group has valuable contributions to make to the group, using the interaction to illuminate existential themes. This requires each member’s rigorous self-examination in the presence of trusted others so that exploration and confrontation are experienced in the spirit intended, which is to foster growth and self-awareness. Focusing on Existential Core Issues

The group may focus on the most prominent existential anxiety addressing mortality, isolation, freedom, or meaning, often looking at the interface of these four foci. This emphasis typically diminishes the focus on transference in the traditional sense as reflecting an important relationship from the past projected onto the present, but it will look at the way in which the patient relationships in the group represent attempts at avoiding existential anxiety, perhaps by being rescued or protected. A powerful focus may center on relationships and their meaning, challenging individuals whose relationships serve as shields from existential isolation, hoping to be cared for by others to reduce their vulnerability or, alternately, denying vulnerability by adopting grandiose and dismissive interpersonal postures. Providing Support for Those Facing Mortal Illness

The existential perspective can be effectively woven into group interventions for those facing mortal illness. Cognitive existential group psychotherapy and supportive expressive group psychotherapy are integrative group approaches utilizing peer support to develop coping strategies to help individuals confronting mortal illness. Recognizing that time and energy are limited forces the question of how one authors life in the face of these limits.

Therapeutic Process Existential group psychotherapy emphasizes engagement, support, confrontation, and empathy

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aimed at a genuine understanding of the inner experience of each member of the group. It also emphasizes the value of self-understanding as a way of informing the individual about personal responsibility in making choices. The heart of the work is reducing avoidance of existential concerns because it is believed that this avoidance diminishes one’s engagement with life and distorts the quality of one’s relationships. Group support is essential in fostering the ability to tolerate existential anxiety. Treatment aims not to placate the individual or provide reassurance that eliminates anxiety but, rather, to engage the individual, with the support of others in the group, to confront the realities of existence, leading to greater self-awareness, self-actualization, and self-authorization. The group therapist utilizes judicious selfdisclosure and transparency, giving feedback and sharing reactions within the group. Existential therapists believe it is important that a therapist’s disclosures always center on the patients’ interests rather than on the therapist’s concern. This requires self-awareness and attention to personal reactions and to countertransference that distorts responsivity to the group. This kind of therapist self-awareness is believed essential to avoid imposing one’s own will on the group or concealing one’s own existential anxiety through a position of pseudomastery. The social microcosm of the group provides an opportunity to learn about misaligned or inauthentic ways of relating. Fending off existential anxiety may be evident by an individual group member’s surrender to others, externalizing and blaming, or adopting a position of grandiosity and diminishing the importance of relationships. The interface with interpersonal and relational models of group psychotherapy is very strong as the individual demonstrates in the group his or her mode of relating in the larger relational world. Working with death and mortality emphasizes the confrontation with one’s vulnerability and the paradox that although the act of dying ends life, the acceptance of the inevitability of death can invigorate life. As one recognizes that time is limited, one can choose to live life in a way that reduces regret for things unsaid or undone. Death is thought to serve as a co-therapist activating and mobilizing individuals in the group to confront the illusion

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that they have unlimited time to address what ails them. Confronting death in this way detoxifies it and makes it less isolating and fearsome. Working with isolation emphasizes the value of human connection and the authentic human encounter while at the same time embracing the paradox that there is a fundamental aloneness that cannot be bridged completely by our relationships with others. It is believed that we can, however, choose to live in our relational world in a way that honors ourselves and others and creates genuine and intimate self–other encounters, rather than entering into relationships only as a way of avoiding anxiety. A third important domain relates to confronting one’s freedom and responsibility, avoiding the paralysis that comes from the fear of choosing one direction because it forecloses other directions. Accepting responsibility for one’s freedom involves assuming responsibility and authorship for one’s life, identifying one’s will, and mobilizing action. This can reduce the existential guilt of failing to be true to oneself. Finally, the existential group model emphasizes core rather than superficial values and attributes. Meaning in one’s life can only be determined on one’s own terms and involves prioritization and determination of how one wants to be known in the world, and then shaping one’s behavior to match that. One of the important messages emerging from existential group psychotherapy that is relevant in all therapies is the value of being alert to existential concerns throughout the course of one’s life rather than waiting for a tragic confrontation with existential limits and boundaries to awaken the importance of personal authorship of one’s life. Molyn Leszcz See also Existential Therapy; Psychodynamic Group Psychotherapy

Further Readings Buber, M. (1971). I and thou (Ich und Du). New York, NY: Scribner. Leszcz, M., & Goodwin, P. (1998). The rationale and foundations of group psychotherapy for women with metastatic breast cancer. International Journal of Group Psychotherapy, 48, 245–273.

Leszcz, M., & Spiegel, D. (2009). Group psychotherapy and the terminally ill. In H. M. Chochinov & W. Breitbart (Eds.), Handbook of psychiatry in palliative medicine (pp. 490–503). Oxford, England: Oxford University Press. May, R. (1969). Existential psychology. New York, NY: Random House. Mullan, H. (1992). “Existential” therapists and their group therapy practices. International Journal of Group Psychotherapy, 42, 453–468. Saiger, G. M. (1996). Some thoughts on the existential lens in group psychotherapy. Group, 20, 113–130. doi:10.1007/BF02109140 Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York, NY: Basic Books.

EXISTENTIAL THERAPY Existential therapists reject the notion of deterministic forces affecting one’s psychological well-being and functioning, such as those traditionally purported in psychoanalysis and behaviorism. Instead, they hold that all human beings have the freedom to shape their own existence through self-reflection; to pursue meaning, purpose, goals, and values in life; to engage in fulfilling encounters with others; and to choose to be true to oneself and authentic with others. Existential therapists acknowledge, however, that with making choices, we also must accept responsibility for our circumstances and actions; overcome anxiety, isolation, and alienation; be willing to actively engage in life for it to be personally meaningful; and accept the unavoidable finality of life, that is, death. In the existential therapy framework, the way one deals with the givens of existence—death, freedom, isolation, and meaninglessness—causes suffering and anguish and is the source of either health or disorder; as a result, the major goal of existential therapy is to facilitate the client’s self-reflection and self-awareness and to alleviate the client’s self-deception and blocks to understanding his or her existence. Existential therapists foster the client’s decision-making process and help the client accept responsibility for the decisions through confronting anxieties, support

Existential Therapy

the client’s courage to act, and instill hope for finding a more meaningful, creative, and satisfying life.

Historical Context Existential psychotherapy arose in Europe in the 1940s and 1950s and has its roots in existential philosophy, dating back to the late 19th and early 20th centuries. Although the term existentialism was coined by the French philosopher Gabriel Marcel in the mid-1940s and later accepted by Jean-Paul Sartre in 1945, the precursors to existential thought can be found in the writings of Søren Kierkegaard (1813–1855), who put forth several ideas about the importance of the self and the relation of the self to the world, suggesting that truth is subjective. Kierkegaard also highlighted the experience of uncertainty in life, which results in a feeling of angst—a combination of feelings of dread and anxiety. However, Kierkegaard viewed the experience of angst as a creative force in life, a necessity for becoming fully human—a person does not discover himself or herself but creates himself or herself. Being a subject (as opposed to an object) requires action and the desire to bring forth into existence the possibilities of what can be (not just what is); it requires passion for life. In contrast, if one allows oneself to be defined by others, one becomes inauthentic and self-alienated. Like Kierkegaard, Friedrich Nietzsche (1844– 1900) highlighted the importance of the subjective self and the process of becoming a human. Nietzsche was particularly critical of the notion of the human as a rational being and was concerned that other attributes of being human, such as passion, spirit, and spontaneity, might atrophy. He insisted on the importance of human potential for creativity and originality, which he called the will to power. Rather than giving into the herd mentality, one needs to become a true self by allowing and accepting the passion, the spontaneity, and the unpredictability of life as it unfolds. Martin Heidegger (1889–1976) built on the ideas of Kierkegaard and Nietzsche by criticizing the Western notion that inner and outer (the subject and the object, respectively) are separate. He proposed that as human beings we are both subjective beings and intimately connected to the outside world from which we emerged. He called this existence being-in-the-world, or Dasein (being-there/

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there-being), connoting that the being is always engaged in the world as neither the subject nor an object alone and it is always in the process of becoming. Heidegger’s phenomenological existentialism stresses the unique experience of being human, where intentional choices must be made toward being authentic and each person must accept individual responsibility for his or her own life—responsibility for overcoming what is (including our progression toward death), for resolving anxiety and guilt related to making authentic or inauthentic choices, and for overcoming isolation. The importance of responsibility was also highlighted by Jean-Paul Sartre (1905–1980), who proposed that humans are condemned to be free while surrounded by the condition of nothingness—a world where there is a void, such as a failed expectation. However, the tension between free will and the dread of commitment and responsibility is often too difficult to bear, which results in inauthentic existence and leads to suffering and emotional problems. At the same time, as Martin Buber (1878–1965) proposed, we are also never perfectly alone; there is not just the I but also an other. This creates a certain betweenness within which we live our lives. Too often, however, the other is reduced to being an it, an object, resulting in the I–It relationship rather than the I–Thou relationship. Reducing someone or being reduced by someone into an object has the consequence of dehumanization and profound isolation. If one is to reach authenticity of being, according to Buber, a certain presence is necessary—a presence that enables the I–Thou relationship and that allows both individuals to be responsible in the here-and-now of the encounter with the other. The ideas of the existential philosophers found their way into the psychotherapy literature in Europe during the late 1920s and early 1930s when Otto Rank (1884–1939), after separating from Sigmund Freud (1856–1939) in Austria, began working on relational, experiential, and here-and-now psychotherapy; art; the creative will; and neurosis as a failure in creativity. According to Rank, the neurotic person lives too much in the past, and as such, he or she actually does not live. The neurotic suffers because he or she clings to the past to protect himself or herself from experience, which for Rank was an emotional surrender to the present. Rank was the first to use the concept of

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here-and-now and to view therapy as learning and unlearning experience. For Rank, the therapeutic relationship allows the patient to learn more creative ways of thinking, feeling, and being in the here-and-now and to unlearn self-destructive ways of thinking, feeling, and being in the here-and-now. In Switzerland, Ludwig Binswanger (1881– 1966) and Medard Boss (1903–1990) both applied Heidegger’s ideas of being-in-the-world and Dasein to their psychoanalytical approach. Binswanger’s and Boss’s existential analysis approach, Daseinsanalysis, highlights the subjective and spiritual dimensions of existence and the idea that a crisis in the therapeutic context is directly related to an impasse in making choices and taking responsibility for the choices on the part of the patient. Another important figure in Europe was Victor Frankl (1905–1997), who also adopted existential concepts and ideas to develop logotherapy—a therapy through meaning—in which he emphasizes that all experiences under all circumstances have meaning and that the central motivation in life is the will to meaning. According to Frankl, we succumb to meaninglessness or the existential vacuum too often through keeping busy with routines and work. In finding meaning, one can find purpose in life. In the United States, existential psychotherapy was introduced in 1958 by the publication of Existence: A New Dimension in Psychiatry and Psychology, a book edited by Rollo May, Ernst Angel, and Henri Ellenberger. May (1909–1994), an important figure who expanded and contributed to existential psychotherapy in the United States, focused on concepts such as freedom, destiny, responsibility, anxiety, love, and will. He emphasized the importance of the struggle between the security of dependence and the desire for and fear of independence and maturity. For May, it is this very struggle through which freedom and destiny can be grasped, embraced, and creatively transformed. Irvin Yalom (1931– ) further developed an existential therapy framework focusing on the four givens of existence: death, freedom, existential isolation, and meaninglessness. For Yalom, these are the ultimate human concerns that affect the quality and composition of one’s life. Yalom postulates that one’s quality of life is proportionately

related to the courage and creativity with which these concerns are faced and the priorities one establishes when exploring these concerns. Yalom’s 1980 book, Existential Psychotherapy, remains an essential textbook for existential therapists. James Bugental (1915–2008) draws further attention to polarities between freedom and destiny and highlights the paradoxes of being as embodied but changing, free but finite, solitary but connected with others. He conceived of self-asprocess, meaning that we are always in the process of change. Accepting change and dealing with change in a meaningful way is an essential part of our journey toward a healthy, meaningful, and satisfying life. More recently, Kirk Schneider’s work built on the writings of Paul Tillich (1886–1965), Buber, Abraham Heschel (1907–1972), and others, as well as his own clinical experiences. He proposes an “awe-based” approach, which highlights the sense of humility and wonder or adventure one experiences simply by living. While the sense of awe may be inherent in living, it also must be cultivated, or it can be destroyed and crushed by the current “quick-fix,” efficiency-oriented culture. Louis Hoffman also brings forth existential-integrative cross-cultural perspectives to both theory and practice of contemporary existential therapy.

Theoretical Underpinnings While no single theory of existential therapy exists, there are several themes and frameworks that contemporary existential therapists hold in common. Existential therapists work from a phenomenological perspective; that is, they accept the subjective experience of the client as his or her true reality. They also reject dualism between the body and the mind or between the experience and the environment. Thus, in this framework, existence can be understood as one’s being-in-the-world, meaning that the world one resides in and responds to is of one’s own creation. Existentialists recognize three modes of living in the world. Umwelt is the biological and physical world and reflects one’s being-in-nature, Mitwelt is the social world and reflects one’s being-with-others, and Eigenwelt is the psychological world of one’s self-awareness and reflects being-for-oneself. Several existential therapists also acknowledge the fourth

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mode, Uberwelt, which is a spiritual dimension that reflects the relationship between a person and the unknown and the tension between absurdity and purpose as well as between hope and despair. This dimension encompasses relationship to the soul, religion, dogmas, ideology, or meaning making that transcends the physical and psychological aspects of life. Within these interwoven dimensions of existence, we experience push and pull between who we want to be and can become (aspirations) and what we fear as we create ourselves and our lives. This reflects the fact that existential therapists do not subscribe to the notion of an essential self. Because nothing is permanent, self is always in flux and in the process of becoming within one’s environment, which is also ever changing. Therefore, for existential therapists, the focus is not so much on one’s personality as on one’s ability to embody experiences and on the patterns within the lived experiences. However, the impermanence in life and the lack of predictability in the world in the context of having to take responsibility for one’s own life produce profound existential anxiety and dread (angst). Even though we may not have a choice about the specific circumstances into which we are born, we come to realize that we have many choices in life that we are free to pursue. Yet our freedom to decide and to act on our decisions also comes with having to accept responsibility for our own actions. In essence, we are condemned to freedom, and we are responsible for our lives, for our actions, and for our failure to take action. Embracing freedom and responsibility is a necessary step toward living an authentic, satisfying life; allowing others to define us or to choose for us is to live an inauthentic life, a restricted existence, which is the foundation of suffering, anguish, and mental and emotional disorders. The responsibility we must assume, however, is ours alone. We alone must decide how to live our life, and we alone must find meaning in and give meaning to life. Aloneness, and the capacity to be  alone, is a key aspect of life, and at times the sense of isolation can be overwhelming. However, healthy relationships with others can be difficult if not impossible to establish if we don’t understand our own significance and purpose in the world as separate, unique individuals. Too often, to obtain

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approval from or gain recognition by others, we give up our freedom and sacrifice our choices, which again results in an inauthentic, restricted existence. At the same time, we do not have unlimited time to do everything that we might wish to accomplish in life. As with everything in life, our own lives are also impermanent and passing. Such a realization might be frightening and may also result in pressure to always make the “perfect” decision, or it may lead to inaction or succumbing to others’ definitions of success. Awareness of one’s mortality brings forth important questions about the meaning of one’s life and one’s purpose in life. Experiencing meaninglessness and a crisis of values is part of life as our worldview, experiences, and encounters with others expand and extend over time.

Major Concepts Although existential therapists may differ slightly on the underlying concepts that drive the theory, some of the generally accepted ideas include Dasein (being-in-the-world), the four worlds, the four givens, existential anxiety (angst), existential guilt, and authentic existence. Dasein

Existential therapists accept the notion of Heidegger and Nietzsche that a human being is always engaged in and part of the world (being-inthe-world). As such, the self is not static but always in flux and in a constant state of becoming through continuous engagement with the personal world. The Four Worlds

Being-in-the-world involves four basic interwoven dimensions: (1) the physical (Umwelt), (2) the social (Mitwelt), (3) the psychological (Eigenwelt), and (4) the spiritual (Uberwelt). Every person has a unique way of existing in these four realms and is uniquely shaped by encounters and experiences along each dimension. As biological beings, we must accept our physical limitations and biological processes and strive for physical security; as social beings, we must find a balance between being alone and being with others and between social

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acceptance and rejection; as self-aware beings, we strive for identity, struggle with personal strengths and weaknesses, and try to make sense of our lives in the context of past actions, current desires, and future goals; and as spiritual beings, we reach out beyond the known world for meaning, hope, and cohesion in the face of the unpredictable and the unknowable. Lack of integration among these dimensions or overemphasis of one over the others is a frequent cause of anguish, despair, or emotional distress or disorder. The Four Givens

As put forth by various existential writers and eloquently elaborated by Yalom, the four givens are the four ultimate concerns in life that cannot be avoided. They are death, freedom, isolation, and meaninglessness, and they can be seen as paradoxes of the four dimensions of existence. Engaging the full spectrum of the paradoxes of human existence allows for the fullness of human being to be experienced. Indeed, increased personal growth, courage, and resilience may result from an existential therapy that provides opportunities to fully and deeply acknowledge the following complexities and paradoxes. Death Death reflects the unavoidable impermanence and finality of life, and it is the only certainty in life. Awareness of death can be frightening and paralyzing, and denial of the certainty of death can have equally detrimental effects. However, a reflection on impending death can have a creative and inspiring effect on a full and productive life. Freedom Freedom and responsibility are essential concepts in existential therapy. They connote the fact that we create our own destiny, even if we didn’t have much choice in the circumstances into which were born. Being free is to be able to choose who we are and can become. Assuming responsibility for the choices we make is fundamental to living an authentic existence and basic to the process of change and transformation, while avoidance of responsibility is at the root of restricted existence and inauthenticity.

Isolation Existential isolation is an inevitable aspect of life. While we are social beings dependent on and striving for relationships with others, we have the capacity for separation. The ability to be alone is  foundational to establishing one’s identity and creating healthy and meaningful (authentic) relationships with others. Meaninglessness As there is no one specific way to be in the world, each person must create his or her own meaning. Experiencing meaninglessness is a call to establish personal values and personal meaning, which emerge through engagement with the world. Abdication of this task results in what Frankl called an existential vacuum—a sense of emptiness, of life without a purpose. Existential Anxiety

Existential therapists differentiate between abnormal, pathological anxiety and normal, inevitable anxiety (angst) that arises from being confronted by the four givens of existence. Facing freedom, taking responsibility for one’s decisions and choices, searching for meaning, and facing mortality can be frightening and can be experienced with a sense of dread. However, this normal anxiety can also be a powerful motivational force toward change, growth, and transformation. Existential Guilt

Existential guilt arises from a realization of living an incomplete, unfulfilled life due to inability to fulfill one’s potential. Unlike pathological, abnormal guilt, existential guilt is also a powerful motivational source toward transformation and authentic existence. Authentic Existence

Authentic existence is a choice and a commitment to openness and engagement with ourselves, with others, and with the world around us to create a meaningful life. It is without pretense, contradictions, or deception and includes acceptance of

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limitations while fulfilling one’s potential. It is a creative, caring, and generative way of being in the world.

Techniques Existential therapists believe that more important than any particular technique are the therapist’s attitude, inquiring stance, and attention to the therapist–client encounter in forging a deep, respectful, I–Thou relationship. Because each client and his or her world are unique, each therapy encounter is also unique in unfolding the subjective reality of the client’s being-in-the-world in the here-and-now of the therapeutic process. Within the context of such a therapist–client relationship, there is space for exploration and challenge in the encounter with the self, the other, and the larger world. The therapist might utilize questioning, empathizing, confronting, supporting, reflecting, and other strategies as the client embraces the courage to face his or her current limitations and the possibilities of living an authentic life.

Therapeutic Process At its roots, existential therapy is deeply selfreflective and at the same time deeply relational. As the client begins the journey, most often starting from a place of angst, anguish, dread, anxiety, and restricted existence, the client is guided toward a deeper reflection and toward increased awareness of the push and pull between what is feared and what is possible. The therapy is a working space where clients take an honest, truthful look at how they make sense of their situation and life (meaning); how they might be implicated in feeling stuck through deceiving themselves and avoiding or relegating making choices for themselves (responsibility); the extent to which anxiety and fear impinge on their ability to face the uncertainty, ambiguity, and finality inherent in life (death); and the ways in which they became strangers to themselves through an inability to be alone and autonomous (isolation). The realization of having given up their freedom, which now has to be assumed again with full responsibility, can be both frightening and exhilarating for the client. It is the vital role of the

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therapist to not only bear witness but also support the process toward effective transformation and integration. The therapeutic here-and-now encounter fosters authentic presence through engagement with what is personal for the client and what is real in the relationship between the client and the therapist. It is through this process that new possibilities can be explored and a different future can be envisioned by the client and the client can become a more engaged and active author of his or her being-in-the-world. Shawn Rubin and Kristopher Lichtanski See also Daseinsanalysis; Existential Group Psychotherapy; Existential-Humanistic Therapies: Overview; Logotherapy and Existential Analysis; Frankl, Viktor; May, Rollo; Yalom, Irvin

Further Readings Bugental, J. F. T. (1965). The search for authenticity: An existential-analytic approach to psychotherapy. New York, NY: Holt, Reinhart, & Winston. Bugental, J. F. T. (1987). The art of the psychotherapist. New York, NY: W. W. Norton. Cooper, M. (2003). Existential therapies. London, England: Sage. Deurzen, E. van. (2002). Existential counselling and psychotherapy in practice (2nd ed.). London, England: Sage. Frankl, V. E. (1963). Man’s search for meaning. New York, NY: Pocket Books. Hoffman, L., Yang, M., Kaklauskas, F. J., & Chan, A. (Eds.). (2009). Existential psychology East-West. Colorado Springs, CO: University of the Rockies Press. May, R. (1983). The discovery of being: Writings in existential psychology. New York, NY: W. W. Norton. May, R., Angel, E., & Ellenberger, H. F. (Eds.). (1958). Existence. New York, NY: Basic Books. Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. St. Paul, MN: Paragon House. Schneider, K. J. (2009). Awakening to awe: Personal stories of profound transformation. Lanham, MD: Jason Aronson. Schneider, K. J., & May, R. (1995). The psychology of existence: An integrative, clinical perspective. New York, NY: McGraw-Hill. Yalom, I. (1980). Existential psychotherapy. New York, NY: Basic Books.

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Existential-Humanistic Therapies: Overview

EXISTENTIAL-HUMANISTIC THERAPIES: OVERVIEW Existential-humanistic psychotherapy includes a broad range of therapies that are based on the philosophies of existentialism, phenomenology, and humanistic psychology. In contrast to psychoanalytic and psychodynamic therapies, as well as early behavioral theory, existential-humanistic therapies focus on intrinsic qualities of the person in the change process. Whereas psychoanalytic and psychodynamic approaches often require years of therapy and focus on the unraveling of the complex role the unconscious plays in the development of one’s character, existential-humanistic therapies believe in the capacity of individuals to understand self and make changes as they uncover the reasons why they have not actualized their true selves. As compared with psychoanalytic, psychodynamic, and behavioral approaches, which tend to view the therapist as the expert directing the process of therapy, existential-humanistic therapies are considerably more client centered, tend to highlight the importance of the counseling relationship in the change process, and view therapy as a journey undertaken by both the therapist and the client to foster the client’s capacity to change. These approaches view the counselor as a facilitator of the client’s understanding of self and as a person who encourages clients to realize the choices they have as they move, sometimes relatively quickly, toward increased congruence between their true self and their actions.

Historical Context Psychoanalysis and related psychodynamic approaches, such as Jungian therapy and object relations therapy, were the predominant forms of therapy conducted well into the middle of the 20th century and suggested that personality was determined through a dynamic interaction of earlychildhood experiences with the development of the conscious and unconscious minds. Closely following the rise of these approaches was the development of the first behavioral approaches, which took a scientific and mechanistic approach to understanding personality development and

posited that one’s character was the result of associations between stimuli or the conditioning of behaviors. Although dramatically different in their underlying philosophical approaches, psychoanalytic, psychodynamic, and early behavioral approaches all assumed that individuals were determined by forces outside their control, such as early-parenting patterns or reinforcement contingencies, and that therapy would involve the therapist acting as the maestro or expert who, alone, had the knowledge to help the client make changes. In the case of psychoanalytic and psychodynamic approaches, therapy could continue for years. With the rise of existential philosophy at the end of the 19th century and the beginning of the 20th century, a new understanding of the person began to take hold. Philosophers such as Søren Kierkegaard, Albert Camus, Friedrich Nietzsche, and Jean-Paul Sartre wrote about the human condition and challenged prevailing notions of the time regarding the nature of being in the world and the development of personality. Their writings reflected a pessimistic view about the nature of being and assumed that meaningfulness could be found only through a deep search for individual truth, not by some outside theory, as promoted by the psychoanalytic and psychodynamic theorists, or from the application of scientific methods, as was being proposed by the early behaviorists. Other philosophers focused on the importance of understanding each individual’s perspective or unique reality. These philosophers, known as phenomenologists, highlighted the importance of individual truth and respect for subjective experience, concepts that were radical in a time when it was assumed that truth could be uncovered only by scientific method. With the rise of existentialism and phenomenology in Europe during the first part of the 20th century and the concurrent increased interest in psychotherapy as a result of the advent of psychoanalysis and psychodynamic approaches, some therapists initially trained in psychoanalytic and psychodynamic methods began to integrate existential philosophy and phenomenology into the way they conducted therapy. These therapists often eschewed the deterministic notions of the psychodynamic approaches and believed that helping clients understand their unique place in the

Existential-Humanistic Therapies: Overview

world and assisting them in discovering their unique sense of meaningfulness were critical factors in the therapeutic process. Viewing the therapist as more of a facilitator than an expert, these therapists were often seen as heretics, and many were kicked out of or voluntarily left their psychoanalytic institutes. One of the early therapies often seen as bridging the psychoanalytic/psychodynamic and existentialhumanistic schools was Alfred Adler’s Individual Psychology. Although Adler believed in both an unconscious and a conscious mind, he proposed that all aspects of the person act in unison. In addition, although Individual Psychology viewed early child-rearing patterns as critical in the development of one’s character, to effect change in a person, it focused mostly on the future, not on uncovering the past. Understanding self and making better choices that match one’s inherent character were seen as critical to this approach. Other approaches soon arose that increasingly challenged the predominance of the psychoanalytic/psychodynamic approaches and respected the unique experience of the client. For instance, Fritz Perls, who developed Gestalt therapy, challenged the notion that defenses were needed to prevent sexual and aggressive instincts from predominating one’s personality. Instead, he viewed defenses as mechanisms used to keep people from understanding their unmet needs. Helping individuals let go of their defenses, suggested Perls, would allow them to discover unmet needs and unfinished business and was critical to their becoming whole and discovering their true self. Meanwhile, prior to World War II, the writings of the existential philosophers became increasingly popular in the United States and began to influence the way therapy was conducted. As a result, and partly due to a backlash against the deterministic and directive approaches of the psychoanalytic/ psychodynamic approaches and the mechanistic, seemingly nonhumane, approach of the behaviorists, existential-humanistic approaches began to arise in the United States during the middle of the 20th century. One of the first of these approaches, and the most popular, was client-centered therapy, developed by Carl Rogers, later known as personcentered counseling. After the war ended, the therapeutic community quickly heard about Viktor Frankl’s existentially

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based logotherapy, which he completed while imprisoned in a Nazi concentration camp. Frankl’s logotherapy became one of the most well-known existential-humanistic approaches to therapy. This approach focused exclusively on how individuals make meaning in their lives and the idea that the choices they make affect both themselves and their world. The 1950s, 1960s, and 1970s saw a number of new approaches that had an existential, phenomenological, and humanistic flavor. The humanists, whose writing had captured the interest of both therapists and lay people, believed in the innate goodness of the individual and that people couldn’t be reduced to reinforcement contingencies or a theory that treated them as objects under a microscope. The humanists also respected the client’s capacity to understand self and to change. Led by individuals such as James Bugental, Sidney Jourard, Abraham Maslow, Rollo May, Carl Rogers, Virginia Satir, and Irvin Yalom, humanism was integrated into a number of approaches to psychotherapy, such as person-centered counseling, existential therapy, human validation process family therapy, transactional analysis, reality therapy, and emotion-focused therapy, to name just a few. Humanistic psychology quickly became known as the third force in psychology, following psychoanalysis, the first force, and behaviorism, the second force. Although the various existential-humanistic approaches used different techniques, they had some common tenets. They believed in the ability of the individual to change and the importance of the therapeutic relationship in facilitating such change. Also, they believed that individuals have a choice in how they live their lives and that change can be made at almost any point in a person’s life, and sometimes rather quickly. They focused more on the client’s subjective reality and less on a preset manner or theory of how a person develops, and they believed in the ability of clients to quickly understand their lives by exploring how they live in the present. They also believed that it was not important to spend years uncovering the past to make change. Finally, although they believed in the need for therapists to have expertise in their approach, they saw their therapies as facilitating the client’s own natural path and did not view the therapist as the director or expert who held the answer to the client’s problems.

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Today, many of the existential-humanistic therapies of the 20th century are still widely used by counselors and therapists alike. And although behavior therapies and cognitive therapies are not viewed as part of the existential-humanistic school, most of them have borrowed some of the basic tenets of the existential-humanistic therapies, such as the importance of therapists’ building a relationship with the client as they help the client explore his or her issues. Even some of the contemporary psychodynamic approaches today incorporate many existential and humanistic ideas.

Theoretical Underpinnings Although the existential-humanistic therapies are a broad group of approaches that use a variety of techniques when working with clients, to some degree, they are all based on existential philosophy and psychology, phenomenology, and humanistic psychology. Existential Philosophy and Psychology

Existential philosophy is based on the works of a number of writers, most of whom became wellknown during the early to middle part of the 20th century, including Kierkegaard, Camus, Nietzsche, and Sartre. Although they all have a different take on existentialism, they share some common principles. For instance, all of them highlight the notion that as humans we are thrust into a seemingly meaningless or absurd world and death looms over us as we try to make some sense out of this absurdity. They also suggest that existence precedes essence—or the idea that we do not choose to be born and that our sense of self and meaning occurs only through the decisions we make through life. They speak of the importance of experiencing others—or being in relationship with others in a real encounter (the I–Thou relationship). They also speak of the angst of life and the importance of recognizing that angst is a natural part of living due to the nature of life and death, and the absurdity of existence. Many of the existential authors had a pessimistic attitude about life and existence and wrote about the dread of living in an absurd world. The existential psychologists and related helpers, however, viewed many of the same concepts through an optimistic

lens. Thus, they developed existential-humanistic theories touting the importance of making good choices in life; speaking of the significance of having open, honest, and real relationships with others; and noting that from moment to moment we choose our values, thoughts, and actions and that such decisions affect us and the rest of the world. Through their writing, these psychologists and related helpers spoke of the value of understanding self and the importance of having clarity about one’s purpose. Phenomenology

Phenomenology is defined by some as the study of experience. Many of the existential philosophers and existential psychologists saw themselves as phenomenologists because they were concerned about the individual’s experience in the world. In contrast to the psychoanalytic and psychodynamic theorists, who were focused on how the individual could be explained by their theory, or the behaviorists, who were concerned with how reinforcement contingencies could be shown to lead to specific behaviors, these individuals focused solely on what the individual was experiencing. Reality, to them, is not an external theory or model. In contrast, to the phenomenologist, reality is the individual’s experience. Thus, the road to understanding self is to allow the individual to become clearer about his or her own experience. The phenomenologist believes that an understanding of one’s experience can be gained through a number of channels, including examining how one communicates verbally and nonverbally, examining how one’s body holds information, examining how one’s actions are messages about the choices one has made, and understanding how individuals may repress experiences. Most of the existential-humanistic approaches and many of the body-oriented approaches tend to embrace phenomenology to some degree; however, the manner in which they encourage clients to understand and relay their experience can differ dramatically. For instance, therapists with a person-centered focus tend to create a therapeutic atmosphere of trust and acceptance, which allows the client to access his or her experience and true self, whereas those who practice existential therapy or Gestalt therapy tend to confront the client

Existential-Humanistic Therapies: Overview

about how he or she is avoiding experiencing his or her true self and the necessity of accessing his or her experience if the client is to find meaning in life. Some of the body-oriented approaches, in contrast, focus on working with muscular “armor” to unleash repressed memories that have prevented access to one’s true self. Humanistic Psychology

The humanistic approach is shaped by a belief in the goodness of the person, in the ability of the individual to become more aware of self, and a conviction that people can change. With its philosophy well aligned with existential psychology, it brings a holistic approach to the field of psychotherapy and proposes that individuals cannot be reduced to select components, as was proposed by the early behaviorists, and that a preset model cannot define, from an outside or objective perspective, how a person is likely to behave or be diagnosed, as was proposed by the psychoanalytic and psychodynamic therapists. This approach proposes that individuals can become increasingly in touch with themselves, or actualize their true selves. Theorists like Rogers and Maslow suggested that individuals were born with a self-actualizing tendency, and if clients were to be placed in an environment that is conducive to facilitating this tendency, they could begin their journey toward actualizing their true selves. Humanists are antideterministic in the sense that they do not believe that individuals are determined by early child-rearing patterns, stimulus– response contingencies, or other external factors. Instead, they believe that at any point in his or her life, an individual can change and move toward self-actualization. They also believe in the importance of having an authentic or real relationship with significant individuals in one’s life. To the humanist, being fully human means being real, open, and transparent with all individuals with whom one has a meaningful relationship. They even suggested that therapists, also being human, should have real relationships with clients within the context of the therapeutic relationship. They believe that such a relationship should be based on openness, honesty, and trust and the therapist should not be focused on being a distant, objective observer who diagnoses the client.

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Short Descriptions of Existential-Humanistic Therapies Daseinsanalysis

This approach focuses on one’s being in the world, and although it uses some of the techniques of traditional psychoanalysis, it rejects the objectification of the individual that takes place in that approach. Instead, it assists the client in understanding his or her experience of the world and finding meaning in relationships. Emotion-Focused Therapy

A combination of existential-humanistic and attachment theories, this approach focuses on fully experiencing one’s emotions to understand how they play a significant, and sometimes maladaptive role, in one’s life and finding ways to experience new emotional experiences that can lead to adaptive behaviors. Existential Therapy

Approaches that are labeled “existential therapy” tend to focus on choice, responsibility, making meaning in life, authenticity in relationships, the finality of life, and anxiety as a natural aspect of living in a world in which one must constantly choose how one defines oneself. Experiential Psychotherapy

This approach focuses on the moment-tomoment experience of the client and the therapist as they explore the client’s underlying problems and purpose of being in the therapeutic relationship. Focusing-Oriented Therapy

This approach facilitates client understanding of self by helping the client attend to internal cues that are messages about self, which individuals are usually not attuned to. Gestalt Therapy

This approach assumes that individual needs have become repressed by the client and that the role of the therapist is to help the client uncover those needs and work on the unfinished business that is the result of those unmet needs.

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Humanistic Psychoanalysis of Erich Fromm

This approach suggests that feelings of anxiety, isolation, and loneliness are the result of the individual’s separation from nature due to the development of consciousness. Humans, thus, have a responsibility of becoming self-realized and developing a sense of identify and meaningfulness in relationships. Logotherapy and Existential Analysis

This approach assumes that when life is focused on meaning, there is harmony. Meaning can be found experientially by how one encounters others, creatively by what one creates, or attitudinally through the moment-to-moment decisions one makes regarding how one lives in the world. Maslow’s Hierarchy of Needs

One of the basic theories of humanistic psychology, it assumes a hierarchy of needs that includes physiological, safety, love and belonging, esteem, and self-actualization needs. Person-Centered Counseling

This approach suggests that there are three core conditions of effective therapy—(1) empathy, (2)  unconditional positive regard, and (3) congruence (genuineness)—and that these three conditions help an individual become self-aware and actualized. Phenomenological Therapy

This approach focuses solely on one’s experience and assumes that each individual’s experience is unique and is the basis for the individual’s reality and understanding of the world.

to help the client become more authentic and reveal his or her real self. Primal Therapy

This approach accesses early emotions and memories in an effort to reexperience them and integrate them into consciousness. Process-Oriented Psychology

This approach has the client identify primary and secondary processes (e.g., conscious and unconscious aspects, respectively) in an effort to help the client understand how secondary experiences present themselves as somatic problems and cognitive impairments. Psychodrama

This approach has the client reenact aspects of the client’s life within a group or theater setting in an effort to work through past traumas and issues. Psychosynthesis

Sometimes called the “psychology of the soul,” this approach focuses on understanding and synthesizing the personal self, or the unique aspects of one’s personality that are associated with things such as how the individual relates to others, and the Transpersonal Self, or the creative and inspirational aspects of the individual. Transactional Analysis

This approach examines the ways in which relationships are affected by how one communicates through one’s parent, adult, or child ego state and how the awareness of such communication can change behavior.

Positive Psychology

A relatively new field that is an outgrowth of existential-humanistic therapy, this approach focuses on the strengths and virtues of the client and helps the client see how such a focus can bring increased happiness in his or her life.

Values Clarification

An approach that helps the client understand his or her unique values and how such values can hinder or enhance his or her relationships. Edward S. Neukrug

Primal Integration

This approach focuses on the expression of deep feelings and early experiences in an effort

See also Daseinsanalysis; Emotion-Focused Therapy; Existential Therapy; Experiential Psychotherapy; Focusing-Oriented Therapy; Frankl, Viktor; Gestalt

Experiential Psychotherapy Therapy; Glasser, William; Humanistic Psychoanalysis of Erich Fromm; Logotherapy and Existential Analysis; Maslow, Abraham; Maslow’s Hierarchy of Needs; May, Rollo; Perls, Fritz; Person-Centered Counseling; Phenomenological Therapy; Positive Psychology; Primal Integration; Primal Therapy; Process-Oriented Psychology; Psychodrama; Psychosynthesis; Rogers, Carl; Satir, Virginia; Transactional Analysis; Transpersonal Psychology: Overview; Values Clarification; Whitaker, Carl; Yalom, Irvin

Further Readings Bugental, J. F. T. (1978). Psychotherapy and process: The fundamentals of an existential-humanistic approach. New York, NY: Random House. Cooper, M. (2003). Existential therapies. Thousand Oaks, CA: Sage. Schneider, K. J., & Krug, O. T. (2010). Existential therapy. Washington, DC: American Psychological Association.

EXPERIENTIAL FAMILY THERAPY See Symbolic Experiential Family Therapy

EXPERIENTIAL PSYCHOTHERAPY In the late 1940s, a pioneering group of young psychiatrists at Emory University in Atlanta, Georgia, forged an innovative approach to psychotherapy based on a radical fidelity to the lived experience of both patient and therapist and a groundbreaking reconceptualization of the role of the therapist in the therapeutic relationship. They pioneered the use of multiple therapists—working together with groups, couples, families, and even individual patients. These collaborations were sometimes planned and ongoing, but other times they emerged spontaneously, with a therapist knocking on a colleague’s door to ask him to join a session. They met weekly to write about their innovative work, writing collaboratively and assigning authorship arbitrarily after an article was completed. They required all first- and secondyear medical students to participate in group psychotherapy and also treated one another in both individual therapy and an ongoing leaderless

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therapy group. The entire group was eventually fired for their success when 75% of the medical students named psychiatry as their intended area of specialization. The group eventually chose the term experiential to describe their work because of the central role of experience in their approach. Carl Whitaker, a member of the group who later became internationally recognized for his work in family therapy, was once asked by a patient in a group, “Why am I here?” Whitaker told the patient that he was there for the experience of being there. The patient then asked Whitaker, “What are you doing here?” And Whitaker answered that he was “the most experienced patient in the group.” This simple story contains two of the essential elements of experiential psychotherapy: (1) a radical fidelity to experience as it is lived by both patient and therapist and (2) a bold new conceptualization of the ways in which the therapist participates in the therapeutic relationship.

Historical Context Experiential psychotherapy is one of the progenitors of the third force in psychology, also known as humanistic psychology. The first movement in psychology was psychoanalysis, which emphasized the importance of the unconscious dynamics of both patient and therapist. The second force in the field was behaviorism, which eschewed the importance of unconscious dynamics, reducing the focus to the study of human behavior, which was understood in learning theory terms as simply a response to reinforcement. Humanistic psychology posited an inherent inclination toward growth and self-actualization, suggesting that full human potential rested not on the amelioration of symptoms but on the provision of certain requirements for psychological well-being. Experiential psychotherapy is a hybrid of sorts, unique among the humanistic approaches in retaining psychoanalysis’s emphasis on the unconscious while introducing a relational approach and an emphasis on the therapist’s “use of self” that have been adopted by a number of other theoretical approaches. Experiential psychotherapy is less well-known than other humanistic approaches, in part because the originators were averse to developing their work into an organized “school” of psychotherapy, going so far as not capitalizing the

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first letter of experiential. They conceptualized their work as more of a broad approach or set of guiding principles applicable to all schools of psychotherapy than a particular method or series of techniques. Over the years, several other well-known theorists such as Leslie Greenberg, Eugene Gendlin, and Al Mahrer have used the term experiential to describe their work, building on the work of the early experiential therapists while generally not referencing it.

Theoretical Underpinnings Experiential psychotherapy rests on the foundation of phenomenology, with its emphasis on experience as it is lived. People live in the world in a way that makes sense to them given the way they experience the world. Because experience is inherently dynamic, the more fully we embrace our experience, the more we change and remain congruent with the world around us. Psychological well-being is the result of an increased capacity for experience, and psychological distress is the result of an impaired capacity for experience, the parts of our lives in which we are not able to fully embrace our experience. Experiential therapists do not seek to ameliorate symptoms but rather to understand symptoms as indications of where we are not fully embracing our experience. For example, depression is not conceptualized as excessive sadness but as an impaired capacity to experience sadness. If we fully embrace our experience of sadness, the experience will shift. If we disconnect from our sadness, we become depressed. Change, therefore, happens at the level of experience. If we want to be in the world differently, we have to change the ways in which we experience the world. Therapy is necessarily experiential, meaning that it provides the lived experiences we need to change the ways we live in the world.

Major Concepts Experiential psychotherapy is based on three major concepts: (1) that the unconscious is naturally oriented toward growth and wellness, (2) that all experience is relational and can only be understood in the context of relationships, and (3) that the therapist’s use of self is a critical element in the therapeutic relationship.

Natural Orientation of the Unconscious Toward Growth and Wellness

Sigmund Freud conceptualized the unconscious as the seat of primitive libidinal drives that require the socialization of the ego and superego to be more responsive to the needs of others. In experiential psychotherapy, the unconscious is understood as the source of our greatest wisdom and health, the most authentic and genuine aspects of who we are. Both patient and therapist seek to expand their access to their unconscious and bring those aspects of their selves into the therapeutic relationship. Accordingly, there is a strong emphasis on dreams, fantasies, associations, and other unconscious productions of both the patient and the therapist. Experience in Relationship

Drawing again from phenomenology, each relationship invites us to embrace different potential aspects of ourselves, so that who we are is an amalgamation of our experiences in relationships. Accordingly, intimate relationships are the most powerful vehicle to help us be more fully ourselves. Experiential psychotherapy is an intimate relationship in which the therapist is the most experienced patient—that is, the therapist is able to more fully embrace all aspects of himself or herself, which is an invitation to the patient to do the same. All impasses in the work are understood as relational and can only be resolved collaboratively. The patient unconsciously invites the therapist to interact with him or her in a way that re-creates problematic relational patterns. The therapist unconsciously cooperates, cocreating a relational reenactment. These reenactments are not seen as problems but rather as opportunities to rework these relational dilemmas experientially in the therapeutic relationship. It follows then that the early experiential therapists emphasized couples, family, and group work to maximize the potential relational interactions. In fact, Whitaker eventually worked only with families and would no longer see individual patients. The Therapist’s Use of Self

Experiential psychotherapy is best known for the concept of the therapist’s use of self, in which the therapist brings as much of himself or herself,

Experiential Psychotherapy

unconscious as well as conscious, into the therapeutic relationship as possible. In fact, unconscious communications between the patient and the therapist are the most powerful therapeutic moments. The therapist shares any aspect of his or her ongoing experience of the relationship with the patient that the therapist believes might be salient, sometimes even sharing facets of his or her experience without understanding how they might be relevant, because sometimes that can only be known in relationship with the patient. The therapist may share emotional responses, unconscious associations, intuitions, associations to stories, and so on. The therapist’s sharing of dreams with the patient is held to be of particular value. This was a dramatic departure from the psychoanalytic framework of that time, which was so uncritically accepted that any departures from therapeutic anonymity were considered potential ethical transgressions rather than theoretical differences. The use of self is focused on the therapist’s inthe-moment experience in relationship with the patient, because that is far more intimate than any historical disclosure by the therapist, which was discouraged. People connect through sharing internal experience, and having shared external experiences is no guarantee of being able to make an intimate connection. The therapist’s use of self can be a validation of what the patient is already consciously experiencing, or the therapist may share experience that is not yet conscious in the patient, and the therapist’s sharing may help the patient more fully embrace his or her own latent experience. The therapist’s use of self also has the advantage of minimizing resistance, as patients are less likely to be resistant to therapists who talk about their own experiences than to hearing someone trying to tell them about their own experience. Because experiential therapists believe that all experience is relational, the therapist’s experience is inexorably a part of the therapeutic process, whether he or she acknowledges it or not. When the therapist withholds his or her experience from the patient, it most often results in the patient mistakenly believing that he or she is the cause of any impasse in the work. In contrast, experiential therapists actually hold the therapist responsible for impasses, believing that the therapist’s capacity to fully embrace any aspect of their shared experience sets the ceiling for what the patient will be able to embrace.

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Techniques In the tradition of Jungian and phenomenological psychologies, experiential therapists believe that the use of any technique has to be congruent with the person of the therapist and so should emerge in the ongoing context of a particular therapeutic relationship, rather than being developed a priori by the therapist outside the relationship. Ideally, techniques are used to deepen the patient’s capacity to embrace his or her experience of the moment. In practice, techniques are most often utilized by less experienced therapists to help them tolerate the range of strong emotions they must learn to metabolize as a therapist, including the feelings associated with not knowing what to do to help. Therapists learn techniques in the same way musicians learn to play scales and then simple pieces. Initially, relying on techniques allows less experienced therapists to manage their own anxiety sufficiently in order to be of help to their patients. After mastering the techniques, therapists have to learn to let go of their reliance on technique in order to learn to play the more complicated pieces and improvise.

Therapeutic Process Experiential therapists focus on the in-the-moment experience that is co-created by the patient and therapist together in their ongoing relationship. The patient’s history and the content of any specific distress can be distractions from this ongoing process. The therapist does not take a history but allows it to unfold, trusting that any history that is relevant will be manifest in the moment as the patient talks about his or her distress. The mantra of experiential psychotherapy is that “any patient can defeat any therapist at any time.” The patient is said to own the therapy and is responsible for setting the agenda and pace of the psychotherapy. Any agendas, treatment plans, or diagnosis held by the therapist are seen as an imposing of the therapist’s experience on the patient rather than as a respectful hearing of the patient’s own experience. There is a particular emphasis on the process of termination in experiential psychotherapy, which is seen as analogous to the process of leaving home. The psychotherapy begins with the patient and the therapist as separate, nonoverlapping, and

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not interdependent. At some point, the patient accepts the status of patient, that is, accepts the need for help, and willingly enters into a transferential relationship of significant dependency with the therapist. In a good termination, the patient transitions from this hierarchal, transferential relationship back to a more equal, reality-based relationship and takes back the dependency the patient has loaned the therapist, thereby consolidating all that the patient has gained during the therapy, individuating, and leaving home with no regrets and no unfinished business. Unlike the pacing and agenda for the main part of the psychotherapy, the therapist is responsible for recognizing signs of an impending termination and bringing that to the patient’s attention. Therapists, like parents, may miss or not accept a pending termination because of their own unmet needs that are being met in the relationship. It is tempting for therapists to pathologize patients in order to shore up their own denial. A therapist who fails to recognize or honor a pending termination risks undoing all the gains that have been made. Avrum Weiss See also Emotion-Focused Therapy; Existential Therapy; Focusing-Oriented Therapy; Gestalt Therapy; Interpersonal Psychoanalysis; Person-Centered Counseling; Phenomenological Therapy; Relational Psychoanalysis; Symbolic Experiential Family Therapy; Whitaker, Carl

Further Readings Felder, R., & Weiss, A. (1992). Experiential psychotherapy: A symphony of selves. Lanham, MD: University Press of America. Gantt, S. (1984). A view of psychotherapy: An integration of experiential psychotherapy and existentialphenomenological philosophy (Unpublished doctoral dissertation). Georgia State University, Atlanta, GA. Malone, K., Malone, T., Kuckleburg, R., Cox, R., Barnett, J., & Barstow, D. (1982). Experiential psychotherapy. Pilgrimage, 10(1), 1–63. Whitaker, C. (1989). Midnight musings of a family therapist. New York, NY: W. W. Norton. Whitaker, C., & Malone, T. (1981). The roots of psychotherapy. New York, NY: Brunner/Mazel. (Original work published 1953)

EXPOSURE AND RESPONSE PREVENTION Exposure and response prevention (ERP; also known as exposure and ritual prevention) is a behavioral treatment to reduce symptoms in a variety of anxiety disorders, such as specific phobia and posttraumatic stress disorder, but sometimes is used in the treatment of other types of disorders such as drug addictions and bulimia nervosa. ERP uses psychoeducation, in vivo exposure, imaginal exposure, and prevention of responses or rituals that patients employ to distract themselves from the anxiety they feel, which preclude them from learning that anxiogenic (anxiety producing) events are not really harmful. Despite its potential application in diverse disorders, ERP has been most extensively studied in relation to obsessive-compulsive disorder (OCD), a dysfunction for which ERP is the psychotherapy treatment of choice. ERP has been shown to be effective when working with OCD clients in a diverse range of developmental stages as well as with diverse rituals.

Historical Context In 1966, Victor Meyer was the first person to document a case study of two chronic clients whose OCD symptoms decreased after ERP treatment. The clients, two females who were admitted in the Middlesex Hospital Medical School, London, had a long history of maladaptive and frequent “washing hands” rituals. The nonperformance of these rituals was associated with “disastrous consequences.” After ERP treatment, which Meyer referred to as a “modification of expectations method,” the rituals were notably reduced. Similarly, reductions in fear levels regarding the imagined consequences of not performing the obsessive rituals as well as decreases in intrusive thoughts were reported. Basically, the treatment consisted of exposing patients to stimuli that evoked anxiety in them, while simultaneously preventing the patients from engaging in the rituals. The treatment is based on learning theory, specifically on the principles of classical and operant conditioning. Since its introduction, ERP has been studied in

Exposure and Response Prevention

several instances and during the past five decades has been considered the treatment of choice for OCD as well as an effective tool in reducing symptoms in other anxiety disorders, addictions, and bulimia nervosa, among others.

Theoretical Underpinnings As a theoretical basis for this behavioral approach, ERP suggests that clients with anxiety disorders have developed a fearful emotional reaction to nonharmful stimuli and situations. Presumably, an association based on the principles of classical conditioning has been formed between the nonharmful stimulus and a threatening and anxiogenic situation. Clients then typically engage in responses that avoid the anxiety. In line with the principles of operant conditioning, responses that reduce the aversive distress of anxiety increase in probability through negative reinforcement, and these responses evolve into rituals. For example, a client with a specific phobia for dogs may avoid getting near or petting dogs and thus may not learn that most dogs are not harmful, while these avoidance behaviors are maintained and strengthened by avoiding the anxiogenic stimulus. In the case of clients with OCD, the compulsions in the form of obsessive rituals are associated with preventing disastrous consequences and annoying intrusive thoughts. For example, a client who washes his hand 40 times during the day may not learn that doing it only 4 times daily is enough to prevent contamination of his body. In the case of addictions, classical conditioning occurs between the cues present during drug intake and the effects of the drug in the nervous system. These cues evoke the wish to consume and are involved in evoking withdrawal symptoms when the drug is not present in the organism. These cues are the ones that need to be exposed to a client when using ERP. Meanwhile, the operant conditioning mechanism maintains the drug-seeking behavior, which comprehends the responses targeted for prevention by ERP. ERP treatment is focused on extinguishing the classical- and operant-conditioned associations. A  successful treatment involves eliminating the operant contingency between performing the rituals or avoidance responses and anxiety reduction by means of response prevention. With the client committed to confronting the anxiogenic stimulus, exposure to it produces the new learning that the

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stimulus is no longer harmful. This occurs because the extinction of the operant behavior decreases the rituals and the maladaptive avoidance responses and the extinction of the classically conditioned emotional reaction (and/or the habituation to the stressful situation) reduces the anxiety responses with which a client reacts to the anxiogenic stimuli and situations.

Major Concepts There are three major concepts related to ERP: (1) OCD, (2) response prevention, and (3) Subjective Unit of Distress Scale (SUDS). Obsessive-Compulsive Disorder

OCD is a specific type of anxiety disorder characterized by intrusive thoughts (i.e., obsessions) that produce fear, worry, and uneasiness. Clients engage in repetitive behaviors (i.e., compulsions) in a ritualistic manner, which they believe prevents the disastrous consequences represented by the intrusive thoughts. The most common rituals involve excessive checking, repeated cleaning, nervous rituals, and hoarding, and the typical intrusive thoughts relate to preoccupation with sexual, violent, or religious contents. These symptoms produce severe anxiety and distress and consume time and financial resources in OCD clients. Response Prevention

Response prevention is the principal component of ERP and distinguishes it from other behavior therapy approaches such as exposure therapy. Basically, response prevention consists of encouraging clients not to engage in responses, such as rituals (or drug-seeking behavior in addicts), that may lead to reducing anxiety produced by intrusive thoughts (or by withdrawal from drugs in addicts). It is theoretically based in the extinction of an operant-conditioned contingency between performing the ritual and anxiety reduction. As clients perform these rituals, they also prevent themselves from extinguishing a classically conditioned contingency by avoiding, rather than confronting and habituating to, the anxiogenic situation or fearful stimuli.

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Subjective Unit of Distress Scale

The SUDS is a rating scale ranging from 0 to 100, with anchors representing levels of distress from 0 = no distress to 100 = extreme distress. This scale permits clients to label how anxious or how much distress they feel in a given situation, and it is used by the client to communicate the anxiety level he or she is feeling before and during ERP sessions.

Techniques With ERP, techniques are closely related to both the phases of the therapy and the source of the anxiety and discomfort. Psychoeducation is always the first technique to be applied. Then, in vivo and imaginal exposure techniques are used while continuously stressing to the client the response prevention component of ERP. Psychoeducation

Psychoeducation is the process of explaining the rationale for why the client should go through ERP, the importance of eliminating the obsessive rituals or other avoiding responses, and the theory behind ERP and how the theory is applied in the techniques of in vivo and imaginal exposure.

of extra exposure conducted by the client on his or her own can be assigned to clients who have enough motivation not to engage in rituals when they are alone. Imaginal Exposure

Imaginal exposure is the creation of a very detailed scene of an intrusive thought or fear, which is registered and then revisited in a repeated fashion. These thoughts and fears are difficult or impossible to be re-created in reality (e.g., fear of eternal damnation), and consequently, they cannot be represented during in vivo exposure. Clients first write a movie script of their scenario, which typically takes from 2 to 5 minutes to revisit all the way through reading or audio recordings. As with in vivo exposure, imaginal exposure can be done gradually using a hierarchy and has the same goal of reducing the fear and discomfort produced by the intrusive thought. Also, clients are asked to refrain from performing rituals and not terminate the session, given that doing so would represent negative reinforcement through relieving the distress of the situation, incrementing the maladaptive rituals, and preventing the fear from being extinguished and habituated.

Therapeutic Process In Vivo Exposure

In vivo exposure is real-life exposure consisting of a prolonged presentation of and/or contact with the feared stimuli or situations (e.g., a contaminated door knob), with the goal of reducing the anxiety in the presence of these stimuli. A gradual plan of exposure is preferred to prevent clients from performing rituals and consequently avoiding the anxiety. An exposure hierarchy (of a recommended number between 10 and 15 items) is developed first, in which real-life situations are ranked from moderately difficult to most difficult using the SUDS. Then, clients are systematically presented with the situations of the hierarchy by the therapist, while the client is encouraged to avoid any ritual or behavior that may distract him or her from the anxiety-evoking situation. Clients are directed to relax in the presence of the stimulus, and they use the SUDS to monitor the quantity of distress that they experience. Homework consisting

ERP treatment may be combined with pharmacotherapy to ensure its effect in reducing symptoms, although some studies report no further benefit when adding pharmacotherapy to ERP. The frequency of sessions varies among studies, and its optimal number is yet to be defined. However, good outcomes are reported in a range of cases that go from weekly sessions to a more intensive treatment that involves multiple sessions per week over the course of 1 month. Good effects are also found when spaced sessions have been used. Spaced sessions may be adequate for highly motivated clients with moderate symptoms, who may engage more in daily exposure homework; meanwhile, patients with severe symptoms and those who may have difficulties complying with ERP tasks may benefit more from more frequent treatment. Although studies report sessions ranging in duration from 30 to 120 minutes to be effective, greater withinsession reduction of fear and anxiety may occur in

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sessions ranging from 90 to 120 minutes. Initial sessions are used to collect information about the client, to construct a therapeutic alliance, to deliver psychoeducation, to establish the hierarchy for in vivo exposure, to identify fear related to the consequences of not performing the rituals or avoidance responses so it can be addressed by imaginal exposure, and to revise the treatment plan. In the following sessions, exposure begins gradually within and across sessions. During the treatment, exposure practices are routinely assigned as homework between sessions and clients are instructed to restrain themselves from performing rituals and avoidance behaviors. The effect of ERP treatment has been shown to maintain from months up to years after its cessation. Gonzalo Miguez and Mario A. Laborda See also Behavior Therapy; Classical Conditioning; Exposure Therapy; Operant Conditioning; Pavlov, Ivan; Prolonged Exposure Therapy; Skinner, B. F.; Systematic Desensitization

Further Readings Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessivecompulsive disorder: A meta-analysis. Behavior Therapy, 27, 583–600. doi:10.1016/S00057894(96)80045-1 Foa, E. B. (1996). The efficacy of behavioral therapy with obsessive-compulsives. The Clinical Psychologist, 49(2), 19–22. Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessivecompulsive disorder: Therapist guide (2nd ed.). New York, NY: Oxford University Press. Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour Research and Therapy, 4, 273–280. doi:10.1016/00057967(66)90023-4 Rankin, H., Hodgson, R., & Stockwell, T. (1983). Cue exposure and response prevention with alcoholics: A controlled trial. Behaviour Research and Therapy, 21, 435–446. doi:10.1016/0005-7967(83)90013-X Rowa, K., Antony, M. M., & Swinson, R. P. (2007). Exposure and response prevention. In M. M. Antony, C. Purdon, & L. J. Summerfeldt (Eds.), Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond (pp. 79–109).Washington, DC: American Psychological Association.

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EXPOSURE THERAPY Exposure therapy is a classical conditioning–based behavior therapy widely used as the treatment of choice for several behavioral disorders, such as anxiety disorders and addictions, among others. With exposure therapy, patients are repeatedly confronted with situations and objects that would normally elicit maladaptive responses, and as a result, these situations and objects gradually stop provoking these responses. For instance, pathological fears and phobias are gradually reduced when patients are repetitively confronted with the situations and objects they are afraid of. In this example, exposure therapy most likely works because patients learn during exposure to the feared situations and objects that they no longer are associated with danger, and consequently, the patients stop being afraid of them.

Historical Context Exposure therapy is one of the many psychotherapeutic approaches that constitute behavior therapy. Most behavior therapies, including exposure therapy, have their roots in the research of learning theorists from early in the 20th century, including Edward L. Thorndike, Ivan P. Pavlov, John B. Watson, and B. F. Skinner. Later, in the 1950s and 1960s, behavior therapy was developed and established as a psychotherapeutic approach to behavioral disorders by clinicians such as Joseph Wolpe, Arnold A. Lazarus, Stanley J. Rachman, Hans J. Eysenck, Cyril M. Franks, Nathan H. Azrin, and Teodoro Ayllon, among many others. Early in the 1900s, Pavlov found that animals create associations between stimuli they encounter in their environment and behave accordingly with these learned associations. In his studies, dogs began salivating in the presence of stimuli that did not provoke this response naturally if the stimuli had preceded feeding in the past, which helped them prepare for the upcoming (expected) feeding. In technical terms, stimuli that elicit a response without training are called unconditioned stimuli, and stimuli that elicit responses after being paired with unconditioned stimuli are denominated as conditioned stimuli. In the case of Pavlov’s dogs, the food is an unconditioned stimulus that elicits

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the unconditioned response of salivation, and cues preceding food become conditioned stimuli that provoke conditioned salivation. This basic finding changed the way we see our relationship with environmental events; it seems that animals, including humans, learn associations between stimuli that are contiguously presented in their lives. Of importance for exposure therapy, Pavlov also found that these learned conditioned responses (which, as noted before, may become maladaptive, e.g., fear as a response to a nonharmful stimulus) could be reduced if the conditioned stimuli were presented in the absence of the unconditioned stimuli, a phenomenon he referred to as experimental extinction. Experimental extinction is at the core of exposure-based therapies. A few years after Pavlov’s discovery, Watson, in his famous and controversial study, evaluated emotional responses to different objects in an 11-month-old infant named Albert, before and after pairing one of them with a loud aversive noise. Initially, Albert had approach responses to the objects he was presented with: a white rat, fire, a dog, a Santa Claus mask, and others. Then, after a few pairings of the white rat with the loud noise, Albert began displaying fear reactions instead of approach responses to the rat, and these fear reactions generalized to other objects never paired with the loud noise but that share some features with the rat (e.g., a white rabbit and a dog). Watson demonstrated that fear responses to an object are something we learn through classical conditioning; they are not innate responses. If our emotional reactions to certain objects are truly fear-conditioned responses, then according to Pavlov’s study of experimental extinction, exposure to these objects should decrease our reaction to them. Mary Cover Jones, a student of Watson’s, tested this hypothesis. Jones treated Peter, a 34-month-old child with fear of rabbits. She systematically exposed Peter to a fear-eliciting rabbit while the boy was eating, until the rabbit stopped eliciting fear reactions in him. Jones’s approach was exposure based, but with a twist. She did not necessarily just extinguish Peter’s fear, but she counterconditioned it by associating the once feareliciting rabbit with appetitive responses provoked by food. Whether Peter’s treatment result was the effect of mere exposure to the feared rabbit or the effect of pairing the feared animal with

an appetitive outcome is unclear, as both ways of implementing exposure therapy have proved to be effective. In the same lines as Jones, Wolpe developed and systematized an exposure technique that is known as systematic desensitization. Based on the findings of classical conditioning, Wolpe presented cats with an auditory cue that was followed by a mild aversive electric shock. As a result of this procedure, the subjects began to elicit fear responses to the cue and to the whole experimental chamber in which they were trained. In Pavlovian terms, the cats acquired a conditioned fear response to the auditory cue and the context of training. Then, Wolpe fed the cats at a distance from the auditory cue source and the experimental chamber, and gradually, over several trials, he moved the chamber closer and closer to the cats while they were eating. At the end of the experiment, the cats stopped displaying fear reactions to the feared situation. Just as Jones counterconditioned Peter’s fear, Wolpe probably did not just extinguish the cats’ conditioned fear but also counterconditioned it by pairing the feared situation with an appetitive outcome. Later, Wolpe translated his basic findings with nonhuman animals to the treatment of anxious human patients. In this approach, patients are gradually confronted with feared situations and objects while a response contrary to anxiety is provoked, usually a relaxing response induced by breathing techniques and/or muscular exercises. Current evidence suggests that mere exposure is enough to reduce responses to feared situations and objects, and that the inclusion of relaxation techniques is not necessary for exposure to be effective. Today, there are many forms of exposure therapies, and all of them have at their core presenting patients with the situations and objects to which they elicit maladaptive responses. Some are extinction based (e.g., flooding therapy), whereas others are counterconditioning based (e.g., systematic desensitization).

Theoretical Underpinnings In theoretical terms, it is thought that exposure therapy works by changing the meaning of the situations and objects that provoke patients’ maladaptive reactions. Nevertheless, which mechanisms provoke this change in meaning is still under debate.

Exposure Therapy

For example, when mere exposure is used to treat fear, it is hypothesized that exposure changes the predictions that patients make when in the presence of the feared object. An object or situation that used to predict danger no longer provokes this prediction and becomes neutral. However, when exposure is used in the form of systematic desensitization to treat fear, it is hypothesized that the treatment prevents the objects and situations from predicting danger, and because of the objects and situations’ new association with appetitive outcomes, they now predict safety. That is, an object or situation that used to predict danger now predicts favorable outcomes.

Major Concepts This section discusses several concepts associated with exposure therapy, including experimental extinction, counterconditioning, exposure techniques, subjective unit of distress scale, and related behavioral disorders.

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These are different techniques with which patients are confronted with the situations and objects that provoke the maladaptive responses. Exposure can take many forms; it can be done in vivo, in virtuo, or using mental representations. Exposure can be graduated or implosive, it can be  spaced or massed in time, it can be selfadministrated or administrated by a therapist, and it can include relaxation or cognitive techniques or be delivered alone. Subjective Unit of Distress Scale

The subjective unit of distress scale is a tool used by patients to evaluate and communicate the level of distress they are experiencing in a given situation. The scale usually ranges from 0 = no distress at all to 100 = the maximum level of distress possible. Patients report their distress using this scale before, during, and after exposure to a feared situation.

Experimental Extinction

This basic phenomenon studied in the learning laboratory refers to a circumstance in which a conditioned response is reduced when the conditioned stimulus that provokes it is repeatedly presented without the unconditioned stimulus with which it was initially associated. In the case of fear conditioning, a fear-eliciting conditioned stimulus stops eliciting fear after being repeatedly presented in the absence of the aversive consequences with which it was initially associated. This phenomenon models some forms of exposure therapy in the laboratory. Counterconditioning

Counterconditioning, also a basic phenomenon studied in the learning laboratory, refers to a situation in which a conditioned response is reduced when the conditioned stimulus that provokes it is repeatedly paired with a second unconditioned stimulus that evokes an opposite response to the one elicited by the unconditioned stimulus with which it was initially associated. In the case of fear conditioning, a fear-eliciting conditioned stimulus stops eliciting fear after being repeatedly paired with an appetitive outcome. This phenomenon models some forms of exposure therapy in the laboratory.

Related Behavioral Disorders

Exposure therapy is widely used to treat most anxiety disorders, including specific phobia, social phobia, panic disorder, and posttraumatic stress disorder. Additionally, exposure techniques are routinely used to treat some aspects of addiction, such as drug tolerance, and to treat some sexual dysfunctions such as vaginismus, among many other behavioral disorders.

Techniques To facilitate exposure therapy, after gathering information and psychoeducation, therapists may use one or more of the following techniques: in vivo exposure, imaginal exposure, and/or in virtuo exposure. Gathering Information and Psychoeducation

Gathering information is a process at the beginning of therapy in which the therapist requests information from the patients concerning their behavioral problems. This process helps delimit the scope of the behavioral problem for which the patient is seeking professional help.

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Psychoeducation is a process by which the therapist explains to patients the nature of their problems and the theories behind the treatment to be used in therapy. In Vivo Exposure

In vivo exposure refers to the process of exposing patients to the situations and objects in the real world that evoke maladaptive responses in them, rather than having patients imagine the situations in therapy or confront the situations using technological aids in the form of virtual reality. Imaginal Exposure

Imaginal exposure refers to the process of exposing patients to the situations and objects that evoke maladaptive responses through the use of imaginal techniques in therapy. With imaginal exposure, patients mentally revisit these situations instead of confronting the situations in the real world or experiencing them via virtual reality. In Virtuo Exposure

In virtuo exposure refers to the process of exposing patients to the situations and objects that evoke maladaptive responses via virtual reality techniques. With virtual reality techniques, rather than patients mentally revisiting these situations or being exposed to them in the real world, patients experience computer-animated situations that resemble the real situations.

Therapeutic Process Exposure therapy typically last between 8 and 16 sessions, with the initial sessions devoted to gathering information about the patient and her or his behavioral problems. After delimiting the situations that cause problems to the patient, 1 session is used to inform the patient about the treatment of choice and its theoretical basis, a process commonly known as psychoeducation. Before exposure begins, the situations and objects that provoke the maladaptive behaviors are hierarchized in terms of difficulty for the patient. Then exposure begins. Patients are confronted with the situations that cause them problems throughout several sessions,

which can be done in vivo, in virtuo, or using imaginal techniques, with or without auxiliary tools such as relaxation or cognitive restructuring. Finally, a last session is dedicated to evaluate the advances accomplished in therapy. Mario A. Laborda and Gonzalo Miguez See also Behavior Therapy; Classical Conditioning; Exposure and Response Prevention; Pavlov, Ivan; Prolonged Exposure Therapy; Systematic Desensitization

Further Readings Antony, M. M., & Roemer, L. (2011). Behavior therapy. Washington, DC: American Psychological Association. Bouton, M. E., Winterbauer, N. E., & Vurbic, D. (2012). Context and extinction: Mechanisms of relapse in drug self-administration. In M. Haselgrove & L. Hogarth (Eds.), Clinical applications of learning theory (pp. 103–133). East Sussex, England: Psychology Press. Craske, M. G. (2010). Cognitive-behavioral therapy. Washington, DC: American Psychological Association. Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24). New York, NY: Guilford Press. Laborda, M. A., McConnell, B. L., & Miller, R. R. (2011). Behavioral techniques to reduce relapse after exposure therapy: Applications of studies of experimental extinction. In T. R. Schachtman & S. Reilly (Eds.), Associative learning and conditioning theory: Human and non-human applications (pp. 79–103). Oxford, England: Oxford University Press. Neudeck, P., & Wittchen, H.-U. (Eds.). (2012). Exposure therapy: Rethinking the model—refining the method. New York, NY: Springer. Richard, D. C. S., & Lauterbach, D. L. (Eds.). (2007). Handbook of exposure therapies. Burlington, MA: Academic Press.

EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY Eye Movement Desensitization and Reprocessing (EMDR) therapy is an integrative psychotherapeutic approach that emphasizes the role of the brain’s

Eye Movement Desensitization and Reprocessing Therapy

information processing system. Mental health problems, excluding those caused by lack of information, organic deficit, toxicity, or physical injury, are conceptualized as the result of inadequately processed memories of disturbing or traumatic experiences. These unprocessed memories contain the emotions, physical sensations, and perspectives experienced at the time of the original disturbing event. EMDR comprises eight phases and a threepronged methodology to identify and process (1) memories of past adverse life experiences that underlie present problems, (2) current situations that elicit disturbance, and (3) needed skills that will provide positive memory templates to guide the client’s future behavior. Using standardized procedures, which include sets of eye movements or other forms of bilateral dual attention stimuli (tactile or auditory), the client’s memories are accessed and processed to an adaptive resolution. Stimulating the information processing system causes internal connections to form as the problematic experience is appropriately integrated and resolved. During this processing, insights automatically arise, along with positive emotions, beliefs, and physical reactions, and the disturbing event becomes both a learning experience and the foundation of resilience.

Historical Context EMDR therapy originated in 1987, when, through self-observation, Francine Shapiro noticed that thoughts became less disturbing after spontaneously generated eye movements. On further experimentation, she determined that repeated eye movements when focusing on a disturbing event resulted in a decrease in negative affect. Working with both civilians and combat veterans, she developed a procedure, which she then evaluated with trauma victims who volunteered for treatment. What was then called Eye Movement Desensitization involved a repeated return to a targeted memory paired with the eye movements, which were believed to trigger an inherent relaxation response. In 1989, a randomized controlled trial demonstrating the efficacy of the procedure for treating traumatic memories was published in the Journal of Traumatic Stress. With its emphasis on apparent desensitization effects, Eye Movement Desensitization reflected a behavioral orientation. Further experimentation

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and observations of the changes initiated by the eye movements resulted in an evolution of the methodology. Procedures were developed that encouraged naturalistic associative reprocessing of comprehensive memory networks by allowing the client’s attention to move spontaneously to internal associations (e.g., other memories, insights) during the sets of eye movements. In 1990, the therapy was renamed Eye Movement Desensitization and Reprocessing to reflect the observation that the apparent desensitization was merely a by-product of the reprocessing and that changes were simultaneously occurring in the affective, somatic, and cognitive domains. At that time, it was also recognized that many “everyday” disturbing life experiences (e.g., arguments, humiliations) can have the same debilitating effects as full-blown trauma and set the groundwork for a wide range of clinical problems. Clinicians were instructed to examine clients for these kinds of experiences and to target them during EMDR therapy. Since then, substantial research has confirmed the importance of everyday adverse life experiences as a basis of pathology. When the initial study was published in 1989, there were no empirically supported treatments for posttraumatic stress disorder (PTSD). Therefore, the positive effects reported in the onesession study resulted in years of controversy regarding the efficacy of EMDR and the role of the repetitive eye movements in the therapy. The problem was compounded by early studies evaluating the effects of the procedure with and without eye movements that reported equivocal results. In 2000, these studies were determined by the International Society for Traumatic Stress Studies Practice Guideline Taskforce to be flawed because of insufficient treatment fidelity and/or length of treatment. Since then, numerous randomized studies have evaluated the role of the eye movements and reported positive results, including decreases in negative emotions, increased recognition of true information, and other memory effects. A recent meta-analysis of the eye movement research has demonstrated significant effects for the eye movements in both clinical and laboratory studies. Clinical observation and research have also indicated positive effects when substituting bilateral (back and forth) tones or taps for the eye movements.

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Subsequent to the publication of the original randomized study, Shapiro continued to refine the procedures, and EMDR therapy was introduced as an eight-phase treatment approach. A randomized study published in 1995 in the Journal of Counseling and Clinical Psychology reported 84% remission of PTSD after three sessions. A humanitarian assistance program launched to treat victims of the Oklahoma City bombing that same year obtained virtually identical results. Since then, research has continued to demonstrate the effectiveness of EMDR therapy, and it is now widely regarded as an empirically validated treatment for trauma. The efficacy of EMDR therapy has been confirmed by more than 20 randomized controlled studies, and it has been designated effective internationally in the practice guidelines of organizations such as the American Psychiatric Association, the Department of Veterans Affairs and Defense, and the World Health Organization (WHO). Although many clinicians influenced by the early controversy believe that EMDR is a form of cognitive-behavioral therapy, the WHO Practice Guidelines have made a clear distinction by indicating the marked differences between the two therapies with respect to both conceptual basis and clinical procedures. Since EMDR therapy does not include the 30 to 100 hours of prescribed homework characteristic of the other empirically validated trauma treatments, its therapeutic effects can be achieved on consecutive days. This provides field teams the ability to use both individual and group therapy protocols to efficiently treat appropriately screened and stabilized trauma victims on-site after both natural and man-made disasters. The EMDR Humanitarian Assistance Programs, which was recognized in 2011 with an award for clinical excellence by the International Society of Traumatic Stress Studies, has been assisting victims pro bono since 1995, both in the United States and internationally. Randomized trials have confirmed that EMDR therapy is both effective and efficient. For instance, three studies have reported that 84% to 100% of single-trauma victims no longer had PTSD after the equivalent of three 90-minute sessions. Additional sessions are needed for multiple traumas. For example, it has been found that 12 sessions with combat veterans resulted in the elimination of PTSD diagnosis in 77.7% of the cases. However,

it is unnecessary to process each trauma individually because positive treatment effects generalize to similar events. Numerous studies and case reports have found EMDR therapy to be effective with a wide range of disorders. Different diagnoses require customized EMDR therapy procedures, which incorporate the three-pronged protocol of the past, the present, and the future. EMDR therapy can be integrated with a specialized treatment framework appropriate for a wide range of populations. It is applied with individual and group protocols.

Theoretical Underpinnings EMDR therapy is guided by the Adaptive Information Processing (AIP) model, which views unprocessed memories of adverse life experiences as the basis of pathology, excluding that caused by organic factors (e.g., genetics, injury, toxicity). Memories are physically encoded experiences that are stored in associative neural networks. These networks provide an important basis for the person’s interpretation of new experiences and significantly influence current perceptions, behaviors, and feelings. Under normal circumstances, the information processing system integrates new experiences with previous ones, gleaning the information that is useful and discarding that which is not. This information, along with the appropriate emotional states, is stored in interconnected memory networks that become available to guide the person’s future actions. However, high levels of disturbance can disrupt the system and cause the unprocessed memories to be stored with the perspectives, affects, and sensations that were experienced at the time of the event. Distressing events can include not only major traumas but also the more ubiquitous childhood experiences of rejection, abandonment, humiliation, and household disruption. Such experiences become stored in a way that does not allow them to connect to more adaptive information, therefore preventing appropriate learning from taking place. Predictably, if a current situation triggers memory networks of inappropriately stored information, the perceptions, emotions, and physical sensations inherent in the unprocessed memory emerge automatically. When this occurs, “the past becomes present.” These negative affects and perspectives shape the  individual’s responses and result in reduced

Eye Movement Desensitization and Reprocessing Therapy

self-esteem, self-efficacy issues, relationship difficulties, and the overt symptoms of a wide variety of diagnoses. The goals of EMDR therapy are to access and process the dysfunctionally stored memories by stimulating the innate information processing system through the use of standardized procedures and protocols. These procedures include the use of bilateral dual attention stimulation, such as eye movement, taps, or tones. The AIP model posits that successful EMDR treatment results in the emergence of the targeted memory from its isolated state to become appropriately integrated with the wider comprehensive memory networks that constitute the totality of the individual’s life experiences. The memory is now stored in a new, adaptive form, capable of being recalled and verbalized by clients without the negative affects, perspectives, and physical sensations that characterized their previous psychological condition. Various theories have been proposed to account for the rapid emergence of insight, memory association, and decrease in disturbance observed during EMDR therapy. One dominant hypothesis is that the eye movements link into the same processes that occur during rapid eye movement sleep. Randomized trials studying the eye movement component of EMDR therapy in isolation have supported this explanation. Two other theories receiving research support are that the eye movements (1) stimulate an automatic relaxation response by triggering the orienting response and (2) tax the working memory, thereby decreasing the vividness of the accessed disturbing image, resulting in a decrease in negative emotions.

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stored in the brain with the affects, perspectives, and physical sensations experienced at the time of the event. These memories are stored in isolation, unable to link with more adaptive information. Because learning cannot take place, they remain essentially unchanged over time. As the perceptions of the present link to existing memory networks, various components of the unprocessed memories can be experienced in the form of emotions, physical sensations, and thoughts or beliefs. Unprocessed memories of trauma and other adverse life experiences (i.e., the more ubiquitous life experiences such as humiliations, rejections, arguments, and childhood household dysfunction) are viewed as the basis of pathology, excluding those caused by genetic defect, toxicity, or injury. Information Processing

Three major concepts that underlie EMDR therapy theory and practice are (1) memory networks and unprocessed memories, (2) information processing, and (3) associative channels.

Processing is viewed as the forging of adaptive associations between networks of information stored in the brain. In EMDR therapy, the disturbing memory is accessed by eliciting image, beliefs, emotions, and physical sensations related to the memory. The information processing system is activated through standardized procedures that include dual attention bilateral stimulation (e.g., eye movements, tones, or taps), resulting in adaptive information linking into the neurobiological network(s) holding the dysfunctionally stored memories. The unprocessed components or manifestations of memory (image, thoughts, sounds, emotions, physical sensations, beliefs) transmute during processing to an adaptive resolution. What is useful is stored, available to appropriately inform future responses. Processed memories are posited to move from implicit and episodic memory systems (e.g., vivid remembrance of what occurred) to full integration within semantic memory systems (i.e., meaning has been extracted).

Memory Networks and Unprocessed Memories

Associative Channels

Memory networks are viewed as the underlying basis of pathology and mental health. Distressing or traumatizing events can disrupt the brain’s information processing mechanisms, which results in the experience becoming dysfunctionally

Encoded memories are stored in networks with neural linkages to events with similar information (e.g., senses, thoughts, emotions, body sensations, and beliefs). The pattern of recovery observed in EMDR reprocessing sessions involves a rapid

Major Concepts

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progression of intrapsychic connections as emotions, sensations, insights, and memories surface and shift with each new set of dual attention stimulation. Hence, EMDR therapy appears to open up associative channels and reveal the interconnections of the memory networks. As processing continues, positive associations arise as part of the learning process in the form of new linkages to relevant memory networks.

Techniques The generic therapeutic protocol underlying comprehensive EMDR treatment includes a threepronged approach following appropriate preparation. The client is first engaged in processing (a) past experiences contributing to present dysfunction, (b)  present triggers that elicit disturbance, and (c) patterns of behavior for future positive functioning. Protocols customized for different diagnoses (e.g., substance abuse, phobias, chronic pain) all incorporate the eight-phases and three-pronged protocol. Guided by the AIP model, EMDR therapy utilizes an eight-phase approach to address the full range of clinical symptoms caused or exacerbated by negative experiences. Phase 1: Client History

The clinician obtains background information, determines client suitability for EMDR treatment, and identifies processing targets from events in the client’s life. The clinician assesses client stability and the availability of positive memory networks necessary to allow processing to take place. The clinician employs direct questioning and specific techniques (e.g., Affect Scan, Floatback) to identify the earlier memories that are the foundation of the client’s current symptoms. Phase 2: Preparation

Clients deemed appropriate are prepared to process the targeted memory experiences. The goals in this phase are to establish a therapeutic alliance, educate the client about the symptom picture, explain the EMDR process and its effects, and teach self-control techniques that foster stabilization. If needed, a variety of resource development procedures that enhance adaptive functioning are

used along with the therapeutic relationship to increase access to positive memory networks. Phase 3: Assessment

The memory to be targeted for processing is accessed and evaluated by identifying the relevant components. This is achieved by eliciting the mental image, currently held negative belief, desired positive belief, current emotion, physical sensations, and baseline measurements of the level of current distress and believability of the desired positive belief. Phase 4: Desensitization

This is the first phase during which memory targets involving negative past experiences and current disturbances are reprocessed. The goal is to neurophysiologically catalyze a life-enhancing learning experience through processing the accessed memory, which results in the emergence of insight and positive emotions, transforming the disturbing event into a foundation of resilience. Standardized procedures, including sets of bilateral dual attention stimuli, are utilized to help activate the information processing system, and systematic feedback is obtained to carefully monitor and guide the client to resolution. During sets of bilateral stimulation, the client maintains a dual awareness of the external stimuli and an internal focus on what emerges in consciousness. Simultaneous shifts in cognition, emotion, and physical sensation associated with the memory reprocessing reveal the insession treatment effects. Positive templates for adaptive future behavior are also incorporated into memory. Phase 5: Installation

The client’s most desired positive self-belief (initial or emergent) is identified and enhanced to increase its connection with currently existing positive cognitive networks and facilitate generalization effects between associated memories. Phase 6: Body Scan

The client identifies and processes any residual negative body sensations until they disappear.

Eye Movement Desensitization and Reprocessing Therapy

Because dysfunctionally stored memories often manifest via physical disturbance, processing is not considered complete until all negative somatic responses disappear. Phase 7: Closure

This phase shifts the focus away from the negative memory to neutral or positive networks. It may incorporate methods to return clients to psychological equilibrium, if needed, and ensure their stability between sessions. Clients are briefed about what to expect between sessions and instructed to maintain a brief log of their psychological experiences or state of mind to identify potential targets for future sessions. Phase 8: Reevaluation

In the sessions following processing, an assessment is made of the client’s current psychological state, the thoughts and feelings that may have emerged since the previous treatment, and the level of integration within the larger social system. In addition, the previous session’s target is accessed to evaluate the maintenance of effects and any other associations that may have emerged. This information is used to guide the direction of treatment.

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body. He then said, “It was a terrible situation, but it’s over now. I hope the child is being taken care of.” He could then think of holding his own child with a feeling of love. Future memory templates were encoded to anticipate comforting his child when she cried. In summary, EMDR is an integrative psychotherapeutic approach that conceptualizes current mental health problems as emanating from past experiences that have been maladaptively stored neurophysiologically as unprocessed memories. EMDR therapy utilizes standardized procedures including bilateral dual attention stimuli to activate the information processing system to bring the client to a robust level of mental health. A three-pronged protocol is used that targets the (1) unprocessed memories of past adverse life experiences underlying the clinical complaints, (2) current situations that trigger disturbance, and (3) positive memory templates needed for future adaptive behavior. Extensive research has validated this approach. Francine Shapiro and Roger Solomon See also Foundational Therapies: Overview; Neurological and Psychophysiological Therapies: Overview; Shapiro, Francine

Further Readings

Therapeutic Process The following brief example describes a session of EMDR therapy with a single trauma: a war veteran who experienced PTSD symptoms resulting from a marketplace bombing incident in which people were killed. He specifically recalled a crying child near its dead mother. On returning home, he could not hold his infant daughter, and when she cried, he experienced flashbacks and panic. The memory was targeted for processing, the worst image being that of the crying child. The negative cognition was “I’m helpless,” while the positive cognition was “I  did the best I could.” The client’s emotions of sadness and guilt were felt in the stomach. During processing, he recalled his activities during this incident, such as calling first aid workers, bringing a blanket to a child, and trying to be a comforting presence. With further processing, he stated that he had done all he could to help the wounded and no longer felt any negative physical response in his

Doering, S., Ohlmeier, M., de Jongh, A., Hofmann, A., & Bisping, V. (2013). Efficacy of a trauma-focused treatment approach for dental phobia: A randomized clinical trial. European Journal of Oral Sciences, 121, 584–593. doi:10.1111/eos.12090 Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 22, 231–239. doi:10.1016/j. jbtep.2012.11.001 Marcus, S., Marquis, P., & Sakai, C. (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting. Psychotherapy, 34, 307–315. doi:10.1037/ h0087791 Oren, E., & Solomon, R. (2012). EMDR therapy: An overview of its development and mechanisms of action. European Review of Applied Psychology, 62, 197–203. doi:10.1016/j.erap.2012.08.005 Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York, NY: Guilford Press.

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Shapiro, F. (2012). Getting past your past. New York, NY: Rodale. Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences. The Permanente Journal, 18, 71–77. doi:10.7812/ TPP/13-098 Shapiro, F., & Laliotis, D. (2011). EMDR and the adaptive information processing model: Integrative treatment and case conceptualization. Clinical Social Work Journal, 39, 91–200. doi:10.1007/s10615-0100300-7 Solomon, R., & Shapiro, F. (2008). EMDR and the adaptive information processing model: Potential mechanisms of change. Journal of EMDR Practice and Research, 4, 315–325. doi:10.1891/19333196.2.4.315 Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61–75. doi:10.1002/jclp.1129 Wilson, S., Becker, L. A., & Tinker, R. H. (1997). Fifteenmonth follow-up of eye movement desensitization and reprocessing (EMDR) treatment of post-traumatic stress disorder and psychological trauma. Journal of Counseling and Clinical Psychology, 65, 1047–1056. doi:10.1037/0022-006X.65.6.1047 World Health Organization. (2013). Guidelines for the management of conditions that are specifically related to stress. Geneva, Switzerland: Author.

EYE MOVEMENT INTEGRATION THERAPY Eye movement integration therapy (EMIT) is a largely nonverbal intervention that utilizes direction of gaze to access different brain processing modalities and change problematic experiences. It is particularly useful for resolving memories of traumatic past events and anxieties about future events or decisions. It can also be used for ongoing trauma, recurrent nightmares, psychosomatic pains, headaches, body image distortions, and many other issues. Because the method is simple and requires minimal cooperation on the part of the client, it is particularly useful when a client is still very upset about a current or recent troubling

experience, making it difficult or impossible to gather information or intervene verbally. This makes it a method of choice for rapid treatment of posttraumatic stress disorder, particularly when a great many people require help after a disaster and mental health professionals are overwhelmed. EMIT can be used as a stand-alone brief intervention, but more often it is used whenever appropriate in longer therapy. EMIT is a process within the larger field of neuro-linguistic programming (NLP).

Historical Context The early roots of EMIT can be found in the lateral eye movement research and split-brain research of Roger Sperry and others in the 1970s, in which they discovered that eye movements to the left or right indicated activation of the contralateral brain hemisphere. In the late 1970s, NLP further clarified the relationship between direction of gaze and  brain processing modality with what are called eye-accessing cues. Direction of gaze is understood to indicate the current sensory processing modality (visual, auditory, or kinesthetic), and eye direction can also be used to select and drive  the modality. EMIT was developed by Connirae Andreas, with assistance from her husband, Steve Andreas, as a stand-alone intervention. Later, Danie Beaulieu placed this intervention in the larger context of therapy, and did pilot research demonstrating its rapid effectiveness. EMIT was developed in 1989, shortly after the introduction of Eye Movement Desensitization and Reprocessing (EMDR) as an alternative eye movement therapy, with significant improvements and changes in both theory and practice.

Theoretical Underpinnings The fundamental theoretical basis for EMIT is a process that is central to many NLP interventions, in which a client is asked to move a troubling image into a different location in his or her personal space in order to elicit a more positive response. For instance, a crying client who is grieving over the loss of a loved one may be seeing an image of that person as a small, distant black-and-white still photo up and to his or her

Eye Movement Integration Therapy

right. In contrast, a positive memory of someone who has died but is remembered with warm feelings of love and connection may be experienced as a life-size, three-dimensional, colorful moving image to his or her immediate left—close enough to reach out and touch. When the image of loss is moved to the location of the positive image, it will typically become life-size, colorful, and moving. This reprocesses the loss, spontaneously replacing the feeling of grief with an experience of loving presence. Generalizing from a variety of similar interventions, NLP understands that every point in a client’s personal visual space elicits a somewhat different way of processing an image or experience. Thinking of a troubling experience while the eyes look around in the visual field is a nonverbal instruction to the brain to reprocess the image in a wide variety of ways that had not been utilized previously, eliciting new responses. For example, a flashback of a nighttime battlefield memory that had elicited intense panic became one in which the client spontaneously enjoyed the beauty of the colorful arc of the tracer bullets in the night.

Major Concepts Major concepts include modalities and submodalities, the relationship between direction of gaze and brain processing, and the distinction between content and process. Modalities and Submodalities

Every thought, memory, or future forecast is experienced as an internal representation in one or more of the five sensory modalities—as a visual image, auditory sounds or words, kinesthetic movements, postures, and sensations, or some combination of these, and more rarely also including smell and taste. Submodalities are the smaller process elements within each modality. For instance, the size, closeness, color, movement, and location of an image are submodalities of the visual modality, and volume, tempo, melody, tonality, and location are all submodalities of the auditory modality. Kinesthetic submodalities include tactile sensations of location, temperature, duration, intensity, and extent.

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Direction of Gaze and Brain Processing Modality

The location of a visual image in a client’s personal visual space, indicated by direction of gaze, is a particularly powerful submodality in determining both the quality and the intensity of a client’s feeling response to the content of the image, whether pleasant or unpleasant. Expressions such as “in your face” or “I put my past behind me” are not just metaphorical expressions; they are literal descriptions of someone’s internal experience of an image. A memory of childhood sexual abuse can be rendered much less disturbing if the image is seen as a small, dim, distant, black-and-white snapshot that is located far behind. Process Versus Content

Most therapy is directed at the content of a disturbing image, or the content of a verbal conclusion or generalization that is derived from it. However, it is far easier and more impactful to change the process elements of an image in order to change the client’s response. EMIT guides the client systematically through a wide range of different ways of processing, enabling the spontaneous selection of ways of processing an experience that are the most useful.

Techniques The fundamental technique is to ask the client to think of a memory or future forecast while looking at a small target, such as the end of a large felt tip pen that the therapist holds in his or her hand. The therapist then moves the target in various ways to change the client’s direction of gaze. Three major factors distinguish this method from EMDR. EMIT (1) uses a greater variety of movements, (2) empowers the client by giving him or her control over the process, and (3) relies primarily on spontaneous change. Variety of Eye Movements

EMDR uses horizontal left–right movements only, while EMIT also makes use of the full range of possible eye movements (diagonals, up–down, circles, spirals, higher horizontal movements, lower horizontal movements, etc.), with the goal of eventually including all points in the visual field to elicit

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as many different kinds of brain processing as possible, systematically sequencing and connecting different kinds of brain processing in different ways. Giving the Client Control

The client is asked to take an active role in telling the therapist about any adjustments he or she would like to make in the process. For instance, the client may be uncomfortable because the visual target is too close, or is moved too fast or too slow, and so on. The client is also asked to report any significant discomfort at any time during the process, so that the process can be paused temporarily or changed to a different set of movements. This respects the client’s needs, facilitates comfortable treatment, and reduces “resistance” and the likelihood of intense emotional abreactions. Therapists are taught a range of ways to adapt the process to accommodate the client’s needs, and how to recognize and deal with glitches in the treatment process. Reliance on Spontaneous Change

In EMIT, the client is asked to focus on the troubling image while following the visual target and simply to report any spontaneous changes in his or her response, without any attempt to direct or specify these changes. This ensures that changes are naturally congruent with the unique needs of the client, many of which are unconscious. In contrast, EMDR asks about the conscious “negative cognition” (thoughts) in response to the troubling image and also asks the client to consciously think of a “positive cognition” to eventually replace the negative one.

Therapeutic Process Although EMIT is sometimes the only method used, EMIT is also used whenever useful and appropriate in conjunction with other methods in a therapy session or in longer term treatment. Before beginning, the client is asked to gaze in different directions while thinking about the troubling experience and report if there is a direction in which the intensity of the unpleasant feeling is stronger. This area will be avoided

initially as the therapist guides the client in connecting other areas in the visual field. This begins the change process by strengthening the client’s resourcefulness. However, it is very important to include and integrate the areas with unpleasant feeling later in order to get a complete change. The client is asked to think of a troubling memory or future forecast and to hold his or her head still while looking at the therapist’s fingertip or other visual target. Then, the therapist moves the target, while watching to be sure the client’s eyes follow the target. Initially, the therapist usually asks the client to move his or her eyes back and forth in a horizontal straight line (often above the horizon) about six to eight times, about 1 second per sweep, being careful to initially avoid any area of more intense feeling identified at the beginning of the session. At the end of the series of sweeping movements, the client is asked to report any 1. change in intensity of feeling on a scale of 1 to 10, 2. perceptual changes (in size, distance, color, etc.) of the image, 3. change in the content of the image, and/or 4. change in the quality of the feeling response.

Then, this process is repeated, usually using a different direction of movement—including diagonal sweeps from the upper left to lower right and from the upper right to lower left; upand-down movements in the right, left, or center of the visual field; side-to-side sweeps above and below the horizon; circles; figure eights; and so on—to access all eye positions. Some sweeps may increase the unpleasant feeling temporarily, but most will immediately decrease the unpleasant feeling and/or increase resourceful feelings. Sometimes, the image being worked with spontaneously changes to a different image that needs to be processed. Changes satisfactory to the client typically occur very rapidly, so a complete session of EMIT can take as little as 5 or 10 minutes, or occasionally as much as 1 hour or so. Steve Andreas and Connirae Andreas

Eye Movement Integration Therapy See also Eye Movement Desensitization and Reprocessing Therapy; Integral Eye Movement Therapy; NeuroLinguistic Programming

Further Readings Andreas, S. (1990). Eye movement integration booklet. Boulder CO: Real People Press.

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Andreas, S. (1993). Eye movement integration with a Vietnam veteran [Video demonstration]. Boulder CO: Real People Press. (Free excerpt on YouTube; search for Steve Andreas, EMI) Andreas, C., & Andreas, S. (1989). Heart of the mind. Boulder CO: Real People Press. Beaulieu, D. (2003). Eye movement integration therapy. Williston, VT: Crown House.

F Theoretical Underpinnings

FAMILY CONSTELLATION THERAPY

Family constellation therapy is influenced by family systems therapy, existential phenomenology, and the South African Zulu culture.

Family constellation therapy is a therapeutic approach that draws from family systems therapy, existential phenomenology, and ancestor reverence concepts from the culture of the Zulus in South Africa. The approach is unconventional in that techniques by the clinician or facilitator are minimal, the client speaks very little, and the resulting therapeutic process does not explore cognitive or emotional content. Instead, the purpose of the approach is to isolate and let go of unconscious, transgenerational mechanisms in the family system. Family constellation therapy is the most commonly practiced form of systemic constellations therapy and shares many similarities with its parent approach.

Family Systems Therapy

Family systems therapy affects the family constellation approach by emphasizing unconscious transgenerational mechanisms. When family injustices or imbalances are not resolved, future generations continue to be affected by them. Specifically, Jacob Moreno’s psychodrama, Eric Berne’s concept of life scripts, and Virginia Satir’s family sculptures shaped Hellinger’s family constellations. Notably, the family sculpture method introduces the technique of putting people in physical stances to experience what it feels like to be in that place.

Historical Context

Existential Phenomenology

Martin Heidegger’s existential phenomenology contributes to family constellations in its interpretation of being. Instead of viewing mind, emotion, and consciousness relative to its parts, philosophers like Heidegger take meaning from a panoramic view of human experiences. Phenomenology emphasizes subjective sensory experience and body–spirit connections beyond what is rational. Within a constellation, the subjective experiences of the client and family representatives and the connections shared among them drive the therapeutic process.

The founder of family constellation therapy, Bert Hellinger (1925– ), was highly influenced by his life experiences, namely, growing up in Nazi Germany, imprisonment in an Allied prisoner of war camp during World War II, becoming a Catholic priest, living in the Zulu culture in South Africa for 16 years, and training in psychoanalysis and the family sculpture method. Hellinger’s life work in family constellations sought to recognize and resolve the collective trauma caused by his experiences with the Nazis and the war. 399

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Zulu Ancestor Reverence

Zulu ancestor reverence adds to constellations with its beliefs in ancestors as a central focal point of the current generation and a source of positive, constructive, and creative influence. This view of ancestors helps clients in constellations find peace, belonging, balance, and rightful place.

Major Concepts Family constellation therapy is based on three major principles: (1) parents give and children receive, (2) every member of the family system has an equal and unequivocal right to belong, and (3) each family system has an unconscious group conscience that regulates guilt and innocence as a means to protect the survival of the group. These principles are clarified by several key concepts: soul, conscience, belonging, balance, and hierarchy. Soul

The soul is not the Judeo-Christian/Islamic soul; rather, it is the family’s driving impulses that are inaccessible to the conscious mind. Conscience

Conscience is not a regulator of values and behavior; rather, it is what bonds or separates us from the family system. Belonging

Belonging is what controls membership in the family system. If the right to belong to the family is violated, consequences may ensue for members of the family system. Balance

Balance refers to the equilibrium between giving and taking in relationships. Family transgressions and abuses may impede this dynamic and negatively affect members of the family. Hierarchy

Hierarchy orders members of the family system in relation to one another. Family members who

behave contrary to the natural hierarchy of the family may cause negative consequences to the family system.

Techniques Family constellation therapy uses several techniques, such as the use of sentences to express personal issues, forming a constellation, and use of healing sentences during sessions. Use of Sentences

In a session, a group of participants sits in a circle. One participant is the client and discloses a personal issue. The facilitator draws the personal issue from the client in no more than three sentences and then, without commentary from the client, elicits information on past traumatic events that may have affected the family system. Forming a Constellation

Next, the facilitator directs the client to select group members to represent the significant characters of the client’s personal issue and to physically move them into places within the constellation (the three-dimensional representation of the issue). Participants do not move or talk while being placed in the constellation, and the client sits and observes the scene in stillness and silence once it is created. The representatives tune into the unconscious mechanisms of the client’s family system. The facilitator may ask them how they are feeling in their places in the constellation. As the underlying dynamics of the family system come into focus, the client has access to previously unrecognized family mechanisms. The constellation reveals how past traumas continue to unconsciously affect living members of the family system. Use of Healing Sentences

The facilitator works to reveal a healing resolution to the constellation by suggesting one or two healing sentences for the client or the representatives to speak, as the client stands in his or her place in the system. No processing occurs in the constellation session.

Feedback-Informed Treatment

Therapeutic Process According to family constellation therapy, disruptions to belonging, balance, and hierarchy cause dysfunctional behavior. The act of creating a constellation presents the client with a healing image of the family system, since excluded members are restored to rightful places, giving and taking are rebalanced, and representatives stand in appropriate relation to one another. This objective is achieved in a single group session, during which the client discloses a singular personal issue, arranges members of the group to represent members of the client’s family constellation, and tunes in to the unconscious mechanisms revealed through the resulting physical arrangement. Healing occurs when the client is able to see previously unrecognized connections between the transgenerational mechanisms of the family system and the personal issue and, ultimately, to accept the reality of the past. The client can reflect on the healing over time and process it in conventional therapy. Kristy L. Carlisle See also Phenomenological Therapy; Satir, Virginia; Systemic Family Therapy

Further Readings Cohen, D. B. (2006). “Family constellations”: An innovative systemic phenomenological group process from Germany. Family Journal, 14(3), 226. doi:10.1177 /1066480706287279 Hellinger, B. (2003). Peace begins in the soul: Family constellations in the service of reconciliation (C. Beaumont, Trans.). Heidelberg, Germany: Carl-Auer-Systeme Verlag. Steifel, I., Harris, P., & Zollmann, A. (2002). Family constellation: A therapy beyond words. Australian and New Zealand Journal of Family Therapy, 23(1), 38–44. doi:10.1002/j.1467-8438.2002.tb00484.x

FEEDBACK-INFORMED TREATMENT Feedback-informed treatment (FIT) is a transtheoretical approach for evaluating and improving the quality and effectiveness of behavioral health

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services. It involves routinely and formally soliciting feedback from consumers regarding the therapeutic relationship and clinical progress and using the information to organize and tailor service delivery. FIT meets the criteria for evidence-based practice set forth by the Institute of Medicine, U.S. Department of Health and Human Services, and the American Psychological Association. It does so by integrating the best available research about what works in treatment, tracking consumer change, and identifying when adjustments need to be made to maximize therapeutic effect.

Historical Context Psychotherapy is an efficacious approach for the amelioration of psychological distress and improvement of functioning. At the same time, research spanning decades shows little or no difference in outcome between competing forms of therapy. The same literature documents that variables long thought to influence effectiveness have little value in predicting clinical outcomes. These include psychiatric diagnosis, professional discipline, type of degree or training, and years of experience. In an effort to provide clinicians with practical information for guiding and improving treatment services, researchers proposed the use of formal, ongoing measurement of progress. In 1986, Kenneth Howard and colleagues published groundbreaking research demonstrating that change in treatment followed a predictable course. Later, the psychologist Michael Lambert documented that routinely providing clinicians with data regarding client response significantly improved retention in care, reduced deterioration, and promoted higher rates of change. Following his work, Scott Miller and associates at the Institute for the Study of Therapeutic Change, and later the International Center for Clinical Excellence, developed two 4-item instruments for use in daily practice. In addition to a measure of progress, clients were asked to rate the quality of the therapeutic relationship. Research had long shown that the client’s experience of the therapeutic relationship was a significant predictor of both retention and outcome. In multiple studies, the combination of ultrabrief alliance and outcome measures enhanced practitioners’ utilization and outcomes. Regardless of which tools

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clinicians ultimately chose, their routine use and incorporation of the findings in sessions with clients improved quality and effectiveness.

Theoretical Underpinnings Four robust research findings provide the empirical foundation for FIT practice. First, change in treatment generally follows a predictable course. Second, the quality of the relationship between client and therapist is an important determinant of retention and effectiveness. Third, it is possible to measure progress and the strength of the therapeutic relationship. Fourth, a significant body of research in psychotherapy and domains of human activity (e.g., medicine, music, sports, and mathematics) documents that feedback enhances performance.

Effect Size

Effect size is a measurement of the amount of change (e.g., between pretreatment and posttreatment distress scores) standardized in terms of the variance of the scores (e.g., the standard deviation of pretreatment distress scores). Expected Treatment Response

Similar to growth curves used in medicine to assess height, weight, and head circumference compared with norms at different ages, an ETR is a normative prediction of a client’s expected rate of change over time in treatment compared with the norms of different baseline distress or other variables. International Center for Clinical Excellence

Major Concepts Some of the major concepts to help understand the use of FIT include the therapeutic alliance, the dose–response relationship, effect size, expected treatment response (ETR), International Center for Clinical Excellence (ICCE), Outcome Rating Scale (ORS), progress, reliable change, and Session Rating Scale (SRS). Therapeutic Alliance

The therapeutic alliance refers to the quality and strength of the collaborative relationship between the client and the therapist. The alliance comprises four empirically established components: (1) agreement on the goals, meaning, or purpose of the treatment; (2) agreement on the means and methods used; (3) agreement on the therapist’s role (including being perceived as warm, empathic, and genuine); and (4) accommodating the client’s preferences.

The ICCE is an international web-based community of providers, educators, administrators, researchers, and policymakers dedicated to improving the quality and outcome of behavioral health services. Members can participate in more than 100 topical forums, create their own discussion group, and access a growing library of how-to documents and videos. It costs nothing to join, and the site is free of advertising and solicitation. Outcome Rating Scale

The ORS is a brief, well-validated, client-rated, four-item visual analog scale measuring a client’s personal experience of well-being in his or her individual, interpersonal, and social functioning. Progress

Progress refers to the benefit of care as reflected in a change of scores on measures of well-being, distress, behaviors, personal goals, or symptoms.

Dose–Response Relationship

Reliable Change

As applied to psychotherapy, dose–response relationship refers to the relationship between the number of sessions or treatments received and the clinical response of a sample of clients. Often, this relationship is summarized in terms of the number of sessions required for a proportion (e.g., 50% or 75%) of the client sample to report a clinically or statistically significant change from their pretreatment level of distress.

Reliable change refers to a change in scores on an outcome scale that is beyond a level expected from measurement error alone. Session Rating Scale

The SRS is a brief, well-validated, client-rated, four-item visual analog scale measuring a client’s perception of the quality of the therapeutic

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relationship (the therapeutic bond, agreement on goals, agreement on method, and agreement with client preferences).

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See also Common Factors in Therapy; Evidence-Based Psychotherapy

Further Readings

Techniques FIT is characterized by inclusiveness of any and all psychotherapy and counseling techniques intended to be effective. The specific techniques in FIT involve the formal, session-by-session measurement of both client well-being (clinical outcome) and client-perceived quality of the therapeutic process (working alliance), using measures that are valid, reliable, and feasible enough for clinicians to use them with high frequency. Therapists then incorporate feedback data into the therapeutic process (see the next section).

Therapeutic Process Therapists use outcome and alliance feedback collaboratively with clients to adjust the treatment and optimize treatment outcome. Therapists may share graphical displays of the client’s well-being or alliance over time to facilitate discussions about whether and how the therapy process might need adjustment, to track the effectiveness of those adjustments, and to inform therapist–client decision making around appropriate transitions such as increased session frequency, referral, or termination. Consisting of an outcomes measure and an alliance measure, the Partners for Change Outcome Measurement System (PCOMS): ICCE Version is one system for conducting FIT. The PCOMS measures can be used with both adults and children as part of any behavioral health care intervention and consist of two brief scales: (1) the ORS, which assesses the client’s therapeutic progress (through ratings of psychological functioning and distress), and (2) the SRS, which assesses the client’s perception of the client–therapist alliance (i.e., the quality of the relational bond with the therapist, the perceived collaboration around therapeutic tasks, and whether the therapist shares the client’s therapeutic objective). FIT, and its implementation through the PCOMS, is intended to inform, influence, and account for the therapeutic process that would otherwise be unfolding without formal corrective feedback when based only on the therapist’s therapeutic orientation and perspective. Scott D. Miller, Mark A. Hubble, and Jason Seidel

Bertolino, B., & Miller, S. D. (Eds.). (2012). The ICCE treatment and training manuals (6 vols.). Chicago, IL: ICCE Press. Bringhurst, D. L., Watson, C. S., Miller, S. D., & Duncan, B. L. (2006). The reliability and validity of the outcome rating scale: A replication study of a brief clinical measure. Journal of Brief Therapy, 5(1), 23–29. Campbell, A., & Hemsley, S. (2009). Outcome rating scale and session rating scale in psychological practice: Clinical utility of ultra-brief measures. The Clinical Psychologist, 13, 1–9. doi:10.1080/13284200802676391 Duncan, B. L., Miller, S. D., Reynolds, L., Sparks, J., Claud, D., Brown, J., & Johnson, L. D. (2003). The Session Rating Scale: Psychometric properties of a “working” alliance scale. Journal of Brief Therapy, 3(1), 3–12. Harmon, S. C., Lambert, M. J., Smart, D. M., Hawkins, E., Nielsen, S. L., Slade, K., & Lutz, W. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17(4), 379–392. doi:10.1080/10503300600702331 Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose–effect relationship in psychotherapy. American Psychologist, 41, 159–164. doi:10.1037//0003-066X.41.2.159 Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Claud, D. (2003). The Outcome Rating Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91–100.

FELDENKRAIS METHOD The Feldenkrais Method® of somatic education guides people to become more effective learners so that they can reduce pain, improve function, and live self-directed and fulfilled lives. Guild Certified Feldenkrais Teachers® use manually and verbally guided movement lessons to encourage students to deepen awareness of their sensing, feeling (emotions), thinking, and moving and come to know themselves more completely. With increased awareness and knowledge, students self-organize individually appropriate choices for more effective

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behavior. Students wear comfortable clothes during lessons that typically last 45 to 60 minutes. Feldenkrais Teachers work with students of all ages and abilities. Many come to the method because of a painful back or other musculoskeletal conditions. Others come seeking stress reduction, help for a child with developmental delay, or assistance to recover from a stroke. Some want to improve performance at work, leisure, or daily activities. Regardless of motivations, Feldenkrais Teachers regard students as whole persons capable of lifelong learning that improves their lives.

Historical Context The originator of the Feldenkrais Method, Moshé Feldenkrais, D.Sc. (1904–1984), grew up in present-day Ukraine and Belarus within a Hasidic Jewish community that valued education highly. After surviving World War I, he left his family in 1918 to immigrate to Palestine, where he worked as a tutor, laborer, and cartographer and studied martial arts. After injuring a knee playing soccer, limited options for medical treatment set him on course to develop his method. In 1930, Feldenkrais traveled to Paris to study engineering, earned his doctorate, and worked in the Joliot-Curie laboratories. He met the founder of judo, Jigoro Kano, and became one of the first European black belts. Feldenkrais escaped from Paris in 1940 and spent the rest of World War II as a scientist with the British Admiralty’s antisubmarine efforts. During that time, he injured his other knee. Motivated by his injuries, Feldenkrais delivered a series of lectures to his colleagues that were his method’s foundation. Feldenkrais returned to the new state of Israel in 1951. Word of his method spread, and it soon occupied his full attention. He moved to Tel Aviv in 1955 and spent the rest of his life teaching his method. He first taught others to teach his method in Israel. He led two teacher trainings in the United States but was unable to teach in all of the second training due to health complications following a car accident that eventually led to his death. Presently, there are nearly 20 professional organizations, or guilds, within the International Feldenkrais Federation that support and promote the Feldenkrais Method. More than 6,000 Feldenkrais Teachers offer the method in more than 30 countries.

Theoretical Underpinnings The Feldenkrais Method arose from a synthesis of interdisciplinary study and direct engagement with leading scientists and scholars of the 20th century. Courtesy of Feldenkrais’s education, life experiences, and multilingual abilities, he had exposure to cutting-edge knowledge and ideas, including the emerging areas of cybernetics and dynamic systems theory. Feldenkrais was an early advocate of the perspective that learned human behavior arises from the interrelationships within a unified body and mind that senses, feels, thinks, and moves within the environment and within cultural and historical (both evolutionary and individual) contexts. Well before contemporary neuroscience confirmed neuroplasticity, Feldenkrais proposed that the brain would change in response to activity throughout life. With refined awareness and attention, learning is a lifelong process that supports effective and adaptive behavior in the face of ever-changing conditions. Feldenkrais designed his method to work with the whole person to refine learning in service of improving life, not just to treat a disease or injury.

Major Concepts The three foundational concepts of the Feldenkrais Method are as follows: (1) movement is essential to life and learning, (2) awareness is tuned with attention during movement, and (3) humans, with unified body and mind, self-organize and learn reliable patterns of behavior and adapt to changing conditions. The concepts discussed in the following subsections expand on these ideas. Avoid Pain

Teachers advise students to move within their pain-free ranges and notice aspects that have no pain and are pleasant. Movements, as needed, can be so small as to be unobservable or can be imagined. Know Thyself

Lessons encourage students to be curious, uncover existing preferences, and know themselves accurately. When people understand more exactly what they are doing, they are better able to do what they truly want.

Feldenkrais Method

Slow Down and Observe Oneself

Teachers invite students to move slowly and fully examine the details of their behaviors. Students are less likely to skip past unclear or difficult aspects of movements when they slow down and pay attention. Pay Attention

Teachers guide students in the use of their attention and invite them to notice unrecognized elements of their behavior. More skillful use of attention improves the ability to make perceptual discriminations and aids learning. Rest, and Notice Changes

Although lessons usually are not tiring, teachers ask students to take frequent, short rests. Rests afford students opportunities to notice changes that occur within lessons, which enhances the learning process. Less Is More

Inspired by the Weber-Fechner law relating the threshold for perceptual differentiation to stimulus intensity, teachers encourage students to reduce effort to enhance their ability to make finer perceptual distinctions. The resulting increased awareness can be sufficient to improve efficiency. Clarify the Self-Image

Teachers help students to clarify their selfimages to improve behavior. Teachers guide them to recognize the midlines of their bodies and extremities, their orientation to gravity and organization for dynamic equilibrium, and their orientation to the horizon through positioning of the head and its teleceptors that receive distant information. Lessons direct students’ attention to regions, such as the area between the shoulder blades, that are often out of sight and out of mind and, in so doing, incorporate them into the self-image. Discovery Learning

Teachers often do not initially disclose a lesson’s function to students to discourage habitual responses and encourage exploration. Teachers

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rarely model a supposedly correct way of doing an action. In turn, students get to experience selfreferenced success while learning. Individual Relevance

Each student takes from a lesson what is personally relevant. While lessons involve speciestypical functions (e.g., walking, reaching), the same lesson can have different effects (e.g., feeling lighter vs. feeling grounded) on people because of their unique backgrounds and resources. Create Options and Choices for Action

Having only one option for action is a compulsion. Instead, Feldenkrais Method lessons promote having choices to solve a problem or address a question. Reversibility

Students learn to balance excitatory and inhibitory states so that behaviors are reversible. With appropriate control, individuals can modulate their activities and change course in a timely manner. Health Promotion

Health is not merely the absence of disease or injury but the ability to recover from a disturbance. With improved awareness and understanding of the learning process, students can lead more resilient lives and gracefully adapt to change. Potent State

The potent state allows one to (a) start an action in any direction, (b) start the action without making preparatory adjustments, and (c) act with maximal efficiency. Within the potent state, a person understands where the middle of a dynamically stable workspace is and where the boundaries of stability are for a given behavior. With improved awareness, individuals may expand the boundaries of what is possible for stable behavior or may recognize that reducing boundaries would be appropriate. With potent organization, movements originate proximally from larger areas such as the pelvis. Many components cooperate for coordinated action that reduces demands on one region,

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such as the neck or low back, and creates easy yet powerful movement.

Techniques Teachers may rely on the extensive repertoire of lessons designed by Feldenkrais or utilize their embodied understanding of the method to structure lessons. Lessons typically occur in two formats: (1) Functional Integration® and (2) Awareness Through Movement®. Functional Integration

Functional Integration lessons use manual contact between the teacher and the student. Touch informs both as they learn about the student’s habits. Teachers manually suggest more efficient modes of organization that support activity and reduce interference, such as excessive muscle tension. Teachers tactilely clarify the skeleton’s structure and its capacity for transmitting force and providing support. Handling is reassuring and supportive, so that students feel safe to explore alternatives and attend to insights from lessons. Teachers often work with students in lying, sitting, or kneeling on a firm, wide table. Awareness Through Movement

Verbally guided Awareness Through Movement lessons facilitate group instruction. Students attentively explore a movement sequence several times with variation, as opposed to executing repetitions of exercises by rote. Lessons often occur while students lie on a floor mat but may involve sitting, kneeling, or standing positions. Select Techniques

Feldenkrais Method lessons establish conditions that invite students to recognize their current organization and consider alternatives. Teachers have students alter their habitual relationship to gravity, such as by lying on the side with the legs drawn up as if sitting in a chair while exploring movements of the trunk, pelvis, legs, shoulders, arms, head, eyes, and breath. Varying positions and movements encourages students to notice the effects of lengthening versus compressing; making small versus large motions; breathing in, breathing out, or stopping the breath during movement; moving

slowly versus moving quickly; moving parts of the self, including the eyes, in the same direction or in opposing directions; or moving parts simultaneously or sequentially. Students may do open kinetic chain movements with the distal part of a limb, such as the foot, and be free to move on the more fixed proximal part, such as the hip and pelvis. In contrast, they may revisit similar movements in a closed kinetic chain with the distal part fixed to the ground while the proximal part moves about. Lessons may involve a sequence performed first on one side, followed by a pause to notice the contrast between the sides before repeating on the other side. Alternatively, students may imagine the movements on the second side before doing a few actual movements to reveal the effects of the lessons. These are just some of the many techniques that teachers use to deliver Feldenkrais Method lessons.

Therapeutic Process Feldenkrais Method lessons may span a handful of sessions addressing a specific concern or may continue for months or years as a personal development practice. In both Functional Integration and Awareness Through Movement lessons, teachers advise students to perform movements within their comfortable range, reduce effort, and be curious about exploring and learning about themselves. Teachers lead students in an active process of selfdiscovery coupled with guidance on using attention to improve awareness of sensations, emotions, thoughts, and movements. Students become familiar with current habits in great detail and explore other possibilities for function. In the process, students typically experience reduced pain, increased ease of movement, and improved function. Teachers do not model a one-size-fits-all way of performing an action and are not prescriptive with their instructions. Instead, students use the information gained in lessons to form individually relevant solutions to their problems and increase choices for more efficient, flexible, resilient, self-directed, and self-fulfilled behavior. Patricia A. Buchanan See also Alexander Technique; Chaos Theory; Mindfulness Techniques; Phenomenological Therapy; Unifying Nonlinear Dynamical Biopsychosocial Systems Approach

Feminist Family Therapy

Further Readings Buchanan, P. A. (2012). The Feldenkrais Method® of somatic education. In A. Bhattacharya (Ed.), A compendium of essays on alternative therapy (pp. 147–172). Retrieved from http://www.intechopen.com/articles/show/title/ the-feldenkrais-method-of-somatic-education Buchanan, P., & Ulrich, B. (2001). The Feldenkrais Method®: A dynamic approach to changing motor behavior. Research Quarterly for Exercise and Sport, 72, 315–323. doi:10.1080/02701367.2001.10608968 Feldenkrais, M. (1972). Awareness through movement: Health exercises for personal growth. New York, NY: Harper & Row. Feldenkrais, M. (1985). The potent self: A guide to spontaneity. San Francisco, CA: Harper San Francisco. Feldenkrais, M. (1996). Body and mature behavior: A study of anxiety, sex, gravitation and learning. Madison, CT: International Universities Press. Feldenkrais, M. (2010). Embodied wisdom: The collected papers of Moshe Feldenkrais. San Diego, CA: Somatic Resources. Ginsburg, C. (2010). The intelligence of moving bodies: A somatic view of life and its consequences. Santa Fe, NM: AWAREing Press. Kaetz, D. (2007). Making connections: Hasidic roots and resonance in the teachings of Moshe Feldenkrais. Metchosin, British Columbia, Canada: River Centre.

FEMINIST FAMILY THERAPY Feminist family therapy emerged in the late 1970s both as a critique of mainstream family therapy’s approach that utilized systemic assumptions and as a model for incorporating feminist principles into therapeutic practice. The feminist critique of family therapy resulted in a dramatic increase in the attention to gender, sex roles, race, culture, and power in family theory and practice. The feminist framework serves broadly as a critical pedagogy within family therapy to identify and address ways in which gender may be combined with other types of oppression, such as race, class, culture, and sexual orientations. The role of differences in power and authority within the therapy setting also is identified and addressed in the therapy process.

Historical Context The formal emergence of feminist family therapy is credited to an article by Rachel Hare-Mustin, in

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the journal Family Process in 1978, titled “A Feminist Approach to Family Therapy.” Her work directed attention to the discrimination of women in family therapy models that failed to question gender stereotypes and male dominance in the family structure, thus reinforcing restricted roles for women and men in family, work, and social life. In the 1980s, the field began to include an increased number of women leaders who advocated new theories to challenge the older mainstream of family therapy and influenced the current discourse in family therapy. The Women’s Project in Family Therapy in 1988, founded by Marianne Walters, Peggy Papp, and Betty Carter, highlighted the absence of gender in systems theories and focused on incorporating feminist principles into the practice of family therapy. In addition, the work of Virginia Goldner, Monica McGoldrick, Froma Walsh, and Cloe Madanes, among others, provided significant critiques of traditional marriage and family models and integrated sound feminist models into family therapy conceptualizations and practices. The next two decades incorporated issues related to racism, homophobia, and social class into family therapy theory, research, and practice. It was at this point that cultural competence was emphasized in the preparation and practice of feminist family therapy, and clinical models for diverse families and specific groups emerged. Around the same time, new feminist treatment models for intimate partner violence, child abuse, addictions and family systems, sexual dysfunction, and feminist approaches to men’s issues arose. An emerging global perspective as well as recent feminist practice in family therapy have increasingly embraced the concept of intersectionality—that is, the complexity of intersecting gender with race, class, sexuality, national identity, and faith.

Theoretical Underpinnings Feminist theory and its application to family therapy argue that the social world is constructed on a premise of male superiority. Feminist family therapy is not a specific model of practice as such; instead, it refers to the application of feminist principles to a broad array of theoretical frameworks and models. Adhering to feminist practices in family therapy requires therapists to examine personal and professional value systems, biases,

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and beliefs related to gender and power that affect therapeutic interaction. Central to the practices of feminist family therapy is the incorporation of a gender lens when working with families. Other important principles include empowerment by relying on the egalitarian role of the feminist therapist to facilitate shared power and a collaborative therapist–client relationship, analyzing how the stress of male and female gender conformity affects families, and using nongendered and culturally accurate lenses when working with families. Families themselves are considered to be the most powerful agent for change within the therapeutic setting. The role of the therapist is to support the family to mobilize their resources toward healthier functioning.

Major Concepts Feminist family therapy is undergirded by the notion that the “personal is political,” meaning personal experience is inextricably embedded in political situations, contexts, and realities. Major concepts stemming from this premise include attending to the role of values in the therapeutic process, gender as a primary organizing principle, identifying potential sources of oppression affecting the family, acknowledging clients as experts on their own experiences, consideration of individual family members as clients, and commitment to social change. Role of Values in the Therapeutic Process

Feminist family therapists challenge not only the assertion but also the possibility of “therapist neutrality.” Rather, therapists are encouraged to acknowledge the role of societal values in shaping ideas about gender, family, and power that both the client and the therapist bring to the therapeutic process. Additionally, the influence of the dominant discourse on therapy models is critically assessed. Gender as a Primary Organizing Principle

All members of society are subject to some form of gender socialization, which shapes beliefs and actions around roles appropriate for men and women. From the feminist perspective, no matter

the family form, interpersonal and family interactions should be conceptualized in this larger social context. As a central organizing structure, gender is overtly addressed in feminist family therapy. Feminist family therapy explores potential sociocultural causes of distress, such as the impact of gender socialization, rather than explanations rooted in pathology or blame. Identifying Potential Sources of Oppression

An analysis of oppression acknowledges that both women and men are subject to stereotypes and oppression, which constrain gender identity and expression as well as affect values and beliefs. Intersections of gender with other structures organizing society, including race, ethnicity, class, and sexual orientation, are also dynamically considered. Feminist family therapists collaboratively assess potential power inequities in clients’ relationships, mitigating further reinforcement of systemic oppressions. Clients as Experts on Their Experiences

Feminist family therapists challenge the idea of a “normal family,” which has traditionally been conceptualized as a nuclear family headed by a heterosexual couple. Instead, feminist family therapists affirm variations in family organization and function, with “normality” defined by the families themselves. Although sociocultural roots of distress are a shared occurrence for the whole family, each family is unique, and each member of the family, as well as the whole family, is considered an expert on the experience of family life and on how the family functions. Because the therapeutic relationship is based on shared power between the therapist and the family, the therapeutic relationship is thus seen as an egalitarian alliance for change. Therefore, families’ unique insights and perceptions inform the family assessment process and serve as a focus of therapy. Consideration of Individual Family Members as Clients

“The family” as a system is primarily defined as the client in traditional models of family therapy. While feminist family therapists appreciate

Feminist Family Therapy

the importance of this unit, the impact of larger societal contexts (e.g., culture, religious affiliation, societal values) on the interactions, identities, power, and well-being of individual members is critically assessed. Therapeutic interventions are introduced with consideration of the effects that system-level changes may have on individuals based on their position in the family. The influence of power differentials on individual choices, responsibility, and family dynamics is prioritized. Commitment to Social Change and Advocacy

Social contexts are central to feminist family therapy. Therapy aims to assist families in understanding, critically examining, and effectively renegotiating gender- and power-based oppressions to develop more egalitarian relationships. Social change is pursued at multiple levels. At the personal level, advocacy involves identifying skills, abilities, and resources through education, training, employment, and other endeavors. At the interpersonal level, the counselor encourages activities such as mentoring, networking, and group work as a means to facilitate empowerment. In the broader social arena, actions that implement social justice and civil rights laws and policies promote access to the resources and opportunities of human rights.

Techniques Feminist family therapy is value driven rather than technique driven. While not exhaustive, the following interventions help enact gender-informed practice that attends to power differentials and cultivate equality within and through the therapeutic process. Egalitarian Role of the Feminist Therapist

Feminist family therapists recognize inherent power imbalances between the client and the therapist. Families are considered the “experts,” with therapists serving as collaborative facilitators. Families and therapists work together to jointly construct the goals and processes of therapy. Judicious therapist self-disclosure may be used to reduce power differentials and foster mutuality.

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Consciousness-Raising

Consciousness-raising helps families connect their personal experiences to broader consequences of a gendered society. As blame lifts from the family itself, clients become empowered to take action not only to promote personal change but also to affect oppressive hegemonic structures. Consciousness-raising may occur through small, leaderless group discussions where families, or individual members, have the opportunity to discuss and share their stories. Through these discussions, experiences become normalized, networks of support are cultivated, and solutions for change may be generated. Bibliotherapy, the use of selected reading materials as therapeutic adjuncts, can also be used toward consciousness-raising with materials challenging clients’ perspectives about “normal” family functioning, gender roles, and relational power dynamics. Gender Role Analysis

Gender role analysis facilitates reconsideration of families as institutions shaped by the dominant discourse. The impact of gender socialization on each family member is explored, as well as how implicit and explicit sociocultural processes contribute to family functioning, presenting issues, and/or well-being. Therapists may use focused discussions or experiential activities to examine external forces (e.g., families of origin, media, societal messages) influencing behavior and relationships. As families begin to understand the influence of socially informed gender roles, they can be supported in renegotiating more desirable gender constructs within their system. Power Analysis

Power analysis assists families in identifying power differentials in relationships, as well as how these dynamics are connected to broader systemic inequities. Families are assisted in recognizing the different kinds of power they may possess, exert, relinquish, or be denied within the family and larger society. Dimensions of family functioning to consider in power analysis include communication and decision-making patterns, system-level prioritization of career aspirations, distribution of

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household and parenting responsibilities, ideas about sex and intimacy, and financial oversight. Resocialization

Resocialization may be applied following a family’s analysis of gender roles and power. Resocialization entails a paradigm shift in which families’ belief systems are reorganized to move from a blaming or pathologizing stance to one that is attentive to sociocultural causes of distress. Therapists accept and validate feelings while also actively reframing and relabeling concerns to reinforce deconstructions of power and detrimental social norms. With the permission of the family, therapists may choose to integrate assertiveness training, analysis of distorted cognitions, and communication skills training, among other interventions, to help develop new coping skills and strategies.

families and therapists. Throughout the therapeutic process, the family is seen as the expert, and the emphasis in therapy is an exploration of the impact of gender and culture on family functioning. Decisions regarding the number of sessions and assessment of goals are more likely to be determined collaboratively. Providing an environment for families to consider the larger social context as related to the challenges experienced internally encourages creative and affirming strategies for creative solutions. Victoria A. Foster and Jessica Lloyd-Hazlett See also Bibliotherapy; Constructivist Therapy; Couples, Family, and Relational Models: Overview; Feminist Therapy; Integrative Family Therapy; Narrative Family Therapy

Further Readings

Social Activism

As the underlying roots of family distress are considered to originate from oppressive sociocultural structures, changes occurring in therapy may not be sustainable without parallel changes also occurring to the dominant discourse in society. Thus, social change is considered crucial for endorsing policies and shifts in the public arena that support healthy family functioning. Engaging in social activism also may be empowering for client family members. Forums for social activism include speaking out in the community, joining organized protests, participating in letter-writing campaigns, lobbying for legal actions, and advocacy within professional organizations. Social activism may involve the therapist and the family members jointly; however, not all feminist family therapists support such joint engagement with clients in activism. While the therapy process is considered a partnership, negotiating appropriate boundaries in family therapy is central to ethical practice.

Becvar, D., & Becvar, R. (2006). Family therapy: A systemic integration (6th ed.). New York, NY: Pearson Education. Haddock, S. A., Zimmerman, T. S., & MacPhee, D. (2000). The power equity guide: Attending to gender in family therapy. Journal of Marital and Family Therapy, 26(2), 153–170. doi:10.1111/j.1752-0606.2000.tb00286.x Hare-Mustin, R. T. (1978). A feminist approach to family therapy. Family Process, 17(2), 181–194. doi:10.1007/978-1-4684-4754-5_20 Hoffman, L. (2011). Exchanging voices: A collaborative approach to family therapy. London, England: Karnac Books. Trask, B. S., & Hamon, R. R. (Eds.). (2007). Cultural diversity and families: Expanding perspectives. Thousand Oaks, CA: Sage. Walsh, F. (2006). Strengthening family resilience. New York, NY: Guilford Press. Walsh, F. (Ed.). (2011). Normal family processes: Growing diversity and complexity. New York, NY: Guilford Press.

Therapeutic Process Feminist family therapy describes a therapeutic framework that identifies the social construction of gender and inequality as central themes in family analysis. The core principles of feminist family therapy are applied across family therapy models to facilitate collaborative relationships between

FEMINIST PSYCHOANALYTIC THERAPY Feminist psychoanalytic therapy is a contemporary psychoanalytical approach to therapy that has influenced the way in which many psychotherapists think about and work with both female and

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male clients. While certainly not consistently feminist, Sigmund Freud (1856–1939) is arguably the first feminist psychoanalytic therapist in that he took seriously the symptoms and experiences of the young women he was treating. Unlike other medical professionals of his day who dismissed young women’s seemingly hysterical symptoms as irrational and untreatable, Freud studied the ways in which psychological symptoms manifest themselves in women, often in response to genderspecific experiences and limitations in their family and social lives. Therapists who take seriously and do not immediately pathologize the symptoms and dilemmas with which their female clients present— low self-regard, struggles with food and eating, difficulties with boundaries and limits, struggles with being vulnerable, trouble with asserting themselves, sexual dissatisfaction, difficulties with control—represent the legacy of Freud’s initial interest in and study of women. Feminist psychoanalytic therapy is more a stance and set of questions than a particular technique. That is, feminist psychoanalytic therapists practice using different techniques—some use contemporary relational techniques in therapy, whereas others use more classical interpretive techniques in therapy—but their work with clients is animated by similar questions. Rather than assuming that men and women follow similar developmental trajectories, feminist psychoanalytic therapists argue that men and women develop differently depending on a variety of factors. The kinds of questions that a feminist psychoanalytic therapist might use to inform her or his work include the following: How has the client’s relationship with her same-gender parent affected her development and identity? How has the client’s relationship with his different-gender parent affected his development and identity? Who was the client’s primary parent, and how has that relationship affected her development? What is the role of gender in the client’s development? How have sexism and gender inequality affected the client?

Historical Context Feminist psychoanalytic therapy developed in direct response to early psychological approaches that assumed male and female development to be the same, downplayed the role of the mother in the development of children’s independence,

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pathologized women, and denied the role of sexism and gender-based trauma in women’s development. Because many of Freud’s patients were women and he was male, because his work occurred during the Victorian era, during which gender prescriptions were quite rigid, and perhaps because of his own personal experiences of gender, Freud focused on the differences between male and female development generally and the development of gender in particular. Other theories at the time generally did not concern themselves with differences in male and female development but instead assumed male development to be the norm. Freud insisted that biological sex is not the same as acquired gender, that biology is not destiny, and that gender is made and not inborn. He did not go quite as far as subsequent theorists in making these claims, and at times, he may have sounded deterministic, as though biology is in fact destiny. But the tools and insights he provided us with are invaluable in understanding the social and familial aspects of gender.

Theoretical Underpinnings Freud made the radical claim that men are made and not born and that boys’ development into men who are heterosexual needs to be explained and is not just natural. Freud developed the theory of the Oedipus complex to account for how men are made from boys who are originally attached to their mothers. It explains how they become men who identify with their fathers and romantically love women other than their mothers. For Freud, the puzzles to be solved in male development include the following: How and why does masculinity develop given that it is women who are most centrally involved in child rearing? How do heterosexual boys shift their love from their mothers to other women? Why would a boy ever give up a mother’s love and his love for her? Freud argued that girls face some similar developmental dilemmas to boys, as well as some that diverge from those of male development. The questions as he saw them were as follows: How does femininity develop, and why do women submit to its limitations? How do heterosexual girls shift their love from their mothers to their fathers and then to other men? Why would a girl ever give up a mother’s love and her love for her mother? How and why do girls change the organ from which

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they derive pleasure from the clitoris to the vagina? While psychologists now recognize this last question as misguided, the other questions remain relevant and important in understanding women’s development. The theory of the Oedipus complex has been critiqued over the years by feminists and gays and lesbians (Jessica Benjamin, Nancy Chodorow, Richard Isay, and Gloria Steinem, to name a few), who argue that it holds the penis in too high regard, that it assumes that maturity entails heterosexuality, and that it considers fathers alone responsible for facilitating separation and individuation. While Freud certainly acknowledged the role of mothers in children’s development, his psychoanalytical theory was still a sexist theory in that it highlighted the role of fathers in helping children, boys and girls, to differentiate and separate from their parents. We now know about the crucial role of early attachment (with either parent) in children’s ability to form a self capable of both separateness and relatedness. But early psychoanalytical theory was more likely to see maternal attachment as merger and overinvolvement. And for many years, psychoanalysts highlighted the role of the father in children’s development as the crucial interrupter of such presumed maternal overinvolvement and merger with their children. While Freud was impressive for his time in his insistence that women’s symptoms had meaning and in his puzzling over male versus female development, early psychoanalysis is nonetheless rife with the pathologizing of women. Freud argued that successful female development should result in women giving up the clitoris as a source of sexual pleasure in favor of the vagina, something that is now commonly accepted as absurd. Freud and many of his contemporaries also took as a given that the penis is inherently superior to the vagina—that even young girls would recognize this clear superiority and would consequently envy men and boys and feel contempt and anger for their own mothers, who lack a penis. Freud worked with female clients to accept the “reality” of their femininity and inferiority; at the same time, he recognized the difficulty in doing so. Even contemporary psychoanalysts sometimes continue to pathologize women. As recently as the 1990s, some therapists were still diagnosing female victims of domestic violence with masochistic

personality disorder. This diagnosis was based on the assumption that victims of domestic violence were drawn to abusive men due to personality traits, rather than acknowledging that domestic violence systematically traumatizes all people, drawing them into a cycle of abuse that is difficult to escape. Other therapists also still blame mothers for multiple diagnoses such as schizophrenia and autism, whose etiologies are understood to be organic in nature. Finally, feminist psychoanalytic therapy grew out of the denial of sexual trauma in women’s lives that plagued both early psychoanalytical thinking and society. While in early stages of his thinking, Freud acknowledged the role of sexual trauma in the development of psychological symptoms (a radical acknowledgment for his time); he subsequently abandoned this thinking in favor of a theory of childhood fantasies of sexual abuse and trauma. Subsequent feminist psychoanalytic therapy has acknowledged the role of childhood sexual fantasy while not denying the realities of childhood sexual abuse.

Major Concepts Major concepts in feminist psychoanalytic therapy are often a function of the theorist who is describing the approach. Based on this delineation, the following major concepts are distinguished: deconstructing the phallocentric nature of psychoanalytical theory, the role of mother and women, and post-oedipal development. Deconstructing the Phallocentric Nature of Psychoanalytical Theory

Early feminist psychoanalytical theorists such as Karen Horney, Ernest Jones, and Clara Thompson focused on questions of masculinity and femininity and tended to be therapists who sought to redress the phallocentric nature of early psychoanalytical theory. They made claims about girls’ early knowledge of the vagina (Freud claimed that girls were only aware of the clitoris), suggested that womb envy may be equally powerful and plausible as penis envy, and argued for a distinct line of female development that from early on differed from male development, not just with the onset of the oedipal stage. They based much of their thinking on clinical experiences with women patients who had

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lived experiences of their bodies and genders that diverged widely from Freud’s theory. Role of Mothers and Women

Anglo-American feminist psychoanalytical theorists in the 1980s and 1990s focused on preoedipal experiences with the mother and how the mother as the primary love object for both boys and girls shapes gender. Chodorow and Benjamin have had particularly far-reaching influence in the field of psychology. One of the central problems they addressed is that women, as the usual primary parent of children, occupy the difficult position of being all important to children, while being devalued by society and often by their own sense of self. Children, in the process of individuation, may also insist on devaluing all that is feminine and maternal within themselves, both to defend against the mother’s power and to assert their individuality. Girl children then have great difficulty in developing a female sense of self that is subjective and agentic, and boy children have difficulty relating to women without devaluing them. Chodorow and Benjamin were both influenced by psychoanalytical theorists such as D. W. Winnicott, Melanie Klein, and Margaret Mahler, who were not explicitly feminist or interested in gender in particular but who focused on attachment, the pre-oedipal period of development, and the important role of the mother in children’s development. Post-Oedipal Development

Contemporary feminist psychoanalytical theorists discuss and elaborate a post-oedipal developmental period during which gender is not solely an oedipal achievement, a final arrival at a solid and fixed gender identity that corresponds to one’s sexual anatomy. They are interested instead in gender fluidity. Contemporary theorists recognize the value of oedipal-level thinking about gender, in which rigid categories and binary oppositions predominate, in children but not in adults. Here, the child develops categories of thinking that organize his or her experience—male and female, black and white, can and cannot, subject and object, active and passive, and so on. It is developmentally appropriate that children should think using such categories; however, it is not developmentally appropriate that adults should remain at this developmental stage.

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Techniques While feminist psychoanalytic therapy does not have one particular technique to which all of its practitioners subscribe, most of them tend to be relational and informed by attachment, collaborative, and respectful of their client’s experience. Relational and Informed by Attachment

Therapists who take a relational approach informed by attachment understand that personto-person relating is one of the most central motivations that people have and that our relationships and attachments are central in the formation of our psychic structure. This is intended as an alternative to the classical psychoanalytical view that innately organized drives and their developmental vicissitudes are, at root, the basis of our motivations and of psychic structure itself. Therapists can be described to have a relational approach if they prioritize their clients’ ways of relating to others as central to understanding themselves. While understanding the way previous relationships inform current relationships is important, relational therapists also maintain that the therapeutic relationship creates a space where such relational dynamics are provoked and can be worked through, understood, and improved. Relational therapists may draw on dynamics that are occurring in the here-and-now within the therapeutic relationship to shed greater light on understanding clients’ relational dynamics and, hence, enable them to understand themselves more. Collaborative

Feminist psychoanalytic therapy is collaborative in that therapists generally work together with clients to develop greater understanding of their difficulties and to develop solutions. This is in contrast to a more authoritarian stance. Depathologizing Women

Because of psychology’s history of pathologizing women and their experience, feminist psychoanalytic therapists pay close attention to their female, and male, clients’ lived experiences and seek to understand maladaptive behaviors in the possibly sexist context in which they developed.

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Therapeutic Process Feminist psychoanalytic therapy can be either short-term or long-term depending on the presenting issue and the client’s level of distress and interest. Therapists maintain an empathic focus on the client’s authentic needs and desires, which may have become muted or confused in a sexist environment. Over time, clients develop more internal freedom to experience and express a range of needs and desires, an increased capacity to act on those desires and advocate for themselves, and a greater ability to develop and sustain satisfying relationships. Leslie C. Bell See also Attachment Theory and Attachment Therapies; Classical Psychoanalytic Approaches: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Feminist Therapy; Freud, Sigmund; Freudian Psychoanalysis; Horney, Karen; Interpersonal Psychoanalysis; Interpersonal Theory; Intersubjective Group Psychotherapy; Klein, Melanie; Mahler, Margaret; Object Relations Theory; Relational Psychoanalysis; Winnicott, Donald

Further Readings Bell, L. (2005). Psychoanalytic theories of gender. In A. H. Eagly, A. E. Beall, & R. J. Sternberg (Eds.), The psychology of gender (2nd ed., pp. 145–168). New York, NY: Guilford Press. Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminisms, and the problem of domination. New York, NY: Pantheon Books. Breuer, J., & Freud, S. (1953). Studies on hysteria (J. Strachey, Ed. & Trans.; 2nd ed.). London, England: Hogarth Press. (Original work published 1895) Chodorow, N. J. (1978). The reproduction of mothering: Psychoanalysis and the sociology of gender. Berkeley: University of California Press. Flax, J. (1990). Thinking fragments: Psychoanalysis, feminism, and postmodernism in the contemporary west. Berkeley: University of California Press. Freud, S. (1961). Some psychical consequences of the anatomical distinction between the sexes. In J. Strachey (Ed. & Trans.), The complete psychological works of Sigmund Freud (Vol. 19, pp. 241–258). London, England: Hogarth Press. (Original work published 1925)

Freud, S. (1964). Femininity. In J. Strachey (Ed. & Trans.), New introductory lectures on psycho-analysis (pp. 139–166). New York, NY: W. W. Norton. (Original work published 1932) Horney, K. (1932). The dread of women. International Journal of Psycho-Analysis, 13, 348–360. Irigaray, L. (1985). Speculum of the other woman (G. C. Gill, Trans.). Ithaca, NY: Cornell University Press. (Original work published 1974) Kristeva, J. (1987). In the beginning was love: Psychoanalysis and faith. New York, NY: Columbia University Press. Rivière, J. (1929). Womanliness as a masquerade. International Journal of Psychoanalysis, 9, 303–313. Thompson, C. (1943). “Penis envy” in women. Psychiatry, 6, 123–125.

FEMINIST THERAPY Contemporary feminist therapy draws from feminism as a concept, movement, and theory by examining and addressing power hierarchies in society that disempower individuals and groups. Conceptually, feminism is a belief in the equality of women and men on social, economic, and political levels. This conceptual understanding of feminism was later expanded to include actions aimed at advocating and promoting gender equality, which marked the beginning of many contemporary feminist movements and a burgeoning body of scholarship that focused on feminist theory and practice. Today, the number of mental health professionals who utilize feminist therapy is growing and expanding across geographic borders to international locales.

Historical Context The “herstory” of contemporary feminist therapy is rooted in the women’s movement of the 1960s. During this time, women (mostly white middleclass women) expressed dissatisfaction with their social status and worked together at the grassroots level to change the social, economic, and political conditions of the time (e.g., unequal access to education, sexism at work, and the inability to exercise reproductive rights). In an effort to increase awareness and openly discuss these issues, women

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across the nation began to form small, leaderless consciousness-raising groups within their homes and communities. These groups served as an impetus for various forms of social action, from opening the doors of higher education for women to the creation of laws that promoted gender equality. With each wave of the feminist movement, a new generation of diverse feminist leaders emerged to continue fighting for equality and justice. Much like the consciousness-raising groups that spurred the women’s movement, feminist therapy emerged as a new modality with no single creator but, rather, a multitude of leaders who shared a commitment to a feminist agenda within the field of mental health. Influential works emerged during the late 1960s and early 1970s that exposed sexist and oppressive practices within therapy as well as the unheard voices of women in research as participants and scholars. Present-day organizations (e.g., Association for Women in Psychology and the Society for the Psychology of Women) and publications (e.g., Psychology of Women Quarterly, Sex Roles, and Women and Therapy) continue to highlight these issues both nationally and internationally and advocate for societal transformation. Historically, the focus of feminist therapy centered on the lived experiences of women; today, this modality has been expanded to include the experiences of diverse individuals across the gender spectrum. These experiences are examined within the sociopolitical and historical context in which they occur; that is, the client and her or his context are understood as interrelated and interdependent. This bidirectional relationship is reflected in the phrases “the personal is political” and “the political is personal”—both of which serve as guiding notions for individual and societal transformation. In helping clients challenge oppressive structures within and beyond the therapeutic walls, feminist therapists aim to create a world of equal opportunity and empowerment.

Theoretical Underpinnings The foundation of feminist therapy comprises distinct ways in which power and distress are conceptualized. From a feminist lens, distress is viewed as a natural consequence of a patriarchal and disempowering society. That said, members of the nondominant culture (e.g., women, racial and sexual

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minorities, and non-able-bodied individuals) are placed in a subordinate status, which is oftentimes linked with deviance and abnormality. To further understand the various forms of oppression that these groups experience, it is important to examine the various types of power that influence well-being. Each individual possesses some type of power. Feminist therapists see power as existing in four realms: (1) the physical body, (2) the psychological self, (3) one’s interpersonal and social context, and (4) spirituality and life meaning. Power within the realm of the body refers to one’s connection with one’s biological needs and overall physical functioning. This realm of power also includes demonstrating respect for how the body keeps one safe and healthy. Power within the realm of the psychological self involves one’s flexibility with regard to the opinions of self and others. This realm of power also includes the ability to soothe the self without causing harm to others and to experience an array of emotions in healthy, developmental ways. Power within the interpersonal and social realm includes one’s ability to engage with others in healthy relationships while maintaining boundaries that support a strong sense of self. This realm of power also includes one’s ability to end relationships that are not healthy while also demonstrating compassion for the strengths and shortcomings of self and others. Finally, power within the realm of spirituality and life meaning refers to one’s ability to find a purpose that aligns with one’s worldview and multiple identities. This realm of power also includes awareness of the ways one’s spirit is nurtured. Although there are several ways in which a client can be disempowered, there are five primary forms of disempowerment recognized within feminist therapy. The first, coercive power, includes manipulating others, oftentimes through the use of rewards for one’s personal gain. The second includes using power that is inherent to one’s position of authority to change another’s behavior and is often referred to as legitimate power. The third, expert power, involves using one’s higher status to influence the behavior of another. The fourth, informational power, involves withholding or disseminating information that might result in a change in the behavior of others. The fifth, referent power, refers to the changing of one’s behavior based on identifying with the person requesting the change.

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Feminist therapists believe that distress due to disempowerment is the primary reason why clients seek mental health services. Essentially, the roots of ineffective behaviors and coping strategies represent experiences with disempowerment. Therefore, the major concepts, approaches and strategies, and therapeutic process are designed around the goals of reinstating power to those who are experiencing powerlessness.

Major Concepts Major concepts for feminist therapy, which may be better understood as guiding principles, include the personal is political, the primacy of the egalitarian relationship, honoring diverse experiences, and empowerment. The commitment to equality runs through each of these guiding principles and shapes a feminist therapist’s role as a clinician, educator, and advocate. In understanding and integrating these guiding principles into practice, transformation can occur within the individual, community, and larger culture. The Personal Is Political

The statement “the personal is political” was a product of the women’s movement. Feminist therapists adopted this statement as a guiding principle to demonstrate that the problems of one woman are actually the problems of many women and that these problems are not rooted in the individual but rather in the larger historical and sociopolitical context. More recently, this statement has also been used in its reverse form, “the political is personal,” to demonstrate the complexity of the bidirectional relationship between the experiences of many diverse individuals and their contexts. In an effort to address oppressive dynamics within these existing relationships, feminist therapists work with and on behalf of clients to promote empowerment and societal change. The Primacy of the Egalitarian Relationship

The egalitarian relationship—marked by mutuality, authenticity, safety, and respect—lies at the heart of feminist therapy. Feminist therapists acknowledge and aim to minimize the inherent power differential that exists within the therapeutic relationship as a result of their evaluative role.

In doing so, they utilize approaches and strategies that empower clients without violating professional responsibilities and standards of practice. Feminist therapists view clients as experts and honor their knowledge, skills, and experiences throughout the therapeutic process. Honoring Diverse Experiences

Traditional theory and practice have primarily focused on the experiences of men, placing women’s experiences on the margins. Therefore, feminist therapists aim to honor women’s experiences with the goal of equally valuing the realities of all individuals. Additionally, feminist therapists seek to understand these realities in the context in which they occur (e.g., the historical, social, and political climate) and place special emphasis on intersecting and interlocking social identities (e.g., gender, age, ability, race, and ethnicity). Put simply, feminist therapists take a diverse, complex approach to client conceptualization that honors diverse experiences. Empowerment

Because of the relationship between powerlessness and distress, empowerment plays a pivotal role in the therapeutic process. To foster empowerment, feminist therapists create an affirmative environment and utilize strategies that aim to help clients navigate a disempowering society. For example, feminist therapists are likely to discuss the role of culture as it relates to a client’s distress instead of placing personal blame. This strategy, as well as others, aims to help clients regain power over their lives and create meaningful, long-lasting personal and social change.

Techniques Feminist therapists draw from a wide range of techniques from multiple modalities to meet the unique needs of each client and align with feminist models of change. Two primary analyses, considered distinctive to feminist therapy, are gender role analysis and power analysis. These approaches, which aim to reduce oppression and promote empowerment, are briefly described in this section.

Feminist Therapy

Gender Role Analysis

The lived experiences of clients are shaped by direct and indirect societal messages that dictate gender role expectations. These expectations, spanning from childhood to adulthood, often stem from important figures (e.g., family members, teachers, and community members) and the broader social context (e.g., social media). During gender role analysis, a feminist therapist works with the client to identify these messages and evaluate how they have influenced her or his thoughts, feelings, and behaviors. With increased insight, the client becomes aware of harmful messages that have been internalized—that is, adopted as part of her or his identity. Then, the feminist therapist and the client explore whether and how to challenge them. Once a plan has been developed, the feminist therapist works with the client to implement the desired changes. Power Analysis

Power is often tied to discussions of gender in the therapy process, with a particular emphasis on the oppression of women and sexual minorities (e.g., gay, lesbian, bisexual, and transgender individuals). These groups are often awarded less privilege in an androcentric culture—that is, a culture that centers on men’s experiences. In an effort to address the competition of power, feminist therapists utilize this form of analysis to promote sharing of power among individuals and groups. Power analysis involves analyzing various forms of power from the vantage of the dominant and subordinate group, emphasizing the role of influencing forces (e.g., racism, sexism, and heterosexism) and internalized messages. Following analysis, feminist therapists empower clients in subordinate and dominant positions to dismantle power hierarchies within one-on-one interactions and/or the broader social structure.

Therapeutic Process The overarching goals of feminist therapy are to increase the client’s awareness of existing privilege and oppression, promote a deeper understanding of the relationship between the client’s distress and her or his environment, and empower the client to take ownership of change. This section provides a brief

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overview of six important aspects of the therapeutic process through the lens of feminist therapy: (1) counselor self-awareness, (2) the egalitarian relationship, (3) assessment and conceptualization, (4) diagnosis, (5) approaches and strategies, and (6) therapeutic closure. By weaving these aspects into the therapeutic process, feminist therapists acknowledge their role as mental health professionals and adhere to ethical codes and standards of practice. Counselor Self-Awareness

Throughout the therapeutic process, feminist therapists critically examine their worldview, values, privilege, and life experiences and how they affect their responses toward the client, therapeutic relationship, and therapeutic process. Additionally, feminist therapists reflect on their training and theoretical preferences and any strengths and limitations therein. By engaging in this ongoing and reflective process, feminist therapists reduce the likelihood of adversely imposing their biases and assumptions. Egalitarian Relationship

There is an inherent power differential present in the therapeutic relationship, with feminist therapists being perceived as the experts over the therapeutic process. This power differential is not congruent with the history and theoretical underpinnings of feminist therapy. Therefore, feminist therapists are  intentional about demonstrating awareness of the power imbalance as well as taking steps to equalize the power distribution. Specific strategies include demystification of the therapeutic process (e.g., providing an overview of feminist therapy and fully explaining any approaches and strategies to be used), empowerment (e.g., relabeling distressing experiences as the result of societal oppression), and identifying client strengths (e.g., focusing on client resilience vs. pathology). These strategies allow both feminist therapists and clients to coconstruct meaning and identify ways to challenge oppressive practices. Assessment and Conceptualization

Assessment and conceptualization begin with the feminist therapist attempting to fully understand the client’s multiple and intersecting identities

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(e.g., older adult, female, and mother from a rural area). Then, the feminist therapist assesses the meaning of these identities within the client’s family and social circle, culture, and larger sociopolitical context. For example, the feminist therapist might ask in what ways the client is rewarded or penalized for her or his cultural identities within these contexts. Finally, the feminist therapist and the client work together to understand the nature of the distress and what is hoped to be achieved with current behaviors and/or coping strategies. Using a feminist lens for assessment and conceptualization allows an opportunity for increased awareness of the roles privilege and oppression play in the client’s life. Diagnosis

There is contention among feminist therapists about the role of diagnosis in mental health. Feminist therapists believe that diagnoses are based on the dominant culture’s idea of normalcy and do not adequately account for cultural differences. Therefore, some feminist therapists eschew diagnosis, while others use it with caution, recognizing that diagnosis is the mainstay of mental health services and is often required by agencies before services can be rendered and third-party payment can be obtained. After a diagnosis has been done, feminist therapists take steps to ensure that power is not abused. To achieve this, feminist therapists could review the process (e.g., review diagnostic criteria with the client) and discuss the pros (e.g., securing third-party payment) and cons (e.g., diagnosis may become part of the client’s medical record) of the diagnosis. The client is then provided an opportunity to discuss her or his reactions to the diagnosis. Approaches and Strategies

Unlike many traditional approaches, feminist therapists collaborate with clients to establish goals congruent with the client’s objectives for seeking therapy. Once these goals are established, the feminist therapist implements a variety of therapeutic strategies that align with a feminist approach. The strategies can be specifically related to feminist therapy (see the “Techniques” section) or can be associated with other theories or therapeutic modalities. As with other components of the therapeutic

process, feminist therapists explain the purpose, goals, and process of each approach or strategy. Feminist therapists also honor the client’s expertise and ability to make informed decisions by consistently assessing the client’s perception of progress. In the event that the client reports insufficient progress, the feminist therapist and client collaborate to determine how best to move forward. Therapeutic Closure

Once the client has achieved the goals she or he had set for herself or himself, it is time for the feminist therapist and the client to conclude therapy. The feminist therapist needs to provide plenty of time for the conclusion of therapy, be attentive to any reactions of the client, and fully prepare the client for the absence of therapy. One of the ways in which the feminist therapist can do this is by slowly shifting the focus to social change. After the client has reached her or his goals, she or he can engage in advocacy and social justice initiatives that align with her or his passions and personal agenda. Cassandra G. Pusateri and Jessica A. Headley See also Cross-Cultural Counseling Theory; Feminist Family Therapy; Feminist Psychoanalytic Therapy; Gender Aware Therapy; Relational-Cultural Theory

Further Readings Broverman, I. K., Broverman, D. M., Clarkson, F., Rosenkrantz, P., & Vogel, S. (1970). Sex role stereotyping and clinical judgments of mental health. Journal of Consulting and Clinical Psychology, 45, 250–256. Brown, L. (2010). Feminist therapy. Washington, DC: American Psychological Association. Chesler, P. (1972). Women and madness. New York, NY: Doubleday. Colins, K. A. (2002). An examination of feminist psychotherapy in North America during the 1980s. Guidance and Counseling, 17, 105–112. Crethar, H., Rivera, E. T., & Nash, S. (2008). In search of common threads: Linking multicultural, feminist, and social justice counseling paradigms. Journal of Counseling & Development, 86, 269–278. doi:10.1002/j.1556-6678.2008.tb00509.x Enns, C. Z., & Williams, E. N. (Eds.). (2013). The Oxford handbook of feminist multicultural counseling psychology. New York, NY: Oxford University Press.

Focused Brief Group Therapy Evans, K. M., Kincade, E. A., Marbley, A. F., & Seem, S. R. (2005). Feminism and feminist therapy: Lessons from the past and hopes for the future. Journal of Counseling & Development, 83, 269–277. doi:10.1002 /j.1556-6678.2005.tb00342.x Evans, K. M., Kincade, E. A., & Seem, S. R. (2011). Introduction to feminist therapy: Strategies for social and individual change. Thousand Oaks, CA: Sage. Feminist Therapy Institute. (1999). Feminist therapy code of ethics (revised). Retrieved from http://www .chrysaliscounseling.org/Feminist_Therapy.html Hill, M., Glaser, K., & Harden, J. (1998). A feminist model for ethical decision making. Women & Therapy, 21, 101–121. doi:10.1300/J015v21n03_10 Hill, M., & Jeong, J. Y. (2008). Putting it all together: Theory. In M. Ballou, M. Hill, & C. West (Eds.), Feminist therapy: Theory and practice (pp. 135–151). New York, NY: Springer. Kahn, J. S. (2011). Feminist therapy for men: Challenging assumptions and moving forward. Women & Therapy, 34, 59–76. doi:10.1080/02703149.2011.532458 Nelson, M. L., Gizara, S., Hope, A. C., Phelps, R., Steward, R., & Weitzman, L. (2006). A feminist multicultural perspective on supervision. Journal of Multicultural Counseling & Development, 34, 105–115. doi:10.1002/j.2161-1912.2006.tb00031.x Porter, N. (2010). Feminist and multicultural underpinnings to supervision: An overview. Women & Therapy, 33, 1–6. doi:10.1080/02703140903404622 Weisstein, N. (1968). Kinder, kuche, kirche as scientific law: Psychology constructs the female. Boston, MA: New England Free Press. Williams, E. N., & Barber, J. S. (2004). Power and responsibility in therapy: Integrating feminism and multiculturalism. Journal of Multicultural Counseling & Development, 32, 390–401.

FISCH, RICHARD See Palo Alto Group

FOCUSED BRIEF GROUP THERAPY Focused brief group therapy (FBGT) is a semistructured, integrative, interpersonal group therapy approach designed to accurately and reliably target reductions in interpersonal distress in eight or

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fewer sessions. Based on a brief version of Irvin Yalom’s interpersonal process group model, it incorporates an evidence-based measure of interpersonal distress, the Inventory of Interpersonal Problems (IIP-32), to bring focus to clients’ therapeutic work. The approach employs evidence-based practice ideas, such as the promotion of the working alliance and group cohesion. Process and outcome assessment results are also presented transparently and in real time to clients, thereby allowing for adjustments in treatment—a practice-based evidence approach.

Historical Context Interpersonal problems have been implicated in a wide range of mental health issues. Interpersonal distress can lead to depression, social anxiety, and a wide range of other diagnostic presentations. Successful treatment of interpersonal issues can directly ameliorate these problems as well as act as a buffer against future distress. FBGT was developed by Martyn Whittingham while at Wright State University’s counseling center between 2006 and 2013. At the time, Wright State University was primarily a commuter campus, and the counseling center operated within the university’s 8-week quarter system. The model was developed to generate measurable reductions in interpersonal distress within a very brief treatment window for university students with a wide range of diagnoses and presenting problems. To aid in this process, group therapy screening, process, and outcome assessments from the CORE-R Battery—a compendium of evidencebased group therapy assessment tools put together by the American Group Psychotherapy Association’s Science to Service Task Force—were used. They informed each aspect of the group with data points that aided the therapist in developing a strong working alliance, in promoting client motivation, and in anticipating and intervening with problematic group dynamics. The model was constantly adjusted based on feedback from the data collected, supervisory notes, and group leader suggestions. Multiple research projects took place evaluating its effectiveness, with most of them focusing particular attention on understanding how clients with different types of interpersonal distress (too socially

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inhibited, too focused on others, or too domineering) were changing in response to the FBGT intervention. Research findings on a college population have shown reductions in depression, social anxiety, hostility, total interpersonal distress, and individualized subscales of interpersonal distress. The assessment innovations in this approach were awarded the Group Practice Award by the Association for Specialists in Group Work in 2010.

Circumplex methodology is widely used in FBGT to focus treatment goals, anticipate group dynamics, manage coleader dynamics, and anticipate transference. The setting of behavioral goals and promotion of behavioral activation during the group therapy itself are key theoretical concepts within this approach. Feedback from other group members after a behavioral activation also serves as a behavioral reinforcer, while simultaneously disconfirming clients’ worst fears around expected rejection from others.

Theoretical Underpinnings FBGT takes a theoretically integrative approach to maximizing the means by which a client may make changes. Rapid promotion of insight takes place during the group screening, followed by setting of behavioral goals, all mediated by a strong working alliance. Behavioral activation then takes place during the here-and-now of the group, thereby also mobilizing Yalom’s therapeutic factors. Individualized debriefings also encourage self-efficacy by transparent sharing of assessment results and discussion of continuity of care. Thus, many approaches to change are present but are organized in a coherent, mutually reinforcing way that builds progressively from start to finish. The group process is based on Yalom and Molyn Leszcz’s model of group interpersonal therapy that utilizes the activation of the here-andnow followed by process illumination. It assumes that the social microcosm operates in groups and that as group members participate in the life of the therapy group, they invariably act out the same interpersonal strategies that are proving problematic to them in the outside world. FBGT utilizes the IIP-32 to help clarify the specific focus of a client’s interpersonal distress. Leonard Horowitz, Lynn Alden, Jerry Wiggins, and Aaron Pincus’s empirically validated circumplex assessment tool, the IIP-32 maps where clients are most distressed in their interpersonal life. Each self-report contains eight scores, mapped around two main axes—(1) agency (related to assertiveness vs. nonassertiveness) and (2) affiliation (related to distance vs. warmth)—and a total distress score. In FBGT, the properties of the IIP32 instrument are unchanged, but the names of the scales are altered to reflect client strengths rather than focusing on an underlying pathology.

Major Concepts Some of the major concepts of FBGT include interpersonal flexibility; homeostasis; shame, guilt, and blame as the enemy of change; being multiculturally informed; and habituation to change. Interpersonal Flexibility

The main goal of FBGT is to generate a flexible style of interaction in clients that enables them to better meet their life goals. Rigidity and extremeness of interpersonal style is seen as linked to interpersonal distress but mediated by culture and context. That is, while in many cases interpersonal distress is caused by rigid ways of interacting, this can be significantly mediated, moderated, or even caused by culture, identity issues, and/or contexts. Thus, the screening seeks to understand the relative impact of interpersonal rigidity and cultural or contextual factors. Homeostasis

Clients and contexts are seen as homeostatic; that is, both people and systems prefer stability of interpersonal expectations and behaviors, even if those stable interactions cause unhappiness. For example, some people may continue to act in ways that are predictable to themselves and others, such as by being submissive, even in a situation when it is not a functional behavior, because they are familiar with their own behaviors and are prepared for the expected responses from others. Deviation from homeostasis can be terrifying because it is unfamiliar and there is often an expectation of rejection or disaster. This concept informs

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the methods of implementing change in FBGT, with only small changes in client behavior encouraged and reality then being tested to disconfirm any expected rejection. Thus, goals are set that are realistically achievable, and once the successful behavior has been attempted, they are reinforced with group leader–invited feedback from the other group members. By attempting small changes that are immediately reinforced and allaying fears of rejection, the possibility emerges of a new, more flexible way of interacting that allows the client to have more behavioral options. Shame, Guilt, and Blame as the Enemy of Change

Consistent with person-centered and interpersonal process approaches, clients are always treated with dignity and empathy. There is a working assumption within this approach that interpersonal behaviors of clients were learned at an early age and were a response to normal needs for time, love, and attention from their sometimes dysfunctional family of origin. Some of what they learned was therefore transferable to other situations, but in some cases, strategies did not generalize well, creating what interpersonal theorists describe as cyclical maladaptive patterns. By explaining that clients’ successful and unsuccessful interpersonal behaviors have always been based on “doing your best with what you knew,” clients are prevented from being tormented by shame and guilt from past decisions. This then allows them to take responsibility for any future changes. Multiculturally Informed

As clients are interviewed during screenings, they are invited to discuss how their context and multiple identities might be affecting their interpersonal distress. This is taken into account in formulating each client’s goals and in continuity of care. For example, a self-identified “gay, Latino” client may report feeling distressed at the poor quality of his interpersonal relationships. During screening, the group leader will then ask how the client’s multiple identities affect social situations and then collaboratively explore treatment options. For example, the aforementioned client may report not yet wishing to come out or explore his gay identity in a support

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group. However, if he is also distressed by and willing to work on a tendency to be too aggressive in his advice giving to close friends, then FBGT could offer a viable treatment. A later referral could then be made to an identity-based support group as the client progresses in his identity work. Once in an FBGT group, clients are also gently encouraged to explore issues of identity and difference as part of the interpersonal process. Habituation to Change

The research performed alongside the development of the model demonstrated a clear pattern. As clients reduced their distress by attempting new behaviors, they became distressed in attempting those new behaviors. In other words, change is anxiety provoking. The process of habituation is explained to clients, and the distress from growth framed as a positive sign of growth that will ultimately disperse as the new behavior becomes a habit.

Techniques FBGT relies on a number of techniques including book ending, rapid movement to insight during screening, debriefing, inoculation, working the axes, feedback loops, triangulation of data, use of note cards, and feet to the fire. Book Ending

The heavy emphasis on skillful, individualized screening and debriefing within this approach has been labeled “book ending.” Individualized screening is considered essential in rapid movement to insight, building the working alliance, and preventing group failure. Individualized debriefing after the group has finished is considered essential to both generalization and transfer and continuity of care. Rapid Movement to Insight During Screening

The IIP-32 is a self-report of interpersonal distress that each client fills out prior to group screening. The therapist scores the instrument and then shows the results to the client in a nonjudgmental manner, asking whether this is a problem the client is currently seeing in his or her life and asking how it is manifesting itself. By asking how many areas of the client’s life it is affecting, for how long, and in what

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contexts, a clearer working alliance is established by gaining agreement on what the specific interpersonal problem is. Moreover, this process is therapeutic in and of itself because it leads to insights. The insight is then translated into behavioral goals.

Feedback Loops

Feedback loops are mechanisms by which members give one another feedback regarding how they are being perceived after a behavioral activation. This results in behavioral reinforcement and the creation of new, adaptive schemas.

Debriefing

Similar to screening, outcome measures are used transparently with clients. During the individualized debriefing, clients are invited to share how they felt the group went for them and are also shown the outcome measures (typically, the IIP-32 and a quality-of-life measure) and invited to comment. The clients and the therapist compare notes to best establish how to move forward and either continue care or leave treatment and continue to implement new behaviors. Inoculation

Inoculation is a technique that was developed in response to a pattern of treatment failures that was identified early in the development of FBGT. The “high 8” interpersonal distress pattern (related to being overly socially uninhibited) was found to be causal in the collapse of groups as a group became overwhelmed by a group member’s intense, inappropriate early disclosure. By nonjudgmentally predicting this pattern during screening and then forming goals related to inhibiting the desire to overdisclose, this form of self-sabotaging is inoculated against. The group member is then able to reflect on the success of this approach of entering social relationships more cautiously and to generalize this to his or her life. Working the Axes

Group members who at times express differences from one another are often expressing a wish to distance themselves from an unacceptable part of themselves, similar to the Jungian idea of the shadow self. These clients are encouraged to explore with one another what aspects of the other person they would wish to embrace within themselves, albeit in a small way. For example, the aggressive, dominant, overly reactive client is encouraged to internalize the parts of his or her identity and behavioral repertoire that can be more considerate and thoughtful of others.

Triangulation of Data

At the end of the last group session and before the individualized debriefings, the group leaders meet by themselves to compare and contrast their clinical judgment with observed behavior changes and the clients’ self-reports from the IIP-32 and other outcome measures. This analysis can be useful in identifying group leaders’ blind spots that can be explored during individualized debriefing. For example, a client who reported during a group session that treatment was working but showed poor outcomes on his or her formal assessment may later reveal that he or she did not want to “bring the group down” by saying that his or her progress had recently been impeded by a relationship failure. This gives the group leaders a chance to explore this in more detail and collaboratively determine with the client in an individualized debriefing session what his or her treatment options are for moving forward. Use of Note Cards

In collaboration with each client, the therapist writes on note cards the client’s goals for the group. The therapist then distributes the cards at the beginning of each session and collects them at the end. The group leader then asks each member to read aloud his or her goals at the beginning of each session. Feet to the Fire

As the group sessions progress, the leaders’ invitations to members to work on their goals become more pointed, with attention on discussing what they are struggling with and whom they want to work on that with increasing as the end of group approaches. The invitations are always framed in a gentle, nonjudgmental, nonshaming way, which reflects the difficulty of trying new behaviors. The group leaders also must bear in

Focusing-Oriented Therapy

mind the baselines members bring with them to the group. For example, someone with severe social anxiety goals may be less involved than another group member; this individual would be considered to be performing extremely well if he or she was simply attending, listening, and occasionally contributing.

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Horowitz, L. M., Alden, L. E., Wiggins, J. S., & Pincus, A. L. (2000). The Inventory of Interpersonal Problems (IIP-32). San Antonio, TX: Psychcorp. Horowitz, L., & Strack, S. (2011). Handbook of interpersonal psychology. Hoboken, NJ: Wiley. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

Therapeutic Process Screening sessions and debriefing sessions are 30 to 45 minutes long, while group therapy sessions run for 90 minutes. Clients first complete the IIP32, which gives them a total score of interpersonal distress and also maps out their particular type of distress. Behavioral goals are formed during the screening process by showing the client the instrument and then collaboratively working with him or her to understand how the profile shown is causing distress. These goals are then acted out during the interpersonal group process. Sessions 1 and 2 involve the group leaders linking clients together, explaining the group process, and setting expectations. The process is warm and encourages group cohesion. Conflict is blocked and reframed. Sessions 3 through 7 are the working stages of the group in which members are encouraged into the here-and-now and then have the opportunity to work on their individual goals in the present moment. The group leaders are less active during these sessions. The last session is devoted to termination, and the leader again becomes active. The process throughout is warm, nonshaming, and encouraging of group cohesion. The group finishes with individualized debriefings. Martyn Whittingham See also Behavioral Activation; Common Factors in Therapy; Evidence-Based Psychotherapy; Functional Analytic Psychotherapy; Interpersonal Psychotherapy; Yalom, Irvin

Further Readings Burlingame, G. M., Strauss, B., Joyce, A., MacNairSemands, R., MacKenzie, R., Ogrodniczuk, J., & Taylor, S. (2005). American Group Psychotherapy Association’s CORE Battery—Revised. New York, NY: American Group Psychotherapy Association.

FOCUSING-ORIENTED THERAPY Focusing-Oriented Therapy (FOT) is an experiential therapy that uses Focusing to facilitate growth. Focusing is a process of noticing and attending to the felt sense, the bodily sensed, and the implicit understanding of situations. Focusing is also taught as a self-help skill, but this is different from its use in therapy. In FOT, the therapist uses Focusing in a therapeutic context, for example, to facilitate other therapeutic procedures.

Historical Context Eugene Gendlin, a philosopher interested in the relationship between explicit and implicit knowing, wanted to see how meanings could be present before they are described. Thinking that psychotherapy must be a place where this happens, he joined Carl Rogers’s clinic at the University of Chicago in the 1960s. There, a series of studies conducted by Gendlin and others showed that successful clients paid direct attention to their felt sense significantly more often than did unsuccessful clients (this finding has been independently replicated several times). Gendlin also developed a procedure, Focusing, to teach people how to pay direct attention to their felt sense, and an instrument, the Experiencing Scale, to measure the degree of attention. This work earned Gendlin the first Distinguished Professional Psychologist of the Year award ever given by the American Psychological Association. Focusing is now taught and practiced around the world as a self-help skill. There is also an informal organization of Focusing-oriented psychotherapists that holds a biannual convention and a formal organization that teaches FOT for complex trauma.

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Theoretical Underpinnings FOT is derived from Gendlin’s philosophy of the implicit (POI), which was created as an alternative to the philosophical assumptions inherent in most Western thinking. For example, Western concepts often implicitly assume inanimate, predefined entities such as molecules, neurons, or repressed memories. In contrast, POI and FOT assume organism– environment interaction that is always in process and therefore can’t be predefined; thus, a person is not just a physical body but in a situation, an ongoing organism–environment interaction. Four additional terms integral to the theoretical underpinnings of FOT are further discussed in this section: implicit knowing, implying, carrying forward, and felt sense. Implicit Knowing

Our living is an ongoing process of interaction with our environment and, thus, also a kind of “knowing.” This knowing is more than just verbal concepts. When we speak, for example, we implicitly “know” what to say even though it has never been said before. This “knowing” is also very precise; if we do not say quite “what we meant,” we notice and correct ourselves. However, it is not tied to particular words; if our listener does not understand, we can say “the same thing” again with different words.

misunderstood, “the same thing” is still implied; so we say “the same thing” again with different words. But if we are understood, then the situation has changed; there is a different implying, so we say something new. When implying changes in the way that was implied, we say that the situation has been carried forward. Felt Sense

Implying cannot be conceptualized and frequently cannot be carried forward by conscious deliberation. But we know implicitly what our situations need, and Gendlin showed that people can learn to direct attention to their implicit knowing. When this happens, implicit knowing is called a felt sense. A felt sense is the bodily “feel” for the implicit meaning of a situation. The felt sense is extremely helpful in psychotherapy. When clients have a fixed conceptual understanding of their situation, it is like their being unable to say “the same thing” over again in different words if they are misunderstood. If their single formulation doesn’t carry forward, they are stuck. In contrast, the ability to sense and symbolize experiencing freshly brings a larger understanding and new ways to carry forward.

Major Concepts Implying

Implying is a technical term in POI that can be thought of as what is “wanted” or “needed” in a particular situation. We speak and act from an implicit sense of what the situation “needs.” Implying is very precise but never fully expressed by any specific words or actions. There is a reason for this: Because living is a process of growth and change, it implies more than “just what it is” at any moment. A person standing in front of us implies a particular environment (situation), a meaningful past, and current possibilities—none of which can be fully defined or conceptualized. But although implying can’t be fully conceptualized, it isn’t chaotic. The POI shows that the implicit has its own order and precision, different from the order and precision of verbal concepts. Carrying Forward

Carrying forward refers to the emergence of the “more” that was implied. If we speak and are

A number of major concepts are central to understanding Focusing and include manner of experiencing, presence/focusing attitude, felt sense, and frozen structures. Manner of Experiencing

In contrast to an emphasis on the content of experience or speech, manner of experiencing concerns process, that is, how the client is experiencing at this moment. Is the client analyzing, telling stories, or experiencing the present moment with a richness of fresh detail? Presence/Focusing Attitude

To observe one’s ongoing felt experiencing, one must be interested, curious, open, and nonjudgmental. Above all, one must refrain from conceptualizing or labeling what is going on. Instead of “This tension in my chest is my fear of other

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people’s anger,” one might say, “It’s not exactly ‘tension’; it’s like something is curled up tight in there.” In the first instance, a bodily experience is being interpreted, whereas in the second, the bodily experience is described without being analyzed or interpreted. Felt Sense

A felt sense is a freshly forming, bodily sense of some life situation. Unlike an emotion, felt senses are intricate, unique, and often expressed in idiosyncratic language. The emotion might be “sad”; the felt sense might be “like a giant squid has its arms wrapped tight around me.”

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Inviting the Client to Check

After making an intervention, the therapist checks with the client for the experiential response to what was offered. This invites the client to further deepen awareness of his or her experiencing and gives the therapist immediate feedback about whether the intervention carried forward the client’s process. The Therapist’s Own Focusing

The therapist must be in contact with his or her own felt sensing for a variety of reasons—for example, to sense when the client is focusing and to model the focusing process for the client.

Therapeutic Process

Frozen Structures

Frozen structures are a manner of experiencing that is limited to only certain meanings of a situation. A client who has difficulty with authority figures might respond stereotypically to anyone perceived as an authority figure. Because frozen structures are closed to other meanings, they are not modified by new experience.

Techniques FOT uses techniques from many schools of therapy, always with special attention to the client’s manner of experiencing. Some of these techniques include empathic prompt, inviting a felt sense and staying with it, inviting a client to check, and a therapist’s own focusing. Empathic Prompt

The therapist might repeat the client’s words, adding the word something to bring attention to the place where a felt sense could emerge: “There is something there in your belly, something you are feeling, like ‘empty.’” Inviting a Felt Sense and Staying With It

Clients may be invited to get a felt sense of what is being talked about. The therapist might ask, “What is that like for you?” or “Where do you feel that inside?” Clients are also invited to stay with or return to felt senses for further steps.

How and to what extent Focusing is used in therapy depends on the client’s problem and the phase of therapy. Typically, therapy begins by building rapport with the client. As an atmosphere of respectful trust is established, the therapist invites the client to pause, slow down, and freshly sense his or her immediately felt experience, while modeling the same behavior: for example, “Yes, you were angry yesterday . . . and I’m wondering . . . if you can sense how it is for you right now . . . if angry is the word that describes it, or . . .” As the client talks more about his or her immediate experiencing, he or she increasingly finds that it does not fit the available words: “It isn’t exactly anger . . . it’s more like frustration . . . or hurt. . . .” Searching for words is an indication that the client is speaking from a felt sense of the problem rather than from a conceptual formulation. To help the client move further from concepts and make more contact with the felt sense, the therapist might make invitations such as “Can you notice where you feel that the most?” and “Perhaps it has its own point of view or mood?” Surprisingly, most people can respond with great specificity and certainty: “It’s behind my sternum . . . it’s scared it might get attacked. . . .” The therapist repeats or paraphrases the client’s words, and because the felt sense always implies more than the spoken words, the client usually finds that the words weren’t quite right and makes a correction or elaboration. The therapist reflects the new words, and the client makes another correction, and so on.

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Foundational Therapies: Overview

Each description of the felt sense implies more than what was said, and when the client hears the therapist’s reflection, that “more” becomes salient, and the client tends to try to describe it. But there is still “more” implied in the new description, so when the therapist reflects that, the new “more” becomes salient, and again the client tries to describe it: It’s not dark anymore . . . more light gray, like fog . . . filling my chest and abdomen . . . it feels strong and weak at the same time . . . irritable . . . no . . . more like vulnerable . . . needing to defend itself, like it needs to prove something. . . .

Always, what is implied is some small step that will carry forward, so the Focusing interaction tends to move in the direction of greater clarity or resolution of the client’s problem. Whether the process takes a minute or two or extends over several sessions, just feeling “what is” allows a deepening awareness of implicit meaning, which inherently tends to loosen rigid patterns, allowing further change and growth. Over the process of FOT, clients learn the value of sensing freshly rather than merely talking about their issues or analyzing them mentally; they may arrive at a therapy session reporting new awareness during the week with greater calm and new relational possibilities. This process can lead to profound changes in the bodily felt experience of self and the world, for example, when a frozen structure melts and opens to the intricacy of the present moment: I’m sensing throughout my body, this feeling of tension . . . it feels scared . . . wanting approval or affirmation. . . . It feels like it’s been there forever . . . my whole life . . . I wanted approval . . . affirmation . . . because the world felt dangerous to be me. . . . and I’m still feeling that way now . . . I’m sensing inside how sad that is, . . . [client’s body straightens, face becomes more intense] but I’m an adult now, I’m not going to live that way any more. . . .

In this way, Focusing can be effectively combined with any modality of psychotherapy, from psychodynamic to cognitive-behavioral, by inviting the client’s fresh awareness of his or her felt experiencing. Rob Parker and Ann Weiser Cornell

See also Emotion-Focused Therapy; ExistentialHumanistic Therapies: Overview; Experiential Psychotherapy; Person-Centered Counseling; Sensorimotor Psychotherapy; Somatic Experiencing

Further Readings Cornell, A. W. (2013). Focusing in clinical practice: The essence of change. New York, NY: W. W. Norton. Gendlin, E. T. (1964). A theory of personality change. In P. Worchel & D. Byrne (Eds.), Personality change (pp. 100–148). New York, NY: Wiley. Retrieved from http://www.focusing.org/gendlin/docs/gol_2145.html Gendlin, E. T. (1984). The client’s client: The edge of awareness. In R. L. Levant & J. M. Shlien (Eds.), Client-centered therapy and the person-centered approach: New directions in theory, research and practice (pp. 76–107). New York, NY: Praeger. Gendlin, E. T. (1996). Focusing-oriented psychotherapy. New York, NY: Guilford Press. Madison, G. (Ed.). (2014). Theory and practice of focusing oriented psychotherapy. London, England: Jessica Kingsley. Parker, R. (in press). Change from the inside: Focusing oriented therapy with an adolescent sex offender. In J. Briere, J. Hopper, D. Rozelle, & D. Rome (Eds.), Contemplative methods in trauma treatment: Integrating mindfulness and other approaches. New York, NY: Guilford Press.

FOUNDATIONAL THERAPIES: OVERVIEW The therapies included in this entry are wellknown to the public and tend to be the most used approaches by counselors and therapists. In addition, these approaches can often be found in many of the dozens of “counseling theory” texts that are used in training programs around the United States and the world. Although some of the approaches are more than 100 years old, they are still widely popular. Other approaches listed here have been developed and gained popularity recently, within the past 25 years.

Historical Context During the end of the 19th century and throughout the 20th century, psychology was largely based on what became known as the first, second, and third forces. The first force, psychoanalysis and its

Foundational Therapies: Overview

derivatives (sometimes called psychodynamic therapies), was based on a medical model that assumed that certain inherent structures were responsible for the development of personality, such as the id, ego, and superego. These models suggested that these structures were developed through a complex interaction of early child-rearing pattern, environmental influences, the impact of instincts or drives, and biological determinism. In addition to classical psychoanalysis, a number of other therapies, such as analytical therapy and individual psychology, were developed soon after psychoanalysis and became some of the more popular approaches used, particularly in the first half of the 20th century. Although these approaches, and others, are still used today by many therapists, their popularity has waned somewhat. However, many of their concepts are embedded in the consciousness of our world, such as the ideas that we have a conscious mind, an unconscious mind, complexes, and drives and that our world is created through a dynamic interaction of the forces mentioned earlier. The early part of the 20th century saw individuals such as Ivan Pavlov and John Watson investigate what became known as classical conditioning. Then, in the late 1920s and the 1930s, operant conditioning was popularized by B. F. Skinner. Soon, this “second force” in psychology influenced the way some practitioners did counseling. Not long after the development of operant conditioning, social learning, or modeling, another behavioral approach, developed by Alfred Bandura, was added to the mix. The early behaviorists believed that through classical conditioning, operant conditioning, and social learning, individuals could be treated for, or even cured of, certain pathologies that troubled them. During the 1940s and 1950s, these principles began to be applied more systematically in the therapeutic milieu. The early behaviorists rarely, if ever, looked “inside” the person, but during the 1950s and 1960s two individuals in particular, Albert Ellis and Aaron Beck, suggested that, like behaviors, cognitions could also be reinforced. It was then that we saw the combining of the early radical behavioral ideas with the more modern cognitive ideas and the development of cognitive-behavioral therapies. As opposed to the psychodynamic approaches, these approaches were easily researched and quickly showed that a number of disorders, especially those in which depression or anxiety was a component, could be

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helped in a relatively short amount of time by applying cognitive-behavioral approaches. Some of the cognitive-behavioral approaches that became particularly well-known during the 1960s and later were behavior therapy, rational emotive behavior therapy, cognitive-behavioral therapy, and reality therapy. Meanwhile, with the rise of Nazi Germany during the 1930s, many philosophers and psychiatrists fled from Germany and other parts of Europe and came to the United States. Although some had been trained as psychoanalysts, a number of them had existential-humanistic leanings and challenged many of the theoretical assumptions of psychoanalytic and related therapies. These individuals were more optimistic than the analysts or even the early, radical behaviorists in that they believed that individuals could come to understand their meaning and purpose in life and make significant changes relatively quickly through the choices they made. Whereas personality development had been seen as a complex interaction of unconscious forces with early child-rearing practices, or the result of behavioral conditioning, these existential-humanistic therapies took on a new flavor—one in which the individual was seen as responsible and capable of understanding self and making choices that better reflected his or her purpose in life. Although sometimes such meaning and purpose was clouded over by defenses, individuals were seen as capable of transcending their defenses and discovering their “true self.” The 1940s, 1950s, and 1960s, saw a flourish of theories in this “third force” of psychology with the popularization of therapies such as existential therapy, person-centered counseling, and Gestalt therapy. Meanwhile, although interest seemed focused on these first three forces, a lone psychiatrist, Milton H. Erickson, began to dabble in some unique ideas that could induce change in people rather quickly. Not concerned with the inner workings of the person or behavioral conditioning, Erickson used hypnosis, stories, metaphors, and whatever else would work to help individuals change their usual, neurotic, or dysfunctional patterns. His approach influenced the thinking of a number of individuals in Palo Alto, California, who were examining the change process through a communication and systemic perspective. These individuals also were concerned with focusing on the individual’s problems and helping the

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individual change quickly. Two approaches in particular that came out of Erickson’s work were Ericksonian therapy and strategic therapy. The latter part of the 20th century saw the growth of therapies based on the philosophies of postmodernism and constructivism. Modernism, which was the prevalent manner in which individuals tended to view the world during most of the 20th century, assumed that an external truth existed and structures could be found within the person that were responsible for how the individual came to understand the world. Thus, strict adherence to a number of theories from the first, second, and third forces of psychology was fairly common as many therapists believed that they had found the “truth” of how the individual developed. In contrast, the postmodern, constructivist approaches suggested that there are no essential truths and that realities are socially constructed, constructed through language, and organized and maintained through narratives. A number of approaches that have become popularized over the past 25 years have adapted this philosophy, although they apply it somewhat differently. However, all of these approaches tend to downplay or reject diagnosis, view the client as an equal in the relationship, do not focus on internal “structures” or mechanisms that cause emotional problems, and work in a collaborative fashion with individuals. Some of the more popular of these approaches are feminist therapy, narrative therapy, and solution-focused brief therapy.

Theoretical Underpinnings Although psychodynamic approaches vary considerably, they have some common elements. For instance, they all believe that an unconscious and a conscious effect the functioning of the person. They all look at early child-rearing practices as being important in the development of personality. They all believe that examining the past, and the dynamic interaction of the past with conscious and unconscious factors, is important in the therapeutic process. Although they tend to be long-term approaches, in recent years, some have been adopted and used in relatively brief treatment modalities. The three foundational approaches from this perspective that are cited in

the encyclopedia are Freudian psychoanalysis, analytical therapy (Jungian therapy), and Adlerian therapy (Individual Psychology). Cognitive-behavioral approaches look at how cognitions and/or behaviors affect personality development and emotional states. All of these approaches believe that cognitions and/or behaviors have been learned and can be relearned. Therefore, they are considered to be antideterminist, in the sense that we are not determined by our past. They tend to spend a limited amount of time examining the past as they focus more on how present cognitions and behaviors affect the person. They all believe that by identifying problematic behaviors and/or cognitions, one can choose, replace, or reinforce new cognitions and behaviors that result in more effective functioning. These approaches tend to be shorter term than the psychodynamic or existential-humanist approaches. The four approaches that are highlighted in this encyclopedia that are foundational cognitivebehavioral approaches are (1) behavior therapy, (2) rational emotive behavior therapy, (3) cognitive-behavioral therapy, and (4) reality therapy. The existential-humanistic approaches tend to be loosely formed around two philosophies: existentialism and phenomenology. Existentialism examines the kinds of choices one makes to develop meaning and purpose in life and from a psychotherapeutic perspective believes that people can choose new ways of living at any point in their lives. Phenomenology is the belief that each person’s reality is unique and to understand that person, you must hear how that person has come to make sense of his or her world. These approaches tend to focus on the “here-and-now,” and they gently challenge clients to make new choices in their lives. Although generally shorter term than psychodynamic approaches, these therapies are often longer than the cognitive-behavioral approaches or postmodern approaches. The three foundational existential-humanistic approaches in the encyclopedia are existential therapy, Gestalt therapy, and person-centered therapy (client-centered therapy). Ericksonian-derived therapies are a unique class of therapy because they do not fit neatly into any one theoretical school. They tend to be pragmatic and focus on fixing problems in any ethical manner

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that might work. They are largely based on the work of Erickson, who is considered by many to be one of the masters of therapy. Erickson was particularly interested in how hypnosis could be used to induce change in individuals, and using a very broad definition of what is a hypnotic state, he began to dabble in helping people change by developing strategies that would induce a new way of being in the world for the person. Along with hypnosis, or perhaps one might say, as a part of the hypnotic state, Erickson used language to promote change and health in people. By using verbal and nonverbal language, metaphors, and symbols, he helped individuals move toward a new way of relating. Today, Erickson-derived therapies are a broad range of approaches that focus on developing strategies that can be used to quickly help a person. They tend not to delve into the past or worry about internal structures that some say cause mental illness or emotional problems. The foundational approaches that take on this perspective in the encyclopedia are Ericksonian therapy and strategic therapy. The most recent addition to the therapeutic milieu are the postmodern constructivist approaches, which tend to be based on the philosophies of constructionism, social constructivism, and postmodernism. Constructionism is concerned with the manner in which individuals construct reality and assumes that one’s development of meaning is a function of how one constructs, or makes sense of, the world. Therapy is concerned with helping individuals reconstruct their world to make it more livable or satisfying. Social constructivism suggests that individuals construct meaning in their lives from the discourses they have with others and the language that is used in their social milieu and in society. Therefore, approaches that take this orientation are concerned with how powerbrokers in the world use language, either consciously or unconsciously, to oppress others and the notion that individuals need to learn about how their meaning-making system has been coopted by individuals in their world, particularly those in power. Postmodernism suggests that all reality should be questioned, which includes many of the past therapies that suggested that certain structures existed that caused mental health problems (e.g., id, ego, superego, core beliefs, lack of

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internal locus of control, and self-actualizing tendency). These approaches downplay or reject diagnoses, respect the individual, see the client as an equal with whom one collaborates, and focus on helping clients understand how language has been used by others and in society to oppress. The postmodern, constructivist approaches suggest that a therapist can assist clients in finding exceptions to their problems and can help clients find innovative solutions rather than harboring past problems that tend to be embedded by oppressive belief systems. Using this approach, therapists help clients find novel and creative solutions to the problems that plague them. The foundational approaches in the encyclopedia that take this perspective are constructivist therapy, feminist therapy, narrative therapy, and solution-focused brief therapy.

Short Descriptions of Foundational Therapies Psychodynamic/Psychoanalytical Approaches

Adlerian Therapy Adlerian therapy assumes that individuals are born with certain talents and abilities that can lead them to a future that is meaningful for them and that serves a social purpose. However, due to parenting, individuals often develop feelings of inferiority, which thwart their natural strivings. The result is a person whose subjective final goal is not in line with his or her natural abilities and talents. This yields neurotic and unhealthy behaviors as individuals develop an unhealthy style of life. Analytical Psychology Analytical psychology, also known as Jungian therapy, suggests that we have a conscious mind that is made up of our mental functions of sensing, thinking, feeling, and intuiting, as well as our attitudes of extraversion and introversion (each person has a unique combination of these); a personal unconscious, which houses trauma and all the information that our conscious mind does not allow in; and a collective unconscious, which houses our archetypes, the universal prototypes that inform us how to be human. The goal of therapy is to make the individual whole by helping him or her regain the repressed parts of self.

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Freudian Psychoanalysis Freud suggested that we are born all id (instincts) and develop our ego and superego—and, ultimately, our personality structure—as a result of the type of parenting we received through the oral, anal, and genital psychosexual stages in the first 5 or 6 years of life. As adults, our personality structure is held intact through a complicated array of defense mechanisms. The purpose of therapy is to uncover how early child-rearing patterns led to the client’s personality structure and resulting defense mechanisms. Cognitive-Behavioral Approaches

Behavior Therapy Based on classical conditioning, operant conditioning, and social learning (modeling), behavior therapy uses these paradigms to help therapists and clients understand the development of symptoms and to develop new ways of responding through counterconditioning. Cognitive-Behavioral Therapy Cognitive-behavioral therapy assumes that embedded core beliefs of which we are unaware affect our automatic thoughts (thoughts we have throughout the day) and that negative core beliefs yield automatic thoughts that result in dysfunctional behaviors, negative feelings, and the resulting physiological responses (e.g., anxiety). The focus of therapy is on changing a client’s core beliefs and automatic thoughts, although behavioral change can facilitate these changing cognitions. Rational Emotive Behavior Therapy This cognitive-based therapy assumes that it is not the activating event (A) that causes consequences (C) such as negative feelings or dysfunctional behaviors but the belief (B) about the event that causes such consequences. Irrational core beliefs, such as “One must be absolutely perfect and competent in all respects,” affect how we feel and act. Thus, the purpose of rational emotive behavior therapy is to help clients acknowledge their irrational beliefs and develop more rational beliefs that will result in better feelings and more functional behaviors.

Reality Therapy Reality therapists assume that each person is born with the five basic needs—survival, loving and belonging, power, freedom, and fun—and that each person develops a quality world, which are pictures in his or her mind of how the person wants to get those needs met. Sometimes, those pictures lead to dysfunctional behaviors, such as when a person envisions using heroin to meet his or her need for love and belonging. The purpose of therapy is to help the client choose new, healthier behaviors that are more functional and will meet the need that is currently being met in dysfunctional ways. Existential-Humanistic Approaches

Existential Therapy This approach assumes that many people have avoided living life authentically and instead have developed mechanisms to not take responsibility for the choices they have made in their lives. Facing life’s responsibility means facing one’s ultimate demise—death and nonbeing—and examining how one communicates with oneself and others. This approach challenges clients to make momentto-moment choices that will reflect meaningfulness and authenticity in life. Gestalt Therapy Gestalt therapy suggests that certain needs in our lives become repressed and lead to unfinished business as they continue to press, in the background, on the organism. Thus, the purpose of therapy is to help individuals rediscover their unfinished business (needs) and satisfy those needs in the here-and-now. A number of mechanisms have been developed to release one’s resistances or blockages to experience that have been developed as a result of these repressed needs. Person-Centered Counseling This approach uses empathy, unconditional positive regard, and congruence on the part of the therapist to help clients understand their subjective experience of the world. In this therapeutic environment, clients are better able to examine the conditions of worth that have been placed on them by significant individuals that have led them to act

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as others would want them to and not in a manner true to themselves. Through this process, clients realize that they have choices in how they might want to change their incongruent ways of living. Ericksonian-Derived Approaches

Ericksonian Therapy Ericksonian therapy is any approach that is inspired by Erickson’s teaching and is goal oriented and problem solving. It suggests that any ethical technique, whether delivered consciously or unconsciously to the client (e.g., hypnosis or metaphors may be delivered unconsciously), can be used to increase the client’s satisfaction and sense of meaning in the world. Strategic Therapy This approach focuses on setting clear goals that will solve the client’s presenting problem. However, goals that solve a client’s presenting problems may not always appear to be directly related to the presenting problem (e.g., an anxious child might feel relief if Dad gets a job). Thus, therapists clearly define the problem, understand it within the context of the client’s relationships, and strategically develop techniques that will change the problem, even if the techniques do not, on the surface, seem to be directly related to the problem. Postmodern Constructivist Approaches

Constructivist Therapy Constructive therapy comprises a number of different approaches and focuses on how individuals develop their meaning-making process, or worldview. It assumes that individuals construct reality based on individual differences and/or social influences and believes that in conversation with a therapist, a client can come to understand his or her self-constructed world and begin to reconstruct a new reality. Feminist Therapy Feminist therapy relies on a collaborative, egalitarian relationship, based on trust, authenticity, and respect, with the focus being on helping clients understand the sociopolitical factors in society that

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have affected them, oppressed them, and prevented them from developing themselves fully. The goal of therapy is to empower clients and help them make new choices for themselves after they have examined their lives in this sociopolitical context. Narrative Therapy This collaborative approach involves therapists showing mystery, respect, and awe to the client as they attempt to understand the dominant narratives that drive the client’s life. Dominant problem–saturated stories are examined and jointly deconstructed as the client sees that there have been exceptions to his or her problem-saturated stories and that he or she can develop new, healthier stories or ways of living. Solution-Focused Brief Therapy This is a very short-term approach to counseling, in which therapists show respect, curiosity, and acceptance to clients as they prepare to help clients find new solutions in their lives. Solutions are generally discovered through the use of questions that seek to understand what the client’s preferred goals are (preferred-goal questions), how the client coped in the past (coping questions), when the client has not experienced the current state (exception-seeking questions), and how the client’s life would be different if the problem did not exist (solution-oriented questions). The answers to these questions help devise a future-focused set of goals. Edward S. Neukrug See also Adler, Alfred; Adlerian Therapy; Analytical Psychology; Bandura, Albert; Beck, Aaron T.; Behavior Therapy; Cognitive-Behavioral Therapy; Constructivist Therapy; de Shazer, Steve, and Insoo Kim Berg; Ellis, Albert; Erickson, Milton H.; Ericksonian Therapy; Existential Therapy; Feminist Therapy; Frankl, Viktor; Freud, Sigmund; Freudian Psychoanalysis; Gestalt Therapy; Glasser, William; Haley, Jay; Jung, Carl Gustav; Kelly, George; Madanes, Cloe; Mahoney, Michael J.; Maslow, Abraham; May, Rollo; Meichenbaum, Donald; Narrative Therapy; O’Hanlon, Bill; Palo Alto Group; Pavlov, Ivan; Perls, Fritz; PersonCentered Counseling; Rational Emotive Behavior Therapy; Reality Therapy; Rogers, Carl; Skinner, B. F.; Solution-Focused Brief Therapy; Strategic Therapy; White, Michael

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Further Readings Corey, G. (2013). Theory and practice of counseling and psychotherapy. Belmont, CA: Cengage. Neukrug, E. (2011). Counseling theory and practice. Belmont, CA; Cengage. Seligman, L. W., & Reichenberg, L. W. (2014). Theories of counseling and psychotherapy. Upper Saddle River, NJ: Pearson.

FRANKL, VIKTOR Viktor Emil Frankl (1905–1997) was an Austrian psychiatrist, neurologist, and philosopher, and the founder of logotherapy and existential analysis, which is a meaning-centred existential/philosophical form of therapy. Born on March 26, 1905, in Vienna, Frankl was the second of three children. His mother, Elsa Frankl, née Lion, hailed from Prague, while his father, Gabriel Frankl, director in the Ministry of Social Service, came from Southern Moravia. During the First World War (1914–1918), the family experienced bitter deprivation; sometimes the children went begging to farmers. In his high school years (1915–1923), Frankl eagerly read the Nature Philosophers, attended public lectures in applied psychology, and became well-read in psychoanalysis. In 1921, Frankl gave his first public lecture: “On the Meaning of Life”; in 1923, he wrote his high school graduation essay, titled “On the Psychology of Philosophical Thought,” which was a psychoanalytically oriented study of the 19thcentury philosopher Arthur Schopenhauer. This was succeeded by publications in the youth section of a daily newspaper. As a result of these essays, an intensive correspondence with Sigmund Freud ensued. Frankl studied medicine and was a spokesman for the Austrian Socialist High School Students’ Association. A year later, he met Freud but soon became more involved with Alfred Adler and his school of Individual Psychology. In 1925, Frankl’s article “Psychotherapy and Weltanschauun” was published in the International Journal of Individual Psychology, an Adlerian journal. In this article, Frankl explored the frontier between psychotherapy and philosophy, focusing on the fundamental question of meaning and values, a topic that became the leitmotif of his life’s work. In 1926, Frankl presented public lectures to congresses in

Duesseldorf, Frankfurt, and Berlin, Germany; in the same year, he used the word logotherapy for the very first time. A year later, Frankl’s personal and professional relationship with Adler deteriorated, and Frankl became involved with Rudolf Allers, a disciple and critic of Freud, and Oswald Schwarz, the founder of psychosomatic medicine. He also was enthusiastic about Max Scheler’s book Formalism in Ethics and Non-Formal Ethics of Values. In 1927, Adler expelled Frankl from his circle of followers for his differing views, but Adler’s daughter Alexandra, Rudolf Dreikurs, and other important Adlerians maintained friendly relations with him. Between 1928 and 1929, Frankl organized youth counseling centers in Vienna and in six other European cities, where adolescents in need could obtain advice and help free of cost. Many individual psychologists joined Frankl’s project. In 1930, Frankl organized a special counseling program at the end of the school term, whereupon, for the first time in years, no student suicides occurred in Vienna. Frankl gained international attention for this work, and subsequently, the originator of orgone therapy, Wilhelm Reich, invited him to Berlin, and the universities of Prague and Budapest issued an invitation to lecture. Shortly before earning his M.D., he started to work in the psychotherapeutic department of the Psychiatric University Clinic in Vienna. From 1931 to 1932, Frankl obtained training in neurology and worked at the Maria Theresien Schlössel in Vienna, and between 1933 and 1937, he was chief of the Female Suicide Pavilion at the Psychiatric Hospital in Vienna, with approximately 3,000 patients annually under his care. In 1937, Frankl opened a practice as a doctor of neurology and psychiatry. The following year saw the outbreak of the Second World War and the Nazi annexation of Austria, known as the Anschluss. In his 1939 paper “Philosophy and Psychotherapy: On the Foundation of an Existential Analysis,” Frankl coined the expression existential analysis. With the Nazi occupation of Vienna, Frankl obtained an immigration visa to the United States but let it pass unused, not wanting to desert his elderly parents. From 1940 to 1942, Frankl was the director of the neurological department of the Rothschild Hospital, the last clinic in Vienna run by the Israelitische Kultusgemeinde Vienna (the official

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Jewish community). Here, in spite of the danger to his own life, he sabotaged Nazi procedures by making false diagnoses to prevent the euthanasia of mentally ill patients. He published several articles in Swiss medical journals and started writing the first version of his book Aerztiliche Seelsorge (The Doctor and the Soul). In 1941, Frankl married his first wife, Tilly Grosser. In 1942, the Nazis forced the young couple to abort their child. In September of that year, Viktor and Tilly Frankl were arrested and, together with his parents, deported to the Theresienstadt concentration camp north of Prague. His sister, Stella, had managed shortly before to escape to Australia; his brother, Walter, and his wife attempted to escape via Italy but were arrested by the Nazis. After half a year in Theresienstadt, his father died of exhaustion (http://logotherapy.univie.ac.at/e/chronology .html). In 1944, Frankl and Tilly, and a short while later his 65-year-old mother, were transported to the extermination camp of Auschwitz. His mother died in the gas chamber, and Tilly was moved to Bergen-Belsen, where she died at the age of 24. Frankl was transported in cattle cars, via Vienna, to Kaufering and Türkheim (subsidiary camps of Dachau). Even under the extreme conditions of the camps, Frankl found his theses about fate and freedom confirmed. In 1945, Frankl came down with typhoid fever. To avoid fatal collapse during the nights, he kept himself awake by reconstructing his manuscript on slips of paper stolen from the camp office. On April 27, the camp was liberated by U.S. troops, and in August, Frankl returned to Vienna, where he learned, within a span of a few days, about the death of his wife, his mother, and his brother, who had died in Auschwitz. Overcoming the despair he experienced from the camps and the death of family and friends, in 1946, Frankl became the director of the Vienna Neurological Policlinic, a position he held for 25 years. With his reconstructed book, The Doctor and the Soul, he obtained his habilitation, or teaching appointment, at the University of Vienna Medical School. He dictated, within 9 days, the book Ein Psycholog Erlebt Das Konzentrationslager, which was later translated into English and published as Man’s Search for Meaning. By 1997, more than 10 million copies of the English edition of this book had been sold, and it was later voted

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by the Library of Congress as one of the 10 most influential books ever written. In 1947, Frankl married Eleonore Schwindt, and within the year their daughter, Gabriele, was born. A year later, Frankl obtained his Ph.D. in philosophy with a dissertation The Unconscious God, which was subsequently published. The years 1948 to 1949 saw Frankl promoted to privatdozent (associate professor) of neurology and psychiatry at the University of Vienna, and in 1950, Frankl created the Austrian Medical Society for Psychotherapy and became its first president. Soon, Frankl was promoted to professor at the University of Vienna and also began receiving guest professorships at overseas universities. In 1961, Frankl became a visiting professor at Harvard University in the United States, and in 1966, he obtained another visiting professorship at Southern Methodist University in Dallas, Texas. Based on his lecture manuscripts, Frankl published The Will to Meaning, which he regarded as his most comprehensive book in English. In 1970, the United States International University in San Diego, California, installed a Chair of Logotherapy, and in 1972, Frankl became a visiting professor at Duquesne University in Pittsburgh, Pennsylvania. During those years, well into the 1960s and 1970s, Frankl was a prolific writer about his theory and about existential theory in general. Many of his books were eventually translated into English. In 1988, at a commemoration of the 50th anniversary of the invasion by Hitler’s troops, Frankl presented a celebrated public address at the Vienna Rathausplatz, where he maintained that there are only two races of men: the decent and the indecent. A few years later, in 1992, the Viktor Frankl Institute was founded in Vienna by a number of academic friends and family members, and in 1995, his autobiography, Was Nicht in Meinern Büchern Steht, was published, the English version of which was published in 1997 as Viktor Frankl— Recollections. With the appropriate title Man’s Search for Ultimate Meaning, Frankl’s last book was published in 1997, and in that same year, he received his 29th honorary doctorate, from Ohio State University. On September 2, 1997, Frankl died of heart failure. Frankl regarded himself as a dwarf standing on the shoulder of the giants who preceded him, such as Freud and Adler and the many philosophers whom he met and who influenced his work, but as

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he said himself, it just so happens that the dwarf can see farther than the giant himself. Frankl endured the horrors of the Holocaust and found that meaning was not wanting, just waiting. Alexander Batthyány and Stephen J. Costello See also Existential-Humanistic Therapies: Overview; Existential Therapy; Logotherapy and Existential Analysis

Further Readings Batthyány, A. (Ed.). (2009). The feeling of meaninglessness: A challenge to psychotherapy and philosophy. Milwaukee, WI: Marquette University Press. Batthyány, A. (Ed.). (2009). Viktor E. Frankl and the development of logotherapy and existential analysis. In The feeling of meaninglessness: A challenge to psychotherapy and philosophy (pp. 7–41). Milwaukee, WI: Marquette University Press. Battino, R. (2002). Meaning: A play based on the life of Viktor E. Frankl. Carmarthen, England: Crown House. Frankl, V. E. (1988). The will to meaning: Foundations and applications of logotherapy. New York, NY: New American Library. Frankl, V. E. (2000). Man’s search for ultimate meaning. New York, NY: Perseus Book Group. Frankl, V. E. (2000). Recollections: An autobiography. Cambridge, MA: Perseus. Frankl, V. E. (2004). On the theory and therapy of mental disorders: An introduction to logotherapy and existential analysis. (J. M. DuBois, Trans). London, England: Brunner-Routledge. Frankl, V. E. (2007). Man’s search for meaning: An introduction to logotherapy (with a new foreword by H. S. Kushner and a new biographical afterword by W. J. Winslade). Boston, MA: Beacon Press. Klingberg, H. (2001). When life calls out to us: The love and lifework of Viktor and Elly Frankl. New York, NY: Doubleday.

FREUD, SIGMUND Sigmund Freud (1856–1939), the founder of the “talking cure” of psychoanalysis, which has led to most of the forms of psychodynamic psychotherapy

extant today, was born in Freiburg, Moravia. He was the first and favored child of the third wife of a wool merchant. In 1861, after Austria abolished restrictions on Jews, the family moved to Vienna and took pride in Freud’s exceptional performance in school. At the Vienna Medical School, he was mentored in the school of Helmholtz by the physicalistic Darwinian physiologist Ernst Bruke. He undertook research in Bruke’s laboratory, eventually publishing some 200 neurological works, including expert monographs on childhood movement disorders and aphasia. Realizing that he could not support a family in research, Freud prepared for psychiatric practice at the Vienna General Hospital, studying disorders of the nervous system under Theodor Meynert. In 1885, on Bruke’s recommendation, he was awarded a bursary to study in Paris under Jean-Martin Charcot, who used hypnosis to induce and remove symptoms of hysteria. Freud’s subsequent essay on differential diagnosis supported Charcot’s psychogenic approach with the observation that the regions of the body liable to hysterical paralysis or anesthesia do not correspond with neurological demarcations. Hysteria, Freud observed, knew nothing of anatomy. In 1886, Freud married Martha Bernays and entered private practice. During the next decade, he fathered six children and made his most important intellectual discoveries. His senior colleague Joseph Breuer had enquired into the life and symptoms of one hysterical patient in great detail, discovering with her that her symptoms linked meaningfully with unexpressed emotions from unremembered but significant events and were eased by expressing them. Thus, she was liable to paralysis of her arm, which she and Breuer traced to a frightening occasion when her arm had gone to sleep and had become immobile while she was nursing her dying father. A whole series of symptoms, including hallucinations and disturbances of speech, were also rooted in experiences from this episode and eased as she and Breuer reconstructed it. This was one of the first systematic observations of the therapeutic effect of recovered memory, and Freud’s practice corroborated Breuer’s sufficiently for the publication of a book of case studies. Freud then sought to improve his therapy by systematically pressing his patients for deeper traumatic memories. In response, female patients increasingly

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reported scenes of seduction (sexual abuse), often at the hands of their fathers. Freud initially thought he had discovered that mental disorder originated in early abuse. After further investigation, however, he concluded that such “memories” were unreliable. Memory was fundamentally reconstructive and liable to distortion by fantasy, including sexual fantasy about parents. Despite Freud’s cautions, another memorybased “seduction theory” disrupted psychiatry a century later. In the fall of 1993, thousands of adults across the United States began recovering apparent memories of sexual abuse in childhood whose truth seemed impossible to assess. This crisis was finally resolved, like that in Freud’s early practice, by acknowledging that memory was reconstructive and readily permeated by fantasy; and the episode itself testifies to the power of sexual fantasy about parents, and hence to the difficulty of resolving claims about abuse in childhood, which can, of course, also be remembered accurately. In light of his growing realization of the unreliability of early memory and the power of fantasy to shape believed experience, Freud ceased pressing his patients for memories. Instead, he asked patients simply to communicate each idea or thought that occurred to them as fully as possible and without censorship, whether or not it seemed sensible or significant. This unconstrained form of self-disclosure, called free association, provided a unique source of relevant information, and in 1895, Freud discovered that it enabled him to understand both his own and his patient’s dreams as expressions of conflicting emotions and desires. This implied that patients’ difficulties and disorders stemmed not, as Freud had previously thought, from memory but rather from recourse to fantasy, that is, to the kind of fictive experience or belief manifest in dreaming, and that such recourse was a response to emotional conflict. Apparently, the mind or brain uses fictive experience or belief to regulate desires stemming from deep emotional conflict, and this, in our uniquely conflicted species, creates the alienation from reality constitutive of mental disorder. We can approach this by generalizing over the contents of desires and beliefs, by speaking of a desire or belief that P, where P can be replaced by any suitable phrase or sentence that specifies the

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situation believed or desired (e.g., “I get a drink of water” in the case of my desire to drink). Then, in general, if a person acts on a desire that P (that he gets a drink of water) and if he succeeds, he will bring about the situation P (that he gets a drink of water) that satisfies the desire; and this in turn will give rise to the believed experience of satisfaction of the desire (that of drinking water). This pacifies the desire, terminating thirst prior to water reaching the bloodstream. Freud discovered that fictive experience or belief—such as that produced in dreams—could serve the same purpose. His simplest example was a dream prompted by eating anchovies or other salty food: that he was drinking cool delicious water. After dreaming this, perhaps several times, he would awake, find himself thirsty, and get a drink. Many people have had such a dream, or its counterpart regarding micturition. In these examples, the dream clearly represents the experience of satisfaction of a desire and therefore seems best understood as caused by that desire and as serving to pacify it, thus temporarily resolving the conflict about continuing sleep and dreaming. This is Freudian wish fulfilment, in which a fictive experience or belief that P pacifies a conflicted desire that P, so masking conflict, but with illusory as opposed to real satisfaction. The same idea applies to neurotic and psychotic symptoms. Thus, Freud understood the main symptom of his patient the Rat Man—a compulsion involuntarily to imagine, as in a waking nightmare, that his father was suffering a terrible torture—as a fictive believed experience that pacified unconscious hostility to his father. His hostility could be traced to early childhood and conflicted with the genuine love he felt toward his father, in favor of which the hostility was subjected to repression. These examples illustrate how emotions that are subject to conflict can be pacified and masked by fictive beliefs and experiences and also how this produces a denial both of the person’s real mental state and of the real nature of the person’s engagement with others. Freud’s interpretations of dreams and symptoms deal with more complex examples, and his concept of wish fulfilment was subsequently extended into the more general and inclusive psychoanalytic concept of phantasy. These extensions preserve the original underlying insight, namely, that the mind or brain uses fictive experiences and

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beliefs to regulate conflicting emotions and desires and that this is liable to produce the denial of both internal and external reality, which is constitutive of mental disorder. Freud provided a similar account of paranoid, depressive, and manic phantasies and delusions, as well as those characteristic of other disorders. From his 1896 book Psychology for Neurologists onward, Freud argued that the production of such desire-regulating fictive experience and belief was a primary process in the mind or brain. This operated with the assistance of the ego (nascent self) from birth, to establish the secondary processes of veridical belief and action in accord with the reality principle. In this perspective, human development involves a continual and oppositional dialectic between fantasy and reality, and psychoanalytic therapies aim to analyze the formations of fantasy masking conflict so as to resolve the conflicting emotions and strengthen the patient’s hold on the dual reality of his or her own mental processes and engagement with others and the world. Between 1899 and 1905, Freud published his major conclusions on memory, dreams, symptoms, and sexuality, and over the next decade these became the center of an international intellectual and therapeutic movement. Although he lectured briefly in the United States and occasionally travelled to conferences, Freud continued to work full-time in Vienna, using his clinical experience in treating patients to elaborate and extend his theories. Thus, he expanded his 1895 discussion of the ego to describe how its executive functions regulated the basic drives of the id via fantasy representations of the parents embodied in the superego or ego-ideal. The functional role of such fantasy figures was later extended to a range of internal objects mediating object relations. These included the object relations characteristic of group psychology, in which members of a group enhance self-esteem through identification, by taking a common figure such as a charismatic leader (or, in the case of leaderless groups, a common figure, cause, or creed) as constituting the superego or ego-ideal. This afects the projection of what is contrary to this ideal into another group, which becomes a target for the morally mandatory hatred and guilt-free aggression characteristic of in-group cooperation for violent out-group conflict.

In this use of his concept of projection, Freud well described the group-binding Nazi idealization of Hitler and the concomitant denigration and persecution of the Jews, from which he secured his family by fleeing to London in 1938. The next year, having finished his essays, including his final outline of psychoanalysis, and suffering increasing pain from the cancer that had caused the removal of much of his jaw, he asked his doctor for the morphine injections that eased his death. Jim Hopkins See also Classical Psychoanalytic Approaches: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Freudian Psychoanalysis; Neo-Freudian Psychoanalysis

Further Readings Fotopolu, A., Pfaff, D., & Conway, M. (Eds.). (2012). From the couch to the lab: Psychoanalysis, neuroscience and cognitive psychology in dialogue. Oxford, England: Oxford University Press. Laplanche, J., & Pointalis, J. B. (1973). The language of psychoanalysis. London, England: Karnac Books. Phillips, A. (2014). Becoming Freud. New Haven, CT: Yale. Segal, H. (1991). Dream phantasy and art. London, England: Routledge. Wollheim, R. (1991). Freud. London, England: Fontana Modern Masters.

Website Neuropsychoanalysis: http://www.karnacbooks.com/ JournalNeuroPsycho.asp

FREUDIAN PSYCHOANALYSIS Sigmund Freud (1856–1939), the father of psychoanalysis, began his career as a neurologist, but his interests soon switched to assisting neurotic patients with their anxiety symptoms. Freud’s theoretical odyssey began with a theory about hysterical symptomology and evolved into a theory about psychotherapy and psychological development and eventually a method for examining cultural phenomena. He is generally considered one of the most important intellectual thinkers of the 20th century.

Freudian Psychoanalysis

Historical Context Psychoanalytic treatment has emerged from the groundbreaking research and writing of Freud and his early followers like Carl Jung, Alfred Adler, Otto Rank, and Sandor Ferenczi. Freud began his career as a neurologist, which oriented him toward a biological approach to mental disorders. Eventually, Freud was drawn into psychiatry through his interest in hypnotic phenomena and hysterical states. His early work with Josef Breuer, published in 1985 as Studies in Hysteria, coupled with his own self-analysis helped lay the foundation for what has been referred to as “classical theory.” Freud’s theoretical development began with the analysis of the etiology of hysteria. He then proceeded to develop a description of the structure of the personality and ultimately described an innovative treatment model referred to as the “talking cure.” This model is based on the principle of psychic determinism, which states that events have a causal basis and are not random. While his theory began as a physiodynamic model, with the introduction of the theory of the Oedipus complex, he graduated to a fully psychodynamic model. Later in life, Freud applied his psychoanalytic insights to the study of culture and its institutions.

Theoretical Underpinnings The bedrock of Freud’s approach can be found in several metapsychological models. Initially, Freud identified the topographic model, which he described as geography of consciousness. Freud identified a system conscious (CS), a system unconscious (UCS), and the preconscious (PCS), which becomes conscious through the action of attention. Freud took great efforts to underline the importance of the unconscious determinants of behavior. For Freud, there was always more that met the eye. The limits of this early model soon became apparent to Freud, who then introduced the expanded structural model. Here, Freud identified his tripartite description of the psyche: id, ego, and superego. He defined the id as the seat of our instinctual life (both life and death instincts), thus retaining his ties to biology. The id operates via the first principle of mental functioning, the pleasure

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principle. The ego was conceived as the mediator of our drives as they come into contact with external reality, and it operates via the second principle of mental functioning, the reality principle. The ego has at its disposal a variety of defense mechanisms to manage the inevitable anxiety associated with the conflicts between our pleasure-seeking drives and the press of cultural norms. In addition, these defenses are called on to manage powerful emotional states that may be experienced as egoalien. These defenses range from the most primitive, disavowal of reality, to the most nuanced, sublimation. Freud left it to his daughter, Anna Freud, to describe the full spectrum of the ego defenses and their methods of operation. The ultimate goal of all defenses is repression, which is the forcing of experience from conscious awareness. Finally, the superego was viewed as the seat of our conscience and ideals. This structure was a legacy of a successful resolution of the Oedipus complex and referred to the internalization of the values and conscience of the father figure. This model is the foundation for the concept of intrapsychic psychoanalysis, which connotes an autonomous internal world of drives, complexes, affects, and defenses. The economic model introduced the concept of libido as the energy of the id, which eventually is invested in the ego and superego. Libido emanates from the id and energizes all three psychic structures. Freud originally identified libido with the sexual instincts. Later, he designated libido as a general “mental energy,” analogous to physical energy, which was related to the unfolding of instincts in general. Finally, he postulated a dynamic model, which helped codify the concept of conflict between the tripartite structures of the mind (the id, ego, and superego). The guiding principles of conflict and defense led him to the concept of the compromise formation. Here, he attempted to explain neurotic symptoms and dreams as the products of conflict or as compromise formations. One example of a compromise formation would be the anxiety symptom resulting from the conflict between an id impulse and an ego defense. Another example would be the manifest (remembered) dream that results from the conflict between latent dream thoughts (thoughts one does not want to experience due to their unacceptable content) and a

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dream censor, which disguises the dream and allows the dreamer to remain asleep. In the genetic model, Freud identifies how the adult is a product of his or her developmental experiences in childhood. The child is father to the man. Coupled with this is the concept of fixation and its corollary, regression, which highlights how individuals can fail to progress sufficiently through developmental tracks and fall back to earlier ways of functioning in the face of stress. Freud’s theoretical forays into developmental psychology are included in his theory of psychosexual development, which describes the traversal of libidinal energy from early oral gratification through the anal and phallic phases. This preoedipal period ends with the individual working through the unconscious oedipal conflict. The cornerstone concept was seen as an unconscious activation of desire for the opposite-sex parent, coupled with rivalry with the same-sex parent, which in young boys would result in the experience of castration anxiety. Successful resolution of this complex through repression of the desire for the opposite-sex parent and identification with the same-sex parent installed the superego through internalization. Psychosexual development culminated in genital sexuality. In this final stage, which occurs during puberty, Freud sees individuals endorsing the norm of heterosexual attraction. The conflicts and solutions emanating from the earlier stages are integrated at this level. Freud’s attempt to apply the oedipal complex to female development was not universally well received. Here, he assumed that the woman already felt castrated due to the lack of a penis and thus developed penis envy, which in effect was a desire for a baby from the father. This was accompanied by resentment of the mother and idealization of the father. This outcome is often related to Karen Horney’s concept of the masculine protest, which suggests that women are motivated to adopt masculine behaviors and attitudes to succeed in the patricentric society. The oedipal theory essentially established Freudian psychoanalysis as a patricentric model of psychological development. The father reigned supreme. Women were viewed as failed men. It is this type of theorizing that eventually stimulated the feminist movement both in the society and in the psychoanalytic community.

Major Concepts Freud was a prolific writer, and there are a host of concepts that help define his theory. A few of these are compromise formation, countertransference, dream work, frame, free association, insight, interpretation, parapraxis, repression, resistance, transference, transference neurosis, and working through. Compromise Formation

Compromise formation refers to the fact that Freud’s model rests on a conflict and defense paradigm. Neurotic symptoms are the compromise formation in the conflict between the id and the ego, and the dream is a compromise formation resulting from the engagement of latent dream thoughts, or underlying meaning of the dream, with the dream censor. Countertransference

Countertransference refers to the therapist’s projection of thoughts and feelings derived from early important relationships onto the patient. Freud felt initially that these feelings were an interference in the therapeutic process and recommended that therapists perform frequent reanalyses to prevent this contamination. Later, he viewed countertransference as a valuable tool in “decoding” the patient’s unconscious. Dream Work

Dream work refers to the processes through which latent dream material is transformed into the manifest content (remembered dream). According to Freud, a day residue, or experiences that are left over from the waking state, triggers unconscious conflict and drives that seek more direct awareness during sleep. To the degree that these latent thoughts are anxiety provoking, the dream censor works to disguise the dream through processes of displacement, condensation, and symbolization. Dream material is of great value to the psychoanalytic process. Therapists generally ask for associations to various images of the dream to reinflate the highly condensed manifest content. Dreams are seen as sources of information about the patient’s internal world, emotions, and object relations, which are of great use to the therapist.

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Frame

The frame refers to the set of agreements reached during the first hour of treatment, which outline the parameters of the treatment. This includes the date, time, and fees for the sessions and cancellation and payment policies. Therapeutic values not discussed but demonstrated in the treatment include the limited use of self-disclosure, a neutral listening stance, avoidance of extra-analytic contact, and minimization of physical contact with the patient.

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physical form. This fundamental concept underlies concepts such as symptom substitution and psychosomatic conversion as unconscious conflicts that continue to seek expression. Resistance

Resistance refers to any form of communication or action that tends to inhibit the psychoanalytic inquiry. It can range from simple tactics such as silence and missed appointments to sophisticated defensive operations such as emotional isolation or intellectualization.

Free Association

Free association is one of the basic parameters and techniques of the psychoanalytic therapeutic relationship. The patient is requested to discuss anything and everything that comes to mind. Insight

Insight refers to the expanded awareness that occurs in the process of analyzing the transference processes occurring in treatment. It is based on the idea that “the truth will set you free.” Interpretation

Interpretation refers to the process through which the unconscious is made conscious by the therapist’s verbal intervention. Generally, a full transference interpretation includes how the experience being captured re-presents in the present moment with the therapist, how it affected the patient’s old experience with primary objects, and the manner in which the patient relates to objects in general currently. Parapraxis

Parapraxis refers to slips of the tongue and other behaviors said to denote unconscious conflicts. Repression

Repression refers to the defense of forcing unpleasant frightening thoughts and feelings from awareness. In fact, all defenses have repression as their fundamental goal. For Freud, there was always the “return of the repressed” in some psychic or

Transference

Transference refers to the process whereby the patient projects thoughts and feelings derived from early important relationships onto the therapist. Freud felt that these were “false connections” and represented a template for falling in love. There are two levels of working with transference. The first is to overcome the resistance to awareness of the existence of the transference in the patient. The second is to secure a resolution of the transference. Transference Neurosis

Transference neurosis refers to the process in which the patient’s primary illness becomes exhibited through and as part of the therapeutic relationship. Working Through

Working through describes the process of continually addressing the resistances presented in the course of treatment. It is seen as the method of establishing enduring insight in patients as to their personal historical narrative and its effects on their current interpersonal life.

Techniques Six of the major technical considerations that Freud emphasized are the psychoanalytic frame, empathy, free association, interpretation of the transference relationship, interpretation of resistance, and interpretation of dreams.

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Psychoanalytic Frame

The psychoanalytic frame is agreed-on during the first hour of treatment. Session timings, fees, payment agreements, and cancellation, vacation, and phone contact policies are addressed. Breaks in the frame by either the therapist or the patient are immediately addressed and rectified. Empathy

The therapist uses his or her empathic capacity to listen into the subtle affective experiences coded in the words and behavior of the patient. Particularly important is the therapist’s attention to his or her own emotional responses (countertransferences) as indicators of the patient’s state of mind. Free Association

Free association is the process of asking the patient to discuss anything that comes to mind and is used to help the patient access unconscious information that can then be discussed with and eventually interpreted by the therapist. Interpretation of the Transference

The therapist listens to all material as a potential comment on the therapeutic relationship (this includes dreams). When the patient responds in ways that can be explained not only by the current situation in the moment but also by some important historical or affective experience, the transference interpretation linking past and present is made. Interpretation of Resistance

Freud suggested that resistance is characteristic of every treatment and must be addressed immediately when it appears. This may take its most problematic form as resistance to the awareness of the transference process. Interpretation of Dreams

Calling dreams the “road to the royal unconscious,” Freud suggested that dreams have manifest and latent meanings. The manifest meanings are the more obvious understanding of a dream,

whereas the latent meanings hold special knowledge about early conflicts related to the development through the psychosexual stages. At times when the patient can hear the interpretation, the therapist offers it to him or her.

Therapeutic Process Freud’s early approaches to treatment included hypnotic suggestion, learned from his predecessors Jean-Martin Charcot and Hippolyte Bernheim. After a period of time, he settled on having the patient lie on the couch and followed the basic rule of psychoanalysis, free association. The patient was instructed to say whatever came to his or her mind, no matter how silly, tangential, or frightening. This process is based on the British tradition of associational psychology, with the assumption that the free associations will allow the therapist to trace back to the source of the patient’s illness. The key to understanding psychoanalytic process is to appreciate that the therapeutic relationship is the center of concern. The patient and the therapist enter a special relationship that allows the conflicts of the past to live anew, with the therapist serving as the failing objects of childhood (e.g., poor parenting). This highlights how emotional psychoanalytic engagement can become and the special preparation required to stand sturdy in a volatile projective field. The psychoanalytic therapeutic process unfolds in the context of a treatment frame that supplies the necessary and sufficient conditions for the unfolding of an interpretable transference relationship. The psychoanalytic frame consists of both practical and therapeutic variables. On the practical front, the patient and the therapist agree before the end of the first session on the date, time, and frequency of sessions. Also discussed and agreed-on are cancellation policies, length of sessions, fees, and payment options. During these frame discussions, many therapists discuss their policies on phone contact and vacations. The client should leave the first hour fully cognizant of the practice parameters. The therapeutic variables, which are related to the therapist’s attitude, are part of the lived experience of the treatment. Therapists are generally expected to use only judicious self-disclosure, adopt a neutral listening stance, and have only minimal physical contact

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with the patient. Extra-analytic contact (social or educational events) is discouraged. During the first hour, the psychoanalytic therapist invites the patient to discuss his or her emotional problems and how the patient believes the therapist can be of help. The therapist listens silently to the patient’s narrative and intervenes empathically when called for to facilitate the patient’s continued internal exploration. Empathic listening and judicious intervention help establish the therapeutic alliance. According to Freud, the therapist should present “evenly suspended attention” to the patient’s materials, situating himself or herself equidistant from each of the psychological agencies (e.g., the id, ego, and superego). Freud originally urged the surgeon or blank screen model (e.g., therapist neutrality and anonymity) as the approach most likely to allow for an interpretable transference. The nature of the therapeutic action of psychoanalytic treatment resides in its capacity to allow the patient’s conflictual past to live in the present through the development of the transference relationship. This process allows the patient to feel feelings and conflicts that initially were present in his or her relationship to the primary objects of childhood (e.g., parents) but now are projected onto the therapist as a modern-day version of those early objects. It is in the process of working through how these current-day versions are constructed, via the patient’s projections, that the patient is able to engage his or her painful defensive adaptations and begin to withdraw the projections and thus free the patient’s current environment from the painful hold of the past. The therapist’s tools for facilitating this psychoanalytic process include empathic listening, addressing the patient’s resistance (attempts to avoid psychic pain), and transference interpretation—all of which eventually lead to insight, emotional resilience, and self-understanding. Allen Bishop See also Classical Psychoanalytic Approaches: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Freud, Sigmund; Horney, Karen

Further Readings Ellman, S. (1991). Freud’s technique papers. Northvale, NJ: Jason Aronson.

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Freud, A. (1966). The ego and the mechanisms of defense. New York, NY: International Universities Press. (Original work published 1936) Freud, S. (1952). On dreams. New York, NY: W. W. Norton. Freud, S. (1965). The origin and development of psychoanalysis. Chicago, IL: Henry Regnery. (Original work published 1910) Freud, S. (1973). Introductory lectures on psychoanalysis (J. Strachey, Trans.). New York, NY: Pelican Books. (Original work published 1917) Freud, S. (1989). The psychopathology of everyday life (J. Strachey, Trans.). New York, NY: W. W. Norton. (Original work published 1901) Freud, S. (2005). Civilization and its discontents (J. Strachey, Trans.). New York, NY: W. W. Norton. (Original work published 1930) Freud, S., & Breuer, J. (1974). 3 studies in hysteria (J. Strachey, Trans.). New York, NY: Penguin Books. (Original work published 1895) Gay, P. (1995). The Freud reader. New York, NY: W. W. Norton. MacKinnon, R. A., Michels, R., & Buckley, P. (2006). The psychiatric interview. Washington, DC: American Psychiatric. McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioners guide. New York, NY: Guilford Press. Sulloway, F. (1979). Biologist of the mind. New York, NY: Basic Books.

FRY, WILLIAM See Palo Alto Group

FUNCTIONAL ANALYTIC GROUP THERAPY Functional analytic group therapy (FAGT) is a treatment modality that uses the natural interpersonal interactions occurring within groups to enhance client capabilities and helps clients to overcome their psychological problems. This is done by building an understanding of how each client’s interpersonal difficulties contribute to his or her psychological problems and by redressing these difficulties through meaningful experiences

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in the group. FAGT understands a therapy group as a social microcosm in which a client naturally comes to face his or her issues and concerns and addresses these issues and concerns directly when they show up during sessions.

Historical Context FAGT grew out of Brazilian community projects around the turn of the 21st century that applied principles of functional analytic psychotherapy (FAP) to improve the effectiveness of existing group therapy formats for chronic pain and for depression. Although originally there was no intention to create a new form of group therapy, distinctive features, such as detailed case conceptualizations and the notion of therapist tasks, soon emerged. First described for the benefit of training and supervision, these features now define FAGT as currently taught in Brazilian workshops. They also distinguish FAGT from other efforts to harness FAP principles for group projects, such as Scott T. Gaynor and P. Scott Lawrence’s “Learning Through In Vivo Experience” in the United States, which illustrates that there are various ways to adapt FAP to groups and FAGT is only one of them.

Theoretical Underpinnings FAGT draws on FAP theory concerning in vivo learning opportunities and clinically relevant behavior (i.e., any in-session sample of a client’s problem behavior or clinical improvement). Whereas Mavis Tsai and Robert J. Kohlenberg developed these notions for FAP in the context of behavior analytically informed individual talk therapy, FAGT resettles them in the group therapy context. In vivo learning opportunities are interpersonal episodes in a group therapy session that have the potential to promote clinical progress during a client’s spontaneous interaction with the therapist or with the group. Functional analytic psychotherapy theory demands that therapists continuously compare a client’s behavior in session with the client’s reports about daily life. In group therapy sessions, therapists harness the reinforcing effects of naturally occurring interpersonal consequences to influence client behavior in ways that will be helpful in daily life.

Major Concepts To transform interpersonal experiences in the group into the particular kind of in vivo learning opportunities an individual client needs, the group therapist builds a contextual understanding of the client’s problems, of the relevant behavior, and of the group. The group therapist organizes this understanding in detailed case conceptualizations. The actions the group therapist will need to perform to promote this transformation are the therapist tasks.

Case Conceptualizations

Three levels of case conceptualization (CC) provide for attuning interventions to clients’ problems and goals, to the specific functions of the target behavior, and to the dynamics of the group. These are the Client CC, the Behavior CC, and the Group CC. The case conceptualization for the client (the Client CC) summarizes and interrelates five types of information: (1) what the client’s needs are; (2) what new takes on daily life may help the client reach his or her goals; (3) what behavior and interpersonal contingencies hinder progress in the client’s daily life; (4) what personal, social, cultural, or other resources can be mobilized for treatment; and (5) what new behavior ought to be learned in the group. The therapist negotiates a first version of the Client CC during one or two preliminary individual sessions and then continuously develops it with new information from every group session. Behavior CC provides a detailed contextual understanding for each of the behaviors targeted in the Client CC. It specifies the target change, the interpersonal contingencies involved, and which resources to mobilize. Functional analysis of episodes in the group that relate to the particular target behavior and comparison with reported parallel incidents in the client’s daily life inform these microformulations. Each time the clinically relevant behavior reoccurs in session, the therapist reviews the Behavior CC to incorporate relevant information from the new episode. Finally, the formulation of the group dynamics summarizes tendencies in the way the group responds to key issues and challenges. The Group CC identifies which behaviors the group tends to

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evoke, weaken, or reinforce in its members and how it tends to do this. Conceptualizing the group dynamics allows highlighting of similarities and differences with an individual client’s daily life environment. As an example, a demanding or meddlesome group may evoke and reinforce behavior in a client that her disengaged family and her indifferent colleagues at work do not. This can enable useful in vivo learning experiences but may hinder generalization of new behavior from the group to daily life. Therapist Tasks

Three rules specify what therapists do, and three other rules specify how they do it. The tasks of group therapists are (a) to observe each client’s interactions with the other group members and with the group therapists, (b) to keep the case formulations up-to-date, and (c) to promote in vivo or here-and-now learning opportunities. They are expected to do these tasks in a directive, reflective, and caring manner. A team of two therapists is preferred over a single therapist. One therapist—the lead therapist— directs the group activities, while the other—the background therapist—observes and notes what happens. After each session, the therapists debrief and jointly plan for the next session. In rare, but sometimes crucial, circumstances, the background therapist intervenes during the session to alert the group to some issue it seems to be missing, or takes the lead therapist aside for a quick discussion. Taking turns as background and as lead therapist will help the therapists to take different perspectives on the group process, sharpening their awareness of clinically relevant behaviors and in vivo learning opportunities. In addition, the input of different therapist styles (e.g., challenging vs. soothing) may elicit a broader range of individual client issues. The lead therapist offers directions for group activities, but this does not mean the clients need to follow the instructions. Consider a case, for instance, of a submissive client who rejects a therapist’s directive for a group exercise. This client may be developing better ways to assert his or her boundaries. Being directive means actively keeping the focus on the goals specified in the case conceptualizations. The group therapists interrupt

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counterproductive interactions and support group dynamics that evoke and shape clients’ improved dealings with their difficult issues. They channel interactions so that the group does not avoid painful but relevant issues, and they take care that the group’s reactions do not weaken individual clients’ in vivo improvements. Effective group therapists reflect on their responses to client behavior and include these responses in the functional analysis. To decide whether a client behavior is a problem or an improvement, the lead therapist considers the behaviors to which the client is responding. Moreover, client behavior changes in session often relate to how the lead therapist responds to the client behavior. When the therapeutic strategy becomes part of the interpersonal patterns that maintain a client’s problem behavior, the lead therapist must change that strategy. The background therapist’s observations make sure the lead therapist’s behavior is included in the functional analysis, but both group therapists must also monitor their inner experience of client behavior to get a full picture of what is happening between them and each client. To intervene in a caring manner means that the therapists are willing to sacrifice their priorities for client needs. Genuine caring rarely means protecting clients from painful issues. More often it involves helping clients abandon deeply rooted avoidance patterns and encouraging them to experience and stay with the difficult feelings evoked by meaningful interactions in the group. Investing time in emotional deepening often opens windows to clients’ needs, difficulties, and strengths and creates opportunities for in vivo learning.

Techniques In FAGT, the term technique refers to the functional definition of therapists’ interventions. As borrowed from functional analytic psychotherapy, the techniques are evoking, reinforcing, blocking, and weakening. To evoke denotes to act in a way that produces a specific client behavior. To reinforce (vs. to weaken) describes responding to a client behavior in ways that increase (vs. decrease) its frequency. To block means to thwart the behavior’s successful emission. These techniques correspond closely to how people unwittingly influence

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the behavior of others in daily life. Group members naturally shape one another’s and the group therapists’ behavior in the same ways. Because of this, once the therapists understand a group’s typical dynamics, they may choose, at times, to allow the natural interactions and contingencies in the group to do their job. The expression tactic refers to the topographical definition of interventions as a different way of describing the same efforts to promote curative interpersonal experiences. Tactics range from bold and risky (e.g., therapist self-disclosure) to basic group therapy procedure (e.g., asking a client who has difficulty dealing with new people to participate in an activity with members he or she did not pay attention to before). Organizing group discussions of “how what you just did affected me” is a frequently used FAGT tactic, which helps clients become better at identifying the consequences of their behavior in the group. Generalizing this new ability to daily life helps clients understand the chains of interactions that lead up to conflict or rejection, so they can try out new behavior directed at their desired interpersonal outcomes. A tactic called “scooping up” is often used to salvage behavior that is too weak to obtain reinforcement from the group. A group therapist focuses on weak improvements to give them a chance to develop into behavior that is more effective. Therapists can ask a client who noticed a clinically relevant behavior improvement in another client to respond to it, or they may even ask the latter client to repeat it. In other cases, they scoop up hardly noticeable reinforcement for a target behavior. On noticing a potentially reinforcing response of a client to someone’s clinically relevant behavior, the group therapist can ask that client to restate his or her response or otherwise highlight it. Depending on the context, a single tactic can match various FAP techniques. For example, a group therapist’s self-disclosure can reinforce a client’s clinically relevant behavior, such as seeking closeness with the therapist. If the therapist were to disclose that a clinically relevant behavior problem did not have the effect on the therapist that the client desired, it may weaken the behavior. Selfdisclosure may also thwart a client from emitting a clinically relevant behavior, evoke client issues, or

cue new behavior that may result in a clinical improvement.

Therapeutic Process The Client CC serves as a guide for the group therapists in deploying various tactics to foster the emergence of clients’ issues and difficulties in the group in order to create here-and-now learning opportunities. Participating in the group, negotiating one’s space in it, collaborating and communicating with the other group members, and trying to have one’s needs met in this context produce a number of challenges for a client. Each client deals with these challenges with a range of clinically relevant behaviors. These behaviors affect the group in ways that, in turn, will influence the client’s behavior. When the group functions in a therapeutic way, the effects of the behavior improvements on the group will feed back to reinforce the improvements. Put differently, the ways the group responds to clinical improvements will function as positive reinforcement, strengthening the improvement. In addition, a well-functioning therapeutic group will respond to clinically relevant problem behavior in ways that will promote change, helping the client to abandon the problem behavior. This process gradually shapes healthier client behavior. Most often, the group therapist does not provide the reinforcement but, with careful consideration of the case conceptualizations, arranges group activities so that the target behavior improvements naturally produce reinforcing effects in the group. The Client CC helps the group therapist identify which behaviors of each individual client constitute clinical progress. The Behavior CC spells out which contingencies influence the target behavior during interaction. This helps decide how to promote a clinically relevant behavior improvement. In addition, the Group CC shows how the group therapists can best harness the group dynamics to create in vivo learning opportunities. When clinical progress on a specific target behavior becomes evident, in the form of new behavior by the client in the group, the group therapist asks that client to monitor generalization of the gains outside the group. When this generalization does not occur spontaneously, the group

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helps the client devise strategies to implement the new behavior in daily life. Treatment ends with an assessment of individual progress and identification of further personal goals. One or two follow-up encounters, often after 3- and 6-month intervals, allow discussion of posttreatment evolution and, when needed, further work to reverse setbacks. Luc Vandenberghe See also Behavioral Group Therapy; Cognitive-Behavioral Group Therapy; Functional Analytic Psychotherapy; Process Groups

Further Readings Gaynor, S. T., & Lawrence, P. (2002). Complementing CBT for depressed adolescents with Learning through In Vivo Experience (LIVE): Conceptual analysis, treatment description, and feasibility study. Behavioural and Cognitive Psychotherapy, 30, 79–101. doi:10.1017/ S135246580200108X Hoekstra, R., & Tsai, M. (2010). FAP for interpersonal process groups. In J. W. Kanter, M. Tsai, & R. H. Kohlenberg (Eds.), The practice of functional analytic psychotherapy (pp. 247–260). New York, NY: Springer. Kohlenberg, R. J., & Tsai, M. (1987). Psychotherapists in clinical practice: Cognitive and behavioral perspectives. In N. Jacobson (Ed.), Cognitive and behavioral therapists in clinical practice: Cognitive and behavioral perspectives (pp. 388–443). New York: Guilford Press. Tsai, M., Kohlenberg, R. J., Kanter, J. W., Holman, G. I., & Loudon, M. P. (2012). Functional analytic psychotherapy: Distinctive features. Hove, England: Routledge. Vandenberghe, L. (2009). A functional analytic approach to group therapy. The Behavior Analyst Today, 10, 71–82. Vandenberghe, L., Ferro, C. L. B., & Cruz, A. C. F. (2003). FAP-enhanced group therapy for chronic pain. The Behavior Analyst Today, 4, 369–375.

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intensity, compassion, and effectiveness of the therapist. FAP therapists view each client as a microculture with complex life stories filled with joy and anguish, dreams and hopes, passions and vulnerabilities, and unique gifts and abilities, carrying deeply rooted cultural, social, and generational experiences in their reinforcement histories. From a behaviorally defined perspective, the qualities of awareness, courage, and therapeutic love are considered to be the building blocks of a therapeutic bond that is the springboard for client change. At the core of FAP is its hypothesized mechanism of clinical change: contingent therapists responding to client problems and improvements as they occur here and now in session. The behavioral underpinnings of FAP provide a conceptually clear framework that facilitates its use with other treatments.

Historical Context FAP was developed by Robert Kohlenberg and Mavis Tsai in the 1980s. They noticed that the therapy of clients who achieved exceptional outcomes had intensity, personal involvement, and unforgettable therapist–client interactions. They used behaviorism, with its advantages of a strong empirical base, operationally defined concepts, and precise language, to clearly define effective therapist behaviors. At the same time, it is well understood that imitating the exact actions of a successful therapist does not take into account that what works for one therapist may not work for another. Thus, FAP describes principles that accommodate the differences among therapists and among clients and avoids the “one-size-fits-all” approach.

Theoretical Underpinnings Major theoretical underpinnings of FAP are based on applied behavior analysis: reinforcement, specification of behaviors of interest, and generalization. Reinforcement

FUNCTIONAL ANALYTIC PSYCHOTHERAPY Functional analytic psychotherapy (FAP) is a behavioral approach based on empirically supported principles that harnesses the power of the therapeutic relationship and maximizes the genuineness,

Central to behavior-analytic treatment is the direct shaping and strengthening of more adaptive behavior through reinforcement—all consequences or contingencies that increase or decrease the strength of behavior. The closer in time and place the behavior is to its consequences, the

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greater will be the effect. This is why FAP focuses on the here-and-now therapist–client interactions that are seen as actual instances of daily life problems, for example, avoidance of being emotionally open both with the therapist and with others in daily life. Specification of Behaviors of Interest

Observation and behavioral definition are necessary to specify behaviors of interest. For the subtle types of issues that psychotherapy clients can present, observation and behavioral definition of problem and goal behaviors can be accomplished if (a) the clients’ problems occur during the session and thus can be directly observed and (b) the therapists have in their own repertoires the clients’ goal behaviors—for example, interpersonal relating skills. Generalization

If both therapy and daily-life environments evoke the same behavior in clients (e.g., hostility, not following through, avoidance of emotion), then they are functionally similar (somewhat akin to the notion of transference). This similarity in environments increases the likelihood of generalization of client gains to daily life. To improve generalization, however, FAP therapists typically assign homework to clients based on their in-session improvements.

Major Concepts A number of concepts related to behaviorism are at the basis of FAP. Major concepts include a contextual view of reality, behavior as action, functional analysis, natural reinforcement, and clinically relevant behavior. Contextual View of Reality

Contemporary behaviorism is a contextual theory that states that our perception of reality is a function of our unique experiential histories. Thus, behaviorism is a powerful way of acknowledging and understanding individuality and the ways in which events, including feelings and thoughts, interact to account for the course of people’s lives.

Behavior as Action

FAP views behavior as anything a person does, including observable events (e.g., walking, loving, crying), private acts (e.g., thinking, feeling, dreaming), and bodily functions (e.g., heart rates, hormonal secretions). Thus, every aspect of being human is encompassed by this definition of behavior, as long as the act is expressed as a verb—for example, instead of having a memory, people remember; instead of having courage, people act courageously. Functional Analysis

Functional analysis answers the question “What is a behavior’s function?” by identifying the contexts that evoke the behavior and the consequences that make it more or less likely. For example, to say that someone has a drinking problem (i.e., topography of what a behavior looks like) is not enough. Instead, a functional analysis may indicate that the drinking alleviates social anxiety, lowers social inhibition, or numbs negative feelings. Understanding the different functions of a behavior leads to the therapist choosing among different therapeutic interventions that might be appropriate. Natural Reinforcement

Natural reinforcers are related to those that occur in one’s daily environment. To be naturally reinforcing, therapists need to connect authentically with their clients, just as people connect in the outside world, including sharing, expressing, disclosing, or amplifying reactions to client behavior. It is, however, crucial for therapists to recognize and shape successive approximations of goal behaviors even if they are not yet at the level to be positively reinforced in daily life. Thus, FAP therapists are expected to be sensitive to client improvements. Clinically Relevant Behavior

Three client daily-life behaviors that can occur during the session are of particular relevance and are referred to as clinically relevant behaviors (CRBs). CRB1s are client problems that occur in session and are expected to decrease during the

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course of therapy. CRB2s are client improvements that occur in session. CRB3s are client interpretations of their own behavior.

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which the therapist actually reinforces improvements by observing in-session gains. Rule 5: Interpret and Generalize

Techniques FAP techniques are given in the form of rules, or guidelines, to facilitate therapist effectiveness. Rule 1: Watch for CRBs (Be Aware)

This rule focuses on being aware of how client behavior in the therapy session may be related to presenting problems. It forms the core of FAP and leads to an intense and interpersonally oriented treatment. The more accurately therapists can detect and respond therapeutically to CRBs, the more likely therapy will be impactful.

FAP interpretations make clients aware of what variables are controlling their behavior, and assess if daily-life events are related to corresponding insession situations (e.g., “Are you withdrawing from me the way you do in other relationships when you start feeling close?” This may serve the function of reducing anxiety). When a CRB2 has occurred, therapists implement generalization by asking clients to try their improved behaviors with significant others (e.g., “You stayed with your emotions despite wanting to shut down; can you try this with your partner?”).

Therapeutic Process Rule 2: Evoke CRBs (Be Courageous)

CRBs pertain to a client’s unique problems and histories. The ideal therapeutic relationship evokes CRB1s, which in turn are the precursors for the development and nurturing of CRB2s. Implementing an evocative therapeutic relationship often entails therapists taking risks and pushing their own intimacy boundaries. Such risks involve therapists being courageous, venturing and persevering, and withstanding fear of difficulty. Rule 3: Be Naturally Reinforcing (Therapeutic Love)

The purpose of this rule is to increase the frequency of improved client behavior. For example, if a client has a history of withdrawing when someone gets close but responds to a therapist’s expression of caring by saying, “I feel soothed by you,” then it is probably a CRB2. It’s important for the therapist to react in a manner that will increase the likelihood that the “staying close” response will strengthen. Rule 4: Be Aware of Impact

It is important for therapists to be aware of their effect on clients. This rule highlights the importance of paying attention to client in-themoment reactions and assessing the degree to

FAP’s five rules are applied flexibly and functionally; thus, therapy looks different from one client to another because of each client’s unique history and CRBs. Effective therapeutic process, however, involves therapists (a) being in touch with contingencies of reinforcement that have shaped their clients, (b) feeling compassion for clients’ history of wounds and losses, and (c) being aware of clients’ CRB1s and CRB2s in the context of this history. Interpersonal risk taking and the sharing of private stimuli (intimacy) are often outside clients’ comfort zones due to cultural, historical, and personal contingencies. Countering the anxiety produced by engaging in new behavior is valued in FAP, requiring both courageous clients and courageous therapists. Mavis Tsai, Stig Helweg-jørgensen, and Robert J. Kohlenberg See also Acceptance and Commitment Therapy; Applied Behavior Analysis; Behavior Therapies: Overview; Behavior Therapy; Behavioral Activation; CognitiveBehavioral Therapies: Overview; Cognitive-Behavioral Therapy; Interpersonal Psychotherapy; Interpersonal Theory

Further Readings Kohlenberg, R., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative

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therapeutic relationships. New York, NY: Plenum Press. Tsai, M., Kohlenberg, R., Kanter, J., Holman, G., & Plummer Loudon, M. (2012). Functional analytic therapy: Distinctive features. London, England: Routledge.

Tsai, M., Kohlenberg, R., Kanter, J., Kohlenberg, B., Follette, W., & Callaghan, G. (Eds.). (2009). A guide to functional analytic psychotherapy: Awareness, courage, love and behaviorism in the therapeutic relationship. New York, NY: Springer.

G determined that psychotherapy was biased against women and that psychotherapeutic techniques and theories not only encouraged and promoted traditional sex roles for women but also devalued women. The task force also determined that psychoanalytical concepts in particular were utilized in a sexist manner and that women were often treated as sex objects. The conclusion of the task force was that the counseling relationship was analogous to the social order of men (male counselors) subjugating women (clients), with men determining what women needed. Feminist therapy developed partly in response to the sexism found in traditional therapies. Feminist therapy was founded on nonsexist principles that included fostering an egalitarian relationship between counselors and clients; recognizing that the personal is political, meaning that the social context is paramount in understanding what is happening in clients’ lives; supporting and validating women’s anger; not blaming the victim; encouraging strengths; and opposing sexist counseling and psychological theories. When theorists realized that traditional male gender role stereotypes may also psychologically damage men, GAT was born. GAT was intended to synthesize the principles of feminist theory with gender theory in order to equally represent both women and men in counseling theory and practice.

GENDER AWARE THERAPY Gender aware therapy (GAT), also known as gender-sensitive therapy, originates from feminist therapy, which takes into account women’s issues and problems from a social perspective and context. GAT’s original goal, developed by Glenn E. Good, Lucia A. Gilbert, and Murray Scher in 1990, was to expand the concept of feminist therapy to include both men and women, along with couples and families. Gender can be defined as the psychological and sociocultural constructs concerning masculinity and femininity that can change over time. Biological sex, which differs from gender, is based on the physiological characteristics of males and females that are determined by hormones, chromosomes, genitalia, and internal organs. GAT integrates nonsexist theories for both men and women and examines the social context and constructs of being male and female, along with the messages and implications assigned to both males and females. Multicultural perspectives can also be taken into consideration by exploring gender roles in the cultural context of the client. The goal of GAT is to assist counselors and clients with creating and living in nonoppressive environments free from gender stereotypes and prejudices.

Historical Context Theoretical Underpinnings

In the past, traditional therapies were found to often subjugate women. In fact, in 1975, a task force from the American Psychological Association

Five major theoretical underpinnings are seen as the foundation of GAT: 449

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1. Gender is central to counseling and the counseling relationship. Gender role socialization, or messages that have been given to both males and females throughout their lives, plays an integral part in what each may consider to be a successful male or female. Rigid gender roles can be linked to depression, unhealthy relationships, and negative outcomes for both men and women. 2. Issues need to be considered within their sociopolitical context. As feminist therapists would say, the personal is political. 3. Gender inequities and injustices occur for both men and women. Counselors need to help find ways to change these injustices with and on behalf of their clients. Gender stereotypes and their implications need to be examined for both men and women. 4. Egalitarian relationships need to be established between counselors and clients in order to de-emphasize the power of the counselor. Clients are viewed as experts in their own lives. 5. Counselors need to have respect for clients’ abilities to make choices for themselves. Choices that are made are not viewed as polarized opposites in terms of male or female and right or wrong. For example, a female could choose to pursue a business career and spend her free time sewing and doing crafts. Likewise, a male could choose to cook and clean in the home and watch football on Saturday afternoons.

Major Concepts Gender aware counselors are aware of the societal messages that women and men receive from families, schools, peers, the media, and religions as to what constitutes appropriate roles and behaviors. Women are socialized to be nurturing, submissive, emotional, dependent, weak, and accepting, while men are socialized to be dominant, independent, aggressive, fearless, self-confident, strong, and competitive. With regard to home life, even domestic chores are gender appropriated: Cooking and cleaning are seen as female chores, while taking out the trash and lawn mowing are male chores. Women are generally seen as more verbally expressive, while men are seen as talented in math and the sciences. Men are generally expected to be providers, and women, even though they may work

outside the home, are still expected to take care of children and household responsibilities. Researchers have found that traditional gender roles have been linked to anger, depression, sexual dysfunction, and substance abuse disorders in men and depression, mood disorders, and eating disorders in women. Women

Women have traditionally been judged on male counseling and psychological models of development that emphasize achievement, individualism, and cognitive problem-solving methods. Women have been socialized and then judged harshly for emphasizing collaboration and interpersonal relationships and intuitive, holistic problem-solving methods. Women have also been socialized to suppress anger, please others and be caretakers, and take the blame for situations. These behaviors could potentially lead to depressive symptoms. For women, gender aware counselors can explore roles of wife, mother, worker, and community member. Counselors can explore career development, balancing work and family; finding mentors and support; body issues related to women, like eating disorders and body image distortions; issues related to sex in a society that has double standards regarding sex; and sexual trauma, including rape, sexual harassment, and sexual abuse. Counselors can also explore the gender-encoded messages women have been sent throughout their lives and help women choose the life they would like to lead instead. Counselors utilizing GAT with women can also take into account the physical changes that mark a woman’s life, such as menstruation, pregnancy, and menopause. These physical changes are not only related to physical and hormonal adjustments but also frequently associated with symptoms of depression. GAT counselors take into account social, cultural, and biological issues and changes that are unique to women’s lives. Men

In GAT, men can explore traditional male roles and attitudes that may include resistance to seeking help, a mind-set that may ultimately lead to resistance to therapy. During therapy, men may need to explore cultural stereotypes of

Gender Aware Therapy

men being independent, autonomous, invulnerable, and blocked from emotions (alexythymia). Men may play out different scripts or roles that have been prescribed to them, such as (a) the tough guy script of being aggressive and fearless, which may lead to problems with intimacy, connection, and possible restricted emotions in a relationship; (b) the violence script, which encourages violence and aggression through sports and fighting and may lead to domestic violence and marital relationship issues; (c) the playboy script, where sex is seen as gratification of physical needs or prowess, which does not allow for intimacy and caring for others and can also lead to rape myths; (d) a homophobic script, which believes that any intimate connection with another male must be avoided and disdained and which may lead to restricted affection between males; (e) a winner script, which states that a man must be competitive and successful, which may lead to men being overly authoritarian and aggressive and may not be helpful in family and couple relationships; and finally (f) the independent script, which says that men must not attach to others or they will be seen as weak. The last two scripts may play out in role conflicts between work and family relationships and could be seen as men putting work ahead of family, meaning that they may not be available for child care or work around the house. Each script can be explored by counselors and clients, with positive and negative ramifications being denoted, challenged, and then possibly changed. Couples and Families

Counselors utilizing GAT with couples could explore each partner’s gender role socialization and how that role plays out in marriage and family relationships. Partners and family members could be helped to realize that household chores are not related to gender but are simply tasks that need to be done. Counselors could explore marital dissatisfaction, communication patterns, sexual intimacy, and commitment related to each of the gender roles explored for men and women.

Techniques All of the techniques for GAT can help both counselors and clients become aware of gender

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role socialization and how these roles affect their lives. These techniques are each briefly described in the following subsections. Counselor Awareness

Effective GAT counselors have a thorough knowledge of the implications of gender and are able to support clients in breaking free from traditional gender-stereotyped roles. They also seek awareness of their own gender stereotypes and biases and become sensitive to how their attitudes may affect their counseling practices. Through personal exploration, counselors can become nonblaming, open, empathetic, understanding, and flexible with their clients as clients explore their own gender role socialization, attitudes, beliefs, roles, and behaviors. Exploration of Problems in Gender and Social Context

Clients and their problems are conceptualized in the social context. Together, counselors and clients can explore and become cognizant of how society labels and stereotypes masculine and feminine behaviors and the resultant problems. Counselors can educate clients about the following: (a) gender ecosystems, (b) how gender is and has been divided, (c) how individuals are socialized according to gender and educated regarding androgyny, and (d) the space on the continuum between the two genders. By educating clients, counselors thereby help clients through a gender role journey of exploring possible gender identity development. Counselors may find two techniques helpful in exploring gender role socialization. Gender inquiry, or a series of questions used to determine how the client self-identifies regarding gender-related issues, is used to explore how clients learned to be male or female. A gendergram, much like a genogram, explores the clients’ histories of gender messages. Both of these techniques can identify significant events and developmental periods of clients’ lives and emphasize important people who distilled information regarding roles, patterns, and themes associated with gendered patterns and beliefs. Through a gender inquiry and gendergram, clients and counselors can explore relationships and messages from mothers, fathers, grandparents, and other significant figures in their past.

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Once a gender history has been taken, counselors can help clients explore how socialization plays into their problems and distress. They can explore both the positive and the negative effects of these scripts and messages. Problems can be explored in the context of gender role expectations.

their lives, their beliefs, and their feelings. GAT focuses on the strengths of both men and women and does not merely look at the “dark side” of traditional gender roles. GAT does not necessarily restrict traditional masculine or feminine behaviors but instead encourages a wider range of behaviors, thoughts, and feelings for both men and women.

Education and Exploration of Alternatives

Once clients’ gender histories have been explored in a sociocultural context, they can be educated about different alternatives for behaviors along with the possible consequences and ramifications for changed behaviors. Therapy can be psychoeducational in nature. Counselors can educate clients regarding gender stereotypes and the positive and negative implications of these stereotypes. Many of the GAT techniques are similar to those of feminist therapy, including disclosure on the part of counselors to create an egalitarian relationship, modeling, discussion, supporting clients, sex role analysis, power analysis, relabeling or reframing behaviors, bibliotherapy, support groups, and finding mentors. Cognitive-behavioral therapy can be utilized by counselors in exploring assumptions and beliefs. Clients are then challenged to reexamine the gender attitudes, beliefs, and behaviors. Termination

The final stage or technique of GAT is termination. It is seen as a way of helping men cope with their vulnerabilities in terms of goodbyes and as an effective method of helping women realize that they can be self-reliant.

Therapeutic Process GAT is egalitarian in nature, whereby counselors respect the choices of clients, are advocates for change in the societal context, understand the clients’ problems in the societal context, and regard the understanding of gender as essential to the counseling process. GAT can facilitate clients and counselors in becoming aware of gender role stereotypes and the ramifications in their lives. Counselors utilizing GAT can assist clients in understanding how traditional gender roles can limit both men’s and women’s choices regarding

Cynthia H. Matthews See also Bibliotherapy; Cognitive-Behavioral Therapy; Feminist Family Therapy; Feminist Therapy; Identity Renegotiation Counseling; Miller, Jean Baker

Further Readings Brooks, G. R., & Good, G. E. (2005). The new handbook of psychotherapy and counseling with men: A comprehensive guide to settings, problems, and treatment approaches (Rev. & abridged ed.). San Francisco, CA: Jossey-Bass. Fitzgerald, L. F., & Nutt, R. (1986). The division 17 principles concerning the counseling/psychotherapy of women: Rationale and implementation. The Counseling Psychologist, 14, 180–216. doi:10.1177/0011000086141019 Good, G. E., Gilbert, L. A., & Scher, M. (1990). Gender aware therapy: A synthesis of feminist therapy and knowledge about gender. Journal of Counseling & Development, 68(4), 376–380. doi:10.1002/j.1556–6676.1990.tb02514.x Mahalik, J. R., Good, G. E., & Englar-Carlson, M. (2003). Masculinity scripts, presenting concerns, and help seeking: Implications for practice and training. Professional Psychology: Research and Practice, 34(2), 123–131. doi:10.1037/0735– 7028.34.2.123 Philpot, C. L., Brooks, G. R., Lusterman, D., & Nutt, R. L. (1997). Bridging separate gender worlds. Washington, DC: American Psychological Association. White, M. B., & Tyson-Rawson, K. J. (1995). Assessing the dynamics of gender in couples and families: The gendergram. Family Relations, 44, 253–260. doi:10.2307/585523

GESTALT GROUP THERAPY Gestalt group therapy is an application of Gestalt therapy within a group context. Both Gestalt therapy

Gestalt Group Therapy

and Gestalt group therapy are based on the phenomenological principles of holism and field theory. Although the primary application of Gestalt therapy has been in individual counseling and therapy, the use of the group as a central milieu for incorporating Gestalt therapy concepts, techniques, and processes, including a focus on interpersonal relations and group processes, has increased over the years. In all applications, a basic assumption of Gestalt work is that individuals must be understood and approached in relation to their environment. Moreover, the influence of Gestalt theory, processes, and techniques on other forms of group work, such as person-centered and psychoeducational groups, is extensive.

Historical Context Gestalt therapy’s primary developers were Frederick S. Perls (1893–1970) and his wife, Laura (1905–1990). Originally trained as Freudian analysts, Perls and his wife moved from Berlin to Holland and then to South Africa to flee Nazi Germany. Soon, they began to experiment with revising aspects of Freudian orthodox practice. Following World War II, they moved to New York City, where they initiated weekly experiential training in what was to become known as Gestalt therapy. After separating from his wife, Perls moved to Miami and then to the West Coast, where he developed innovations associated with Gestalt therapy in groups, particularly at the Esalen Institute in California. The “hot seat,” drawn from the work of the psychiatrist J. L. Moreno, became centrally connected with Perls’s work; here, a group member would sit in an empty chair, known as the “hot seat,” while Perls focused intensely on him or her while the others observed. Although Perls did not write about group therapy, he practiced it in training workshops. Following an individually focused model with himself and one client at a time as the central source of activity, he would encourage the group to provide support and feedback once he was finished focusing on the client. Subsequently, other approaches to Gestalt therapy in groups arose. For instance, the New York Institute in the early 1950s moved beyond the hot seat and focused more on interactive

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processes in the group. Here, a kind of floating hot seat emerged that capitalized on the spontaneous participation of members in the group. It also became usual to find Gestalt group leaders experimenting with new, spontaneous, experiential exercises that were focused on increasing contact among group members as they emphasized awareness and use of the whole group process to benefit member growth and change. As Gestalt groups evolved, they became thought of as small, cohesive communities and were based on the basic principle of Gestalt itself, which means the whole is greater than the sum of its parts. With this in mind, the Gestalt Institute of Cleveland, established in 1954, came to adhere to four principles: (1) primacy of direct experience, (2) awareness and use of group processes, (3) creating active contact among participants, and (4) use of interactional group experiments introduced by an actively involved group leader. Gestalt group therapy has evolved from its original individually centered practice to one that includes a focus on group process and group development. In this approach, the leader focuses on individual members and their relationship within the group context. The assumption is that the therapeutic experience in the group depends on the inseparable connection of these elements. The implications of this belief for group therapist practice signify the emergence of a genuine Gestalt group therapy, with greater focus on interpersonal relations.

Theoretical Underpinnings The German word Gestalt translates into English as “the whole is greater than the sum of its parts.” In a group, what can and does occur cannot be explained simply by the contributions of separate individuals. Rather, it results from multiplicative sources. In turn, individual behavior needs to be understood in context, where the larger “field” is salient. A related Gestalt perspective is that what is being attended to in the present—the “figure”— needs to be viewed in relation to its surrounding “ground.” Gestalt group therapists assist members to attend to what emerges at any point in the group as figural for them, standing out from the background. This allows members (the basic Gestalt term is organisms) to self-regulate in the

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group, adapting continually to what becomes figural over time and serves to direct the therapeutic process. Group members are encouraged to pay close attention to their direct experiencing of events, giving credence to what they are experiencing and how this leads them to think, feel, and behave, as opposed to why. Perls maintained that awareness, and awareness alone, can be curative. In this increasing self-awareness, a major goal is to transcend relying on the environment for support and, instead, to move toward self-support, as one gains an ever-improving capacity for positive selfregulation. To heighten awareness in Gestalt groups, therapists focus members on direct experiencing in the present moment, attending to matters such as group members’ use of verbal and nonverbal language, postures, interpersonal interactions, and on-group processes.

Contextualized Behavior

Individual members are viewed in relation to one another and the group. The group context both influences members and is influenced by them. Here-and-Now Awareness

Developing and heightening awareness is the key to healthy functioning. Perls observed that awareness alone can be curative. The group leader insists on maintaining a present focus in the group, fastening on to all things occurring or that potentially could occur in the now. Direct Contact and Experience

The primacy of a direct, face-to-face, here-andnow experience is considered to provide the essential material for growth and change to occur.

Major Concepts Gestalt group therapists, and by extension those group leaders whose practice is influenced by a Gestalt perspective, align with concepts such as figure–ground perception, self-regulation, contextualized behavior, here-and-now awareness, direct contact and experience, unfinished business, releasing energy, viewing the group as an organism, openness to process and spontaneity, the group leader as an artist-manager of relationships and learning processes, and group development stages.

Unfinished Business

Thoughts, feelings, and actions can linger without completion. Sometimes they are “unfinished” because energy is lacking; at other times, the stakes are too high or the process too painful to consider moving ahead. Gestalt group leaders help members choose to move the unfinished matter, presently in the “ground,” to the figural forefront. They help the unfinished become finished. Releasing Energy

Figure–Ground Perception

Members are led to cull the figure from the ground in their group experience. That is, they learn to identify and attend to what matters at the moment, to pull it from the surrounding background, and to work on it. At another time, what was figure may become ground in this dynamic process. Self-Regulation

A central goal is for members to improve their capacity for self-regulation in the group, where they learn how to attain a dynamic sense of balance and equilibrium and are increasingly able to attend to their needs as they arise.

Unfinished business may express itself through blocked energy. Or, conversely, blocked energy may result in unfinished business. Blocked energy can be expressed in many ways. For instance, one member may hold himself in with arms and legs crossed, while another continually looks to the floor, as if afraid or apprehensive. In both cases, it is the role of the Gestalt group therapist to assist members to explore these bodily expressions and help them identify how energy is being blocked. Viewing Group as an Organismic System

In Gestalt groups, the group is viewed as an organism with systemic properties. It is seen as alive and dynamic, and each of its parts—its

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individual, interpersonal, and group-as-a-whole levels—interact and affect one another. Openness to Process and Spontaneity

Gestalt group therapists are watchful for unfolding events, treating them as spontaneous opportunities for change. They realize that groups are open, dynamic systems that can offer opportunities for learning and growth at any point. Group Leader as Artist-Manager of Relationships and Learning Processes

Group leaders are concerned with creatively developing and managing learning conditions and in directly promoting interaction and growth among members. Group Development Stages

Gestalt group therapy generally is understood as progressing through developmental stages. One model suggests three stages of development: (1) identity and dependence, (2) influence and counterdependence, and (3) intimacy and interdependence.

Techniques Gestalt group therapists, and those influenced by Gestalt concepts, draw from a range of techniques, including using exercises and experiments, empty chair, making rounds, attending to verbal and nonverbal language, and helping members express resentments and appreciations. Using Exercises and Experiments

Both of these approaches are used to raise awareness and increase direct engagement. Exercises are preplanned activities that are introduced into the ongoing interaction, while experiments are spontaneously created activities that emerge from the present flow of interaction. Empty Chair

This technique makes use of an empty chair in the group circle to allow a member to explore

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polarities through dialoguing. For instance, a member may be asked to talk with different aspects of himself and herself (e.g., top dog/underdog; opposite vs. same feelings) or to complete unfinished business (e.g., talking with a deceased parent in the empty chair). Making Rounds

This exercise typically is used at the beginning of a group session as a kind of warm-up experience. Members “go round,” taking turns individually to briefly describe a current feeling (e.g., “How are you feeling right now?”) or something more intense (e.g., “Say something you might not ordinarily express in a group”). Attending to Verbal and Nonverbal Language

How members express themselves, with or without words, can afford a potent avenue for exploration in a group. A variety of techniques exist to explore language usage, such as (a) exploring nonverbal, body language, such as exploring what a particular movement or stance might mean; (b) personalizing pronouns, such as substituting an impersonal “it” for “me” (e.g., from “It’s unsafe in here,” to “I feel unsafe in here”); and (c) changing questions to statements (e.g., from “Is that really the best way to handle the situation,” to “I do not agree with that way to proceed”). Helping Members Express Resentments and Appreciations

In a Gestalt approach, it is believed that appreciations exist underneath resentments, that resentments held against others or situations continue because of associated appreciations. It is assumed that if appreciations were not present, then resentments would not be firmly held on to. So in the Gestalt view, the reason why a resentment is continued is the appreciation underneath. Gestalt group leaders help members express both resentments and connected appreciations. For instance, this approach sometimes is used to close meetings, asking members to express both what they appreciate and what they resent about the session they just experienced. The group leader may want to invite participants as follows:

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“In closing today, what have you appreciated about our meeting, and also can you tell us what you have resented?”

Therapeutic Process Gestalt groups progress therapeutically through three basic means: (1) focusing on one member at a time, (2) being interactive by drawing from the open-ended process and through the interactions that take place, and (3) having a one-on-one focus but also allowing interactions with group members. Increasingly, leaders also make use of the group context, particularly of group development stages, such as identity and dependence, influence and counterdependence, and intimacy and interdependence. In Stage 1, the group leader seeks to foster a climate of trust and help members identify commonalities and similarities. In Stage 2, the group leader attempts to help members express their differences, cope with authority, and legitimize role flexibility. The final stage is characterized by increased genuine contact and interpersonal intimacy and is marked by the leader supporting ongoing movement unobtrusively. It is important to point out, though, that rarely does any one group progress in such a linear fashion as just described. In reality, there are some starts and stops, some recursiveness, and maybe even some lurching forward and back. But in general, the progressive stages outlined provide a loose pattern that can assist leaders in planning, performing, and processing their groups. Throughout all these developmental stages, the overall goal of the Gestalt group is to increase awareness and self-regulation through interactions with one another and the group itself. Robert K. Conyne See also Gestalt Therapy; Group Counseling and Psychotherapy Theories: Overview; Perls, Fritz; Training Groups

Further Readings Fairfield, M. (2004). Gestalt groups revisited: A phenomenological approach. Gestalt Review, 8, 336–357. Feder, B. (2008). Gestalt group therapy: A practical guide. Metairie, LA: Gestalt Institute Press.

Kaplan, M. (1978). Uses of the group in Gestalt therapy groups. Psychotherapy: Theory, Research, and Practice, 15, 80–89. Kepner, E. (1980). Gestalt group process. In B. Feder & R. Ronall (Eds.), Beyond the hot seat: Gestalt approaches to group (pp. 5–24). New York, NY: Bruner/Mazel. Passons, W. (1972). Gestalt therapy interventions for group counseling. Personnel and Guidance Journal, 51, 183–189. Perls, F., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York, NY: Julian Press. Polster, I., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. New York, NY: Bruner/Mazel. Yontef, G. (1990). Gestalt therapy in groups. In I. Kutash & A. Woolf (Eds.), Group psychotherapists hand book (pp. 191–210). New York, NY: Columbia University Press.

Websites The Association for the Advancement of Gestalt Therapy: www.aagt.org The Gestalt Directory: www.gestalt.org The Gestalt Therapy Network: www.gestalttherapy.net International Gestalt Journal: www.international-gestalt -journal.org Manchester Gestalt Center for Psychotherapy and Counselling: http://123webpages.co.uk/user/index .php?user=mgc&pn=1?

GESTALT THERAPY Gestalt therapy is an existentially based humanistic therapy arising out of Fritz and Laura Perls’s discrimination and integration of ideas from many traditions, philosophies, narratives, disciplines, and theories beginning in Germany in the 1920s. Born as a revision of Sigmund Freud’s theories, it has evolved into a major contributor to mainstream psychotherapy—from a psychoanalytical/biological/Aristotelian/deterministic foundation to a humanistic/existential/experiential psychotherapy wherein restoration and holism replace dissection and fragmentation and phenomenology (personal meaning making) replaces interpretation.

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Gestalt is a German word that translates into English as “a whole,”“a pattern,”“an organization,” or “a configuration.” While the hallmark of Gestalt psychology is finding shared ways by which people organize their perceptions and phenomenology, the task of Gestalt therapy can be seen as becoming aware of and understanding the idiosyncratic organizing patterns of each individual.

Historical Context Fritz Perls, M.D., codeveloper of Gestalt therapy with his wife, Laura Posner Perls, Ph.D., was a psychiatrist and psychoanalyst. In 1926, Perls became an assistant to Kurt Goldstein, M.D., at the Neuropsychiatric Institute in Frankfurt, Germany. Goldstein, collaborating with the experimental Gestalt psychologist Adhémar Gelb, worked with brain-injured World War I German soldiers. Their organismic, holistic, and integrative approach to working with and understanding these soldiers was in sharp contrast to the usual approach of the times, which was attending to piecemeal body or brain parts. Fritz took this holistic approach and integrated it into Gestalt therapy. He was also heavily influenced by several of his own analysts, especially Wilhelm Reich and Karen Horney. At the same time, Laura Perls was a psychology doctoral student at Frankfurt am Mein University, studying with luminaries such as Adhémar Gelb, Max Werthheimer in Gestalt psychology (including field theory), Martin Buber and Paul Tillich in philosophy, as well as working in Goldstein’s laboratory. She also trained and became a psychoanalyst. Later in New York City, Fritz Perls was heavily influenced by Paul Goodman (she was his collaborator on his seminal 1951 book Gestalt Therapy), Erich Fromm, Clara Thompson, and Harry Stack Sullivan. Although Gestalt therapy today seems to be enjoying a renaissance in the United States after some decades of losing popularity, it is burgeoning in most of Europe, Australia, Mexico, and South America. In the United States, much of what Gestalt therapy introduced to the world from the late 1930s until today has been integrated into many contemporary psychotherapies—for example, the importance and usefulness of the “real” relationship, not just transference; the

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organismic/environmental field (ecology); the importance of awareness; and the movement from interpretation to phenomenology.

Theoretical Underpinnings Every serious approach to psychotherapy requires a worldview of human nature and behavior if it is to provide an integrated approach to psychotherapy. Without such a worldview, “therapy” is reduced to a collage or hodgepodge of haphazard techniques, beliefs, traditions, and procedures used without consideration of the context that produced them—eclectic rather than integrative. Gestalt therapy’s worldview sees human beings as self-regulating organisms of the field who create meaning via their phenomenological organization (meaning making). Self-regulation involves human beings going toward (aggressing) need satisfaction in interaction with their world at the boundary, discriminating what to take in and assimilating and what to reject in the service of survival and to allow higher order needs to flourish. To rephrase, children are born self-regulating in a contextual world and are usually able to survive by the meaning they make of what they experience. They are able to respond appropriately enough for them and the environment to survive. Especially in complex societies, this is not done without creating some character problems (personality issues) for later living in the world. Thus, Gestalt therapy’s process goal is to restore self-regulation within the person’s environment and not to “fix” people in any particular way. Given this basic assumption, some of the theoretical givens of Gestalt therapy include its reliance on existentialism, field theory, phenomenology, and dialogue. Gestalt therapy was heavily influenced by the existentialists (and Buddhists). The existential themes that had the most meaning for Fritz Perls were authenticity (being true to oneself despite external pressures); freedom (the power to act or think as one chooses without restraint but within limits); responsibility for our choices, the meanings we make, and the actions we take; and anxiety that is created by being authentic in a world that has no meaning except that which we create. Thus, existential anxiety is to a large part normalized as part of being human. Field theory was established by Gestalt perceptual psychology, particularly the work of

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Kurt Levin (borrowing from quantum field theory). It maintains that everything is related to everything else and is in constant movement and flux. An individual person is affected not just by his or her psyche but also by genetics, hormones, biochemicals, family, ethnicity, religion, class, race, nationality, politics, economics, history, geography, weather, and so on. The person is not “in” the field but rather “of” the field, interacting, effecting and being affected. Phenomenology is the process by which human beings make meaning of their sensorial experience— what they see, hear, touch, taste, and smell. Meaning is the relationship between figure (what stands out) and ground (background). In other words, meaning is not in the figure and not in the ground; rather it is in the relationship between the two. How individuals choose, organize, and contribute to the construction of what becomes figural for them and what background they bring to bear are critical. Thus, figure organizes ground, and ground gives meaning to the figure. Depending on the ground and the need that a person brings to the figure of a wooden baseball bat, the meaning could be anticipation of a fun game, a weapon, firewood to keep warm, a wedge to hold a cover open, an instrument to break open a car window, a museum piece, a collector’s item, a childhood dream, and so on. Gestalt therapy borrows heavily from Buber’s concept of I–It and I–Thou dialogic relating. While much of life is I–It (strategic relating), primary relationships, close friends, and, hopefully, therapeutic relationships have more of an I–Thou quality—not managed and without attempts to control the outcome. The “freshest fish” (most “experience near”) for Gestalt therapy is the relationship between the therapist and the client. While much of what the client brings into therapy is his or her phenomenological narrative of things happening in his or her outside life (which is as it should be to begin), it is only in the relationship between the client and the therapist that both people have access to the “same” transactions. Thus, each person, client and therapist, has the opportunity to share and engage in a real relationship—a sharing of their two phenomenologies—wherein differences occur that may lead to awareness. Frequently, the inevitable and inadvertent ruptures of connection and the subsequent repair, with

humility, authenticity, and responsibility, can be some of the most important therapeutic interactions. To put it another way, when the potential value of the relationship is in the outcome, I–It (strategic relating) is appropriate to the situation; when the potential value of the relationship is in the relating, I–Thou (authentic relating) is appropriate to the situation. Most relationships are in some kind of balance of both domains. What makes Gestalt therapy so deliciously difficult to define is exactly what makes it so exquisitely creative, vital, and procreative. With the three major pillars as a foundation (field theory, phenomenology, and dialogue), each Gestalt theorist or therapist organizes the various other elements within the domain of Gestalt therapy differently. Gestalt therapy is based on the metatheory that there is no single and fixed Gestalt therapy theory. Rather, each Gestalt therapy theorist or therapist organizes, prioritizes, and integrates many of the same ideas and concepts in different orders of priority and integrations. Each theorist and therapist within Gestalt therapy is doing at the microlevel what Fritz Perls, Laura Perls, and Paul Goodman did in the larger (macro) field—choosing, organizing, and integrating from all of what was in the larger field at those times, including the history of the field. Fritz Perls was emphatic that there was nothing new in Gestalt therapy, that it was the organization (Gestalt) of all of these elements that was new. The Chilean biologists and philosophers Humberto Maturana and Francisco Varela remind us that we are always looking through a lens, which is why we need multiple lenses to maintain perspective and to keep “objective reality” in “parentheses.” Thus, perspective and awareness are born out of difference. The lens you use both determines and limits what you see. If you only use a telescope, you will never see an ant, and if you use only a microscope, you will never see an elephant.

Major Concepts Some of the major concepts that underlie Gestalt theory include the following: the whole is different from (sometimes more than) the sum of its parts, organismic/environmental field as an ecosystem, self-regulation, character, awareness and insight, difference, process, ecology, and body and voice.

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The Whole Is Different From (Sometimes More Than) the Sum of Its Parts

All the parts of a car laid out on the ground give you many metal, rubber, ceramic, liquid, and plastic bits and pieces. However, organize them in a very particular relationship to one another and you have a car in which you can now drive away— certainly different from and, in this instance, more than the sum of its parts. Organize them randomly and you may have an art project—or a pile of junk. Organismic/Environmental Field as an Ecosystem

In contrast to classical psychoanalysis at the time, Fritz Perls maintained that to understand any living organism, you must understand it in its interaction with its environment, a living system of the larger field. Classical psychoanalysis was interested in the individual psyche and not particularly in the person’s interaction with his or her environment. This concept has been slowly assimilated into most current psychotherapeutic models. Self-Regulation

The biological imperative for any living organism is survival. Given this, Gestalt therapy assumes that human beings are born self-regulating within their environment. Their interactions with the field (their world), in the service of survival, accumulate clusters of habits and ways of perceiving and acting—originally healthy—that sometimes become fixed and habitual (below awareness) and continue acontextually, sometimes interrupting selfregulation in the present. The relevant past is the past that interrupts healthy functioning in the present, where it is accessible, palpable, experiential, experimentable, and verifiable. Character

Character is made up of fixed clusters or patterns of perceptual organization (meaning making) and behaviors from historical or background influences, which are below awareness, recurring, and invariant. These are the matrices that make up character. Children make the best creative adjustment they are capable of in the service of survival. When a

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child is born into a crazy, explosive, alcoholic, wartorn, erratic, or controlling family, she may learn to keep her mouth shut, stay back, and scan until the world looks safe again. This is healthy. When, however, this style of being in the world becomes fixed, habitual, and goes below the awareness threshold (procedural memory), this is the birth of character. Character, then, is the freeze-framing of what was once a creative, adaptive, and usually healthy perception and/or response and is now acontextual, anachronistic, and obsolete. Character is made up of actual experiences and introjects, which are rules and “shoulds” that are crammed down the child’s throat by parents, culture, church, government, and so on—and swallowed whole by the child—before the child has the ability to discriminate. Concurrently, contact boundary history, traumas, attachment history, vicarious learning, media, and culture all contribute to character formation. Through the prism of Gestalt therapy’s character, transference can be seen as “character in motion”—the transferring of ways of perceiving others that have become fixed and below awareness and are triggered in the present. Again, the methodology of awareness through difference becomes important for the client to learn how to discriminate between the dialogic relationship in the room and the transferred relationship. Discrimination can only happen experientially if there are two relationships to compare and access difference. For this, the therapist must “show up.” Again, difference precedes and is required for awareness. Awareness and Insight

Awareness is both the methodology and part of the goal of Gestalt therapy—an integral requirement for the restoration of self-regulation within the person’s environment. One of the defining characteristics of awareness (cognitive, affective, and sensorial) is being in contact with what you are doing when you are actually doing it. Insight, as compared with awareness, is something you believe you know about yourself, and often based on noticing, interpreting or speculating, and extrapolating. Insight is primarily a cognitive analysis of a real or alleged pattern of what one does or why one does what one does.

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Difference

How people deal with differences is at the root of most difficulties in relationships—especially intimate relationships. Difference is typically seen in a negative way, according to most Western phenomenology. Having a bad reputation, difference is seen as dangerous, a threat to connection or autonomy, critical, disloyal, betrayal, and/or leading to conflict and therefore frequently avoided. Difference, which requires two individuals (needing a boundary to separate and connect), is absolutely necessary for awareness. There can be no awareness without difference. Here, physics and psychology are very similar: Change (movement) is needed for difference, difference is needed for awareness, and awareness is needed for choice. The distilled and fundamental task of therapy is awareness— requiring the welcoming and engaging of difference rather than trying to get rid of it. Trying to get rid of difference ultimately leads to deferring (confluence or fusion, with accompanying loss of self), withdrawal or isolation (with accompanying loss of other), or conflict (trying to eradicate difference by making the other like me). Conflict typically escalates to eventual explosion and then withdrawal. Process

Process refers to the repetitive patterns, sequences of perceptions, and contacts and behaviors, unique to each individual, that organize and structure one’s meaning making and behavior. When below the awareness threshold, these repetitive patterns or processes (character) organize what one sees, hears, touches, smells, and tastes— contouring the meaning of these as well as the behavior one responds with. These characterological processes interrupt self-regulation in the present, and the task of therapy is to interrupt those interruptions by bringing them into awareness. Differences in phenomenology between the client and the therapist frequently serve as the catalyst to highlight these processes—the “fresh fish.” Ecology

Ecology is the branch of biology that studies the relationship of living organisms to their

environment, including other organisms. The similarity of “character” and “pollutants” is both striking and illuminating. Some ecologists define “pollutants” as “resources out of place.” There is nothing inherently wrong or bad about the pollutant. What makes it “bad” is that it is out of place or balance. Even arsenic, a highly poisonous substance, has been found to be useful in the treatment of cancer and syphilis. Similarly, character, useful perceptually organizing the world and responding to it in one’s initial context, can prevent self-regulation when invoked in another context without awareness. For instance, an Inuit dressed in furs for a Siberian winter would be wearing a “resource out of place” in Karachi in July. It would probably kill him. Body and Voice

From Wilhelm Reich to Fritz Perls and from Elsa Gindler to Laura Perls, the body has always been an important dimension of Gestalt therapy— especially breathing and voice. Fritz Perls maintained that the voice was the single best diagnostic cue of how a person is in the world (e.g., tight, breathless, soft, sharp, relaxed, supported by breathing or not).

Techniques Techniques are the least important part of Gestalt therapy. However, some therapists still erroneously believe that Gestalt therapy is a bag of techniques that define the therapy—a leftover from a few loud, charismatic, misled, and self-appointed practitioners from the 1960s who copied some of Fritz Perls’s experiments and codified them into cliché techniques separated from their origins. When the client and the therapist are stuck and one of them does something different and useful information is generated, this is creativity. When that same transaction with the world is used again in a similar situation, perhaps with a different client, this is technique. The creativity is born of the ground from which Gestalt therapy emerges and not from fitting the client into the therapist’s procrustean assortment of techniques. What makes Gestalt therapy is the field, phenomenological, and dialogic stance of the therapist in the service of awareness and the restoration of the client’s

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self-regulation. With this in mind, a number of ideas underlie how at least some Gestalt therapists conduct therapy, including using experiments, making contact with clients, dialogue, examining figure formation and destruction, and being connected and maintaining self. This section concludes with a discussion of some typical techniques that have been used over the years. Experiments

The purpose of the use of experiments in Gestalt therapy is fundamentally based on the experiment yielding new and different experiential data, which allows awareness. It is the difference that is crucial, whether arrived at by an experiment or by any other means (dialogue, movement, breathing, psychoeducation, etc.). Contact

Contact is the meeting between one person and another, or a person and his or her environment. One cannot “make” contact with another person. A person can optimize the possibility of contact happening by sharing his or her primary experience of the moment, regardless of the content. If the other person is receptive and even willing to share his or her primary experience at that moment, contact can happen in the “in-between.” Of course, such authenticity must be modulated by the context, the degree of connection already established with the other, and “common” sense. Laura Perls maintained that “mental health” might be defined as contact and withdrawal, both with support. Figure Formation and Destruction

How people form and dissolve figures helps Gestalt therapy track where on the cycle of experience the interruption to a smooth flow occurs. This may in the future lead to a complete process system of “diagnosis.” Incomplete Gestalten (“unfinished business”) are frequently considered to be interruptions to self-regulation. Being Connected and Maintaining Self

Although not original to Gestalt therapy, the basic human dilemma is seen as how to be

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connected to another and maintain a self. This is not a problem searching for a resolution but rather a living process in the endless dance of connection and separation—one not unlike breathing. Use of Techniques

Although therapists are warned to avoid using specific “techniques” as a goal in and of itself, there have been a number of techniques that have become known over the years to have originated with Gestalt therapy. These approaches are sometimes used by Gestalt therapists, and others, in an effort to help the client become more aware of self, gain insight, and understand how he or she has become cut off from parts of self. A few of the more prominent approaches are as follows: (a) using “now” language, (b) I–Thou communication, (c) experiencing the present, (d) making statements out of questions, (e) the dialogue game, (f) the empty chair technique, (g) I take responsibility for that, (h) playing the projection, (i) exaggeration technique, and (j) making the rounds. Many of these well-known Gestalt techniques came from Fritz Perls’s experiments at increasing awareness at different times in his career. They neither define Gestalt therapy, nor are they necessary to do Gestalt therapy.

Therapeutic Process The therapeutic process in Gestalt therapy emerges out of the therapist meeting the client from a dialogic, horizontal, and supportive stance. Therapy can be short-term or protracted, depending on the needs and desires of the client in consultation with the therapist. The goals of Gestalt therapy are awareness and choice at three levels—(1) awareness of content, (2) awareness of process, and (3) awareness of awareness (learning how to become aware—deutero learning)—so that therapy can become self-sustaining and self-regulation can be restored and maintained. Robert W. Resnick See also Horney, Karen; Humanistic Psychoanalysis of Erich Fromm; Mindfulness Techniques; MindfulnessBased Cognitive Therapy; Reich, Wilhelm; Sullivan, Harry Stack

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Further Readings Brownell, P. (2010). Gestalt therapy: A guide to contemporary practice. New York, NY: Springer. Buber, M. (1958). I and thou. New York, NY: Scribner. Goodman, P. (1960). Growing up absurd: Problems of youth in the organized system. New York, NY: Random House. Perls, F. S. (1947). Ego hunger and aggression: The beginning of Gestalt therapy. New York, NY: Random House. Perls, F. S. (1969). Gestalt therapy verbatim. Lafayette, CA: Real People Press. Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York, NY: Dell. Perls, L. (1992). Living at the boundary. Gouldsboro, ME: Gestalt Journal Press. Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. New York, NY: Vintage Books/Random House. Resnick, R. W. (1984). Gestalt therapy east and west: Bi-coastal dialogue, debate or debacle? Gestalt Journal, 7(1), 13–32. Resnick, R. W. (1995). Interviewed by Malcolm Parlett—Gestalt therapy: Principles, prisms and perspectives editors note. British Gestalt Journal, 4(1), 3–13. Resnick, R. W. (1997). The “recursive loop” of shame: An alternate Gestalt therapy viewpoint. Gestalt Review, 1(3), 256–269. Resnick, R. F., & Estrup, E. A. (2000). Supervision: A collaborative endeavor. Gestalt Review, 4(2), 121–127.

GLASSER, WILLIAM In 1905, the parents of William Glasser (1925–2013) emigrated from Russia to the United States to escape the pogroms aimed at Russian Jews. In 1915, after several moves, they settled in Cleveland, Ohio. His parents insisted that the family become assimilated into American culture and refused to adopt ghetto-like behaviors that would have led to a lifestyle isolated from the wider American community. It is likely that this parental worldview influenced Glasser as he developed reality therapy, a system of therapy that shuns the viewpoint that clients are helpless victims subject to oppression by their history, their unconscious,

or their cultural environment. His ideas remain relevant and controversial in the current professional milieu. After earning a degree in engineering from Case Western Reserve University, Glasser realized that his main interest was working with people, and so he obtained a degree in psychology. He then earned a degree in psychiatry, thinking this credential would provide him with additional opportunities to work more directly with people. In 1946, he married Naomi Silver, and in 1953, they settled in Los Angeles, California, where he completed his internship in psychiatry at the Veterans Administration Hospital. During his work there, Glasser became dissatisfied with conventional therapy (i.e., the psychodynamic method) and discussed his dissatisfaction with his supervisor, G. L. Harrington, to which Harrington made his famous and oft-quoted reply, “Join the club.” Over the course of several years, Glasser created reality therapy out of his experience with clients and, together with Harrington, developed its basic principles: (a) personal responsibility, (b) behavior as a choice, (c) focus on the present rather than the past, and (d) the centrality of human relationships as the core of mental health. Glasser gave his first public lecture on his work in 1962, labeling his work “reality psychiatry.” Because the psychiatric profession would not accept the principles that he taught, he renamed his system “reality therapy,” having discovered that psychologists, counselors, social workers, and educators greeted his ideas with enthusiastic acceptance. As a result of his ongoing work in a mental hospital and his subsequent assignment to the Ventura School for Girls, a residential correctional institution, he published his most famous work, Reality Therapy, in 1965. He then founded the Institute for Reality Therapy, now called William Glasser International. Crowds of educators also attended his public lectures and found the principles of reality therapy practical and beneficial in the classroom, in the school counseling office, and as an administrative tool. School systems sought his services and successfully used the theory and practice of reality therapy. He referred to the use of reality therapy in schools not as therapy but as creating “schools without failure.” The underlying principle was that when children fail in school, the real failure is the

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school itself. When school personnel used mutually respectful relationship-building techniques to inculcate personal responsibility, student achievement increased and discipline problems decreased. After many years, the applications to schools evolved into more systemic interventions, resulting in the Glasser Quality School program. This program is not widely implemented, but schools that have filled their educational atmosphere with principles emanating from choice theory and its most significant delivery system, reality therapy, demonstrate a commitment to Glasser’s work. After 46 years of married life and having raised three children, Naomi died of cancer in 1992. Before her death, she reportedly said, “Bill, you won’t do well by yourself. I hope you can find someone with whom you will be happy.” After 3 years, he fulfilled her wish by marrying Carleen Floyd, an instructor in his institute and Midwest region representative to the institute’s board of directors. For many years until his retirement in 2011, they traveled the globe together, teaching choice theory and reality therapy, a legacy that Carleen continues. In addition to his lifelong creation of ideas and their application, Glasser maintained his ability to see humor and to express it. In fact, he taught that besides the human needs of belonging, power, freedom, and survival, fun is a genetic need that brings human beings together. Moreover, when satisfied appropriately, fun is a reward for learning and a signal of positive mental health. For instance, in one of his training tapes where he counseled a female hypochondriac whom no physician could help, he humorously told her that she had a serious case of “jangled nerves” and that it affected every part of her body. He stated, “Yes, you’re sick. There’s not a part of you that’s well because your nerves are everywhere.” He did this with an engaging sense of humor accompanied by compassion and a desire to see her improve her health. While many people readily implemented the principles of reality therapy and enrolled in training sessions sponsored by his institute, they continually expressed the desire for more training and even for a certification process. Under Glasser’s leadership, his institute responded to these requests by establishing a program whereby mental health professionals and educators as well as anyone

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seeking to use reality therapy could take intensive training. Glasser himself led the first “certification week,” the name given to the final step in this 18-month program, in Los Angeles in 1975. Always seeking to develop new ideas, Glasser discovered the psychological explanation for human motivation known as control theory or control system theory, as explained by William Powers in his book Behavior: The Control of Perception, published in 1973. Over the years, Glasser altered control theory by adding human needs as motivators of human behavior, as explained in several books, such as Control Theory, published in 1985, and an updated discussion in the book Take Charge of Your Life, published in 2011. Because of Glasser’s added emphasis on behavior as a choice, in 1998, he changed the name to choice theory, as seen in his book Choice Theory. Choice theory now serves as the psychological underpinning for the application of reality therapy, the Glasser Quality School program, and lead management, which is the application of choice theory to managing and supervising. Although reality therapy constitutes a freestanding system, some of the ideas described in the literature of reality therapy contain similarities to cognitive therapy and solution-focused therapy. However, Glasser’s two major contributions to the theory and practice of counseling and psychotherapy are (1) the structured system of client self-evaluation and (2) the utilization of human needs as the source of human behavior. In this age of cultural consciousness and global mobility, choice theory and its major application, reality therapy, have proven their worth. Representatives from around the world have sought training and have even become qualified instructors because of Glasser’s vision of choice theory as a universal explanation of behavior. Indigenous instructors in Africa, Asia, Australia, Europe, and the Middle East teach and practice choice theory/reality therapy. At the conferences of William Glasser International, held around the world, representatives from every continent except Antarctica attend and discuss their use of choice theory and reality therapy. In 2008, the European Association for Psychotherapy endorsed reality therapy, stating that it accepts reality therapy as a proven

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scientific method. This achievement represented an 8-year effort led by the European Association for Reality Therapy under the direction of Glasser. In 1988, Glasser appointed Bob Wubbolding as director of training for the institute, a position he held until 2011. With Glasser’s endorsement, Wubbolding extended the theoretical base of reality therapy through 13 published books. In addition, Wubbolding is a frequent presenter at national conferences such as the American Counseling Association and the Brief Therapy Conference sponsored by the Milton Erickson Foundation. Wubbolding continues to teach reality therapy and choice therapy throughout the United States and other countries and publishes internationally with John Brickell, director of the Centre for Reality Therapy, United Kingdom. In addition, Wubbolding facilitated the recognition of reality therapy by the American Psychological Association, which published his book Reality Therapy: Theories of Psychotherapy in 2011. A major trend in reality therapy is to increase the scope and the number of research studies. At this time, reality therapy has been successfully applied in settings such as schools, addictions corrections programs, and child care centers, as well as to the treatment of disorders such as attention-deficit/hyperactivity disorder. When Glasser first utilized his ideas, he had only a general vision of his future impact. Yet his personal influence as well as his 23 books and his numerous lectures around the world have given both him and his teachings a deserved place in the history of counseling, psychotherapy, education, and mental health. The mission of William Glasser International (formerly the William Glasser Institute) is to teach choice theory to an increasing number of people around the world to enable them to implement the principles of reality therapy in their personal and professional lives. This method of counseling, along with the theory underlying it, choice theory, originally developed and extended by a man who first was an intern in a mental hospital and then became a world-famous psychiatrist, can change lives. By satisfying an individual’s five universal needs—(1) survival or self-preservation, (2) love and belonging, (3) power or inner

control, (4) freedom or independence, and (5) fun and enjoyment—the individual can enhance his or her own life by making better choices and maintaining more rewarding human relationships. Robert E. Wubbolding See also Adler, Alfred; Adlerian Therapy; Ellis, Albert; Existential Therapy; Frankl, Viktor; Rational Emotive Behavior Therapy; Solution-Focused Brief Therapy

Further Readings Glasser, W. (1965). Reality therapy. New York, NY: Harper & Row. Glasser, W. (1981). Stations of the mind. New York, NY: Harper & Row. Glasser, W. (1984). Control theory. New York, NY: HarperCollins. Glasser, W. (1998). Choice theory. New York, NY: HarperCollins. Glasser, W. (2011). Take charge of your life. Bloomington, IN: iUniverse. Hinton, D., Warnke, B., & Wubbolding, R. (2011). Choosing success in the classroom by building student relationships. International Journal of Choice Theory and Reality Therapy, 31(1), 90–96. Honeyman, A. (1990). Perceptual changes in addicts as a consequence of reality therapy based on group treatment. Journal of Reality Therapy, 9(2), 53–59. Lojk, L. (1986). My experiences using reality therapy. Journal of Reality Therapy, 5(2), 28–35. Marcotte, C., & Bilodeau, S. (2007). Reality therapy and research in group homes project. Montreal, Quebec, Canada. Retrieved from http://www .centrejeunessedequebec.qc.ca/ McClung, C., & Hoglund, R. (2013). A Glasser quality school leads to choosing excellence. International Journal of Choice Theory and Reality Therapy, 32(2), 54–64. Passaro, P., Moon, M., Wiest, D., & Wong, E. (2004). A model for school psychology practice: Addressing the needs of students with emotional and behavioral challenges through the use of an in-school support room and reality therapy. Adolescence, 39, 503–517. Wubbolding, R. (2011). Reality therapy: Theories of psychotherapy series. Washington, DC: American Psychological Association. Wubbolding, R., & Brickell, J. (1999). Counselling with reality therapy. Milton Keynes, England: Speechmark.

Gottman Method Couples Therapy

GOTTMAN METHOD COUPLES THERAPY Gottman method couples therapy is based on extensive research about how stable relationships work and how unstable relationships fail. Gottman described a core triad of balance in couple relationships that includes interactive behavior, perception, and physiology. In couples who are stable and happy, there is greater positivity than negativity in both interactive behavior and perception. In addition, couples who are stable are more likely to derive a sense of calm and well-being from the relationship instead of a sense of vigilance or activation of the flight-or-fight response. The therapy aims to rebalance behavior, perception, and physiology in such a way that the couple is able to establish a stable relationship and to ultimately know how to interrupt or repair inevitable problems in the future.

Historical Context Gottman method couples therapy is grounded in decades of research by John Gottman and his associates. He is perhaps best known for his research about predicting divorce among newlyweds. He founded The Love Lab at the University of Washington, where much of his research on couples’ interactions was conducted. Gottman has received numerous research awards from the National Institute of Mental Health and several professional associations.

Theoretical Underpinnings Gottman method couples therapy is an integrative approach. It focuses on emotion in the relationship. It also integrates elements of behavioral, cognitive, existential, psychodynamic, and narrative approaches within a systemic framework. Gottman method therapists use the sound relationship house to describe how and where things in a relationship are going well and how and where to intervene. At the base, or bottom level, of the house is the love map. Above that is the fondness and admiration system. Next is turning toward versus turning away. Taken together, these three levels describe the

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couple’s friendship. Fourth is a positive perspective, also known as positive sentiment override. The fifth component is managing conflict. Sixth is making dreams and aspirations come true. At the top of the house is creating shared meaning. Trust and commitment form the walls of the house.

Major Concepts Some of the major concepts that underlie this approach include sentiment override, four horsemen of the apocalypse, emotional disengagement and withdrawal, perpetual problems, and diffuse physiological arousal. Sentiment Override

Sentiment override is the general state of the relationship and can be either positive or negative. When positive sentiment override is present, a partner’s actions are interpreted through a positive or informational lens. Where negative sentiment override is the primary state, partners view each other’s actions as negative. In relationships where there is positive sentiment override, positive comments and behavior significantly outweigh negative ones and contribute to an emotional bank account that cushions the relationship. Four Horsemen of the Apocalypse

Four behaviors that Gottman calls the four horsemen of the apocalypse are especially damaging and are predictive of failure of a relationship. These include criticism, defensiveness, contempt, and stonewalling. While criticism, defensiveness, and stonewalling occur in all relationships, they occur less often in stable relationships than in troubled ones and are generally repaired. Contempt, however, is not present in stable relationships. Contempt is extremely corrosive to couple relationships. Emotional Disengagement and Withdrawal

Unstable couple relationships may be characterized by a lack of any positive affect rather than by negativity. Couples may not display any emotional connection and may be essentially withdrawn from the relationship.

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Gottman Method Couples Therapy

Perpetual Problems

Perpetual problems are often about differences in personality or relationship needs that are essential parts of each individual’s sense of self. They have generally been ongoing for several years and are not likely to be solved. The ability to dialogue about perpetual problems is important so that couples can adapt to persistent problems that inevitably exist in relationships. Diffuse Physiological Arousal

Diffuse physiological arousal (DPA) is a general alarm mechanism in the body that allows one to cope effectively with situations perceived to be dangerous. During DPA, the ability to solve problems, think creatively, or cooperate is lessened. Couple conflict can activate DPA, which limits a couple’s access to the tools they learned when they were calm. Thus, DPA must be experienced in session so that the tools can be overlearned while the couple is in a state of arousal.

Techniques Techniques are designed to minimize relapse after therapy. The approach allows for variation in how therapists accomplish the goals of therapy, which are to modify conflict, enhance friendship and intimacy, and create shared meaning. Each of these affects the others. While Gottman offers a number of specific interventions for particular issues, he stresses that therapists must tailor therapy to the needs of each case. To modify conflict, interventions are structured to allow each person to understand his or her partner’s point of view and to eliminate the four horsemen in order to down-regulate escalating quarrels. Other interventions are designed to develop six critical skills: (1) softened startup, (2) accepting influence, (3) making effective repairs, (4) de-escalating quarrels, (5) compromising, and (6) physiological soothing of self and partner. Techniques for enhancing friendship and intimacy are designed to allow couples to talk about feelings and needs, increase awareness about how each seeks and responds to bids for emotional connection, and learn to manage failed bids for connection. Techniques designed to create shared meanings help the couple intentionally create

rituals of emotional connection as well as a sense of shared purpose.

Therapeutic Process Generally, sessions are scheduled for 90 minutes. The first three sessions are typically devoted to assessment of couple strengths and challenges and include both conjoint and individual sessions. During the final formal assessment session, goals for therapy as well as the order for working toward those goals are discussed. Once the initial assessment is completed and specific goals are established, the therapist will utilize techniques that address specific areas of focus. A mass and fade treatment approach is used, with sessions occurring more frequently in the beginning and then fading, using structured vacations as therapy is winding down. Each session begins with inquiry about how the couple is doing, which provides time for them to talk about anything that is immediate. This opportunity to catch up allows clients to bring in their major concerns and the therapist to track where therapy is going. Then, the couple will talk to each other empathically to process their most important needs, with the therapist providing assistance to stay on track. Rather than dominating this discussion, the therapist thinks of and introduces interventions that will provide tools the couple can use in the interaction. Homework is used to help the couple make progress throughout the week and generalize their skills. Marvarene Oliver See also Cognitive-Behavioral Family Therapy; EmotionFocused Family Therapy; Existential Therapy; Narrative Family Therapy; Psychodynamic Family Therapy

Further Readings Gottman, J. M. (1994). What predicts divorce? The relationship between marital processes and marital outcomes. Hillsdale, NJ: Lawrence Erlbaum. Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York, NY: W. W. Norton. Gottman, J. M., & Gottman, J. S. (2008). Gottman method couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (pp. 138–166). New York, NY: Guilford Press.

Group Analysis

GROUP ANALYSIS Group analysis views the essential nature of humans to be social, both unconsciously and consciously. From this perspective, the individual person is as compelled by social forces as by those of the id, and defends against their recognition. In fact, group analysts refer to the “social unconscious,” defined in terms of the existence of social, cultural, and communicational arrangements of which people are unaware. Our psychological problems originate between people, and our symptoms disguise what cannot be communicated in our relationships. Group analysis helps people translate their disguised symptoms into interpersonal communication. Their symptoms come to be located in the dynamic matrix of the group. Patients collectively constitute the norm from which they individually deviate. In this way, “normal” reactions are reinforced, while “abnormal” reactions in time are modified. Uniquely, group analysis focuses on small (6–12 members), median (12–30), and large (30–400) groups. It is generally accepted that personal therapy is available in small as well as median and large groups. However, these larger groups also provide sociotherapy for organizations and even for societies as wholes.

Historical Context S. H. Foulkes (1898–1976), a German psychoanalyst who also studied Gestalt psychology with Kurt Goldstein, founded group analysis, or group analytic psychotherapy, as it is otherwise known. Adapting the ideas of Goldstein, who championed the importance of considering the whole person when addressing traumatic brain injuries, and of the sociologist Norbert Ellias, who insisted that it was impossible to understand the experiences of individual persons outside the context of their social milieu, Foulkes began to look at the individual within the context of all of his relationships—family, social, cultural, political, and historical—and also emphasized the importance of historical and cultural continuity in the interactions of people who meet face-to-face in a group. Foulkes fled Nazi Germany and arrived in England in 1933. There, he began integrating psychoanalysis,

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Gestalt psychology, and sociology to develop a method for treating people in small groups. During World War II, when he was posted at Northfield Military Hospital, near Birmingham, England, he had a chance to use some of his group ideas to work with the returning soldiers. After the war, he started meeting with colleagues interested in group work. In 1952, he started the Group Analytic Society. Around 1960, Foulkes and a group of colleagues formed a private practice in London that eventually became known as the Group Analytic Practice. In 1967, Group Analysis: The International Journal of Group-Analytic Psychotherapy, was begun under the editorship of Foulkes. As interest in group analysis grew, a need for training developed, and this was met by the founding of the Institute of Group Analysis in London in 1971. Today, group analytic training is available in many European countries, and the European Group Analytic Training Institutions Network provides opportunities for dialogue and exchange between the training institutions. Group analysis has been supported by three important book series: (1) The International Library of Group Psychotherapy and Group Process, edited by Malcolm Pines and Earl Hopper; (2) The International Library of Group Analysis, edited by Malcolm Pines; and (3) The New Library of Group, Analysis, edited by Earl Hopper. In 2011, the Group Analytic Society was renamed the Group Analytic Society International, and today, it maintains an informative website and coordinates many group analysis activities, including a conference meeting every third year in a different European city. Group analysis has been a dynamic and developing field for nearly 75 years. Harold Behr and Liesel Hearst’s book Group-Analytic Psychotherapy is a good place to begin exploring group analysis in depth. It contains an extensive bibliography that includes contributions that are necessarily left out of a brief article like this. Jason Maratos has recently edited a comprehensive book of articles by group analysts that conveys the depth and scope of the field.

Theoretical Underpinnings Group analysis is based on a number of traditional psychoanalytical concepts as well as knowledge of

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groups and systems. It differs from psychoanalysis in its emphasis on the social nature of the individual. Group analysis sees the individual as an abstraction who can only be understood in context. Drawing on psychoanalysis, Gestalt psychology, and sociology, Foulkes valued many viewpoints. He understood the communication in a group to occur on several levels: (a) current relationships, (b) individual transference relationships, (c) projected feelings and fantasies, and (d) the primordial level of archetypal universal images. The group analyst’s dilemma is where to focus attention amid these multiple levels of complexity. Theory can be helpful when considering where and when to intervene. Group analysis has developed a number of important theoretical additions since Foulkes’s original contributions. Pines, who is considered Foulkes’s successor, has also functioned in an integrative way through his teaching, writing, supervising, and editing. He brought self psychology into the realm of group analysis. Meg Sharpe introduced the experience and the study of the large group to the American Group Psychotherapy Association (AGPA), and she and Pines coled the first large group at AGPA in 1995. A number of important theoretical developments have been made in group analysis. Earl Hopper theorized the nature of the social unconscious in group and organizational life. Especially interested in traumatized groups and traumatogenic processes in general, he argues that a traumatized group has experienced a failure of dependency so that the members feel helpless and fear annihilation. The group becomes incohesive, unable to accomplish its tasks. The members become isolated from one another; they become a collection of encapsulated individuals, or an aggregate. Aggregates oscillate with masses, which exhibit a oneness in beliefs and values. Hopper represents this situation with the formula (ba) I:A/M, translated as the basic assumption of Incohesion: Aggregation/Massification. He considers this to be the fourth basic assumption of groups, adding to Wilfred Bion’s original three basic assumptions: (1) dependency, (2) fight-or-flight, and (3) pairing. Morris Nitsun developed the idea of the antigroup as a counterpoint to Foulkes’s emphasis on the positive impact of groups. Nitsun examines the destructive forces in groups and their creative

potential. Naming and understanding the antigroup has been useful in identifying the forces that discourage students from running groups and individuals from joining therapy groups, challenging them to find ways to transform the destructive forces into something useful. In his book The Group as an Object of Desire: Exploring Sexuality in Group Therapy, Nitsun invites the group analyst to pay attention to sexuality and desire, which have often been marginalized in group work. Farhad Dalal applies his group analysis ideas to an understanding of racial conflicts, in which he sees the psyche as “colour coded” and the concept of race as being used by the powerful to perpetuate their position. He emphasizes what he calls the “radical” Foulkes—the one who argued that the “we” precedes the “I.” Tom Ormay further developed this idea, giving it a name, “nos” or the “we,” adding the “nos” to Freud’s psychic structure of the id, ego, and superego.

Major Concepts Some major concepts of note in group analysis include Foulkes’s basic law of group dynamics, conductor, matrix, mirroring, condenser phenomenon, resonance, and ego training in action. Foulkes’s Basic Law of Group Dynamics

Foulkes understood the healing power in groups as deriving from group members’ tendency to reinforce one another’s normal reactions and wear down and correct one another’s neurotic reactions. He saw that the members of the group collectively constitute the very norm from which they individually deviate. Conductor

Based on the metaphor of an orchestra and its conductor, Foulkes favored the term conductor to describe the group analyst. Führer, meaning “leader” or “guide” in German, Foulkes’s first language, was an emotionally laden term used almost exclusively in Germany as an epithet for Hitler. “Conductor” also fits Foulkes’s understanding of group leadership. The conductor’s authority is located in relationship with and in the context of the orchestral

Group Analysis

members who make the music. Each member brings something of his or her individuality to the score to create resonances with the others, while simultaneously being influenced and nudged as needed by the conductor. Matrix

The concept of dynamic matrix is used to describe all of the relationships within a group. Each group member influences and is influenced by the web of communication that constitutes the matrix. The matrix can be positive, like a nurturing mother, or more negative, like a spider’s web. It is the group analyst’s job to maintain a healthy matrix. Foulkes also used the term foundational matrix to characterize our common social– cultural–biological background. This common background, both conscious and unconscious, is vitally important in understanding one another. Mirroring

Foulkes compared the group to a hall of mirrors in which group members could see rejected and split-off parts of themselves in others. As members see themselves in others, they become better able to integrate those split-off parts of themselves. Pines described three forms of mirroring: (1) antagonistic, (2) dialogic, and (3) the absence of mirroring. At times, what is seen in the other is violently rejected and a destructive cycle ensues, resulting in deep tensions between members. Louis Zinkin used the concept of malignant mirroring to describe the pathological attraction that arises between two members who get into a standoff with one another. Condenser Phenomenon

The group amplifies, loosens, and stimulates, as well as concentrates, the interactions of the group members. This happens at the conscious, the individual unconscious, and the social unconscious level. Resonance

The group, for Foulkes, resembled strings that vibrate and reinforce one another. Each member resonates in the key to which he or she is attuned.

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This is easily observed when an event in a group sets off startling, different resonances in each of its members. Ego Training in Action

Freud’s understanding of the ego being strengthened through analysis is carried into the group situation, where the ego is actively engaged by the various group members. In the context of the group, one’s defenses are activated, and one gets a chance to try new behaviors that are more adaptable. This experience brings the members one step closer to life outside the group.

Techniques The foundation of the group analyst’s technique is the therapeutic alliance with each group member, in which acceptance, empathic attunement, and genuineness are all important. The primary purpose of the group analyst’s technique is to help group members make emotional contact to understand and achieve the conscious and unconscious goals that brought them to therapy. Based on this foundation, David Kennard and his colleagues have outlined a number of techniques used by group analysts, each of which is discussed in the following subsections. Maintenance

Often referred to as dynamic administration, maintenance involves deciding where the group meets, how the chairs are arranged, who joins the group and when and how messages are delivered from absent group members, time boundaries, fees, and guidelines for the outside contact of group members. Although group analysts differ in how each of these matters are dealt with, they generally agree that it is important to pay attention to their dynamic significance. Open Facilitation

Open facilitation refers to interventions used to move the group forward that are not based on a specific hypothesis. Open-ended questions like “Can you tell us more about that?” is one example.

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Guided Facilitation

Guided facilitation refers to remarks that are not simply open-ended but have a specific hypothesis in mind; for example, “The tone you used makes me wonder if you are angry.” Interpretation

The conductor makes interpretations when he or she believes that they will deepen and extend the scope and depth of understanding of the personal, interpersonal, and group dynamics. These interpretations may be made to the individual, a subgroup, or the group as a whole. The group affords opportunities to see and understand horizontal transferences toward peers, perhaps as siblings, as well as vertical transferences to the conductor, perhaps as a parent. Because group analysis sees the essence of persons as social, there is often a focus on ways in which history, culture, and ethnicity contribute to the problem or serve to defend against seeing the problem. Group analysis is the treatment of the person in the group, of the group, and by the group, including the conductor. In this process, the conductor leaves as much as possible to the group. No Immediate Response

During the course of a group, especially as it matures, the conductor may remain silent, reserving the right to intervene later depending on further developments. “Trust the group” is a phrase often heard in group analysis and refers to the confidence the conductor places in the group as a whole to work with whatever comes up.

Therapeutic Process The type of group that forms the foundation of group analysis is referred to as a slow-open group of seven to nine members. As members achieve their goals, they graduate from the group, and new members join. Typically, one or two members leave and join the group every year or two. Members who benefit most from the group typically stay for 2 or more years. In general, groups meet weekly for 90 minutes for 40 weeks per year, taking off for holidays and a break in the summer.

Group analysts agree that most people can profit from an appropriate group, whereas only some can profit from individual therapy. The group is often seen as wiser and more powerful than any one individual. Group is seen as more and less than individual treatment, and the two are seen as complementary to one another. Pat de Maré extended our understanding of median groups and large groups. The large group is sometimes described as a group you cannot take into view with a single glance. De Mare experimented with groups of various sizes and thought about them from a group analysis perspective. He especially championed the median group, seeing it as existing since the beginning of civilization, when the elders of the community met to decide issues important to them and their citizens. He argued that the small group often contains dynamics similar to those of the family and focuses on insight, whereas the median group focuses on wider issues, such as gender, politics, social class, and ethnicity, that have shaped who we are, and thus, it focuses on outsight. De Maré believed that the small group focuses on socializing the individual, whereas the median group focuses on humanizing society. The large group is often available in training settings or at group conferences. It is especially helpful in giving individuals an experience of observing themselves when there is a threat to their individual identity. How does one find a voice or become a member in such a large group? Anxieties related to developing as a mature citizen arise when in the context of the large group. Silently voting is the most common experience many have in a large group. Dialogue is encouraged in large groups convened from a group analysis perspective. Some vote, however, by leaving or trivializing the process. Some stay, deal with their anger, frustration, and disappointment, and find their way to dialogue and koinonia, or “impersonal fellowship,” as de Mare would describe it. All group members actively engage in treatment. All participate, respond, understand, and interpret. The conductor is responsible for monitoring and maintaining the boundaries of the group. Sharpe, in writing about self-disclosure, encourages the group analyst to resist the temptation to give group members personal information that might not contribute to and might divert or impede the

Group Counseling and Psychotherapy Theories: Overview

development of the group or the individuals within it. While the conductor works to maintain safety within the group, he or she leaves as much as possible to the group. Everything that happens involves the group as a whole as well as each individual. The individual is a nodal point in the group matrix, a spokesman for the group as well as for himself or herself. All communications—verbal and nonverbal, conscious and unconscious—are relevant. The aim of the group is insight plus adjustment, through what is referred to as ego training in action. This is achieved through social processes such as mirroring, resonance, and condenser phenomena, as well as the modification of individual resistance and defenses. In the group, ego boundaries can be loosened and individuals can rediscover and redefine themselves. More of the individuals and their energies can be made available for creative expression of themselves and their involvement with others. One way to think about therapeutic progress is to see the group members moving from being made by history to making history. They learn to know and express their individual identities in relationship to and with regard for others. They become citizens in the deepest meaning of that word. Dale C. Godby, Earl Hopper, and Meg Sharpe See also Modern Analytic Group Therapy; Psychodynamic Group Psychotherapy; Relational Group Psychotherapy; Tavistock Group Training Approach

Further Readings Behr, H., & Hearst, L. (2005). Group-analytic psychotherapy: A meeting of minds. London, England: Whurr. Dalal, F. (2002). Race, colour and the processes of racialization: New perspectives from group analysis, psychoanalysis and sociology. London, England: Routledge. Foulkes, S. H. (1986). Group-Analytic psychotherapy: Method and principles. London, England: Karnac Books. (Original work published 1975) Hopper, E. (2003). Traumatic experience in the unconscious life of groups: The fourth basic assumption: Incohesion: Aggregation/massification or (ba) I:A/M. London, England: Jessica Kingsley.

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Hopper, E. (Ed.). (2012). Trauma and organizations. London, England: Karnac Books. Hopper, E., & Weinberg, H. (Eds.). (2011). The social unconscious in persons, groups, and societies: Vol. 1. Mainly theory. London, England: Karnac Books. Kennard, D., Roberts, J., & Winter, D. A. (Eds.). (1993). A work book of group-analytic interventions. London, England: Routledge. Maratos, J. (Ed.). (2014). Group analysis for the 21st century: A book of foundational readings. London, England: Karnac Books. Nitsun, M. (1996). The anti-group: Destructive forces in the group and their creative potential. London, England: Routledge. Nitsun, M. (2006). The group as an object of desire: Exploring sexuality in group therapy. London, England: Routledge. Pines, M. (1998). Circular reflections: Selected papers on group analysis and psychoanalysis. London, England: Jessica Kingsley. Sharpe, M. (Ed.). (1995). The third eye: Supervision of analytic groups. London, England: Routledge. Weinberg, H. (2014). The paradox of Internet groups: Alone in the presence of virtual others. London, England: Karnac Books.

GROUP COUNSELING AND PSYCHOTHERAPY THEORIES: OVERVIEW Group counseling and psychotherapy theories and therapies span a wide spectrum of approaches and provide the frameworks to guide group leaders in the facilitation of their groups. Most of the theories and therapies are adaptations from individual theories and therapies but are applied to the group counseling and psychotherapy setting, which provides unique interactions and forces that apply to groups. The complexities of groups make it challenging to work with the individual group members while at the same time working with the group forces and factors to help all group members. Group mental health treatment has shown considerable efficacy, with many studies providing evidence that it is beneficial for a wide variety of conditions and issues. Whether referred to as group counseling, group therapy, or group

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Group Counseling and Psychotherapy Theories: Overview

psychotherapy, the group process focuses on both the group as a whole and the individual members, with leadership and facilitation skills and competencies being critical to effective outcomes. Some of the defining features for mental health groups are the relationships and socialization among group members, support building, how individuals maintain and build boundaries with one another and the leader, an awareness of interdependence, positive aspects for cohesion, amelioration of feelings of isolation and alienation, emotional expressiveness with interpersonal learning, fulfilling a need for belonging and acceptance, practicing new ways to behave and relate, an increased understanding of personal relationship attributes and communication skills and their impact on others, receiving and giving

interpersonal feedback and how these can be more constructive, and increased ways to be altruistic.

Historical Context The history of theories and methods for group counseling and psychotherapy is rich with important contributions to both theory and methods, and it is impossible to present all of those in this limited space. Table 1 presents a brief overview of some benchmarks and theorists but omits many other significant contributors. The history begins with Dr. Joseph Pratt, who in the early 1900s used psychoeducational groups to treat tuberculosis patients. The application of psychoanalytical principles to group treatment began within a short time after the efficacy of

Table 1. Overview of Group Counseling and Psychotherapy Benchmarks and Theorists Theorist/Clinician

Time Frame

Theory/Focus

Joseph Pratt

1907

(Psycho)educational groups for tuberculosis patients

Jacob Moreno

1917

Psychodrama—action-oriented treatment

Cody Marsh

1930s

Milieu therapy, which emphasized relationships among group members

Alfred Adler

1929

Emphasized the impact of early-childhood experiences

Trigant Burrow

1928

Emphasized the group as an entity

Samuel Slavson

1930s

Assisted in founding the American Group Psychotherapy Association

Harry Stack Sullivan

1936

Emphasized relationships; founded the Washington School of Psychiatry

Kurt Lewin

1940s

Experiential groups, group-as-a-whole perspective, and action research

Jacques Lacan

1953

Language as a focus

Albert Ellis

1962

Irrational thoughts and beliefs about events fuel reactions

Aaron T. Beck

1964

The interaction of genetics, biological factors, and experiences produces core beliefs

Wilfred Bion

1940s–1960s

Emphasized here-and-now group experiences and group processes such as pairing and fight-or-flight

S. H. Foulkes

1952; 1971

Founded the Group Analytic Society and the Institute of Group Analysis

Fritz Perls

1969

Emphasized the now of experiencing; holistic

Carl Rogers

1970

Encounter groups and sensitivity training

Group Counseling and Psychotherapy Theories: Overview

Pratt’s treatment was disseminated and found to be applicable for other types of conditions and problems. Applying psychoanalytical techniques emphasized the therapeutic more than the educational processes, and these processes began to be explored and used, eventually becoming the basis for group psychotherapy. Since that time, a number of individuals have influenced the theory and practice of group work. Table 1 highlights some of those individuals and touches on how they influenced group work. Current theories and methods range across a broad spectrum of therapeutic approaches, and each can be effective for the appropriate audience, condition, problem, or issue.

Theoretical Context The theories and therapies presented here are groups categorized as behavioral, experiential, humanistic, or psychoanalytical/psychodynamic, and groups that do not easily fit into any category or that stand alone as significantly different. Group theories and therapies categorized as behavioral have their roots and methods based in behavioral psychology and focus on the use of a wide range of behavioral techniques based on operant conditioning, classical conditioning, and modeling. Group experiential theories and methods emphasize activities as a means to access important therapeutic concerns and issues. These groups often involve the use of movement—creative activities such as the use of art, play, or role-play to access emotions and insight. Groups from the existential-humanistic perspective are based on existential philosophy, phenomenology, and humanism. These groups emphasize the potential of the person to change, help individuals see the choices they have in their lives, and propose that individuals’ psychological difficulties arise out of the inevitable confrontation with life’s ultimate concerns of death, freedom and responsibility, isolation, and the search for meaning. These groups focus on here-and-now experiencing, whereby issues can be examined and challenged, their universality recognized, and their recurring nature understood. Psychodynamic/psychoanalytical groups have extended the knowledge and understandings from the psychoanalytical perspective, including the early beginnings from Sigmund Freud, Alfred Adler, and Carl Jung, to

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emphasize the dynamic interaction between childhood development and how patterns from the past are recapitulated in the present. The final category is a collection of group theories and methods that are not easily categorized: system centered, Tavistock, and self-help groups. The theories and methods for group counseling and group psychotherapy describe a wide variety of treatment options that extend and enhance the growth, development, and healing of individual group members. These are also still in the process of development as new information comes to light and other aspects of group treatment are researched. Group counseling and psychotherapy as a modality has come to be recognized as being much more than working with individuals in a group setting and that group leadership has a unique set of skills and knowledge.

Short Descriptions of Group Counseling and Psychotherapy Theories Behavioral Group Theories and Therapies

Acceptance and Commitment Therapy Acceptance and commitment therapy (ACT, pronounced like the word act) was developed in the late 1980s and incorporates mindfulness, awareness, and acceptance while increasing clients’ psychological flexibility. It has been used successfully in the group setting for the treatment of work-related stress, substance abuse, pain management, and personality disorders. Although further research is needed, results from recent studies promote this therapy as significant and promising. Behavioral Group Therapy Behavioral group therapy is based on using operant conditioning and respondent conditioning principles to treat maladaptive behaviors. It is used often in conjunction with cognitive psychotherapy techniques as a part of cognitive-behavioral therapy. Other variations include clinical behavior analyses and functional analytic psychotherapy. There is considerable evidence to support the efficacy of this treatment modality for numerous conditions. Cognitive-Behavioral Group Therapy Cognitive-behavioral group therapy is based on the principles of behaviorism, Aaron Beck’s cognitive therapy, and Alfred Ellis’s rational emotive

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behavior therapy. This therapy emphasizes the guidance role for the group leader; structured sessions; how one’s thinking affects behaviors, feelings, and actions; the here-and-now; and relief from symptoms. Focused Brief Group Therapy This approach to group counseling integrates Irvin Yalom’s model of interpersonal group counseling with the use of an evidence-based measure of interpersonal relationships (Inventory of Interpersonal Problems [IIP-32]). Early on in the group process, clients receive information about their interpersonal relationships through the IIP-32, and then, they can work on targeted issues, based on feedback from the instrument, with group members. Work is focused and usually takes about eight sessions. Functional Analytic Group Therapy Functional analytic group therapy uses the functional analysis of natural and spontaneous interactions in the group setting for therapeutic change. This therapy proposes that groups demonstrate social microcosms in which clients naturally encounter the interpersonal and emotional challenges they have difficulty with in their daily life. The group experience is used to address their difficulties in vivo and to enhance members’ capability to make sense of and manage their interpersonal and emotional experience. Experiential Group Theories and Therapies

Activity-Based Group Psychotherapy Activity-based psychotherapies saw their beginnings in the work of S. R. Slavson and Jacob Moreno, who were active, experiential group psychotherapists. This early work has now evolved into experiential therapies using art, music, equine, dance, adventure, and wilderness activities.

event. Other members are actors in the scenes where they interact with the protagonist under the guidance of the director. There are typically three sections for a session: (1) warm-up, where activities are used to bring members to the present and encourage emotional presence; (2) the action section, comprising the re-creation of the selected life event or situation; and (3) the discussion or sharing, where group members comment on the actions, their triggered feelings, and other reactions that emerged. Psychoeducational Groups Psychoeducational groups combine cognitive and affective materials and experiences to focus on a commonly held condition, problem, or issue. Cognitive processes focus on the dissemination of information intended to provide knowledge about the etiology of the condition or problem, its course of development, possible treatment strategies and/ or outcomes, and coping mechanisms and procedures. The affective processes address the emotional content for group members and provide opportunities for emotional expression and for group curative (therapeutic) factors to emerge. Training Groups Training groups, also called T-groups, are primarily used for educational purposes as a means for teaching group processes and procedures as well as interpersonal relationship skills. While training groups are used in other settings and modalities, they are usually a major contributor to the education of mental health students in training. Training groups are not therapy groups, but they can produce therapeutic outcomes for some participants. The focus is on the here-and-now experiencing—members are in charge of their own disclosures and can choose what to disclose and when, and group members act as observerparticipants. The group leader functions as a guide and facilitator.

Psychodrama Psychodrama was developed by Jacob Moreno and uses spontaneous drama and role-play to re-create life situations as a means to gain insight into a group member’s behavior and its impact on others. One group member becomes the protagonist to portray the lead in the re-created situation or

Humanistic Group Theories and Therapies

Existential Group Psychotherapy The existential model proposes that individuals’ psychological difficulties arise out of the inevitable confrontation with life’s ultimate concerns of

Group Counseling and Psychotherapy Theories: Overview

death, freedom and responsibility, isolation, and the search for meaning. The group setting allows these to be examined as they unfold in the here-and-now experiencing, where they can be examined and challenged, their universality recognized, and their recurring nature understood. Gestalt Group Therapy Gestalt group therapy follows the principles of Gestalt therapy, such as a focus on experiencing in the present moment and an exploration of relationships with oneself and with others. Attention is given to becoming more aware, the concept of unfinished business, perception and meaning making, and opportunities to experiment with new ways to be and act. Interpersonal Group Therapy Viewing all psychological problems as being related to interpersonal issues, interpersonal group therapy provides a vehicle to help clients examine how interpersonal struggles are associated with the process of negotiating the social world. Through processing here-and-now interactional patterns, members recognize and realize the impact of their behavior patterns. Leaders also use transference dynamics and transparency to help members attain interpersonal learning. Interpersonal gains made within the group are often generalized to significant others and can also positively affect all realms of a client’s life. Interpersonal Integrative Group Therapy Interpersonal integrative group therapy capitalizes on the theory and basis of interpersonal therapy and combines these with techniques from other theoretical perspectives. While the primary focus is on the interpersonal interactions within the group that are used as a means to build group members’ interpersonal skills, the group leader emphasizes interpersonal processes rather than the intrapsychic life of the individual and uses the group to foster changes in interpersonal behaviors.

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encounter groups in the United States. Principles central to understanding the role, purpose, and definition of process groups are as follows: (a) process groups use experiential learning about group dynamics and personal style, (b) they are not based on pathology, and (c) they have a focus more on personal growth and self-understanding than on curing a specific disorder. Psychodynamic and Psychoanalytical Theories and Therapies

Adlerian Group Therapy Adlerian group therapy uses the principles and practices proposed by Alfred Adler, which constitute a growth model for therapy. A variety of cognitive, behavioral, and experiential techniques are used to help group members change their beliefs about self, others, and life. Basic features include the exploration of family-of-origin experiences and their current influence on members’ lives. Jungian Group Psychotherapy Jungian or analytical group psychotherapy uses the concepts and principles developed by Carl Jung. Emphasis is placed on an integration of the unconscious forces and motivations behind behavior and the wisdom of the soul as guidance in addressing concerns. Group Analysis Group analysis, or group analytic psychotherapy, addresses conditions and issues from the perspective that psychological problems originate between people and their symptoms disguise what cannot be communicated in their relationships. Group analysis techniques help group members translate their disguised symptoms located in the dynamic matrix of the group into interpersonal communication where group-determined “normal” reactions are reinforced and “abnormal” reactions are modified. Group analysis uniquely focuses on small, median, and large groups, giving attention to the constraints of the social unconscious.

Process Groups Process groups have their roots spread wide: from community meetings of various traditions, from the Hopi to Quakers, through more recent incarnations of Tavistock experiences in Europe, to

Intersubjective Group Psychotherapy Intersubjectivity is a concept in modern schools of psychoanalysis that refers to shared meanings constructed in interactions with others that form a

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bridge between the personal and the shared. Outcomes from recent research on mirror neurons support the concepts of intersubjectivity and empathy. Modern Analytic Group Psychotherapy Modern analytic group psychotherapy, as developed by Hyman Spotniz, uses many of the principles and techniques of classical analysis, except for interpreting defenses and resistance. Its basis is that unexpressed aggression and hostility have negative effects on cognitive and physical functioning. Treatment is focused on the leader joining with group members in their efforts to protect the fragile ego while permitting or encouraging the ego to express aggressive and hostile feelings in productive ways. Relational Group Psychotherapy “Relational” refers to what happens between people, including inner representations and phenomena, and to the relationships people and groups have with their individual and collective ideas. Relational group theory, on which relational group psychotherapy is based, builds on neo-Freudian, Kleinian Middle School, interpersonal, intersubjective, and self-theory constructs. The common denominator is the dynamic, life-supporting qualities of inner and outer relationships, rather than primarily metapsychological entities like drives, defenses, ego structure, or an archeological unconscious. Relational theory assumes that the defining characteristics of group life are cocreated by the members’ (including the therapist’s) conscious and nonconscious participation, maintained, and worked through intersubjectively. Lacanian Group Therapy In Lacanian psychoanalysis, the group narrative is listened to within a three-register frame: (1) the Imaginary, where group members relate to one another as the look-alike and/or the rival; (2) the Symbolic, where the deciphering of the signifiers (key words, phrases, images) holding repression are uncovered; and (3) the Real, which uses enactments as passages to the act and blockages, which are then confronted. Group process examines two basic dialogues: (1) in the group (register of the Imaginary) and (2) of the group (register of the Symbolic).

Psychodynamic Group Therapy Psychodynamic theory is fundamentally an educational theory with an overall goal of helping group members become aware of their basic, unexamined assumptions about life—that is, making the unconscious conscious. The windows into the unconscious are few—for example, dreams, free association, slips of the tongue, transference, and analysis of defenses. Psychodynamic group therapy provides a vehicle for clients to project onto the group members while interpretation of unconscious material can be made by the leader and the members, sometimes allowing for a richer therapeutic environment than is found in individual psychodynamic therapy. Attachment Group Therapy Attachment theory, originated by John Bowlby, initially focused on children and their development of secure or insecure attachment styles. Attachment theory was subsequently extended to adult attachment styles and their impact on relationships and overall functioning in life. More recent developments in neurobiology have supported secure attachment as an important component of affect regulation, along with the ability of a healing relationship to promote more secure attachments. Group therapy, with its experiential learning, is ideally suited for members to explore their attachment styles, discover their implicitly learned models of self and others, and develop more secure ways of relating. Other Group Theories and Therapies

Systems-Centered Group Counseling Systems-centered therapy and training assumes that the necessary and sufficient condition for change in any group is discriminating, and integrating differences among group members. Systems-centered therapy and training accomplishes this by introducing its method of functional subgrouping, wherein members learn to first join on similarities before the difference gets explored in a different subgroup. This creates a group norm in which no one works alone and participants learn to see themselves not only as persons with personal development goals but also as members who can contribute to the group’s goals and join

Guided Imagery Therapy

subgroups with other members who are exploring something similar; learning to see themselves in these different roles lowers defensiveness and the human tendency to personalize. Systems-centered therapy and training leaders intervene according to the phase of system development, weakening the restraining forces to change that are relevant to the group’s phase, thus lowering the stress in change. Systems-centered therapy and training introduces a comprehensive systems theory and an integrative set of methods and skills that link to the phase of development, so that members learn to weaken the defenses that generate the symptoms that have brought them into therapy. Tavistock Group Training Approach The Tavistock Group Training Approach grew out of the work of Wilfred Bion and Melanie Klein and, as such, shares many similarities with psychodynamic group therapy, but it is not a therapeutic method per se. The major focus of this approach is to promote learning about groups’ and individuals’ conscious and unconscious behavior and adaptation in various task-based settings, and may also be considered a training event. Major topics of intervention and learning relate to boundaries, authority, role, task, and organizational structure, which are the focus of these events.

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group was organized but who serves as the facilitator for group sessions. Nina W. Brown See also Acceptance and Commitment Group Therapy; Activity-Based Group Psychotherapy; Adler, Alfred; Adlerian Group Therapy; Attachment Group Therapy; Beck, Aaron T.; Behavioral Group Therapy; CognitiveBehavioral Group Therapy; Ellis, Albert; Existential Group Psychotherapy; Focused Brief Group Therapy; Freud, Sigmund; Functional Analytic Group Therapy; Gestalt Group Therapy; Glasser, William; Group Analysis; Interpersonal Group Therapy; Interpersonal Integrative Group Therapy; Intersubjective Group Psychotherapy; Jung, Carl Gustav; Jungian Group Psychotherapy; Lacanian Group Therapy; Modern Analytic Group Therapy; Process Groups; Psychodrama; Psychodynamic Group Psychotherapy; Psychoeducational Groups; Relational Group Psychotherapy; Rogers, Carl; Self-Help Groups; System-Centered Group Counseling; Tavistock Group Training Approach; Training Groups; Yalom, Irvin

Further Readings Coyne, R. (2010). The Oxford handbook of group counseling. New York, NY: Oxford University Press. Wheelan, S. (2005). The handbook of group research and practice. Thousand Oaks, CA: Sage.

Self-Help Groups Self-help groups and support groups can be essentially the same, but they can also have some defining differences. Similarities include the following: (a) group membership is composed of individuals with the same condition, illness, issue, or concern; (b) groups do not have a set duration and are open whereby members choose when or if to attend; (c) the topics for discussion are determined by group members; and (d) primary goals are encouragement, support, and dissemination of information relative to the needs of group members. The major differences are in the preparation and role of the group leader. Self-help groups and some support groups do not have a professionally trained leader, and group members assume the tasks of leadership and act as both a member and the leader. There are support groups that have a professionally trained leader who may or may not have the condition around which the

GROWTH MODEL See Human Validation Process Model

GUIDED IMAGERY THERAPY Guided imagery therapy utilizes a client’s capacity for imagination and creativity for therapeutic gains such as increased insight, enhanced coping, and rehearsal of desired outcomes. Imagery practices can take several forms within the counseling session, and clients can also employ these tactics on their own. The efficacy of guided imagery has been well documented, though there are important considerations for the implementation and facilitation of these techniques.

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Historical Context Guided imagery has historical roots in similar practices of visualization and metaphor or storytelling from indigenous traditions, Eastern and Western religious practices, and holistic medicine. In the field of counseling, it is often viewed as a contemporary or New Age practice and associated with spirituality due to these historical affiliations. The techniques of guided imagery are, however, separate from any spiritual or religious practice and have been incorporated in different forms throughout counseling and psychology. Guided imagery is also popular within other fields. In medicine, for example, studies indicate that the use of guided imagery can reduce chronic pain, alleviate symptoms associated with cancer treatments, and improve physical health and well-being. Athletes and sport psychologists also frequently utilize guided imagery for the mastery of complex physical movements, preparation for competition, and enhanced concentration. Within the mental health professions, the efficacy of guided imagery is tied to a variety of benefits, including alleviation of grief, recovery from eating disorders, stress reduction, and enhanced insight and motivation.

Theoretical Underpinnings Imagery has been used within therapeutic work in a variety of ways. Sigmund Freud (1856–1939), for example, often focused on a patient’s fantasies and daydreams in his practice of psychoanalysis. The practice of hypnosis similarly aimed to help clients connect with and integrate various parts of themselves through interpreting the fantasies of the unconscious. Carl Jung (1875–1961) also incorporated these concepts through his focus on dreamwork and the exploration of client imagery, particularly as it related to symbols of the unconscious. Jung believed that a person’s psyche attempts to create a balance or equilibrium, which can result in certain aspects of a person’s personality being hidden from awareness. He believed that if the unconscious remained hidden to an individual, it would often break free in undesirable ways into a person’s conscious living. Therefore, it was important to uncover these unconscious components and reintegrate them with the conscious self.

Imagery is also included in movements of psychology such as psychodrama and Gestalt therapy, among others. Fritz Perls (1893–1970) often used imagery spontaneously in counseling sessions as part of his Gestalt approach. In Gestalt therapy, clients are encouraged to act out their fantasies, imagine conversations with others or parts of themselves, and attribute motivations to their physical actions to gain awareness of their experience in the here-and-now. Perls often guided clients through these experiences by questioning the meaning behind behaviors in session and inviting clients to own and explore these meanings.

Major Concepts Guided imagery can take a variety of forms based on the goal of the intervention and the comfort level of the counselor and the client. Dialogic Imagery

In this form of imagery, clients study their own visualizations aloud as the counselor poses questions related to what the client is experiencing. This process can involve reimagining dreams or fantasies, or it can involve a here-and-now examination of client metaphors. For example, a client who says that he or she feels “weighed down by rocks” might be asked to imagine details about the rocks, including their size and texture, how many there are, how the weight feels, and so on. The counselor may ask the client to think of what each rock might represent or to take the perspective of the rocks and consider himself or herself from an external perspective. Counselors may additionally suggest an initial focus, such as a path, meadow, house, or mountain, and ask the client to begin filling in the details as his or her imagination takes hold of the setting and the story. The counselor in these cases is only active in the sense of exploring the client’s experience in an open-ended way, allowing the client to imagine and communicate the details. Scripted Imagery

This form of imagery is more structured in that the counselor either reads or plays a prerecorded script. The client typically remains silent during these scripted experiences as he or she listens to the

Guided Imagery Therapy

full script and attempts to imagine the content. Following the guided imagery, the counselor will often ask a client to describe aspects of the experience and reflect on how he or she felt about various parts. This form of imagery is more common in group settings, as all group members can participate simultaneously in listening to the scripted instructions and later share their experience with the group. Scripted imagery is also common in sports, teaching, medicine, and other nontherapeutic settings due to the ability to focus content on certain topics and confine processing to the goals of the group. It can be a safe practice to begin with for clients who are unsure of how they might experience guided imagery.

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may have difficulty accessing visual imagery, particularly when in the room with another person, and therefore may not benefit from the technique. Begin With Relaxation

Although imagery can take several forms, certain guidelines can assist counselors in facilitating this technique in counseling.

Jumping immediately into imagery can be disorienting for a client, and therefore, it is advisable to begin first with guiding the client through relaxation techniques. The counselor instructs the client to find a position that the client can comfortably hold for the length of the experience. Often the most comfortable positions consist of sitting upright in a chair with feet flat on the ground and hands on the lap, though the client can choose variations of this position based on his or her comfort level. The counselor then encourages the client to close his or her eyes or fix his or her gaze on his or her hands to help focus the client’s attention and block out other visual stimuli. Next, the counselor leads the client through relaxation techniques designed to calm the client’s mind and body in preparation for the visualization. This often consists of guiding the client through deep breathing and/or progressive muscle relaxation. Breathing techniques can include asking the client to inhale or exhale for a certain count or to place his or her hands on the chest and stomach to encourage deeper breathing patterns. The counselor may also choose to follow these relaxation techniques with a neutral visualization, such as asking the client to imagine a meadow or a field, prior to proceeding with more complex or emotionally arousing visualizations.

Assess Client Readiness

The Intervention

It is important prior to utilizing guided imagery with a client that counselors assess whether the client will benefit from such a practice. Counselors should consider whether they have adequate time to implement the technique in session from start to finish. Counselors should also ensure that clients understand the purpose of the technique and how it might relate to the counseling goals. Some clients may be skeptical or uncomfortable with the idea of guided imagery and may need to be provided with evidence of its effectiveness to assist them in deciding whether they would like to try it. The decision to proceed with guided imagery should be made based on the client’s agreement. Some clients

Interventions can follow the varied approaches outlined previously, with the counselor directing the imagery or taking a more passive role by asking clarifying questions as the client proceeds through the experience. It is important that the counselor does not attempt to prescribe meaning or interpret the client’s experience. For example, if a client is describing a house, the counselor may want to explore the size or shape of the house, how many rooms it has, how the client may feel in approaching the house, and so on. However, the counselor should be aware of whether his or her questions to the client prescribe any specific meanings, such as asking the client if the client feels afraid. An exception

Artistic Imagery

Asking clients to draw or write to display their fantasies, dreams, or other unconscious content can also activate imagery. Counselors can direct the subject of artistic expression or leave it open-ended for clients to choose on their own. Once the client has completed the drawing, writing, or other artistic expression, the counselor can guide him or her through questions to explore the meanings of the symbols in the work.

Techniques

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to this could be if a client is feeling stuck within a scenario, in which case the counselor can offer suggestions for how to get unstuck. For instance, a client who finds himself or herself on a cliff with no handholds to assist in climbing further up may be instructed to try imagining that a handhold suddenly appears or that the client is able to fly up to a safer path. In scripted guided imagery, it is important for the counselor to let the client produce his or her own specific details about the images. For example, the guided script may instruct the client to imagine a gentle flowing stream falling down from a snowy mountain. The client is asked to picture this in his or her mind, and the counselor then guides the client through various actions like moving alongside the stream, taking a drink, sitting down to rest, or beginning up the mountain. Other details, including how the client pictures each step, how the client feels about the experience, and what meaning each part holds, are left to the client’s discretion and not prescribed by the counselor. Coming Back to the Here-and-Now

Rather than ending an imagery experience abruptly, the client should be eased back into the here-and-now. The counselor can conclude the imagery by guiding the client back to a neutral visualization or asking the client to slowly become more aware of the present moment, eventually opening his or her eyes. The process of letting go of the imagery may take some time, and the counselor should allow the client to gradually bring himself or herself back to the present. Processing the Experience

At the end of the guided imagery, the counselor can allow sufficient time to explore what the experience was like for the client, as well as what insights were achieved. It is important that the counselor does not interpret the client’s imagery. The counselor can assess, through open-ended questions, how the client felt at various times of the imagery, what sensory details accompanied certain components of the visualization, and what meanings the experience had for the client. The counselor should refrain from closed-ended questions or statements that assume client meanings, such as stating, “That heavy rock

sounds like it represents your relationship difficulties, so when you threw it away you must have felt a lot of relief!” Instead, the counselor can ask the client, “What did that rock represent to you? Is there anything similarly heavy in your life right now?” and “What did it feel like when you threw it in the stream?”

Therapeutic Process Much of the therapeutic process is explained through the description of techniques, but it is worth noting that successful implementation of guided imagery necessitates a strong therapeutic relationship. Trust must first be built between the counselor and the client, particularly if the imagery consists of anything that could be emotionally difficult. It is also important that the counselor and the client have identified goals for the imagery to be intentional and helpful for the client. It can be helpful to the process for counselors to have personally experienced guided imagery so that they are aware of some of the challenges and benefits associated with the technique. To help clients through the process, counselors may need to understand client difficulties in sustaining attention, blocking out external stimuli, and responding to verbal cues. In implementing the technique, counselors should speak in a soft, steady, monotone voice and allow for moments of silence when clients are visualizing particularly complex images or actions. Counselors who have experienced imagery themselves will likely be more sensitive to the importance of these strategies and feel less inclined to rush the experience for the client. Although guided imagery is found to be highly effective in many respects, there are some considerations for its implementation. First and foremost, counselors must know whether clients have a history of trauma or abuse and whether they fully understand the images or emotions associated with that history. Guided imagery may indeed be traumatic to clients who find themselves reexperiencing elements associated with their past traumas if they are unprepared for the experience. Guided imagery may still be a useful technique in these situations, but counselors may wish to pursue it carefully and only after they and the client are able to regulate the emotional arousal or level of distress caused by these experiences.

Guided Imagery Therapy

Similarly, asking clients to close their eyes during a guided imagery session may be threatening for some individuals. Especially in working with children or adults who feel unsafe or vulnerable, the option to fix the gaze elsewhere can be offered. Attention to these considerations helps ensure that the guided imagery is appropriate for each client. Hannah B. Bayne See also Analytical Psychology; Art Therapy; Body-Mind Centering®; Gestalt Therapy; Holotropic Breathwork; Mindfulness-Based Cognitive Therapy; Psychodrama

Further Readings Cheung, M. (2006). Therapeutic games and guided imagery: Tools for mental health and school

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professionals working with children, adolescents, and their families. Chicago, IL: Lyceum Books. Enns, C. Z. (2001). Some reflections on imagery and psychotherapy implications. Journal of Counseling Psychology, 48, 136–139. doi:10.1037//0022– 0167.48.2.136 Hall, E., Hall, C., Stradling, P., & Young, D. (2006). Guided imagery: Creative interventions in counseling and psychotherapy. London, England: Sage. Owen, D. W. (2010). Spontaneous and guided imagery in counseling: Putting fantasy to work. Turkish Psychological Counseling and Guidance Journal, 4, 71–80. Utay, J., & Miller, M. (2006). Guided imagery as an effective therapeutic technique: A brief review of its history and efficacy research. Journal of Instructional Psychology, 33, 40–43.

H work of Gregory Bateson and the sciences of nonlinear, self-organizing systems. The unity principle affirms that a living organic system is a whole made of parts, which in turn is part of a greater whole, where everything is ultimately connected to everything else in increasing levels of complexity. Organicity means that when all the parts are connected within the whole, the system is selforganizing and self-directing. Therapy, therefore, strives to respect organic wisdom and looks for disconnections that need healing. Mind–body holism means that one’s mind and body are integrated and can be used therapeutically together. Mindfulness is both a way of life and a quality of awareness that helps people study the organization of their experience. Nonviolence emphasizes that one must feel safe for mindful exploration.

HAKOMI THERAPY Hakomi therapy (HT) integrates the use of mindfulness, the mind–body interface, and nonviolence in healing and growth processes. Sessions can be short or long depending on the agenda. A central use of HT is deep psychodynamic transformation.

Historical Context HT was first developed by Ronald S. Kurtz in the 1970s. Kurtz integrated findings from a number of existing and body-oriented psychotherapies through the filters of experimental psychology, the sciences of complex adaptive systems, and Eastern wisdom traditions. He discovered that encouraging a mindful state of consciousness in clients could greatly enhance their ability to discover the unconscious beliefs that were organizing their experience, and what was needed for transformative reorganization.

The Organization of Experience

People develop core organizing beliefs to make sense of the world. These filter all inputs before making them available to the consciousness. Many clients have organized basic human possibilities (e.g., intimacy, independence) out of their experience, due to wounding experiences.

Theoretical Underpinnings The theoretical underpinnings of HT are based on five underlying principles and systems theory, the organization of experience, character theory, mindfulness, and the role of the body.

Character Theory

While every person and presenting issue is unique, Hakomi character theory offers a nonpathologizing schema of common ways of organizing one’s experience related to developmental factors. This theory helps make clear which human

Principles and Systems Theory

The methods and techniques of HT are based on its five underlying principles derived from the 483

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possibilities, such as intimacy, people might have organized out of their experience.

and count on this force to help move clients from fragmentation toward increased wholeness.

Mindfulness

Cooperation of the Unconscious

Mindfulness enables one to focus attention on studying the organization of one’s experience. It helps one gain the psychic distance to realize, “I am not just my anger or fear. My awareness that witnesses my anger and fear is not angry or fearful. I can notice how my anger operates in relation to various inputs and what it needs to moderate.” The qualities of compassion and awareness accompanying mindful consciousness comprise what various theorists call an Essential, Organic, or Larger Self, as opposed to the multiplicity of internal ego parts that are conditioned by historical events.

When there is sufficient safety and a therapeutic space free from imposed agendas, one’s unconscious will allow the negentropic force to provide signals leading toward the wholeness needed and allow the therapeutic process to unfold. If the therapeutic process is stuck, the cooperation of the unconscious is not present, often because the client does not feel safe.

Role of the Body

One’s overall experience is historically conditioned or organized. The qualities of one’s relationships and dreams are used by therapists to understand the unconscious meanings that formed them. Likewise, posture, gestures, voice tone, breathing, heart rate, movement, and other bodily manifestations can be used as beginning points for therapy.

Major Concepts Some of the major concepts of HT include loving presence, negentropy, cooperation of the unconscious, categories of experience, a mindful state of consciousness, experimental attitude, following and leading, and managing the process and gathering information. Loving Presence

Loving presence is when the therapist’s delight in the client fosters a safe, collaborative, encouraging therapeutic relationship regardless of whether there is progress. Such an open presence allows the client’s process to unfold naturally. Negentropy

Ilya Prigogine, Nobel laureate in chemistry in 1977, suggested that there is a force in living organic systems, negentropy, that functions to create wholes out of parts. Therapists can look for

Categories of Experience

HT encourages mindful awareness of one’s present-moment experience. A client can become aware of and curious about many categories of experience, such as thoughts, sensations, emotions, memories, or meanings, which serve as indicators of the unconscious core beliefs that created them. The common process of an HT session moves from open, mindful attention to some category of a client’s experience to continued mindfulness of the spontaneous unfolding that may involve many other categories, until it reaches the level of the core belief that organized the original indicator. The therapeutic emphasis is on the core narrative beliefs that form the client’s experience as storyteller, rather than on the content and variations of the client’s story. A Mindful State of Consciousness

Using mindfulness clinically involves inviting a client to change his or her state of consciousness. Ordinary, everyday consciousness is fast, habitual, goal directed, and effortful, with a narrow external focus that is aware of space and time. Hakomi therapists assist clients in shifting into a mindful state of consciousness that intentionally slows down, suspends judgments, and becomes curious and exploratory in a relaxed, receptive way, with an open focus that may lose awareness of space and time, like artists or children lost in their preoccupations. Experimental Attitude

Humans are nonlinear systems with emergent possibilities, as opposed to machines where one

Hakomi Therapy

input predictably leads to one result. Thus, a Hakomi therapist maintains an experimental attitude seeking to cooperate with the client’s unconscious leading. Every aspect of the process, from saying hello to inviting mindfulness of an impulse or gesture, is considered an experiment yielding new information, anticipated or not, that informs the next step. Following and Leading

Because a primary task of the therapist is trusting in the signals of the client’s organic unfolding—as opposed to diagnosing or interpreting—the therapist’s first impulse is collaborating with and following the client’s present-moment experience. When the process seems to be hindered, the therapist can lead through numerous interventions. Leading by the therapist is always done without attachment to the intervention employed, always experimentally tracking and contacting what experience it evokes and weaving the result into the unfolding process. This requires the therapist to be comfortable with a measure of mystery, unpredictability, and not knowing. Managing the Process and Gathering Information

The main thing a Hakomi therapist manages in a session is states of consciousness, making judgments about when ordinary consciousness is appropriate and when a client should be invited or returned to a more mindful state. Once a process starts unfolding, Hakomi therapists gather information through tracking what is happening and generally refrain from asking explanatory questions that risk taking the person out of mindful exploration.

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being aware of the bodily expressions of the client’s internal experience. Tracking allows the therapist to join immediately and deeply with the client through informing the construction of a simple contact statement meant to demonstrate understanding of what seems experientially primary: “A little sad, huh?” The “huh?”—or some equivalent— indicates a willingness to be corrected, as opposed to being invested in one’s interpretation. First-order contact is used in ordinary consciousness to build a bridge of interpersonal understanding: “You really tried hard.” Second-order contact serves to deepen intrapsychic mindful exploration: “Some emotion arises?”—with the implication in the therapist’s voice that perhaps this is something worthy of more mindful, curious attention. Accessing and Deepening

Accessing is the stage of the HT process that invites a transition from ordinary consciousness to a mindful state of consciousness, where an issue can best deepen into relevant core material. It can be done in many ways, often through referencing the body: “Why don’t we slow down and notice how this conflict with your boss registers in your body?” Deepening encourages clients to stay in an intrapsychic, mindful relationship with their own experience while naming it, but not break continuity with it by returning to a conversation with the therapist. Experiments in Mindfulness

Some techniques commonly used by Hakomi therapists are tracking and contacting, accessing and deepening, experiments in mindfulness, taking over, jumping out of the system, child states, riding the rapids, missing experiences, exploring barriers, and transformation.

The many experiments that can be introduced to foster the unfolding of a session are always done in a state of mindfulness and often follow a standard format. First, there is an invitation to selfstudy in mindfulness: “Notice what occurs spontaneously when . . .” Second, there is a description of the experiment to come: “When I say these words, . . . ” or “When you begin to reach out for your partner, . . .” Third, a pause allows the “noise” of the instructions to subside. Fourth, the actual experiment is done, for instance, saying the words “It is okay to see.” Fifth, tracking and contact are used in the service of deepening.

Tracking and Contacting

Taking Over

In addition to following the meaning of a client’s verbal expressions, tracking in HT involves

The organic signals attempting to lure the person toward healing and wholeness are often not

Characteristic Techniques

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easy to detect because of the “noise” surrounding the person due to hypervigilance, bodily tensions, multiple parts in conflict, and more. Taking-over techniques are a unique way Kurtz devised of dealing with defenses by doing for clients what they were already doing for themselves. Supporting defenses in this way promotes safety and relaxes tensions, lowering background noise and allowing the signals to emerge more clearly. If a client hears a voice in his or her head saying, “Oh no, it isn’t!” in response to the experimental words “It’s okay to see,” the therapist or a group member could take over saying the “Oh no” when the experiment is repeated. Likewise, if the client’s shoulders tighten in fear, the tightening can be taken over physically by a group member or the therapist, with coaching from the client on how to do it precisely right. When fearful defenses are supported instead of confronted, safety is provided from without, and the client is freer to explore more deeply within. Jumping Out of the System

Sometimes resistance or defenses show up systemically between the client and the therapist. The technique of jumping out of the system can be helpful. The therapist must first become aware of the system. Then the system itself can be named nonjudgmentally and can itself become the focus for mindful exploration. For example, the therapist might say, “I notice that you talk fast, almost like you are not sure there is enough space to have your say?” Child States

When mindfully following a thread from an initial experience that deepens into various categories of experience, a therapeutic regression may lead to an earlier memory and a child state of consciousness. In this dual state of consciousness, clients experience the reality of early episodes while knowing that they are in a current therapy session. This state can be a creative space for transforming core beliefs the child developed that have become overgeneralized to relationships where they are no longer as functional. Riding the Rapids

Deepening into early memories and core material may result in another state of consciousness,

termed riding the rapids, characterized by spontaneous strong emotional release and simultaneous attempts to hold back the emotion, a state not conducive to mindfulness. Such expression can be supported verbally and with nonverbal takingover techniques until it resolves. Missing Experiences

When mindful exploration deepens toward core material, what the client has organized out of his or her experience as dangerous becomes more evident. This missing experience can then become the focus of experiments in mindfulness designed to help the client reconsider the previously negated possibility. If the client’s core belief is “I can’t risk accepting support because of the memory of hurt and disappointment. I need to stay self-reliant,” the positive content for a missing experience experiment would be some version of the precise opposite: saying “You don’t have to do everything yourself” or “It’s okay to be supported,” or the client physically leaning into another person’s support. The common result of such mindful experiments is to evoke clients’ verbal and nonverbal barriers that block or disconnect them from the possibility of gratifying support. Exploring Barriers

Mindfully exploring the barriers raised against experiences previously organized out is the essence of transformative therapy. For barriers to moderate, they need some condition of safety, nurture, or assurance not present when they were formed. The therapist can experiment with introducing the needed condition in conjunction with the missing experience. Transformation

Transformation in HT happens when the client is able to organize into his or her experience an aspect of life previously organized out. A client who was painfully unsupported while young and compensated by becoming self-reliant is enabled to distinguish past from present and allow in available support. Transformation requires an experience to counteract a previous experience, as opposed to simple insight into what happened.

Haley, Jay

Therapeutic Process The linear structure of an HT session, which must always accommodate to what arises spontaneously, typically includes the following steps: 1. Establishing an interpersonal therapeutic relationship that provides the conditions of safety and trust necessary for mindfulness 2. Accessing, by inviting a transition from ordinary consciousness to a mindful state of consciousness 3. Deepening, by maintaining a mindful state and trusting where it leads 4. Processing, through discovering core material, experimenting with missing experiences, and working through barriers until transformation is made possible 5. Integrating and completing while ending in ordinary consciousness

Gregory J. Johanson See also Accelerated Experiential Dynamic Psychotherapy; Coherence Therapy; FocusingOriented Therapy; Gestalt Group Therapy; Internal Family Systems Model; Person-Centered Counseling; Schema Therapy; Sensorimotor Psychotherapy

Further Readings Johanson, G. (2009). Psychotherapy, science and spirit: Nonlinear systems, Hakomi therapy, and the Tao. Journal of Spirituality in Mental Health, 11/3, 172–212. doi:10.1080/19349630903081093 Johanson, G., & Kurtz, R. (1991). Grace unfolding: Psychotherapy in the spirit of the Tao-teaching. New York, NY: Bell Tower. Kurtz, R. (1990). Body-centered psychotherapy: The Hakomi method. Mendicino, CA: Life Rhythm. Roy, D. M. (2007). Body-centered counseling and psychotherapy. In D. Capuzzi & D. R. Gross (Eds.), Counseling and psychotherapy: Theories and interventions (4th ed., pp. 289–360). Upper Saddle River, NJ: Prentice Hall. Weiss, H., Johanson, G., & Monda, L. (Eds.). (2015). Hakomi: Mindfulness-centered, somatic psychotherapy. New York, NY: W. W. Norton.

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HALEY, JAY In a career that began as an original member of Gregory Bateson’s Palo Alto team of researchers in the 1950s, Jay Haley (1923–2007) is among a handful of indispensably important people in the creation of communication theory, strategic family theory, and systemic family therapy. Contagiously inquisitive and committed, Haley devoted his life to establishing a radically alternative way of understanding human behavior as a product of interaction taking place in the present moment between people in intimate relationship with one another. He was involved with the development of many of the earliest and most influential observation-based theoretical concepts about the relationship and contextual basis for understanding human behavior and the development of effective and efficient methods for promoting constructive change by seeing the patient and family members together in therapy. A gifted and prolific author, he wrote many of the most significant books and training materials in the field of family therapy, including Strategies of Psychotherapy (1963) and Techniques of Family Therapy (1967, coauthored with Lynn). A phenomenally effective and influential teacher and supervisor, Haley leaves a lasting legacy. From personal experience and in talking with a number of other professionals he mentored, Haley willingly spent much of his time teaching others the art of effective therapy. Like the many other books and articles he wrote, Teaching and Learning Therapy (1996) remains among the most useful books in print about how to help people change. In accord with his colleagues in Bateson’s renowned research team—widely known as the Palo Alto Group— Haley devoted his career to demystifying the nature of human interaction and the practice of therapy, contributing some of the most widely read books in the field, such as Problem Solving Therapy (1976), Leaving Home (1980), and Uncommon Therapy (1973). The training materials he produced—books, articles, and video recordings— stand as his vibrant inheritance to the behavioral sciences. Haley completed undergraduate degrees at the University of California, Los Angeles, and at the University of California, Berkeley, and a master’s

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degree in communications from Stanford University in Palo Alto, California. In 1952, while a student at Stanford University, Haley met Bateson, which led to his joining John Weakland, William Fry, and later Don Jackson as a key member of the Palo Alto Group. Together with Bateson and the other team members, Haley developed the first purely communication/interactional theory of human behavior, central to which is the concept of the double bind, which is when an individual receives conflicting messages from another that results in confusion and stress (e.g., a parent tells his child that he loves him but at the same time turns away in revulsion). In addition to helping create communication/interactional theory, many innovations derive from the contributions of the Palo Alto Group, including recording sessions for later analysis; seeing patients and family members conjointly—thus developing what later became family therapy; and using one-way observation mirrors and therapeutic teams in the real-time moment of conjoint family therapy. In the decade the Palo Alto Group worked together, the members published more than 70 professional papers, including the profoundly influential “Toward a Theory of Schizophrenia” (Bateson, Jackson, Haley, & Weakland, 1956), “The Question of Family Homeostasis” (Jackson, 1957), and “The Family of the Schizophrenic: A Model System” (Haley, 1959). This 10-year collaboration revolutionized thinking about the contextual and relational nature of emotional illness and, in so doing, launched systemic family therapy. A pivotal aspect of research in the Palo Alto Group included the study of the hypnotic and clinical work of Milton H. Erickson. Involvement with Erickson greatly influenced Haley, who incorporated many of Erickson’s techniques of hypnosis into his method of therapy. Based on his work with Bateson, Jackson, Weakland, and Fry, in combination with his study of Erickson, Haley created one of the most widely used and effective models of problem-solving therapy: strategic family therapy. It can be said, without exaggeration, that Haley was intimately involved with many of the most important developments in the field. In 1959, he became one of the first members of the Palo Alto Group to join Jackson when he founded the Mental Research Institute (MRI), serving as

Director of Research. In 1962, in collaboration with Jackson and Nathan Ackerman, Haley helped found the journal Family Process, and for the first decade, he was its editor. In 1967, he left MRI to join Salvador Minuchin and Braulio Montalvo at another influential early family center, the Philadelphia Child Guidance Institute. In 1975, he cofounded, with his then wife and fellow family therapy pioneer Cloe Madanes, the Family Therapy Institute of Washington D.C., where he continued teaching and developing his strategic family therapy approach until 1990, when he retired and moved back to his hometown, La Jolla, California. Retirement for Haley meant continued writing and producing documentary films with his wife, the anthropologist Madeline Richeport-Haley, and continuing travel to teach his approach. Even at the time of his death, Haley was a clinical supervisor and research professor in marital and family therapy at Alliant International University in San Diego, California. When asked, Haley would readily describe, often spontaneously, the many lessons he learned from Don Jackson, Erickson, Bateson, and Weakland. Although he was one of the irreplaceable direct links to the beginnings of the marriage and family therapy discipline, Haley regularly underplayed the importance of his own contributions in the development of systemic theory applied to understanding human behavior and the art of bringing about constructive change. His characteristic deflecting away from his own importance is fitting because Haley, like his contemporaries, did not believe in individuals, as the term is usually understood—he was concerned with context and patterns of interaction of which individual behavior is a part. This deep understanding of how behavior emerges out of interaction, relationship, and context is among his greatest legacies. Wendel A. Ray See also Multisystemic Therapy; Palo Alto Group; Strategic Family Therapy

Further Readings Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956). Toward a theory of schizophrenia. Behavioral Science, 1(4), 251–264. doi:10.1002/bs.3830010402

Healing From The Body Level Up Haley, J. (1959). The family of the schizophrenic: A model system. Journal of Nervous & Mental Disease, 129, 357–374. Haley, J. (1963). Strategies of psychotherapy. New York, NY: Grune & Stratton. Haley, J. (1973). Uncommon therapy: The psychiatric techniques of Milton H. Erickson. New York, NY: Basic Books. Haley, J. (1974). Problem solving therapy. San Francisco, CA: Jossey-Bass. Haley, J. (1980). Leaving home: The therapy of disturbed young people. New York, NY: McGraw-Hill. Haley, J. (1996). Learning and teaching therapy. New York, NY: Guilford Press. Haley, J., & Hoffman, L. (Eds.). (1967). Techniques of family therapy. New York, NY: Basic Books. Jackson, D. (2005). The question of family homeostasis. In W. Ray (Ed.), Don D. Jackson: Essays from the dawn of an era (pp. 99–110). Phoenix, AZ: Zeig, Tucker & Theisan.

HEALING FROM THE BODY LEVEL UP Healing From The Body Level Up (HBLU) is a holistic psychotherapy and mind–body healing methodology that addresses the somatic, psychological, and  spiritual aspects of an issue simultaneously. Developed by the biomedical research scientist Judith A. Swack, HBLU integrates biomedical science, psychology, spirituality, applied kinesiology, neuro-linguistic programming, and energy psychology with original research on the structure of complex damage patterns. HBLU can treat clients for a wide range of unconscious self-sabotage patterns and blocks from simple phobias to complex dysfunctional family system patterns. In addition to being a healing methodology, HBLU is a valuable modality for facilitating personal growth, spiritual evolution, and self-actualization. HBLU sessions are generally 90 minutes long and treatment (depending on the issue) usually takes between 8 and 15 sessions. For example, HBLU has been demonstrated to be effective for treating posttraumatic stress disorder in 1 to 6 sessions in both men and women, and both military and civilian clients, and to eliminate addictive behaviors in clients in 1 to 9 sessions.

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Historical Context As a biomedical research scientist, with a Ph.D. in biochemistry and postdoctoral training in human immunology, Swack became interested in the mind–body connection and how it affects physical and emotional health. In her research, she observed that many mind–body healing techniques such as hypnosis for weight loss and smoking cessation, holy water and prayer for healing cancer, and meditation for trauma and stress gave inconsistent results. Exploring the mind–body connection further, she obtained her certification as a Master Practitioner of Neuro-Linguistic Programming and a certification in hypnotherapy and trained in Thought Field Therapy/DX. She also learned other energy psychology techniques, spiritual techniques, shamanic techniques, and energy transmission techniques. Beginning in 1981, Swack applied scientific research methods to the nascent field of mind–body healing to identify and develop reliable and reproducible procedures. Through her research, she mapped patterns and created protocols for reproducibly treating an extensive range of conditions from chronic body pains (e.g., fibromyalgia, headaches, back pain), to persistent medical conditions (e.g., high blood pressure, diabetes, chronic infections), to mental health conditions (e.g., attention deficit disorder and learning disabilities, anxiety, posttraumatic stress disorder) and self-sabotaging behaviors (e.g., binge eating and other addictive behaviors, people pleasing, self-neglect). She also developed HBLU protocols for developing healthy relationships and self-esteem and for promoting self-actualization in one’s career, spirituality, and related areas of life.

Theoretical Underpinnings HBLU begins with the philosophy that every person has an individual soul, which is an extension of and connected with the energy of the divine source (i.e., God). The soul embodies in human form to manifest one’s soul mission (i.e., make a unique and personal contribution to the world so that when one dies, one leaves it a better place). The ability to manifest one’s mission is what makes life feel meaningful and deeply satisfying. HBLU assumes that the soul embodies to experience the fullness of life and all that it has to offer

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so that it can learn, grow, and evolve. HBLU assumes that if people are not on track with their soul mission or not getting the desired results in some area of their life, there must be some type of damage pattern at the conscious mind, unconscious mind, body, or soul levels of the being that is causing self-sabotaging behaviors or interfering with or blocking their success. In HBLU, the soul is referred to as the deepest wisdom because it is the essence of an individual, the innermost level of awareness, and the place of ultimate truth for that individual. HBLU provides clients and healing facilitators with a way to 1. identify the type of damage, or interference, patterns by accessing information from the client’s deepest wisdom/soul, unconscious mind, and body by muscle testing and 2. choose and apply an effective technique or protocol to heal those interference patterns, thus aligning the conscious mind, unconscious mind, body, and soul.

be free of interference patterns at all four levels. This is called “being in alignment.” Interference Patterns

Interference patterns (also called damage patterns) come from three different sources: life experience, wounded ego structure, and external interference. Life experience interference patterns include traumas from this life, past lives or ancestry, limiting beliefs, addictions, grudges, a dysfunctional family system, and seduction patterns. HBLU uses the Enneagram model of personality to describe wounded ego structure. In this model, there are nine different types (e.g., the Perfectionist, the Observer, and the Helper/Giver), each with its own strengths and weaknesses. The external interference category includes damage patterns caused by other people, natural disasters, supernatural energies (i.e., curses, demons, and ghosts), and toxic belief systems caused by cultural and gender stereotyping and damaging religious beliefs.

Techniques Major Concepts A number of concepts related to HBLU are used in this approach. They include alignment of the levels and damage, or interference, patterns. Alignment of the Levels

In the HBLU model, human beings are multidimensional systems functioning at four levels simultaneously: 1. The conscious mind: The level of rational, concrete, linear, logical thinking 2. The unconscious mind: The level of emotion, imagination, memory, creativity, and metaphor 3. The body: The level of physical survival and reproduction 4. The soul: The level of soul mission and connection with God (a divine source) and all life

To easily achieve a desired goal, a person’s deepest wisdom must set the goal, and the person must

Techniques in the HBLU menu of options work in minutes, are able to be performed by clients, and effectively clear the interference pattern from wherever it is located in the four levels. Accessing the Deepest Wisdom Through Muscle Testing

Muscle testing is an applied kinesiology technique based on the same principle as lie detector testing (i.e., the body will register true or false answers to questions). Facilitators can obtain this same information by testing the difference in muscle strength on true and false statements. It is done by having the client hold out the arm and pressing it after asking a question. The arm typically holds strong for a true statement and goes weak on a false statement. Meridian-Tapping Techniques

Scientific research has shown that phobias and traumas are irrational and exaggerated reactions caused by shocking experiences that trigger the fight/flight/freeze reflex. Environmental cues can

Healing Touch

trigger this conditioned response, resulting in phobic reactions. In HBLU, clients eliminate these phobic reactions by activating the body’s calming reflex using meridian-tapping techniques. Clients focus on a negative emotion and then stimulate the nerve endings (which correspond to acupuncture meridians) through tapping (with fingertips) selected areas of the face, torso, and hands combined with the left brain/ right brain integration technique of humming a tune followed by counting numbers and then again humming a tune. These techniques are known by various names, including thought field therapy, emotional freedom technique, and natural bio-destressing.

Therapeutic Process The HBLU healing process is structured as a collaboration between the client and the facilitator. The client’s deepest wisdom dictates all of the goals, directions, and healing steps, and the facilitator offers a comprehensive menu and knowledge of the structure of the damage patterns and an extensive menu of healing techniques and protocols. The HBLU healing process involves asking the client’s deepest wisdom to identify the priority goal by sending questions into the body and muscle testing the answers. The client’s deepest wisdom then selects the priority interference pattern from an interference pattern menu. The client reads about the selected pattern from an HBLU manual and discusses the pattern with the HBLU facilitator until the client understands consciously what the pattern is and how it interferes with the goal. The client’s deepest wisdom selects the priority technique or protocol for clearing the pattern by muscle testing through the technique and protocol menu. The client finds the physical location of the negative energy or feelings associated with that pattern in the body, allowing the conscious mind, unconscious mind, body, and soul levels to align and focus on the problem. The client performs the technique and clears the problem at all levels simultaneously. The client finishes the healing by testing the results and writing what he or she has learned from doing the healing. Judith A. Swack

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See also Energy Psychology; Neuro-Linguistic Programming; Prayer and Affirmations; Reiki

Further Readings Swack, J. A. (2002). Healing From The Body Level Up. In F. P. Gallo (Ed.), Energy psychology in psychotherapy: A comprehensive source book (pp. 59–76). New York, NY: W. W. Norton Professional Books. Swack, J. A. (2009). Elimination of post traumatic stress disorder (PTSD) and other psychiatric symptoms in a disabled Vietnam veteran with traumatic brain injuries (TBI) in just six sessions using Healing From The Body Level UpTM methodology: An energy psychology approach. International Journal of Healing and Caring Online, 9(3). Retrieved from http://hblu.org/ post-traumatic-stress-disorder-ptsd.html Swack, J. A. (2012). Elimination of PTSD and psychiatric symptoms in one to six sessions in two civilian women and one female Iraq war veteran using Healing From The Body Level Up (HBLU) methodology: An energy psychology approach. International Journal of Healing and Caring Online, 12(3). Retrieved from http://www .wholistichealingresearch.com/user_files/documents/ ijhc/articles/Swack-12-3.pdf

HEALING TOUCH Healing Touch is a biofield or “energy” therapy that involves the practitioner using his or her hands either on or above an individual’s body to direct healing energy in an effort to facilitate general health and well-being. Healing Touch is based on a philosophy that, in addition to the physical, humans have an energetic, spiritual dimension necessary for sustaining life that must be taken into account during the healing process. Healing Touch is used in a variety of health care settings, including pain clinics and cancer centers, as well as private practices, and is administered by trained practitioners who are often health care professionals, particularly nurses.

Historical Context Hands-on healing and energy-based therapies have been found in cultures around the world throughout history. These complementary therapies, which are often rooted in ancient Eastern healing practices,

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are now becoming mainstream. In 1994, the Office of Alternative Medicine (now the National Center for Complementary and Alternative Medicine) at the National Institutes of Health referred to these practices as “biofield therapies,” and in 2001, the  National Center for Complementary and Alternative Medicine redefined the concept of “frontier medicine” to include biofield therapies and defined them as those therapies “for which there is no plausible biomedical explanation.” These therapies are often controversial given the fact that the “energy” involved has yet to be reliably measured, in comparison with bioelectromagnetic therapies, which use magnets or electrical fields. Nurses have provided much of the early research leadership in the area of biofield therapies, beginning with the seminal work of Delores Krieger in the development of Therapeutic Touch and continuing with the Healing Touch Program founded by Janet Mentgen. Nurses often recognize the importance of entering and leaving another person’s space or energy field and the impact on healing that the presence of one person can have on another. Healing Touch was established in the 1980s by Mentgen and was developed from a foundation in Therapeutic Touch. Healing Touch combines selected techniques from other energy healers and ancient healing practices, as well as those developed by Mentgen, into a standardized curriculum. Healing Touch involves a positive intention by the practitioner for the participant’s highest good, with placement of the practitioner’s hands in specific patterns or sequences on or above the client’s body. Healing Touch is taught as a multilevel, didactic program that includes a 1-year mentorship leading to certification, generating a cohort of highly skilled certified practitioners.

Theoretical Underpinnings The holistic nursing perspective is exhibited in the history of the profession in studying factors addressing the physical and also the psychological and spiritual aspects of a person, which influence the process of healing. Within the holistic nursing paradigm, the concept of energy healing and energy therapies has been emerging, supported by advances in research on mind–body interactions, such as meditation and mindfulness, and increased consumer interest in complementary and integrative

therapies. Interaction with energy is a fundamental concept in the practice of nursing, recognized in the Nursing Interventions Classification Code, and a therapeutic component of selected nursing theories. Jean Watson’s theoretical transpersonal caring model concerns viewing the human being as a multidimensional system of energy, with a consciousness that can be affected by another to promote well-being. This model includes expanding the view of the individual to one of an energetic being composed of a spirit, a universal mind, and a consciousness. The work of the nursing researcher and theorist Martha Rogers suggests that each human being is surrounded by an energy field that is in constant interaction with the environment, with disruptions in this field manifesting as illness. These theories have led the North American Nursing Diagnosis Association to have an approved nursing diagnosis of “disturbed energy field.” Rogers advocates the use of noninvasive modalities, such as biofield therapies and Healing Touch, to promote healing on the physical, mental, emotional, and spiritual levels.

Major Concepts Major concepts of Healing Touch include grounding and centering by the practitioner, the practitioner’s intention, and attuning or connecting with the client’s energy. Grounding and Centering

To facilitate Healing Touch, a practitioner begins by entering a mindful or meditative state, referred to as grounding and centering. This process may involve various techniques including deep breathing and focusing on the breath, or consciously connecting to universal energy. This process allows the practitioner to become more relaxed and centered, aiding in his or her ability to provide Healing Touch to the client. This preparation is part of providing what has been termed a healing presence and may play a role in the beneficial process of Healing Touch itself. Intention

During the time in which a Healing Touch practitioner prepares for a session by grounding

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and centering, the practitioner consciously sets a positive intention for the client’s highest good. In the philosophy of energy therapies, it is believed that universal or life energy follows thought and intention. Therefore, this step of the therapeutic process is a hallmark of Healing Touch. The intention may or may not be verbalized to the client but is always focused on the client’s optimal well-being. Attunement

Following the centering preparation process and the setting of an intention, Healing Touch practitioners connect with the client’s energy field through a process known as attunement. To attune to or connect with a client’s energy field, the practitioner will place his or her hands lightly on the client’s body, usually at the hands, shoulders, or feet. This process allows the practitioner to begin to assess the energy field of the client and may help to relax the client through connecting with the practitioner’s meditative state.

Techniques A Healing Touch therapy session involves components of what has been termed the Basic Healing Touch Sequence. This sequence is used during each session with a client throughout the therapeutic process.

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Pre- and Postintervention Energy Field Assessment

The Healing Touch practitioner uses his or her hands during the pre-intervention energy assessment to detect any disturbances in the client’s energy field. These disturbances or imbalances may present as temperature changes, as movement, or as holes, spikes, or bulges. Additionally, practitioners may perceive disturbances in the client’s energy field visually or through auditory information. Throughout the session, the practitioner may reassess the energy field following an intervention using Healing Touch techniques to determine any improvement in the client’s energy field. Healing Touch Intervention

Following the pre-intervention energy field assessment, the Healing Touch practitioner uses various techniques from the curriculum designed to balance the energy field and address any disturbances noted. These techniques involve placement of the hands at specific locations on or above the client’s body. During this phase of the session, the practitioner intentionally channels energy through his or her hands to address the energy field disturbances noted as part of the pre-intervention energy field assessment. Following the Healing Touch intervention, the practitioner reassesses the client’s energy field to determine whether additional intervention is needed or if new imbalances in the field have arisen.

Intake

During the intake phase of a Healing Touch session, the practitioner gathers information from the client about current issues in the client’s life that prompted the desire for the session and for which Healing Touch may be beneficial. A lengthy initial intake is conducted during the first session with the client to gather information about the client’s health history, medications and supplements, health care providers, living situation, and health practices, including diet and exercise. This detailed intake gives the practitioner a better idea of other issues, outside of those initially shared by the client, that may have an impact on the client’s present situation. After collecting this information, the practitioner and the client set a mutual goal for the outcome of the session.

Evaluation and Response

At the conclusion of the Healing Touch session, the practitioner reports back to the client what he or she had noticed during the energy field assessments, the techniques that were used to bring balance to the energy field, and the outcomes. The client provides any feedback from his or her experience during the session. These outcomes and feedback are discussed in the context of the mutual goal set for the session and the overall goal of the therapeutic process. The client and the practitioner discuss the need or desire for additional sessions, as well as other supportive care therapies that might be useful for the client in improving wellbeing given the mutual goals and the information from the intake at the beginning of the session.

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Therapeutic Process Healing Touch typically involves at least three sessions, with more sessions taking place as discussed and agreed on by the client and the practitioner. The first session involves a more detailed intake, gathering information from the client about his or her situation, including information about the client’s health and well-being. Each session involves a mutual goal discussed and agreed on by the client and the practitioner. The Healing Touch techniques used during each session are guided by this mutual goal and the energetic assessment. Practitioners conclude with a final Healing Touch session that includes discharge planning and strategies for the client to maintain health and wellness. Counselors and therapists with training in Healing Touch can integrate these techniques into their practice in a variety of ways. Specific Healing Touch techniques can be used to reduce anxiety and promote relaxation, allowing clients to feel more comfortable and potentially more open to communication. Healing Touch techniques may be conducted simultaneously with interview methods to gain further information about memories or experiences associated with specific locations of the body. Oftentimes, clients may be more forthcoming about current issues hindering their wellbeing following the use of simple Healing Touch techniques that promote relaxation. These methods appear to aid in building trust between the practitioner and the client and could be used at the beginning of a session to enhance the therapeutic process of the practitioner–client interaction. Given that Healing Touch can have positive effects at the physical, emotional, mental, and spiritual levels, these techniques offer additional tools for counselors and therapists when working with clients. Joel G. Anderson See also Bioenergetic Analysis; Body-Mind Centering®; Energy Psychology; Reiki; Therapeutic Touch

Further Readings Anderson, J. G., & Taylor, A. G. (2011). Effects of healing touch in clinical practice: A systematic review of randomized clinical trials. Journal of Holistic Nursing, 29(3), 221–228. doi:10.1177/0898010110393353 Hover-Kramer, D. (2002). Healing Touch: A guidebook for practitioners (2nd ed.). Albany, NY: Delmar.

Jain, S., & Mills, P. J. (2010). Biofield therapies: Helpful or full of hype? A best evidence synthesis. International Journal of Behavioral Medicine, 17(1), 1–16. doi:10.1007/s12529-009-9062-4

HEART RATE VARIABILITY Heart rate variability (HRV) is defined as the amount of fluctuation in the length of the intervals between heartbeats. Thus, the more regularly one’s heart beats, the lower is one’s HRV, and the less regularly one’s heart beats, the greater is one’s HRV. These intervals in time are known as R-R intervals and can be measured on an electrocardiogram, otherwise known as an ECG/EKG. The ECG/EKG translates the heart’s electrical signals into a waveform, which can then be measured. These measurements can then be studied and applied to research. Over years of research, a link between HRV and health has been noted. Generally speaking, a low HRV correlates with poor physical and mental health outcomes and a higher HRV correlates with positive physical and mental health.

Historical Context Humans have studied HRV in its simplest form for thousands of years simply by noticing the quickening of the pulse rate after the increase of exercise or other forms of aroused states. Herophilos, a Greek physician in 300 BCE, is one of the first known individuals to publish writings on the heart rate as measured by timing the pulse with a clepsydra or water clock. Galen, also a physician of the Greco-Roman period, wrote myriad texts using the pulse as a diagnostic assessment tool. His notions about the pulse dominated medical literature for the next 16 centuries. In the 18th century, tools for measuring the passing of time became more accurate, including the stopwatch, created by John Floyer. This device allowed Floyer to determine both heart rate and respiration. Floyer published works on the natural pulse and how deviations could affect the understanding of disease. Increased accuracy in timepieces allowed for the ability to note fluctuations in the arterial pulse.

Heart Rate Variability

In the 19th century, Carl Ludwig discovered that heart rate regularly increased during the inhalation of breath and decreased during exhalation This discovery later was called respiratory sinus arrhythmia (RSA). Later that same century, Willem Einthoven used galvanometers to accurately measure changes in electric activity and produced the first continuous recordings of electrical activity of the heart, which later became known as the ECG/ EKG. The ECG/EKG is still used today; however with the advent of the digital age also comes the improved ability to analyze waveforms and ultimately improve the ECG/EKG’s ability to assess physiological responses. As biofeedback began to be applied to the reduction of stress, the measurement and use of HRV became a central component of building skills for managing physical stress reactions.

Major Concepts Several major concepts are important to understanding HRV in the context of biofeedback: heart structure and the nervous system, and time and frequency domains. Heart Structure and the Nervous System

The heartbeat is located in the sinoatrial (SA) node of the heart, where pacemaker cells work with the autonomic nervous system (ANS) to create the electrical impulses that allow the heart muscle to contract. The SA node generates impulses so that the heart will beat at a rate of 100 to 120 beats per minute (bpm). A healthy human does not have a resting heart rate of 100 to 120 bpm as the ANS adapts internal and external stimulus responses to adjust the heart rate to beat at around 60 to 90 bpm. The ANS comprises two subsystems—the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS)—which work to counteract each other. Typically, the SNS stimulates organs, such as the heart. Prolonged increases in the SNS can lead to a heart attack, stroke, and stress-related illnesses. The PNS, contrastingly, inhibits organ response. When activated, the PNS inhibits heart rate. A number of factors are associated with the regulation of the heart and the heartbeat, which include respiration, body temperature, blood pressure, and cardiac output. A number of the listed biological functions

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related to heartbeat are also used in conjunction with biofeedback. To effectively determine how HRV can affect an individual, it is important to understand how it is measured. Time and Frequency Domains

Two primary approaches, time domain and frequency domain, are used to understand and quantify the changes in HRV to provide a better understanding of both client health and disease. Time domain measures are the easiest to use but provide less detailed information. Time domain measures look at the normal heartbeat, thus excluding any abnormal beats. Simple descriptive statistics are then used to calculate a given interval between beats. Due to ease of calculation, it is the most widely used time index. Frequency domain measures look at the HRV at varying frequency ranges. These are typically divided into low, medium, and high frequencies, which correspond to certain physiological processes. Both frequency and time domain methods have advantages and disadvantages; however, one common disadvantage is their inability to measure abnormal beats, which requires removal of any heartbeat that is not considered a normal beat from being included in measurements.

Theoretical Underpinnings HRV is linked to the nervous system as well as respiration. The Nervous System and HRV

Heart rate in healthy individuals ranges from 60 to 90 bpm. Heart rate also includes the net effect of the PSN, which slows the rate the heart beats, and the SNS, which accelerates the heartbeat. The PSN affects the heart almost instantly, whereas it takes about 5 seconds for the SNS to begin to increase the heart rate and up to 30 seconds for it to reach its peak level. Therefore, rhythmic changes in heart rate reflect the complex interactions between both the PSN and the SNS. The physiological origins of HRV represent the activity of the cardiovascular system and the brain’s ability to control blood flow via constriction and dilation of the venal and arterial systems.

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Respiration and HRV

Research has determined that respiration can dramatically alter heart rate along with the R-R interval rate independent of the nervous system. The increase of lung volume increases HRV and reduction of lung volume reduces HRV. Therefore, the pacing of breath is critical to accurately interpreting HRV as well as creating potential longterm changes to the physiological system.

Therapeutic Process While the predominant use of HRV is primarily around the medical uses of HRV to predict death after myocardial infarction, it is also used in the counseling world as a biofeedback tool to address mental health issues. In the 1980s, Paul Leherer and others began to experiment with HRV as a clinical tool. Their basic premise was to use cardiorespiratory intervention, which consisted of feeding back to a client beat-bybeat data using slow-breathing techniques designed to maximize RSA. The ultimate goal was to match the RSA pattern to the HRV pattern. Today, HRV is an important piece of biofeedback. HRV as a subcomponent of biofeedback is used in counseling sessions to help clients learn to use the signals from their body to control their reactions to stress. This technique teaches clients to use their thoughts and will to control body responses. These techniques can be particularly useful for a variety of clients but should not be implemented unless a medical doctor has supported its therapeutic use in counseling. It is often appealing to the client population because it is noninvasive, it can provide an alternative or supplement to medication therapy, and it ultimately allows clients to have control of their health. Many clients are able to train their HRV and respiration in as little as one session, and they typically do not need more than six. HRV has many applications to address both physical and mental health and is growing in popularity as an assessment tool in medicine and as a mental health treatment tool in counseling. Continued research is necessary to increase our depth of understanding as well as provide greater insight into best practices for all. Julie A. Strentzsch

See also Bioenergetic Analysis; Biofeedback; Integrative Forgiveness Psychotherapy; Neurofeedback; Wellness Counseling

Further Readings Billman, G. (2011). Heart rate variability: A historical perspective. Frontiers in Physiology, 2(86), 1–13. doi:10.3389/fphys.2011.00086 Karim, N., Hasan, J. A., & Ali, S. S. (2011). Heart rate variability: A review. Journal of Basic and Applied Sciences, 7(1), 71–77. Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. doi:10.3389/fpsyg.2014.00756. eCollection 2014 Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. (1996). Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Circulation, 93, 1043–1065. doi:10.1161/01.CIR.93.5.1043

HEARTMATH Research has established that the heart and brain interact in a dynamic and complex relationship, with the heart capable of directly influencing the processes underlying emotional experiences and cognitive performance (which includes mental processes, e.g., learning, memory, thinking, and capacity of judgment). When practicing heart-centered, sustained positive emotions, more ordered information is flowing from the heart to the brain, creating increased mental clarity, improved cognitive functions, reduced stress, and other benefits. HeartMath focuses on the role of the heart in physical, emotional, and mental processes, as well as stress reduction and many other applications involving interactions between the heart and the brain.

Historical Context William James, a psychologist and philosopher, started the debate about the physiological nature of emotions in 1884 by stating that emotions arise from changes that occur in the body, which is then fed back to the brain and felt as a true emotion. In the 1920s, the experimental physiologist Walter Cannon asserted that emotions occurred within the

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brain during a “fight-or-flight response” to real or perceived threats. In more recent years, other notable researchers have demonstrated that both brain and body signals are necessary for a full experience of emotion and brain functionality. These neurological (nervous system) and hormonal influences shape how the heart and the brain interact.

Theoretical Underpinnings Psychophysiology, or the study of the physiological basis of mental processes, provides a theoretical lens for HeartMath research. This research has found that psychophysiological patterns, measured by beat-to-beat changes of the heart, change during stress and other emotional states. Specifically, natural changes in the heart rate, known as heart rate variability (HRV), are generated largely by the interaction between the heart and the brain via neural traffic that flows through the sympathetic (speeding up) and parasympathetic (slowing down) branches

of the autonomic nervous system (ANS). HRV thus reflects heart–brain interactions and ANS dynamics. In general, emotional stress, including emotions such as anger, frustration, and anxiety, leads to heart rhythm patterns that appear incoherent (lacking synchronized activity). This disharmony in the ANS can tax the nervous system and bodily organs and impede the flow of information throughout the psychophysiological systems. This in turn has negative consequences such as impaired cognitive functions and diminished ability to self-regulate emotions. In contrast, sustained positive emotions, such as appreciation, compassion, and love, generate a smooth, ordered, sine wave-like pattern in the heart’s rhythms. This reflects increased synchronization in higher level brain systems and in the activity occurring in the two branches of the ANS, as well as a shift in autonomic balance toward increased parasympathetic activity. Sustained positive emotions thus help to emotionally self-regulate better, improve cognitive function, and enhance well-being (see Figure 1).

Frustration

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Figure 1 Heart Rate Variability Pattern Source: R. McCraty, M. Atkinson, & D. Tomasino, Science of the Heart: Exploring the Role of the Heart in Human Performance, p. 18. Boulder Creek, CA: HeartMath Research Center, Institute of HeartMath (2001). Copyright 2001 by Sage Publications. Reprinted by permission. Note: The heart rate variability pattern shown in the top graph, characterized by its random, jerky form, is typical of feelings of anger or frustration. Sincere positive feeling states, like appreciation (bottom), can result in highly ordered and coherent HRV patterns, generally associated with enhanced cardiovascular function.

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Major Concepts A number of concepts are used in the HeartMath approach. Major concepts include heart breathing, heart feeling, coherence, and emotional selfregulation. The counselor helps the client learn to emotionally self-regulate and reach the desired state of coherence. Heart-Focused Breathing

In heart-focused breathing an individual focuses on deep breathing, typically consisting of six breaths per minute, or inhaling and exhaling as deep as comfortably possible. The purpose of the deep breathing is to help to induce coherence. Heart Feeling

Clients can learn to produce extended periods of physiological coherence by actively generating and sustaining positive feelings. Coherence

Coherence is used to describe a functional mode in which two or more of the body’s systems become entrained. For example, entrainment can  be observed between heart rhythms, blood pressure oscillations, and low-frequency brain rhythms. Coherence is the state when the heart, mind, and emotions are in energetic alignment and cooperation. Emotional Self-Regulation

Emotional self-regulation involves changing a learned negative emotional response into a more positive emotional response, which helps achieve coherence.

Techniques The Institute of HeartMath has developed many techniques for coherence building, with one of the more notable techniques being the Quick Coherence® Technique. The Quick Coherence Technique helps the practitioner to create a more coherent state, offering access to the heart’s intelligence by balancing thoughts and emotions to achieve a neutral state for clear thinking. It is a

powerful technique that connects the practitioner with the heart to help release stress, balance emotions, and improve health. Step 1: Heart Focus

Clients are asked to focus their attention on the area around their heart, in the center of their chest. If they prefer, they can place their hand over the center of their chest to help keep attention in the heart area. Step 2: Heart-Focused Breathing

Next, clients are asked to imagine that their breath is flowing in and out of their heart or chest area. They take slow, casual, deep breaths by inhaling for 5 seconds and exhaling for 5 seconds, or whatever is comfortable. Step 3: Activate a Positive Feeling

As clients maintain their heart focus and heart breathing, they are encouraged to activate a positive feeling, such as appreciation, or to recall an enjoyable occasion or special place and try to reexperience that feeling. Alternatively, they can focus on a calm, neutral feeling. Quick Coherence is especially useful when a client starts to feel a draining emotion, such as frustration, irritation, anxiety, or stress. Using Quick Coherence at the onset of less intense negative emotions can keep them from escalating into something worse. The technique is especially useful after an emotional blowup to bring oneself back into balance quickly.

Therapeutic Process The practice of coherence for the purpose of emotional self-regulation and changing a negative emotional response to a coherent response usually takes 4 to 6 weeks. Usually, one or more sessions are recommended with a counselor, who can guide the client with coherence practice. The role of the counselor is to instruct the client in heart-focused breathing and find ways to call on positive emotions, such as appreciation, gratitude, and love. However, the Quick Coherence method can also be self-taught. It is suggested to do a coherence

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practice at least twice a day, for 5 minutes (in the morning and evening), or whenever a stressful event happens. The practice is determined to be successful when the baseline HRV pattern shifts from incoherent to coherent. Guidance might be needed from the counselor to help the client identify and recall positive feelings. Rollin McCraty and Annette Deyhle See also Biofeedback; Cognitive-Behavioral Therapy; Coherence Therapy; Emotion-Focused Therapy; Heart Rate Variability

Further Readings McCraty, R., & Tomasino, D. (2006). Emotional stress, positive emotions, and psychophysiological coherence. In B. B. Arnetz & R. Ekman (Eds.), Stress in health and disease (pp. 342–365). Weinheim, Germany: Wiley-VCH. McCraty, R., Atkinson, M., & Tomasino, D. (2001). Science of the heart: Exploring the role of the heart in human performance. Boulder Creek, CA: HeartMath Research Center, Institute of HeartMath. McCraty, R., Atkinson, M., Tomasino, D., & Bradley, R. T. (2009). The coherent heart: Heart–brain interactions, psychophysiological coherence, and the emergence of system-wide order. Integral Review, 5(2), 10–115. McCraty, R., & Childre, D. (2010). Coherence: Bridging personal, social and global health. Alternative Therapies in Health and Medicine, 16(4), 10–24.

HELLERWORK Hellerwork, or Hellerwork Structural Integration, is a direct descendant of Rolfing, developed by Ida Rolf in the 1930s. Its founder, the first president of the Rolf Institute, NASA engineer Joseph Heller (1940– ), added his own take on body movement education and verbal dialogue, fostering awareness of emotional challenges to Rolf’s deep fascia connective tissue–oriented massage techniques. Hellerwork is intended to realign the body and counteract the ravages of gravity and physical and emotional stress. As a side effect of that realignment, changes occur in balance and overall health, including pain reduction, emotional changes, and

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improvement of biomechanical problems, such as back pain, gait dysfunction, and repetitive stress microtrauma injuries (e.g., carpal tunnel syndrome, etc.). Some research indicates improvement in childhood behavioral problems and autism. Heller refers to “growing people” rather than fixing problems.

Historical Context Heller was born in Poland in 1940 and came to America in his teens. He attended the California Institute of Technology and became a NASA aerospace engineer at the Jet Propulsion Laboratory in California. As an engineer, he worked directly with the interaction of structure and stress, which later translated into his humanistic processes awareness of body movement. During the transitional 1970s, he became interested in holistic, humanistic psychology, and human potential movements, wherein it is often assumed that the body, mind, and spirit are interwoven. Starting with bioenergetics and Gestalt therapy, he trained with luminaries of the period such as Buckminster Fuller, futurist; John Lilly, who developed the flotation tank and dolphin whisperer; Virginia Satir, family therapist and foundational modeling subject for neuro-linguistic programming; Judith Aston, a pioneer in work with body movement structural patterns; Carolyn Conger, energy worker; Brugh Joy, a physician pioneering in ideas of preventive medicine that were then new to Western consciousness; and Sidra Stone and Hal Stone, who developed energetic healing and the Gestalt-based Emotive Voice Dialogue Method. Heller’s 6 years studying with Rolf led to his leaving aerospace engineering and becoming in 1976 the first president of the Rolf Institute. Heller believed, as Rolf did, that emotions were stored in the body, especially the connective fascia. Poor body function or posture was a reflection of gravitational and other stored stresses and being reeducated to move and live more comfortably in a normal body would create a more healthy life both physically and emotionally. However, by 1978, Heller left the Rolf Institute to teach his own approach, incorporating more of Stone’s Emotive Voice Dialogue principles and his own ideas on movement, sometimes said to be

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influenced by the Alexander technique and yoga principles. By 1979, he had established the Hellerwork Institute in San Francisco, California, and his own residential resort practice and training facility in Mt. Shasta, California. Many people in the Hellerwork community point out that Heller’s theories about the effects of fascia and connective tissue on body, mind, and spirit have been substantiated by later research indicating that the fascia may be the source of the energy fields of the body, chi, and acupuncture meridians.

Theoretical Underpinnings Heller presupposes a “greater field in which we live, interact, and express ourselves.” He postulates that the context of Hellerwork is to “enhance the individual’s awareness of and relationships to that field” through a healing relationship between the client and the Hellerworker during an 11-part sequence of sessions that create more functional patterns in line with gravity (Heller & Hanson, 2005, p. 1). In Hellerwork and Rolfing, the focus is on the fascia, not the muscle, as is common in standard massage methods. Fascia is a layer of connective tissue that covers muscles and some body organs like a skin diver’s wet suit. If you have ever prepared meat to cook, you have probably noticed a translucent, glistening, clear substance that covered the meat’s surfaces and stretched like a web between the sections of meat when you separated them. That is fascia. Healthy fascia is lubricating and moist to facilitate movement of muscles and tissues within the body. Chronic stress of any kind, lack of activity, or physical trauma can cause the fascia to contract and knot up, with resulting loss of movement and pain, which then has a chain reaction effect on other areas of the body that depend on the problem area to function normally. Patterns of fascial contraction may also result from emotional trauma, which can then create restrictions on movement that dictate changes in activity and stimulate abnormal emotional and mental patterns of behavior in a negative spiral that further encourages the contracted fascia to become hard and stiff, creating habitual abnormal function. Rather than treating the symptoms (the pain or tension this work usually relieves), Hellerwork

intends to rebalance the whole body and create a more aligned state of well-being that Heller defines as “normal” or “average,” because the symptom or pain in one area is often an expression of misalignment and fascial contraction elsewhere in the body. Although Heller still used deep tissue massage in a series of sessions (a format sometimes called “the recipe” in Structural Integration circles), as in Rolfing, he added new movement education routines and homework between sessions and an active dialogue between the practitioner and the client to encourage faster health optimization and self- discovery. Heller found that physical realignment alone was not enough for the changes he sought. As he trained people in his techniques, Heller spoke of training not Hellerworkers but “growing people.” Heller called what his practitioners did “process dialogue,” perhaps to differentiate it from therapy, which would require licensure. Hellerwork is a unique branch of the legacy of Structural Integration. Simply put, Heller and Rolf both put emphasis on deep connective tissue work and taught that the functioning anatomical parts of the body were metaphors for our emotional lives, and vice versa. For instance, the arms can be used to draw people and things into our lives or push them away. An excessive emphasis toward or away in our interactions may require bodywork on the hands and arms. Similarly, we all need to stand on our own two feet, and if we have problems with that, lower body work may be needed. Heller’s viewing the body as an energetic process changed his perception of movement, and he enhanced the deep massage approach with different take-home exercises, including undulations and verbal dialogue, as taught initially by close friend Hal Stone and his wife at the Hellerwork Institute. Aging ingrains stress and trauma patterns in the body, shortening the connective tissues, which shortens and stiffens the body, as is commonly seen in human aging. Releasing the deep connective fascia with deep Rolfing-style massage counteracts this and other stresses. Movement education and home movement exercises refine the basic daily functions of sitting, standing, walking, and so on, in harmony with gravity to maintain and enhance the new normal established by Hellerwork. Verbal dialogue invites

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clients to discover the relationship between their bodies and their attitudes and emotions. This sets up a cycle whereby as clients take responsibility for their attitudes, their patterns of emotional and movement self-expression improve between sessions and even after the formal Hellerwork sessions are completed.

Major Concepts Although the major ideas of Hellerwork concerning connection between the mind, body, and spirit are discussed in the “Theoretical Underpinnings” section, there are also four Hellerwork foundational principles as expressed in the Client’s Handbook: • We recognize the existence of a greater field in which we live, interact and express. • Our purpose is to enhance the individual’s awareness of the relationship to that field. • Within the context of a healing relationship, we work with structure, psyche and movement to improve function and well-being. • Our process follows an ordered sequence organizing the body along the line of gravity to induce change towards a more functional pattern. (Heller & Hanson, 2005, p. 1)

Techniques The Hellerwork techniques are presented as a series of 11 sessions, which endeavor to release tension and stress by combining the following: Deep connective tissue massage, delivered in a multilayered series of sessions, as in Rolfing, with the goal of realigning the body and releasing chronic tension and stress Dialogue between the client and the Hellerworker to create awareness of emotional stresses that contribute to problems in the body and all aspects of life Movement education enhancing basic activities such as sitting and standing to maintain and enhance the changes between sessions and after formal work with the Hellerworker ceases Themes, which are the somatic, emotional, and developmental issues that correspond to the area of

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the body being worked on (Heller calls the attitudes and emotions that relate to each part of the body “themes” because over the years he and his students have observed areas of bodywork focus routinely eliciting specific issues and emotions from the client in a predictable order.) Breath and sound as a means of self-discovery

The first seven sessions may be seen as being about breaking up body adhesions and old thought patterns. The last four sessions then integrate the newly freed parts in an improved balance.

Therapeutic Process Hellerworkers begin with a standard progression of 11 sessions, each with a somewhat prescripted theme. They then approach the client through what they discover in the moment with the individual client’s body and dialogue. Often the client will arrive talking about the very issues that the session is designed to explore, because the sessions order reflects years of observation and experience with how the healing process typically flows. The first three sessions focus on the superficial “sleeve layer” of the body and connected themes related to childhood development issues of breathing, standing, walking, and reaching out. Typically, the first session includes history taking and photographs to initiate a process of recording the changes to come in the client’s body and posture. The goal at this time is to begin opening the connective tissue sleeve by releasing the fascia round the chest and thus releasing the rib cage and thoracic outlet to improve breath. The bigger picture is to balance the rib cage over the pelvis and legs. The theme of “inspiration” is addressed both as the intake of breath and an exploration of the definition of “inspiration” as the drawing in of spirit. How does the client do that in his or her life? Sessions 2 and 3 are about the client standing on his or her own two feet and reaching out. Sessions 4 through 7 deal with the client’s body core and fine motor muscle movement. Thematic issues of adolescence are addressed as control and surrender, the guts, holding back, and losing one’s head, with bodywork on the inner leg muscles, pelvis, head, and neck, encouraging lengthening of the back and aligning the head over the torso.

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The final four sessions address integrating everything and being a mature grown-up, wholeness and self-expression, and male and female life issues.

medication is also complementary to other therapies, such as mental health counseling, psychiatry, pharmaceuticals, acupuncture, meditation, massage, and so on.

Christopher J. Rogers

Historical Context See also Alexander Technique; Body-Oriented Therapies: Overview; Complementary and Alternative Approaches: Overview; Feldenkrais Method; OrthoBionomy; Reich, Wilhelm; Rolfing; Yoga Movement Therapy

Further Readings Alexander, J. (2001). Mind body spirit. London, England: Carlton Books. Bosser, A. (2008). Relieve stiffness and feel younger again with undulation. Issaquah, WA: Vital Self. Cowen, V. (2011). Therapeutic massage and bodywork for autism spectrum disorders: A guide for parents and caregivers. London, England: Singing Dragon. Heller, J., & Hanson, J. (2005). Hellerwork client’s handbook. Los Alamitos, CA: Hellerwork International. Retrieved from http://www.hellerwork .com/files/6313/9173/5260/heller.handbook.pdf Heller, J., & Henkin, W. (2004). Bodywise: An introduction to Hellerwork for regaining flexibility and well being. Berkeley, CA: North Atlantic Books. Schultz, R. L., & Feitis, R. (1996). The endless web: Fascial anatomy and physical reality. Berkeley, CA: North Atlantic Books. Vanderbilt, S. (2004, June/July). Hellerwork: Structural integration for mind, body and spirit. Massage & Bodywork. Retrieved from http://www.abmp.com/ members/login.php?article_id=684&sid=lnkpojf87rvd hp11ikgm0cs935

HERBAL MEDICINE Herbal medicine is the practice of using any part of a plant to heal illness and promote vitality. It is also known as herbalism and botanical medicine. Practitioners of herbal medicine are often referred to as herbalists. The majority of the world’s population rely on herbal medicines for some part of their health care. Herbalists typically emphasize a more natural approach to medicine and use a holistic view of a person’s health, treating the causes rather than the symptoms of illness. Herbal

Since before recorded history, people all over the world have used plants for medicine. The knowledge of medicinal plants has been passed down from generation to generation through verbal language, such as songs, stories, or rituals. Traditional Chinese Medicine (TCM) dates back more than 5,000 years. The first Materia Medica is believed to have been written in the 1st century CE and is credited with setting the example for all future herbals and pharmacopeia. In the early 19th century, when allopathic doctors were bloodletting, purging, and using mercury as conventional medicine, Samuel Hahnemann introduced homeopathic medicine. Currently, homeopathy is the only form of botanical medicine approved by the U.S. Food and Drug Administration. In the 19th century, Samuel Thomson founded modern herbalism in the United States, leading eventually to physio-medicalism, eclectic medicine, and naturopathy. In 1847, the American Medical Association was formed to promote allopathic medicine. The Flexner Report of 1910, a study of the state of medical education at the time, and numerous legislative changes of the early 20th century hampered the use of what was deemed alternative medicine. By 1939, all of the botanical and eclectic medical schools had been closed down. Even though allopathic medicine has been the primary system of medication promoted by medical doctors since 1939, on occasion allopathic medicine imitates herbal medicine. Specifically, allopathic medicine, typically through pharmaceutical companies, will use part of a plant in the formulation of a prescription. Other allopathic medicines created by pharmaceutical companies will synthetically imitate a part of a plant to induce a particular effect. However, herbalists use the actual plant, in part or in whole, to aid the client. This is because herbalists believe that while the effects of whole or part of plants can be wellknown, the complex interactions between chemicals within the plant are almost impossible to know.

Herbal Medicine

Theoretical Underpinnings Herbal medicines were used for thousands of years before being studied scientifically by modern standards. Most herbal medications are based on theories of TCM or physio-medicalism. Both theories focus on the balancing of the mind–body–spirit functions, resulting in equilibrium of chi (energy) in the body. All living things are thought to have energy. Most herbalists base their practices on the idea that when an individual is having health issues, it is because the person’s chi is out of balance. A practitioner of herbal medication considers the whole person when deciding which herbs to use. A herbalist also typically believes in vitalism, which refers to the life force believed to be present in all living things. Vitalism posits that the body has the innate ability to restore itself to balance if supported. Herbalists, especially those who support the Eastern traditional concept that a person’s chi is out of balance, play a significant role in restoring the balance of energy in the mind–body– spirit connection through herbs.

Major Concepts A number of concepts in herbal medicine are introduced here. Major concepts include cleansing herbs, restorative herbs, tonic herbs, sedative herbs, and stimulating herbs. Cleansing Herbs

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Stimulating Herbs

Stimulating herbs are helpful when an individual is in a sluggish state. Examples of stimulating herbs are coffee and ginger.

Techniques Herbs can be used in the form of teas, tinctures, syrups, salves, and powders; some herbs can be smoked. Herbal medicine can also be used in conjunction with complementary therapies to achieve a balance of mind–body–spirit in the client. Herbal Tea

Herbal tea consists of the herb of the herbalist’s choice combined with hot water to make a hot liquid for the client to drink. Herbal Tinctures

Herbal tinctures are herbal liquid mixtures. The herb is combined with a liquid such as distilled water, vinegar, glycerol, or alcohol (primarily vodka or rum, approximately 80–100 proof). Herbal Syrups

Herbal syrup is made by combining herbs with a thick liquid substance such as honey or molasses. Herbal Salves

These herbs cleanse an individual of unwanted energy. Herbs that cleanse a body include black walnut and fennel.

A herbal salve combines the herb with substances such as organic oil or beeswax.

Restorative Herbs

Herbal Powder

Restorative herbs bring helpful energy to an individual. Examples of restorative herbs are alfalfa and kelp.

Herbal powder can be used in a variety of ways. It can be used to smoke, inhale, or burn in incense, in order to reach the client’s chest or sinus passages. When the herb is combined with clay, baking soda, cornstarch, or some other type of powder, the mixture can be used as a body powder.

Tonic Herbs

Tonic herbs help build and nourish an individual. Examples of tonic herbs include chamomile and St. John’s Wort. Sedative Herbs

Sedative herbs are used when someone is distressed. Sedative herbs include catnip and thyme.

Smoking Herbs

Herbs can be smoked to allow the client to receive medicinal benefits. The individual can smoke the herb in rolling papers or in a pipe bowl, or the herb can be inhaled through a vaporizer.

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Herbal Medicine in Conjunction With Complementary Therapies

In herbal medicine, it is important to address the causes of the ailment rather than just addressing the symptoms. Sometimes, the medication used alone will not have the success it could have when combined with another therapy. If the cause of the ailment is emotional and the client is seeing a mental health counselor, it is possible that talk therapy may open up a pathway for the herbal medication to work. With the client’s written permission, such as an informed consent form, the herbalist and the mental health counselor can cooperate. However, it is not always necessary for the two professionals to talk for the two complementary therapies to work successfully together.

Therapeutic Process Time periods may vary when using herbal medicines to correct an imbalance in the mind–body– spirit connection. In some cases, such as indigestion, a herb may be used just once, and it can take action in minutes. In the case of systemic imbalance, herbs may be taken for several months until balance is achieved. When herbal medication is used in conjunction with a complementary therapy, such as mental health counseling or acupuncture, the healing time is ultimately dependent on the client’s needs. Herbs must be used cautiously, especially if the client is also taking pharmaceutical medications. Drug interactions between herbs and pharmaceuticals can affect the effectiveness of both medications, depending on which liver pathways are involved. In the United States, herbal supplements are not regulated in the same way as drugs, so the concentration of the various chemical constituents can vary. An expert herbalist will consult with definitive resources for drug and herb interactions to avoid possible risks of interaction and will carefully determine a safe dosage of the herb. However, if an individual ever has any questions about medicines of any type, that person should consult with a medical professional. The mental health professional can use herbs in talk therapy with the client once it is determined that the client is able to participate in herbal therapy without drug interaction effects. Herbalists believe that challenges with health occur because

of dysfunction and imbalances in the body. Thus, herbalists view those with mental health issues as having a physical imbalance rather than a disease, independent of other health concerns. The mental health professional who is open to a holistic approach will have herbal remedies available in session that are tailored to meet each individual client’s needs in order to address acute symptoms in session. There are innumerable ways in which herbal remedies can be used during a mental health counseling session, but only a few are listed here. One example is that if a client is experiencing anxiety during a session, the mental health professional can offer a cup of chamomile tea as a calming agent. For a client who is experiencing a panic attack in session, a combination of cherry plum, chestnut bud, impatiens, and agrimony essential oils can be utilized by the therapist, as each provides relief of the various symptoms related to emotions that trigger panic attacks. Finally, the essential oil scents of lavender and lemon can be used as mood elevators in sessions for those experiencing depressive symptoms. However, it is important that mental health professionals are aware of their states’ guidelines regarding herbal therapy and their ethical obligation to use evidence-based methods so that there are no legal or ethical violations when working outside a mental health professional’s scope of practice. Jacqueline Ciccio Parsons and Rebekah R. Pender See also Homeopathic Medicine and Counseling

Further Readings Fritchey, P. (2005). Practical herbalism, ordinary plants with extraordinary powers. Warsaw, IN: Whitman. Gao, D. (Ed.). (2013). Traditional Chinese medicine: The complete guide to acupressure, acupuncture, Chinese herbal medicine, food cures and qi gong. London, England: Carlton Books. Spinella, M. (2001). The psychopharmacology of herbal medicine: Plant drugs that alter mind, brain, and behavior. Cambridge: Massachusetts Institute of Technology. Wood, M. (2004). The practice of traditional Western herbalism, basic doctrine, energetics and classification. Berkeley, CA: North Atlantic Books.

Holding Therapy Wood, M. (2005). Vitalism: The history of herbalism, homeopathy and flower essences. Berkeley, CA: North Atlantic Books. Xue, C. C., & Li, C. G. (2003). Principles in designing traditional medicine education programs. Pacific Health Dialog, 10(2), 99–105.

HOLDING THERAPY Holding therapy (HT) is generally used to treat aggressive children and children with autism. HT utilizes techniques such as eye contact, therapeutic physical holding, psychodrama or reenactment, inner child metaphor, and cognitive restructuring. There is considerable controversy surrounding HT, with many psychologists, therapists, and related mental health professionals suggesting that it may not be an effective intervention and that it has potential for harm. HT has sketchy theoretical foundations, appears to misapply psychological principles, lacks empirical research and accompanying literature, and has been criticized as having the potential to cause harm to children. Although it shares some theoretical attributes with attachment therapy, it is considered a far cry from this more traditional and sensitive approach to working with children.

Historical Context Developed by the psychologist Robert Zaslow in 1966, HT was initially called rage reduction therapy. In the 1970s, Zaslow’s approach influenced Foster Cline, a well-known proponent of attachment therapy, at the Evergreen Clinic in Colorado, where the Evergreen Model of HT was practiced. In 1983, Nikolas Tinbergen wrote a book that claimed HT as a cure for autism, and in 1988, Martha Welch wrote a book, Holding Time, in which she also claimed that HT was a cure for autism. In addition, HT began to be used with abused or adopted children who were diagnosed with attachment disorder. Currently, HT is considered by most counseling and therapy professionals as unconventional and controversial. It is seen by many as inhumane, risky, possibly life threatening, and unethical. Research is limited, and the few studies available examined HT as

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part of the techniques used at facilities focused on attachment issues. Despite the lack of research and concerns about its practice, HT continues to have a following among practitioners who base the efficacy of their practice on anecdotal evidence. Today, when taking into consideration the substantial fears surrounding the ethics and effectiveness of HT, best clinical practices for aggressive children who are deemed to have an unhealthy attachment cycle ought to be based on the principles of trauma treatment and counselors and others should refrain from holding the child other than for the purpose of immediate safety of the child or others.

Theoretical Underpinnings Based on Zaslow’s rage reduction therapy as well as concepts drawn from traditional attachment theory, HT is grounded in a number of psychoanalytical concepts such as catharsis, regression, breaking down of resistance, and breaking down of defense mechanisms. The basic premise of HT is to restore an interrupted or frozen attachment cycle, which has occurred before birth, during infancy, or during early childhood, with a healthier attachment style. This approach believes that abusive and adverse caretaking results in the development of embedded anger, which is then projected onto current caretakers. In therapy, a child receives input from the therapist and a parent or caregiver through forced eye contact, enforced holding, and cognitive restructuring, which is more like strong suggestion or advice giving. HT proponents believe that these new parenting styles result in new attachment styles and decreased aggression.

Major Concepts The main concepts include attachment cycle, attachment disorder, eye contact, holding, and cognitive restructuring. Attachment Cycle

Attachment cycle is the bonding or affection that occurs prior to birth, during infancy, and in early childhood between a child and his or her parent or caretaker.

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Attachment Disorder

Attachment disorder is the resulting aggressive behaviors that a child has due to an interrupted or frozen attachment cycle. This occurs when children receive abusive parenting at a young age and this abusive parenting results in embedded anger, which becomes the child’s major style of relating to others.

ones through forced holding and eye contact and by reenacting past parenting. While restrained, the parent and the therapist will tell the child that he or she is loved and will hug, kiss, and reassure the child so as to replace the past, abusive parenting. Many HT therapists also encourage parents to do similar practices at home.

Holding

Psychodramatic Reenactment

With holding, the child’s hands and feet are generally restrained, and the child’s head is held in the therapist’s lap. Then, the parent is encouraged to reassure, control, comfort, and encourage the child to express himself or herself verbally and not to resist. This purportedly provides a safe place in which the child can release negative emotions and allows negative feelings to be replaced with positive ones.

Here, the child is encouraged to act out his or her past abusive situations to release the suppressed negative feelings, such as anger, fear, and feelings about his or her early life.

Eye Contact

Perhaps more accurately called “forced eye contact,” here the therapist holds the child’s head on his or her lap and forces the child to look at the therapist. Then, the therapist verbally instructs the child to stop resisting, look at the therapist, and admit that the therapist has control. Such control is seen as a step toward giving up past, dysfunctional ways of acting and taking on new ways of attachment with caretakers. Cognitive Restructuring

Cognitive restructuring is the replacement of negative thoughts and their resulting feelings with positive ones. In HT, this is conducted in a somewhat unconventional manner, as noted in the next section on techniques.

Techniques Some prominent HT intervention strategies include cognitive restructuring, psychodramatic reenactment, inner child metaphor, and therapeutic holding. Cognitive Restructuring

This process occurs when the child’s negative thoughts and resulting feelings from his or her unhealthy attachment cycle are replaced by positive

Inner Child Metaphor

This guided imagery and conversational technique allows the child to reenter early life experiences. The child may use a toy, such as a teddy bear, to symbolize his or her younger self. The child’s present self and younger self converse in an attempt to correct the past unhealthy attachment cycle and solidify new, positive feelings and behaviors. Therapeutic Holding

Therapeutic holding occurs when the therapist forcibly holds the child’s head on his or her lap while the child’s hands and feet are restrained. Then, the therapist and the parent encourage the child not to resist and offer reassurance and comfort to the child, all of which facilitates a reparenting process. It is assumed that eventually the child will make eye contact, stop resisting, give up his or her control, and take on new, positive patterns of relating. Bottle-Feeding

When a child’s behaviors reflect past early abusive attachment styles (e.g., hysterical crying, screaming, resisting), the parent will hold the child and bottle-feed him or her to offer new, positive parenting that can replace the abusive past parenting.

Therapeutic Process HT often takes place in a residential setting over a  2-week period, with sessions lasting as long as 3  hours. Initially, an assessment, with focused

Holotropic Breathwork

attention on early history, is conducted, followed by the signing of a contract to comply with the goals and techniques of treatment. During the early sessions, rapport building is focused on, and the child’s first years of life are reviewed. At this point, psychoeducation is offered concerning how the child’s early life has resulted in a negative attachment style, and the resulting cognitive schemas that drive that attachment style are highlighted. Rules, expected changes, and expected behavior are also explained. Around the third session, resistance at home and during the early sessions is examined. At this point, the child is encouraged to release suppressed negative feelings, such as anger, rage, and fear, that are the result of past, abusive parenting. These negative feelings are validated, and the child’s understanding of his or her relationships with early and current caregivers is identified. As the sessions continue, holding becomes increasingly employed as the child expresses feelings about his or her early life, and cognitive restructuring is begun to help change the child’s internal cognitive structures. During the sessions, the child may revert to infantile behavior, such as crying and screaming, and the parent may bottlefeed the child in an attempt to reparent the child in a positive manner. Such sessions continue with holding and forced eye contact, and reparenting occurs as the child begins to gain a new sense of who he or she is in relation to his or her current parents and lets go of the anger and rage that are the result of past parenting. Later sessions involve a review of all the previous sessions and the lessons learned. Follow-up meetings are scheduled, with the objective of assessing the home life after therapy and maintaining the progress attained during therapy. Wangui Gathua See also Attachment Theory and Attachment Therapies; Freudian Psychoanalysis; Rebirthing

Further Readings Crawford, S. (1986). Holding therapy. Adoption & Fostering, 10, 43–46. doi: 10.1177/030857598601000411 Meyeroff, R. (1999). Comparative effectiveness of holding therapy with aggressive children. Child Psychiatry and Human Development, 29, 303–313. doi:10.1023/A:1021349116429

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Pignotti, M., & Mercer, J. (2007). Holding therapy and dyadic developmental psychotherapy are not supported and acceptable social work interventions: A systematic research synthesis revisited. Research on Social Work Practice, 17, 513–519. doi:10.1177/1049731506297046

HOLOTROPIC BREATHWORK Holotropic breathwork, developed by Stanislav Grof and Christina Grof beginning in the 1970s, is a therapeutic practice that involves the combination of breathing technique and other elements that enable clients to access nontraditional states of consciousness. The therapy is typically done in group settings with dyads of “breathers” and “sitters” working side by side with other dyads, with the experience lasting 3 to 4 hours. Some practitioners have adopted techniques to be used with individual, shorter sessions.

Historical Context Stanislav Grof, the originator of holotropic breathwork, is a trained psychiatrist and psychoanalyst who has held appointments at The Johns Hopkins University, the University of Maryland, and the Esalen Institute. The term holotropic is a composite word that is derived from the Greek holos, meaning “whole” and trepein, meaning “moving toward or in the direction of something.” Grof’s interest in the use of hallucinogenics for preconscious access led to his looking for nonordinary states of consciousness similar to those experienced by novice shamans. He credits the methods used for years by healers, including the importance of the influence of breathing on consciousness, the traditional use of music in shamanic practice, and the use of therapeutic touch.

Theoretical Underpinnings Holotropic breathwork draws from Eastern spiritual teaching and practices that have accessed nonordinary states of consciousness for centuries. Grof gives modern attribution to the influence of Abraham Maslow’s spontaneous mystical experiences, Fritz Perls’s Gestalt therapy, Alexander Lowen’s bioenergetics, and the field of depth psychology.

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Major Concepts Some of the major concepts that help explain this approach are the following: facilitators, breathers, sitters, perinatal experience, and transpersonal experience. Facilitators

Facilitators are practitioners who coordinate and supervise the holotropic breathwork experience. Breathers

Breathers are active participants in the holotropic experience. Sitters

Sitters are present for breathers as caretakers throughout the holotropic experience. Sitters assist in creating a safe emotional and physical space for breathers, help pace breathing, take breathers to and from the bathroom, and provide water, Kleenex, blankets, or other basic care.

Bodywork

If bodywork is done as part of enhancing the induction, it is only with the permission of the breather and ceases when the breather so requests. Supportive physical contact by sitters is only done when requested or offered and accepted through a trained facilitator. Drumming, Music, and Relaxation

The holotropic breathwork method combines drumming, music, relaxation, and changes in breathing to induct special forms of awareness. Breathers are prepared for induction by combining rhythmic music with breathing, sensory, and social isolation (by wrapping the body in blankets and obstructing light with an eye mask). Sharing the breathwork experience simultaneously in a group setting intensifies the experiential field. The setting requires conditions that allow for loud music and the freedom for breathers to express without self-conscious concerns. At the end of the session, participants can express resolution through the drawing of a mandala (a graphic symbol representing wholeness and universality).

Perinatal Experience

Perinatal experience refers to a belief that people, through holotropic breathwork, experience and recall birth trauma that leaves a psychic residue. Transpersonal Experience

A transpersonal experience is the intentional access of material that is outside the normal expression of human consciousness. Transpersonal experiences include a sense of universal oneness, past life memories, communicating with animal spirits, and alignment with the collective unconscious.

Techniques Some of the major techniques used in holotropic breathwork are intensified breathing, bodywork, and drumming, music, and relaxation. Intensified Breathing

Intensified breathing is the practice of mindfulness breathing, which is breathing faster and more effectively with focus on inner process.

Therapeutic Process Participants are screened and educated before they partake in a holotropic breathwork experience. This includes explaining nontraditional states of consciousness, perinatal and transpersonal domains, and the importance of trust in the process. Physical and emotional contraindications for participation in holotropic breathwork include cardiovascular disorders, pregnancy, epilepsy, immediate physical injuries, and contagious diseases. Breathwork can release repressed emotions and residual problems that can arise from the release. Those with particularly risky psychological states can benefit from breathwork, but special conditions may need to be arranged in case of a dissociative reaction. Because of the special situations and interventions, holotropic breathwork should not be performed by an untrained practitioner. During the breathwork experience, breathers lie on a soft surface such as a sleeping bag or yoga mat. The session begins with the breather in a reclined, comfortable position and with music suitable for aiding in smooth deep breathing playing.

Homeopathic Medicine and Counseling

The intent of the music is not to program the breather’s experiences but to respond to the phase of the breather’s experience at that time. It is recommended that the music have a steady rhythm with constant intensity and without jarring or dissonant breaks. The music should be programmed without lapses between pieces. Generally, vocal music is avoided, particularly if it is in a recognizable language, as it could suggest a particular reasoning for the breather. The breathwork session has a complete pattern for the music: initiating with dynamic, uplifting, and emotionally reassuring works, culminating in “peak” or “breakthrough” music (sacred music or powerful orchestral pieces), resolving to uplifting and emotional “heart music,” and ending in music that is meditative in tone. Physical manifestations that occur during holotropic breathwork are seen as manifestations of emotional or physical stress. Grof points to two methods of releasing such tensions during breathwork: (1) abreaction or catharsis and (2) muscular tensions. Abreaction or catharsis can include crying, screaming, coughing, twitches, tremors, and vomiting. Muscular tensions can include contractions of varying durations, similar to isotonic and isometric exercise. The breather is asked to focus attention on the area of greatest concern and even to intensify the sensations. Assistance from the facilitator and/or the sitter can help intensify these experiences. Breathers may find themselves having tremors, jolts, or coughing. They may enact with various physical movements of expression (climbing, crawling, flying, etc.) or by vocalizing in gibberish, baby talk, or animalistic sounds. The benefit of the session is not in relation to the depth and amount of repressed or unconscious material that is exposed but lies in the degree to which the material is reflected on and integrated after the experience. There is a need to ease the breather back into everyday life. This may include the facilitator conducting follow-up interviews with the participants. Continued work through the experience can be done using Gestalt work, psychodrama, psychomotor work, and Eye Movement Desensitization and Reprocessing therapy. Marty Jencius See also Breathwork in Contemplative Psychotherapy; Gestalt Therapy; Maslow, Abraham; Psychodrama; Regression Therapy; Therapeutic Touch

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Further Readings Grof, S. (2012). Healing our deepest wounds: The holotropic paradigm shift. Newcastle, WA: Stream of Experience Productions. Grof, S., & Bennett, H. Z. (1992). The holotropic mind: The three levels of human consciousness and how they shape our lives. San Francisco, CA: Harper San Francisco. Grof, S., & Grof, C. (2010). Holotropic breathwork: A new approach to self-exploration and therapy. Albany: State University of New York Press.

HOMEOPATHIC MEDICINE COUNSELING

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Homeopathic medicine is the practice of treating a disease by using minute amounts of a substance that in larger amounts would produce symptoms of the disease. This concept is often simplified to the Law of Similars, which proposes that like cures like—a substance that causes similar symptoms can be used to negate disease. This system of medicine is practiced widely throughout the world and is resurging in countries where allopathy has been the predominant form of medicine. In the United States, homeopathy is mostly used as a form of complementary or alternative medicine (CAM)—mainly to supplement allopathic medicine. More than one third of Americans consistently use CAM for mental health issues, most frequently for anxiety, depression, and pain management. Most of them (approximately 20% of Americans) use homeopathy or herbal medicine for mental health issues. According to patients, the chief advantages of seeking treatment from a homeopathic physician are empathy, accessibility, and a holistic approach.

Historical Context Hippocrates first proposed the Law of Similia, the idea that a similar substance can cure a similar illness. In the 1840s, Samuel Hahnemann introduced homeopathy in his book The Organon of the Medical Art. This book not only provides extensive guidance on the treatment of mental illnesses but also emphasizes that the body, mind, and spirit are interconnected.

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Theoretical Underpinnings Hahnemann believed that the structure, not the composition, of the chemical is most important in determining clinical efficacy. Homeopathy is a holistic approach, simultaneously addressing the needs of the body, mind, and spirit.

Major Concepts Major concepts of homeopathy include potentization, the Law of Similars, the Law of Simplex, vital force, and holism.

always better than administering a combination of treatments, or a “cocktail.” Vital Force

The spiritual aspect of a person is often called the vital force. If the vital force is unbalanced or weak, disease is inevitable. Studies have shown that a well-trained homeopath can evaluate the vital force in a patient and can use this knowledge to treat the patient better. Holism

Potentization

Potentization is the repeated dilution of a chemical until only the slightest traces of the original substance are left, accompanied by succession— repeatedly striking the container of medicine against an elastic object, such as a book. This is believed to change the structural properties of the drug. The theory suggests that the lower the dose of a substance, the less toxic it becomes. This is sometimes expressed as the principle of minimum dose, which states that the more a substance is diluted, the greater its effect will be. Because the original substance changes the structure of the molecules around it, it may even be possible to remove the original substance entirely.

Holism posits that a person must be treated in his or her entirety, considering not just the person’s physical state but also emotional and spiritual factors.

Techniques Although many of the study results are controversial, limited evidence may support the use of homeopathy with panic disorders, social phobias, depression, headaches, and anxiety. Regardless of the actual efficacy of these treatments, knowledge of homeopathic medicine principles can be helpful for mental health professionals.

The Law of Similars

Prescribing

The Law of Similars, often summarized as “Like cures like,” proposes that if a substance produces toxic disease symptoms when administered to a healthy person, the same substance can cure disease if administered in tiny doses to an ill person. The idea is that nature will not allow two similar diseases to exist simultaneously in the body. One example of this is the use of belladonna from the deadly nightshade plant. Belladonna can cause a healthy person to experience symptoms very closely mimicking the symptoms of scarlet fever, but when administered in extremely small quantities to a person diagnosed with scarlet fever, it has been shown to cure the disease.

Many practitioners prescribe homeopathic cures; for example, British physicians prescribe either homeopathy or acupuncture for about 40% of their cases. But practitioners who do not prescribe homeopathic remedies should be knowledgeable about them because many of their patients may be self-medicating. In general, homeopathic medications are so diluted that interactions are unlikely. But patients may confuse homeopathic cures with herbal ones, which may interact adversely with conventional drugs.

The Law of Simplex

The Law of Simplex states that there is one single best cure for a disease and a single cure is

Providing Feedback to Prescribers

Mental health professionals who do not have prescribing privileges can provide ongoing feedback to the prescriber if they are knowledgeable about the effects, side effects, and interactions of these and other medications.

Horney, Karen

Monitoring Patient Self-Medication

Most of the world’s population treat themselves, usually with some form of traditional medicine. The use of these practices in the West is increasing. Most use of homeopathy in the United States is outside of a provider’s prescription; as many as two thirds of Americans with depression or anxiety use CAM, mostly homeopathy and herbalism.

Therapeutic Process Every individual and each situation are different, but some homeopathic practitioners use the 1:10 rule, which states that a treatment regimen usually lasts about 1/10 as long as the duration of the disease preceding it. Therefore, a headache that has lasted for 2 hours (120 minutes) might respond in about 12 minutes, whereas an anxiety condition that has persisted for 10 years could take a full year to rebalance. Jacqueline Ciccio Parsons See also Complementary and Alternative Approaches: Overview; Herbal Medicine

Further Readings Adler, U. C., Krüger, S., Teut, M., Lüdtke, R., Bartsch, I., Schützler, L., . . . Witt, C. M. (2011). Homeopathy for depression–DEP-HOM: Study protocol for a randomized, partially double-blind, placebo controlled, four armed study. Trials, 12(1), 43–49. doi:10.1186/1745-6215-12-43 Bell, I. R., Lewis, D. A., II, Lewis, S. E., Brooks, A. J., Schwartz, G. E., & Baldwin, C. M. (2004). Strength of vital force in classical homeopathy: Bio-psycho-socialspiritual correlates within a complex systems context. Journal of Alternative & Complementary Medicine, 10(1), 123–131. doi:10.1089/107555304322849048 White, K. P. (2009). What psychologists should know about homeopathy, nutrition, and botanical medicine. Professional Psychology: Research & Practice, 40(6), 633–640. doi:10.1037/a0016051

HORNEY, KAREN As one of the second generation of psychoanalysts following Sigmund Freud (1856–1939), Karen Horney (1885–1952) is acknowledged as the first feminist in the field of psychoanalysis. She was a

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founding member of the Berlin Psychoanalytic Institute, where she actively trained and taught. But during her lifetime, very few of her early colleagues in Berlin or Vienna anticipated the profound paradigm shift in the theory of psychodynamic treatment she was about to create in the decades following her pivotal move to the United States in 1932. Horney began her clinical practice in Berlin in 1910, and by 1924, she was writing extensively on the limitations of Freud’s instinct-driven theory of psychoanalysis, especially as applied to women. After her immigration to the United States, she made contact with sociologists, anthropologists, and philosophers of her day and was especially close to Margaret Mead, Ruth Benedict, Harold Lasswell, Abram Kardiner, Erich Fromm, and John Dollard. Learning that psychoanalysis cannot be divorced from the society in which one lives, Horney absorbed sociocultural understanding into her psychoanalytical framework. This led to her first major work in 1937, The Neurotic Personality of Our Time, a critique of Freud’s commitment to a 19th-century philosophy of knowledge where behavior was fundamentally attributed to the discharge of psychosexual energy. This was her first challenge to the idea of the universality of Freud’s assumptions. Horney’s cultural critique convinced her that no amount of amending Freud’s theories at the margins was going to be effective in rescuing psychoanalytic therapy from a culture-bound posture leading to a closed system of thinking. Within 2 years, she presented the field with a comprehensive review of every aspect of the closed superstructure Freud had imposed on his great discovery of free association. Her 1939 text, New Ways in Psychoanalysis, acknowledged the indisputable importance of Freud’s work but also questioned libido theory and, therefore, Freud’s entire theory of instincts, which proved to be a most difficult historic moment for both theorists and practitioners of existing orthodox psychoanalysis. Having deeply immersed herself for nearly three decades in assessing the clinical usefulness of Freud’s theoretical structures, Horney was now prepared to offer her own genuinely original formulations of psychoanalysis and psychoanalytical treatment. She called her approach “a constructive theory of neurosis” to highlight differences from Freud’s essentially pessimistic view of instincts

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and civilization as pitched in endless war with each other. In her view, emotional distress is not instinct driven but is the result of conflicting and compulsive characterological trends in the personality, developed as an attempt to find safety from anxiety, vulnerability, shame, and self-hate. Healthy, genuine needs give way to compulsive drives that by their nature create “vicious circles of unattainable goals.” These splits are unintegrated and thus render the patient fragile and vulnerable. Describing both interpersonal and intrapsychic dynamics, Horney carved out three prominent narcissistic constellations, each with its own transference and countertransference implications. In her 1945 book Our Inner Conflicts, she initially described the movements toward, against, and away, vis-à-vis the other, as compulsive character trends; later, she referred to them as compulsive character solutions with the corresponding intrapsychic dynamics of compliance, dominance, and detachment, respectively. No less crucial is Horney’s change in the focus of psychoanalysis from the instinctual conflicts of the past to the immediately present cutting edge of character conflict. The emerging dynamic becomes framed in the experiential here-and-now. The psychodynamics of this theoretical change in how to treat inner conflict, coupled with the importance of the practitioner’s involvement in the patient’s phenomenological present, is richly formulated in her 1950 book Neurosis and Human Growth: The Struggle Toward Self-Realization. The work, which some say is Horney’s magnum opus, was the culmination of her efforts to describe human pathology in the context of human possibility. Horney was an experience-near theorist committed to careful listening to the immediate narrative. The posture, therefore, emphasizes a moment-to-moment immersion in the phenomenological world of each client. As the analytic therapist focuses on the dynamic present, dissociative states representing disconnected characterological structures come more clearly into focus, and with that, the characterological present becomes more relevant than the historical past. As the treatment proceeds, the therapist and eventually the patient become witnesses to the cutting edge of conflict created by split-off parts of the personality. In the midst of these conflicts, it is incumbent on the therapist to maintain an

empathic, introspective, and subjective attunement to the process as it unfolds. Immersion in the phenomenological present creates an evolution in language away from constructs such as ego, guilt, and objectivity toward the more experience-near language of self, shame, and subjectivity. With these metapsychological changes, Horney anticipated contemporary theories of selfpsychology, intersubjectivity, and relational schools of thought. She opened up the complex and often painful interplay between the authentic self, the overidealized self, and the self-hating self. The mechanisms that have come to the fore in this paradigm shift are those of disavowal, splitting, dissociation, and fragmentation. In addition to anxiety, panic, and depression, Horney brought into the center of treatment specific characterological issues such as diffuse selfdissatisfaction, identity, loneliness, confusion, and lack of direction, and a range of addictive disorders. Many of these narcissistic disturbances have become endemic in contemporary life and are now a major focus of treatment. In the psychodynamics she chose to emphasize, Horney anticipated much of contemporary theorizing, although her prescience (for the historical reasons cited) has been decidedly underacknowledged. As the phenomenological perspective progressively draws a patient into subjectivity and self, it inevitably draws him or her into shame itself. Shame can go by many different names—discomfort, awkwardness, embarrassment, ridicule, stigmatization, loss of face, humiliation. Each term forms a useful continuum for the therapist to help approximate a patient’s subjective moment. Shame is an emotion that often cannot be frontally identified, or often even named. As suggested, shame is inhibited by even subtle objectified postures by the therapist. Objectification blocks access to shame because it creates the threat of distance. Conversely, subjective immersion is the gateway through which a patient’s shame can reveal itself. As the therapy proceeds and as greater levels of deeper attunement become possible, the patient will increase the growing intensity of self-expression. What started out as a feeling of awkwardness, for example, may step by step enter into issues of embarrassment, disrespect, hurt, and humiliation. The therapeutic posture Horney emphasized was finding the past in the present rather than the

Human Validation Process Model

present in the past. This change in posture brought many dimensions of psychic conflict into bold relief. She saw disavowed, dissociated, or unacknowledged shame as connecting the damaged self to the real self, maintaining that symptoms were a means of staying safe and keeping hope alive. Again, this was placing human pathology squarely in the context of human potentiality. Both Horney’s clinical theory and her clinical posture placed her remarkably close to contemporary work with patients with trauma histories and their attendant characterological disturbances. The spectrum of trauma is seen as extending from any rupture in empathic attunement from childhood all the way to grave physical or sexual abuse in childhood or adulthood. On the other hand, incorporating trauma into classical theory has been difficult. Classical theory, as a model based on instinctual drive, gives insufficient attention to relational attunement and cultural bias; thus, theorists and clinicians have found it difficult to find a “rightful place” for trauma and its attendant feelings in Freudian dynamics. Since Horney emancipated psychoanalytical psychology from its cultural restraints, the field has grown enormously. The paradigm shift has led to an explosion of theoretical and clinical work by many, stressing some of the most vital issues of our day. Each of these innovative works has left behind an outdated, objectified view of psychoanalysis and contributed to a subjectively vibrant fusion of science and humanism. Jack Danielian See also Cyclical Psychodynamics; Experiential Psychotherapy; Feminist Psychoanalytic Therapy; Intersubjective Group Psychotherapy; Phenomenological Therapy; Self Psychology

Further Readings Danielian, J., & Gianotti, P. (2012). Listening with purpose: Entry points into shame and narcissistic vulnerability. New York, NY: Jason Aronson. Horney, K. (1937). The neurotic personality of our time. New York, NY: W. W. Norton. Horney, K. (1939). New ways in psychoanalysis. New York, NY: W. W. Norton. Horney, K. (1945). Our inner conflicts: A constructive theory of neurosis. New York, NY: W. W. Norton.

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Horney, K. (1950). Neurosis and human growth: The struggle toward self-realization. New York, NY: W. W. Norton. Paris, B. J. (1994). Karen Horney: A psychoanalyst’s search for self-understanding. New Haven, CT: Yale University Press. Quinn, S. (1987). A mind of her own: The life of Karen Horney. New York, NY: Summit.

HUMAN VALIDATION PROCESS MODEL The human validation process (HVP) model is a systemic therapy approach that focuses on family growth and health rather than dysfunction and pathology. This approach facilitates the use of existing strengths and resources within each family member and also considers the role played by the community and other larger systems in the family’s development and growth through time. Change is not only considered possible, it is encouraged. Therapists working from this theory focus on the process of interpersonal interactions, body language, and other nonverbal cues, as well as the content of conversation between family members. The HVP model emphasizes the roles of selfesteem and communication in influencing family functioning. Family life-fact chronologies are considered in the family dynamic, and therapeutic work often explores and includes at least three generations when possible. Hallmarks of this theory include the use of self-disclosure, therapeutic risk taking, touch, nurturance, and personal congruence.

Historical Context Virginia Satir was an important figure of the era of experiential therapy, and she developed this systemic model by focusing on the process of communication between family members, known as the interpersonal process. First developed in the 1950s, the model was developed early in the humanistic counseling movement, a time when various therapy models were being expanded to address family complexity while upholding the strong belief in human potential. In 1951, Satir began a private practice in Chicago, Illinois, where she first began to develop her theoretical approach.

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Later, she joined a group of forward-thinking, systemic-minded practitioners who formulated an interactive style of addressing the needs of the entire family. She became a cofounder of this group of experiential therapists, known as the Mental Research Institute, in Palo Alto, California. Soon after this time in her career, Satir became involved with the Esalen Institute, where she further explored ways of connecting with clients on a deeply personal level. Following her intuition and further developing the concepts of understanding, compassion, and empowerment toward authenticity, the HVP theory was established. The HVP model, as we know it today, draws from a wide range of theoretical concepts centered on the inherent goodness and tendency toward growth and self-worth in people who are part of families that are interconnected through the generations. The model’s style and concepts are borrowed from theories that encourage healthy communication, building selfesteem, and drawing out an authentic expression of the whole self, such as person-centered theory, Gestalt therapy, Jungian personality theory, transactional analysis, and psychodrama. Originally called conjoint family therapy, this model initially focused on communication patterns and building self-esteem. Satir encouraged authentic expression of concerns and emotions by requesting direct, open communication from her clients. As she had noticed them since she was a young child, Satir began wondering more about the relationships between family members, observing changes in communication style when family members interacted with one another. Before long, Satir came to view symptoms as an expression not of one person in the family but of the entire family as an interrelated system. Symptoms were seen as the family needing a new way to grow and thrive. In her approach, she believed it essential to validate each individual’s perspective, particularly the family member identified as having the most problems. The model called on each family member to take personal responsibility toward his or her own part of the system. Historically, this model held similar notions of the balance between individuation and connectedness as Bowenian theory but used a more compassionate and personally engaging approach through physical movement and experiential engagement among family members in concert

with the counselor. Following the “here-and-now” philosophy of existential work, HVP called on family therapists to focus less on techniques and more on personal connection. Through modeling congruence and unconditional positive regard, this model called on counselors to provide a warm and collaborative atmosphere of acceptance to facilitate each person’s expression of emotions. Counselors utilizing this model extend understanding of family dynamics and shape interactions within sessions in a spontaneous, playful, and engaging way. A large part of the power of this approach resides in the shift from pure talk therapy toward a more interactive, kinetic way of connecting with the family through movement, touch, and personal connection that demonstrates the interconnected nature of the system as a whole. This model has also been referred to as process therapy, the humanisticexperiential model, communication/validation family therapy, and the growth model.

Theoretical Underpinnings Underlying this approach is a focus on a systemic understanding of the family and belief in the potential of the person and the family. A Systemic Focus

This theory is rooted in a systemic approach to counseling, which sees the interconnectedness of family members in the family system. Within this system, growth can be facilitated if individuals understand self and others and how the communication patterns that are developed within the family affect the family dynamics. Within the family system, subjective perceptions make up family reality, and these perceptions can act as barriers to healthy growth when they are unrealistic, rigid, or otherwise limiting. Because perceptions are related to how one communicates, one goal of this approach is to develop clear and authentic communication patterns. The model also explores spoken and unspoken rules and the different methods of connection that exist between and among family members. Rules define how and when family members communicate and are the basis for how the family acts as a system while indicating the reasons why a particular family member may have become the symptom bearer. This family member’s

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personal struggle is often evidenced through a low sense of self-worth. Human Potential

The HVP model is rooted in the belief in human potential, the ability of people to change and grow, and the importance for all individuals to authentically express themselves. Wellness, wholeness, and balance are explicit aims of this theoretical approach, and change and growth are viewed in the context of biological and environmental factors and their reciprocal and circular influence on each other. Personal accountability is fostered, and family health and wellness arise from a balance between individual expression and finding a sense of bonding and peace between, within, and among family members. The goals of the therapeutic process are focused on the encouragement of growth and health rather than on the relief of sickness and dysfunction. Much emphasis is placed on interpersonal connection and its role in the expression of feelings and the exploration of meaning. The goal of therapy from this perspective is not to change an individual but to shift the family environment to one of acceptance and connection. This model outlines eight facets of potential that are seen as inherent in every human being: the physical, intellectual, emotional or intuitive, sensual, interactional, contextual, nutritional, and spiritual components of living, growing, and functioning. Expectations, roles, and values play a large part in how the family organizes and makes meaning from life experiences. Within the HVP model, unrealistic expectations can constrain one’s natural resourcefulness and full potential, thereby leading to defensiveness and symptomatic behavior.

Major Concepts Major concepts of HPV include how the family communicates, the function of symptoms in the family, the rules that families maintain, and the self-esteem and self-worth of the family members and the family as a whole. Communication

HVP therapists work to affirm and validate individual self-expression through healthy

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communication. Early on, Satir noticed that high self-esteem is related to effective communication, yet communication, in turn, influences the development of self-esteem as a reciprocal foundation of mental health. Emotional suppression is seen as a barrier to self-expression and communication and is thereby discouraged within the family system. Family systems can support the growth of individual members when they experience clear, consistent communication and model personal congruence. This model views communication as occurring implicitly and explicitly and affecting self-esteem. As the family members improve their communication skills, they experience more genuine, positive connections with one another, and individual self-worth and self-esteem are increased. Five communication styles are identified within this theoretical framework: (1) the blamer, (2) the computer or super reasonable one, (3) the distractor or irrelevant one, (4) the placater, and (5) the leveler or congruent communicator. This model assumes that each family member leans toward one of the first four styles when under stress and coping with transition. Congruent communication, the fifth style, is considered optimal and is seen as a desirable state of communication in which a person is able to communicate or reflect emotions and thoughts that match each family member’s internal states or beliefs. Function of Symptoms

Through the eyes of the HVP family counselor, symptoms indicate a “blockage of growth” in the family and serve a purpose in that they hold a survival function for the system. As the family dynamics have unfolded through time, the symptom bearer is seen as the family member who holds the pain, loss, and stress for the family. When families first arrive for counseling, the symptom bearer can usually be recognized as the one in the family whom most of the family members deem to be causing the most problems or drawing the most attention. The process that the family uses to transfer symptoms to the symptom bearer is seen as preventing the family’s ability to adapt and develop in a healthy direction despite life’s challenges. One goal of HVP is to help families understand how the symptom bearer is carrying pain for the family rather than being the one who is “ill.”

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Family Rules

Rules to maintain order within family systems are seen as important, but they must be few, reasonable, flexible, relevant, and consistently enforced. Exploring and defining these rules and how communication styles maintain these rules are a frequent focus of HVP intervention. Communication rules, when healthy, promote agreement of healthy functioning between family members by providing clear expectations and flexibility to respond to life’s challenges and stressors when necessary. Self-Esteem and Self-Worth

Self-esteem and self-worth, for both individuals and the family unit, are seen as central to healthy family growth. Identifying patterns within the family, based on communication style and self-worth, defines whether the family is an open or closed system, and this exploration serves as an important emphasis of the therapeutic process. An open system shows that members hold a high sense of selfworth, communicate clearly, and follow overt and adaptable rules. Closed systems indicate that family members have a low sense of self-worth, communicate indirectly, follow covert rules or adjust their needs toward old rules that may no longer apply to current situations, and convey chaos and disorganization.

Techniques While this model proposes concepts for addressing and facilitating systemic change, its primary emphasis promotes change through personal connection and engagement among the family members and the counselor in a fluid exchange. Some of the techniques, or methods of engagement with the family, include family sculpting, family reconstruction, reframing, owning responsibility, the use of metaphor, the use of humor, personal touch, and personal reflection.

sculpture to explore and draw out perceptions, unexpressed emotions, and blocks to growth for the family. Family Reconstruction

Family reconstruction occurs during psychodrama enactments during which the “star” (the family member who is, for the moment, the center of attention) is asked to reconstruct the family’s significant events, including the parents’ family history, the story of the parents’ relationship from the beginning to now, and the birth of children to the parents, with particular attention to the star’s birth. These enactments might include acting out daily family drama scenes and holding personality “parts parties,” creating nurturing triads through contact, and facilitating family mapping of events and important emotional points of pain for the family through time. Reframing

The counselor utilizes this method of adjusting communication to reset the expectations of a particular perception by placing a positive view or “frame” on a statement or issue. For instance, a child who is not talking much may be reframed as the “reflective person” in the family. Reframing can also serve as a method of redirecting the focus in the room and can help shift the family’s energy from trying to change the symptom bearer toward a balanced perspective coming from the other family members. Owning Responsibility

To enhance personal responsibility for each person’s own growth and to stand behind their own perceptions, the family members are asked to use “I” statements. An example would be to encourage a family member to say, “I feel sad when you do not acknowledge my feelings.” This form of communication promotes self-efficacy and requests personal responsibility for each family member’s part in the interaction while reducing blame.

Family Sculpting

In this process, each family member takes a turn creating his or her “sculpture” of the family by moving each family member into various body and stance positions to capture the family dynamics in still-life fashion. Then, the counselor examines this

Metaphor

Both the therapist and the family members are asked to describe the family interactions and their views of what is happening in terms of symbols that represent relationship interactional patterns.

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Humor

This method, often used to alleviate stress in the family, allows for connection through fun, playful, or humorous “notice” moments from the counselor to illuminate family interactions, distances, or connections, to join with the family and disengage tension so that the family is ready for therapeutic work. Personal Touch

In this technique, the counselor hugs, gently touches, or holds the person in a deep moment of pain in an effort to connect with family members and to join family members together as a primary form of validation. This gesture serves to honor each family member’s experience, reinforce a therapeutic intervention, and foster a nurturing, supportive connection. This method can also help lower defenses and blocks to communication. Personal Reflection

Moments of personal reflection are when a family member intentionally reflects on self and decides to self-disclose to others in an attempt to make a deeper, more meaningful connection with that family member. These are courageous moments as the family members decide to try a more honest and real way of reflecting on their experiences and connecting with one another, putting away their own old defenses and fears of not being accepted by one another.

Therapeutic Process The HVP model focuses on the process of growth and eliciting change through a series of phases that can be circular and experienced as the family becomes better able to embrace change and respond to life circumstances in a more adaptable way. These phases also reflect the goals of the model’s outcome. Forming Deep Connection

The first, most vital essence of conducting the therapeutic process calls on the HVP family counselor to create a deep, personal connection from the counselor’s own inner spirit to each family member’s inner spirit as a method of building trust

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through a strong therapeutic alliance. Paying close attention to the content and tone of each family member’s communication of thought and emotion, the HVP counselor also focuses intently on the family member’s facial expression and body language as a way to connect with that person and note his or her style of expression. Through this intentional focus with each person, the HVP counselor notes strengths and signs of inner resources for the potential for growth. Also, family members’ potential blocks to this growth are identified to begin modeling and conducting the facilitation of congruence and clear communication. This careful attention is given to effectively draw out each family member’s honest perceptions through a caring and compassionate tone of voice and accepting presence. Raising Awareness

The next phase elicits change by moving toward asking more specific questions to clarify meaning, to call for honest expression, and to establish a new sense of personal awareness regarding authentic experiences for both the individuals and the family as a whole. This phase is conducted through the use of clarifying questions and the previously noted techniques. Building Understanding

This level of facilitating change brings about new awareness in a way that brings deeper meaning for the family and helps adjust trends in the family’s general thinking and responsiveness toward stress or pain. This method helps the family shift away from the content toward the process by which the family members communicate and respond to one another. Promoting Acceptance

Through this phase of facilitating change, the counselor promotes both self and other acceptance to celebrate each family member’s unique contribution of cherished personal strengths to the family’s adaptability and cohesiveness through more balanced and understanding gestures of communication. Within the counseling session, the counselor encourages the family members to share more authentically with one another, coming from

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a place of care and concern rather than leaning on old patterns of blaming, placating, or discounting. Conveying Consistency and Cohesiveness

Once the family has practiced honest, clear communication and has begun to build a sense of individual and family value and worth, the counselor encourages the family members to continue authentic expression and adaptable connection in their daily lives. This is an important phase of extending their newly adjusted concepts and compassion to promote healthy development for each family member and growth toward the family’s values and goals. Each of the phases can cycle back around, particularly as new situations or stressors can tempt the family to fall back on older patterns. As the family learns to become more comfortable with the uncomfortable, adaptability and flexibility become more readily accessed while clarity of communication and rules produce more meaning and receptive responsiveness between and among the family members through time. Adele Logan O’Keefe and Esther N. Benoit See also Existential-Humanistic Therapies: Overview; Experiential Family Therapy; Person-Centered Counseling; Satir, Virginia; Systemic Family Therapy

Further Readings Banmen, J. (2002). The Satir model: Yesterday and today. Contemporary Family Therapy, 24(1), 7–22. doi:10.1023/A:1014365304082 Bitter, J. R. (2009). Theory and practice of family therapy and counseling. Belmont, CA: Brooks-Cole. Cheung, G., & Chan, C. (2002). The Satir model and cultural sensitivity: A Hong Kong reflection. Contemporary Family Therapy, 24(1), 199–215. doi:10.1023/A:1014338025464 Dermer, S., Olund, D., & Sori, C. F. (2006). Integrating plays in family therapy theories. In C. F. Sori (Ed.), Engaging children in family therapy: Creating approaches to integrating theory and research in clinical practice (pp. 37–65). New York, NY: Routledge/Taylor & Francis. Freeman, M. L. (1999). Gender matters in the Satir growth model. American Journal of Family Therapy, 27(4), 345–363. doi:10.1080/019261899261907

Haber, R. (2002). Virginia Satir: An integrated, humanistic approach. Contemporary Family Therapy, 24(1), 23–34. doi:10.1023/A:1014317420921 Hecker, L. L., & Wetchler, J. L. (2003). An introduction to marriage and family therapy. New York, NY: Routledge Mental Health/Taylor & Francis. Lee, B. K. (2002). Congruence in Satir’s model: Its spiritual and religious significance. Contemporary Family Therapy, 24(1), 57–78. doi:10.1023/A:1014321621829 Satir, V. M. (1988). The new peoplemaking. Palo Alto, CA: Science & Behavior Books. Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model. Palo Alto, CA: Science & Behavior Books. Satir, V. M., & Bitter, J. R. (1991). Human validation process model. In A. M. Horne & J. L. Passmore (Eds.), Family counseling and therapy (2nd ed., pp. 13–45). Itasca, IL: Peacock. Walsh, W. M., & McGraw, J. A. (2002). Essentials of family therapy: A structured summary of nine approaches (2nd ed.). Denver, CO: Love.

HUMANISTIC PSYCHOANALYSIS OF ERICH FROMM Erich Fromm (1900–1980) viewed most people who live in a dehumanizing and alienating society as themselves dehumanized and alienated. We can be fully healed and whole, he believed, only within a culture that itself is moving toward becoming healed and whole. He offered not only innovations in psychotherapy but also a program for restructuring society along more cooperative, less alienating lines. The aim of analysis, said Fromm, is to know oneself. The method is designed to help a patient discover and fathom his or her hidden total experience. “Hidden” means bringing what we have not known was within us into awareness. “Total” means knowing all of the self, not just bits and pieces. Ultimately, the goal of therapy is to have the patient fully exercise his or her own latent powers in a way that acknowledges the needs and concerns of others as well as his or her own. This perspective combines personal and social humanism. Fromm sought to help every person live in a joyful, fulfilling way within a psychologically and spiritually enriching social context. Such deeper,

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more individuated persons exercise positive freedom, which is a holistic, integrative activity of a person’s entire organism, much like Kurt Goldstein’s concept of organismic self-regulation.

Historical Context Born on March 23, 1900, in Frankfurt, Germany, Fromm was surrounded by subcultures and social upheavals that sensitized him to how cultural forces affect us. He completed his Ph.D. in sociology at the University of Heidelberg in 1922. During the 1920s, he studied psychoanalysis with Frieda Reichmann, whom he later married when he was 26 and she was 36. He began a clinical practice in 1927, with much help from Frieda in completing the requirements for becoming a psychoanalyst. He subsequently trained with Wilhelm Wittenberg in Munich and Karl Landauer in Frankfurt and then graduated from the Berlin Institute under Hans Sachs and Theodor Reik. In 1929, he became a cofounder of the Frankfurt Psychoanalytic Institute and also joined the Frankfurt Institute for Social Research, later known simply as the “Frankfurt School” of socialistleaning European psychoanalysts. There he worked to clarify the links between social structures such as the family, workplaces, distributions of wealth, and the psyche and its impulses. That connection faded as some of those colleagues came to consider him insufficiently committed to the socialist cause. By contrast, many psychoanalysts in Europe and America viewed him as “too socialist.” Such critiques were ironic, because a central thrust of Fromm’s thinking was how people give up their capacity to think independently and instead identify with an ideology created by others. Fromm joined Carl Jung, Alfred Adler, and others who rejected Sigmund Freud’s insistence that sexual libido and its repression were the root cause of mental illness. When the Nazis gained power, Fromm moved to Geneva, Switzerland, and then to New York City. After his relationship with Reichmann ended, he shared ideas and had a relationship with Karen Horney. He joined Horney, Harry Stack Sullivan, and Margaret Mead in asserting that culture and intersubjectivity drive human behavior more strongly than economic and psychosexual factors. It was then that he became a cofounder of the William Alanson White Institute. In 1943, his relationship

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with Horney ended, and in 1944, he married Henny Gurland Fromm, who died in 1952. He went on to become a professor at the National Autonomous University in Mexico City and, remarkably enough, also taught at Michigan State University and New York University. In Mexico City, he founded the Mexican Institute of Psychoanalysis, which he directed until 1976. Fromm was remarried in 1953, to Annis Freeman. In his final years, he returned to Switzerland, where he died just before his 80th birthday.

Theoretical Underpinnings Fromm’s early influences included Freud’s theories and discoveries. Later, along with Alfred Adler, Horney, and Harry Stack Sullivan, Fromm came to be labeled a “neo-Freudian.” The four were interested in real lived relationships and looked askance at the ideological rigidity of Freud’s libido theory. The others had all been influenced by Adler’s outlook and cross-fertilized one another’s ideas. Horney’s stress on awareness, borrowed from Zen Buddhism, became a thread in Fromm’s thinking. In Fromm’s view, the individual psyche is inherently social in nature. Every person embodies the entire range of possible human responses. There is no inclination toward any kind of behavior that a self-knowing analyst cannot find somewhere within himself or herself. At birth, we each have a potential to develop and express qualities that range from the viciously destructive, through bland conformity, to deep spiritual realization. Yet we differ in our potentialities. An apple sapling may become huge and bountiful, or end up puny and weak, but it will never bear oranges. The social influences of family, workplace, and community, which themselves reflect the larger society’s norms and values, bend our potentialities in one direction or another. This bending begins in infancy and childhood but can be somewhat undone by analysis after reaching adulthood. With his training as a sociologist as well as a psychoanalyst, Fromm, along with Michel Maccoby, carried out a psychosocial study of a Mexican peasant village that could easily be termed anthropology. With this background and interest, it is not surprising that throughout his career, Fromm addressed the interplay among personality, social structure, and culture. He wanted

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to restructure society along more humanistic, lifeenhancing avenues.

Major Concepts Among the major concepts highlighted by Fromm are universal human needs, central relatedness, alienation, repression, dissociation, benign neurosis, malignant neurosis, narcissism, the pathology of normalcy, socially patterned defects, the burden of freedom, modes of getting, human versus being, authority, and forms of destruction. Universal Human Needs

Fromm hypothesized that there were eight human needs, which if unmet can cause mental health problems. They include the following: 1. Effectiveness—the need to be accomplished 2. Excitation and stimulation—active striving toward a goal 3. Identity—a sense of one’s individuality and unique way of being in the world (This is often sacrificed for the price of belonging to some group.) 4. Frame of orientation—a need for understanding the world and our place in it 5. Relatedness—a need for a shared connection with others 6. Rootedness—a need to establish roots and feel at home again in the world from which we find ourselves alienated 7. Transcendence—a need to create and care for something beyond oneself, such as artistic expression or children 8. Unity—a sense of oneness with the social and natural worlds

Central Relatedness

Central relatedness occurs when people connect in a real manner with one another rather than with the images they want one another to see. Alienation

We can be alienated from ourselves, one another, society, or nature. This results from (a) the structure

of societies, (b) deficiencies in our relationships within ourselves and with others, and (c) family relationships based on power and domination rather than truly loving connections. Repression

For Fromm, repression includes that which was conscious and then pushed out of awareness and that which one has never been aware of. Fromm believed that a parent’s attitudes and anxieties, based on social mores, form the basis of what can be admitted to consciousness and are transmitted through them to their children. This, says Fromm, is the basis for social repression. Dissociation

Dissociation is a type of detachment from self, and Fromm believed that information that tended to be out of consciousness was more likely reflective of dissociation than of repression. Benign Neurosis

Benign neurosis is when character flaws that exist due to past traumatic events lead to pathological coping strategies. However, in this case, the character structure is fairly intact, and the prognosis for improvement or cure is usually favorable. Malignant Neurosis

Malignant neurosis is when character flaws from past traumatic events damage the nucleus of the character structure, resulting in a poor prognosis. A psychopath (a narcissist, a manipulative person who has little empathy) is an example. Narcissism

Fromm suggested that narcissism, or the egotistic admiring of self and seeing the world in terms of one’s own interests, ideas, or feelings, was a central problem for many people. The Pathology of Normalcy

The concept of pathology of normalcy reflects the belief that one’s self, based partly on societal values, is healthy when indeed it is often not. This is difficult to treat because much of society supports the neurosis.

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Socially Patterned Defects

When an entire society sanctions dysfunctional behaviors, such as the failure to satisfy some or all of the basic human needs, it is said to be sanctioning socially patterned defects in individuals. Mental health occurs when people develop full maturity and can transcend these societal values. The Burden of Freedom

Fromm believed that we may disown responsibility for our choices and instead look to authority figures to tell us how to live. In this context, a person may resort to conformity to accepted norms, authoritarianism, or destructiveness toward others and their possessions, ideas, or self-concepts.

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we lose our humanity. Ultimately, Fromm suggests, we have a choice between “having” or “being.” Authority

Fromm suggested that in today’s world there is much irrational authority—that is, authority that is motivated by power, greed, and deception. Such power is often used to manipulate and humiliate others. Rational authority, in contrast, is when a person who has expertise and competence, and who respects another who does not have such expertise and competence, can share his or her knowledge with the other in positive ways. Forms of Destructiveness

Modes of Getting

In Man for Himself, Fromm conceptualized modes of getting what we need or want. These are passively receiving (which requires a willing giver), exploiting others or the world (i.e., taking by force or guile), hoarding (preserving) what we have, exchanging or trading (which for our time, he labeled the marketing orientation), and producing items ourselves. Each of these modes is on a continuum along which one can express oneself in harmful ways at one extreme and helpful ways at the other. For example, in the receptive orientation, “submissive” can be transformed into “devoted.” In the exploitive orientation, “rash” can become “selfconfident.” In the hoarding orientation, “stingy” can become “economical.” And in the marketing orientation, “wasteful” can become “generous.” Although the negative tendencies come from an impoverished view of self and the world, a person can learn to express them positively. Everyone must be able to accept, to take, to save, and to exchange. Everyone must be able to follow authority, guide others, and assert himself or herself. We don’t have to become someone completely different, but we can change constructively within the context of our starting points. Having Versus Being

Fromm believed that individuals idolize having. Rather than embracing personal qualities and actions, we measure our worth based on how much “stuff” we have. In this process, he suggests,

While destruction and aggression are not synonyms, they are closely related as destruction can be a product of aggression. Fromm classified three types of aggression and three types of pseudo-aggression. Aggression Benign: This type of aggression is beneficial and promotes the well-being of people and groups. Examples are self-defense, self-assertion to attain useful goals, and aggression that promotes the larger social good. Defensive: Defensive aggression is when we foresee and plan for future threats based on past experience, and it can be advantageous or disadvantageous, such as in military buildups. Malignant: The act of malignant aggression involves an intent to harm another.

Pseudo-Aggression Accidental: Accidental pseudo-aggression is when one might hurt another without intending to. In this case, unconscious motives may exist, but we cannot assume so. Playful: Playful pseudo-aggression is aggression through playful activities and exercising skill such as in archery, sword fighting, and so on. Aggression may emerge in competitiveness. Self-assertive: Self-assertive pseudo-aggression is when a person moves toward a goal without undue

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hesitation, doubt, or fear. A person low in this quality is likely to be shy and have trouble avoiding and confronting threats.

Techniques A number of techniques drive the humanistic analytical method of Fromm’s and include the following: on and off the couch, a phenomenological approach, sharing one’s own perceptions of what patients are saying and doing, a nonjudgmental attitude, cutting off resistances, discovery of personal narcissism, changing one’s actions, becoming aware of one’s body, dream analysis, learning to think critically, and concentrating and meditating. On and Off the Couch

Early in his career, Fromm used the classical psychoanalytical technique of having patients lie on a couch and free-associate, while he himself listened, observed, and took notes. Later, he moved to sitting face-to-face in direct dialogue with the client. Freeassociating on the couch, he concluded, can keep a person in an infantile state of mind and feeling. It is necessary for the patient’s adult side to react to and confront the archaic material in order to escape its childlike grip. The analytic cure includes the conflict that occurs when rational and irrational sides of the personality meet and a growth-promoting resolution of that conflict occurs. A Phenomenological Approach

Phenomenology has to do with the ability of the analyst to understand the subjective experience of the client. Fromm, thus, believed that one can only formulate a plan of analysis after having immersed oneself in the experience of the patient. What urges and what deep goals drive this person? What fears and recollections of past traumas limit him or her? Analysis begins with understanding the patient’s inner world. Sharing One’s Own Perceptions of What Patients Are Saying and Doing

Here, the analyst tells the patient the full truth of his or her perception of the situation. Halftruths and beating around the bush leave the

patient untouched. Such dialogue requires a focus on awareness in the present and avoidance of intellectualization by either the analyst or the patient. A Nonjudgmental Attitude

Fromm shared Carl Rogers’s emphasis on an intentionally cultivated nonjudgmental attitude that allows the other to feel fully heard. This means full acceptance of a patient, not feigned approval. He listened with an ear that is “neither tolerant nor judging.” Cutting Off Resistances

The analyst blocks off one retreat after another by gently challenging the patient to become aware of a crucial avoidance or self-deception while being sensitive to the main resistances and repressions. This also tells whether the patient is someone who can be analyzed and how deep the therapy might go. Discovery of Personal Narcissism

A narcissistic person has not learned to truly love himself or herself and is therefore greedy for all the admiration he or she can get from self and others. Such greed results from frustration of deep needs and longings. It interferes with realistic contact with others and the world. Helping the patient identify, face, and release is one of therapy’s great challenges. We can find happiness only when we release egocentric narcissism that is constantly worrying, “What’s going on with me?” Instead, we need to become interested in what is happening in the people and the world around us. Changing One’s Actions

Despite years of analysis, unless you behave differently, you will have your same old problems. Fromm encouraged patients to try out new solutions and actions and to consciously experience the anxiety that often accompanies doing so. Becoming Aware of One’s Body

Sensitivity to situational or chronic tensions anywhere in the body offers reliable information

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about preferences, hopes, and fears even when the mind and emotions are confused. Dream Analysis

In dream analysis, Fromm would often look for “universal symbols,” which replaces Carl Jung’s concepts of “archetypes.” Both labels refer to the universal quests and questions that appear in all cultures in all times. The main point, he believed, is to lead the patient toward individuation and aliveness. Learning to Think Critically

Only by thinking critically can we be free, said Fromm. Because this ability has not yet been mastered by most, we unthinkingly accept stories spun by those in positions of power to control the restless rest. The Brazilian educator Paolo Freire labeled these the “dominant narrative.” Concentrating and Meditating

We can think critically only if we can witness our own thinking process. Concentration, or the ability to maintain one’s mental focus, has been shown to make people more effective in diverse realms of life. Fromm points out that practicing concentrative meditation for a minimum of 15 minutes each day can help greatly in developing this faculty.

Therapeutic Process Fromm downplayed the value of interpretation and believed that direct experience was crucially important in therapy. He was more interested in present passions than in childhood traumas, reports the anthropologist, sociologist, and psychoanalyst Michael Maccoby. In Fromm’s view, what blocked development was less our memories than our choices. Fromm believed that the central element in helping a patient become fully himself or herself was making the unconscious, conscious. This process is a journey of personal discovery that requires emphasis on the direct experience of one’s sensations, thoughts, feelings, and inclinations toward action during the therapeutic hour. He liked to use

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his first hour with a new patient to ask why he or she had come and get a life history, taking note of what was said, what was not said, and the feelings the person expressed while speaking. Patients who experienced analysis with him speak of feeling truly “seen.” Fromm believed that it was important to offer one’s own perceptions and a response in a straightforward manner, believing that anything less was valueless. He suggested gently challenging some patients and being more confrontational with others who could handle such interactions. Fromm believed that the analyst’s task is to show the patient real alternatives in such a manner that the patient has a sense of self-discovery. A common form of resistance to such awareness is the wish for an easy compromise that integrates parts of fundamentally opposed paths. This impossible solution inhibits real change. Fromm believed that resistance is an issue not just in analysis but also in many daily-life problems. He felt it important for the patient to fully open up to himself or herself and not take small steps that he or she believes denote therapeutic progress. We should not fool ourselves into thinking we are making progress, such as when some patients use free association and believe that all that comes into one’s mind is useful. Moreover, he said, dwelling on one’s misfortunes could lock a person into a lifelong posture of being a self-pitying victim. For Fromm, transference is a widespread phenomenon. In his view, everyone transfers some perceptions and feelings about one person onto others. Everyone longs for a close relationship with someone who offers love, guidance, and caring. The analyst must beware of falling into a submission–dependency relationship in which the patient becomes even more powerless and depends on the analyst as a support for everyday living. In countertransference, the analyst has irrational and sometimes unknown attitudes toward the patient. He or she may want the patient’s approval, praise, or even love—although a capable analyst should be beyond all that. But in Fromm’s view, much of the concern about transference and countertransference is secondary to the relational dialogue between two human beings talking to and affecting each other. From such dialogue, authentic contact can occur.

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Hope was fundamental to Fromm’s view and his approach to psychotherapy. Just as patients had dissociated from troubles in life and relationships and from the past events that caused them harm, so too had many of them dissociated from their positive potentialities and talents. Finally, Fromm speaks of the importance of creating a wise, fulfilling culture that can enhance people’s lives. Doing this combines self-development with cooperative and collaborative social arrangements. He liked to quote Ortega y Gasset’s line, “I am myself and my circumstances. And if I do not save my circumstances, I cannot save myself.” Fromm’s student Maccoby speaks of “The Two Voices of Erich Fromm.” His exploratory, skeptical, analytic side tries to help suffering people free themselves from fear and develop their creative potential. His prophetic side was both spiritual and cultural. He saw neurotic symptoms as responses to oppression and alienation, whether in the family, the company, or the statehouse. He sought to help realize an age of worldwide peace and solidarity. At his or her best, the analyst helps the patient discover the revolutionary self within the neurotic. Victor Daniels See also Adlerian Therapy; Classical Psychoanalytic Approaches: Overview; Existential Therapy; Existential-Humanistic Therapies: Overview; Freudian Psychoanalysis; Gestalt Therapy; Meditation; Mindfulness Techniques; Neo-Freudian Psychoanalysis; Person-Centered Counseling; Reich, Wilhelm

Further Readings Fromm, E. (1941). Escape from freedom. New York, NY: Avon. Fromm, E. (1947). Man for himself: An inquiry into the psychology of ethics. New York, NY: Holt, Rinehart, & Winston. Fromm, E. (1955). The sane society. New York, NY: Henry Holt. Fromm, E. (1956). The art of loving. New York, NY: Harper. Fromm, E. (1973). The anatomy of human destructiveness. New York, NY: Henry Holt. Fromm, E. (1976). To have or to be. New York, NY: Harper & Row. Fromm, E. (1994). The art of listening. New York, NY: Open Road.

Funk, R. (Ed.). (2009). The clinical Erich Fromm: Personal accounts and papers on therapeutic technique. New York, NY: Rudopi. Maccoby, M. (2006). The two voices of Erich Fromm: The prophetic and the analytic. Society, 32(5), 72–82.

HUMANISTIC-EXPERIENTIAL MODEL See Human Validation Process Model

HYPNOTHERAPY Meaning “sleep” in Greek, hypnosis has more similarities to the waking state than to the state of sleep, and hypnotherapy has been the term applied to psychotherapy done in the context of a hypnotic trance. This entry explores the history of hypnosis and hypnotherapy, common terms used in the hypnotherapy process, the types of interventions employed, and the process for varying types of treatments.

Historical Context Medical and psychological treatments using trance states have been traced to antiquity, including Asclepian “dream temples” throughout the Mediterranean, surgical operations in Calcutta (now Kolkata), catalepsy and pain control by Indian fakirs, and in other cultures such as those of China, Africa, pre-Columbian America, and Mongolia, to name just a few. By 1775, the charismatic physician Franz Mesmer (1734–1815) had promoted “animal magnetism” in Vienna and Paris. He would stare into people’s eyes, place magnets and metal rods on or near their bodies, pass his hands across their bodies, and cure them of their ills. But within 10 years, a Commission of Inquiry chaired by Benjamin Franklin debunked the Mesmeric theory and concluded that his effectiveness was due to the power of the imagination. At that time, suggestion and imagination were not considered a subject matter for science, and that would remain the case for several decades.

Hypnotherapy

In 1842, the physician James Braid (1795–1860) first used the word hypnotism. Observing the work of practitioners of animal magnetism, he concluded that the subjects were in an altered state of consciousness and that a certain eye fixation could produce the condition he observed. He eventually decided that it was a purely psychological experience related to a type of concentration and used the term hypnotism to distance his work from those doing animal magnetism. In the course of history, many other well-known names have been attached to its development and interest, including Ambroise-Auguste Liebeault (1823–1904), Hippolyte Bernheim (1840–1919), Jean-Martin Charcot (1825–1893), Pierre Janet (1859–1947), Josef Breuer (1842–1925), and Sigmund Freud (1856–1939). As each practitioner used the phenomenon, new techniques and concepts shaped their early theories of personality and included the following: suggestion, subconscious, unconscious, and dissociation. Today, the scientific community generally regards hypnosis as a state of heightened internal concentration that can best be experienced by those with the personality trait of hypnotizability or absorption.

Theoretical Underpinnings Historically, hypnosis has been used as an adjunct to medical care and psychotherapy, and in the age of psychoanalysis, hypnoanalysis became a common treatment modality. The goal of hypnoanalysis was to uncover historical events (wishes, behaviors, perceptions, thoughts, and feelings) considered to be the cause of psychological and psychophysiological difficulties. In addition to the recall of important developmental information, hypnoanalysis often provided an emotional catharsis and a corrective emotional experience. Fewer therapists today use hypnoanalysis, and a greater number are utilizing strategic psychotherapy approaches during trance to relieve presenting symptoms and alter the psychodynamic, interpersonal, or cognitive reactions that have developed presenting problems. Hypnosis is now used in combination with a number of different psychodynamic and strategic psychotherapies including cognitive behavioral therapy, ego state therapy, desensitization therapy, and experiential rehearsal

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therapy. Today, it is generally recognized that a suggestion alone is insufficient to secure the necessary change and that an experiential component is needed for long-term symptom amelioration. When conducting hypnotherapy, it is important that each person’s unique problem, history, and current life context be considered. With this background information, the increased concentration provided by a hypnotic trance improves a subject’s ability to locate, isolate, or create the needed feelings, thoughts, and/or behavior and then link them together into a constructive outcome. Research regarding the use of hypnosis has been seldom taught in universities. Consequently, most health care professionals are unaware of the body of empirical research that supports the use of hypnosis for various clinical problems. Areas in which hypnosis has been demonstrated to be effective and supported by empirical evidence include traumaand stress-related disorders, irritable bowel syndrome, depression, reduction of various somatic symptom disorders, osteoarthritis, obstetric problems, temporomandibular disorder, fibromyalgia pain, effects associated with cancer treatment, and the treatment of viral warts. Because it is noninvasive, hypnotherapy should be considered as an intervention of first choice.

Major Concepts Conscious and Unconscious (or Subconscious)

Although hypnotherapists will work with the conscious mind, with the bulk of memory, skills, feelings, attitudes, urges, patterns of perception, and motor behavior being outside of personal awareness, hypnotherapists often work with the unconscious. Therefore, successful hypnotherapy is concerned with locating and using appropriate aspects of these unconscious experiences for the purpose of helping clients achieve their goals. Hypnotizability and Suggestibility

Hypnotizability has to do with the likelihood that and the extent to which an individual will experience trance. There are several research tools that can assess hypnotic susceptibility, one of the more common ones being the Hypnotic Induction Profile. Standardized tests for suggestibility are also available.

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Induction Stage Versus Treatment Stage

Regardless of whether a prehypnosis inventory is completed, hypnotherapy usually involves separation of the stage of induction from the stage of intervention. The aim of the induction stage is to stabilize a state of consciousness that allows for heightened internal concentration. Once this is achieved, treatment stages can follow. Trance Phenomena

As induction is achieved, individuals reduce attention to external foci and often experience dissociation, amnesia, disorientation to the passing of time, and other hypnotic phenomena such as a degree of age regression. The purposeful elicitation and utilization of some of these phenomena are often crucial to the success of psychotherapy during a trance. Experience Retrieval

Experience retrieval consists of retrieving a memory in a manner that allows the person to reexperience a past feeling. Such retrieval is a critical aspect of therapy. For instance, if a person has a fear of elevators, it would be important to help that person learn how to be calm on the elevator. Desired feelings of calmness and comfort need not have occurred in the context of elevator travel. For instance, the person may have had the experience of calmness on the sofa with a pet dog. He or she can bring these desired experiences into the foreground and associate them to imagined and anticipated elevator travel. Such counterconditioning allows the client to replace the anxiety that was originally conditioned to elevator stimuli, thus creating a new conditioned response and new self-image.

Techniques Hypnotherapy can only begin after consent to treatment is given by the client, a biopsychosocial diagnosis is completed, and a treatment plan has been agreed on. At that point, a number of conventional interventions developed from other forms of psychotherapy can be employed while a person is under a hypnotic trance. Some of these include desensitization, situational rehearsal, reciprocal inhibition,

mindfulness, imagined dialogue, dissociative review, building self-nurturing and self-instruction, guided imagery, imagined encounters, cognitive-behavioral techniques, and even analysis, insight, confrontation, and others. In addition, there are a number of standard procedures often used in hypnotherapy, including interpersonal utilization, establishing rapport, reframing, suggestion and ambiguity, therapeutic metaphor or therapeutic stories, revivification, and self-hypnosis, which are described in the following subsections. Because of the unique needs of each client, a certain level of improvisation and spontaneity is necessary for implementing any intervention. Interpersonal Utilization

Interpersonal utilization is a therapist’s acceptance and use of rigid behaviors, thoughts, or beliefs that help build a therapeutic alliance. For instance, if a client states that he is so upset that he can’t sit down, the therapist can invite him to continue to stand and even to pace around as they talk. Thus, a possible resistance is removed, and the undesirable behavior comes under the control, as it were, of the therapist, who is now requesting its continuance. Establishing Rapport

Since the accomplishment of a hypnotic trance often depends on the level of trust between the therapist and the client, establishing rapport is critical and increases the likelihood of success. Many clinical trainers stress the value of acceptance, empathy, and matching client behaviors, even breathing at the same rate as the client, to develop a better understanding of the client’s experience. Reframing

Reframing is an intervention to change rigid, and harmful, beliefs or attitudes without flatly disagreeing with them. For instance, if a client stated, “My pain is my punishment for making such stupid decisions,” a therapist might state, “Your pain was a punishment in the past, but now you are making appropriate decisions and no longer need pain as a reminder.”

Hypnotherapy

Suggestion and Ambiguity

The major verbal tool of hypnotherapy is suggestion, which ranges from direct to indirect. Direct suggestions, such as “Close your eyes,” are easily identifiable. An indirect suggestion, on the other hand, might state, “You don’t need to keep your eyes open.” Indirect suggestions are often used so that clients will react in a manner that is unique to them, thus establishing a more egalitarian relationship. Many suggestions are not easily classified as being direct or indirect. Take the suggestion “Now ‘go’ to a place that makes you feel comfortable.” Consider the possible ambiguity: 1. “go”—how or in what way? 2. “a place”—does this mean a memory, a thought process, or imagining I am somewhere? 3. “makes you feel”—does this have to make me feel, or is it okay if I just allow myself to feel? 4. “comfortable”—does this mean physically relaxed, mentally accepting of myself, or forgetting my anxiety, and so on?

A masterful use of suggestions takes finesse, and hypnotherapists learn how to use them efficiently and effectively over time. Therapeutic Metaphor or Therapeutic Stories

A wide variety of stories have been used in trance to focus a subject’s attention, stimulate a subject’s own thinking and imagining, convey an important attitude or idea, and so on. The construction of a metaphoric story requires thoughtfulness and skill if it is to accomplish the goal of experience retrieval. One might think of a movie or book that, in the telling, evoked feelings or ideas within the reader or observer. Similar story patterns can be useful for retrieving various desired and required experiences, attitudes, and understandings.

treatment as past, harmful memories are often the cause of present-day symptoms. Although methods for accomplishing such retrieval vary as a function of the school of hypnotherapy studied, they all have the basic goal of reexperiencing the memory and working with it to relieve symptoms. Self-Hypnosis

In many instances, clients are taught to do selfhypnosis so that they may continue to employ the same sorts of gains and learning that occurred during the office visit. Although used in many different treatment plans, self-hypnosis is particularly important for individuals suffering from the side effects of cancer treatment, such as nausea, or for types of ongoing pain, irritable bowel syndrome, test preparation, and other ongoing anxietyproducing situations.

Therapeutic Process A common misconception is that a hypnotherapist can put a person into a trance and magically suggest the removal of an undesirable symptom. In fact, the course of hypnotherapy is based on a number of factors, including the complexity of the presenting problem, the communication skills of the client, and whether there are additional mental health or interpersonal issues with the client. If all factors are optimal, hypnotherapy may proceed rather rapidly. This is sometimes the case for the treatment of simple phobias, performance anxiety, and uncomplicated posttraumatic stress disorder. However, treatment can be long-term, especially when dealing with issues such as major depression, resilience throughout cancer treatment, the reduction of physical symptoms such as hot flashes during menopause, and difficulties associated with obstetrics. Stephen R. Lankton See also Autogenic Training; Ericksonian Therapy; Narrative Therapy; Strategic Therapy

Revivification

Revivification is the process of retrieving and reexperiencing a memory. Particularly in hypnotherapy, memory retrieval is a crucial aspect of

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Further Readings Barrett, D. (Ed.). (2010). Hypnosis and hypnotherapy (2 vols.). Santa Barbara, CA: Praeger.

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Erickson, M. H. (2009). Further clinical techniques of hypnosis: Utilization techniques. American Journal of Clinical Hypnosis, 51, 341–362. doi:10.1080/0002915 7.1959.10401792 Hilgard, E. R. (1965). Hypnotic susceptibility. New York, NY: Harcourt Brace & World. Lankton, S., & Lankton, C. (2008). The answer within: A clinical framework of Ericksonian hypnotherapy. Bethel, CT: Crown House. (Original work published 1983) Lynn, S. J., Rue, J. W., & Kirsch, I. (Eds.). (2010). Handbook of clinical hypnosis (2nd ed.). Washington, DC: American Psychological Association.

Nash, M. R., & Barnier, A. J. (Eds.). (2008). The Oxford handbook of hypnosis: Theory, research and practice. New York, NY: Oxford University Press. Shor, R. E., & Orne, E. C. (1962). The Harvard Group Scale of Hypnotic Suggestibility. Palo Alto, CA: Consulting Psychologists Press. Spiegel, H., & Spiegel, D. (1978). A manual for the Hypnotic Induction Profile. New York, NY: SoniMedica. Weitzenhoffer, A. M., & Hilgard, E. (1962). Stanford Scale of Hypnotic Suggestibility: Form C. Palo Alto, CA: Consulting Psychologists Press.

I problems, in the 21st century, many therapeutic models see such change as normal and adaptive.

IDENTITY RENEGOTIATION COUNSELING Identity Renegotiation Counseling (IRC) focuses on improving clients’ experiences of identity validation and reducing their experiences of invalidation. IRC teaches that people have plural identities, which are continuously changing, competing for dominance, and proving to be more or less adaptive in any given situation. The goal of treatment is for clients to become more effective at working within their interpersonal contexts to resolve identity confusion and conflict. Counseling is relatively brief, generally requiring less than 15 sessions. IRC grew out of work with adolescent drug abusers but has demonstrated good results with individuals, couples, and families experiencing other kinds of identity transition such as divorce, stepfamily development, graduation, retirement, and coming out as lesbian, gay, bisexual, or transgender.

Theoretical Underpinnings In the early 1900s, symbolic interactionists described relationships as the source of one’s sense of self. The self was understood as a set of multiple, situational, competing identities that were fluid and located within interpersonal interactions. IRC combines symbolic-interactionist and social-constructionist foundations in that it views people as participants in an ongoing process of enacting identities through language. Identity narratives are created in interaction, making sense of past experience and predicting future behavior based on what is “like” or “not like” what has gone before. People can collaborate to strengthen desired identities and reduce the power of identities that do not fit within a relational context. Identity narratives are not only descriptions of behavior but also interpretations of behavior. Identity change, from this perspective, occurs as people change both their behavior and their stories. Behavioral theories offer an important element to IRC, explaining how people can work with contextual factors such as incentives and models to achieve behavior changes that will support new identity stories.

Historical Context IRC was developed by Thomas W. Blume in the late 20th century, a period characterized by rapid social and intellectual change. In this postmodern social context, social-constructionist theories suggest that globalization and increased saturation with media inputs have reduced individuals’ abilities to achieve stability and comfort in their career, personal, and social identities. Whereas many therapeutic models of the 19th and mid-20th centuries assumed that identity stability was necessary and redefining oneself in midlife was an indication of deeper personal

Major Concepts Effective counseling with IRC depends on mastery of a few concepts, including identities, identity stories, validation, influence, and identity problems. 529

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Identities

IRC challenges the popular goal of achieving a single, consistent identity; in IRC, consistency is not considered adaptive. For example, when a police officer is at work, he or she needs to be careful and alert to danger, but at home, the officer’s family wants a person who can be touched, who smiles, and who welcomes surprises. Every person manages multiple identities that appear in specific places and relationships, and these include shared identities. One can perceive similarity with others because of shared career field, language, gender, sexual orientation, racial and ethnic characteristics, religion, national or tribal affiliation, ability, age, and other identifiers. Identity Stories

Identities in IRC are interpersonal, created and maintained in narratives (stories); and stories always include both a teller and an audience. Every telling of a story is different, shaped to get a desired response from a particular audience. Internal storytelling is important for self-recognition and selfworth, but even a person’s internal stories are assumed to have an audience, albeit an imaginary one in the person’s mind. Validation

Validation is viewed in IRC as a universal goal. It may take the form of simply getting attention— proving that an individual exists—or it may include more meaningful recognition of the individual’s personal characteristics or accomplishments. If feedback from others does not match the individual’s identities, even if it is positive in tone, it is not validating—it creates identity confusion or conflict. Influence

All language or symbolic activity represents the values of groups. A group gains control by asserting and repeating “dominant” identity stories about its members and others. For example, men around the world have often described women in ways that have limited women’s options. Social constructionists use postmodern concepts of

influence and power to explain how individuals are “positioned” by different messages coming from multiple “discourse communities.” Identity Problems

IRC identifies three kinds of identity problems: (1) identities can be in conflict when an individual attempts to meet conflicting expectations, (2) identities can also be confusing in times of transition when the individual and/or others have difficulty merging observations into a coherent identity story, and (3) identities can be negative when the dominant identity stories focus on failure and/or unacceptable behavior.

Techniques The techniques of IRC fall into two categories: (1) narrative techniques and (2) behavioral techniques. Narrative Techniques

Narrative techniques include listening to and retelling identity narratives, in individual as well as couple and family formats. Using both written and oral methods, the counselor focuses on a client’s words as well as on the structure and content of a story. Conversations are viewed as opportunities for becoming more familiar with dominant identity stories and also as spaces where new identity stories can emerge. Behavioral Techniques

Behavioral techniques focus on the behavioral foundation of stories. Problematic behaviors are identified and behavioral alternatives are explored to develop plans for identity change. Once the behavioral goals are clear, clients can work to challenge a problematic story and create a desired story through action.

Therapeutic Process IRC typically follows a sequence consisting of the following stages: (a) orientation, (b) awareness building, (c) negotiation training, and (d) identity change.

Imago Relationship Therapy

Orientation

During the orientation phase, the counselor begins with a narrative intake and case formulation process, noting stories that demonstrate plurality and multiplicity. Couple and family sessions are especially helpful; stories that come out in this format are often more complex than those told in individual sessions. Awareness Building

With awareness building, the counselor helps connect identities to relationships and discourse communities that exert influence over clients’ feelings and behavior. Negotiation Training

The negotiation training begins after clients learn to perceive influence processes. At this point, clients are taught new ways to collaborate with others so that differences are respected and they can make changes together. Identity Change

Finally, during the identity change phase, clients are coached in using these collaborative skills as they begin to take an active role in modifying their relational identity stories. Thomas W. Blume See also Adlerian Therapy; Behavior Therapies: Overview; Ego Psychology; Feminist Therapy; Internal Family Systems Model; Narrative Therapy; PersonCentered Counseling

Further Readings Bamberg, M. (2011). Who am I? Narration and its contribution to self and identity. Theory & Psychology, 21(1), 3–24. doi:10.1177/0959354309355852 Blume, T. W. (2010). Counseling for identity renegotiation. Identity: An International Journal of Theory and Research, 10, 92–105. doi:10.1080/15283481003711700 Davies, B., & Harré, R. (1990). Positioning: The discursive production of selves. Journal for the Theory

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of Social Behaviour, 20, 43–63. doi:10.1111/ j.1468-5914.1990.tb00174.x Gergen, K. J. (2008). Therapeutic challenges of multibeing. Journal of Family Therapy, 30, 335–350. doi:10.1111/j.1467-6427.2008.00447.x

IMAGO RELATIONSHIP THERAPY Imago Relationship Therapy was developed as a marriage therapy theory. The theory was developed from an eclectic combination of transactional analysis, Gestalt psychology, systemic theories, and cognitive therapy. This theory postulates that individuals are highly influenced by their childhood caregivers and ultimately select or become attracted to individuals who embody aspects of their childhood caregiver. This theory also infuses an array of practical interventions within the therapy.

Historical Context Imago Relationship Therapy is the brainchild of Harville Hendrix, a clinical pastoral counselor, with a Ph.D. in psychology and theology. Hendrix gradually developed this theory through his own research and clinical experience with couples. Hendrix and his wife, Helen LaKelly Hunt, developed the Imago Model in the late 1970s and published a book a decade later, titled Getting the Love You Want. It became a best seller and gave its readers insight into the psychology of attraction, including the notion that we enter into all romantic relationships with expectations directly influenced by our childhood caregivers.

Theoretical Underpinnings The major underpinning of this therapy is that the source of all relational struggles is a result of childhood relational experiences. People learn about love and connection through their earliest interactions with caregivers. Individuals then enter into relationships with people who have similar interaction patterns as their caregivers, or they project or provoke those images onto their romantic partner. This would be evidenced by a daughter marrying a man who withdraws from conflicts just as

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her father withdrew from conflict. The theory postulates that a person can heal his or her painful childhood experiences through the therapeutic process of addressing the current relational struggles that reactivated those childhood experiences.

Major Concepts Imago Relationship Therapy proposes a relational view of growth, which posits that for an individual to grow and heal, he or she must do so in the context of a relationship. Additionally, Hendrix identified four basic functions of the self: (1) thinking, (2) feeling, (3) sensing, and (4) acting. These functions are directly related to personal functioning and personality and also include related defense behaviors. An individual operating from the thinking function responds cognitively and may appear devoid of emotions, while an individual operating from the feeling function responds with feelings and emotions. An individual using his or her intuition as the primary reaction or response evidences the sensing function. The acting function is evidenced when a person’s primary response is to perform to appease those around him or her. People tend to externalize or internalize reactions and behaviors in these functions, specifically as a result of the receipt of messages in these basic functions. Often an individual is in a relationship with a person whose reaction and behavior pattern is complementary.

Techniques The therapist is not the expert in this therapy but rather the facilitator of the couple’s development and process. Many of the techniques used by the Imago therapist are communication skills, conflict resolution strategies, and direct behavioral modification techniques. In this aspect, Imago Relationship Therapy is very eclectic and can include a variety of therapeutic techniques.

sit closely while facing each other, to maintain eye contact and intimacy. The therapist sits directly facing the couple to closely monitor the interaction. The dialogue has a sender, the person verbally communicating a message, and a receiver, the person who is to receive the message being communicated. The receiver is tasked with mirroring, validating, and empathizing with the sender. At the conclusion of the dialogue, the roles are switched and the process is repeated. This strategy is also used in parent–child interactions. Homework

Imago Relationship Therapy often utilizes homework, both paper assignments and behavioral assignments, such as using the couple’s dialogue at home with each other. Mirroring

This technique is used in the couple’s dialogue. Once the sender has communicated his or her message, the receiver mirrors it by paraphrasing what the sender said. Once the receiver has summarized or paraphrased the message, the sender can add to it or clarify. Once the sender has clarified, the receiver mirrors back the entire message. Validating

The receiver then validates the message received from the sender by acknowledging the logic or thoughts, using phrases like “I understand that you think . . .” or “I see the logic behind . . .” Empathizing

The receiver then empathizes with the sender by using “feeling” words about what the sender is feeling about the message, using phrases such as “I can tell that you feel very . . .” or “It is clear that this has made you feel . . .”

The Couple’s Dialogue

This technique is a highly structured process that creates emotional safety within the couple’s relationship for the couple to communicate. The dialogue is introduced and monitored by the therapist within the session. The therapist has the couple

Therapeutic Process Imago Relationship Therapy has several process options depending on the couple. Wade Luquet developed an Imago Model that consists of six sessions that infuse the philosophy of relationship

Impact Therapy

exploration with skill development. Imago Relationship Therapy has also been heavily used in weekend workshops, either as part of the couple’s therapy or by itself as a brief interlude into the theory and skills. Amanda A. Brookshear See also Cognitive-Behavioral Therapy; Gestalt Therapy; Systemic Family Therapy; Transactional Analysis

Further Readings Brown, R. (1999). Imago Relationship Therapy: An introduction to theory and practice. New York, NY: Wiley. Hendrix, H. (1990). Getting the love you want: A guide for couples. New York, NY: Harper & Row. Hendrix, H., & Hunt. H. (1997). Giving the love that heals: A guide for parents. New York, NY: Harper & Row. Luquet, W. (2007). Short-term couples therapy: The Imago model in action (2nd ed.). New York, NY: Routledge.

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had clients talk with different aspects of self, which he defined as ego states; Fritz Perls, who had had individuals actively have conversations with an empty chair in his Gestalt therapy approach; and Milton Erickson, who would use any creative and often active technique to get clients to change. All of these experiences made Jacobs think that counseling could be more visual and active than what most counselors were being taught. In addition, he believed that the counselor could be creative, use visual props, and use a legal pad or whiteboard to write out suggestions for the client to look at. Today, impact therapy embraces the use of props, such as chairs, writing boards, cups, toys, and movement, to engage clients and help them change. In 1991, Danie Beaulieu, a psychologist from Quebec, Canada, started studying with Jacobs and eventually wrote numerous books and articles about impact therapy. Jacobs, Beaulieu, and Christine Schimmel have presented their ideas throughout the United States and in several countries.

Theoretical Underpinnings

IMPACT THERAPY Impact therapy is an active, multisensory, creative, theory-driven approach to counseling that uses visual and tangible props, such as furnace filters, cups, toy hammers, THINK signs, chairs, and a whiteboard, as well as movement, experiential activities, pictures, metaphors, and other multisensory techniques to stimulate the attention of the client, focus the session, and make abstract concepts concrete.

Historical Context Originated by Ed Jacobs in the early 1990s, impact therapy was influenced by the works of Albert Ellis, Eric Berne, Fritz Perls, and Milton Erickson, all of whom used active approaches to therapy. Although Jacobs was first taught the more traditional client-centered approach to therapy, he wanted to be more active in his approach. He was intrigued by the active approaches of therapists such as Albert Ellis, who urged clients to actively change their irrational thinking; Eric Berne, who

Impact therapy has at its core the idea of being multisensory during counseling to have more impact—to talk to the clients’ eyes as well as their ears by using props, chairs, or a whiteboard. Over the years, two forms of impact therapy have emerged, with one emphasizing the use of creative techniques within the larger framework of established counseling theories and the other emphasizing the use of creative techniques when applying Ericksonian hypnosis principles. When using established theories such as rational emotive behavior therapy (REBT), transactional analysis (TA), reality therapy, Adlerian therapy, and Gestalt therapy, Jacobs and Schimmel emphasize being concrete by using various multisensory techniques. The more sensory modalities are used to communicate with clients, the more the chances of reaching them. If clients can see and think about their difficulty while looking at or interacting with a prop or a small chair or something on a whiteboard, they will have a tangible representation of the problem. The images will continue to resonate long after the session has ended in ways that words alone cannot do; this creates more functional memory and, therefore,

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impact. In addition, the positive energy between the therapist and the client that is fostered by implementation of this creative approach adds significantly to the productivity of every session. Multisensory techniques help build a strong therapeutic relationship because of the client’s active involvement in the development and exploration of the metaphor or staging. Impact therapy works well with diverse backgrounds because it does not rely solely on the verbal exchange between the counselor and the client.

Major Concepts The counseling process map used in impact therapy is RCFFC (rapport, contract, focus, funnel, and close), which is explained in detail in Jacobs and Schimmel’s book Impact Therapy: The Courage to Counsel. Briefly, the counselor first focuses on rapport building and immersing oneself into the client’s world; then, the counselor attempts to develop a clear contract or goal for the session. Next, the counselor focuses the session by cutting off rambling and long-winded stories and uses multisensory techniques such as props, movement, or a whiteboard. The next step is to funnel the session to meaningful content using counseling theories such as REBT or TA, which can be made visual by writing out rational and irrational sentences, as in REBT, or by drawing circles representing the different parent, adult, and child ego states, as in TA. Finally, the counselor spends time closing the session and obtaining valuable feedback regarding the impact of the session. Impact therapists use a depth chart as a way to think about a session and its depth. A 10 to 1 scale is conceptualized, with 10 being the surface and 1 being very deep work. An impact therapist tries to make sure that his or her sessions go at least below 7, where there is some impact. Having this scale in mind and using the RCFFC process map help counselors make sure that their sessions have some positive effect.

Techniques Impact therapy integrates a number of novel techniques into existing, established counseling theories. It uses multisensory, creative techniques to make points or concepts clearer during the session.

The following is an example of how a novel technique might be used: A folded sheet of paper can represent the client’s unwillingness to embrace new challenges, resulting in falling far short of his or her potential. In asking the client to sculpt the sheet at every session, the counselor and client can get a good sense of how much change took place since the previous session. Did the client’s actions during the week help expand the sheet or fold it even more? Did the client tear apart some of it? Did the client let others take charge of his or her sheet? Did the client start to make changes but stopped himself or herself?

By engaging the visual and the kinesthetic bank of data into the process, a richer therapy session is obtained. In relying on concrete tools during the session, impact therapists make sure that the client will have several reminders during the week to pursue the change. Impact therapy embraces the concept that the brain likes novelty and sets forth the idea that counseling should not be boring. By making psychotherapy novel, interesting, and engaging, impact therapy tends to cause clients to stay with counseling instead of giving up after one or two talk–listen sessions. In impact therapy, therapists systematically use mnemonic techniques to help clients retain and apply new understandings and new competencies.

Therapeutic Process The impact therapist tries to have impact in each session by making the session visual and concrete. The following subsections describe how a session might go, with the final subsection presenting an example. Initial Stage

A client comes in and tells the counselor why he or she is there. The counselor listens and assesses the client’s comfort with counseling; the counselor tries to gather enough information to get an idea of what the issue is. Impact therapists are taught to not listen to too many stories or to details that are not relevant for helping.

Improvisational Therapy

Contract Stage

Once the counselor has established a rapport and some idea of what is going on, a contract is formed—usually mutually agreed on by the counselor and the client, although there are times when it is obvious what the client needs. Focus and Funneling Stage

In this stage, the counselor gets the client deeper into the issue, often by using some counseling theories and multisensory techniques as in the example below. Closing Stage

The counselor makes sure that there is time to summarize what has occurred and talk about possible actions or readings before the next session.

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over, he will see “mom” written on one piece and “dad” written on the other. The therapist’s technique of labeling the puzzle pieces helps the child further explore the situation and leads to a discussion about how both parents are okay but they simply don’t fit well together. Using REBT, the counselor challenges the child’s irrational thought that “they must fit together for me to be okay.” The counselor then adds a third piece to represent the child, which fits with both the “mom” piece and the “dad” piece separately, but the three pieces do not all fit together. This often helps the child feel deeply secure as he knows from deep down inside that he will “fit” with both, and it further challenges the child’s faulty thinking. The impact therapist closes the session by hearing from the client with regard to what stood out from the session and offers the child the pieces of the puzzle to remember the session. Ed Jacobs and Danie Beaulieu

Example

During the initial stage, a 10-year-old child talks about his parents’ divorce and the feelings he has. The impact therapist listens and asks questions to get a better sense of what is happening with the parents. During the contract phase, the impact therapist sees that the child is holding on to the false hope that his divorced parents will get back together, so a contract is developed to help the child deal more realistically with his parents’ divorce. At that point, the counselor says something like “Let me help you better understand what is going on with you and your parents with regard to their divorce.” During the focus and funnel phase, the impact therapist creates a multisensory experience to address that false hope. The impact therapist gives the child two pieces of a jigsaw puzzle that don’t fit together and asks him to connect them. After trying to fit the pieces together, the boy realizes that they simply don’t fit. When the boy complains and says that something is wrong, the therapist asks him, “Which piece is wrong? Which one should change so that they could fit together?” Most of the time, the boy will come to the conclusion on his own that neither of the pieces is wrong—he can get pieces to connect using other pieces but not with the two he has. This serves as a lesson for the young client to see the situation in a different light. When the child turns the pieces

See also Cognitive-Behavioral Therapies: Overview; Creative Arts and Expressive Therapies: Overview; Ego-Oriented Therapies: Overview; Erickson-Derived or -Influenced Theories: Overview

Further Readings Beaulieu, D. (2006). Impact techniques for therapists. New York, NY: Routledge. Haley, J. (1993). Uncommon therapy: The psychiatric techniques of Milton Erickson. New York, NY: W. W. Norton. Jacobs, E., & Schimmel, C. (2013). Impact therapy: The courage to counsel. Star City, WV: Impact Therapy.

IMPROVISATIONAL THERAPY Improvisational therapy is a therapeutic orientation introduced by Bradford Keeney with his 1990 book Improvisational Therapy: A Practical Guide for Creative Clinical Strategies. As a therapeutic orientation, improvisational therapy is unique in that it is arguably the first model-free therapy. It invites practitioners to be freed from rigidly following previously established clinical methods, strategic protocols, diagnostic instruments, and interpretive frameworks that dictate how a therapy

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session ought to unfold. Instead, practitioners are encouraged to tap into their own unique creativity, imagination, and playfulness, allowing a unique therapy to be invented for each particular clinical situation. Improvisational therapy is resource focused, which means it emphasizes clients’ strengths and gifts to create positive outcomes. It is also an outcome-based orientation in which the therapist utilizes the outcome of each action or communication in a session to organize his or her next move toward bringing forth resourceful rather than impoverishing experiences for the client. The emphasis in improvisational therapy is on live clinical performance, where therapeutic explanation and interpretation are minimized in favor of attending to the creative participation of the therapist in the interaction as it unfolds in a session.

Historical Context Keeney had written his first major contribution to the field of cybernetics and its implications for the practice of systemic family therapy with his 1983 book Aesthetics of Change. This book became a seminal text in the field of family therapy, whose theory and practice at the time were inspired in large part by cybernetic and systemic epistemology, especially the work of Gregory Bateson, who had been Keeney’s mentor. Improvisational therapy was introduced by Keeney in response to the discourse that had begun to take place in the field of systemic family therapy during the 1980s, in which cybernetics was presented as an explanatory lens through which to interpret both family interaction and live clinical work, rather than a pragmatic invitation to participate more fully in the circular patterns of interaction in therapy. This shift in the discussion of the implications of cybernetics for the practice of therapy coincided with a shift in the field of family therapy away from an emphasis on systemic interaction toward an emphasis on interpretation and narrative. Seeing that the term cybernetics no longer delivered a clear distinction between circular interaction and circular interpretation, Keeney replaced the term cybernetics with the metaphor of improvisation, arguing that the latter could more readily convey the essence of cybernetics in the context of therapeutic interaction. Improvisational therapy is not a departure from the cybernetic and systemic epistemology set

forth in Aesthetics of Change; rather, it is a more pragmatic, performance-oriented articulation of how circular patterns of interaction can be effectively utilized in live clinical practice.

Theoretical Underpinnings Improvisational therapy finds its therapeutic roots in cybernetics—the study of circular patterns of organization. In the context of therapy, cybernetics examines the way human behavior and communication (including so-called problems and solutions) are held inside circularly organized patterns of interaction that include the participation of family members and/or others in the client’s relational network. The latter idea is at the heart of systemic therapy, which traditionally eschewed all forms of mental health diagnosis, preferring to work inside the relational weave of family interaction in order to effect change. Improvisational therapy extends the circular pattern of interaction to include the participation of the therapist, noting the way every interaction and communication in therapy contributes either to feeding the vicious cycles that maintain problematic experience or to feeding a virtuous circle that offers clients more possibilities, choices, and resourceful outcomes. As both a practice and an organizing principle in therapy, improvisation affirms the core contribution of cybernetics to the practice of therapy: Act to know how to act next in order to bring forth change. To put it differently, every action in therapy takes place inside the circularity that organizes the interaction between the therapist and the client. Improvisational therapy allows practitioners to participate more freely in order to serve change based on the unique interactions that arise rather than a preformed model, method, or theory that dictates how a session should unfold.

Major Concepts The core concept underlying improvisational therapy is improvisational performance, and it is argued that therapy ought to belong to the field of creative performing arts rather than the social sciences. The emphasis is on allowing therapists the freedom to creatively and spontaneously act, respond, and change in order to serve resourceful change in a session. Improvisation allows the practitioner’s

Inner Child Therapy

participation in therapy to be directed by the moment-to-moment unfolding of live interaction with a client rather than by any predetermined theoretical hermeneutics or action choreography. A key concept underlying improvisation is utilization. Here, therapists utilize the outcome of each communication during a session to direct their next action. Improvisation should not be misunderstood as inviting directionless chaos. Rather, improvisational therapists are acutely attentive to the way their actions help bring forth the circle of interaction with the client and how a therapist serves to maintain either the client’s impoverished situation or a more resourceful therapeutic reality. Improvisational therapy can be used with individuals, couples, and families in the context of brief or long-term therapies. It is characterized by creativity, imagination, and the invention of therapeutic strategies that serve change.

Techniques It can be argued that improvisational therapy is technique-free, in that it seeks to free practitioners from being hindered by particular protocols or habits of practice that develop through an emphasis on models. At the same time, improvisational therapists are free to use any therapeutic technique that may suit each unique clinical situation as it arises. In fact, improvisational therapy encourages the spontaneous invention of new therapeutic techniques as they serve the particular clinical situation at hand.

Therapeutic Process Improvisational therapy invites practitioners to consider the structure of a therapeutic session as comparable to a screenwriter’s storyboard or a three-act dramatic play, with a clear beginning, middle, and end. The beginning act typically starts with the presentation of problems or suffering, and the goal of each session is to move toward a final act that brings forth a context that holds more possibilities, choices, and resources for the client. This final act does not necessarily mark the end of therapy; it simply means that the session feels well formed or complete. To get from the beginning to the end, a session must move through a middle transition that acts as a fulcrum point, holding both the initial problem discourse as well as more

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resourceful communication. This three-part structure allows the therapist the freedom to act in relationship to the goal of moving a session toward the final act, without the need to follow a particular model or protocol. Instead, practitioners limit their interpretation to noticing whether or not their communication is feeding the problemsaturated discourse that is typical in Act I or helping the session move somewhere different—more creative or resourceful. Improvisation means that therapists are free to act in response to the interaction as it unfolds, doing so in any way that brings forth movement toward change. Hillary Keeney See also Ericksonian Therapy; Palo Alto Group; Strategic Family Therapy

Further Readings Keeney, B. P. (1983). Aesthetics of change. New York, NY: Guilford Press. Keeney, B. P. (1991). Improvisational therapy: A practical guide for creative clinical strategies. New York, NY: Guilford Press. Keeney, H., & Keeney, B. (2012). Circular therapeutics: Giving therapy a healing heart. Phoenix, AZ: Zeig, Tucker & Theisen. Keeney, H., & Keeney, B. (2013). Creative therapeutic technique: Skills for the art of bringing forth change. Phoenix, AZ: Zeig, Tucker & Theisen.

INDIVIDUAL PSYCHOLOGY See Adlerian Therapy

INNER CHILD THERAPY Inner child therapy is based on the premise that people struggle emotionally because they have unresolved issues from childhood. In this method of psychotherapy, the therapist guides the client through a deep exploration of the traumatic events of childhood and directs the client in reworking the associated troublesome emotions.

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Inner Child Therapy

Historical Context Inner child therapy became popular in the 1990s, when John Bradshaw released his best-selling selfhelp book Homecoming: Reclaiming and Championing Your Inner Child. Bradshaw constructs unresolved issues as psychological wounds and purports that inner child therapy will initiate a healing process.

Theoretical Underpinnings Inner child therapy is theoretically eclectic. Jungian theory provided the foundation for much of Bradshaw’s work. Reclamation and nurturance of the inner child, in Jungian tradition, releases creativity and promotes healing by releasing the wonder child, a Jungian archetype. Inner child therapy, however, is easily integrated into most theoretical orientations. From a psychodynamic perspective, inner child therapy provides some techniques for reworking issues that are uncovered in the exploration of early-childhood experiences. In existential terms, inner child therapy is a mechanism through which the ever-emerging self incorporates past selves. Inner child therapy easily lends itself to the missing developmental experiences identified in Adlerian theory. The techniques of inner child therapy resonate with the here-and-now experiments of Gestalt therapy. Clients often maintain a childlike perspective of childhood events and rigidly adhere to immature beliefs that emerged during traumatic experiences. Errant conclusions formed as a child become the adult cognitions that produce distress, making inner child therapy an especially good fit with cognitive-behavioral approaches. The major concepts of inner child therapy have emerged as an integration of theoretical and practical approaches.

Major Concepts The initial work of inner child therapy is to explore the dynamics and events of early development. Psychotherapy clients often present with a history of childhood abandonment, rejection, shaming, physical abuse, sexual abuse, neglect, or exposure to violence. Such clients can benefit from reprocessing the events of the past without the cognitive limitations and psychosocial crises of their childhood.

Psychosocial Development

Erik Erikson’s stages of psychosocial development and Jean Piaget’s delineation of cognitive development provide insight on how the child’s stage of development at the time of a difficult event determines how the child conceptualizes the event. The developing of trust is the task of infancy. Trust is the ability to predict, and although people do not recall their infancy, inconsistencies in caregiving interfere with their development of trust. The psychosocial tasks of young children are the development of autonomy and initiative. Children are self-centered at this preoperational stage of cognitive development and limited in their ability to take the perspective of others. When troublesome events occur, they are apt to believe that they are at fault and develop pervasive dynamics of guilt and shame. During the early school years, children are concrete in their cognitions and rigid in their interpretations. In this stage of accelerated learning, children who are not successful often internalize poor performance as personal inferiority. During adolescence, the task of identity development can be compromised by violence or sexual abuse. Victimized adolescents may identify with their perpetrators. Unresolved Childhood Issues

The inner child therapy popularized by Bradshaw draws from and synthesizes its major concepts from traditional and nontraditional therapists. In the early 1900s, Alfred Adler highlighted the importance of the missing developmental experience of childhood. In the 1950s, the psychiatrist Milton Erickson, who did not work from a specific theoretical orientation, used age regression and guided imagery in an early model of strategic therapy. In the 1970s, Eric Berne’s work in transactional analysis introduced the concept of the parent, child, and adult ego states and the possibility that the child ego state could be contaminated. In his lifescript theory, Claude Steiner described a child’s vulnerability quotient and the child’s corresponding susceptibility to injunctions inadvertently given by significant others. Reclaiming the Inner Child

The ultimate goal of inner child therapy is to heal childhood wounds and integrate the child of the past with the current adult.

Integral Eye Movement Therapy

Techniques To accomplish the acceptance and integration of the wounded child, inner child therapy incorporates psychodynamic exploration, group therapy, guided imagery, and letter writing in a four-stage process.

Therapeutic Process The therapeutic process of inner child therapy comprises four stages: (1) revisiting the trauma, (2) initiating the grief process, (3) nurturing the inner child, and (4) freeing the wonder child. Revisiting the Trauma

Initially, inner child therapy entails revisiting traumatic childhood events, understanding and grieving over the emotional losses, and developing a healthier narrative about the self. Recollection of childhood events is accomplished through deep dialogue. Clients who do not have clear memories of childhood are given an Index of Suspicion questionnaire, which associates their current constellation of symptoms with a specific stage of early development. Wounding during infancy produces symptoms with oral-stage underpinnings, such as eating disorders. Symptoms at later developmental stages are associated with addictions, trust and intimacy issues, excessive shame, and narcissism. Initiating the Grief Process

In the second stage of inner child therapy, the therapist facilitates reexperiencing the pain of the original wound. From this re-created experience, normal grief emerges, and the natural healing process begins. The role of the therapist at this stage is to validate the client’s experience and assist in the negotiation of the grief process. At this stage, the client is encouraged to handwrite a letter to his or her wounded inner child from his or her adult self, and respond from the inner child in a letter written with the nondominant hand. The therapist provides affirmations to launch the healing process. During the second stage, recovery includes participation in group therapy, 12-step recovery programs, or other self-help groups.

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Nurturing the Inner Child

The third stage of inner child therapy focuses on the internalization of a positive narrative, development of healthy relationships that break the old dysfunctional patterns, and nurturance of the inner child. Ongoing recovery often includes creating opportunities to have experiences that were missed in childhood, continued guided imagery, ongoing self-help group involvement, and the development of a family of affiliation. Freeing the Wonder Child

When the client reaches the final stage of inner child therapy, he or she should be able to access the inner child at any time to get in touch with his or her true desires and authentic feelings and to free the creative wonder child. Nicki Nance See also Ericksonian Therapy; Guided Imagery Therapy; Transactional Analysis

Further Readings Bradshaw, J. (1990). Homecoming: Reclaiming and championing your inner child. Deerfield Beach, FL: Health Communications. Haley, J. (1993). Uncommon therapy: The psychiatric techniques of Milton H. Erickson. New York, NY: W. W. Norton. Newman, B. M., & Newman, P. R. (2003). Development through life: A psychosocial approach. Belmont, CA: Wadsworth. Steiner, C. (1990). Scripts people live: Transactional analysis of life scripts. New York, NY: Grove Press.

INTEGRAL EYE MOVEMENT THERAPY Integral eye movement therapy (IEMT) is a method for reducing the intensity of negative emotional experiences. Based on eye movement integration therapy, this therapeutic approach utilizes a number of procedures to identify relevant key experiences in the client’s personal history. While concentrating on one of these key experiences, the therapist instructs the client to move his or her eyes and track the movement of the therapist’s pen or

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finger. Duration of sessions may be as short as 5 to 20 minutes or may be longer if the problem is more involved, such as when the client is struggling with identity issues. IEMT is a treatment of choice when a client’s emotional problems arise from memories of external life events over which the client had little or no control.

resolving the emotions elicited by memories, the client’s emotions become free of historical events and much more in response to present events.

Major Concepts Major concepts of IEMT are eye movement deviation, patterns of chronicity, and identity process.

Historical Context Although IEMT was founded in 2006, its origins can be traced to various eye movement therapeutic processes developed in the 1980s and 1990s. Eye movement integration therapy was developed by Connirae Andreas and Steve Andreas in 1989, and Eye Movement Desensitization and Reprocessing therapy was developed by Francine Shapiro in 1987. The “lazy-8” pattern, which has the eyes moved in a modified figure-of-eight pattern, is used in some neuro-linguistic programming trainings, and similar eye movements are used in the emotional freedom technique, developed in 1995. Various explanations exist for the mechanism of action associated with eye movement therapy, but the most consistent observation is that the intensity of the emotional component of a traumatic memory diminishes. Eye movement processes have been successfully applied in the treatment of posttraumatic stress disorder. IEMT has been applied with individuals who have experienced trauma and also in the area of identity (“who I am” vs. “how I feel”), based on David Grove’s 2005 work on exploring identity through the use of pronouns.

Theoretical Underpinnings IEMT assumes that clients have learned an emotional map that dictates both the context in which emotions are experienced and the kind and intensity of the emotion. Reducing the emotional intensity of memories of trauma using sweeping eye movements as directed by the therapist significantly improves psychological welfare by changing this emotional map that guides how the person feels. The application of IEMT is not limited to just traumatic memories but can also be applied to “memories of emotion” (i.e., remembering previous occasions when he or she felt the undesired emotion) using the same treatment process. By

Eye Movement Deviation

Eye movement deviation refers to an unconscious eye movement in which the motion of the eyes momentarily veers from what is directed by the therapist. The therapist directs the client to move his or her eyes in a specific manner while concentrating on the memory. The eyes may skip or jump across or around a particular area in the visual field. This kind of movement usually signifies that the mental representation has changed to a different aspect of the memory or to a completely different point of time in the client’s personal history. It is this deviation that indicates that a change has occurred. At this point, the therapist may either choose to carry on with the eye movements in expectation of further change or stop to recalibrate the client’s experience before deciding to carry on or discontinue. Patterns of Chronicity

Chronicity is where a problem persists over time despite attempts at therapeutic intervention. Five behavioral patterns interfere with therapeutic progress, contributing to the maintenance of emotional distress. Each of these patterns has a specific method of challenge and intervention according to the IEMT model. These interventions are designed to provoke the emotional responses that help maintain the chronicity of the problem. These patterns are (1) the three-stage abreaction process, in which negative emotions emerge and escalate at critical stages of the change process; (2) “what if” questions by the client that distract from and interfere with belief change and new belief formation; (3) the “maybe man” pattern of verbal qualification and vagueness, in which the client does not make a definite commitment with regard to his or her own experience; (4) testing for evidence of the problem while ignoring evidence of

Integral Psychotherapy

change; and (5) passivity in treatment, in contrast to being willing to be active in the process of change. Identity Process

Common issues of identity are explored and resolved using eye movements that follow an exploration of pronouns and other linguistic references to identity. For example, a client may say, “I  hate my self.” The two pronouns I and self as well as the emotion of hate can be explored using the IEMT process. The identity process has two phases: (1) elicitation using a series of questions based on the client’s use of pronouns and (2) treatment using eye movements.

Techniques The therapist opens the session with the assumption that the client has an emotion that he or she wishes to change. Rather than describing the emotion or discussing the issues around it, the therapist simply asks the client to assign a score to indicate the intensity of the feeling. This emotion is then worked with using the IEMT processes. During the entire interaction, the therapist is listening and observing for indicators of the patterns of chronicity and will challenge these accordingly. The primary intention of the IEMT practitioner is to observe emotional responses to these challenges and then work with these emotions using the IEMT eye movement process.

Therapeutic Process Problematic emotions are identified, and recall of these emotions is paired with eye movements. There are six components to this process: (1) the client identifies a problematic emotion; (2) the client is asked how familiar this emotion is; (3) the client recalls the earliest experience of this emotion; (4) the client is asked, “How vivid is this memory?”; (5) the client focuses on this memory while eye movements are used; and (6) the client is asked to recall the memory and notice any change in feeling response (testing). The eye movements are brought about by the  therapist using his or her forefinger to direct the eyes out to the peripheries of vision while the

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therapist observes for a deviation that suggests that change has occurred. Sessions using only IEMT can be very short, ranging from 5 to 20 minutes in duration, depending on how many different emotional issues are addressed. Practitioners often use the IEMT processes intermittently with other therapies as relevant issues arise. Clients may be instructed to experiment with the IEMT process for themselves as homework in order to continue the work after, or in between, sessions. Andrew T. Austin See also Eye Movement Desensitization and Reprocessing Therapy; Eye Movement Integration Therapy; NeuroLinguistic Programming

Further Readings Andreas, S. (1993). Demonstration with a Vietnam veteran with PTSD [Video demonstration]. Boulder, CO: Real People Press. Beaulieu, D. (2003). Eye movement integration. Williston, VT: Crown House.

INTEGRAL PSYCHOTHERAPY Integral psychotherapy has emerged in the past two decades as a holistic, unified, and integrative approach to counseling derived from writer Ken Wilber’s integral theory and most notably developed by Andre Marquis, Elliott Ingersoll, and Mark Forman. One of the distinguishing features of integral counseling is its emphasis on viewing and conceptualizing phenomena from multiple perspectives rather than reductionistically privileging one or two perspectives. As such, it recognizes the “true but partial” nature of most extant counseling approaches and draws heavily from a number of traditions, including psychodynamics, behaviorism, existential-humanism, family systems, transpersonal, and biomedical approaches. In addition, it draws from other integrative and unified approaches, such as cyclical psychodynamics, emotion-focused therapy, developmental constructivism, and accelerated experiential dynamic psychotherapy. Also, spirituality occupies a central role within this unified system. A fundamental goal

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of integral counseling is to facilitate counselors’ appreciation of the disparate dimensions of people and their circumstances.

Historical Context Wilber initially developed his work within the context of transpersonal psychology, a field in which he is considered a leading theorist. While much of his writing over the past two decades has shifted in focus, his work continues to prominently address the transpersonal dimensions of human experience. Transpersonal psychology emerged from humanistic psychology, distinguishing itself from the latter with its focus on spiritual issues as well as the contemplative, mystical, and other transcendent aspects of human nature. Transpersonal means “beyond the personal” and involves individuals moving beyond the sense of being a separate “self” and thus experiencing deeper connections to, or identification with, others, the natural world, and the universe. Influential transpersonal psychologists include William James, Carl Jung, Roberto Assagioli, and Abraham Maslow.

Theoretical Underpinnings One of the conceptual foundations of Wilber’s integral theory is that of perennial philosophy, which is often referred to as the essential core of the world’s great spiritual, or wisdom, traditions. Among the core claims of this perspective is that the material, known world that most people would typically agree is real is not as “real” as the nonmanifest, spiritual source, also called the Ground of Being. In other words, according to Wilber, the spiritual Ground of Being is more real than the physical world we observe. Perennial philosophy also suggests that humans can not only know this truth, or reality, directly—in contrast to conceptual knowledge—but that they can also realize their ultimate identity as the spiritual source or ground. Another core claim of perennial philosophy is that reality is organized as a great chain or nest of being. This great chain involves continuous levels of being and knowing that range from matter (physics), to body (biology), to mind (psychology), to soul (theology), to spirit (mysticism). Several of the key developers of integral counseling are agnostic and, therefore, are skeptical about some of the spiritual aspects regarding the nature of

reality that Wilber posits. These agnostic contributors to the approach state that it is not necessary to believe the specific spiritual claims to identify as an integral counselor. Wilber’s work has developed through five phases. Phase 1 is the Romantic-Jungian phase and conceives of spiritual development as a return to what was present in early childhood but was lost as a person developed into an adult. Phase 2 involves a shift away from the “return-to-the-past” view to a framework more like Western developmental psychology. This phase also includes Eastern and other contemplative stages; in it, spiritual development is viewed as something that emerges only after adult mental faculties have been achieved. Phase 3 introduces the notion of lines of development, which posits that development involves multiple aspects or lines (e.g., cognitive, moral, emotional, interpersonal, and spiritual) that develop quasi-independently as opposed to being a singular process. Phase 4 introduces the idea of the four quadrants, which reveals that all phenomena have, and can be viewed from, four different dimension-perspectives. Phase 5 is postmetaphysical in that Wilber attempts to demonstrate that transpersonal dimensions of human experience are a function of structures of consciousness that themselves have developed throughout evolutionary history, in contrast to preexisting archetypal structures that exist independent of the subjects experiencing them. At the heart of integral theory’s integrative, unifying potential is the tenet that all phenomena can be viewed from four different perspectives (Phase 4). The four perspectives are the interiorindividual, the exterior-individual, the interiorcollective, and the exterior-collective (see Figure 1). Historically, most counseling approaches emphasize one of these quadratic perspectives rather than recognizing the significance of incorporating all of the quadrants into counseling. For example, classical psychoanalysis and person-centered therapy emphasize the experiential (interior-individual) quadrant; behavioral and biomedical approaches emphasize the behavioral (exterior-individual) perspective; feminist, diversity, and relational psychodynamics emphasize the cultural (interiorcollective) perspective; and family systems and social justice approaches emphasize the social (exterior-collective) perspective. Integral theory posits that each of these approaches captures

Integral Psychotherapy

Upper Left: Interior-Individual

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Upper Right: Exterior-Individual

First person/self/consciousness/subjectivity

Third person/brain/organism/objectivity

Classical psychoanalysis, person-centered counseling

Behavioral and biomedical therapies

Experience—as felt “from the inside”

Behavior—as seen “from the outside”

General epistemology: phenomenology

General epistemology: empiricism

• • • • • • • •

• Any noteworthy patterns of behavior: what specific behaviors bring the patient to therapy and what specific behaviors will indicate a successful outcome • Medical disorders • Medication • Diet • Alcohol and/or drug use • Aerobic and/or strength training • Patterns of sleep and rest • Consciousness as described by neurotransmission and the functioning of brain structures • Observable changes in, for example, depression: appears tearful, no longer engages in pleasurable activities, significant weight loss or gain, psychomotor agitation or retardation, lower levels of available serotonin, social withdrawal

• • • •

Any noteworthy patterns in the patient’s self-experience Self-image, self-concept Self-esteem, self-efficacy Instability/stability Joy, zest, purpose, motivation Depression, sadness, emptiness Anxiety, “jitters,” feeling “revved up” Cognitions (e.g., thoughts, beliefs, attitudes, interpretations) Imagery Political, religious, and/or spiritual beliefs and/or experiences Consciousness as experienced as mind The experience of, for example, depression: sadness, loss of interest in pleasurable activities, fatigue, feelings of worthlessness, difficulty concentrating, frequent thoughts of death, suicidal ideation, etc.; also how one interprets events such as the death of a loved one, divorce, profound loss, or child birth Lower Left: Interior-Collective

Lower Right: Exterior-Collective

Second person/culture/worldview/intersubjectivity

Third person/social systems/environment/interobjectivity

Relational psychodynamics, feminist and diversity approaches

Family systems and social justice approaches

Cultural worldview—the group’s experience “from the inside”

Social systems—the group’s behavior “from the outside”

General epistemology: hermeneutics

General epistemology: systemic/ecological analyses

Figure 1 Selected Aspects of the Four Quadrants Pertinent to Counseling Source: Adapted from “What Is Integral Theory?” by A. Marquis, 2007, Counseling and Values, 51(3), pp. 164–179. doi:10.1002/ j.2161-007x.2007.tb00076.x

important truths about human nature, pathology, and treatment yet each is only partially true because it does not account for other important variables and dynamics disclosed from the other quadratic perspectives. In integral theory, each quadrant provides a perspective that may be central to any given client’s suffering and positive change. Thus, from an integral perspective, counseling without taking into account all four quadratic perspectives is incomplete and fails to capture the multiple dimensions of human nature and experience. An integral view allows potentially contradictory counseling approaches, like behaviorism and feminist therapy, to fit together

so that they complement each other with their different perspectives and interventions.

Major Concepts Wilber developed several influential concepts that have contributed to integral psychotherapy. The Spiritual Nature of Human Nature

In this approach, the deepest nature and ultimate identity of each person is Spirit—the source, ground, and cause of all existence. Even if we are unaware of our ultimate nature and of what

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drives us, we are motivated to realize—or become aware of—our ultimate spiritual nature. Such realization is a developmental process that involves disidentifying exclusively with one’s present level of consciousness, identifying with the next level, and then integrating the essential aspects of those levels. A given person’s development is rarely manifested or experienced as simply as this logic of development explicates, in part because in addition to being “pulled from above,” we are also “pushed from below,” wherein people are often more concerned with acquiring substitute gratifications such as money, sex, food, power, and fame, This push and pull is evidence of another human potential—that is, failure to develop or realize our spiritual nature. The Spectrum of Development: Structures of Consciousness

According to Wilber, the Great Nest of Being reveals itself in humans as levels, stages, or waves of development; these are the structures (patterns) of consciousness. The term levels emphasizes that each stage occurs in a specific sequence and is qualitatively distinct from other stages and that each subsequent stage is more complex than prior stages. The word waves underscores the fluid nature of the stages of development; rather than being separate, stairlike, or rigid, they flow through one another. Structures connotes the relatively stable, holistic, and integrated nature of each stage. This approach incorporates a comprehensive model of human development, spanning from  prepersonal, to personal, to transpersonal/suprapersonal realms (each including three to four stages). The prepersonal, or bodily, realm involves infancy and early childhood, in which development is primarily a matter of physical and emotional differentiation. Here, a child’s psychological sense of self (or person) has not fully emerged; hence it is “prepersonal.” The personal, or mental, realm involves later childhood and early adulthood, in which development is primarily mental (learning mental rules and social rules). In this realm, selfhood is increasingly coherent, autonomous, and stable; hence, it is “personal.” The transpersonal, or spiritual, realm involves the remainder of life, and development is primarily a process of realizing that one’s ultimate identity is a spiritual Self that transcends the separate, personal self; hence, it is “transpersonal” or “suprapersonal.”

Another key thesis of Wilber’s theory is that each level of development is associated with a correlative psychopathology as well as an optimal treatment approach. Because the four quadrants and a full spectrum of developmental levels are central to Wilber’s model, integral theory is often referred to as AQAL, or all-quadrants, all-levels. AQAL also stands for all-lines, all-states, and all-types. Lines of Development

Development is not a single, monolithic process. Rather, Wilber posits that humans have multiple aspects (lines) and that each develop quasi-independently of one another. Some of these lines are cognition, morality, emotion, selfidentity, needs, object relations, values, worldview, and spirituality. States of Consciousness

In contrast to developmental stages—which are relatively stable, enduring traits—states of consciousness are much more fleeting and temporary. In addition to nonordinary states of consciousness (e.g., those induced by meditation, electroencephalogram biofeedback, drugs, fasting, etc.), people experience various states of consciousness that “come and go.” Most emotional and motivational experiences are states of consciousness, as are many clients’ presenting problems. In other words, most episodes of mania, depression, psychosis, or anxiety are episodic rather than permanent, stable traits. Personality Types

Independent of their level of development, individuals have certain personality types, or styles of behaving and being in the world. Some personality types may better handle some situations or types of work than others may; however, in general, no specific personality type is consistently privileged over the others. Self-System

The self, or self-system, is a key structure— being not only the center of each person’s psychological universe but also responsible for essential psychological functions. These functions include (a) organizing and providing coherence to

Integral Psychotherapy

experience, (b)  identifying with select aspects of experience, (c)  metabolizing—or psychologically digesting—one’s experience, (d) navigating one’s way through life and developmental processes, (e) willing choices and initiating action, (f) defending against aspects of experience that threaten one’s sense of self, and (g) balancing and integrating the various levels, lines, and states. Integrally Informed Counseling

Many integral therapists now prefer to call themselves integrally informed therapists, because integral theory provides principles to guide one’s conceptualization and practice without exact prescriptions for how to counsel. For example, many clinicians who call themselves integral or integrally informed therapists practice in a deeply psychodynamic or existential manner, whereas others are more cognitive or cognitive-behavioral. These therapists would contradict the basic premises of integral theory only if they fail to incorporate each quadrant, or the levels, states, lines, or types that are relevant to a given client.

Techniques Because integral (or integrally informed) counseling is not so much a distinct theoretical approach as it is a distinct metatheoretical approach, integral counselors draw from the entire spectrum of psychotherapeutic techniques, from exposure and empty chair work to analysis of transference and cognitive restructuring. Moreover, the same integrally informed counselor may appear quite person centered with one client and quite behavioral and directive with another, based on different client dynamics or developmental needs. Because integral counselors have so many interventions to choose from, Andre Marquis created the Integral Taxonomy of Therapeutic Interventions (ITTI), which categorizes more than 200 interventions within the AQAL model; the ITTI offers suggestions regarding the use of counseling interventions. Integral counselors draw heavily from contemplative spirituality and use many different forms of meditation and contemplative prayer with their clients. In addition to interventions that derive from previously established approaches (whether counseling or spiritual traditions), integral counselors have developed several unique interventions, such as Integral Life

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Practices (ILPs). Wilber suggested that the most likely path to significant transformation is through the simultaneous expression of every feasible aspect of the person (i.e., from body, emotions, and mind to soul and spirit). This intensive developmental practice is a form of psychospiritual cross-training. Accordingly, counselors use ILPs to combine multiple dimensions of development, tailored to each client and tentatively offered as a method to promote optimal transformation.

Therapeutic Process Most therapists begin counseling with an intake assessment, either formal or informal. The “Integral Intake” is a comprehensive, researchsupported idiographic assessment form organized by the AQAL model. The form or process of integral counseling can vary tremendously, from very brief and coping-focused to long-term, transformative, in-depth work. Integral counseling also varies as a function of whether the therapeutic work is focused on translation (horizontal growth that involves changing surface structures within the client’s current developmental stage) or on  transformation (vertical development that involves changing deep structures, which entails a shift to the next developmental stage). Often, what is most relevant and important is to help clients stabilize and optimize their functioning at their current level of development, which is translative work. However, for those clients motivated to do the significant work involved, integral counselors also foster their developmental transformations. In either case, Wilber posited that the key factor, or curative catalyst, in the change process is awareness. In other words, only by becoming conscious of an aspect of experience that has been, or is being distorted, ignored, or denied can the self possibly differentiate from and then integrate it in a healthy manner. Based on a recent study of integral therapists, it appears that the type of awareness needed for significant change is much more than mere conceptual insight. Rather, it seems that the awareness must be a visceral, immediately felt sense more akin to a deep bodily or emotional appreciation than simply an intellectual awareness. A significant aspect of such deep awareness, and a technique that integral counselors frequently use, is the process of making what one is currently

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embedded in (and thus subject to) an object of one’s awareness. For example, rather than view and react to the world from various unacknowledged assumptions or emotions, such assumptions and emotions are made objects of one’s awareness; in this manner, one can gain clarity and understanding so that one has the freedom to perceive and act differently if one so chooses. Integral counselors tend to be deeply immersed in their own personal and spiritual development, and this is reflected in their lifelong practice of their own ILPs. Accordingly, they often view counseling as a sacred practice, one in which they join with, empathically attune to, and compassionately care for their clients in an effort to help them diminish their suffering (or harvest as much wisdom as possible from it) and maximize their well-being. The integral counseling perspective emphasizes that the counselors’ presence, capacity for compassion, genuineness, empathy, and positive regard are fundamental functions of their own personal and spiritual development. Primary to any other component of integral psychotherapy is the counselor’s recognition of clients as beings worthy of dignity, compassion, and care.

Ingersoll, R. E., & Rak, C. F. (2006). Psychopharmacology for helping professionals: An integral exploration. Toronto, Ontario, Canada: Thomson Brooks/Cole. Ingersoll, R. E., & Sink, C. (Eds.). (2007). Integral theory in counseling [Special issue]. Counseling and Values, 53(3), 162–234. Ingersoll, R. E., & Zeitler D. A. (2010). Integral psychotherapy: Inside out/outside in. Albany: State University of New York Press. Marquis, A. (2008). The integral intake: A guide to comprehensive idiographic assessment in integral psychotherapy. New York, NY: Routledge. Marquis, A. (2009). An integral taxonomy of therapeutic interventions. Journal of Integral Theory and Practice, 4(2), 13–42. Marquis, A. (2013). Methodological considerations of studying a unified approach to psychotherapy: Integral methodological pluralism. Journal of Unified Psychotherapy and Clinical Science, 2(1). Marquis, A., & Wilber, K. (2008). Unification beyond eclecticism and integration: Integral psychotherapy. Journal of Psychotherapy Integration, 18(3), 350–358. doi:10.1037/a0013560 Wilber, K. (2000). Integral psychology: Consciousness, spirit, psychology, therapy. Boston, MA: Shambhala.

Andre Marquis See also Developmental Constructivism; ExistentialHumanistic Therapies: Overview; Integrative Approaches: Overview; Meditation; Non-Western Approaches; Transpersonal Psychology: Overview; Unified Theory; Unifying Nonlinear Dynamical Biopsychosocial Systems Approach

Further Readings Du Plessis, G. P. (2012). Integrated recovery therapy: Toward an integrally informed individual psychotherapy for addicted populations. Journal of Integral Theory and Practice, 7(1), 124–148. Fall, K., Holden, J. M., & Marquis, A. (2010). Theoretical models of counseling and psychotherapy (2nd ed.). New York, NY: Routledge. Forman, M. (2010). A guide to Integral psychotherapy: Complexity, integration, and spirituality in practice. Albany: State University of New York Press. Ingersoll, R. E., & Marquis, A. (2014). Understanding psychopathology: An integral perspective on etiology and treatment. Columbus, OH: Pearson Merrill Prentice Hall.

INTEGRATIVE APPROACHES: OVERVIEW Integrative therapies consist of a broad range of therapeutic approaches that are not confined by the “pure forms” of a single theoretical framework. Although the various integrative psychotherapies are quite diverse, all of them share a similar goal— that of transcending a “one-size-fits-all” mentality and incorporating sundry ways of conceptualizing and intervening so that the applicability, effectiveness, and efficiency of psychotherapy are enhanced. Although the previous proliferation and fragmentation of literally hundreds of therapies had clearly become unmanageable, a clear consensus has emerged that no single integrative approach has demonstrated superiority over other integrative approaches. Thus, most integrative therapists emphasize the process of continued exploration and development of psychotherapy integration, rather than the establishment of a dominant integrative approach. In fact, all of the leaders of the integrative movement have stressed the open-ended

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and ever-developing nature of psychotherapy integration, which should ensure that it will continue to evolve as new research and ideas emerge.

Historical Context Rivalry and sectarianism characterized the different single-school, or pure-form, psychotherapies in the first half of the 20th century. Given that differing schools of psychotherapy commonly incorporated knowledge and methods from disciplines such as medicine, the natural and social sciences, and philosophy and literature, it was particularly ironic that most therapists were ignorant of, or hostile to, alternative psychotherapeutic systems. Jumping forward, there are now hundreds of distinguishable psychotherapies; however, very little research demonstrates the consistent superiority of one single-school approach or intervention over the others; examples to the contrary—such as the superiority of exposure approaches for specific phobias—are far more the exception than the norm. Given this situation, for the past three decades, the majority of English-speaking therapists have reported practicing eclectically or integratively, because they perceive the limits and drawbacks of practicing solely within the parochial confines of any of those single-school approaches to outweigh the benefits that such pure-form therapies have to offer. Many current students of counseling and psychotherapy find it hard to believe how intolerant the preceding generations of therapists were of theories and interventions of approaches other than their own. In 1950, John Dollard and Neal Miller recast psychoanalytic therapies in the concepts and language of behaviorism, which resulted in modifying traditional psychoanalytical technique. Frederick Thorne’s work in the late 1950s is often considered the inauguration of eclecticism in counseling and psychotherapy, and a decade later, Arnold Lazarus articulated a comprehensive technical eclecticism. In the early 1970s, Jerome Frank initiated what would become the common factors approach with his classic Persuasion and Healing; in it, he argued that change in psychotherapy involves a healing setting in which a special form of a trusting, safe, and emotionally charged relationship is cultivated in which therapeutic rituals based on a sound theoretical rationale occur. A few years later, Paul

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Wachtel authored the classic theoretical integration of psychoanalysis and behaviorism. In 1980, Sol Garfield and Marvin Goldfried published key integrative works. Since the founding of the Society for the Exploration of Psychotherapy Integration in 1985, five different integrative approaches—each with numerous different subtypes—have been developed and are now well established: (1) eclecticism, (2) common factors, (3) theoretical integration, (4)  assimilative integration, and (5) metatheoretical integration (the latter is sometimes considered synonymous with “unified” psychotherapies); these are described in more detail subsequently. The International Journal of Eclectic Psychotherapy was published from 1982 to 1986, and then, its name was changed to the Journal of Integrative and Eclectic Psychotherapy (published from 1987 to the present); the Journal of Psychotherapy Integration has been published since 1991; and the Journal of Unified Psychotherapy and Clinical Science has been published since 2012.

Theoretical Underpinnings Discussing the theoretical underpinnings of a class of counseling and psychotherapy approaches that, by definition, combine more than one theoretical approach is difficult. For this reason, the five different categories of integrative approaches are each discussed separately in this section. Eclecticism

Eclecticism, the most common form of integration, attempts to provide a specifically tailored treatment for each individual and his or her specific issues. The determination of the treatment approach is guided not only by theory but also by research and/or what has been beneficial in previous work with similar clients with similar problems; for this reason, its foundation has been described as “actuarial,” in contrast to theoretical. Technical and systematic eclecticism evolved as a response to concerns pertaining to the haphazard nature of unsystematic eclecticism (or syncretism); the former involves utilizing techniques derived from a theory other than one’s own guiding theory, which affords the therapist an expanded and flexible technical repertoire that is drawn from the

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empirical literature. Exemplars of eclecticism include the works of Arnold Lazarus, John Norcross, Larry Beutler, and John Clarkin.

consistent, coherent structure that differs from either of its constituent parts. Exemplars of theoretical integration include the works of Paul Wachtel and Anthony Ryle.

Common Factors

Followers of the common factors approach, the commonians, argue that a significant percentage of the effectiveness of the different counseling approaches is due to what those diverse approaches have in common with one another, in contrast to their unique, specific differences. This position is corroborated by numerous meta-analyses of psychotherapy outcome studies that have demonstrated that as little as 15% of clients’ improvement is due to the specific interventions or single-school approaches to which many counselors hold allegiance. Some of the common factors that appear to be therapeutic to clients are empathy, warmth, congruence, being helped to understand their problems, being encouraged to practice facing those things that disturb them, having the opportunity to speak to an understanding person, being helped to understand themselves, the personhood of the counselor, and the Hawthorne effect (people often improve due to having special attention devoted to them). Overall, the commonians believe that the most helpful forms of counseling will emphasize those therapeutic elements that are common to all, or most, forms of counseling, while also acknowledging and implementing theory-specific, unique interventions as needed. Exemplars of common factors include the works of Jerome Frank, Sol Garfield, Bernard Beitman, Bruce Wampold, Scott Miller, Barry Duncan, and Mark Hubble. Theoretical Integration

Theoretical integration has been characterized as both the most important and sophisticated integrative approach as well as overly ambitious; the latter is asserted because most theoretical approaches contain philosophical assumptions that are incompatible with other approaches. The theoretical integrationist attempts to synergistically integrate two or more of the pure theories, along with their associated interventions. Although it is usually impossible to integrate the totality of different systems, the essential components of different theories can be synthesized into a new, internally

Assimilative Integration

Assimilative integration involves counselors who—while being firmly grounded in a single, preferred counseling approach—include and incorporate (assimilate) interventions or perspectives from other counseling approaches (provided that they do not contradict the premises and intentions of one’s “home theory”—their preferred way of thinking about human nature, factors and dynamics of human development, change processes within counseling, etc.) into their preferred mode of theory and practice. In accordance with Jean Piaget’s descriptions of assimilation and accommodation, this approach does not require counselors to fundamentally alter the theoretical conceptualizations of their home theory. Exemplars of assimilative integration include the works of Stanley Messer, Jeremy Safran, George Stricker, Jerry Gold, and Louis Castonguay. Metatheoretical Integration

Metatheoretical integration (unified psychotherapies) is the most appropriate category for transtheoretical therapy, integral psychotherapy, and developmental constructivism. Meta refers to that which is beyond, transcending, or more comprehensive. Thus, metatheories are theoretical frameworks of a more comprehensive order—at a higher level of abstraction—than traditional single theories. A key advantage of this higher level of abstraction is that, unlike single theories, which necessarily disagree with or contradict other single theories on key points, metatheories operate from a conceptual space beyond the single-school theories such that their organizing principles allow the different therapies to complement, rather than contradict, one another. These metatheoretical approaches also allow utilizing and capitalizing on the strengths of both single-school approaches and other integrative approaches. Exemplars of metatheoretical integration include the work of James Prochaska, Carlo DiClemente, Michael Mahoney, Andre Marquis, Elliott Ingersoll, and Mark Forman.

Integrative Approaches: Overview

Recently, Jeffrey Magnavita and Jack Anchin formally inaugurated the unified psychotherapy movement, and they argue that unification is the fourth developmental wave in the history of psychotherapy (the first three are single-school approaches, the rapprochement that characterized early eclecticism, and the maturation of psychotherapy integration). Unified psychotherapies—of which there are many—have in common the utilization of a metatheoretical, systemically derived biopsychosocial framework that takes into account all (or as many as possible) levels of the human and its various ecological systems, as well as their complex interactions. Metatheoretical integration and unification are not completely synonymous; technically, the former is a method for achieving unification. Exemplars of unified psychotherapies include the works of Magnavita, Anchin, Gregg Henriques, David Allen, and Marquis.

Short Descriptions of Integrative Therapies Accelerated Experiential Dynamic Psychotherapy

This short-term dynamic therapy integrates attachment theory, neuroscience, constructivism, and emotion theory (among others) and emphasizes the inherently transformational nature of core affect, which is defined as the visceral, emotional experience that emerges when defenses are in abeyance.

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Cognitive Analytic Therapy

This time-limited approach integrates aspects of cognitive and psychodynamic therapies. It provides a relational model of personality development and psychopathology in which the self is socially constructed. Common Factors in Therapy

One of the major approaches to psychotherapy integration, this approach rests on the evidence that much of the effectiveness of the different therapies is a function of what those different approaches have in common with one another, for example, a therapeutic relationship, the provision of feedback, and creating hope and expectancy. Contextual Therapy

Combining techniques and concepts from several systemically based theories as well as psychodynamics, contextual therapy facilitates clients’ understandings of the systemic patterns, loyalties, entitlements, and obligations that developed within their family relationships and helps them make constructive changes. Cyclical Psychodynamics

One of the major forms of psychotherapy integration, assimilative psychotherapy integration involves incorporating—assimilating—various techniques and concepts from other approaches into one’s preferred, or home, theoretical approach.

Arguably the quintessential theoretical integration, this approach integrates psychodynamic, behavioral, systems, and experiential therapies and emphasizes how many people’s difficulties derive from vicious circles in which internal states (e.g., affect, assumptions, expectations, wishes) and external behaviors and contexts reciprocally influence one another. Many interventions—from insight to exposure—are used to break such vicious circles.

Biopsychosocial Model

Developmental Constructivism

Introduced within the medical field by George Engel in the 1970s, this general systems approach urges practitioners not only to attend to the biomedical aspects of disease but also to understand the ways in which psychological and social components interact with biological factors in the etiology, course, and treatment of disease, as well as the patient’s experience of them.

Developmental constructivism emphasizes the complex, nonlinear dynamics involved in human change processes—from humans’ active construction of their sense of self and the world, through the pervasive and mostly tacit nature of organizing (structuring) processes, to compassion as the foundation from which to assist clients with regard to both their immediate needs and their lifelong development.

Assimilative Psychotherapy Integration

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Developmental Counseling and Therapy: Theory and Brain-Based Practice

Eye Movement Desensitization and Reprocessing Therapy

This theory of assessment and treatment emphasizes the following: (a) that relationships and knowledge are co-constructed, (b) the application of Piagetian stages of cognitive development, (c)  the importance of culture in the counseling relationship, (d) the centrality of neuroscience in counseling, and (e) the importance of matching treatment to each client.

This approach views many mental health issues as deriving from the brain’s inadequate information processing of traumatic experiences and memories thereof. Eye Movement Desensitization and Reprocessing therapy consists of eight phases within a three-pronged process of identifying and processing (1) memories of traumatic or other detrimental experiences that have resulted in the present problems, (2) current circumstances that trigger disturbance, and (3) skills that provide constructive memory templates for more adaptive functioning.

Eclecticism

One of the major approaches to psychotherapy integration, eclecticism aims to tailor treatment specifically to each client. Although it tends to be atheoretical, its proponents stress the need to blend techniques and concepts from divergent approaches in a flexible yet systematic—rather than in a haphazardly syncretic—manner. Emotion-Focused Therapy

This evidence-based integration of personcentered, experiential, constructivist, and psychodynamic approaches works directly with clients’ emotions to help clients become aware of, express, regulate, reflect on, and transform their emotions. Emotions are viewed as primary organizers of people’s lives and relationships, and the meanings they construct.

Integral Psychotherapy

Integral psychotherapy is an interdisciplinary, unified approach that emphasizes the importance of viewing and conceptualizing human nature, suffering, and treatment from multiple perspectives. With only a handful of unifying constructs—most notably the four quadrants, levels of development, and states of consciousness—it coherently organizes numerous, apparently contradictory counseling theories and their associated interventions. Integrative Forgiveness Psychotherapy

This approach emphasizes that unforgiveness— grievances, judgments, and attack thoughts against oneself, life, and others—is the core dynamic underlying all other problems; thus, the solution is forgiveness.

Evidence-Based Psychotherapy

Considerable controversy surrounds what constitutes evidence-based psychotherapy. Some emphasize the need for demonstrated efficacy in controlled clinical trials with clients who have specific disorders as classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM). By contrast, the American Psychological Association, since 2005, has defined evidence-based practice in psychology as the integration of (a) the best available research— which includes but is not limited to controlled clinical trial research—with (b) clinical expertise and (c) the client’s culture, preferences, and characteristics.

Integrative Milieu Model

This intensive approach for clients with severe psychological distress views problems as expressions of deep emotional pain, not of medical disease. Thus, treatment involves promoting empathy, respect, and community so that the client’s humanity and well-being, as well as the meanings of the suffering, are promoted. Interpersonal Psychotherapy

This evidence-based, time-limited approach posits that most psychiatric conditions derive from problematic dynamics within interpersonal relationships.

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It has been used in the treatment of various disorders, including depression, bipolar disorder, and chronic pain.

key insights from the major perspectives can be assimilated and integrated into a coherent whole and thus effectively guide the process of psychotherapy.

Multimodal Therapy

Unified Therapy

This technically eclectic, systematic, and comprehensive approach is grounded largely in social learning theory. Emphasizing the importance of flexibly accommodating treatment to each client, multiple dimensions of the person—represented by the acronym BASIC I.D.: behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biology—are assessed and treated.

Unified therapy is an integration of psychodynamic, cognitive-behavioral, and family systems concepts and techniques. It is designed for the psychotherapy of adult individuals exhibiting selfdestructive behavior patterns and addresses the interpersonal triggers to acting-out behaviors typical of those found in Clusters B and C personality disorders as noted in DSM-V. The ideas on which the integration is based are derived from dialectical philosophy and epistemology.

Multitheoretical Psychotherapy

This approach utilizes strategies from seven different therapies that correspond to three domains of functioning (thoughts, feelings, and actions) that are influenced by four contextual dimensions (interpersonal patterns, cultural contexts, social systems, and biology). Positive Psychology

This interdisciplinary field of study, which is a subdiscipline of psychology, explores and promotes well-being, meaning, and strengths. It includes psychotherapy treatments for clients diagnosed with mental disorders as classified in the DSM and coaching interventions for clients who want to flourish and be more successful yet do not have a diagnosable mental disorder. Transtheoretical Model

This approach has demonstrated that human change processes occur through stages and that a client’s stage of readiness for change is a key variable influencing the form of treatment processes and principles that will most effectively promote positive change for that given client at a given time. Unified Theory

The unified theory offers psychotherapy an integrative metatheoretical approach that defines and organizes the science of human psychology such that

Unifying Nonlinear Dynamical Biopsychosocial Systems Approach

The unifying nonlinear dynamical biopsychosocial systems approach to personality, psychopathology, psychological health, and psychotherapy merges multiple influences, particularly systems theory, the biopsychosocial model, holistic approaches, the interpersonal tradition, psychotherapy integration, evidence-based practice, and solution-focused strengths-based psychotherapy. Emphasis is placed on highly tailored treatment to help the client initiate or resume effective pursuit of emotionally meaningful goals centered on agency (the sense of self) and/or communion (relatedness to others) through developing healthier processes for regulating the self and the social environment. Andre Marquis See also Accelerated Experiential Dynamic Psychotherapy; Assimilative Psychotherapy Integration; BöszörményiNagy, Ivan; Cognitive Analytic Therapy; Common Factors in Therapy; Contextual Therapy; Cyclical Psychodynamics; Developmental Constructivism; Developmental Counseling and Therapy: Theory and Brain-Based Practice; Eclecticism; Emotion-Focused Therapy; Evidence-Based Psychotherapy; Eye Movement Desensitization and Reprocessing Therapy; Integral Psychotherapy; Integrative Forgiveness Psychotherapy; Integrative Milieu Model; Interpersonal Psychotherapy; Lazarus, Arnold;

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Multimodal Therapy; Multitheoretical Psychotherapy; Positive Psychology; Seligman, Martin; Shapiro, Francine; Transtheoretical Model; Unified Theory; Unified Therapy; Unifying Nonlinear Dynamical Biopsychosocial Systems Approach

Further Readings Anchin, J. C., & Magnavita, J. J. (2006). The nature of unified clinical science: Implications for psychotherapeutic theory, practice, training, and research. Psychotherapy Bulletin, 41(2), 26–36. doi .org/10.1037/e565822006-007 Marquis, A. (2013). Methodological considerations of studying a unified approach to psychotherapy: Integral methodological pluralism. Journal of Unified Psychotherapy and Clinical Science, 2(1), 45–73. Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration. New York, NY: Oxford University Press. Stricker, G., & Gold, J. (Eds.). (2006). A casebook of psychotherapy integration. Washington, DC: American Psychological Association. Stricker, G., & Gold, J. (Eds.). (2013). Comprehensive handbook of psychotherapy integration. New York, NY: Springer. Unified Psychotherapy Project. (2014). Home page. Retrieved from http://www.unifiedpsychotherapyproject.org

INTEGRATIVE BODY PSYCHOTHERAPY Integrative Body Psychotherapy (IBP) is a body–mind psychotherapy. It is based on the understanding that the body and the mind are not separate and that they must be worked with simultaneously for any authentic, lasting change of depth. Awakening somatic presence involves more than muscles and tissues; it embodies a profound energetic essence of being, sometimes called one’s spirit, soul, life force, chi, core, or authentic sense of self. The primary emphasis of IBP is to provide the tools to create heightened aliveness and a connection to an authentic, underlying state that provides a stable sense of self, well-being, authenticity, and mental and emotional clarity.

taught psychology while he was Director of Counseling at the University of the Pacific School of Dentistry. At the center of the human potential movement at Esalen Institute, he studied with wellknown masters such as Fritz Perls, Abraham Maslow, Alexander Lowen, John Pierrakos, Rollo May, Carl Rogers, Moshé Feldenkrais, and Ida Rolf. He participated in a number of therapies, including analytical, Gestalt, Reichian, and object relations. He became a Gestalt trainer at the San Francisco Gestalt Institute and became internationally known for his work on human sexuality after publishing his book Total Orgasm. He has received many honors for his contribution as one of the pioneers in the development of body psychotherapy. He wrote Body Self and Soul with Dr. Marjorie Rand and established the IBP Central Institute professional training program. In 1986, Beverly Kitaen Morse, Ph.D., became Executive Director of the IBP Central Institute and codeveloper of IBP theory and practices. As her thesis, Morse developed, with Rosenberg, the IBP couple’s somatic psychotherapy to keep love and sexuality alive and fulfilling. They cowrote The Intimate Couple, providing body–mind health skills to awaken the body and the sense of self for enhancing mutuality and limbic attunement and for resolving battlegrounds and emotional betrayals.

Theoretical Underpinnings Three major concepts underlying IBP are understanding (1) the body–mind connection, (2) how breath and movement are related to healing, and (3) the importance of somatic presence. There is pain in the world; however, IBP asserts that most pain is due to repetitive patterns developed from our earliest childhood relationship experiences that are stored in our brain and throughout our body. If we want in-depth, lasting change, we must release these patterns from both mind and body. If we have an insight and change our mind, we may feel better temporarily, but the pattern will return. The same is true for bodywork. If the psychological connection is not also resolved and released, the pattern will return.

Historical Context After many years of developing his system of body psychotherapy, Jack Lee Rosenberg, D.D.S., Ph.D., founded the IBP Central Institute in 1980. Rosenberg

Body–Mind

Faulty repetitive brain patterns and associated physical–emotional holding patterns originated

Integrative Body Psychotherapy

in childhood are embedded in everyday thought. They are perpetuated through habitual emotions, thoughts, fears, longings, and lack of effective insight and release. Early childhood emotional injuries, generational themes, and traumas create an alternate state that often overrides and distorts the natural underlying state of well-being, growth, and development. This alternate state can cause emotional, physical, and relational dysfunction. Breath and Movement

High-charge breathing enlivens and awakens the body. This involves taking a series of full breaths through the mouth, and expanding and then releasing the upper chest. Particular grounding and flowing movements create an inner integration that is felt as clarity and well-being. IBP therapy is practiced from this state. Breathwork provides heightened aliveness and brings unconscious relevant material from the past and the present to the surface and intensifies it for processing. This is calming as it balances the autonomic nervous system. The inner state shifts from a stress and fight-or-flight mode—problem orientation, fear, anxiety, and defensiveness—to well-being and wisdom. Somatic Presence

Presence is being in the moment. For IBP, it also implies body–mind consciousness and inner connectedness. Inner awakening and integration generate an interior world of somatic experiences, including knowledge of one’s inner thoughts, sensations, and emotions, and heighten the ability to focus and discern between faulty and supportive inner signals.

Major Concepts The arenas of core self, primary scenario, character style, and emotional agency organize, simplify, and bring into awareness the most relevant selfpatterns. While core self holds our authenticity and the existential themes of life, the other three contain the repetitive patterns that both support and undermine. Working within the arenas resolves related problems so that each issue need not be separately solved.

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Core Self

Core self is who you are—your authentic sense of being. Although infants embody who they are genetically and spiritually and are authentic in needs, emotions, and responses, very early in life something happens to interfere, alter, or mask authenticity. Primary Scenario

The primary scenario is the history of one’s early relationships and reflects one’s psychologicalemotional, preverbal, and nonverbal learning that begins in the limbic brain in utero and continues to build through childhood. This learning creates an “inner movie” that forms attitudes, beliefs, emotions, behaviors, and meaning throughout life. We rely on this inner movie to make sense of our current experiences. To trust our inner voice, we must be able to bring our inner movie into awareness and be able to know the truth. Relational-emotional patterns of the brain are foundational and less accessible through talk therapy or rational thought than later intellectual patterns of the neocortical brain. The Basic Fault

The Basic Fault is the most pervasive, generational scenario theme that undermines well-being and one’s sense of self throughout life. Common to us all, the underlying somatic sense of this early bonding-attunement injury is “I’m all alone.” To provide reason for this dark feeling, we conceive, “I’m not good enough.” We then become expert at finding evidence. This primitive insecurity hides beneath our sense of self and others and is triggered by many different thoughts and feelings, making it difficult to understand or resolve. Somatic awakening and psychological practices can unmask this false illusion. Character Style

Character style is a false self-defense initially formed to protect against overwhelming emotions of abandonment or inundation anxieties, especially when they are, like for most of us, felt simultaneously. Abandonment anxiety causes a feeling of loss and a flood of emotions; inundation anxiety creates the sensation of being overwhelmed and

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cut off from emotions, self, and others. When both anxieties function simultaneously, we become split off, left to intellectually figure who we are, thereby creating a false self. This sets up a relationship pattern characterized by not too close, not too far away, no one can tell me what to do, rigid ideas, and an authenticity gap. This can easily confuse self and others and can destabilize self and destroy any relationship. The self-assessment guide with the breathwork brings a style out of the shadows for authenticity. Emotional Agency

In emotional agency, one exchanges selfabandonment for hypervigilance toward others. Infants are born with a capacity for self-agency or the inner voice of self-care and personal destiny. Agency originates in the first years of life to heal parents. Because this is impossible, the failure perpetuates the feeling “I’m bad and I have done something wrong, I am not worthy of love.” The pleasing, doing behaviors are not the problem; rather, the numbing of the authentic sense of self to better focus on others is the problem. Psychological and somatic practices together reconnect an authentic, self-supportive core. Core Self

Once psychological issues are resolved, one is left with the foundation of core self, which is existential, spiritual, and transpersonal. One is then faced with issues of existence, such as impermanence, unknowing, aging, authenticity, death, integrity, what happens after death, who am I, and why am I here.

Techniques With IBP, clients are provided with body–mind techniques for self-exploration, problem solving, and healing so that they can eventually become their own therapist. These tools include breath and presence exercises, exploring and healing through primary scenario charting, good-parent messages, agency mantras, character style and sexual self-assessment guides, and the steps out of fragmentation.

IBP therapists train to become energetically present, empathic, and supportive and to recognize authenticity so as not to replace the false self with another programming. Touch is limited to avoid creating dependency. Therefore, self-release techniques, including the standing cross-crawl, orgastic pattern, and sustaining constancy series, are taught. Body and mind are worked with simultaneously.

Therapeutic Process Therapy begins with the client and the therapist building an attuned relationship. Information is collected concerning personal issues, underlying earlychildhood patterns, addressing present dilemmas, and the somatic state. At the same time, the client is introduced to body–mind health skills such as presence, boundaries, contact, journal work, meditation, and mindfulness. The breathwork to process psychological themes and to produce a state of awakened incorporation then begins with the client lying down. This enlivening–integration process is inevitably interrupted by faulty patterns of thought, behavior, and emotions. Thus, it creates the opportunity to reevaluate and release dysfunctional patterns that cause stress, insecurity, emotional instability, disconnection, anxiety, and/or depression. As one becomes more present and energetically charged, truth and authenticity emerge, and destructive body–mind patterns are released. IBP is an educational, experiential, and interrelationship somatic psychotherapy. It focuses on exploring underlying body and mind patterns to simplify and deepen the process for more immediate, authentic, and lasting therapeutic results. When unresolved, haunting, out-of-date, faulty emotions, beliefs, fears, and insecurities, originating from past generations, childhood, and later traumatic themes, routinely distort all  perceptions, particularly of one’s self and relationships. Jack Lee Rosenberg and Beverly Kitaen Morse See also Cognitive-Behavioral Therapy; Eye Movement Desensitization and Reprocessing Therapy; Mindfulness-Based Stress Reduction; Object Relations Theory; Sensorimotor Psychotherapy; Somatic Experiencing

Integrative Family Therapy

Further Readings Rosenberg, J. (1973). Total orgasm. New York, NY: Random House. Rosenberg, J., & Kitaen-Morse, B. (1996). The intimate couple. Atlanta, GA: Turner. Rosenberg, J., Rand, M., & Asay, D. (1985). Body, self and soul. Atlanta, GA: Humanics.

INTEGRATIVE FAMILY THERAPY Integrative Family Therapy (IFT) focuses on understanding human behavior by combining the interpersonal and intrapersonal factors of a family system. It provides an eclectic medium where the therapist is able to view the family as a system while keeping a pulse on the behaviors and thought processes of each individual within the system. It therefore views individuals autonomously while simultaneously fitting them within the bigger social and environmental realm of the family system. IFT is generally practiced as a brief method of treatment, and it emphasizes that change occurs outside of therapy sessions and stresses the use of techniques and homework throughout the course of therapy.

Historical Context During the 1970s, at around the same time when Paul Wachtel and James Prochaska developed their ideas about integration of theoretical approaches in psychotherapy, Nathan Azrin introduced the concept of mutual reinforcement and reciprocity. Azrin claimed that human behavior is maintained by reinforcement of the person who performed the behavior (intrapersonal), that individuals have a tendency to treat others as they are treated (interpersonal), and that mutual reinforcement partially accounts for concepts such as friendship, joy, and love. As a result, Neil Jacobson, of the University of Washington, and Andrew Christensen, of the University of California, Los Angeles, developed Integrative Behavioral Couple Therapy, an empirically supported treatment for couples. This theory integrated to family therapy many of the systematic approaches that had been developed during the 1950s. In this model of therapy, partners learn to be kinder to each other through behavioral

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exchange (contingency contracts), to communicate better, and to improve their conflict resolution skills. The two key themes in this therapeutic approach are acceptance and change. By the end of the 1970s, Marvin Goldfried, Paul Wachtel, and Hans Strupp organized an association, the Society for the Exploration of Psychotherapy Integration, and not long after, the International Journal of Eclectic Psychotherapy was published (now the Journal of Integrative and Eclectic Psychotherapy). These momentum-building movements within the field paved the way for Integrative Behavioral Couple Therapy to influence the creation of the IFT approach. Since the inception of IFT about four decades ago, there has been an ever-increasing movement toward integration of the interpersonal and intrapersonal approaches of different theoretical orientations and treatment techniques.

Theoretical Underpinnings IFT is driven by a number of values and beliefs. For instance, it believes that each individual within a family system has a story that must be shared. This personal story is based on the individual’s assumptions that are viewed as intrapersonal communication. As these personal stories surface within the family, the individual realities of each person begin to emerge, and through this process, the therapist comes to understand each individual’s personal vulnerabilities and defenses. IFT views people as having the basic right to autonomy and to determine their own tools and journey to resolve their own problems. Also, IFT stipulates that family members are more than the sum of their experiences and their physiological and psychological makeup. This assumption brings out the importance of interpersonal dynamics and the roles they play within the family system. Therefore, each individual is viewed as a unique entity and, as such, deserves to be respected as an individual. Meanwhile, the therapist remains cognizant of the important roles the interpersonal dynamics are playing. In addition, IFT believes that the therapist is first and foremost a human being, and thus, he or she needs to be aware of his or her own worldviews, stories, experiences, realities, and, most important, the role of his or her interpersonal dynamics with each individual family member and

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the family as a unit. Within this approach, the therapeutic relationship is of utmost importance, and there must be a connection between the client and the therapist. Finally, it is essential that the therapist must not want or care for each individual family member more than the family member wants or cares for himself or herself. Given the above values and assumptions, IFT combines a wide range of theoretical orientations. It is experiential, using many nonverbal modes of communication, as when it applies role-playing and role reversal techniques. It may be behavioral or structural, such as when sessions focus on behaviors. It may involve reframing and/or realigning of family roles and responsibilities within the family system and may also include a cognitive or constructivist understanding, such as when individuals are asked to understand how their thoughts affect themselves and their family or when they are asked to reflect on how they come to construct reality. Finally, it may be existential and humanistic, such as when clients process their life choices, existential life tasks, and vulnerabilities.

Major Concepts Two major concepts that drive this approach are assessment of the family and system resources. Assessment of Family

The Integrative Family Therapist often conducts a number of assessments to gain further information and to create a layer of understanding for individuals within the family system. These include processes called novelty/automaticity, wherein a therapist determines whether each member of the system has the ability to utilize novelty and generate new processes in the family; access to new information, such as when the therapist determines if the family has the ability to inquire and learn new information; flow of relating, where the therapist identifies the rhythm and the dance of the family and how the family exchanges information; ambiance, in which the therapist assesses the culture of the family and how safety, caring for one another, and egocentric attitudes are managed and balanced within the family; and family development, whereby the therapist assesses each family member’s stage of development and determines if appropriate tasks at each level have been mastered.

System Resources

Family Forms Map With the family forms map, the therapist identifies the structure of the family to assess the available resources within a family system. These resources include but are not limited to the extended family of both spouses and, in some cases, to what is available in the community for the family to utilize. Economic Map In the economic map, the therapist identifies the financial stability of the family system and assesses the ability of the family members to cope with potential familial hardships and the current financial stressors they are experiencing. Again, the therapist utilizes all the resources available to the family within the community. Social Map With the social map, the therapist identifies whether the family creates an environment of social support for its members and if recreational activities are a part of the family dynamic. The therapist also utilizes the available social and recreational activities in the surrounding communities to stimulate family involvement. Time–Energy Map The time–energy map identifies how much time and emotional and physical energy a family is willing to commit for the betterment of itself and assesses how receptive the family is to the therapist’s suggestions, homework, and recommendations throughout the course of the therapy.

Techniques Generally speaking, Integrative Family Therapists are eclectic when it comes to the use of the techniques available to them. Depending on the issues at hand based on the above assessments, almost all of the various therapeutic techniques that a family therapist may otherwise utilize can also be used in this approach. This is considered to be one of the strengths of IFT, as it provides greater flexibility for the therapist to determine the best available resources in addressing a family’s needs.

Integrative Forgiveness Psychotherapy

Therapeutic Process Although IFT often has a clear therapeutic focus and goal, the therapist does not typically assume that the same topic that was addressed in the previous session needs to continue to be addressed in the current session. Therefore, he or she does not start a new session with an agenda, and the client is viewed as unique and autonomous. The client is deemed the expert and the major healing agent in the process of counseling and is therefore given the responsibility of identifying topics that require processing. Although there is no general time frame prescribed for IFT, most therapy processes last an average of 12 to 15 sessions. The sessions are goal oriented and typically focus on topics that are of importance to the client. The therapist, by maintaining an empathic and collaborative stance, allows the client to take the lead in his or her process of change and choice of technique. S. Dean Aslinia and Amir Abbassi See also Integrative Approaches: Overview

Further Readings Jacobson, N. S., & Christenson, A. (1996). Integrative couple therapy. New York, NY: W. W. Norton. Pinsof, E. M. (1995). Integrative problem-centered therapy. New York, NY: Basic Books.

INTEGRATIVE FORGIVENESS PSYCHOTHERAPY Developed by Philip H. Friedman, integrative forgiveness psychotherapy posits that there is one core problem underneath all other problems, unforgiveness, and one core solution, forgiveness. Unforgiveness is defined as judgments, grievances, and attack thoughts against oneself, others, and circumstances.

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In the 1970s, Friedman experienced transpersonal/ spiritual disciplines such as yoga and Arica, which emphasized union and oneness as well as deep inner peace, love, and happiness. His exposure to the Foundation for Inner Peace’s A Course in Miracles in the late 1970s shifted the emphasis to forgiveness of grievances, judgments, and attack thoughts. Lack of forgiveness generates emotional distress (anger, guilt, shame, depression, anxiety, and fear) and numerous interpersonal problems and separates a person from his or her true self. Forgiveness guided by a higher power, inner spirit, or higher intuition is the means to reconnect to the core: love, peace, joy, magnificence, the inner light, strength, holiness, blessings, and the divine Self or Light. Mediating the transition from unforgiveness to forgiveness is the higher part of the mind or the higher power, Holy Spirit, or higher intuition. Friedman learned that each individual can, with practice, learn to connect with his or her inner guidance (the still small voice or the Holy Spirit). This, in turn, connects clients and therapists with their higher or divine Self, Being, Essence, Soul, and inner Light/God within. By the late 1970s, forgiveness had become a core concept of Friedman’s integrative approach. In 1995, Friedman added energy therapy and healing as a potent concept to his integrative approach focusing on energy meridians and chakras. Known to practitioners of Chinese medicine and yoga for centuries, these approaches were adapted for the Western, psychologically minded psychotherapists in the early 1980s. The original focus was on interventions designed to release the assumed disruption in the flow of energy in and around the human body, which was said to cause emotional problems. Friedman later hypothesized that the disruption of energy flow in and around the body was caused by unforgiveness. These multiple streams of influence converged on the integrative forgiveness psychotherapy model.

Theoretical Underpinnings Historical Context In the 1960s and early 1970s, Friedman trained in a wide range of traditional therapeutic approaches, including behavioral and cognitive-behavioral therapy, multimodal therapy, and family systems and existential-humanistic approaches to psychotherapy.

Friedman originally developed his version of integrative psychotherapy by using a three-dimensional “metamodel” to organize, classify, and systematize the major concepts, techniques, and roles used by therapists at that time. This integrative approach focused on the intrapersonal, interpersonal, and

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transpersonal (spiritual) aspects of therapy and healing and on the major concepts, roles, and techniques used in the field. The nine categories in the 3 × 3 × 9 integrative metamodel were originally adapted from the nine domains of consciousness in the enneagon, as discussed by Oscar Ichazo in the Arica system of enlightenment (see Figure 1). The nine categories are (1) humanities, (2) economic, (3) political/legal/judicial, (4) social, (5) philosophical/ethical, (6) spiritual/religious, (7) pure science, (8) applied science, and (9) recreation. The three focus dimensions (intrapersonal, interpersonal, and transpersonal) were drawn from the different theoretical frames being used in the field of knowledge and psychotherapy. The three structure dimensions (concept, technique, and role) were inferred from different aspects of the field of psychotherapy. A few examples from each of the nine categories are as follows: the humanities, representing language, drama, and bibliotherapy; economics, representing bargaining and negotiation; political/

legal/judicial, representing battling, injustice, and conflicts; social and educational, representing boundaries and prior learnings; philosophical/ ethical, representing purpose and vision; spiritual/ religious, representing forgiveness, miracles, and healing; the pure science, representing energy, triangles, the triune brain, and evolution; the applied sciences, representing trauma, wounds, and cure; and recreation and nature, representing flows, paths, growth, and the journey. The generic idea is that if a white light were to shine through a prism made of the three-dimensional metamodel, it would encompass all technical and theoretical aspects of the psychotherapy field and, at the same time, allow for the evolution of the field. In a sense, Friedman thought of the threedimensional metamodel as a kind of periodic table of elements for the psychotherapy field. As a scholar of the field, as well as a psychotherapist and teacher, Friedman was exploring an epistemological “map” that would encompass everything.

Integrative Psychotherapy

1. Humanities 2. Economic

CATEGORY

3. Political/Legal/Judicial 4. Social 5. Philosophical/Ethical 6. Spiritual/Religious 7. Pure Science 8. Applied Science 9. Recreation Intrapersonal

Role

Interpersonal

Technique

FOCUS Transpersonal

Concept

STRUCTURE

Figure 1 Three-Dimensional Metamodel of Integrative Psychotherapy Source: P. Friedman, “Integrative Energy and Spiritual Therapy,” in F. Gallo (Ed.), Energy Psychology in Psychotherapy: A Comprehensive Sourcebook, p. 199. New York, NY: W. W. Norton (2002).

Integrative Forgiveness Psychotherapy

Friedman’s integrative forgiveness approach also focuses on the importance of fitting the theory and techniques to both the therapist’s style and the client’s needs. Today, the approach is very flexible and open, which allows the therapist to look at the client’s problems and treatment options through multiple lenses. Integrative forgiveness psychotherapy has a strong empirical component focused on practicebased evidence and ongoing assessment of change in the client, session by session. This aspect of the treatment has its roots in Friedman’s early training in mathematics, research, and behavioral psychology.

Major Concepts Some of the major concepts of integrative forgiveness psychotherapy are using practice-based evidence and assessment, having a multidimensional approach, focusing on forgiveness, seeing integrative and differentiating tendencies, seeking both client and therapist growth, having energetic exchanges and healing, using a wide range of interventions, and focusing on treatment goals. Practice-Based Evidence and Assessment

Integrative forgiveness psychotherapists adhere to a practice-based evidence approach to psychotherapy. They engage in a thorough empirical assessment of the client at intake, using a variety of scales to assess stress symptoms (e.g., depression, anxiety, anger, interpersonal sensitivity, and obsessing), wellbeing, happiness, flourishing, life satisfaction, hope, optimism, quality of life, forgiveness, self-compassion, gratitude, beliefs, feelings, and relationships (e.g., marriage and family). They also have clients fill out short questionnaires, session by session, that let them track change over time. Done correctly, this assessment approach is cost-effective and easy to administer, score, and track in a clinical practice. Multidimensional Approach

Integrative forgiveness psychotherapists have a multidimensional approach drawn from both Eastern and Western approaches to healing. This includes multimodal behavior therapy, body-centered approaches, energy therapy (e.g., meridian-based acupressure points and chakras), attitudinal healing and A Course in Miracles, cognitive therapy and

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positive psychology, the law of attraction, humanistic psychology, neuropsychology, systemic and relationship therapy, emotion-focused therapy, and spiritual psychology. A Focus on Forgiveness

The integrative forgiveness psychotherapy approach relies heavily on the assessment and change of forgiveness of self, others, and circumstances. This requires letting go of grievances, judgments, and attack thoughts toward oneself and others and reconnecting with both inner guidance and the divine or the true Self. Grievances, judgments, and attack thoughts and the accompanying emotions of anxiety, guilt, anger, sadness, and shame (the path of the “ego,” fear, darkness, and unhappiness) are seen as separating the client from his or her divine or authentic Self. The path of the divine, true, or authentic Self (also called the path of love, light, and happiness) is seen as existing equally in all people, and it consists of love, peace, happiness, joy, worthiness, value, strength, creativity, resilience, resourcefulness, compassion, holiness, magnificence, sinlessness, and light. This journey from the path of the “ego,” unhappiness, darkness, fear, and grievances to the path of love, light, happiness, forgiveness, and the divine Self is called the two-path model of happiness and change. Integrative and Differentiating Tendencies

The integrative forgiveness psychotherapy approach allows the therapist to see similarities between the therapist and his or her clients and between concepts from a variety of different theoretical approaches. For example, most clients are similar in seeking help during major life transitions. The integrating tendency allows the client and the therapist to see their similarities with others and to join with others to create harmonious relationships, such as marriage, family, and work groups. A complementary differentiating tendency leads to experiencing oneself as unique and different from others and allows each person to become his or her own person. Client and Therapist Growth

Because we all struggle with similar issues, the integrative forgiveness psychotherapist is aware that the healing and growth process is going on

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simultaneously for both the client and the therapist. Some integrative forgiveness therapists will pray or meditate for their clients at the beginning of the day and may also use this time to engage in self-forgiveness and forgiveness of others.

and a copy is given to the client. Near the end of the therapy sessions, a reassessment of progress toward these goals is made by the client on a 10-point scale.

Techniques Energetic Exchange and Healing

Awareness on the part of the integrative forgiveness psychotherapist of an energetic exchange between the therapist and the client works to create and maintain a harmonious balance in that interchange. The therapist uses energy healing techniques with himself or herself and teaches them to the clients. Wide Range of Interventions

The integrative forgiveness psychotherapist draws on a wide range of intervention tools and techniques from a variety of theoretical disciplines as long as these techniques empirically demonstrate that they are catalyzing positive change in clients. For example, the therapist may use acceptance, affirmations, afformations, amplification/ heightening, assertiveness, behavior rehearsal, clarification, conflict resolution, cognitive restructuring, emotional recognition and softening, energy tapping, feedback, forgiveness exercises, focusing and refocusing, goal setting, gratitude, guided imagery, and a variety of homework exercises. The therapist might also use intending and choosing, journal writing, letter writing, loving kindness exercises, marital therapy, meditation/mindfulness, parts (ego states) therapy, percussive suggestion technique, questioning, reflection, reframing, relationship enhancement, role-playing, storytelling, and values clarification. The integrative forgiveness therapist is flexible in attitude and approach and relies on both the analytical mind and intuition to decide what interventions to use, when, and with which clients. Treatment Goals

The integrative forgiveness psychotherapist keeps the goal of treatment in the foreground. The initial goals, usually 10 or more, are arrived at jointly with the client in the second or third therapy session and are written down by the therapist,

Some of the more common techniques used in integrative forgiveness psychotherapy are assessments, goal setting, facilitating hope and optimism, and relationship enhancement; the psychological uplifter, on-going feedback, and homework; affirmations, afformations, forgiveness, and letter writing; and positive pressure point techniques (energy therapy) and tracking change. Assessments, Goal Setting, Hope and Optimism, and Relationships

The techniques used in integrative forgiveness psychotherapy are guided by the thorough assessment process and the setting of 10 or more written goals for treatment. The integrative forgiveness therapist assesses, in particular, where the individual client is on the dimension of hope, optimism, meaning/purpose, gratitude, forgiveness, self-worth, well-being, life satisfaction, self-compassion, flourishing, positive and negative beliefs, and interpersonal relationships in different contexts. Couples and families are assessed for their interaction and communication patterns, both functional and dysfunctional: especially their ability to listen nonjudgmentally; to express themselves in a nonblaming/nonattacking manner; to forgive; to turn to one another; to appreciate, understand, and respect one another; to be influenced by their partner; and to engage in repair efforts. Psychological Uplifter, Feedback, and Homework

Developing a safe, nurturing, hope-filled therapeutic relationship is essential for the integrative forgiveness therapist. The “psychological uplifter” exercise is specifically designed to help clients with this at the beginning of therapy. Providing constructive, supportive feedback and reinforcing positive changes week by week is also a key therapeutic ingredient. Weekly homework assignments are very important. For example, a therapist may

Integrative Forgiveness Psychotherapy

routinely assign two or three chapters in Friedman’s book The Forgiveness Solution, which not only provides didactic information and exercises but also develops the two-path model of happiness/ unhappiness and change. Written assignments in the book focus on assessment as well as grievances, judgments, and attack thoughts toward oneself, others, and circumstances in both the present and the past. Stories and quotes in the book and the therapy sessions provide models of change, optimism, and hope. Joining with the client before pacing, guiding, and reframing can help with the remoralization process. The early goal-setting process helps with this as well as with nonjudgmental listening and gentle, perceptive questions. A series of exercises at the beginning of therapy are designed to strengthen self-acceptance and self-worth. Other exercises—“I am entitled to miracles,” “anything is possible,” and “releasing and choosing”—generate hope and re-empower the client. Affirmations, Afformations, Forgiveness, and Letter Writing

Affirmations and afformations, along with letter writing and guided forgiveness imagery exercises, are frequently used via the book and in sessions. Clients are generally given a copy of Friedman’s The Forgiveness Solution as well as CDs with 14 guided relaxation and forgiveness imagery exercises. When appropriate, role-playing or behavior rehearsal is used. There are many forgiveness exercises in The Forgiveness Solution, which also includes a strong focus on gratitude. Other handouts or books are shared when appropriate. Positive Pressure Point Techniques and Tracking Change

A series of energy therapy exercises called the positive pressure point techniques (a variant of the emotional freedom techniques, thought field therapy, and the tapas acupressure technique) are combined with the law of attraction, and, along with forgiveness, affirmations and imagery, are routinely used. During this whole process, clients are assessed weekly. The positive changes they report, such as decreased distress and increased wellbeing, flourishing, happiness, and overall positive

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feelings, are fed back to them in a nurturing way. Clients are encouraged from the beginning to take small positive steps every week toward one or more of their goals.

Therapeutic Process Much of the therapeutic process was described in the “Techniques” section because they go together. However, the steps of the therapeutic process might look like this: Step 1: Before the first appointment, meditate/pray for the welfare of all the past, current, and new clients. Step 2: Over the phone, create a hopeful and optimistic attitude. Step 3: Use a series of sophisticated self-assessment questionnaires and psychological tests. Step 4: Conduct a thorough, skillful interview where warmth, safety, and rapport are created in addition to information and hope. Step 5: Introduce the psychological uplifter, the twopath model of happiness and change, feedback on the questionnaires and tests, and goal setting (over two therapy sessions). Step 6: Give clients a copy of The Forgiveness Solution, and assign two or three chapters per week along with the exercises. Meanwhile, continue to engage in the usual sharing, questioning, rapport building, and client feedback. If a couple is being seen, after two or three individual therapy sessions, initiate a couple assessment session and then couple therapy. Step 7: Continue ongoing meditation or prayer for all clients while assigning gentle and uplifting exercises, especially energy exercises such as the positive pressure point technique exercises. These exercises are graded in complexity and taught weekly. Step 8: Review, usually weekly, the written homework assignments returned by clients, and then positively reinforce clients for doing the exercises. Step 9: Give positive feedback as changes start to show up, which are often substantial in the first five sessions. A decrease in stress levels, negative feelings, and negative beliefs generally occurs simultaneously with increases in well-being, happiness, flourishing,

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positive feelings, and positive beliefs, though stress levels usually decrease faster. Step 10: Throughout the integrative forgiveness psychotherapy sessions, constantly encourage and teach a shift in perception and the developing of new perspectives. For example, clients are taught to see all communication as either an expression of love or a call for love. Step 11: Throughout the integrative forgiveness psychotherapy sessions, support a change of identity in the client from an ego-based set of perceptions, which are usually quite self-critical and judgmental, to an authentic/true Self set of perceptions based on self-compassion and self-love. Step 12: Facilitate and encourage a shift from an egobased set of perceptions that is accompanied by a feeling of helplessness, hopelessness, weakness, failure, inadequacy, and being a victim of others or circumstances to an authentic or divine/true Self set of perceptions based on feelings of empowerment, strength, hope, competence, success, innocence, worthiness, and the ability to cope with the many challenges of life.

Philip H. Friedman See also Advanced Integrative Therapy; Assimilative Psychotherapy Integration; Emotional Freedom Techniques; Integrative Approaches: Overview; Integrative Family Therapy; Multimodal Therapy; Transpersonal Psychology: Overview

Friedman, P. (1992). Friedman well-being scale and professional manual. Plymouth Meeting, PA: Foundation for Well-Being. Friedman, P. (2002). Integrative energy and spiritual therapy. In F. Gallo (Ed.), Energy psychology in psychotherapy: A comprehensive sourcebook (pp. 198–215). New York, NY: W. W. Norton. Friedman, P. (2006). Pressure point therapy. In P. Mountrose & J. Mountrose (Eds.), The heart & soul of EFT and beyond (pp. 260–268). Sacramento, CA: Holistic Communications. Friedman, P. (2010). The forgiveness solution: The whole body Rx for finding true happiness, abundant love, and inner peace. San Francisco, CA: Conari Press. Friedman, P. (2014). EFT, change, forgiveness and the positive pressure point techniques. In D. Church & S. Marohn (Eds.), The clinical EFT handbook (Vol. 2, pp. 517–538). Fulton, CA: Energy Psychology Press. Friedman, P., & Toussaint, L. (2006). Changes in forgiveness, gratitude, stress, and well-being during psychotherapy: An integrative, evidence-based approach. International Journal of Healing and Caring, 6(2), 11–28. Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration. New York, NY: Oxford University Press. Piedmont, R., & Friedman, P. (2011). Spirituality, religiosity and quality of life. In K. Land, A. Michalos, & M. J. Sirgy (Eds.), Handbook of social indicators and quality of life research (pp. 313–330). New York, NY: Springer.

INTEGRATIVE MILIEU MODEL Further Readings Foundation for Inner Peace. (1975). A course in miracles. Mill Valley, CA: Author. Friedman, P. (1980). Integrative psychotherapy. In R. Herink (Ed.), The psychotherapy handbook (pp. 308–313). New York, NY: New American Library. Friedman, P. (1981). Integrative family therapy. Family Therapy, 8(3), 171–178. Friedman, P. (1982). Assessment tools and procedures in integrative psychotherapy. In A. Gurman (Ed.), Questions and answers in the practice of family therapy (pp. 46–49). New York, NY: Guilford Press. Friedman, P. (1982). The multiple roles of the integrative marital psychotherapist. Family Therapy, 9(2), 109–118. Friedman, P. (1989). Creating well-being: The healing path to love, peace, self-esteem, and happiness. Saratoga, CA: R&E.

The integrative milieu model is a model of intensive psychotherapy wherein a patient suffering from severe psychological distress, often labeled schizophrenia, bipolar disorder, or major depression, receives various forms of group and individual psychotherapy in an environment that promotes empathy, community, respect, and humanistic growth. The integrative milieu approach operates from the premise that psychological distress is not a medical disease but an expression of deep emotional pain. It was developed by the psychotherapist Kevin McCready as an evidence-based treatment approach to replace the contemporary practice of hospitalization and psychiatric day-treatment programs. An integrative milieu program is designed around the paradigm that suffering has important meaning

Integrative Milieu Model

and, therefore, the path out of suffering is not in symptom-reducing techniques alone but in the overall promotion of one’s humanity. The goals for this treatment method include respectful support of the patient’s developing identity, uncovering the unconscious causes of his or her distress, and exploring the nature of the patient’s existence and experience.

Historical Context While working in a California state hospital, McCready witnessed what he considered to be the ineffective and harmful effects of the psychiatric practice of “symptom reduction” by way of psychotropic medications (drugs that affect the mind), electroconvulsive treatments, and psychosurgery. He noticed not only short-term symptom suppression but also a decrease in the patients’ positive long-term functioning and sense of self. Instead of patients recovering, they became more disabled. In 1990, McCready left the hospital and founded the San Joaquin Psychotherapy Center in Clovis, California, where he developed and implemented the integrative milieu program. Today, the integrative milieu program is practiced at the Sequoia Psychotherapy Center in Fresno, California; at Associated Psychological Health Services in Sheboygan, Wisconsin; and throughout the world by trained practitioners.

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Major Concepts Some of the major ideas associated with the integrative milieu model are as follows: emotional pain is not a disease; healing comes from within; there are a number of experiences in life that can foster healing, which the integrative milieu model calls an integrated environment; and this program is done in an outpatient environment. Emotional Pain Is Not a Disease

The integrative milieu model is based on the premise that psychological distress is not a disease, a chemical imbalance, or a genetic abnormality. A patient’s symptoms are natural, emotional, and behavioral responses to psychological suffering and trauma, and they need to be expressed. Healing Comes From Within

The integrative milieu approach believes that all people have an innate ability to work through, heal, learn from, and find meaning in their suffering and distress. As opposed to viewing patients as “sick” and in need of being cured by “experts,” this approach assumes that patients overcome problems by growing as humans and by connecting with others who support, observe, guide, and explore along with them. Integrated Environment

Theoretical Underpinnings The integrative milieu philosophy is that all human emotions are normal and necessary for a full experience of life and that effective psychotherapy only occurs when patients and therapists are immersed in an environment that integrates respect, dignity, empathy, and humanity. Based on psychodynamic, humanistic, and existential theories, the integrative milieu method recognizes that symptoms of psychological distress arise as a result of experience and not because of biological disease, chemical imbalance, or faulty genes. In fact, because studies have shown that psychotropic medication can cause debilitating side effects, decrease recovery rates, and increase the duration of disability, the integrative milieu model is an ideal treatment approach for individuals who choose not to use such medications.

Positive experiences of life like emotional intimacy, creativity, social interaction, recreation, and community all facilitate personal growth and psychological healing. This program gets its name from the creation of a milieu, or environment, wherein these activities are integrated with the therapeutic expression and exploration of trauma, pain, and distress. Outpatient Design

The integrative milieu program is a nonresidential, outpatient program designed to promote independence, autonomy, coping, and self-reliance, thus preventing patients from becoming dependent on structured environments. Patients are responsible for attending their group and individual therapy sessions, for their own lunchtime meal, and, often

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with the help of family, for managing their own housing and transportation. Patients are expected to behave appropriately, respectfully, and autonomously around the clinic, which in turn results in minimal behavioral problems.

Techniques The integrative milieu program creates a therapeutic environment that promotes each patient’s autonomy, sense of respect, and humanity by acceptance of the philosophy that psychological suffering is a natural part of the human experience and that through the respectful, empathic exploration of one’s experience, one’s humanity will be restored and healing will occur. The groups’ design keeps the focus less on technique and more on human understanding. The therapy day is intentionally modeled after a standard workday, complete with lunch break. After the patients’ therapy day is completed, they are on their own until the following day. Patients are responsible for determining their own goals and for deciding how long they stay in the program. When they feel they are ready, patients autonomously make the choice to leave therapy. Individuals who approach their psychological pain in this way address and work on the underlying causes while simultaneously improving their ability to function in the world.

Therapeutic Process The integrative milieu method is designed as a fivegroups-a-day, day-treatment program that also includes individual psychotherapy. Patients can join or leave at any time, and they can attend all groups together, regardless of symptoms or diagnosis. This creates a population that mirrors everyday life: a diversity of people each struggling in different ways. The groups are arranged so as to ease patients into the process of intense psychotherapy and then “cool them down,” so they can depart for the day, coping skills intact. The community group fosters a sense of community and allows members to greet one another and to report on how they are doing that morning, receive group news, and establish group and individual goals for the day. The expressive arts group involves art, music, or movement therapy and allows patients to engage in emotional expression using various creative media that rely mostly on deep, nonverbal, psychological

processes. The process group is traditional group psychotherapy and enables patients to delve into their psychological distress, exploring traumas, anxieties, hopes, and fears. The topic group has patients discuss topical issues of their choice on an intellectual level and allows patients to come out of the emotional depths of the previous group by reminding them that there is a world outside their personal pain to which they must return. The recreation group helps patients wind down and provides a healthy and essential opportunity for play, mastery, bonding, and socializing in the context of fun and relaxation. In addition, each patient receives individual psychotherapy, which provides focused attention to emotional pain and trauma and offers a venue to address issues not worked on within the group context. Toby T. Watson and Pepe Santana See also Art Therapy; Contemporary PsychodynamicBased Therapies: Overview; Existential-Humanistic Therapies: Overview; Music Therapy

Further Readings Breggin, P. (1991). Toxic psychiatry. New York, NY: St. Martin’s Press. Karon, B. P., & VandenBos, G. R. (1994). Psychotherapy for schizophrenia: The treatment of choice. Lanham, MD: Rowman & Littlefield. McCready, K. F. (2002). Creating an empathic environment at the San Joaquin Psychotherapy Center. In P. Breggin, G. Breggin, & F. Bemak (Eds.), Dimensions of empathic therapy (pp. 67–78). New York, NY: Springer. Szasz, T. (1974). The myth of mental illness. New York, NY: Harper & Row. Whitaker, R. (2012). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the rise of mental illness in America. New York, NY: Broadway Paperbacks.

INTERACTION FOCUSED THERAPY Interaction Focused Therapy (IFT) is a problemsolving approach that places emphasis on understanding the nature of the contexts and relationships of which individual behavior is a part. The primary focus of attention is to what one can observe to be transpiring in the present moment in the interaction between the people involved regarding how

Interaction Focused Therapy

problems or complaints develop and are perpetuated. Members of a family are viewed as only relatively independent and, whether they admit it or not, as continually responding to reflected appraisals from others in their family. Individual behavior, especially “symptomatic” behavior, becomes comprehensible when attention is focused on what is transpiring between people in the present moment of interaction.

Historical Context IFT is grounded in communication theory set forth by the cultural anthropologist Gregory Bateson and his team of researchers, which included the psychiatrist Don D. Jackson, the chemical engineer and cultural anthropologist John Weakland, the communication analyst Jay Haley, and the psychiatrist William Fry, during the 1950s. It is also grounded in the family therapy and Brief Therapy pioneered by Jackson, Weakland, the psychiatrist Richard Fisch, and the psychologist Paul Watzlawick at the Mental Research Institute during the 1960s and 1970s.

Theoretical Underpinnings From the IFT perspective, one cannot not communicate. Exchanges of behavior (both analogic and digital) are understood as questions or proposals about the nature of the relationship— proposals that are contextually coherent and recursively organized such that any attribution of meaning (i.e., causal explanation) is a product of observer-imposed punctuation. IFT adheres to a non-blame-evoking view that all people are doing the best they can considering contexts and relationships of which they are a part. Members of a system define the nature of the relationship by symmetrical and complementary communication, which is when communication is based on one person being in a more powerful or “one-up” position. Behavior experienced or complained of as being symptoms emerges when consensus about the nature of the relationship cannot be achieved. When a therapist enters a system (e.g., a family) and begins to understand the nature of communication between members and how that communication reinforces the current way of functioning, then he or she can devise methods to induce change in the system.

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Major Concepts Some of the concepts underlying this approach to therapy include circular causality, the primary focus of therapy being on defining relationships, the belief that behavior makes sense in context, how patterns and redundancy maintain the system’s way of responding, and having a nonpathological, nonnormative approach. Circular Causality

IFT views the symptoms of the identified patient within the total family interaction, with the explicit theoretical belief that there is a relationship between the symptom of the identified patient and the total family interaction. Primary Focus on Defining Relationships

In every communication, people continually attempt to define the nature of that relationship. Each person, in turn, responds with his or her definition of the relationship—which may affirm, deny, or modify that of the other. Therapy focuses on observable exchanges of behavior taking place in the present between the members of the client’s primary relational context. Behavior Makes Sense in Context

All behavior (including symptomatic behavior) is communication and, therefore, inseparable from the contexts and relationships of which it is a part. Pattern or Redundancy

As time passes, certain behaviors are maintained as acceptable while others are excluded, such that observable patterns of interaction emerge among the members. These redundancies can be understood metaphorically as the rules governing relationships within a given family system. These patterns define relationships, connect members of the family, and are the focus of therapy. A Nonpathological, Nonnormative Approach

While there is a possibility of historical, genetic, or so-called hereditary factors, such factors are not independently observable except in cases of severe mental or physical deficiency. Therefore, IFT maintains that

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all behavior becomes comprehensible within the context of relationships. Behavior occurs as a part of patterns of interaction with others, is mutually causative, and is self-reinforcing. Thus, individuals are not seen as harboring pathology and should not be compared with a normative group, as occurs with the use of diagnostic tools such as the Diagnostic and Statistical Manual of Mental Disorders.

Techniques A few of the techniques used in this approach are gathering specific information, circular questioning, identifying problem-maintaining behaviors, using the client’s frame of reference, assigning tasks, and sharing responsibility. Gathering Specific Information

Keeping the preceding presuppositions in mind, the IFT therapist joins the client by gathering information about the problem. Typically, the therapist asks questions about, and is trying to make sense of, who is involved, how communication transpires between people, and when and where difficulties occur. The therapist examines the client’s language, worldview, and punctuation about the problem (i.e., the client’s explanation or reasons for the problem) and also when the client decided that this was the best explanation for the difficulty. In this process, questions are asked to learn what brings the client in to talk about the problem now: In what context would the symptom make sense if the symptom (i.e., the behavior being complained of) were an unlabeled comment about the untenable nature of the relationship? In this process, the therapist listens for incongruences and how the symptom is protective of others. Circular Questioning

Circular questioning and positive connotation are used to bring forth and understand patterns of interaction (i.e., relational logic) that make the symptom coherent. The therapist examines the effects of the behavior of one person on other people in the system. Exploring the effects of behavior on others rather than the motives of behavior reveals the rules of a relationship, such as who is doing what and to whom, and in what way it is a problem: What happens then? What do other

family members do? Who else is involved? What is going on then? Attempts to resolve the problem often lead to maintaining the problem. Identifying Problem-Maintaining Behaviors

Inquiry is made into what family members have done to try to solve the problem. In this process, the therapist might ask what things were like before the family members settled on this explanation for their situation. The therapist looks for overt and covert coalitions and tries to comprehend what the future will look like once the situation has changed. Questions are asked to obtain information and so that family members can overhear and digest the relationship ramifications of responses. Other questions the therapist may use to identify patterns of interaction and problemmaintaining behavior include the following: • In what situation would the symptom (and the way others respond to it) make sense (i.e., an adaptive response to the complex, untenable nature of the situation)? • How does the behavior calibrate closeness and distance? • What are the advantages and disadvantages of change? • How is the problem both a problem and a solution to a larger relational dilemma?

Using the Client’s Frame of Reference

Once a relationship-focused hypothesis is validated, the IFT therapist adopts and works within the client’s frame of reference or worldview to offer an alternative way of understanding the situation. Such contextual framing allows family members to interact in ways that no longer call forth and perpetuate the problem. The objective is to develop a therapeutic relationship that allows all members of the relational system to change, using therapeutic reframes based on the emerging relationship information that allow family members a legitimizing logic for behaving differently. Assigning Tasks

The therapist gives tasks to the client and/or the family members to disrupt the behavior pattern calling forth and perpetuating the symptom. Based

Internal Family Systems Model

on a systemic hypothesis of how the behavior of  family members reinforces existing patterns, tasks are given to interrupt problem-maintaining interactions. Information from how tasks are completed is used to either refine or solidify a therapeutic reality. The adaptive and often protective nature of behavior is reinforced using positive connotation (e.g., reframing a behavior in a positive light) of the behavior of all family members. Subsequent tasks are prescribed to maintain constructive changes. Tasks often are direct behavioral prescriptions, paradoxical interventions in which it is hoped that the clients will rebuke the therapist’s prescription and do the opposite, and positive connotations, or reframing the problem in a positive light.

members say what they say about the nature of the relationship, both among themselves and to the therapist? • In ways that fit the language of the client, the therapist makes covert relationship implications overt by reframing the basis of the dependency or the protective character of the behavior.

Once a relationship hypothesis is verified, the IFT therapist identifies solvable problems, sets goals, designs interventions to achieve those goals, and examines and takes responsibility for the effectiveness of outcome. Three categories of active intervention are used to evoke change: (1) direct behavioral prescriptions, (2) paradoxical interventions, and (3) positive connotations. Wendel A. Ray and Leah Tucker

Sharing Accountability

An IFT therapist is accountable for his or her actions and takes responsibility for behaving in such a way as to evoke constructive change. This position of accountable action is succinctly set forth by Jackson, who suggested that the therapist is responsible for ensuring that families that are stuck in rigid ways of interacting should have these patterns disrupted by the therapist. Such families, suggested Jackson, do not have to be conscious of how the patterns are disrupted because change can occur through a number of ways, many of which the therapist may be conscious of but the family may not.

Therapeutic Process In this approach, the therapist first develops a relationship-focused hypothesis that includes all members of the family. This is done while using a nonjudgmental stance and adhering to the conviction that there is nothing wrong with the symptomatic person or anyone else in the relationship nexus. Positively connoting (reframing) all members of the treatment unit is critical. Some ideas useful to make contextual or relational sense of behavior are as follows: • If the symptom were an unlabeled message about the untenable nature of relationship rules, what would the message be and to whom? • What is implied about the nature of relationships between members of the family by how family

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See also Brief Therapy; Haley, Jay; Madanes, Cloe; Palo Alto Group; Strategic Family Therapy; Strategic Therapy; Systemic Family Therapy

Further Readings Fisch, R., Ray, W., & Schlanger, K. (Eds.). (2009). Focused problem resolution (Selected papers of the MRI Brief Therapy Center). Phoenix, AZ: Zeig, Tucker & Theisan. Ray, W. (Ed.). (2009). Interactional theory in clinical practice (Selected papers of Don D. Jackson; Vol. 2). Phoenix, AZ: Zeig, Tucker, & Theisan. Ray, W., & Nardone, G. (2009). (Eds.). Insight may cause blindness and other essays (Selected papers of Paul Watzlawick). Phoenix, AZ: Zeig, Tucker, & Theisan. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York, NY: W. W. Norton. Weakland, J., & Ray, W. (1995). Propagations: Thirty years of influence from the mental research institute (MRI). New York, NY: Haworth Press.

INTERNAL FAMILY SYSTEMS MODEL The internal family systems (IFS) model is an integrative approach to treatment that focuses on healing wounds associated with individual, couple, and family trauma. Developed from the foundational principles of Sigmund Freud’s ego states, transactional analysis, and psychosynthesis, this

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approach uses enactments, recognition of active parts, direct access, and a multitude of imaging techniques to improve the clients’ internal and external relationships.

Historical Context The IFS model was developed in the mid-1990s by Richard C. Schwartz, marriage and family therapist and founder of the Center for Self Leadership in Illinois. IFS has been researched in multiple studies and has been shown to be effective for treating trauma in individuals, couples, and families. With divorce rates in Westernized societies reported to be high (more than 50% in some Western countries) and with an increased prevalence of nontraditional family units, IFS, among other experiential models of therapy, has been found to be useful to assist clients to recognize their multiple parts of self, accept such parts, and work toward finding balance and harmony with their internal system of parts.

IFS is to help families and individuals recognize their internal parts, accept their multiple parts, achieve balance within their internal system of parts, and allow the self to lead the internal system of parts. As a result of achieving these goals, family members might be able to reconceptualize and change their interactions with one another.

Major Concepts Major concepts of this approach, defined in the following subsections, include multiplicity of the mind, self, multiple parts, and the internal system. Other important concepts include managers, exiles, firefighters, protection, polarization, and alliance. Multiplicity of the Mind

Multiplicity of the mind maintains that individuals have many different subminds or subparts and each of these subparts has the overall goal of achieving self-preservation for the individual as a whole.

Theoretical Underpinnings IFS is an integrative approach founded on concepts from ego state psychoanalytical theories, strategies from Bowenian-based therapy, and forms of structural and narrative-based family therapy. IFS assumes that every individual has a self in addition to multiple subparts that interact internally in a manner similar to the way people interact with one another. The self is typically the leader of the parts, and the intention of each of the subparts is to contribute positively to the overall individual while also seeking self-preservation of the individual as a whole. The parts form dynamic methods of interaction with other internal parts as well as with the parts of others. Each of these parts has a variety of responsibilities for protecting the individual against actions and behaviors that could offset the individual’s harmony and balance within his or her internal system of parts. When individuals and families experience traumatic events, feel pain, or are threatened, one or more of these internal parts can begin to take on extreme roles to protect the individual as a whole. Individuals might then become stuck in patterns of internal and external interactions that are governed by their extreme parts instead of being led by the self. The goal of

Self

IFS assumes that all individuals have a true self that is separate from the parts. When the self is differentiated from the parts, it is secure, relaxed, and confident. Multiple Parts

An individual is composed of multiple parts that play a distinct role in the individual’s life. Each part has its own distinct memories, thoughts, feelings, and interests. Parts can become extreme, take over the roles of other parts, and even take over the self. Parts are primarily grouped into three categories: managers, exiles, and firefighters. Managers are responsible for how individuals interact with the external world and attempt to prevent unwanted experiences, emotions, and exiles from reaching consciousness. Exiles are often a result of trauma, pain, or fear, and the managers and firefighters attempt to isolate these parts from the rest of the internal system. Firefighters react to the release of exiles to the conscious mind by distracting the other parts through impulsive behaviors such as sex or substance use.

Interpersonal Group Therapy

Internal System

The internal system consists of the types of relationships between each of the parts and the self. The three primary relationships consist of protection, polarization, and alliance. Protection primarily consists of the firefighters and the managers working together to protect the individual from feelings resulting from trauma, pain, or exiles. Polarization occurs when two parts are in conflict with each another to determine how an individual might behave or feel in a given situation. Alliance is when two parts work jointly to achieve the same goal.

Techniques When applying IFS to working with families, techniques include the introduction of IFS language, enactments, recognition of active parts during a session, working with one family member at a time, and working with family members inside and outside of the session. IFS Language

Therapists teach clients to utilize the IFS language so they can become free from perceiving themselves and others through the eyes of their extreme parts. Enactments

Therapists stage role-plays or enactments between family members or of interactions between the parts of family members. Recognition of Active Parts

Therapists openly identify the parts of a client and the relationships between the parts that are active during a session.

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for his or her parts while learning to lead his or her internal system with the self. Other techniques therapists use include creating diagrams of relationships between parts, direct access, journaling, and a multitude of visualization techniques. Direct access describes the process of facilitating communication between the self and the parts, parts and other parts, and the therapist and the client’s parts.

Therapeutic Process Early sessions begin with the therapist assessing the client’s parts and the relationships between the parts. The clients learn the IFS language and how to recognize their multiple parts within the self and other family members. Often therapists will prompt the clients to make contracts based on their initial therapeutic goals. Following this phase, the therapist will use various techniques, such as imagery, enactments, and direct access, to help the clients successfully manage their extreme parts, to find balance between the parts and the self, and to differentiate the self from the parts throughout therapy sessions. Robert M. Carlisle See also Acceptance and Commitment Therapy; Dialectical Behavior Therapy; Mindfulness-Based Stress Reduction; Psychosynthesis; Structural Family Therapy; Transactional Analysis

Further Readings Schwartz, R. C. (1995). Internal family systems therapy. New York, NY: Guilford Press. Schwartz, R. C. (2009). An introduction to internal family systems therapy. Oak Park, IL: Trailheads. Schwartz, R. C. (2013). Moving from acceptance toward transformation wither internal family systems therapy (IFS). Journal of Clinical Psychology, 69, 805–816. doi:10.1002/jclp.22016

Working With One Family Member

Therapists can work with one family member in session while the other family members watch. As the therapist works with the individual family member, other family members can be asked for feedback and reactions. In contrast, when working with an individual outside of the family session, the primary goal is to help the client take responsibility

INTERPERSONAL GROUP THERAPY Interpersonal group therapy is based on the assumptions that psychological problems are interpersonal struggles with others and that all symptoms have interpersonal underpinnings related to how one

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negotiates the social environment. The primary target of change in an interpersonal group therapy is relational, but positive changes in the interpersonal realm of clients’ lives are also viewed as affecting other realms as clients generalize their learning and apply it outside the group. Interpersonal group therapy has been shown to be efficient and effective with a wide range of client problems across a variety of settings.

Historical Context Although the earliest versions of interpersonal group therapy were developed by Joseph Pratt in the United States in the early 1900s to treat patients with tuberculosis, they were later used during World War II to treat those with emotional reactions. Then, in the first half of the 20th century, Kurt Lewin, a social psychologist, identified the concept of feedback in group therapy, which is core to contemporary interpersonal group therapy. Feedback, or the opportunity to discover how individuals appear to others in the group, was advanced in the training group (T-group), developed by Lewin, and in the encounter group, developed by the psychologist Carl Rogers in the 1940s. In 1947, Jacob Moreno, known for developing psychodrama, put forth the term here-and-now, which emphasized that early familial conflicts could be brought up and processed in the group to produce psychological change. But it was Irvin Yalom and Morton Lieberman’s 1973 work on encounter groups and Yalom’s classic book The Theory and Practice of Group Psychotherapy that solidified the interpersonal group therapy approach. Yalom, an existential psychiatrist at Stanford University in California, advanced the concept of feedback by teaching recipients to check with other group members to determine the feedback’s legitimacy and to reduce distortions.

Theoretical Underpinnings Harry Stack Sullivan, a psychiatrist and psychoanalyst, was the first to propose that early in life, children receive parental responses of disapproval that can evoke a sense of insecurity and lead to persistent and immature forms of thinking known as parataxic distortions. His theoretical foundation, which was first applied to an interpersonal

therapy group, emphasized the interpersonal dimension of psychological problems as crucial for healing. His position was that to treat psychological problems, which are defined as problems with other people, other people are required. One way of treating psychological problems in groups is through the use of what Yalom originally termed curative factors, which included universality, altruism, instillation of hope, imparting information, corrective recapitulation of the primary family, socializing techniques, imitative behavior, cohesiveness, catharsis, interpersonal learning, and existential factors. Such curative aspects of groups are believed to operate in every type of therapy group and are described as the core elements beneficially affecting client growth in groups. More recently, called therapeutic factors, they have been distilled to four primary factors: (1)  instillation of hope, (2) secure emotional expression, (3) awareness of relational impact, and (4) social learning.

Major Concepts Group process is explicitly used as a mechanism of change by developing and exploring interpersonal relationships in the therapy group. The major concepts include the group as a social microcosm, cohesion, and transference and insight. Group as a Social Microcosm

Yalom noted that group members display their maladaptive interpersonal patterns in the group just as they have created them in life and suggested that the feelings and reactions that surface should be treated like data, particularly if they are repeated and are acknowledged by members and leaders. Once reactions are identified and explored, members are encouraged to practice new, more effective behaviors that can be generalized outside the group. Cohesion

Cohesion is often described as a group member’s sense of belonging and acceptance, bonding, and a working alliance of the group members that includes a commitment to the group leaders, other members, and the group as a whole.

Interpersonal Group Therapy

Transference and Insight

Transference is a form of interpersonal distortion toward the leaders or other group members that stems from relationships with earlier important figures in one’s life. When such interactions are processed in the moment, those distortions are realized and highlighted, leading to greater insight and more accurate perspectives about the self.

Techniques Some major techniques used in interpersonal group therapy are working with transference to gain insight (already discussed under “Major Concepts”), here-and-now processing, and using leader transparency. Here-and-Now Process Illumination

Through here-and-now interactional patterns, group members recognize and realize the impact of their behavior patterns through leaders’ verbal responses and reflections about a specific interaction that has just occurred in group. Leaders will highlight parataxic distortions of group members and note how they stem from earlier relationships. Reflective feedback, focused on observing the thoughts and feelings underlying behaviors in group, can illuminate a group member’s harsh or off-putting reactions and help the member consider how this style interferes with the goal to have better relationships. Transparency

Therapist transparency, which includes being honest and genuine with group members, is one manner of providing direct feedback to group members about their behaviors and interactions. Such genuineness is one mechanism of encouraging members to check out their perspectives or irrational feelings and a way by which members can seek resolution of their transference.

Therapeutic Process Interpersonal groups can last from as few as eight sessions to several years, and although there is not sufficient evidence that interpersonal therapy groups move through predictable developmental

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stages, some suggest that members gradually disclose personal content and reactions as they build safety with one another. Slowly, and gently, leaders shape the group reactions with here-and-now processing to help members attain interpersonal learning. Carl Rogers documented in Carl Rogers on Encounter Groups examples of group member process, including how members may approach group therapy with anxiety or hesitation, experience the process, and subsequently change not only behaviors but also life goals, hopefulness, and personality dynamics. Juxtaposed with the fear and intrigue of revealing oneself and receiving honest feedback is often the thrill and excitement of being accepted within a group that understands the core of one’s being. The discovery of expressing the  deeper emotional self and contributing to a unique and life-giving connection with others can provide a profound sense of hope and human connection that is seen as natural, real, and nothing short of amazing. Increases in daily functioning are often demonstrated by members trying on new encounters and ways of being outside the group. People often move from feeling unlovable and alone, to risking being authentic to one’s inner self, to feeling cared for and accepted by others. Members who learn to define themselves as acceptable—in the most authentic presentation imagined—may thus increase their faith in others, experiencing hopefulness that life and love are abundant in the world. Rebecca R. MacNair-Semands See also Existential Group Psychotherapy; Group Counseling and Psychotherapy Theories: Overview; Process Groups; Process-Oriented Psychology

Further Readings Burlingame, G. M., Fuhriman, A., & Johnson, J. E. (2002). Cohesion in group psychotherapy. In J. Norcross (Ed.), A guide to psychotherapy relationships that work (pp. 71–88). New York, NY: Oxford University Press. Fehr, S. S. (2003). Introduction to group therapy: A practical guide (2nd ed.). Binghampton, NY: Haworth Press. Kivlighan, D. M., Jr., & Kivlighan, D. M., III. (2014). Therapeutic factors: Current theory and research. In J. L. DeLucia-Waack, D. A. Gerrity, C. R. Kalodner, &

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M. T. Riva (Eds.), Handbook of group counseling and psychotherapy (2nd ed., chap. 4). Thousand Oaks, CA: Sage. Rogers, C. R. (1970). Carl Rogers on encounter groups. New York, NY: Harper & Row. Yalom, I. D. (with Leszcz, M.). (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

INTERPERSONAL INTEGRATIVE GROUP THERAPY Interpersonal integrative group therapy is an approach that utilizes talk therapy, group interaction, and experiential learning to decrease a range of symptoms that may result from faulty interpersonal learning. Using a varied group of techniques, integrative interpersonal group therapy strives to bring past relationships into the group experience and explore how those past relationships affect current functioning. This approach uses the observation of group interaction to facilitate greater understanding of the past in order to show how and why the present is shaped the way it is.

Historical Context Harry Stack Sullivan was one of the first major theorists to argue that the basic premises of Sigmund Freud’s psychoanalytical drive theory were inaccurate with regard to human motivation, the nature of experience, and clinical technique. Instead, he emphasized interpersonal relations and the individual’s actual experience with his or her family. His work foreshadowed both the experiential and the relational psychodynamic approaches that followed. Sullivan believed that personality develops through repetitive interactions with the family and, further, that children develop interpersonal coping styles in response to these patterns as a means to manage anxiety and these coping styles are readily generalized to other relationships. With Sullivan’s influence, groups that focused more specifically on the interpersonal nature of personality development began to flourish during the 1960s. Today, these kinds of groups are commonplace and have become more popular than traditional psychoanalytic groups, which focus mostly on inherent drives.

Theoretical Underpinnings Interpersonal integrative group therapy combines a number of theoretical constructs, including interpersonal theory, experiential learning, relational psychodynamic theory, and family systems theory. It combines these theories by assuming that the techniques and strategies of these approaches derive meaning from the relational emphasis embedded in interpersonal theory. Interpersonal Theory

Interpersonal theory is based on the belief that understanding the past shows how and why the present is currently constructed. Group leaders facilitate change by providing a relationship that allows group members to undergo those feelings, needs, and experiences that were too threatening to confront as children. Experiential Learning

Experiential learning dictates that events are understood in terms of experiences that emerge from interactions among group members. This leads to change that shows rather than tells clients that current relationships can be different. When a group member can feel the emotions he or she has been afraid to feel, or experiences directly the wishes or thoughts regarded as unacceptable, that person is better able to accept and surmount the anxieties associated with those feelings and experiences and move on with his or her life. Relational Psychodynamic Theory

Whereas traditional group analytic practice stressed the importance of the relationship between a group member and the group leader, contemporary practice shifts this importance to member-to-member interaction in the here-and-now. Relationships among members are examined and discussed and are used as a vehicle to help group members understand past relationships and to understand how past relationships affect current relationships. Family Systems Theory

A family systems perspective suggests that psychological problems are best explained in terms of circular, recursive events, with a focus on the interpersonal

Interpersonal Integrative Group Therapy

contexts in which they developed. Thus, group leaders work on developing new, adaptive interactions with group members that break older patterns and are healthier for the group members. They do this partly by examining and working with what the group members say and how they communicate what they say.

Major Concepts Effective interpersonal integrative group therapy relies on three core concepts: (1) the potency of interpersonal learning, (2) group members’ ability to engage and collaborate, and (3) the group leader’s emotional availability. Interpersonal Learning

The potency of interpersonal learning is related to the group leader’s ability at managing multiple relationships. This requires the leader to be able to simultaneously make contact with individuals and the group as a whole. Such a leader will be able to build effective therapeutic alliances, allowing the group to flourish. Ability to Engage and Collaborate

The ability of group members to interdependently work toward mutual goals is key to an effective group. The importance of learning how to engage and collaborate with others in a diverse heterogeneous environment cannot be overstated; it frequently leads to an appreciation of differences and a more realistic view of commonalities among group members. Change is derived not only from understanding oneself but also from being understood by another. Emotional Availability

Effective group leaders are emotionally available, transparent, and present to a group member’s pain, allowing the necessary trust to build in the therapeutic relationship. In feeling understood, a group member receives the support necessary for an increasingly self-reflective attitude toward his or her feelings and behavior.

Techniques Interpersonal integrative group therapy leaders use a variety of techniques to effect change. This section

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discusses four such techniques: (1) working in the here-and-now, (2) corrective emotional experience, (3) the group as a social microcosm, and (4)  the process dimension. Working in the Here-and-Now

Working in the here–and-now focuses on bringing conflicts into the present within the group setting. For instance, if a group member states that he or she is embarrassed to talk about certain things, the group leader might encourage the member to risk talking about something embarrassing within the trusting relationship of the group. To accomplish this, the group leader must (1) provide a “holding environment” that is safe and allows the patient to reexperience and integrate threatening emotions; (2) listen for recurring patterns, themes, and feelings; and (3) focus the group member inward and make him or her a participant in the change process. Corrective Emotional Experience

This technique assumes that in therapy emotional expression is a necessary but not sufficient condition for change and that a cognitive component is also essential. Once a group member has taken the risk to express a strong emotion and the feared catastrophe has not occurred, the group leader then facilitates a group discussion that provides an opportunity for the reconstruction of a new cognitive framework about the feared event. Group as a Social Microcosm

Eventually, group members will engage in maladaptive patterns of relating to others in the group that reflect how they have related to significant others from their past. In essence, the group has become a social microcosm of each member’s life. When this occurs, the group leader actively facilitates feedback from the group, which allows each member to experience, identify, and change his or her maladaptive interpersonal behavior. Group leaders thus encourage members to point out one another’s blind spots and share responses and feelings in reaction to one another’s interpersonal behavior. Process Dimension

In each group, members must experience a relationship in which old conflicts are aroused yet are

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not responded to in the problematic ways they have been in the past. When a group member has the experience of change, rather than being advised, reassured, or interpreted, he or she is better prepared to make enduring changes. In such cases, it is important that group leaders comment directly about what is occurring in the group. These process comments may highlight an individual pattern (e.g., body language, voice tone), an interpersonal pattern (e.g., patterns of communication, repetitive conflicts, levels of intimacy), or a group-as-awhole pattern (e.g., group energy, cohesion, and avoidances).

Therapeutic Process In integrative interpersonal group therapy, groups are generally composed of 6 to 10 members who meet for 90-minute sessions once a week. Treatment usually lasts from 6 months to 1 year. John V. Caffaro See also Experiential Psychotherapy; Interpersonal Psychotherapy; Relational Psychoanalysis; Sullivan, Harry Stack

Further Readings Caffaro, J. V. (2013). Sibling abuse trauma: Assessment and intervention with children, families, and adults (2nd ed.). New York, NY: Routledge. Caffaro, J. V., & Conn-Caffaro, A. (2003). Sibling dynamics and group psychotherapy. International Journal of Group Psychotherapy, 53(2), 135–154. doi:10.1521/ijgp.53.2.135.42818 Teyber, E., & McClure, F. (2011). Interpersonal process in therapy: An integrative model. Stamford, CT: Cengage Learning. Yalom, I., & Leczcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

INTERPERSONAL PSYCHOANALYSIS Interpersonal psychoanalysis (IP) is a theory of how personality develops and how to facilitate personality change. Based on analytic concepts and techniques, IP states that psychological intimacy is

thoroughly interpersonal; thus, it emphasizes the exploration of the analytic process through the relationship between the analyst and the patient and understanding of the unconscious and defense mechanisms within this context.

Historical Context Beginning more than 70 years ago, the interpersonal school has evolved into a complex and diverse category of psychoanalytical thinking. Its roots can be found in the American school of psychoanalytical history, and its founders include Harry Stack Sullivan (1892–1949), Erich Fromm (1900–1980), Frieda Fromm-Reichman (1889– 1957), Clara Thompson (1893–1958), and Karen Horney (1885–1952). Sullivan was not traditionally trained in analysis but integrated his interests in the social sciences into IP. Likewise, Fromm’s and Thompson’s interest in political and social reform and gender issues has had an impact on IP theoretical development. Over time, Horney developed her own cultural-interpersonal school of thought but with an emphasis on the interpersonal influences on the development of the psyche. IP developed alongside the British school of psychoanalytical thought, including object relations, but IP emphasizes interpersonal relations rather than an internalized object. IP continued to develop alongside other well-known psychoanalytical traditions, including post-Freudian ego psychology and self psychology, with which it shares some common features. Because of its emphasis on theoretical openness and clinic flexibility, over time IP has developed many offshoots and perspectives, making it one of the most used, but difficult to pin down, of the psychoanalytical theories. While traditionally trained analysts and psychoanalytical treatment are much less common than they once were, there are still major training institutes throughout the United States that emphasize an IP psychoanalytical orientation. Additionally, an IP foundation can be found in modern interpersonal therapy. Interpersonal therapy is considered an evidence-based, dynamic, manualized treatment. This work is implemented in the three traditional areas of psychoanalytical exploration—the patient’s childhood recollections, current and past relationships, and transference/countertransference enactments—but with a greater emphasis on

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exploration of current relationships outside the therapeutic setting. The underlying interpersonal theory of interpersonal therapy incorporates the importance of the interpersonal context and the environment in the course of psychiatric illness. It focuses on how the self is defined and can be understood through personal relationships; however, this relational learning is based on actual interactions with past significant others and the potential re-creation of prior patterns in present relationships.

Theoretical Underpinning To understand IP, one must first be familiar with some basic psychoanalytical ideas. Founded by Sigmund Freud (1856–1939), psychoanalytical theory is both a theory of personality development and a method for treating psychopathology. Psychoanalytical theories posit that personality develops in early life based on the mother–child dyad. Problems in the basic attachment between mother and child can result in defense mechanisms (psychological strategies used to protect the self from pain) rooted in the unconscious. Psychoanalytical treatment involves the exploration of the role of the unconscious in one’s thoughts, feelings, and behaviors and often involves the interpretation of defense mechanisms. Psychoanalysis is one-on-one therapy that uses techniques such as free association and dream analysis to understand problematic personality features of the patient that are rooted in the unconscious but are acted out in the patient’s defense mechanisms. As with all psychoanalytical theories, IP emphasizes the original mother–infant bond as the source of all personality. However, IP is based on the belief that personality develops from the relationship between the mother and child and that the dynamics of that relationship become the foundation for an adult self, as opposed to a focus on drives and instincts. This leads to an analytic focus on the acting out of this relationship in later life. IP contrasts with other psychoanalytical theories in that it does not concern itself with biological determinism and “one-person” psychology. IP consists of a “twoperson” psychology in which individuals develop from an interpersonal context, and how they communicate with others is an expression of that development.

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At its core, IP is concerned with people and how they live and structure their experience. All relationships, but especially the therapeutic relationship, are tools for understanding the unconscious, defensive responses and the development of the self. The analyst understands a patient’s personality problems by developing a relationship with the patient and analyzing that relationship. All other social interactions in the patient’s life can be used in the same way. Successful therapeutic work is the gradual changing of the patient’s inner and outer worlds (interpersonal fields) by the analyst’s resisting and interpreting the patient’s attempts to transform himself or herself as a symbolic representation of anxiety from that mother–child relationship. The analyst offers interpretations about how current relational interactions may be connected to the patient’s past. In this sense, the patient’s current relational interactions are an “acting out” of past relational anxiety. These interpretations can evoke insights and reenactments for the patient. With insight into the connection between the patient’s past and present, the patient is able to work on personality change.

Major Concepts There are several core concepts that underlie all interpersonal psychoanalytical theory. These concepts not only detail the foundations of the theory but also serve to clarify how IP is different from other psychoanalytical schools of thought. This section details these major concepts. Interpersonal Field

The interpersonal field is the most frequently used theoretical and clinical metaphor in IP. It is defined as the intersection between the experiences of two or more people. Each person’s interpersonal field operates both consciously and unconsciously and includes elements of his or her past and his or her present. It can be described as having a fixed shape and capable of being acted out. In our interpersonal field, we are always both influencing and being influenced by one another. Both psychological health and psychopathology are found in understanding a person’s interpersonal field.

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Self and Self System

The self is a core aspect of character but is best understood as a self system that is made up of many interactional and relational parts. Selfhood cannot develop alone; it is created and needs confirmation in intimate relationships. In a sense, the self is a process that is formed within interactions. Early patterns of relational interaction between mothers and infants form patterns of relational involvement that become a coordinated self system. Self-awareness and identity, as aspects of the self system, emerge from a need to process, manage, and avoid anxiety. Rather than assuming intrapsychic drives to be a source of anxiety, IP considers anxiety as the result of the need for security and satisfaction. IP posits that the self as an integrated unit is an illusion and that the self is composed of multiple “selves.” The degree of integration of these various self states depends on an individual’s unique developmental history. Anxiety

Ultimate negative experiences and feelings start in infancy with anxious mothers transmitting negative feelings to their infants. These early-life relational patterns develop into personality characteristics that make individuals sensitive to the disapproval of others, which creates insecurity and affects self-esteem. As a result, all relational interactions are seen as an individual’s (conscious or unconscious) attempt to manage anxiety. This anxiety starts in the mother–infant dyad and continues to be acted out in here-and-now sensitivities to others. Attachment, Relationship, and Love

A search for attachment, relationship, and love is fundamental to the human condition. Attachment is seen as a life span issue in which adults continue to struggle to relate and be intimate with others. Other Core Concepts

Other core concepts include uniqueness and creativity: Individuals are said to naturally strive for individuality and have the potential for creativity. Other concepts such as cognition, emotion, and language are all understood as manifestations of

current relational states and as representations of the original mother–child relational dynamic.

Techniques Psychoanalytical theory, in general, and IP in particular, would be somewhat resistant to the suggestion that the analyst engages in specific “techniques” rather than simply participating in an outgoing dynamic relational process with the patient. Nevertheless, the unique relationship that is intentionally created by the interpersonal analyst has some specific and specialized characteristics. This section serves to detail some of those specifics. Participation-Observation

This concept is core to the analytic process, in which the analyst and the patient work together to observe the patient’s relational interactions with others and with the analyst. Additionally, both the analyst and the patient actively participate in their relationship, and information about their dynamic is an important part of the therapeutic inferences. Spontaneity and Naturalness

Both parties are given freedom to hear as well as speak. A patient’s associations are mingled with the analyst’s in a way that allows the relationship to be explicit, self-conscious, and mutual. Transference and Countertransference

The transference reaction of the patient (how the analyst is the projected representation of important relationships or objects in the patient’s life) and the countertransference reaction of the analyst (the patient is also a symbolic representation of relationships or objects in the analyst’s life that offer additional information regarding the patient’s unconscious defense mechanisms) play out within the therapeutic alliance such that the clinical authority shifts from the authority of the analyst to the authority of the discourse itself. In this social model of the transference– countertransference matrix, both parties in the analytic dyad are both participants and observers. Productive analysis is seen as occurring after enactment. In other words, in IP, the analyst and

Interpersonal Psychotherapy

the patient discuss events, memories, and experiences (both internal and external) in the patient’s life and then reflect on the psychodynamic enactment of transference and countertransference that unfolds between them. This immediate and heightened awareness of countertransference on the part of the analyst is considered absolutely central to the analytic engagement. Detailed Inquiry

This is a technique in which the analyst asks specific questions about common aspects of everyday living to elicit information about the relational dynamics affecting the patient. The analyst develops psychodynamic hypotheses that are offered in analytic collaboration. This detailed inquiry includes questions about both here-and-now relationship data and historical data from the patient’s past. Intentional questioning and analytic exploration lead to the psychodynamic hypotheses. Working Through

The concept of “working through” involves collaboration between the analyst and the patient in which the momentary recognitions, insights, and fleeting changes that are a part of analysis are transformed into definable aspects of the personality through the use of repetitive, progressive, and elaborative explorations of interpersonal events. This collaboration leads to new levels of understanding and experience. The analyst makes inferences about the patient’s characteristic patterns of living based on observation and participation. Additionally, the patient is encouraged to use the analytic process to reflect on the analyst as well as on himself or herself.

Therapeutic Process At its core, IP is the mutual pact between the patient and the analyst to explore the enactment between them and what is simultaneously being talked about in the here-and-now. The analyst participates in a major way in the analytic situation, shifting from interpretations of transference and countertransference to explorations of interpersonal interactions using a fluid and vital interactional method. The patient experiences and is perceived by the

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analyst as having a real relationship with the analyst. The analyst avoids being too empathic and active so that the patient is blocked from recapturing projected or dissociated experiences. At the same time, the analyst is directly participating in the enactment. This working through of the transference is the primary goal of the therapeutic interaction. The relationship between the analyst and the patient is an ongoing enactment. In comparison with traditional psychoanalysis, IP is less likely to use the past and more likely to use the immediate relational context to facilitate the emergence of previously unknown aspects of the patient’s history. The analyst’s self-disclosure is an important, but controversial, feature of this treatment. The analyst offers nondefensive interpretations of the patient’s transference and, in this sense, is still using a relational projective model. As a result, the analyst’s countertransference reaction must be carefully monitored, as it offers a fertile ground for continued understanding of the patient but also threatens to derail treatment by focusing on the enactment of the analyst’s relational issues rather than the patient’s. Francesca G. Giordano See also Classical Psychoanalytic Approaches: Overview; Ego Psychology; Freudian Psychoanalysis; Neo-Freudian Psychoanalysis; Object Relations Theory; Self Psychology

Further Readings Lionells, M., Fiscalini, J., Mann, C. H., & Stern, D. B. (1995). Handbook of interpersonal psychoanalysis. Hillsdale, NJ: Analytic Press. Stern, D. B., Mann, C. H., Kantor, S., & Schlesinger, G. (1995). Pioneers of interpersonal psychoanalysis. Hillsdale, NJ: Analytic Press. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: W. W. Norton.

INTERPERSONAL PSYCHOTHERAPY Interpersonal psychotherapy (IPT) is an evidencebased, time-limited therapeutic approach designed to decrease symptoms of major depression and enhance overall psychosocial functioning. IPT is

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based on the premise that psychiatric disorders often occur in the context of significant interpersonal relationships. Although initially created to treat symptoms of major depressive disorder, IPT has been shown to be highly efficacious in treating multiple psychiatric conditions and a wide range of client populations.

Historical Context IPT was developed by Gerald Klerman and Myrna Weissman and their colleagues in 1969, as a timelimited approach for the treatment of major depression. Since its creation, IPT has become widely utilized among mental health practitioners due to its relative ease of use. Over the years, IPT has been successfully modified to treat a number of psychiatric disorders (e.g., bipolar, substance abuse, bulimia) and different age and racial/ethnic groups. Presently, there is extensive literature documenting its efficacy not only with individuals who experience depression but also with those who suffer chronic pain. More recent studies have demonstrated efficacy with adolescents who engage in nonsuicidal self-injury, elderly clients, as well as other diverse and low-income client populations.

Theoretical Underpinnings IPT is grounded in the psychological concept of attachment. Attachment theory suggests that individuals experience psychological distress when relational challenges occur reminiscent of early-life disruptions with key attachment figures (e.g., mom, dad, or other caregiver). Humans are inherently social beings and are best able to explore the world when they have a secure base to return to at times of distress. IPT focuses attention on one or two of four interpersonally relevant problem areas: (1) grief, (2) interpersonal role disputes (conflict with significant others), (3) role transitions (life change), and (4) interpersonal deficits (challenges with initiating and sustaining relationships). Clients’ presenting concerns, while often multifactorial, always occur in a social and interpersonal context. For example, one client may seek counseling because he or she is having difficulty communicating wants and needs with his or her spouse, partner, children, or employer. Another may present

with difficulty in effectively engaging in social relationships, while another client may express a desire to break old patterns and create new ones. Unanticipated role transitions (loss of a job, transition to parenthood, or new relationships) or role disruption (separation, divorce, or death) can significantly affect individuals. These various stressors take a toll on relationships with romantic partners, friends, children, and/or coworkers and may create feelings of guilt, disappointment, and rejection. Potential unresolved feelings often limit the client’s ability to effectively engage with others. Distinct from cognitive-behavioral therapies, IPT places emphasis on improving social supports and communication style as the primary approach to alleviate depressive symptoms. Consequently, the therapist focuses the sessions on identifying the most effective way of getting the client’s interpersonal needs met rather than on altering cognitions.

Major Concepts Several concepts are utilized in this approach, including interpersonal inventory, communication analysis, use of the therapeutic relationship, grief and loss, role disputes, role transitions, and interpersonal deficits. Interpersonal Inventory

Obtaining the interpersonal inventory is the process whereby therapists gather detailed information regarding the client’s most significant relationships with others. Communication Analysis

Communication analysis is a process used to examine and identify ineffective communication patterns. This technique is done through a detailed account of important interactions the client has had with a significant other. Use of the Therapeutic Relationship

Through the use of the relationship, the therapist provides immediate feedback about interpersonal style and behaviors observed in the session and how such observations relate to the client’s other interpersonal relationships. The therapeutic

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relationship and counseling environment become another experimental setting in which to practice newly acquired interpersonal skills.

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Encouragement of Affect

Encouragement of affect describes a series of techniques that allow the client to process painful emotions about past or current events.

Grief and Loss

In IPT, the term grief refers to the loss of a loved one. Goals include facilitation of the grieving process and reestablishment of relationships. The therapist assists the client in processing positive and negative feelings about the most recent interactions with the loved one.

Role-Playing and Modeling

Role-playing and modeling can be used to help the client consider alternative options and experiment with newly learned interpersonal skills in a safe setting.

Role Disputes

Homework as an Experiment

In this context, role disputes has to do with conflicts with significant others. Goals include clear identification of the specific dispute and making choices about how to address the conflict. The therapist assists the client in changing certain behaviors and adjusting expectations, or in some cases terminating the relationship, if needed.

In IPT, homework assignments are highly personalized. Assignments can range from investigating different options in the resolution of a dispute to the client practicing expressing his or her wants and needs in a romantic relationship.

Role Transitions

Goals include mourning former life roles (e.g., working) and developing a sense of mastery of the new roles (e.g., being retired). The therapist assists the client in a realistic assessment of what has been lost and the potential opportunities associated with the new role. Interpersonal Deficit

Clients with certain interpersonal deficits, such as depression, will often isolate themselves. IPT attempts to decrease social isolation and assist the client in forming new relationships and increasing social contact. Self-care strategies and activity pacing are incorporated to facilitate progress toward the client’s interpersonal objectives.

Techniques Many of the techniques used in IPT are also commonly used in psychodynamic and cognitivebehavioral therapies. Different combinations of the techniques can be utilized at different stages of therapy.

Therapeutic Process IPT typically lasts between 12 and 20 sessions. The frequency of sessions tapers off toward the end of treatment to a maintenance phase. The initial session involves the completion of the interpersonal inventory used to gather information about the client’s key relationships. The therapist forms a conceptualization of the client’s challenges and presents it to the client for agreement. Collaboratively, the client and the therapist identify one of four areas to focus on: (1) interpersonal dispute, (2) grief and loss, (3) role transitions, or (4) interpersonal deficits. The therapist develops a personalized set of specific strategies based on the identified problem area. The last few sessions, also known as the termination phase, are devoted to reviewing treatment progress, assisting the client in addressing other conflicts that may not have been discussed, and helping the client apply the newly acquired strategies to future conflicts. Chinwé U. Williams See also Attachment Theory and Attachment Therapies; Cognitive-Behavioral Therapy; Interpersonal Theory; Psychodynamic Family Therapy; Relational-Cultural Theory

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Further Readings Klerman, G., Weissman, M., Rounseville, B., & Chevron, E. (1984). Interpersonal psychotherapy of depression. New York, NY: Basic Books Poleshuck, E. L., Gamble, S. A., Cort, N., Hoffman-King, D., Cerrito, B., Rosario-McCabe, L. A., & Giles, D. E. (2010). Interpersonal psychotherapy for co-occurring depression and chronic pain. Professional Psychology: Research and Practice, 41, 312–318. doi:10.1037/ a0019924 Stuart, S., & Robertson, M. (2003). Interpersonal psychotherapy: A clinician’s guide. New York, NY: Arnold. Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York, NY: Basic Books.

INTERPERSONAL THEORY The origins of interpersonal theory are credited to Harry Stack Sullivan (1892–1949), who provided the framework for understanding the person in the context of his or her relationships. According to Sullivan, interpersonal situations, or social experiences, influence intrapersonal development. Interpersonal theory is focused on the client’s manner of relating in interpersonal relationships, in general, and within the therapeutic relationship, in particular. The therapeutic relationship itself is the primary source of information about the client in relationships, as well as the vehicle for change. Through a new and therapeutic experience that is facilitated by the therapist, the client can learn more functional ways of interacting that are adaptive across situations, relative to the dysfunctional patterns of interacting that are presumed to account for current difficulties. Although there are variations of contemporary interpersonal theory, they generally converge on several key principles that have origins in Sullivan’s work.

Historical Context Influenced by the advances made in the electric and magnetic field theoretical perspective in physics at the time, Sullivan focused his interpersonal perspective on the interrelations between two persons in a common environment and the interpersonal fields of force that shape each person’s being. In

contrast to psychoanalytical drive theory, Sullivan viewed personality as interpersonal, personality being the characteristic patterns of interactions manifested within these interpersonal force fields over time. Sullivan put the focus of inquiry on the observable behaviors in interactions and placed abnormal personality on a continuum with normal personality. In so doing, Sullivan did much to advance the theory as well as the science of studying interpersonal phenomena. In the 1950s, the California-based Kaiser Foundation Research group, whose most notable member was Timothy Leary, attempted to systematize and operationalize Sullivan’s principles. Through observations of the interactions between patients in small-group settings, the various types of interpersonal behaviors were categorized. A statistical method for data reduction, called factor analysis, was utilized to reveal the dimensions underlying these data. The individual interpersonal behaviors were shown to reside in a circular array with two underlying dimensions that were forms of agency and communion. These two dimensions are perpendicular, defining the y- and x-coordinate system, respectively, with the specific behavioral variables residing along the circumference of the circle. The theoretical assumption that an individual’s characteristic force field is expected to pull for certain behaviors from the other person that are complementary became a formally testable assumption within the circular or circumplex model. Since Leary’s time, Sullivan’s formulations continued to be advanced by figures such as Lorna Benjamin, Robert Carson, Donald Keisler, and Jerry Wiggins. These contemporary interpersonal theorists share several key ideas. Each utilized agency and communion in some form, and each embraced a circular or circumplex model to describe the predictable patterns of interpersonal behaviors that occur in interpersonal interactions, at either the specific behavioral interchange level or the broader personality disposition level. Although Sullivan emphasized obtaining insight in therapy, along with experience, not all contemporary interpersonal theoretical approaches emphasize insight.

Theoretical Underpinnings According to interpersonal theory, individuals seek satisfaction and security in interpersonal relationships. Threats to satisfaction and especially to

Interpersonal Theory

security are anxiety provoking, and individuals are generally motivated to avoid anxiety-provoking interpersonal situations. Sullivan proposed that the strategies one characteristically employs in interpersonal situations to avoid anxiety are directly observable in the patterns of interpersonal behaviors between persons. This is different from the Freudian notion of defenses, whereby defenses are presumed to reside in the mind and not be directly observable. Sullivan’s interpersonal personality is not viewed as being fixed during an early developmental period; personality is constituted in a person’s recurrent pattern of relationships over time. In each new situation, individuals tend to draw on earlier experiences and make use of established patterns of responding. For some, these patterns may be dysfunctional, but they will still be adhered to quite rigidly. Contemporary interpersonal theory maintains Sullivan’s assertion that each person continually emits a force field pushing others to respond with certain actions while constraining other actions. In this way, complementary responses are pulled from others that affirm and validate one’s self-concept. Although the self-concept develops through social interactions, it is also maintained through them. Those interpersonal behaviors that maintain the self-concept are more likely to occur, whereas those that invite a challenge to it are more likely to be avoided. Thus, the interpersonal behaviors that are characteristically employed by a person in interpersonal situations are believed to be in accordance with the person’s self-concept. As the person develops, a congruence is sought between the interpersonal behaviors and the selfconcept, and this process occurs outside the person’s awareness. Complementary behaviors in interactions reduce tension, providing comfort and stability in the relationship. Thus, one’s characteristic patterns of interpersonal behaviors may be functional in that they maintain the self-concept. However, maintaining patterns of interaction can occur at a cost when it restricts the range of interpersonal interactions one will experience with important others. The therapist’s role is to provide a different experience for the client so that the client may learn new ways of interacting in relationships. Abnormal personality is placed on a continuum with normal personality, in which abnormal individuals take a more inflexible and extreme approach

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to their interpersonal interactions. Abnormal personality is therefore characterized by an overreliance on the same unhealthy patterns in new situations. Importantly, however, because patterns of behaving were learned, they can be unlearned and new learning can occur. Interpersonal theory thus indicates that therapeutic attention should be directed at present functioning, that is, the outcome of personality formation and not its causes or origins. Interpersonal theory provides a means for conceptualizing the person within his or her relationships through understanding the nature of the interactions between the therapist and the client, which then becomes the basis for facilitating a new and therapeutic experience for the client.

Major Concepts The core concepts of contemporary interpersonal theory include the metaconcepts of agency and communion along with the interpersonal circumplex, the principle of complementarity, and extremity/inflexibility. Metaconcepts of Agency and Communion

The metaconcepts of agency and communion are regarded as fundamental dimensions of human relatedness and are the central components of contemporary interpersonal theory. Agency and communion have been studied across disciplines, with different forms existing for each. Agency encompasses control, mastery, power, and dominance. Communion encompasses warmth, affiliation, intimacy, and union. Agency and communion together can characterize the fundamental challenges of living in social groups in general, which are also presumed to be present in dyads. Individuals seek to maintain self-esteem (agency) and to relate to others (communion). Circumplex

Empirical examinations of interpersonal behaviors have consistently shown a circular array of interpersonal behaviors with underlying dimensions representing forms of agency and communion. The two interpersonal dimensions are perpendicular and together underlie a circular, or circumplex, arrangement of the various forms of interpersonal relatedness (see Figure 1). Contemporary interpersonal

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Cold Dominant

AGENCY

Dominant

Warm Dominant

Extremity/Inflexibility Warm

Cold COMMUNION

Warm Submissive

Cold Submissive

process is termed correspondence, whereby warmth tends to evoke warmth and coldness evokes coldness.

Because normality and abnormality are placed on a continuum, the interpersonal perspective of psychopathology is one of continuity. The extremity and lack of flexibility a person demonstrates by imposing his or her force field indiscriminately across people and situations is an indicator of the maladaptive nature of the person’s recurrent interpersonal patterns.

Submissive

Figure 1 A General Model of Interpersonal Behaviors Located on the Interpersonal Circumplex, Showing Specific Octant-Level Categories in Relation to the Primary Interpersonal Dimensions

theories often make use of circumplex models to describe global interpersonal personality dispositions and specific interaction behaviors. A person’s interpersonal style can be located on the interpersonal circumplex. Complementarity

Interpersonal transactions are motivated primarily by the desire to avoid anxiety, which is caused by challenges to agency, including autonomy and self-esteem, and communion, including threats to interpersonal security. Complementarity in interpersonal relationships is exhibited in certain patterns of response tending to elicit predictable responses in others based on agency and communion. A complementary relationship exists when a person responds with behavior that conforms to the other person’s preferred definition of the interpersonal situation. Specifically, dominance, or agency, elicits the opposite type of behavior in the other. This process is referred to as reciprocity, whereby dominance, for example, tends to evoke submission and submission evokes dominance. Affiliation, or communion, elicits a similar type of behavior in the other. This

Techniques The interpersonal therapist is a participantobserver, participating in the actual relationship experience within the therapy context while focusing on the interactions to determine the evoking pattern of the client, which is the client’s preferred definition of the interpersonal situation and is viewed as the client’s attempts at maintaining comfort within the treatment relationship. As an example of focusing on agentic behaviors during therapeutic interactions, the interpersonal therapist might monitor how often the therapist and the client each determine the topic of conversation by initiating a topic, thus leading the conversation, versus following the other in the conversation. Focusing on communal behaviors might involve the interpersonal therapist matching the client on warmth and sharing a feeling of intimacy, for example, or matching the client on coldness and maintaining a distance. The therapist’s own reactions to the client’s behaviors can also provide a rich source of information about the client’s characteristic manner of relating to others. Through the process of responding to the pulls of the client to behave in a certain way (i.e., the client’s preferred definition of the interpersonal situation), the therapist can become hooked into reenacting difficulties with the client. However, this is not viewed as problematic, provided that the therapist is able to recognize the pattern and uses that recognition to inform the nature of the unfolding therapeutic relationship and what should be the new experience.

Interpersonal Theory

Because the range of interpersonal behaviors have been located on the interpersonal circumplex, it can provide a visual map of the client’s interpersonal style along with the complementary style of the therapist, thus allowing for an efficient translation from contemporary interpersonal theory to clinical practice. In addition, there are a host of well-researched interpersonal circumplex assessments currently available. These assessments enable interpersonal data to be organized within a common model, facilitating the application of the core principles of contemporary interpersonal theory.

Therapeutic Process Contemporary interpersonal theory acknowledges the therapist as a fellow human being engaging in interpersonal interactions with his or her client. Therefore, the interpersonally oriented therapist is not exempt from deriving satisfaction from the interpersonal relationship with the client and may even find himself or herself colluding with the client’s dysfunctional behaviors for a limited time. However, the therapist is responsible for facilitating a new and therapeutic experience for the client, which is done by first identifying the client’s preferred definition of the interpersonal situation and then progressing from it to the new experience. To accomplish this, the therapist can apply the principle of complementarity, which relies on the dimensions of agency and communion. To facilitate a new therapeutic experience, the therapist must first know what the preferred definition of the interpersonal situation is for the client. Research has supported the presence and use of complementarity in successful therapy dyads across counseling orientations, particularly when considering the beginning, middle, and end stages of therapy. The attainment of rapport in the beginning stage can be understood as a function of complementarity. The therapist is presumed to be flexible and have skills in relationship building, so the therapist can explicitly conform to the client’s preferred definition of the interpersonal situation. This process may be implicit if their styles are already complementary. A failure to obtain complementarity at this stage is associated with premature termination of therapy.

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Because the high levels of complementarity attained in the beginning stage are comforting to the client, the client will relate to the therapist similarly to how the client relates to significant others in his or her life. The therapist might get  unintentionally hooked into the client’s dysfunctional pattern of relating, but the task is still the same during the middle stage. The therapist must redefine the relationship away from the client’s preferred definition of the interpersonal situation, but in doing so, the loss of control over the relationship will be anxiety provoking for the client. Some amount of anxiety can motivate change, while too much anxiety is countertherapeutic. Therefore, the therapist must find a balance between high and low levels of complementarity when seeking to move the relationship forward. Failure to manage the struggle to redefine the relationship during the middle stage can result in premature termination. However, the relationship cannot progress to a new experience for the client without any tension or conflict occurring first. For the ending stage, the typical tasks of the therapist are to help the client identify new behaviors and to complement these behaviors, which will be reinforcing to both the client and the therapist. The resulting mutually defined relationship is expected to be more satisfying to the client as well as to the therapist. This new experience is expected to generalize to other important relationships in the client’s life. Sandro M. Sodano See also Interpersonal Group Therapy; Interpersonal Psychotherapy; Sullivan, Harry Stack

Further Readings Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorder (2nd ed.). New York, NY: Guilford Press. Carson, R. C. (1969). Interaction concepts of personality. Chicago, IL: Aldine. Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality, psychopathology, and psychotherapy. New York, NY: Wiley. Leary, T. F. (1957). Interpersonal diagnosis of personality. New York, NY: Ronald. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: W. W. Norton.

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Tracey, T. J. G. (2002). Stages of counseling and therapy: An examination of complementarity and the working alliance. In G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 265– 297). Needham Heights, MA: Allyn & Bacon. Wiggins, J. S. (1991). Agency and communion as conceptual coordinates for the measurement and understanding of interpersonal behavior. In D. Cicchetti & W. M. Grove (Eds.), Essays in honor of Paul E. Meehl (pp. 89–113). Minneapolis: University of Minnesota Press.

INTERSUBJECTIVE GROUP PSYCHOTHERAPY Intersubjective approaches address the subjectivities of all the participants in a therapy interaction, including the therapist. These approaches stress the idea that in every meeting there are two or more subjective experiences that meet, each with a need for recognition of their subjectivities. Intersubjectivists criticize “one-person psychology,” in which the sole focus is the internal experience of the client, and claim that the psyche is a result of the interactional context; thus, analytic exploration should focus on what occurs in the interaction and in the subjective experience of all the participants. The application of intersubjective approaches to group psychotherapy means that what happens in the group originates from the inner worlds of the participants, not just from one member’s psyche. Moving further from a “two-person psychology” to a “multiperson psychology,” the group is a cocreated shared experience to which every member (including the group therapist) contributes.

Historical Context Philosophically, intersubjective approaches were inspired by postmodernism, which argued that there are many narratives and no objective truth, so that everything is relative and subjective. Intersubjective scholars (e.g., Robert Stolorow, George E. Atwood, and Donna M. Orange) were influenced by self psychology, which emphasized the importance of empathy and empathic failures in the therapeutic process, thus moving from perceiving the therapist as an objective or detached

figure to one whose internal life influences his or her responses. However, in contrast to self psychology, in intersubjective approaches, the therapist’s subjectivity is elevated to a central position. Starting in the late 1970s, intersubjective writers began to criticize the psychoanalysts Sigmund Freud, Melanie Klein, and Wilfred Bion, arguing that the detached objective observation of the patient was just an illusion. Later, in the 1980s, Jessica Benjamin formulated a sequence of theoretical stages for the development of intersubjectivity and put the therapist’s subjectivity at the focus of the therapeutic process. Applications of intersubjective and relational approaches to groups have been published since the 1990s, focusing at first on the difficult group patient as a cocreation of the problematic member, the group therapist, and other group members. Today, intersubjective group therapy is influential in focusing on being with the patient rather than being an observer of the patient and making interpretations about the patient from one’s observations.

Theoretical Underpinnings Intersubjective psychotherapists believe that the subject becomes real only when authentically meeting another subject. Groups provide numerous opportunities for such meetings, with their variety of interactions. The group experience is perceived as cocreated by all the participants, including the group therapist. The interaction in the group is between many subjects, sometimes perceived as separate objects with clear boundaries and sometimes expected to fulfill one’s needs (which is termed self objects). The subjective expression of one member encourages the experience and expression of the others’ subjectivity. Looking at the therapeutic process through this lens, the meanings of the main concepts in traditional psychodynamic therapy, transference and resistance, change. Transference is understood as a result of a mutual interaction rather than a distortion created only in the patient, and the therapist’s countertransference is seen as the therapist’s transference, instead of being perceived as a response to the patient’s transference. Resistance is seen as a natural response to misattunement of the therapist or uncaring and alienating acts of group members.

Intersubjective Group Psychotherapy

In contrast to traditional analytical approaches, in intersubjective therapies interpretation is not the only vehicle of change. Instead, moments of open and honest communication can be transformative to the patient, and the group provides many such moments. The group reenacts early attachment experiences by unconsciously playing out previous relationships, into which the therapist and all group members are drawn. The group members’ and therapist’s reactions and interpretations reveal early attachment patterns, all of which can be discussed and examined.

Major Concepts Many concepts are used for both the intersubjective and the relational approaches. Some of the most important ones are enactment, moments of meeting, nonconscious experiences, dissociation, and reparation. Enactment

Enactment is a powerful emotional, nonreflective interaction among the group members and the therapist. It is an automatic and unformulated event involving all participants in a therapeutic interaction. Moments of Meeting

Moments of meeting refers to therapeutic and transformative moments in the treatment where the subjectivities of the participants become real and acknowledged. Nonconscious Experiences

Traditionally, the unconscious has been perceived as a cauldron of repressed, destructive, and dangerous drives. However, intersubjective therapists believe that there are nonconscious experiences that have never been repressed yet are not present in our awareness. They are usually nonverbal and exist in implicit memories. Dissociation

Dissociation refers to thoughts, experiences, or self states that are not admitted into experience. These experiences are split off, usually because

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they are incompatible with how one sees oneself. What is enacted is that which is dissociated. Reparation

Rather than striving to be perfect, the therapist acknowledges that there will inevitably be misattunements and injuries and focuses on recognizing and repairing such issues. The emphasis is on acknowledging empathic failures and discussing them with the group, thus attempting to repair the hurt and creating powerful experiences within the group that members wish to have had with their significant others.

Techniques When led appropriately, the subjective perception of the participant is validated in the group, which creates understanding and empathy instead of judgment. The therapist is not supposed to reflect reality or confront the member with “the objective truth.” In addition to interpretation, the group leader focuses on enactments and his or her analysis. Attention is given to nonverbal communication of group members, assuming that early experiences, especially traumatic ones, reside in the implicit memory and are engraved in the body. The analysis of enactments should include the acts of all the group members and of the therapist. An implication for group therapists is that they allow themselves to be drawn into enactments, with its attending confusion, anxiety, and heightened emotions, while continuing to process their emotions and developing an understanding of the enactment.

Therapeutic Process The group therapist helps the group members explore and share their experiences by facilitating meaningful interactions in the group. As the group develops, the therapist pays attention to his or her subjective experience and how he or she contributes to the interactions. The therapist strives to create more authentic moments of meeting—thus creating the experience that he or she really sees— and recognizes the uniqueness of each group member. It is also important for the therapist to notice injuries and work to repair them and to focus on

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enactments in the group process. Working through these enactments allows members to have a reparative experience where they can re-own previously dissociated parts of the self. Every member experiences the group as a whole, other members’ subjectivities, and his or her own uniqueness. The struggle between being separated and connected, belonging and feeling lonely creates a unique learning experience for the group members. Every individual brings a desire to be acknowledged by the group and struggles with this deep need through the group process. Haim Weinberg See also Intersubjective-Systems Theory; Relational Group Psychotherapy; Relational Psychoanalysis; Self Psychology

Further Readings Grossmark, R. (2007). The edge of chaos: Enactment, disruption, and emergence in group psychotherapy. Psychoanalytic Dialogues, 17, 479–499. doi:10.1080/10481880701487193 Schermer, S. L., & Rice, C. A. (2012). Towards an integrative intersubjective and relational group psychotherapy. In J. L. Kleinberg (Ed.), The WileyBlackwell handbook of group psychotherapy (pp. 59–87). Malden, MA: Wiley. Wright, F. (2004). Being seen, moved, disrupted, and reconfigured: Group leadership from a relational perspective. International Journal of Group Psychotherapy, 54, 235–251. doi: http://dx.doi .org/10.1521/ijgp.54.2.235.40388

INTERSUBJECTIVE-SYSTEMS THEORY Intersubjective-systems theory is a contemporary relational psychoanalytical perspective. This theory uses a phenomenological-contextual systems approach, which views personal (or subjective) emotional experience as constitutively connected to the relational systems in which it arises, and these two components are necessarily illuminated and addressed together. Perceptions about the relational context are constantly organized into safe, unsafe, and desirable—themes that maintain

psychological stability by preserving a familiar world of experience. An analyst (or therapist) using this approach works to understand the unconscious beliefs that shape perceptions and lead to relational difficulties, varying self-experience, behavioral enactments, and distressing symptoms. A process combining deep emotional understanding, interpretation, and a dialogic search for alternative perspectives brings relief. Concepts based on the use of hypothetical internal Cartesian entities such as the self, the superego, and the unconscious—a practice common among other psychoanalytical relational theories—are set aside in favor of the consideration of nonlinear relational processes of mutual influence. First named as “intersubjective theory” in 1976, it was changed to “intersubjective-systems theory” in 2002 to distinguish it from other uses of the word intersubjective.

Historical Context Robert D. Stolorow and George E. Atwood met in 1972 while teaching at Rutgers University. They were part of a group (including Silvan Tomkins) interested in the revival of Henry Murray’s Personology, which is the in-depth study of the single individual through a phenomenological perspective (in contrast to the laboratory-based cognitive and behavioral studies then popular in academia). Stolorow and Atwood studied the lives of psychoanalytical theorists and discovered a connection between theoretical precepts and psychobiography. By 1976, these studies of subjectivity had been collected together in a book, Faces in a Cloud, published 3 years later and offering a theory of subjectivity itself. Philosophy also influenced the development of intersubjective-systems theory, including the hermeneutic tradition of Wilhelm Dilthey and Hans-Georg Gadamer, who emphasized the role of interpretation in all human understanding. Dilthey, especially, emphasized the differences between gaining knowledge in the human sciences, which rely on empathy, and the method of observation used in the natural sciences. The philosophical phenomenology of Edmund Husserl, Martin Heidegger, Friedrich Nietzsche, and Jean-Paul Sartre and their frameworks for psychoanalysis, the structuralism of Claude Levi-Strauss, and the

Intersubjective-Systems Theory

cognitive psychology of Jean Piaget all influenced the crystallization of this theory.

Theoretical Underpinnings Stolorow and Atwood developed these ideas together for more than 40 years. They collaborated with Bernard Brandchaft, who developed (among many other contributions) the concepts pertaining to systems of pathological accommodation; Donna Orange, who enriched certain philosophical perspectives; and Daphne Socarides Stolorow, who, with Stolorow, formulated ideas about the centrality of affectivity, the need for emotional understanding across the life span, and how that need determined the nature of relatedness, from narcissistic relating to whole-person relating. Other contributors included Jeffrey Trop and his work on conjunctions and disjunctions and William J. Coburn’s studies of complexity and nonlinear systems theory.

Major Concepts Concepts that have an important role in intersubjectivity-systems theory include subjective emotional development, the organization of experience, selfhood, transference, unconscious process, affectivity, and concretizations. This section discusses how each is conceptualized in intersubjectivitysystems theory. Subjective Emotional Development

Developmental trauma is thought to be the result of states of intolerable affect felt in the absence of an understanding other. When inadequate caretaker systems fail to respond appropriately, the child (or adult) is left in a distressed and emotionally flooded condition, unable to integrate frightening affects. Certain relational interactions, contexts, and affects are thereafter associated with emotional pain and are avoided at all costs (consciously or unconsciously). Possible outcomes include the development of an accommodated selfhood, a crushing self-ideal, self-loathing, obsessional processes, a defensive narcissistic grandiosity, and a dissociative process. Recurring and accumulating malattunements or individual traumatizing experiences give rise to the creation of

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rigidified and highly activated perceptual-information organizing processes known as organizing principles (with associated symptoms). These encode creative solutions that maintain the once essential connection to caregivers, protect against a sense of annihilation or engulfment, and preserve a familiar world. Intersubjective-systems analysts consider the conditions of the early relational system in which the child develops, and any experiences of trauma, to understand why each analysand (client) has formed his or her particular hermeneutic about the world. Organization of Experience

Built from past, usually forgotten experiences, organizing principles are usually unconscious in the sense of being out of awareness or “prereflective.” Organizing principles forever shape experience unless interrupted by analysis or incommensurate (counteracting) life experiences. The development of personality emerges from the intersection of a child’s potential with his or her formative context, and the impact of the accrual of a unique set of organizing principles, referred to as “character.” Once formed, organizing principles continually sort all incoming perceptual information into significant categories by acting as a signaling system of either (a) potential danger, known as the repetitive dimension, or (b) the conditions for the possibility of fulfillment of needed experiences, the developmental dimension. Additionally, a futureoriented dimension of emergent growth, called the expansive dimension, is potentially available as an  outgrowth of current contextual resources. Organizing principles shape information (which is usually ambiguous) into familiar scenarios, often resulting in impactful and troubling meaning making. Relational (or emotional) experience is understood as being the result of subjective organizing, not objective truth. Organizing principles are activated in the transference with the analyst and become the basis of the analytic work. Selfhood

In older theories, “the self” has been defined as an entity or thing. In contrast, intersubjectivesystems theory studies selfhood as an aspect of

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subjective emotional phenomenology. Selfexperience is found to vary according to changing relational and situational conditions and activated organizing principles. The felt sense of me-ness fluctuates with the oscillating dimensions of organizing principles, resulting in an increase or decrease in the sense of self-esteem, sense of agency, sense of identity, and so on. An overall sense of selfhood is emergent from personality, character, style, and mood, all interacting with historical, cultural, and social circumstances. It is thought that a stabilizing benign illusion of unchanging me-ness is necessary to provide a sense of continuity across time in light of fluctuations in self-experience. Transference

Transference is conceptualized as relational experience shaped in the present moment by unconscious organizing activity. When the analysand has unconscious expectations that the analyst will respond in the same manner as early caretakers, with demeaning, intrusive, or abandoning reactions, his or her self-experience is said to be in the repetitive dimension. The assumed dangerousness of the full expression of affectivity leads to “resistances,” which can then be understood and interpreted. Because emotional experience emerges from systems of mutual influence, any understanding of an analysand by an analyst is influenced by the latter’s own organizing processes and prejudices and also the contextual moment. Occasionally, this can lead to “conjunctions” and “disjunctions,” which interrupt the therapeutic process based either on what superficially appears as agreement (but is not) or on incompatible meanings, both of which can cause impasses. The analyst must reflect on his or her contribution to the impasse by bringing any organizing into conscious reflective selfawareness and engage in a dialogical process (within a hermeneutics of trust) to reach an agreed-on understanding, because all experience is understood to be perspectival. Unconscious Process

The traditional outlook on the psychoanalytical concept of the unconscious is to view it as a

container. A phenomenological-contextual study of what organizes and affects subjective experience reveals not a storehouse but three interconnected, unconscious protective processes named in this theory: prereflective, dynamic, and unvalidated, which operate in different ways to maintain psychological stability and safety. The prereflective unconscious process organizes experience through the “lighting up” of new situational approximations of the familiar cognitive-somatic patterns of organizing principles. The dynamic unconscious repressing process acts to prevent historically dangerous or prohibited affects, thoughts, needs, or memories, from being expressed or fully known to conscious experience. The unvalidated unconscious process memorializes all unformulated experience left incoherent by a lack of responsiveness by others. The magnitude of the encompassed experience repressed by the dynamic unconscious fluctuates in response to the context. Therefore, more vulnerable self-experience crystallizes into consciousness given a safe emotional situation (e.g., analysis during a developmental transference), and there is increased backgrounding of vulnerability in the repetitive transference. Unvalidated unconscious self-experience can come into being later, given a conducive articulating and symbolizing surround. Affectivity

Pain is not considered to be pathology, but it does signal the need for an attuned other. Theoretical considerations of the etiology of repetitive organizing principles and symptoms suggest an emphasis on the importance of integrating repressed and unvalidated affect, which can mean facing existential factors such as loss, limits, and the mortality of self and the beloved other. The facing up to traumatic experiences and their outcomes, and our limited resources and situations, by experiencing and integrating grief, is an important component of living authentically. Once grief is largely integrated, it becomes possible for the analysand to identify what really matters and shape his or her life accordingly, eschewing collective preoccupations. Affects such as shame and self-loathing disperse as repetitive organizing principles lose their hold on perception, allowing other affects such as awe, joy, and

Intersubjective-Systems Theory

appreciation to arise. There can be great improvement in the analysand’s sense of being. Concretizations

Concretizations are symbolic representations of subjective truths, and they play an important role in the formation of symptoms, symbolic objects, behavioral enactments (an organizing principle in action), somatizations (body symptoms), delusions, hallucinations, fantasies, and imagery in dreams. Concretizations stand as metaphors for experience, materialized into a symbol to maintain psychological stability and continuity or to communicate what cannot be said. They are considered to be creative coping strategies rather than a sign of defectiveness.

Technique The philosophical foundations of this theory teach that “emotional kinship in the same darkness” offers a common ground for finding the precise conditions for the integration of unconscious affective experience. The analyst practices “sustained empathic inquiry” and “dwelling with,” necessary to precisely articulate (symbolize) the other’s disavowed intolerable experience, while furnishing a “relational home” (deep emotional understanding and support), a process that helps the analysand integrate affect, become emancipated from repetitive retraumatization, handle his or her situation, and live well. The analyst provides this facilitating context in two ways: first, by illuminating the analysand’s emotional world, using interpretations informed by precise emotional, cognitive, and intersubjective awareness—a relational process based on the evolving and ongoing transferences—and, second, by responding appropriately to the analysand’s organizing and creative use of the analysis. All understanding is an emergent property of an intersubjective system rather than the authoritative pronouncements of analyst or theory. Specific, preformulated techniques would interfere with the careful investigation of emotional phenomena that ongoingly emerge in the interplay of subjectivities, unique to every analytic couple. Changes to the analytic process and “structure” are

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negotiated based on the meanings given to any particular choice, explored, and framed within the analyst’s ultimate concerns: the healing of emotional pain and the facilitation of new developmental directions.

Therapeutic Process Intersubjective-systems theory’s emphasis on emotional integration reduces the grip of organizing principles over an analysand’s perceptual reality. His or her world of experience is then expanded by a lessening of the necessity for protective processes and a reduction in symptoms. The stifling hold on “reality” of old themes is loosened, and alternative, more accurate interpretations of perceptual experience are achievable. This results in less automaticity and an opening for reflection about meaning making. There is an increase in the ability to distinguish past from present relationship dynamics and to relate to others in their subjective wholeness. The relationship with the analyst provides the possibility for the formation of new and developmentally advanced organizing principles, and the ability to embrace more opportunities follows. The expression of authentic selfhood, a broadening of the ability to experience a full range of affectivity and improved relationships, leads to a stable, appreciative, and compassionate self-experience. Analysts are responsible for providing a context in which analysands can learn to tolerate existential anxiety and weather the inevitable traumas of life rather than avoid them. A more fully integrated affectivity becomes the bedrock for contentment, creativity, authentic and healthy concern for others, and other developments that become a part of self-constituting values. Such changes can open up the possibility for greater happiness, more expansive ways of living, and the ability to form relationships of deep mutual understanding. Penelope S. Starr-Karlin See also Existential Therapy; Phenomenological Therapy; Relational Psychoanalysis; Self Psychology

Further Readings Atwood, G. E. (2012). The abyss of madness. New York, NY: Routledge.

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Atwood, G. E., & Stolorow, R. D. (2014). Structures of subjectivity (2nd ed.). New York, NY: Routledge. Atwood, O., & Stolorow, R. E. (1997). Working intersubjectively: Contextualism in psychoanalytic practice. Hillsdale, NJ: Analytic Press. Stolorow, R. D. (2007). Trauma and human existence: Autobiographical, psychoanalytic, and philosophical reflections. New York, NY: Analytic Press. Stolorow, R. D. (2011). World, affectivity, trauma: Heidegger and post-Cartesian psychoanalysis. New York, NY: Routledge.

Stolorow, R. D., & Atwood, G. E. (1992). Contexts of being: The intersubjective foundations of psychological life. Hillsdale, NJ: Analytic Press. Stolorow, R. D., Atwood, G. E., & Brandchaft, B. (Eds.). (1994). The intersubjective perspective. Northvale, NJ: Jason Aronson. Stolorow, R. D., Atwood, G. E., & Orange, D. M. (2002). Worlds of experience: Interweaving philosophical and clinical dimensions in psychoanalysis. New York, NY: Basic Books. Stolorow, R. D., Brandchaft, B., & Atwood, G. E. (1987). Psychoanalytic treatment: An intersubjective approach. Hillsdale, NJ: Analytic Press.

The SAGE Encyclopedia of

Theory in Counseling and Psychotherapy

Editorial Board Editor Edward S. Neukrug Old Dominion University

Editoral Board Allen Bishop Pacifica Graduate Institute Nina W. Brown Old Dominion University Sarah P. Deaver Eastern Virginia Medical School David Donnelly University of Rochester Andre Marquis University of Rochester Rip McAdams The College of William and Mary Jane E. Myers University of North Carolina at Greensboro Suzan K. Thompson Military Integrative Therapies, LLC Richard E. Watts Sam Houston State University Jeffrey Zeig Milton H. Erickson Foundation

Managing Editor Kevin C. Snow Old Dominion University

Associate Editors Hannah B. Bayne Virginia Tech Cherée F. Hammond Eastern Mennonite University

The SAGE Encyclopedia of

Theory in Counseling and Psychotherapy

2 Edited by Edward S. Neukrug Old Dominion University

Copyright © 2015 by SAGE Publications, Inc.

FOR INFORMATION: SAGE Publications, Inc.

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15 16 17 18 19 10 9 8 7 6 5 4 3 2 1

Contents Volume 2 List of Entries vii Reader’s Guide xi Entries J K L M N O P R

591 599 607 623 691 731 753 845

S T U V W Y Z

905 997 1021 1035 1043 1057 1063

Appendices Appendix A: Chronology 1067 Appendix B: Resource Guide—Journals and Professional Associations 1073 Appendix C: Bibliography 1083 Index 1161

List of Entries Accelerated Experiential Dynamic Psychotherapy Acceptance and Commitment Group Therapy Acceptance and Commitment Therapy Ackerman, Nathan Ackerman Relational Approach Activity-Based Group Psychotherapy Acupuncture and Acupressure Adler, Alfred Adlerian Group Therapy Adlerian Therapy Advanced Integrative Therapy Adventure-Based Therapy Alexander Technique Analytical Psychology Animal Assisted Therapy Applied Behavior Analysis Archetypal Psychotherapy Aromatherapy Art Therapy Assimilative Psychotherapy Integration Attachment Group Therapy Attachment Theory and Attachment Therapies Attachment-Focused Family Therapy Attack Therapy Autogenic Training Bandura, Albert Bateson, Gregory. See Palo Alto Group Beck, Aaron T. Behavior Modification Behavior Therapies: Overview Behavior Therapy Behavioral Activation Behavioral Group Therapy Berg, Insoo Kim. See de Shazer, Steve, and Insoo Kim Berg Bibliotherapy Biodynamic Psychology Bioenergetic Analysis Biofeedback

Biopsychosocial Model Body-Mind Centering® Body-Oriented Therapies: Overview BodyTalk Böszörményi-Nagy, Ivan Bowen, Murray Bowenian Therapy. See Multigenerational Family Therapy Brain Change Therapy Brainspotting Breathwork in Contemplative Psychotherapy Brief Solution-Based Group Therapy. See Focused Brief Group Therapy Brief Therapy Cautious, Dangerous, and/or Illegal Practices: Overview Cerebral Electric Stimulation Chaos Theory Characteranalytical Vegetotherapy Chess Therapy Classical Conditioning Classical Psychoanalytic Approaches: Overview Client-Centered Counseling. See Person-Centered Counseling Co-counseling. See Re-evaluation Counseling Cognitive Analytic Therapy Cognitive Enhancement Therapy Cognitive Processing Therapy Cognitive-Behavioral Family Therapy Cognitive-Behavioral Group Therapy Cognitive-Behavioral Therapies: Overview Cognitive-Behavioral Therapy Coherence Therapy Collaborative Therapy Common Factors in Therapy Communication Theory of Couples and Family Therapy. See Human Validation Process Model Communication/Validation Family Therapy. See Human Validation Process Model vii

viii

List of Entries

Complementary and Alternative Approaches: Overview Concentrative Movement Therapy Constructivist Therapies: Overview Constructivist Therapy Contemplative Psychotherapy Contemporary Psychodynamic-Based Therapies: Overview Contextual Therapy Conversion Therapy. See Sexual Orientation Change Efforts Core Energetics Core Process Psychotherapy Couple and Family Hypnotic Therapy Couples, Family, and Relational Models: Overview Creative Arts and Expressive Therapies: Overview Critical Incident Stress Management Cross-Cultural Counseling Theory Cyclical Psychodynamics Dance Movement Therapy Daseinsanalysis de Shazer, Steve, and Insoo Kim Berg Developmental Constructivism Developmental Counseling and Therapy: Theory and Brain-Based Practice Developmental Needs Meeting Strategy Dialectical Behavior Therapy Directive Therapy Drama Therapy Eclecticism Ecological Counseling Ecotherapy EcoWellness Ego Psychology Ego State Therapy Ego-Oriented Therapies: Overview Ellis, Albert EMDR. See Eye Movement Desensitization and Reprocessing Therapy Emotional Freedom Techniques Emotion-Focused Family Therapy Emotion-Focused Therapy Energy Psychology Erickson, Milton H. Erickson-Derived or -Influenced Theories: Overview Ericksonian Therapy Evidence-Based Psychotherapy

Existential Group Psychotherapy Existential Therapy Existential-Humanistic Therapies: Overview Experiential Family Therapy. See Symbolic Experiential Family Therapy Experiential Psychotherapy Exposure and Response Prevention Exposure Therapy Eye Movement Desensitization and Reprocessing Therapy Eye Movement Integration Therapy Family Constellation Therapy Feedback-Informed Treatment Feldenkrais Method Feminist Family Therapy Feminist Psychoanalytic Therapy Feminist Therapy Fisch, Richard. See Palo Alto Group Focused Brief Group Therapy Focusing-Oriented Therapy Foundational Therapies: Overview Frankl, Viktor Freud, Sigmund Freudian Psychoanalysis Fry, William. See Palo Alto Group Functional Analytic Group Therapy Functional Analytic Psychotherapy Gender Aware Therapy Gestalt Group Therapy Gestalt Therapy Glasser, William Gottman Method Couples Therapy Group Analysis Group Counseling and Psychotherapy Theories: Overview Growth Model. See Human Validation Process Model Guided Imagery Therapy Hakomi Therapy Haley, Jay Healing From The Body Level Up Healing Touch Heart Rate Variability HeartMath Hellerwork Herbal Medicine Holding Therapy Holotropic Breathwork Homeopathic Medicine and Counseling Horney, Karen

List of Entries

Human Validation Process Model Humanistic Psychoanalysis of Erich Fromm Humanistic-Experiential Model. See Human Validation Process Model Hypnotherapy Identity Renegotiation Counseling Imago Relationship Therapy Impact Therapy Improvisational Therapy Individual Psychology. See Adlerian Therapy Inner Child Therapy Integral Eye Movement Therapy Integral Psychotherapy Integrative Approaches: Overview Integrative Body Psychotherapy Integrative Family Therapy Integrative Forgiveness Psychotherapy Integrative Milieu Model Interaction Focused Therapy Internal Family Systems Model Interpersonal Group Therapy Interpersonal Integrative Group Therapy Interpersonal Psychoanalysis Interpersonal Psychotherapy Interpersonal Theory Intersubjective Group Psychotherapy Intersubjective-Systems Theory Jackson, Donald. See Palo Alto Group Jung, Carl Gustav Jungian Group Psychotherapy Jungian Therapy. See Analytical Psychology Kelly, George Kernberg, Otto Klein, Melanie Lacanian Group Therapy Lacanian Psychoanalysis Laing, R. D. See Phenomenological Therapy Lazarus, Arnold Linehan, Marsha Logotherapy and Existential Analysis Madanes, Cloe Mahler, Margaret Mahoney, Michael J. Maslow, Abraham Maslow’s Hierarchy of Needs May, Rollo Meditation Meichenbaum, Donald Mentalization-Based Treatment Metaphors of Movement Therapy

ix

Method of Levels Milan School of Systemic Family Therapy. See Systemic Family Therapy Miller, Jean Baker Miller, William R. Mind–Body Therapy. See Psychosocial Genomics Mindfulness Techniques Mindfulness-Based Cognitive Therapy Mindfulness-Based Stress Reduction Minuchin, Salvador Modern Analytic Group Therapy Morita Therapy Motivational Interviewing Movement Therapies. See Dance Movement Therapy; Yoga Movement Therapy Multigenerational Family Therapy Multimodal Therapy Multisystemic Therapy Multitheoretical Psychotherapy Music Therapy Narrative Family Therapy Narrative Therapy Nature-Guided Therapy Neo-Freudian Psychoanalysis Neurofeedback Neuro-Linguistic Programming Neurological and Psychophysiological Therapies: Overview Neuroprocessing Neuropsychoanalysis Non-Western Approaches Object Relations Theory O’Hanlon, Bill Operant Conditioning Orgonomy Ortho-Bionomy Other Therapies: Overview Palo Alto Group Parent–Child Interaction Therapy Pastoral Counseling Pavlov, Ivan Perls, Fritz Personal Construct Theory Person-Centered Counseling Phenomenological Therapy Play Therapy Poetry Therapy Positive Psychology Possibility Therapy Postural Integration

x

List of Entries

Prayer and Affirmations Primal Integration Primal Therapy Process Groups Process Therapy. See Human Validation Process Model Process-Oriented Psychology Processwork. See Process-Oriented Psychology Prolonged Exposure Therapy Provocative Therapy Psychedelic Therapy Psychoanalysis. See Freudian Psychoanalysis Psychodrama Psychodynamic Family Therapy Psychodynamic Group Psychotherapy Psychoeducational Groups Psychosocial Development, Theory of Psychosocial Genomics Psychosynthesis Pulsing Radix Rational Emotive Behavior Therapy Rational Living Therapy Reality Therapy Rebirthing Rebirthing-Breathwork Recovered Memory Therapy Re-evaluation Counseling Regression Therapy. See Primal Therapy Reich, Wilhelm Reichian Therapy. See Orgonomy Reiki Relational Group Psychotherapy Relational Psychoanalysis Relational-Cultural Theory Relationship Enhancement Therapy Reparative Therapy. See Sexual Orientation Change Efforts Response-Based Practice Rogers, Carl Rolfing Rollnick, Steve. See Miller, William R. Rubenfeld Synergy Satir, Virginia Schema Therapy Scream Therapy. See Primal Therapy Self Psychology Self-Help Groups Self-Relations Psychotherapy

Seligman, Martin Sensorimotor Psychotherapy Sexual Identity Therapy Sexual Minority Affirmative Therapy Sexual Orientation Change Efforts Shapiro, Francine Skinner, B. F. Social Cognitive Theory Solution-Focused Brief Family Therapy Solution-Focused Brief Therapy Somatic Experiencing Status Dynamic Psychotherapy StoryPlay Therapy Strategic Family Therapy Strategic Therapy Structural Family Therapy Sullivan, Harry Stack Support Groups. See Self-Help Groups Supportive Psychotherapy Symbolic Experiential Family Therapy Systematic Desensitization Systemic Constellations Systemic Family Therapy Systems-Centered Group Counseling Tavistock Group Training Approach Therapeutic Touch Training Groups Transactional Analysis Transformational Systemic Theory. See Human Validation Process Model Transpersonal Psychology: Overview Transtheoretical Model Trauma-Focused Cognitive-Behavioral Therapy Unified Theory Unified Therapy Unifying Nonlinear Dynamical Biopsychosocial Systems Approach Values Clarification Voice Dialogue Wellness Counseling Whitaker, Carl White, Michael Wilderness Therapy. See Adventure-Based Therapy Winnicott, Donald Writing Therapy Yalom, Irvin Yoga Movement Therapy Zimbardo, Philip George

Reader’s Guide The Reader’s Guide is provided to assist readers in locating articles on related topics. It classifies articles into twenty general topical categories: Behavior Therapies; Body-Oriented Therapies; Cautious, Dangerous, and/or Illegal Practices; Classical Psychoanalytic Approaches; Cognitive-Behavioral Therapies; Complementary and Alternative Approaches; Constructivist Therapies; Contemporary PsychodynamicBased Therapies; Couples, Family, and Relational Models; Creative Arts and Expressive Therapies; EgoOriented Therapies; Erickson-Derived or -Influenced Theories; Existential-Humanistic Therapies; Foundational Therapies; Group Counseling and Psychotherapy Theories; Integrative Approaches; Neurological and Psychophysiological Therapies; Other Therapies; Theorists; and Transpersonal Psychology. Entries may be listed under more than one topic. Behavior Therapies

Core Energetics Feldenkrais Method Hakomi Therapy Holotropic Breathwork Integrative Body Psychotherapy Orgonomy Ortho-Bionomy Postural Integration Primal Integration Primal Therapy Pulsing Radix Rolfing Rubenfeld Synergy Sensorimotor Psychotherapy Somatic Experiencing Yoga Movement Therapy

Acceptance and Commitment Therapy Applied Behavior Analysis Behavior Modification Behavior Therapies: Overview Behavior Therapy Behavioral Activation Classical Conditioning Dialectical Behavior Therapy Exposure and Response Prevention Exposure Therapy Functional Analytic Psychotherapy Multimodal Therapy Operant Conditioning Parent–Child Interaction Therapy Prolonged Exposure Therapy Social Cognitive Theory Systematic Desensitization

Cautious, Dangerous, and/or Illegal Practices

Body-Oriented Therapies

Attack Therapy Cautious, Dangerous, and/or Illegal Practices: Overview Holding Therapy Psychedelic Therapy Rebirthing Recovered Memory Therapy Sexual Orientation Change Efforts

Alexander Technique Biodynamic Psychology Bioenergetic Analysis Body-Mind Centering® Body-Oriented Therapies: Overview Characteranalytical Vegetotherapy Concentrative Movement Therapy

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Classical Psychoanalytic Approaches

Adlerian Therapy Analytical Psychology Classical Psychoanalytic Approaches: Overview Ego Psychology Freudian Psychoanalysis Interpersonal Theory Neo-Freudian Psychoanalysis Object Relations Theory Self Psychology Cognitive-Behavioral Therapies

Acceptance and Commitment Therapy Adlerian Therapy Cognitive Analytic Therapy Cognitive-Behavioral Therapies: Overview Cognitive-Behavioral Therapy Critical Incident Stress Management Dialectical Behavior Therapy Functional Analytic Psychotherapy Guided Imagery Therapy Impact Therapy Method of Levels Mindfulness-Based Cognitive Therapy Mindfulness-Based Stress Reduction Motivational Interviewing Multimodal Therapy Rational Emotive Behavior Therapy Rational Living Therapy Reality Therapy Schema Therapy Trauma-Focused Cognitive-Behavioral Therapy Complementary and Alternative Approaches

Acupuncture and Acupressure Advanced Integrative Therapy Alexander Technique Aromatherapy Autogenic Training BodyTalk Brainspotting BreathWork in Contemplative Psychotherapy Complementary and Alternative Approaches: Overview Contemplative Psychotherapy Ecotherapy Emotional Freedom Techniques Energy Psychology

Healing From The Body Level Up Healing Touch HeartMath Hellerwork Herbal Medicine Homeopathic Medicine and Counseling Integrative Forgiveness Psychotherapy Meditation Mindfulness Techniques Morita Therapy Non-Western Approaches Prayer and Affirmations Rebirthing-Breathwork Reiki Therapeutic Touch Constructivist Therapies

Coherence Therapy Collaborative Therapy Constructivist Therapies: Overview Constructivist Therapy Ericksonian Therapy Feminist Therapy Gender Aware Therapy Identity Renegotiation Counseling Narrative Therapy Personal Construct Theory Response-Based Practice Solution-Focused Brief Therapy Contemporary Psychodynamic-Based Therapies

Accelerated Experiential Dynamic Psychotherapy Archetypal Psychotherapy Attachment Theory and Attachment Therapies Contemporary Psychodynamic-Based Therapies: Overview Core Process Psychotherapy Cyclical Psychodynamics Emotion-Focused Therapy Feminist Psychoanalytic Therapy Holding Therapy Interpersonal Psychoanalysis Intersubjective-Systems Theory Lacanian Psychoanalysis Mentalization-Based Treatment Neuropsychoanalysis Psychosocial Development, Theory of

Reader’s Guide

Relational Psychoanalysis Self Psychology Couples, Family, and Relational Models

Ackerman Relational Approach Attachment-Focused Family Therapy Cognitive-Behavioral Family Therapy Couple and Family Hypnotic Therapy Couples, Family, and Relational Models: Overview Emotion-Focused Family Therapy Family Constellation Therapy Feminist Family Therapy Gottman Method Couples Therapy Human Validation Process Model Identity Renegotiation Counseling Imago Relationship Therapy Integrative Family Therapy Internal Family Systems Model Multigenerational Family Therapy Multisystemic Therapy Narrative Family Therapy Psychodynamic Family Therapy Relationship Enhancement Therapy Solution-Focused Brief Family Therapy Strategic Family Therapy Structural Family Therapy Symbolic Experiential Family Therapy Systemic Constellations Systemic Family Therapy Creative Arts and Expressive Therapies

Adventure-Based Therapy Animal Assisted Therapy Art Therapy Bibliotherapy Chess Therapy Creative Arts and Expressive Therapies: Overview Dance Movement Therapy Drama Therapy EcoWellness Impact Therapy Improvisational Therapy Music Therapy Nature-Guided Therapy Play Therapy Poetry Therapy Psychodrama Wellness Counseling Writing Therapy

Ego-Oriented Therapies

Adlerian Therapy Analytical Psychology Developmental Needs Meeting Strategy Ego Psychology Ego State Therapy Ego-Oriented Therapies: Overview Freudian Psychoanalysis Gestalt Therapy Inner Child Therapy Internal Family Systems Model Psychosocial Development, Theory of Transactional Analysis Voice Dialogue Erickson-Derived or -Influenced Theories

Brain Change Therapy Couple and Family Hypnotic Therapy Directive Therapy Ego State Therapy Erickson-Derived or -Influenced Theories: Overview Ericksonian Therapy Impact Therapy Improvisational Therapy Interaction Focused Therapy Metaphors of Movement Therapy Nature-Guided Therapy Neuro-Linguistic Programming Possibility Therapy Psychosocial Genomics Self-Relations Psychotherapy Solution-Focused Brief Therapy StoryPlay Therapy Strategic Therapy Existential-Humanistic Therapies

Daseinsanalysis Emotion-Focused Therapy Existential Therapy Existential-Humanistic Therapies: Overview Experiential Psychotherapy Focusing-Oriented Therapy Gestalt Therapy Humanistic Psychoanalysis of Erich Fromm Logotherapy and Existential Analysis Maslow’s Hierarchy of Needs Person-Centered Counseling

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Phenomenological Therapy Positive Psychology Primal Integration Primal Therapy Process-Oriented Psychology Psychodrama Psychosynthesis Transactional Analysis Values Clarification

Modern Analytic Group Therapy Process Groups Psychodrama Psychodynamic Group Psychotherapy Psychoeducational Groups Relational Group Psychotherapy Self-Help Groups Systems-Centered Group Counseling Tavistock Group Training Approach Training Groups

Foundational Therapies

Adlerian Therapy Analytical Psychology Behavior Therapy Cognitive-Behavioral Therapy Constructivist Therapy Ericksonian Therapy Existential Therapy Feminist Therapy Foundational Therapies: Overview Freudian Psychoanalysis Gestalt Therapy Narrative Therapy Person-Centered Counseling Rational Emotive Behavior Therapy Reality Therapy Solution-Focused Brief Therapy Strategic Therapy Group Counseling and Psychotherapy Theories

Acceptance and Commitment Group Therapy Activity-Based Group Psychotherapy Adlerian Group Therapy Attachment Group Therapy Behavioral Group Therapy Cognitive-Behavioral Group Therapy Existential Group Psychotherapy Focused Brief Group Therapy Functional Analytic Group Therapy Gestalt Group Therapy Group Analysis Group Counseling and Psychotherapy Theories: Overview Interpersonal Group Therapy Interpersonal Integrative Group Therapy Intersubjective Group Psychotherapy Jungian Group Psychotherapy Lacanian Group Therapy

Integrative Approaches

Accelerated Experiential Dynamic Psychotherapy Assimilative Psychotherapy Integration Biopsychosocial Model Cognitive Analytic Therapy Common Factors in Therapy Contextual Therapy Cyclical Psychodynamics Developmental Constructivism Developmental Counseling and Therapy: Theory and Brain-Based Practice Eclecticism Emotion-Focused Therapy Evidence-Based Psychotherapy Eye Movement Desensitization and Reprocessing Therapy Integral Psychotherapy Integrative Approaches: Overview Integrative Milieu Model Integrative Forgiveness Psychotherapy Interpersonal Psychotherapy Multimodal Therapy Multitheoretical Psychotherapy Positive Psychology Transtheoretical Model Unified Theory Unified Therapy Unifying Nonlinear Dynamical Biopsychosocial Systems Approach Neurological and Psychophysiological Therapies

Autogenic Training Biofeedback Brain Change Therapy Cerebral Electric Stimulation Cognitive Enhancement Therapy

Reader’s Guide

Developmental Counseling and Therapy: Theory and Brain-Based Practice Eye Movement Desensitization and Reprocessing Therapy Eye Movement Integration Therapy Heart Rate Variability Hypnotherapy Integral Eye Movement Therapy Neurofeedback Neuro-Linguistic Programming Neurological and Psychophysiological Therapies: Overview Neuroprocessing Neuropsychoanalysis Other Therapies

Brief Therapy Chaos Theory Common Factors in Therapy Cross-Cultural Counseling Theory Ecological Counseling Evidence-Based Psychotherapy Feedback-Informed Treatment Metaphors of Movement Therapy Other Therapies: Overview Pastoral Counseling Provocative Therapy Re-Evaluation Counseling Relational-Cultural Theory Self-Relations Psychotherapy Sexual Identity Therapy Sexual Minority Affirmative Therapy Status Dynamic Psychotherapy Supportive Psychotherapy

Frankl, Viktor Freud, Sigmund Glasser, William Haley, Jay Horney, Karen Jung, Carl Gustav Kelly, George Kernberg, Otto Klein, Melanie Lazarus, Arnold Linehan, Marsha Madanes, Cloe Mahler, Margaret Mahoney, Michael J. Maslow, Abraham May, Rollo Meichenbaum, Donald Miller, Jean Baker Miller, William R. Minuchin, Salvador O’Hanlon, Bill Palo Alto Group Pavlov, Ivan Perls, Fritz Reich, Wilhelm Rogers, Carl Satir, Virginia Seligman, Martin Shapiro, Francine Skinner, B. F. Sullivan, Harry Stack Whitaker, Carl White, Michael Winnicott, Donald Yalom, Irvin Zimbardo, Philip George

Theorists

Ackerman, Nathan Adler, Alfred Bandura, Albert Beck, Aaron T. Böszörményi-Nagy, Ivan Bowen, Murray de Shazer, Steve, and Insoo Kim Berg Ellis, Albert Erickson, Milton H.

Transpersonal Psychology

Analytical Psychology Holotropic Breathwork Integral Psychotherapy Jung, Carl Gustav Maslow, Abraham Maslow’s Hierarchy of Needs Psychosynthesis Transpersonal Psychology: Overview

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J pastor father. As a result, he was at first unable to look at the contents of the dream but eventually came to interpret it as God pouring scorn on the Church and his father’s beliefs. This interpretation freed Jung to explore his own religious path, culminating in his later work Answer to Job, in which he wrote about the dark or shadow side of the Godhead. In 1903, Jung married the heiress Emma Rauschenbach, her wealth ensuring that he was able to live the rest of his life in comfort, free from financial concerns. The marriage produced five children, four daughters and a son. In the course of his long married life, Jung had extramarital relationships, most notably with Sabine Spielrein and Toni Wolff. His relationship with the former generated a great deal of prurient as well as serious interest, resulting in several books, a play, and three films. From the point of view of his work as a psychoanalyst, the most important outcome of this liaison was his later work The Psychology of the Transference (1946). In writing that work, he was finally able to explore the erotic feelings that had existed decades before between himself and Spielrein, his first psychoanalytic patient. His long-lasting affair with Wolff, a former patient, led to their close personal and professional collaboration for 40 years and a triangular relationship between the two of them and his wife, Emma. Jung trained as a psychiatrist and worked in that capacity at the Burghölzli Hospital in Zürich, Switzerland, from 1900 to 1909. It was in the course of his work there that he first encountered

JACKSON, DONALD See Palo Alto Group

JUNG, CARL GUSTAV Analytical psychology is the creation of the Swiss psychiatrist and analytical psychologist Carl Gustav Jung (1875–1961). He was born at Kesswil by Lake Constance in Switzerland, the fourth-born but first surviving child of his parents, he remained an only child up to the age of 9 years, with the arrival of a sister, Trudi. He was a solitary child, finding solace in dreams and daydreams, which set the stage for his interest in an inner life. His father, Paul Jung, was a country parson of the Basel Reformed Church, and his mother, Emilie Preiswerk, had recurring bouts of mental illness that required hospital treatment. Each important event in Jung’s life was presaged by a significant dream, starting with one at the age of 4 years that he remembered for the rest of his life. Another dream, at the age of 12, possibly the most significant of all, may be summarized as follows. He found himself in the gloomy courtyard of the gymnasium at Basel, Switzerland, and saw before him the cathedral, above which sat God on His throne. This scene of harmony and beauty was shattered by God dropping a turd on the cathedral. At the time of this dream, Jung was a devout Christian following the religious teachings of his 591

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Spielrein, when she was admitted as an inpatient in 1904 with a diagnosis of psychotic hysteria. Jung was a gifted psychiatrist and spent a great deal of time talking with patients in the hope of discovering the origin of their illness. He also conducted extensive research using word association tests to further his experimental work on complexes. Complexes may be defined as autonomous subpersonalities that lie below the level of consciousness and, when activated, intrude on the conscious mind in a disturbing and harmful way. One well-known example is that of a mother complex. This area of Jung’s work was so important to Jung that he considered calling his approach complex psychology. Jung’s most significant professional collaboration was with the pioneer of psychoanalysis, Sigmund Freud (1856–1939). Jung first applied psychoanalytical ideas in his work as a psychiatrist in 1904, with Freud starting a correspondence between them in 1906. This led to their first meeting in Vienna in 1907. The coming together of the two was based on mutual advantage, with Jung deriving a theory to underlie his work on complexes and Freud finding in Jung’s research a method that could provide proof for his own ideas. Jung became Freud’s heir apparent and was appointed president of the International Psychoanalytic Association at the second psychoanalytic conference at Nuremberg, Germany, in 1910. Three years later, the Freud–Jung relationship collapsed into mutual diagnosis, and a split between them in 1913 has had repercussions for their followers in the psychoanalytical world since that time. As a foreword to setting out some of the main concepts of Jung’s metapsychology, it should be noted that he viewed psychology as the discipline that could resolve the major debates in philosophy, sociology, biology, anthropology, comparative religion, and other fields. This view was an encyclopedic vision of psychology as the discipline to unite the circle of science. His two signature concepts—(1) collective unconscious and (2) archetypes—exemplify this vision, representing as they do innate universal structures in the mind or ancient thought forms common to humanity. Archetypes are patterns of instinctual behavior that erupt into consciousness in symbolic form and underlie the quest for individuation, which is defined as becoming wholly and indivisibly oneself, distinct from others. According to Jung, the

collective unconscious is inherited, not developed, by individuals and is universal and impersonal. It is the realm of the archetypes. Allied to these is Jung’s concept of the Self, sometimes thought of as the God-image, which transcends and defines the psychic realm. Jung’s writings on typology, in particular the concepts of introversion and extraversion combined with the four ways of functioning—thinking, feeling, intuition, and sensation—shed light on the different personality types to be found in people. Among his other concepts, anima and animus represent the feminine and masculine principles, respectively; persona describes the mask or front that is presented to the world; dreams perform a compensatory function to the conscious personality; and synchronicity stands for meaningful coincidence, an acausal connecting principle that synchronizes inner and outer events. In 1913, Jung began a confrontation with the unconscious that lasted until 1930. His fantasies and paintings from that time were transcribed by him into the Red Book, which was published in 2009 and can be thought of as Jung’s individuating process or spiritual autobiography. On the back cover of the Red Book is a statement made by Jung in 1957, which ends by saying that the numinous beginning, which contained everything, was then. The numinous is a key concept in Jung’s approach and may be defined as a fleeting experience of a religious or spiritual nature that is awesome and mysterious. His discovery of alchemy in 1928 led him away from his work on the Red Book; his researches into alchemy last continued for the rest of his life. The dialectics of the alchemical process, that of union and separation, result in the symbolic higher marriage of opposites. Symbolism is able to unite the opposites of spirit and matter in a single image. A central goal of Jungian psychoanalysis is the coming into being of the capacity for symbolization, combined with the potential for patient and analyst to be mutually transformed by the psychological alchemical process. Jung travelled extensively in the course of his life to other parts of Europe, including England. He also ventured farther afield to the United States, his first voyage there being with Freud and fellow psychoanalyst Sandor Ferenczi in 1909. In the course of his travels, Jung also visited some

Jungian Group Psychotherapy

parts of Africa and India, particularly after he retired in 1946. Visiting tribal cultures was important for Jung, as he sought to understand the common symbols that were present in all cultures. In 1955, his wife passed away, at which point he became increasingly reclusive. He died in 1961 in Zurich, Switzerland. In 1995, the International Association for Analytical Psychology was formed, which serves as the professional body for Jungian psychoanalysts worldwide. The work started by Jung continues in training institutes, developing groups, and/or analytical psychology clubs in every continent. Jung’s corpus of written work has largely been disseminated through the 20 volumes of C. G. Jung: The Collected Works, the Freud/Jung Letters, the 2 volumes of the C. G. Jung Letters, and an autobiographical work, Memories, Dreams, Reflections. Ann Casement See also Analytical Psychology; Classical Psychoanalytic Approaches: Overview; Freud, Sigmund; Freudian Psychoanalysis

Further Readings Casement, A. (2001). Carl Gustav Jung. Thousand Oaks, CA: Sage. Jung, C. G. (1953). Psychology and alchemy (Vol. 12). London, England: Routledge & Kegan Paul. Jung, C. G. (1954). The practice of psychotherapy (Vol. 16). London, England: Routledge & Kegan Paul. Jung, C. G. (1959). The archetypes and the collective unconscious (Vol. 9). London, England: Routledge & Kegan Paul. Jung, C. G. (1961). Memories, dreams, reflections. London, England: Random House. Jung, C. G. (1966). Two essays on analytical psychology (Vol. 7). London, England: Routledge & Kegan Paul. Jung, C. G. (1971). Psychological types (Vol. 6). London, England: Routledge & Kegan Paul. Shamdasani, S. (2003). Jung and the making of modern psychology: The dream of a science. Cambridge, England: Cambridge University Press.

JUNGIAN GROUP PSYCHOTHERAPY A Jungian (or analytical) approach to group psychotherapy is a unique psychodynamic, or

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depth, therapy that seeks to foster the wholeness and unique personal characteristics of the patient in a psychotherapy group. Jungian approaches to group psychotherapy integrate the analytical psychology of Carl Gustav Jung (1875–1961), a Swiss psychiatrist and one of the seminal psychotherapists and thinkers of the 20th century. Jung’s analytical psychology suggests that each individual’s unconscious contains the drive for a unique expression of the person’s life; thus, analytical psychology seeks to bring the individual in contact with his or her own unconscious purpose in life and to encourage its expression. Because of his emphasis on the unique individual potential and wholeness of each patient, Jung himself was not enthusiastic about the potential for group psychotherapy. Nonetheless, some Jungian analysts today offer psychotherapy groups in which the group is treated as a means for furthering individual growth, and they believe that the unique qualities of a group offer an opportunity to facilitate the individuation of each client.

Historical Context Jung was an early disciple of Sigmund Freud (1856–1939), and the two had a close collaborative relationship from 1902 to 1913. Freud was hopeful that Jung would become the “crown prince” of the psychoanalytical movement, but Jung viewed the dynamic unconscious more broadly than did Freud. Jung disagreed with Freud’s insistence that the unconscious contained predominately or exclusively aggressive and sexual drives; this disagreement led to a rupture between the two theorists. Jung went on to develop his own theory, called analytical psychology to distinguish it from Freud’s psychoanalysis. Beginning in the 1920s, Jung published prolifically and wrote on a series of groundbreaking studies that described the positive potential of the unconscious, outlined personality typology, and explored the common or “collective” unconscious of humanity. Jung’s ideas became popular with many in the “human potential” movement in the 1960s and 1970s and remain an important, though frequently unacknowledged, influence in psychology to this day. Over the years, Jungian analysis of the individual has thrived and become a vital therapeutic modality. Although

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Jung did not favor group psychotherapy, a small number of Jungian analysts and Jungian-oriented therapists have sought to integrate his ideas into psychotherapy groups. In contrast to Jung, Jungian group analysts believe, perhaps paradoxically, that a psychotherapy group offers a unique setting for supporting individual patients as they seek to express their unique way of being.

Theoretical Underpinnings As a major variation of psychodynamic, or depth, psychotherapy, Jungian analytical psychology follows the psychodynamic assumption that the motivations of individual patients, and of the group, will often be outside of their conscious awareness. Jung developed his theories in the shadow of the 19th-century European philosophical emphasis on materialistic science and objective, observable phenomena. Jung’s personal, scientific, and clinical work convinced him that the old scientific model was reductive and failed to account for more intuitive ways of knowing and experiencing wholeness and individuality in life. As a result, he sought to develop a theory that could explain not only the aggression and sexuality that he observed in his patients but also their strivings for unique personal wholeness, their attempts to make sense of their experiences through symbols and artistic endeavor, and the broad human need for connection, meaning, and creative expression. In more recent years, some therapists have taken Jung’s original concepts and used them within the group setting. These Jungian group therapists believe that the nature of the group offers the individual the opportunity to examine how his or her self is perceived by others in the group and gives the individual an opportunity to experiment with new, unexamined aspects of self within a safe environment.

Major Concepts Although Jung’s works takes up many volumes, six of the more important concepts for Jungian group therapy are discussed in this section, including Jung’s view of the dynamic unconscious, individuation, the ego–self-axis, the problem of the opposites, an alchemical approach to transference, and archetypes and the collective unconscious.

Jung’s View of the Dynamic Unconscious

Jung believed that the dynamic unconscious contained sexual and aggressive drives as well as positive drives, which combine to express the unique way of being for each person. Inherent in the unconscious, Jung believed, was a desire to affiliate in groups, a need for creative expression, the impulse to make meaning of human experience, and an undefined additional unconscious potential. A Jungian group therapist would use the differing perspectives of a group to explore a variety of ways of understanding unconscious material. Individuation

At the center of Jung’s theory is the idea of individuation, which is the unconscious need and desire of every human being to live a unique life that is in accord with his or her deepest and truest nature. However, an individual’s true nature is often hidden from his or her self, and the individual must challenge himself or herself to find it. In a psychotherapy group, individual members can support each other in finding and expressing their strivings for individuation. The Ego–Self Axis

The ego–self axis is an interaction between the individual’s center of consciousness (the ego) and the individual’s most positive and inspiring unconscious (the self). If the ego is in a healthy alignment with the self, an individual will experience support, inspiration, and growth through contact with his or her personal unconscious. An individual ego that is too critical of, or shut off from, the self will result in alienation and despair. An individual ego that is uncritically overwhelmed by unconscious material can result in inflation, a naive spirituality, or foolish idealism. A group setting provides an opportunity for individuals to experiment with greater openness to the self or improved functioning of the ego, as appropriate. The Problem of the Opposites

Jung maintained that every psychological phenomenon also brought with it an opposing energy. For instance, Jung suggested that each

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person had an animus and an anima—or a masculine and a feminine side, respectively. He stated that when an individual identified too strongly with either pole of an opposite, he or she became “polarized.” He stated that psychological maturity involved being able to recognize and integrate psychological phenomena that are diametrically opposed—the opposites of one’s personality. Group members can help each other see their polar opposites, and members can also experiment with opposing parts of self within the group setting. In addition, members in a psychotherapy group will frequently become polarized into opposing positions; the multiplicity of perspectives in the group is a helpful way to reduce this tension. An Alchemical Approach to Transference

Jung used medieval alchemy, or the notion that a base metal could be transformed into a precious metal (e.g., iron into gold), as a metaphor for the process of analytical psychology. He emphasized that both the patient and the analyst were mutually transformed through contact with each other. In a psychotherapy group, members allow themselves to soften ego boundaries and experience empathy deeply with one another and with the therapist, thus transforming themselves and one another. In a Jungian perspective, it is also inevitable and desirable that the group therapist will also experience change and growth. Archetypes and the Collective Unconscious

Analytical psychotherapy seeks awareness of the power of archetypes, which are patterns of psychological organization observed throughout time and across cultures. Archetypes reveal a common human, or collective, unconscious that manifests itself as similar drives, patterns, and needs expressed universally in human culture. For instance, all cultures seem to have similar stories that symbolically reflect the “mother” or the “wise person” or the “warrior.” Jungian psychotherapy groups give group members permission to access their archetypes and to understand how they become uniquely expressed in each member. By expressing the range of this material, the group can experience the power of the archetype to enhance dignity and meaning in individual members.

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Techniques Jung was averse to prescribing particular techniques for conducting analytical psychology. Rather, he believed that the analyst must be open to influences from the patient and respond authentically and to all aspects of the patient’s personality toward the goal of helping the individual become whole. Nonetheless, it is possible to infer some technical guidelines based on Jung’s key principles. A Broad Perspective on the Unconscious

Jungian analysts leading groups seek to recognize the broad potential of their patients’ unconscious and to integrate interpretations about sexual and aggressive drives with interpretations about a patient’s other potential unconscious motivations. The group therapist thus seeks to foster curiosity and exploration about the unconscious dynamics observed in a group. The therapist in a group invites other members to participate in “amplifying” a possible unconscious motivation. To amplify in a group suggests that many members would offer perspectives on the unconscious motivations that they observe in a group. In keeping with Jung’s orientation, the group therapist tries to avoid reductive interpretations but encourages a curious attitude that is open to multiple possibilities. Fostering Individuation

Jungian analysts are constantly looking for ways to encourage individuation in their clients, that is, encouraging each member to increasingly embrace all aspects of self and become more fully who he or she is. Jung encouraged patients to learn about these aspects of self in individual therapy. In a group, individual members are encouraged by both the therapist and the other members to uncover the opposite and lost parts of self and to express their visions of what their lives could be by discussing their hopes, dreams, and visions for their lives. This process of mutual encouragement and goal setting in the group aids individuals with their individuation processes. Encouraging a Healthy Ego–Self Axis

To encourage a healthy ego–self axis, the group analyst looks at the individual’s relationship

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to his or her unconscious and seeks to increase access to the unconscious for those whose selfknowledge is restricted. The analyst also encourages critical thinking in patients who become overwhelmed by their unconscious content. The therapist introduces the group members to the concept of “the self,” which helps members see positive and healing potential in the unconscious. As individual members explore their contact with the self, other members in the group become more open to their own self, and the group explores the effects of contact with this aspect of consciousness. If a group member seems to have an overly harsh ego perspective toward his or her own self, other group members can share their perspectives and encourage greater openness. If, on the other hand, an individual member’s sense of connection with the self is so powerful that his or her ego functioning deteriorates, the group can be a very effective means of helping to ground the member in everyday reality. Avoiding Polarization

To encourage patients in a group to appreciate their wholeness and complexity, analysts help a patient hold a “both/and” attitude toward seemingly irreconcilable positions. The analyst encourages group members to avoid becoming polarized and tries to have them accept all aspects of their selves. In addition, sometimes group members will become locked in positions toward one another—as if their position alone holds the truth. A Jungian group therapist encourages all group members to help each other see multiple perspectives. Jungian group psychotherapy encourages personal growth in each member by challenging his or her fixed and rigid viewpoints and requiring each member to experiment with the multiple competing perspectives. An Alchemical Approach to Transference

An analyst who approaches clients with alchemy in mind will be aware of the mutual nature of the transference, and he or she may be more inclined to self-disclosure as a result. The exchange of influence can result in the analyst’s vulnerable and related attitude toward the patient. The group therapist also encourages this attitude between the

members of the group. In a Jungian psychotherapy group, the deep empathy that develops among members softens ego boundaries, and members help transform one another as they pursue their individual life journeys. The Jungian group therapist is also open to being deeply influenced by individual members and by the entire group. Although the therapist may be circumspect in disclosing the nature of this influence to group members, he or she will use that experience to inform interventions with the group. Amplification of Archetypes and the Collective Unconscious

A Jungian analyst working with dream or other unconscious material in a group seeks to amplify the patient’s material through an openended exploration of the themes that emerge in a group. Such amplification helps the patient become more aware of hidden aspects of self—or opposites that the person is fearful of facing. In addition, as a result of the amplification, the patient may become aware of the similarities that his or her unconscious material has to common cultural themes, myths, and narratives expressed by other group members. This awareness can help foster a sense of connectedness and appreciation of others.

Therapeutic Process Although the principles of analytical psychotherapy can be applied in group or workshop settings that are as brief as a few hours or a weekend, Jungian analytical psychotherapy in groups more typically requires a long-term commitment from both patients and therapists. Regardless of the length of the therapy, a Jungian group therapist consistently attends to the strivings for individuation that he or she observes in each patient. Analysis is concluded when the analyst, most group members, and the individual group member all believe that the member has been able to confidently express more of his or her unconscious potential, has come to terms with his or her complex nature, and has developed a vital connection with his or her own unconscious. Justin Hecht

Jungian Group Psychotherapy See also Classical Psychoanalytic Approaches: Overview; Ego Psychology; Existential-Humanistic Therapies: Overview; Freudian Psychoanalysis

Further Readings Edinger, E. (1972). Ego and archetype. Boston, MA: Shambala. Hecht, J. B. (2011). Becoming who we are in groups: One Jungian’s approach to group psychotherapy. GROUP, 35(2), 151–165. Jung, C. G. (1943). Individuation. In Collected works (Vol. 7, p. 173). Princeton, NJ: Princeton University Press. Jung, C. G. (1943). Individuation: The mana-personality. In Collected works (Vol. 7, p. 238). Princeton, NJ: Princeton University Press.

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Jung, C. G. (1946). The psychology of the transference. In Collected works (Vol. 16, p. 233) Princeton, NJ: Princeton University Press. Jung, C. G. (1952). Symbols of transformation. In Collected works (Vol. 5, pp. 121–444). Princeton, NJ: Princeton University Press. Jung, C. G. (1957). The transcendent function. In Collected works (Vol. 8, p. 69). Princeton, NJ: Princeton University Press. Jung, C. G. (1964). Man and his symbols. New York, NY: Bantam Doubleday Dell.

JUNGIAN THERAPY See Analytical Psychology

K child, assembled the chassis of an old car to have transport to attend school. When the car proved unreliable, he, at age 13, left home to continue his education, living with family in Wichita, Kansas. In the period between his graduation from Park College, Missouri, in 1926, majoring in mathematics and physics, and the completion of his Ph.D. in psychology in 1931 at the University of Iowa, he undertook courses in sociology and labor relations and subsequently completed a teaching qualification in education at the University of Edinburgh as an exchange student. While studying, he held a variety of part-time jobs in the increasingly difficult economic conditions of the Great Depression, including teaching speech, drama, and public speaking, and working as an aeronautical engineer for an aircraft manufacturing company. He completed his Ph.D. in 9 months, with a thesis on reading and speech disabilities. Two days after his graduation, he married Gladys Thompson. In 1931, the Kellys left for Hays, Kansas, where Kelly would occupy a psychology teaching post at Fort Hays Kansas State College. Although interested in physiological psychology, the circumstances he saw around him—great poverty, deprivation, and, as drought turned the area into a dust bowl, starvation—could not be ignored. This led to much experimentation as Kelly sought to mobilize whatever skills he could to improve the lot of those in need. Kelly had begun to recognize that what seemed true of himself, particularly his active nature, was also true of others. Those enduring these limiting, devastating circumstances were not merely passive victims; there remained

KELLY, GEORGE George Kelly (1905–1967) developed personal construct theory (PCT), a theoretical approach to personality theory and therapeutic intervention. PCT is a pragmatic approach, emphasizing the usefulness of beliefs, feelings, and actions rather than their veracity. A distinguishing feature is emphasis on sense making involving discriminations, whereby some things are seen as similar to and different from certain other things, with both similarity and difference essential for understanding people’s functioning. The originality and breadth of his perspective drew on varied life experiences and extensive practice and evaluation of therapeutic intervention. In a 1969 essay titled The Autobiography of a Theory, Kelly gives an account of the development of his theoretical ideas, which includes a broad-ranging theory not only about the processes of therapy but also concerning the functioning of people more generally. He detailed key events that led to his insights, not because he regarded these insights as shaped by those situations but because these were events that he had necessarily made sense of. But it was he, Kelly, who was the active agent in this process, rather than being passively molded by his environment. Kelly was an only child, born in 1905 near Perth, Kansas. His parents were farmers. The area was isolated and sparsely populated, and his formal schooling was intermittent. Self-reliance and invention were essential, and Kelly, a determined 599

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available choices and possibilities that they could implement to improve their lives. Helping people access those alternatives was the key to therapeutic intervention. When a 12-year-old child with school-related issues was referred to the psychology department at Fort Hays Kansas State College, Kelly set the child’s evaluation as a class exercise. This proved an effective learning tool and resulted in a positive outcome for those involved, including the child. Consequently, in 1932, Kelly set up a psychological clinic that offered free diagnostic, therapeutic, and assessment services, staffed by himself and trained students. This service subsequently expanded, with the establishment of traveling and satellite branch clinics, a model for subsequent community mental health centers. The establishment and running of the clinic was a steep learning curve, given Kelly’s limited training in clinical psychology and the absence of similar models for such a service. Applying diagnostic labels proved pointless because of isolation from support services to which patients could be referred. Returning to psychoanalysis, which he had previously rejected, Kelly was impressed by Sigmund Freud’s clinical understanding. The interpretations Kelly offered clients often brought them profound relief. But Kelly was wary of dogmatism and certainties and became discomfited by his “insights.” He cautiously experimented with increasingly preposterous interpretations, offered to clients in the same way as his former “real” ones—and they frequently worked. He realized that what clients needed was not necessarily a “correct” interpretation of their situation but novel ways of looking at it. Clients were taken in a different direction and given a framework that prepared them for the events ahead. Because of staffing and other resourcing issues, the clinic was forced to wait-list clients, and Kelly suggested that, in the meantime, those future clients might be helpful to another distressed person. Often though, when those who had adopted his suggestion were removed from the wait list and offered therapy, they thought therapy was now unnecessary; their altruistic actions had given them a new perspective. The problem had not necessarily gone away, but it had become manageable. Such insights and Kelly’s interest in drama formed links to another approach to understanding

actions and therapy. He explored how the roles we commit ourselves to and the actions that underlie such commitments can, in and of themselves, lead to change. He and his students evaluated a type of role therapy in which the client experiments with living an alternate role temporarily. This technique, fixedrole therapy, produced positive results. For fixedrole therapy clients, the alternate role was not so much the authentic way to continue life as an invitation to explore and evaluate different ways of living. Kelly initiated many therapeutic practices that are now widely accepted. Such practices include a detailed procedures manual for clinic workers, with an extensive list of ethical practices; evaluation of therapy effectiveness, which included postintervention follow-ups; and methods for initial assessment and subsequent evaluation, including the sorting of self-descriptive terms, predating the Q-sort, and the rating of self and others on bipolar dimensions (e.g., intelligent/stupid, lovable/unappealing), predating semantic differential methodology. During World War II, Kelly and his family moved to Washington, where Kelly worked in the U.S. Navy’s Aviation division. After the war, in 1946, Kelly became the clinical psychology director at Ohio State University. He aimed to reorganize the department and place it at the forefront of clinical training. In preparation for publishing his theoretical insights, Kelly met weekly with postgraduates, reading sections of his writings for discussion and criticism. The first formal presentation of his theory occurred in 1951, when he presented a paper titled “The Psychology of Personal Constructs,” which eventually became the title of his book, published in 1955. The world, Kelly argued, is not given to us prepackaged in interpretable parcels. We, throughout our development, make discriminations about the world we experience, though we may not be able to verbalize them. We start to see patterns, with some things similar to or different from other things. Initially, these discriminations are fairly primitive. For example, young children may regard all small four-legged animals as “doggies.” But children continue to notice further differences: Doggies bark, but kitties purr. Others help them make further useful distinctions, such as between those animals that might bite and those that will not. Kelly termed these contrasts “personal constructs.” These differentiations are

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bipolar dimensions, each pole central to the meaning of the other; thus, for example, we have no understanding of north except in relation to south, or hot except in contrast to cold. While no person’s construing is identical with another’s, we may share degrees of similarity. Taking into account how other people make sense of things is an important basis for productive and respectful relationships between people, a moral dimension integral to Kelly’s approach. According to Kelly, the way construing is used, not just its content, is important for long-term satisfying living. As we behave in ways reflecting our construing system, we test its effectiveness, just as scientists do when conducting an experiment. Scientists develop hypotheses (people’s constructs), devise an experiment to test out the effectiveness of their assumptions (people’s behavior on the basis of their construing), and evaluate the outcome, either revising their hypotheses (construing) or continuing on, depending on the experimental (behavioral) outcome. Effective experimentation is as essential for well-functioning human beings as for competent scientists. As to therapy, PCT is theoretically coherent, with both an encompassing general personality theory as well as a therapeutically oriented perspective about fostering change. However, it is also methodologically eclectic, in that many different techniques, developed by various practitioners and from differing theoretical stances, can be useful in interventions in a theoretically consistent integration. The processes whereby we change our construing involve both loosening up our current construing to explore alternative perspectives and reconfiguring our prior perspective into a modified, tightened alternative. Loosening techniques include free association and fixed-role therapy, whereas tightening includes techniques such as listing priorities, as well as Kelly’s best-known methodology, the repertory grid. Helping clients deal creatively with new challenges in their lives by coordinating loosening and tightening generates viable alternative options for problem solving, providing clients with an approach that can be applied beyond their current predicament. The publication of Kelly’s theory in 1955 in his book The Psychology of Personal Constructs generated much interest, both approving and critical. Kelly was invited to present at meetings

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throughout the world. He was the first American psychologist to present in the Soviet Union. His approach was adopted by a group of British-based psychologists led by Don Bannister. In 1965, he received a distinguished appointment to the Riklis Chair of Behavioral Science at Brandeis University, near Boston, but he died unexpectedly in 1967. Subsequently, personal construct groups were formed in North America, Europe, and Australasia, with alternating biennial local and international conferences. A PCT center was established, now attached to the University of Hertfordshire. The Journal of Constructivist Psychology and an e-journal, Personal Construct Theory and Practice, promote the theory, research, and practice. Beverly M. Walker See also Constructivist Therapy; Personal Construct Theory

Further Readings Butt, T. (2008). George Kelly. New York, NY: Palgrave Macmillan. Fransella, F. (Ed.). (2003). International handbook of personal construct psychology. Chichester, England: Wiley. Fransella, F., Bell, R., & Bannister, D. (2004). A manual for repertory grid technique. Chichester, London: Wiley. Kelly, G. A. (1955). The psychology of personal constructs. New York, NY: W. W. Norton. Maher, B. (Ed.). (1969). Clinical psychology and personality: The selected papers of George Kelly. New York, NY: Krieger. Walker, B. M., & Winter, D. A. (2007). The elaboration of personal construct psychology. Annual Review of Psychology, 58, 453–477. doi:10.1146/annurev. psych.58.110405.085535

Website PCP-net: http://www.personal-construct.net/

KERNBERG, OTTO Otto F. Kernberg (1928– ), best known for his work in object relations and its relationship to

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personality disorders, primarily borderline personality disorder and narcissism, was born on September 10, 1928, in Vienna, Austria. His family fled Nazi Germany in 1939 and emigrated to Chile. His education in Chile included biology and psychology, with the intent of becoming a psychiatrist. He graduated from the Universidad de Chile medical school in 1953. He first came to the United States in 1959 to study with Jerome Frank at Johns Hopkins Hospital and emigrated in 1961 to join the C. F. Menninger Memorial Hospital, where he was director of Psychotherapy Research at the Menninger Foundation. During that time, he worked as supervising and training analyst at the Topeka Institute for Psychoanalysis. In 1973, he moved to New York, where he was director of General Clinical Service at the New York State Psychiatry Institute. In 1974, he was appointed professor of Clinical Psychiatry at Columbia University, where he was training and supervising analyst. In 1976 to 1995, he was appointed at Cornell University as professor and director of the Institute for Personality Disorders for New York Hospital. Most notably, from 1997 to 2001, he was president of the International Psychoanalytic Association. He is a distinguished life fellow of the American Psychiatric Association. Kernberg saw the relationship between deficits in object relations and the emergence of psychopathology. He developed a framework for organizing personality disorders that included a structural design based on severity. Kernberg believed that object relations was a natural extension of psychoanalysis. He saw the mother– child relationship as fundamental to understanding healthy psychological development. He proposed a continuum of pathology that ranged from the chronically psychotic, through severe personality disorders, to neurotic functioning, to normal functioning. Kernberg contended that every mother–child relationship consisted of three components: (1) an image of self, (2) an image of other, and (3) an affective disposition. The affective disposition is mitigated by the child’s drive state when the interaction with the mother occurs. If the child is deprived as part of the interaction, he or she will be left feeling frustrated and lacking object sustenance. The three-part configuration of self, other, and affectional disposition defines what is

known as the internalization system. This internalization system is complex and varies over time, based on the changing nature of the relationship between the mother and the child, as the child and the mother each develops. Kernberg identified three systems that over time reflect the stages in childhood development. Kernberg’s first system stage was labeled introjection. In this stage, the child experiences primitive emotions in relationship to the primary caregiver without a real understanding of who is the primary caregiver. The child at this stage is unable to identify the source of these feelings or the significance associated with them. The experience at this stage is assumed wholly by the child and identified as either negative or positive in its completeness. The second system stage was labeled identification. In this stage, the child is able to set aside highly emotional responses to a point where previously unattributable responses are replaced by identification and awareness of the self–object relationship. The child is able to identify self and identify the other, with both of these roles complementing each other. At this stage, the child also learns to adapt emotive responses previously unmodulated in the introjection stage. The child is able to identify himself or herself as an interactant in relationship to the separate object. Integration of ego occurs in the third and most highly developed stage in the system, ego identity. In this stage, various representations of self and other are integrated into one sense of self. The various representations and identifications are brought together into personality organization, and the self emerges as the essence in the individual and guides the way in which the individual sustains relationships. In this stage of development, the self reflects all of the possible representations of relationships with the object. Kernberg contributed to object relations theory through his developmental model, explaining certain intrapsychic tasks that one must accomplish to develop healthy relationships. Failure to successfully navigate these tasks can result in the risk of developing certain pathologies. Not accomplishing the first developmental stage, introjection, where the infant clarifies the difference between self and others, increases the risk of developing psychoses. Not accomplishing the

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second developmental stage, identification, results in increased risk of developing borderline personality qualities. Individuals with borderline personality are unable to see relationships as multifaceted and contextual but, rather, see them as all-good or all-bad, a condition Kernberg refers to as identity diffusion. In the case of patients with narcissism, their development is typically more advanced than that of patients with borderline personality disorder in that they have developed an integrated self, although distorted by a sense of grandeur. Kernberg postulates that those with pathological narcissistic tendencies need to construct an inflated view of themselves to protect their sense of self. Their overtly expressed narcissism, which others around them experience, protects their unexpressed ideal self and prevents them from having feelings of failure and humiliation. To treat those with maladaptive object relations, Kernberg developed transference-focused psychotherapy (TFP). TFP is a form of intensive psychoanalytic therapy suitable for clients with borderline personality disorder, with the intent of integrating the split-off parts of self and the object representations. It requires a minimum of three 45- or 50-minute sessions per week. The intent of the therapy is to address unreconciled representations of self and the significant object and to reduce the use of identity diffusion as a defense mechanism. These relationships emerge as a form of transference on the therapist. The therapist uses consistent interpretation and reevaluation by the client to create a more integrated self. The typical goals of TFP are better affective control, better behavioral control, and more gratifying relationships. To develop a better integrated representation of self and object and to modify the client’s defense mechanisms, the client’s internal representations of previous relationships are challenged and interpreted as part of the therapeutic relationship. Clarification, confrontation, and interpretation are processed as the client transfers his or her object experience onto the therapist. TFP starts with the development of the treatment contract. The treatment contract consists of general guidelines that apply to the client and the therapist. The therapeutic process of TFP consists of a diagnostic description of the internal object relations; elucidating the self and object relationship, including

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the transference/countertransference; and the integration of self representations that have been split off. Of greatest concern is reduction of suicidal and self-destructive behaviors and addressing the ways in which clients can subvert the treatment. Kernberg’s model of narcissistic and borderline personality was not without its critics. His model was inspired by Margaret Mahler’s work; however, it was critiqued for not having significant detail. Critics also argue that his ideas were foundationally based on his work with adult clients and applied deductively to infants. Heinz Kohut disagreed with Kernberg on several ideas. Kernberg saw narcissistic personality as a continuum with borderline personality, whereas Kohut saw both disorders as being distinctly different. They also differ in their ideas on the development of the narcissistic personality, with Kohut focusing on the libidinal drives and Kernberg focusing on aggression. And finally, both Kernberg and Kohut differed on the analytic process and whether transference is to be challenged (Kernberg) or allowed and encouraged (Kohut). Despite these differences, Kernberg is regarded as one of the most influential theorists who connected psychoanalysis with object relations and also in the development and treatment of personality disorders. Marty Jencius See also Freudian Psychoanalysis; Interpersonal Psychoanalysis; Klein, Melanie; Mahler, Margaret; Object Relations Theory; Relational Psychoanalysis; Sullivan, Harry Stack

Further Readings Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2005). Psychotherapy for borderline personality: Focusing on object relations (1st ed.). Arlington, VA: American Psychiatric. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York, NY: J. Aronson. Kernberg, O. F. (1976). Object-relations theory and clinical psychoanalysis. New York, NY: J. Aronson. Kernberg, O. F. (1980). Internal world and external reality: Object relations theory applied. New York, NY: J. Aronson. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press.

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Kernberg, O. F. (1989). Psychodynamic psychotherapy of borderline patients. New York, NY: Basic Books. Kernberg, O. F. (2012). The inseparable nature of love and aggression: Clinical and theoretical perspectives (1st ed.). Washington, DC: American Psychiatric. Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F. (2002). A primer on transference-focused psychotherapy for the borderline patient. Northvale, NJ: J. Aronson.

KLEIN, MELANIE The British psychoanalyst Melanie Klein (1882–1960), née Reizes, was born in Vienna, Austria, into a Jewish middle-class family. Klein was a bright, ambitious child and did well in grammar school, but financial problems prevented the family from supporting her desire to train in medicine; instead, circumstances forced her to marry at the age of 21. Within a few years, she had three children and moved to Budapest with her husband; however, a life of domesticity did not suit the independent and strong-willed Klein, and she became depressed. Seeking treatment with the Freudian analyst Sandor Ferenczi, Klein discovered a new and exciting intellectual pursuit in psychoanalysis. Ferenczi encouraged her to train as an analyst and to venture into the as yet unexplored field of child analysis. Klein began by analyzing her own children and went on to develop an innovative method of child analysis, called the psychoanalytic play technique, and a new school of thought in psychoanalysis based on the earliest, infant–mother relationship: object relations theory. Klein became a psychoanalyst in 1919 and, soon after, divorced her husband and moved to Berlin, where she joined the Berlin Psychoanalytic Society. The society’s president, Karl Abraham, supported Klein’s work with children, and she soon developed the psychoanalytic play technique. Klein’s play technique treats children’s play as equivalent to the free associations of an adult on the couch: Play is seen as symbolizing unconscious phantasies (Klein preferred this British spelling to emphasize the unconscious nature of the phantasies, in contrast to conscious fantasies, or daydreams). Thus, play activities are the material on which interpretations are based. To gain as much access as possible to unconscious phantasies, Klein

provided her young patients with a wealth of play materials, including small figures, animals, cars, paper, pencils, water, and cups, but the psychoanalytic play technique is most decidedly not play therapy. Klein advocated making “deep” interpretations of oedipal and pre-oedipal phantasies, which she believed helped relieve anxieties in the young child; as evidence, she cited the release of inhibitions in play immediately following such interpretations. Her work with children led Klein to challenge some basic tenets of Freudian theory. She proposed that the young child has an early superego and is capable of transference, which Freud held was not possible until after the resolution of the Oedipus complex, leading to the formation of the superego at around age 6. Klein’s new ideas were controversial in Berlin, so when Abraham died suddenly in 1926, she welcomed an invitation from Ernest Jones, president of the British Psychoanalytical Society (BPS), to move to London, where many psychoanalysts were eager to learn her play technique. Soon after her arrival, the controversy over Klein’s approach prompted a debate with the Freuds in Vienna, where Anna Freud was developing a different method of child analysis. Anna Freud disagreed with Klein’s deep analysis of children and argued that instead the analyst should seek to strengthen the child’s ego and serve as an external superego for the young child. Sigmund Freud also criticized Klein’s challenges to his theory about the timing of the Oedipus complex and the development of the superego. Jones and several other key members of the BPS supported Klein in the debate, and the dispute was left unresolved only to reemerge later when the Freuds moved to London at the beginning of World War II. Over the next decade, with the support of a loyal group of followers in the BPS, Klein developed a distinctly new approach to psychoanalysis known as object relations theory, which challenged not only Freud’s account of child development but also his view of the adult psyche and his method of analyzing adults. Klein’s most controversial idea was her claim about the existence of aggressive phantasies derived from the workings of the death instinct in the infant psyche. Even though the death instinct is a classical Freudian concept, Klein’s vision of the infant’s mind as a cauldron of destructive phantasies was seen as going too far.

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Her most important and influential contribution was the idea that the infant has a primary object relationship with the mother. In Freud’s view, the infant feels love for the mother only because she satisfies his or her basic physiological needs. In contrast, Klein argued that the infant is predisposed from birth to seek a relationship with a caregiver independent of other needs; thus, the relationship to a love object is primary. In Klein’s view, this relationship is represented within the psyche by a complex world of mental representations, or “internal objects.” This inner world of mental objects populates the ego and the superego, and the dynamic relationships among them determine the mental health of the individual. Klein’s fundamental idea of personality being made up of mental objects in relationship with one another has inspired various psychoanalytical schools of object relations theory, including the approaches of Donald Winnicott and Otto Kernberg. Kleinian object relations theory proposes the existence of two fundamental phases in the child’s development: (1) the paranoid-schizoid position and (2) the depressive position. In the paranoid-schizoid position, the infant’s mind is dominated by primitive defense mechanisms that split the object into part objects and into good and bad. Hate for the bad objects and greed and envy of the good objects inspire phantasies of attacking and destroying the mother’s body. Klein emphasized psychotic defenses such as denial, splitting, and projection, and identified a new mechanism: projective identification. This defense has now developed a variety of definitions within various approaches, but in Klein’s original conception it refers to the projection of parts of the self into the object and identification of the object with those parts. The paranoid-schizoid position is followed by the depressive position as the child begins to grasp the concept of whole objects and his or her psyche becomes dominated by feelings of unconscious guilt for having attacked his or her love object in phantasy. This guilt leads the child to attempt to repair the objects through acts of reparation toward the mother. Early in development, the organization of the ego oscillates between these two states: Successful reparations will allow the depressive position to predominate, while unsuccessful ones will bring the paranoid-schizoid position to the fore. In the course of normal

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development, the ego eventually works through the depressive position and develops a mature internal object world. This account of infant development led Klein to view adult personality in a new light. Depression in adults is caused by a failure to work through the depressive position, whereas schizoid and psychotic states represent a reemergence of the paranoid-schizoid position, with its primitive defenses producing symptoms of paranoia and distortions of reality. This object-relational view of the adult in a paranoid-schizoid state made it possible to conduct analysis with more seriously ill patients, such as schizophrenics, who had previously been considered unreachable. Klein’s object-relational view of adult personality together with her experiences conducting deep analysis with children also led to innovations in her analytic technique with adults. Whereas Freudian technique aims to reconstruct past relationships by interpreting free associations, Kleinian technique focuses on immediately interpreting the transference to reach the patient’s current inner world of objects. Klein also advocated making deep oedipal and pre-oedipal interpretations from the start and paying close attention to the countertransference as a way of understanding the patient’s primitive defenses, such as projective identification. Changes in the transference relationship are taken to indicate changes in the internal world of the patient. Thus, the mutative factor is analysis of the transference, not insight into the unconscious and past relationships, as suggested by classical psychoanalysis. Klein’s challenges to Freudian psychoanalysis and ventures into working with psychotic patients prompted a second debate with Anna Freud, known as the Controversial Discussions, following the Freuds’ arrival in London in 1938. Anna Freud quickly became an influential member of the BPS and, with the support of her followers from Vienna and a handful of British analysts, argued that Klein’s ideas were not sufficiently Freudian and were incompatible with classical psychoanalysis. Klein was also criticized for working with psychotic patients without a medical qualification. The controversy went on for several years and was eventually resolved in 1944 when the two sides agreed to disagree and set up separate training programs for their groups. The BPS still offers

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separate training for Freudians and Kleinians, but there is also a strong group of Independents who bridge the gap. Kleinian object relations theory is currently practiced by a large Kleinian group in London and is also popular among South American psychoanalysts, especially in Argentina, but it has been largely rejected by American psychoanalysts, who are mostly ego psychologists and who reject the notion of the death instinct. Kernberg is among the few American analysts who have been influenced by various aspects of Kleinian theory beyond the basic concept of object relations. However, Klein’s ideas have had a much larger influence on academic developmental psychology through the work of the psychoanalyst John Bowlby, who trained with Klein and was inspired by object relations theory to develop his famous theory of infant attachment. Gail Donaldson

See also Attachment Group Therapy; Classical Psychoanalysis; Freud, Sigmund; Freudian Psychoanalysis; Kernberg, Otto; Neo-Freudian Psychoanalysis; Object Relations Theory; Winnicott, Donald

Further Readings Grosskurth, P. (1986). Melanie Klein: Her world and her work. New York, NY: Knopf. Hinshelwood, R. D. (1989). A dictionary of Kleinian thought. London, England: Free Association Books. King, P., & Steiner, R. (Eds.). (1991). The Freud-Klein controversies: 1941–45. London, England: Routledge. Klein, M. (1975). The collected writings of Melanie Klein (4 vols.). London, England: Free Press. Mitchell, J. (Ed.). (1986). The selected Melanie Klein. New York, NY: Free Press. Segal, H. (1979). Klein. London, England: Karnac Books.

L the United Kingdom as World War II was ending. He was interested in witnessing the new developments in treating war neurosis by the use of group treatment. After his visit, he wrote his article “British Psychiatry and the War,” in which he expressed his respect for the work of these two pioneers in applying psychoanalysis to group work in a military hospital. He took some of Bion’s ideas and made them part of his own developments in what are called “the cartel” and “the pass” in Lacanian psychoanalysis.

LACANIAN GROUP THERAPY Lacanian group therapy is an approach to group analysis that differs from other group approaches in the way the group narrative is understood. The French psychoanalyst Jacques Lacan’s well-known statements “The unconscious is the discourse of the Other” and “The unconscious is structured like a language” become the guiding orientation that informs the group therapist in the analytic process of Lacanian group therapy. Sigmund Freud, unlike Lacan, was not able to make use of Ferdinand de Saussure’s structural linguistics, nor did he benefit from the anthropological findings of Claude Lévi-Strauss. However, Lacan, drawing from both Saussure and LéviStrauss, demonstrated the importance Freud had placed on careful interpretation of a patient’s speech (e.g., the cases of the “rat man” and “Dora”) as the means by which one may decipher the unconscious. In doing so, Lacan was able to validate many of Freud’s insights and ultimately developed his own expanded theory of the unconscious.

Theoretical Underpinnings For Lacan, the unconscious is intimately tied to both the structure of language and the impossibility of language to grasp all of our reality. Lacan’s concept of the unconscious is anchored in Freud’s own theory of the unconscious, but it is complemented and expanded by his application of the structural linguistics (and the derived linguistic signifiers) of Saussure (1857–1913) and the anthropology of Lévi-Strauss (1908–2009). Lacan transferred elements from Saussure and Lévi-Strauss to expand and modify Freud’s id, ego, and superego into what he called the three basic registers of human experience: (1) the symbolic, (2) the imaginary, and (3) the real. The symbolic, also called the (big) Other, refers to the realm of language, or more specifically the way a person’s mental structure is organized by the particular linguistic signifiers of his or her language. The imaginary reflects the realm of meanings associated with those linguistic signifiers. This equates to Freud’s concept of ego, the initial form of

Historical Context Lacan (1901–1981) is considered by many as the most influential psychoanalyst since Freud (1856– 1939). Lacan’s work influenced psychoanalysis in Europe, South America, the Middle East, Australia, and, increasingly, the United States. Lacan was deeply impressed by the work of fellow psychoanalysts Wilfred Bion (1897–1979) and John Rickman (1891–1951). He spent 5 weeks in 607

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identity. It is also called the (little) other, the lookalike and/or rival. The imaginary constitutes everyday reality. The real remains outside the realm of the symbolic and the imaginary. In moments of trauma, individuals encounter the real. During trauma, individuals try to grasp experience through the symbolic and the imaginary; however, the impossibility encountered in language prevents them from fully expressing the experience. This is why Lacan also refers to the real as the impossible. If, for instance, we are suddenly struck by an earthquake and experience loss and destruction, we have an experience that is hard to put into words. The same thing happens with the traumatic experiences that patients bring into a group insofar as they defy accurate expression.

Major Concepts Basic concepts that guide the work of the Lacanian group therapist include desire, speech, jouissance, and the dialogue in and of the group. Desire

When the human infant is introduced to language, there is a gain and there is a loss. The gain is the social connection with others through language, the symbolic. However, in moving from the world of nature to the universe of culture, the new being is not the same. A basic lack is introduced, what Lacan calls a “lack of being.” It is this lack that constitutes desire. Desire moves us in search of others. Following Freud, Lacan asserts that an object that has been lost becomes an object of desire.

therapist is actually negating the importance of what the patient is referring to. This realization may begin to bring the patient’s discourse into what Lacan calls full speech, as opposed to empty speech. In full speech, both conscious and unconscious elements are present, whereas in empty speech, the patient is using avoidance or negation, or another kind of defense. Jouissance

In Lacanian psychoanalysis, jouissance stands for the French term for “enjoyment” and is based on Freud’s elaborations in “Beyond the Pleasure Principle.” It is assumed that individuals can only experience a certain amount of pleasure but sometimes compulsively attempt to push beyond those limits. Such a compulsion produces a mixture of suffering and enjoyment. Jouissance is crucial to the proper diagnosis of neurosis, perversion, and psychosis. As such, the three realms, or “registers”— the symbolic, the imaginary, and the real—operate in different ways in relation to these conditions. Through their symptoms, patients express their relation to both the signifiers that have organized their psyche and the ways of enjoyment present in the unconscious through fantasies. For instance, a person may often cry when in fact he or she is angry, or may act angry when he or she is afraid. Sometimes the patient may revise his or her assumptions after simply being questioned in an emphatic way by the therapist. Jouissance is particularly relevant in determining a person’s relationship to the real. The Dialogue in the Group

Speech

Speech is the particular way in which each group and each individual is affected by the symbolic (language). Lacan wanted to restore the “the talking cure” to its place of distinction in psychoanalysis. In group therapy, Lacan’s emphasis on full speech versus empty speech is central to the interventions of the therapist. In a group session, if a patient says, for example, “That does not matter to me,” the therapist may simply repeat the sentence back to the patient. In hearing that from the therapist, the patient may become surprised and may begin to realize that the

The dialogue in the group is the discourse in the group as it evolves naturally. It is what appears as reality on a conscious level; therefore, it is the imaginary element of the group discussion, also called the signified in linguistic terms. It establishes the transference among members of the group, called horizontal transference. The Dialogue of the Group

The dialogue of the group refers to the repressed unconscious processes behind the common narrative of the group: the motives, identifications,

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fantasies, and desires of group members as they are stimulated in the group encounter. Through this dialogue, the therapist examines the horizontal transference among members as well as the transference to the therapist, who is placed in the position of the Other. Transference toward the therapist is called vertical transference.

Techniques In contrast to other theories that operate on a model of intersubjectivity, Lacanian theory places the therapist in an asymmetrical position vis-à-vis the group members and the group as a whole. The group members are considered to be the subjects in question, whereas the therapist is in the position of the object. This guides the therapist’s interventions, whether they are directed to an individual group member or to the group as a whole. Scansion and Punctuation

We use scansion in poetry to determine the rhythm of a line. We use punctuation to signal a break or the end of a sentence. In group therapy, these techniques are directly related to group members’ use of speech and the dimension of time. In individual therapy sessions, the therapist may use scansion to vary the length of a session to uncover or emphasize certain meanings and/or interpretations. In group therapy sessions, scansion is related to the therapist’s attention to the dialogue of the group. For example, a therapist may intervene to move a group member and/or the entire group to full speech by repeating a word or a phrase that the group member or members may use inadvertently without special meaning. Mediation

Through mediation, the therapist may clarify, ask questions, express doubts, and even feign confusion in response to the members’ use of language. The therapist mediates the effects of the members of the group on one another. The focus is on the imaginary, or signified, meanings and on the preconscious and conscious reality. Mediation prepares the group members for their common task of learning from one another.

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Interpretation

Interpretation is the optimal technique used by the therapist to confirm an insight that the group members are close to realizing. Interpretation is also a way the therapist may disrupt the status quo of jouissance by pointing out contradictions, omissions, and denials. In this latter use of interpretation, the therapist creatively deconstructs the patient’s narrative in an attempt to mobilize the group and group members’ desire for the revelation of the truth hidden by the symptom.

Therapeutic Process The Lacanian approach to group therapy attempts to put the group and its members in touch with the three registers (the imaginary, the symbolic, and the real) at different levels of depth depending on the configuration of each group. The techniques in the group therapy are geared to differential treatment depending on the diagnosis of each patient. There may be effects, events, situations, and moments in the group that defy the work with signifiers and meaning, such as when group members confront trauma, finding it impossible to express themselves with language. At these junctures, the work that has taken place with the two basic dialogues (in and of the group) makes it possible for group members to access the aspect of human experience that defies language. For instance, in a group session, a young woman arrives in the group after being assaulted in the street. She can barely speak and is shaking. Gradually, through the help of group members, she beings to speak and explain what has just happened to her. In the process, she is transforming an experience of the real, of what could not be represented, into a narrative that begins to transform the real through the symbolic and the imaginary. Trauma affects the experience of space and time for the patient. The dialogues in and of the group bring these dimensions back into the narrative and have a healing effect for patients. Macario Giraldo See also Freud, Sigmund; Freudian Psychoanalysis; Group Analysis; Group Counseling and Psychotherapy Theories: Overview; Lacanian Psychoanalysis

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Further Readings Dor, J. (1997). Introduction to the reading of Lacan: The unconscious structured like a language (J. Feher Gurewich, Ed., in collaboration with S. Fairfield). Northvale, NJ: Jason Aronson. Giraldo, M. (2012). The dialogues in and of the group: Lacanian perspectives on the psychoanalytic group. London, England: Karnac Books. Lacan, J. (1947). British psychiatry and the war. Psychoanalytical Notebooks of the London Circle, 4, 9–34.

LACANIAN PSYCHOANALYSIS Lacanian psychoanalysis is a form of psychoanalytic theory and practice derived from Jacques Lacan’s reformalization of Freudian concepts. Drawing from philosophy, structural linguistics and anthropology, logic, and mathematics, Lacan (1901–1981) developed key Freudian insights relevant both to the centrality of speech and language in analysis and to construction of a theoretically derived diagnostic framework.

Historical Context Lacan’s early training was at the Faculté de médecine de Paris, where he treated a number of patients suffering from automatism. This work coincided with his developing interest in surrealist and psychoanalytical approaches to unconscious processes. He became involved in the nascent French psychoanalytical movement, entering analysis with Rudolph Lowenstein in 1932. Lacan was among the diverse audience of French intelligentsia at Alexandre Kojève’s lectures on Georg Hegel. His first formal psychoanalytical paper—on the “mirror stage”—was presented at the 14th Congress of the International Psychoanalytic Association in 1936. In “The Function and Field of Speech and Language in Psychoanalysis” (1953), Lacan outlined elements of his psychoanalytical “linguistic turn.” He conducted a series of public seminars that supported important developments in late-20th-century French philosophy; he also formed three psychoanalytical schools between 1953 and 1980. Écrits, a selection of essays, was

published in 1966. During the last decades of his career, Lacan focused on using mathematical formalism to develop his approach.

Theoretical Underpinnings The best known of Lacan’s early contributions to psychoanalytical theory was his account of the “mirror stage.” As the founding moment of both the imaginary order and the ego, it describes ego formation as a process of recognition and identification with one’s image as reflected in a mirror. The mirror models the ego as a complete “whole” that reflects the idealized prescriptions for identity circulating in an individual’s familial and cultural contexts; the ego thus becomes ensnared within a circuit of identification and competition with an idealized self-image. Because Lacan’s first presentations of the mirror stage drew on psychological observations, it has often been misinterpreted as a developmental stage. Lacan’s use of philosophy (e.g., Hegel, Sartre) and structuralism to inform his rereading of Freud is seen in his emphasis on the role of desire in human relations. His distinctions among need, demand, and desire hinge on assumptions concerning individuals’ physical interdependence (e.g., during infancy) and the fact that human “being” is inseparable from its articulation in language. Lacan’s use of the term need approximates Freud’s use of the term instinct and represents a more or less strictly biological concept (e.g., hunger). “Demand” is required by our reliance on others to get our needs met (e.g., the infant’s dependence on a caretaker for food, hygiene, and shelter requires that it convey to the caretaker something of its needs) and is conditioned by the fact that our requests ultimately must be expressed in the language of our social environment. Hence, “demand” is addressed to an “other” via the language of the “Other.” While an other’s response to a demand may temporarily satisfy a need, it is inevitably inadequate to satisfy the demands for recognition and love that, over time, become symbolically intertwined with the expression of our needs. In the gap that opens up between need satisfaction and the impossibility of exacting from the other an indisputable proof of love, “desire” emerges as a residue of insatiability, a force or tension that, once activated, incessantly seeks its own renewal.

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Lacan claimed that Freud had realized the role of language in psychoanalytical inquiry but lacked the theoretical tools necessary to develop its most radical implications. For example, Freud’s account of oedipalization (“castration”) was understood by Lacan to address the subject’s forced choice between accepting and rejecting the paternal “signifier.” This signifier is the father’s “No!”—which interrupts the imaginary bond of the mother–child duality and represents the signifier that “founds” the symbolic ordering of social life according to preexisting categories and modes of being. What is essential about this “primordial” signifier is its intrinsic independence from that which it is supposed to represent. Psychosis, for example, emerges from a refusal of castration; the intensity of “imaginary” meanings and experiences is difficult for the individual to separate from, since the (paternal) signifier that would have introduced a mediating third term has been foreclosed. Through Lacan’s structuralist lens, castration represents an alienation of being in language that the subject accepts in exchange for a place from which to speak and be represented in socially constructed reality.

Major Concepts In Lacanian group therapy, a number of concepts underlie the approach, including the notion that the unconscious is structured like a language; jouissance and fantasy; the imaginary, the symbolic, and the real; and object a. Unconscious Structured Like a Language

Lacan’s account of the unconscious begins with Freud’s own preoccupation with manifestations of the unconscious that are linguistic in form: slips of the tongue, jokes, and dreams. The Freudian unconscious speaks, thus, through the “discourse of the Other”—a language that is addressed to, insinuates itself within, affects, and exceeds us. Lacan took signifiers (the formal, combinatory elements of speech) rather than signs (meanings) as the basic elements of language. In analysis, signifiers take on particular importance, as Lacan asserts that the unconscious can only be discerned through attention to the “letter” of the analysand’s speech (signifiers in their literal, “opaque” material aspect) rather than its ostensible meanings (significations).

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Hence, the analyst adopts an intentionally ignorant stance toward the ordinary meanings of the analysand’s speech. This stance allows the analyst to hear and speak from the place of an unconscious knowledge produced by signifying events (e.g., a slip of the tongue) that disrupt the analysand’s significations by exceeding what he or she “meant” to say. Unconscious knowledge produces its effects less by revealing the what and why behind the analysand’s symptom and more by illuminating how his or her symptom functions to maintain a particular relation to the Other’s desire. Jouissance and Fantasy

While jouissance is sometimes translated as “enjoyment,” the latter’s temperate connotations fail to convey its paradoxical admixture of pleasure and pain, intoxication and uncanniness. Lacan suggests that the subject must “pay” for the right to represent himself in language by sacrificing “a pound of flesh” (castration)—a renunciation of jouissance, which the subject then locates in the Other. In Lacanian parlance, castration is a symbolic function manifested concretely in familial and societal imposition of prescriptive norms, rules, and prohibitions. The limits set by castration simultaneously drain jouissance from the body and imply that the body could enjoy fully, could experience a “complete” jouissance, only if such prohibitions were not imposed. Fantasy is the subject’s response to his or her perceived lack of jouissance, the jouissance he or she imagines the Other to enjoy. Lacan suggests that the structure of a given subject’s fantasy reflects his or her solution to the problem posed by this forfeiting of jouissance to and for the Other (i.e., it is a response, an answer to the question of what the Other wants of the subject). The Imaginary, the Symbolic, and the Real

Lacan presents the imaginary, the symbolic, and the real as interrelated “orders” that cover the field of psychoanalytical phenomena. The imaginary is characterized by its structure of dual relations, particularly between the ego and its idealized others but also between words and their significations. The imaginary’s functioning is demonstrated in the mirror stage. Imaginary relations are founded in

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the dual relation of the ego with its narcissistic counterpart, the prototype of which is identification with the projection of one’s bodily form in a mirror. The mirror reflection suggests a subjective autonomy and synthesis that presage the seductive power of the image to compel the ongoing dramas of recognition and identification that constitute the ego’s domain. Lacan characterized the ego’s formation as a moment of profound alienation, and imaginary relations as dominated by rivalry and aggression. Lacan affords the symbolic a privileged role in analysis. Lacan understood language to be an autonomous system that functions in large part outside our awareness. He uses the notion of the symbolic’s ordering of the social field through kinship structures to illustrate our dependency on the signifier: To be recognized as a subject—in the familial, social, juridical, national, and cultural senses—means to accept and speak from one’s place in a predetermined structure of kinship and to participate in the legal transactions, ritualized behaviors, and speech acts necessary to reproduce this structure over time. The analyst addresses his or her interventions to the unconscious subject that speaks through but eludes representation in the symbolic; the analyst’s aim is to engage the subject in getting its signifiers “un-stuck” and, thus, to revitalize desire by keeping the fluidity of signifying repetition alive. The order designated as the real changes across Lacan’s teachings. In his earlier seminars, the real is “impossible” because it cannot be imagined or symbolized. The real’s impossibility is also a function of its mute “fullness,” a chaos or void that Lacan sometimes associated with undifferentiated, “indifferent” materiality. Lacan became preoccupied with topology in his later work, and his account of the symptom shifts accordingly, moving from an emphasis on how the subject avoids confrontation with the Other’s lack to an emphasis on how the jouissance of the symptom functions to knot the symbolic, imaginary, and real together in a manner particular to a given analysand. Object a

Lacan uses the small letter a to denote the other (autre in French)—a person in reality that I perceive to be more or less like myself—in contradistinction

to capital letter A, the Other (Autre in French), denoting an irreducible otherness. Rather than being an object (person, thing, or activity) toward which a preexisting desire is “drawn” (e.g., we might experience ourselves as “drawn” to a person we find desirable or to an activity we feel actualizes an important aspect of our being), object a functions as the cause or impetus of our desire. Lacan associated object a—an object of neither satisfaction (need) nor demand—with a surplus jouissance, produced in excess of the “exchange value” of commodified desires. Hence, rather than representing desire for some “thing,” say a particular trait or bodily attribute, object a stands in for a pure “desirousness” or “will to desire” of the other. Lacan links object a to the gaze and the voice (e.g., to certain ways of being looked at or spoken to).

Techniques Interpretation

Lacanian interpretation problematizes notions of meaning and focuses on the register of desire. The aim is to stimulate the analysand’s curiosity and engage the unconscious in active production of new meanings and connections through interpretations that are polyvalent. As analysis progresses, the analyst may present more direct and constructive interpretations in an attempt to symbolize affects or elements of the analysand’s experience that seem to have escaped prior symbolization. Punctuation

Punctuation serves to intervene in the analysand’s flow of speech and disrupt his or her consciously intended signification. Just as the insertion of written punctuation reconfigures the meaning of a sentence or text, an analyst’s punctuation opens up the analysand’s discourse to enigmatic and unintended meanings by hinting that the analysand is saying more than the analysand thinks he or she is. Punctuation can take a number of concrete forms, from a repetition of what the analysand has said but with a different rhythm, emphasis, or tone to a moment of silence, an interruption, or a quizzical facial expression; the analyst may also punctuate by ending the session precipitously.

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Scansion

Scansion, or the variable session length, is a form of punctuation that operates across, rather than within, sessions. The analyst may punctuate a session by ending it at a particularly significant moment, perhaps just after an analysand has made a slip or has recounted an unsettling dream. Alternatively, the analyst may interrupt the session soon after it has begun and in the middle of, say, an analysand’s recounting of the past week’s events; the analyst may also extend a session to sustain the effects of the emergence of unconscious meanings and/or to nourish the development of an associative chain. The aim is to accentuate the uncanny affects associated with the emergence of unconscious material and to stop the analysand from “time managing” his or her sessions to avoid, contain, or control manifestations of the unconscious.

Therapeutic Process Lacanian analysis does not have a predetermined length, but many analyses continue for several years or more. In the early stages of analysis, the analyst listens beyond the analysand’s stock narratives of what he or she is suffering from—first, because such narratives typically represent a cooptation of the subject’s desire by familial and cultural norms and, second, because they impede mobilization of the analytic unconscious. The analyst makes a preliminary diagnosis of the analysand’s position vis-à-vis the Other, based on Lacan’s diagnostic distinctions between neurosis (based on repression and subdivided into obsession, hysteria, and phobia), perversion (based on disavowal), and psychosis (based on foreclosure). Diagnosis supports the analyst’s knowing how to situate himself or herself in relation to the analysand’s subjectivity, as well as indicating which forms of intervention to privilege and which to avoid. Lacanians typically refrain from interpretations in the early stages of analysis, relying instead on punctuation and scansion. Manifestations of transference allow the analyst to understand the analysand’s fantasied relation to the Other’s desire. The end of analysis is indicated less by a resolution of the symptom (Lacan rejects the notion of cure) than by a reconfiguration of the subject’s relation to the symptom. Suzanne Barnard

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See also Classical Psychoanalytic Approaches: Overview; Lacanian Group Therapy

Further Readings Barnard, S., & Fink, B. (Eds.). (2002). Reading seminar XX: Lacan’s major work on love, knowledge, and feminine sexuality. Albany: State University of New York Press. Dor, J. (1998). Introduction to the reading of Lacan: The unconscious structured like a language (J. Gurewich, Ed., with S. Fairfield). New York, NY: Other Press. Fink, B. (1997). A clinical introduction to Lacanian psychoanalysis: Theory and technique. Cambridge, MA: Harvard University Press. Lacan, J. (2007). Écrits: The first complete edition in English (B. Fink, Ed.). New York, NY: W. W. Norton. Nasio, J.-D. (1998). Five lessons of the psychoanalytic theory of Jacques Lacan (D. Pettigrew & F. Raffoul, Trans.; SUNY Series in Psychoanalysis and Culture, H. Sussman, Ed.). Albany: State University of New York Press.

LAING, R. D. See Phenomenological Therapy

LAZARUS, ARNOLD Arnold A. Lazarus (1932–2013), “Arnie” to those who knew him well, was an acclaimed clinical psychologist and distinguished professor emeritus in the Graduate School of Applied and Professional Psychology at Rutgers University in New Jersey. Born in Johannesburg, South Africa, Lazarus was the youngest, by many years, of four children born to a middle-class South African family. Partly as a reaction to being mercilessly bullied by his second eldest sister’s husband, Lazarus began competitive bodybuilding, boxing, and a lifelong interest in nutrition and health. As his muscles and boxing skills grew, so too did his intellectual curiosity, and he began publishing articles and editorials on health and fitness in local newspapers and magazines. Lazarus’s formal academic pursuits began at the University of the Witwatersrand in

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Johannesburg, South Africa, where he earned his Ph.D. in clinical psychology in 1960. In 1957, Lazarus married Daphne Ann Kessel and had two children with her, Linda Sue and Clifford Neil, in 1959 and 1961, respectively. Immediately upon receiving his Ph.D., Lazarus started his career as a private practitioner. In 1963, he accepted an invitation to be a visiting assistant professor at Stanford University in California for a year. He, along with his wife and two children, then returned to Johannesburg as a lecturer at the University of the Witwatersrand Medical School and as a private practitioner. In 1966, Lazarus immigrated to the United States with his family to serve as director of the Behavior Therapy Institute in Sausalito, California, where, in collaboration with some of his former graduate students from Stanford, he built one of the nation’s first behavioral health care practices. In subsequent years, he taught at Temple University Medical School in Pennsylvania (1967–1970) and at Yale University in Connecticut, where he also served as director of clinical training (1970–1972) before joining the faculty as a distinguished professor at Rutgers University in 1972, where he taught at the Graduate School of Applied and Professional Psychology until he retired from formal academia in 1999. Despite turning his attention to academic and scholarly matters, Lazarus’s feisty, fighter’s spirit did not falter, and soon after entering clinical practice, he began to “duke it out” with the status quo and the prevailing norms of Freudian psychoanalytic and other psychodynamic theories and therapies. Consequently, he began working with the psychiatrist Joseph Wolpe on what Lazarus termed behavior therapy and, in fact, coined the term, along with behavior therapist, in the professional literature in 1958. Lazarus found that focusing solely on behavioral techniques was too limiting, which led him to incorporate cognitive factors into his method. When he began publishing his assertions on the value of technical eclecticism (i.e., using empirically supported methods without adherence to the method’s theoretical foundation), and especially his views on the need to broaden the base of behavior therapy by including cognitive processes, he encountered resistance from several of his behavioral colleagues. They accused him of trying to bring “mentalism” back into the field and of

pandering to the psychoanalysts. Lazarus was undeterred, however, and when his 1971 book Behavior Therapy and Beyond was published (arguably the first book on what subsequently came to be called cognitive-behavioral therapy), the staunch behaviorists went from anger to rage over his insistence that cognitive processes needed to be included. Professor H. J. Eysenck, who was the editor-in-chief of the journal Behavior Research and Therapy, expelled Lazarus from the editorial board. Wolpe, who had been Lazarus’s mentor and had chaired his doctoral dissertation in South Africa, felt betrayed and became enraged. Lazarus argued that Wolpe’s orientation was too narrow and fueled the flames of Wolpe’s ire by publishing several papers on “broad-spectrum behavior therapy.” Matters became worse when in 1976 Lazarus published his book Multimodal Behavior Therapy, for which Cyril Franks, the founder of the Association for Advancement of Behavior Therapy (now the Association for Behavioral and Cognitive Therapies), wrote in the foreword, “To my way of thinking, this book represents a sampling of the best that modern developments in broad-spectrum behavior therapy have to offer, a culmination of years of thinking” (p. ix). Lazarus subsequently dropped the word behavior from multimodal behavior therapy, saying that it made no sense to selectively emphasize the behavioral modality, and changed the name of his approach to multimodal therapy, which is arguably one of the most comprehensive approaches to psychological therapy ever conceived. In general, Lazarus’s pioneering work on behavior therapy became cognitivebehavioral therapy, which he broadened and refined to multimodal therapy. In addition to his emphasis on technical eclecticism, a hallmark of Lazarus’s clinical work was the origination of his BASIC I.D. formulation, which is the foundation of multimodal therapy. Lazarus stressed that most of our experiences comprise moving, feeling, sensing, imagining, thinking, relating to one another, and physiological processes. In other words, he concluded that human life and conduct are products of ongoing behaviors, affective processes, sensations, images, cognitions, interpersonal relationships, and biological functions. The first letters of each of these modalities yield BASIC IB, but by referring to the biological modality as “drugs/biology” (because psychiatrically one

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of the most common biological interventions is the use of psychotropic drugs), Lazarus arrived at the acronym BASIC ID. It is crucial to remember that the “D” not only stands for drugs and all other somatic interventions, it also includes the full spectrum of health habits, such as nutrition, hygiene, exercise, sleep, and substance use. In 1981, to fully differentiate the “ID” of BASIC ID from any Freudian connotation of the word, and to further demarcate it from the “I” of “imagery,” Lazarus changed his multimodal acronym to BASIC I.D. BASIC I.D. is intended not only to serve as a comprehensive template for problem identification and clinical decision making but also to account for the full range of human phenomenology— everything from anger, disappointment, disgust, greed, fear, grief, awe, contempt, anxiety, depression, and boredom, to love, hope, faith, ecstasy, optimism, and joy. An important supposition is that all seven components interact with each other. Applying this theory clinically requires the therapist not to neglect or ignore any of the modalities. If, for example, a person is suffering from a generalized anxiety disorder, a comprehensive treatment protocol will focus on the affective modality and also provide a functional assessment of the reciprocal impact on the other six modalities. Moreover, Lazarus pointed out that it is also essential to recognize and include factors that fall outside the BASIC I.D., such as sociocultural, political, and other macro-environmental events. What’s more, his fighter’s passion never left him, and among his final efforts was a serious challenge of rigid, therapeutic boundaries, which Lazarus believed hamper therapists’ clinical effectiveness. To be sure, Lazarus had strong opinions and some controversial writings on the issue of therapy boundaries, as highlighted in his 2002 book Dual Relationships and Psychotherapy. In particular, he argued that therapists need to be more tolerant of dual, nonsexual, nonexploitative relationships for the benefit of the client. Lazarus was open to interactions with his active clients outside the therapy sessions and shared that he had meals with them and attended important events, such as weddings of clients, and on rare occasions even invited clients to his home. Nevertheless, he cautioned that therapists must remain careful not to misuse their power. Lazarus also acknowledged that this approach is not appropriate for all clients at all

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times but that knowing when to cross certain boundaries can enhance clinical effectiveness. As a reflection of his influential work in the field of clinical psychology, Lazarus received numerous professional honors and awards, including but not limited to two lifetime achievement awards (from the Association for Behavioral and Cognitive Therapies and from the California Psychological Association), the Distinguished Service Award from the American Board of Professional Psychology, the Distinguished Psychologist Award from the American Psychological Association’s Division 29 (Psychotherapy), and the very first Cummings PSYCHE Award. Also, he was inducted, as a charter member, into the National Academies of Practice as a Distinguished Practitioner in Psychology. With 18 books and more than 350 scientific and professional publications to his credit, coupled with his unequaled eloquence, humor, charm, and visionary genius, Lazarus was a highly sought after speaker who gave numerous presentations nationally and abroad. Lazarus influenced students, colleagues, and clients through his innovative and broad-minded approach to the complexities of psychological intervention. Clinical practice for Lazarus was a vehicle not just to help people but also to educate the next generation of therapists and to generate new ideas for both improved applications and research. His son, Clifford N. Lazarus, and daughter-in-law, Donna Astor-Lazarus, now run The Lazarus Institute (founded in 2003), where Arnold Lazarus held a free, clinical supervision group until the last week of his life. Clifford N. Lazarus See also Behavior Therapy; Cognitive-Behavioral Therapy; Eclecticism; Multimodal Therapy; Therapeutic Touch

Further Readings Lazarus, A. A. (1958). New methods in psychotherapy: A case study. South African Medical Journal, 32, 660–664. Lazarus, A. A. (1971). Behavior therapy and beyond. New York, NY: Springer. Lazarus, A. A. (1976). Multimodal behavior therapy. New York, NY: Springer. Lazarus, A. A. (1981). The practice of multimodal therapy. New York, NY: Mc-Graw Hill. (Updated

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paperback edition, 1989, Johns Hopkins University Press) Lazarus, A. A., & Zur, O. (2002). Dual relationships and psychotherapy. New York, NY: Springer.

LINEHAN, MARSHA Marsha M. Linehan (1943– ), the developer of dialectical behavior therapy (DBT), was born in Tulsa, Oklahoma, on May 5, 1943. Linehan’s passion for science, spirituality, and helping others was key to the development of DBT. Since the publication in 1993 of the manual on which it is based, DBT has been widely adopted as a treatment for borderline personality disorder and suicidal behaviors. Over time, Linehan and her colleagues in several parts of the world have investigated the use of DBT to treat other disordered behaviors, such as substance use, eating disorders, and depression. More recently, DBT skills are being studied for their effect in enhancing quality of life in families, schools, and organizations. DBT is a cognitive-behavioral therapy that uses principles of acceptance and change to increase functional behavior and decrease maladaptive behavior. It developed as a result of Linehan’s attempt to apply what many would consider two opposing approaches—problem solving and acceptance—to the problems of suicidal persons experiencing despair and a sense of not belonging. Her academic background led her to approach these problems from the perspective of a behavior therapist, and key personal experiences resulted in her attempts to create conditions where persons would experience connectedness, love, and freedom. The treatment is based on the foundations of behavioral science, contemplative/mindfulness practice, and dialectical philosophy. Linehan made headlines in 2011 when the New York Times ran an article on its front page covering an address she gave at the Institute of Living in Hartford, Connecticut. During her address, Linehan described her 26-month experience as a patient at the hospital, beginning in 1961 at the age of 17. Although she described her treatment providers as caring, she also noted that the treatment she received only made things worse. Having been raised Roman Catholic, with an Irish father

and a Cajun French mother, her faith has been a central force throughout her life. A pivotal moment occurred at age 20 when she experienced praying, feeling loved, and saying, “I love myself”— something not experienced before. She says that as a result of this experience she never again suffered the way she had done in her adolescence. Her profound experience of self-acceptance and connection offered her new hope for how to help those suffering from mental illness, and her experience as a patient contributed to her unwavering stance that mental health treatments must be based on empirical evidence, not theoretical formulations. Linehan received her Ph.D. in social psychology in 1971 from Loyola University of Chicago. She chose this area of study specifically due to her interest in applying scientific methods to alleviate human suffering. She subsequently pursued clinical training but often faced roadblocks due to not having a traditional degree in clinical psychology. Through her tenacity and willingness to do whatever it took, including working in a clerical position, Linehan began work at Suicide Prevention & Crisis Service, Inc., Buffalo, New York, in 1971. She insisted that the administration there send her their most desperate suicidal patients and distinguished herself by ensuring that no patients killed themselves. Following her unconventional training experience, the crisis center recognized her work at the level of a postdoctoral clinical intern in psychology, even though she did not have the required training for such an internship. In 1972, Linehan began a postdoctoral fellowship in behavior modification at the State University of New York at Stony Brook, studying with Gerald Davison and Marvin Goldfreid, two pioneers in the clinical application of behavior modification. She became an assistant professor at Catholic University of America in 1973, with interests in behavior therapy and assertiveness training. Linehan sought a means of fostering the conditions for suicidal persons to experience connectedness, freedom, and joy. Her own path to this was rooted in the contemplative traditions of Catholicism, and she was particularly influenced by the spiritual direction of Gerald May and Tilden Edwards. However, she was keenly aware that the language used in one religious tradition may cause problems for those of other traditions, as well as for those who do not espouse a religious

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or spiritual tradition. Furthermore, she was attempting to bring these practices into the field of psychology and was faced with how to reconcile them with its scientific values. She searched for a means to define the practices that would foster patients’ experiencing connection and belonging and that would not rely on language and conceptual formulations that might easily be rejected. Linehan decided that Zen most easily provided a means of operationally defining practices in a way that didn’t rely on religious or spiritual concepts. She spent 6 months at Shasta Abbey in California and studied with Fr. Willigis Jäger, a Zen master (Roshi) and Catholic Benedictine monk in Germany, and with Fr. Patrick Hawk, a Zen master and Catholic Redemptorist priest in Tucson, Arizona. Fr. Hawk Roshi studied with Robert Aitken Roshi, the founder of the Diamond lineage of Zen and one of the first to teach Zen practice in Western culture. Fr. Hawk Roshi named her as a Zen Roshi shortly before his death in 2012, and Fr. Jaeger Roshi named her a Roshi in the Sanbo-Kyodan School shortly thereafter. Despite this, she is careful to point out that she does not describe herself as Buddhist. Linehan joined the faculty of the Department of Psychology at the University of Washington in 1977. In 1980, she founded the Behavioral Research & Therapy Clinics there, which served as the laboratory where she began developing DBT in earnest through research funded primarily by the National Institute of Mental Health and the National Institute of Drug Abuse. Her first federally funded randomized controlled trial of treatment for suicidal persons began in 1981, and randomized controlled trials and other clinical studies have continued to this day. She identified and developed the strategies of the treatment through meticulous observation of her treatment sessions, which were then coded by her research assistants. It was at this time that the treatment came to be known as dialectical behavior therapy, a name taken from a colleague’s description of how Linehan’s efforts to balance the change-oriented strategies of behavior therapy and the acceptance-oriented practice of mindfulness while “walking the middle path” sounded much like dialectical philosophy. Linehan’s training in behavior therapy led her to observe that therapists and patients were both easily overwhelmed by the magnitude and quantity of

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the problems they faced. She also observed the reinforcement of dysfunctional patient behaviors and punishment of necessary therapist behaviors. Moreover, it was observed that therapists could easily become hopeless and judgmental about patients. To address these problems, Linehan developed a set of skills that balance teaching acceptance of persons and things as they are with specific strategies for solving problems, getting interpersonal needs met, and regulating emotions. She also outlined a hierarchical set of treatment targets to provide clarity about how to approach treatment and developed the DBT consultation team. The DBT consultation team helps therapists provide treatment skillfully, attends to how contingencies operate in treatment, and helps motivate therapists. With the 1993 publication of Cognitive Behavioral Treatment for Borderline Personality Disorder, which summarized Linehan’s research and outlined DBT, the demand for training in DBT grew. What followed were efforts at replicating research on the treatment and identifying effective means of dissemination. She founded an annual DBT Strategic Planning Meeting at the University of Washington to coordinate the efforts of those conducting research on DBT at multiple sites around the world. In addition, she and her graduate students founded the Linehan Training Group, the precursor to the current Linehan Institute, to meet the demands for treatment dissemination. She also has an interest in the use of technology as a means of increasing access to treatment and founded Behavioral Tech Research, Inc., a company involved in the research and development of online and computer-assisted treatment and training tools. Linehan is the recipient of numerous honors, has served in several leading positions in key professional organizations, and has been featured in the popular media, including National Public Radio, Newsweek, O Magazine, and the The New York Times. In 2009, the American Association of Suicidology created the Marsha M. Linehan Award for Outstanding Research in the Treatment of Suicidal Behavior in her honor, and in 2011, Time listed DBT as one of the 100 Most Important New Discoveries. Anthony P. DuBose

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See also Behavior Therapy; Cognitive-Behavioral Therapy; Dialectical Behavior Therapy; EvidenceBased Psychotherapy; Mindfulness Techniques

Further Readings Carey, B. (2011, June 23). Expert on mental illness reveals her own fight. The New York Times. Retrieved from http://www.nytimes.com/2011/06/23/health/23lives .html?pagewanted=1 Hayes, S. C., Follette, V. M., & Linehan, M. M. (Eds.). (2004). Mindfulness and acceptance: Expanding the cognitive behavioral tradition. New York, NY: Guilford Press. Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press.

LOGOTHERAPY ANALYSIS

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EXISTENTIAL

Logotherapy and existential analysis, conceived by the Viennese neurologist and psychiatrist Viktor Frankl (1905–1997), is an internationally acknowledged and empirically based, meaning-oriented school of therapy and counseling. Existential analysis is the philosophical and scientific underpinnings and assumptions of this particular treatment modality; logotherapy is its clinical application. So it is both an analysis (explicating existence as it unfolds) and a therapy (offering concrete tools and techniques to deal with various disorders and conditions). The central tenet of Franklian psychology and philosophy is that “one is in order when one’s life is oriented to meaning”; in contrast, disorder occurs when the disparate parts of the personality are out of harmony and out of sync with one another. If illnesses arise from nature, their cure comes from the “spirit” or “noetic core” of a person. The spirit, which can never be sick, refers to the uniquely human dimension of the person and, thus, to meaning, conscience, love, humor, the transcendental categories of being (the true, the good, and the beautiful), and metaphysics, to give some examples.

Frankl construes the human being in three dimensions: (1) body (soma), (2) mind (psyche), and (3) spirit (noös). He calls this his “dimensional ontology.” Frankl emphasizes the physiological/ biological, emotional/intellectual, and spiritual/ social dimensions of selfhood. Key and core themes are meaning, emptiness, death, anxiety, finitude, boredom, freedom, and resilience (the “defiant power of the human spirit”). According to Frankl, meaning may be found in three main ways: (1) creatively, by encountering meaning in all that we make or give to the world; (2) experientially, through all our experiences and encounters; and (3) attitudinally, by encountering our unavoidable suffering. Everything can be taken from us, yet there still remains the freedom to choose our inner attitude to our conditions, which Frankl calls the “last of human freedoms.” Logotherapy is any meaning-centered intervention leading to attitudinal and, thus, behavioral change. It helps us deal with “blows of fate,” which at times assail us and challenge how we come to define ourselves. Having experienced the horror of the Holocaust firsthand, Frankl is mindful of what he calls the “tragic triad” of human existence—(1) suffering, (2) guilt, and (3) death—but Frankl, always seeking the full picture of the sometimes sad human scene, urges us to pay equal, if not more, attention to the “triumphant triad” of (1) healing, (2) meaning, and (3) forgiveness. Frankl advances his case for a “tragic optimism,” one that does justice to both dimensions of human reality. It is this understanding of reality that contributed to the critical acclaim for his best-selling book Man’s Search for Meaning (1946), which, in 1991, was voted by the Library of Congress as one of the 10 most influential books ever written. In this book and others, Frankl urges us to understand that the quest for meaning is personal and universal and that when the “will to meaning” is frustrated or thwarted, existential frustration results, which may culminate in a neurosis.

Historical Context Logotherapy is often referred to as the third Viennese school of psychotherapy, following the psychotherapy schools of Sigmund Freud (1856– 1939) and Alfred Adler (1870–1937), both of

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whom were mentors and teachers of Frankl. Freud’s psychoanalytic school, the first Viennese school of psychotherapy, stressed pleasure as being a predominant force in the life of a subject; Adlerian individual psychology, the second Viennese school of psychotherapy, emphasized the striving for superiority or success. In contrast, Frankl’s logotherapy insists that how one finds meaning and purpose was paramount in a life that struggles to be human. To differentiate his own therapy from the earlier Viennese schools of depth psychology, Frankl coined the term height psychology. Believing that Freud and Adler placed too much emphasis on early-life experiences and conditions and how defense mechanisms determine behavior, Frankl attempted to balance their narrow and determinist approach to humans by asserting that the past pushes us but the future pulls us. According to Frankl’s approach, the logos (“spirit” or “meaning”) draws us. Historically, Frankl was exposed to existentialism and phenomenology and was much influenced by Max Scheler’s philosophical anthropology. All the while, Frankl was intent on seeing the logos (meaning) in the pathos (suffering). In this sense, logotherapy is more than a school of psychological thought—it is a practical philosophy of life, one that it is hoped will lead a person from existential floundering to ethical flourishing. In fact, the subtitle of Frankl’s first book, The Doctor and the Soul, is “From Psychotherapy to Logotherapy.” Indeed one of logotherapy’s explicitly stated aims is to purge both psychology and psychotherapy of their psychologism. Logotherapy and existential analysis represents an integral nonreductionism. It is holism at its best.

Theoretical Underpinnings According to Frankl, when one focuses on the determinants of human experience, as did Freud and Adler, people’s ability to consciously decide how they react or respond to adverse life conditions is systematically underestimated and undermined. Accordingly, he considered many of the “old psychologies” to be disproportionately concerned with deficits and limitations. Frankl, therefore, began to study not only the life histories of the mentally ill but also those of individuals who had remained mentally healthy under the same or

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similar life conditions to determine which internal resources were being activated. In other words, his proposal was to investigate not just what makes people sick but also what keeps them healthy and thriving. These studies led Frankl to the belief that people are not entirely conditioned and determined but can decide to distance themselves from their inner and outer conditions and exert freedom of will—that is, their capacity for self-determination. Frankl held that many if not all of the earlier psychological models tended toward a reductionist psychologism and pathologism, which attempted to explain deeply and psychologically healthy human and existential concerns, such as the quest for meaning, freedom, and authenticity, not as expressions of human maturity but as mere compensations for psychological defects and frustrated “lower” needs. Logotherapy, however, holds that the search for meaning and purpose is a natural and important process that cannot be wholly reduced to defensive processes, and that it reflects intrinsic developmental concerns and addresses existential issues by specifying psychological processes that support or derail healthy psychological development, maturity, and self-integration. Logotherapy encourages and helps patients to mobilize their remaining resources, which, even during precarious times in a person’s life, can exert a protective and curative influence. According to logotherapy, awareness of individual meaning and purpose is the most potent resource and, in turn, also the most effective in activating other psychospiritual resources. Logotherapy stood out for a long time as one of the very few meaning- and growth-oriented alternatives to the dominant approaches to psychotherapy, which were largely deficit based. Only in recent decades have new approaches that have also moved away from this deficit approach emerged (e.g., positive psychology, solution-focused therapy). Logotherapy, thus, defines the awareness of one’s capacity to choose and the search for meaning as basic psychological needs that are essential for growth, integrity, and well-being. Conversely, alienation, indolence, and psychopathology result from conditions that thwart these central aspects of human psychology: When people view themselves as mere victims of outer and inner circumstances, or feel that their lives no longer have purpose, they despair and begin to feel hopeless,

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lack fulfillment, and lose interest in life. According to Frankl, such inner emptiness and ennui constitutes a frustration of the will to meaning; that is, a sense of despair and hopelessness means that one has lost touch with one’s ability to change and find meaning. Thus, the fundamental pillars on which logotherapy rests—its postulates—are the freedom of the will (we are free to choose and change despite restrictions), the will to meaning (humankind’s main motivation), and the meaning of life (to be detected and discovered in everyday experiences and epiphanies). Logotherapy’s call is to wholeness, which includes the unification of psychic and somatic components of the human personality. Wholeness consists in this unification and in the synthesis of the spirit (noetic core). This procedure or process of unification and synthesis complements and completes the process that is involved in making conscious the unconscious.

only to look beyond oneself but also to reach out and respond to the meaning offered by each life situation and to actualize the meaning potential of the moment. To be receptive to such offers of meaning and to be able to decipher them, it is often necessary to look beyond one’s own immediate current needs, urges, and drives and to view oneself as an active participant and contributor to life. A medical doctor who consciously decides to delay immediate pleasures (e.g., going out with friends) and instead remains a little longer in the hospital to talk with a confused or anxious patient, or an emergency physician who on his day off makes the decision to volunteer during a catastrophe in an adjacent town exemplifies this ability to forgo personal pleasure for the sake of others. Selftranscendence enables individuals to develop interest and to become engaged not in their own existences but in the existences of others. Intentionality and Meaning

Major Concepts In applied logotherapy, freedom and meaning are referred to as two basic human abilities: the ability to self-distance and the ability to self-transcend. Self-Distancing

Self-distancing refers to the human capacity to observe oneself and one’s own psychological actions, thought tendencies, and affective reactions. Hence, the overly anxious person who is able to say to himself or herself, “I feel this anxiety, but who says that I cannot do what is necessary and meaningful with this anxiety, rather than not doing it and feeling anxious anyway?” is on the road to recovery. This person has anxiety yet can still decide what to do with it, rather than letting the anxiety overcome him or her. In other words, this ability to self-distance enables an individual to “stop taking all that nonsense from oneself” and instead focus on current meaningful offers from life. Self-Transcendence

The concept of self-transcendence is closely related to self-distancing, but whereas the latter primarily deals with gaining relative independence from inner and outer obstacles to live a fulfilled life, self-transcendence represents the capacity not

In brief, logotherapy holds that fulfillment in life is not the result of being preoccupied with the question of whether we feel good but of asking what we are good for. A number of research studies imply that when individuals move from an egocentric viewpoint (e.g., What does life owe me? When I do this, will I be as happy? Will I get the acknowledgment I deserve?) to a selftranscendent viewpoint (e.g., What do I owe life? When I do this, will it be good for the sake of the project itself? How can I make sure that my choices and behavior will have a positive impact on what I am about to do?), they not only show heightened frustration tolerance but also experience a greater sense of purpose and increased positive feelings. Accordingly, these intentional acts that focus on fulfilling a selftranscendent viewpoint result in growth, integrity, well-being, and self-worth and are the by-products or side effects of fulfilling a mission or purpose. So, for Frankl, life does not owe us happiness; rather, it offers us meaning. This principle also guides some treatment applications in clinical logotherapy, especially in milder cases where often only a correction of one’s outlook in life may be sufficient to trigger one’s psychological healing processes. Thus, for example, a logotherapist may encourage a person suffering from moderate to low self-esteem to not only

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uncover the unconscious causes of the low selfesteem in the unchangeable past (in his or her childhood, learning history, genetic makeup, etc.) but also discover the many opportunities to contribute something worthwhile and meaningful in the present (i.e., to bring forth reasons for an ameliorated engagement with life through more worthwhile experiences and encounters). Here, in the present, the patient can proactively engage by applying both self-distancing and self-transcendence. Instead of focusing on and being hindered by a current lack of self-trust and its putative causes, the individual may try to open up to his or her surroundings and seek to find, and fulfill, a meaningful task. Once the patient can honestly say to himself or herself, “I know what I am good for,” the patient is on the road to recovering his or her nearly lost knowledge of the value and intrinsic worth of each person, including himself or herself. As the example illustrates, logotherapy views self-transcendence as both a human (psychological) and an existential resource: On the one hand, it refers to our ability to connect to something beyond ourselves; on the other hand, such a connection is thought to be possible only because the meaningfulness does exist “out there,” if only as potentials to be actualized. In other words, logotherapy is based on the idea that meaning is an objective reality, as opposed to a mere illusion arising within the perceptional apparatus of the observer. To summarize, according to logotherapy, humans are called upon, on the grounds of their freedom and responsibility, to bring forth the best possible in themselves and in the world by perceiving and realizing the meaning of the moment in each and every situation. These meaning potentials, although objective in nature, are linked to the specific situation and person and are therefore continually changing. Thus, logotherapy does not declare or offer a general meaning of life. Rather, suffering and acting persons are aided in achieving the openness and flexibility that will enable them to shape their day-to-day lives in a more meaningful manner.

Techniques Three major techniques often used in logotherapy are (1) paradoxical intention, (2) dereflection, and (3) Socratic dialogue.

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Paradoxical intention, developed by Frankl in 1938, is a relatively simple technique whereby patients consciously and intentionally disrupt the vicious circle of anticipatory anxiety and anxietyrelated and obsessive-compulsive symptoms by (a) acknowledging the nonvolitional nature of their overwhelming and irrational feelings, (b) trying to refuse to be blackmailed and threatened by these anxious and irrational feelings, and (c) finally using humorous exaggeration as a means to break their spell. Using paradoxical attention and guided by the logotherapist, patients learn to overcome their obsessions or anxieties by self-distancing and humorous exaggeration, thus breaking the circle of  symptom amplification. In numerous studies, paradoxical intention has been shown to be a particularly effective and fast-working therapeutic technique; in fact, research in this area has demonstrated that self-distancing can reduce symptoms to a similar, and sometimes greater extent than, for example, psychopharmacotherapy for obsessivecompulsive disorder. This technique is often used to treat compulsive disorders, anxiety disorders, and vegetative syndromes. Dereflection

Instinctive, automatic processes are impeded and hindered by exaggerated self-observation. By the same token, some mild and well-founded sensations of anxiousness or sadness will be increased and amplified by self-observation, making them more noticeable and engendering even more intense observation (excessive self-scrutiny). Dereflection is the process of breaking this circle of neuroticisim by drawing the patient’s attention away from the symptom to a more naturally flowing process. This technique is often used with sexual disorders, sleeplessness, and anxiety disorders. Socratic Dialogue

Socratic dialogue is a conversational method frequently used by logotherapists. Specific questions are framed to raise into consciousness the possibility of finding, and the freedom to fulfill, meaning in one’s life. In the philosophical setting, this technique of guiding by maieutic questioning was introduced by the Greek philosopher

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Socrates, who characterized it as a sort of “spiritual midwifery.” Certain attitudes and expectations may be obstacles to meaning fulfillment. They can alienate a person from the meaning potentialities in his or her life, thus accentuating neurotic disorders or even producing them via repeated poor decision making. It is important to note that the logotherapist must refrain from imposing his or her own values or meaning perceptions. Rather, the logotherapist guides patients toward perceiving their unrealistic and counterproductive attitudes and encourages patients to develop a new outlook that may be a better basis for a fulfilled and full life. This technique is often used with the adjustment or alteration of a wide range of attitudes that have been found to be deleterious to intentionality and meaning making.

Therapeutic Process When working with patients, the logotherapist not only attempts to arrive at a whole picture of the patient’s presenting problems but also listens to the patient’s personality strengths. Thus, the positive and problematic aspects both unfold in the course of the existential analysis as the person’s existence begins to be explicated and unrolls. The logotherapist always attempts to orient the patient toward meaning—to see the logos in the pathos. The therapeutic process is at once an analysis and a therapy. Then, techniques may be offered from a wide repertoire to help with anxiety or phobias or depression, but the essence of the existential encounter is the dialogue that ensues between the two persons present. Finally, the hope is that thus motivated and heard, the patient will be able to

draw on his or her inner resources, harnessing the defiant power of the human spirit through the person’s attitudinal change to both himself or herself and the world. Ultimately, logotherapy leads to more responsible freedom, to a heightened sense of purpose and meaning, to fullness of life, to values, and to reasons for happiness. Logotherapy also leads to the gates of ultimate meaning—it is left to each person whether or not to enter. Alexander Batthyány and Stephen J. Costello See also Existential-Humanistic Therapies; Frankl, Viktor

Further Readings Batthyany, A., & Guttmann, D. (2005). Empirical research in logotherapy and meaning-oriented psychotherapy. Phoenix, AZ: Zeig, Tucker & Theisen. Costello, Stephen J. (2010). The ethics of happiness: An existential analysis. Lima, OH: Wyndham Hall Press. Frankl, V. E. (1955). The doctor and the soul. New York, NY: Alfred A. Knopf. (Original work published 1946) Frankl, V. E. (1959). Man’s search for meaning. Boston, MA: Beacon Press. (Original work published 1946) Frankl, V. E. (2009). The feeling of meaninglessness: A challenge to psychotherapy and philosophy (A. Batthyány, Ed. [with an introduction]). Milwaukee, WI: Marquette University Press. Lukas, E., & Hirsch, B. Z. (2002). Logotherapy. In E. Smith (Ed.), Logotherapy reader (pp. 5–8). Vienna, Austria: Viktor Frankl Institute. Schwartz, J. M. (1996). Systematic changes in cerebral glucose metabolic rate after successful behavior modification treatment of obsessive-compulsive disorder. Archives of General Psychiatry, 53, 109–113. doi:10.1001/archpsyc.1996.01830020023004

M families with different pathologies. While at the Mental Research Institute, she also became interested in the work of Milton Erickson and in family therapy. Returning to Argentina in 1968, she was one of a few in her country familiar with the latest developments in family therapy. Although most of her experience was as a researcher, she suddenly found herself in demand as a supervisor and teacher of therapy. In 1971, she returned to the United States with her husband, an economist in the World Bank, and her two daughters. With the help of Salvador Minuchin, she obtained a job at the Philadelphia Child Guidance Clinic, training Puerto Rican paraprofessionals in family therapy. Soon she was also training psychiatric residents, psychology interns, and social work students. She divorced her husband in 1972. The next 2 years, she developed her skills as a supervisor and, later, for several years, taught at the University of Maryland Hospital, Howard University, and the Children’s Hospital of Washington, D.C. During this time, she developed a professional relationship with Jay Haley, whom she married in 1975, and together they founded the Family Therapy Institute of Washington, D.C. For more than 20 years, Madanes has taught large-group workshops all over the world. In addition, she has used the technique of observation to supervise clinicians and teach students: From behind a one-way mirror, Madanes, along with her students, observes therapists; then, Madanes offers suggestions to guide them. With the publication of

MADANES, CLOE The family therapist and teacher Cloe Madanes (1940– ), one of the founders of the strategic approach to family therapy, was born in Buenos Aires, Argentina, the oldest of three children. Her grandparents were Jewish immigrants from Russia and Poland. Her father was a lawyer, and her mother was one of the first two women who were admitted to law school at the University of La Plata, but she dropped out after 2 years when she married and became pregnant. Madanes decided by the age of 12 years that she would be a psychologist. To prepare for her future career, she read works by Sigmund Freud, Wilhelm Stekel, Simone De Beauvoir, and Alfred Adler. She hid the books under her mattress because her father thought that they were inappropriate for a child. An outstanding student, Madanes graduated from the American High School in Buenos Aires with a merit scholarship to Radcliffe; however, her parents refused to let her go, believing that a young woman should not be so far away from her family. Instead, she obtained a licenciada in psychology from the University of Buenos Aires. In one of her last classes, she learned about communication theory work being done by Gregory Bateson and the Palo Alto group at the Mental Research Institute in Palo Alto, California. In 1965, she decided to continue her studies at the Mental Research Institute, where she became Paul Watzlawick’s research assistant and finished Don Jackson’s research after Jackson died, comparing 623

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her first two books, Strategic Family Therapy and Behind the One-Way Mirror, Madanes introduced play and pretending into family therapy. Because of her knowledge of play therapy with children, she developed playful strategies that included the whole family. She also incorporated playful strategies into marital therapy. Some feminists were offended by her playful, light-hearted approach to marital therapy. However, Madanes refused to see women as oppressed victims, which at that time was the ideology of many feminist therapists. In the 1980s, with the increased awareness of child sexual abuse, Madanes developed the Steps for Repentance method for the rehabilitation of juvenile sex offenders. This method, inspired by Tibetan Buddhist ideas on compassion, is applicable to a wide range of antisocial behaviors, and Madanes considers it one of her most important contributions. In the 1990s, she published two books on the subject, Sex, Love and Violence and The Violence of Men; at the same time, she switched to a different subject and published The Secret Meaning of Money. In 2006, she published a collection of her papers titled The Therapist as Humanist, Social Activist, and Systemic Thinker . . . and Other Selected Papers. Madanes has presented her work at professional conferences all over the world and has given keynote addresses for the American Association of Marriage and Family Therapy, the National Association of Social Workers, the Erickson Foundation, the California Psychological Association, the American Counseling Association, and many other national and international organizations. She has been Primary Faculty at the Evolution of Psychotherapy Conference since 1985. Over the years, Madanes has received many awards for her contributions, including the 1996 Egner Foundation Award for Distinguished Contribution in the fields of psychology, anthropology, and philosophy from the University of Zurich, Switzerland, and the 2000 Award for Distinguished Contribution to Psychology from the California Psychological Association. In 2001, she was awarded the degree of Doctor of Humane Letters, honoris causa, by the trustees of the University of San Francisco. In 2013, the Cloe Madanes Center Against Child Abuse opened in Montevideo, Uruguay, funded by the Office of the

President of the Republic of Uruguay. Madanes has been featured in Newsweek, The Washington Post, and the Boston Globe. Her books have been translated into more than 20 languages. Sal Minuchin best summarized Madanes’s contribution when he wrote the following for the back cover of Madanes’s 2006 book The Therapist as Humanist, Social Activist, and Systemic Thinker . . . and Other Selected Papers: Cloe Madanes has a unique voice among family therapists. She is the only one among us for whom techniques like ordeals, tasks, unbalancing and pretending commingle with shame, injustice, repentance and reparation. She has worked with the most difficult patients, perpetrators of violence and incest, and has come out with clear sequential steps of intervention committed wholly to the process of healing.

Since 2002, Madanes has worked with the author and speaker Anthony Robbins to create the Robbins-Madanes Training program in collaboration with her daughter and son-in-law, Magali and Mark Peysha, respectively. Her latest book, Relationship Breakthrough, is the result of this collaboration. Cloe Madanes See also Strategic Family Therapy; Strategic Therapy

Further Readings Madanes, C. (1990). Sex, love, and violence: Strategies for transformation. New York, NY: W. W. Norton. Madanes, C. (1994). The violence of men. San Francisco, CA: Jossey-Bass. Madanes, C. (2006). The therapist as humanist, social activist and systemic thinker . . . and other selected papers. Phoenix, AZ: Zeig, Tucker & Theisen. Madanes, C. (2009). Relationship breakthrough. New York, NY: Rodale.

MAHLER, MARGARET Born into a Jewish family in Sopron, Hungary, Margaret Mahler (1897–1985) is one of the founding pioneers in psychoanalytical theory and

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practice. She is most noted for her separationindividuation theory of child development, which emphasizes identity formation as occurring within the context of relationships. After immigrating to the United States in 1938, Mahler’s work as a child psychiatrist informed her theory regarding the interplay between our internal (psychological) development and our external social environment. This approach was considered scandalous within her professional community, which tended to minimize sociocultural and relational contributors to our sense of self. Her conceptual framework regarding the nature of attachment relating, specifically our need for both closeness and distance, is imbedded in many theoretical constructs regarding attachment, interpersonal relationships, family, and broader social system functioning. In her separation-individuation theory of child development, Mahler hypothesized that the process of becoming—of separating (differentiating out from our perceptual and emotional fusion with others) and individuating (developing concrete autonomous skills and abilities)—occurred through a lifelong process of connecting and separating. Like the ebb and flow of a tide, each person continually needs to relationally “move in,” experiencing self within the context of “we” (symbiosis). Likewise, we continually need distance, to “move out” to reestablish connection to self as an “I” as we synthesize the good, bad, and indifferent of current relationships or explore new roles, relationships, and challenges. The cycle nears its conclusion as we feel the tug to move back toward connection, but with skepticism, fear, or resentment. This ambivalence is anchored by our dual encounter with the exhilaration of self-mastery and autonomy (as well as the comfort of disconnection in reaction to disappointment) and the joy of love, of knowing others, and of being known (as well as the despair of loneliness). The process of overcoming this ambivalence occurs as we move back in, gradually making peace and honoring these competing drives and experiences, accepting that we need distance from and connection with imperfect others, even as they need the same from our imperfect selves. As we relax into and accept the strengths (the good) and limits (the bad) of self and other, deeper levels of care and trust are made possible. This informs the internalized attachment schemas forming our core sense of

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self, a safe harbor in the presence of anxiety in all its varying forms and intensities throughout life. The cycle begins again within our ongoing and new relationships. Each iteration and developmental stage reflects and provokes identity formation, which in turn allows for a continual evolving of our ability to engage in reciprocating relationships and manage the anxieties associated with them. Mahler believed that our capacity to understand and live with a both-and rather than an either-or response to this ebb and flow influences our level of health or distress as individuals and a society. As children progress through their first and subsequent iterations of connecting, separating, and reconnecting, Mahler offered a nuanced application of what a parent’s relational attunement may look like in any given moment within the child’s current cycle. Each of Mahler’s six development stages—(1) normal autism, (2) symbiosis, (3) differentiation, (4) practicing, (5) rapprochement, and (6) object constancy—suggests thematic attachment behaviors, varying along a continuum from a more hands-on to a hands-off approach. However, the affective and cognitive stances remain the same: one of openness and embrace of the child’s need or challenge. The child’s developmental level, current context, and personality inform the actual attachment-based response. For example, in the earliest stages (Stage 1, normal autism, to Stage 2, symbiosis) of the infant’s first and most foundational iteration, the child needs a high level of reassuring and affirming connection expressed physically and verbally in between moments of needed breaks from affective or physical engagement. The parents’ job is to welcome the child’s dependency needs and varying moods. A third-grade student revisiting these stages after a tough day at school or a bad nightmare may need extra hugs or time together doing activities of special meaning. Meanwhile, adolescents often experience new depths of symbiosis with a reciprocating peer. But they still need to frequently nestle in, though on their own terms; the attuned parent reads those moments and responds accordingly. As the toddler takes the first steps away from the parent or the adolescent prepares to move away from home emotionally and physically, both are entering the substages of separation-individuation (Stage 3, differentiation; Stage 4, practicing; Stage 5,

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rapprochement; and Stage 6, object constancy). Attachment behaviors begin to look different as steps of autonomy are supported without parental judgment or abandonment, and moments of reconnection are not forced or disparaged. Here, the attentive parental stance is with arms open, allowing the child to venture away even while keeping a watchful eye: The toddler begins to crawl away from the lap of the parent, while the adolescent wants extended curfews and increased privacy. Those same hands provide a welcoming embrace when the child returns with whatever affective need drives the refueling, whether excitement over new discoveries, anger at limitations, guilt or shame due to failure, or just longing for the embrace of a loved one. The toddler’s return may have been precipitated by a bump on the head or the need for reassurance after the first of many power struggles to come. The adolescent may seek reconnection after a betrayal by a peer or an encounter with law enforcement. Hence, attachment behaviors include relationally moving in and moving out in response to the developmental need and circumstance of the relational other. Mahler’s developmental model has practical applications beyond child development. Her cycle of symbiosis to object constancy is easily applied to numerous types of relationships, for example, adult intimacy, the embrace of a new belief system or community, and mentor–mentee relationships, such as the supervisor and supervisee. New relationships with people, organizations, or ideas often include a honeymoon period in which we experience symbiosis. The need to reconnect with previous interests and relationships or to focus on other tasks of the day, or emerging awareness of the imperfections of the new person, place, or cause begins the separation-individuation process. We remain connected, in deeper or perhaps a more limited form, as we come to terms with the positive and negative elements in the self, the other, and the relationship. The challenges of connection and separation are evident in systems theories such as David Olson’s cohesion construct within the circumplex model and Murray Bowen’s differentiation concept within general systems theory. Similar to Mahler’s concept of whole-object relating, Bowen maintains that our lifelong challenge is to move out from fusion, experienced as either enmeshment or disengagement, and into differentiation.

On a societal level, Mahler’s hunch regarding the universal struggle between connection and autonomy, and the tendency to “split” (be cut off from some element of human experience as a defense) rather than to engage in whole-object relating, can be observed within a culture as it struggles with the concepts of community and individuality. This struggle is most evident in the  macrosystem values shaping its political, economic, military, education, and religious systems. Mahler’s own life reflects her relational challenges, navigating between symbiosis and object constancy. Her childhood was dominated by a rejecting mother and a doting father, who appeared to treat her as a substitute mate or the son he never had. Despite her success as a physician in Europe and the United States during an era of overt and persistent sexism, she also lived in fear for her life due to her Jewish identity; her father died shortly after Germany’s invasion of Hungary (1944), and her mother died a year later in an Auschwitz concentration camp. Her adult relationships with friends, colleagues, and students have been characterized as either overly connected or highly conflictual. She was both loved and disliked, both celebrated and feared. It is easy to speculate that Mahler’s experience of deep longing for embrace in the face of rejection inspired her professional work with children and the birth of her developmental theory. Regardless, her life and work invite us to observe in self and others the lifelong challenge to become a self within the context of a relationship and to see the humanity in that struggle as we continually navigate our own needs for connection and separation. Anna A. Berardi See also Classical Psychoanalytic Approaches: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Ego Psychology; Intersubjective-Systems Theory; Object Relations Theory; Relational Psychoanalysis; Self Psychology

Further Readings Brandell, J. R. (2010). Contemporary psychoanalytic perspectives on attachment. Psychoanalytic Social Work, 17, 132–157. doi:10.1080/15228878.2010. 512265

Mahoney, Michael J. Coates, S. (2012). John Bowlby and Margaret S. Mahler: Their lives and theories. In L. Aron & A. Harris (Eds.), Relational psychoanalysis: Vol. 4. Expansion of theory (pp. 131–157). New York, NY: Routledge/Taylor & Francis. Edward, J., Ruskin, N., & Turrini, P. (1992). Separation/ individuation: Theory and application (2nd ed.). New York, NY: Routledge. Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York, NY: Basic Books. Stepansky, P. E. (Ed.). (1988). The memoirs of Margaret S. Mahler. New York, NY: Free Press.

MAHONEY, MICHAEL J. Michael J. Mahoney (1946–2006) represented one of the most integrative theorists in counseling and psychotherapy, reflecting a spirit of true critical inquiry that led to revisions of his thought throughout his career. Known for his gentle demeanor and pointed Irish wit, he was also a self-proclaimed iconoclast, which led to questioning—and frequently heated debate—of many of the accepted core assumptions and practices within psychology. A prolific author/editor of more than 250 scholarly articles and chapters and 19 books, Mahoney contributed significantly to a number of theoretical orientations, from his early work in classical behaviorism, to his key role in the cognitive revolution, to foundational articles in sport psychology, and culminating with his articulation of constructivism, a comprehensive developmental metatheory that describes human beings as actively complex, socially embedded, and developmentally dynamic self-organizing systems. Human Change Processes: The Scientific Foundations of Psychotherapy effectively introduced constructivism to the psychological mainstream, and Constructive Psychotherapy: A Practical Guide provides a detailed description of its clinical applications. Born in Streator, Illinois, to Irish parents, Mahoney’s early life was marked by personal and academic difficulties. An early diagnosis of asthma prevented the young Mahoney from engaging in

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his favored baseball and other aerobic sports and likely contributed to a sense of uniqueness and isolation. Of diminutive stature and defiant temperament, he often found himself in altercations with numerous schoolmates and academic administrators. As a consequence of an adolescent trauma, he dropped out of high school and began traveling throughout North America, supporting himself doing construction work and seeking inspiration to hopefully emerge as a fiction writer. However, at the age of 18, his respiratory condition worsened, and physicians advised Mahoney to abandon manual labor and to consider relocating to a more arid climate where he might pursue an education, or else face a premature demise. Heeding the warning, Mahoney began attending Joliet Junior College as a probationary student to complete basic coursework, including a number of classes in philosophy, his main area of interest. He also began working as a psychiatric aide at a local hospital, which was his first introduction to the mental health profession. His roles in the hospital varied, and he often found himself coleading groups as well as acting as a substitute recreational therapist, occupational therapist, and crisis interventionist, using his philosophical understanding in a type of inchoate cognitive therapy that involved reasoning with patients about their difficulties. The harsh Illinois winters continued to be a problem for his health, and a random coin toss decided that he would pursue his undergraduate degree at Arizona State University (ASU). On arriving, he was told he would need to decide on a major within a week, and burdened by indecision and anxiety, Mahoney elected to seek out a therapist for assistance with the decision. Randomly pulling a name from the Phoenix phone book, he selected the renowned psychotherapist Milton H. Erikson. He spent his life savings of $60 on the consultation, during which Erikson compassionately guided him toward a major in psychology. This chance encounter in his life path would be one of many formative meetings in his career. The psychology department at ASU in the late 1960s was thoroughly rooted in orthodox behaviorism, and Mahoney excelled as a brilliant and disciplined student. His first academic paper, assisted by his mentor Dave Rimm, was published when he was only 23 years of age. Rimm also

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introduced him to basic relaxation techniques, which would continue to evolve as a central element in Mahoney’s therapeutic approach. Mahoney obtained his doctorate from Stanford University in 1972, finishing in just 4 years. Despite his early academic success in the Skinnerian tradition, Mahoney was sensitive to the limitations of pure behavioral models, and it was Albert Bandura’s Principles of Behavior Modification that opened him to the relevance of cognitive processes in change, contrary to the behaviorist dismissal of mental events as an unknowable “black box.” He was soon exploring cognitive processes at length, culminating in his first book Cognition and Behavior Modification, in which he articulated the evidence supporting meditational models of learning, arguing that cognition is a critical interceding factor between brute stimulus and response. This position was much to the irritation of B. F. Skinner himself, who openly criticized Mahoney for venturing down the blind alley of mentalism, and would be the beginning of an ongoing debate between the two that would last until Skinner’s death in 1990. Mahoney’s work of this period, along with that of Aaron T. Beck and David Meichenbaum, would serve as the foundational pillars for what would later become known as the “cognitive revolution” in psychology. After graduation, Mahoney obtained an appointment at Pennsylvania State University (Penn State), where he also began a small private practice, eventually focusing on treating difficult clients who were often described as “borderline” or “personality disordered.” Here, he also began pursuing ideas related to change processes in a wide range of fields, including studies of complexity, intersubjective field theory, dynamic systems, chaos theory, autopoiesis, and other evolutionary sciences. He was particularly influenced by the work of Friederich Hayeck, William Bartley, Humberto Maturana, and Walter Weimer, which led him toward a more perspectival, postmodern epistemology, highlighting multiple modalities of knowing and the active nature of the mind in organizing experience. His book Scientist as Subject: The Psychological Imperative critically examined the epistemological presuppositions of scientific inquiry as well as the politics of research and graduate training. Having taken up Olympic weightlifting in his early 20s as a method of conditioning given his

respiratory limitations, Mahoney began publishing a number of articles related to elite athletic performance and the implementation of relaxation, visualization, and other cognitive-behavioral skills. In 1980, he served as a resident psychologist for the U.S. weightlifting team at the U.S. Olympic Training Center in Colorado Springs, Colorado. Mahoney was active as a weightlifter over the course of his life, eventually becoming a national champion and also medaling internationally. His interest in sport and athletic performance influenced much of his later thinking on embodiment and the importance of physical rituals in influencing change. In 1985, Mahoney left Penn State for the University of California, Santa Barbara. Here, he developed relationships with two renowned existential-humanistic therapists, James F. T. Bugental and Viktor Frankl, whose work emphasized the centrality of a genuine, empathic relationship in the psychotherapy process, as well as the construction of meaning and the intractable presence of isolation, anxiety, and suffering in human life. These dialogues also led to Mahoney incorporating a number of holistic interventions outside the cognitive-behavioral mainstream, including Gestalt approaches, creative dance, restrictive sensory stimulation, massage and other bodywork, and a variety of meditation techniques from different contemplative religious traditions. In 1990, Mahoney took a position at the University of North Texas, where he remained for 15 years. In his book Human Change Processes, he provided a systematic articulation of constructivism, defined as a view of human beings that emphasizes their active participation in the creation of meanings around which they organize their lives, along with integrating theoretical concepts and clinical techniques from a broad range of counseling approaches. The central themes in Mahoney’s constructivism include (a) the inherent activity of the organism, (b) the directness of that activity toward self-organization, (c) the centrality of processes associated with “selfhood” or personal continuity in referencing and organizing experiences, (d) social embeddedness that is predominant in humans and inseparable from our symbolic capacities, and (e) a view of development that is dialectical and dynamic. From a technical standpoint, Mahoney eschewed the idea of a precise, scripted approach to treatment in favor of

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a diverse spectrum of behavioral, cognitive, psychodynamic, contemplative, and body-based interventions applied at the individual pacing of each client to explore and potentially modify the client’s own personal meanings and core ordering processes. In 2005, Mahoney left Texas for Salve Regina University in Rhode Island, where he taught until his death. His last work focused on existential realities such as suffering, meaninglessness, and death and their minimization in the psychological sciences, along with highlighting the risks of manualized approaches to treatment and rigid training programs that he felt often stripped students of a genuine sense of awe and critical self-reflection. In addition to his extensive psychological work, Mahoney also released a book of poetry and completed a quasi-biographical novel, which remains unpublished. Highly regarded as an exemplary educator, he was selected by the American Psychological Association in 1981 as a Master Lecturer and in 1988 as a G. Stanley Hall Lecturer. He is recognized as one of the leading figures in psychotherapy integration and constructivism and was a fellow of both the World Academy of Art and Science and the American Association for the Advancement of Science. E. Scott Warren See also Beck, Aaron T.; Behavior Therapies: Overview; Behavior Therapy; Cognitive-Behavioral Therapies: Overview; Constructivist Therapy; ExistentialHumanistic Therapies: Overview; Frankl, Viktor; Meichenbaum, Donald

Further Readings Mahoney, M. J. (1974). Cognition and behavior modification. Cambridge, MA: Ballinger. Mahoney, M. J. (1991). Human change processes: The scientific foundations of psychotherapy. New York, NY: Basic Books. Mahoney, M. J. (2000). Behaviorism, cognitivism, and constructivism: Reflections on persons and patterns in my intellectual development. In M. R. Goldfried (Ed.), How therapists change: Personal and professional reflections (pp. 183–200). Washington, DC: American Psychological Association. Mahoney, M. J. (2003). Constructive psychotherapy: A practical guide. New York, NY: Guilford Press.

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Mahoney, M. J. (2004). Scientist as subject: The psychological imperative. Clinton Corners, NY: Percheron Press. (Original work published 1976) Mahoney, M. J. (2005). Suffering, philosophy, and psychotherapy. Journal of Psychotherapy Integration, 15, 337–352. doi:10.1037/1053-0479.15.3.337 Rimm, D. C., & Mahoney, M. J. (1969). The application of reinforcement and participant modeling procedures in the treatment of snake phobic behavior. Behavior Research and Therapy, 7, 369–376. doi:10.1016/00057967(69)90066-7

MASLOW, ABRAHAM One of the original leaders of the humanistic movement, Abraham Maslow (1908–1970) was born in Brooklyn, New York, as the oldest of seven children. Maslow had a difficult childhood and stated throughout his life that he was lonely, unhappy, and struggled with the difficult circumstances surrounding his first-generation Jewish Russian immigrant parents. His eventual development of his hierarchy of needs and his research on self-actualizing individuals may have come from a personal understanding of how difficult surroundings can affect an individual’s personal growth. Growing up in a working-class neighborhood, he had many encounters with his parents that led to negative childhood memories. Maslow recounted stories of both his father and mother that had a profound effect on him throughout his childhood. A particularly potent story he recalled about his mother involved her smashing two kittens’ heads against the basement floor when he brought them home from school one afternoon. This experience, among others, left him with a distaste for both parents based on the poor way they treated him as well as their personal worldviews, eventually leading to an estrangement. While this estrangement lasted for some time, he eventually reconciled with his father later in his life. As Maslow grew up, he began to develop a love for learning and went to the City College of New York after graduating high school in 1926. He immediately had difficulty with the transition and eventually transferred to Cornell for one semester the following year. Eventually returning to City

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College of New York to study law, he later went to the University of Wisconsin and earned three degrees in psychology. During this time, he married his great love, Bertha Goodman, his first cousin. While at the University of Wisconsin, Maslow studied primates and behaviorism related to sexuality under his mentor and advisor Harry Harlow. Graduating with his doctorate in psychology in 1934, he was hired as a postdoctoral fellow at Columbia University, working under E. L. Thorndike. During his time at Columbia, Thorndike gave Maslow an intelligence exam in which he was said to have scored at the genius level. Maslow continued his research on sexuality, but with a focus on female sexuality. In 1937, he began a long career as a faculty member at Brooklyn College. During his tenure at Brooklyn College, he was profoundly affected by the work of many researchers in the psychological movement, including the Gestalt psychologist Max Wertheimer and the anthropologist Ruth Benedict. While at Brooklyn College, he collaborated with these researchers and mentors and began his research on self-actualization. As Maslow continued his research, he struggled with what he saw as major gaps in the popular psychological theories of the time. Maslow came to the conclusion that psychoanalysis was too focused on a negative view of human nature that emphasized psychopathology instead of understanding the exceptional or normal person. Furthermore, he felt that behaviorism missed the deeper and more important aspects of an individual, focusing instead on superficial factors. As he continued to delve into new research, he found that what was missing was an overall theory on positive mental health. What did a person need to feel fulfilled? Following this line of research, Maslow began to shift his thinking to a more humanistic view of human nature. Splitting from those in the psychoanalytical and behaviorism fields, Maslow began to develop the concept that once an individual has his basic needs met, he or she will begin to seek more intrinsically motivated goals and continue searching for fulfillment. These ideas became the bases of some of Maslow’s most important work in his career. Maslow is perhaps most well-known for his theory known as the hierarchy of needs. Originally

presented in his 1943 article “A Theory of Human Motivation” and later, in more detail, in his book Motivation and Personality, this theory, based on the ideas of developmental psychology, suggests that individuals have inner systems of motivation that drive human behavior. According to Maslow, there are five motivational needs: (1) physiological, (2) safety, (3) belonging and love, (4) esteem, and (5) selfactualization. The system works hierarchically: Lower needs must be addressed before higher needs become influential. The lowest level is physiological, in which the individual must ensure the basic elements necessary for survival, including air, water, food, sex, and sleep. Once these basic needs are completed, the individual transitions to working on safety needs, the focus of which is geared toward personal security and stability. The third level is the need for belonging and love. Having established basic survival and security, the individual can focus on his or her social and intimate relationships with others. Successful relationships with others set up the individual for tackling the esteem needs. These are attained through positive feelings of self-worth and through the praise and respect received from others. The final stage of Maslow’s hierarchy of needs is self-actualization. This highest stage of human behavior is one in which the individual can make full use of his or her talent and ability. Maslow’s system is typically taught as a pyramid, with physiological needs forming its base while self-actualization is at the upper tip. One aspect that Maslow was particularly focused on was the self-actualization stage. Compelled by what he called metamotivation— that is, a special gift of being able to maximize one’s own potential—he researched what led certain individuals to reach the level of self-actualization that many do not. One element that he saw over and over again was that these individuals were not focused on any one goal but, instead, looked within themselves. Maslow believed that less than 1% of humans were self-actualized, but he noted certain characteristics that were common in the self-actualized population. For example, someone who is self-actualized has a clear perception of reality, dedication, acceptance of others, and peak experiences. These qualities were just a few of the qualifications of a self-actualizer, and

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Maslow included individuals like Albert Einstein as part of this group. Maslow continued to work at Brooklyn College until 1951, when he moved to Brandeis University in Massachusetts. He was elected president of the American Psychological Association in 1966 and retired from teaching in 1968. In 1970, at the age of 62, he died of a heart attack while jogging. Maslow’s work has been influential in many different areas of counseling and psychological theory. Various theoretical models were developed, and research on the hierarchy of need, self-actualization, and intrinsic motivation is still being conducted. For example, self-determination theory uses the concept of intrinsic motivation and applies it to the three principles of (1) competence, (2) autonomy, and (3) relatedness. Furthermore, the Personal Orientation Inventory, developed by Everett Shrostrom, was based on Maslow’s work on selfactualization. Today, Maslow’s hierarchy of needs is often cited in the counseling field as well as in popular culture, making an impact throughout the world. Heather D. Dahl See also Existential-Humanistic Therapies: Overview; Maslow’s Hierarchy of Needs

Further Readings Hoffman, E. (1998). The right to be human: A biography of Abraham Maslow (2nd ed.). New York, NY: McGraw-Hill. Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 370–396. doi:10.1037/ h0054346 Maslow, A. H. (1954). Motivation and personality. New York, NY: HarperCollins. Maslow, A. H. (1962). Toward a psychology of being. New York, NY: Van Nostrand. Maslow, A. H. (1970). Religions, values, and peak experiences. New York, NY: Penguin Books.

MASLOW’S HIERARCHY

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Abraham Maslow’s hierarchy of needs identifies a range of core needs and desires that can have a motivating effect on an individual’s behavior and

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sense of self. This concept of human motivation can then provide a map for understanding a person’s current state, as well as determining what else may be needed or desired for future growth. Needs progress from the most basic and instinctual impulses to a sense of personal integration and even spiritual transcendence. This hierarchical view of motivation takes a holistic and dynamic approach to understanding human nature in that it incorporates the body, the mind, and social influences.

Historical Context Maslow first published his concept of human motivation in 1943 to fill what he felt was a significant gap in the current theoretical approaches to psychology. Through his own clinical practice, he discovered that although the conceptualizations of human nature of the leading theorists of the day (Sigmund Freud, Carl Jung, Alfred Adler, etc.) all had value, the efficacy of each approach varied by individual or condition. Maslow reasoned that the one thing that seemed to be lacking in all of them was the idea that each person has an essence, or higher self, and that achieving this higher sense of self is among our instinctual needs. He also believed that rather than reducing a person to symptoms or analyzing the minutiae of a person’s life, individuals could be viewed holistically, or as a sum of many parts that could all be significant to understanding the problem. Maslow’s hierarchy and concept of motivation are thus made up of levels that incorporate the body, mind, soul, and social experience of an individual. Maslow did not intend his concepts to become a theory in their own right, and though his hierarchy of needs and constructs of motivation have contributed greatly to clinical practice and humanistic models of counseling, they are still not viewed as an integrated theory of counseling. However, his concepts have met his real intent, which was to extend and expand an understanding of human nature beyond the more psychoanalytical views of his time.

Theoretical Underpinnings Maslow described his approach as holistic and dynamic, distinguishing it from what he felt were

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the more traditional reductionist and analytic approaches within counseling and psychology. He saw the value in the available theoretical approaches and did not intend to negate or challenge them, but he did seek to develop concepts he felt were lacking. A holistic approach to the individual was important to him because he saw that people have many different driving forces apart from any one determinant. Unconscious and instinctual impulses are important, as are relationships and a person’s own sense of self. His model, therefore, addresses human needs as containing physiological, social, and spiritual components. Similarly, he identified his model as dynamic because it drew concepts from other theories to create an integrated framework to understand motivation. His model contains elements of biological drives, social connectedness, cognitions, behaviorism, positive psychology, and universality. Although he did not originally intend his ideas to fall within a theoretical framework, his concepts of human nature and motivation best fit within other humanistic approaches in that they stress the importance of individuation, understanding a person within his or her context, and viewing individuals through a positive lens of growth and motivation toward further development.

Major Concepts Maslow believed that individuals are motivated by their most pressing current needs and that these needs can change based on what the individual has already achieved. As one level of needs is satisfied, a person will begin to desire the next level, and this will motivate his or her thoughts and behaviors. He identified five levels of needs: (1) basic, (2) safety, (3) belonging and love, (4) esteem, and (5) self-actualization. Basic Needs

Basic needs consist of the satisfaction of physiological drives, such as the need to satisfy hunger. If a person is starving or suffering from poor health, nearly all of that person’s attention will be devoted to resolving or satisfying these needs. The person’s thoughts and actions will be dominated by the need for food, warmth, or shelter. Consequently, it would be difficult for a person to truly care about satisfying other higher order needs

without first fulfilling needs at the most basic level. Once these needs are satisfied, however, an individual will tend to focus his or her attention on the next level of the hierarchy. Safety Needs

The next level within Maslow’s hierarchy of needs is that of safety and protection. Individuals who feel threatened in their environment or have an overall sense of anxiety or instability may be dominated by fear and motivated primarily toward seeking protection or comfort. A sense of safety and stability may vary for different individuals, but the need for structure or relief from the threat becomes primary for individuals who feel threatened. Safety can feel threatened by a wide range of influences, such as war or violence, natural disasters, economic uncertainty, or unemployment. Some individuals who experience heightened anxiety may likewise remain in this level, as their sense of security is constantly threatened by real or perceived fears. The primary motivator in this level is to obtain a degree of structure and stability in order to offset feelings of chaos or threats to personal safety. Belonging and Love

When an individual has the basic needs satisfied and feels secure, he or she will most likely begin to desire connection with others. In this stage, the absence of significant others will be felt more strongly than in previous levels, when other desires outweighed the need for love and belonging. An individual in this level will be more sensitive to feelings of loneliness and isolation and will seek out relationships with others. Maslow believed that every person—provided that other lower order needs were met—craved intimacy and the ability to both give and receive love. If the desires for love and belonging are not met, an individual will most likely remain within this level and be unable to move toward fulfilling other higher order needs. Esteem Needs

The next level of Maslow’s hierarchy involves an individual’s sense of self as well as how others value him or her. Maslow believed that every person has a need for a stable, relatively high

Maslow’s Hierarchy of Needs

self-evaluation and likewise also has a need to feel respected and esteemed by others. If a person is able to satisfy these needs, then he or she will feel confident and capable. However, individuals who do not possess a high esteem of themselves and/or are not valued by others for what they contribute will likely become discouraged and will be unable to progress to the final level. The Need for Self-Actualization

Finally, Maslow theorized that even if all other needs are met, there exists within each individual an additional desire to strive to be the best he or she can be and to be fully true to himself or herself. A person can, for example, have met all basic needs, feel a sense of security, have several close relationships, and be highly competent and esteemed by others, yet he or she may still feel unfulfilled. Maslow believed that the highest human need is to fulfill one’s true purpose by engaging in pursuits that utilize a person’s unique talents and passions. Maslow made a distinction in later writings that this higher order need most likely occurs in adulthood, as it is closely linked with professional pursuits and other life roles.

Techniques Although Maslow’s hierarchy does not provide a theoretical approach with corresponding techniques, it does provide a foundation for viewing human nature, understanding blocks to personal growth, and conceptualizing an ideal for psychological well-being. Counselors utilize the hierarchy to position a client’s current dominant needs and thus understand what might be needed to facilitate change. A client who is having difficulty paying bills and purchasing enough food for her or his family cannot, according to Maslow’s hierarchy, be expected to explore interpersonal skills or delve into issues of self-esteem. These other needs may indeed be important, but the client is primarily concerned with satisfying more basic needs and likely does not have much need for philosophical discussions of identity. Similarly, a person who has been unemployed for 6 months and who is struggling with self-confidence issues due to a frustrating job search is likely more concerned with finding a job and less focused on becoming fully self-actualized. Maslow’s hierarchy thus allows the

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counselor to work within the client’s reality and select approaches that correspond to the more essential goals within the client’s level of need fulfillment. There are several additional considerations Maslow provides regarding higher and lower order needs to assist in the application of his model. For one, Maslow believed that the higher order needs were evolutionary in that they distinguished human beings from other living things. Basic needs such as food, water, shelter, and safety are more instinctual, whereas self-actualization is a distinctly human ambition. Likewise, human beings have less of an urgent need for higher order needs. A person may not be able to live long without access to food and water, but he or she can still sustain life in the absence of self-esteem or self-actualized identity. Even though higher order needs are not necessary for survival, Maslow stated that individuals who are able to satisfy these higher needs tend to be healthier, less anxious, less prone to disease, and able to live longer and more enriching lives than individuals who satisfy only the most basic needs. Related to treatment, individuals who are actively in pursuit of higher order needs also demonstrate decreased psychopathology, which suggests that working toward these needs is facilitative of mental health. Maslow also believed that individuals pursuing higher order needs were more responsive to psychotherapy than individuals who needed to satisfy lower order needs. Therefore, clients who are struggling to meet lower order needs would not benefit as much from insight-based therapies and would instead need to be connected to resources to resolve their more pressing concerns. Despite the value of higher order needs for well-being, Maslow was careful to acknowledge that it is difficult to obtain and sustain these needs. The higher the need, the more difficult it can be to achieve. Individuals must have the time to build a foundation that can sustain each level, and their environment must be able to facilitate it. For example, love and belonging typically require the development of interpersonal skills, the investment of time and energy in the formation of relationships, and continued work to maintain them. Self-esteem can be difficult to maintain in an environment where jobs are scarce and individuals are not able to work within their area of competency. It is therefore important for counselors to develop

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an understanding of the client’s resources, both personal and environmental, in order to determine his or her position within the hierarchy as well as the conditions needed for the client to move to higher levels.

Rowan, J. (1998). Maslow amended. Journal of Humanistic Psychology, 38, 81–92. doi:10.1177/00221678980381008 Zalenski, R. J., & Raspa, R. (2006). Maslow’s hierarchy of needs: A framework for achieving human potential in hospice. Journal of Palliative Medicine, 9, 1120–1127. doi:10.1089/jpm.2006.9.1120

Therapeutic Process In the progression of therapy, the counselor first determines which level the client is in and then works to understand the various components influencing the current placement in the hierarchy. Understanding the client’s desires can assist in identifying the goals of therapy as well as facilitating motivation to work toward change. In addition, the therapeutic relationship itself can provide some satisfaction of various needs within the hierarchy. A close therapeutic relationship can, for example, provide a sense of love and belonging for a client who is struggling with a lack of connection with others. Acceptance and affirmation from the counselor can assist with self-esteem, as can the awareness of progress made over time. Exploration of the client’s desires and passions can help the client gain awareness of what self-actualization may look like for him or her. Thus, the hierarchy of needs can be useful both in structuring treatment as well as in understanding the role of the counselor in facilitating client progress toward higher order needs. Hannah B. Bayne See also Classical Psychoanalytic Approaches: Overview; Maslow, Abraham; Person-Centered Counseling; Positive Psychology; Psychosocial Development, Theory of

Further Readings Koltko-Rivera, M. E. (2006). Rediscovering the later version of Maslow’s hierarchy of needs: Transcendence and opportunities for theory, research, and unification. Review of General Psychology, 10, 302–317. doi:10.1037/1089–2680.10.4.302 Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 370–396. doi:10.1037/ h0054346 Maslow, A. H. (1968). Toward a psychology of being (2nd ed.). New York, NY: Van Nostrand Reinhold. Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York, NY: Harper & Row.

MAY, ROLLO Rollo Reece May (1909–1994), “father” of existential psychotherapy and a founder of the humanistic movement or third force in psychology, was one of the mid- to late 20th century’s leading and most influential psychologists. May was no stranger to the inevitable existential crises and anxiety to which, as he asserted, all human beings are subject, and his psychology sprang partly from his own personal history and experience. May was born in Ada, Ohio, in 1909. Named by his mother after a fictional character from children’s books, May was the eldest son of six siblings. His older sister suffered from schizophrenia, and with his father not home much, May felt responsible for taking care of her, his emotionally unstable mother, and his younger brothers. His parents’ tumultuous and acrimonious marriage eventually ended in divorce, but not before the painfully frightening, volatile, and unpredictable family dysfunction piqued May’s loneliness, resentment, insecurity, anxiety, codependency, and curiosity about psychology. May’s transition to adulthood was stormy. Banished from Michigan State University for publishing politically radical rhetoric, May was forced to transfer elsewhere. After graduating from Oberlin College in Ohio, May volunteered to spend 3 years in Saloniki, Greece, teaching English at Anatolia College. In his 1985 semiautobiographical book My Quest for Beauty, May writes about how he felt terribly lonely and bored, became unable to function, took to his bed for weeks, and wandered around aimlessly in the freezing rain on nearby Mt. Hortiati. He knew he desperately needed psychological support, but in 1931, there were few English-speaking psychotherapists in rural Greece. May attributes his recovery from this major depressive episode to his

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serendipitous rediscovery of beauty in a field of wild Greek poppies. May’s self-diagnosed “nervous breakdown” in Greece recalls Carl Jung’s devastating, prolonged yet immensely productive “confrontation with the unconscious” during midlife, following his bitter rift with Sigmund Freud in 1913. Like Jung, May was severely shaken, depressed, and disoriented. He could no longer fend off his psychological demons. But for both, this unbidden “breakdown” or “constructive illness” set them on the path toward a new, more authentic, creative, and meaningful life. What makes the concept of existential crisis so essential to May’s psychology is its potentiality to positively transform the personality by subverting self-defeating defense mechanisms, perceptions, and patterns of behavior, forcing us to fight for new life, open up to new experiences, and find and re-create ourselves anew. As the direct result of his existential crisis in early adulthood, May relinquished his rigid, compulsive, self-abnegating attitude toward life, decided to pursue his passion for art and beauty, had his first love affair, attended seminars with Alfred Adler in Vienna, studied philosophy and theology, graduated from Union Theological Seminary in 1938, and authored by the age of 30  his first book The Art of Counseling (1939), which innovatively blended depth psychology with pastoral counseling. May served for 3 years as an ordained congregational minister in New Jersey but found the practical reality of this pastoral role frustrating in effectively counseling parishioners— except at funerals, where the terrifying existential fact of mortality and raw emotional reactions to death could not be denied. Feeling he could be of more help to people as a psychotherapist, May enrolled at Columbia University in New York to study clinical psychology. However, in 1943, May experienced a second existential crisis when he contracted tuberculosis, a then frequently fatal disease. His prognosis was guarded at best. Confined to various sanatoria for several years, May observed—as did his Viennese contemporary, the psychiatrist Viktor Frankl, who was confined in Nazi death camps during World War II—that one of the factors determining which individuals survived and which died was the willful rather than passive attitude taken toward their existential predicament. We are responsible for how we

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choose to confront fate or destiny, which, for May, includes those elements of life beyond our control. Anxiously facing his own mortality, May became fascinated with existential philosophy, devouring the writings of Søren Kierkegaard and Friedrich Nietzsche in particular, writings that would profoundly inform his existential psychology and psychotherapy. Personal responsibility, integrity, choice, courage, meaning, commitment, values, a sense of purpose, and the conscious acceptance and assertion of one’s existential freedom and will, despite deterministic forces like sickness, death, family, genes, culture, and circumstance, became central themes in May’s existential psychology. After recovering from his illness, May received the first doctorate in clinical psychology granted by Columbia University in 1949. His dissertation, under the mentorship of the existential theologian and philosopher Paul Tillich, whom May met while still a seminary student and later befriended, was published in 1950 as The Meaning of Anxiety. This comprehensive scholarly treatise stimulated the psychological study of anxiety, boldly distinguishing between normal, ontological, or existential anxiety and neurotic, psychotic, or pathological anxiety and debunking the misconception of mental health as defined by the absence of anxiety. Revised in 1977, May’s groundbreaking book remains relevant, providing a much-needed counterpoint to the pathologizing and suppressive treatment of anxiety still predominant today. In this sense, May, always the courageous rebel and trailblazer, anticipated and spoke out against the pitfalls of too dogmatically applying the traditional medical model to the treatment of psychological, spiritual, and existential angst, distress, or despair. Demonstrating his lifelong cultural activism motivated by what Adler termed social interest, May also successfully fought against the powerful American Medical Association for the right of nonphysicians to practice psychotherapy in the dawning days of clinical psychology. As evidenced by his emphasis on existential anxiety, death, and the problem of evil—with a few exceptions, taboo topics for psychology and psychiatry—May never fully lost interest in theology, seeing psychotherapy as a secular stand-in for religion and promoting the rapprochement of spirituality and psychology, which is increasingly popular these days. After becoming a clinical psychologist,

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May pursued postgraduate psychoanalytical training at the William Alanson White Institute of Psychiatry, Psychoanalysis & Psychology in New York under the tutelage of luminaries like Harry Stack Sullivan, Erich Fromm, and Fromm’s wife, Frieda Fromm-Reichman; May later became a supervising and training analyst at the institute, a position he held for many years. When interviewing prospective candidates for analytic training, May, the archetypal “wounded healer,” preferred pupils who authentically struggled with their own neurotic tendencies to those pretentiously presenting some blandly well-adjusted persona. In 1958, May coedited and contributed two seminal chapters to Existence: A New Dimension in Psychiatry and Psychology, in which European existential analysis was introduced, explained, and exemplified. This well-received volume established May as the preeminent American exponent of existential therapy, which he felt more profoundly addresses the same “ultimate concerns” (to quote Tillich) as religion: mortality, suffering, meaninglessness, alienation, faith, responsibility, evil, and so on. Rocked by yet a third existential crisis, a difficult divorce from his first wife following three decades of marriage, May once more managed to channel his anguish, confusion, and anxiety creatively into his writing, publishing in 1969 his celebrated and erudite magnum opus, Love and Will, in which May muses about the meaning of sex and love, will and intentionality, evil and creativity and introduces his controversial, revolutionary, paradoxical paradigm of the daimonic—the basic and indispensable undergirding dynamic myth of May’s existential psychology and therapy. In Love and Will, May defines the daimonic as “any natural function that has the power to take over the whole person. Sex and eros, anger and rage, and the craving for power are examples” (p. 123). He contends that daimonic emotions like anger or rage, for instance, are not necessarily negative but can be both destructive (evil) and constructive depending on how we relate to them, emphasizing the futility and dangers of chronically denying, avoiding, or repressing rather than consciously acknowledging and confronting the daimonic. May’s stern warning that the way mental health professionals deal with the daimonic (or avoid doing so, as is often the case today) would be  fateful for the future survival of psychotherapy has proven

prescient given the suppressive, technique-driven, symptom-focused, and pharmaceutical approach taken by current therapies. May touted the immense importance and healing power of existential presence, empathy, and the hereand-now relationship in therapy over technical skills. Although known as one of the pioneers of humanistic psychology, along with Abraham Maslow and Carl Rogers, May’s existential approach to psychotherapy differed from most American humanistic psychologists in that he retained rather than rejected his psychodynamic perspective but modified and deepened it with the philosophical tenets of phenomenology and existentialism. Moreover, May took a more European, tragic view of life than most of his more optimistic (sometimes naive) humanistic colleagues. Like Freud (the id) and Jung (the shadow), May never minimized, sugarcoated, or denied the darker, dangerous, shadowy, unconscious side of humanity. His 1972 book Power and Innocence, a psychological analysis of the sources of violence in our society, penned during the Vietnam War, seems tragically prophetic in light of today’s epidemic of school shootings, terrorism, and random mayhem. May’s theoretical orientation is best described as an “existential depth psychology,” in which the rich clinical wisdom of Freud, Jung, Adler (with whom he studied), Otto Rank (whose lesser known contributions May valued highly), Ludwig Binswanger, Medard Boss, Eugène Minkowski, and Roland Kuhn is creatively combined with the sobering insights of existential philosophers like Kierkegaard, Nietzsche, Karl Jaspers, Jean-Paul Sartre, Tillich, and others. However, unlike some existentialists, May did not succumb to continental nihilism, maintaining that man’s innate capacity for cruelty, evil, hatred, and destructiveness is counterbalanced by our potentiality for kindness, goodness, love, and creativity and that life’s suffering, meaninglessness, and absurdity can be dealt with and made bearable by the creation of meaning through myths, religion, art, eros, science, and psychotherapy. Relocating from Manhattan to San Francisco in 1974, May continued to practice, supervise, teach, and write, despite his slowly declining health, until his death from congestive heart failure in 1994. The Stanford University psychiatrist Irvin Yalom, perhaps the most prominent and popular spokesperson for existential therapy today, was one of May’s patients, subsequently becoming a close friend and professional colleague. A recipient of the American

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Psychological Association’s Distinguished Career Award, May authored many books, including Man’s Search for Himself (1953), Psychology and the Human Dilemma (1967), The Courage to Create (1975), Freedom and Destiny (1981), The Discovery of Being (1983), and The Cry for Myth (1991). Stephen A. Diamond See also Adler, Alfred; Existential Therapy; ExistentialHumanistic Therapies: Overview; Frankl, Viktor; Freud, Sigmund; Jung, Carl Gustav; Maslow, Abraham; Freudian Psychoanalysis; Rogers, Carl; Yalom, Irvin

Further Readings May, R. (1969). Love and will. New York, NY: W. W. Norton. May, R. (1972). Power and innocence: A search for the sources of violence. New York, NY: W. W. Norton. May, R. (1975). The courage to create. New York, NY: Bantam Books. May, R. (1977). The meaning of anxiety (Rev. ed.). New York, NY: W. W. Norton. (Original work published 1950) May, R. (1986). The discovery of being: Writings in existential psychology. New York, NY: W. W. Norton. May, R. (1991). The cry for myth. New York, NY: W. W. Norton.

MEDITATION Meditation is an intentional practice of calming one’s body and mind in a fashion that leads to an altered state of consciousness characterized by expanded awareness, greater presence, and a more integrated sense of self. Meditation is practiced for religious, spiritual, and psychological or emotional well-being. While the majority of meditation methods have their roots in religious and spiritual practices, modern medical and scientific research has led to these techniques being incorporated into mainstream medical and psychotherapeutic interventions.

Historical Context The practice of meditation has long been utilized in various spiritual or religious practices. Meditative practices have been recorded in writings as far

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back as 1500 BCE (Hindu Vedic writings), 1 to 200 BCE (Buddhist), 10 to 200 CE (Judaic), 20 BCE (Christian), and 800 to 900 CE (Islamic). While many religious and spiritual practices (e.g., sacrifices, various superstitions and rituals, belief in no longer recognized deities) have waxed and waned over the years, meditation has been practiced for a long time and has flourished. Distinct from the scope of religious teachings, personal experiences (compassion, deeper appreciation for life, greater sense of inner balance, improved health and well-being) have been recorded, which serves to strengthen belief in the utility of meditation. Until recently, the benefits of meditation were regarded as anecdotal and unsubstantiated. However, beginning in the 1960s, research on Transcendental Meditation began to closely investigate how the body responds to meditative practice and opened up a greater understanding of its physical and psychological benefits. Since then, there has been a proliferation of medical and scientific studies exploring how this ancient practice affects the psychophysiological systems of the body. Today, there are numerous kinds of meditative practices, including the following: (a) mantric (reciting of a specific word or phrase), (b) Vipassana/ insight (focusing on the interconnection between the mind and the body by way of purifying the mind of the mental factors that cause distress and  pain), (c) Lectio Divina (reading, reflecting, responding, and listening intended to promote communion with God), (d) Centering Prayer (concerned with the intention of developing and maintaining harmony with God’s presence and action during prayer), and (e) Dhikr (an Islamic prayer in which the individual expresses, either silently or aloud, his or her remembrance of God).

Theoretical Underpinnings The basic purpose of meditation is to awaken in order to gain clarity as to the true nature of life as well as one’s own true nature. Many of us have numerous layers of thoughts, feelings, memories, and experiences that have served to shape and define who we are. Over the years, our experiences tend to reinforce these layers of learnings, creating a significant separation from our true selves. The basic purpose of the psychotherapeutic process is

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to help uncover, discover, and recover that part of the client’s self (true nature) that has been repressed, split off, denied, silenced, and/or forgotten in order to help reintegrate the client with a more balanced and integrated experience of himself or herself and his or her life. The purpose of integrating meditation practices with psychotherapy is to dampen the chronic overstimulation of the sympathetic nervous system and elevate the functioning of the parasympathetic nervous system, thus allowing the body’s own healing mechanisms to facilitate a return to health and wellness. When the parasympathetic nervous system is activated, it stimulates the vagus nerve, leading to a reduction in heart rate, blood pressure, or both, as well as promoting the production of acetylcholine. Interestingly, a cell repair and growth enzyme, ornithine decarboxylase, is not produced unless the parasympathetic nervous system is activated, generally in deep sleep. Integrating meditation into the psychotherapeutic experience also capitalizes on involving the client more actively in his or her healing process, as well as reinforcing the client’s innate psychobiological healing capacities. Both empower the client to take greater responsibility and limit reliance on the therapist as the sole guide for healing. It is important to clear up some common misconceptions regarding meditation. Meditation is not medication. It does not make the client a better something (e.g., parent, lawyer, teacher). It does make the client more something (e.g., patient, spiritual, outgoing) or less something (shy, anxious, depressed). Similarly, meditation is not practiced for a particular, specific outcome.

Major Concepts The practice of meditation is directly related to the functioning of the autonomic nervous system. Through meditation, balance can be restored to a dysregulated nervous system. Autonomic Nervous System

In recent years, the practice of meditation has been shown to have great benefits with regard to regulating the autonomic nervous system. The autonomic nervous system is the part of the peripheral nervous system that controls visceral functions (heart rate, digestion, respiratory rate, salivation,

perspiration, pupillary dilation, urination, and sexual arousal). The autonomic nervous system is made up of two branches: (1) the sympathetic nervous system and (2) the parasympathetic nervous system. The sympathetic nervous system typically controls what is known as the fight, flight, or freeze response. The parasympathetic nervous system controls what is referred to as the relaxation or healing response. The fight, flight, or freeze response is triggered when there is a perceived threat (real or imagined) and is designed to initiate our protective survival mechanisms. When the threat is over, the parasympathetic nervous system activates to heal the body from the effects of the fight, flight, or freeze response and to restore a sense of calm. Research has shown that numerous emotional and physical symptoms and conditions (e.g., irritable bowel syndrome, anxiety, dermatological conditions, hypertension, posttraumatic stress disorder, adrenal fatigue, ulcers, panic attacks, insomnia, headaches) have their roots in the dysregulation of the autonomic nervous system. The practice of meditation has been shown to positively affect autonomic dysregulation, thus allowing clients to better heal from their symptomatic distress. Autonomic Dysregulation

When the autonomic nervous system is functioning properly, the sympathetic nervous system and the parasympathetic nervous system perform in consort to maintain autonomic nervous system equilibrium in the body. Under chronic stress, these two systems tend to fail to work in harmony, and thus the autonomic nervous system becomes dysregulated toward sympathetic nervous system overactivation. The sympathetic nervous system remains activated most of the time, and the parasympathetic nervous system is prevented from turning on and allowing the body to heal and repair. The body then remains in a continual state of fight, flight, or freeze. Many psychobiological processes begin to degenerate, resulting in a variety of chronic health conditions and overall poor health. Meditation reduces autonomic dysregulation by dampening the overstimulation of the sympathetic nervous system and facilitating the activation of the parasympathetic nervous system. For this reason, meditation has been taught to various populations for different outcomes: (a) prison inmates, to

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help improve mood and behavior and to reduce recidivism; (b) individuals who have suffered trauma, to help reduce anxiety and the accompanying startle response; (c) those undergoing chemotherapy, to reduce anxiety and the side effects of the medications; (d) high school students, to improve classroom behavior and academic performance; (e) children who are scheduled for surgery, to prepare them for the procedure; and (f) those with depression and anxiety, to reduce problematic symptoms. Meditation has been shown to bring about not only changes in brain structure and function, such as significant increases in left-sided anterior activation, a pattern previously associated with positive affect, but also improvement in immune function, such as increases in antibody titers to influenza vaccine. In addition, studies have shown that specific molecular changes occur throughout the body as a result of meditation. For example, meditators showed a range of genetic and molecular differences, including altered levels of gene-regulating machinery and reduced levels of pro-inflammatory genes, which in turn correlated with faster physical recovery from a stressful situation, after periods of meditation. To date, empirical evidence has documented the beneficial qualities of meditation practices. Such practices can be integrated into the psychotherapeutic process, especially when it involves helping individuals regulate their autonomic nervous system as well as their accompanying emotions.

Techniques There are many techniques of meditation. The five listed in this section are those most frequently integrated into the psychotherapeutic experience. Insight Meditation

Insight meditation refers to being aware of surrounding sounds and activities. In this technique, the meditator sits with his or her eyes closed and with relaxed breathing. The meditator allows his or her mind to be fluid and to flow from one thought to the next; he or she does not focus on any one thought, feeling, or sound and does not make judgments about what he or she is thinking, feeling, or hearing.

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Centering Prayer

To employ the Centering Prayer technique, the meditator chooses a sacred word as the symbol of his or her intention. The meditator introduces the sacred word to his or her awareness and remains focused on the word. When thoughts or feelings arise, the meditator returns gently to the sacred word. At the end of the prayer period, the meditator remains in silence with eyes closed for a couple of minutes. Breath Meditation

Breath meditation refers to watching one’s breathing. The CenterPoint Breathing technique discussed in the “Introduction” subsection of the “Therapeutic Processes” section is often recommended for breath meditation. Walking Meditation

Walking meditation brings the meditative experience into the meditator’s outward activity. The meditator spends a moment standing still. He or she takes some deep breaths and then begins walking at a relaxed, fairly slow but normal pace. As the meditator walks, he or she pays attention to the sensations in his or her body and continues to do so throughout the duration of the walking experience. Metta or Compassion Meditation

This meditation cultivates compassion toward oneself and others. The meditator sits quietly with eyes closed and with relaxed breathing and then recites the following phrases several times: “May I be happy. May I be well. May I be safe. May I be peaceful and live with ease.”After pausing for several moments, the meditator then directs the meditation toward others with the following phrases: “May all beings be happy. May all beings be well. May all beings be safe and live with ease.”

Therapeutic Process When introducing meditation into the psychotherapeutic process, therapists often use a threestep process: (1) education, (2) an introduction to the process, and (3) integration. Throughout this process, it is important to keep it as uncomplicated as possible.

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Education

Because many people equate meditation with a specific religious practice, it is important for the therapist to address concerns the client may have regarding this. The therapist can reassure the client by noting that recent medical and scientific discoveries have demonstrated that a meditation practice has important medical and psychological benefits that relate to the client’s treatment and that the techniques the therapist will teach the client will not interfere with the client’s religious practice and beliefs. In an easy and understandable fashion, the therapist discusses the autonomic nervous system, parasympathetic nervous system, and sympathetic nervous system interactions, and how each affects a person’s health, healing, and well-being. It is important for the therapist to have a user-friendly information sheet outlining the benefits of meditation for the client’s condition, which the client can read and share with the important people in his or her life. Introduction

To introduce the client to meditation, the therapist instructs the client in an easy breathing technique that the client can practice at home, such as CenterPoint Breathing. The steps a therapist observes to introduce the client to CenterPoint Breathing are as follows: 1. Have the client sit comfortably with eyes closed. 2. Invite the client to simply watch his or her breathing. 3. Have the client take a deep breath in through the nose and exhale through the mouth. Encourage the client to exhale as completely as is comfortable and then to breathe in and out easily. 4. Repeat this sequence twice. 5. Have the client return to simply watching his or her breath, paying particular attention to the pause at the end of each exhaled breath. Have the client rest comfortably in that pause until it becomes time to gently inhale again, then exhale and return to resting in the pause.

The therapist allows the client several minutes to experience this technique for himself or herself.

He or she also encourages the client to take time every day to do this breathing meditation, articulating to the client to start out slowly by meditating at a designated time every day for 2 to 3 minutes and increasing the length of time gradually. The therapist can remind the client that what is important initially is that the client takes the time to meditate every day, not the length of time. The client’s mind may wander during meditation, so the therapist can reassure the client that this is normal. In addition, the therapist can remind the client to, simply and without judgment, pause at the end of each out breath when the client becomes distracted. Frustration and impatience are part of the process, so the therapist can make the client aware of this and encourage the client to stay with it. Integration

Each psychotherapeutic session begins with 5 minutes of meditation, including a word or phrase for the client to focus on that will serve as a platform for the ensuing session. Other methods that can help integrate meditation into the therapeutic process include the following: (a) discussing with the client how a daily meditation practice can assist in moving the client’s healing in a positive and lasting direction, (b) giving the client a collection of healing sayings to use during meditation, and (c) encouraging the client to journal about his or her meditation practice and any observations or insights he or she has gained during the therapeutic process. Thomas B. Roberts See also Advanced Integrative Therapy; Breathwork in Contemplative Therapy; Complementary and Alternative Approaches: Overview; Mindfulness Techniques; Prayer and Affirmations

Further Readings Aiken, G. (2006). The potential effect of mindfulness meditation on the cultivation of empathy in psychotherapy: A qualitative inquiry (Doctoral dissertation). Saybrook Graduate School and Research Center, San Francisco, CA. Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S., . . .

Meichenbaum, Donald Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564–570. doi:10.1097/01.PSY.0000077505.67574.E3 Deatherage, G. (1975). The clinical use of “mindfulness” meditation techniques in short-term psychotherapy. Journal of Transpersonal Psychology, 7, 133–143. Kabat-Zinn, J. (2005). Bringing mindfulness to medicine: An interview with Jon Kabat-Zinn, Ph.D. Interview by Karolyn Gazella. Advances in Mind-Body Medicine, 21(2), 22–27. Nhat Hanh, T. (1991). Peace is every step: The path of mindfulness in everyday life. New York, NY: Bantam Books. Roberts, T. (2009). The mindfulness workbook: A beginner’s guide to overcoming fear and embracing compassion. Oakland, CA: New Harbinger.

MEICHENBAUM, DONALD Donald Meichenbaum (1940– ) is known as one of the founders of cognitive-behavioral therapy and in a survey of clinicians was voted “one of the ten most influential psychotherapists of the 20th century.” Born in the Bronx, New York, Meichenbaum attended New York City public schools and eventually attended the City College of New York (CCNY) from 1958 to 1962 for his undergraduate degree in psychology. Meichenbaum tells the story of how he entered CCNY with the desire to become a chemical engineer. On his arrival at CCNY, all incoming freshmen attended a meeting with the Dean of Engineering, who told the incoming students to look around the room, because in 4 years only one in four would graduate as an engineer. Meichenbaum’s reaction was to immediately console his three friends and “inoculate” them against the stress of future failure. It turned out that he was better at counseling than he was at engineering. Thus, his career toward becoming a psychotherapist began. The next step in the journey of going from an undergraduate in psychology at CCNY to becoming a noted clinical researcher was entry into the Clinical Psychology program at the University of Illinois in Champaign. At that time (1962–1966), a behavioral perspective of psychotherapy was

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dominant. Behavior therapy, which was becoming an increasingly dominant force in counseling and therapy at that time, viewed a client’s thoughts and feelings within an operant and classical conditioning framework, and thoughts were viewed as “coverants” (covert operants). The works of B. F. Skinner, Sidney Bijou, Donald Baer, Joseph Wolpe, Hans Eysenck, Leonard Krasner, Leonard Ullmann, and others were the major framework for viewing psychotherapeutic interventions. Illustrative of this behavioral influence was Meichenbaum’s doctoral dissertation topic: “Training Schizophrenics to Talk to Themselves: A Self-Instructional Training Procedure.” On graduation from the University of Illinois with a Ph.D. in clinical psychology, Meichenbaum took a job at a new university in Ontario, Canada—the University of Waterloo—where he remained for 40 years. The next phase of his research was influenced by the development of social learning theory, as advocated by Albert Bandura and Richard Walters, as well as the introduction of computer-based models of thoughts and feelings. Concepts like encoding, decoding, and appraisal processes; belief systems and schemas; attribution biases; mental heuristics; and cognitive errors were coming to the fore. A “cognitive revolution” was taking place with the work of Daniel Kahneman and Amos Tversky, Richard Lazarus, and Irving Janis. These concepts found their clinical counterpart in the pioneering work of Albert Ellis, Aaron Beck, Arnold Lazarus, and Michael Mahoney. With this shifting zeitgeist from a behavioral to a cognitive perspective, Meichenbaum and his graduate students conducted a series of clinical studies extending the self-instructional training model to children and adults who evidenced impulsivity, poor emotional and behavioral self-regulation, metacognitive deficits, and anger control problems. He also developed Stress Inoculation Training, which included three phases: (1) educational, (2) skills acquisition, and (3) application training. Stress Inoculation Training was successfully applied to a host of clients who evidenced aggressive behavior, pain control, and anxiety disorders. This research was summarized in Meichenbaum’s seminal 1977 book Cognitive-Behavior Modification: An Integrative Approach. Soon thereafter followed several more books— Stress Inoculation Training, Stress Reduction, Pain

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and Behavior Medicine, Facilitating Treatment Adherence, and Nurturing Independent Learners. One of Meichenbaum’s contributions was to demonstrate that various forms of behavior therapy interventions could be made more effective and sustainable if they incorporated the client’s cognitive and affective processes. He also developed innovative cognitive-behavioral interventions that could be applied to a diverse group of clients. Yet another conceptual and clinical change was about to take place in Meichenbaum’s journey. He became more involved with clients who had experienced traumatic and victimizing experiences, including returning soldiers, victims of various forms of abuse, and natural disasters survivors. He was struck with the impressive and consistent findings that no matter which traumatic event one studied, in most instances, 75% of individuals are affected but go on to evidence resilience and, in some instances, posttraumatic growth. In contrast, 25% evidence posttraumatic stress disorder and related psychiatric conditions and adjustment difficulties. This clinical observation led to work on what distinguishes these two groups and the implications for ways to bolster resilience. His 2012 book Roadmap to Resilience summarizes this work. Meichenbaum became fascinated by the “stories” that individuals tell others as well as themselves that distinguish the 75% from the 25%. He has now come to embrace a cognitive narrative perspective and views the psychotherapist’s task as a way to help clients alter their “stories” and develop coping responses to accompany these reauthoring, restorying, resilient-enhancing activities. Meichenbaum now highlights the fact that human beings are not only Homo sapiens, but they are also “homo narrans,” or “storytellers,” and that the nature of the story that individuals tell themselves is the basis of behavior change. Thus, Meichenbaum’s journey has taken him from viewing cognitions and emotions as conditioned responses and as discriminative stimuli in an operant sense, to an information-processing perspective, to a narrative perspective with features of plots, characters, and themes. He has blended these three elements into an integrative psychotherapeutic approach. In 2006, Meichenbaum took early retirement from the University of Waterloo and, like many folks living in Canada, moved to Florida, where he

is presently research director of The Melissa Institute for Violence Prevention and the Treatment of Victims of Violence in Miami, Florida. The initial form of counseling/psychotherapy that Meichenbaum offered his fellow freshman engineering students is still evident, but now it occurs on a much larger scale. His contributions have been recognized by the Clinical Division of the American Psychological Association with a Lifetime Achievement Award. He has received other accolades from various psychological organizations. He has presented in all the 50 U.S. states, in all the provinces in Canada, and internationally. Donald Meichenbaum See also Bandura, Albert; Beck, Aaron T.; Behavior Therapies: Overview; Cognitive-Behavioral Therapies: Overview; Constructivist Therapies: Overview; Ellis, Albert; Lazarus, Arnold; Mahoney, Michael J.; Pavlov, Ivan; Skinner, B. F.

Further Readings Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York, NY: Plenum Press. Meichenbaum, D. (1985). Stress inoculation training. New York, NY: Pergamon Press. Meichenbaum, D. (1994). Treating individuals with PTSD. Clearwater, FL: Institute Press. Meichenbaum, D. (2002). Treating individuals with anger-control problems and aggressive behaviors. Clearwater, FL: Institute Press. Meichenbaum, D. (2012). Roadmap to resilience. Clearwater FL: Institute Press. Retrieved from www .roadmaptoresilience.org Meichenbaum, D., & Biemiller, A. (1998). Nurturing independent learners. Boston, MA: Brookline Books. Meichenbaum, D., & Jaremko, M. (1983). Stress reduction and prevention. New York, NY: Plenum Press. Meichenbaum, D., & Turk, D. (1987). Treatment nonadherence: A practitioner’s guidebook. New York, NY: Plenum Press. Turk, D., Meichenbaum, D., & Genest, M. (1983). Pain and behavior medicine. New York, NY: Guilford Press.

Website The Melissa Institute: www.melissainstitute.org

Mentalization-Based Treatment

MENTALIZATION-BASED TREATMENT Mentalization-based treatment (MBT) is an evidence-based, manualized form of psychodynamic psychotherapy. Mentalizing involves imaginatively observing and interpreting other people’s and one’s own state of mind. The capacity to mentalize is key to making sense of our own feelings and to relating to other people, particularly those who are closest to us. The development of a child’s ability to mentalize is influenced by the quality of early relationships with caregivers; the child’s acquisition of mentalizing skills can be undermined by emotional neglect, abuse, or highly insensitive parenting. MBT seeks to improve a patient’s ability to mentalize when the patient is in stressful interpersonal situations.

Historical Context The mentalization-based approach to treatment was developed in the context of working with patients with personality disorders and observing their temporary but frequent failures of interpersonal understanding (mentalizing), which led to overwhelming affect and strong emotional dysregulation. In the 1990s, Anthony Bateman and Peter Fonagy formulated MBT as a method for working with patients with borderline personality disorder (BPD) in a partial hospital setting. MBT is now applied to a variety of disorders in a range of settings: Clinical reports suggest that it may be helpful in work with a range of disorders, including eating disorders and antisocial personality disorders, and with children. In a randomized controlled trial of MBT for BPD in a partial hospital setting, significant positive changes in mood states and interpersonal functioning were associated with an 18-month treatment program. The benefits, relative to treatment as usual (TAU), were large (the number needed to treat was around two) and increased during the 18-month follow-up period. At the 8-year follow-up, the MBT group continued to show clinical and statistical superiority to the TAU group on suicidality, diagnostic status, service use, use of medication, global functioning, and vocational status, although their general social function remained impaired.

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Two well-controlled single-blind trials of outpatient MBT have been conducted with adults with BPD and self-harming adolescents. In both trials, MBT was superior to TAU in reducing self-harm, including suicidality, and depression.

Theoretical Underpinnings Interpersonal understanding and communication is now understood as a major, evolutionarily protected human capacity. Impairments in theory of mind (the ability to attribute mental states, e.g., thoughts, beliefs, and wishes to oneself and others and to understand that others’ mental states may differ from one’s own) have long been associated with pervasive developmental disorders such as autism, Asperger’s syndrome, and psychosis. Mentalization theory has enriched this understanding of the relationship between mental health and our ability to understand both our own and others’ behavior in terms of underlying mental states. In personality disorders, difficulties with mentalizing tend to occur when the attachment system (the behavioral system that serves to maintain or achieve closer proximity to the attachment figure when the individual feels threatened, thereby ensuring safety and security) is activated. Thus, at times when an individual feels threatened and in need of reassurance, the individual is particularly likely to find it difficult to think about what is going on both in the individual’s own mind and in others’ minds. This can cause significant distress and difficulties in functioning, particularly when it  comes to dealing with close relationships or challenging interpersonal experiences.

Major Concepts The concepts central to MBT are mentalization, attachment, and mentalizing failure. This section briefly discusses each of these concepts. Mentalization

Mentalization is the capacity to understand other people’s and one’s own behavior in terms of mental states. The acquisition of this capacity is influenced by the quality of early relationships with caregivers, including experience of trauma. It is vulnerable to disruption under interpersonal

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stress. Individuals with BPD are particularly likely to find it difficult to mentalize in the context of attachment relationships. However, the loss of mentalization is rarely total. Attachment

The capacity to mentalize has been linked with attachment security in childhood. Parents who are securely attached, in part by virtue of their mentalizing capacity, mentalize in their interactions with their infants, enabling their infants to become securely attached to them. Securely attached infants develop better mentalizing capacity in childhood. Neglect and trauma in attachment relationships (which often feature in the histories of patients with personality disorders) contribute to the disorganization of the attachment system and intergenerational transmission of impaired mentalizing capacities. Mentalizing Failure

Mentalization can be inhibited by intense emotional arousal, which often occurs in the context of attachment relationships. When this happens, individuals may fall back on primitive, prementalistic modes of thinking. These include psychic equivalence (in which mental events are considered to have the same status as physical reality), the pretend mode (when subjectivity becomes completely separated from reality), and teleological thinking (the assumption that emotional difficulties can be solved by action, e.g., that anger can be resolved by destruction of property or violence).

Techniques Psychotherapy traditionally uses patients’ capacity to consider their sense of their own mental state alongside the psychotherapist’s perception of it. Patients who struggle to understand behavior in terms of mental states in the context of attachment relationships are likely to struggle to benefit from such approaches. The MBT therapist does not assume that the patient has such social cognitive capacities. Thus, the MBT therapist’s task is not to tell patients how they feel, what they think, or how they should behave—or to explain to them the underlying conscious or unconscious reasons

for their difficulties. The theory holds that any therapeutic approach that moves toward claiming to know how patients are is likely to be harmful. Instead, the therapist adopts a “mentalizing stance”—that is, a stance of inquisitiveness, curiosity, open-mindedness, and, perhaps ironically, not knowing—focusing on the mind of the patient as the patient experiences himself or herself and others at any given moment. The patient is helped to learn more about how the patient thinks and feels about himself or herself and others and how that might trigger the patient’s reactions, and how difficulties in understanding himself or herself and others lead to impulsive actions (e.g., self-harm or violence). The therapist helps the patient recover the capacity to mentalize when it is temporarily lost, including the breaks in mentalizing that inevitably occur in the therapeutic relationship. When such failures (on the part of both the patient and the therapist) occur, the therapist must articulate what has happened to demonstrate that he or she is continually reflecting on what goes on in his or her mind and on what he or she does in relation to the patient.

Therapeutic Process The therapist seeks to model an attitude that is curious about mental states and respects their lack of clarity (the mentalizing stance). The task is to explore the different mental processes at work and accept that diverse outlooks may be acceptable. This requires that therapists acknowledge moments when they themselves fail to mentalize, which are treated as learning opportunities. Mentalizing in the therapeutic relationship has to be approached sensitively to avoid overactivating the attachment system, because if this occurs, it will reduce the patient’s fragile capacity to mentalize even further. Peter Fonagy and Elizabeth Allison See also Object Relations Theory

Further Readings Allen, J. G., & Fonagy, P. (2006). Handbook of mentalizationbased treatment. Chichester, England: Wiley. Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Arlington, VA: American Psychiatric.

Metaphors of Movement Therapy Bateman, A. W., & Fonagy, P. (Eds.). (2012). Handbook of mentalizing in mental health practice. Washington, DC: American Psychiatric.

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Metaphors of Movement (MoM) is an approach to therapeutic change that focuses on the exploration of metaphors expressed in a client’s communication, much of which is out of the client’s usual awareness. The client is asked to explore and discover more about these metaphors. If the client does not spontaneously offer a metaphor for the problem at hand, then the therapist will guide the client toward finding a metaphor to describe the client’s situation by asking the client to think about what the problem is like. Sessions can be up to 3 hours in duration, and the work is divided into three phases: (1) one-to-one work in therapist–client interaction, (2) self-exploration following the session, and (3)  discussion and follow-up with the therapist. MoM is particularly useful when applied to what are termed stuck states and in helping people move on from trauma. Whereas creating kinesthetic change is the focus of most therapy, MoM focuses on changes in clients’ coping behaviors as expressed in their metaphors.

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Influenced by the work of Charles Faulkner, MoM is much more active in guiding the client to develop his or her metaphor and ultimately confront and modify the behavior (or lack of it) that is revealed in the metaphor.

Theoretical Underpinnings Because metaphorical communication is highly organized and dense, a wealth of important information can be extrapolated from even a very simple metaphor. Metaphor is processed and expressed primarily by the nondominant hemisphere of the brain, which offers a unique window into nonverbal and mostly unconscious processes. MoM utilizes inductive and deductive logic and inference to expand, develop, and enrich the metaphoric experience for the client. This makes the information available to the dominant hemisphere, enabling a change of the coping strategy employed to cope with the problematic situation.

Major Concepts The major concepts of MoM include the MoM elaboration process, extrapolating from the metaphor to enrich it further, and identifying and challenging boundary violations. MoM Treatment Algorithm

Historical Context The use of metaphor as a medium for teaching and change in preliterate and literate cultures dates back several thousand years, long before the parables of the Bible. With the popularization of Milton Erickson’s hypnotherapy and metaphorical storytelling as therapy that came with the development of neuro-linguistic programming (NLP) in the early 1980s, increased attention was given to metaphor as a therapeutic medium. A logical next step was to elicit a client’s own metaphor and then to work within that metaphor to discover appropriate changes. One such model is that of “Clean Language” utilizing “Symbolic Modeling,” developed by James Lawley and Penny Tompkins. This is a method derived from David Grove’s work with posttraumatic stress disorder, in which a client discovers his or her own metaphor for the problem, with minimal intervention by the therapist.

The process of metaphor elicitation and development has seven distinct phases: (1) elicitation of the metaphorical representation, (2) simple exploration of the metaphoric representation, (3) eliciting the coping behavior represented in the metaphor, (4) viewing the application of the coping behavior within the metaphor, (5) exploration of alternative coping behaviors, (6) application and exploration of common idioms and phrases that match the metaphoric situation, and (7) evaluation of the client’s ability to utilize the new coping strategy. Extrapolating From the Metaphor

Using everyday expressions and idioms that fit the client’s metaphor, the therapist infers and demonstrates additional aspects of the client’s metaphorical experience. For instance, if a client says that he or she is “in the pit of despair,” the

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therapist may point out that the client is “in the dark,” “trapped,” “very low,” “not going anywhere in life,” and so on. Boundary Violation

A boundary violation is a highly specific, patterned, and predictable unconscious behavior in which the client jumps from the metaphor into a different category of experience. For example, the client may say that his “past” is outside the metaphoric pit of despair, thus jumping from the category of metaphor into the category of personal history. MoM assumes that a boundary violation is a naturally occurring behavior that serves to distract, keeping the obvious solution to the problem outside of conscious awareness. This is countered by insisting that the client stay within the metaphoric experience and learn more about it.

Techniques A number of techniques have emerged from the MoM model, including the application of the coping behavior to the metaphor and the challenging of boundary violations. Application of the Current Coping Behavior to the Metaphor

The practitioner challenges the problem metaphor by applying the coping behavior to the metaphor. For instance, for the client in the pit of despair who wants help to move forward, the therapist may offer, “Let’s say we are walking down an imaginary road, and we come across a poor fellow in a pit of despair. We could tell him, ‘It’s all right, just move forward.’ Would that be good advice?” Usually, the client can immediately see that the poor fellow will just stumble into the wall of the pit. Because the problem metaphor remains unchanged by the coping behavior, alternative behaviors can be explored. Challenging Boundary Violations and Disrapport

Boundary violations were observed after the original development of MoM, and it was noticed that challenging boundary violations produced the most benefit, even if this led to a loss of rapport between the client and the therapist. Disrapport is

the term that has been applied to the relationship that can emerge in MoM sessions where clients are free to experience a full range of emotions without being constrained by the parameters of the rapport with the therapist.

Therapeutic Process MoM sessions are typically 2 to 3 hours long, to explore the structure of most metaphors and to evoke a rich experience that the client can continue to process on his or her own after the session. MoM treatment can last a few sessions or continue over long periods of time depending on the client and the client’s situation. Andrew T. Austin See also Erickson, Milton H.; Neuro-Linguistic Programming

Further Readings Faulkner, C. (2005). Metaphors of identity: Operating metaphors and iconic change [Audio]. Lyons, CO: Genesis II. Lawley, J., & Tompkins, P. (2000). Metaphors in mind: Transformation through symbolic modeling. London, England: Developing Company Press.

METHOD

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LEVELS

The Method of Levels (MOL) is a transdiagnostic cognitive therapy that addresses the dilemmas, tensions, and conflicts underlying symptom patterns rather than focusing on the symptom patterns directly. With its unique theoretical framework, it has similarities with approaches such as motivational interviewing and provides a bridge between cognitive-behavioral therapy and person-centered counseling. MOL optimistically and respectfully provides the time and the focus for people to generate their own solutions to the difficulties they experience. It is very much an experiential therapy, in which a conversation is developed to first generate some of the distress the person experiences outside of therapy and then to facilitate the processing of this distress in such a way that new perspectives and insights are

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developed and the person is able to find a more contented and satisfying way to live.

Historical Context The impetus for MOL began in the 1950s when the perceptual control theorist William T. Powers explored the effects of engaging in conversations to become aware of background thoughts or metacognitions. Timothy A. Carey learned of Powers’s work and, between 2002 and 2007, with mentoring from Powers, developed MOL in the National Health Service in Scotland as a complete psychological therapy. He evaluated its impact and trained colleagues in its use. Warren Mansell, a clinical psychologist, researcher, and academic from the University of Manchester, learned about this approach and, along with his colleague Sara Tai, began conducting further research and teaching perceptual control theory (PCT) and MOL to their undergraduate and graduate students.

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two control systems specify simultaneous but incompatible experiences. Wanting to experience the progress of a stellar career and desiring the warmth and intimacy of close family relationships can, in some contexts, interfere with each other. As more career progression is sought, family closeness diminishes. When efforts are made to restore familial closeness, the career may suffer. This is an example of perceptual conflict. MOL has as its primary purpose the resolution of perceptual conflict. In PCT, Powers proposes a learning mechanism that is so fundamental that it, itself, does not have to be learned. Reorganization involves random changes and error reduction. When the system experiences chronic, intrinsic error, random changes are generated. If a change reduces error, then that change persists until error increases once again. If the change does not reduce error, then another random change occurs. Control, therefore, is the state of normal daily functioning; perceptual conflict disrupts this process, and reorganization restores it.

Theoretical Underpinnings PCT provides the theoretical underpinnings for MOL. PCT is an explanation for the way in which the phenomenon of control functions in living things. The formal definition of control is quite similar to the colloquial understanding of “making things be right.” A single cell, if it is to survive, must be able to act on its external environment to ensure that its internal environment is maintained in its “right” state. For people to live contentedly, they must have sufficient control to act on their environments to experience them as they intend. Powers articulates a control system as the basic unit of organization, and using this unit, he describes a hierarchy of control systems that control increasingly complex perceptions from intensities and sensations to programs and principles.

Major Concepts The major concepts in MOL are control, perceptual conflict, and reorganization. Control is a dynamic, seamless process that is essential to life. To live is to control. Control, then, provides a framework from which routine day-to-day functioning can be understood and also the way in which this functioning can be disrupted. The main psychological way control is disrupted is when

Techniques Attitudes and principles are emphasized in MOL over specific techniques. The primary resource for an MOL therapist is to adopt an attitudinal stance of nonassuming curiosity. At all times, the task is to help the distressed person explore his or her distress in such a way that the distressed person reorganizes the conflict satisfactorily. It is proposed that reorganization and awareness are linked such that those experiences that are in awareness indicate the control systems that will be reorganized. MOL, therefore, involves asking curious questions about whatever it is the person wants to speak about and then looking for clues as to where the next most useful place might be to direct the person’s attention. These clues come in the form of “disruptions,” which are brief changes in the person’s manner, behavior, or speech flow. The person might pause, look away, increase or decrease the volume of his or her voice, or speak faster or slower. The person might grin slightly, or the person’s eyes might mist with tears. All these changes are indicators that the person may have become briefly aware of something that he or she wasn’t thinking of before. The therapist, on noticing these disruptions, directs the person’s attention there.

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Therapeutic Process MOL is an iterative process of redirecting awareness to areas of experience that might, if reorganized, alter the nature of the conflict. There are two main goals in MOL: (1) ask about the current problem and (2) ask about disruptions. When an MOL therapist asks about a disruption, that becomes the new topic of conversation, and the process of asking about the current topic and then asking about disruptions begins again. Each MOL session is regarded as a discreet, problem-solving experience involving the redirecting of awareness to promote reorganization. In practice, systems are developed so that people are able to book appointments at their own initiation to self-regulate the timing of their therapeutic process. Timothy A. Carey See also Cognitive-Behavioral Therapy; Motivational Interviewing; Person-Centered Counseling

Further Readings Carey, T. A. (2006). The method of levels: How to do psychotherapy without getting in the way. Hayward, CA: Living Control Systems. Carey, T. A. (2008). Hold that thought! Two steps to effective counseling and psychotherapy with the method of levels. Chapel Hill, NC: Newview. Mansell, W., Carey, T. A., & Tai, S. J. (2012). A transdiagnostic approach to CBT using method of levels therapy: Distinctive features. London, England: Routledge.

MILAN SCHOOL OF SYSTEMIC FAMILY THERAPY See Systemic Family Therapy

sequence of achievements, Jean Baker Miller (1927–2006) may be remembered for the ways in which she related to the world. Her 1976 book Toward a New Psychology of Women was the foundation in which relational-cultural theory (RCT) was born and continues to be expanded today. Her life work exemplified her belief that each life is shaped, transformed, and ultimately defined by relationships. Her lived experience is a story of one growth-fostering relationship after another, each marking a milestone and creating the legacy of a woman whom many considered to be a key relationship in their own lives. Raised in poverty in the Bronx, New York, Miller suffered several hardships from polio to the Great Depression. In such difficult times, many families saw the rise of hardworking women, the power of their nurturance, and, consequently, a cultural push back against female empowerment. As a child, Miller’s polio resulted in frequent visits to the hospital, in which contact with two hardworking nurses positively changed Miller’s view of working women. Because of the inspiration and efforts from these two nurses and the tireless support of her own mother, Miller began realizing the power of supportive and fortifying relationships as a protection from trauma, illness, and hardship. She also began to wonder about the cultural paradox—the value of these strong women and the marginalization they experienced. This influenced her later position that such growth-fostering relationships are central to lifelong resilience and that the positive experiences in these relationships encouraged her to take risks and explore opportunities that she may not have considered possible. When she began to conceptualize these relationships within her work, she defined them as being characterized by at least “five good things”: 1. A sense of zest or energy for each of the people in the relationship 2. A sense of empowerment inspiring action on behalf of self and others

MILLER, JEAN BAKER There is irony in praising a woman who fostered a movement resistant to the glorification of individual achievement; yet there is ample reason for acknowledgment of her value and contribution to be shared. Rather than reducing her life to a

3. A growing or greater clarity or understanding of self, the others in the relationships, and relationships in general 4. A greater sense of worth for all those in the relationship 5. A growing desire for more connection.

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Her story is a story of relationship, opportunity, and the willingness to take risks. Miller earned admission to Hunter College High School in New York City, a school for girls with exceptional abilities. During that time, she experienced another growth-fostering relationship with a teacher who encouraged her to apply to Sarah Lawrence College in Bronxville, New York—something she believed to be out of reach for a girl of her means. After graduating from Sarah Lawrence College with a B.A. in personal communications, an experience rich with exposure to women who served as advisors, mentors, and examples to her, Miller continued her education. With the support and encouragement of her mentors, Miller received a full scholarship to Columbia University in New York City, earning a doctorate in psychiatry in 1952. During her time at Columbia, she developed a powerful commitment to social justice and became part of a student advocacy group focused on equity in health care and national health insurance. An interesting twist occurred when the dean of the medical school deemed participation in the student advocacy group to be risky and insisted that Miller drop out of the group or risk losing her scholarship. Faced with the decision, Miller’s commitment to social justice reigned, and she lost her scholarship. Despite this disillusioning experience, Miller once again rallied against injustice and completed her degree in 1952. A few years later, in 1955, she married Mike Miller, a sociologist and economist with whom she shared a passion for social justice. His family’s economic hardships inspired his political consciousness and work for social justice. Collectively, the couple worked to end the devaluing of women and marginalized groups, believing that the dominant groups in society legitimized unequal relationships. The couple had two children while embarking on a shared mission to end social injustice by creating a society that fostered the growth of all people. Their relationship served as an energizing force for both of them, but it also taught Miller about the overwhelming demands and complicated choices women had to make if they wanted both a career and a family. She described these as both forced choices and false choices that often devalued the relational work of women. Miller was first introduced to The Feminine Mystique by Betty Friedman in the early 1960s, sparking her interest in women’s psychology and

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shaping her goal of depathologizing women’s behavior and directly addressing the forces that devalued the role of women. Through involvement with women’s committees and private practice, Miller began to develop theories regarding women’s psychological and developmental strengths. Rather than regarding women’s relational behaviors as strengths, society views them as behaviors that are simply expected of women. Miller recognized this lack of respect for women’s strengths and began to give the world a rational view of women. Her 1976 book Toward a New Psychology of Women, in which she formally introduced RCT, was yet another example of risk taking that stemmed from the encouragement of a growthfostering relationship (with writer Anne Bernays) and Miller’s willingness to face her own selflimiting belief of not being capable of writing a book. Rather than emphasize independence and competition, Miller understood that growthfostering relationships, such as so many she herself experienced, encouraged people to take risks and explore opportunities. Miller expanded this theory through her work as a clinician and a scholar on both a therapeutic and a societal level. The theory reminds clinicians to work to build a better connection with the client rather than attempt to interpret or analyze what the client is saying. Because relationships are the central need in human life, RCT posits that all problems develop through relational disconnection within cultural contexts. Compared with traditional psychotherapy techniques, Miller believed that connecting with clients—and helping them foster more meaningful connections in their lives—was far more useful. In 1986, Miller began to direct the Elizabeth Stone Center for Developmental Services and Studies, a part of Wellesley College in Massachusetts that worked closely with Stone House, an alternative to hospitals, serving people who would have traditionally been sent to psychiatric wards. The center was also the institutional home for Miller and fellow psychologists to initiate and expand their collaborative theory-building group, focusing on a new model for women’s psychology. The group had a commitment to an evolving approach in theory building. Before relinquishing responsibilities as director of the center, Miller established the Colloquium Series. Ideas about women’s psychological experiences were regularly exchanged,

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attracting audiences of up to 800 people and resulting in the publication of several papers on theoretical issues. No longer being director of the center, Miller was able to focus on education and on formulating the RCT model. As part of the Stone Center, the Jean Baker Miller Training Institute was created to honor Miller and to train people in the relational-cultural approach in psychotherapy. The institute continues its work today by providing training and resources to clinicians, practitioners, scholars, activists, educators, health care providers, business professionals, leaders, and more. Miller died in 2006, but her vision of growing by supporting the growth of others continues to live on. Her message of hope inspires us to live a life in connection. Many of the published biographies of Miller have been written by those who shared in growth-fostering relationships with her and seem to honor the work of Miller as a legacy of connection. She has been consistently described as a woman whose life and work exemplified the power of hope through relationships. Deborah C. Sturm See also Cross-Cultural Counseling Theory; Feminist Therapy; Relational-Cultural Theory

Further Readings Hartling, L. M. (2008). Jean Baker Miller: Living in connection. Feminism & Psychology, 18, 326–335. doi:10.1177/0959353508092085 Miller, J. B. (1976). Toward a new psychology of women. Boston, MA: Beacon Press. National Library of Medicine. (n.d.). Changing the face of medicine: Dr. Jean Baker Miller. Retrieved from http://www.nlm.nih.gov/changingthefaceofmedicine/ physicians/biography_225.html Pearce, J. (2006, August 17). Jean Baker Miller, 78, Psychiatrist, is dead. The New York Times. Retrieved from http://www.nytimes.com/2006/08/08/us/08miller .html?_r=0 Walker, M., & Rosen, W. B. (2004). How connections heal: Stories from relational cultural therapy. Wellesley, MA: Guilford Press. Wellesley Centers for Women. (n.d.). Jean Baker Miller, M.D.: Noted feminist, psychoanalyst, social activist 1927–2006. Retrieved from http://www .wcwonline.org/Inactive-Researchers/jean-bakermiller-md

MILLER, WILLIAM R. William R. Miller (1947– ), along with Stephen Rollnick, founded the counseling approach known as motivational interviewing. Its development can be traced to Miller’s work in 1975 to 1976 at a summer internship in a Veterans Administration hospital, where he worked with patients suffering from alcoholism. Still interested in working with addiction, after graduating with his Ph.D. in clinical psychology from the University of Oregon in 1976, he accepted a faculty position at the University of New Mexico. In 1982, Miller spent 6  months on a sabbatical in Norway, where he worked with new psychologists, helping them develop therapeutic skills with difficult clients. Miller, who had been working from a modified client-centered perspective, found his supervisees to be engaged and interested in hearing more about his clinical approach. To clarify his own thinking about his approach and to help the young clinicians understand his clinical methods, Miller began to piece together some of his guiding clinical principles. He labeled his approach “motivational interviewing” and distributed what he had put together to his group. Notably, he found that when conducting an interview, he was helping the patients make their own argument for change. He had no intention of publishing these notes, but in response to a request from a friend, he developed an article manuscript, which was eventually published in the British journal Behavioural Psychotherapy. He acknowledges that he thought nothing more would come of it. Several years later, Steve Rollnick, a psychologist in Australia, read the publication, and after some years, when Miller visited Australia, the two met to talk about some of Miller’s ideas. Their discussion eventually led to the publication of Motivational Interviewing: Preparing People to Change in 1991. The first edition outlined the basic tenets of motivational interviewing, emphasizing the role of ambivalence in change and how to help clients make a commitment to change. It also outlined the active ingredients of effective counseling, which included feedback, responsibility, advice, menus, empathic listening, and self-efficacy. These ingredients combined with the five general principles of motivational interviewing (expressing empathy,

Miller, William R.

developing discrepancy, avoiding argumentation, rolling with resistance, and supporting selfefficacy), which constituted much of the early approach to motivational interviewing. Motivational interviewing could be characterized at this stage as a person-centered approach that emphasized avoiding generating client resistance while helping clients explore the discrepancy between their values and their behaviors. The first edition of Motivational Interviewing was oriented toward providing a model that could be used with addictive disorders. Given its focus on client ambivalence, working with client resistance, and developing a commitment to change in clients, it was a good fit for working with addicted clients. It also fit nicely with James Prochaska’s emerging Transtheoretical Model of behavior change and its emphasis on the different stages of motivation. Many of the motivational interviewing principles, such as developing discrepancy and rolling with resistance, appealed to counselors working with addicted clients in the early stages of change. Together, motivational interviewing and the transtheoretical model provided an intuitively appealing approach that was an alternative to the more confrontational models for working with addicted clients. In 1993, Miller was one of the project directors for Project Match, a clinical study on addiction treatment outcome, which at the time was the largest clinical trial ever conducted on therapeutic outcomes. Motivational enhancement, a variation of motivational interviewing, along with 12-step facilitation and cognitive-behavioral coping skills, was one of the three approaches selected for the research project. The research indicated that all three methods were effective in working with an addicted population. The visibility of Project Match and the popularity of the manuals used for the three treatment methods exposed motivational interviewing to many counselors who had not been exposed to it before. In 1992, the second edition of Motivational Interviewing was published. Although similar to the first edition, it focused less on addictive disorders and more on global behavior change. It also placed more emphasis on having clients make changes and on rejecting the righting reflex (trying to fix the problem for the client), developing discrepancy (helping clients see their mismatch

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between where they are and where they want to be), and the importance of change talk. In this edition, Miller and Rollnick defined motivational interviewing as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Another important addition was the concept of the motivational interviewing spirit, which included a belief in collaboration, evocation, and autonomy. It seemed clear in the second edition that Miller and Rollnick’s description of motivational interviewing was evolving from a prescriptive approach to a more conceptual one. Reflecting this more general use of motivational interviewing in the second edition, Miller and Rollnick moved away from chapters describing the types of specific motivational interviewing interventions and focused more on motivational interviewing applications in a variety of settings. Last, they added a review of research on motivational interviewing, providing evidence that motivational interviewing had superior effects compared with no-treatment control groups. By the time the second edition of Motivational Interviewing was published, motivational interviewing was considered a cutting-edge approach to working with individuals who had addiction problems. Its popularity also spread to substance abuse prevention, with motivational interviewing being identified by the National Institute of Alcohol Abuse and Alcoholism as a highly recommended, evidenced-based approach for dealing with college students having alcohol abuse problems. Motivational interviewing was also being used by counselors working with a variety of other healthrelated problems and by counselors in correctional settings. By 2002, in response to a growing need for training in motivational interviewing, Miller and his colleagues set up a program called Motivational Interviewing Network of Trainers, which prepared more than 300 trainers. Motivational interviewing attracted an international audience, resulting in the first edition of Motivational Interviewing being translated into Italian, German, Spanish, Portuguese, and Chinese. During the years between the second edition of Motivational Interviewing and the publication of the third edition in 2013, the influence of motivational interviewing continued to grow. In that time, the number of trainers in the Motivational Interviewing Network of Trainers expanded from

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300 in 2002 to more than 2,500 in 2013; 25,000 articles cited motivational interviewing, including 200 randomized clinical trials conducted on motivational interviewing; and motivational interviewing was being taught in 45 languages. Of all the counseling approaches to working with substance use disorders, motivational interviewing has arguably the highest level of research support for its efficacy. The use of motivational interviewing has also expanded to working with other issues, including applications in public health, patient compliance with medical treatment, and offender populations. In fact, motivational interviewing appears to be applicable to any population or issue where reluctance to change might be a concern. It could also be applicable to career counseling, school counseling, and a variety of mental health issues in addition to substance use disorders. Results from the 200 randomized clinical trials indicate that, as with research on many counseling approaches, the outcome of motivational interviewing studies was influenced by therapist characteristics more than the fidelity of the counselor to the motivational interviewing approach. In addition, Miller and Rollnick hypothesized that only a few motivational interviewing–inconsistent responses (e.g., confrontive or directive statements that could raise client defensiveness) may reduce the effect of using motivational interviewing, even when there are many more motivational interviewing–consistent responses. Last, they have found some strong indicators that the more a counselor can help a client generate talk about making changes (change talk), the more the client is likely to change. Although much has been learned, research on motivational interviewing continues to be refined, and there is still more to be discovered about this approach’s effectiveness. In response to research that supported the role of counselor characteristics in the effectiveness of motivational interviewing, Miller and Rollnick placed even greater emphasis on the spirit of motivational interviewing in the third edition of Motivational Interviewing. Miller and Rollnick define the spirit of motivational interviewing as being the mind-set and the “heart-set” of the approach and identify four key elements: (1) partnership, (2) acceptance, (3) compassion, and (4) evocation. Identifying and emphasizing the spirit of motivational interviewing has also helped

them respond to critics who have implied that the use of motivational interviewing approaches and strategies can be seen as manipulative. They emphasize that it should be practiced in such a way that it “is done for and with someone, not on or to them” (Miller & Rollnick, 2013, p. 24). For more than 30 years, Miller has strived to ensure that motivational interviewing has evolved in response to outcome research and to counselors’ experiences with this approach that began with a single modest article. His dedication to maintaining an open, scientific mind-set has contributed to an evidence-based counseling style that has been widely accepted as an effective way to work with the issue of substance abuse as well as other health-related and mental health–related issues. The intuitive appeal of motivational interviewing, the positive tone of the method, and its effectiveness in evoking motivation in resistant populations make it likely that motivational interviewing will continue to make an important contribution to the counseling profession for years to come. Charles F. Gressard See also Evidence-Based Psychotherapy; Palo Alto Group; Person-Centered Counseling; Rogers, Carl; SolutionFocused Brief Therapy; Transtheoretical Model

Further Readings Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2007). Motivational interviewing in the treatment of psychological problems. New York, NY: Guilford Press. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527–537. doi:10.1037/a0016830 Rollnick, S., Miller, W. R., & Butler, C. C. (2007). Motivational interviewing in health care: Helping patients change behavior. New York, NY: Guilford Press. Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. New York, NY: Guilford Press. Wagner, C. C., & Ingersoll, K. S. (2012). Motivational interviewing in groups. New York, NY: Guilford Press.

Mindfulness Techniques

MIND–BODY THERAPY See Psychosocial Genomics

MINDFULNESS TECHNIQUES Mindfulness techniques include a variety of activities designed to place counseling clients in full contact with their experiencing. Mindfulness itself has been described as a practice of offering one’s full mental and sensory attention to what is unfolding in the present moment both internally (i.e., emotional, cognitive, and physical sensations) as well as externally (i.e., relationally and in one’s physical environment). Additionally, this attention is placed within a basic attitude of nonjudgmental acceptance and compassion for self and others.

Historical Context Mindfulness and mindfulness techniques, as they are used in counseling practice today, were first described by the Buddha more than 2,500 years ago. Although Sigmund Freud was unimpressed with Buddhist psychology and meditation, later psychoanalysts, such as Karen Horney, were intrigued. For example, Horney communicated regularly with Zen master D. T. Suzuki Roshi, and both Carl Jung (in 1949) and Eric Fromm, along with Richard DeMartino (in 1960), coauthored books with Roshi. However, it was Mark Epstein’s groundbreaking 1995 book Thoughts Without a Thinker: Psychotherapy From a Buddhist Perspective that initiated real interest in Buddhist psychology among the more psychodynamically inclined practitioners. In 1979, the biologist Jon Kabat-Zinn developed a program for patients with chronic pain and other difficult to treat medical conditions called mindfulness-based stress reduction, which is now broadly used in hospitals and medical centers across the United States and Europe. Mindfulness-based stress reduction later became the foundation for mindfulness-based cognitive therapy, which in turn gave rise to a number of other mindfulness-based therapies, such as dialectical behavioral therapy, developed by Marsha Linehan, and acceptance and

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commitment therapy, developed by Kelly Wilson, Kirk Strosahl, and Steven Hayes. Mindfulness techniques have been used to treat depression, anxiety, borderline personality disorder, eating disorders, substance abuse, and posttraumatic stress disorder. They have been used with children, adolescents, adults, and the elderly; with individuals and couples, and in group counseling.

Theoretical Underpinnings Underlying the use of mindfulness and meditation in the therapeutic context is the assumption that pain is inevitable because every person will experience illness, loss, grief, and anxiety. However, those who make use of mindfulness techniques believe that the source of such suffering arises from an inability to accept things as they are or reject what is unwanted. Those who embrace mindfulness in their therapeutic work share the belief that suffering can be diminished by helping clients experience the world with less judgment and greater acceptance. Mindfulness activities in general, and meditation in particular, are viewed as tools for building skill in accepting experiences for what they are and reducing the tendency to prize some experiences and to devalue others. The use of mindfulness techniques can be considered to lie on a continuum from implicit to explicit. Implicit use of mindfulness techniques describes the process by which the therapist uses techniques to benefit the therapist’s own wellbeing and to enhance his or her own presence with clients. In contrast, explicit use of mindfulness describes a range of uses to address client difficulties, from teaching clients to make use of mindfulness techniques to implementing mindfulness and meditation within the therapeutic setting.

Major Concepts Underlying the practice of mindfulness are the foundational qualities of awareness, present-moment focus, and an accepting, nonjudgmental attitude, as well as the basic skills of noticing, labeling, leading with curiosity, and offering compassion. Foundational Qualities

Although mindfulness techniques are applied broadly and used for a wide range of difficulties,

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all mindfulness techniques or activities have some of the same foundational qualities: They feature full awareness or attentiveness and a presentmoment focus, and they offer a gentle and accepting (nonjudgmental) attitude that is applied to whatever is noticed or to whatever that emerges. The capacity to maintain focused attention on ever-shifting internal and external stimuli is known as bare attention. Basic Skills

The practice of mindfulness requires that the practitioner gain four basic skills: (1) noticing, (2) labeling, (3) leading with curiosity, and (4) offering compassion. To notice is to bring one’s attention to what is unfolding within the mind and body. These thoughts and sensations are observed both for how they are experienced and for how they change over time. Clients are invited to notice when the mind has begun to wander, at which point the client is asked to bring his or her thoughts back to the present. Importantly, clients are asked to notice and return their thoughts gently to a focal point while avoiding being harsh with themselves. Also important to all mindfulness techniques is the practice of labeling thoughts and sensations as they arise from moment to moment. For example, while sitting, a client may notice a sensation of discomfort in her knee, at which point she silently labels that sensation as “pain.” If the discomfort is followed by the intention to rub the knee, the intention is labeled “intending to rub my knee.” Finally, the motions of lifting her arm, placing her hand on her knee, and rubbing are all carefully observed and labeled: “lifting my arm,” “placing my hand,” and, finally, “rubbing my knee,” respectively. Labeling can also be extended to outside stimuli, such as “the phone ringing” or “a cricket chirping,” or to each step of everyday tasks, such as “placing toothpaste on the toothbrush.” The purpose of labeling thoughts, feelings, sensations, and movement is to remain in full contact with presentmoment experiencing while avoiding judgment of that experiencing. As an extension of a nonjudgmental attitude, mindfulness techniques also foster a general disposition of curiosity about what is happening in any given moment. Often referred to as beginner’s mind, clients are asked to engage mindfully by

approaching activities and people as if for the first time, leading with curiosity and avoiding judging sensations, thoughts, emotions, or situations as positive or negative, rational or irrational. Instead, clients are asked to simply accept that the feeling, thought, or sensation has arisen, that it will change and then will eventually pass. Finally, also in support of the nonjudgmental attitude, mindfulness necessitates an attitude of compassion directed at one’s self as well as toward others. This aspect of mindfulness has been particularly key to the application of mindfulness in Western psychology to address low self-esteem, which is often seen in clients in the West.

Techniques The application of mindfulness practice through mindfulness techniques can occur in a wide variety of activities ranging from seated meditation, to mindful eating, to walking and breathing. The following are some of the broadly used mindfulness techniques. Seated Meditation

Seated meditation practices are similar in that the participant is seated, either on the floor or in a chair, in such a way that careful attention is given to both posture and awareness. The gaze is generally focused about 5 feet in front of the participant, forward and down, and should be gentle and not strained. The back is straight, and the chin is tucked slightly, with the tongue resting lightly on the back of the front teeth. The jaw and shoulders are relaxed. Seated meditation may be placed in four primary categories: (1) concentration meditation, (2) guided meditation, (3) insight meditation, and (4) mindfulness meditation. In concentration meditation, a word, sound, mantra, or physical object becomes the focal point of attention. Practitioners often begin with these types of meditations to gain skill in focusing and maintaining attention. A guided meditation, on the other hand, is one in which the meditator follows the live or recorded voice of another person, focusing on the imagery that is described. This type of guided meditation frequently has a specific purpose in mind, such as anxiety reduction, and can readily be done within

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group or individual counseling settings, or clients can do guided meditations at home with recordings. Insight meditation is undertaken to glimpse into the nature of the mind itself. Finally, mindfulness meditation is one in which the client is encouraged to notice the fullness of his or her experiences as he or she sits. All thoughts, feelings, and sensations are noted, but none are given preference or judged negatively. As thoughts wander, the practitioner gently notices and returns attention to present-moment experiencing.

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done while lying down, clients are directed to focus concentration first on the top of the head and then move downward over the face, neck, and arms and eventually to the feet. Body scans can range from a few moments to 45 minutes and may be self-guided or guided by a live or taped voice. Yoga

Perhaps the most commonly used mindfulness technique is the use of the breath as a focal point of mindfulness or meditation. In this technique, the client is asked to focus on the breath, though the directions for this attention may differ. For example, clients may be asked to focus on the sensation of the exhale only or on both the inhale and the exhale.

The practice of yoga has also been used by a number of mindfulness-based and mindfulnessinfluenced therapies. Yoga comprises a number of physical postures. Clients are invited to give focused attention to each posture and to the sensations and limitations within the body as each posture is executed. Clients’ movements are slow and careful, allowing the client to note shifts in their capacity for stretching and holding postures over time. Yoga is incorporated into mindfulness techniques to both enhance body awareness as well as encourage a nonjudgmental acceptance of the body as it is.

Mindful Eating

Walking Meditation

In this activity, clients are asked to examine their food fully and deeply, first by looking carefully at the color and texture of the food and then by noticing the aroma of the food and any nuances. Clients are then asked to slowly place some of the food in their mouths, putting down their spoon or fork between bites. Clients are asked to feel the food in their mouths, notice the sensation of the texture, the temperature, and the flavors. Any nuances or changes in the food while chewing are noted but not judged. Often clients are asked to consider the origins of the food, including the sun, soil, and rain as well as the human beings who helped nurture, cultivate, and prepare the food before the participant began eating. Careful attention is given to feelings of fullness as well as to any urges to continue to eat even after feeling full.

Walking meditation is similar to a seated meditation except that the focus of the mind is shifted from the breath and passing thoughts and emotion to the sensations in the feet, legs, and ankles. Although there are a number of variations of walking meditation, it begins by placing one’s hands behind one’s back and setting one’s gaze forward and down. Walking meditations are generally done at a slow and contemplative pace but can be done at a more moderate or even fast pace to fit the needs of the client. Each step is taken with careful attention to the sensations in the bottom of the foot and the shift from the rear of the foot to the front.

Mindful Breathing

Body Scans

Many authors note that it is possible to go through an entire day without giving any thought or awareness to the physicality of the body; thus, body scans are designed to bring the participant in contact with the experience of the body. Frequently

Therapeutic Process Many therapists are now teaching mindfulness within individual or group therapy sessions. Time in individual sessions may be set aside both at the opening of the session and at the close of the session to first bring presence to the session and finally to help clients carry over what was learned in the session into day-to-day living. Group therapy may also begin or end with mindfulness techniques led by the group leader.

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The essential therapeutic process of mindfulness techniques, whatever form they may take, is that the client first learns to be present, avoiding the tendency to get lost in the past or to worry about the future. The second step in the therapeutic process is that clients are able to notice their thoughts and feelings with compassion while avoiding harsh self-judgments. Often this translates to less judgment of others and of circumstances. Finally, clients begin to develop greater flexibility in how they respond to difficult situations because they have developed skill in pausing and noticing thoughts and feelings before acting on them. Cherée F. Hammond See also Acceptance and Commitment Group Therapy; Acceptance and Commitment Therapy; Contemplative Psychotherapy; Dialectical Behavior Therapy; Meditation; Mindfulness-Based Cognitive Therapy; Mindfulness-Based Stress Reduction

Further Readings Baer, R. (2011). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications. Boston, MA: Academic Press. Epstein, M. (1995). Thoughts without a thinker: Psychotherapy from a Buddhist perspective. New York, NY: Basic Books. Fromm, E., Suzuki, D. T., & De Martino, R. (1960). Zen Buddhism and psychoanalysis. New York, NY: Harper & Row. Germer, C. K., Siegel, R. D., & Fulton, P. (2012). Mindfulness and psychotherapy. New York, NY: Guilford Press. Linehan, M. (1993). Cognitive behavioral therapy for borderline personality disorder. New York, NY: Guilford Press. Molino, A. (Ed.). (1998). The couch and the tree. New York, NY: North Point Press.

MINDFULNESS-BASED COGNITIVE THERAPY Adapted from Jon Kabat-Zinn’s mindfulness-based stress reduction, mindfulness-based cognitive therapy (MBCT) was initially developed in the 1990s to assist clients who were experiencing multiple

depressive relapse. Since that time, it has been adapted to meet the needs of those experiencing anxiety, bipolar disorder, and some psychotic disorders. MBCT focuses on assisting clients in noticing the transient nature of thoughts and feelings and in being able to tolerate thoughts and feelings as they arise.

Historical Context Zindel Segal, Mark Williams, and John Teasdale adapted mindfulness-based stress reduction after finding that it had success with depressed clients. MBCT draws heavily from Buddhist principles of mindfulness, as does mindfulness-based stress reduction, and from Aaron Beck’s cognitive therapy and group therapy principles.

Theoretical Underpinnings MBCT blends two primary theories: (1) cognitive therapy and (2) mindfulness-based stress reduction. Both mindfulness-based stress reduction and MBCT draw on the Buddhist philosophy of suffering (dukkha). This notion stresses that suffering is a natural part of life but that the tendency to wish for things to be different from how they are or attempts to avoid inevitable difficulties amplify suffering. Like cognitive therapy, MBCT attempts to identify thoughts that result in disturbing feelings and dysfunctional behaviors. However, unlike cognitive therapy, MBCT is not concerned with identifying distorted thoughts and then changing those thoughts. Instead, MBCT focuses on assisting clients in noticing distressing thoughts and the transient nature of those thoughts and feelings and, ultimately, being able to tolerate thoughts and feelings as they arise. Counselors who make use of MBCT assert that sad feelings are a natural and inevitable part of human life. However, for people who have experienced more than one major depressive episode, two primary processes are believed to contribute to depression relapse. First, they have developed habits in which inevitable sad feelings are associated with depressive content. Second, they tend to ruminate on that content with regret about the past or worry about the future. Skills taught through MBCT are designed to help clients notice and interrupt the process of evaluating thoughts,

Mindfulness-Based Cognitive Therapy

feelings, and experiences as “good” or “bad.” Clients are then encouraged to notice how those thoughts and feelings arise and pass away on their own.

Major Concepts Some concepts that are essential to MBCT include inviting the difficulties in, awareness of “autopilot,” kindness and self-compassion, and gathering the scattered mind. Inviting the Difficulties In

In MBCT, clients are encouraged to intentionally call to mind their difficulties and to notice where in the body these difficulties are felt. As temptations to ignore or push away these feelings emerge, these temptations are noted and allowed to pass. Clients are asked to be open and inviting to whatever painful feelings begin to emerge while maintaining an awareness of the breath. Awareness of Autopilot

Clients are taught to notice the ways in which they respond automatically to events, thoughts, and feelings (“autopilot”) and how frequently they act without awareness.

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Techniques Many of the same mindfulness activities are shared with mindfulness-based stress reduction, including the raisin exercise, in which a raisin is eaten slowly and mindfully, noting its color, texture, shape, aroma, and flavor. Body scans, yoga, daily mindfulness activities, and a commitment to 45 minutes per day of formal meditation and 15 minutes per day of mindful activities of daily living are all central to both MBCT and mindfulness-based stress reduction. In addition, several mindfulness techniques and activities have been developed specifically for MBCT, including the 3-minute breathing space activity, the pleasant experiences calendar, the unpleasant experiences calendar, and homework. Three-Minute Breathing Space

The 3-minute breathing space activity is a threestep mini-meditation used as a first mode of responding in challenging situations. In the first step, participants are asked to bring awareness to the current experience. The second step is to bring the focus of attention onto the breath and its effect on some aspect of the body. Finally, in Step 3, the client is asked to expand attention to the body as a whole while maintaining a sense of the breath. Pleasant Experiences Calendar

Kindness and Self-Compassion

Mindfulness is believed to include not only moment-to-moment awareness but also the presence of compassion that is offered to self and others. Consequently, clients are taught to engage in practices that cultivate self-compassion, and counselors are encouraged to create an environment of compassion within the sessions. Gathering the Scattered Mind

MBCT educates clients about the tendencies of the mind to try to figure out ways to reduce symptoms of anxiety or depression and how these tendencies actually work to increase those symptoms, often by triggering rumination and feelings of aversion toward symptoms. Clients are taught to anchor thoughts with focus on the breath while allowing feelings to unfold as they are.

The pleasant experiences calendar is an activity in which clients are asked to log at least one pleasant event daily. The purpose is to draw attention to pleasant events that might otherwise be missed and to help develop skill in noticing moment-tomoment experiencing. Unpleasant Events Calendar

Like the pleasant experiences calendar, clients are asked to log daily events that are experienced as unpleasant, giving careful attention to thoughts, feelings, and bodily sensations. Homework

MBCT makes extensive use of homework, including a required 45 minutes per day of seated meditation, 15 minutes per day of mindfulness

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activities, such as mindful dishwashing, and journaling activities, such as the pleasant experiences calendar.

Therapeutic Process MBCT is a structured group program of eight, 2-hour weekly sessions. Clients who seem to benefit most from MBCT are those who have experienced three or more depressive relapses but are not currently experiencing significant symptoms of depression. The process begins with a preclass participant interview. In this initial interview, the counselor explores with the potential client the client’s hopes for the class and willingness to complete the assigned homework. The counselor describes the process of recurrent depression and how MBCT can help. The essential structure of each session is similar in that sessions are opened with a mindfulness activity and each session includes sitting meditation, generally lengthening the sitting from one session to the next. Each session also allows time for clients to process their progress on homework assignments, including the challenges and successes that were experienced. Cherée F. Hammond See also Cognitive-Behavioral Therapies: Overview; Dialectical Behavior Therapy; Mindfulness Techniques; Mindfulness-Based Stress Reduction

Further Readings Barnhofer, T., & Crane, C. (2009). Mindfulness-based cognitive therapy for depression and suicidality. In F. Didonna & J. Kabat-Zinn (Eds.), Clinical handbook of mindfulness (pp. 221–244). New York, NY: Springer. Fjorback, L. O., Arendt, M., Ornbol, E., Fink, P., & Walach, H. (2011). Mindfulness-based stress reduction and mindfulness-based cognitive therapy: A systemic review of randomized controlled trials. Acta Psychiartrica Scandinavica, 124, 102–119. doi:10.1111/j.1600-0447.2011.01704.x Segal, Z., Williams, M. G., & Teasdale, J. D. (2012). Mindfulness-based cognitive therapy for depression (2nd ed.). New York, NY: Guilford Press. Williams, M., Teasdale, J., Segal, Z., & Kabat-Zinn, J. (2007). The mindful way through depression: Freeing yourself from chronic unhappiness. New York, NY: Guilford Press.

MINDFULNESS-BASED STRESS REDUCTION Based in Buddhist philosophy, mindfulness-based stress reduction (MBSR) is an 8-week structured group program that was developed for medical patients with chronic pain, cancer, and other physical difficulties to treat their physical health concerns. Since that time, MBSR has been used to treat anxiety and depression as well as other mental health symptoms and continues to be offered to individuals with chronic pain and other physical and mental health issues.

Historical Context MBSR arises out of Buddhist philosophy, particularly the Buddhist practices of meditation and mindfulness. Mindfulness is defined as the ongoing cultivation of a nonjudgmental awareness and acceptance of the present moment. MBSR was developed by Jon Kabat-Zinn, at the University of Massachusetts, in 1979 and became widely popularized by his book Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness, written in 1990.

Theoretical Underpinnings Buddhist philosophy, and the Four Noble Truths in particular, provide the theoretical foundation for MBSR. The first of these truths is that duhkha, or “suffering” (e.g., pain, illness, and aging), is inevitable. However, the second Noble Truth states that the true roots of human suffering arises from the wish that things be different from the way they are, from deep regret about how they have been, or from fear about the future, also described as desire or craving. The third Noble Truth sheds light on how people can reduce their suffering by accepting things as they are and by letting go of the need to change things or to cling to things. The fourth Noble Truth describes an ethical path of behavior that will help reduce suffering and bring liberation, The Eightfold Path. Borrowing from the third Noble Truth, learning to accept things as they are with friendliness and curiosity rather than judgment and resistance,

Mindfulness-Based Stress Reduction

MBSR instructors teach participants to notice what is unfolding within and around them and to pause before responding. Through mindfulness and meditation practice, participants reduce automatic responding and become more flexible in difficult situations. In practice, this may include approaching pain with curiosity by offering the following questions: What is the feeling tone of this pain? Where is the pain most dense? As it radiates out, what is the periphery of this pain? Where does it end? What is its texture? How does it change?

Major Concepts Some of the major concepts of MBSR include the breath as an ally, relationship with symptoms, and mindfulness of daily life. The Breath as an Ally

A central theme in MBSR is that through rigorous practice of formal and informal mindfulness and meditation, the breath can be used as a focal point and source of clarity and calm even in the most difficult situations and with the most painful of physical symptoms. Relationship With Symptoms

The MBSR program is less interested in progress or results, such as the reduction or elimination of symptoms, and more interested in shifts in the relationship with those symptoms. The goal is for the client or patient to become less rejecting toward the symptoms and more accepting of and flexible with the arising and diminishing of symptoms. Mindfulness of Daily Life

Participants are asked to bring present-moment awareness to daily activities such as taking out the garbage, washing dishes, raking leaves, and brushing one’s teeth. Careful present-moment awareness is given to each aspect of the activity while noting tendencies to prefer some experiences over others. Participants are encouraged to return to the breath during everyday activities and interactions.

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Techniques Some techniques often used in MBSR are the body scan, practicing formal meditation, practicing walking meditation, the raisin exercise, yoga, and homework. Body Scan

The body scan is an activity in which participants focus on the sensations of the body, beginning at the top of the head and moving down to the toes. The body scan is often practiced in a reclined position but may be done while seated and may be self-guided or guided by a live or recorded voice. Formal Meditation

Formal seated meditation is taught and practiced within the weekly group sessions. Seated meditation can be done in a chair, to accommodate physical limitations, or on the floor on a meditation cushion. Meditations may be guided or have a focal point, such as the breath. Walking Meditation

Walking meditation is a practice of focused attunement to the sensations of the feet, ankles, and legs while walking. This practice can be undertaken as a formal practice or while moving from one activity of daily living to another and can be adjusted in pace to fit the needs of the participant. The Raisin Exercise

The raisin exercise is a signature MBSR activity in which participants are asked to eat a raisin mindfully, noticing its shape, texture, and aroma as well as its flavor and texture in the mouth. Yoga

Yoga is used to cultivate body awareness by focusing attention on bodily sensations as the participant moves slowly and mindfully from one posture to another. Careful attention is given to honoring physical limits. Clients are discouraged from striving to execute yoga poses that are more

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difficult than the client can safely or comfortably execute. Striving to do poses that are unsafe or uncomfortable can happen when a client has not fully accepted his or her level of physical fitness or flexibility or when he or she wishes them to be different from what they are.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York, NY: Dell. Santorelli, S. (2000). Heal thyself: Lessons on mindfulness in medicine. Boston, MA: Harmony. Stahl, R., & Goldstein, E. (2010). A mindfulness-based stress reduction workbook. New York, NY: New Harbinger.

Homework

All participants in the 8-week program are required to commit to 45 minutes per day of seated meditation. This meditation is sometimes done to recordings made by the MBSR instructor or may be done independently. Additionally, participants are asked to engage in a minimum of 15  minutes per day of mindful activity in their day-to-day lives.

Therapeutic Process This training program provides eight, 2.5- to 3-hour weekly sessions as well as an all-day intensive retreat offered in Week 6. The session is generally provided in a silent retreat format. Furthermore, extensive homework is required of all participants. Class sessions begin with education on mindfulness and meditation, the rationale for the methods being used, advice on meditation at home, and opportunities for questions and answers. The classes in Weeks 5 through 8 are experiential in nature and offer opportunities for a wide range of meditation exercises and for participants to ask questions. The program is generally followed by a final interview, the purpose of which is to debrief the client, to reinforce learning, and, occasionally, to collect data for research purposes. Cherée F. Hammond See also Cognitive-Behavioral Therapies: Overview; Dialectical Behavior Therapy; Mindfulness Techniques; Mindfulness-Based Cognitive Therapy

Further Readings Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits a meta-analysis. Journal of Psychosomatic Research, 57, 35–43. doi:10.1016/S00223999(03)00573-7

MINUCHIN, SALVADOR The life of Salvador Minuchin (1921– ) offers a good example of the influence of family and social context in shaping individual identity—a central tenet of his Structural Family Therapy model. He was born in Argentina on October 13, 1921, the first of three children, to a strict and fair father, who owned a small business, a protective mother, who ran the household, and a large extended family ensconced within a closely knit community of immigrant Russian Jews, which represented one quarter of the population of a small rural town. Within this multilayered context, the young Minuchin grew up as an Argentinean Jew, not only embracing the Hispanic code of honor but also relying on his family and community for protection from the anti-Semitic undertones of the host culture—a complex experience that sensitized him to the workings of families and larger systems and to the need for interdependence, mutual loyalty, and social justice. He also experienced the impact of socioeconomic changes on family life. When his father lost his business as a result of the Great Depression and temporarily became an arriero, herding horses across the plains, 9-year-old Salvador contributed to the family’s subsistence by helping his mother sell produce. Later, when the family business was rebuilt under the leadership of an uncle, the hierarchical arrangement of the household shifted, as symbolized by the uncle sitting at the head of the table during his visits. Throughout the family’s financial ups and downs, Minuchin’s parents kept their commitment to the education of their children, and after finishing high school in 1940, their firstborn entered the school of medicine. He was in his fourth year at the Universidad Nacional de Córdobawhen when a right-wing military coup deposed the elected government and

Minuchin, Salvador

advanced over all aspects of the country’s life, including education. The universities, which for the previous quarter of the century had been run by an elected body including representatives of professors, students, and alumni, were placed under the control of the state. An active participant in the student resistance, Minuchin spent 3 months in jail, his first encounter with institutionalized authority. Expelled from the university and later readmitted, he graduated in 1946 and prepared to practice as a pediatrician. However, that same year, Juan Perón, a member of the military junta, was elected president, and the political climate once again became inhospitable to the young professional. Meanwhile, events far away beckoned: The state of Israel was created and soon found itself at war with its neighbors. In 1948, Minuchin left Argentina to join the Israeli army as a physician. After the war, Minuchin traveled to New York to train as a child psychiatrist. There he worked with psychotic children at a hospital and in institutional housing. He met and married Patricia Pittluck, a developmental psychologist, who in addition to having her own academic career provided an invaluable sounding board for her husband’s ideas. Back in Israel in 1951, Minuchin codirected five residential institutions for disturbed children, most of them Holocaust orphans and émigrés from Asia and the Middle East. The experience sharpened his understanding of cultural diversity and impressed on him the value of working therapeutically with groups rather than individuals. Although the move to Israel was intended to be permanent, within 3 years, the Minuchins, now new parents, returned to the United States. Attracted to Harry Stack Sullivan’s interpersonal psychiatry, Minuchin joined the William Alanson White Institute to train as a psychoanalyst. But in 1957, he became the intake psychiatrist at the Wiltwyck School for Boys, a residential school for troubled youngsters, where he soon found out that longterm, interpretive techniques delivered in a protected environment did not help action-oriented youths from the poor neighborhoods of New York City. With a small group of colleagues—Dick Auerswald, Charles King, Braulio Montalvo, and Diana Rabinowitz—and a minimum of theory, Minuchin undertook to work with the young clients in the context of their families. The team installed a one-way mirror, took turns learning from one another how to interview families, and over the

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course of 8 years developed a theory of family functioning in underprivileged families and devised action-oriented techniques to help that population. Families of the Slums (1967) recounts the Wiltwyck experience and outlines the basic principles of what eventually became known as Structural Family Therapy: Faulty family organization supports symptomatic behaviors, and the purpose of therapy is to disrupt dysfunctional family patterns and nurture healthier ones. Minuchin’s reputation as a clinician grew, and in 1965, he was appointed director of the Philadelphia Child Guidance Clinic, affiliated with the Children’s Hospital of Philadelphia and the University of Pennsylvania. Despite the opposition of the local psychiatric establishment, Minuchin developed the clinic from a staff of fewer than a dozen into one of the largest and most respected family therapy training centers in the world. Noting that the clinic’s clients were mostly African American or Latino while the staff was primarily White, Minuchin recruited minority professionals, but even more significantly, he obtained a grant from the National Institute of Mental Health to train paraprofessional community leaders as therapists. Together with Braulio Montalvo and Jay Haley, whom he brought to Philadelphia, Minuchin created a training program based on live supervision of all sessions, a method that helped the community workers transform their spontaneous responses to clients into therapeutic interventions. The same inductive approach to training was utilized to shift the thinking and practice of the clinic’s professionals from an individual to a family systems framework. In 1975, 1 year after the publication of his book Families and Family Therapy, Minuchin stepped down as director and dedicated the next 8 years to teaching his model through the clinic’s Family Therapy Training Center. The center’s in-house training programs and Minuchin’s own national and international presentations attracted hundreds of practitioners eager to learn “the steps of the dance,” captured by Minuchin and his disciple Charles Fishman in Family Therapy Techniques, and by the early 1980s, Structural Family Therapy was the most influential and widely practiced school of family therapy. The clinic’s affiliation with the Children’s Hospital of Philadelphia also made it possible for Minuchin to study and treat the families of

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children with asthma, diabetes, and anorexia. Research conducted at the hospital showed that maladaptive family patterns were partly to blame for the course of the illness and that family therapy helped the patients improve. Psychosomatic Families, written with the pediatrician Lester Baker and the researcher Bernice Rosman, discusses the findings of this research and illustrates its therapeutic application with abundant clinical material. After Minuchin left Philadelphia in 1983, he spent 1 year consulting in England, and on his return to the United States, he founded his own center in New York, from where he continued teaching and writing on families and family therapy. In Family Kaleidoscope, he analyzed the dynamics of violence and healing in clinical and legal cases, both contemporary and historical. Family Healing, coauthored with Michael Nichols, blends vignettes from Minuchin’s personal history with clinical cases to illustrate his understanding and treatment of families throughout various phases of family development. Institutionalizing Madness, with Joel Elizur, argues for a family focus to counter the often dehumanizing nature of mental health service delivery. In Mastering Family Therapy, with his disciples WaiYung Lee and George Simon, Minuchin presents a model of supervision and training intent on expanding and diversifying therapists’ use of themselves as instruments of change. The return to New York, where Minuchin’s career had started in institutional settings for marginalized children, also renewed his commitment to searching for ways to alleviate the plight of poor urban families caught in the net of well-intended but unwittingly disempowering services. With the help of grants and a small group of collaborators, Minuchin led multiyear projects to introduce family-friendly approaches in child welfare and substance abuse programs. In 1996, when Salvador Minuchin turned 75, he and his wife, Patricia, left New York for Boston, where their children and granddaughter lived. There, through a contract with the Massachusetts Department of Mental Health, Minuchin offered live supervision and consultation to therapists who provided home-based treatment to children and their families. Both this work and the efforts at system change pioneered earlier in New York are featured in Working With Families of the Poor, which Minuchin coauthored with Patricia Minuchin and Jorge Colapinto.

Another move, this time to Florida in 2004, slowed down but did not end Minuchin’s contributions to the field of family therapy. He continued teaching and coauthored two more books: Assessing Families and Couples, with Michael Nichols and Wai-Yung Lee, and The Craft of Family Therapy, with Michael Reiter and Charmaine Borda. In the latter, published in 2013, Minuchin decries the current emphasis on theory in the training of family therapists and advocates for the inductive, experiential approach that he utilized in an informal practicum for graduate students conducted at his Florida home. His 92nd birthday found Salvador Minuchin still invested in the future of family therapy and faithful to the pedagogical principle, first embraced more than 50 years ago at Wiltwyck, that the best learning comes from doing. Jorge Colapinto See also Haley, Jay; Strategic Family Therapy; Structural Family Therapy; Sullivan, Harry Stack

Further Readings Minuchin, P., Colapinto, J., & Minuchin, S. (1998). Working with families of the poor. New York, NY: Guilford Press. Minuchin, S. (1974). Families & family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S., Montalvo, B., Guerney, B. G., Rosman, B. L., & Schumer, F. (1967). Families of the slums. New York, NY: Basic Books. Minuchin, S., & Nichols, M. P. (1993). Family healing: Tales of hope and renewal from family therapy. New York, NY: Free Press. Minuchin, S., Reiter, M., & Borda, C. (2013). The craft of family therapy: Challenging certainties. New York, NY: Routledge.

MODERN ANALYTIC GROUP THERAPY Modern psychoanalysis was developed by Hyman Spotnitz, M.D., and it is highly effective in the treatment of character problems that have their origins in the early, preverbal period of human development. A distinguishing aspect of the modern psychoanalysis method is the use of individual and

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group treatment in combination. Typically, a patient participates in a weekly group as well as individual therapy. This makes for a powerful therapeutic intervention because the report of interpersonal issues in an individual can be brought to life in the group experience.

Historical Context Modern group analysis is an outgrowth of the pioneering work of Spotnitz, who developed the principles of modern psychoanalysis in the 1950s. Spotnitz’s work centered on creating a new psychotherapeutic method for the treatment of pre-oedipal disorders— character problems like depression, which has its roots in the first days, weeks, and months of life, before children have language. Standard treatments at the time used language and interpretation to address events that shaped the character development of patients before they had language to describe what affected them in their development. Unlike his classically trained analytic peers, who employed an emotionally remote stance in relation to patients, Spotnitz advocated the use of emotions induced in the therapist as a guide for responding to patients. What was a unidirectional relationship became a cocreated experience with Spotnitz’s innovations. Spotnitz highlighted the power of group as a therapeutic method. Until then, group was seen as a tool for socializing patients and, at best, a poor cousin to individual treatment. One of Spotnitz’s students, Louis R. Ormont, expanded the theory and practice of modern analytic group treatment by placing emphasis on the group’s curative effect. Ormont emphasized the healing power of relationships. In group, these relationships develop member to member and member to leader.

Therapeutic Underpinnings The premise behind modern analytic group therapy is to encourage the group to establish a safe environment in which the participants can take emotional chances. In this process, the therapist wants to see how relationships get formed and maintained. As the group continues, it is expected that some group members will resist the group rules and group process. It is through the analysis of resistance that the leader and the members get to know the struggles of each member, as resistance is a window into how

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the group member relates to the world around him or her. For example, if someone repeatedly arrives late for group, the therapist may ask about the lateness. If he or she replies from a reality perspective and says, “The train was late,” the therapist may ask, “Was there an emotional reason why you arrived late?” It is through this process of investigation that the group members begin to identify with one another, and their understanding of unconscious motivation deepens. The leader encourages the development of a culture of curiosity and interest that slowly gets established. The group members come to realize that while the story of their lives outside the circle has meaning, the more important stories are the ones unfolding in the room. The members engage in an ongoing study of each individual’s character in the service of helping participants achieve the goals they’ve identified for themselves. Attachments form, emotions can run high, and relationships in the group become increasingly important. This allows one to experience issues in real time, unlike individual work, where the patient reports on his or her difficulties. For most adults, there is some aspect of intimate life that is difficult to tolerate. Participants arrive in group with functional and dysfunctional methods of relating that are learned in their formative years. For example, patients often describe an unwillingness to deal with conflict and the feelings associated with such conflict, like frustration and anger. By encouraging the expression of feeling and the building of relationships, and through analysis of resistances and transference, patients can begin to understand how their early issues affect daily life.

Major Concepts Based on some traditional psychoanalytical techniques as well as some modern contemporary psychodynamic approaches, the major concepts of modern analytic group therapy include transference and countertransference, search for understanding and authenticity, self-feelings versus object feelings, feelings versus states of mind, and resistance. Transference and Countertransference

The emotional attitudes that a patient acquired early in life are directed at the therapist (the transference) and may elicit a counterreaction

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(countertransference) in the therapist. Transference is the key to understanding what the patient missed out on in his or her maturation and what is needed in the therapy for the patient to become a better integrated person. Countertransference feelings can be used to craft therapeutic responses that employ the therapist’s emotions in relation to the patient’s needs.

resist treatment. This can occur in myriad ways, such as coming late to group, being hostile in group, withdrawing in group, or rejecting suggestions by the therapist or the other group members. One role of the therapist is to understand these resistances and, in a timely fashion, explain them to the patient so that he or she can move beyond them and begin to work on underlying issues.

Search for Understanding and Authenticity

A well-functioning group engages all of the group members in the search for understanding and authenticity. The struggles and triumphs of life get lived openly through the group process, and everyone benefits from the exposure. Self-Feelings Versus Object Feelings

Self-feelings—or feelings that begin with “I feel . . . ”—include the following: frustration, sadness, anxiety, happiness, fear, shame, guilt, jealousy, hurt, envy, anger, and rage. Object feelings, or feelings directed toward another person, include love, hate, affection, anger, and sexual excitement.

Techniques Some of the major techniques used by modern analytic group therapists include being emotionally available, having the group offer emotional support and helping the patient develop emotional antibodies, joining, bridging, immediacy and interpersonal availability, and interpreting transferences and resistances. Therapist Emotional Availability

The role of the therapist is to model emotional availability so that all feelings are seen as welcome and available to group members. The therapist does this by using listening skills, acceptance, and empathy with the patients.

Feelings Versus States of Mind

Whereas self-feelings and object feelings are all considered “feelings,” states of mind include the following: disgusted, exhausted, identified, cautious, confused, suspicious, confident, mischievous, depressed, smug, overwhelmed, hopeful, surprised, grateful, admiring, shocked, shy, bored, protective, distraught, disappointed, and lost. For example, if someone says, “I feel disappointed in you,” he or she is not actually talking about his or her feelings; that person is reporting a state of mind, usually with the intention of inducing guilt in and controlling the other person. If the person says, “I’m hurt and frightened by what you said and angry with you for not considering me!” the communication is clear, and the other person is in a better position to respond emotionally. When someone says, “I’m frustrated,” he or she is actually reporting on a condition; a more complete communication would be “I’m frustrated (self-feeling) and angry with you (object feeling).” Resistance

When patients begin to get close to important, yet painful, issues, they will often find ways to

Emotional Support and Emotional Antibodies

One goal of the group is to have members assist one another in learning how to manage their emotions. Therapists can do this by offering support to the patients and by encouraging group members to offer support. For instance, in one group, Susan was attempting to develop a career as a choreographer, but she had little success at her auditions and so felt deeply rejected. The group members were devoted to seeing her succeed and supported and challenged her so that, in time, she became emotionally inoculated against the disorganizing effects of being turned down. Eventually, she developed emotional antibodies that helped her contend with what was hampering her in attaining her goals, until one day, she got hired. Joining

Modern analytic group therapy places an emphasis on initially forming a therapeutic alliance with patients, sometimes called joining. This is often done by allowing the patient to take the lead and to initially practice a high degree reflection of what the client is saying. The

Modern Analytic Group Therapy

goal is to be experienced as a nonintrusive entity entering the patient’s world. Bridging

Bridging is the process of connecting members to one another. Relationships start to flow across the room as people make connections in a positive and negative union. Everyone talks and contributes, and no one gets overlooked. Patients have an opportunity to improve their relationship skills by working horizontally, member to member, and vertically, member to leader. Immediacy and Interpersonal Availability

For group treatment to succeed, the members must be helped to live and communicate, in the moment, with their feelings and to engage the other person in a progressive communication process. Interpreting Transferences and Resistance

For patients to move more deeply into an understanding of their issues, the therapist needs to interpret or explain a patient’s transferences and resistances to him or her. This must be done only when the patient is able to hear such interpretations.

Therapeutic Process Prior to the beginning of the group, a screening interview ensures that group members are appropriate for the group. Generally, patients who are ready for group want to acquire a greater degree of emotional freedom and interpersonal availability, and they arrive in group curious about themselves and their relationships. Generally, a modern analytic group is of mixed gender and meets once a week for 90 minutes. Prior to starting the group, a contract is established in which the group members commit to the following: arriving on time, eventually becoming active participants, maintaining confidentiality, putting thoughts and feelings into words to avoid acting out, working at understanding themselves and their relationships in the group, avoiding socializing outside the group with the other group members, and paying the fee on time. In the initial phase of treatment, the group process is dedicated to identifying the needs, wants,

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and goals of the members so that they might be addressed in a new way, on an emotional level that leads to personality integration. The method is not so much about explanation as it is about exploration. The group is devoted to helping members achieve the goals they’ve identified for themselves (e.g., “I want to get married,” “I want to get a new job”). As the group continues, resistances can be explored, and patients can begin to examine their fears about being a member of the group—a member who can freely express his or her feelings in healthy ways. Soon, transference issues are explored. In this process, patients find aspects of their siblings, coworkers, parents, and supervisors in the character of their fellow group members and the group leader. Through this process, they can better understand why these people are able to elicit such strong reactions in them. It then becomes possible to experiment with new behaviors and new ways of communicating and relating. As group continues, there is a unique opportunity to help patients become better acquainted with the full spectrum of emotions and learn how to best utilize feelings in relationship with other people. Here, the leader encourages immediacy and emotional availability on the part of the group members and offers emotional support to the clients. Group then moves toward a new phase where new ways of relating are attempted in the face of emotionally laden material. As a group member takes on these challenges and makes the effort to stretch and flex in ways that were previously unknown, there is verbal recognition and reinforcement from the group. Over time, the voices of the group’s members begin to take up space in the mind of each member. These voices, which are by and large nutritious, replace the voices of negativity and doubt that most patients arrive with. Sometimes called introject substitution, these newly incorporated voices contribute to the development of an insulation barrier in each member. Harsh words, which once might have elicited a reactive, disorganized response, can now be considered and responded to. In effect, the members develop an observing ego, which operates separately from the participating ego, when confronted with emotionally charged experiences. From this position of engaged detachment, the member can consider what he or she is experiencing and formulate a response. Over time,

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this ability develops into a very useful interpersonal skill that gets carried outside the group treatment room to enrich the member’s life at home, at work, and in the community at large. Elliot M. Zeisel See also Cognitive-Behavioral Group Therapy; EmotionFocused Therapy; Object Relations Theory; Psychodynamic Group Psychotherapy

hypochondriacal temperament or hypersensitivity to symptoms. Influenced by Zen Buddhism, though not considered a religiously based therapy, and similar in philosophy to third-wave cognitivebehavioral approaches (e.g., dialectical behavior therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy), Morita therapy employs psychoeducation, journaling, and experiential learning in naturalized contexts to promote coexistence with distressing thoughts and feelings, and purpose-driven actions.

Further Readings Furgeri, L. (Ed.). (2001). The technique of group treatment: The collected papers of Louis R. Ormont, Ph.D. Madison, CT: Psychosocial Press. Grotjahn, M. (1977). The art and technique of analytic group therapy. New York, NY: Jason Aronson. Ormont, L. (1992). The group therapy experience. New York, NY: St. Martin’s Press. Rosenthal, L. (1987). Resolving resistances in group psychotherapy. Northvale, NJ: Jason Aronson. Spotnitz, H. (1976). Psychotherapy of pre-oedipal conditions. New York, NY: Jason Aronson. Zeisel, E. M. (2009). Affect education and the development of the interpersonal ego in modern group analysis. International Journal of Group Psychotherapy, 59(3), 421–432. doi:10.1521/ ijgp.2009.59.3.421 Zeisel, E. M. (2012). Meeting maturational needs in modern group analysis: A schema for personality integration and interpersonal effectiveness. In J. L. Kleinberg (Ed.), The Wiley-Blackwell handbook of group psychotherapy (pp. 217–229). Chichester, England: Wiley.

MORITA THERAPY Morita therapy was originally developed to treat shinkeishitsu, an anxiety neurosis, closely corresponding with the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) diagnosis for anxiety disorders (mainly social phobia, panic, obsessive-compulsive disorder, and generalized anxiety disorder), depression, and personality disorders, especially Cluster C personality disorders (anxiety- or fear-related disorders). The core of these problems was seen by Shoma Morita as arising from what he termed a

Historical Context Morita therapy was developed in 1919 by Shoma Morita, who served as the chairman of psychiatry at Jikei University School of Medicine, near Tokyo, Japan. Originally designed as a four-stage treatment—(1) isolation and rest, (2) light activity of daily-living occupational therapy, (3) strenuous occupational therapy, and (4) complex activities reintegrating patients into normalized occupational roles—Morita therapy was first practiced as an inpatient residential intervention. It has since evolved and is now frequently practiced in outpatient settings. Like other mindfulness-based approaches, Morita therapy was designed to address a specific disorder but has expanded its application to address a wide range of human suffering and performance.

Theoretical Underpinnings Morita proposed that human behavior is influenced by two often opposing drives: (1) a drive to live fully and (2) a drive for security. He suggested that feelings of anxiety and discomfort were a natural result of living and should not be targeted as pathological. In fact, according to Morita, the attempt to avoid feelings of anxiety or discomfort creates a contradictory mental attitude toward life. The neurotic fixation on avoiding distressing thoughts and feelings has the paradoxical effect of exacerbating suffering and disrupting purposeful actions. The goal of Morita therapy is to help people achieve arugamama, acceptance of life as it is, while fully engaging in purposeful activities. Purpose is defined as both actions required to meet the needs of a given situation (i.e., basic daily roles, tasks, and contextual demands) and what holds

Morita Therapy

value (i.e., an individual’s life purpose). Morita noted the role of misdirected attention in maintaining a fixation on trying to control or avoid distressing thoughts and feelings. Morita therapy employs attention exercises in which patients practice maintaining a moment-to-moment focus during simple tasks and are asked to notice the impact of occupational engagement on directing attention. For example, a therapist might encourage a patient to sweep the floor while maintaining attention on the moment-to-moment sensory experience of each motion of the broom rather than on judgments about the adequacy of sweeping. Experiential exercises used by contemporary practitioners are often designed to bring patients into contact with their direct experience of the world as opposed to their thoughts or feelings about that experience.

Major Concepts The major concepts of Morita therapy include the naturalness of internal experience, a de-emphasis of symptom control, the paradoxical effect of control efforts on private experiences, the relationship of self-centered attention and suffering, the importance of coexisting with unpleasant internal experiences, arugamama, mindfulness and skillful use of attention, and purpose-directed actions. Naturalness of Internal Experience

Thoughts, feelings, and body sensations are regarded as natural and are not targeted as pathological.

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self-centered and problem-focused attention associated with greater suffering. Coexisting With Unpleasant Internal Experience

An important skill for patients to cultivate is the capacity to coexist with unpleasant thoughts and feelings. Arugamama

A primary goal of Morita therapy is to help patients achieve acceptance of life as it is, with the understanding that living fully naturally includes distressing thoughts and feelings. Mindfulness and Skillful Attention

“Emotional problems” are considered problems of misdirected attention. Purpose-Directed Action

Success in Morita therapy is measured by progress toward achieving one’s purpose rather than symptom reduction.

Techniques Techniques include both traditional stage-specific interventions and interventions emphasized by contemporary practitioners (i.e., metaphor, experiential exercises, mindfulness practice, and purpose-centered activities within a patient’s normal environmental context).

De-Emphasis of Symptom Control

Purposeful behavior is emphasized, and symptom control or elimination is de-emphasized. Paradoxical Effect of Control Efforts

Efforts to control or manipulate thoughts, feelings, or body sensations are thought to exacerbate distress and suffering. Self-Centered Attention and Suffering

Efforts to “work on” distressing thoughts and feelings are thought to result in increasingly

Isolation and Rest

Stage 1 of traditional Morita therapy is intended to bring the patient into direct contact with the suffering related to attempts to control and avoid anxiety and to elicit boredom, the first expression of the drive to live fully. Journaling

During isolation, Morita encouraged patients to do limited journaling about their internal experience, providing them feedback as a means of education and guidance.

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Psychoeducation

Further Readings

A basic overview of the principles and philosophy of this approach, traditionally a part of the isolation and rest phase, now often occurs in the initial phase of outpatient treatment.

Fujita, C. (1986). Morita therapy: A psychotherapeutic system for neurosis. New York, NY: Igaku-Shoin. Nakamura, K., Kitanishi, K., & Maruyama, S. (2010). Guidelines for practicing outpatient Morita therapy (I. Ishiyama, Trans.). Tokyo, Japan: Japanese Society of Morita Therapy. Spates, R. C., Tateno, A., Nakamura, K., Seim, R. W., & Sheerin, C. M. (2011). The experiential therapy of Shoma Morita: A comparison to contemporary cognitive behavioral therapies. Annals of Psychotherapy and Integrative Health, 14, 14–25.

Metaphor

Metaphor is often preferred to illustrate concepts rather than purely conceptual, rule-based learning. Occupational Engagement and Experiential Exercises

Learning by doing is emphasized, and patients are encouraged to confirm concepts through their own experience, often in the context of day-to-day tasks. Purposeful Activity

Patients are encouraged to focus their efforts on meeting the needs of the situation and on valuecentered actions. Mindfulness Practice

Morita therapists employ a variety of attentional practice methods in addition to acceptance, and outward-directed intentional actions.

Therapeutic Process Contemporary Morita therapy in an outpatient setting often lasts between 8 and 15 sessions. The early sessions involve gathering information from the patient about his or her situation, psychoeducation, and providing a general overview of the treatment. The subsequent sessions often include graded involvement in a patient’s identified purpose (e.g., cleaning the house, exercise, or social engagement). The therapist works with the patient to apply Morita principles in achieving their identified purpose. James F. Hill See also Acceptance and Commitment Therapy; Dialectical Behavior Therapy; Mindfulness-Based Cognitive Therapy

MOTIVATIONAL INTERVIEWING Motivational interviewing is a client-centered, goal-driven counseling approach widely used with a variety of mental health conditions. Described more as a way of being than a specific set of techniques and interventions, motivational interviewing was originally developed in the 1980s as a treatment for individuals with drinking problems. It has since undergone several phases of development, all aimed at providing therapeutic conditions that stimulate intrinsic motivation for change. Motivational interviewing has a core goal of increasing the client’s own desire or motivation for change, which is facilitated by exploring the reasons why clients are resistant to change. The theory posits that most people teeter between a desire to change problematic behavior and a desire to continue those problematic behaviors. Clinicians then use client ambivalence as a tool for helping clients move toward making changes that are congruent with their own values and goals.

Historical Context In the 1980s, William R. Miller originally developed motivational interviewing as a treatment for problem drinkers. Through Miller’s own work with clients and interns, he realized that the traditional confrontation style of therapy was less effective in sustaining client change. The traditional confrontational model of treatment typically involved having clients label themselves (e.g., “I am an addict”), confronting client denial, and also

Motivational Interviewing

a more directive counseling style that puts the clinician as the expert who establishes goals that the client should then work to accomplish. In the 1980s, Miller trained a group of counseling interns in person-centered counseling and in how to help clients establish intrinsic motivation for change in the treatment of problem drinkers. This training unintentionally sparked the beginnings of motivational interviewing, leading to a clinical trial that found Miller’s treatment approach effective in treating addiction. Since the 1980s, more than 200 studies have explored the effectiveness of motivational interviewing with a wide range of client issues. It is classified as an evidenced-based practice by the National Registry of Evidence-Based Programs and Practices, demonstrating its effectiveness as supported by research. The most important findings show that the style of the clinician, specifically his or her use of empathy, is one of the most important predictors of client change. For Miller and his colleagues, this is rooted in Carl Rogers’s necessary and sufficient conditions for change. In 1989, Miller began collaborating with Stephen Rollnick, which led to several manuscripts aimed at making motivational interviewing applicable and usable in health care settings. Today, motivational interviewing has been shown to be effective in treating substance abuse disorders and a host of psychological and physiological issues. There are no specific time frames within which motivational interviewing should be used because this approach is influenced by clients’ readiness for change. However, it can be used as a brief intervention in settings that have a limited time frame for services.

Theoretical Underpinnings The phenomenological perspective of the client is valued in motivational interviewing, as in most of the existential-humanistic approaches in counseling. By taking time to understand the worldview, experiences, and perspectives of the client, the motivational interviewer effectively engages the client and establishes a therapeutic alliance. Through that alliance, the interviewer creates a safe, supportive atmosphere in which the client’s ambivalence about change can be explored. Ambivalence is a key construct in motivational

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interviewing that is seen as a normal occurrence in clients. By focusing on the ambivalence about a decision and not the decision itself, the clinician allows the client to come to his or her own decision as opposed to leading the client toward one extreme. This also helps empower clients to rely on their own ability to make the right decisions in their lives. A cornerstone of motivational interviewing is eliciting the client’s intrinsic motivations for change. The motivational interviewer will help the client explore both sides of his or her ambivalence about change to have the client identify the pros and cons of changing. This process is undergirded by a neutral stance on the interviewer’s part, in which the interviewer avoids leaning toward either side of the client’s ambivalence. As clients begin to crystallize their decisions, the interviewer will reflect and emphasize statements that embody change talk in clients. Change talk is any client dialogue that centers on their commitment to change. Motivational interviewers spend a large portion of treatment time in supporting and working to draw out client change talk. This aspect is more akin to a cognitive-behavioral perspective in that the client is encouraged to consider his or her life circumstances and begin to develop change strategies.

Major Concepts Motivational interviewing draws on the principles of person-centered counseling, developed by Carl Rogers, and elements of the stages of change model, developed by James Prochaska, Carlo DiClemente, and John Norcross. Key concepts include expressing empathy, avoiding confrontation, responding to client ambivalence, creating discrepancies, and bolstering client self-efficacy. Expressing Empathy

Empathy is the capacity to express understanding of the perspectives, feelings, and experiences of another person. In motivational interviewing, empathy is an active therapeutic tool that allows clients to honestly explore their ambivalence to change. Through expressing empathy, a safe, nonjudgmental relationship develops between the client and the clinician, allowing for clients to feel

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accepted. This acceptance, facilitated by a strong therapeutic bond, augments the process of deep exploration of problematic issues and experiences. Ambivalence

A key concept in motivational interviewing is the belief that people often struggle when it comes to decision making and, at times, people are stuck between two different choices in their lives (e.g., having the desire to stop smoking marijuana but not wanting to let go of the feelings of relaxation when it is used). Instead of focusing on the reasons why the client should stop using marijuana, a clinician using this approach would focus on the client’s ambivalence about making the decision to stop using marijuana. As clients lean toward one decision, they are often pulled toward the opposite extreme, which is the dilemma of ambivalence. Much of the clinician’s work using this approach is to help clients fully explore their options. Avoiding Confrontation

The creed of collaboration, not confrontation, is pervasive in motivational interviewing because change is more likely to occur in a relationship that is collaborative and egalitarian. The clinician does not presume to know what is best for the client, nor does he or she directly challenge the client, as confrontation creates defensiveness in clients, which increases resistance. In this approach, resistance occurs when there is a conflict between the client’s and the clinician’s interpretation of the problem or solution. In those situations, the clinician is encouraged to “roll with the client’s resistance.” Instead of directly challenging the client, the clinician focuses on having the client define his or her understanding of the problem and identify steps toward a resolution. Power struggles are continuously avoided while being careful not to communicate approval of certain problematic behaviors. Creating Discrepancies

An important activity in motivational interviewing is increasing clients’ motivation for change, which is facilitated when clients become aware of a disparity between their current situation

and their future goals. The focus of creating discrepancies is on the client’s personal goals and not the clinician’s. In working to help clients perceive the discrepancy, it is important that the clinician is not coercive and does not pressure the client. This supports an underlying theme in motivational interviewing, that the change has to come from within the client for it to be successful and sustainable. Supporting Self-Efficacy

This approach believes that the potential for growth and change lies within the client; the clinician is not an expert on the best ways for a client to change. Self-efficacy is the client’s belief in his or her own capabilities. By rolling with resistance, avoiding confrontation, and expressing empathy, clinicians effectively communicate to clients that the power is in the client’s hands. Clinicians encourage clients to formulate a variety of options for change versus providing the client with ways to change. In addition, clinicians take a strengthsbased approach to empower clients by focusing on previous successes and personal strengths exhibited by the client.

Techniques Motivational interviewing relies on a collaborative counseling style as opposed to using a series of techniques. The most commonly used strategies are open-ended questions, affirmation, reflection, and summaries, creating the acronym OARS for the ways in which clinicians can respond to clients’ desire to change. Open-Ended Questioning

The use of open-ended questions such as “Can you tell me more about that” or “What about that experience struck you the most?” gives the clinician a clear picture of the client’s subjective experience and helps establish rapport. In addition, open-ended questioning positions the client as the source of expertise and knowledge on his or her life. Finally, the use of open-ended questions invites a deeper level of thinking and introspection on the client’s part, thereby initiating talk about the change process.

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Affirmation

Summaries

An additional way to build rapport is by using statements that recognize client strengths, or affirmations. When using affirmations, clinicians should be genuine, and the affirmation needs to be appropriate for the context. Clinicians can affirm the client’s step toward change, personal strengths, and also good intentions. A specific technique called reframing involves offering a positive interpretation of a negative client statement. For example, the client says, “I’m a total failure. Despite my efforts, I’ve never been able to stay sober for more than 3 months.” The clinician offers a reframe, “I can hear your disappointment at your previous tries, but I also hear that you were able to sustain periods of sobriety in the past.” The clinician in this example not only highlights the client’s previous success at sobriety but also changes the client’s label of “failure” to “try.” By using reframing, the clinician is affirming the client’s capability to change.

Last, clinicians use this special type of reflection to review what the client has said. Summaries can be used at the end of a session to recap overarching themes, or they can be used to make connections between sessions to highlight progress or change talk. They can also be utilized as a bridge from one topic to another. Summaries facilitate rapport building by communicating that the clinician has been listening, and they also help ensure that the clinician understands the client’s perspective.

Reflection

Reflection, or reflective listening, is arguably one of the most critical components of motivational interviewing. Reflection involves the use of careful active listening followed by the expression of accurate empathy. It serves to strengthen rapport as well as reinforce clients’ talk about change. Three types of refection are highlighted that focus on the clients’ dialogue about change: (1) simple reflection, (2) amplified reflection, and (3) double-sided reflection. Simple reflection repeats what a client has said in a neutral manner (e.g., “You feel overwhelmed by the idea of discontinuing your marijuana use”). Amplified reflection repeats what the client has said in a way that intensifies or amplifies the client’s ambivalence, thereby focusing on the change talk (e.g., “Being overwhelmed makes you think you cannot change”). The last type of reflection, double-sided reflection, recognizes what the client has said and also highlights previous statements the client has made about change (e.g., “You recognize that it may not be easy to stop using marijuana, but you also realize it’s important for you to stop”). Regardless of the type of reflection used, the focus of using reflection is expressing empathy and encouraging change talk.

Therapeutic Process The therapeutic process in motivational interviewing involves four overlapping processes. The first process, called engaging, centers on building the therapeutic alliance and establishing rapport. In this phase, the clinician avoids common barriers to rapport building such as advice giving, agreeing, or communicating approval. Instead, the focus is on reflective listening and affirming. The second process, focusing, establishes a clear direction or goal for therapy. This is an ongoing, collaborative process between the client and the clinician that will identify a set of intended outcomes, which will guide the remainder of counseling. Evoking, the third process, is perhaps the most active. With the goals in mind, the clinician works toward eliciting the client’s motivations for change. The goal of this stage is to have clients voice their own reasons for wanting to change. In the last process, planning, clients are ready to act on their previous change talk. This phase involves the development of a change plan that maps out a path to beginning and sustaining desired change. Clinicians are warned that ambivalence about change can happen at any stage in motivational interviewing. Empathy, affirmation, and reflective listening can be utilized throughout all stages. LaShauna M. Dean See also Miller, William R.; Person-Centered Counseling; Solution-Focused Brief Therapy

Further Readings Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91–111. doi:10.1146/annurev. clinpsy.1.102803.143833

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Miller, W. R., & Moyers, T. B. (2007). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions, 5(1), 3–17. doi:10.1300/ J188v05n01_02 Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37(2), 129–140. doi:10.1017/S1352465809005128 Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guildford Press. Olmstead, T., Caroll, K. M., Canning-Ball, M., & Martino, S. (2011). Cost and cost-effectiveness of three strategies for training clinicians in motivational interviewing. Drug and Alcohol Dependence, 116, 195–202. doi:10.1016/j.drugalcdep.2010.12.015 Passmore, J. (2011). Motivational interviewing techniques: Reflective listening. The Coaching Psychologist, 7(1), 50–53. Rollnick, S., Butler, C. C., Kinnersley, P., Gregory, J., & Mash, B. (2010). Competent novice motivational interviewing. British Medical Journal, 340(7758), 1242–1245. doi:10.1136/bmj.c1900

MOVEMENT THERAPIES See Dance Movement Therapy; Yoga Movement Therapy

MULTIGENERATIONAL FAMILY THERAPY With his experience as a psychiatrist, Murray Bowen developed multigenerational family therapy to explain an individual’s dysfunction or pathology with consideration to the individual’s family. The importance of the family was virtually not considered or understood prior to the development of Bowen’s theory; thus, Bowenian family systems theory is considered a first-generation family therapy theory. This theory seeks to understand how a family’s functioning affects the family’s individual members. Multigenerational therapy has Bowenian theory as its foundation and seeks to identify how the family’s current dysfunction is a result of generational patterns. The multigenerational family therapist focuses on the facts related

to the family rather than the family’s thoughts, feelings, and emotions. Multigenerational family therapy was the first theory to coin terms now commonly understood and referenced in family systems theories, such as triangles, sibling position, and differentiation. Multigenerational family therapy is more theoretical than application oriented; therefore, there are few techniques but numerous concepts and tenets.

Historical Context Bowen received his medical degree from the University of Tennessee Medical School in 1937 and continued his training in New York until 1941, when he began to serve in the army during World War II. He was slated to begin a fellowship in surgery at the Mayo Clinic at the completion of his service, but as a result of his experience during the war, he developed an interest in psychiatry. In 1946, he started psychiatric training at the Menninger Clinic Foundation. During this time, he started to see problems with his psychoanalytical training. Psychoanalytical theory does not include families in the counseling session and seeks to understand a person’s dysfunction through investigation of the unconscious. Bowen, however, sought to understand the individual as part of a system, which often meant including the family in the counseling session. Bowen also explored individual dysfunction through investigation of the immediate family as well as previous generations of the family. Bowen, along with his colleague Michael Kerr, viewed the symbiotic familial relationships as a biological and evolutionary process developed through adaption and necessity, like those seen in nature, thus applying Charles Darwin’s theory of evolution and adaption to family systems. It was these observations that led Bowen and Kerr to develop a natural systems theory that sought to explain human behavior and interactions, called family systems theory and later called Bowenian theory or multigenerational therapy. In 1954, Bowen relocated to Maryland to work on a research project at the National Institute of Mental Health (NIMH). At NIMH, Bowen and his colleagues continued to expand on his theory. During this project, Bowen observed schizophrenic patients and their families. This work solidified Bowen’s belief that families were undeniably

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connected and could even be viewed as emotional units. Oftentimes it was observed that a schizophrenic patient and the patient’s mother seemed to be a cohesive complementary unit as opposed to two separate individuals. It was also noted that family relationship had a certain cycle, like those often seen in nature (e.g., tides), as the family would fluctuate in emotional closeness. Just as Darwin established a physical relationship between humans and other animals, Bowen established an emotional relationship between family members.

Theoretical Underpinnings There are several key assumptions within this theory on what helps dictate human interactions. First, humans, although intelligent and high-functioning beings, can behave in a manner still dictated by their primal instincts. This is evidenced by an individual’s selection of sexual mates. These instinctual drives can be contradictory, because people have an instinctual desire to be independent and self-reliant while also having an instinctual desire to be connected to or part of a community. The second assumption of the theory is the belief that disturbances within an individual can actually be caused by disturbances within the individual’s system and that changes within a system are caused by individuals within the system. This can be seen by a child’s misbehavior being a result of violence taking place between his or her parents, or by a parent’s decision to no longer drink alcohol resulting in changes for each member within the family system. This intricate connection between the system and the individual is deeply ingrained in Bowenian theory. Bowen additionally explained that each individual has three distinctly separate systems that ultimately guide human behavior: (1) the emotional system, (2) the intellectual system, and (3) the feeling system. Each of these systems plays a part in the individual’s behavior and interactions. Bowen believed that the emotional system consists of the instinctual reactions each individual has as a result of the evolutionary process. Examples of this include exploding in anger during an argument with a family member or a child running away from home due to anger or frustration. The intellectual system consists of the individual’s ability to reason. For example, a family may delay having

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children to save money, or a parent may limit the amount of television a child views to encourage the child to be physically active. The feeling system (not to be confused with the emotional system) is the bridge between the two systems; it allows an individual to connect reason to action. This can be observed when an individual explains his or her frustration to a partner in a calm manner or when a parent grounds a child for calling him or her a name. Bowen hypothesized that it was the emotional system that dictated most human actions and behavior because it is so ingrained in our instinctual nature. This default to the emotional system then influences the interactions within a family system. This theory also provides insight into why people who typically respond logically and thoughtfully can suddenly react illogically and ignorantly in stressful situations. In Bowenian theory, each system is understood and utilized through counseling, as the thinking system can provide the individual with greater understanding of a problem, the emotional system can provide clues to instinctual reactions, and the feeling system can provide insight into upsetting patterns or situations. The foundation of Bowenian theory is the understanding that a system, whether it be family, business, or community, is a unified emotional unit. Each family system has developed ways of interacting that over time have become patterns; these patterns are often continued through several generations of a family. These patterns of interacting within a family become the stabilized norm or homeostasis of the family. This homeostasis wields a powerful force for the system’s individuals and can lead to the repetition of patterns that can be helpful or harmful to a family system. These patterns can often even extend into systems outside the family.

Major Concepts Multigenerational family therapy has eight core concepts. These core concepts are interconnected cornerstones of Bowenian theory and, when combined, can illuminate a family system’s interactions. Each of these core concepts provides insight into the individual’s adaptive responses, which are developed naturally as a way to decrease tension and anxiety while increasing functionality.

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Differentiation of Self

Differentiation of self is often acknowledged as the most important or foundational concept in Bowen’s theory. Differentiation of self refers to the individual’s ability to remain autonomous while being part of a system. People who are highly differentiated are able to make decisions and act as individuals, using their intellectual system to operate independently of their systemic relationships. These individuals are likely to be self-aware and possess the ability to regulate their own emotions. People with high levels of differentiation are able to remain calm and respond thoughtfully when people within the system become anxious or emotionally agitated. These individuals are able to see themselves as distinctly different and separate from the system. On the other end of the spectrum, people with low differentiation of self often make decisions by using their emotional system. These individuals may lack an understanding of themselves and effective coping skills, thus relying on others within the system to regulate their emotional state. People with low differentiation are not able to remain calm and often react emotionally when others within the system become anxious or emotionally agitated. These individuals are not able to understand where the system ends and where the individual begins; the system and the individual are often fused together and thus lack differentiation. Bowen identified an individual’s increased differentiation of self as an important goal of therapy. He also believed that for counselors to be effective they must have high levels of differentiation from their own family. Triangles

Two-person relationships are common within systems but are composed of constant shifts in intimacy, which ultimately result in instability within the relationship. When this two-person relationship becomes anxious or tenuous, the member most uncomfortable with the anxiety will seek relief by involving a third person. Bowen believed that the smallest stable relationship is a triangle (three individuals), which often causes two-person relationships to inadvertently or knowingly seek

out stability by including a third member. This is evidenced by a child being invited into an argument between his or her parents or an affair occurring outside a committed two-person relationship. This concept has become commonly known and acknowledged in family therapy. The addition of a third person allows the anxiety and focus to be shared among three people as opposed to two; this shift relieves some of the anxiety between the two individuals. This can be seen as an adaptive response because it naturally occurs as a way to relieve tension. Nuclear Family Emotional System

This concept identifies four different mechanisms that are used within a nuclear family: (1) emotional distance, (2) marital conflict, (3) dysfunction in one spouse, and (4) transmission of the problem to the child. Each of these mechanisms is used throughout the relationship but especially during times of stress to keep the family within its established level of functionality. A family may employ one or all of these mechanisms. Each mechanism often takes place within the parental relationship. It is believed that children often utilize the mechanisms their parents employed within their nuclear family. Emotional Distance Emotional distance occurs when an individual within a relationship emotionally or physically distances himself or herself from the other individual, typically as result of deepened intimacy or heightened stress. An example of this is when a wife learns about another couple’s infidelity and responds by distancing herself from her husband to prevent similar pain of her own. This distance can result in the formation of a triangle and additional distancing, such as if the wife’s husband begins an affair as a result of the wife’s emotional distance. Martial Conflict Marital conflict occurs when the partners within a relationship fluctuate between emotional closeness and distance. Anxiety within the systems often results in anxiety within the relationship, thus causing the martial relationship to shift. Martial

Multigenerational Family Therapy

conflict is best demonstrated when the partners within the relationship blame one another for the anxiety or dysfunction. Dysfunction in One Spouse Dysfunction in one spouse occurs within a couple with little differentiation of self. One of the individuals in the relationship can be overly dysfunctional, and the other individual responds overtly by taking control. As one member underperforms, the other member overperforms. An example of this can be seen in a family where one member is an alcoholic and thus another member takes over the primary tasks in the family to keep the system functioning and keep attention off the alcoholic’s behavior. Transmission of the Problem to the Child Transmission of the problem to the child occurs when the stress in the parental relationship results in an increased focus on a child. This focus results in the projection of any systemic dysfunction onto the child. In this case, the child’s misbehavior can become the focus of the parents’ concerns and efforts, and they may decide to seek counseling for the child’s problems instead of the family system as a whole.

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hypothesizes that family interactions can be transmitted across generations. The patterns that often occur within a family can be repeated in the children’s families and then transferred to their children’s families, and so on. It has been noted that this is often not noticed unless it is somewhat dysfunctional. This type of transmission is more likely to affect one sibling more than the others, just as in the family projection process. Bowen also concluded that people often marry individuals with similar levels of differentiation, which also leads to continuation of the patterns across generations. Emotional Cutoff

Emotional cutoff occurs in a family when an individual within the system emotionally or physically separates himself or herself from the system. This is often a result of low levels of differentiation and can create the illusion of differentiation while also leading to unhealthy relational patterns. An example of this is when a son has an argument with his father and as a result ceases all communications and interactions with him, which would likely alleviate some tension but does not resolve the problem in a functional way. Sibling Position

This concept addresses the unique relationship that can exist within a family when one child becomes emotionally involved with one parent as a result of the parent’s level of differentiation and stress. Typically, families with more stress and with parents with low levels of differentiation can produce this type of interaction. Parents simply project their own anxiety and stress onto one of their children, which creates an alliance between that child and one of the parents. An example of this is when a mother asks her son to sleep in the same bed with her after she has separated from her partner.

This concept identifies the importance of a person’s sibling position within the family and how that position can assist or impede the person’s relationships in the future. This concept suggests that the sibling position of each partner might affect the dynamic of the relationship. Partners who are both the oldest child may experience some conflict due to the roles and expectations each of them experienced as the oldest child in their family of origin. Partners who were raised with different sibling positions, such as an oldest child in a relationship with a youngest child, may experience a more functional relationship due to previously established roles and functions in their family of origin.

Multigenerational Transmission Process

Societal Emotional Process

The concept of multigenerational transmission process has become a hallmark foundation of Bowen’s theory and is the reason why this theory is often called multigenerational theory. This concept

This concept places importance on the influence the environment can play on a family system, and vice versa. Bowen believed that the society that a family was a part of could play a role in the family’s

Family Projection Process

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level of differentiation and anxiety, while the level of differentiation that occurs within families could also affect the society around them. This concept acknowledges that the family is guided by societal norms. For example, some cultures tend to have low levels of differentiation as a societal norm, and thus low differentiation within this culture can be seen as an adaptive response that allows the family to be within the acceptable cultural and societal norms.

Techniques Multigenerational family therapy is not a techniquedriven theory; the majority of Bowen’s writings discuss his theory and the major concepts that are foundational to the theory. There are some techniques found in Bowen’s writings, but to practice family therapy the therapist must first understand the major concepts to help increase differentiation within the family and reduce anxiety through increased awareness and the development of functional patterns of interacting and communicating. The Family Diagram

The Family diagram (also called a genogram) is a visual representation that documents the multigenerational family history; this diagram includes the relational patterns and organizational structures found in Bowen’s theory (e.g., triangles, emotional cutoffs, and sibling positions). The genogram is developed during family sessions to gather the family history, and it is used to inform the family and the therapist about the family’s patterns by calling attention to recurrences through several generations.

this is when a therapist says, “You say you are feeling closer and more connected, but you are sitting across the room from one another.” This is especially helpful to point out discrepancies between what the family says and how the family behaves. It is important not to state opinions or interpretations during the session. The Family Evaluation Interview

The therapist asks questions about the family’s history, interactions, and behavior. This initial evaluation is done with one, multiple, or all members of the family. This type of fact-based questioning is used throughout the therapeutic process to reveal family interactions. Some questions that may be asked are “Who made the decision to come into counseling?” or “How do each of you handle stress?” “I-Statements”

To model emotional neutrality, which is the result of a high level of differentiation, the therapist uses “I-statements” such as “I notice that the mood in the room has changed.” The therapist also encourages the family to use these “I-statements” during their treatment. Emotional neutrality allows individuals to rely more on their thinking system than on their emotional system, which can result in families using more reason in interactions, thus increasing functionality and differentiation. A family member might be encouraged to say, “I feel hurt when you yell at me,” rather than stating, “You are a terrible person who yells at everyone.” Teaching the Family About Emotional Systems

Emotional Neutrality

The therapist is to remain emotionally neutral in the therapeutic process. Bowen believed that families with low levels of differentiation would unknowingly triangulate the therapist during the course of treatment, and the therapist must not allow his or her emotions to be involved in the treatment of the family. Factual Statements

The therapist is also encouraged to make factual statements about the family. An example of

During the course of treatment multigenerational therapists teach the family about emotional systems and how families contribute to dysfunctional patterns. This teaching is done subtly through modeling new approaches when the family is experiencing stress or anxiety, or more directly through talking about observations when the family is calm.

Therapeutic Process A multigenerational therapist does not attempt to make changes within the family but rather attempts

Multimodal Therapy

to evoke change by increasing awareness of family processes among the family members. Furthermore, change that is caused by a member outside the family is not likely to be as impactful as change caused by a member within the system. The therapist remains emotionally neutral, preventing any form of entanglement with the family. The therapist operates as an investigator by gathering information about the family. Through the use of family diagrams and factual questioning, the therapist starts to understand the family’s relational patterns. The therapist then determines how the family members define their relationships, seeks clarification for the roles, and teaches the family about emotional systems and key patterns observed within the family. Through this process, the family ascertains the events that led to relational changes or shifts in the family. The identification of these events can start a conversation about the family’s functioning and patterns. Through this process, the family is made aware of its own interactions and patterns and may then seek to reduce anxiety by making changes to the engrained patterns. Typically, the spousal members are recognized as the responsible members of the system, but this therapy can be done with the entire family, one member, or multiple members. Amanda A. Brookshear See also Bowen, Murray; Freudian Psychoanalysis; Strategic Family Therapy; Structural Family Therapy

Further Readings Brown, F. H. (2006). Reweaving the family tapestry: A multigenerational approach to families. New York, NY: W. W. Norton. Gilbert, R. M. (2004). The eight concepts of Bowen theory: A new way of thinking about the individual and the group. Falls Church, VA: Leading Systems Press. Guerin, P. J., Fogarty, T. F., Fay, L. F., Burden, S. L., & Kautto, J. G. (1996). Working with relationship triangles: The one-two-three of psychotherapy. New York, NY: Guilford Press. Hall, C. M. (1981). The Bowen family theory and its uses. New York, NY: Jason Aronson. Kerr, M. E. (1999). Murray Bowen, Bowen theory, and the family movement. Family Systems Forum, 1(2), 5–7.

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Kerr, M. E., & Bowen, M. (1988). Family evaluation. New York, NY: W. W. Norton. Papero, D. V. (1990). Bowen family systems theory. Boston, MA: Allyn & Bacon. Titelman, P. (Ed.). (1998). Clinical applications of Bowen family systems theory. Binghamton, NY: Haworth Press. Toman, W. (1993). Family constellation: Its effects on personality and social behavior (4th ed.). New York, NY: Springer. Walsh, W. (1980). A primer of family therapy. Springfield, IL: Charles C Thomas.

MULTIMODAL THERAPY As a graduate student in the 1950s, Arnold Lazarus broke away from his training in traditional psychotherapy. Despite favoring the nascent behavioral movement, Lazarus soon realized that the narrowfocused behavior therapy was too limited and began developing cognitive-behavioral therapy, broad-spectrum behavior therapy, and ultimately multimodal therapy (MMT). Lazarus based MMT on his realization that seven transactional dimensions need to be addressed for therapy to be optimally effective. Called the BASIC I.D., these dimensions represent behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biological processes. Today, MMT is a comprehensive, biopsychosocial model of human functioning as well as a paradigm of human personality that is used around the world when working with a wide variety of clients.

Historical Context In the mid-1950s, when Lazarus was a graduate student in clinical psychology at the University of the Witwatersrand in Johannesburg, South Africa, he was drawn to a coterie of faculty members who espoused conditioning therapy. They eschewed psychodynamic formulations in favor of a Pavlovian-based learning theory. The leader of this group was a medical practitioner, Joseph Wolpe, who developed systematic desensitization based on relaxation, assertiveness training, and aversive conditioning, for clinical use. Lazarus was immediately enamored of this active approach, in contrast to

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the psychoanalytical processes he had been taught. Wolpe became his mentor, chaired his doctoral dissertation, and supervised his assessment and treatment of several patients. In 1958, Lazarus coined the terms behavior therapy and behavior therapist, which he felt were better than the conditioning therapies, to separate their work from that of traditional psychotherapists. In 1966, he and Wolpe coauthored a book, Behavior Therapy Techniques, a succinct account of this new approach. Soon thereafter, Lazarus felt that Wolpe’s behavioral model was too narrow and rigid and, at the very least, cognitive factors should be included, and in 1971, he published what is arguably the first book on cognitive-behavioral therapy, Behavior Therapy and Beyond. Lazarus drew a distinction between “narrow-band behavior therapy” and “broadspectrum behavior therapy.” When clinical followups showed a higher relapse rate in patients who received narrow-band rather than broad-spectrum treatment, he developed a more detailed assessment approach. Lazarus concluded that while many systems tend to assess the usual “ABC” variables (i.e., affect, behavior, and cognition), most of them overlook or omit significant sensory, imagery, interpersonal, and biological issues. As such, untreated excesses and deficits in these areas of human functioning may leave clients vulnerable to backsliding. In other words, therapeutic breadth is emphasized. He felt that it is necessary to provide a set of distinct assessment procedures that facilitates treatment outcome by shedding light on the interactive processes that contribute to clients’ problems and by pinpointing a selection of appropriate techniques and their best mode of implementation.

range of physiological and biological factors beyond the use of substances, prescribed or otherwise. This approach to assessment and therapy was termed multimodal therapy. While at Stanford University in 1963, Lazarus was impressed by the work of Albert Bandura and often ascribed social and cognitive learning theory as the theoretical framework on which MMT rests because its tenets are open to verification or disproof. Instead of postulating putative unconscious forces, social learning theory rests on testable factors (e.g., modeling, observational learning, the acquisition of expectancies, operant and respondent conditioning, and various self-regulatory mechanisms). Nevertheless, irrespective of theoretical considerations, a technically eclectic outlook is central and pivotal to the MMT approach. Alternatively, theoretical eclecticism, or attempts to integrate different theories in the hope of producing a more robust technique, is considered misguided. Therefore, while drawing on effective methods from any discipline, the multimodal therapist does not embrace divergent theories but remains consistently within social cognitive learning theory. To reiterate, MMT is predicated on the fact that human beings have BASIC I.D.s and thus calls the therapist’s attention to no less than these seven discrete but interactive modalities. Furthermore, in addition to being a comprehensive biopsychosocial assessment and treatment model, the BASIC I.D. stands alone as a paradigm of human personality and functioning. With its emphasis on problem identification and, whenever possible, specifically tailored, empirically supported interventions, MMT transcends standard psychiatric diagnoses and nomenclature.

Theoretical Underpinnings Lazarus hypothesized that most psychological problems are multifaceted, multidetermined, and multilayered and that comprehensive therapy calls for a careful assessment of seven dimensions or “modalities” in which individuals operate: behavior, affect, sensation, imagery, cognition, interpersonal relationships, and biological processes. Given that the most common biological intervention is the use of psychotropic drugs, the first letters from the seven modalities can be combined to produce the  convenient acronym “BASIC I.D.”—although the “D” modality actually represents a complete

Major Concepts The primary concepts associated with MMT are the already mentioned BASIC I.D., modality profiles, the therapeutic relationship, and technical eclecticism. BASIC I.D.

As previously discussed, the BASIC I.D. refers to seven, reciprocally interactive dimensions of human psychology. In addition to serving as a comprehensive biopsychosocial assessment and

Multimodal Therapy

treatment template, the BASIC I.D. can stand alone as a paradigm of human personality, functioning, and phenomenology.

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profiles, and the Multimodal Life History Inventory (MLHI). Bridging

Modality Profiles

A modality profile is a list, or a matrix, of identified problems across the BASIC I.D. and the best therapeutic interventions to address them. Whenever possible, MMT endeavors to use empirically supported and evidence-based treatments. The Therapeutic Relationship

While MMT looks to scientific evidence when available, it is far from a purely technique-driven approach. Indeed, for MMT, the therapeutic relationship is the soil that enables the techniques to take root. Thus, a trusting and honest therapeutic connection—a good working alliance—is a cornerstone in the foundation of MMT. While the therapeutic relationship is regarded as the technique- enabling soil, MMT also recognizes that the therapeutic relationship, per se, is usually insufficient to produce optimal outcomes. Indeed, an experienced multimodal therapist will often transition between degrees of active-directive and supportive-nondirective intervention, both within a given individual and across clients in general. Technical Eclecticism

Technical eclecticism is the practice of using a specific technique without necessarily agreeing with the theory that spawned it. In other words, techniques may work for reasons other than those their originators believed and propounded. For example, a multimodal therapist might use the Gestalt empty chair technique for behavioral rehearsal or assertiveness training rather than to explore clients’ relationships with themselves. What’s more, knowing precisely when and how to best use specific methods in a manner that is uniquely suited to a given client is part of the multimodal therapist’s artistry.

Techniques Common techniques used in MMT are bridging, tracking, second-order BASIC I.D., structural

Simply put, bridging is a strategy whereby the therapist skillfully and in a nonconfrontational manner helps a client segue from one modality to another. Employed by many experienced and effective therapists, bridging can readily be taught to novices via the BASIC I.D. formulation. The technique is best described through the use of an example. Let’s say a therapist is interested in assessing a client’s emotional response to an event. The therapist might ask, “How did you feel when your father yelled at you in front of your friends?” Now suppose that instead of discussing his feelings, the client responds with a defensive and irrelevant intellectualization (e.g., “My dad had strange priorities, and even as a kid I used to question his judgment”). If additional probes into this client’s feelings yield only similar abstractions, it would likely be counterproductive to confront the client and point out that he is evading the question and that he seems reluctant to face his true feelings. Instead, in situations of this kind, bridging is usually more effective. First, the therapist would deliberately attune to the client’s preferred modality, which in this case is the cognitive domain. After a 5 to 10-minute discourse, the therapist would then endeavor to branch off into other directions that seem more productive. For example, the therapist might say, “Tell me, while we have been discussing these matters, have you noticed any sensations anywhere in your body?” This sudden switch from the cognitive modality to the sensory modality may then begin to elicit more pertinent information (given the assumption that, in this instance, discussing sensory accounts would likely be less threatening to the client than discussing affective material). The client might respond to this question by referring to some sensations of tension or bodily discomfort—for instance, “My neck feels very tense”—at which point the therapist might ask him to focus on the specific tension and discuss any associated images and cognitions. The therapist might then venture to bridge into the affective domain by saying, “Beneath the sensations, can you find any strong feelings or emotions? Perhaps

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they are there lurking in the background?” At this juncture, it would not be unusual for the client to give voice to his feelings. The client might say, “I feel angry, and a little sad.” Thus, starting where the client is and then bridging into a different modality often results in the client’s becoming willing to traverse the more emotionally charged areas he or she may have originally been avoiding. Tracking

Tracking is a strategy that may be employed when clients are puzzled by affective reactions. For example, a client might say, “I don’t know why I feel this way” or “I don’t know where these feelings are coming from.” The first step in tracking involves asking the client to recount the unpleasant event or incident. In true multimodal form, the client is then asked to consider what behaviors, affective responses, images, sensations, and cognitions come to mind. As with bridging, this technique is best described through the use of an example. Let’s say a therapist is working with a client who reported having panic attacks “for no apparent reason.” Working together, the therapist and the client were able to put together the following string of events. The client had initially become aware that her heart was beating faster than usual (sensation). This brought to mind a memory of a time when she had passed out after drinking too much alcohol at a party (image).This memory still brought about a strong sense of shame (affect). As such, the client started believing that she would pass out again (cognition), and as she dwelled on her sensations, this cognition was intensified and culminated in her panic attack. Thus, in this case, the client exhibited an S-I-A-C-S-C-A pattern (sensation–imagery– affect–cognition–sensation–cognition–affect). Thereafter, the client was asked to note whether any subsequent anxiety or panic attacks followed a similar “firing order.” Subsequently, she confirmed that her two trigger points were usually in the sensory and imagery modalities. This alerted the therapist to focus on sensory training techniques (e.g., diaphragmatic breathing and deep muscle relaxation), followed immediately by imagery exercises (e.g., the use of coping imagery and the selection of  mental pictures that evoked profound feelings of calm).

While tracking can be useful in uncovering fairly reliable patterns behind negative affective reactions that clients find puzzling, it should not be assumed that these patterns are universal and that therapists can use the same treatment techniques, in the same sequence, for all clients. Second Order BASIC I.D.

The initial BASIC I.D. is used to translate presenting complaints and vague, general, or diffuse problems (e.g., “I feel depressed or anxious”) into specific, discrete, and interactive difficulties, which can then be addressed with various techniques. Hence, the initial BASIC I.D. assessment, or modality profile, provides a detailed, macroscopic picture of a client’s identified problems. A second-order BASIC I.D. assessment takes an item on the modality profile and “zooms in” to examine it under a “higher magnification” by making a detailed inquiry into the associated behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations associated with the problem on the initial BASIC I.D. assessment. Secondorder BASIC I.D. assessments are typically applied when therapy falters. When this occurs, a secondorder BASIC I.D. may help shed light on the situation. This procedure can also help determine the reasons behind factors such as noncompliance and poor progress. Structural Profiles

Structural profiles are clients’ self-assessments of their proclivities and their relative strengths and limitations across the BASIC I.D. Often using a 7-point Likert-type scale, or any quantitative rating, clients rate themselves in terms of how behavioral, emotional, sensory, visual, thinking, social, and physically/health oriented they are. This information is then used to determine interventions of choice that are congruent with clients’ self-ratings of their preferred modalities. For example, if one gives oneself a rating of 2 on imagery and a rating of 7 on cognition, it clues in the therapist that emphasizing visualization techniques might not be as useful as focusing on cognitive methods. Or if one’s structural profile indicates a strong penchant for sensation and a low behavioral

Multimodal Therapy

inclination, sensory interventions might be initially prioritized over behavioral assignments. Multimodal Life History Inventory

After conducting the initial interview, many multimodal therapists elect to have their clients complete the MLHI. This 15-page questionnaire, completed as a homework assignment, frequently facilitates treatment by providing a more comprehensive problem identification sequence to be derived than would typically be possible from the interview alone. The MLHI also generates a valuable perspective regarding a client’s style and treatment expectations and is organized in a manner that allows for easy determination of specific excesses and deficits across a client’s BASIC I.D. Although clients with major psychological problems may not comply, many outpatients who are reasonably motivated will find the exercise useful for speeding up routine history taking and readily providing the therapist with a BASIC I.D. analysis.

Therapeutic Process How does a therapist assess each of the BASIC I.D. modalities? In addition to, or in lieu of the MLHI, this is achieved through the use of a range of questions. For example, to assess the client’s behavior, the therapist might ask, “What is this individual doing that is getting in the way of his or her happiness or personal fulfillment (self-defeating actions, maladaptive behaviors)?” or perhaps “What does the client need to increase and decrease?” or even “What should he or she stop doing and start doing?” To assess the client’s affect, the clinician might ask, “What emotions (affective reactions) are predominant?” “Are we dealing with anger, anxiety, depression, or combinations thereof and, if so, to what extent (e.g., irritation vs. rage, sadness vs. profound depression)?” The therapist might ask, “What appears to generate these negative affects— certain cognitions, images, or interpersonal conflicts?” and “How does the person respond (behave) when feeling a certain way?” In addition to assessing each modality separately, it is also important for the therapist to look for interactive processes that occur between and among the modalities

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(i.e., the impact that various behaviors have on the client’s affect, and vice versa). To assess the client’s sensations, the therapist might ask, “Are there any specific sensory complaints (e.g., tension, chronic pain, tremors)?” and “What positive sensations (e.g., visual, auditory, tactile, olfactory, sensual, and/or gustatory) does the person report?” Or, staying with the notion that one must also assess the interactions among modalities, the therapist might ask, “What feelings, thoughts, and behaviors are connected to these negative sensations?” To assess the client’s imagery, the clinician might ask, “What fantasies and images are predominant?” and “What is this client’s self-image?” The therapist might also assess for specific success or failure images that the client holds and ask whether the client experiences any negative or intrusive images (e.g., flashbacks to unhappy or traumatic experiences). As with the other modalities, the therapist might also assess how the client’s images are connected to ongoing cognitions, behaviors, affective reactions, and so on. To assess the client’s cognitions, the therapist might ask, “Can we determine the client’s main attitudes, values, beliefs, and opinions?” and “Are there any definite dysfunctional beliefs or irrational ideas?” Or the therapist might assess the client’s predominant “should statements” or try to detect any problematic automatic thoughts that undermine his or her functioning. To assess the client’s interpersonal functioning, the therapist might ask, “Who are the significant others in this client’s life?” or “What does this client want, desire, expect, and receive from others, and what does he or she, in turn, give to and do for them? The therapist might also ask, “What relationships give this particular client pleasure and pain?” Finally, to assess the client’s biological dimension, the therapist might ask, “Is this client biologically healthy and health conscious?” “Does he or she have any medical complaints or concerns?” “What relevant details pertain to diet, weight, sleep, exercise, alcohol, and drug use?” When there are any doubts, suspicions, or misgivings, the therapist refers the client to a medical practitioner. A client presenting for treatment may use one of the seven modalities as his or her entry point, but it is more typical for people to enter into treatment with problems in several modalities. The therapist

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initially engages the client by focusing on the issues, modalities, and/or areas of concern that he or she presents. Deflecting the emphasis too soon onto other matters that the therapist may deem more important may make the client feel invalidated. Once rapport has been established, however, the therapist usually can easily shift to more significant problems (i.e., bridging). The multimodal therapist will carefully note the specific modalities across the BASIC I.D. that are being discussed, and which ones are omitted or glossed over. By thinking in BASIC I.D. terms, the therapist is apt to leave fewer important avenues unexplored. What’s more, given its all-inclusive and structured nature, even relatively novice therapists can achieve a high degree of effectiveness by using MMT. Although MMT is an eclectic and flexible approach, in MMT the selection and development of specific techniques are not capricious. On the contrary, the position of MMT is that creative eclecticism is warranted only when (a) manualized or empirically supported treatments do not exist for a particular disorder or (b) empirically supported treatments are not achieving the desired results. Thus, when evidence-based treatments fail to be helpful, one may resort to less authenticated procedures or endeavor to develop new strategies. It must be emphasized, however, that a rag-tag combining of techniques without a sound rationale will likely result only in syncretistic confusion. Finally, although a modality profile may include several identified problems, it is rarely necessary to address each and every one in therapy. Because of the reciprocal and interdependent nature of the BASIC I.D. modalities, a positive ripple effect often occurs. Thus, by resolving one or a few problem areas, other problems that may not have been specifically worked on in treatment may also improve. Clifford N. Lazarus and Arnold A. Lazarus See also Behavioral Therapy; Cognitive-Behavioral Therapy; Eclecticism; Lazarus, Arnold

Further Readings Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.

Lazarus, A. A. (1989). The practice of multimodal therapy. Baltimore, MD: Johns Hopkins University Press. 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, NY: Basic Books. Lazarus, A. A. (1993). Tailoring the therapeutic relationship or being an authentic chameleon. Psychotherapy, 30, 404–407. doi:10.1037/00333204.30.3.404 Lazarus, A. A. (1997). Brief but comprehensive psychotherapy: The multimodal way. New York, NY: Springer. Lazarus, A. A., Beutler, L. E., & Norcross, J. C. (1992). The future of technical eclecticism. Psychotherapy, 29, 11–20. doi:10.1037/0033-3204.29.1.11 Lazarus, A. A., & Lazarus, C. N. (1991). Multimodal Life History Inventory. Champaign, IL: Research Press. Lazarus, A. A., & Lazarus, C. N. (1998). Clinical purposes of the Multimodal Life History Inventory. In G. P. Koocher, J. C. Norcross, & S. S. Hill (Eds.), Psychologists’ desk reference (pp. 15–22). New York, NY: Oxford University Press. Lazarus, A. A., & Rego, S. A. (2013). What really matters: Learning from, not being limited by, empirically supported treatments. The Behavior Therapist, 16(3), 67–69. Lazarus, C. N. (1991). Conventional diagnostic nomenclature versus multimodal assessment. Psychological Reports, 68, 1363–1367. doi:10.2466/ pr0.1991.68.3c.1363

MULTISYSTEMIC THERAPY Multisystemic therapy(MST) is a structured treatment that uses intensive, home-based family counseling as a method for treating youth with antisocial behaviors. Rooted in social ecology theory, MST treats youth and their families in their natural environments in the home, school, and community. Youth between the ages of 12 and 17 years at risk of out-of-home placement, such as those involved in the juvenile justice system or with child protective services, are the focus of MST. MST utilizes nine guiding principles to develop specific assessment and treatment formats. Interventions are developed jointly with the youth, family members, and school or agency representatives. Clinicians generally

Multisystemic Therapy

provide treatment in the home; are on call 24 hours a day, 7 days a week; and have a small caseload of four to six clients for whom they provide multiple, intensive family sessions within a week. Treatment lasts between 3 and 5 months. MST has been widely studied by its developers and is evidence based. It is currently used in a majority of U.S. states and internationally.

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contributing factors, such as negative peers, and designed to increase positive social (prosocial) behaviors and people within the youth’s ecology. Emphasis is placed on stopping cyclic reciprocal behavior, such as negative reinforcement occurring when parents stop assigning chores in response to youth violence.

Major Concepts Historical Context Scott W. Henggeler began developing MST in the mid-1970s in response to research on the ineffectiveness of out-of-home juvenile offender placement. His research showed that placing youth in facilities, such as residential treatment or juvenile detention centers, exacerbated antisocial behaviors, created deeper networks of delinquent youth, and left unaddressed the problems in the youth’s environment contributing to offending behaviors. He learned that many teens leaving these facilities reengaged in antisocial behaviors, such as theft, truancy, drug use, and curfew violations, or learned new behaviors from peers. MST was developed to address the evidence that multiple factors in the individual, home, school, and community contributed to juvenile delinquency and the failure of outof-home placement. At the Medical University of South Carolina in the 1990s, Henggeler coformed the Family Services Research Center to study evidence-based treatment methods and created MST Services, a university-affiliated organization, to manage the MST model.

Theoretical Underpinnings Based on social ecology theory, MST posits that adolescent behavior is influenced by the interaction of multiple factors occurring in a youth’s life, family, school, and community. Treatment for antisocial behavior must address the factors influencing each individual teen, focus within their natural ecological settings, and involve all elements of the systems affecting their life. Home- and communitybased treatment addresses the common barriers to treatment for delinquent youth, such as transportation. Detailed assessments, including all environmental factors contributing to delinquent behaviors, form the basis of individualized treatment plans aimed at eliminating antisocial behaviors and their

MST is based on, and treatment must connect to, nine guiding principles. It should aim at (1) finding the fit; (2) being positive and strengths focused; (3)  increasing responsibility; (4) being present focused, action oriented, and well-defined; (5) targeting sequences; (6) being developmentally appropriate; (7) continuous effort; (8) evaluation and accountability; and (9) generalization. Finding the Fit

Assessment focuses on finding the connections (or fit) between antisocial behaviors and their environmental occurrence context. Positive and Strengths Focused

Therapeutic involvement should emphasize positive elements and be strengths based. Increasing Responsibility

Interventions should increase family and individual responsibility. Present Focused, Action Oriented, and Well-Defined

Clearly defined interventions require specific action by family members to succeed and are focused on the here-and-now. Targeting Sequences

Interventions target sequences that occur in multiple systems influencing antisocial behaviors. Developmentally Appropriate

Interventions should match the developmental level of youth.

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Continuous Effort

Interventions require youth and their families to put in regular effort toward completion of treatment. Evaluation and Accountability

Clinicians are accountable for successful treatment. Effectiveness is evaluated continuously. Generalization

Interventions are designed for parental maintenance following treatment and are generalizable to other family problems.

officers, positive peers, etc.) by following the nine guiding principles. Future sessions involve working toward and adjusting treatment goals and interventions based on barriers to achieving them that arise from the youth and their family. Clinicians meet weekly with their MST team and supervisor to review cases and apply the model to problems, treatments, and barriers. Following supervision, clinicians review treatment plans with consultants, who ensure fidelity to the MST model. Treatment ends when prosocial behaviors within the home, school, and community have replaced the identified problem behaviors and those behaviors are sustained for a period of 1 to 2 months. Kevin C. Snow

Techniques MST interventions embrace many approaches, including empathy, warmth, and cognitive-ehavioral techniques. Regular training, supervision, and consultation ensure that treatments align with the nine guiding principles. Several proprietary concepts are unique to MST and its treatment protocol, but finding the fit is the essential concept of the model. Assessment begins the process of locating the connection between problem behaviors and the environmental placement of those problems (the fit). Once the fit is defined for each identified problem, treatment interventions are developed to decrease antisocial behaviors and increase positive social (or prosocial) behaviors. Throughout treatment, challenges to success, such as parental failure to implement behavioral consequences, are addressed, and interventions are adjusted to overcome the barriers.

Therapeutic Process Clinicians, having small caseloads of four to six families, are available on call 24 hours a day, 7 days a week. Services are delivered within the home, school, or community settings. Early sessions involve detailed assessments of the multiple contributing factors within the youth’s environment leading to antisocial behaviors. Specific treatment goals are developed in subsequent sessions, utilizing a systems approach and incorporating input from all involved parties (e.g., parents, extended family, teachers, probation

See also Cognitive-Behavioral Family Therapy; Ecological Counseling; Solution-Focused Brief Family Therapy; Structural Family Therapy

Further Readings Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic therapy for antisocial children and adolescents (2nd ed.). New York, NY: Guilford Press. Swenson, C. C., Henggeler, S. W., Taylor, I. S., & Addison, O. W. (2005). Multisystemic therapy and neighborhood partnerships: Reducing adolescent violence and substance abuse. New York, NY: Guilford Press. Wells, C., Adhyaru, J., Cannon, J., Lamond, M., & Baruch, G. (2010). Multisystemic therapy (MST) for youth offending, psychiatric disorder and substance abuse: Case examples from a UK MST team. Child and Adolescent Mental Health, 15, 142–149. doi:10.1111/j.1475-3588.2009.00555.x

MULTITHEORETICAL PSYCHOTHERAPY Multitheoretical psychotherapy (MTP) is an integrative model encouraging therapists to combine interventions from more than one theoretical source, based on clients’ individual needs. MTP focuses on the interaction between three concurrent dimensions of functioning: thoughts, feelings, and actions. These dimensions are shaped

Multitheoretical Psychotherapy

byfour contextual dimensions: biology, interpersonal patterns, social systems, and cultural contexts. MTP describes key strategies from seven psychotherapy theories corresponding to these seven dimensions.

Historical Context MTP was developed by Jeff Harris and colleagues between 2000 and 2008, while he was working at the University of Hawaii at Manoa’s Counseling and Student Development Center. It was designed as a practical method for training psychotherapists to acquire a broad repertoire of intervention strategies and to plan for integrative treatment. MTP is considered a second-generation model of psychotherapy integration because it builds on principles found in earlier models. MTP encourages multidimensional integration in a way similar to Arnold Lazarus’s multimodal psychotherapy. A multitheoretical framework is proposed similar to the one described in James O. Prochaska and Carlo C. DiClemente’s transtheoretical model. Harris is now a professor at Texas Woman’s University, where his research focuses on developing and testing MTP as a training and treatment method. A simple introduction to MTP, called “Key Strategies Training,” has been developed. MTP is being applied to the treatment of depression, trauma, and addictions.

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Theoretical Underpinnings MTP describes key strategies from seven psychotherapy theories focusing on different dimensions of functioning. The relationship between the psychotherapy theories and the focal dimensions is illustrated in Table 1. MTP does not try to reconcile the underlying differences between these theories but encourages psychotherapists to combine strategies from more than one source. The psychotherapy integration literature describes four different routes to integration, and MTP combines features of technical eclecticism and theoretical integration. Like other models of technical eclecticism, MTP describes intervention strategies that can be utilized from different theories based on the needs of individual clients. Like other models of theoretical integration, MTP describes the relationship between distinct theories and where each approach might be most useful.

Major Concepts Five Principles for Psychotherapy Integration

MTP is based on five principles, suggesting that psychotherapy should be (1) intentional, (2) multidimensional, (3) multitheoretical, (4) strategy based, and (5) relational. Intentional integration involves acting with direction and purpose based on collaborative dialogue with clients. Multidimensional

Table 1 A Multitheoretical Framework for Psychotherapy Theories Focusing on Concurrent Dimensions of Functioning

Focal Dimensions

Cognitive

Thoughts

Behavioral

Actions

Experiential-humanistic

Feelings

Theories Focusing on Contextual Dimensions of Functioning

Focal Dimensions

Biopsychosocial

Biology

Psychodynamic-interpersonal

Interpersonal patterns

Systemic-constructivist

Social systems

Multicultural-feminist

Cultural contexts

Source: Modified from J. E. Brooks-Harris, Integrative Multitheoretical Psychotherapy. Boston, MA: Houghton Mifflin (2008).

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integration involves recognizing the ways different dimensions interact to cause distress. Multitheoretical integration advocates the use of different theories based on the focal dimensions established for each client (see Table 1). Strategy-based integration involves using intervention strategies drawn from a variety of theoretical sources. Relational integration recognizes that psychotherapists can make intentional choices about the relationship styles they cultivate with different clients. Multidimensional Adaptation

MTP describes the purpose of psychotherapy as fostering adaptation. In this context, thoughts, actions, and feelings can be either adaptive or maladaptive. Functional thoughts are the intended outcome of cognitive strategies. Effective actions are the desired result of behavioral interventions. Adaptive feelings are the expected consequence of experiential strategies. MTP proposes that psychotherapy can help clients embrace thoughts, actions, and feelings that can help them adapt to biological, interpersonal, systemic, and cultural contexts. Key Strategies

MTP describes a catalog of key strategies that represents diverse options for intervention. Each of the seven theories listed in Table 1 has been detailed with 12 to 16 key strategies. Key strategies are more complex than microskills—such as open questions or summarization—and can be implemented at different levels of complexity. The following are three examples of key strategies: COG-6: Forming and testing hypotheses about the client’s beliefs and perceptions BHV-8: Prescribing specific actions or assigning homework that activates behavior or alters longstanding patterns EXP-7: Identifying, connecting, and integrating different parts of self

MTP’s description of each key strategy includes a theoretical context, a strategy marker, suggestions for use, an expected consequence, and a case example.

Techniques To choose which theories to emphasize and which strategies to implement, MTP describes a five-step process of integrative treatment planning: 1. Watching for multidimensional focus markers involves listening to clients for markers that indicate a useful focus for treatment. 2. Conducting a multidimensional survey allows psychotherapists to explore clients’ thoughts, actions, and feelings within the contexts of biology, interpersonal patterns, social systems, and culture. 3. Establishing an interactive focus on two or three dimensions results in agreement on a useful place to start the process of therapeutic exploration and change. 4. Formulating a multitheoretical conceptualization allows psychotherapists to use more than one theory to understand clients and to promote multidimensional change. 5. Choosing interventions from a catalog of key strategies encourages therapists to translate theory into practice.

Therapeutic Process Throughout psychotherapy, MTP encourages intentional choices based on collaborative dialogue with clients. MTP recognizes that different relationship stances have been advocated by different theories, including collaborative empiricism, social reinforcement, empathic attunement, health promotion, participant-observation, social choreography, and cultural consultation. Different relationship styles can be cultivated based on clients’ needs and preferences. Jeff E. Harris See also Eclecticism; Integrative Approaches: Overview; Multimodal Therapy; Transtheoretical Model

Further Readings Brooks-Harris, J. E. (2008). Integrative multitheoretical psychotherapy. Boston, MA: Houghton Mifflin. Ivey, A. E., & Brooks-Harris, J. E. (2005). Integrative psychotherapy with culturally diverse clients. In

Music Therapy J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 321–339). New York, NY: Oxford University Press. Harris, J. E., Kelley, L. J., Campbell, E. L., & Hammond, E. S. (2014). Key strategies training: An introduction to multitheoretical psychotherapy. Journal of Psychotherapy Integration, 24(2), 138–152. doi:10.1037/a0037056

Websites 3D Recovery: www.3DRecovery.com Multitheoretical Psychotherapy: www.multitheoretical.com

MUSIC THERAPY Music therapists use music experiences as a professional practice to engage and foster change and/or growth in clients. These music experiences allow clients to view their health in an alternative and creative way. Music therapists practice within four main methods—improvisation, recreative, composition, and receptive—which are the foundation of practice and subsequently inform theory and research.

Historical Context The belief that music affects health is at least as old as the writings of Aristotle and Plato. As a profession, music therapy began shortly after World War II. At the time, musicians were hired to play music for hospitalized veterans. Physicians soon realized the therapeutic value that performed music provided their patients. However, they also realized that musicians may find it challenging performing for severely physiologically and psychologically ill patients and so called for musicians to be “trained” to work with these clinical populations. The psychologist E. Thayer Gaston was greatly influential in creating the profession as it is viewed today. He developed a college curriculum to educate and train music therapists at the University of Kansas in the 1940s. Shortly thereafter, similar music therapy training programs were developed at colleges and universities across the country. In 1950, music therapy was officially recognized as a profession. The current professional association is the American Music Therapy Association.

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In 1983, the Certification Board for Music Therapy was established to enhance the credibility and competency of music therapists. Today, it maintains strong standards for education and training. Currently, accredited music colleges and universities offer degrees in music therapy at the undergraduate, master’s, and doctoral levels. Many schools offer equivalency or certificate degrees in music therapy for those who have a completed a degree in another field. Although music therapy students receive traditional music training, allied health classes such as anatomy, physiology, and psychology are also commonly required for degree completion.

Theoretical Underpinnings Kenneth E. Bruscia’s theory defining music therapy posits the foundational and fundamental characteristics of the roles of the therapist, the client, and the music within music therapy. Although this theory provides an overview of all areas of music therapy, an integrative perspective is presented for music therapists who work within a psychotherapy and counseling context. The theory also functions as a learning tool for both music therapists and non–music therapists alike in understanding theory, research, and practice in music therapy. There is a vast array of theories and philosophies that are foundational for music therapy practice, particularly as it relates to psychotherapy. The various theories and philosophies fall into five main categories, or a combination of these categories. First, there are theories and philosophies in music therapy that accommodate theories from traditional psychotherapy. For example, a psychodynamic music psychotherapy theory addresses how one projects the unconscious onto music. Second are theories and philosophies that accommodate a more specific psychotherapy approach. For example, Jungian archetypal theory is helpful to explain how certain types of music relate to universal, deeply embedded human themes (“the warrior,” “earth mother,” etc.). The third category includes indigenous music therapy theories and philosophies on the roles of sound and sound relationships, and/or philosophical discussion on the nature of music. For example, what are the essential characteristics, if any, of music and music making that provide the foundation for growth

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and/or health? The theories in this category promote the idea that music therapy theory does not need to accommodate or assimilate theories from other disciplines such as psychotherapy or counseling. Fourth, theories and philosophies that have a phylogenetic basis propose that music and music making are a part of our biological makeup and, perhaps, even necessary for health. These theories assert that it is important for clients not only to be exposed to music in their lives to grow and change but also to interact with music experiences. The fifth category includes theories that have been developed from specific models of music therapy. There are several common models that are used (see the “Techniques” section). For example, in music-centered music therapy, using improvisation with clients provides the means for clients to understand self. Finally, there are those theories that do not fit nicely into one of the categories listed above—for example, music therapy theories that accommodate or assimilate theories on the metaphysics of music or the psychology of music.

Major Concepts There are six major concepts in music therapy. Inherent in each of these concepts is the idea that music functions as both a medium and a means— the music is the medium, and music experiences are the means. Music Therapy Has Four Main Types of Experiences

There are four main types of music experiences: improvisation, recreative, composition, and receptive (listening). Improvisation is spontaneous music making with musical instruments. The instruments used may vary from traditional instruments, such as piano, guitar, or percussion, to culture-specific instruments. Vocal improvisation is also widely used, with or without instruments. Recreative methods include learning or performing music. In this method, musical development does not mean that the client becomes “good” at making music but that growth, change, or meaning is found in the act of making music. In composition methods, the music therapist assists the client with writing songs, lyrics, or pieces of music. Receptive methods

include processes in which the client listens to music and, importantly, responds to the listening experience. Although listening to music may be therapeutic by nature and many may enjoy listening to music, this method focuses on the listening within the therapeutic relationship and the subsequent internal experiences that may emerge. Music Therapy Is Method Based Rather Than Outcome Based

“Method based” implies that there is a systematic process in working with clients in achieving goals and objectives. The therapist has a knowledge base that meets the needs or health concerns of the client. “Outcome based” implies that health may only be achieved by prescriptive music experiences. Therefore, the client would be solely dependent on the therapist for growth or change. Music Therapy Is Typically Experiential Instead of Verbal

In music therapy, there are aspects of the session where traditional verbal techniques may be used, and some sessions may even have a high verbal component, while other sessions may be all music experiences. Thus, depending on the circumstances (e.g., client, session, etc.), music therapists may use verbal techniques in preparing the client for a music experience and/or clarifying the client’s feelings and emotions during and after a music experience. Music Therapy Is Creative

Musical ability or talent is not a necessary component for a client to receive music therapy. Music therapists presume that musical products employed within various music experiences are creative experiences and are valued as part of the process. Creativity in the music allows for the client to imagine, think, or experience new ways of being. For example, a client who may have difficulty expressing emotions verbally may find that a music experience more suitably describes his or her emotions. Music Therapy Is Relationship Based

Whereas the focus of many therapeutic professions is on the therapist–client relationship only,

Music Therapy

music therapy also focuses on the relationships within and through the music. Therefore, the following relationships may occur: (a) the client’s relationship with the music, (b) the client’s relationship with the therapist, (c) the therapist’s relationship with the client, (d) the therapist’s relationship with the client’s music, (e) the intrapersonal relationships the client has with the music and with the therapist, and (f) the intrapersonal relationships the therapist has with the music and the client. Music Therapy Is a Science, Art, and Humanity

The use of music and music experiences is a movement between science, art, and humanity. As a science, music therapy has predictable and observable changes. As an art, the engagement in the music experience provides meaning in and of itself. As a humanity, music therapy situates the client, the therapist, and the music experiences in the larger health context of the client’s community. For example, the client’s “health” is related to the client’s community or culture’s “health”; that is, an individual’s health is dependent on the individual’s culture.

Techniques This section discusses six of the most commonly practiced models of music therapy. Each has its own theory, practice, and research traditions and, therefore, its own specific techniques. Analytical Music Therapy

Developed by the British music therapist Mary Priestly, analytical music therapy is a combination of traditional psychoanalytical theory and improvisational methods. The premise of analytical music therapy is that emotional problems occur due to the repression of memories and are manifested in destructive or relational patterns The main goal is for the client to free or “let go of” these destructive patterns through the music experience. These negative emotions are then less likely to be avoided while being subconsciously expressed through the music. The music therapist is specifically trained in using improvisation and composition throughout the music therapy session. The technique involves the client and the therapist (a) discussing current

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issues and problems, (b) exploring those issues and problems through the music experience, and then (c) discussing how the music experience relates to the client’s personal life. Bonny Method of Guided Imagery and Music

The Bonny method of guided imagery and music was developed by Helen Bonny while working with Walter Pahnke at the Maryland Psychiatric Research Center in the late 1960s and early 1970s. During this time period, psychedelic drugs were used to induct clients into an altered state of consciousness, which was believed to lead to a deep level of exploration into the psyche. While drugged, the patients imaged, which provided the psychiatrists at the research center access to the clients’ consciousness. Bonny developed music programs that could elicit the same altered state of consciousness without the use of drugs. Although other psychotherapy and counseling fields use guided imagery and music, the Bonny method of guided imagery and music is a specific method that requires advanced training and education. This model is the only receptive model of music therapy. Culture-Centered Music Therapy

As suggested by the music therapy scholar Brynjulf Stige, the relatively new approach of culture-centered music therapy is associated with social science theories and has a progressive or activist dimension in expanding the role of the music therapist within the client’s culture or community. One of the basic premises is that there is a communal aspect of making music with others that goes beyond the boundaries of traditional forms of psychotherapy and counseling. This technique involves incorporating each method of  music therapy within the client’s culture or community. Music-Centered Music Therapy

Music-centered music therapy, proposed by the music therapist and researcher Ken Aigen, promotes the idea that music is the means to reach clinical goals and objectives; there is no need for verbal interpretation or discussion. This concept is closely related to Nordoff-Robbins music therapy

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and the aesthetic philosophy of John Dewey. Client experience is of utmost importance; goals and objectives are both developed and treated purely with music. There is then congruence between the client’s personal process and the client’s musical development. Typically, improvisation and compositional techniques are used for music-centered music therapy. Neurological Music Therapy

Developed by the music and neuroscience professor Michael Thaut at Colorado State University, neurological music therapy is based in neuroscience and the idea that music perception, and music, influences changes in nonmusical behavior and brain functions. The fundamental premise is the understanding of how the brain works with music and without music and that music experiences have a tremendous impact on brain function. For example, the technique may involve playing a musical instrument to activate the auditory cortex, which then activates the motor circuits in improving brain functioning in stroke patients. Nordoff-Robbins Music Therapy

Developed by the composer Paul Nordoff and the special-needs educator Clive Robbins, NordoffRobbins music therapy (NRMT) uses improvised and individually composed music to promote the internal development of the client. Some of the core concepts of NRMT are that humans (a) are inherently musical, (b) have a “music child” that can be accessed through music, and (c) have a “conditioned child” that is incomplete, debilitated, or assessed as “unhealthy.” Through the use of music improvisation, the client is able to create a new self called the “being child.” NRMT therapists are specifically trained to use improvisations and compositions, with limited verbalizations, to work with the client throughout the session. It is through the music that the health objective is achieved.

Therapeutic Process Music therapy is an interactive and reflexive process involving the music therapist, the client, and the music experiences. The process includes assessment, treatment, and evaluation with both groups and individuals. Assessment, treatment, and

evaluation occur throughout the treatment as well as within specific sessions. For example, a music therapist will use an assessment tool that provides the treatment goals and objectives, and near the end of treatment the client’s progress is evaluated. Also, assessment, treatment, and evaluation may be completed within a specific session. For example, the therapist assesses something in a specific music experience, which leads to a specific treatment objective, and the therapist evaluates that objective completely within one session. There is no typical music therapy process with regard to length of a session and number of sessions. The length and style of a session are based on the client’s needs and the music therapist’s training, education, and/or orientation. The music therapist develops a relationship with the client through the music. This is not a social or entertainment-based relationship but one based on the inherent meaning found through and with the music. Michael L. Zanders See also Behavior Therapies: Overview; Client-Centered Counseling; Contemporary Psychodynamic-Based Therapies: Overview; Creative Arts and Expressive Therapies; Integrative Forgiveness Psychotherapy

Further Readings Aigen, K. (2005). Music-centered music therapy. Gilsum, NH: Barcelona. Bonny, H. (2002). Facilitating guided imagery and music (GIM) sessions. In L. Summer (Ed.), Music consciousness: The evolution of guided imagery and music (pp. 269–297). Gilsum, NH: Barcelona. Bruscia, K. E. (Ed.). (1991). Case studies in music therapy. Gilsum, NH: Barcelona. Bruscia, K. E. (1998). Defining music therapy (2nd ed.). Gilsum, NH: Barcelona. Kenny, C. B. (Ed.). (1995). Listening, playing, creating: Essays on the power of sound. Albany: State University of New York Press. Priestly, M. (1994). Essays on analytical music therapy. Gilsum, NH: Barcelona. Standley, J., Johnson, C. M., Robb, S. L., Brownell, M. D., & Kim, S. (2008). Behavioral approaches to music therapy. In A. A. Darrow (Ed.), Introduction to approaches in music therapy (2nd ed., pp. 105–127). Silver Spring, MD: American Music Therapy Association. Stige, B. (2002). Culture-centered music therapy. Gilsum, NH: Barcelona.

N the emergence of narrative family therapy as socialconstructivist thought was beginning to gain attention in the field of family therapy in the latter half of the 20th century. White’s early perspectives of postmodern thought were informed by Gregory Bateson, who in the 1970s was a member of the Palo Alto Group, an intellectual center for the study of family therapy at the time that included Don Jackson and Jay Haley as members. Bateson introduced White to the “interpretive method” as a way of examining strategies of power and the way people make meaning of the world around them. Bateson proposed that individuals do not know reality directly but rely on interpretations of their experiences as guided by mental maps. A major tenet of Bateson’s was that the formations of these maps are influenced by society and culture and are not reality but merely imperfect representations of reality. White was further influenced by the work of the French historian-philosopher Michel Foucault, who argued that knowledge is embedded in the shifting cultural ages of history and accompanied by related shifts in power. Foucault maintained that shifts in knowledge and power are driven by those in dominant positions of power and form social discourses that individuals use to form their reality. White’s interest in liberating people from the effects of systematic oppression was also heavily influenced by his wife, Cheryl White, a feminist and social activist, who founded the Dulwich Center in Adelaide, Australia, in 1983, which served as a testing ground of sorts for exploring new narrative practices and ideas with school and native aboriginal communities.

NARRATIVE FAMILY THERAPY Narrative family therapy, developed by Michael White and David Epston, is likely the most visible result of the convergence of postmodern thought and the evolving counseling profession during the latter part of the 20th century. This form of counseling adheres to the social-constructionist view of reality— that is, that each person in a family system constructs reality through the use of self-defined narratives in social exchanges with others. This theory maintains that language is not merely used to transmit one’s reality but that language forms one’s reality as influenced by the values of those in positions of power and privilege, which sway the formation of language. These cultural influences in effect establish norms that individuals internalize and compare themselves against as they construct stories of their lives. Therefore, narrative family therapists do not view problems as originating in one individual in the family system but as the reflections of destructive, problem-saturated narratives resulting from the influence of larger, dominant cultural narratives that permeate each family member’s reality. Accordingly, narrative family therapists assist families in externalizing problems, deconstructing self-limiting or destructive stories, and creating and internalizing new stories that offer new possibilities and realities.

Historical Context Michel White, a social worker from Australia, is widely credited with being the leading force behind 691

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In the 1980s, White also became interested in the work of David Epston, a family therapist from New Zealand at the Family Therapy Centre in Auckland, who is widely regarded as the second most influential force in the formation of the narrative method. Epston’s interests included anthropology and the role of storytelling, and he was known at the time for his work forming antianorexia and antibulimia groups and his innovative use of writing letters to clients and families to extend the therapeutic effect of conversations. Epston was the first person to offer the idea of the narrative metaphor to White, and the two men collaborated to define this new theory, which countered the prevailing thought across existing theories of family therapy that placed therapists in the position of the “expert,” relying on models based on analytic interpretation and definitions of normal family functioning, and locating dysfunction in individual family members. The two colleagues wrote Narrative Means to Therapeutic Ends in 1990, and in a series of international conferences attended by a wide variety of family therapists that followed, the title of “narrative family therapy” was adopted for the theory behind White and Epston’s work. White died in 2008, and Epston continues as the codirector of the Family Therapy Centre, but others have furthered their groundbreaking work. Stephen Madigan, a Canadian who collaborated with White and Epston, is one of the most prominent and active narrative therapists in North America today. In 1992, he opened the Vancouver School for Narrative Therapy and remains focused on clarifying the effect that knowledge imparts on community discourse that supports the marginalization and oppression of the underprivileged.

Theoretical Underpinnings Narrative family therapists support a socialconstructivist view of reality and believe that the narratives that people use to describe their lives come from interactions with others as influenced by dominant cultural narratives. Therapists using narrative therapy do not solve problems but adopt a collaborative, respectful, curious, and nonexpert stance to help family members separate themselves from problem-saturated and limiting narratives. By externalizing problems and positioning them

outside the family system, the narrative family therapist facilitates the family in working together toward fighting a common enemy. The stories families tell include many important thoughts, beliefs, and events that define them and are internalized. These thin descriptions are problem laden and include labels or language imposed by people or institutions of power. By deconstructing these self-limiting narratives and labels and examining their effect on self-concept, the therapist promotes and supports the family in constructing thick descriptions that include multiple viewpoints, move beyond mere labels, and open doors for reauthoring alternate narratives that create new realities for each family member and the family as a whole.

Major Concepts Narrative therapists believe in the concept of the narrative metaphor, which maintains the idea that reality is formed and maintained by stories that are influenced by certain dominant narratives in culture and are linked over time to make sense of one’s life. Therefore, the narrative therapist believes that the self-narratives that individuals and families share with others are not reflections of reality but actually form their reality. The major ideas that flow from this philosophy include (a) the collaborative therapeutic relationship, (b) the narrative perspective, (c) the influence of dominant cultural narratives, and (d) thin and thick descriptions. The Therapeutic Relationship

As a postmodern approach to therapy, narrative therapy rejects viewing families as cybernetic systems to be reprogrammed by an expert therapist, as modern theories maintain. Instead, narrative therapists assume a not-knowing stance driven by a tradition of hermeneutic theory, which focuses on interpretation of beliefs and assumptions in the construction of meaning and knowledge. Because narrative therapists recognize the importance of forming a collaborative relationship with families that is respectful and curious, conversations emerge in which sources of meaning are explored over time and new meanings are created that liberate the family from the effects of existing dominant cultural

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themes. Narrative family therapists conduct therapy with families as opposed to providing therapy to families. The Narrative Perspective

A perspective represents both a way of viewing and giving meaning to life and a way of living. The narrative perspective not only a view of where problems are located and approaches for assisting people to find more meaningful stories but also invites the therapist to address problematic social discourses. The development of this perspective was heavily influenced by Bateson’s work on the interpretive method, which acknowledges that we cannot know reality directly, but rather, our knowledge of the world is carried in a series of mental maps. It is the interpretation of events over time that forms the stories that constitute our lives. Dominant Cultural Narratives

A family’s collective identity and reality, as formed by the stories they tell, involve interpretations of past experiences and internalization of the meanings attached to them. These interpretations and meanings are influenced by larger cultural narratives that transmit messages of privilege and normality against which family members compare their own experiences while selecting the language that constructs the stories of their lives. Narrative therapy recognizes the power dominant cultural narratives exert, particularly when a family’s experiences fall outside the customary or preferred ways of behaving in a certain culture. Toxic beliefs that form the basis of oppression based on race, class, gender, and so forth are also contained in cultural narratives and internalized by family members. Therefore, the narrative family therapist joins the family in externalizing and deconstructing dominant cultural narratives that are problematic and self-restricting to free the family from the problem as they co-construct alternative stories.

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stories are consciously or unconsciously omitted, and the stories include descriptions or labels imposed on the family by others with definitional power. Descriptions incorporated into the family’s history that include oppressive or self-limiting truths are known as thin descriptions. Thin descriptions mask complexities of life and meaningmaking processes and lead to thin conclusions that disempower individuals. As oppressive and controlling influences present in the family’s story are identified and interpreted by the therapeutic partnership, client families begin making meaning of their own experiences and shed destructive cultural assumptions that bring problems into the family’s reality. Alternatively, thick stories emerge through the skillful use of questions by the narrative family therapist. These descriptions are more elaborate than their thin counterparts and include subjective experiences, hopes, and dreams as well as the family’s shared values and beliefs that are free of the restrictions of dominant cultural narratives. By telling and retelling alternative stories, the family replaces problem-saturated narratives with multistoried lives as they become more aware of the alternatives and numerous possibilities that exist.

Techniques In contrast to many other theories, narrative family therapy relies more on the therapist’s attitudes and perspectives than on a set formula of techniques. Much like person-centered and existential therapy, the therapist’s way of being and personal characteristics are paramount to establishing a climate that allows clients to view their life stories from other perspectives. Narrative family therapy does not establish a set of techniques but rather challenges the therapist to apply a set of specific skills such as questioning, externalizing, and deconstructing problem narratives; searching for unique outcomes; assisting clients with reauthoring and reinforcing their new stories; and writing letters.

Thin and Thick Descriptions

Questioning

The problem-saturated stories that families bring to therapy contain many important facts and events necessary to understand the family’s plight. However, many items and pieces of the family’s

Narrative therapists are said to be masters at asking questions and judiciously use questions throughout the counseling process that access and surface new thoughts. Through respectful and

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attentive listening when openings present themselves, the narrative therapist asks questions that assist the family in externalizing the problem, deconstructing its source and influence, identifying unique outcomes, or reauthoring their stories. Using questions in this way supports the therapist’s role as a respectful and curious collaborator and adds thickness to family members’ narratives, which highlights positive alternatives for the family’s future. Externalizing and Deconstructing

Externalization is an attitude promoted by the therapist to frame the problem as the problem and remove dysfunction or pathology labels from any individual in the family system. Because any number of stories can be created to describe an event in the family system, the therapist engages in externalizing conversations to encourage family members to describe their relationship to the problem and how it has affected many pertinent areas of their lives. Externalizing in this way illuminates alternative descriptions of current problems by each family member and opens him or her to examining his or her relationship to the problem and the effects of internalizing it. As the stories are externalized, family members experience enough separation from the problem so that the therapist is able to next ask questions about takenfor-granted realities and that lead to the problemsaturated narratives. By deconstructing the sources and effects of externally imposed values, beliefs, and truths that have been internalized, the therapist assists family members in better understanding how they were recruited into the problem according to culturally transmitted norms of gender, age, class, and so on, which are sustained in the problem narratives. Searching for Unique Outcomes

Probing for unique outcomes adds thickness to thin descriptions of family narratives and opens possibilities for including alternatives. Identifying unique outcomes orients individual family members and the family as a whole to specific aspects of their past. It is through this exploration that the therapist is able to illuminate contradictions and exceptions to the previously internalized dominant

cultural values, beliefs, and truths that contributed to the formation of the problem narrative. Identifying unique outcomes provides the family with proof of the power of external influences on their current narratives and proof that these narratives can be changed. Reauthoring and Reinforcing

As families separate from their problems, and contradictions to dominant stories in the past are illuminated and unique exceptions identified, the therapist is able to lead the family on an exploration of the meaning of the unique outcomes and how they may be incorporated into creating new narratives. Once again using questions, the therapist and the family interpret the formation of redescriptions and new meanings attached to the unique outcomes of the past. By shifting to using questions that probe the unique possibilities associated with the exceptions of the past, the family is able to move from past and present foci to allow for the creation of narratives for the future as well. One of the most effective ways of strengthening the new, developing story is by creating a receptive audience who serve as “witnesses.” The therapist serves as an initial audience to witness the family’s changing narrative, but the client family should be encouraged to identify other audience members to share it with. It is key that any audience be composed of supportive and optimistic people who can offer validation to the family’s new reality. Documenting

Epston wrote letters to clients between sessions, and many narrative therapists continue this practice today. Letters serve a number of different purposes, including prolonging the therapeutic effect of sessions, supporting families in maintaining curiosity about change, keeping families connected to their emerging alternative stories, and stimulating family members to continued discourse for meaning making that supports internalizing alternative stories. Letters provide a great tool for maintaining continuity of the narrative process because they can be read and reread over time. A narrative therapist may use summary letters to recap sessions and remind family members of emerging stories, themes, and unique outcomes.

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Letters may also be written to invite and encourage the participation of reluctant family members in the process, note duplications of roles in the family to those wishing to change them, thank family members for their participation and inform them that they no longer need to play their role in the alternative narrative, and, at the conclusion of therapy, predict continued success and encourage the family to continue to search for new possibilities. Whatever the narrative therapist’s form and purpose as a collaborator, the narrative therapist maintains transparency by exposing his or her thoughts to the family in letters and by providing room for confirmation or challenge as the process of co-construction progresses.

Therapeutic Process Narrative family therapy is a nondirective, collaborative, and relatively brief form of family therapy. Throughout the therapeutic process, therapists consistently and skillfully ask questions to promote the development of new narratives. This allows client families to feel safe and respected within the therapeutic relationship and be willing to share in examining internalized and self-limiting truths transmitted from the dominant culture. Over time, family members and the family as a whole become more aware of the effect that dominant cultural narratives have had in creating problem-saturated narratives, and they become empowered to reauthor their stories of the past, present, and future. Once armed with new, problem-free stories, the therapist provides reinforcement and support to the family through the use of letters and by facilitating the recruitment of others who can serve as audiences or witnesses to the family’s new narratives. Herman R. Lukow II and Emilie Godwin See also Constructivist Therapies: Overview; Constructivist Therapy; Existential-Humanistic Therapies: Overview; Palo Alto Group; White, Michael

Further Readings Beels, C. (2009). Some historical conditions of narrative work. Family Process, 48(3), 363–378. doi:10.1111/j.1545-5300.2009.01288.x

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Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, T., & Trepper, T. S. (2012). From Ericksonian roots to postmodern futures: Part I. Finding postmodernism. Journal of Systemic Therapies, 31(4), 63–76. doi:10.1521/ jsyt.2012.31.4.63 Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, T., & Trepper, T. S. (2013). From Ericksonian roots to postmodern futures: Part II. Shaping the future. Journal of Systemic Therapies, 32(2), 35–45. doi:10.1521/ jsyt.2013.32.2.35 Epston, D. (2008). Saying hullo again: Remembering Michael White. Journal of Systemic Therapies, 27(3), 1–15. doi:10.1521/jsyt.2008.27.3.1 Goldberg, H., & Goldberg, I. (2008). Family therapy: An overview (7th ed.). Belmont, CA: Thompson. Lewis, R. E. (2003). Brief theories. In D. Capuzzi & D. R. Gross (Eds.), Theories of psychotherapy (pp. 286–310). Upper Saddle River, NJ: Pearson. Minuchin, S. (1998). Where is the family in narrative family therapy? Journal of Marital and Family Therapy, 24(4), 397–403. doi:10.1111/j.1752-0606.1998.tb01094.x Schwartz, R. C. (1999). Narrative therapy expands and contracts family therapy’s horizons. Journal of Marital and Family Therapy, 25(2), 263–267. doi:10.1111/j.1752-0606.1999.tb01127.x Shalay, N., & Brownlee, K. (2007). Narrative family therapy with blended families. Journal of Family Psychotherapy, 18(2), 17–30. doi:10.1300/J085v18n02_02 White, M. (2007). Maps of narrative practice. New York, NY: W. W. Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton.

NARRATIVE THERAPY Narrative therapy (NT) is a strengths-based approach to psychotherapy that uses collaboration between the client or family and the therapist to help clients see themselves as empowered and capable of living the way they want. In the face of crisis or trauma, NT helps clients achieve a “This too will pass” attitude, while positioning the therapist as an appreciative ally in the process. NT is useful with individuals and is used extensively with families due to its ability to separate clients from problems and unite families against problematic patterns. NT also lends itself well to joining with families because it stresses strengths and achievements over problems.

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Historical Context In the 1980s, Michael White from Adelaine, Australia, and David Epston from Auckland, New Zealand, developed what has come to be known as “narrative family therapy.” White passed away in 2008, but not before NT became widely accepted as a standard option in family therapy. White and  Epston’s original book Narrative Means to Therapeutic Ends was inspired and shaped by Michael Foucault’s theory of power and knowledge. Foucault’s work highlights how social power forges the knowledge that people use to interpret their lives. Using these ideas, NT challenges the dominant knowledges that restrict clients from progressing in their lives. More recently, NT has been influenced by the work of therapists such as Stephen Madigan, who helped popularize techniques such as therapeutic letter-writing campaigns, and William Madsen, who developed collaborative family therapy. Of particular importance was the development of collaborative therapy by Madsen, a narrative approach outlined in his book Collaborative Therapy for Multi-Stressed Families. This book has become a guide for many agencies supporting families due to its straightforward and practical approach to working with systems and multistressed youth. It is also commonly assigned as required reading for many family therapy programs and courses.

Theoretical Underpinnings NT refers to a range of social-constructionist and constructivist approaches to the process of therapeutic change. Therefore, NT is based on the idea that problems are manufactured in social, cultural, and political contexts. Change occurs largely by exploring how language is used to create and maintain problems. Interpretation of one’s experience is at the core of NT, which collapses these experiences into narrative structures or stories that provide a framework for understanding them. To deepen understanding, problems have to be viewed from the context in which they are situated. This includes exploring society as a whole and exploring the impact of various aspects of culture that help create and maintain the problem. To help clients shift their perspectives and change their behavior, NT points out and brings to

mind exceptions to a client’s or family’s stance of no control. It assumes that many of our patterns of behavior are supported by self-fulfilling prophecies or false beliefs about ourselves that have been shaped by the world around us. Using these exceptions, new stories or narratives are created that better match the client’s sense of self. NT is strengths based. This means that the narrative therapist will choose to focus on strengths over problems whenever possible. NT assumes that a client or family will rely on their strengths to overcome problems in their lives, making them an important part of the therapeutic process. Focusing on strengths over problems also helps promote a more collaborative atmosphere where the narrative therapist can admire the client or family outside of the problematic context. This greatly contributes to the joining process and makes it easier to discuss problems without judgment. According to some research, therapists can actually learn more about problems by asking about strengths. NT is goal directed. Narrative therapists are less concerned with what caused a problem and more concerned about what changes will look like when the problem is no longer as much of a problem. NT is also referred to as a future-focused approach for this reason. Treatment plans are positively worded and stress how improvement will be noticed versus how problems will be resolved. Finally, NT does not accept resistance as a useful concept in therapy. That is not to say that narrative therapists do not experience resistance; instead, they interpret it as misunderstanding, rather than some of the other meanings that therapy sometimes chooses to assign. If a narrative therapist is experiencing a client or family as resistant, he or she will respond by considering what is not being understood about the client or family, always taking special care to avoid overresponsibility for a client or family in order to encourage empowerment, recognizing the relatively small role the narrative therapist plays in each client’s or family’s life.

Major Concepts Consistent with a social-constructionist or constructivist paradigm, some of the major concepts include collaboration, dominant stories, social context, thick and thin descriptions, alternative stories and reauthoring, and community of support.

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Collaboration

Thin and Thick Descriptions

Collaboration is among the most important concepts in NT because it helps promote a nonhierarchical relationship between the family and the psychotherapist. Madsen referred to the psychotherapist’s role in this relationship as an appreciative ally, or someone who appreciates the strengths and struggles of the family while striving to gain local knowledge, which is information about the family’s norms, values, and structure that helps elucidate the context where problems exist. The strengths-based and future-focused nature of NT naturally facilitates a more collaborative relationship than problem-based approaches to psychotherapy, which generally establish the psychotherapist as the expert in the relationship.

Thin description is how many clients in NT describe their dominant stories at the onset of therapy. It allows little space for the complexities and contradictions of life. It also allows little space for people to articulate their own particular meanings of their actions and the context within which they occurred. Often, thin descriptions of people’s actions are created by others with the power of definition in particular circumstances (e.g., parent, teachers, health professionals). One goal of the therapist is to help clients develop thick descriptions of their stories, which are more complex narratives that deepen and broaden their story and help individuals view their stories in new ways. Alternative Stories and Reauthoring

Dominant Narratives or Stories

Dominant narratives or stories in NT are made up of events linked by a theme and occurring over time and according to a plot. A story emerges as certain events are privileged and selected over other events as more important or true. As dominant stories take shape, they invite the teller to further select only certain information while other events become neglected, and thus, the same story is continually told. These self-fulfilling prophecies become a template for how clients understand themselves. For example, a client who considers himself or herself as a “late person” may avoid engaging in behaviors to improve timeliness because “I’m going to be late anyway.” Social Context

Social context is where dominant stories are created and maintained. The ways in which we understand our lives are influenced by the broader stories of the culture in which we live. Some of these stories will affect us positively and others negatively. The meanings that clients give to events in their lives do not occur in a vacuum. There is always a context where the dominant stories in our lives are formed. This context contributes to the interpretations and meanings that we give to events. Gender, class, race, culture, and sexual preference are powerful contributors to the plot of the stories by which we live.

When initially faced with seemingly overwhelming thin conclusions and problem stories, narrative therapists are interested in dialogues that promote alternative stories. Alternative stories are examples of clients behaving outside of the problematic context. This process has been referred to as reauthoring in previous literature and is described metaphorically as “shining a light on moments of competence.” Some of the techniques used to facilitate the reauthoring process are discussed in the following section. Community of Support

A community of support is another important concept in NT. A community of support includes anyone that a client or family chooses. It is important because it speaks to the importance of a client’s or family’s support outside of therapy, as well as the impact that a client’s or family’s social context has on the creation and maintenance of the dominant story. Communities of support are called on often in NT to assist with techniques such as letter-writing campaigns and to get a perspective on clients outside of the problematic context. Letter-writing campaigns are described in more detail in the next section, on techniques.

Techniques NT involves the use of a wide variety of techniques to help clients or families examine their lives

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within context and create alternative stories. Psychotherapists select techniques based on their relationship with the family or client and on the ongoing assessment of their progress. Techniques are generally implemented with fluidity rather than in a directive or overly structured way. Some of the more common techniques are joining, unique outcomes or exceptions, externalization, deconstructive questions, reauthoring questions, preference questions, reconnection interviews, therapeutic letter writing, letter-writing campaigns, and definitional ceremonies. Joining

The term joining is used to describe the process involved with establishing a therapeutic relationship in NT. Joining is how the therapist helps position himself or herself as an appreciative ally in clients’ lives. Some of the strategies used to join with clients and families are strengths assessment, listening, and collaboration.

another character in the client’s stories. For example, a client might name anxiety “the Goblin” and talk with his psychotherapist about how he copes when the Goblin comes into the classroom. Deconstructive Questions

Questions used to help narrative therapists, and their clients, to better understand the clients’ problems and dominant narratives are deconstructive questions. Deconstructive questions help narrative therapists learn about a problem’s influence and effects on clients and their community, cultural and other supports, and tactics and strategies. They can also help narrative therapists learn about clients’ preferences or opinions about a problem’s influence, effects, tactics, and supports. An example of a deconstructive question might be “How does anxiety keep making it difficult for you to get where you want to go?” or “When is anxiety most likely to show up in your life?” Reauthoring Questions

Unique Outcomes or Exceptions

As a client increasingly feels comfortable sharing his or her problem-dominated stories, the therapist will try to identify themes that are at odds with the client’s story by asking the client if there were times when there were exceptions to the story. In this manner, clients can begin to view their lives in new ways that do not include the problem narrative. Here, the therapist might be seen asking the client questions like “Was there ever a time when you did not have this problem?” or “Were there times when you effectively managed the problem?” or “Can you tell me about a time when you were able to overcome your problem?”

Reauthoring questions help build and support alternative stories by examining life outside the problem. They also clarify client preferences and values, develop alternative stories in realms of action and meaning, examine new possibilities from alternative stories, and develop support for the enactment of new stories. An example of a reauthoring question might be “What do you think it means that you were able to make it to work on time every day this week?” or “What do you think someone else would say about someone who was able to do that?” or “What do you think your life would look like if you didn’t have the problem?” Preference Questions

Externalization

In externalization, the therapist and the client work collaboratively to find language to describe and ways of thinking about problems as separate from one’s identity. Externalizing client problems often involves referring to problems as entities in and of themselves, which helps remove the sense that the problem resides within the person. This also helps to de-pathologize the individual. Sometimes, especially with children, this can involve imagining

Questions intended to help narrative therapists and their clients better understand client preferences are preference questions. Preference questions are often used with deconstructive questions when learning about cultural supports or tactics to deal with a problem. They can also help evince client preferences about a problem’s influence and effects. An example of a preference question in NT might be “What would that be like?” or “What do you think about that?”

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Reconnection Interviews

Reconnection interviews can help narrative therapists consider a client’s problem and/or the client’s reaction to the problem from the perspective of a respected friend or family member. This allows for outside feedback from someone who can see the client or family outside of the problematic context. When facilitating a reconnection interview, a narrative therapist will ask a client to find a person in his or her past who would recognize and appreciate life outside the problematic story. Clients then provide details of the relationship with that person, finding a specific event that happened in the presence of him or her that highlights an example of life then, outside the current problematic story. The narrative therapist will then link that story and its meaning to the present and  the future, attempting to bring that person’s presence more into the client’s current life. Therapeutic Letter Writing

Narrative therapists will sometimes write letters to their clients following a session to reflect more deeply on the themes discussed or to express positive sentiments regarding a client’s strengths as demonstrated in that session. Therapeutic letters are generally relatively short in length and are intended to promote progress between therapy appointments. Letter-Writing Campaigns

One of the more risky narrative techniques, letter-writing campaigns involve having clients choose others in their community of support to write letters to them about them. For example, a family might choose five people who know them outside the problematic story to write them letters. Their lettered stories live outside the professional and cultural inscriptions that define the family’s suffering and are also stories that stand on the belief that change is possible. They are used in NT to better examine and reinforce alternative or preferred stories. Definitional Ceremonies

Definitional ceremonies, sometimes called outside witness groups, are the witnessing or a retelling

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of a client’s stories to a carefully chosen group of friends or significant others in the client’s life. Witnesses are advised not to congratulate the client but to dialogue with the client about how he or she has changed his or her understanding of the dominant story. This helps solidify and reinforce the reauthoring of a client’s story.

Therapeutic Process Joining is the first step in NT. The ability of a narrative therapist to join with a client or family depends largely on how well he or she is able to understand the context of the problem while focusing on strengths and areas of competence. Many narrative therapists will spend the first session discussing only strengths as part of a strengths assessment to help determine how the client will overcome constraints to their progressing. All narrative therapists spend significant time early on establishing a relationship that is collaborative and free of judgment. Externalization often works well in achieving this outcome, which is vital to the success of the approach. Future-focused treatment planning generally follows the initial joining efforts. Achieving a future focus involves the narrative therapist encouraging the client or family to imagine what life would be like if the problem were not there. If a client or a family is not able to do this, the narrative therapist encourages them to remember life before the problem was there or when the problem was less intrusive. Using an image of life outside of the problematic context as a starting point, the future-focused treatment plan sets short-term goals and considers how progress might be noticed when it happens. Throughout and following this process, deconstructive and reauthoring questions are used to reinforce the  story of the client or family outside of the problematic context. During therapy, sessions are used primarily as an opportunity to check in on successes and revisit the collaborative therapy plan. During these times, narrative therapists take great care to notice and point out examples of the client or family acting in accordance with their preferred stories. As clients move toward an increased sense of mastery and competence in their lives, sessions are generally lessened. Termination correlates with clients

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reaching their stated goals and adopting a “This too will pass” attitude toward new problems in their lives. Robert Rice See also Constructivist Therapies: Overview; Feminist Therapy; Solution-Focused Brief Therapy; White, Michael

specific model in the broad field of ecotherapies that explore and apply the ecopsychology research about how contact with nature can have therapeutic benefits. NGT has been used in the treatment of mood disorders such as anxiety and depression, substance abuse, relationship issues, and child and adolescent therapy.

Historical Context Further Readings Anderson, H., & Goolishian, H. (1992). The client as expert: A not knowing approach to therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 25–39). Newbury Park, CA: Sage. Duvall, J., & Beres, L. (2011). Innovations in narrative therapy: Connecting practice, training, and research. New York, NY: W. W. Norton. Epston, D., & White, M. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton. Freedman, J., & Combs, G. (1996). Shifting paradigms: From systems to stories. In J. Freedman & G. Combs (Eds.), Narrative therapy: The social construction of preferred realities (pp. 1–18). New York, NY: W. W. Norton. Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Madigan, S., & Epston, D. (1995). From “spy-chiatric gaze” to communities of concern: From professional monologue to dialogue. In S. Friedman (Ed.), The reflecting team in action: Collaborative practice in family therapy (pp. 257–276). New York, NY: Guilford Press. Madsen, W. C. (2007). Collaborative therapy with multistressed families. New York, NY: Guilford Press. White, M. (2007). Maps of narrative practice. New York, NY: W. W. Norton. Wylie, M. S. (1994). Panning for gold. Family Therapy Networker, 18(6), 40–48. Zimmerman, J., & Dickerson, V. (1996). If problems talked: Narrative therapy in action. New York, NY: Guilford Press.

NATURE-GUIDED THERAPY Nature-guided therapy (NGT) takes a systemic approach to therapy, seeking to assist people not solely in terms of their individual psyches, relationships, family systems, or social and cultural milieu but also in the person–nature connection. It is a

NGT originated in the Australian prison system in the mid-1970s when the clinical psychologist George W. Burns was researching targeted reinforcers for behavior therapy programs. He observed that nature contexts were most commonly rated as rewarding, relaxing, and enhancing. Researching this observation—across multiple disciplines that often did not find their way into the psychotherapy literature—he found considerable evidence showing the therapeutic benefits of human–nature contact. Over the next couple of decades, he developed and clinically trialed the Sensory Awareness Inventory (SAI). In 1998, he published his findings and therapeutic applications in the book NatureGuided Therapy.

Theoretical Underpinnings NGT is grounded in the theory that throughout our long evolutionary history, we have developed a “biological fit” with nature. This adaptation to our natural environment has been a crucial fact in our physical, psychological, social, and spiritual wellbeing. In recent centuries—a very brief time in our evolutionary history—we have gone from nomadic to agrarian to high-density, highly urbanized environments, which has resulted in an increasing detachment from our historic and evolutionary connections with nature. Growing industrialization, urbanization, and technology are claimed to have outstripped our biological evolution, resulting in a negative effect on our personal well-being, as seen in factors such as the escalating rates of depression in the urbanized, developed world. Because we are now living in a world vastly different from the environments in which we evolved, this mismatch is seen as a cause of much emotional discontent and physical disease. NGT seeks to help people reconnect with nature in ways that will benefit their well-being by taking

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the evidence-based findings and translating them into practical, beneficial therapeutic interventions.

Major Concepts Four major concepts underpin the evidence that human–nature contact can reduce levels of stress, lift feelings of depression, enhance experiences of well-being, improve parasympathetic nervous system functioning, and facilitate optimal functioning: 1. In nature, people commonly escape the pressures and stressors of day-to-day life, such as when gardening, walking through a park, or vacationing at the beach. 2. In nature, there is a sense of being part of an overall larger context, and this tends to alter people’s perspective on other issues. 3. Nature provides a rich variety of sensory stimulation that helps shift internal focus and depressive ideation. 4. Nature, in which we evolved, is conducive to both psychological and physical feelings of well-being.

Techniques The threefold process on which NGT bases its specific strategies and interventions for therapy is as follows: 1. Assist a person to reconnect with his or her positive sensory experiences of nature. 2. Help facilitate a mindful awareness of the sensory connections with nature. 3. Engage the person in individualized human–nature connections to enhance his or her well-being.

These three steps are facilitated by the specific techniques discussed in the following subsections. Sensory Awareness Inventory

Information is gathered about clients’ sensory experiences that provide them with pleasure, comfort, and enjoyment. Listing 10 to 20 items under headings for each of the five basic senses, plus one category for activities or things they enjoy doing,

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provides both the therapist and the client with 60 to 120 items that enhance the client’s sense of wellbeing. Most of these items are usually nature based and serve as the foundation on which to offer therapeutic activities and mindfulness exercises. Psychoeducation

Psychoeducation informs the client about the research, the client’s own personal experiences from the SAI, and the values to be derived from the therapeutic exercises. Nature-Guided Interventions

The SAI serves as a basis for offering natureguided interventions. For example, if a person lists the activity of walking with enjoying the sight of the ocean, the sound of breaking waves, the smell of the salt air, and the feel of the sea breeze on his or her skin, an intervention to help relaxation, improve mood, or shift unwanted cognitions may be to take a daily walk along the beach. Nature-Guided Imagery Interventions

Where it is not possible, practical, or safe for a person to engage in in vivo activities, it is possible to introduce them to such experiences by guided imagery. Nature-Guided Mindfulness

Nature-guided mindfulness—either in vivo or imagery based—invites the client to select a preferred place in nature where the client can sit quietly for 10 to 15 minutes, mindfully attending to each sense modality—first being aware of his or her visual experiences of nature, followed by auditory, olfactory, taste, and tactile sensations. Couple and Family Therapy

In couple and family therapy, individuals complete the SAI and then share their inventories with each other and engage in shared exercises to increase well-being of the self, the other, and the relationship. The inventories are used to recall past mutual nature-based pleasures, extend current and future mutual pleasure, and reinforce relationship bonds.

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Therapeutic Process NGT tends to be a Brief Therapy without a prescribed number of sessions. Some people find that in one or two sessions they have sufficient skills to alter mood, cognitions, and behavior in more helpful ways. With long-standing and intense issues, it may serve as an adjunct to other therapeutic interventions such as cognitive-behavioral therapy, Brief Therapy, solution-focused therapy, positive psychotherapy, hypnotherapy, mindfulness, and various counseling approaches. A follow-up session is recommended to assess the client’s progress and offer recommendations for maintaining that progress. George W. Burns See also Ecological Counseling; Ecotherapy; EcoWellness

Further Readings Burns, G. W. (1998). Nature-guided therapy: Brief integrative strategies for health and wellbeing. Philadelphia, PA: Brunner-Mazel. Burns, G. W. (2005). Naturally happy, naturally healthy: The role of the natural environment in well-being. In F. A. Huppert, N. Baylis, & B. Keverne (Eds.), The science of well-being (pp. 405–431). Oxford, England: Oxford University Press. Burns, G. W. (2009). The path of happiness: Integrating nature into therapy for couples and families. In L. Buzzell & C. Chalquist (Eds.), Ecotherapy: Healing with nature in mind (pp. 92–103). San Francisco, CA: Sierra Club Books. Burns, G. W. (Ed.). (2010). Happiness, healing, enhancement: Your casebook collection for using positive psychotherapy. Hoboken, NJ: Wiley.

NEO-FREUDIAN PSYCHOANALYSIS The term neo-Freudian psychoanalysis has been loosely defined to include a wide variety of postFreudian viewpoints and, at times, has included the work of Alfred Adler, Carl Jung, Karen Horney, Erich Fromm, and Harry Stack Sullivan. Horney and Fromm have emerged as the most prominent spokespersons for this sociocultural offshoot of classical psychoanalytic theory. Both

Horney and Fromm are also classified as “character analysts.” A major thrust of their work centers on character types that emerge as a result of interaction with an ill society. The neo-Freudian character analysts have contributed significantly more in the area of developmental theory and psychopathology than in psychotherapy process. Neo-Freudian ideas have often been described as a blend of psychotherapy, social science, and literary movement.

Historical Context The heyday of neo-Freudian thinking was between 1930 and 1950. At that time, neoFreudians were in dialogue and conflict with the firmly entrenched psychoanalytic ego psychologists, such as Anna Freud and David Rappaport. Neo-Freudians were bringing a new and vital interdisciplinary discussion to the analytic institutes. Also, during this period, there was a growing interest in group and family therapies, which helped prepare for what was to become a major conflict over the relative importance of intrapsychic versus environmental factors in development and psychopathology. The wide and diverse interests of the neoFreudian pioneers did not allow for the necessary cohesion to establish a separate school of thought, and traditional psychoanalytic institutes rejected the socio-psychoanalytic attack on Freudian orthodoxy. Horney and Fromm were politically astute and elected to bypass the traditional analytic institutes’ discussions of their new ideas. Instead, they produced a large number of very accessible and popular books for the lay public spelling out their major arguments. This produced further animosity in the classical analytic community. The traditionalists felt that the neo-Freudians were going over their heads to the public. Classical analysts were also responding to the neo-Freudian interest in issues beyond the consulting room (i.e., cultural and economic issues). The pivotal event highlighting this conflict of approaches was the removal of Horney from her training analyst position in the New York Psychoanalytic Society for essentially “undermining” Freudian theory and changing psychoanalysis into a “social psychology.” Fortunately for psychoanalysis, Horney was undeterred and along with several colleagues formed a new

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institute to develop their ideas. In addition, she was important to the founding of the Association for the Advancement of Psychoanalysis.

Theoretical Underpinnings The major conceptual shifts that characterize Horney and Fromm and their theories is a repudiation of the primacy of Freudian instinct theory, a move to a more life-span approach to development to replace psychosexual theory, and a rejection of the general pessimism attendant to Freudian psychic determinism. In its place, a field theory and cultural view of psychological development and illness is offered. Neo-Freudian psychoanalysis is often referred to as sociopsychoanalysis. Neurosis is seen as emerging from a neurotic culture, and as Fromm suggests, there is a “pathology of normalcy.” In this concept, Fromm draws attention to the self-negating accommodations required in the Western socioeconomic context. While this theory had considerable currency in the mid-20th century, it has not survived as a discrete approach. The basic principles espoused by these psychoanalysts, however, have become integrated into many of the contemporary approaches to psychoanalytic treatment, especially those that rely on field theory and relational concepts. Horney’s invocation of the Self in terms of Real and Ideal Self states set the stage for a more fully elaborated set of theories found later in the work of Sullivan and Heinz Kohut. There is also a strong element of existential choice and self-actualization in their theories, which are seen more developed in the work of Carl Rogers and other humanistic psychologists. Karen Horney

The context for understanding the work of Horney is her revolt against Freud’s theory of female development. Much of what follows in this entry addresses Horney’s analysis of masculine civilization’s devaluation of women and women’s resultant internalization of this identity. While her researches on the Feminine Type took place in the mid-20th century, many of her ideas still serve to fuel the ongoing feminist path in psychoanalytic theorizing. She was writing in a time when female

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domesticity was encouraged and when women’s professional options were very limited. Horney stands out in her vigorous attack of Freud’s early physiodynamic theories and especially his patricentric view of female development. In a series of provocative articles, she attacked Freudian concepts such as penis envy and the sexual basis of neurosis, and in their place, she substituted concepts such as womb envy, dread of the vagina, and the proposition that women rather than desiring a penis longed for the power denied by the masculine culture. She asserted the existence of a primary femininity and claimed that the wish for motherhood was not derivative of failed masculinity, as Freud had suggested. According to Horney, neurosis emerges from living in a neurotic culture and within a family system that is struggling with that culture. She argued that the classical parent–child interaction cannot be extracted from the cultural milieu. Traditional analysts frequently critique Horney’s emphasis on here-and-now neurotic solutions at the expense of their historical antecedents and unconscious elements. It was, in fact, for this sociopsychoanalytic here-and-now approach that Horney was forced to leave the New York Psychoanalytic Society, after which she founded her own institute. Coupled with this theoretical challenge, Horney also repudiated instinct theory, which set the stage for her cultural theory of human development. This shift from biological determinism to object relations predicts the eventual emergence of contemporary intersubjective theory steeped in postmodern sensibilities and quantum field theory. Erich Fromm

Fromm was a prominent and accessible writer on psychoanalytic issues who played a major role in establishing the importance of the social and economic setting as crucial in establishing the client’s internal world and personality orientation. Working from a Marxist perspective, he helped outline the importance of capitalism in the formation of character structure. He endeavored to help society move toward a democratic, humanistic socialism. For Fromm, modern society has failed humans in their search for meaning and personal fulfillment.

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Fromm was deeply immersed in an existentialist paradigm for understanding the nature of the human situation and the construction of personality. He posited that one of humankind’s deepest needs is to overcome a sense of aloneness and that a complete lack of relatedness would lead to insanity. He was particularly interested in the character formations that led individuals to want to eschew their freedom to become or be authentically themselves. Focusing on the confluence of people’s innate biological vulnerability and the fact that human evolution has separated humans from their instinctive oneness with nature, Fromm says that humans are given a freedom to choose between engaging the world in love and productivity and seeking refuge in character orientations that destroy freedom and integrity. Fromm, like Horney, tended to publish his ideas for the general public and avoided the rigidity of “analytic institute” dialogue. This led to considerable push back from traditional psychoanalytic theoreticians, who tended to view him as a wealthy and rather Pollyannaish individual unwilling to look at humankind’s darker nature. However, others have noted that this does not hold up in light of his many writings on human destructiveness and the necrophilius character. He fulfilled the role of gadfly and provocateur to the rather conservative and staid traditional analysts of the mid-20th century.

Major Concepts Neo-Freudian psychoanalysts did not codify a coherent set of principles to guide psychotherapy. They did, however, provide a forceful challenge to traditional intrapsychic psychoanalysis in positing the influence of culture and object relations on the emerging personality and resultant psychopathology. Their approach is founded in a mix of psychoanalytic principles and existential philosophy. Emerging from this matrix are the concepts of personal freedom, choice, and the potential for self-actualization through personal accountability. The following offer some of Horney’s and Fromm’s ideas that place them clearly in the neo-Freudian camp. Karen Horney

Safety and Satisfaction The drive for safety and satisfaction are seen to  replace the pleasure principle as the primary

motivators of infant development. These concepts predict the development of attachment research. Basic Anxiety Basic anxiety emerges from the dysfunctional family system and involves a lack of emotional containment, feelings of being small and helpless, and a generalized fear of the world. Basic Hostility Basic hostility is a repressed reaction of rage to those hostile environments that have created the self-imposed restraints necessary for security and the resultant basic anxiety. Basic hostility and basic anxiety are in a reciprocal relationship. The Ideal Self The Ideal Self refers to the Self that people aspire to achieve. However, because it is an ideal, it is impossible to achieve. Therefore, pursuit of the Ideal Self is at the expense of discovering the Real Self. Horney suggested that the Ideal Self refers to the Self that contemporary women aspire to achieve. It is, however, patterned after the ideal woman seen in man’s eyes and is thus in line with patriarchal values. The Real Self The Real Self refers to a set of potentials at the core of the personality that is too often obscured by the neurotic solutions to our cultural illness and emerges from exercising our freedom to choose a path consonant with our internal endowment. The Masculinity Complex This complex refers to the envy of men and the wish to be a man, which is internalized in response to the patriarchal culture. It is rooted in the discrimination of women. Neurotic Styles These coping styles are strategies to manage basic anxiety. Horney ultimately identified three patterns: (1) moving toward people, (2) moving away from people, and (3) moving against people. These patterns act out helplessness and compliance, isolation, and hostility, respectively.

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The Feminine Type The feminine type is characterized by an overvaluation of love from a man, excessive competitiveness with other women, the adoption of a compliant and dependent stance, sexualization within the family environment, and the use of projective identification (externalized living) to survive in the male-dominated culture. In addition, Horney identifies the devaluation of behaviors that detract from sexualized femininity. Erich Fromm

The Thrown Condition The thrown condition is a term that denotes the existential conditions of helplessness and vulnerability that mark the human condition, including the perpetual defeat by death. Freedom Freedom denotes Fromm’s belief that human beings are free to create their lives in an authentic and loving manner but the forces of the thrown condition make this a difficult choice. Escapes From Freedom There are three major routes humans use to attempt to escape the task of creating themselves authentically: 1. Destructiveness, which aims at eliminating the object and is in direct relationship to the amount of the expansiveness of life the Self curtailed. 2. Authoritarianism, which aims at fusing the Self with somebody or something outside the Self, with the aim of symbiosis. 3. Automaton conformity, which relates to nonthinking mimicry.

Personality Orientations This typology refers to the basic personality orientations (character types) that Fromm identified that result from developing in our Western socioeconomic matrix. These include the following: The receptive orientation, which sees everything of value outside the Self. There is a dependent stance toward life. It is highly correlated with need and entitlement to be loved.

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The exploitative orientation also views everything of value outside the Self; however, one has to work to get it by whatever means. There are no expectations that one will be given anything. The hoarding orientation is characterized by gaining security through hoarding and saving. There is little productive thinking, and there is a pedantic orderliness and cleanliness present. The marketing orientation is based on selling oneself as if one were a product. Human qualities are transformed into assets and tools to bring a greater reward. The productive orientation is characterized by relatedness in all realms of human experience, the use of reason and love rooted in productiveness.

To Have or To Be This relates to Fromm’s conviction that the receptive, exploitative, hoarding, and marketing orientations are about accumulation and having, while the productive orientation is about being or becoming a full human being.

Therapeutic Process The main contributions to psychotherapeutic technique based on the work of Horney center on two fundamental shifts. First and foremost, she helped usher in the shift away from a decidedly patricentric classical theory to a more matricentric, dyadic, and mother–child object relations approach. This she did with the assistance of the other “mothers of analysis,” Anna Freud, Helen Deutsch, and Melanie Klein. The feminine presence in psychoanalysis also helped move the focus of analytic work away from oedipal to pre-oedipal issues. While early-childhood experiences were important, there was an equal focus on the here-andnow struggle with neurotic coping styles. The emotional climate of the therapeutic contact also moved from one solely devoted to unearthing pathology to one of mobilizing the constructive forces of the personality. It was the goal of therapy to replace the Ideal Self with the Real Self. Coupled with this is the underlying field theory approach, which endorses the social matrix for emotional disorder. Horney’s approach helped evolve the psychoanalytic listening perspective from a more distant and sterile analytic inquiry

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into a more available and warm listening presence that exuded more elements of positive psychology and optimism. Horney’s emphasis on the failing family system, and not just the mother’s mind, helped pave the way for a more systems approach to therapeutic intervention. Horney and the other neo-Freudians adopted many of the classical concepts related to the importance of childhood relationships, the importance of the unconscious, and the importance of defense analysis. They supported the importance of technical paradigms, including free association and dream analysis. The focus of interpretation, however, was not focused on oedipal dynamics (intrapsychic) but on interpersonal and field (family) experience. Foremost for Horney is her assessment of how the family had become a vehicle for the derailing of young girls’ development through sexualization and the devaluing of assertive capacities. Perhaps one of the most important contributions emanating from Horney’s work is the highlighting of self-responsibility and the ability to make choices to articulate a new vision for one’s life. Eschewing the psychology of victimization and emancipating the constructive forces of the psyche are the fundamental underlying principles of her work in psychoanalysis. In this work, she helped establish the foundation for future approaches such as the existential-humanistic approaches that emphasized responsibility and choice in the development of the Self. Allen Bishop See also Adler, Alfred; Adlerian Therapy; Analytical Psychology; Classical Psychoanalytic Approaches: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Freud, Sigmund; Freudian Psychoanalysis; Horney, Karen; Humanistic Psychoanalysis of Erich Fromm; Jung, Carl Gustav; Jungian Group Psychotherapy; Klein, Melanie; Rogers, Carl; Sullivan, Harry Stack

Further Readings Fromm, E. (1941). Escape from freedom. New York, NY: Henry Holt. Fromm, E. (1955). The sane society. New York, NY: Henry Holt. Fromm, E. (1973). The anatomy of human destructiveness. New York, NY: Henry Holt.

Horney, K. (1937). The neurotic personality of our time. New York, NY: Henry Holt. Horney, K. (1967). Feminine psychology. New York, NY: Henry Holt. McLaughlin, N. (1998). Why do schools of thought fail? Neo-Freudianism as a case study in the sociology of knowledge. Journal of the History of the Behavioral Sciences, 34(2), 113–134. doi:10.1002/(SICI)15206696(199821)34:23.0.CO;2-T McLaughlin, N. (2000). Revisions from the margins: Fromm’s contributions to psychoanalysis. International Forum of Psychoanalysis, 9, 241–247. doi:10.1080/080370601300055679 Sayers, J. (1991). Mothers of psychoanalysis. New York, NY: Henry Holt. Westcott, M. (1986). The feminist legacy of Karen Horney. New Haven, CT: Yale University Press.

NEUROFEEDBACK Neurofeedback, or biofeedback for the brain, is a noninvasive method of brain wave neuromodulaton and neurorehabilitation that is facilitated by the use of a computer software interface and electroencephalogram (EEG). The definition of neuromodulation is the alteration or changing of some aspect of neuronal functioning. Neurofeedback treatment is often recommended for people who have different types of brain dysregulation. Neurofeedback involves measuring brain wave frequencies over time. With advances in neuroscience and neurocounseling, and the introduction and understanding of neurofeedback as a counseling intervention, helping professionals can utilize many efficacious neurofeedback treatments and/or refer clients to certified neurotherapists. Neurofeedback has the capability of assisting persons to live in a more efficient and effective manner and has significant potential in preparing future helping professionals, research, and practice.

Historical Context From the beginning of time, humankind has tried different methods of self-regulation. Praying, meditating, exercising, and using substances to alter consciousness were often early methods to alter and regulate the mind and the body. As early as

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1875, a British physician, Richard Canton, discovered that the brain had electrical impulses, or waves. Around 1924, Hans Berger, a German psychiatrist, created the first device to measure and record the amplification of brain waves. This was the beginning of the electroencephalograph. Berger’s basic method of gathering brain wave electrical activity is still used today. Brain research continued throughout the next few decades with promising discoveries. In the early 1960s, researchers such as Joe Kamiya and Barry Sterman, working with alpha states and low beta states, respectively, published work that allowed neurofeedback to gain acceptance in the psychological realm. Sterman was hired by NASA (National Aeronautics and Space Administration) to help astronauts who were having seizures because of exposure to jet fuel. He began working with cats and teaching them through a basic reward system to control their resting brain waves. His research was not immediately available to the public for security reasons, but it became the underpinning for today’s neurofeedback protocol for attentiondeficit/hyperactivity disorder (ADHD) and seizure work. Joel Lubar continued this work and began to replicate and expand the protocols for children with ADHD. Margaret Ayers began working with neurofeedback and brain traumas, and Siegfried and Sue Othmer used their physics background to develop new amplifiers and new training protocols. Using neurofeedback, Eugene Peniston began working with veterans in the early 1990s and published positive outcomes in addictions and trauma. In the early 2000s, Leslie Sherlin began working with athletes to develop peak performance. Since that time, much research has been done on a norm-based quantitative EEG and low-resolution brain electromagnetic tomography for diagnosis and treatment. The majority of the research today focuses on the validation of neurofeedback protocols for specific symptom relief.

Theoretical Underpinnings To understand neurofeedback, a concise summarization of the major brain wave categories is needed. Five brain waves are typically observed during neurofeedback: (1) delta, (2) theta, (3) alpha, (4) beta, and (5) gamma. Delta waves are typically 0 to 4 Hertz (Hz) and are observed when someone

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is sleeping. Theta waves (5–8 Hz) are observed when persons are drowsy, daydreaming, or meditating. Alpha waves (9–13 Hz) are often seen when persons are relaxed, idling, and not focusing on a task. Beta waves (13–18 Hz) are required to solve a problem or complete a task. Gamma waves (35–45+ Hz) are often considered insight, consolidation, and higher level cognition waves. An easy pneumonic to assist in remembering the different brain wave categories is Do Think About Brain Growth. There are many unique and different causes of brain dysregulation. The most widely recognized source is genetic inheritance. Early prenatal developmental and birth complications may also cause dysregulation. The manner in which one eats may cause dietary deficiencies. Environmental toxins may also influence dysregulation. Other possible causes of dysregulation include suppressive psychosocial environments, head injuries, and alcohol and/or drug abuse. Additional conditions such as seizures, strokes, and chronic ailments also influence the brain’s efficiency. Even extended use of prescribed medications can alter brain efficiency. Finally, cognitive decline associated with aging and lack of exercise is an additional source of dysregulation.

Major Concepts To understand neurofeedback, one should have basic knowledge of neuroplasticity, the efficacy guidelines, the goals of neurofeedback, and for whom the process seems to have worked best— that is, knowledge of the evidence-based research. Neuroplasticity

Fifty years ago, researchers discovered that the brains of mice and cats could be trained with operant and classical conditioning. Neuroscientists now understand that the malleable, 3-pound human brain has the capability to adapt and develop new living neurons by engaging new tasks and challenges throughout life. This neuroplasticity can rearrange neuronal pathways by creating new neurons, called the process of neurogenesis; this can especially occur in the hippocampus. There is a growing body of research demonstrating that the brain can be taught to self-regulate and become

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more efficient through neurofeedback. Many practitioners now believe that humans are capable of intentionally controlling neural functioning when trained properly. Efficacy Guidelines

Neurofeedback has been applied to many physiological and psychological problems. All areas of neurofeedback’s efficacy have not been thoroughly demonstrated, as the expense of double-blind controlled research studies is often restrictive. The Association for Applied Psychophysiology and Biofeedback and the International Society for Neurofeedback and Research, two professional organizations, developed efficacy guidelines and levels. There are five levels of efficacy ratings. These efficacy levels are essential to know, so that clinicians can advocate for neurofeedback with proper knowledge of research outcomes. A rating of Level 1 suggests that a particular protocol is not empirically supported, except through anecdotal evidence or non-peer-reviewed case studies. This rating does not mean that a particular neurofeedback treatment is not worthwhile, but it does let the practitioner know what research has been accomplished. Level 2 has the rating of possibly efficacious by means of positive outcome research but with no control group. Level 3 is probably efficacious, indicating that the protocol has produced positive effects in more than one clinical, observational wait list or within-subject or between-subject study. Level 4 is an efficacious rating, indicating that the protocol has been shown to be more effective than the outcomes for a notreatment or placebo control group and that at least two studies have demonstrated the same degree of efficacy. Level 5 is efficacious and specific, with outcomes that are statistically superior to those of a credible placebo in two or more independent studies. There are very few neurofeedback protocols that have achieved a Level 5 rating. However, in the area of ADHD, the research has been consistent and has shown the effects of neurofeedback training to be profound and long lasting. This rating and meta-analyses support the use of neurofeedback as an evidenced-based treatment for children with ADHD.

Goals of Neurofeedback

Neurofeedback is a therapeutic intervention that utilizes hardware and software capabilities in which the client interacts with audio or video programs or games that can lead to changes in irregular brain wave patterns. Often, regional cerebral blood flow is also observed along with the brain waves that are associated with physiological, behavioral, and psychological problems. It is essential to understand that neurofeedback clients receive no electrical input. The outcome of neurofeedback is to offer feedback of bandwidth activity relating to the client’s neuronal needs and goals. There are three main neurofeedback goals. The first is to normalize and reregulate brain functioning, the second is to restore brain efficiency, and the third is to optimize daily brain performance. Often, just living life and making poor life choices causes brain dysregulation. This may create a state of neurological overarousal, underarousal, or instable arousal. Examples of overarousal include anxiety, anger, obsessive-compulsive disorder, insomnia, impulsiveness, and distractibility. Examples of underarousal include depression, lack of concentration, and difficulty waking. Illustrations of instability are less obvious but include migraine headaches, seizures, bipolar disorders, fibromyalgia, and posttraumatic stress disorder. In the instable arousal state, the body has a difficult time transitioning from one brain state to another.

Evidence-Based Research

As noted previously, neurofeedback has been particularly successful in the treatment of ADHD. Other neurofeedback research studying veterans with posttraumatic stress disorder found only a 20% relapse of panic attacks. Several other neurofeedback studies demonstrated a 70% reduction in epileptic seizures and discussed major improvements in depression after a 1-year follow-up. One landmark study discussed an increase of more than 12 IQ (intelligence quotient) points in children with learning disabilities. Finally, several studies stated an 80% sobriety rate after a 4-year followup for alcoholics in a treatment program who also received neurofeedback training.

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Techniques Some of the important techniques related to neurofeedback are establishing a baseline and brain wave functioning assessment, determining treatment protocol, and teaching heart rate variability. Establishing a Baseline and Brain Wave Functioning Assessment

Neurofeedback reregulates neuronal activity through the same principles of operant and classical conditioning as do many other learning activities. The client’s current brain wave functioning is first assessed by establishing a baseline. Often, this EEG assessment is conducted by measuring brain wave activity at five different locations on the scalp: (1) midline (CZ), (2) left occipital lobe site (O1), (3) left prefrontal cortex (F3), (4) right prefrontal cortex (F4), and (5) above the midline (FZ). This five-channel EEG or a more intensive and thorough, 19-channel EEG may be used for assessment. Attaching noninvasive electrode sensors to the scalp with conductive paste and having the client keep his or her eyes open or closed, read, listen, and complete a mathematical problem, such  as counting backward from 100 by sevens, measures several conditions and tasks. Determining Treatment Protocol

After the baseline data are analyzed, a neurofeedback treatment protocol is determined and discussed with the client. The neurofeedback clinician then reinforces and inhibits the required brain waves by setting desired thresholds. The client’s job is to observe or listen to a computerized game, video, or music on a computer monitor. The neurofeedback outcome is to eventually teach the client to have the right brain wave for the right task at the right time, allowing the brain’s response to become automatic and generalize to future tasks. Teaching Heart Rate Variability

Often, the biofeedback skill of heart rate variability is taught to the client before the neurofeedback training begins. Using a HeartMath software program is a simple and elegant method of assisting clients to focus on their breathing, control the variability of their heart rate, and begin to relax.

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Teaching skin temperature control is another method of helping clients understand how much control they have over their physiology.

Therapeutic Process Individual treatment for neurofeedback sessions last approximately 20 to 40 minutes. To gain the most effective, overall treatment effect, neurofeedback clients usually require at least 20 sessions. To obtain the maximum treatment effect, continuous, repeated sessions are required. Treatment plans are customized for each individual, and the number of sessions is based on the severity of symptoms and the number of symptoms. The treatment can usually be completed in 20 to 40 sessions, and the cost of neurofeedback is slightly more than that of a regular therapeutic hour. In some extreme cases, such as a diagnosis of autism, as many as 60 sessions may be required. Neurofeedback is a painless treatment with very few contraindications. A few clients have reported mild headaches. When side effects are shared with the neurotherapist, brain wave thresholds can be changed to eradicate the unwanted symptom. The most common consequence of a neurofeedback session is a tired brain, much like the tiredness experienced after physical exercise. A major benefit of neurofeedback is that it can be the treatment choice for a variety of physical and psychological problems. A primary reason for employing neurofeedback is to resolve the problems at the source, the brain. Neurofeedback relies on established principles of operant and classical conditioning and learning, and the results can be objectively documented with brain wave charts, statistics, and behavioral checklists. The results tend to be long lasting unless another incident occurs to dysregulate the brain, such as a major illness or organic brain trauma. Neurofeedback has assisted many clients to sometimes reduce or even eliminate medications and certain symptoms. Another important neurofeedback benefit is that clients learn to rely on internal, not external, methods for staying healthy and living life effectively. Lori A. Russell-Chapin See also Biofeedback; Brain Change Therapy; EvidenceBased Psychotherapy; Heart Rate Variability; HeartMath

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Further Readings Chapin, T., & Russell-Chapin, L. (2014). Neurotherapy and neurofeedback: Brain-based treatment for psychological and behavioral problems. New York, NY: Routledge. Demos, J. N. (2005). Getting started with neurofeedback. New York, NY: W. W. Norton. Doidge, N. (2007). The brain that changes itself. New York, NY: Penguin Books. Myers, J., & Young, J. S. (2012). Brain wave biofeedback: Benefits of integrating neurofeedback in counseling. Journal of Counseling & Development, 90, 20–28. doi:10.1111/j.1556-6676.2012.00003.x Othmer, S. (2007). Overview of neurofeedback mechanisms: Setting the agenda for research. Woodland Hills, CA: EEG Institute. Russell-Chapin, L., & Chapin, T. (2011). Neurofeedback: A third option when counseling and medication are not sufficient. Alexandria, VA: American Counseling Association. Retrieved from http://counselingoutfitters .com/vistas/vistas11/Article_48.pdf Sherlin, L., Arns, M., Lubar, J., & Sokhadze, E. (2010). A position paper on neurofeedback on the treatment of ADHD. Journal of Neurotherapy, 14, 66–78. doi:10.1080/10874201003773880 Swingle, P. G. (2010). Biofeedback for the brain. New Brunswick, NJ: Rutgers University Press. Yucha, C. B., & Montgomery, D. (2008). Evidence-based practice in biofeedback and neurofeedback. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

NEURO-LINGUISTIC PROGRAMMING Neuro-linguistic programming (NLP) works directly with the structure of the subjective experience that elicits a client’s problem response, in contrast to exploring the historical events that created the structure. For instance, there are fundamentally two ways to recall a memory (1) by being inside it, as if the event were actually happening again, or (2) by viewing the same event as an outside observer, as if watching a distant movie of it, which is often described as being “objective.” A client with a phobia remembers an unpleasant memory by being inside it and fully reexperiencing the feelings of terror and shock. But a client who is grieving a loss does exactly the opposite: He or she

recalls a memory of love and connection as if viewing it from a distance, so the client is unable to experience the special feelings he or she had with that person and has only a feeling of emptiness. The process for resolving a phobia is to learn how to take a distant objective point of view, while the process for resolving grief is to learn to reexperience the loving memory by being inside it so that the loving feelings can be experienced again. This example illustrates several key principles of NLP: 1. The subjective structure of a problem indicates exactly what needs to be done to resolve it. 2. Every mental ability can be a valuable skill in one context and the basis for a serious problem in another. 3. These process changes can be made without the therapist knowing the content of the phobia or grief, so it is not necessary for the client to discuss disturbing or embarrassing information. 4. Because the client already has the ability to remember in the two different ways, it is simply a matter of teaching him or her the application of the ability, making treatment very rapid, in many cases one session or less.

Historical Context NLP was originally developed in the mid-1970s by Richard Bandler and John Grinder, from studying the verbal and nonverbal behavior of three exceptionally skilled and effective therapists: Virginia Satir (family therapy), Fritz Perls (Gestalt therapy), and Milton Erickson (hypnotherapy). By examining these therapists’ behavior (and largely ignoring their theoretical ideas about their work), they were able to extract specific linguistic and nonverbal behaviors that these therapists used to elicit new and more useful behavioral responses in their clients. Building on this, Bandler and Grinder and their students proposed universal principles, which have been used to develop specific precise intervention protocols for quickly resolving a number of common client problems, including anger, anxiety, shame, regret, codependence, trauma, posttraumatic stress disorder, grief, phobias, habits, compulsions, and relationship issues. Because NLP replaces a dysfunctional process with a functional one, it can be used to teach

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positive and generative skills such as motivation, making decisions, spelling, improving memory, and developing a secure and stable identity. Therapy becomes simpler and faster because the therapist needs to learn only one process for addressing each kind of problem, such as the processes for treating phobia and grief illustrated above. While many other therapies gather extensive historical and developmental information about family interaction patterns, attachment styles, and so on, NLP only attends to these as they become evident in the context of the problem being addressed.

Theoretical Underpinnings Every thought, memory, or future forecast— including the most abstract thinking—is experienced as an internal representation in one or more of the five sensory modalities. Three of these modalities, visual (images), auditory (sounds or words), and kinesthetic (movements, postures, and tactile feelings), or some combination of these, predominate in most problems. Although smell and taste are seldom relevant, they are often very important when present. Submodalities are the smaller process elements within each sense modality. For instance, the size, closeness, color, movement, and location of an image are elements of the visual modality. Volume, tempo, melody, tonality, and location are all elements of the auditory modality. Kinesthetic submodalities include tactile sensations of movement, temperature, duration, intensity, hardness, extent, and so on. The submodalities of a troubling memory can be changed regardless of the content represented, and this kind of change is much easier, faster, and more impactful than attempting to change the content. For instance, an image of chocolate cake that is close, large, three-dimensional, and in color tends to elicit a strong feeling of desire. If the same image is far away, small, twodimensional, and grey, it will elicit much less intense feeling. This intervention can be very useful in a variety of problems involving impulsivity, including addictions and weight maintenance.

Major Concepts The major concepts in this approach to counseling describe a therapy that is very different from

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traditional, verbal-based therapies. Some of these are primary versus secondary experience, process versus content, specifying the client’s outcome, fundamental presuppositions, attention to nonverbal communication, injunctive versus descriptive language, scope of experience, categorization, and joining and separating. Primary Versus Secondary Experience

Primary experiences are those that are represented in one or more of the five modalities. They are the most powerful experiences in eliciting responses, the basis of most problems, and an individual’s most skilled and effective behaviors. In contrast, words are secondary in importance and always refer to groups or categories of experience. Words can be used to elicit primary experience, but they can also be used to keep an “intellectual” distance from experience and be a barrier to change. Process Versus Content

Most therapies focus on changing the content of a problem. In contrast, most NLP interventions are directed at changing the process, not the content. For instance, a client may be asked to change the tempo, melody, accent, loudness, or location of a troublesome critical or depressing voice. Although the words remain unchanged, the client’s feeling response often changes significantly because the client’s feeling response is primarily to these nonverbal aspects of the message, which are mostly unconscious. Specifying the Client’s Outcome

A client usually enters therapy with a poorly specified outcome that is usually stated as a negative—the client wants something not to happen—and usually it is extremely global, such as “I never want to feel bad.” A well-specified outcome must be initiated and controlled by the client; specified in positive, sensory-based terms; appropriately contextualized, with specific evidence to know when it has been attained; and congruent with the client’s other goals, outcomes, and values if the change is to last without creating conflict.

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Fundamental Presuppositions

One fundamental presupposition is that every individual always does the best he or she can at any moment in time given his or her perceptions, knowledge, abilities, and limitations. This normalizes even the most extreme and destructive behavior and focuses the therapist on changing the client’s abilities and limitations so that more useful and appropriate behaviors result. Another fundamental presupposition is that every behavior has a positive intention. This separation of behavior from intention makes it easy to validate and agree with the intention and use this alliance as a basis for jointly exploring alternate new behaviors that could satisfy the intention without the problematic consequences. This is easier than trying to stop a problem behavior, which is usually very difficult or even impossible, because that would oppose the positive intention that drives the behavior. Another presupposition is that every behavior is appropriate in some contexts. This makes it possible to validate the behavior in those contexts, while exploring alternative behaviors in other contexts where the behavior has problematic consequences. Additional presuppositions also serve to guide and orient the therapist’s work in useful ways. Attention to Nonverbal Communication

Most therapies attend primarily to the verbal component of a client’s communication, hence the common term talk therapy. But because most problems are not under the client’s conscious control, the nonverbal components—which are largely unconscious for most people—are much better indicators of the process of communication and also of useful changes in that process. NLP includes extensive and precise therapist training in attending to the client’s nonverbal behavior. The therapist is also trained to utilize the nonverbal components of his or her own communication—such as voice tone, tempo, postures, and gestures—to elicit more useful responses in the client. Injunctive Versus Descriptive Language

Most therapies are focused on describing a problem, or the history of a problem, so that the

client can consciously understand it. NLP is more often focused on injunctions and the spontaneous, unconscious changes that occur in response: “Do this, and find out what happens,” “Make that image of abuse into a small transparent slide, then put it far behind you, and find out how that changes your response to it.” Scope of Experience

Most problems can be described as some kind of “tunnel vision,” in which the scope of experience is so narrow that few alternatives are apparent. Expanding the scope of an experience to include the larger context is commonly referred to as “seeing the big picture,” which creates a more balanced perspective in space—the problem seems smaller and easier to solve when seen in relation to the larger context. This larger context also often includes more information about alternative possibilities for dealing with the problem. When a client’s problem is being “stuck” with a horrible still picture (often metaphorically described as being “frozen in time”), a process instruction to turn that still picture into a movie and then to lengthen that movie so that it starts much earlier and ends much later increases the scope of time, providing a larger perspective. However, a client who is confused and troubled by “overwhelm” may discover that he or she has six different colorful movies, with loud sound, playing inside his or her head simultaneously, so that it is impossible to attend to any one of them. A client who is overwhelmed needs to be taught how to reduce the scope of his or her experience and focus on just one movie at a time, so that he or she can attend to it and process it. Categorization

People not only attend to a certain scope of experience, but they also categorize it in some way, by joining it with other experiences that are similar. A change in categorization will result in a different response, a reframing pattern often called “redescription.” For instance, when someone categorizes a problem as “insoluble,” it is reasonable to feel hopeless and despairing. If the same experience is recategorized as a “challenge,” it becomes something that may still be difficult but can be overcome

Neurological and Psychophysiological Therapies: Overview

with effort and skill. When a client thinks of an event as a “failure,” it can be useful to ask the client to recategorize it as useful feedback about his or her responses and behaviors and to use this information to learn how to be different in the future, in contrast to futile dwelling on the unchangeable past. Joining and Separating

All therapeutic change involves joining two or more scopes or categories into one experience or separating two or more scopes or categories that are inappropriately joined. For instance, an isolated troublesome image of failure can be demoralizing, particularly if it is very large and colorful. However, if it is seen together with four images of success of the same size, it will elicit a more balanced and empowering response. A client who thinks of himself or herself as stupid can realize that many, or most, of the examples in the category “stupid” are actually examples of simple ignorance or lack of knowledge, not stupidity. When all those examples of ignorance are put into a separate category, the category “stupid” becomes much smaller and less disturbing, and easier to change.

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Therapeutic Process The first step is to elicit and specify the client’s outcome in positive, sensory-based terms, making sure that it is attainable and appropriately contextualized and that the evidence for success is specified, so that the results of testing after treatment are unambiguous. The next step is to determine the structure of the client’s subjective experience of the problem and to determine what kind of change is likely to be appropriate. Next is to select and deliver an appropriate process to achieve the outcome and finally to test the results in the client’s experience in appropriate contexts to confirm that the treatment has been successful. Treatment for a relatively simple and specific outcome such as anxiety, overwhelm, or a phobia can take as little as 30 or fewer minutes; a more general or more complex outcome or group of outcomes may require a number of different interventions over several sessions. Steve Andreas and Connirae Andreas See also Erickson, Milton H.; Eye Movement Integration Therapy; Perls, Fritz; Satir, Virginia; Solution-Focused Brief Therapy

Techniques NLP is a comprehensive methodology including a wide range of techniques. Some change inner thoughts, some change external behavior, and some change feelings directly. Each method is precise and used for a specific outcome. Each has a clear structure and sequence, and each is explicit about what the method accomplishes and how it does that. One fundamental technique involves asking the client to make a change in his or her representation of the problem and to report how his or her experience changes as a result of this. For instance, a client may be asked to add loud, inspiring background music to the image of a troubling representation and then to report any spontaneous change in feeling in response. The resulting change in feeling is typically instantaneous, providing immediate feedback on the effectiveness (or ineffectiveness) of the intervention. The therapist suggests changes that are likely to work, but the client is the ultimate authority, reporting whether or not the change actually makes a useful difference.

Further Readings Andreas, C., & Andreas, S. (1989). Heart of the mind. Boulder, CO: Real People Press. Andreas, S. (2006). Six blind elephants: Understanding ourselves and each other (2 vols.). Boulder, CO: Real People Press. Andreas, S., & Faulkner, C. (1994). NLP: The new technology of achievement. New York, NY: William Morrow.

NEUROLOGICAL AND PSYCHOPHYSIOLOGICAL THERAPIES: OVERVIEW Neurological and psychophysiological counseling theories have been described by some as the “last frontier” or “missing link” for the future development of the mental health professions. The emergence of these new theories is grounded

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Neurological and Psychophysiological Therapies: Overview

in recent advances in neuroscience that prove that the brain can change and grow, which challenges the long-held notion that the human brain is unalterable. What has become clear in the past 10 years or so is that the mechanics of the brain drive mental processes and that actual change in brain activity and structure can be directly attributed to psychological and physical processes. Whereas neurological counseling focuses on linking psychological events and brain responses, such as the changes in the brain caused by the expression of empathy, psychophysiological counseling focuses on linking physical events and brain responses, such as developing quicker hand–eye reactions. To become competent in using these theories requires that a counselor be knowledgeable about basic neuroscience, the brain’s structure and functioning, its sensitivity to environmental factors, and the limitations of assistive technology. Once adequately prepared, the counselor is able to identify neurological disconnects and select from a wide array of therapies and technologies to focus efforts on the appropriate regions of the client’s brain and to educate the client on brain-based structural, chemical, biological, and developmental hurdles.

Historical Context For thousands of years, generations of philosophers and scientists have recognized the importance of the brain and have tried to explain the link between the brain and the mind. Writings from as far back as 1700 BCE contain detailed accounts of brain injuries and include the first descriptions of the brain. Hundreds of years later, in Ancient Greece, Hippocrates wrote of brain disturbances as a means of explaining epilepsy and posited the brain as the seat of intelligence, as did Plato and other scholars of that day. Aristotle, however, suggested that the heart was the source of thought and emotion, with the brain functioning as a cooling mechanism for the blood that flowed through the heart. In the 17th century, René Descartes, a French philosopher and physiologist, and Thomas Willis, an English doctor and founding member of the Royal Society, became prominent figures in brain research. Descartes maintained that the mind controlled consciousness and self-awareness and the

brain acted as the seat of intelligence, the controller of the body’s biological functioning, and the provider of behavioral responses in relation to one’s environment. Although this was later disproved, he described the pineal gland as a linkage between the functions of the mind and the body. Descartes’s association of the mind with psychological and mental processes and the brain with physical and biological processes bolstered a dualistic mind– body dichotomy that many continue to debate today. At the beginning of the 19th century, the Scottish neurologist Charles Bell linked partial facial paralysis to lesions on specific nerves (Bell’s palsy), the English surgeon James Parkinson published his essay on “shaking palsy” (Parkinson’s disease), and Czech J. E. Purkinje was the first to describe the neurons in the brain (Purkinje cells). Later in the century, the French surgeon Paul Broca and the German physician and psychiatrist Carl Wernicke documented locales in the brain linked with specific functioning and discovered a separation of function between the left and right hemispheres. Broca identified the area on the left side of the brain responsible for speech production, while Wernicke discovered an area on the left side that controls speech comprehension. What many consider a hallmark in the development of neuroscience is attributable to the misfortune of a 25-year-old American railroad construction foreman, Phineas P. Gage. While working with explosives, an iron bar more than 3 feet in length and more than 1 inch in diameter was blown through Gage’s head, severely injuring or destroying the frontal lobes of his brain. Although the specifics have been clouded by poor documentation and the passage of time, there are many reports that Gage experienced a profound personality change after this brain injury. Gage will be forever known as one of the first cases that confirmed the frontal cortex’s involvement in personality, reigniting the mind–body dualism debate. The 20th century marked a significant period of growth in our understanding of the brain. In 1906, the Nobel Prize in Physiology was awarded to the Italian scientist Camillo Golgi and the Spanish scientist Santiago Ramon Cajal for their work in defining the cell structures of the brain. Although Golgi’s research maintained that the cells of the brain formed a continuous network and the nervous

Neurological and Psychophysiological Therapies: Overview

system was a single entity, his work supported Cajal’s findings of a contiguous network of separate brain and nerve cells that affect one another. Around the same time, Sir Charles Scott Sherrington described the existence and functions of the synapse and identified the motor cortex region of the brain. The first half of the 20th century also saw the first attempts at brain imaging. The American surgeon Harvey Cushing, considered by many to be the father of modern neurosurgery, became recognized as the first scientist to electrically stimulate the human sensory cortex and use X-rays to detect tumors in the brain. A monumental achievement in neuroscience was the development by Jan Friedrich Tonnies of the first modern multichannel ink-writing electroencephalogram (EEG) machine, which recorded the minute electrical charges of neurons on the surface of the cortex. The invention of the EEG opened a new line of brain research, and in 1924, the German neurologist Hans Berger used this technology to first record the electrical activity of a human brain, his son’s, and identified alpha and beta rhythms. Associating alpha waves with relaxed states and beta rhythms with alertness, Berger saw the potential to use EEGs to improve diagnosis and measure therapeutic outcomes. A decade or so later, William Walter, a neurophysiologist who followed Berger’s work, improved the EEG machine and identified delta waves, which he associated with deep sleep states, and theta waves, associated with deep relaxation, drowsiness, and meditative states. In the 1950s and 1960s, researchers became interested in the chemistry of the brain and learned more about how medication might provide an alternative to lobotomy or electroshock. In 1949, lithium was discovered to be an effective treatment for bipolar depression, followed by the Food and Drug Administration’s approval of the chemical chlorpromazine (Thorazine) for its calming and antipsychotic properties. Other antidepressant, antianxiety, and antipsychotic drugs followed, with names like Iproniazid, Valium, and Librium. At the same, Joe Kamiya maintained that low-frequency alpha brain waves could be reinforced through operant conditioning and that individuals could use feedback to alter alpha brain wave activity and produce a relaxed state. Meanwhile, the public was becoming aware of biofeedback and neurofeedback due to the writings of the research psychologist

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Barbara Brown, who conceptualized neurofeedback as linking the self-regulation of brain waves to  activating different circuits in the brain. Simultaneously, Antoine Remond experimented with voluntary control of brain waves, which led to his discovery of a signature EEG pattern associated with what would later be classified as attentiondeficit disorder. The booklet The Alpha Average outlined his discoveries, and the disciplines of biofeedback and neurofeedback were born. By the 1970s, biofeedback researchers like Neal Miller and Leo DiCara provided evidence that visceral conditioning was possible, and Elmer and Alyce Green established clinical protocols and integrated skin temperature into biofeedback. The American inventor Hershel Toomim, intrigued by Remond’s earlier findings, developed the first standardized, calibrated, and stand-alone biofeedback machine. Toomim’s machine combined measures of electromyography (the electrical currents of muscles), temperature, galvanic skin responses, and brain activity (EEG). Toomim’s wife, Marjorie, subsequently published a monumental study of galvanic skin responses for clinical use, and in 1972, Hershel added a computer to the mix to produce the first programmable biofeedback system. The computer was also integrated with existing imaging technologies, resulting in the creation of computerized axial tomography scans and positron emission tomography scans, which allowed for the exploration of the brain without surgery. In 1977, Raymond Damadian created the first magnetic resonance imaging (MRI) machine, and the examination of detailed, three-dimensional images of tissues, nearly as detailed as photographs, became possible. What may be the most significant development in neuroimaging was the creation of the functional MRI (fMRI) in the early 1990s. The fMRI revolutionized the field of neuroscience because surgeons could watch images while the brain was actually working. If the MRI provided snapshots of the brain, the fMRI provided movies and allowed physicians and researchers to observe patterns of blood flow to regions of the brain as patients performed mental and physical tasks. As a result of the fMRI, there is now evidence that many aspects of psychotherapy, such as expressing empathy or exercising insight, are biological interventions because these activities stimulate specific neurological regions associated with wellness.

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Theoretical Underpinnings The brain–body link is no longer mysterious, and it has been established that the brain can continue to grow and develop by exercising specific brain pathways through emotional and physical stimulation. Whether a particular therapy uses technology, hypnosis, or touch, all these methods are based on recent discoveries in neuroscience. Neuroplasticity

Recent advances in structural and functional neuroimaging have disproven the belief that the adult human brain is an inflexible, hard-wired organ. It is now understood that neuroplasticity is the fundamental process that enables lifelong learning, development, and environmental adaptation. The underlying mechanism of neuroplasticity is experience-dependent reorganization of existing neuronal structures and networks. Plasticity occurs through structural changes, such as synaptic generation or pruning, and functional changes, by long-term synaptic potentiation or depression. These synaptogenic and functional changes are widespread, occurring throughout the cortical and subcortical brain regions, and sometimes rapid, occurring in fewer than 3 hours. Neuroplasticity allows the brain to compensate for injury and develop new capabilities. These synaptic adaptations are profoundly influenced by experience. Pioneers in the field of cognitive neuroscience are now examining the effectiveness of targeted psychological exercises to promote brain plasticity and alter neural circuitry, thereby fostering psychological well-being. Recent research has shown that mindfulness therapy can increase gray matter concentration in the hippocampus, cingulate cortex, temporal-parietal junction, and cerebellum—areas that are involved in learning, memory, emotional regulation, and perspective taking. Other areas of investigation have targeted retraining the specific neural circuits involved in anxiety and depression, and the results, thus far, are promising. Neurogenesis

Unlike neuroplasticity, which involves the growth of new connections on existing neurons, neurogenesis is the process by which new neurons are produced. Neurogenesis occurs primarily during

prenatal development; however, recent experimental work has demonstrated that more prescribed neurogenesis occurs in the adult brain and is essential for certain functions such as olfaction and memory. Neurogenesis in the hippocampus is believed to contribute to learning and memory. Aging is associated with a decline in hippocampal neurogenesis. Research has linked new neuronal growth in the hippocampus to increased memory capacity and clarity. There is also evidence that indicates that hippocampal neurogenesis may be involved in the creation and maintenance of addictive behavior. The understanding that neurogenesis occurs in this brain region offers a promising new target for the development of mental health and cognitive interventions. What remains largely unknown is how therapeutic practices contribute to neurogenesis, and vice versa. Stress Reaction

Stress is defined as an emotional response to a stressful stimulus that produces predictable biological and behavioral changes. As illustrated by Yerkes-Dodson Law, moderate degrees of stress can be beneficial, producing enhanced performance and drive. In contrast, elevated stress is associated with numerous physical, emotional, and cognitive consequences. Stress is associated with cognitive deficits in executive abilities housed in the prefrontal cortex, such as judgment, planning, and decision making. Physiologically, stress activates the hypothalamic-pituitary-adrenal axis, which results in the release of stress hormones, glucosteroids, in the blood. Stress-induced glucosteroid production in turn inhibits neurogenesis. For example, in animal studies, chronic stress produced by electric shock reduces cell proliferation and neuronal differentiation and increases cell mortality. In contrast, reward-based stressful experiences that produce elevated glucosteroid levels are actually associated with increased neurogenesis. These findings suggest that in humans, positive and rewarding experiences may buffer the brain from the negative effects of elevated stress. Mirror Neurons

In the mid-1990s, researchers at the University of Parma, led by Giacomo Rizzolatti, identified a

Neurological and Psychophysiological Therapies: Overview

special type of brain cell, mirror neurons, that fired when monkeys executed an action sequence and when they observed or heard a similar action being done by another monkey or a human participant. The mirror neuron system involves the premotor cortex, sensorimotor cortex, posterior parietal lobe, superior temporal sulcus, and insula. It is now generally believed that humans have complex mirror neuron systems that allow us to carry out actions and understand the actions and intentions of others. The shared representation of motor actions forms a foundational cornerstone of higher order social processes. Mirror neurons are believed to be involved in response facilitation, mimicry, simulation, imitation learning, understanding actions, understanding intentions, empathy, theory of mind, and language. The existence of mirror neurons has implications for cognitive neuroscience, language, social psychology, and psychotherapy. For example, mirror neurons may explain aspects of social cognitive theory first investigated by Albert Bandura. Bandura observed that we acquire knowledge and behavior by observational learning and imitation. According to Christian Keysers at the University of Groningen in the Netherlands, certain social emotions such as guilt, shame, pride, embarrassment, rejection, and disgust are based in the mirror neuron system in the insula. Mirror neurons are hypothesized to play a central role in the experience of empathy. Highly empathic individuals have been shown to have particularly active mirror neuron systems. It has also been hypothesized that autism is associated with a breakdown in the mirror neuron system, thus impairing an individual’s ability to understand the experiences of others. The implications for conducting psychotherapy are profound.

Short Descriptions of Neurological and Psychophysiological Therapies There are a variety of neurological and psychophysiological approaches to counseling that foster the release of various neurotransmitters and stimulate different regions and pathways in the brain. What all these approaches have in common is the belief that the mind and the brain are inseparable and that counseling leads to positive changes in the brain.

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Autogenic Training

Autogenic training is a relaxation technique developed by the German psychiatrist Johannes H. Schultz that involves repeating a set of visualizations that result in a state of relaxation. Clients conduct 15-minute sessions at multiple times during the day, usually in the morning, at lunch time, and in the evening. Biofeedback

This technique can be used to reduce anxiety and prevent or treat migraine headaches, chronic pain, incontinence, and high blood pressure. Small electrodes are attached to the skin at various points of the body to capture breathing rate, blood pressure, skin temperature, sweating, or muscle activity. The signals are sent to a display that translates the signals into visual or audio representations, such as images, sounds, or flashes of light. The therapist introduces relaxation exercises, and the client controls different body functions by controlling the sound or the light display selected. Brain Change Therapy

Brain Change Therapy (BCT) is grounded on the concept of “self-directed neuroplasticity” and recognizes neurological research that has demonstrated that people have the ability to turn brain circuits on and off in a way that changes their psychophysiological states. BCT starts with the assumption that repatterning of neural pathways results in therapeutic change through practicing of focused attention. BCT integrates principles from hypnosis, biofeedback, and cognitive therapy. Cerebral Electric Stimulation

This therapy provides support to the nervous system for self-correcting electrical circulation throughout the body. It results in promoting deep relaxation and improved brain functioning, which may also result in improved speech and motor skills. Cognitive Enhancement Therapy

Cognitive enhancement therapy is a manualized approach that uses performance-based neurocognitive training exercises. Training assists

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participants in overcoming a variety of neurocognitive impairments and issues related to cognitive style, social cognition, and social adjustment. Cognitive enhancement therapy typically encompasses more than a year of treatment and utilizes both individual and group settings Developmental Counseling and Therapy: Theory and Brain-Based Practice

Using Jean Piaget’s theory of cognitive development, this approach first determines a client’s developmental level and then applies any of a number of interventions that would be most effective at that level. Being collaborative and crossculturally sensitive and appropriately matching developmental level and intervention strategy are critical if clients are to change. It is assumed that accurately matching level and strategy will add new neural connections and positively affect the client’s emotional/cognitive style. Eye Movement Desensitization and Reprocessing

Eye Movement Desensitization and Reprocessing therapy is a three-pronged protocol that addresses past memories, present disturbances, and future actions to alleviate the client’s distressing symptoms. Popularized in the treatment of posttraumatic stress disorder, Eye Movement Desensitization and Reprocessing is aimed at processing problematic distressing experiences to resolve them and learning new lessons from the experiences that lead to healthier thoughts and behaviors. Eye Movement Integration Therapy

client is trained to relax physically and emotionally, reduce anxious thoughts and negative emotions, and engage in deep breathing exercises. Hypnotherapy

Hypnotherapy is used for treating a wide range of medical, dental, and psychological problems. A skilled practitioner interjects verbal communication while the client is in a hypnotic state to direct the client’s imagination in order to alter thoughts, feelings, and actions. Integral Eye Movement Therapy

Often used for clients who have had serious trauma that developed from life events over which they had little control, this approach assumes that emotional maps are formed through the memories of these events. The therapeutic process includes having clients focus on troubling events and adjusting eye movements to determine any changes in the client’s feeling state. Neurofeedback

This therapy is a type of biofeedback targeted at training the brain to operate more efficiently. Using electrodes as biofeedback does, neurofeedback most commonly uses video or sound to provide real-time feedback to the client. Positive feedback is applied for desired brain activity and negative feedback for undesirable brain activity. Neurofeedback guided by the use of a quantitative EEG that provides computerized statistical analysis is held to be the most accurate form of neurofeedback, most often used in clinical settings.

Based on brain research, this nonverbal therapy is often used to treat trauma and assumes that the relationship between eye position and brain processing is critical in the treatment of individuals. Therapeutic intervention includes asking the client to recall a troubling memory and then asking the client to move his or her eyes in a particular manner in an attempt to determine which eye movements decrease unpleasant feelings.

Neuro-Linguistic Programming

Heart Rate Variability

Neuroprocessing

This therapy is a form of biofeedback that focuses on self-regulation of heart rhythms. The

This therapy recognizes that traumatic histories may result in obstacles to one’s neuroprocessing,

Neuro-linguistic programming is an approach that connects neurological processes (“neuro”), language (“linguistic”), and behavioral patterns learned through experience (“programming”). Practitioners believe that these processes can be changed to achieve specific goals in a client’s life, including improved communication and personal development.

Neuroprocessing

language, or executive functioning. Specific training profiles are entered into the system, and training in the brain occurs as the client attempts to modify his or her own brain activity to match the profile. Neuropsychoanalysis

As the name implies, this therapy combines the lessons from neuroscience and psychoanalysis to promote a better understanding of one’s mind and  brain. Unconscious functioning discovered through the techniques of psychoanalysis is combined with the underlying brain mechanisms that control consciousness. Herman R. Lukow II and Ana Mills See also Autogenic Training; Biofeedback; Brain Change Therapy; Cerebral Electric Stimulation; Cognitive Enhancement Therapy; Eye Movement Desensitization and Reprocessing Therapy; Heart Rate Variability; Hypnotherapy; Neurofeedback; Neuro-Linguistic Programming; Neuroprocessing; Neuropsychoanalysis

Further Readings Bennett, E. D., & Smith, J. N. (2011). Neurology for smarties: Symptom recognition, referral, and support. Retrieved from http://counselingoutfitters.com/vistas/ vistas11/Article_57.pdf Charney, D. S., Nestler, E. J., Sklar, P., & Buxbaum, J. D. (Eds.). (2013). Neurobiology of mental illness. New York, NY: Oxford University Press. Grawe, K. (2007). Neuropsychotherapy: How the neurosciences inform effective psychotherapy. Mahwah, NJ: Lawrence Erlbaum. Ivey, A. E., D’Andrea, M. J., & Ivey, M. B. (Eds.). (2012). Neuroscience: The newest force in counseling and psychotherapy. In Theories of counseling and psychotherapy: A multicultural perspective (7th ed., pp. 49–86). Thousand Oaks, CA: Sage. Ivey, A. E., & Zalaquett, C. P. (2011). Neuroscience and counseling: Central issue for social justice leaders. Journal for Social Action in Counseling and Psychology, 3, 103–116. Makinson, R. A., & Young, J. S. (2012). Cognitive behavioral therapy and the treatment of posttraumatic stress disorder: Where counseling and neuroscience meet. Journal of Counseling and Development, 90(2), 131–140. doi:10.1111/j.1556-6676.2012.00017.x Myers, J. E., & Young, J. S. (2012). Brain wave biofeedback: Benefits of integrating neurofeedback in

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counseling. Journal of Counseling and Development, 90(1), 20–28. doi:10.1111/j.1556-6676.2012.00003.x Roche, R. A. P., Commins, S., & Dockree, P. M. (2009). Cognitive neuroscience: Introduction and historical perspective. In R. A. P. Roche & S. Commins (Eds.), Pioneering studies in cognitive neuroscience (pp. 1–18). Maidenhead, England: McGraw-Hill. Snyder, P. J., Nussbaum, P. D., & Robins, D. L. (2006). Clinical neuropsychology: A pocket handbook for assessment. Washington, DC: American Psychological Association.

NEUROPROCESSING Neuroprocessing, also known as brain mapping, is a therapeutic technique designed to assess cognitive processing and its relationship to mental disorders. This therapy is related to biofeedback in that it allows the client to better understand how to modify thoughts, feelings, and behaviors for optimal brain functioning and mind—body wellness. Much like biofeedback, neuroprocessing is used both as an assessment tool and as an intervention to address mental and physical disorders. The primary method utilized in neuroprocessing is an assessment called a quantum electroencephalograph (qEEG). This is an electroencephalograph (EEG) that displays brain wave data and uses algorithms to depict the brain wave paths for a more nuanced understanding of brain activity. The  quantum aspect depicts the neuroprocessing through colorful topographic images to illustrate the brain functions in a user-friendly and clinically useful way. The topographic images of cortical brain activity are detected from the electrodes placed in strategic positions on the client’s scalp. Once the client data are collected, they are often compared with normative databases to determine whether any abnormalities are present. Using neuroprocessing as an intervention appears to exercise the brain’s ability to self-regulate. The brain typically conducts multiple levels of processing at once, and if disorders are present, there is interference in its processing system. Disorders sometimes result in one area of the brain overcompensating for another. Once that is discovered, treatment can be targeted to the appropriate area of the brain for correction and optimal functioning. With neuroprocessing, a qEEG pinpoints whether

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Neuroprocessing

the brain remains in patterns of high or low arousal. Patterns of arousal are related to a variety of disorders, such as anxiety (high arousal) or depression (low arousal). Neuroprocessing is often used to treat disorders of attention and focus such as attention-deficit/hyperactivity disorder (ADHD), autism and learning disabilities, sensory processing disorders, and a variety of mental disorders.

Historical Context Neuroprocessing is the product of modern technological developments and attempts to more accurately diagnose mental disorders. Historically, individuals sought to understand the mysteries of the brain and its relationship to mental illness by using fairly primitive techniques. For instance, in the 1800s, some practitioners engaged in phrenology, the study of brain size and brain contour, believing falsely that these were indicative of mental health or pathology. Then, in the mid-1900s, some practitioners performed lobotomy—the removal of portions of the prefrontal cortex— falsely assuming this therapy would remedy various forms of chronic mental illness, such as schizophrenia. Also during the mid-1900s, some practitioners treated mental disorders such as depression and schizophrenia with electroconvulsive therapy, in which the client’s brain is given electric shocks via electrodes attached to his or her head. Although these early attempts at electroconvulsive therapy were found to be harmful, in more recent years, this approach has been significantly changed and has been shown to have some positive outcomes, especially with those who have long-term, intractable depression. During the 1970s, scientists began experimenting with biofeedback of alpha and beta brain waves. For instance, an individual may hear sounds or visualize colored lights depending on the brain wave being produced. Through biofeedback, individuals can control the type of brain wave being produced. Today, uncovering the mysteries of the brain and its relationship to mental health continues to drive clinical exploration and empirical research. In recent decades, modern and less invasive techniques, such as qEEG and singlephoton emission computerized tomography (SPECT) brain imaging, have facilitated a more individualized and nuanced understanding of the influence of the brain in mental health. Over the

past 50 years, data from EEG have shown particular brain wave activity to be correlated with some psychiatric disorders, and with the development of the qEEG, a more nuanced understanding of the relationship of brain waves to psychiatric disorders has developed. Today, neuroprocessing is taught to both lay technicians and mental health professionals. There are national certification programs as well as regulation and continuing education requirements. Some practitioners may work in medical settings, whereas others may practice in educational or private settings. Practitioners have used brain mapping to assess a variety of disorders. For example, Helena Kerekhazi has used neuroprocessing for more than 25 years in educational settings to assist in better understanding learning disabilities, attention disorders, and sensory processing disorders as well as to design individual education plans for children with special needs. Since the 1990s, the qEEG technique of neuroprocessing has been researched. It has been used in studies assessing the neurological damage from cocaine abuse as well as studies examining the possible neurobiological underpinnings of obsessive-compulsive disorder. In other studies, the qEEG has been used to better understand the influence of antidepressants and various medications. Because neuroprocessing is a new approach, the research base is still in its infancy, but clinical and anecdotal reports seem to indicate the effectiveness of neuroprocessing in treating anxiety, chronic pain, migraines, autism (high-arousal right-brain training), head traumas, ADHD, and other learning disabilities. Clinical reports indicate that it enhances the ability of the client to increase a sense of calm and control over his or her mind– body system. In addition, some recent studies indicate that neuroprocessing may be helpful in  differential diagnosis of mental disorders. Understanding these more refined levels of discrimination and subtypes, such as between unipolar and bipolar depression, may assist in developing more accurate and customized treatment procedures. Other research has used neuroprocessing to distinguish between ADHD and anxiety disorders, which are sometimes misdiagnosed due to overlapping symptoms. For example, some symptoms, such as psychomotor agitation, overlap in ADHD and anxiety. qEEG readings

Neuroprocessing

discriminate between disorders that can appear to be behaviorally similar. qEEG indicates that ADHD has excess theta activity and not enough beta. An individual with an anxiety disorder is more likely to have a qEEG reading demonstrating excess beta and not enough alpha. Correct assessment of brain functions and alignment with disorders allows for customized and more accurate treatments. Accurate diagnosis can decrease the frustration and demoralization that may accompany the diagnostic process. Assessing brain activity in neuroprocessing adds an important quantitative dimension to therapies that have been clinically observed but may not have a large body of quantitative data behind them yet, such as thought field therapy, which is an energy therapy.

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Quantitative EEG

qEEG is an assessment tool that converts traditional EEG data into colorful topographical images. Electrodes are placed on strategic positions on the client’s scalp to detect cortical activity. The qEEG measures brain wave bands (e.g., alpha, beta, gamma, and theta) to assess the level of brain activity or arousal. For example, some studies have found that people with an anxiety disorder have little alpha activity and an abundance of beta activity. qEEG assessments of adolescents or adults with ADHD display excess alpha activity and normal levels of theta activity. However, individuals diagnosed with both ADHD and anxiety have very different brain wave patterns. Data derived from qEEG are compared with normative databases to assist in diagnosing disorders.

Theoretical Underpinnings Neuroprocessing draws from systems theories, learning theory, and anatomical models. Systems theories focus on the influence of one part of a system on another and also on the whole. Neuroprocessing operates on the assumption that the brain is a system that can be positively influenced by making changes based on brain feedback. The neurofeedback process allows clients to understand that they have some degree of control over their mind–body system, and in some clinical reports, brain patterns change in therapeutic directions. The ability to participate in changing brain wave patterns adds credence to the theory around the neuroplasticity of the brain (i.e., the brain’s ability to form new neural networks that lead to more productive thought patterns and behaviors). Regarding anatomical theory, cortical areas expand in areas targeted by the tasks in the neurofeedback programs. For example, a client with an anxiety disorder is given the qEEG, performs neurofeedback tasks designed to decrease anxiety by decreasing beta amplitudes and increasing alpha, and is then measured again. The qEEG topographical map indicates the changes in the expected cortical areas.

Neuroplasticity

Neuroplasticity refers to the human brain’s ability to change over the life span. Historically, it was believed that the brain developed during a critical period in childhood, with little variation during adolescence and adulthood. Current scientific understanding is that the brain changes synaptic connections and neural pathways when behavior is changed. Based on this understanding, neuroprocessing attempts to produce positive and effective outcomes by engaging this adaptable function of the brain (e.g., by changing thinking or other brain processes such as awareness). Autonomic Activity

Autonomic activity describes the function of the autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems. When mental disorders are present, the autonomic nervous system typically produces dysfunctional autonomic responses, and techniques such as neurofeedback can engage the somatic nervous system in changing dysfunctional autonomic responses to produce better brain wave activity and adaptive physiological responses.

Major Concepts A few concepts are important for the understanding of neuroprocessing. They include qEEG, neuroplasticity, autonomic activity, and biofeedback process in neuroprocessing.

Biofeedback Process in Neuroprocessing

The primary objective of neuroprocessing is to utilize a brain-focused biofeedback program, generally referred to as neurofeedback.

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Neuroprocessing

Neurofeedback includes attaching sensors to the client’s scalp and asking the client to watch a visual display that is programmed to target specific disorders. Other biofeedback interventions may include using biofeedback to measure changes in the brain before and after meditation. Neurotherapy uses EEG feedback in combination with cognitive-behavioral therapy to change awareness, thoughts, and behaviors to shift brain waves from maladaptive states to more adaptive states.

Techniques The primary technique used in neuroprocessing is a qEEG assessment of brain activity before and after a neurofeedback procedure. In neurofeedback, sensors are applied on the scalp, and the client is asked to follow visual cues (something like a video program) that assess and direct brain activity toward adaptive brain wave bands or toward integrating parts of the brain that have not yet been engaged in productive activity. The qEEG assessment is conducted during the video program, and the neuroprocessing professional manipulates the program to shift the brain waves into the target areas. Other techniques may be more passive, such as asking the client to become more aware of his or her consciousness in meditation. The psychiatrist Daniel Amen has applied SPECT imaging to study the brain and its relationship to mental and physical wellness with similar goals as neuroprocessing. SPECT, considered nuclear medicine rather than neuroprocessing because radioactive isotopes are injected into the client to identify unstable atoms producing gamma energy, serves as a tracking system of the brain anatomy and processes. Amen’s method using SPECT has been applied in six clinics around the United States with reports of clinical success. There is also an emerging body of empirical research in this area, but it has not yet been widely validated. Some of the initial findings from this approach are descriptions and data illustrating seven types of ADHD and multiple types of other disorders, such as anxiety. This possible refined level of the brain or biological aspect could play an important role in more accurately and efficiently treating clients with mental disorders.

Therapeutic Process Neuroprocessing is used either as an adjunctive assessment tool for diagnosis of disorders or as a precursor to a therapeutic process called neurofeedback. Initial qEEG assessment displays general brain activity in terms of which areas “light up” (are activated) when stimulated and specific brain wave bands that are either aroused (dominant) or underaroused (asleep). Clients present with a specific mental diagnosis, and the qEEG assessment either confirms that the brain activity is consistent with the diagnosis or indicates that the diagnosis needs to be refined or corrected. Neurofeedback programs are utilized according to the target brain wave bands that need to be modified (e.g., increase of alpha or decrease in beta), and clients observe these programs while their brain activity is monitored. There is some variation from clinic to clinic, but typically blocks of 20 sessions are recommended because changing the brain’s neuroplasticity requires frequent and consistent attention until new brain patterns are learned and integrated into experience. Clients are interviewed in between sessions to ascertain symptom reduction. Initial data indicate that neuroprocessing is an effective therapy for refining the diagnosis, assessing the effects of medication therapy, and reducing the symptoms of mental disorders. Christine Berger See also Behavior Modification; Behavior Therapy; Biofeedback; Brain Change Therapy; Cerebral Electric Stimulation; Neurofeedback; Neurological and Psychophysiological Therapies: Overview

Further Readings Amen, D. (2009). Change your brain, change your life: The breakthrough program for conquering anxiety, depression, obsessiveness, anger and impulsiveness. New York, NY: Random House. Amen, D. (2013). Healing ADD revised edition: The breakthrough program that allows you to see and heal the seven types of ADD. New York, NY: Berkley Trade. Collura, T. F. (2013). Technical foundations of neurofeedback. London, England: Routledge. Larsen, S. (2012). The neurofeedback solution: How to treat autism, ADHD, anxiety, brain injury, stroke, PTSD and more. Rochester, VT: Healing Arts Press.

Neuropsychoanalysis

NEUROPSYCHOANALYSIS Neuropsychoanalysis is an approach to psychotherapy and research that attempts to bridge the gap between neuroscience and psychoanalysis. It strives to bring into accord neurological findings with Sigmund Freud’s theory of psychoanalysis. Neuropsychoanalysis aims to integrate brain research by mapping subjective experience such as thoughts, feelings, and motivation onto neural correlates, specific physiological states and functions of the brain. Neuropsychoanalysis rests in the intersection of philosophy, neuroscience, psychoanalysis, psychiatry, and psychology and draws on an understanding of how neurological processes are turned into psychological processes. Through the use of psychodynamic principles, such as object relations and conflict theory, the process explores what “lies beneath the surface” by exploring the client’s unconscious conflicts that interfere with everyday functioning. The influence of the unconscious is applied to underlying brain and neurological processes, which contributes to symptoms such as phobias, anxiety, depression, and compulsions.

Historical Context Mark Solms is credited with popularizing the term neuropsychoanalysis through the introduction of the journal Neuropsychoanalysis in the late 1990s. However, its roots reach back to Freud’s theory of psychoanalysis, beginning in the 1890s. Trained as a neurologist, Freud tried to find a treatment for patients who suffered from neurosis and hysteria. This led him to eventually publish a book with Josef Breuer based on the treatment of a patient dubbed Anna O. This book launched psychoanalysis as a discipline, which was otherwise known as the “talking cure.” Soon after this, Freud attempted to develop a neurological and physiological foundation for his theories. This resulted in the 1895 uncompleted monograph Project for a Scientific Psychology, which was left unpublished until after his death. This unfinished strand of thought is where neuropsychoanalysis picks up.

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in neurology, especially the technology of brain imaging. Neuropsychoanalysis attempts to better understand the underlying neurological basis of psychiatric disorders such as depression and schizophrenia. The insights into the interpersonal neurobiology of mental processes such as emotion and reasoning take into account how the interaction between the brain and the mind shapes psychological life. Neuropsychoanalysis is not without controversy in trying to integrate two disparate fields— neurology and psychoanalysis—because of their different philosophical assumptions.

Major Concepts There are a number of concepts in neuropsychoanalytical theory that guide in the investigation of neural correlates. Major psychoanalytical and neurological concepts include repression, unconscious, drives, libido, oedipal behaviors, and dreams— each of which are discussed in turn in this section. Repression

Repression represents what is unacceptable to the conscious mind or the prefrontal cortex. As a result, the unconscious mind excludes distressing impulses, desires, or fears in an attempt to ward off anxiety. Unconscious

The unconscious refers to the level of human consciousness where thoughts are automatic and not a part of our conscious awareness. Neuropsychoanalysis is used to uncover unconscious desires, impulses, and conflicts, which are then applied to underlying brain structures, such as the limbic system. Drives

Neuropsychoanalysis strives to integrate the soma (brain) and psyche (mind). Drives and instinctual motivations arise from the evolutionarily older part of the brain—the brainstem and, specifically, the pons region of the brain. Libido

Theoretical Underpinnings Neuropsychoanalysis is a relatively new field, having emerged in the 1990s because of the advances

Libido is the driving force of all behavior and embodies survival and sexual instincts that influence psychosocial development. Factors in the formation

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of attachment and trauma influence early brain development: namely, the limbic system, the prefrontal cortex, and the anterior cingulate cortex, which play a role in an individual’s ability to progress successfully through each stage. Oedipal Behaviors

In the Oedipus/Electra complex, a child becomes fixated on the opposite-sex parent and competes with the same-sex parent for attention. This process allows the child to loosen his or her ties from a parent as he or she strives for independence and separateness. The process of moving toward individuation is involved in the production and management of neurotransmitters, such as testosterone, dopamine, and oxytocin, associated with affiliative behaviors. Dreams

Freud famously declared dreams to be the “royal road to the unconscious.” By saying this, he highlighted the insightful primacy that dreams offer about psychical life. Dreams have been found to have a cognitive problem-solving function associated with brain reorganization.

Techniques The practice of neuropsychoanalysis uses neuroscience as a foundation for the use of psychoanalytical concepts such as free association, interpretation, and transference/countertransference. The techniques used by a neuropsychoanalyst are targeted toward rewiring the neuropathways of the client’s brain through a reworking of memories that allows the client to gain new perspectives. Redefining neurotic beliefs and emotions makes room for new neural pathways to form and promotes change in areas of the brain such as the prefrontal cortex.

Interpretation

Interpretation is the process that a therapist uses to access a client’s unconscious conflicts that affect everyday functioning. Once the conflicts are brought to awareness, the therapist attributes meaning to them. Interpreting dreams enables a client to uncover latent and manifest content, which allows for the further development of the right hemisphere of the brain. Transference/Countertransference

Another way in which unconscious content emerges is through the transference–countertransference relationship. Therapy focuses on understanding transference and countertransference from the perspective that memories from early attachment relationships are reactivated in therapy and draws on the ways the client and the therapist regulate each another through affective bodily expression.

Therapeutic Process Neuropsychoanalysis requires a considerable investment of time, energy, and money; therapy typically involves multiple sessions per week and may last for a number of weeks, months, or years. The process typically begins with an evaluation or consultation whereby the therapist evaluates the suitability of the client for analysis. Throughout therapy, the therapist draws on neuropsychoanalytical techniques to analyze and diagnose the client’s dysregulating symptomatology. The therapeutic alliance is used to interpret the regulating systems of both the client and the therapist, allowing the brain to ultimately reorganize itself. Leslie W. O’Ryan and Jacob W. Glazier See also Ego Psychology; Freudian Psychoanalysis; Object Relations Theory; Self Psychology

Free Association

Further Readings

In free association, the client is encouraged to communicate whatever comes into his or her mind without censoring the thoughts in order to gain insight into what he or she thinks and feels. This allows the client to shift dominance from a left- to a right-hemispheric state, where he or she is able to recognize and express emotions.

Kaplan-Solms, K., & Solms, M. (2002). Clinical studies in neuro-psychoanalysis: Introduction to a depth neuropsychology. New York, NY: Karnac Books. Northoff, G. (2011). Neuropsychoanalysis in practice: Brain, self, and objects. Oxford, England: Oxford University Press. doi:10.1093/med/9780199599691 .001.0001

Non-Western Approaches Schore, A. N. (2002). Advances in neuropsychoanalysis, attachment theory, and trauma research: Implications for self psychology. Psychoanalytic Inquiry, 22(3), 433–484. doi:10.1080/07351692209348996

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Non-Western approaches to counseling and psychotherapy is a broad and nonspecific category that encompasses methods considered to have their origins outside Western developments in counseling and psychotherapy. “Non-Western” in this context usually refers to the people and cultures of India, China, Japan, and Korea, although in some sources “non-Western” includes Africa, South America, and the Pacific Islands. Some sources utilize the label “non-Western” to designate those approaches that are rooted in indigenous cultures and often include spiritual and faith-based beliefs and practices.

they have unfamiliar names, they were and are also means to psychotherapeutic ends. Before Western theories, techniques, and approaches emerged, people across the planet had found ways to achieve intrapersonal and interpersonal goals as well as to reach mental health and wellness. Many non-Western approaches are experiencing a transcultural awakening as our predominately Western world of counseling and psychotherapy are embracing these as complementary approaches with distinct benefits. While readers may consider how the practice of meditation and the choreographed, internal energy work of taijiquan may hold promise as primary tools in modern counseling and psychotherapy, it is likely that practitioners of these arts a millennium ago, who would have lacked our “mental health” vocabulary, experienced profound benefit through their practice. Gifts from the past are being rediscovered, and a renewal of interest in their values is sparking modern applications as well as empirical explorations.

Historical Context

Theoretical Underpinnings

The origins of non-Western approaches to counseling and psychotherapy predate the West’s formalization and professionalization of methods that aim to help people with psychological need. Ancient artifacts from early civilizations reveal methods of herbal medicine, bonesetting, and surgery; modernity has less evidence for how early peoples supported, guided, and helped their neighbors with psychological, emotional, and behavioral difficulties. It is naive if not unreasonable to believe that such needs did not exist throughout our evolution or that remedies of some sort were nonexistent. However, it was in the Western Hemisphere and in our more recent past that the terms counseling and psychotherapy developed. Through our everyday vocabulary, people in the West, as well as many in a growing number of countries and nations, recognize these terms. There is no doubt that counseling and psychotherapy are invaluable tools that have become well integrated into modern society. Interestingly, the meaning of counseling or psychotherapy is overly broad and often imprecise. The remainder of this entry describes approaches with long and robust histories, each deeply embedded in non-Western cultures, and although

Two concepts, worldview and epistemology, are imperative to understanding the significance and importance of non-Western approaches to counseling and psychotherapy.

NON-WESTERN APPROACHES

Worldview

Worldview is broadly defined as the way individuals experience their worlds as an outcome of how they live their lives. Worldview extends beyond the mere vocabulary people use to explore and explain their beliefs about their world; it reflects the culture, ethos, mores, and social constructions of people’s day-to-day lives. Worldview in the context of counseling and psychotherapy is a broad, culturally reflective lens through which individuals experience all aspects of life, with specific attention to how people view issues related to mental health. Cultures, groups of people who share a common worldview, therefore form their worldviews as well as perpetuate them. NonWestern approaches to counseling and psychotherapy are congruent with the worldviews from which they emerge. It is critically important to consider how nonWestern approaches answer (or support) questions

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such as the following: To what do we attribute mental illness? Who cares for those individuals, and how? Does science or tradition inform our understanding of how people help individuals with psychological difficulties? The answers to these questions are as numerous as there are worldviews. Readers can best comprehend all approaches to counseling and psychotherapy, Western as well as non-Western, by first carefully and respectfully considering the worldview that informs each approach. Epistemology

Epistemology is the study of knowledge. Simply stated, it is the study of knowledge and justified beliefs. To understand what theoretical differences may exist between Western and non-Western approaches to counseling and psychotherapy, we consider epistemology. Western epistemology often considers what is empirically proven to be supreme. Congruent with a worldview of valuing scientific inquiry, Western approaches to mental health are often held to the scrutiny of scientific rigor. In the West, validity and reliability are paramount concepts in developing reproducible methods of treating individuals who are challenged by biological, social, or psychological difficulties. Non-Western approaches, emanating from significantly differing worldviews and resources, prize methods and their accompanying theories that have deep historical and cultural relevance. In many non-Western approaches, anecdotal evidence, the common narrative of a culture, is the paramount test for efficacy. People establish their global fund of knowledge by all practical tools and resources available to them at that time. Consider a simple example: With the advent of the microscope, the world of microbiology revealed itself. Before discovering (knowing) that microorganisms could be responsible for health as well as illness, explanations for both were based on the best extant knowledge available to the people at that time. With development, old theories are refuted, and new ones emerge. As time progresses, theories that have limited utility or that have been soundly dismissed disappear. However, when theories and methods continue to have utility that is of practical benefit to the people, they are retained despite the newer

developments. Traditional, indigenous, and folk practices are labels that often accompany nonWestern approaches; however, there is abundant anecdotal support for the use of many non-Western approaches worldwide. Numerous non-Western approaches to counseling and psychotherapy have withstood time and scrutiny; and although they are perhaps less amenable to empirical validation, non-Western approaches have found favor in the Western world. Epistemologically, as global access expands, the more people know about successful approaches in counseling and psychotherapy, the stronger their armamentarium for treatment becomes.

Major Concepts The predominant concept underpinning the nonWestern approaches to counseling and psychotherapy covered here is self-regulation. Often adapted from religious, faith-based, or spiritual traditions, such self-regulation aims at cultivating those qualities of humanity prized by and congruent with an individual’s aspirations and worldview. The major concepts that are the goals of these approaches include awareness, concentration, mental clarity, equanimity, “a healthy body and healthy mind,” proactivity over reactivity, and, not the least, health preservation. Techniques to achieve such personal and societal aspirations are vast in number, worldwide, and have deep and rich histories.

Techniques There exist a vast number of non-Western approaches in counseling and psychotherapy. In this section, five commonly encountered nonWestern practices are briefly described. Their origin, purpose, and practice or integration with other approaches to mental health are highlighted. Meditation

Meditation has a rich tradition in many of the world’s religious and faith traditions. In the context of counseling and psychotherapy, the practice of meditation is often secularized—meaning that the religious pursuits originally attached to the practice have been de-emphasized, leaving individuals who

Non-Western Approaches

learn to meditate to do so without interference with their religious or spiritual beliefs. Meditation is often divided into two broad types: (1) awareness meditation and (2) concentration meditation. Awareness meditation is a method for practitioners to invite insights from any and all possible sources. The phrases an open mind and an open heart often characterize this type of exercise. In a sense, awareness meditation can be practiced as a means to attain mental health or to complement other approaches in treatment. A goal of awareness meditation is for the practitioner to become more attuned to the world and to expand or develop human potential. Concentration meditation requires the practitioner to focus the mind and all conscious awareness. The point of concentration may be a word, a phrase, or an image (cognitive concentration), or it may be a posture or breathing pattern (body-regulating concentration). Both exercises are practiced over time diligently for the practitioner to attain whatever goal he or she may aspire to. Meditation is often utilized in the reduction of anxiety and in coping favorably with stresses of daily living. It is also used quite extensively in the pursuit of relaxation. One popular form of meditation is “mindfulness meditation,” with an overarching goal of enhancing meaning and equanimity in daily life. Mindfulness

Mindfulness describes the product of practicing a life with acute awareness. To be mindful describes a level of attention that is attainable only through training and practice. Mindfulness is adapted from spiritual contexts such as Chan (Chinese) and Zen (Japanese) Buddhism and Indian Buddhist and Hindu origins. When encountered in the Western world of counseling and psychotherapy, mindfulness is often made secular; the aim is to make daily living a more conscious and present endeavor for clients, patients, and most certainly their clinicians and therapists. The techniques associated with mindfulness training are often referred to as mindfulness practice. Practice, as acclaimed in many non-Western approaches, is a pursuit rather than a destination. Simply stated, mindfulness practice is a remedy to  living mindlessly. Many Western counseling approaches value mindfulness. Often the addition

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of mindfulness training and practices to complement more contemporary Western-oriented therapeutic theories and methods (e.g., behavioral and cognitive therapies) offers measureable benefits to clients and patients, including greater self-awareness as well as enhanced cognitive, behavioral, and affective self-regulation. Literature across the allied mental health professions is replete with references to mindfulness and warrants continued exploration and study. Yoga

Yoga is imbedded deeply in Hinduism. It is a cognitive-behavioral discipline, and like other nonWestern approaches in counseling and psychotherapy, yogic practice in mental health has transformed from a religious discipline to a more secular, less spiritual one. Yoga stems from many branches of unique physical discipline, some with austere postural demands and some that are much more easily practiced by less physically able yoga aesthetes. There is a wide range of yoga training available in the West. Like other principally physical or bodyoriented practices, such as taijiquan, and additional types of meditation trainings, yoga is often included as a complementary practice utilized by mental health clients and patients to enhance primary treatment goals and objectives. Yoga is characterized by physical postures (often referred to as poses), one’s breath and awareness during these postures, the transition between postures, and, in many schools and methods of training in yoga, mental imagery as well. A primary focus of yoga is to increase mind–body coherence. Training in yoga, therefore, is to enhance the capability and capacity for a healthy body and a healthy mind. One major element in the practice of yoga is breath. Breathing is fundamental throughout all poses in yoga; a growing literature in the neurosciences as well as exercise physiology reports the neurobiological effects that benefit yoga practitioners. Qigong

Literally, “vital energy exercise,” qigong (or chi gong) has a 1,000-year history in China. Throughout Chinese history and still at the base of Traditional Chinese Medicine, qi is the vital

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essence of life. Qi is often translated as “breath” but is always understood to be the vital energy of life. Qigong is a broad category of physical and mental exercises that purport to sustain, increase, and heal, the vital energy that gives and sustains life, which is found in all human (and nonhuman) life. Qi, under the microscope of Western science is elusive and often characterized as the “human spirit.” Qigong, then, includes many ways to regulate health and well-being as well as to treat illness. Qigong exercises align on a continuum. Qigong can be a very meditative practice. Breath control and often complex accompanying mental imagery is qigong on the “stillness” side of the continuum. On the other end is the physically demanding qigong, with martial arts–like vigor and routines. Two examples: Zhan zhuang, “standing pole” qigong, involves a practitioner standing perfectly still in one of several postures. From this stillness and regulated breath, the practitioner is able to balance vital energy, keep his or her energy robust and vigorous in order to keep the mind and body healthy. Ba Duan Jin qigong, “eight pieces of silk qi exercises,” is more calisthenic, containing intensely regulated stretches and movements. According to Traditional Chinese Medical theory, where qigong originated, where there is dysregulation or an imbalance of energy (qi) in the body, there is mental and physical illness. The daily and often life-long practice of qigong is therefore viewed by qigong practitioners as “life cultivating and life preserving.” However, when illness occurs, qigong can be utilized as a treatment. In many contemporary hospitals across Asian countries, qigong is often prescribed as part of a patient’s treatment and rehabilitation. In the West, qigong is encountered in a variety of settings, including increasingly in integrative medicine departments at several large, research-oriented hospitals. Taijquan

Taijiquan (tai chi chuan) literally translates from Chinese as “the grand or ultimate fist.” Taijiquan is an “internal martial art,” one of the pantheon of Chinese martial arts practiced daily by an increasing number of people worldwide. The martial art aspect of taijiquan often appears

invisible. The practice is to heighten the practitioner’s sense of self-awareness, as knowing one’s self is a prerequisite to defending one’s self. Taijiquan is characterized by slow and graceful movements among upright and regal postures, which is often called “stillness in motion.” As with meditation, there are many different schools of taijiquan. Like qigong, taijiquan is practiced as a health preservation exercise. The movements are meticulously guided by the practitioner’s intent, thereby linking the mind and the body. Key instruction in taijiquan highlights balance, posture, breath, and intent. The prearranged movements of taijiquan string together to create complex forms called routines. These routines are practiced repeatedly until the movements become a method of meditative awareness. Like qigong, taijiquan originates from a fundamentally different worldview of mental health, that of Traditional Chinese Medicine. Taijiquan as an approach to counseling is most often a practice to better integrate the mind and the body—to cultivate physical and mental health and well-being. Not unlike yoga or qigong, taijiquan has been adopted in many settings as both physical and mental exercise. It, too, has an increasing reference in the allied mental health literature, often as a complementary practice.

Therapeutic Process Non-Western approaches to counseling and psychotherapy are not traditional talk therapies. In these non-Western practices, the spoken narrative is often one of instruction, training, or teaching. Counselors or psychotherapists are masters or gurus or healers. These non-Western approaches are practiced by the client or the patient often alone or in groups (classes), usually without a counselor or a therapist present. The goal primarily is to enhance self-awareness and to strengthen physical and mental health. Like many Western approaches, these practices promote self-discovery, self-insight, and integration of mind and body. They focus on cultivating well-being. Often, nonWestern approaches are viewed solely as complementary to traditional Western counseling and psychotherapy, but this is not fully accurate. By themselves, these practices have a robust history of

Non-Western Approaches

effectiveness in human prosperity, health, and development. Numerous non-Western practices have gained attention in the professional literature over the past decade and appear to be significantly influencing Western approaches to counseling and psychotherapy. Kurt L. Kraus See also Acupuncture and Acupressure; Body-Mind Centering®; Hakomi Therapy; Meditation; MindfulnessBased Stress Reduction; Morita Therapy; Reiki

Further Readings Bankart, C. P. (1997). Talking cures: A history of Western and Eastern psychotherapies. Pacific Grove, CA: Brooks/Cole. Bein, A. (2008). The Zen of helping: Spiritual principles for mindful and open-hearted practice. Hoboken, NJ: Wiley.

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Germer, C. K., & Siegel, R. D. (Eds.). (2012). Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice. New York, NY: Guilford Press. Lam, K. C., & Yu, Y. (2014). The Qigong workbook for anxiety: Powerful energy practices to rebalance your nervous system and free yourself from fear. Oakland, CA: New Harbinger. Pedersen, P. B., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (Eds.). (2007). Counseling across cultures (6th ed.). Thousand Oakes, CA: Sage. Rinpoche, P. (1992). The heart treasure of the enlightened ones (commentary by D. K. Rinpoche). Boston, MA: Shambhala. Wallace, A. B., & Shapiro, S. L. (2006). Mental health and well-being: Building bridges between Buddhism and Western psychology. American Psychologist, 61, 690–701. doi:10.1037/0003-066x.61.7.690 Wong, X. (Compiler-in-Chief). (2003). Life cultivation and rehabilitation of traditional Chinese medicine [In Chinese and English]. Shanghai, People’s Republic of China: Shanghai University of Traditional Chinese Medicine.

O Psychoanalytic Institute. The result of these “Controversial Discussions” was the establishment of two separate training tracks as well as a “Middle School” of nonaligned analysts that included Donald Winnicott, John Bowlby, and Michael Balint. Probably the most important context for the emergence of object relations theory was that Klein centered her interest on the development and treatment of her child patients. In contrast, Freud had not had direct experience in this area, having only supervised the parents of Little Hans in their treatment of his phobia. Freud’s developmental psychology was based on retrospective reconstruction from the analysis of his neurotic patients, while Klein’s work was based on direct, hands-on experience. Meanwhile, Wilfred Bion (1897–1979) became a candidate at the British Institute after a distinguished career as a surgeon. He completed training analyses with John Rickman (1891–1951) and Klein, and his primary areas of interest were group dynamics, theories of thinking, and psychotic process. His concept of normal projective identification, which is described later in this entry, represents his most significant contribution to the field of psychotherapy. Out of the work of Klein and Bion came the Klein-Bion model. Two important variables in the development of this perspective came from observations Klein made in the treatment of disturbed children. She was struck by the intensity of both anxiety and sadistic fantasy in the children’s play. In searching classical Freudian theory for an explanation of this phenomenon, she concluded that Freud’s model of the “death instinct” best explained the anxiety and sadism. This became the cornerstone of her

OBJECT RELATIONS THEORY Object relations theory is the legacy of a dynamic intellectual discourse among several psychoanalysts in Britain and Scotland, although the theory was most influenced by the writings and clinical work of Melanie Klein (1882–1960) and Ronald Fairbairn (1889–1964). Both addressed this new paradigm while working independently and fewer than 500 miles from each other. Their writing helped switch the psychoanalytical theory of motivation away from the basic drive reduction/pleasure principle perspective of Sigmund Freud (1856–1939). In its place, these theorists saw the infant motivated by the need to be in relationship with another mind. Children are seen as building up their internal world through the introjection of a wide array of object representations and related affects. These introjections (i.e., the internal mother) then serve as a template for the projective understanding of the child’s world. While Klein held steadfastly to Freudian instinctual theory, Fairbairn veered away into a less biological or less instinctual understanding of an individual’s motivation and focused on the environmental provision in terms of effective mothering. Fairbairn presents what could be considered a pure object relations theory, eschewing Freud’s pleasure principle in favor of object seeking as the primary motivator.

Historical Context During the 1940s, the Kleinian approach competed with Anna Freud’s ego psychological approach for preeminence at the British 731

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object relations theory. In her view, children are born with competing life and death instincts and the experience of birth and infantile helplessness activates the death instinct first and foremost. She believed that it was only through ensuing sound parenting that the “life instinct” triumphs over the death instinct. She was in agreement with Freud that the projection of the death instinct in the world took the form of aggression. In addition to Klein and Fairbairn, a number of psychoanalysts have helped develop various aspects of today’s comprehensive object relations approach. These include Margaret Mahler (1897–1985) and her theories of separation-individuation, John Bowlby (1907–1990) and his followers on the subject of attachment and loss, and Michael Balint (1896–1970) and his work on the “basic fault.” Donald Winnicott (1896–1971) has contributed to the objects relations discussion with his work on early infant development and “good enough” mothering. One of his very useful conceptualizations focused on defining the True and False Self states. This developmental concept refers to the emergence of a False Self, which is designed to protect a core True Self, which has been traumatized by faulty parental responsiveness to the normal and appropriate gestures of growth exhibited in the first months and years of life. The False Self lives in compliance and projective identification with the environment. It assumes the role of a “caretaker” self, which takes over from the failing environment. The True Self emerges from the mother’s supportive and empathic engagement with the child’s unfolding instinctual life. Otto Kernberg (1928– ) has contributed a comprehensive object relations approach that eschews the Kleinian emphasis on the death instinct. According to Kernberg, self and object representations are constructed from the vicissitudes of aggressive and libidinal drives, and that integration of positively and negatively valenced internal object representations leads to a more robust ego. Object relations theory also signaled a movement away from the patricentric and oedipal focus of Freudian psychoanalysis and substitutes a more matricentric mother–child paradigm. In general, object relations theory is considered a pre-oedipal paradigm and assumes that the infant is father to the child. This is another way of saying that early infant development (including perinatal mental

states) is the proper subject of psychotherapeutic work. Current research in this paradigm includes the study of prenatal mental life. Today, the contemporary Klein-Bion model of object relations has gained the most adherents, generated the most significant research and clinical advances, and is the focus of this entry.

Theoretical Underpinnings The Klein-Bion model takes as its starting point the shift in the theory of motivation. In seeking a relationship with another mind, the infant struggles with the differential activation of loving and destructive instincts dependent on whether the parental environment is gratifying or frustrating, respectively. Instincts unfold in the context of object relations. Rather than view development in terms of psychosexual stages, as Freud does, Klein views the infant progressing through two highly charged emotional positions in relation to internal and external objects. The first is the paranoid schizoid position, which is characterized by anxiety and sadistic conflict with the primary objects. Objects are alternately loved and hated. Defenses of splitting and projective identification predominate. With “good enough” parenting, the child is eventually ushered into the depressive position, characterized by whole object relations, concern for objects, guilt for having attacked the objects in the paranoid schizoid position, and reparation as a way to repair and revitalize the internal objects. These emotional positions are part and parcel of developing an internal world that is animated by internal objects (i.e., internal mother or father). This internal world is achieved through the process of internalization, or introjection. Underlying the above theory is the Kleinian assumption that anxiety and sadism are direct expressions of the death instinct as it unfolds as aggressive phantasy. These phantasies are stimulated by inadequate and frustrating parental care. The parents, as primary objects, are the targets for this instinctual or phantasy projection. The child is then faced with experiences of hating the parent (death instinct activation, related to frustration) and loving the parent (life instinct activation, related to gratification). According to Klein, the child splits these two states initially due to the terror of recognizing that the good parent and the bad parent are one and the same.

Object Relations Theory

Major Concepts A number of unique elements constitute the major concepts of object relations therapy from the Klein-Bion perspective and include alpha function, alpha elements, beta elements, death instinct, depressive position, envy, internal object, introjection (internalization), normal projective identification, object, paranoid schizoid position, projective identification, reparation, splitting, and unconscious phantasy.

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Depressive Position

Depressive position refers to the achievement of whole object relations through the reduction of splitting and the replacement of projective identification by repression. It is characterized by feelings of guilt and concern and is the instigator of creative reparation, which restores the conflicted internal world and is manifested in creative engagement in the external world. Envy

Alpha Function

Alpha function refers to the ability of the therapist or mother to make sense of the projected beta elements and return them to the patient or child, respectively, as useable alpha elements. This is correlated to reverie and the capacity to use one’s countertransference and life experience to make sense of what the patient is projecting. Alpha Elements

Alpha elements are the products of alpha function, which in therapy can take the form of verbal interventions. They allow the client to take in and hold on to mental experience that was formerly projected due to anxiety. The more alpha elements are accrued, the more the patient develops the capacity for his or her own alpha function (to make sense of his or her own thoughts and feelings). Beta Elements

Beta elements are those bits of indigestible mental experience that are expelled in normal projective identification (interpersonal communication). Death Instinct

The death instinct was postulated by Freud to be a silent instinctual drive toward the dissolution of life and is identifiable as destructive aggression when projected out in behavior. According to Klein, this concept helped her understand the significant aggression and sadism found in child play therapy. Today, some analysts view this concept as related to the psyche’s capacity to destroy those internal connections that cause overwhelming emotional experience.

Envy is a powerful and primitive derivative of the death instinct. Envy is seen as an attack on the good object for “its goodness.” Envy represents a “spoiling” attack on the vital connection to the good object. Internal Object

Internal object refers to the internal representation of an external object taken in through multiple experiences, which is considered to be a concrete aspect of the ego. Introjection

Introjection, or internalization, is the process through which external experiences are installed in the inner world as psychological structures. Normal Projective Identification

Normal projective identification relates to the process of interpersonal communication and affect induction rather than the simple evacuation associated with defensive projective identification. Beta elements are transformed by alpha function into alpha elements, which are then returned to the child or the patient to serve as resources for dreaming, thinking, and feeling. Object

Object refers to a person (usually the primary objects of childhood). Paranoid Schizoid Position

Paranoid schizoid position refers to the first developmental position of infancy, characterized

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by conflict, anxiety, and the splitting of object and self representations into good and bad. The defense of projective identification is prominent in this developmental period.

countertransference affective experience to both inform himself or herself of the projected experience of the patient and determine his or her empathic response.

Projective Identification

Negative Transference

Projective identification refers to the expelling of an unwanted aspect of the self and its placement in an object with the intent of controlling that object. It is the prototype of an aggressive object relationship.

Negative transference refers to a prominent role of sadism, destructiveness, and aggression that is expected to emerge in the transference relationship. No analysis is complete without engaging this core experience.

Reparation

Play Technique

Reparation is the source of creative engagement and action in the external world and represents the simultaneous action of repairing the internal world compromised during the cruelty to the internal objects of the paranoid schizoid position.

Through a variety of play materials, the child’s play is seen as an externalization of his or her internal and unconscious processes. Reverie

Splitting refers to the defense of separating good and bad object experiences in the service of internal regulation and the avoidance of painful synthesis.

Reverie refers to the listening capacity most clearly aligned with negative capability. This concept endorses approaching each hour with a patient as if it were the first, eschewing “memory and desire.”

Unconscious Phantasy

Infant in the Child

Unconscious phantasy refers to the movement of biological or instinctual experience into psychological experience. It is seen to undergird all mental activity. Object relations unfold in the context.

Infant in the child refers to the importance placed on the therapist’s ability to listen to the patient’s experiences as expressing issues from multiple levels, including adult, child, infant, and even prenatal.

Splitting

Techniques Some techniques critical to the Kline-Bion model are a here-and-now emphasis, metabolizing projective identifications, negative transference, play techniques, reverie, and infant in the child. Here-and-Now Emphasis

Here-and-now emphasis denotes the necessity of working in the immediate setting and focusing on anxiety. Working the transference relationship to a fever pitch allows the patient to produce all the relevant historical detail. Metabolizing Projective Identifications

Metabolizing projective identifications refers to the therapist’s capacity to reflect on and utilize the

Therapeutic Process The Klein-Bion model of therapeutic process is based on Bion’s definition of normal projective identification. Normal projective identification is a sophisticated mode of interpersonal communication that involves the patient inducing affective experiences in the therapist as a mode of communicating mental experience that the patient cannot as yet put in words. Put another way, “I can’t tell you what I am feeling, but I can certainly have you feel it.” When an indigestible mental experience (beta element) is projected into the therapeutic field, the experienced therapist accepts this experience into his or her subjective world, where it stimulates the therapist’s corresponding states. The therapist is then able to reflect (reverie, alpha

O’Hanlon, Bill

function) and develop an intervention (alpha element), which is then given back to the patient. This alpha element is a digested and more easily assimilated experience than the one that was expelled. In a certain way, this is what may be described as turning gristle (mental) into baby food, which the patient’s mind can digest and then use to think, dream, and feel. The affective experiences that are created in the therapist constitute, in the broadest sense, the therapist’s countertransference to the patient. These emotional reactions are the only emotional facts the therapist has to work with in the session. Therapy then is the ongoing process of interpersonal communication whereby beta elements are digested and returned by the therapist in forms useable by the patient’s mind. The patient needs to have the therapist’s mind to serve as an auxiliary mind in the process of not only development but also therapeutic change. What is described here is an ongoing process of projection and introjection and a focus on countertransference listening capacities. The Klein-Bion description of the transference relationship builds on the early work of Freud. In addition to the projection of internalized object experiences, Klein adds the role of unconscious phantasy. Transference represents the projection of the entire internal world or the “total situation.” Current phantasies (oral/hunger) are then amalgamated with object representations (“I could eat you up!”). The listening perspective endorsed in this approach is one of negative capability and reverie. The therapist attempts to forget all that he or she knows and understands in order to be receptive to what is new in the patient’s presentation. Memory and the desire to cure are seen to interfere with this receptive capacity. Regarding interpretation, this model endorses the early and deep interpretation of unconscious material. Where more classically trained therapists call for measured and well-timed interventions, the Kleinian approach argues that the process of immediately and courageously engaging the major anxieties presented in treatment is relieving and contributes to the establishment of the therapeutic alliance. Allen Bishop See also Classical Psychoanalytic Approaches: Overview; Ego Psychology; Freud, Sigmund; Freudian Psychoanalysis; Kernberg, Otto; Klein, Melanie; Neo-Freudian Psychoanalysis; Winnicott, Donald

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Further Readings Bion, W. (1967). Second thoughts. London, England: Heinemann. Bleandonu, G. (2000). Wilfred Bion: His life and works 1897-1979. New York, NY: Other Press. Casement, P. (1991). Learning from the patient. London, England: Guilford Press. Guntrip, H. (1977). Personality structure and human interaction. New York, NY: International Universities Press. Hinshelwood, R. D. (1989). A dictionary of Kleinian thought. London, England: Free Association Books. Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York, NY: Jason Aronson. Segal, H. (1973). The work of Melanie Klein. London, England: Karnac Books. Spillius, E. (Ed.). (1994). Melanie Klein today: Developments in theory and practice: Vol. 1. Mainly theory. London, England: Routledge.

O’HANLON, BILL William “Bill” O’Hanlon (1952– ) is a practicing therapist, writer, motivational speaker, and consultant widely known for his contributions to the development of the solution-oriented counseling approach. A student of Milton Erickson and early collaborator with other practitioner-theorists such as Steven De Shazer and Michele Weiner-Davis, O’Hanlon now refers to his model of counseling and psychotherapy as possibility therapy to allow room for clients to discuss problems alongside discussion of their strengths, competencies, and solutions. Raised in the Chicago, Illinois, area, O’Hanlon grew up in a large Irish Catholic family. As one of eight children, including two half brothers from his father’s first marriage, O’Hanlon experienced his family of origin as a village. He recalls his family needing to remodel the attic into another shared bedroom to accommodate his large blended family, and sometimes their extended family and friends. While O’Hanlon was himself shy, most of his siblings were outspoken. He grew accustomed to multiple conversations at dinnertime and remembers adopting the stance of an observer to his own family’s dynamics from an early age. He credits his family-of-origin experiences as formative to his development as a family therapist. Believing that

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people are sensitized by their life experiences, O’Hanlon considers that his family of origin predisposed him to relationships, empathizing with others, and wanting to help in a nonjudgmental way. One important family dynamic revolved around the practice of blaming. If things went wrong or undesirable things happened, members of the family tended to blame, even when logically it did not make sense. When he began learning about therapy and started to practice, he did not want to blame clients for their own problems. Instead, he was moved to focus on listening, helping, empathizing, and validating, partly to prevent what he felt happened to him in his family of origin from happening to his client. The goal of developing a helping approach that reduced or avoided the need to blame led O’Hanlon to embrace the principles of family systems therapy. He resonated with the idea that the family environment is something that is created together by the family members and so both positive and negative experiences are shared creations. This idea countered the tendency in families, including O’Hanlon’s own family, to blame individuals for negative experiences. The acknowledgment of the shared interaction and creation of family dynamics seemed to O’Hanlon to be the answer to his dissatisfaction with other concepts related to family environments. As a young college student, O’Hanlon faced one of his greatest challenges. He found himself overwhelmed in a large university setting among outsized classes, isolated from the contact and support of his family. His shyness intensified as he began to spend much of his time alone. This was soon followed by depression and, later, suicidal ideation. A promise to a friend not to kill himself became the turning point out of this crisis point in his life. This also deepened his fascination with understanding how people find meaning within themselves and with other people. O’Hanlon turned to psychology to gain the knowledge and understanding he sought. What he found in psychology was the same blaming, often in the form of pathologizing and objectifying people’s life experience, that he had developed a sensitivity to earlier in life. O’Hanlon quickly became dissatisfied with the apparent acceptance within professional psychology of the need to diagnose a client with a mental disorder before therapeutic help could begin. It was his exposure to Milton Erikson’s work in family

systems therapy in his third year of college that would later serve as the basis of his therapeutic orientation for the rest of his professional life. As a junior, he read Jay Haley’s book about Erickson and became fascinated by systemic and strategic therapy concepts. After spending time as a clinicbased counselor in Arizona, O’Hanlon sought out the opportunity to study with Erickson himself. The charismatic and dynamic Erickson played a key role in encouraging O’Hanlon to become a new kind of therapist. During this time, Erikson shared an influential story about his clinical work with a client. Erikson approached the client with kindness, focusing on inner resources, and what abilities were present in the client rather than correcting the client. Erikson sought out what was working in the client’s life and gave it back to the client. This optimistic approach and belief that this client, as all people, had the resources to change had a profound effect on O’Hanlon’s desire to become a therapist and, more specifically, to understand the type of therapist he wanted to be. In addition to the impact of Erickson, O’Hanlon was also profoundly influenced by Peter Berger and Thomas Luckmann’s The Social Construction of Reality, first published in 1966. The framework of social constructionism expanded O’Hanlon’s awareness of how reality is shaped, and in turn shaped by, culture, language, gender, background, and other discourses or ways of knowing. He came to accept the view that diagnosis is not a neutral act and that therapists always bring their own biases, values, and experiences into the therapy relationship. As opposed to the phenomenology of strict constructivists, O’Hanlon also resonated with the social-constructionist concept that individual and social interaction with reality brings forth meaning. The active, ongoing, and dynamic co-construction of experience can be tapped into within a helping relationship to galvanize clients’ competencies and sense of personal agency and ultimately devise novel solutions to what may seem like insurmountable problems. Later, O’Hanlon worked with a client in crisis whose primary therapist was unavailable. With the understanding that he would not be working with this client for very long, O’Hanlon determined not to ask about the client’s problem but rather to ask about what the primary therapist had done in the previous sessions. Together, O’Hanlon and the client

Operant Conditioning

were able to recognize what was most helpful and useful to the client. With O’Hanlon’s encouragement, the client agreed to repeat what had been working well and left the session reinvigorated. O’Hanlon himself was also inspired by the experience, and his self-examination of what he had done differently led him to recall that the problem had not been discussed. This and other clinical experiences helped solidify the importance of connecting with clients’ strengths, often in brief therapy encounters, and working with the possibilities inherent in language to cocreate therapeutic change. In 1981, O’Hanlon found his theoretical approach to therapy changing to reflect the insights and influences of the many experiences he had had by that point in his professional journey. He found himself incorporating these realizations into work with all or most clients, discussing the nature of the problem less and asking about what is helpful for clients more. These were his first steps toward developing his theory of solution-oriented therapy. Concurrently, Steve de Shazer, Insoo Kim Berg, and others were developing solution-focused therapy. O’Hanlon saw that there were not only strong similarities between solution-focused and solutionoriented models but also some notable differences. Solution-oriented therapy was more person centered, and it relied more on joining with clients and validating their concerns than solution-focused therapy, especially as conceived by de Shazer. This included making more room for dialogue about problems and validation of client efforts toward and frustrations with change. Subsequently, O’Hanlon identified the term possibility therapy as more representative of his beliefs about professional helping. O’Hanlon published his first book in 1987, Shifting Contexts: The Generation of Effective Psychotherapy, coauthored with James Wilk. He has published 37 books, including Out of the Blue: Six Non-Medication Ways to Relieve Depression, published in 2014. Along with these publications, O’Hanlon has numerous journal articles, book chapters, audio programs, video programs, computer programs, and Internet courses to his credit. Of all his works, Guide to Possibility Land can be seen as the one that provides the clearest insight into his thoughts about working with people. His work seeks to help people relieve suffering in a way that respects them, does not harm them, or

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make things worse but helps them move forward. O’Hanlon recognizes that this may require the use of other theories. However, he feels that his loyalty to his clients is more important to him than his theory. Brief, solution-focused or solution-oriented therapy is today considered to be an evidencebased practice and counseling theory of choice for initial encounters with clients from different backgrounds and for a wide variety of problems, including depression, anxiety, and substance use disorders. Jeffry Moe and Elsa Soto Leggett See also de Shazer, Steve, and Insoo Kim Berg; Erickson, Milton H.; Haley, Jay; Possibility Therapy; SolutionFocused Brief Therapy

Further Readings Berger, P. L., & Luckmann, T. (1991). The social construction of reality: A treatise in the sociology of knowledge. London, England: Penguin Press. Haley, J., & Erickson, M. H. (1973). Uncommon therapy. New York, NY: W. W. Norton. O’Hanlon, B., & Beadle, S. (1999). A guide to possibility land. New York, NY: W. W. Norton. O’Hanlon, S., & Bertolino, B. (2013). Evolving possibilities: Selected works of Bill O’Hanlon. Philadelphia, PA: Routledge.

Website Bill O’Hanlon: www.billohanlon.com

OPERANT CONDITIONING Adaptive behavior is anything an animal does that aids its Darwinian fitness, that is, anything that helps it to survive and reproduce. Adaptive behavior comes in two varieties, although the division is not sharp. Reflexes and many “instincts” are built in. For example, a child withdraws his or her hand from the hot fire without instruction, but the same child may have to learn not to touch a hot kettle. The first behavior is the result of natural selection during phylogeny, the evolution of the species. The second is the result of operant conditioning, voluntary behavior modified by its (in this case, painful)

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consequences during ontogeny, the life of the individual. Operant conditioning is also the result of selection, but selection by positive and negative consequences—reinforcers and punishers—during ontogeny. Reinforcement selects from responses emitted by the organism in a conditioning situation. The varied responses that occur in a given situation are termed the organism’s repertoire. Operant conditioning is usually distinguished from classical, or Pavlovian, conditioning: In operant conditioning, the organism learns that a behavior leads to a specific consequence; in classical conditioning, it learns that a stimulus leads to a specific outcome. Most learning situations involve both processes to some degree. Behavior-analytic psychotherapy, or applied behavior analysis (ABA), is the clinical application of the principles of operant conditioning. Its aim is to identify and eliminate consequences that maintain undesirable behavior and implement consequences that promote desired behavior. ABA has been applied to psychotherapy for a wide variety of mental health concerns but has been found to be particularly useful when working with individuals with autism, individuals with intellectual disabilities, individuals with severe mental health disorders, children on behavioral change, and certain forms of anxiety, as well as in providing parents with tools for parenting and in reinforcing new behaviors when providing other forms of therapy.

Historical Context E. L. Thorndike’s pioneer animal-learning experiments in the late 19th century led to his law of effect: Behavior immediately followed by something the organism likes (positive reinforcement) will tend to increase in frequency, and it will decrease in frequency if accompanied by something it does not like (punishment). But the study of operant conditioning only took off with the work of B. F. Skinner. In the early 1930s, he invented the “Skinner box,” an automated apparatus for the study of operant conditioning in animals such as rats or pigeons. With its aid, he and his students discovered reinforcement schedules, rules that deliver reinforcement depending on time elapsed or the number of responses emitted in the presence of a given stimulus, such as a light or a tone. A fixed-ratio (FR) schedule, for example, delivers a bit of food to a hungry animal after it

completes a fixed number of lever presses. A variable-interval schedule delivers a reinforcer for the first response after a time interval that varies from one reinforcer to another. Each reinforcement schedule generates its own distinctive pattern of behavior. Skinner invented a new technical language and philosophy of science. After World War II, he and his students and followers proposed influential, and often controversial, applications for operant conditioning ranging from psychotherapy, to teaching, to the justice system, to the “design of cultures.” Skinner’s emphasis on practical applications led to effective, but sometimes labor-intensive, treatment for a wide range of behavioral problems: for example, token economies for psychiatric patients or behavioral treatments for autistic spectrum disorders, an area where reinforcement schedule–based methods have been especially successful. Today, the principles of operant conditioning are used in a wide range of behavior therapy approaches and are often integrated by counselors and therapists into other theoretical orientations.

Theoretical Underpinnings The relation response → consequence in the presence of a certain discriminative stimulus is termed a 3-term contingency of reinforcement. For instance, mammals and birds readily learn to respond in a desired manner when a green light is on but not when a red is on—that is, they discriminate—after sufficient training under a 3-term contingency. Operant conditioning is more complex than classical conditioning because it involves a minimum of three terms rather than just two—response, (discriminative) stimulus, and consequence, rather than just stimulus and consequence—as well as a feedback relation between the organism’s behavior and its consequence. Operant conditioning is an empirical phenomenon and as such is not tied to any particular theory. Nevertheless, much of operant conditioning research, notably among ABA practitioners, is still pursued within the framework of Skinner’s radical behaviorism. Other approaches to operant conditioning—cognitive, computational, associative, and theoretical—have come to prominence in recent years, but their impact has been more at the level of fundamental research on operant conditioning than on its clinical applications.

Operant Conditioning

Skinner’s radical behaviorism rejects the kind of inferred-process theories widely used in the rest of psychology, restricting itself to the discovery of lawful relations between dependent (behavioral) and independent (environmental) variables. Skinner did not deny the existence of what he called “private” events but treated them as stimuli and responses not fundamentally different from external stimuli and responses (“The skin does not make a difference”). According to Skinner, the same operant conditioning principles explain all behavior, whether overt or covert. If there are internal variables, they belong to neuroscience, not the science of behavior. This position has been criticized as eccentric because ruling out all internal variables would set behavioral psychology apart from the developed sciences, which all depend on theories that involve inferred entities, such as gravity, atoms, and genes (genes and atoms were inferred long before they could actually be observed). Testable theoretical accounts for several learning phenomena, such as habituation, interval timing, choice, and reversal learning, have been proposed. All involve variables that cannot be directly measured.

Major Concepts This section first examines conditions of learning, including contiguity, contingency, and biological preparedness. Then it explores reinforcement, punishment, and choice; it concludes with a discussion of stimulus control. The Conditions for Learning: Contiguity, Contingency, and Biological Preparedness

A subject will learn the relation between a behavior and a consequence (operant learning) if the following conditions are met: Contiguity: The consequence should follow the reinforced response closely in time. (Conditioning with delayed reinforcement is possible but slow and unreliable.) Contingency: The response must be a good predictor of the consequence (free—response independent— reinforcers impair conditioning). Biological preparedness: The response and the consequence must be linked in the natural repertoire of

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the subject. For instance, a pigeon will easily learn a relation between pecking (a food-related behavior) and food or between a sudden wing flap (a defensive behavior) and the termination of an electric shock. Learning is much harder if the consequences are flipped—wing flap for food, and so on.

Reinforcement, Punishment, and Choice

The effect of operant learning on behavior depends on the motivational value of the consequence. The probability of a behavior will increase (reinforcement) if the consequence is a reward (positive reinforcement) or the removal of an aversive event (negative reinforcement). It will decrease (punishment) if the consequence is the omission of a reward (negative punishment) or the presentation of an aversive event (positive punishment). Reinforcement and punishment affect the strength of the response, which is reflected in its rate (e.g., pecks per minute), its probability, or the proportion of time the organism devotes to it. According to a proposal by Richard Herrnstein, response strength is proportional to its relative reinforcement rate (how much it is reinforced relative to other behavior emitted in that situation). In a two-choice situation, it takes the form of the much studied matching law: The ratio of the rates of the two responses matches their reinforcement rate ratio. J. A. Nevin has pointed to another dimension of responding, namely, its resistance to change (also termed behavioral momentum), that is to say, its modifiability by extraneous variables such as free reinforcers or changes in the reinforcement rate. For instance, if reinforcement or punishment is discontinued (extinction), the resistance to change of the behavior will determine how long it will take to get back to its baseline level. Resistance to change is related to the rate of reinforcement, more or less independently of the contingent relation between the reinforcer and the behavior, and to the consistency of reinforcement in the organism’s past. Primary reinforcers and punishers are events that have their effects without special training but still require special circumstances for them to reinforce and punish behavior. According to behavioral regulation theory, for example, an organism has a preferred distribution of activities (bliss point). Any manipulation that forces it away from this bliss point is punishing (aversive), whereas any

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manipulation that brings it closer is reinforcing. For example, laboratory studies have shown that a rat prefers to keep its rate of lever pressing low and its rate of heroin intake high. This bliss point can be reached if the animal has free access to heroin: It can consume as much heroin and make as few lever presses as it likes and still hit the spot. Making heroin access contingent on lever pressing forces the rat to compromise. If it does not increase its rate of lever pressing, it will consume much less heroin than its preferred level. So it will increase its lever pressing until the marginal cost of an extra lever press is matched by the marginal benefit of the extra bit of heroin. Deviations from the preferred level of lever pressing are less aversive than deviations from the preferred level of heroin intake. In economist’s language, the demand for heroin is inelastic while the demand for lever pressing is elastic. Hence, increasing the rate of lever pressing to increase the rate of heroin intake is more satisfying (closer to the animal’s bliss point) than is reducing the rate of heroin intake to keep the rate of lever pressing down. Another useful concept from economics is substitutability. Heroin and methadone are perfect substitutes for each other. Hence, if methadone is made freely available, heroin will fail to reinforce lever pressing: By substituting methadone for heroin, the rat will be able to stay at its bliss point. Its need for heroin will be fulfilled by substituting methadone for it, and it will not have to increase its rate of lever pressing, hence keeping it to its preferred level. This kind of optimality analysis, borrowing from economics, has revealed the common properties of many operant conditioning arrangements. Conditioned reinforcers and punishers acquire their reinforcing or punishing properties through pairing with primary or previously acquired conditioned reinforcers or punishers. The reinforcing or punishing value of a conditioned reinforcer or punisher is a hyperbolic function of the delay of the primary reinforcer or punisher it signals (hyperbolic discounting). This has interesting consequences: If given the choice between a large, delayed reward and a smaller, more immediate one, organisms will usually prefer the latter if the overall delay of the rewards is small and the former if the overall delay of the rewards is large. For instance, if given the choice between $100 now and $105 tomorrow, most people will prefer the

$100 now. But if given the choice between $100 in 1 year and $105 in 1 year and 1 day, their preference would switch to the $105. Stimulus Control

Stimuli correlated with reinforcement and punishment can exercise stimulus control over an operant response. An organism consistently reinforced in the presence of a single value on a unidimensional stimulus such as wavelength (e.g., green at 550 nanometers) will respond more slowly if shown other wavelengths. The resulting generalization gradient shows how response strength varies with stimulus value. Gradients have a bell-shaped form usually centered on the stimulus value reinforced during training. A flat gradient indicates lack of stimulus control, whereas the subject responding only at the value used in training indicates perfect stimulus control. The shape of the gradient depends on the organism’s history and its sensory apparatus: The greater the exposure to the stimulus dimension (e.g., wavelength, frequency) and higher the rate of reinforcement in the presence of a particular stimulus value, the sharper is the gradient. An early experiment showed that pigeons reared in monochromatic light show flat generalization gradients. The sharpest gradients are obtained through discrimination learning, where behavior is reinforced in the presence of one stimulus but not in the presence of another. The closer two stimuli are to each other, the steeper the gradient and the more likely its peak will be displaced away from the unreinforced stimulus value (peak shift). There are two ways by which a stimulus can control behavior, which can be illustrated through the two potential outcomes of reinforcement devaluation procedure. In reinforcement devaluation procedure, the value of a reinforcer is devalued, for instance, by pairing it with something aversive (i.e., food with poison), after it has been used to reinforce a response in the presence of a particular stimulus. After reinforcement devaluation, responding in the presence of the stimulus signaling the reinforcer will sometimes be suppressed. If so, the response is said to be a goaloriented behavior, and its controlling stimulus is a discriminative stimulus or an occasion setter, signaling that the response will be reinforced. If not suppressed, the response is said to be a habit

Operant Conditioning

elicited by the stimulus through direct stimulus– response links. Factors affecting the sensitivity of a response to reinforcer devaluation procedures are the amount of training (behavior becomes less sensitive to reinforcer devaluation after increased training) and the schedule of reinforcement (behavior is less sensitive to reinforcer devaluation in variable–interval schedules than in variable–ratio schedules). (See the following section on techniques for a description of these schedules.)

Techniques Shaping

Before a behavior can be reinforced, it must first occur “for other reasons”; that is, it must be emitted spontaneously. Reinforcement is selection, but behavioral variation is the process through which it must work. Several factors that affect behavioral variation have been identified, but a general theory is still lacking. Reinforcement itself reduces variability, unless variability is itself the target of reinforcement. Extinction increases variability, notably through a phenomenon variously known as regression, resurgence, or spontaneous recovery, whereby suppressed but previously reinforced behaviors return. Shaping is a technique used to train behavior that would have never been emitted spontaneously. It consists in reinforcing successive approximations to the target behavior, while progressively tightening the criterion for reinforcement as the behavior gets closer to the target. Although effective in many clinical or animal-training settings— training dancing dogs or ping-pong-playing pigeons—shaping is still an intuitive rather than a scientific process. The variables that promote behavioral variability and the laws that determine which behavior is a necessary antecedent to another—the necessary learning sequences for shaping complex behaviors—are not well understood. Shaping is used to teach behaviors that, while complex, are not easily broken down into simpler parts (e.g., catching or throwing a ball). Chaining

Operant chaining is used to teach a sequence of behaviors that can be broken into a series of simpler substeps or components. The process of designing these substeps is referred to as a task

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analysis. The steps are then shaped sequentially. For backward chaining, the last step in the sequence is the first to be taught, then the next to last, and so on, until the entire sequence is learned. In this process, reinforcement is typically presented only after the completion of the final step in each trial. In this way, each additional step becomes the discriminative stimulus for the remainder of the steps, which reliably result in reinforcement. This process is effectively used in the operant acquisition of behaviors where components are topographically different from one another and need to occur in sequence (e.g., putting on clothing). For some skills, it is more effective to begin each training trial at the first step in the process, called forward chaining. This is more likely to be combined with total task presentation; that is, all substeps in the sequence are presented in each training trial, with appropriate cues or assistance provided to successfully complete the entire chain each time. This is used for sequences of behaviors with distinct steps that would not reasonably lend themselves to shaping or backward chaining (e.g., brushing one’s teeth). Schedules of Reinforcement

Schedules of reinforcement are rules describing the conditions under which a response will be reinforced. The most commonly studied are interval schedules, whereby reinforcement depends on the time elapsed since the last reinforcement, and ratio schedules, whereby reinforcement depends on the number of responses emitted since the last reinforcement (the ratio value). Chain schedules are a succession of schedules, each associated with a different stimulus, where the reinforcer for schedule n − 1 is access to schedule n, until the last schedule in the chain, which gives access to a primary reinforcer. For instance, a pigeon might have to peck a red key under an FR 15 schedule. The 15th peck would turn the key from red to green, and pecking on it would now be reinforced according to an FR 30. The 30th peck would turn the key blue, and pecking would now be reinforced according to an FR 60. With FR 60 being the last schedule in the chain, the 60th peck would lead to food rather than to another schedule. Tandem schedules are like chained schedules, except that the transition from one schedule to the next is not signaled by a stimulus change. In multiple schedules, the subject

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is successively exposed to several schedules, each signaled by a different stimulus. In simple schedules, only one response is explicitly reinforced, whereas in concurrent schedules, several responses (two levers, three pecking keys, etc.) are concurrently reinforced. If the reinforcer is access to another schedule leading to primary reinforcement rather than to a primary reinforcer itself, it is a concurrent chain schedule. Schedules of reinforcement are used as research tools for the study of choice and preference in the case of concurrent and concurrent chain schedules and for the study of temporal learning in the case of fixed-interval schedules. Schedules are also a research topic in their own right, as different schedules induce different patterns of responding. For instance, ratio schedules lead to much higher response rates than do interval schedules, even when the reinforcement rates are the same. Variable (random)–ratio and variable–interval schedules maintain a constant rate of responding over a wide range. Animals pause after reinforcement in FR and fixed-interval schedules, with the duration of the pause roughly proportional to the ratio or interval of the schedule. Variable-interval schedules can sustain a very steady rate of responding despite low reinforcement rates. The effective application of schedules of reinforcement is integral to effective ABA in teaching and in maintaining desirable behaviors.

Therapeutic Process Today, many operant conditioning techniques are used in therapy, including cognitive-behavioral approaches. Positive reinforcement is used most commonly. For instance, some patients can be given tokens for exhibiting appropriate behavior. These tokens can be accumulated and exchanged later for other reinforcers. Use of charts or stickers at home by parents involves the same behavior principles as more formal token systems. Verbal attention and approval by a therapist or loved ones also can function as reinforcers. Stimulus control can also be used to profit. At a very basic level, a maladaptive behavior under stimulus control (e.g., overeating) can be reduced if the discriminative stimulus (e.g., caloric food) for this behavior is withdrawn from the environment. More sophisticated uses of stimulus control are also possible. For instance, stimulus control

therapy of insomnia relies on the assumption that insomnia is partly due to behavior other than sleeping having been reinforced in the presence of stimuli present in the bedroom. The goal of the therapy is to reestablish stimulus control of those stimuli over sleeping. Tinnitus retraining therapy makes use of a phenomenon called fading, in which a neutral stimulus is presented concurrently with an already established discriminative stimulus. The intensity of the discriminative stimulus is then progressively faded until it is no longer presented. This results in a transfer of its controlling properties over the neutral stimulus. In tinnitus retraining therapy, patients are taught to ignore an external stimulus, whose intensity is progressively reduced, leading this response to transfer to the tinnitus, which the patients are now able to ignore. For obvious ethical reasons, the use of punishment remains controversial and is usually restricted to extreme cases (e.g., to stop self-harming behavior such as head banging, which could severely harm the patient if not rapidly stopped), especially as other techniques relying on positive reinforcement, extinction, or stimulus control can be used to reduce the frequency of an undesirable behavior. These techniques are as efficient as punishment and pose none of the ethical problems or have the problematic behavioral side effects (e.g., development of anxiety and aggressive behavior) linked to aversive techniques. For instance, differential reinforcement of other behaviors and differential reinforcement of alternative behavior rely on positive reinforcement of behavior incompatible with the target behavior whose frequency the therapist is trying to reduce. If the undesirable behavior is itself maintained by reinforcement (e.g., harmful behavior reinforced by the attention the patient receives as a consequence of it), discontinuing those reinforcers will lead to a decrease in the frequency of the reinforced behavior (extinction). J. Jozefowiez and J. E. R. Staddon See also Applied Behavior Analysis; Behavior Modification; Chess Therapy; Classical Conditioning

Further Readings Domjan, M. E. (2009). The principles of learning and behavior (6th ed.). Independence, KY: Wadsworth. Jozefowiez, J., & Staddon, J. E. R. (2008). Operant behavior. In R. Menzel & G. Byrne (Eds.), Learning

Orgonomy and memory: A comprehensive reference: Vol. 1. Learning theory and behavior (pp. 75–102). Oxford, England: Elsevier. Lattal, K. A. (2012). The five pillars of the experimental analysis of behavior. In G. J. Madden (Ed.), APA handbook of behavior analysis: Vol. 1. Methods and principles (pp. 33–63). Washington, DC: American Psychological Association. Staddon, J. E. R. (1983). Adaptive behavior and learning. Oxford, England: Oxford University Press. Second edition, 2010, electronically available at http:// dukespace.lib.duke.edu/dspace/handle/10161/2878) Staddon, J. E. R. (2014). The new behaviorism. Florence, KY: Psychology Press. Staddon, J. E. R., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology, 54, 115–144. doi:10.1146/annurev.psych.54.101601 .145124

ORGONOMY Developed in the early 20th century by Wilhelm Reich (1897–1957), a physician, scientist, and psychoanalyst, Reichian therapy, or orgonomy, is a systematic, psychodynamic, and somatic approach that provides character and biophysical restructuring. Its engaged verbal therapy, paired with somatic interventions, contrasted the widely accepted psychoanalytic approach of Reich’s mentor, Sigmund Freud (1856–1939). Orgonomy recognizes the functional identity of mind and body, and Reich’s theories can be considered the foundation of the somatic therapies that followed. Also known as medical orgone therapy and orgonomic therapy, Reichian therapy recognizes how armoring against the free flow of life energy blocks authenticity and open expression and affects an individual’s capacity to experience aliveness, meaning, and fulfilling relationships. Orgonomists believe that a loving sexual life is a vital aspect of satisfying relationships. In Reichian therapy, the therapeutic focus is less on the story the patient relays and more on how the patient actually is and how he or she relates and functions. Character defenses are established early on as the individual finds how best to survive when life events impinge on the developing authentic self. These adaptations create distorted ways of being that conform to the perceived expectations

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of significant others or circumstances in the hope of securing emotional needs and avoiding pain. Orgonomists establish a contactful relationship with the patient and help define and change the patient’s destructive defenses, simultaneously working with the body to release biophysical holding through deep massage and pressure and expressive exercises that allow the patient to have inner sensate contact with self, increased breathing, and release of emotion. Character restructuring and biophysical interventions help the patient gain access to an authentic self, lower levels of stress and reactivity, and ameliorate trauma and symptoms such as posttraumatic stress disorder, depression, anxiety, and psychogenic pain.

Historical Context Reich developed orgonomy in the 1930s. Raised in the Ukraine in a farm setting that stimulated his interest in biology and natural science, he set up his first laboratory at the age of 8 years for collecting butterflies and insects under the guidance of a private teacher. His interest in natural life functions determined his later preoccupation with  the biological foundations of humankind’s emotional life. As a physician, scientist, and psychoanalyst, Reich early on became interested in questions of psychic energy and drives, particularly sexuality, which at that time was a taboo subject. Reich’s interests led to discoveries of bioenergetic problems, including the biological basis of instincts, the nature of pleasure and tension, the role of genitality, the function of the orgasm, and the sources of neurotic anxiety. Reich left Europe in 1939 for New York City and began publishing in English, training American physicians in his therapeutic techniques and continuing his research. In 1942, he purchased a large plot of land and farmhouse in Rangely, Maine, which became his permanent laboratory and teaching center, called Orgonon. There, he studied single-celled organisms, human blood composition, and the origins of life and experimented with the basic energy he found in all living things. He built what he called an orgone accumulator made up of organic and metal layers that attracted and contained atmospheric energy. Reich’s work was informed by his experimental study of the amoeba, which illustrated the principles of expansion, contraction, and pulsation, so critical to his work with patients.

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Orgonomy

He wrote prolifically on politics, sexuality, family practices, and society. The first phase of his career was in the psychoanalytical movement, but his extensive clinical work and research led to conflicts with Freud. While Freud moved away from the concept of libido as a biological sexual energy, Reich was convinced otherwise. Reich believed that dammed-up sexual energy was a factor in creating an imbalance in the body, leading to neurotic symptoms, and he argued that the function of the orgasm is to maintain an energetic equilibrium by discharging excess energy. Reich also discovered that in psychic disturbances, this biological energy is bound up not only in symptoms but, more important, in characterological and muscular rigidities he defined as armor. This theory set him apart from his colleagues, as it indicated that libido was a real physical energy. Thus, Reich developed therapeutic techniques to eliminate patients’ character and biophysical armor to allow for the flow and discharge of bioenergy. Reich was frustrated with analysts who relied on the nonengaged blank screen approach that centered on free association, interpretation, and dream analysis. He often felt that approach was chaotic and that the analysts’ use of interpretations contributed to intellectualization and interventions that were not guided by the patient’s felt experience. Instead, Reich focused on topics of resistance, latent negative transference, chaotic associations used as avoidance, and defensive character traits that block contact with felt experience. Reich was an iconic and controversial figure who was singled out during the McCarthy era of the 1950s and eventually imprisoned for contempt of court. In 1947, an article by a freelance writer titled “The Strange Case of Wilhelm Reich” implied that Reich was a danger to the public. The author challenged the medical authorities to take action against Reich through the Food and Drug Administration. This resulted in a 10-year campaign by the FDA to discredit his work. The FDA focused on the orgone energy accumulator and the experiments Reich was doing with patients. In 1954, the FDA filed a Complaint for Injunction against Reich in Maine. It declared that orgone energy does not exist and asked the court to prohibit the shipment of accumulators in interstate commerce and to ban Reich’s published literature.

Reich responded with a letter to the judge, which stated that he would not appear in court as it would allow a court of law to judge his scientific research and validate a complaint not founded on scientific research and science. The judge did not accept his letter and escalated the injunction. One of Reich’s students, without Reich’s permission, moved some accumulators and books from Maine to New York. The FDA then charged Reich with contempt of court. Reich was convicted and sentenced to 2 years in federal prison. Reich appealed, but meanwhile the government destroyed his orgone accumulators, and his literature was burned in Maine. In New York in 1956, the FDA burned several tons of Reich’s publications, including major works such as  Character Analysis (with M. Higgins and C. Raphael, 1980) and The Function of the Orgasm (1973). With his appeals denied, he was taken to a federal penitentiary in Pennsylvania in 1957 and soon after died of heart failure. Throughout his life, and continuing today, many of those who have studied his contributions realized the applicability of his visionary ideas to clinical modalities.

Theoretical Underpinnings Reich suggested that character structures are created early in life to protect against difficult feelings and experiences that need to be avoided or forgotten by the conscious mind. Core natural feelings of love, aggression, and anxiety can be inhibited due to a variety of early conditions. When a person’s natural impulses are thwarted and denied, the person learns to redirect healthy needs and expressions into distorted behaviors. Embedded in the character style is the patient’s entire history and response pattern. Orgnonomy focuses on the patient’s survival strategies and history right there in the therapy room. Character-analytic techniques are distinguished by an active and dynamic approach. The orgonomist sees the patient’s defensive structure and engages it so that the patient can become conscious and self-aware of his or her characteristic stance and the problems it creates. The patient can access the content and feelings underneath the defensive facade. So, rather than follow the patient’s content or story line, the orgonomist makes observations on how the patient is in the room and with the therapist. This approach creates a lively, present-centered

Orgonomy

form of treatment that breaks through the patient’s habitual style. Through working from the outside in, the patient can unravel his or her own subjective experience—the cognitive, emotional, and historic elements that contribute to the patient’s unique character and biophysical condition. Reich felt that the analysts of his time focused too much on positive feelings and shied away from bringing out a patient’s negativity, resistance to therapy, and criticisms of the therapist. Orgonomists understand that patients and therapists hide behind pseudo-positive feelings that mask patients’ real negativity toward self and others. Therapists should help patients express and tolerate their aggressive or anxious feelings, including those directed at their therapist. Based in his growing biophysical knowledge and experimentation, including his study of the function of the orgasm and the fact that the energy is absorbed by organic material, Reich identified specific energy in the body, which he called orgone energy. Naming his therapy approach orgonomy, Reich saw how the character armor is replicated in the patient’s physicality and that one’s character style molds the body and results in blocked energetic movement. The body, in its entirety, reflects chronic character defenses, which affect the muscular, cardiovascular, autonomic nervous, hormonal, and immune systems. Deep patterns of reactivity and developmental trauma are reflected in the body. The autonomic nervous system, which regulates fight, flight, or freeze responses, can create chronic heightened reactivity patterns over a lifetime, affecting the entirety of physical and mental functions. Orgonomy purports that the lack of the capacity to self-regulate is linked to deeply stored psychological or biophysical wounds and ruptures in early infancy and beyond, affects the development of the brain, and, in turn, has major ramifications on a person’s ability to self-regulate. Orgonomists help patients see that their attitudes and historical restrictions affect the way energy moves, which can lead to constriction in all systems within the body. In turn, biophysical contractions influence patients’ attitudes toward life. Orgonomists understand that attitudes, cognitions, feelings, sensations, and behaviors are a function of the freedom, or lack thereof, of movement (motility), energy circulation, and the capacity for natural pulsation: expansion and contraction

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within the body. Until the mind–body patterning is realized and dismantled, patients’ access to relevant material and its expression is stymied. Patients do not have the capacity to develop to genitality, a term used to define health whereby all earlier developmental blocks are eradicated, resulting in a healthy self-regulating core, defined identity, and sexual expression. Orgonomy includes a precise map of blockages, called segmental armoring, starting with the head and eyes (ocular) and moving down to the mouth, neck, chest, abdomen, and pelvis. These areas of blockage are correlated with early developmental fixations and are worked through methodically from top to bottom, so to speak. A diagnostic map of character types plus the map of biophysical armoring creates a systematic approach. Knowing the character type allows the orgonomist to utilize precise interventions.

Major Concepts Reichian therapists embrace the concepts of character analysis, segmental body armoring, and the treatment approach delineated in the previous section. The major concepts include a focus on character, not symptoms; contact; resistance analysis; working with negativity; sexuality and energy economy; and pulsation. Focus on Character, Not Symptoms

Orgonomists concentrate on a patient’s presenting character structure, not the patient’s symptoms, and readjust the character patterns that lead to the symptom picture. As character propensities are understood, behaviors can change and symptoms diminish. Importance of Contact

Orgonomy stresses the importance of patient contact with the self and the therapist. Contact means the capacity for present-centered energetic aliveness that enables connection to one’s thoughts, feelings, and sensations. Contact is encouraged as the therapist helps the patient remove body armor and break through deadening habits, which allows greater movement of energy and increased experience of sensation.

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Orgonomy

Resistance Analysis and Working With Negativity

Employing resistance analysis, Reich saw that the main resistance to analysis was revealed not by what the patient said or did but by the manner in which the patient said or did it. The detached, ultra-self-sufficient patient is resisting by the very nature of the individual’s chronic detachment, as it walls the person off from therapeutic exploration. Orgonomists hold that the positive feelings a patient has for his or her therapist only go so far in helping the patient and can even reinforce the patient’s defensive structure. Thus, orgonomists encourage dialogue about the inevitable resistance to the therapist and the therapy and how that resistance may be manifesting. Patients may hide layers of feelings, including hatred, envy, resentment, distain, contempt, and self-loathing, that need to be brought to the surface. Negativity or disagreeable feelings about therapy that are hidden or expressed covertly are called latent resistance. Resistance points are critical junctures in treatment, and once they are worked through, therapy can deepen. Sexuality and Energy Economy

Orgonomists realize that a satisfactory sexual life is more than successful sexual mechanics and that it includes a capacity for real gratification in the sexual act through surrendering physically and emotionally within a relationship. Calling this capacity for love and gratification orgastic potency, Reich suggests that this type of sexual openness releases built-up energy with total convulsions followed by complete relaxation and a tender attitude toward one’s partner. Orgone energy is built up in the organism by intake of food, fluid, and air as well as by being absorbed directly into the skin. It is discharged by activity, excretion, emotional expression, and conversion into body heat. It is used up in growth as well. In the usual course of events, more energy is built up than discharged. To maintain a stable energy level, excess energy must be discharged at more or less regular intervals. This, according to Reich, is the function of the orgasm accompanied by orgastic convulsion. Orgonomists embody a concept of good health based on an energy metabolism of charge and discharge, called sex or energy economy. Open

discussion of sexual issues is encouraged as well as work on the biophysical segmental armoring to open all the upper segments first, leading to later work on the pelvic segment. The therapist intervenes systematically, starting with the musculature of the head, eyes, mouth, and neck and then moving to the thoracic and abdominal regions sequentially—opening those before releasing the pelvic segment. Interventions include deep massage or pressure on the musculature at specific points, for example around the head, eyes, face, and jaw. The therapist applies pressure to the chest to increase breathing and massages the diaphragm, belly, and back to release tension. Direct pressure on the musculature is accompanied by patients’ expression of sound or emotions and deeper access to felt experience. At this point, further expression may be encouraged in the form of kicking or pounding fists or other forms of physical, vocal, or emotive expression. Each specific area of armor becomes more mobile, flexible, and capable of expression. The patient learns to increase his or her capacity to relax. As the armor is released from the top down, more energy and sensation can flow into the pelvic region and can be released. Issues emerging from these various segments are understood and integrated emotionally by the patient. Pulsation

Reich understood that all life forms pulsate; that is, they expand and contract. Organs, vessels, and cells naturally pulsate, and humans emotionally expand with pleasurable, aggressive, or longing feelings and contract with irritability, depression, loss, and other disheartened feelings. Orgonomy helps regulate pulsation and establishes a healthier bandwidth. The autonomic nervous system is a pulsation between the sympathetic and parasympathetic systems, and orgonomy stabilizes that balance. Life force pulsates, and individuals can learn to feel part of that greater pulsation.

Techniques Orgonomic techniques are built on an evolving therapeutic relationship with a clear frame and the consistency of weekly treatment. Present-centered character focus, contact, and appropriate tracking

Orgonomy

are the necessary variables for the verbal portion. The therapist also focuses on the patient’s physicality through breath work and direct interventions in the musculature to address the unique biophysical tensions that cause problems for the patient. The following subsections describe some of these major techniques. Therapeutic Relationship

Establishing a trusting relationship between the therapist and the patient is critical, as the treatment can be intensely emotional. This relationship allows for confrontational and forthright interventions as well as the gentleness necessary to work through trauma. The orgonomist seeks to understand the patient and utilizes the best-suited approach for each character type. For some patients, direct feedback is useful; for others, a subtler, more nuanced approach is needed. Here-and-Now Focus on Character

Orgonomists utilize an interactively lively, present-centered approach to dismantle a patient’s character patterns. The character style of a patient is often obvious to a practiced orgonomist, so the orgonomist points out, confronts, and engages the dominant aspects of the patient’s personality, such as a tendency to dominate and control or to be consistently obsequious and compliant. Then, the patient can explore the function of his or her repetitive style. Defenses, such as intellectualization, rationalization, combativeness, withholding, focusing on the other, and contactless talking, are interrupted. The patient learns, in the here-and-now, how he or she is and how he or she presents, and develops an understanding of his or her defensive function. The character style begins to change, and the content deepens along with the biophysical work. Contact and Tracking

The orgonomist tracks a patient’s body language, way of speaking, eye contact (dullness, brightness, movement, and expression), attitudes, and demeanor. Seeing what is noticeable in the patient’s character style, what stands out, and what is obvious in the relationship with the therapist becomes the focus. How that style reflects specific

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attitudes, approaches, and behaviors in all aspects of a patient’s life and whether these ways of being and behaving are functional is discussed. This approach emphasizes process over content. The orgonomist tracks and comments to the patient and helps the patient investigate in the here-andnow the ideas and feelings that surround a set of behaviors obvious in the moment. The patient begins to make contact without intellectualization but, rather, with real affect and connection to historically relevant material. This brings awareness as to why the patient acts the way he or she does and the real-life consequences of the patient’s actions. Biophysical Techniques

On a full-size bed, the patient, in comfortable, loose-fitting clothes, lies down on his or her back and breathes with knees up and feet on the bed. The patient inhales through the mouth and exhales with an “ahh” sound, which allows the throat to stay open and the voice to flow out. The therapist may give a special breathing pattern for the patient to follow, with the goal of allowing breathing to become natural, spontaneous, and expanded over time. The therapist will notice the quality of breathing and work with the armoring pattern of the patient. The segments include ocular, oral, cervical, thoracic, abdominal, and pelvic. The therapist begins with the ocular and moves to the pelvis only after the first segments have been opened over time. The therapist may loosen various segments with direct massage and pressure to help release muscular holding. There are particular interventions for all these segments to help release blockage and muscular holding. Expressive exercises help the patient release emerging feelings. The patient may be helped to cry more fully or to express anger, fear, rage, longing, or grief. The patient may be asked to kick his or her legs, pound his or her fists, reach his or her arms with longing, scream in fear with his or her eyes wide open, or engage in other exercises that help expressions to emerge. At the end of the session, the patient lies quietly, often covered with a blanket, allowing the parasympathetic relaxation response to take over and integrate the events of the session.

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Ortho-Bionomy

Therapeutic Process Reichian therapy is a mind–body approach that can last many years. A goal is for the patient to feel safe within the therapeutic relationship. As the patient develops a more authentic self, freed of dysfunctional character elements and biophysical holdings, he or she becomes autonomous and responsible, has an improved sense of self-esteem, feels genuine, and can activate from a truer selfexperience. The healthy ability to self-regulate in all areas of life is established. Sexual functioning is improved, and the individual has a greater capacity to be in fulfilling relationships. Patricia R. Frisch See also Bioenergetic Analysis; Body-Oriented Therapies: Overview; Characteranalytical Vegetotherapy; Core Energetics; Integrative Body Psychotherapy; Radix; Reich, Wilhelm

Further Readings Baker, E. (2000). The man in the trap. Princeton, NJ: American College of Orgonomy Press. Baker, E. (2011). My eleven years with Wilhelm Reich. Princeton, NJ: American College of Orgonomy Press. Herskowitz, M. (1997). Emotional armoring: An introduction to psychiatric orgone therapy. Piscataway, NJ: Transaction Books. Placzek, B. (Ed.). (1981). A record of friendship, the correspondence of Wilhelm Reich and A. S. Neill. New York, NY: Farrar, Straus & Giroux. Reich, W. (1973). Ether, God and Devil. New York, NY: Farrar, Straus & Giroux. Reich, W. (1973). The function of the orgasm. New York, NY: Farrar, Straus & Giroux. Reich, W. (1973). Selected writings: An introduction to orgonomy. New York, NY: Farrar, Straus & Giroux. Reich, W., & Higgins, M. (Ed.). (1988). Passion of youth, Wilhelm Reich, an autobiography 18971922. New York, NY: Farrar, Straus & Giroux. Reich, W., & Higgins, M. (Ed.). (1994). Beyond psychology letters and journals 1934-1939. New York, NY: Farrar, Straus & Giroux. Reich, W., & Higgins, M. (Ed.). (1999). American odyssey, letters and journals 1940-1947. New York, NY: Farrar, Straus & Giroux. Reich, W., Higgins, M., & Raphael, C. (Eds.). (1980). Character analysis. New York, NY: Farrar, Straus & Giroux.

ORTHO-BIONOMY Ortho-Bionomy is a noninvasive approach for pain and postural/structural imbalance due to injury, surgery, or chronic stress. Comfort and home exercises without forceful movements are emphasized, although the technique was developed by an osteopath. This is sometimes described as a “homeopathic” use of osteopathic principles to encourage self-healing. The patient’s body is always moved in the direction of comfort, which encourages relaxation and trust in the process and the practitioner. This facilitates rapid neuromuscular reeducation and gait training, postural release, and home care– based therapeutic routines.

Historical Context The British osteopath Arthur Lincoln Pauls read Lawrence Jones’s 1964 article “Spontaneous Release by Positioning” while still in osteopathic college. He was intrigued by Jones’s observation that if he placed a patient in a position that exaggerated his or her osteopathic lesion for 15 or 20 minutes, the patient’s body would self-correct without forceful manipulation. Pauls was a martial artist, and his observations of fighting postures, yoga, tai chi, and even sleep positions had already prepared him for a positional approach, as it had similarly affected Moshé Feldenkrais in his development of the Feldenkrais Method. Pauls sought to decrease treatment times and discovered that by subtle movements and by incorporating gentle compression toward a patient’s joint, spontaneous release could be achieved in just 30 seconds or fewer. Pauls soon found that these changes were consistent and easily taught to both patients and practitioners. In 1976, he began teaching his system in the United States and then Europe. Pauls tended to approach his teachings as a philosophy and demanded the hyphen in Ortho-Bionomy as a reminder of the “vital gap” between the practitioner and the patient.

Theoretical Underpinnings Pauls taught Ortho-Bionomy as the “correct application of the natural laws of life” and said it “is

Ortho-Bionomy

really about understanding your whole life cycle. Naturally, we focus on the structure, because that is the literal skeleton upon which our life is built. When your structure works right, your circulation works better. You think better.” This is in keeping with the teachings of the founder of osteopathy, Dr. Andrew Taylor Still (1828–1917), who taught that the primary goal of manipulation is the improvement of circulation. Ortho-Bionomy relies on the reflex action of proprioception, whereby movement decompresses tissue to active proprioceptors surrounding the joints. This fundamentally signals the nervous system to reset the area, thus eliminating habitual patterns in the tissues that caused the pain and other symptoms. If those symptoms are not alleviated, they can negatively affect the individual’s mind, thoughts, emotions, and spirit. When the somatic cause is dealt with, the systems integrate with wide-ranging effect. This comforting effect, initiated from within the physical body structures, creates a balance of body, mind, and spirit, which enhances and is compatible with any healing system. The Society of OrthoBionomy International reports that these techniques have been incorporated in varied health care settings, such as sports medicine, HIV and AIDS clinics, and outpatient chemotherapy clinics. Ortho-Bionomy practitioners include dentists, medical doctors, chiropractors, osteopaths, nurses, lymphatic drainage therapists, physical and occupational therapists, body workers of all kinds, psychotherapists, and social workers. The neurological feedback about joint and soft tissue position allows the muscle to release chronic response patterns and splinting along with the habitual pain signals back along the nerve pathways. For example, in as little as one session, an ilium that is rotated posterior and has been chronically held in position by the body may be released by rebalancing the tone around the joint, thus interrupting the pain signals of sciatica. In OrthoBionomy, the positioning alone permits the release of somatic tension, but it may require more than one positioning to facilitate the release of all the different muscles around any given joint.

Major Concepts Although the major concepts are touched on in the “Theoretical Underpinnings” section, one other

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concept, to be “gentle and that less is more,” is critical in this process. Most bodywork involves moving against the body’s resistance or through it to guide the body to a new being, but in Ortho-Bionomy, resistance is respected, and the positioning cues the patient’s body to release. Through the proprioceptive response of the body, the patient can release the unwanted habitual somatic patterns in the individual’s body, which releases the trauma and pain physically and emotionally. This release liberates better physical integration and an increase in range of motion in the joint, which releases a greater range of possibility throughout all parts of the individual’s life. Ortho-Bionomy can be beneficial for both patients and practitioners. Patients do not have to fear pain or pressure from the therapeutic process and are free to find comfort at their own speed. Practitioners benefit by no longer having to fear injury to their own bodies from applying pressure to help others. They do not have to be absorbed in fixing and correcting, which frees them to be more present for and supportive of their patients’ personal healing process.

Techniques Ortho-Bionomy incorporates a wide range of static, active, and even energetic nontouching techniques. However, the core of Ortho-Bionomy is identifying any areas of discomfort or dysfunction in the body and moving the patient into positions of comfort that allow disruptive and unwanted patterns of somatic tension to be released and replaced by comfort and a feeling of well-being. This feeling of well-being may then spread from the body into daily life, relationships, and emotional health. Ortho-Bionomy Phases 1 through 7 reflect Pauls’s evolution of the philosophy and techniques of Ortho-Bionomy: Phase 1: Observation of unconscious movement while sleeping Phase 2: Observation of conscious movement while sitting in a chair or during other activities such as martial arts or yoga Phase 3: Pauls’s observations of people’s ability to self-correct using strain/counterstrain techniques, as found in Jones’s work

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Phase 4: Weaving observation into a system by combining gentle contact on tension points with comfortable movement to initiate corrective reflexes; posture analysis and reeducation as needed for any and all joints of the body Phase 5: Introduction of new techniques that allow greater expression of a person’s innate self (the practitioner begins the movements, but the patient’s own reflexes continue through to relief) Phase 6: Aura or electromagnetic field work, whereby self-balancing is initiated by an interaction of the practitioner’s and the patient’s body energy fields Phase 7: Mental pattern projection to catalyze selfcorrection reflexes and to promote specific postural or other changes, integration, and well-being

Therapeutic Process The patient lies on a table with shoes off, wearing loose-fitting, comfortable clothing. The practitioner explores the areas of pain or dysfunction elucidated by the patient and may gently touch those areas to test for tenderness or ask the patient to demonstrate range of motion for later progress evaluation. The practitioner guides the patient through a series of positions relevant to the areas of complaint and limited motion, which triggers proprioceptive neurological reflex responses that release the unwanted patterns causing the pain and other problems. The practitioner usually gives the patient homework in the form of instructing the patient in positions to use at home to reinforce and accelerate the work done in session. The practitioner is then freed to concentrate on encouraging the comfortable evolution of the patient and to work more energetically with the patient during sessions. Christopher J. Rogers See also Body-Oriented Therapies: Overview; Complementary and Alternative Approaches: Overview; Feldenkrais Method; Hellerwork; Reich, Wilhelm; Yoga Movement Therapy

Further Readings Anderson, D. (1994). Muscle pain relief in 60 seconds: The fold and hold method. New York, NY: Wiley.

Chaitow, L. (2006). Muscle energy techniques with DVD-ROM (3rd ed.). Philadelphia, PA: Churchill Livingston. Chaitow, L. (2007). Positional release techniques with DVD-ROM (advanced soft tissue techniques) (3rd ed.). Philadelphia, PA: Churchill Livingston. Kain, K. (1997). Ortho-bionomy: A practical manual. Berkeley, CA: North Atlantic Books. Knittel, L. (2003). Inside-out bodywork. Yoga Journal. Retrieved from http://www.yogajournal.com/health/1004 Overmyer, L. (2008). Ortho-bionomy, osteopathic principles stimulate self-healing. Massage Magazine, July, 74–77. Overmyer, L. (2009). Orthobionomy: A path to self-care. Philadelphia, PA: North Atlantic Books. Pauls, A. (2002). The philosophy and history of orthobionomy: “The evolvement of the original concept.” British Columbia, Canada ALP. Seidl, B. (1997). Advanced techniques in ortho-bionomy: A unique approach to the integration of body, mind and spirit. Unpublished manuscript.

OTHER THERAPIES: OVERVIEW The other therapies entry includes a broad range of theories and therapies that do not easily fit into any of the major theoretical orientations or categories listed in this encyclopedia. Each has a unique history and theoretical underpinnings, and they, generally, do not relate to one another. The descriptions provided in this entry give insight into why each of these therapies is distinctive in nature and is not included in other categories.

Short Descriptions of Other Therapies Brief Therapy

Brief Therapy focuses on time-sensitive interventions that aim to quickly move the client out of psychological distress by using strengths-based methods and the therapeutic alliance. Chaos Theory

This theory suggests that a small change can have an effect over time on a larger scale in a nonlinear way. Therapists work with the disorder that occurs in clients’ lives as they move toward a new, organized transformative state for the clients.

Other Therapies: Overview

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Common Factors in Therapy

Metaphors of Movement Therapy

This approach focuses on the belief that various therapies share similar components related to treatment outcome, which may be the ingredients most important to successful therapy. Some of these elements include the client’s experience of the relationship, the creation of hope and expectancy, structure and focus, and the qualities of the therapist.

Metaphors of Movement therapy focuses on the use of the metaphors that clients express, usually without awareness. Generally, clients spontaneously provide their own metaphors, but some therapists may suggest possible metaphors that relate to a client’s presenting problem, with the focus being on finding how the metaphor offers coping behaviors for the client.

Cross-Cultural Counseling Theory

Cross-cultural counseling theory focuses on the belief that counseling always involves a crosscultural experience between the counselor and client. It highlights the notion that clients from traditionally oppressed minority groups have been particularly harmed when attending counseling due to bias by counselors and the particularly white and European/Western approach that permeates most counseling theories. To ensure counselor effectiveness, this approach highlights the importance of the counselor having an awareness of his or her own cultural and personal biases, knowledge of other cultures, and cross-cultural skills to work effectively with clients from all groups, but particularly nondominant groups. Ecological Counseling

This approach focuses on the integration of environmental and human factors and how they can be used in the counseling session as the narrative provides the story of the way the client lives his or her life.

Pastoral Counseling

Pastoral counseling focuses on the integration of counseling and theology in an effort to help individuals with their emotional, psychological, and spiritual growth. Although there are various types of pastoral counseling, ultimately, the task of pastoral counseling is to help clients find meaning in their spiritual lives so that it can help them in their psychological world. Provocative Therapy

This approach uses the frame of reference of the biopsychosocial world of the client to identify new, more helpful behaviors rather than previous, less helpful behaviors that the client exhibited. Although many of the techniques are existentially based, Provocative Therapy also uses mild confrontation to push the client toward change. Reevaluation Counseling

Approaches that are labeled “evidenced-based psychotherapy” have demonstrated effectiveness through peer-reviewed and controlled research. Mental health practitioners are encouraged to use those approaches that show the best efficacy for the client’s problems.

This approach uses an interchangeable role between the counselor and the clients in the sense that it emphasizes a bidirectional counseling role, with each participant being the “counselor” at different points in the process. The focus of this approach is on equality in the therapeutic relationship, with the goal being increased awareness of how socially generated stressors have caused distress and of how discussion and emotional discharge can bring relief.

Feedback-Informed Treatment

Relational-Cultural Theory

This transtheorectical approach facilitates greater communication between the client and the therapist by systematically soliciting feedback. Information regarding the quality of the therapeutic relationship and the clinical progress made are used to inform and tailor service delivery.

This feminist approach focuses on healthy human development and identification of interpersonal relationship struggles. It focuses on how unresolved issues in personal relationships as well as issues within the larger social system (e.g., “isms” in society) can cause stress in clients and helps

Evidenced-Based Psychotherapy

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clients resolve their issues through sociopolitical awareness and healthy interpersonal connections.

discuss their relationships and by affirming the validity and importance of the clients’ interconnected identities, beyond sexual orientation.

Self-Relations Psychotherapy

Self-relations psychotherapy focuses on how one’s reality and sense of identity are constructed through what is called “frames” or “filters.” It suggests that the client’s reality becomes “locked” and that therapy provides an opportunity to creatively and consciously transform negative symptoms to a positive, newly constructed reality.

Status Dynamic Psychotherapy

In addition to honoring traditional therapeutic change processes, this approach takes therapy one step further by examining how clients’ statuses, or relational positions, influence their sense of self. Supportive Psychotherapy

Sexual Identity Therapy

This approach offers a model to mental health professionals on how they can work with clients whose sexual identity is in conflict with their religious beliefs. It focuses on being nonjudgmental and on helping clients accept their sexual orientation and how it might conflict with their religious beliefs. Ultimately, some clients may choose to live with their dissonance, others may choose not to act on their sexual orientation in an effort to be true to their religious beliefs, and still others may change their religious affiliation to one that is accepting of their sexual orientation. Sexual Minority Affirmative Therapy

Sexual minority affirmative therapy focuses on empowerment and support of sexual minority clients by creating a safe environment for clients to

Supportive psychotherapy works by helping clients reduce presenting symptoms through increasing their sense of self-esteem and building skills and by helping clients learn how to cope with their symptoms rather than reconstructing personality. It is generally used for individuals who do not have the psychological resources to withstand long, intensive psychodynamic therapy. Heather D. Dahl See also Brief Therapy; Chaos Theory; Common Factors in Therapy; Cross-Cultural Counseling Theory; Ecological Counseling; Evidence-Based Psychotherapy; Metaphors of Movement Therapy; Pastoral Counseling; Provocative Therapy; Re-Evaluation Counseling; Relational-Cultural Theory; Self-Relations Psychotherapy; Sexual Identity Therapy; Sexual Minority Affirmative Therapy; Status Dynamic Psychotherapy; Supportive Psychotherapy

P psychiatrist, soon joined Bateson’s research team. In January 1954, Bateson attended a lecture given by Jackson, also a psychiatrist, on the subject of family homeostasis, and soon Jackson joined the team. Thus, the original Palo Alto Group began a series of four research projects that over the next decade would usher in a radically contextual and relationship-based alternative understanding of human behavior. The dominant focus in the behavioral science research at that time—and continuing today—was biologically and psychologically oriented. Explanation and treatment of emotional and behavioral pathology were to be found in earlychildhood trauma and genetically inherited traits. In distinct contrast, the Bateson team intentionally decided not to base their research on the search for pathology and instead to investigate processes of communication using cultural anthropology methodology and Harry Stack Sullivan’s interpersonal theory of human behavior, introduced to the group by Jackson. The complementary fit of these orientations provided the team of researchers a set of presuppositions and a conceptual frame to use as guiding principles of investigation. According to Weakland, cultural anthropology methodology focuses inquiry on directly observable communication—while remaining aware that important and observable messages may be very subtle and hard to see. Concern is deliberately with the influential aspects of communication, of which “information” is only one. Researchers keep in mind that even the hardest “facts” and the clearest messages are subject to differing interpretations.

PALO ALTO GROUP The earliest reference to the “Palo Alto Group” dates from 1960 and refers to three overlapping and interrelated teams of researchers that worked together in Palo Alto, California, over a 60-year span beginning in 1952 and continuing to the present day. Under the leadership of the renowned cultural anthropologist Gregory Bateson, the original team of researchers included John Weakland, Jay Haley, William Fry, and Don D. Jackson. In 1958, all original members of the Palo Alto team joined Jackson in founding the Mental Research Institute (MRI), with Weakland, Haley, and Fry as research associates, Bateson serving as a consultant, and Jules Riskin, Virginia Satir, Richard Fisch, and Paul Watzlawick joining the team. The third team, referred to as the Palo Alto Group, began work in 1965 with the founding of the MRI Brief Therapy Center by Fisch, Weakland, and Watzlawick, with Jackson and Haley as consultants. The original Palo Alto Group began when Bateson secured a grant from the Rockefeller Foundation to study the nature of paradoxes in communication processes. Bateson asked Weakland, a chemical engineer studying cultural anthropology under the tutelage of the anthropologists Ruth Benedict and Margaret Mead, to join the project. Based in the Anthropology Department at Stanford University, Bateson and team had an office at the Palo Alto Veteran’s Administration (VA) Hospital. Haley, then a graduate student in mass communication at Stanford, and Fry, a 753

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Palo Alto Group

Attention is given to the nuances and complexity involved in how people interact with one another, including contradiction, in communication situations—even when these can at first be characterized only roughly—rather than inappropriate atomization and oversimplification to fit the observational or statistical tools already available. In cultural anthropology methodology, attention is given to the whole system involved in any communicative interaction, including the researcher taking his or her own preconceptions and the effect of his or her presence in an interaction into account equally with the behavior of the people being observed. From the moment Jackson joined the Palo Alto Group, he brought his understanding of Sullivan’s interpersonal theory of human behavior into the project. Sullivan defined psychiatry as the study of processes that involve or go on between people in interpersonal relations in any and all circumstances in which these relations exist. A person can never be understood in isolation from the complex of interpersonal relations in which the person lives and has his or her being. The feeling of anxiety is a central concept and is defined as a singularly distressing experience that is a product of intense, denied rejection by significant others in important relationships—other people on whom the person depends for his or her very survival. Prestige in the eyes of important others is vital. Anxiety is experienced whenever a person has acted in a way that is not acceptable to his or her significant others (particularly parents) and can be so debilitating that a person will do just about anything to avoid or reduce the experience. Jackson’s grasp of the implications of Sullivan’s interpersonal theory was an essential aspect of the Bateson team investigation of communication processes and can be seen as a precursor to what Bateson, Jackson, Weakland, Haley, and Fry were later to refine into a communication/interactional approach to understanding human behavior. The data investigated by the Palo Alto Group included a wide range of behavioral phenomena occurring in natural settings, including observing animals in the San Francisco Zoo, analyzing the nature of the relationship between a professional baseball player who had an emotional breakdown and his parents, studying a psychologist who used a one-way viewing screen to observe and work

with juvenile delinquents and their parents, bringing film cameras and sound recorders into the homes of families to observe them interact in their natural environment, and even the study of a proctologist whose hobby was ventriloquism, among many other inquiries. While observing otters play in the San Francisco Zoo, Bateson noticed two males suddenly go from a posture of play to combat when in the midst of frolicking one otter bit down too hard on the ear of the other. The sudden change in the two otters’ behavior toward each other revealed that biting down too hard on the ear altered the meaning of the exchange. Bateson had an epiphany that the playing animals had exchanged a metamessage, or a message about a series of messages (a light bite conveys play, and a hard bite means combat). With this observation of a species responding to a message about a message, understanding of the communicative nature of behavioral exchanges took a quantum leap forward. The focus of research shifted to making sense of how behavior emerges from the contexts and relationships of which it is a part. Asking questions such as “If behavior is a message, to whom is the message directed?” and “In what context would this behavior make sense?” opened the way for a radically alternative way of understanding that the behavior of one person simultaneously shapes and is shaped by the behavior of others in the moment of interaction. With the team office being in the Palo Alto Veteran’s Administration Hospital, Haley suggested that patients offered a relevant object of study. Meeting together with patients and family members allowed the team to observe how some forms of mental illness are induced from the nature of the relationship dynamics in a family in ways similar to the way trance phenomena are induced in hypnosis. Haley and Weakland were sent to begin collaboration with the father of modern medical hypnosis, Milton H. Erickson. Working with patients helped bring together the observations of Palo Alto Group members and paved the way for making interpersonal sense of behavior. The team began to comprehend the vital importance of complex but comprehensible contexts of learning and contingencies of reinforcement evident as emotionally disturbed people defined the nature of their relationships with members of their family. Combined with the concept of

Parent–Child Interaction Therapy

family homeostasis, the concept of the double bind emerged as a way of describing the sending of conflicting messages, as anxiety began to be understood as having a protective quality, and as a way of handling situations in such a way that tests the reactions of others as safely as possible, with the least risk of negative personal and interpersonal consequences. Other vital theoretical precepts emerged. Bateson’s concepts of learning and deutro-learning (i.e., learning to expect certain kinds of contexts) began to reveal the profound ways in which people in intimate relationships influence one another. By placing the primary focus of attention on the nature of interaction among significant family members and between the interviewer and the patient, these researchers pioneered understanding of how the nature of contexts and relationships set in motion reinforcement contingencies for learning the expectations and experiences that shape, bring forth, and perpetuate characteristic patterns of behavior. Symptoms were comprehended as unlabeled metaphors of the untenable nature of family relationships, where explicitly clear statements are too dangerous. Messages, or more specifically what they imply, get lost in translation in ways so subtle that they often escape the notice of even the most awake and astute participant. By focusing on the patterns of interaction that connect the behavior of people, communication theory offered an altogether new and effective method of understanding behavior in context and opened new alternatives for promoting constructive change. By shifting the focus of attention away from what is purported to be going on inside people to what is going on between people in the interaction taking place in the present moment, systemic family therapy was created. Most, if not all, systemic and brief therapy models of practice trace their lineage directly to the contributions of Bateson’s team, the early research and training in family and brief therapy at MRI, and the MRI Brief Therapy Center. In chronological order, systemic approaches directly emergent from the Palo Alto Group include Jackson’s conjoint family therapy, Satir’s variation of conjoint family therapy, Haley and Cloe Madanes’s strategic family therapy approach, and the MRI brief therapy articulated by Fisch, Weakland, and Watzlawick, which are among the most influential

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and emulated approaches in use today. In turn, structural family therapy, developed by Salvador Minuchin; Mara Selvini Palazzoli, Gianfranco Cecchin, Luigi Boscolo, and Giuliana Prata’s Milan systemic family therapy; Steve deShazer and Insoo Kim Berg’s solution-focused brief therapy; as well as most narrative and postmodern models are in direct lineage of the Palo Alto Group. Wendel A. Ray See also Brief Therapy; Couple and Family Hypnotic Therapy; Ecological Counseling; Erickson-Derived or -Influenced Theories: Overview; Multisystemic Therapy; Multigenerational Family Therapy; SolutionFocused Brief Family Therapy; Solution-Focused Brief Therapy; Strategic Family Therapy; Strategic Therapy; Structural Family Therapy; Systemic Family Therapy

Further Readings Bateson, G. (1972). Steps to an ecology of mind. New York, NY: Ballantine Books. Bateson, G. (1979). Mind and nature: A necessary unity. New York, NY: E. F. Dutton. Haley, J. (1973). Uncommon therapy. New York, NY: W. W. Norton. Ray, W. (Ed.). (2005). Don D. Jackson—Essays from the dawn of an era: Selected Papers (Vol. 1). Phoenix, AZ: Zeig, Tucker & Theisan. Sullivan, H. S. (1953). Conceptions of modern psychiatry. New York, NY: W. W. Norton. Watzlawick, P., Beavin-Bavelas, J., & Jackson, D. (1967). Pragmatics of human communication. New York, NY: W. W. Norton. Weakland, J. H. (1967). Communication and behavior: An introduction. American Behavioral Scientist, 10(8), 1–4.

PARENT–CHILD INTERACTION THERAPY Parent–child interaction therapy (PCIT) is a type of therapy used primarily with children between 2 and 7 years of age who have disruptive and problem behaviors and their families. This therapeutic approach to strengthening parent–child relationships combines behavior modification and play therapy techniques. The child and parent are

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seen together in monitored play sessions where the parent receives live, step-by-step coaching from therapists who are behind a two-way mirror. Considered an evidence-based treatment, this approach has demonstrated statistically and clinically significant results in reducing children’s maladaptive behaviors, improving appropriate behaviors, reducing parent stress, and increasing overall parental efficacy. It has a wide range of applications for improving behavior in children who have been diagnosed with oppositionaldefiant disorder, conduct disorder, and attentiondeficit/hyperactivity disorder and those exposed to abuse, trauma, and loss.

Historical Context PCIT was developed by Sheila Eyberg during the mid-1970s as a clinical response to families experiencing difficult and stressful circumstances, whose parent–child interactions were marked by negative and emotionally hurtful interactions. The efficacy of this therapeutic approach has been widely demonstrated in clinical populations by empowering parents with the skills to build nurturing and secure relationships with their children. Since its development, adaptations of the PCIT have been made for use in schools for a variety of classroom settings that focus on teacher–student interactions.

Theoretical Underpinnings PCIT combines play therapy with the more discrete and didactic approaches of behavioral therapy. Broadly, the aim of behavioral therapy is to modify quantifiable behaviors that are learned through interactions with the environment. The therapist instructs parents in the use of rewards and punishment to increase desirable child behaviors and reduce inappropriate ones. Play therapy emphasizes the development and nurturing of a therapeutic relationship that is child directed. Parents are taught how to communicate acceptance of the child through responsive, warm reflections of behavior and emotions during play. PCIT is influenced by the research of the developmental psychologist Diana Baumrind associating parenting styles with child outcomes. The aim of PCIT is to create an environment that balances the child’s

dual needs for nurturance and limits, thus promoting more behavioral and emotional regulation.

Major Concepts The central focus of PCIT is teaching parents the skills to improve the parent–child relationship by changing negative parent–child interactional patterns through parent skill training and coaching. This therapy is divided into two stages: (1) the relationship training stage, which aims at restructuring the parent–child relationship through facilitating the development of a secure attachment relationship, and (2) the positive-discipline parenttraining stage, which emphasizes contingencies that are consistent for child behavior. Child-Directed Approach

Parents follow a play therapy format in which the primary aim is to develop a warm, loving, and nurturing bond by providing differential attention. Parents are coached in the PRIDE relationshipbuilding skills: praise, reflection, imitation, description, and enthusiasm. Parent-Directed Approach

The parent is instructed and coached in a positive-discipline program that entails the following: limit setting, consistency, predictability, and follow-through.

Techniques Relationship enhancement and child behavior management skills are taught to parents, and then the parent is coached while playing with the child during relationship enhancement sessions. Parent– child interaction data are recorded by the therapists and reviewed at the end of the session with parents. Parents are given homework play assignments to complete between sessions. Assessments

Assessments are conducted before, during, and after therapy. A core battery of assessment procedures can include a semistructured intake interview, Child Rearing Inventory, Eyberg Child

Pastoral Counseling

Behavior Inventory, Therapy Attitude Inventory, Dyadic Parent–Child Interaction Coding System, and Sutter-Eyberg Student Behavior Inventory. Equipment

It is optimal to have the following equipment: two-way mirror, toys, video camera, transmitter– receiver, toy clean-up box, and behavioral recording data sheet. Adaptations have been made for settings that lack two-way mirrors and recording devices; walkie-talkies or having the therapist sit in the room are acceptable modifications.

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the child-directed interaction sessions are 10 labeled praises, 10 reflections, and 10 behavioral descriptions. Once mastery of the child-directed interaction stage is achieved, parents progress to the parent-directed interaction sessions, in which the parent is instructed and coached in positivediscipline techniques. Once mastery is achieved in the parent-directed interaction, the skills are gradually expanded for use outside the therapy room, for generalization at home and in public spaces. Tami Sullivan See also Attachment Theory and Attachment Therapies; Behavior Therapies: Overview; Play Therapy

Teaching Sessions

The therapist meets with the parents in teaching sessions to present play and discipline skills. These skills are reinforced by therapist modeling and role-playing with parents. Child-Directed Interaction Sessions Play and discipline skills are first taught to the parent and then modeled and role-played with the therapist. Next, the therapist, who is behind a twoway mirror, provides step-by-step coaching using a transmitter–receiver system while the parent and child play together in the playroom. Spouses are encouraged to take turns playing with the child and observing. Parent–child interactions are coached following a PRIDE sequence. Parent-Directed Interaction Sessions The aim of this phase of therapy is to teach parents more effective means of disciplining their child through the use of effective commands, labeled praise, and redirection techniques.

Therapeutic Process PCIT is a mastery-based rather than a time-limited approach; duration of therapy ranges from 12 to 20 sessions. Discrete parenting skills taught in each session are coded, charted, and reviewed with the parents to provide immediate feedback. The primary therapeutic goals are to decrease problem behavior, increase parenting skills, decrease parenting stress, and ultimately improve the quality of the parent–child relationship. Mastery criteria for

Further Readings Eyberg, S. M. (2005). Tailoring and adapting parent–child interaction therapy for new populations. Education and Treatment of Children, 28, 197–201. Eyberg, S. M., & Matarazzo, R. G. (1980). Training parents as therapists: A comparison between individual parent–child interaction training and parent group didactic training. Journal of Clinical Psychology, 36, 492–499. doi:10.1002/jclp.6120360218 Eyberg, S. M., & Robinson, E. (1982). Parent–child interaction training: Effects on family functioning. Journal of Clinical Child Psychology, 11, 130–137. doi:10.1080/15374418209533076 Herschell, A., Calzada, E., Eyberg, S. M., & McNeil, C. B. (2002). Parent–child interaction therapy: New directions in research. Cognitive and Behavioral Practice, 9, 9–16. doi:10.1016/S1077-7229(02)80034-7

PASTORAL COUNSELING Pastoral counseling is the integration of psychology and theology to aid individuals in psychological, emotional, and spiritual growth. The identity of the pastoral counselor is what differentiates pastoral counseling from other forms of counseling. Pastoral counselors are representatives of various faith traditions and communities. In pastoral counseling, spiritual growth may take precedence at times over psychological and emotional growth. The task of pastoral counselors is to facilitate clients’ openness to God’s kindness in their lives. In practice, the human effort of pastoral counselors is active along

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with the kindness of God. The openness of clients to the pastoral counseling process can lead to healthier psychological and spiritual functioning in their respective religious communities.

Philosophy (Ph.D.), Doctor of Ministry (D.Min.), and Doctor of Pastoral Counseling (D.P.C.). Yearly, pastoral counselors provide 3 million hours of treatment in institution- and community-based settings.

Historical Context

Theoretical Underpinnings

The origin of pastoral counseling can be traced to nearly 2,000 years ago with the Judeo-Christian tradition. Prophets, priests, and wise people were the representatives of religion who employed the ethic of care. Regarding Christianity, Jesus had transformative conversations with individuals, which resulted in addressing human need and the relief of suffering (Mark 10:17–22; Matthew 15:21–28; Luke 19: 1–10). When exploring the origins of pastoral counseling, there are two strands that developed together. One strand was Clinical Pastoral Education, which concentrated on the training of seminary students in hospital settings. The other strand was more generalized and concentrated on the integration of psychology, psychiatry, and the wisdom from spiritual traditions. The strand of Clinical Pastoral Education began with Rev. Anton Boisen and Dr. Richard Cabot at Worchester State Hospital in Worchester, Massachusetts, in 1925. Cabot, a medical ethicist, was an avid proponent for seminary students to be supervised for 1 year in psychiatric and general hospitals in working with patients. Later, in 1967, the Association for Clinical Pastoral Education was formed. The second strand of pastoral counseling was a clinical focus in the combination of psychiatry and religion in mainstream counseling. In 1937, Norman Vincent Peale, a prominent minister, and Smiley Blanton, a psychiatrist, formed the American Foundation of Religion and Psychiatry in New York City. The American Foundation of Religion and Psychiatry later became the Blanton-Peale Institute, which provided psychotherapy in a religious context. One hundred counselors from the American Foundation of Religion and Psychiatry founded the American Association of Pastoral Counselors in 1963. Today, there are more than 100 pastoral counseling centers in the United States that are separate from the church. Presently, Protestant and Catholic universities offer degrees in pastoral counseling, including Master of Science (M.S.), Doctor of

There are a variety of theoretical underpinnings that have affected the discipline and identity of pastoral counseling. Regarding theoretical underpinnings, there were four influential theologians who constructed the work of pastoral counseling in the 20th century: Seward Hiltner, Carroll Wise, Paul Johnson, and Wayne Oates. Hiltner authored a primary text for pastoral counseling that involved psychodynamic experience and Rogerian nondirective techniques. Influenced by Freudian psychoanalysis and Rogerian techniques, Wise asserted that the counseling relationship connects the meaning of the Gospel to a client’s need. Johnson utilized Rogerian techniques and was influenced by the work of the neo-Freudian Harry Stack Sullivan. Conversely, Oates was not as influenced by Sigmund Freud and Carl Rogers. Oates viewed the pastoral counseling relationship through a theological framework. The pastoral counselor was a representative of Christ’s care for people in need. Three of the seminal theorists of pastoral counseling were heavily influenced by Freud and Rogers, whereas Oates was focused on the theological implications of pastoral counseling.

Major Concepts The major concepts are the areas pastoral counselors integrate into their practice. Religion, pastoral theology, spirituality, and the integration of theology and counseling are all areas that influence the identity and practice of pastoral counselors. Religion

Religion is a set of life-guiding principles in a belief system that are practiced by a religious community in specific cultural contexts. Pastoral Theology

Pastoral theology is the discipline that influences and informs the pastoral counselor’s view of pastoral counseling.

Pavlov, Ivan

Spirituality

Spirituality involves the profoundest dimensions of human experience and transcends to the level of greater causes, meanings, and reality. Theology and Counseling

Theology and religion are viewed as ways in which people seek to answer their ultimate questions about life and death. Theology encompasses the beliefs people hold concerning their origin, destiny, and relationship to the world. Counseling is another way for people to answer ancient problems concerning the purpose and meaning of humanity.

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See also Analytical Psychology; Freud, Sigmund; Freudian Psychoanalysis; Jung, Carl Gustav; Maslow, Abraham; Neo-Freudian Psychoanalysis; Person-Centered Counseling; Prayer and Affirmations; Rogers, Carl; Sullivan, Harry Stack

Further Readings Hiltner, S. (1979). Preface to pastoral theology. Nashville, TN: Abingdon. Townsend, L. (2009). Introduction to pastoral counseling. Nashville, TN: Abingdon. Wicks, R. J., & Parsons, R. D. (Eds.). (1993). Clinical handbook of pastoral counseling (Vol. 2). Mahwah, NJ: Paulist Press.

Techniques It would be impossible to state specifically the techniques that all pastoral counselors employ. The techniques pastoral counselors utilize are as varied as the techniques that mainstream counselors use. However, psychoanalytical and Rogerian techniques have influenced the field of pastoral counseling profoundly.

Therapeutic Process Pastoral counseling is based on the formation of a relationship between the counselor and the client that reflects the healing presence of God. Once the relationship is formed, pastoral counselors discuss the spiritual resources of clients as a basis for healing. These resources of healing could be scriptures, songs, religious practices, and/or prayers that aid the client in spiritual, psychological, or emotional growth. Furthermore, pastoral counselors focus on goals in pathway thinking and agency thinking. Pathway thinking is how clients map possible routes to different experiences. Agency thinking is a way in which clients can initiate new goals. The termination of pastoral counseling includes focusing on how clients constructively change their spiritual, emotional, or psychological issues. When situations are impossible to change, clients can change their attitudes. A therapeutic process of pastoral counseling would include the following: relationship, spiritual resources, planning for change, and maintenance of change. Matthew Wardell Bonner

PAVLOV, IVAN Due to his industrious studies on classical conditioning, Ivan P. Pavlov (1849–1936) is considered one of the most prominent researchers in psychology. He was born in Ryazan, Russia, a small village where his father was the local priest. Although initially interested in theology and considering following in his father’s footsteps, Pavlov was heavily influenced by Charles Darwin’s On the Origin of Species, which contributed to his shift in vocation and dedication to the study of science instead of religion. Pavlov studied medicine at the University of Saint Petersburg in Russia, where he received his doctorate in medicine and then traveled to Germany to continue specializing in physiology. During his early work, he focused on the study of the digestive system, which earned him the Nobel Prize in Physiology or Medicine in 1904. During Pavlov’s research on the physiology of gastric and salivary glands in dogs, he and his colleagues noticed that secretion of saliva may be induced not only in response to food but also due to psychic causes, as the salivary glands would often activate at seemingly unnecessary times. Pavlov concluded from his experiments that this psychic activity allowed organisms to differentially respond to stimulation from the environment and to adapt to it. Pavlov demonstrated this in one of his many experiments. When a stimulus such as food is placed in the mouth of most mammals, salivation

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is a naturally occurring (or unconditioned) response to such stimulation. Additionally, if Pavlov’s dogs had experienced presentations of the food stimulus preceded by another stimulus that initially did not produce salivation (e.g., the ring of a bell), this initially neutral stimulus came to elicit the salivation response by itself. The neutral stimulus had become a conditioned stimulus. In other words, Pavlov identified what is now called classical or Pavlovian conditioning, a learning mechanism that is at the basis of many behaviors beyond gland secretions or other reflexive actions, including emotional reactions and normal and abnormal behavior. Classical conditioning is one of the principal theories used in behavioral modification, which is applied in various clinical settings (e.g., exposure therapy). Moreover, Pavlovian conditioning is thought today to be an adaptive tool that helps organisms regulate themselves by recognizing the causal and predictive relationships between events. Based on the path of his discoveries regarding classical conditioning in glands and the ideas proposed by the illustrious Russian physiologist Ivan Sechenov in Reflexes of the Brain, which posited that the entire behavior of humans may be explained in physiological reflex terms, Pavlov became interested in studying the function of the brain. Pavlov’s scientific vision made him think that the acquisition and extinction of conditioned responses was indicative of brain function, which resulted from the interaction between organisms and the environment. Specifically, Pavlov’s studies led him to suspect that excitatory processes in the brain result in the acquisition of conditioned responses, whereas inhibitory processes are responsible for the extinction of conditioned responses (i.e., a phenomenon in which presenting a conditioned stimulus by itself after a conditioned response was acquired results in the attenuation or elimination of such a response; e.g., Pavlov observed that after presenting the bell repeatedly without food, the dog no longer salivated). Interestingly, Pavlov thought that abnormal behavior, such as the ones he observed in neurotic and psychotic patients, was due to a conflict between these inhibitory and excitatory processes. The initial evidence of the role of classical conditioning in the development of abnormal behavior came from Pavlov’s studies on experimental neuroses. Again using dogs as experimental subject,

Pavlov and colleagues assessed whether neurotic behavior could be induced and then treated. Dogs were trained to discriminate between a circle associated with food, which provoked a conditioned excitatory salivary response, and an ellipse associated with the absence of food, which provoked the inhibition of such a response. The dogs easily learned this discrimination, as evidenced by the amount of salivary secretions evoked by the respective stimuli. The response was higher to the circle relative to the ellipse. Of importance, training of the discrimination was then manipulated to become increasingly more difficult by making the ellipse more circular on successive trials. Eventually, the ellipse and the circle were hardly able to be differentiated by the dog, which was unable to respond appropriately to the task. The procedure had apparently generated a direct conflict between inhibitory and excitatory processes. Furthermore, a once peaceful dog became highly excitable, aggressive, and showed erratic behavior as well as other emotional responses indicative of distress. Pavlov’s curiosity in psychopathology did not stop at identifying a potential source of experimental neurosis but continued on with the intent to give treatment to neurotic dogs. Interestingly, similar efforts to induce neurosis were replicated by one of Pavlov’s students with children who were trained to master increasingly difficult levels of discrimination between two sounds until they had difficulty discriminating, at which point, they showed signs of distress. However, those particular experiments were found to be ineffective in reducing the subjects’ symptoms of the experimentally induced neurosis. Research conducted in Pavlov’s laboratory on experimental neurosis is important not only based on the merits of the specific results but also because it illustrated a methodology through which psychopathological causes and treatment could be studied with a high degree of experimental control. Therapeutic approaches that followed Pavlov’s research focused on the experimental methods of classical conditioning rather than on the specific underlying neural mechanisms proposed by the physiologist. Pavlov’s studies on experimental neurosis were the basis for the use of classical conditioning in psychotherapy (e.g., systematic sensitization). Pavlov was also a pioneer in linking physiology to individual differences that resulted in personality types. In 1924, during a flood that affected his

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laboratory, Pavlov noticed that some dogs were frightened, others were excited, and some seemed withdrawn while being rescued from the rising waters. These events, in addition to previous observations of dogs manifesting different personalities regarding aggressiveness and friendliness, inspired Pavlov to investigate individual differences. Pavlov developed rigorous research practices that led him to theorize about nervousness. He hypothesized that individual nervous systems differ in their levels of excitation and inhibition. For him, the baseline levels of excitation and inhibition are individually determined by various physiological variables and therefore result in diverse types of personality. These ideas evolved into the theory of physiological bases of extraversion and introversion elaborated by Hans J. Eysenck and the concept of arousability developed by Jeffry A. Gray. In Pavlov’s diverse research interests, from his research on the physiology of the digestive system to his studies of classical conditioning, psychopathology, and individual differences, we can find a common pattern: All the studies were always conducted with a rigorous methodology, paying extreme attention to detail and empirical control. This might be one of the greatest lessons researchers in psychology learned from Pavlov’s work. In addition to the Nobel Prize, Pavlov received much academic recognition for his industrious research. He collaborated in the foundation of the Department of Physiology at the Institute of Experimental Medicine, St. Petersburg, Russia, where he used the facilities as the headquarters for his research, mentored several doctoral students, and conducted much of his research. His most important legacy is the discovery of classical conditioning, an important learning mechanism that allows an organism to adapt to a changing environment. The discovery that neurosis can be experimentally induced, and the idea that classical conditioning principles can be involved in its acquisition and potentially in its treatment, set a precedent for the future development of behavior therapy in the 1950s. Even today, the knowledge established by Pavlov has generated a productive line of research and theory regarding classical conditioning in the field of basic learning and behavioral psychology. Pavlov’s methods for studying conditioned responses is still used to assess processing of the brain in modern neuroscience, while

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translational and clinical research based on the principles of classical conditioning is still informing psychotherapeutic approaches, as in the case of exposure therapy. Through his life, Pavlov demonstrated scientific brilliance and a great instinct for research. Affected by pneumonia at the age of 86, Pavlov asked one of his colleagues to record every detail of his passing, a last indication of his dedication to his rigorous and scientific approach to life. Gonzalo Miguez and Mario A. Laborda See also Behavior Therapies: Overview; Behavior Therapy; Classical Conditioning; Exposure Therapy; Operant Conditioning; Skinner, B. F.; Systematic Desensitization

Further Readings Pavlov, I. (1927). Conditioned reflexes. Oxford, England: Oxford University Press. Pavlov, I. (1928). A physiological study of the types of the nervous systems, i.e., of temperaments. In Lectures on conditioned reflexes: Twenty-five years of objective study of the higher nervous activity (behaviour) of animals (pp. 370–378; P. Gantt & W. Horsley, Trans.). New York, NY: Liverwright. doi:10.1037/11081-034 Pavlov, I. (1928). Relation between excitation and inhibition and their delimitations: Experimental neuroses in dogs. In Lectures on conditioned reflexes: Twenty-five years of objective study of the higher nervous activity (behaviour) of animals (pp. 339–349; P. Gantt & W. Horsley, Trans.). New York, NY: Liverwright. doi:10.1037/11081-034 Pavlov, I. (1994). Psychopathology and psychiatry. New Brunswick, NJ: Transaction. Wolpe, J., & Plaud, J. J. (1997). Pavlov’s contribution to behavior therapy: The obvious and the not so obvious. American Psychologist, 52, 966–972. doi:10.1037/0003–066X.52.9.966

PERLS, FRITZ Fritz Perls (1883–1970), codeveloper (with his wife, Linda Perls) of Gestalt therapy, was born to lowermiddle-class German Jewish parents in Berlin, Germany. He grew up before World War I and then lived through the chaos of the Weimar Republic—a time of great economic stress, hyperinflation, and

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the rise of Adolf Hitler and Nazism in the early 1930s. He served as a medical officer in the German army during World War I, developing an abhorrence for war and causing his politics to drift decidedly to the left. After completing medical school in 1920, Perls was living and working in Berlin, immersed in his friendship circle of artists, philosophers, poets, intellectuals, and, especially, members of the Bauhaus movement. He began his own psychoanalysis with Karen Horney, which was soon interrupted when Perls left Berlin in 1926 to work with Kurt Goldstein in Frankfurt. When Perls moved to Frankfurt from Berlin, he continued his analysis with Clara Happel, a student of Horney, and it was around this time that he began training in psychoanalysis. Perls and Horney, however, maintained a strong connection, with Horney being Perls’s mentor, supervisor, colleague, and friend; years later, in 1946, Horney supported Fritz and Laura Perls’s move to New York City. In Frankfurt, Perls worked as an assistant to Kurt Goldstein, M.D., and the Gestalt psychologist Adhemar Gelb, Ph.D., at the Frankfurt Neuropsychiatric Institute, where Goldstein and Gelb were treating World War I soldiers as organized wholes (heavily influenced by Gestalt psychology), not just as body parts and pieces needing fixing. While in Frankfurt, Perls met Lore Posner (aka, Laura Perls), a doctoral student at the university working in Goldstein’s lab. The zeitgeist in Frankfurt in the 1920s was teeming with influences from existentialism, phenomenology, wholism, Gestalt psychology, psychoanalysis, linguistics, behaviorism, somatics, and Bauhaus design. Well-known philosophers, psychologists, and psychiatrists, such as Martin Buber, Paul Tillich, Kurt Goldstein, Adhemar Gelb, and Max Werthheimer, were all living and working there. Laura Perls worked and studied with Buber and Tillich as well as the phenomenologist Edmund Husserl for her doctoral studies and contributed much to Fritz’s formulation of Gestalt therapy theory—although frequently not sufficiently credited. Fritz was also influenced by Kurt Lewin (field theory), Kurt Koffka, Wolfgang Köhler, and Prime Minister Jan Smuts (who was also a philosopher) in South Africa and by Harry Stack Sullivan, Erich Fromm, and Clara Thompson in the United States.

The intellectual and bohemian culture of Frankfurt around 1926 was similar to that of Paris in the next decade. Fritz Perls and, to a somewhat lesser extent, Laura Perls were some of the connective tissue between what was, what was coming, and what might be. They were trained by the generation of psychoanalysts who were going beyond Sigmund Freud and integrating Freud’s work with some of the swirl of voices being heard around them, adding their own idiosyncratic perspectives to the evolving mix. In addition to his intellectual pursuits, Fritz was also influenced by the famous German theater director, Max Reinhardt, with whom he studied acting in Berlin. In 1927, Perls left Frankfurt for Vienna to complete his psychoanalytical studies, which he did in 1928. He returned to Berlin and set up his practice as a Freudian psychoanalyst for the next several years. Beyond his short analysis with Horney in Berlin, Perls, on Horney’s recommendation, had a personally and professionally rewarding analysis with Wilhelm Reich, who heavily influenced him. In 1929, Fritz and Laura Perls married in Berlin and had their first child, Renate, in 1931. Because of their subversive political activities protesting the rising National Socialist dictatorship and because they were Jewish, the couple left Nazi Germany one night in 1934. They lived and tried to work in Holland, but without work permits and because of the poor economy and large number of refugees, they found it difficult to survive in Holland. Ernest Jones, the first English-speaking psychoanalyst and president of the International Psychoanalytic Association, offered a position to Perls if he would emigrate to South Africa and establish a psychoanalytical training institute there. Perls, it is said, without asking anything much about the arrangements (logistics, money, structure, contract, etc.) immediately agreed, so the couple left for South Africa in 1935. Materially and professionally, Fritz and Laura Perls flourished in South Africa: having another child (Steven), establishing a psychoanalytical training institute, building a Bauhaus home, writing, and so forth. In 1936, Perls went to the Psychoanalytic Conference in Czechoslovakia and presented on “Oral Resistances.” His paper was coldly received; Perls often told the story of being queried and chided by an official of the International Psychoanalytic Association as to whether he didn’t

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believe that all resistance was anal. Perls shot back that he didn’t know psychoanalysis was based on “belief”! Soon after, Fritz and Laura Perls’s certification as training analysts in South Africa was revoked by the association’s ruling that only people who had already been trainers in Europe could be trainers outside Europe. Perls was disheartened and angry as he wanted to become an important innovator in the modernization of psychoanalysis. In South Africa, Perls was influenced by the philosophical, holistic writings of Prime Minister Jan Smuts. Anticipating Smuts’s retirement in 1948 and the next ruling party to be the Nationalists, who were to introduce apartheid, Perls emigrated to New York City in 1946. He was sponsored by Horney, who now lived there. Laura Perls and their two children followed in 1947. In New York City, Perls found a group of analysts at the William Alanson White Institute who were most congruent with his views. This group, which primarily followed the teachings of Sullivan, was crucial to Perls’s theoretical development. Sullivan, the innovator of interpersonal psychoanalysis, confirmed Perls’s ideas about the relationship of any organism, from an amoeba to a person, to the field (organismic/environmental field, or ecology) being crucial to the understanding of that organism. During this period, Perls was both influenced by and had influence on the William Alanson White Institute faculty. While in New York, Perls met the philosopher, author, and social commentator Paul Goodman, who was in therapy with Laura Perls. Perls collaborated with Goodman and Ralph Hefferline (a Columbia University psychology professor who was also in therapy with Laura Perls) on rewriting one of Fritz’s manuscripts that was published in 1951 as the seminal text Gestalt Therapy: Excitement and Growth in the Human Personality (eventually known as PHG). Most people believe that Hefferline organized the exercises section of the book, while Perls and Goodman collaborated on the theoretical section, with many ascribing much of the theory to Goodman. Importantly, many of the theoretical roots of Gestalt therapy in PHG can be found in Perls’s earlier writings. Fritz and Laura Perls began training therapists in New York in the late 1940s and officially established the New York Institute for Gestalt Therapy in 1952.

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With the publication of PHG, Perls was invited to present his work across the United States, stimulating the creation of Gestalt therapy institutes in Cleveland (with Erv Polster, Edwin, Sonia Nevis, etc.) and later in Los Angeles (with Jim Simkin and Bob Resnick) and San Francisco (with Abe Levitsky), to name a few of the larger ones. Perls left New York City in 1956 and bounced around for several years from Miami, to San Francisco, to Los Angeles, finally going on a round-the-world trip and ending up living at the Esalen Institute in Big Sur, California, where he and Simkin established training in Gestalt therapy for hundreds of therapists. Perls’s disregard for professional boundaries created a lot of confusion in discriminating between Gestalt therapy and Perls’s personality, resulting in a bad reputation in some quarters for Gestalt therapy. For instance, Perls’s sexual escapades with women, his sometimes outrageous behavior, and his unpredictable, strong reactions were often erroneously attributed to Gestalt therapy when they actually reflected Perls’s complex and contradictory personality. His deficits sometimes detracted from his genius, creativity, sweetness, and generosity. Gestalt therapists, as other professional therapists, follow the ethical codes of their professional organizations. Perls was a mischievous dialectician who would provoke the status quo by going to an extreme position. For example, in response to what he saw as the overly socialized, conforming, and intellectual zeitgeist of America in the 1950s, he would say things such as “The intellect is the whore of intelligence” and “Lose your mind and come to your senses.” Unless one understood the context of these remarks—attempting to rebalance the issues of conformity or independent thinking and the overuse of the intellect at the expense of emotions and sensations—it could be easy to dismiss Perls as just a simplistic troublemaker. Few psychotherapy theorists were influenced by so many and in turn influenced so many others themselves. Many of Perls’s cutting-edge ideas in his early days have been integrated into most contemporary psychotherapies. Perls remained at Esalen until 1969 and then moved to Lake Cowichan, Canada, to establish the first Gestalt community. Having traveled to Chicago after an opera tour of Europe, he died

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there on March 14, 1970, at the age of 78. Perhaps apocryphal, his last words to a postsurgery nurse who was trying to stop him from pulling tubes out of his body were “Don’t you tell me what to do!” Robert W. Resnick See also Gestalt Therapy; Horney, Karen; Psychoanalysis; Reich, Wilhelm

Further Readings Buber, M. (1958). I and thou. New York, NY: Scribner. Goldstein, K. (1939). The organism: A holistic approach to biology derived from pathological data in man. New York, NY: American Book. Horney, K. (1950). Neurosis and human growth. New York, NY: W. W. Norton. Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York, NY: Dell. Perls, L. (1992). Living at the boundary. Gouldsboro, ME: Gestalt Journal Press. Reich, W. (1933). Character analysis (M. Higgins & C. M. Raphael, Eds.; V. R. Carfagno, Trans.; 3rd enlarged ed.). New York, NY: Farrar, Straus & Giroux. (Original work published in Germany) Resnick, R. W. (1995). Interviewed by Malcolm Parlett— Gestalt therapy: Principles, prisms and perspectives editors note. British Gestalt Journal, 4(1), 3–13.

PERSONAL CONSTRUCT THEORY George Kelly’s personal construct theory (PCT) is an early example of constructivist psychology, an approach that takes the standpoint that people construct their own “versions” of the world through their subjective psychological processes. This implies that an individual can construe the same event in different ways at different times and that different people may construe the same event in different ways. Kelly’s theory takes this viewpoint (“constructive alternativism”) but elaborates it far beyond a simple philosophical proposition. While the major focus of application of PCT is psychotherapy, it has been applied in a wide range of other contexts including education, management/organizational development, architecture, and market research, to name but a few.

Historical Context Kelly saw his theory very much as an alternative to its psychological bedfellows in the 1950s— behaviorism and psychoanalysis. He emphasized that from the point of view of his theory, a person is not to be seen as a puppet manipulated by unconscious processes or a mere receiver of external stimuli but that the solutions to a person’s problems lie in reconstruing—seeing himself or herself and his or her circumstances in a different way, perhaps radically so. Kelly did not see any need for theories of motivation that view people as being kick-started into action, because, for Kelly, a person is in a perpetual state of motion from the time he or she comes into being as a construing organism. Kelly seems to have found Freudian ideas both frustrating and helpful. While there are some echoes of psychoanalytical theory in PCT, there are many fundamental differences, and PCT is not a psychodynamic (or, for that matter, a behaviorist or cognitive) theory. The PCT approach is to see a person and his or her problems from that particular person’s point of view and use that understanding to help him or her reconstrue. That essential aspect of truly understanding a person in his or her own unique terms through the individual’s system of bipolar dimensions (e.g., good vs. evil; good natured vs. hard to get on with), which Kelly called “personal constructs,” is the hallmark of PCT and the basis of the many methodologies developed from it. Another significant influence on Kelly was psychodrama, partly due to its focus on the varying aspects or roles of a person. Indeed, Kelly said that the title for his magnum opus could have been Role Theory. There are many allusions in his theory to the idea that people are playing out roles that they have constructed. The implications of that are extremely important in the context of a person who is trying to change from being who he or she is to someone who might be quite different. If it is accepted that a person is playing a role and that he or she has many different roles, it follows that it might be possible for a person to be able to create a new role for himself or herself. As Kelly says, a person does not have to be a “victim of their biography.” Kelly is probably unique in setting out PCT in its entirety in a two-volume work, first published as The Psychology of Personal Constructs in 1955.

Personal Construct Theory

Although there is a huge literature on PCT, very few significant amendments or additions have been made to Kelly’s original theory. Kelly anticipated that at some stage in the future, his theory, like other types of theory, would be replaced by another, more useful way of understanding people. If the current production of literature is anything to go by, it would seem that PCT is still considered useful and not yet in need of replacement.

Theoretical Underpinnings Perhaps understandably for someone who studied physics and thought of becoming an engineer, Kelly sets out his theory in the form of a Fundamental Postulate elaborated with 11 corollaries, rather in the style of an engineering blueprint. The corollaries describe the nature, formation, change, and organization of personal constructs, as well as how they are applied. Finally, in his Sociality Corollary, Kelly takes his theory into the realm of the interpersonal by saying that to the extent that a person can construe the construing of another person, he or she can play a role in relation to that other person. In his Fundamental Postulate, Kelly states what, from a PCT point of view, a person is in business for—namely, anticipating (predicting) what is going to happen in his or her personal world and testing out those predictions by behaving. For Kelly, behavior is the experiment that a person conducts to see whether the hypotheses he or she forms, based on the application of his or her personal constructs, are validated or invalidated. These processes usually take place at a very low level of awareness. For instance, a young woman may have the bipolar distinction sensible versus reckless in her idiosyncratic system of personal constructs. For some people, reckless may not be the opposite in meaning to sensible, but for this young woman it is, and this construct represents one of her “pathways of movement”— people, including herself, who are not sensible are construed as being reckless. Furthermore, the meanings that this person attaches to the labels sensible and reckless may be quite different from the meanings that others would ascribe to those words. Now, suppose that someone whom this person considers sensible offers her a lift in his car, which she accepts because she predicts that it will

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be safe to do so. The man then drives at 80 miles per hour along a road with a 40-mile-per-hour speed limit. Her construing of this man has been invalidated because she now reconstrues him as a reckless person who drives too fast and she changes her behavior by no longer accepting lifts from him.

Major Concepts In addition to its central feature, the bipolar construct, PCT embraces a range of concepts, and some of the most important of these are considered in this section. Person as Scientist

All psychological approaches to understanding human behavior have either an explicit or an implicit model of the person; for example, some may view the person as a self-actualizer, whereas others may view the person as an information processor. However, from a PCT standpoint, people are seen as similar to scientists, in the sense of using their “mini-theories” (their bipolar personal constructs) to create personal hypotheses, which they test by behaving, as in the previous example. Reflexivity

PCT is reflexive in the sense that it applies as much to the person who is applying it to others as it does to those others. Indeed, Kelly described how PCT itself explained why he chose to create PCT rather than some other psychological theory. The PCT practitioner’s clients are seen as being engaged in exactly the same psychological processes as the professional—construing their world and trying to make sense of it. In that sense, the PCT practitioner is his or her own client and needs to reflect on his or her own construing in a professional relationship, as well as the construing of his or her client. Resistance to Change

From a PCT point of view, people who are not doing what they or others want them to do are not “resisting change” but behaving as they are because it makes more sense to them to behave in that way rather than in some other way—even if their

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current behavior is highly undesirable from their own point of view or that of others. In her seminal work with those who stutter, Fay Fransella found that such people choose to be disfluent, not in the sense of their preferring to have such a debilitating speech impediment but because it makes more sense to them to stutter than to be fluent speakers. PCT has a range of “professional constructs,” each with its own special meaning (which is quite different from their usual meaning), to help the PCT practitioner understand why a person is having difficulty in changing. Examples of those professional constructs are anxiety, threat, hostility, and guilt. Anxiety occurs when an event cannot be construed adequately because it is outside the “range of convenience” of a person’s constructs. A person will feel threatened when his or her “core constructs”—those constructs that relate to the person’s very identity—may imminently be changed. A person is being hostile when he or she “cooks the books”—that is, distorts evidence that suggests that he or she may not be the sort of person he or she construes himself or herself to be. Kelly said that when a therapist observes hostility, the therapist should look for guilt. He said that because guilt is experienced when a person is “dislodged” from his or her “core role,” that is, when the person believes that he or she has behaved in a manner that is contrary to the way in which that person thinks he or she should have behaved in some important respect. A person who finds himself or herself in such a position may become hostile to stave off the feelings of guilt that might otherwise be experienced.

technique was invented by Kelly himself and is unusual in that it contains both qualitative (the personal constructs) and quantitative data. A repertory grid is composed of columns and rows, forming a matrix of cells. The column headings in the grid are the things, or elements, construed (e.g., people, situations, or aspects of the self). The rows contain bipolar personal constructs, which are usually elicited from the individual by asking him or her to compare and contrast the elements. After the grid has been designed, it is completed by rating or rank-ordering each of the elements on each of the constructs. Numerous computer programs have been developed to analyze repertory grids, using methods such as principal components analysis and cluster analysis. Kelly placed great weight on a mathematical relationship between constructs indicating a psychological relationship among them. So if the ratings in the grid are similar for the constructs loyal versus disloyal and kind versus cruel, then the hypothesis would be that the person who completed the grid would expect someone who is loyal also to be kind. Self-Characterizations

Kelly’s self-characterization method is an early example of a narrative technique. In its original form, a person is asked to write a character sketch of himself or herself in the third person, as if he or she is a character in a play, from the point of view of a sympathetic observer. This technique, which reflects Kelly’s notion that if you want to know what is wrong with someone you should ask them, is simple but can be extremely effective.

Techniques Although a great many techniques have been created by PCT therapists over the years, two of the most well known are repertory grids and selfcharacterizations, which were invented by Kelly himself. These two techniques are considered assessment techniques, whereas Kelly’s “Fixed Role Therapy” is a therapeutic intervention (technique), discussed in the “Therapeutic Process” section. Repertory Grids

The most well-known and most used technique in PCT is the repertory grid. The repertory grid

Therapeutic Process From a PCT perspective, people seeking therapy do so because they are “stuck” in the sense that they are unable to reconstrue and move on without professional help. A cornerstone of the therapeutic process is the assumption, alluded to earlier, that people are as they are because it makes more sense to them, from the point of view of how they construe the world, to be as they are rather than to change to being someone different. Accordingly, the therapeutic process has to involve understanding the client’s idiosyncratic construing of the world in terms of his or her personal constructs.

Person-Centered Counseling

A “diagnosis” can then be done by applying the professional constructs referred to earlier in this chapter. The only major therapeutic intervention that Kelly himself described is Fixed Role Therapy, which exemplifies the approach of experimentation that is used in PCT. Fixed Role Therapy invites a person to try out a new role (applying new personal constructs and existing constructs in a different way) for size by undertaking behavioral experiments both within the consulting room (e.g., role-play) and in the outside world. Contemporary approaches to personal construct psychotherapy range from methods focused on the resolution of dilemmas, in which the preferred pole of one construct (e.g., happy in a construct happy vs. sad) is associated with the nonpreferred pole of another (e.g., insensitive in a construct sensitive vs. insensitive), to those more concerned with the therapeutic relationship, focusing on the therapist’s and the client’s construing of each other’s construing and the implications of this for the client’s other significant relationships. PCT therapy has been applied with couples, families, and groups as well as individuals across the life span. Nick Reed and David A. Winter See also Constructivist Therapy; Kelly, George; Psychodrama

Further Readings Bannister, D., & Fransella, F. (1986). Inquiring man (3rd ed.) London, England: Routledge. Caputi, P., Viney, L. L., Walker, B. M., & Crittenden, N. (Eds.). (2012). Personal construct methodology. Chichester, England: Wiley-Blackwell. Fransella, F. (Ed.). (2003). International handbook of personal construct psychology. Chichester, England: Wiley. Fransella, F., Bell, R. C., & Bannister, D. (2004). A manual for repertory grid technique. Chichester, England: Wiley. Fransella, F., & Dalton, P. (2000). Personal construct counselling in action. London, England: Sage. Kelly, G. A. (1991). The psychology of personal constructs (2 vols.). New York, NY: W. W. Norton. (Original work published 1955) Walker, B. M., & Winter, D. (2007). The elaboration of personal construct psychology. Annual Review of

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Psychology, 58, 453–477. doi:10.1146/annurev .psych.58.110405.085535 Winter, D. A. (1992). Personal construct psychology in clinical practice: Theory, research and applications. London, England: Routledge.

PERSON-CENTERED COUNSELING Person-centered counseling is an existentialhumanistic approach to counseling and psychotherapy that has influenced the manner in which most counselors and psychotherapists conduct clinical work. Developed by Carl Rogers during the mid-20th century, this approach was originally called client-centered counseling and stood in stark contrast to the then popular psychoanalytical approach of Sigmund Freud and the behavioral approach of B. F. Skinner. Using the word client instead of patient, the approach was novel for its time, as it stressed the individual’s potential to understand his or her predicament and change if he or she is placed in an environment that provided psychological safety and facilitated self-understanding. Continuing to be popular today, this nondirective approach helps the client recognize how he or she has been incongruent or nongenuine in his or her life—that is, how the client’s feelings, behaviors, and thoughts are out of sync. Such incongruence occurs due to the client’s need to be loved by significant others and willingness to act in accordance with how significant others want the client to act in order to gain such love. This results in a denial of one’s own way of being and sense of self. Although incongruence generally starts early in life as parents or other important people impose their wishes or conditions on the client, an individual’s nongenuineness can continue throughout one’s lifetime as additional significant others place conditions on the individual. However, if a counselor shows acceptance and understanding, the client can break this pattern and begin to hear his or her inner voice; that is, get in touch with his or her true self. Person-centered counseling attempts to facilitate this process through the use of three core conditions: (1) genuineness, (2) unconditional positive regard (UPR), and (3) empathic understanding. Seen as one of the early existential-humanistic approaches, person-centered counseling and the

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core conditions of genuineness, UPR, and empathy continue to have a profound impact on the manner in which most counselors and psychotherapists conduct counseling and therapy.

Historical Context Developed by Rogers in the 1940s, personcentered counseling eventually became one of the most important approaches to counseling and psychotherapy. Rogers had been raised in a strict Pentecostal Christian home, and although he entered the seminary at a young age, he eventually rejected the dualistic thinking of his parents and of his religion and became interested in understanding the human condition from a humanistic perspective. Put off by the psychoanalytical training in his doctoral psychology program at Columbia University, Rogers was influenced by individuals like Otto Rank, who had split from Freud and had moved toward a more existential-humanistic approach, as well as John Dewey, a humanistic educational philosopher and psychologist. Rogers eventually embraced many of the existentialhumanistic beliefs of the time, such as the belief that people had a natural tendency to be good if placed in a loving environment that allowed them to actualize their true selves and a belief in the subjective nature of the person; that is, a belief that reality is a construction of the person’s perceptions. Soon, he began to develop an approach that was based on the three core conditions. Rogers’s early approach was called clientcentered therapy. This contrasted with the psychoanalytical and behavioral approaches of the time, which were counselor centered. Such approaches assumed that the counselor was the expert and had the knowledge to help the client and that the counselor should direct or guide the client toward change as a function of this knowledge. On the other hand, Rogers believed that the counselor should provide the three core conditions in an effort to develop a therapeutic environment that would facilitate client self-understanding. Client awareness, and eventually client change, would be a product of this selfunderstanding, and the role of the counselor was to simply provide this safe and facilitative environment so that the client could unravel this new knowledge of self on his or her own. As Rogers refined his approach, he came to believe that the skills needed for the counselor were

important skills for any person to adopt if the person was to live a life based on realness, mutual understanding, acceptance, and caring for others. Thus, he changed the name of his approach to person-centered counseling, stressing that one need not be a client to reap the benefits of the personcentered approach, as even friends and significant others could facilitate such understanding. Over the years, Rogers would criticize other approaches that had a more directive approach and were based on the counselor’s expert knowledge of a theory. During the 1960s, Rogers’s nondirective approach became one of the most popular approaches of the time, and its popularity continued into the 21st century. Person-centered counseling was originally viewed as a short-term approach when compared with the rather long-term approach of psychoanalytic therapy. Whereas psychoanalysts would meet with their clients three, four, or five times a week for years, person-centered counselors tended to meet much less frequently and would continue only as long as the client wanted to continue. During the late 1990s and the first part of the 21st century, as brief approaches to counseling became increasingly popular, person-centered counseling began to be seen as a long-term approach. This is somewhat ironic given its history. In recent years, research has continued to validate the three core conditions that Rogers so strongly advocated for. In fact, research by Bruce Wampold, John Norcross, and others asserts that these conditions seem to be an important ingredient of the “common factors” in the therapeutic relationship—factors that appear to be essential in the development of positive client outcomes. Although, there continue to be a fair number of person-centered counselors today, due to the popularity of the shorter term approaches, there are few person-centered purists. However, as a testament to the staying power of the person-centered approach, most counselors today continue to stress the importance of the three core conditions when working with clients.

Theoretical Underpinnings As adherents to an existential-humanistic approach to counseling and psychotherapy, person-centered counselors have a phenomenological perspective of the person, which means that the counselor accepts the reality of the client and assumes that

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the client’s sense of the world is based on his or her unique understanding of reality. Person-centered counselors believe that individuals are born with an actualizing tendency, which drives the individuals toward their full potential. However, this tendency can be thwarted when others place expectations on the individuals to act in a manner incongruent to their actual self. Called conditions of worth, a person’s need to be regarded by others is so strong that rather than follow the actualizing tendency, the individual attenuates to these conditions in an effort to gain love from significant others. When conditions of worth result in behaviors that are in contrast to the individual’s natural way of being, the individual is said to be acting in an incongruent or nongenuine manner; that is, the individual’s feelings, thoughts, and behaviors are not in sync with one another. Incongruence will yield defensiveness, distortions of situations, anxiety, or a general sense that the individual is out of sync with self. Although conditions of worth can be placed on a person at any point in a person’s life by any significant other, they are often first experienced from an individual’s parents or guardians. When children have such conditions placed on them, to maintain the significant others’ love, they learn to behave in a manner in which the parents or guardians want them to behave as opposed to how they want to behave. This incongruence between one’s actions, feelings, and thoughts can continue into adulthood as grown children continue to act as they believe others would want them to behave in contrast to who they actually are. In actuality, the individual has lost touch with his or her true self and is acting out a false sense of self. Personcentered counselors suggest that this process, which usually happens outside of the person’s awareness, can be reversed if the client is placed in an environment that is conducive to unearthing the conditions of worth and facilitative of the client understanding his or her true self. Such an environment, suggest person-centered counselors, involves the expression of the three core conditions within the therapeutic setting. Person-centered counselors have an interesting take on the concept of choice and free will. Because the client is seen as incongruent or nongenuine, he or she will be out of touch with his or her true self. Thus, reality for this individual is partially based on the client’s false sense of self, and accordingly,

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the choices made by such a person are somewhat based on this false sense. Thus, the choices made will often continue the client’s nongenuine self. After the client is in counseling or therapy, however, he or she will begin to actualize self, or live out the true self, and begin to make decisions based on this newfound self. At this point, choices become increasingly congruent for the client; that is, the client’s feelings about self, thoughts about self, and eventual actions match one another. In fact, as the client gains increasing clarity of self, the choices become clearer, almost as if there is no choice—that is, there is an obvious path for the client to take.

Major Concepts Person-centered counselors are driven by the philosophy behind existential humanism, and most of their major ideas flow from that orientation. Some of these include actualizing tendency, need for positive regard, conditions of worth, nongenuineness (incongruence), organismic valuing process, choice and self-determination, nondirective counseling, necessary and sufficient conditions, and growth and change. Actualizing Tendency

Person-centered counselors believe that individuals are born with an actualizing tendency, which drives the individual toward behaviors that are congruent with his or her sense of self. However, this tendency can be thwarted by conditions of worth. Need for Positive Regard

All individuals are born with a need to be positively regarded by others. This need can be so great that if a person perceives that a significant other is willing to withdraw his or her positive regard if the individual does not act in a certain manner, then the individual becomes willing to forgo his or her true self and act in a manner incongruent to that true self. Conditions of Worth

Conditions of worth are conditions or expectations placed on a person that are incongruent with how the person actually wants to behave. Such

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conditions can result in a person acting in a manner reflective of a false self as his or her true self becomes repressed in an effort to please and be regarded by the significant other. Nongenuineness or Incongruence

Nongenuineness, or incongruence, is when an individual’s feelings, thoughts, and behaviors are not in sync. In an effort to be regarded by a significant other, an individual will sometimes act in ways that others want him or her to act instead of being real or true to the individual’s own self. This usually occurs when an individual has conditions of worth placed on him or her that results in that individual living out a false self. When a person lives a life that is nongenuine or incongruent, he or she tends to become defensive, distort situations, feel anxiety, or have a general sense that he or she is out of sync with self. Organismic Valuing Process

The organismic valuing process is the innate process of moving toward those who value a person’s real self and offer positive regard and acceptance. However, if conditions of worth are placed on an individual, the person may lose touch with his or her organismic valuing process. Listening to one’s organismic valuing process will result in positive selfesteem and a positive self-image. Ignoring one’s organism valuing process will result in incongruence.

self-determination. By offering the three core conditions, such an environment is created, and the client will naturally begin to hear himself or herself more clearly and begin the process of becoming more congruent; that is, the client becomes more true to his or her real self. Necessary and Sufficient Conditions

In developing his approach to counseling, Rogers suggested that there were six conditions that were necessary for counseling to be effective and they were alone sufficient for positive outcomes in counseling: 1. The client and the counselor meet and are in contact with each other. 2. The client is incongruent and is struggling with some issues. 3. Within the context of the therapeutic relationship, the counselor is congruent or genuine. 4. The counselor shows unconditional positive regard to the client. 5. The counselor is empathic with the client. 6. To some degree, the client recognizes that the counselor is empathic and is showing unconditional positive regard to the client.

Growth and Change Choice and Self-Determination

When a client is afforded an environment by the counselor that offers the three core conditions, that client will begin to make choices that are in sync with his or her true self and actualizing tendency. Person-centered counselors believe that clients can and will make positive choices for their lives if afforded such an environment and that clients will determine both the direction of counseling and the direction of their lives when given the opportunity to hear themselves clearly in counseling or therapy.

Person-centered counselors believe that growth and change occur through the counselor’s ability to exhibit the necessary and sufficient conditions of therapy. Typically, growth and change are experienced in a variety of ways by clients, including an increased sense of trust in self, increased self-esteem, the ability to make decisions more easily, a greater awareness of self and of the selves of others, an increased sense of psychological adjustment, a greater belief in one’s ability to make decisions and the diminution of the need for others to make decisions for a person, and greater acceptance of self.

Nondirective Counseling

Person-centered counselors believe that it is critical for the counselor to create an environment that is conducive to client self-discovery and

Techniques In contrast to many other theories, person-centered counseling has only three techniques: (1) the use of

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empathy, (2) showing UCR, and (3) being genuine or congruent in the therapeutic relationship. In fact, Rogers and others generally did not consider these attributes as techniques, instead suggesting that they were qualities to be found in the counselor, qualities that all people might consider embracing if they were to live congruent, loving, and accepting lives. This section briefly describes these three techniques or qualities.

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or destructive feeling is a whole person who is loving and giving. It involves understanding that conditions of worth that have been placed on a person have, ultimately, been responsible for the individual living an incongruent life, which has led to distortions in reality, defensiveness, and destructive ways of living. And it involves the belief that by showing UPR the individual will become in touch with his or her true self, which, by its very nature, will be a more loving and caring person.

Empathy

The cornerstone of person-centered counseling, empathy is the ability to understand the feelings, thoughts, and experiences of another person and letting that person know that one has gained a deep understanding of him or her. It involves putting oneself in the shoes of another person and reflecting back this understanding to the person. Empathy can be shown in many ways, such as reflecting back the client’s content and feelings, through metaphor or analogy, by sensing the deeper feelings of the client and reflecting these feelings, and more. However, empathy is not the same as sympathizing with the client, identifying with the client, or interpreting the client’s experiences. Over the years, a number of models have been developed to help in the development and expression of empathic understanding. These models have often been used to teach counselors microcounseling skills and break down the learning of skills into small component parts. One such model, the Carkhuff Scale, operationalized the original definition of empathy by Rogers and was quite popular in the later part of the 20th century. Although used less frequently today, such models still have an important place in the training of counselors and others in empathy.

Genuineness or Congruence

Genuineness, sometimes called congruence, is when an individual’s feelings, thoughts, and actions are in sync. It indicates that what a person feels is reflected in his or her thoughts and that thoughts and feelings match the kinds of behaviors exhibited. For the counselor, it means that his or her feelings, thoughts, and actions are congruent, or in sync, within the confines of the therapeutic relationship. Although a counselor may be struggling with his or her own issues outside of the therapeutic relationship, within the relationship, he or she is whole and genuine. It means that if the counselor is having ongoing negative or positive feelings about the client, the counselor will be aware of those feelings and will consider sharing those feelings if he or she believes that it will benefit the therapeutic relationship. Rogers suggested that if a counselor initially feels negatively toward a client, he or she should wait a bit before sharing that feeling, as once a relationship is developed, the counselor can facilitate client understanding, see the client more clearly, and understand the client’s pain. It is only then that the counselor can comprehend why the client acted the way he or she did. Such understanding generally dissipates the negative feelings.

Unconditional Positive Regard

Also called acceptance, UPR is accepting the client unconditionally within the context of the therapeutic relationship. It means that the counselor is able to hear the client fully and that the client has a sense that he or she can say anything to the counselor without being judged. Such UPR can only be achieved by a counselor if he or she believes that, ultimately, UPR will be healing for the client, even if the client says some outrageous things. It is the belief that underneath any negative

Therapeutic Process Person-centered counseling is a nondirective approach that can last from a few sessions to many years. Throughout the therapeutic process, counselors consistently apply the three core conditions of empathy, UPR, and genuineness, sometimes called congruence. This allows the client to feel safe within the therapeutic relationship and to be increasingly willing to examine all parts of himself or herself. Over time, clients become more aware

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of their true selves, are more in touch with their feelings and thoughts, have higher self-esteem, become increasingly autonomous, and are better able to make decisions in their lives. Edward S. Neukrug See also Existential Group Psychotherapy; Existential Therapy; Existential-Humanistic Therapies: Overview; Experiential Family Therapy; Gestalt Therapy; Interpersonal Group Therapy; Process Groups; Rogers, Carl

Further Readings Kirschenbaum, H. (2009). The life and work of Carl Rogers. Alexandria, VA: American Counseling Association. Kirschenbaum, H., & Henderson, V. (Eds.). (1989). Carl Rogers dialogues. Boston, MA: Houghton Mifflin. Kirschenbaum, H., & Henderson, V. (Eds.). (1989). The Carl Rogers reader. Boston, MA: Houghton Mifflin. Kramer, R. (1995). The birth of client-centered therapy: Carl Rogers, Otto Rank, and “the beyond.” Journal of Humanistic Psychology, 35(4), 54–110. doi:10.1177/00221678950354005 Neukrug, E. S. (2011). Person-centered counseling. In Counseling theory and practice (pp. 214–244). Belmont, CA: Cengage. Neukrug, E. S., Bayne, H., Dean-Nganga, L., & Pusateri, C. (2012). Creative and novel approaches to empathy: A neo-Rogerian perspective. Journal of Mental Health Counseling, 35(1), 29–42. Rogers, C. R. (1942). Counseling and psychotherapy: New concepts in practice. Boston, MA: Houghton Mifflin. Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications and theory. Boston, MA: Houghton Mifflin. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. doi:10.1037/h0045357 Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston, MA: Houghton Mifflin. Rogers, C. R. (1980). A way of being. Boston, MA: Houghton Mifflin. The top 10: The most influential therapists of the past quarter-century. (2007, March/April). Psychotherapy Networker. Retrieved from http://www .psychotherapynetworker.org/ index.php/magazine/ populartopics/219-the-top-10

PHENOMENOLOGICAL THERAPY Phenomenological therapy is a philosophical therapy that is firmly based in dialogue. It proceeds through careful description and aims to explore people’s difficulties in living as experienced rather than by referring to psychodiagnostic categories or other theoretical concepts. It seeks to achieve understanding by encouraging a person to set his or her problems against the wider horizon of the human condition. It avoids prescription, interpretation, and explanation and emphasizes description of purpose, meaning, values, conflicts, dilemmas, and paradoxes instead.

Historical Context Phenomenological therapy is based on the method of phenomenology, which originated with the philosopher Edmund Husserl’s work in the early part of the 20th century. Phenomenology, literally the science of appearances, is a method for systematic description of conscious awareness, which results in grasping what is essential about something so that we can understand better what it means. Such conscious awareness can help a person set aside his or her usual assumptions and bias. Several psychiatrists saw the importance of this new method for the human and social sciences. Both Karl Jaspers in Germany and Ludwig Binswanger in Switzerland started applying phenomenology to psychiatry to connect more closely with the way in which their patients were experiencing the world. Their efforts to apply phenomenology to their work with their patients happened concurrently with the German philosopher Martin Heidegger’s application of phenomenology to the philosophy of human existence. His book Being and Time showed that human existence may be better understood if one starts with an ontological analysis, that is, by establishing what is essential to Being. He described the fundamental ways in which human beings (Dasein) stand out in the world in relation to time. The Swiss psychiatrist Medard Boss worked with Heidegger for many years to apply this framework to psychotherapy and developed a particular form of therapy named Daseinsanalysis.

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Many other philosophers and psychotherapists were inspired by phenomenological ideas and generated alternative forms of therapy. Jean-Paul Sartre and Merleau Ponty in France, who with others like Simone de Beauvoir and Albert Camus developed existentialism, greatly influenced phenomenological forms of therapy. In the United States, Fritz Perls’s Gestalt psychotherapy and Carl Rogers’s personcentered therapy were both influenced by the phenomenological principle of attending to what is actually happening to the person. Eugene Gendlin’s focusing therapy is directly based in phenomenological principles. In the United Kingdom, R. D. Laing’s alternative psychiatry was also inspired by these ideas, as was George Kelly’s personal construct psychology. Laing’s phenomenological descriptions of family interactions and schizophrenic experience are a good example of the method. The European School of ExistentialPhenomenological Therapy, sometimes known as the British School, is deeply rooted in phenomenological principles. This method has also engendered numerous forms of phenomenological qualitative research, which have been applied to psychological research with great success.

Theoretical Underpinnings Phenomenology requires people to pay systematic attention to not only the way in which human awareness shapes our own consciousness but also the way in which we perceive objects that we direct our consciousness toward. It also affects the process of thinking and experiencing. It is a study of human consciousness and its functional principle of intentionality. Scientists have long neglected the mysterious process of consciousness because it is not open to objective study. They have preferred to study the objects in the world, which can be objectively studied, or the physical brain, which underpins the complex processes of the mind. Such study isolates and analyzes something that has become objectified. In this process, essential connections between the object and the environment, on the one hand, and the object and the subject, on the other, are often lost sight of. Phenomenology on the contrary brings object, process, and subject together in one intentional arc that unites all these elements, which is particularly relevant to psychotherapy.

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Major Concepts Phenomenological observation requires researchers or therapists to clear their minds and to suspend their usual prejudice and assumptions so that attention becomes more fully available and can be focused carefully as intentionality. Husserl showed how to remove preconceptions and clear the mind in order to observe the world and our consciousness of it more diligently. These processes when applied to the practice of psychotherapy lead to a number of concepts that become the cornerstones of progress. Time Genetic Constitution

Phenomenology reminds and emphasizes the importance of time. As human beings, we are born and live for a period of time, and then we die. We are never able to be all we are capable of being, and we are constantly changing. When people begin to grasp that they affect the change in their lives, their therapy starts in earnest. It will take a lot longer for most people to begin to take responsibility for all the life choices they make. Awareness of how they either engage or disengage from the situations they are in will take even longer. Phenomenological therapy assumes the capacity of all human beings to evolve by self reflection. Agreement with this premise, or rather a discovery of its truth in practice, is essential to the success of the work. Transforming the Dynamic Self

Most clients who come to therapy have lost track of their ability to be many different things and have lost faith in their ability to deploy their talents in new ways and to make new connections and meanings in the world. Phenomenological therapy assumes the importance of this capacity for connectivity and transformation and aims to stimulate and inspire it. Owned Living and Intersubjectivity

Husserl showed the importance of intersubjectivity, which is the dialogical connectedness between people. Many people forget about this, deny it, distort it, or avoid it. Owned living is when a person is not just at the mercy of circumstances

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or other people’s dictates but is able to self reflect and face his or her temporality and limitations. People have often translated owned living as authentic living and disowned living as inauthentic living, thus missing the deeper meaning of the need for clarity about the limits of life. Worldview

Human beings create their lives in a world that is multidimensional and where all layers of existence have to be taken into account and dealt with appropriately and ably. The four-world model, based on Heidegger’s idea of the fourfold, considers a person’s engagement in 16 areas of human existence, arrived at by the four dimensions of life (physical, social, personal, and spiritual) squared against themselves. The fourfold world model can be used to perform a structural existential analysis of the position a person holds in the world and how that person deals with challenges on all dimensions.

Techniques Phenomenological therapy involves a dialogue between the client and the therapist and seeks to assist clients in seeking understanding of the human condition. Rather than using specific techniques, the therapist is more concerned about the therapeutic process and uses the following concepts to guide his or her dialogue with the client. Description

This is the hallmark of phenomenological therapy. Clients are invited to observe and attend to their own experience carefully before describing it until it sounds accurate to them. Bracketing

Clients are encouraged to consider what they take for granted and to set aside their usual prejudice to examine their experience anew. The therapist applies the same method to personal bias.

Affectivity

Horizontalizing

A person’s engagement with the world and his or her consciousness are filtered through the person’s affectivity, or emotional compass. A person moves toward and away from the world according to the values he or she seeks out or avoids. The emotional compass is a model that describes the entire spectrum of the sensory, emotional, mental, and intuitive qualities of awareness that show a person how he or she feels about the various aspects and events in the world. These feelings always refer to values and lead to action. They can be articulated in language.

The story that the client tells is examined for its limits and horizons. Each person is centered in his or her own world and can only see as far as his or her vision reaches. It is important to locate a person’s experience within his or her situation and context and not immediately expect the person to jump beyond this.

Paradox

Human living happens in a force field of contradictory influences. At each dimension of existence, human beings are faced with difficulties and opposing ideas and realities. We have to deal with life and death on the physical dimension, love and hate on the social dimension, strength and weakness on the personal dimension, and meaning and absurdity on the spiritual dimension. The art of human living is to learn how to work with these paradoxes and contradictions.

Equalizing

The therapist initially aims to hold his or her attention evenly and to let every aspect of the client’s story come to the fore without favoring any particular aspect. Eventually, how the client is organizing his or her experience and what his or her blind spots and habits of emphasis are will become obvious. Dialogue

As a philosophical method, phenomenological therapy is centered on dialogue, where the client and the therapist debate the issues in mutuality and with the focus on understanding something by talking through the issues.

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Actualizing

Phenomenology allows a person to become aware of how he or she engages or disengages with certain aspects of life. Actualizing and taking ownership of one’s own experience creates a new energy and enthusiasm of engagement. Perspectives

Everything in the world can be looked at from different angles and has multiple facets. Phenomenological therapists enable their clients to explore those facets and adumbrations they had not considered before. Directionality and Purpose

Human beings live in time and move forward toward a certain destination and objective, even when they are not aware of what this is or are confused about it. Phenomenological therapy helps people retrieve their sense of direction and purpose. This immediately creates a greater sense of connectivity and meaning. Dialectical Enquiry

Human experience, like nature, is embedded in a struggle between opposing forces. As humans, we evolve as we overcome the tensions and polarities by finding a way to synthesize and surpass them. Our values and purpose are what provide us with the forward thrust to transcend the problems and follow a project. Hermeneutics

Interpretation in phenomenological therapy is hermeneutical. This means that the final interpretation is the responsibility of the client rather than of the therapist. Meaning is not derived from a theoretical model but from the experience of the client. Heuristics

Phenomenological therapy is a search for truth and an investigation or enquiry into what is actually the case. The objective is always that of greater understanding. As part of this enquiry, therapists

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may use certain heuristic devices, such as the four-world map or the emotional compass. Verification

All phenomenological methods highly value the principle of verification, whereby one constantly checks that one’s account of reality coincides with the experience of those who are actually implicated in it. This means that the therapist will not impose meanings or observations but will check them out for veracity with the client. Therapists proceed slowly toward greater accuracy by inviting correction from the client.

Therapeutic Process The therapeutic process begins by the therapist entering into the relationship with the client in a manner that is respectful of the client’s way of being. Phenomenological therapy requires the therapist to be fully engaged with the client and to be truly present, in a wholehearted manner. In resonating with the client’s worldview, the therapist will be able to participate in it and thus understand it from the inside. Much of the therapy is based on dialogue. The conversation is open and receptive. The objective is a joint enquiry into what creates difficulty for the client. In this conversation, the therapist is direct and speaks as simply and truly as possible. The therapist is also directional rather than directive or nondirective. This means that attention is paid to the direction of the client’s life, so that the client’s important projects are elucidated and tracked. All through the work, the therapist will use phenomenological methods to bracket assumptions that appear both in the client’s words and in the therapist’s mind. Gradually, a picture emerges of the client’s worldview, beliefs, and values and also of the way in which he or she has stagnated or become scared to move on. There will be occasions when paradoxes or contradictions are encountered. When this occurs, the therapist uses dialectical methods to enable the client to discover a purpose and meaning that can carry the client beyond the conflict by surpassing it and making decisive new choices. A joint search for truth and understanding will guide the process. This is a philosophical enquiry

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where the client learns to ask the right questions to come up with informative answers. The client learns about the human ability to make sense of experience and puzzles out new meanings in the world. The phenomenological therapeutic process includes lessons about the importance of engagement with life and its many challenges. Clients frequently get a sense of the productivity of their learning and so stop fearing new and more challenging experiences, realizing that troubles and difficulties can be moments of breakthrough rather than breakdown. From a phenomenological perspective, getting better at intelligent engagement with living makes life more meaningful and worthwhile.

Laing, R. D. (1961). Self and others. New York, NY: Routledge. Laing, R. D. (1967). The politics of experience. New York, NY: Pantheon House. Laing, R. D. (1970). The divided self. Harmondsworth, England: Penguin Books. (Original work published 1959) Perls, F., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy. New York, NY: Julian Press. Rogers, C. (1951). Client-centered therapy. London, England: Constable. Spinelli, E. (2005). The interpreted world: An introduction to phenomenological psychology (2nd ed.). London, England: Sage.

Emmy van Deurzen See also Daseinsanalysis; Existential Group Psychotherapy; Existential Therapy; ExistentialHumanistic Therapies: Overview; Focusing-Oriented Therapy; Gestalt Therapy; Perls, Fritz; PersonCentered Counseling; Rogers, Carl

Further Readings Adams, M. (2013). Existential counselling in a nutshell. London, England: Sage. Cooper, M. (2003). Existential therapies. London, England: Sage. van Deurzen, E. (2012). Existential counselling and psychotherapy in practice (3rd rev. ed.). London, England: Sage. van Deurzen, E. (2010). Everyday mysteries: Handbook of existential therapy. London, England: Routledge. van Deurzen, E., & Adams, M. (2011). Skills in existential counselling and psychotherapy. London, England: Sage. Gendlin, E. T. (1978). Focusing. London, England: Bantam Books. Heidegger, M. (1962). Being and time (J. Macquarrie & E. S. Robinson, Trans.). London, England: Harper & Row. (Original work published 1927) Husserl, E. (1931). Ideas (W. R. Boyce Gibson, Trans.). New York, NY: Macmillan. (Original work published 1913) Husserl, E. (1960). Cartesian meditations: An introduction to phenomenology (D. Cairns, Trans.) The Hague, Netherlands: Nijhoff. (Original work published 1929) Husserl, E. (1977). Phenomenological psychology (J. Scanlon, Trans.). The Hague, Netherlands: Nijhoff. (Original work published 1925)

PLAY THERAPY Play therapy is an approach to counseling children in which trained counselors integrate play into their therapeutic approach as a way to prevent or resolve difficulties. Because many children do not have the cognitive development to participate in traditional talk therapy to verbalize and analyze their problems, they can use play, art, music, games, and other playful media to communicate in a way that is meaningful to them. Play is considered the language of children, and the toys are the words to express their experiences. Play allows children the space to distance themselves from troubling events and project their thoughts and feelings onto the toys. Children can re-create and reenact events in ways that allow them to change the outcome and thus gain mastery of their thoughts and feelings. Play therapy becomes the platform to address concerns and to work toward optimal growth and development. While play therapy was developed to work with children between the ages of 3 and 11 years, many counselors integrate play into their work with adolescents, groups, and families.

Historical Context The development of play therapy parallels the progression of theoretical advances in the overall counseling field. In 1909, Sigmund Freud first mentioned integrating play as a treatment modality in the work he conducted with Little Hans. While Freud did not work with the child directly,

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he asked Little Hans’s father for descriptions of the child’s play and then provided interpretations and suggestions for how the father could work with his child to help gain mastery of the child’s fears. In 1919, Hermine Hug-Hellmuth began to directly incorporate play as a central component of psychoanalysis in understanding the conflicts and personality structures of children. Anna Freud also began to observe children’s play as a way to establish relationships with children, and in the late 1930s, Melanie Klein began to use play with children as a direct substitute for traditional talk as the medium of expression in psychotherapy. In 1938, David Levy developed what he termed Release Therapy, in which a child who has experienced a specific stressful situation would be given play materials related to the situation and allowed free play time to act out various scenarios in order to reenact the event and release the painful thoughts and emotions. In 1955, Gove Hambidge built on Levy’s work and established an even more structured, direct approach in which he would establish rapport and then ask the child to repeatedly play out the exact traumatic situation in order to cope and gain mastery over the event. In contrast, during the 1950s, Virginia Axline modified Carl Rogers’s client-centered therapy into a nondirective, client-centered play therapy approach. She believed that children will naturally move toward growth if counselors develop a warm and accepting relationship where children can take the lead in their play and counselors can reflect their feelings in such a way that the children can gain insight into their own problems. In the 1960s, Bernard Guerney and Louise Guerney developed Filial Therapy, in which counselors train parents in the basic tenets of nondirective client-centered play therapy so that the parents can work directly with their children in special play sessions at home to build the parent–child relationship. As theoretical approaches continued to expand in the next few decades, counselors incorporated play therapy with those orientations, including cognitive-behavioral play therapy, Gestalt play therapy, brief solutionfocused play therapy, and eclectic prescriptive play therapy. In 1982, the Association for Play Therapy (APT) was established to further promote theoretical development, research, and clinical practice for individuals who want to gain more specialized

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knowledge and expertise in play therapy. In addition to the International Journal of Play Therapy, APT manages credentials for licensed mental health professionals who want to become a Registered Play Therapist or a Registered Play Therapist-Supervisor. As a way to further encourage continued training and research, APT offers designations for Approved Centers of Play Therapy Education and Approved Providers of Play Therapy Continuing Education.

Theoretical Underpinnings While counselors who utilize play therapy may adhere to a variety of theoretical orientations, their approach can be divided into two major categories: (1) nondirective and (2) directive play therapy. From a nondirective approach, children have the power to make all of the decisions about what happens in the playroom. In contrast, counselors utilizing a directive approach structure activities and lead children in scenarios within the playroom. While some counselors may strictly use one approach or the other, many use a combination of these approaches. Counselors may begin with a nondirective approach to build the therapeutic relationship and assess the presenting issues and then move to more directed activities to address concerns as they emerge. Nondirective Play Therapy

In nondirective play therapy, counselors do not direct or manage the play but, instead, provide a safe, genuine relationship where children can explore their own challenges and direct their own process. Axline outlined eight basic principles of nondirective play therapy: 1. The therapist must build a warm, friendly, genuine relationship with the child client that will facilitate a strong therapeutic rapport. 2. The therapist must be completely accepting of the child, without desiring the child to change in any way. 3. The therapist must develop and maintain an environment of permissiveness so that the child can feel free to completely explore and express his or her feelings.

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4. The therapist must pay constant attention to the child’s feelings and reflect them in a manner that encourages the child to gain insight into and enhance his or her understanding of self. 5. The therapist must always be respectful of the child’s capacity for solving his or her own problems if given the opportunity and resources necessary. The child must be solely responsible for his or her own decisions and must be able to freely choose whether and when to make changes. 6. The therapist must not take the lead in therapy. This responsibility and privilege belongs to the child. The therapist always follows the lead of the child. 7. The therapist must never attempt to hasten the course of therapy. Play therapy is a slow and gradual process that depends on the child’s pace, not the therapist’s. 8. The therapist must only set limits that are essential for anchoring therapy to reality and to return to the child responsibility for his or her role in the therapeutic process.

Directive Play Therapy

In directive play therapy, counselors lead the play sessions by tailoring activities to the needs of the individual child. Specific toys are selected for a child to work out a particular problem or to reexperience a particular situation. Repetition becomes important so that children can gradually play out the experiences until the experiences become less overpowering, the thoughts attached can be restructured, and the emotions can be released.

Major Concepts Counselors who utilize play therapy often promote the therapeutic powers of play. Researchers have demonstrated the efficacy of play therapy with a wide range of presenting problems, including depression, anxiety, concentration, phobias, aggression, abuse, grief, divorce, terminal illness, and severe trauma. The therapeutic factors are the benefits that children can obtain within the context of play therapy beyond the overarching presenting issue.

Because play is a natural way for children to have fun, counselors who utilize play in therapy can quickly build a nonthreatening therapeutic relationship and assist children in overcoming resistance to therapy. Children are allowed to communicate in their own way and allow the toys to speak for them. Through the use of role play, they can express strong emotions and gain mastery over difficult experiences by trying out alternative solutions and visualizing new possibilities. They can build competence by trying out new behaviors in the playroom and creatively thinking about how to solve problems in new constructive ways. Additionally, counselors demonstrate a caring, supportive relationship, which can help children build stronger attachments and positive social relationships in their lives outside the playroom. Like many other alternative approaches that do not predominantly rely on clients talking about their issues, play therapy is an effective, creative way to engage clients to work through difficulties and focus on optimal growth for the future.

Techniques Counselors are guided by their theoretical orientation and can utilize a variety of techniques in their approach to play therapy. While these skills may appear very similar to the techniques utilized in traditional talk therapy, the approach may differ when working with children in play sessions. The basic techniques include tracking, restating content, restating feelings, returning responsibility, and limit setting. Tracking

The most fundamental skill in play therapy is tracking. Because play is the child’s language, tracking allows the counselor a way to describe the behavior in a literal, noninterpretative way. Particularly in beginning play sessions, counselors utilize tracking to build the relationship with the child. Just as sportscasters give a play-by-play of a game, counselors let children know that they are paying attention by concretely describing what the children are doing or what the play objects are doing while the children create their play scenes.

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Restating Content

Similar to paraphrasing with adult clients, counselors restate what children verbalize in their play. The purpose of restating content is to demonstrate genuine interest in what the children are saying. Counselors try to match the content of the message in an age-appropriate way so that the children understand that they have been heard and have the opportunity to gain insight into their verbalizations as needed. Reflecting Feelings

Developmentally, children may have very limited “feeling-word” vocabularies and may not be able to clearly articulate how they are feeling about particular situations. Counselors reflect what children are expressing verbally and nonverbally in play sessions as a way to help children understand the variety of feelings they may be experiencing and also to help expand their feelingword vocabulary. Children are given permission to express themselves in a variety of ways in the playroom, so counselors reflect those emotions in such a way that children can feel validated and understood. Returning Responsibility

Adults often do for children things that children should and could be doing for themselves. To promote independence and self-efficacy, counselors empower children to make their own choices and to complete their own tasks in play sessions. When children ask for help on a task that they can clearly address on their own, counselors simply reiterate that they can handle the situation and encourage them to make the decision for themselves. Sometimes counselors may not be absolutely sure that clients can manage on their own, so they start by reflecting the content and feelings being expressed and watch for a response to know if they need to collaborate on the task in order to build responsibility within the child without fully taking over for the child. Limit Setting

While counselors do not typically set limits on what children can verbalize or symbolically express

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during their play, they do let children know what specific behaviors are not permitted in the play session. Counselors may differ in their approach to setting limits in the playroom, but they do agree that limits are needed to protect clients from hurting themselves, the counselor, and the materials in the room. Counselors also limit children from taking toys out of the playroom, leaving without permission before the time is up for the session, or staying after the end of the session. Other limits may be set based on the theoretical orientation and personality of the counselor. For instance, nondirective counselors keep limits to a minimum to encourage clients to have autonomy and permissiveness in the playroom, while directive counselors tend to structure the sessions in a way that lets children know what toys they will use and what they are expected to do in session.

Therapeutic Process An essential component of the therapeutic process is the personality of the counselor. Effective play counselors have been described as having the following characteristics: appreciation and respect for children, a sense of humor, self-confidence and selfreliance, openness and honesty, willingness to use play as a vehicle for communication, flexibility and the ability to handle ambiguity, and the ability to set limits and maintain personal boundaries. Counselors must also be able to set up a welcoming space that mirrors a sense of comfort, happiness, and safety. The toys that go into the playroom are also carefully chosen to enhance the therapeutic process. Counselors purposely select toys that allow children to explore real-life experiences, test limits, and express a range of feelings. The toys generally fall into one of the following categories: family toys, scary toys, aggressive toys, expressive toys, and fantasy toys. Family toys are used to explore relationships and can include items such as a dollhouse, baby dolls, play kitchen, and puppets. Scary toys can include sharks, insects, dinosaurs, and scary puppets to allow children to deal with fears and phobias. Aggressive toys are used to symbolically express anger and control and can include weapons, soldiers, shields, and handcuffs. Expressive toys include items such as art materials, modeling compounds, and pipe cleaners to allow

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for creativity. Fantasy toys include dress-up clothes, masks, and medical kits to allow for pretend and role-play opportunities. The purpose is not to fill a room with a bunch of random toys but, instead, to carefully select items that will promote free expression and creativity. Another key component of the therapeutic process is the involvement of the parents or guardians of the child. They may bring the child into therapy with the hope that the counselor will immediately fix whatever the presenting issue may be. They may also have concerns about the perception that the counselor is just playing with their children instead of doing traditional talk therapy. A counselor skilled in play therapy is able to explain the value of play therapy and partner with the parents or guardians to set realistic goals for what they want to see happen as a result of the process. Counselors begin by completing a comprehensive assessment of the situation, which may include personal observations in a variety of settings, reports from family members and teachers, or formal diagnostic assessments. While the techniques that are utilized vary according to the counselor’s theoretical orientation, the counselor explores what themes continue to reappear, what feelings are being expressed, and what the next steps need to be as the child plays and interacts in sessions. The counselor continues to work with the child in a nondirective or directive way until the therapeutic goals have been reached and the child’s attitude and behaviors have improved from the initial functioning. Kathleen Levingston See also Adventure-Based Therapy; Art Therapy; Creative Arts and Expressive Therapies: Overview; Dance Movement Therapy; Drama Therapy; Integrative Approaches: Overview; Music Therapy; Narrative Therapy; Parent–Child Interaction Therapy

Further Readings Association for Play Therapy. (2013). About play therapy. Retrieved from http://www.a4pt.org/?page=AboutAPT Axline, V. (1969). Play therapy. New York, NY: Ballantine Books. Kaduson, H., & Schaefer, C. (Eds.). (1997). 101 favorite play therapy techniques. New York, NY: Jason Aronson.

Kottman, T. (2010). Play therapy: Basics and beyond (2nd ed.). Alexandria, VA: American Counseling Association. Landreth, G. (2012). Play therapy: The art of the relationship (3rd ed.). New York, NY: Routledge. O’Connor, K. (2000). The play therapy primer (2nd ed.). Hoboken, NJ: Wiley. Schaefer, C. (Ed.). (2011). Foundations of play therapy. Hoboken, NJ: Wiley.

POETRY THERAPY Poetry therapy and bibliotherapy are terms used synonymously to describe an intentional process in which language, story, and symbol act as catalysts for psychological health and well-being. Poetry therapy is an interactive process with three essential components: (1) the literature, (2) the trained facilitator, and (3) the client. A trained facilitator selects a poem or other form of written or spoken media to serve as a catalyst and evoke feeling responses for discussion. Literature is either imported (brought in from elsewhere) or exported (brought out of the client through writing). The interactive process helps the individual develop on the emotional, cognitive, and social levels. A poetry therapist works with individuals, families, and groups. Poetry therapy has a broad range of applications with people of all ages and is used for health, maintenance, and marginal populations. It has been successful with those suffering from addiction; those with learning disabilities; families with problems; the frail elderly; survivors of violence, abuse, and incest; the homeless; and veterans.

Historical Context Poetry therapy has been documented as far back as the fourth millennium BCE in Egypt, where healing words were written on papyrus and then dissolved in a solution so that the words could be physically ingested by a sufferer and take effect quickly. In ancient Rome, a Roman physician named Soranus prescribed tragedy for his manic patients and comedy for those who were depressed. Centuries later, in 1751, Pennsylvania Hospital employed complementary treatments for mentally

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ill patients, including reading, writing, and publication of their writings. By World War I, the term bibliotherapy was adopted by librarians who saw the value of selecting and using books helpful to patients. Early pioneers included the psychiatrist Karl Menninger, the writer Robert Schauffler, the psychoanalyst Smiley Blanton, and the pharmacist and lawyer Eli Greifer, who volunteered in many hospitals to prove that “poem therapy” was effective. By the 1960s, poetry therapy had begun to flourish in the hands of professionals in various disciplines, including rehabilitation, education, library science, recreation, and the creative arts. Jack J. Leedy, Ann White, and Gil Schloss formed the Association for Poetry Therapy in 1969. Leedy, a psychiatrist, edited the first volume by practitioners, called Poetry Therapy. Today, the National Association for Poetry Therapy is still in existence as a membership organization. The credentialing body is a separate organization, the National Federation for Biblio/Poetry Therapy.

Theoretical Underpinnings The power of literature is derived largely from imagery or seeing with the mind’s eye. Research has shown that imagery is linked with learning, relaxation techniques, life meaning, and life enjoyment. Imagery is the language of dreams and the unconscious and, as such, serves as a catalyst for bringing unconscious material into conscious awareness. Dramatic plays, videos, and short stories may be chosen to help people gain control over their life situation; the viewer or reader identifies with the characters and seeks solutions that are unique and universal. Symbolic representation and imagery are poetic qualities that can be found not only in poetry but also in fiction, myths, fairy tales, and dramatic plays. When participants externalize feelings through writing, the literature is a black-and-white testament to feelings and thoughts previously without form. The externalization allows individuals to view their feelings from a different perspective and often leads to insight. The poetic elements play a central role in heightening the emotional impact of literature with the potential for catharsis—cleansing through

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the release of emotion. The concept of catharsis, conceived of by Greek philosopher Aristotle, involved controlling, directing, and releasing emotions. In the early 19th century, the poet William Wordsworth referenced such cathartic relief in the poem Intimations of Immortality.

Major Concepts Several different poetry therapist practitioners have contributed their own theories. The major concepts include, but are not limited to, the following: interactive biblio/poetry therapy, Receptive/ Expressive/Symbolic model, journal therapy, and transformative writing. Interactive Biblio/Poetry Therapy

Interactive biblio/poetry therapy, devised by Sister Arleen Hynes and Mary Hynes-Berry, refers to a group process in which four different phases occur: (1) Recognition (Identification), (2) Examination (attention to details with the assistance of guided questions), (3) Juxtaposition (many different thoughts are expressed and compared to stretch the mind), and (4) Application (participants explore how the material is relevant to their own lives). Receptive/Expressive/Symbolic Model

Nicholas Mazza’s Receptive/Expressive/ Symbolic model makes the distinction between prescriptive poetry, where the facilitator selects the literature, and the expressive/creative mode, in which people write for self-expression. The ritual of forming a writing circle to work on one’s inner life and the use of story and symbols validate a feeling or event as significant. Rituals give stability in times of change. Examples of rituals are writing letters and burning the letters to dispel unfinished business, writing holiday cards, and eulogy writing. Journal Therapy

Katherine Adams is an advocate for writing down thoughts and feelings to sort through problems and come to a deeper understanding of oneself and issues in one’s life. Through reading one’s own words, the writer is able to perceive experiences more clearly, reflect, problem solve, and experience relief of tension.

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Transformative Writing

Sherry Reiter suggests 10 principles of transformative writing that act as catalysts for change: mastery, ritual, safety, freedom, venting (containment and release), the magic of the poetic, bearing witness, creativity, integration, and theory of self and relativity (self in the world).

Techniques Techniques include, but are not limited to, the following: expressive writing, prescriptive reading, journal therapy, performance poetry, and life review. Expressive Writing

Expressive writing employs different genres that lend themselves to specific needs. For example, preschool and older children benefit from collaborative storytelling. Junior high school kids read, write, and react enthusiastically to soap opera scenarios. Teens are especially responsive to song lyrics and may choose to write their own. Prescriptive Reading

Prescriptive reading is the technique of reading articles, short stories, novels, and poems specifically chosen to reflect the conflicts or concerns of the specific reader. A poem may also be memorized to increase ego strength and regulate emotions. Discussion follows the reading. Journal Therapy

Journal therapy is a way to discover what has been learned over time through reflecting on personal experiences. Performance Poetry

Performance poetry is a technique that is popular with teens and adults, in which performance, voice, and individualistic expression are applauded by an audience. Life Review and Reminiscence

Life review and reminiscence have been particularly effective in helping older persons. Albums,

letters, memoirs, and interviews may be used to integrate a person’s life experience into a meaningful whole.

Therapeutic Process A typical poetry therapy session consists of three steps: (1) warm-up, (2) body, and (3) closure. Warm-Up

The poetry therapist creates a gentle, nonthreatening atmosphere in which clients feel safe and are able to share feelings openly and honestly. The group agrees to respect any confidential issues that are brought up. A warm-up consisting of a word game, word associations, a song, or other verbal introduction is used to “break the ice” so that everyone feels comfortable. Body

In the body of the session, the facilitator suggests a creative writing theme or uses writing that has already been published to help participants explore feelings, thoughts, ideas, and personal issues. The developmental level, cultural makeup, literacy level, circumstance, and emotional fragility of the participants are assessed prior to making a literary selection. Closure

At the end of the session, the facilitator will help provide closure. Factors for the facilitator to consider include the length of the session, the degree of selfdisclosure and group unity, and the degree of tension encountered during the workshop. Closure provides a time for “winding down” and “tying up loose ends.” Poetry therapy may be used in short-term therapy, as in the case of grieving the loss of a pet, or for working on developmental issues, such as midlife transition. Poetry therapy may also be used in long-term therapy, as in the case of working on deep-seated psychological problems or maladaptive behavior patterns. Sherry Reiter See also Activity-Based Group Psychotherapy; Bibliotherapy; Common Factors in Therapy; Creative

Positive Psychology Arts and Expressive Therapies: Overview; Guided Imagery Therapy; Narrative Therapy; Writing Therapy

Further Readings Adams, K. (Ed.). (2013). Expressive writing: Foundations of practice. Lanham, MD: Rowman & Littlefield. Hynes, A. M., & Hynes-Berry, M. (2012). Biblio/poetry therapy—the interactive process: A handbook. St. Cloud, MN: North Star Press. Mazza, N. (2004). Poetry therapy: Theory and practice. London, England: Routledge. Reiter, S. (2009). Writing away the demons: Stories of creative coping through transformative writing. St. Cloud, MN: North Star Press.

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like clinical psychologists or licensed professional counselors. Both licensed therapists and professional/executive/personal/life coaches may administer well-being interventions. Coaches are advised to have clients evaluated by a mental health counselor or therapist and/or a family physician before coaching in order to screen clients for mental or physical disorders that may be causing or worsening their life problems. Clients who lack motivation to improve their work or relationships may be taking a medication or may have a physical disorder like diabetes that is making them tired or amotivational. In this situation, clients need the help of a physician before embarking on professional coaching or psychotherapy.

Historical Context

POSITIVE PSYCHOLOGY Positive psychology or well-being, an integrative approach to therapy, can be defined as the science of the study and promotion of happiness, meaning, and strengths. The study of happiness includes basic research on who is happy and why. This research centers on individuals and entire countries as researchers identify the happiest countries in the world. Positive psychologists argue that we should assess “gross happiness level” along with gross national product or wealth to see whether a country is truly successful. The promotion of happiness refers to positive psychology interventions or treatments designed to help people build happier and more meaningful lives. These interventions are called psychotherapy treatments if applied to clients with a serious and diagnosable mental disorder or psychological disturbance. Well-being treatments are often added to existing treatments like cognitive-behavioral therapy to make the treatment stronger or to prevent relapse once the treatment is over. This application has been pioneered in the field by Giovanni Fava and Michael B. Frisch. Positive psychology interventions are called coaching interventions (and not therapy or treatments) if applied to clients who want to be happier or more successful in life but who do not have a serious and diagnosable mental disorder or psychological disturbance. Treatment clients are best treated by licensed mental health professionals,

Positive psychology or well-being is a subdiscipline of psychology that was created in 1998. It is also an interdisciplinary field of study created at the same time and studied by researchers in many other disciplines such as medicine, economics, and sociology. Well-being is the preferred term here because it is interdisciplinary and, therefore, encompasses any and all academic disciplines studying the topic of happiness. Both the interdisciplinary discipline and the subdiscipline of psychology known as positive psychology or well-being were created in 1998 by Marty Seligman as part of his tenure as president of the American Psychological Association. Seligman thought that the discipline of psychology had been hijacked by the field of abnormal psychology from the end of World War II in 1945 to 1998 in so far as it focused primarily on what was wrong with people instead of focusing on what was right—that is, human strengths and happiness. The aftermath of the war, including the return of the veterans, many of whom were psychologically distressed, had brought a new focus on and government funding for the treatment of mental disorders. For example, the newly created National Institute of Mental Health and the Department of Veterans Affairs health care system almost single-handedly encouraged and funded the profession of clinical psychology for many decades after the war. President Kennedy’s 1963 initiative to establish community mental health centers, primarily outpatient counseling clinics, in cities and towns throughout the

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United States further encouraged a focus on understanding and curing mental disturbance and disability, a new frontier for medical and psychological science at the time. In 1998, Seligman dubbed the new field positive psychology, a term used earlier by Abraham Maslow, the humanistic psychology pioneer who studied genius, happiness, and “self-actualization” in an informal way. In sharp contrast to humanistic psychology, Seligman insisted that all claims, theories, tests, and interventions in positive psychology be subjected to rigorous testing, using the latest procedures and conventions of social and natural science. Only those findings subject to empirical test would find their way into the annals of positive psychology, a view that prevails to this day due to Seligman’s indefatigable efforts to build a discipline from the ground up. While some ideas came from humanistic psychologists, the applied or interventionist arm of the field quickly morphed into a methodological and practical “sister” to cognitive-behavioral therapy (with basic research under the umbrella of social and personality psychology). Interventions are called skills training and consist of specific thoughts and behaviors that are highly reminiscent of cognitive-behavioral therapy. In contrast, the theories are quite diverse and are usually an integrative mix of two or more models or schools of psychotherapy. Philosophical treatments of happiness and the good life stretch back in time to at least the 4th century BCE with the ancient Greeks, including the Epicureans, Stoics, Plato, and Aristotle. Psychology research on happiness, meaning in life, and human strength or virtue predates the emergence of positive psychology as a field, including a seminal review article on subjective well-being written by Ed Diener in 1984. This article summarized and synthesized psychological work to date and moved the field forward for the next 30 years with specific terminology and a clear research agenda. Beginning in the late 1950s and early 1960s, sociologists, many identified with the Social Indicators Movement, such as Alex Michalos, began to study the quality of life, well-being, and happiness of communities and countries as a whole. In the late 1950s, gerontologists and medical researchers began to study the quality of life, happiness, and well-being of medical patients and older people.

Finally, a few researcher-practitioners, such as Giovanni Fava, Michael B. Frisch, and Michael Fordyce, developed and tested happiness training interventions prior to 1998.

Theoretical Underpinnings The greatest human strength and the desired outcome or end point in all positive psychology interventions is what Sonja Lyubomirsky calls “chronic” or stable happiness. Happiness consists of three elements: (1) high positive affect, (2) low negative affect, and (3) satisfaction with life or contentment. You are considered happy to the extent that you feel generally satisfied and content with your life. In addition, positive affective or emotional experience should greatly predominate over the daily experience of negative affects or feelings like depression, anger, or anxiety (although even the very happy will be upset when goal striving is blocked or thwarted). To say that positive psychology or well-being is a science means that it conforms to the standards of science followed by other subfields of psychology like neuroscience or social psychology. It means that any claim, theory, or intervention must be tested using the latest standards of science. For example, according to Seligman, evidence-based research support or empirical validation is essential for a well-being or positive psychology theory, intervention, or assessment to be judged viable and worthy of widespread application. Indeed, this emphasis and even insistence on empirical validation distinguishes positive psychology or well-being from earlier humanistic approaches to human happiness, meaning, and strengths, making this an integrative approach to therapy. More specifically, Seligman has insisted on randomized controlled trials and replication to establish the effectiveness of well-being interventions, including his own positive psychotherapy. To be considered evidence based or empirically validated, an intervention must be found superior to a control group in two randomized controlled trials with at  least one trial conducted in an independent laboratory—that is, outside the laboratory of origin (e.g., the author’s lab); this standard holds true for both clinical and coaching interventions and treatments.

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Major Concepts Positive psychology textbooks such as Positive Psychology: The Science of Happiness and Flourishing by William Compton and Edward Hoffman cite four comprehensive theories of wellbeing: (1) Seligman’s well-being theory, (2) Frisch’s quality-of-life therapy, (3) Edward Deci and Richard Ryan’s self-determination theory, and (4) Carol Ryff’s psychological well-being theory. Seligman’s Well-Being or PERMA Theory

Seligman’s well-being or PERMA (positive emotion, encouragement, relationships, meaning, and achievement) theory posits five constituent parts to human well-being. Well-being includes more than happiness and positive emotion (or the p in PERMA). It also includes engagement with the world or frequent high-flow activities; relationships in which one feels cared for and supported by others; meaning, altruism, or prosocial behavior—that is, involvement in activities and causes beyond individual, selfish concerns, which benefit others or society as a whole; and achievement in some area or areas. Frisch’s Quality-of-Life Therapy

Frisch’s quality-of-life therapy is one that focuses on the pursuit of goals and wishes within a set of 16 outlined avenues for achieving happiness. Frisch argues that after temperament, 50% to 80% of happiness depends on the successful pursuit of our most cherished needs, goals, and wishes, described as the “Sweet 16” areas of life said to make for human happiness in cultures around the world. These areas are specifically defined to allow for easily targeted interventions but can be summarized as goals and values that may or may not include the following: spiritual life; self-esteem; regard; health; relationships with friends; relationships with lovers, partners, or spouses; relationships with children; relationships with relatives; work and retirement; play or recreation; helping; altruism or prosocial activities; learning; creativity; money or standard of living; and surroundings (i.e., home, neighborhood, and community). Only areas of life that are valued as important to the client are considered in quality-

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of-life therapy or its companion assessment, the Quality of Life Inventory. That is, the targets for intervention or assessment will consist of only those areas in the Sweet 16 deemed important to a particular client. Deci and Ryan’s Self-Determination Theory

In contrast to Frisch’s goals and wishes, Deci and Ryan’s self-determination theory asserts that human happiness requires the fulfillment of three basic needs: 1. Autonomy, or a sense of freedom to choose one’s behavior, as in pursuing intrinsic motivations or goals 2. Competence, or a feeling of mastery and selfefficacy in controlling one’s internal and external environment 3. Relatedness, or a sense of closeness to other people and feeling cared for by others

Other needs can also be important and may vary in their happiness-boosting properties depending on an individual’s psychology. Ryff’s Psychological Well-Being Theory

Ryff’s psychological well-being theory is a theory that identifies six key aspects necessary to achieving happiness. A sense of well-being—“selfrealization”—as well as the ability to function effectively in the world include the following: 1. Self-acceptance, or liking oneself, in spite of any failings or frailties 2. Positive relations with others 3. Autonomy, or the ability to direct, determine, and regulate the self in the service of goals that are personally and freely chosen, which also includes the ability to resist outside pressure to do the bidding of others when this is contrary to one’s personal or intrinsic motivation 4. Environmental mastery, or the ability to find, choose, and create environments that fit our unique abilities and goals

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5. Purpose in life, or the fashioning of personal goals that give one’s life a sense of direction, meaning, and purpose 6. Personal growth, or the realization of one’s personal potential in a lifelong process of learning and growth

Techniques Four well-being interventions have been found to be useful to clinicians and coaches: (1) assess the positive, (2) maximize the time in flow, (3) apply strengths to the goals and flow, and (4) the Five Paths to Happiness. Each is described in the following subsections. Assess the Positive

Evidence-based well-being assessments are conducted before, during, and after therapy to assess an entire new realm of human functioning ignored in the past, including positive affect, life satisfaction or contentment, and clients’ strengths. This testing is seen as an alternative to or supplement of traditional psychological assessments of negative affect or feelings, negative symptoms, and mental disorders. Figure 1 displays the results of positive mental health testing using the evidence-based Quality of Life Inventory. The Quality of Life Inventory assesses overall satisfaction with life and meaning and explains it in terms of a satisfaction profile similar to a Minnesota Multiphasic Personality Inventory-2 profile of negative mental health. Because clients’ overall contentment is made up of the sum of satisfactions in specific profile areas of life, interventions are “prescribed” for areas of unhappiness (as well as for other positive personal goals). Boosting satisfaction in these areas of unfulfillment will, therefore, increase overall happiness and quality of life. Maximize Time in Flow

A flow is an activity that requires our total attention; we are not distracted by other worries or concerns. A flow is an activity with a definite challenge that requires us to use our maximum skill, as in reading a book written at or just slightly above our reading level. As much as possible, we want to find out our flow activities and carry out these flow activities in all spheres of life

and at all possible times—at home, with family and friends, in hobbies, at work, and in retirement—in order to maximize our happiness and life satisfaction. While affect is often neutral or absent during flow activities, it is decidedly positive after such activities. Apply Strengths to Goals and Flow

In this technique, counselors ask clients to identify big and little things that they are good at and that people like about them. Next, the counselor urges clients to take pride in these strengths, talents, and (positive) traits and to use them to achieve their goals, such as when clients use their excellent conversational skills to make new friends or to ask for help with a favorite hobby. Strengths and talents can also be clues to what activities are flow activities for clients; clients’ time spent on flow activities should be maximized each day. Five Paths to Happiness

The Five Paths to Happiness, or CASIO, technique supports clients in solving their problems and boosting their satisfaction with any area of life, such as love, work, or play, by applying one of five strategies or paths, represented by the CASIO acronym (circumstances, attitude, standards, important, and other). Thus, the counselor may tell clients to boost happiness in an area like work by (a) changing their circumstances or situation by asking themselves, “What do I want?” and “How can I get it?” or “How can I change my behavior or the situation to make it better?”; (b) changing their attitude by getting all the facts, finding a better way to look at the problem, and seeing themselves survive and thrive eventually, even if the worst happens; (c) setting more realistic but challenging goals and standards for being satisfied in the area of concern; (d) emphasizing what is most important and controllable in the area; and (e) boosting satisfaction in other areas of life that they care about even though they are not areas of concern.

Therapeutic Process The therapeutic process will differ from one client to the next, depending on whether the case is a coaching or therapy case. In therapy cases, positive

Positive Psychology

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(Raw Score: 1.2)

T Score: 39 (%ile Score: 16)

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Quality of Life Inventory Profile at Start of Therapy or Coaching

Source: Excerpt from Client Online Profile Report. Copyright 1994, 2014 by Michael B. Frisch and Pearson Assessments. All rights reserved.

psychology assessments or interventions are typically added to the usual therapy regimen used by a clinician for a specific Diagnostic and Statistical Manual of Mental Disorders (fifth edition) disorder like depression, anxiety, or bulimia. For example, a well-being assessment may be added to a traditional assessment to develop positive goals for clients, something Aaron T. Beck describes as essential for lasting change in psychotherapy. Interventions may also be included as part

of termination to prevent relapse. In contrast, coaching cases consist of positive psychology assessments or interventions alone. Michael B. Frisch See also Beck, Aaron T.; Existential-Humanistic Therapies: Overview; Maslow, Abraham; Maslow’s Hierarchy of Needs; Possibility Therapy; Seligman, Martin; Solution-Focused Brief Therapy; Wellness Therapy

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Further Readings Compton, W. C., & Hoffman, E. (2013). Positive psychology: The science of happiness and flourishing (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning. Diener, E., & Biswas-Diener, R. (2008). The science of optimal happiness. Boston, MA: Blackwell. Fredrickson, B. (2013). Love 2.0: Finding happiness and health in moments of connection. New York, NY: Hudson Street Press/Penguin. Frisch, M. B. (2013). Evidence-based well-being/ positive psychology assessment and intervention with quality of life therapy and coaching and the Quality of Life Inventory (QOLI). Social Indicators Research, 114, 193–227. doi:1007/s11205-0120140-7 Frisch, M. B., Clark, M. P., Rouse, S. V., Rudd, M. D., Paweleck, J., & Greenstone, A. (2005). Predictive and treatment validity of life satisfaction and the Quality of Life Inventory. Assessment, 12(1), 66–78. doi:10.1177/1073191104268006 Kashdan, T. B., & Ciarrochi, J. (2013). Mindfulness, acceptance, and positive psychology: The seven foundations of well-being. Oakland, CA: New Harbinger. Layous, K., Chancellor, J., & Lyubomirsky, S. (2014). Positive activities as protective factors against mental health conditions. Journal of Abnormal Psychology, 123, 3–12. doi:10.1037/a0034709 Lyubomirsky, S. (2013). The myths of happiness. New York, NY: Penguin Press HC. Rashid, T., & Seligman, M. (2014). Positive psychotherapy. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (10th ed., pp. 461–498). Belmont, CA: Brooks/Cole, Cengage Learning. Rodrigue, J. R., Mandelbrot, D. A., & Pavlakis, M. (2011). A psychological intervention to improve quality of life and reduce psychological distress in adults awaiting kidney transplantation. Nephrology Dialysis Transplantation, 26(2), 709–715. doi:10.1093/ndt/gfq382 Seligman, M. E. P. (2011). Flourish. New York, NY: Free Press.

POSSIBILITY THERAPY Possibility Therapy, originated by the psychotherapist Bill O’Hanlon in the 1990s, is a present- to future-oriented approach to change in counseling

and therapy. It stands on two principles: (1) acknowledgment and (2) possibility. The premise of Possibility Therapy is that people get stuck at some point in their lives in one or more areas: cognitively, emotionally, perceptually, neurologically, physiologically, behaviorally, or relationally. Those stuck places create suffering for the person and others around them. Thus, the goal of Possibility Therapy is to get people unstuck as quickly as possible and to relieve their suffering. It is light on theory and heavy on method.

Historical Context Although the approach was developed in the 1990s, many of its ideas are rooted in theories that came before it. For instance, its focus on acknowledgment is derived from a strong emphasis on validation and acceptance of clients, similar to unconditional positive regard found in personcentered counseling. From social constructionism, it derives a sense of skepticism of fixed states, traits, diagnoses, and experiences. The use of storytelling, the nonconscious change methods, and its future orientation are derived from the work of the psychiatrist Milton H. Erickson. Its emphasis on finding and expending strengths, previous solutions, exceptions, and abilities is from solution-oriented counseling and therapy approaches. Finally, its emphasis on client expertise and collaboration derives from collaborative, strengths-based approaches to change.

Theoretical Underpinnings Possibility Therapy does not orient to pathology (what is wrong with, damaged, or deficient in the client) or to diagnoses to guide treatment. Influenced by social constructionism, Possibility Therapy operates under the assumption that emphasizing people’s abilities and hopes elicits a better environment for change than does highlighting and focusing on people’s failings and flaws. The approach is also not a normative one. Except for some broad ethical stances, such as not supporting physically harming oneself or others and not supporting criminal acts, the approach does not have a model of what is normal, healthy, or the right way to live or be. Instead, the model serves the client by taking seriously what the client

Possibility Therapy

says he or she is suffering from and wants to change, without searching for some underlying meaning or theoretical construct to explain the client’s experience or behavior.

Major Concepts Seven basic premises drive Possibility Therapy: 1. People are influenced by their sense of what is possible for their future. 2. People are influenced by their past, thoughts, genetics, environments, and feelings, but their actions and the course of their lives are not necessarily determined by any of these factors. 3. People are more likely to cooperate when they and their feelings and points of view, as well as their abilities and strengths, are validated and respected. 4. Counselors and therapists can never know the truth about people because they are always influencing what aspects of that truth get spoken and heard. 5. No one knows for certain what causes behavioral, psychological, emotional, or relational problems (although there is no shortage of people who will claim to know). 6. What therapists do in therapy either works or doesn’t. If it doesn’t work, it is best to first try something different rather than deciding that the person, couple, or family is unmotivated, resistant, or unable to change. 7. There are many pathways to change. No one technique, method, or philosophy works for everyone, although, again, there is no shortage of people who will profess to know the one right and effective way to help people change.

Techniques There are many change methods used in Possibility Therapy, because it borrows from whatever works in other approaches, being nondogmatic as to theory and method. The following are a few of the more frequently used methods (except when they don’t serve to help or validate clients).

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Collaboration

Possibility Therapy puts equal weight on client and therapist expertise. Thus, the therapist is not seen as an aloof expert or the person who “holds the answer” to the client’s problems. Instead, an equal relationship is built where the therapist invites the client to work with him or her. Questions that a therapist can use to invite collaboration include the following: What are you concerned or worried about? What would you like to have happen here? What has been working so far? What has been frustrating or difficult in the situation up to now? How have you dealt with that frustration or difficulty at your best moments? If you could do one small thing that might make a difference, what would that be? How will you know that things are heading in a good or better direction? How will you know when the situation is resolved? Or at least better enough? Is there anything you would like me to understand that you are not sure I have so far? Is this conversation helpful or going in the right direction?

If the therapist has a concern or an ethical issue, he or she could say, “Here’s what I am concerned about . . .” Dissolving Impossibility Talk

It is important for therapists to both acknowledge and validate clients without closing down the possibilities of change for them. Too much emphasis on change and possibility can give clients the message that the therapist does not understand or care about their suffering or dilemmas. Too much emphasis on acknowledgment can give clients the message that they cannot change or might encourage wallowing in the pain and hopelessness. The following methods are designed to combine both acknowledgment and invitations to change and

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possibility. These methods are designed to be respectful, to deeply empathize with clients’ suffering, and to evoke possibilities; however, if they are used disrespectfully or superficially, they start to become formulaic. Method 1: Spinning problems into the past. Use the past tense when people speak about current problems or limitations. Method 2: Modifying generalizations. Respond to generalized statements by restating them with slight changes in the quantifiers and qualifiers (e.g., “usually,” instead of “always”). Method 3: Spinning reality/truth claims into perceptions. Limitations are often less in reality than in peoples’ perceptions. Reflect limitation statements by inserting perception phrases into them.

Often Used Techniques

In addition to being collaborative and dissolving impossibility talk, the Possibility Therapist often uses other techniques such as storytelling, self-disclosure, solution-oriented evocation questions, hypnosis, and task assignments.

Therapeutic Process The six primary steps in Possibility Therapy are as follows: 1. Create an atmosphere of change and possibility: Here the therapist uses possibility language, assumes change can happen, and does not assume that the client is irrevocably damaged or pathological. 2. Acknowledge pain, suffering, problems, explanations, feelings, and points of view while keeping possibilities for change open: In this step, the therapist validates the client’s current reality without assuming that things will stay the same. He or she also listens without trying to make things more positive than they seem to the client. 3. Connect with or evoke motivation: In this step, the therapist reflects about the people involved in the problem situation and considers what they are motivated for and what they are

motivated away from or want to avoid. Then, the therapist experientially connects clients to their motivations to bring about change in the problem situation. 4. Orient to preferred future and goals: Here, the therapist finds out what clients want out of therapy or the minimal change they hope for. Then, the therapist connects clients to hope and futures with possibilities. 5. Elicit solution patterns in the areas of viewing (point of view, meaning, attribution), doing (action, interaction, and language), and context: In this step, the therapist explores exceptions to the problem. He or she explores positive coping methods and times and tries to find any context in which the problem would not occur. In addition, the therapist finds out where attention is focused in nonproblem moments or times and identifies any alternate stories or ideas that are different from typical or problematic stories or ideas. 6. Introduce or notice and encourage small changes: In this last step, the therapist identifies anything anyone involved in the problem situation is willing or able to do to make a small change in the viewing, doing, or context. Usually, this will involve some rigidly repetitious aspect of the problem situation. It might involve deliberately taking some action that is part of the solution patterns evoked or identified.

Typically, if a therapist uses these steps, he or she will notice relatively quickly that the client begins to shift from talking about problems, revisiting the past, and complaining about suffering to talking about the present and the future and the possibilities for change. Bill O’Hanlon See also Ericksonian Therapy; Person-Centered Counseling; Solution-Focused Brief Therapy

Further Readings O’Hanlon, B. (2003). A guide to inclusive therapy. New York, NY: W. W. Norton. O’Hanlon, B. (2006). Change 101. New York, NY: W. W. Norton.

Postural Integration O’Hanlon, B., & Beadle, S. (1998). A guide to possibility land. New York, NY: W. W. Norton. O’Hanlon, B., & Bertolino, B. (1998). Invitation to possibility-land: A teaching seminar with Bill O’Hanlon. Philadelphia, PA: Brunner/Mazel. O’Hanlon, S., & Bertolino, B. (1999). Evolving possibilities: B. O’Hanlon’s selected papers. Philadelphia, PA: Brunner/Mazel.

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More recently, a number of members of the International Council of PsychoCorporal (Bodymind) Integration Trainers, who were both PI trainers and psychotherapists, developed Psychotherapeutic Postural Integration, which places PI within a more explicit psychotherapy framework.

Theoretical Underpinnings

POSTURAL INTEGRATION Postural Integration (PI) is a process-oriented somatic therapy that employs manipulative bodywork integrated with a variety of other techniques, derived principally from Gestalt therapy, bioenergetics, and Reichian psychotherapy, to facilitate the client’s process of holistic change. It is not directly presented as a psychotherapy but rather as a mode of self-experienced exploration in which the practitioner supports and facilitates the client’s process of change. Thus, PI does not attempt to diagnose or pathologize (except to the extent that character structures are recognized); the desired outcome is the client’s own sense of positive change, greater self-integrity, and an enhanced capacity to feel and express.

Historical Context PI was developed in the 1970s by Jack Painter, former professor of philosophy at the University of Miami. In the 1960s, with the burgeoning human potential movement, he experienced various forms of therapy in his own process of personal development, including Rolfing, Characteranalytical Vegetotherapy, Reichian psychotherapy, and Gestalt therapy, as well as many other practices from Asian cultures, such as acupuncture, Zen, and yoga. Aware of both the benefits and the limitations of the therapies he had personally undertaken, he became interested in developing a coherent method that integrated the most effective aspects of these approaches. He began developing his own style of “deep, wholistic bodywork,” which ultimately he refined as PI; he founded the International Centre for Release and Integration and began promoting and training others in this new approach.

Based on neo-Reichian approaches to psychotherapy and personal development, one of the foundational principles of PI is that the patterns of muscular tension that form an individual’s habitual posture not only reflect repressed emotions but also are the mechanism through which emotions are repressed. PI works with an integrated approach of hands-on bodywork (in the form of targeted deep tissue massage) while simultaneously encouraging cognitive awareness (mindfulness) and emotional expression and release. The therapeutic relationship is arguably more critical in PI than in most other therapies. The issue of the client’s trust in the therapist regarding emotional safety extends not only to the psychological but also to the physical. Bodywork in PI is usually performed with the client at least partially and perhaps fully unclothed. The client is in the therapist’s hands literally as well as metaphorically, with all the vulnerability that this implies. The practitioner therefore needs exceptional skill in setting and holding appropriate boundaries and in communicating nonjudgmental acceptance.

Major Concepts PI grew out of humanistic psychology and the human potential movement. Practitioners of this therapy tend to be person centered and with a commitment to self-direction, authenticity, and self-actualization. Bodymind

Bodymind is a term from humanistic psychology that proposes an alternative to Cartesian mind–body dualism. Bodymind refers to a unified system in which mind, body, and spirit are dynamically interrelated and changes in one area propagate throughout the whole system.

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Body Armor

Body armor may be thought of as chronic muscular tension that is the physical manifestation of psychological repression. By hardening and desensitizing areas of the body, unwanted feelings may be controlled or excluded from conscious awareness—for example, deep pelvic tension to both minimize and avoid awareness of sexual excitation. Character Structures

In a development of Wilhelm Reich’s and other psychoanalytical theories of character, Alexander Lowen’s bioenergetics proposed a character typology in which psychological character types are associated with certain patterns of body armor. A character structure is thus an organized system of psychological and physical defenses whose aim is the security and survival of the individual.

Techniques PI works with the bodymind. The primary aim of the practitioner is to soften and release body armor, both as an end in itself and to assist the client to connect with the emotional dimension of the armor and, in a more psychotherapeutic mode, become aware of its psychological origin. PI works on many levels at the same time: physical, cognitive, emotional, energetic, and relational. Deep Tissue Massage

Slow and deep tissue massage is used to soften and release body armor, working especially on the myofascial structures. Gestalt Therapy

PI emphasizes the importance of good contact, here-and-now awareness, emotional expression, and dialogue between conflicting emotions. Reichian Breathwork

The practitioner will draw attention to the client’s style of breathing: any patterns of overbreathing or underbreathing and the degrees of chest and belly breathing. The client will be invited to try

altering the pattern, often assisted by work on the musculature of the rib cage and diaphragm. Contact

PI operates at the contact boundary (a term from Gestalt therapy): the place where the client and the practitioner literally touch and also bring awareness to the subjective experience of that touch (physical, emotional, and psychological reactions). In this, the practitioner may act as both a focus and a catalyst for the client; the nature of the practitioner’s contact in an armored body area (e.g., persistent, nurturing, or provocative) encourages the client to shift from the simple perception of sensation to a deeper awareness.

Therapeutic Process Sessions may be between 1 and 2 hours in length. The basic format of a session is an initial body reading in which both the client and the practitioner focus on the patterns of muscular holding currently present; this may be followed by bioenergetic movement exercises aimed at both increasing client awareness and preparing the body for touch, and breathwork; next comes the hands-on work of deep tissue massage, during which there may be a Gestalt dialogue, in which a client has a conversation with a part of self or with imagined others to address unfinished business. This leads to an emotional release. Last, there is a final body reading to help the client notice the change that has occurred. Both the client and the practitioner are very active and engaged in a creative shared dialogue about what is felt, sensed, and thought. The sessions are cumulative and progressive, producing a controlled softening of body armor, which allows the client to restructure the bodymind into a more effective way of being. There is a formal sequence of 10 sessions, starting at the extremities (hands and feet) and working toward the core, covering the entire body, and ending with a final whole-body “tuning.” In practice, most clients will need certain steps to be repeated, as later stages addressing deeper layers of the musculature can only be undertaken if the superficial layers have softened sufficiently to allow access. The number of sessions also depends greatly on the client’s self-awareness and ability to engage with

Prayer and Affirmations

the process, as well as the establishment of a therapeutic relationship that contains a very high level of trust. Richard Lawton See also Bioenergetic Analysis; Gestalt Therapy; Rolfing

Further Readings Erken, R., & Schlage, B. (Eds.). (2012). Transformation of the self with bodymind integration: Postural integration—energetic integration—psychotherapeutic postural integration. Berlin, Germany: Holzinger. Lowen, A. (1958). The language of the body. New York, NY: Macmillan. Painter, J. W. (1986). Deep bodywork and personal development: Harmonizing our bodies, emotions and thoughts. Mill Valley, CA: Bodymind Books. Painter, J. W. (1987). Technical manual of deep wholistic bodywork: Postural integration. Mill Valley, CA: Bodymind Books. Reich, W. (1972). Character analysis (3rd ed.; F. R. Carfagno, Trans.). New York, NY: Macmillan. (Original work published 1933)

PRAYER

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AFFIRMATIONS

Prayer and affirmations can be spiritual and/or religious in nature and are often associated with successful coping, recovery, and optimism. As counselors learn to integrate the client’s faith practices more fully within their counseling interventions, prayer and affirmations to a higher power have emerged as techniques that can be highly effective if incorporated appropriately.

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often seen as lying beyond the scope of the counseling professional. However, with research and U.S. census trend data revealing that a majority of individuals (between 70% and 95%) view faith as an integral part of their identity and thus as an important resource in recovery and well-being, it has become evident that faith-related counseling skills, such as the use of prayer and affirmations, are important to the counseling relationship.

Theoretical Underpinnings Prayer and affirmations involve diverse belief systems and practices of individuals. These practices may or may not include a deity, and there may be rules or guidelines for the practice. Even within religious traditions, there can be great differences among individuals in how they choose to pray or affirm their beliefs. Even though prayer and affirmations are varied, they have been associated with many positive outcomes, such as recovery from addiction, enhanced pain management, stress reduction, and optimism. Recovery programs for addiction often utilize a 12-step model that stresses releasing control to one’s higher power, whether a religious figure or another symbol of strength that exists outside of the individual. Releasing full control of one’s circumstances can have the effect of instilling hope and reducing guilt and negative self-talk. Prayer that has a foundation in a religious or faith tradition can also provide clients with a sense that they are not isolated in their struggle and that their higher power has a greater purpose for their lives. Affirmations can also serve as meditative reminders of a client’s belief system, allowing the client to step back and gain a broader perspective on his or her circumstances.

Historical Context Counseling theory has been neutral toward religion over the years. For instance, Sigmund Freud (1856–1939) suggested that religion hides the reality of life, and the cognitive therapist Albert Ellis (1913–2007) suggested that religion often was the source of the development of dogmatic thinking. Because a number of major theorists viewed religion in this negative context, counseling has traditionally held a predominately secular orientation, with spiritual and religious concerns

Major Concepts The following sections briefly describe prayer and affirmations and then offer some ethical considerations as to when one might use them. Prayer

The act of prayer involves the intent to communicate with, petition, and/or establish a meaningful relationship with a higher power. It can be done

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privately or with others, spoken aloud or through silent meditation. There are various types of prayer, including the following: Adoration: Worship and celebration of the higher power Confession: Asking for forgiveness of transgressions Thanksgiving: Acknowledgment of positive events, circumstances, and blessings and extension of gratitude to the higher power Supplication: Asking the higher power to intervene in one’s life Reception: Clearing the mind and listening to gain insight from a higher power—similar to meditation Obligatory: Specific words to pray or designated times of the day when prayer should occur

Some research suggests that prayers of thanksgiving, reception, and adoration have positive effects on well-being and optimism, whereas prayers of confession and supplication may have less positive effects. Affirmations

Affirmations are statements that acknowledge aspects of a higher power. Affirmations can be used in meditative practice as a focusing thought or as a form of worship and reflection on the nature of one’s relationship with a higher power. Examples of affirmations include statements such as “I am fearfully and wonderfully made,” “God has a plan for me,” or “The universe flows in me and through me.” These affirmations can be reassuring and can reframe negative or self-defeating thoughts. Ethical Considerations

Although incorporating prayer and affirmations in counseling can be beneficial, there are also ethical considerations to take into account. To practice ethically, counselors are advised to assess the importance of faith as a factor in the client’s life, as well as the extent to which the client would want to have it included in counseling. Attention should be given to the client’s beliefs about prayer and/or affirmations, including how the client prays. Counselors should not assume that prayer is a

universal experience, nor should they implement prayer in session without first understanding the client’s beliefs. In some cases, prayer or affirmations may be unwise to pursue with a client, particularly if the client is a member of a cult, if the client associates his or her faith with condemnation or fear, or if there is significant psychopathology. Additionally, counselors should be aware of their own motives for including prayer or affirmations in counseling. These techniques should only be used if they are consistent with the client’s belief system and should not be integrated based on the counselor’s own agenda or faith tradition.

Techniques Prayer and affirmations can be included in counseling in a variety of ways. Counselors can pray on their own asking for guidance before a session. Clients who view prayer as a personal resource can also be encouraged to utilize prayer outside the counseling session. Occasionally, it may be appropriate to pray within a session, though it is recommended that the counselor take the following steps when incorporating prayer into the session: 1. Assess the client’s belief in the importance of prayer and what the client expects from prayer. 2. Consider the potential impact of prayer on the counseling relationship, including power differentials that may occur if the client begins to see the counselor as a spiritual authority. 3. If prayer is included, use it to focus on the counseling process and client goals. Prayers can highlight client progress, summarize session content, or request guidance from a higher power to enhance the counseling relationship and/or the client’s well-being. 4. Encourage the client to lead in-session prayers, and carefully explore client motivations if he or she wants the counselor to lead the prayer. Counselors can explain that there are many differences in how to pray and that prayer is a personal act of reflection. Thus, the client should be seen as the expert on how to pray for his or her concerns. 5. After the praying, help the client process the experience and reflect on any feelings or insights elicited from the prayer.

Primal Integration

Therapeutic Process Prayer and affirmations can be positive interventions to incorporate a client’s faith or belief system in counseling, but it is important for counselors to acknowledge and control for ethical considerations and impacts on the counseling relationship. Clients may begin to view the counselor as having a direct link to the higher power, which may lead to dependency on the counselor or unrealistic expectations of the change process. Counselors who successfully integrate prayer and affirmations into their practice conduct careful assessment and research prior to implementing prayer or affirmations in the counseling setting. Hannah B. Bayne See also Meditation; Mindfulness-Based Stress Reduction; Pastoral Counseling

Further Readings Frame, M. W. (2003). Integrating religion and spirituality into counseling: A comprehensive approach. Belmont, CA: Brooks/Cole. Juhnke, G. A., Watts, R. E., Guerra, N. S., & Hsieh, P. (2009). Using prayer as an intervention with clients who are substance abusing and addicted and who self-identify personal faith in God and prayer as recovery resources. Journal of Addictions & Offender Counseling, 30, 16–23. doi:10.1002/j.2161-1874.2009.tb00053.x Weld, C., & Erikson, K. (2007). The ethics of prayer in counseling. Counseling and Values, 51, 125–138. doi:10.1002/j.2161-007X.2007.tb00070.x Whittington, B. L., & Scher, S. J. (2010). Prayer and subjective well-being: An examination of six different types of prayer. International Journal for the Psychology of Religion, 20, 59–68. doi:10.1080/10508610903146316

PRIMAL INTEGRATION Originating from a critique of Arthur Janov’s work on primal therapy, primal integration embraces many of Janov’s concepts, including the emphasis on deep feelings and early experiences. A depth therapy, primal integration focuses mostly on trauma, including perinatal trauma and trauma

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from birth, as it attempts to have clients work through early memories. The intended outcome is for clients to become warmer, more “human,” less defensive, and more in touch with their real, authentic selves than they were before entering therapy.

Historical Context Primal integration as a separate approach was created by the staff of the Center for the Whole Person in 1962 and later adopted and expanded by Frank Lake and William Emerson using ideas from Stanislav Grof. Grof’s research, which extended over 50 years, examined the nature of memory during four stages of birth. Lake, on the other hand, suggested that there were four levels of trauma during birth. Lake and Grof eventually developed a 16-cell matrix derived from the four stages and the four levels and found many common syndromes related to the 16 cells. William Swartley, a Canadian psychologist, brought primal integration to Britain in 1978 and ran a successful course in London until his death 2 years later. His work was taken up by Juliana Brown and Richard Mowbray and still continues today. The International Primal Association has its headquarters in the United States and produces conferences and newsletters that focus on primal therapy and primal integration.

Theoretical Underpinnings Primal integration draws on a number of theoretical assumptions. For instance, it draws from Carl Jung’s belief that there are mental functions, which include sensing, feeling, thinking, and intuition, and it develops methods of working with individuals based on each of these functions. In addition, primal integration draws from the work of Grof, who suggested that there are four basic perinatal matrices (BPMs) reflecting the four stages of birth. Memories from birth, suggested Grof, affect an individual as he or she grows into adulthood. Finally, from Lake, a British doctor who did research on individuals who were given LSD, came an examination of trauma, including the trauma of birth. His lengthy case histories established the four levels of trauma. Grof and Lake corresponded and worked out a 16-cell matrix derived from the four stages and the

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four levels. They found that many common syndromes can be traced to at least one of these 16 cells. Case studies by Grof and Lake seem to validate their initial research.

Major Concepts Primal integration is focused on Jung’s mental functions, Grof’s stages of birth, and Lake’s work on levels of trauma and early memories. Jung’s Mental Functions

Jung suggested that there are four mental functions, and primal integration addresses each of the client’s functions. In addressing the “sensing function,” primal integration focuses on the body and early trauma to the body. One outgrowth is the use of bodywork, such as when a client hits soft objects with a bat, has a whole-body catharsis, and rolls on the floor on mats. To address the “feeling function,” primal integration focuses on the here-and-now and the relationship between the client and the therapist, drawing from humanistic theories such as person-centered counseling, Gestalt therapy, psychodrama, and focusing. With regard to the “thinking function,” primal integration has a more psychodynamic focus and draws on concepts such as transference, countertransference, attachment, defenses, internal objects, projective identification, and insight. And for the “intuitive function,” there is a focus on fantasy, meditation, and enactments, and an interest in previous lives and the subtle body. Basic Perinatal Matrices

Grof suggested that there are four stages of birth, or BPMs, each with its own unique contribution. BPM 1 is undisturbed life in the womb; this is usually peaceful, sometimes even ecstatic as an experience, but it can also be negative, depending on the experiences and moods of the mother. BPM 2 is the stage where there is immense pressure, but the cervix has not yet opened; this, if prolonged or problematic, can be the origin of claustrophobia and other panicky reactions. BPM 3 is the journey down the birth canal; if this is prolonged or obstructed, powerful emotions may be evoked, and fantasies of death, terror, explosions, evil

ceremonies and the like may be experienced. BPM 4 is the emergence from the womb, including the cutting of the umbilical cord, and may be experienced as a triumph or a disaster. Although doubt has been cast on the accuracy of these memories, it is important to realize that to go back this far can only be done through reliving, not through ordinary recall. Levels of Trauma

Lake’s work on trauma suggests that there are four levels, from no trauma to intense trauma, and that trauma can occur at any point in one’s life, including in the womb. Memories from such early trauma are embedded in one’s psyche and body and affect the person in unconscious ways. The four levels are the following: Level 1: This level is pain free and need satisfying and is considered the ideal state. Level 2: This is when the trauma is bearable, and even perhaps strengthening, because it evokes effective and mostly nonneurotic defenses. Level 3: During this level, the individual tries to oppose the pain. However, because the pain is so strong, the individual represses it, or if the person is an infant, the young child splits off and dissociates from the pain. Level 4: Also called transmarginal stress, this level refers to trauma that is so powerful and/or so early that the person cuts himself or herself off from it completely and may even turn against the self, wanting to die. Some research suggests that many child accidents are in fact unconscious attempts at suicide, based on this fourth level of trauma.

Memory

Any approach to therapy that includes the trauma of birth has to explain why such memories are possible when many suggest that memory cannot be retrieved prior to 3 or 4 years of age. Primal integration deals with this by suggesting that there are four memories: (1) intellectual or cognitive, (2) emotional, (3) bodily, and (4) subtle or soul. Intellectual or cognitive memory is located mostly in the cerebral cortex, and most research focuses on this type of memory. Emotional memory is

Primal Therapy

found mainly in the limbic system and takes the form of images rather than words. It is best accessed by reexperiencing the events concerned. It often resides in our muscles, as Wilhem Reich and other body therapists have discovered. Bodily memory is held all over the body and can only be uncovered by reexperiencing or reliving it. Graham Farrant calls it cellular memory, and much of the primal work in psychotherapy focuses on this level of memory. Subtle or soul memory is held in the body, not in the brain, and it holds memories of previous lives and of lives lived at other levels of the transpersonal realm.

Techniques Primal integration involves access to a wide range of techniques. From the sensing function, it draws on bodywork, reenactments of birth, holotropic breathing, and cathartic expression. From the feeling function, it draws on existential confrontation, chairwork, focusing, and psychodramatic enactments. From the thinking function, it employs insight, exploration of the family of origin, and early attachment patterns. And from the intuitive function, it draws on guided fantasy, exploration of previous lives, and respect for visions, mythology, and dreams. Thus, primal integration can draw on a wide array of techniques as it attempts to help a person heal himself or herself of past trauma.

Therapeutic Process Common with other therapies in the humanistic realm, primal integration focuses on helping the client reveal his or her real self and become more authentic. It assumes that once a person deals with his or her trauma, his or her true self will emerge, and the person can become increasingly self-actualized. After a person begins primal integration therapy, he or she will quickly confront his or her trauma when the therapist uses one or more of the many techniques at his or her disposal. These techniques tend to lead to a good deal of cathartic work. This may then result in a complete “rebirth,” where everything changes. Eventually, the client will become warmer, more “human,” less defensive, and more in touch with his or her real, authentic self. John Rowan

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See also Analytical Psychology; Body-Oriented Therapies: Overview; Gestalt Therapy; Jung, Carl Gustav; Orgonomy; Person-Centered Counseling; Psychodrama; Reich, Wilhelm

Further Readings Brown, J., & Mowbray, R. (1994). Primal integration. In D. Jones (Ed.), Innovative therapy: A handbook (pp. 13–27). Buckingham, England: Open University Press. Chamberlain, D. (1984). Consciousness at birth: A review of the empirical evidence. San Diego, CA: Chamberlain Communications. Chamberlain, D. (1998). The mind of your newborn baby. Berkeley, CA: North Atlantic Books. Emerson, W. (1984). Infant and child birth re-facilitation. Guildford, England: Institute for Holistic Education. Fedor-Freybergh, P. G., & Vogel, M. L. V. (1988). Prenatal and perinatal psychology and medicine: Encounter with the unborn: A comprehensive survey of research and practice. Nashville, TN: Parthenon. Grof, S. (1975). Realms of the human unconscious. New York, NY: Viking Press. Lake, F. (1980). Constricted confusion. Oxford, England: Clinical Theology Association. Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York, NY: W. W. Norton. Verny, T. (1982). The secret life of the unborn child. London, England: Sphere. Woolger, R. (1988). Other lives, other selves: A Jungian psychotherapist discovers past lives. New York, NY: Bantam Books.

PRIMAL THERAPY Primal Theory asserts that unmet needs and unresolved repressed traumatic incidents from birth, infancy, and childhood remain in the subconscious mind and are compounded with subsequent unresolved traumas, layer on layer throughout life, causing physical and emotional pain and repeated patterns of dysfunctional behavior. Primal therapy provides a method by which these repressed traumas are brought to consciousness, reexperienced fully in the present, and transformed into mere remembered past history that no longer causes suffering.

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Historical Context Primal therapy is a psychotherapeutic approach to healing introduced by the American psychologist Arthur Janov in the late 1960s. Janov graduated from the University of California, Los Angeles, and Claremont Graduate School. He worked at the Veteran’s Administration Hospital and the Los Angeles Children’s Hospital and was a practicing Freudian psychoanalyst before developing primal therapy. According to Janov, during a psychoanalytical session, a patient spoke of a disturbing theatrical performance he had seen in which an actor skipped around the stage crying and screaming “Mama,” vomited into a bag, and then invited the audience to do the same. Acting on intuition, Janov encouraged his patient to call out for his mother in the same manner. The patient started hesitantly but then suddenly began to contort and wail like an infant, crying out, “Mama, Mama!” This experience ended with a piercing scream. Afterward, the patient said, “I made it! I don’t know what, but I can feel.” Intrigued, Janov later suggested to a second patient that he call out for his mother. That patient had a similar experience, reporting that his “whole life seemed to have suddenly fallen into place.” Janov named these experiences “primals” and has since devoted his life to developing primal therapy. He has authored several books, conducts extensive research, and trains therapists in his method. The Primal Scream, published in 1970, was Janov’s first book. It became a bestseller throughout the United States and across the Western world following translation into many languages. His ideas were new, unique, and resonated with young adults who were trying to free themselves from what they believed was a cultural emphasis on superficial appearances, hypocritical social behavior, and suppressed emotions. The book title became a pop culture phrase, and Janov became a media personality after a number of celebrities (notably Dyan Cannon, James Earl Jones, John Lennon, Yoko Ono, and Roger Williams) were vocal about their experiences in primal therapy. John Lennon’s album Plastic Ono Band contains many songs he wrote during and after his experience with primal therapy. Several therapies inspired by Primal Theory sprang up and enjoyed some brief popularity,

including rebirthing, regression, and scream therapy. None were connected to Janov, nor were they related to Primal Theory in theory or method.

Theoretical Underpinnings When the brain becomes overwhelmed with injurious data (extreme physical or emotional pain), it blocks, redirects, and stores the data in the subconscious mind. These traumas are individually called primal scenes and collectively called primal pain. The beginning of primal pain is often rooted in the birth imprint, the “imprint” made by trauma during the birth process. Births that are considered normal and nondetrimental by medical and societal standards are, in reality, often traumatic. The birth experience has an amplified impact because the nervous system of an infant before, during, and shortly after birth is extremely vulnerable and highly impressionable. Traumatic birth events are exceptionally defining because the stakes are so high, swaying between life and death. The birth imprint, embedded deep in the brain and nervous system, is compacted and partially hidden by later developments in the cortex and life experience, but it is always the preeminent influence, laying the foundation, either positive or negative, for the rest of an individual’s life. It predisposes the development of specific defense mechanisms for survival in an individual’s environment and determines how he or she will respond to the world. The effects manifest both psychologically and physically. If an infant has a gentle birth and thereafter remains with his or her mother and family in a loving environment, the child’s imprint will be that of feeling loved. Birth trauma can be greatly mitigated by nurturing parents and supportive extended family members. If children are allowed to express their natural and organic needs and the needs are met, they are likely to grow into happy, content, and healthy adults. For example, when an infant asks for attention by crying and is picked up immediately by its caregiver and then fed and cuddled in close mutual gentle embrace with eyes meeting, it stops crying because its needs are met and it bonds with the caregiver. Too often, however, infants are separated from their mothers shortly after birth, they are fed on schedules, and parents are taught that if they pick up infants immediately after they

Primal Therapy

begin to cry, they are “spoiling” them. Such treatment, though “normal,” is not natural. In fact, Primal Theory asserts the opposite: True “spoiling” is giving what is not needed (usually material things) while giving very little of what is needed (nurturing and time). There can be no excess of healthy attention and nurturing. As parents become overwhelmed with increasing responsibilities, children are sometimes treated as burdens rather than blessings. Even the most well-meaning parents may ignore, shame, or actively punish children for needing to be held close, for needing their full attention, or for wanting to be more active than the parent has the time or inclination for. Parents may also unconsciously use their children to act out their unmet needs, driven by their own birth imprints. Children are forced to conform their behavior to parental needs rather than to their own developmental needs. When children reach adolescence, they are inclined to look elsewhere for warmth and acceptance, choosing equally deprived friends, with whom they engage in destructive behaviors such as indiscriminate drug use, alcohol, and sexual encounters. These behaviors often continue into adulthood and are defended as “just having fun.” In reality, “act-outs” (unconscious or semiconscious symbolic re-creations of unresolved traumas or repressed primal scenes) are desperate attempts to intimately relate to others and to reduce emotional suffering. They are driven by deep pain, not by conscious choice. Acting-out can lead to temporary feelings of relief, but because it does not allow one to make real connections with the causative trauma, there is no resolution, and the suffering continues. When real needs are not met, the “Real Self” is also denied. The Real Self still exists and is always pushing to have its needs met, no matter how daunting the task. It will even settle for harmful attention (e.g., anger or rage) because any attention is better than none at all. Hence, parents are often perplexed when children “never learn” and always seem to “demand” attention by being “bad.” Primaling allows the individual to experience the “finite pain” of repressed scenes that caused years of suffering and, finally, satisfy the original unmet needs. The effects of having a completed primal compare with having chronic physical wounds cleaned, sutured, and healed, and are often like the

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profound transformations some describe after having experienced a near-death experience.

Major Concepts The major concepts in primal therapy include primal pain and the birth imprint, as discussed in the previous section, as well as causes to symptoms, and feeling, which are discussed in this section. To conclude this section, an example of a primal experience is presented. Causes to Symptoms

According to Primal Theory, primal therapy works from causes to symptoms rather than from symptoms to causes, going much deeper and resulting in a more thorough healing than possible with other approaches. Primal therapy emphasizes that when excessive trauma is experienced in utero, during a difficult birth, or in infancy, it can reach life-threatening intensity. For the infant to survive, memories of such traumas are repressed, but they leave a profound and lasting birth imprint. The birth imprint, compounded by further childhood trauma, causes primal pain. During a primal therapy session, when a patient experiences a full “primal,” or complete “feeling,” the repressed memory (a primal scene) emerges to consciousness and is experienced safely with full expression of any and all associated emotions, such as anger, fear, terror, loss, and the need that could not be expressed at the time of the original trauma. Feeling

The act of “feeling” (primaling) is reacting consciously and fully to a formerly repressed traumatic memory (i.e., a primal scene) and connecting it to the present dysfunctional behavior, thereby resolving the original pain. It allows the body to respond naturally to a repressed memory that has emerged to consciousness. Healing takes place during and after a full primal, and the acting-out connected to the healed trauma ceases. A Primal Experience

One patient was shocked during a primal to suddenly feel the sharp cutting sensations of his

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infant circumcision. For several weeks before, he had found that vocalizing the words “Mama, help!” or just “Mama!” transported him to memories of desperately crying out for his mother as a baby. Until this session, he had no idea what the emergency was. His cries of “Mama” at one point suddenly stopped, and he felt the need to kick his legs upward, as if to ward something off. This kicking motion immediately provoked excruciating sensations of cutting around the shaft of his penis. After the session, the physical pain of the memory subsided, but there was no immediate emotional resolution. In subsequent days and weeks, however, without any conscious effort, he experienced a flood of vivid recollections of longforgotten sensations of embarrassment, shame, and shyness associated with sex, dating, and marriage. These painful memories emerged after his circumcision primal because they had always been linked unconsciously to that preverbal trauma. After a few months, a change gradually took place, and he was able to have intercourse without experiencing the anxiety associated with intimacy that had bothered him since puberty. After a completed primal, as the body realigns and balances, there is a conscious realization that the suffering previously related to that primal scene is entirely gone. Spontaneous cascading memories are released from multiple phases of one’s life over days and sometimes even weeks—all related to that primal scene—that play a powerful role in creating an awesome effect of understanding without thinking. There is profound clarity and integration of a vital aspect of life that was formerly unknown or distorted. The torment resulting from that particular primal scene is now integrated and resolved, and life feels infinitely more valuable than before.

Techniques A patient’s temperature and pulse may be taken before and after a session to compare pre- and postprimal vital signs. Sessions are conducted in rooms with soft lighting. Patients lie on a mat. Therapists sit beside them as patients state what is currently on their minds, such as intrusive disquieting thoughts, uncomfortable bodily sensations, or inexplicable sadness in their present life. As these present-day incidents are fully addressed,

they inevitably “trigger” (act as catalysts for) memories of much earlier or deeper unresolved traumas. Therapists listen for emotional signs (e.g., anger, tears, nervous laughter) that may denote feelings “on the rise.” Therapists “follow” patients as they reexperience each scene, supporting and encouraging them to express the emotions they could not express originally. Intervening only if they digress from the current focus of feeling, therapists keep patients “on track,” ensuring full expression of experiences in the present while encouraging access to older memories and feelings as they arise naturally. When patients talk “about” incidents, they are encouraged to speak directly to the person or persons involved, as this brings the scenes into greater vividness, resulting in complete resolution.

Therapeutic Process Primal therapy typically begins with a 3-week-long “intensive” period (although some independent primal therapists require an intensive period of only 1 or 2 weeks), during which the patient meets with a therapist daily for open-ended sessions (no time limit). The patient otherwise isolates himself or herself in a motel room, abstaining from distractions such as reading, television, or phone calls. After the intensive period, the patient has open-ended sessions once or twice weekly and attends group sessions to begin interaction with other patients. As patients make progress, they attend groups and learn to “buddy” (have primal sessions with other patients), eventually eliminating the need for a therapist unless crises arise. Patients may also participate later in therapist-led primal retreats. The intensive phase and early sessions with a knowledgeable therapist are critical to learn how to address primal scenes effectively, to express the feelings associated with repressed memories completely, and to effect permanent changes. As patients learn how to recognize triggers that indicate emerging primal scenes, instead of ignoring or acting out, they proactively choose to “feel” the original pain. Formal primal therapy typically lasts about a year, although if patients have strong personal support systems—spouses, close friends, secure jobs, and so on—formal therapy length may be reduced.

Process Groups

Because sexuality is an element of everyone’s core being, many enter primal therapy with sexual concerns. Changes occur naturally and organically as the feeling process connects traumas of the past with present-day suffering, resulting in patients becoming healthier overall. There is no active “reparative” endeavor to alter orientation or inclination. As the Real Self emerges, individual sexuality falls clearly and comfortably into place. Primaling creates a change in attitude and behavior that heals beyond intellectual insight. As one learns to recognize the memories emerging from the subconscious mind, it becomes second nature to confront and reexperience unresolved traumas. Resolution takes place, individuals become healthier, and the journey continues throughout life. Over time, many therapists have expanded treatment approaches to include practical skills. These skills, simultaneous with the primal process, include making changes in diet and exercise and attending parenting or couple sessions. Patients are encouraged to become actively responsible to themselves and others. This can create a more immediately rewarding quality of life and provide triggers for critical memories, which often accelerate therapeutic changes. Frances Rinaldo See also Primal Integration

Further Readings Alexander, T. S. (1996). Facing the wolf: Inside the process of deep feeling therapy. New York, NY: Dutton. Howes, R. (2010, February). In therapy. Psychology Today. Retrieved from http://www.psychologytoday .com/blog/in-therapy/201002/cool-intervention3-primal-therapy Janov, A. (1970). The primal scream. New York, NY: Putnam. Janov, A. (1972). The primal revolution: Toward a real world. New York, NY: Simon & Schuster. Janov, A. (1983). Imprints: The lifelong effects of the birth experience. New York, NY: Perigee Books. Janov, A. (1996). Why you get sick, how you get well: The healing power of feelings, West Hollywood, CA: Dove Books.

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Janov, A. (2000). The biology of love. Amherst, NY: Prometheus Books. Janov, A. (2011). Life before birth: The hidden script that rules our lives. Chicago, IL: NTI Upstream. Reese, R. (1988). Healing fits: The cure of an epileptic. Los Angeles, CA: Big Sky Press.

PROCESS GROUPS The process group is an experiential approach to learning about group dynamics. In process groups, usually 8 to 15 individuals sit in a circle and talk with one another, most often with the assistance of a leader or a consultant. In addition to learning about group dynamics, often process group participants develop an understanding of their interpersonal patterns, communication styles, and characteristics of personal and professional development. Currently, many clinical training programs use process groups to teach group psychotherapy to trainees and to offer support and personal growth opportunities. Similarly, modern organizations and businesses use process group models to help employees better understand group dynamics and gain insight into their management and leadership styles. Industrial and organizational psychology uses process consultations, developed by Edgar Schein to understand organizational dynamics that may be affecting productivity, morale, communication, and structural issues.

Historical Context In the late 19th century, the German psychologists Wilhelm Wundt and Émile Durkheim sought to understand human behavior through the analysis of the collective rather than the individual. In 1943, the German Gestalt psychologist Kurt Lewin coined the term group dynamics to reflect the flow and variety of behaviors group members experience while working together. Interest in group dynamics accelerated following the atrocities of World War II, as scientists and social theorists sought to understand how humans could act with profound cruelty and obedience, on the one hand, and incredible self-sacrifice, bravery, and altruism, on the other. After emigrating from Germany, Lewin helped set up the Research Center for

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Group Dynamics at the Massachusetts Institute of Technology and the National Training Laboratories in Bethel, Maine, to study group dynamics through observation of unstructured and semistructured groups. Simultaneously, in England, Wilfred Bion, Sigmund Foulkes, and others developed a therapeutic community at the Northfield Hospital and assisted at the Tavistock clinic, where they began holding unstructured group gatherings for the study of group dynamics. Bion’s classic book Experiences in Group, published in 1961, emerged from his Tavistock experience. This text outlined what were in his view the common stances, or basic assumptions, exhibited in group interaction: (a) dependency (looking for the one person, usually the leader, to provide answers and solve problems), (b) pairing (having two members dominate the group activities), and (c) fight-or-flight (in fight mode, the group is marked by aggressiveness and hostility, and in flight mode, the group avoids the work or tasks of the group). These experiences and experiments set the stage for process groups to be used in a variety of settings. Through the 1960s and 1970s, experiments in process groups expanded and were widely available in varied forms, including leaderless groups, marathon groups that lasted for days, T-groups (training groups), encounter groups, and human relations groups (which attracted those curious to learn about themselves in relation to others). Since the 1980s, process groups have become increasingly refined for more specific purposes. Currently, process groups are regularly used to help train clinicians to understand and personally experience the less apparent dynamics of group processes. Process groups have also continued in the public sector as established organizations encourage private individuals to attend process group trainings both to learn more about group dynamics and to foster personal growth and increased self-awareness.

experiences enhance and deepen the participants’ understanding of such dynamics in a much fuller way than just academic study of similar principles.

Major Concepts Process groups have developed a set of unique approaches to maximize learning from the experience. These include set structural elements, a nonpathology focus, here-and-now interactions, and having the leader and the members repeatedly examine and discuss the emerging group processes. Structural Elements

Structural elements refer to the setting, and the boundaries, guidelines, and agreements the participants follow. Process groups have firmly set time boundaries as to when each session begins and ends, and participants are expected to attend he entire process. The leader will often give an instruction to the group to examine and discuss the unfolding processes of the group. Often all members are encouraged to share their experience of the emerging group process, and sometimes the directive of sharing the talking time between members is included. Confidentiality is requested, and members are encouraged not to share what happens in the group with others in any manner that would identify other members. The research into process groups shows that these groups generally move through certain stages of development, such as Tuckman’s model of forming, storming, norming, performing, and adjoining, and commonly, the group consultant will comment on the stage of development. Generally, time is set aside at the end of the group experience for the leader and the members to talk about the group dynamics that occur and to bring cognitive learning to the experience. Nonpathology Focus

Theoretical Underpinnings Process groups are conducted from the viewpoint that experience is the best teacher. Process group participants encounter group dynamic phenomena such as the stages of group development, the formation of cohesion, subgrouping or scapegoating dynamics, and termination processes. These

The leader focuses on members’ strengths, relational tendencies, and reactions to the group dynamics and avoids using an individual pathology framework for understanding members. Likewise, members are also encouraged not to use diagnostic language about themselves or other members as the primary focus is on the group

Process Groups

dynamics and personal growth and not on treating the emotional challenges of the members. Here-and-Now Interactions

Process group members are encouraged to share the experiences in the moment, without explanations about their own personal history. If a member is feeling happy or frustrated with what is happening in the process, the member is encouraged to share his or her personal experience without adding the story of his or her childhood or other outside-the-group information.

Techniques Process group consultants’ comments are almost always directed toward the group dynamics and not toward individual members. Leaders may draw on their training in group theory, social psychology, and/or organizational consulting to interpret the group dynamics. These interpretations may be descriptive as the leader will discuss group stage development or subgroup dynamics as they appear to be occurring in the group. Other leaders will use more symbolic or metaphoric interpretations as they engage the members in exploring the unconscious dynamics occurring in the group. Examples of leader interventions may include statements such as “This group seems to like to focus on problems more than on solutions” or “The members in this group aren’t sure if they want to be enemies or friends.”

Therapeutic Process The length or the number of meetings of process groups can vary depending on the setting. Many times, process groups are conducted at conferences or special events and can last between 12 and 20 hours over the course of 2 or 3 consecutive days; many urban areas offer process group experiences that are scheduled once a week for about 90 minutes and last between 3 and 12 months. One important goal concerning length is for the group to have time to traverse and reflect on the stages of group development. The members work to stay in the present moment or the here-and-now of the unfolding group process as they notice and speak of their

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current thoughts and feelings. The leader and members reflect on the process and comment on what is occurring. Common themes explored include feelings of intimacy or distance, inclusion or exclusion, being excited and engaged or bored and withdrawn, and the projections toward the leader’s competence and care. Often subgroups or factions (e.g., demographic variables such as gender balance) are discussed and explored to see their impact on the group’s behavior. The group will explore what has happened or has not occurred in the group to create the myriad thoughts, feelings, behaviors, and dynamics. Commonly, during this process, members may hear feedback about their communication style, their role in the group, and how they affect others through the process. Process group members often report on the experiences being helpful in areas of personal growth, such as gaining insight into their relational tendencies and more awareness and confidence in social and group settings. The process group remains a unique and focused method of experiential learning about group dynamics and oneself. Francis J. Kaklauskas and Elizabeth A. Olson See also Experiential Psychotherapy; Group Counseling and Psychotherapy Theories: Overview; Tavistock Group Training Approach; Training Groups; Yalom, Irving

Further Readings Bion, W. (1961). Experiences in groups. London, England: Tavistock. Freud, S. (1959). Group psychology and the analysis of the ego (J. Strachey, Trans.). New York, NY: W. W. Norton. (Original work published 1922) Kaklauskas, F. J., & Olson, E. A. (2008). Large group process: Grounding Buddhist and psychological theory in experience. In F. J. Kaklauskas, S. Nimanheminda, L. Hoffman, & M. S. Jack (Eds.), Brilliant sanity: Buddhist approaches to psychotherapy (pp. 133–160). Colorado Springs, CO: University of the Rockies Press. Le Bon, G. (1920). The crowd: A study of the popular mind. London, England: Ernest Benn. (Original work published 1895) Lieberman, M. A., Yalom, I. D., & Miles, M. B. (1973). Encounter groups: First facts. New York, NY: Basic Books.

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Nitsun, M. (1996). The anti-group: Destructive forces in the group and their creative potential. London, England: Routledge. Rogers, C. R. (1970). Carl Rogers on encounter groups. New York, NY: HarperCollins. Schein, E. H. (1998). Process consultation revisited: Building the helping relationship. Boston, MA: Addison Wesley Longman. Swillel, H. I., Land, E. A., & Halperin, D. A. (1993). Process groups for training psychiatric residents. In A. Alonso & H. L. Swiller (Eds.), Group therapy in clinical practice (pp. 237–254). Washington, DC: American Psychiatric Press. Tuckman, B. W., & Jensen, M. (1977). Stages of small group development. Group & Organizational Studies, 2, 419–427. doi:10.1177/105960117700200404 Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

PROCESS THERAPY See Human Validation Process Model

PROCESS-ORIENTED PSYCHOLOGY Process-oriented psychology, also known as Processwork, was developed by Arnold Mindell as a teleological, therapeutic paradigm for developing awareness and change through the deeper meaning within human experience. The teleological perspective views events as having meaning and purpose, and individuals and communities as having an innate tendency to evolve their own deeper sense of self and connection toward a point of resolution. This paradigm currently has applications for a wide range of psychotherapies and body–mind therapies, working with people in coma states, organizational development, conflict resolution, and multicultural community building.

Historical Context In the late 1970s, Mindell, then a Jungian analyst, noticed that the dynamics of a client’s dreams can parallel the client’s somatic and emotional experiences and have repeated themes in his or her

relationship life and can even be associated with synchronicities in the client’s world. He termed this phenomena dreambody. Mindell used this conceptual framework as the basis for facilitating conflict and diversity issues in large groups, which he termed Worldwork. In the late 1990s, Mindell incorporated his knowledge of quantum physics into his theory, especially quantum wave function, which mathematically formulates the patterned behavior of matter. He hypothesized that, much like quantum wave function, our subtle or sentient experiences form patterns.

Theoretical Underpinnings Mindell’s work was informed by a cross section of philosophies and paradigms including Jungian and Gestalt psychologies, indigenous beliefs, Taoism, sociology, and physics to facilitate the process of engagement with the disowned or “other/not me” in the client’s experience. The philosophy underlying Processwork is that individuals, or groups, have a preference in how they identify themselves, but this sense of self is often challenged by issues of difference that appear within themselves, their relationships, or their communities. Processwork holds many of the humanistic and transpersonal values, embracing a deep value and belief in the person and his or her ability for self awareness and reflection. Processwork adds specific facilitation skills beyond these paradigms to effect client and community change.

Major Concepts The underlying major concept of Processwork is that a person’s awareness is the basis for facilitating personal and social change. Understanding the three levels of awareness, dreambody, and deep democracy helps us understand this overarching belief. Levels of Awareness

There are three levels of awareness within each person: (1) consensus reality, (2) dreaming level, and (3) essence level. Consensus Reality Consensus reality is the everyday reality that is shared and agreed on by most people—the “what

Process-Oriented Psychology

is” reality of our world—which then provides a shared pattern of experience and belief that become promoted collectively as a preferred way of being. Dreaming Level Dreaming represents a phenomenon unique to an individual and not only refers to night dreaming but also represents an individual’s personal meaning attributed to his or her inner world as with persistent images from dreams or reoccurring body symptoms. Externally, the dreaming level represents the people or roles missing that are meaningful and important in the client’s lives, such as a client’s comment “If only someone would see how hard I try.”

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principles of deep democracy support awareness and interaction with diverse or conflicting feelings, points of view, and experiences to develop a deeper understanding and incorporation of diverse ways of being within society.

Techniques A person’s sense of self or identity evolves from the relationship between aspects that support his or her identity in the world and those that have elements of difference that can polarize, disturb, or challenge them. To facilitate this process, the therapist employs primary and secondary process and edges, signals, channels, and amplification and unfolding.

Essence Level The essence level represents a unified sense of self within the context of space and time. In this nondualistic or nonpolarized level of consciousness, people have an experience of “sentience,” a transpersonal awareness that is a subtle yet meaningful experience. This can further be described as the “seed” or prethought stage of a tendency before awareness and action. Dreambody

Human awareness gives a meaningful context to sensations and experiences. This context can be elaborated as the client’s awareness focuses on the experience. For example, when a client says, “My headache feels like someone is pressing in on my temples,” this initial statement allows the therapist to respond, “Show me how that someone creates that pressure in you.” Dreambody alludes to attributes of human experience less identified by a person and unique in his or her own psychological perception and construct of awareness. Deep Democracy

Processwork has a basic premise that useful and meaningful solutions occur when there is a genuine interaction between diverse roles. Deep democracy extends this premise in working with large groups, where diversity issues and conflicts inhibit social sensitivity and community cohesiveness. In groups, marginalization occurs when mainstream or majority viewpoints repress differing, minority viewpoints. Similar to individual therapy, the

Primary and Secondary Process and Edges

The more familiar identity is called the primary identity, and the less familiar and potentially emerging identity is called the secondary identity. Primary process is the supporting of this primary identity with qualities and aspects that a person will use to define his or her sense of self within the world. Secondary processes are attributes and capacities that are disowned or marginalized by the person in an attempt to reduce his or her interaction with these aspects and limit any threat to the individual’s primary identity. Often there is reluctance or inability to understand and integrate this new experience as though a psychic boundary separates the primary from the secondary processes. This boundary is called the “edge,” representing the edge of the person’s current identity. At the edge reside beliefs, values, and judgments, which reinforce the primary identity and hinder the fluid transition into unknown experiences. Signals

Signals are information that a person becomes aware of, such as body movements and gestures, images, sounds, feelings, or bodily sensations that he or she can describe. In therapy, signals that persist or repeat are significant. Channels

Processwork describes six channels of awareness that provide the medium for information, or signals, and defines process as the ongoing flow of

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signals through various perceptual channels. Channels are the ways in which we experience ourselves, others, and the world around us. The channels are the visual channel, auditory channel, proprioceptive or feeling channel (referring to inner-body feeling experiences), kinesthetic or movement channel, relationship channel (where we experience the process occurring in relationship), and world channel (happenings in the world around us). People’s experience of themselves and their world can change based on potential new information in different channels. Initially, the therapist notices which channel the client’s primary identity is expressed in and seeks the client’s potential awareness in other channels. Hence, process becomes the ongoing flow of signals through various perceptual channels.

See also Cognitive Analytic Therapy; Experiential Psychotherapy; Transpersonal Psychology: Overview

Amplification and Unfolding

PROCESSWORK

Amplification is asking the client to focus attention on some aspect of his or her experience and report to the therapist what the client notices as his or her attention remains with the experience. Clients are helped to identify with less conscious sensations and experiences first through amplification of aspects that are more secondary for the client. The client can then follow through with embodying and supporting the tendencies of this sensation. This process is termed unfolding.

Therapeutic Process Processwork skills are used to enhance individuals’ and groups’ sensitivity, knowledge, and capacities by engaging with perceived challenging or disturbing elements in themselves or in others to realign their sense of self and identity. The therapeutic process initially involves the therapist gleaning the nature of the primary/secondary dichotomy within the client’s experience. The facilitation of the client’s more secondary experiences across various channels allows for potential new awareness to develop. This awareness when developed further allows clients to develop a new sense of self incorporating elements once secondary to them but important in that the sensitivity, knowledge, and skills are useful for them in some aspects of their lives. Alan Richardson

Further Readings Mindell, A. (1982). Dreambody: The body’s role in revealing the self. Portland, OR: Sigo Press. Mindell, A. (1992). Riding the horse backwards: Process work in theory and practice. London, England: Penguin-Arkana. Mindell, A. (1995). Sitting in the fire: Large group transformation using conflict and diversity. Portland, OR: Lao Tse Press. Mindell, A. (2000). Quantum mind: The edge between physics and psychology. Portland, OR: Lao Tse Press. Mindell, A. (2013). Dancing with the ancient one. Portland, OR: Deep Democracy Exchange.

See Process-Oriented Psychology

PROLONGED EXPOSURE THERAPY Prolonged exposure therapy is an approach to treatment that focuses on reducing symptoms related to posttraumatic stress disorder (PTSD) and related disorders. Based on cognitive-behavioral therapy, this approach uses psychoeducation, breathing retraining, imaginal exposure, in vivo exposure, and talk therapy to decrease a wide range of symptoms that may result from a traumatic situation. Therapy is generally 90 minutes long and usually takes between 8 and 15 sessions. This approach to PTSD has been shown to be efficacious when working with a wide range of clients who have experienced trauma related to rape, military combat, car accidents, disasters, abuse, and more. It has been successfully used by the U.S. Department of Veterans Affairs with military personnel and by clinicians in general.

Historical Context Prolonged exposure therapy was developed during the mid-1980s by Edna B. Foa, director of the Center for the Treatment and Study of Anxiety at

Prolonged Exposure Therapy

the University of Pennsylvania. Since then, prolonged exposure therapy has been researched in multiple studies and shown to be effective when treating those with PTSD and related disorders. With returning soldiers from the wars in Iraq and Afghanistan experiencing high rates of PTSD, this approach has become particularly important, receiving an Exemplary Substance Abuse Prevention Program Award from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration in 2001. In recent years, the approach has been expanded for use with related disorders with a wide variety of clients.

Theoretical Underpinnings A cognitive-behavioral approach, prolonged exposure therapy suggests that fear structures in one’s memory are developed and continue following a traumatic event. Such structures are formed in an effort to protect the individual from a recurrence of the event by creating images of the event so that when the individual confronts similar situations, he or she knows to avoid them. However, when new situations are faced, the original response sometimes becomes generalized to the new situation, even if the new event is not potentially harmful. Thus, the individual’s fear structures may continue to be triggered by a series of similar stimuli, and the individual is not able to successfully reduce his or her physiological distress that results from the stimuli. Some of the responses that a person might have to the fear structures include a feeling of panic, a pounding heart rate, a shaking body, disassociation, and other symptoms often associated with panic and severe anxiety. Classical conditioning suggests that if exposure to potentially fearinducing situations becomes continually paired with a calm mood, the fear-inducing situations will eventually be habituated to or experienced calmly by the client.

Major Concepts A number of concepts related to cognitivebehavioral theory are used in this approach. Major concepts include breathing retraining, fear structures, imaginal exposure, PTSD, and the Subjective Unit of Distress Scale (SUDS).

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Breathing Retraining

Breathing retraining is a process used to reduce physiological arousal by teaching new, slow, rhythmic breathing techniques to clients. Fear Structures

Fear structures are brain structures that are formed in an effort to protect the individual from a recurrence of an event by creating images of the event so that when the individual confronts similar situations, the individual knows to avoid them. Imaginal Exposure

Imaginal exposure describes the purposeful reliving of an event through memory. Posttraumatic Stress Disorder

Often the result of a trauma, PTSD is a psychological response that occurs as a result of the original event and includes symptoms such as severe anxiety, depression, guilt, anger, nightmares, dissociation, body shaking, and physiological reexperiencing of the event even though the event is not recurring. Subjective Unit of Distress Scale

The SUDS is a device for measuring an individual’s physiological or psychological distress. The scale ranges from 0 to 100, with 0 representing no distress and 100 representing extreme distress.

Techniques With prolonged exposure therapy, techniques are intimately related to the stages of therapy. In the order they are conducted, they include gathering information, psychoeducation, breathing retraining, in vivo exposure, and imaginal exposure. Gathering Information

Gathering information is the process whereby therapists inquire about the clients’ original trauma and subsequent situations that cause distress. Psychoeducation

Psychoeducation describes the process of educating clients about the theory behind prolonged

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exposure therapy and the goals of prolonged exposure therapy.

See also Behavior Therapies: Overview; Classical Conditioning; Exposure and Response Prevention; Systematic Desensitization

Breathing Retraining

Through breathing retraining, therapists teach clients how to reduce physiological arousal through implementing slow, rhythmic breathing techniques. In Vivo Exposure

In vivo exposure refers to having clients develop a hierarchy of distress based on their sense of how they would feel if they were to place themselves in a situation related to the trauma that would cause them distress. In a systemic manner, clients can slowly place themselves in such situations and use their breathing to maintain a sense of calm. The SUDS scale may be used to monitor the client’s amount of distress. Imaginal Exposure

Imaginal exposure is the ongoing revisiting of the original traumatic memory so that clients eventually habituate to the event and no longer feel extreme distress from memories of the event. Clients are asked to recall the event in extreme detail. Clients can use their breathing to maintain a sense of calm, and the SUDS scale may be used to monitor the amount of distress they are experiencing.

Therapeutic Process Prolonged exposure therapy typically last between 8 and 15 sessions. Early sessions involve gathering information from the client about his or her situation, psychoeducation, a general overview of the treatment, building a therapeutic alliance, and teaching breathing retraining. The next sessions involve developing the hierarchy for in vivo exposure, which can be followed up with homework so that the client can practice such exposure. This is followed by a number of sessions that focus on imaginal exposure. Therapists conclude with a final session that examines the progress made in therapy. Edward S. Neukrug

Further Readings Foe, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York, NY: Oxford University Press. Nacasch, N., Foa, E. B., Huppert, J. D., Tzur, D., Fostick, L., Dinstein, Y., . . . Zohar, J. (2010). Prolonged exposure therapy for combat- and terror-related PTSD: A randomized control comparison with treatment as usual. Journal of Clinical Psychiatry, 72, 1174–1180. doi:10.4088/JCP.09m05682blu Peterson, A. L., Foaa, E. B., & Riggs, D. S. (2011). Prolonged exposure therapy. In B. A. Moore & W. E. Penk (Eds.), Treating PTSD in military personnel (pp. 42–58). New York, NY: Guilford Press.

PROVOCATIVE THERAPY Provocative Therapy is named from the Latin provocare, meaning to “call forth from,” and is effective in its ability to call forth new and useful behaviors from clients who have previously exhibited negative behaviors and beliefs. Provocative Therapy works with clients within their biopsychosocial world to assist them to develop more effective behaviors and strategies. Originally developed in 1963 by Frank Farrelly while working with chronic schizophrenics, the techniques used in Provocative Therapy, such as sensory-rich language, are applicable to the full range of client issues, groups, and family work.

Historical Context Trained as a master’s level social worker in 1956, Farrelly worked with the psychologist Carl Rogers for many years at Mendota Mental Health Institute in Madison, Wisconsin, and was a therapist on Rogers’s research project with chronic schizophrenics. Farrelly took part in therapy listening sessions, where client interviews were taped and presented for discussion in weekly meetings with colleagues. In 1963, he began to develop Provocative Therapy.

Provocative Therapy

He found that by confronting his own feelings in response to a client and by using countertransference as a tool in which he would express his own thoughts about the client’s experience, he could build trust effectively and rapidly. The level of honesty, self awareness, and flexibility required of the provocative therapist in an interview may be quite challenging for an aspiring provocative therapist to achieve, and supervision is required during this process. Provocative Therapy was eventually used in individual therapy, group therapy, and family therapy and within the therapeutic community work at Mendota. Farrelly subsequently became a clinical professor in the School of Social Work at the University of Wisconsin and an assistant clinical professor in the Department of Psychiatry at the University of Wisconsin. In the 1970s, he was one of the individuals whom Richard Bandler and John Grinder modeled when they were developing neurolinguistic programming. Farrelly also worked in private practice and gave seminars and lectures around the world until his death in 2013. Provocative Therapy continues today, and provocative techniques have also been subsequently incorporated by his students into Provocative Coaching, as well as into Nick Kemp’s Provocative Change Works.

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5. Clients need to recognize that the choices they make affect society and to take responsibility for their behaviors. As Farrelly would say, “Some people need boundaries taking out, and some people need boundaries putting in.” 6. People are treated as they are subjectively perceived. 7. Therapists have the responsibility to have clients hear feedback and to have the clients act on this feedback by taking responsibility for their actions and developing their own solutions to their problems. 8. People have more ability than is generally assumed and can develop new coping strategies and useful behaviors. 9. All experiences, including those in adulthood, are important for the change process, and growth can occur at any point in a person’s life. 10. Clients’ behavior with their therapist is a good approximation of their habitual behavior. 11. Nonverbal communication is significant; it’s not what is said but how it is said. 12. People can be understood.

Theoretical Underpinnings Provocative Therapy shares with many of the existential-humanistic theories the assumption that people can change at any point in their lives and that the choices people make affect others and society. Additionally, it embraces postmodern beliefs that drive the theory, including the following: 1. Growth occurs in response to challenge. If a challenge is not overwhelming, a “fight” rather than “flight” response is stimulated, and people develop coping strategies and new and useful behaviors. As Farrelly would say, “When the pain begins, the learning starts.” 2. People can make a major change in their lives, and maintain this new behavior, regardless of the duration or degree of the problem state. 3. Change doesn’t have to take a long time. 4. If individuals receive useful feedback, then they can make changes themselves.

Major Concepts Most of the major concepts are incorporated in the 12 assumptions listed in the “Theoretical Underpinnings” section and the techniques discussed in the following section. In general, the Provocative Therapy approach tends to focus on demonstrating acceptance of a client nonverbally and producing change in the client with appropriate provocation and humor.

Techniques Although many techniques from person-centered counseling and other humanistic and postmodern therapies can be used, techniques specific to Provocative Therapy include talking as if talking to an old friend, use of sensory-rich language, use of nonverbal communication to demonstrate acceptance, use of humor, playing devil’s advocate, and being in charge.

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Talking As If Talking to an Old Friend

Provocative therapists talk to each client as if they are talking to an old friend, with a twinkle in the eye and affection in the heart, putting aside their professional dignity on behalf of the client. In addition, therapists use the language of the client, in the present, and avoid professional jargon. Use of Sensory-Rich Language and Nonverbal Demonstration of Acceptance

By using sensory-rich, varied language, with metaphors and storytelling, and verbal and nonverbal responses, therapists get the attention of clients and convey their reactions effectively to, and on behalf of, the clients, demonstrating nonverbally their acceptance of the client. This enables the client to confront issues rather than avoid them.

3. Assisting clients in clarifying their self-image and in the development of adaptive behaviors 4. Consolidation and integration of new behaviors

Nick Kemp See also Existential-Humanistic Therapies: Overview; Person-Centered Counseling; Solution-Focused Brief Therapy

Further Readings Brandsma, J., & Farrelly, F. (1974). Provocative therapy. Fort Collins, CO: Shields. Freud, S. (1928). Humour. International Journal of Psychoanalysis, 9, 1–6. Rogers, C. R. (1951). Client centered therapy. Boston, MA: Houghton-Mifflin.

Use of Humor

Websites

Humor, exaggeration, and mimicking are used to lampoon the problem, not the client. Humor is a key tool to assist the client to make insights and increase the client’s understanding in an acceptable, nonoverwhelming fashion.

Association for Provocative Therapy: www.provocativetherapy.eu Provocative Change Works: www.provocativechangeworks.com Provocative Therapy: www.provocativetherapy.com

Playing Devil’s Advocate

The therapist plays devil’s advocate on behalf of the client’s problem, thus provoking the client to “do the work” and take responsibility for himself or herself. Being in Charge

The therapist uses all these devices to remain in control of the interaction with the client, responding to what comes back from the client rather than letting the client control the interview and avoid change.

PSYCHEDELIC THERAPY Psychedelic therapy relies on hallucinogens or entheogenic drugs to augment therapy. During the 1950s, before many of these drugs were criminalized, psychedelic therapy showed promise as an effective augmentation of psychotherapy. Reactions to the drugs varied widely and ranged from fearful to joyful, enlightening to depressing, and spiritual to personal. Therapists’ interpretations of these responses also varied significantly, making it difficult to standardize this approach.

Therapeutic Process Provocative Therapy has four stages; the duration of therapy is 20 to 25 sessions on average, but it can range from 2 through 200 sessions. The stages are as follows: 1. Assisting clients to confront their issues 2. Having clients acknowledge that change is required by themselves

Historical Context The origins of psychedelic therapy can be traced back to the introduction of lysergic acid diethylamide (LSD) in 1943, when Albert Hofmann, a pharmacologist at Sandoz Pharmaceutical laboratories in Switzerland, identified its powerful psychological properties. His discovery attracted scientific curiosity and resulted in thousands of studies with the

Psychedelic Therapy

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drug over the next decade. The psychiatrist Humphry Osmond coined the term psychedelic in 1957, during his investigations in Canada with the psychiatrist Abram Hoffer; they subsequently introduced the concept of psychedelic therapy. Psychedelic therapy boasted extraordinary results, with success rates between 50% and 90% for its use among alcoholics. Contemporary addictions researchers, however, were skeptical of the research design and the selection criteria used for subjects. One such concern stemmed from the fact that the subjects had vastly different reactions, and it was unclear whether their response had more to do with individual differences, the setting, or the drug itself. Attempts to isolate the effects of the drug, though, had damaging results for the subjects, with the majority having negative and even terrifying experiences. In 1962, Timothy Leary, a psychologist at Harvard, drew controversy when he was fired for engaging in psychedelic research of questionable scientific value. Over the next few years, his name became synonymous with the recreational (ab)use of LSD and psychedelic drugs, and he forged a connection between psychedelics and the counterculture. Researchers using psychedelics struggled to retain their credibility during this period. By 1967, despite the clinical optimism, the Food and Drug Administration in the United States made psychedelics illegal, as did many nations around the world. New substances and novel approaches have led to a resurgence in psychedelic science. Research continues to examine the use of psychedelics in palliative care, addictions therapy, and psychotherapy. The neuroscientists Franz Vollenweider, in Switzerland, and Marc Geyer, in the United States, are exploring the use of psychedelics in the growing field of neuroscience.

and are often used in shamanic rituals and also in psychedelic therapy. Some entheogens are peyote, psilocybin mushrooms, and cannabis.

Major Concepts

Recreating psychotic symptoms in a patient frequently meant stimulating feelings of paranoia. Thus, reassurances from an empathic helper assisted in minimizing the negative consequences of these reactions. Some therapists preferred to create a stronger connection with the patient by taking a dose of LSD at the same time.

Three important concepts for understanding psychedelic therapy are psychedelic, hallucinogens, and entheogens. The term psychedelic was coined by Osmond in 1957 by combining psyche with the Greek term delos, meaning “to bring to light.” “Psychedelic” denotes a mind-manifesting experience. Hallucinogens are chemicals, including mescaline and LSD, that produce changes in visual perception, mood, and thought. Entheogens are spiritually inducing substances, or those that reveal the “God within,”

Theoretical Underpinnings After reviewing the extant literature on mescaline, Osmond found that the investigators recognized similarities between psychosis and chemically induced hallucinations. Arriving in Saskatchewan, Canada, in 1951, he began exploring these ideas through self-experimentation with the newly available drug LSD. Working closely with the psychiatrist Hoffer, he compared LSD reactions with descriptions of psychosis by schizophrenic patients and also with reports of delirium tremens from alcoholic patients, which had some similarities to psychosis. Based on their findings, the researchers concluded that the drug was a psychotomimetic, a chemical that mimicked or modeled psychosis. This led them to theorize that they may have discovered a way to help alcoholics experience a psychosis similar to delirium tremens. They went on to suggest that if alcoholics were given LSD before their problem drinking became too severe, it might help them generate the psychological willpower necessary to seek help at an earlier point in their disease process.

Techniques Psychedelic therapy relied chiefly on an empathic therapist–patient relationship, attention to the set and setting, and conventional follow-up treatments. Osmond recommended that staff have a psychedelic experience before working with individuals who had experienced psychosis or patients about to take LSD. Empathy

Set and Setting

A carefully constructed, comfortable, nonthreatening environment was critical to therapy, and

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some therapists also insisted on adjusting the lighting, adding specific music, and incorporating artwork as soothing and distracting influences to guide a patient into a positive experience.

orchestra, like his family, was attempting to work together while he, the out-of-tune piccolo, disrupted that cadence. This allowed him to see that his family was not to blame for his problems and that he must take ownership of his behavior.

Techniques Based on the Therapist’s Theoretical Orientation

Psychedelic therapy was routinely followed up with regular psychotherapy; however, the approaches to psychotherapy differed significantly and depended on the orientation of the therapist. Typically, the patient brought personal items, including photographs or letters, which often became the subject of discussions. For example, a family photograph could focus a conversation about broken relationships or feelings of guilt toward children. Dosage

Patients often did not return for repeat doses of LSD; thus, one intense session was used to set the stage for subsequent therapeutic interactions. Many patients agreed that its intensity was sufficient to cultivate the willpower to want to stop drinking, to generate perspective on a pattern of dysfunctional behavior, or to inspire one to accept a power greater than oneself. The overwhelming result was a humbling experience and one that therapists argued prepared patients for success in conventional psychotherapy.

Erika Dyck See also Complementary and Alternative Approaches: Overview; Existential Therapy; Freudian Psychoanalysis; Meditation; Phenomenological Therapy; Prayer and Affirmations

Further Readings Dyck, E. (2008). Psychedelic psychiatry: LSD from clinic to campus. Baltimore, MD: Johns Hopkins University Press. Hoffer, A., & Osmond, H. (1967). The hallucinogens. New York, NY: Academic Press. Langlitz, N. (2013). Neuropsychedelia: The revival of hallucinogen research since the decade of the brain. Berkeley: University of California Press. Strassman, R. (2001). DMT the spirit molecule: A doctor’s revolutionary research into the biology of near-death and mystical experiences. Rochester, VT: Park Street Press.

PSYCHOANALYSIS See Freudian Psychoanalysis

Therapeutic Process Psychedelic therapy sessions typically involved an intense 6- to 8-hour session with a helper present, followed by a night’s sleep under observation and a brief period of reflection the following morning. After a single psychedelic session, patients continued with conventional psychotherapy for several months or years. Reactions were highly personal. For instance, one man treated for alcoholism explained that he found himself gripped in a hallucination that had turned him into a piccolo. He believed that he was part of a beautiful orchestra but that he was out of tune, which disrupted the otherwise harmonious symphony. By the end of his session, he explored this insight as a metaphor explaining that the

PSYCHODRAMA Psychodrama is a therapy modality that arose in parallel to the classical psychoanalysis of Sigmund Freud. It is sometimes used as an adjunct to the talk therapies frequently used in modern counseling and is designed to access the client’s emotional and psychological content that is otherwise beyond verbal description. Developed by the psychiatrist Jacob Levy Moreno (1889–1974), psychodrama is used to help the client (called a protagonist) obtain catharsis by revisiting a source of distress through reenactment. Reenactment (role-play, action, enactment, tableau) is the literal development of a scene

Psychodrama

with multiple actors, dialogue that is loosely scripted, and in vivo exposure. The goal of the reenactment is, with the support of those participating in the psychodrama, to facilitate recognition of how a past interaction influences current distress and to help the client overcome the effects of the event on his or her current ability to creatively respond to life stressors. Psychodrama may be likened to family counseling in that it is its own specialty, with its own history and literature, yet its influence is inextricably woven into the way contemporary counseling is provided. As such, the early psychodramatists, such as Moreno, argued that psychodrama is a form of individual therapy because the tableaus being reenacted are focused on the experience of a single person. More modern interpretations point to the experience of others in the sharing phase as an experience that is therapeutic to those other than the protagonist, while also acknowledging that psychodrama may be used as part of an overarching therapy plan.

Historical Context Psychodrama was developed by Moreno following his service as a physician during World War I. Accounts of how Moreno came to develop psychodrama vary. Moreno himself argued that the genesis of psychodrama dates to his own experience with childhood imaginative play, while others note the likelihood that life experiences such as observations of combatant and civilian groups during World War I shaped his theory’s emphasis on the individual in the context of the group. Moreno grew up and lived in Vienna, Austria, and was a contemporary of many of the early figures of psychotherapy (i.e., Freud, Alfred Adler, Viktor Frankl, and Carl Jung). As with most counseling theorists, Moreno’s work is likely a reflection of the context in which he was raised. While in Vienna, Moreno trained as a psychiatrist and is known to have met Freud. However, he was not a part of Freud’s psychoanalytical community and held significant disdain for psychoanalysis, believing that it was myopically focused on the individual. Among his other criticisms of Freudian psychoanalysis were Freud’s avoidance of religion, a central organizing principle for many people, which Moreno thought critical to human development; and a bias toward seeing humans as

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inherently faulted, which Moreno believed was inaccurate. Rather than developing his work in response to that of Freud or of other theorists, Moreno claimed that his theories derived from a combination of knowledge dating to Ancient Greece and his own observations of human behavior.

Theoretical Underpinnings Psychodramatists argue that a unique aspect of psychodrama is its rejection of the notion that humans are motivated by basic needs or drives. Moreno posited that we develop roles as a result of the influences of both biology and social interaction. He termed the space between biology and social feedback spontaneity or s-factor and described spontaneity as the flexibility with which one adapts to a novel situation or develops a new adaptation for a familiar situation. Therefore, human development is presented as a continuous process of tapping into one’s creativity to make meaning out of the situation or circumstances one is presented. Furthermore, though there are certain biological reflexes with which we are born (e.g., sucking), some creative learning between a child and caregivers is required for the child to successfully meet his or her needs. In the case of a baby using a bottle, there is the biological need to feed, the reflex to suck, and the context that the caregiver provides to create an environment of safety for the child to appropriately latch onto. The identity one develops is the aggregate of learned roles. The social connection between individuals, for instance, the child and the caregiver, is intangible but perceptible. This connection is termed tele and is operationalized through Moreno’s work on sociometry. Sociometry, the aspect of Moreno’s work that emphasized the relationships between individuals and communities at large, underlies the way in which psychodrama is understood to work. Drawing from the tele, the curative factor is seen as how the protagonist connects with the other persons facilitating the psychodrama so that he or she may revisit and rescript a distress-inducing event.

Major Concepts Psychodrama is grounded in the principle that immediacy allows the client to approach psychological wounds otherwise hidden by the roles the

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client has accepted. Psychodrama relies on certain roles being played out in the enactment to facilitate client catharsis. Protagonist

The protagonist refers to the client, who is the principal actor in the psychodrama. Director

The director is the counselor who is facilitating the psychodrama. The director may either instruct the protagonist and the auxiliaries as to which roles should be adopted and how they should be reenacted or co-construct the reenactment with the protagonist. The director is responsible for ensuring continued momentum in the role-plays. Auxiliaries

Auxiliaries are the other participants in the psychodrama. Those who assume the role of an auxiliary may be other professionals who typically work with the director in facilitating psychodramas. In situations where the auxiliaries are not other professionals, they may be other members of a therapy group. When other group members are auxiliaries, the protagonist is asked to intentionally choose group members who seem to best fit specific roles (e.g., one’s mother or father). Audience

The audience refers to those who are present to witness the enactment but are not participating in the action. Audience members may be called on to share their personal experiences of the action on the conclusion of the role-play.

Role

Roles are the labels that one puts on others, as well as self, based on perceived characteristics. Roles can be developed based on a trial-and-error process where the role is adopted and then others respond, through observations of other members of society, or through otherwise ingrained rules about what characterizes a particular role (i.e., the belief that one’s role as a man is characterized by not crying). The adoption of roles comes before one develops an identity, as the self is understood as the integration of multiple roles. Spontaneity

Spontaneity underpins the way in which catharsis is achieved in psychodrama. The protagonist (the client) is charged with tapping into his or her own spontaneity to identify how distress-inducing circumstances were previously approached. He or she may be charged with developing a new way of approaching the same distress-inducing situation. Moreno posited that the use of spontaneity allows clients to access content otherwise hidden by the defenses that precluded their description in talk therapy.

Techniques Psychodrama is characterized by a series of role-plays that are most likely to facilitate the protagonist’s catharsis. Although role-plays may be considered the technique associated with psychodrama, specific processes and modifications to the role-plays serve as the tools used by psychodramatists.

Stage

Data Collection and Preparation to Develop Role-Play

The physical space in which the action takes place is called the stage. While it is not necessary to have a full variety of props or a formal theater stage, setting boundaries for where the audience will be, what the context of the enactment is, and the freedom of movement of the protagonist, director, and auxiliaries are considerations in psychodrama.

Before the participating psychodrama group is convened, the protagonist and the director meet to discuss background information. The director may then either co-construct the role-play that will be enacted or, based on his or her assessment, identify how to conduct the warm-up activities, set up the stage, and identify which prompts to provide the protagonist and the auxiliaries.

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Warm-Up

Doubling

This is the first stage of the psychodrama and is used to ensure that those who will be participating in the role-play are psychologically and emotionally ready. In the warm-up stage, those acting reflect on their own emotional and psychological state, address anxieties about assuming a different role, and maximize their ability to be spontaneous in the role-play. This is akin to introducing an intervention to clients before simply asking them to execute it.

An auxiliary may be tasked with serving as a companion to the protagonist in the enactment. This “double” helps convey nonverbally or verbally the feelings the protagonist has and helps bring to awareness underlying emotions, which may then influence the direction the rest of the role-play takes. The nonverbal double may also foster a sense of courage in the client (i.e., simply help the client to not feel alone as the distressing event is approached). A verbal double, sometimes called a spontaneous double, may identify the underlying emotions in the role-play and provide suggestions to the protagonist or speak as the protagonist.

Action or Enactment

The second stage of psychodrama, the action or enactment stage, is when the protagonist and the auxiliaries enact the situation identified as distress inducing. The action phase may include more than a single role-play and may include a rescripting of events. Because the auxiliaries were not present at the original event that the protagonist is reenacting, they rely on their own interpretation of their roles. What is said in the action stage may require some direction and repetition to appropriately facilitate the client’s new experience of the initially distressing event. Sharing

Following the action stage, those who observed (audience) or participated (protagonist and auxiliaries) are invited to share their personal reactions to what took place. Those who acted as an auxiliary may suggest what they believe their character experienced or may share their own personal experience from being an actor in that role. Analysis of what the protagonist did or said in the role played is discouraged. The director may, however, create an opportunity for the audience and the auxiliaries to gently challenge the understanding that the protagonist has shared of the events. Role Reversal

Role reversal is a technique whereby the protagonist is asked to assume the role of another person in the tableau. This may allow the protagonist to develop a different perspective on the events that led to distress by garnering a different understanding of the motivations of those involved.

Mirroring

Mirroring is when an auxiliary assumes the role of the protagonist so that the protagonist sees how others view his or her actions. The protagonist may then reevaluate his or her behaviors and statements during the distress-inducing event. In a situation where the role-play presents a new way of approaching the event, the protagonist also is afforded the opportunity to consider whether or not the new way is something that works for him or her.

Therapeutic Process The psychodrama process includes the stages (phases) of warm-up, action or enactment, and sharing. The way psychodrama is used in practice varies. Although a client may seek out counseling with the express intent of engaging in psychodrama, it may be more likely that the client will be exposed to psychodrama as part of another type of therapy group. Regardless of the venue, the director may develop the role-plays with varying degrees of input from the protagonist but should be mindful of how pushing a protagonist beyond the protagonist’s level of readiness without the protagonist’s prior input could be retraumatizing. Daniel M. Paredes See also Drama Therapy; Emotion-Focused Therapy

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Further Readings Blatner, A. (2000). Foundations of psychodrama: History, theory, and practice (4th ed.). New York, NY: Springer. Dayton, T. (1994). The drama within: Psychodrama and experiential therapy. Deerfield Beach, FL: Health Communications. Haworth, P. (1998). The historical background of psychodrama. In M. Karp, P. Holmes, & K. B. Tauvon (Eds.), The handbook of psychodrama (pp. 15–28). London, England: Routledge. Karp, M. (1998). An introduction to psychodrama. In M. Karp, P. Holmes, & K. B. Tauvon (Eds.), The handbook of psychodrama (pp. 3–14). London, England: Routledge. Konipik, D. A., & Cheung, M. (2013). Psychodrama as a social work modality. Social Work, 58, 9–20. doi:10.1093/sw/sws054 Lipman, L. (2003). The triadic system: Sociometry, psychodrama, and group psychotherapy. In J. Gerhsoni (Ed.), Psychodrama in the 21st century: Clinical and education applications (pp. 3–14). New York, NY: Springer. Marineau, R. F. (2007). The birth and development of sociometry: The work and legacy of Jacob Moreno (1889–1974). Social Psychology Quarterly, 70, 322–325. Moreno, J. L. (1964). Psychodrama (Vol. 1, 3rd ed.). Beacon, NY: Beacon House. Wilkins, P. (Ed.). (1999). Setting the stage: The instruments and techniques of psychodrama. In Creative therapies in practice: Psychodrama (pp. 20–39). London, England: Sage.

PSYCHODYNAMIC FAMILY THERAPY Psychodynamic family therapy is an approach to family therapy that integrates classical Freudian psychoanalytical theory’s interest in the unconscious aspects of individual personality development and function with an interest in the social context, and especially the family context, in which individual and relational dysfunction develops. Most of the pioneers of psychodynamic family therapy were physicians trained in Freudian psychoanalysis who, with the birth of the systems paradigm in the 1960s and 1970s, came to view Freud’s individually focused psychoanalytical ideas as antiquated and inadequate. In therapy, the Freudian psychoanalyst addressed relationships

with real events and people only as those events influenced a client’s unconscious internal conflicts. Today, however, proponents of psychodynamic family therapy tend to view individual conflicts and relational patterns as interlocking systems that must be addressed within the treatment process. Like their Freudian predecessors, psychodynamic family therapists acknowledge that repression of early problematic experiences inhibits individuals from relating freely to the outside world. However, unlike their predecessors, psychodynamic family therapists aim to discover and address the repressed but unfinished problems affecting a family as well as its individual members. Shedding the cold, “blank screen” approach of the classical psychoanalyst, today’s psychodynamic family therapists work to create a warm and secure therapeutic or “holding” environment, in which family members can feel safe to work through their repressed issues. Key Freudian psychoanalytical techniques are applied in psychodynamic family therapy, along with more contemporary techniques aimed at helping families understand and change unwanted interaction patterns. From a psychodynamic family therapy perspective, it is the therapist’s interpretation of family members’ early conflictual relationships that makes them conscious through language and, thus, accessible in therapy, as a tool for individual and family change.

Historical Context Beginning in World War II and throughout the 1940s, Freudian psychoanalytical theory became dominant in American psychological practice as a number of psychoanalytically trained theorists and clinicians traveled to the United States from Europe to escape Nazi persecution. The classical Freudian approach to mental health treatment sought to correct the damage of childhood conflicts resulting from destructive interactions in one’s family of origin, and Freud believed that treatment was most effective if conducted with individuals apart from the harmful influences of their family members. In the 1950s, some psychoanalysts began to move away from the Freudian focus on the individual toward viewing select family relationships as the unit of psychodynamic treatment. Among these were the American psychiatrists Nathan Ackerman, Ivan Böszörményi-Nagy, and Harry Stack Sullivan. Ackerman, who is sometimes regarded as the

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“grandfather of family therapy,” adopted the view that individual symptoms were units of interpersonal behavior displayed in the context of shared family conflict. Böszörményi-Nagy’s contextual approach to psychiatric treatment emphasized the importance of family loyalties and ethical obligations to the mental health of individual family members. Sullivan emphasized the importance of peer relationships in personal and social development, stressing that the seeds for later disturbance were sown in early dealings with others. This emerging “interpersonal” view in psychiatry was formalized in the 1960s with the development of a psychodynamic family therapy training program at the Washington School of Psychiatry in Washington, D.C. In the 1970s, the program recruited the psychiatrists David Scharff and Jill Savage (now Scharff), whose object relations view of family treatment centered on addressing parents’ destructive projections of past relational conflicts from their families of origin onto their current family relationships with spouses and children. By the mid-1980s, the Washington School of Psychiatry had become (and remains) a leading center for psychodynamic family therapy in the United States, and during the 1990s, the Scharffs went on to form the International Institute for Object Relations Therapy in Chevy Chase, Maryland, where they actively continue to promote their object relations approach as the primary bridge between psychoanalytic and family therapies.

Theoretical Underpinnings At the core of all psychodynamic treatments is the discovery and interpretation of unconscious psychological impulses, or drives, and the defenses against them. Whereas proponents of Freudian psychoanalytical theory contend that these instinctive drives are sexual and aggressive in nature, psychodynamic family therapists view the drives as being toward attachment to constant and attentive other people. Drawing on Heinz Kohut’s Self Psychology theory, psychodynamic family therapists acknowledge a direct relationship between a child’s success in satisfying his or her drive for a safe and secure relationship with a parent or primary caregiver and the child’s success in making and sustaining relationships later in life. Those children who grow up feeling insufficiently attended to and nurtured by primary caregivers

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may, as adults, demand acceptance excessively and inappropriately from others in defense of an uncertain and negotiable self-image. From a traditional Freudian perspective, individual personality development occurs through each person’s unique pattern of gratifying and repressing his or her instinctive drives. From an interpersonal or family psychodynamic perspective, it is the unconscious storing, or introjection, of unique early relational experiences or so-called object relationships that is at the core of personality development. It is peoples’ inner world of internalized object relationships that forms the blueprint for how they will come to regard themselves and relate to others in later life. This is due to the fact that very young children do not view their parents as individuals but, rather, as a part of themselves or, in Kohut’s terms, as self objects. As a result, the good or bad qualities they attach to their early object relationships with significant others become the bases for their self-assessments of “good me” or “bad me,” which then become a part of their responses to future interpersonal situations. Psychodynamic family counselors hold that marital partners often choose and relate to each other in unconscious ways that are intended to resolve the negative self-assessments stemming from their early family-of-origin relationships. As a defense against the anxiety caused by these assessments, the partners unconsciously externalize, or project, unwanted perceptions of themselves onto each other and their children and then respond, or identify, in family relationships based on a partner’s or child’s resemblance to the projected perceptions. From a psychodynamic family counseling point of view, family problems occur whenever family member relationships are based on these projective identifications rather than on the reality of how members truly behave. Resolution of family problems lies in family members gaining insight into and, thus, freedom from burdensome projections so that their relationships can develop honestly and in the present.

Major Concepts In their work with families, psychodynamic family therapists draw on concepts from both classical (Freudian) and interpersonal psychoanalytical theories. Those concepts include, but are not limited to, psychological drives, intrapsychic conflicts,

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defense mechanisms, Self Psychology, object relationships, the holding environment, splitting, and projective identification. Psychological Drives

Psychological drives are instinctual needs that have the power to direct individual behavior. Whereas Freudian psychoanalysts were interested in clients’ sexual and aggressive drives, psychodynamic family therapists are more interested in clients’ drives toward secure attachments to other people. Intrapsychic Conflicts

Intrapsychic conflicts refer to unconscious mental struggles that result when one’s impulses and drives are incongruent with or unmet by existing realities. Psychodynamic family therapists seek to discover how such conflicts that occurred in early relationships may be preventing clients from relating effectively in the present. Defense Mechanisms

Defense mechanisms are unconscious psychological strategies that people apply to protect themselves from the overwhelming anxiety created by intrapsychic conflicts. Projective identification and splitting are two defense mechanisms that are of particular interest to psychodynamic family therapists.

subconsciously to shape their adult social relationships and interactions. A primary goal of the psychodynamic family therapist is to help clients gain insight into how these introjected object relationships from the past may be at the source of problems in their current relationships. The Holding Environment

A holding environment refers to the safe and nurturing environment that children need from their parents or caregivers for healthy psychological development to occur. It also refers to the comparable environment that the therapist seeks to create for the client in order to promote optimal growth and healing. Splitting

Splitting refers to a defense mechanism used initially by very young children to cope with the anxiety of negative experiences with their parent or caregiver. Unable to reconcile the negative experience with their need and desire for a caring parent, they form two distinct internal images of the parent and acknowledge only the good image while minimizing or repressing the bad image. As children grow older, most of them are able to integrate the two conflicting images and accept others as having both good and bad qualities; but if the conflict is not resolved, then their view of others (and themselves) as either all good or all bad will impair their ability to develop satisfying adult relationships.

Self Psychology

Self Psychology is Kohut’s version of psychoanalysis, which emphasizes the importance of parental modeling and nurturance to the healthy psychological development of children. It supports the interpersonal view of psychodynamic family therapy by describing the means by which an individual’s sense of self-esteem is a product of the quality of his or her relationship with parents or primary caregivers.

Projective Identification

Projective identification is an unconscious mental process in which relating individuals defend against anxiety by projecting unwanted, or splitoff, aspects of themselves onto each other and then relating to each other on the basis of those projections rather than on each other’s actual behavior. For psychodynamic family therapists, the projective identification process is seen as a primary source of relational difficulty to be addressed in therapy.

Object Relationships

Object relationships refer to images, or introjects, of subjective experiences in early relationships with caregivers that children carry into adulthood as objects in their subconscious and that they use

Techniques Despite the differences between traditional (individual) and interpersonal (family) psychoanalytical theories, the two share five common techniques

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aimed at clients’ insight into the unconscious processes that are affecting themselves and their relationships with others. Those techniques are listening, analysis of resistance, analytical neutrality, transference, and interpretation. In addition, psychodynamic family therapists are likely to assume more active influence on the therapeutic process than their more traditional psychoanalytical counterparts through the application of techniques such as expanding the field of participation, working in the here-and-now, and addressing complementarity. Listening

For psychodynamic family therapists, listening is the most important technique that can be applied in the therapeutic process because it is only through effective listening that the therapist can achieve accurate insight into a family’s complex array of conscious and unconscious dynamics. Effective listening involves resisting the temptation to be drawn in to reassure, advise, or confront families in favor of sustained but silent immersion in their experience. Methods for achieving this include a therapist maintaining balanced attention to what clients are saying without directing notice to any one thing in particular; avoiding the practice of note taking in session, as it requires selective attention to what has been said; and maintaining emotional control so as not to be inadvertently attentive to a particular topic as a result of its striking an emotional chord. Because desired family outcomes are seen as a by-product of insight and understanding, the psychodynamic family therapist characteristically suspends direct effort to promote outcomes in favor of establishing, through effective listening, a climate for deep analytical exploration. Analysis of Resistance

Psychodynamic family therapists do not differ from classical psychoanalysts in their belief that points of client resistance to the unfolding of therapy hold the clue to understanding important intrapsychic conflicts that may be at the source of the resistance. As a result, they attempt in therapy to analyze and understand the resistance by identifying and processing the observed resistance with the clients and by examining their own thoughts

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and emotions (countertransference) in response to it. However, in contrast to the classical psychoanalytical model, psychodynamic family therapists also look for ways in which the resistance of individual family members speaks to the unconscious relational processes affecting the cohesiveness and interaction patterns of the entire family. Transference

Transference refers to the client’s projection of feelings, attitudes, and desires onto the therapist. It is used in psychodynamic family therapy to understand what the dominant emotions are within a family and toward whom in the present or past those emotions are directed. Through the transference process, family members form a bond with the family therapist and act toward the therapist as though he or she is the actual person toward whom the emotions are directed. By releasing pentup emotions, gaining new insights, and learning new ways to interact within the transference process, family members are able to work through their unfinished business of the past and more objectively face the issues in their present lives. Analytical Neutrality

In contrast to some models of family therapy in which the therapist works to become an active part of the family system, psychodynamic family therapists tend to adopt a more neutral stance of involved impartiality so that they can be attentive to what is happening to themselves within the therapeutic process (i.e., countertransference) as well as what is taking place within the family. Although careful to create a warm and safe therapeutic, or holding, environment, they remain outside the family system in order to be an impartial target, or object of transference, onto whom various family members can project and work through their unfinished problems of the past. Interpretation

Interpretation has been referred to as the workhorse in psychodynamic family therapy. It refers to the family therapist sharing his or her acquired understanding of a family’s problematic and often unconscious processes to help the family members resolve their problems through greater conscious

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insight into those processes. Psychodynamic family therapists are careful to provide interpretations only after acquiring deep understanding of the family and in such a way that family members are able to modify the new understanding as needed to align it with their shared experience. Interpretation is intended to help families understand the problems they are facing and also to convey that the family therapist is working hard to understand and assist them. Working in the Here-and-Now

In a sharp departure from the focus of classical psychoanalysts on analyzing past relationships, psychodynamic family therapists often find considerable therapeutic power in analyzing relational interactions that occur spontaneously within the therapy session itself. Interactions, such as an angry look, an interruption, a hurtful comment, or loss of temper, that occur in the therapy session are shared and, thus, felt by everyone. Psychodynamic family therapists may call attention to such interactions when they occur, viewing them to be a powerful medium for family-wide engagement in the transference and interpretation processes. Expanding the Field of Participation

Psychodynamic family therapists often work to engage all family members in the therapy session. When a recurring issue between two family members is raised, it is not uncommon for the therapist to ask other family members to offer their thoughts and feelings about the issue and about the family members who repeatedly engage in it. For psychodynamic family therapists, the purpose of expanding family member participation is twofold. First, it supports the establishment of an inclusive holding environment wherein all family members can feel free to interact and express themselves. Second, it leads to more useful interpretations by illuminating the context in which family interactions occur and other family members emotionally respond to them. Examining Complementarity

Complementarity refers to the degree of harmony that exists among the roles of various family members. Psychodynamic family therapists assume

that marital partners often take on roles that are regulated by early relational experiences rather than by the adaptational needs of their current relationship. When this occurs, their relationship is subject to a failure of complementarity, whereby there is an imbalance between the partners in the level of satisfaction received from their individual roles. By examining the complementarity of current family roles, a psychodynamic family therapist can discover important clues about relationships in the past that may be keeping the family from adapting successfully to its present relational context.

Therapeutic Process The primary goal of psychodynamic family therapy is to free family members from the unconscious restrictions imposed by early relationships. To achieve this goal, the family therapist first establishes a warm and safe holding environment in which family members feel free to interact with one another for the sake of growth and healing. Next, the family members are encouraged to share their early relational experiences with caregivers so that the family therapist can assess and interpret for them the intrusive internalized conflicts and projective identifications that may be negatively affecting their current interactions. Once the intrusions are identified, the therapist then helps the family members to resolve or work through them and learn to interact with one another on the basis of current realities rather than past object relationships. Successful treatment is measured more by the family’s increased insight and self-understanding than by immediate relief of symptoms. Rip McAdams See also Ackerman Relational Approach; Adlerian Therapy; Attachment Theory and Attachment Therapies; Contextual Therapy; Freudian Psychoanalysis; Interpersonal Psychoanalysis; Object Relations Theory; Self Psychology

Further Readings Ackerman, N. W. (1966). Treating the troubled family. New York, NY: Basic Books. Bowlby, J. (1988). A secure base: Parent/child attachment and healthy human development. New York, NY: Basic Books.

Psychodynamic Group Psychotherapy Böszörményi-Nagy, I. (1987). Foundations of contextual therapy: Collected papers of Ivan Böszörményi-Nagy. New York, NY: Brunner Mazel. Burnham, J. C. (Ed.). (2012). After Freud left: A century of psychoanalysis in America. Chicago, IL: University of Chicago Press. Gerson, M. J. (2010). The imbedded self: An integrative psychodynamic and systemic perspective on couples and family therapy. New York, NY: Routledge. Kohut, H. (1977). The restoration of the self. New York, NY: International Universities Press. Scharff, D. E., & Scharff, J. S. (1987). Object relations family therapy. Northvale, NJ: Jason Aronson. Spillius, E., & O’Shaughnessy, E. (2011). Projective identification: The fate of a concept. New York, NY: Routledge. St. Clair, M. (2004). Object relations and self-psychology: An introduction (4th ed.). Belmont, CA: ThompsonBrooks/Cole. Zimmer, J., & Shapiro, R. (1976). Projective identification as a mode of perception of behavior in families of adolescents. International Journal of Psychoanalysis, 5, 523–530.

PSYCHODYNAMIC GROUP PSYCHOTHERAPY Although Sigmund Freud (1856–1939) never applied his principles to group therapy, he did have a regular group that met in his apartment beginning in 1902. The Wednesday Psychological Society included psychoanalysis luminaries such as Karl Abraham (1877–1925), Alfred Adler (1870–1937), Sandor Ferenczi (1873–1933), Carl Jung (1875–1961), and Otto Rank (1884–1939), who kept notes and collected the dues. Founded to discuss psychoanalytical theory, over time, it became so highly personal and contentious that in 1908 Freud disbanded the group and re-formed it under a new name that he hoped would keep it more academic in focus: The Vienna Psychoanalytic Society. Today, psychodynamic group psychotherapy is grounded in Freud’s psychoanalytical theory, and most modern theories of psychological treatment owe some debt to Freud’s pioneering insights. For instance, his concepts of the unconscious, free association, transference, and countertransference are now woven into the fabric of Western society,

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and these concepts, in the context of group process, are critical to psychodynamic group therapy.

Historical Context For all practical purposes, group therapy came into being as a viable therapeutic modality during and just after World War II. The necessity of treating large numbers of soldiers and civilians requiring psychological care during those war years led to seeing them together in groups. As military doctors, nurses, and medics began to work with their patients in groups, they began to notice that groups had a powerful and unanticipated effectiveness as a treatment modality. Meeting in groups made treatment more potent, and thus, group therapy came to be. This time period was also the heyday of psychoanalytic therapy. However, most centers of psychoanalytical training did not view this new group therapy as a particularly useful modality. Analysts practiced one-on-one therapy, typically with patients lying down and facing away. They depended on the fantasies, projections, and transferences of their patients to make inferences about what was going on in their client’s unconscious and to reconstruct the etiology of their client’s personality and psychopathology. Many psychoanalysts felt that the multiperson setting of group therapy would interfere with those curative factors. In particular, they believed that the presence of many people would preclude the effective use of transference and free association for the individual members. For the early group therapists, it soon became apparent that psychodynamic principles would work effectively in group settings. They found that transference was alive and well in groups, though in a somewhat different form. The transferences in groups, at least initially, are horizontal rather than vertical; that is, members project their expectations and fears onto their fellow group members, or even onto the group as a whole, more powerfully than onto the leader. When members experience distorted views of the therapist (vertical transference), the group often gains by comparing the differing views of the leader held by various members. Analysts in that era also believed that free association, the “divining rod” that takes patients to the deepest recesses of the unconscious, would not

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work in a group setting. It turned out that in groups, “free association” became “group process” and the associations of the whole group became data that helped illuminate the deeper processes of the group and the individual members. Just as analysts assume that all content is related, group therapists listen for how topics that arise are connected. In fact, while it may appear that topics occur randomly in group meetings, psychodynamic theory suggests that topics are almost always related. Also at this time in history, the foundations of Freud’s theory were undergoing revision. For Freud, psychopathology was an internal, solitary struggle between the innate, biological instincts of individuals and the dictates of society. The goal of maturation was healthy independence. Freud’s followers, however, began to formulate the fundamental thrust of personality as relational. The goal of maturation was no longer the ability to be independent but, instead, the ability to be in healthy relationships. This began early with Freud’s daughter Anna (1895–1982), who is typically credited with founding object relations theory by suggesting that the goal of instincts is not self-preservation or procreation but rather to be in relationship. Adler suggested that inner conflict was not the driving force of personality; rather, it was the individual’s innate desire to relate to and build a sense of community with others. Jung moved away from Freud’s highly individualized theories by proposing the collective unconscious, which assumed that all people share a similar heritage to which they can relate. At around the same time, Rank viewed this issue from the opposite side—separation anxiety. For Rank, personality is forged in response to a dread of separation, which he traced to leaving the womb. As psychodynamic theory became relationally based, group therapy became an obvious psychodynamic treatment modality. Although today’s psychodynamic groups are still based on many traditional psychoanalytical concepts, such as the unconscious, transference, and projection, they are also heavily influenced by the interpersonal modifications of classic psychoanalytical theory. Modern groups emphasize corrective relational experience as a primary healing factor.

therapists with “solutions,” not problems. In other words, the problems that are presented are the result of the patient’s attempts at adaptation as he or she unconsciously tries to resolve past conflicts. However, such adaptation either no longer works or becomes too much of a burden for a person to carry. The dynamic assumption is that whatever atypical behavior the counselor or therapist sees can be understood and altered if the problem it is attempting to solve can be unlocked. These dynamic assumptions can be worked at individually or in a group format; however, the group process offers a rich and somewhat different focus from individual therapy as patients can gain a better understanding of the unconscious, projection, resistance, and transference by viewing other patients’ experience in the group and by gaining feedback from the group leader and from group members.

Major Concepts An overall goal of psychodynamic group therapy is to help individuals become aware of their basic, unexamined assumptions about life—that is, making the unconscious conscious. To do this, a number of traditional psychoanalytical processes are integrated within a group format. Thus, many of the major concepts of psychodynamic group therapy are basic to all types of psychodynamic work and are highlighted in this section. Unconscious Processes

The most radical of Freud’s hypotheses, and the one on which all others rest, is the suggestion that there is an out-of-awareness world of perceptions, memories, and affects that influences how persons perceive and react to their world. Psychopathology occurs when people react to current stimuli or relationships as if they were reacting to those archaic, unconscious assumptions. In group therapy, unconscious assumptions are continually present and are immediately available for observation as fellow group members confirm or contest the assumptions on which others operate. Transference

Theoretical Underpinnings Psychodynamic group therapy is based on the conviction that patients come to counselors and

Transference is the distorting of current relationships on the basis of much earlier relationships. As such, understanding this process in a

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patient becomes a primary means of inferring the patient’s earlier, formative relationships. In fact, it has been suggested that transference explains why we can never really know another person as we are always transposing earlier relationships onto those we are close to. In groups, transference is often more evident, because a panel of trusted peers is available to assess the perceptions of individuals. Resistance

Patients resist change, and the examination of resistance is another window into the unconscious. Typically, resistance is misunderstood as resistance to growth, or even therapy itself. In fact, resistance occurs when patients anticipate pain or discomfort (rejection, overwhelming affect, etc.). Careful examination of resistance provides data about what patients “expect” will be painful and thus indicates that a patient is close to understanding an important part of self. In groups, the resistance that individuals exhibit is much more transparent because the other group members come to expect and name it. Determinism

Psychodynamic theory assumes that all human behavior is lawfully connected, and thus, all behavior is predictable if we could understand how past events affect current-day living. Philosophically, determinism posits that whatever happens is determined by prior factors and that no other result is possible. Therapeutically, this leads to the conviction that the behavior therapists observe in their patients and themselves is determined by the past. In therapy groups, members can observe different styles of relating and can associate those styles to history. For example, the adult who was beaten as a child is likely to view personal intimacy as potentially dangerous.

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Epigenetic Development

Psychodynamic theory assumes that personality is formed developmentally, with each subsequent stage depending on the prior stage. Inadequately mastered early stages of development will adversely influence all succeeding stages. It is assumed that problems in early developmental stages can be repaired by healthy interpersonal interactions later in life. In mature groups, members come to understand the critical developmental times in the lives of other group members and can help them understand how particular times in their history have influenced their views of themselves and the world. Group Process

Where psychoanalysts followed free association as a guide to unconscious material, group therapists follow group process. Just as analysts believed that free association was anything but “free,” group therapists assume that whatever topics arise in group are in some way linked to what had gone before and that by trying to understand those links, important information about unconscious material might be detected.

Techniques Interpretation

Psychodynamic therapists make interpretations. They try to discover the unconscious narratives that explain the dysfunctional behavior of patients. Interpretations need not be correct to be helpful, because just making them implies that there is an explanation for otherwise irrational behavior. In group therapy, interpretations often follow observation of the interpersonal styles demonstrated in group interactions.

Adaptive Behavior

Free Association

All human behavior, however atypical or odd, is adaptive, which means that the behavior arose as a response to perceived danger or to gain interpersonal nurturance, and thus makes sense within this context. In group therapy, other members become aware of traditional defenses that individual members demonstrate, and they can flag and name them when they occur.

To the degree that patients can set aside logic and simply report what comes to mind, they can gain clues into some of the deepest workings of their unconscious. In groups, how one relates to others is a kind of free association as the members transfer their earlier relationship patterns onto the other group members in a “free”-form manner.

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Analysis of Defenses

Patients develop defenses to protect themselves from anticipated danger or pain. These defenses can range from denial, to anxiety, to depression, to psychosis, and so on. A careful analysis of defenses can help understand the danger or pain underneath the defenses and the origins of the defenses— why they were created. In therapy groups, these defenses, especially those that defend against intimacy and interpersonal vulnerability, are especially evident and can be acknowledged, interpreted, and, in time, understood by patients. Appreciation of Countertransference

Modern psychodynamic practitioners understand that they are not “experts” analyzing patients. They are involved in a relationship with their patients, and as part of those relationships, they are “invited” to have certain feelings. Practitioners can feel very differently with different patients as they enter each patient’s interpersonal field. This is perhaps the richest source of data practitioners have about their patients. And this is to be distinguished from classic countertransference, in which the therapist’s past precludes accurately understanding patients. Sitting in a therapy group provides a rich opportunity for a therapist to assess his or her countertransference because it can be measured against the feelings of group members. For example, if the therapist finds himself or herself feeling angry at a particular patient, it is often difficult to determine if this is countertransference or an accurate response to the interpersonal field of the patient. In group therapy, the therapist can observe the reactions of other group members and can see if they share the same reaction.

Therapeutic Process Psychodynamic groups typically do not begin with an agenda or topic, but there is an expectation that members will be as honest as possible in sharing feelings, reactions, and memories. As the group begins, one patient will bravely decide to share intimate parts of himself or herself. This sharing will stimulate the associations and contributions of others. Soon, other group members will reveal parts of themselves by talking about

their problems or by demonstrating them through their actions in the group. The role of the therapist is to provide a safe environment where members can share and reveal their characteristic interpersonal style. In this setting, members will come to understand their characteristic assumptions about themselves and how they typically interact in interpersonal relationships. Through feedback from the group leader and from group members, they will have a chance to gain knowledge about their defenses, their resistances, their transferences, and their unconscious and slowly begin to know why they respond to others in the manner that they do. Then, they can decide to correct distortions in current relationships that are the result of unconscious conflicts from past relationships. Some have called this process a “corrective emotional experience.” J. Scott Rutan See also Cognitive-Behavioral Group Therapy; Existential Group Psychotherapy; Gestalt Group Therapy; Interpersonal Group Therapy; Psychoeducational Groups; Tavistock Group Training Approach

Further Readings Alonso, A., & Swiller, H. I. (1993). Introduction: The case for group therapy. In A. Alonso & H. I. Swiller (Eds.), Group therapy in clinical practice (pp. xxii–xxiii). Washington, DC: American Psychiatric Press. Billow, R. M. (2003). Relational group psychotherapy: From basic assumptions to passion. London, England: Jessica Kingsley. Gans, J. S., & Alonso, A. (1998). Difficult patients: Their construction in group therapy. International Journal of Group Psychotherapy, 48, 311–338. Greene, L. R. (2012). Group therapist as social scientist, with special reference to the psychodynamically oriented therapist. American Psychologist, 67, 477–489. doi:10.1037/a0029147 Kauff, P. F. (1997). Transference and regression in and beyond analytic group psychotherapy: Revisiting some timeless thoughts. International Journal of Group Psychotherapy, 47, 201–210. Malcolm, J. (1981). Psychoanalysis: The impossible profession. New York, NY: Vintage Books. Nitsun, M. (1996). The anti-group: Destructive forces in the group and their creative potential. London, England: Routledge.

Psychoeducational Groups Ormont, L. R. (1967). Group resistance and the therapeutic contract. International Journal of Group Psychotherapy, 18, 147–154. Rutan, J. S. (1992). Psychodynamic group psychotherapy. International Journal of Group Psychotherapy, 42(1), 19–35. doi:10.1016/B978-012564745-8/50016-9 Rutan, J. S., Stone, W. N., & Shay, J. J. (2007). Psychodynamic group psychotherapy (4th ed.). New York, NY: Guilford Press. Shay, J. J. (2011). Projective identification simplified: Recruiting your shadow. International Journal of Group Psychotherapy, 61, 239–261. doi:10.1521/ ijgp.2011.61.2.238 Stone, W. N. (2005). Group-as-a-whole: A self psychological perspective. Group, 29, 239–255. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

PSYCHOEDUCATIONAL GROUPS Psychoeducational groups—also referenced in the literature as structured, guidance, and themed groups—are groups that are usually organized and presented for members who have a commonly held condition, issue, illness, or disorder and that feature a balance of cognitive material and emotional expression. Many cognitive-behavioral therapy groups could also be characterized as psychoeducational. Psychoeducational groups are generally time limited, with the duration of the group specified in advance, where once the group is formed, no new members are added, the format is structured, the leaders are active and directive, and there are predetermined goals and objectives. The major purposes for this modality are to present information that members can use to cope more effectively with the issue, condition, illness, or disorder that brought them to the group; to learn new skills; to provide opportunities for emotional expression; and to experience personal growth and development. Psychoeducational groups are an essential part of other treatment modalities such as Linenhan’s Dialectical Behavior Therapy and McFarlane’s multifamily groups for the treatment of severe psychiatric disorders. Psychoeducational groups differ from many clinical or psychotherapy groups in several ways, such as in structure and direction, time, leader

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facilitation tasks, and group stage development. The structure and direction for psychoeducational groups are different because of the following reasons: (a) leaders do not usually engage in pregroup screening or have the option to select or reject group members; (b) the leader predetermines the goals and objectives and preplans the focus, emphasis, and activities; and (c) the group is generally closed, not accepting new members after the group begins. Time for psychoeducational groups differs in that the groups generally have a specific duration, such as a predetermined number of sessions over a scheduled period of time, which is communicated to members prior to the group’s beginning. A short duration can mean that there is insufficient time to allow many group processes and therapeutic factors to unfold. Leader facilitation tasks for psychoeducational groups can differ because there is more emphasis on dissemination of information and exploration of family-of-origin factors is discouraged, as is deepening the experience or intensifying emotions. These groups may not be of sufficient length to complete all of the group stages: beginning, conflict/transition, working, and termination. Group leaders have to be emotionally prepared to not have the group experience the productive or working stage, as the process to reach this stage may not have time to be developed. There are numerous similarities with other types of groups, including clinical groups. The group leader’s preparation and facilitation skills, and fundamental group factors are critical components for all types of groups and may be more so for psychoeducational groups because of time constraints. Leader preparation includes instruction and supervised practice in group leadership, understanding of the leader’s personal issues and unfinished business that can produce potential countertransference, and a knowledge base for the issues and conditions that will be addressed in the group. Leader facilitation skills consist of observation and use of group dynamics, a focus on group process, managing problem or difficult member behaviors, enforcing group rules, and identification and repair of empathic failures. Psychoeducational group leaders also have to be aware of fundamental group factors, which include the effect of culture and diversity on group members, ethics and ethical decision making, the importance of group

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therapeutic factors and how to foster their emergence, and creation of the therapeutic alliance.

Historical Context Although Joseph Pratt used psychoeducational groups as the starting point for applying the group modality to treatment in the early 1900s, the actual designation or term psychoeducational groups did not emerge until late in the century, around 1990. Pratt was a physician who decided to treat tuberculosis patients with a structured educational and psychological group approach in which both information dissemination and establishing relationships between group members were emphasized. He also became interested in psychology and began to apply many psychology principles to his group work. Many recognize his work as the beginning of group therapy. Pratt began groups with medically ill patients, and this practice continues even today, with psychoeducational groups conducted for a variety of medical illnesses, such as diabetes, cancer, vascular and cardiac diseases, and AIDS. These groups also have a significant emotional component in treatment and healing. Other areas in which psychoeducational groups are being increasingly used include emotional disturbances such as anorexia and schizophrenia; skills development such as communication and relationship building; caregiver support for those caring for people with cancer and Alzheimer’s disease; court-ordered and incarcerated felons, such as perpetrators of intimate partner violence; training groups for mental health professionals; personal growth and development; life transitions such as career, aging, and divorce; and prevention and wellness. Since the early 1930s, much of the psychotherapy field’s attention, research, and emphasis moved to exploring group processes, leadership, and techniques as applied to group psychotherapy, although many of the groups described and studied could be classified as psychoeducational groups. Another prominent contributor to psychoeducational group development was Kurt Lewin, who created the structure for training groups and experiential learning principles, which led to the development of the National Training Laboratory. Lewin’s other contributions include the use of field theory, understanding how environment influences

behavior, social influences on groups, and the importance and impact of group leaders’ training and facilitation. The principles of experiential learning are key components for psychoeducational groups because much of their emphasis is on learning. Although research and applications attention was given primarily to psychotherapy groups, the outcomes proved applicable to psychoeducational groups as well. Among the contributions that link to psychoeducational groups are those from Wilfred Bion, the work done through the Tavistock Institute, Harry Stack Sullivan, Heinz Kohut and Carl Rogers, and Albert Ellis and Aaron Beck. Bion contributed the group-as-a-whole perspective and the basic assumptions of dependence, fightor-flight, and pairing; focused on the task of the group; and instituted group-as-a-whole interventions, such as group process commentary, where the leader comments on his or her observations of the group as a whole. Tavistock groups emphasized the importance of the leader’s management of boundaries with regard to both time and space. Sullivan proposed the importance of the interpersonal approach; both Kohut and Rogers emphasized the importance of empathy; and Ellis and Beck drew attention to the importance of emotional reactions. Other concepts that grew out of research and theory for psychotherapy groups that also apply to psychoeducational groups include the therapeutic contract, linking or bridging, the critical importance of the therapeutic alliance, curative or therapeutic factors, stages of group development, how important messages are contained in group process, and how the group’s progress can be facilitated with group process commentary.

Theoretical Underpinnings Theories that provide the framework for psychoeducational groups include the learning theories: behavioral, cognitive, constructivist, and connective theories; social-interpersonal theories, such as person-centered and interpersonal theories; and creative/expressive theories and therapies. Behavioral research provides evidence for those theories about how people learn, the role of memory, and how transfer occurs. Cognitive theories demonstrate the importance of conceptualization, clear objectives, reasoning, and problem solving. Constructivist

Psychoeducational Groups

theories include the subjective experiencing of individuals in making meaning and the importance of engagement, participation, and social and cultural factors. Connective contributions include the intersection of prior learning and experiencing, perceptions, and the use of technology. Social-interpersonal theories address relationship building and communication that can enhance relationships and help them become meaningful and enduring. Learning socialization skills is also an important component using social-interpersonal theories. The role of creative/expressive techniques is a significant contributor to these groups, and the theories that underlie their uses provide an understanding of how they can enhance the learning of group members.

Major Concepts The major concepts associated with psychoeducational groups are the components for leaders, the principles of experiential learning, an emphasis on cognitive learning, social interactions and communication with others, and here-and-now experiencing. Components for Leaders

Psychoeducational groups are best if organized around the blended components of the leaders’ knowledge, level of self-development, attention to the structural and science factors for the group, teaching and group process skills, and selection of techniques and strategies. It is helpful when group leaders know the fundamentals about groups, such as group stage development and expected member behaviors, observation and use of group dynamics, the importance of fostering the emergence of group therapeutic factors, specific information about the central focus of the particular group, and the principles of instruction. The leader’s level of self-development is critical for developing the therapeutic alliance, as it is the leader’s essential self that conveys warmth, caring, genuineness, tolerance, and respect. This self-development is also important for cultural and diversity sensitivity, constructive use of objective countertransference, modeling how to manage and contain personal emotions, increasing the capacity to be empathic, and the ability to make process commentary. The importance of the structural and science factors

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cannot be overstated, as these are the factors for optimal positive group functioning to establish trust, safety, and a constructive and positive group climate and to encourage participation. The structural and science leader tasks are planning, organizing, directing, evaluating, structuring sessions, and matching the group members’ needs to the material. Teaching and group process skills help balance the cognitive and affective needs and expectations for the group. Presenting cognitive material can be accomplished in various ways, such as through lectures, discussions, the media, readings, and the Internet. Affective tasks include the skills of facilitating members’ self-disclosure and interactions among members and with the group leader, giving and receiving feedback, encouraging emotional expression, and modeling how to manage conflict constructively and to manage and contain intense feelings. The range of techniques that can be used is vast, and group leaders need to understand how to select techniques that are compatible with the needs of the group and of individual members, to not rely solely on techniques and activities, and to have the facility to demonstrate how these are enhancements to members’ self-understanding, growth, development, and healing. Principles of Experiential Learning

The principles of experiential learning are a major component for psychoeducational groups. The three principles are (1) a social and supportive environment that promotes intrapersonal and interpersonal learning, (2) that learning is enhanced with active participation, and (3) that behavioral change is fostered by the group’s interactions and feedback and by members’ appreciation of one another. Experiential learning includes participation, discussion of group process, as well as group activities. Participation is critical, as research seems to support that the level of involvement can determine personal gains both cognitive and affective. A discussion of the group’s process can produce personal learning and understanding for group members. It seems to be helpful for members to discuss what took place in the group session, such as the level of participation, the group-level resistance, empathic failures and their repair, and other process topics. Group activities offer directed and

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guided opportunities for members to discover unrealized or overlooked inner resources, encourage self-disclosure, increase socialization by encouraging member interactions, assist in reducing resistance and defensiveness, teach new ways to understand self and others as well as new behaviors, and promote the emergence of many group therapeutic or curative factors.

suppressed or denied, when members lack the words, or when they have a need to express feelings and to then provide time and space where group members can feel safe to express these feelings. Opportunities for expressing feelings are also provided through the use of exercises and other activities that facilitate members’ expressions of feelings.

An Emphasis on Learning

Members’ Interactions

A critical component for psychoeducational groups is cognitive learning. Therefore, there needs to be an emphasis on learning, and it is the leader’s responsibility to know the principles of learning and retention of material and to implement these when planning the teaching and learning strategies to maximize them. This component requires that the leader attend to the quality and accuracy of the material disseminated, select the best modality to present the material, schedule the sessions to provide opportunities for members to learn and practice new skills, and identify other resources that can provide the needed information.

Psychoeducational groups can be major opportunities for social interactions, for teaching relating and communication skills, and for members to learn how to give and receive feedback. The interactions among members can address the curative factors of universality, existential factors by reducing isolation and alienation, catharsis with expression of feelings and the interpersonal learning feedback loop described by Irving Yalom, the installation of realistic hope, and opportunities for altruistic actions.

Expression of Feelings

The other critical component is the affective piece, and although it may appear that the focus or topic for the group is very cognitive, the leader is likely to find that the affective piece is more important for some group members. While having a balance of cognitive and affective components is very important, it is essential that the leader maintain space and time for expression of feelings, as these can be the most important part for some members because the group may be the only place where they can openly express some feelings, especially negative feelings. It is essential that the leader assist members in their expression, but it is also essential that the leader not let the members’ feelings become too overwhelming or too intense for individual members or the group as a whole to handle. Feelings can be triggered during discussions when members bring important and urgent matters to group sessions. Comments or other members’ stories, and even lectures in some instances, can also be triggers that cause intense feelings to emerge. Leaders have to remain alert to indirect expressions of feelings, when feelings are being

Here-and-Now Interactions

Psychoeducational groups offer group members encouragement to be in the moment with their thoughts and feelings, to create new ideas and thoughts, and to be able to verbalize these and receive immediate feedback and support. They can learn the value of empathic responding for oneself and for others, strategies for managing intense and difficult feelings, and how to give and receive constructive feedback.

Techniques Techniques are drawn from various theoretical perspectives and can be categorized as dissemination of information, experiential learning, and process enhancement. A defining characteristic of psychoeducational groups is the dissemination of information, which is the cognitive component and one of Yalom’s therapeutic or curative factors. This is also a part of the group’s structure and directions, which are primarily the group leader’s responsibility to plan, develop, and present. Group leaders take into account the abilities and needs of the target audience, select important and helpful information for that audience, and select the mode

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for presenting. Dissemination of information can be accomplished through a variety of ways: expert speakers, the media, print materials, Internet sources, and mini-lectures that provide a modest amount of information at a session. Experiential learning uses the principles developed by Lewin to foster active participation and provide a personal connection to learning for each group member as part of the affective component. Activities and techniques include rehearsal, roleplay, skills practice, and creative/expressive activities such as art, writing, music, drama, stories, such as fairy tales, poetry, and the like. The creative/ expressive activities are used as stimuli but not interpreted by the leader, as would be done by trained professionals in those techniques. Process enhancement refers to the leader techniques and strategies that encourage selfexploration and self-disclosure and provide for emotional expression and member-to-member interactions in the here-and-now. Leader strategies include emotional presence, the identification of empathic failures and their repair, a focus on feelings, and the provision of adequate structure and direction. It can also be helpful for the group leader to openly speak the process commentary when needed.

Therapeutic Process The therapeutic process of psychoeducation groups is similar to that of other types of counseling and psychotherapy groups in that the initial tasks are the same. Those tasks are to establish a therapeutic alliance, provide structure and direction, establish safety and trust, reduce ambiguity and uncertainty, facilitate interactions among group members, and encourage emotional expression. Although the leader may have a predetermined focus and emphasis that has set the major goals and objectives for the group, it is essential that the leader engage members in collaborative goal setting, whereby the members’ individual goals are combined with the purpose and emphasis of the group to develop group goals and objectives that incorporate both. Along with the collaborative goal setting, the leader addresses ethical issues and concerns, such as the need and limits of confidentiality, reporting and documentation requirements, and other expectations of the leader and the members. It is

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also helpful for group members to discuss and collaborate on setting the group’s rules and to understand the expectation for group participation as a member. The therapeutic process also involves efforts to provide some symptom relief, such as a reduction in anxiety; to establish a realistic hope for growth, coping, and healing; and to promote universality among group members. These tasks can be accomplished with the focus on information, identifying member inner resources that will allow members to participate in their own growth and healing, and facilitating the development of coping skills that fit each individual member and his or her circumstances. A general template for sessions begins with an opening that sets the time boundary for the group to begin. This may be a ritual opening, such as a short meditation period, identification of current feelings brought into the group, or a short exercise in the first couple of sessions. The opening provides a transition to the here-and-now for group members and focuses their attention. The leader then provides a session focus and objectives, subject to members’ approval and the absence of something urgent and important a member may need to address or unfinished business from the previous session. The planned procedure then includes information about a predetermined topic related to the mission and purpose of that particular group, identification of members’ emotional connections to that topic, a short discussion, and, when appropriate and when time permits, an activity that encourages disclosure, self-exploration, and enhancement of the material for that session. The session can close with a summary of what transpired, a review of the process for the session, or a transition period of silence or meditation. Leaders are encouraged to establish a consistent procedure for ending sessions. Group closing or termination is an opportunity to consolidate and make visible members’ progress, reinforce the use of members’ personal inner strengths and competencies, provide encouragement and support for continued growth and healing, reflect on and appreciate the altruistic acts of fellow group members and the leader, complete unfinished business among group members, and provide group members with an opportunity to learn more satisfactory ways to end an experience and relationships. There are many activities that

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can be used to provide closure, with the emphasis on the extent to which the members’ and group goals were accomplished, the major cognitive and affective learning gained, what was personally helpful for each group member, feelings about the group and its members, and feelings being experienced about the group’s ending. Nina W. Brown See also Behavior Therapies: Overview; CognitiveBehavioral Therapies: Overview; Creative Arts and Expressive Therapies: Overview; ExistentialHumanistic Therapies: Overview

Further Readings Brown, N. (2011). Psychoeducational groups. New York, NY: Routledge. Johnson, D., & Johnson, F. (2013). Joining together (11th ed.). Upper Saddle River, NJ: Pearson. McFarlane, W. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York, NY: Guilford Press.

PSYCHOSOCIAL DEVELOPMENT, THEORY OF Psychosocial theories emphasize the role of relationships as they relate to psychological and personality development. Erik Erikson’s theory of psychosocial development is the most widely known and applied psychosocial theory, but other notable figures include Arthur Chickering and Linda Reisser, James Marcia, Otto Rank, and Karen Horney. Erickson’s theory is not usually applied as a therapeutic approach; however, the general concepts are frequently used by behavioral health professionals to understand the nature of client problems and their possible origins or underlying issues. This theory is often classified as neoFreudian because of Erikson’s involvement in the psychoanalytical movement and because it shares some similarities with Sigmund Freud’s psychoanalytical theory in terms of how individuals progress through the early stages of psychological development. However, rather than a focus on how instincts drive and shape behavior, the theory of

psychosocial development shifts the focus to how relationships and social needs shape behavior.

Historical Context In the late 1800s and early 1900s, the psychoanalytical movement, championed by Freud, dominated the mental health profession by explaining how instincts and childhood sexuality affect psychological development. Erikson was trained in psychoanalysis and was personally analyzed by Anna Freud, Sigmund Freud’s daughter. Although trained as an analyst, Erikson eventually came to believe that social and cultural factors played a bigger role in development than Freud had suggested. Eventually, Erickson’s ideas developed into a theory of development and were highlighted in his 1950 book Childhood and Society and his 1968 book Identity: Youth and Crisis. In contrast to Freud’s theory, which focused on childhood development, Erikson’s eight stages of psychosocial development emphasized lifelong development and stressed social influences in contrast to Freud’s focus on instincts and childhood sexuality. Erikson’s personal history is compelling, given his influence on the study of psychosocial development and identity. His mother, a Danish Jew, was initially married to a Jewish man, Waldemar Salomonsen. However, when Erikson was born, Salomonsen had been absent for a number of months, and because of Erikson’s blue eyes and blond hair, some believed he was the child of an affair. Eventually, his mother married another Jewish man, Theodor Homberbger, who officially adopted Erikson, giving him the name Erik Homberger. The fact that Homberger was not his biological father was kept from Erikson for a number of years. As a child with light features, he was often teased at school. These early-childhood factors likely influenced his later ideas about the importance of psychosocial factors in identity development, for which he is most famous. As a young adult, he lacked a formal college education and was a free-spirited aspiring artist. Through a friend, he became associated with the psychoanalytical movement and received a certificate from the Vienna Psychoanalytic Society. In 1930, he married Joan Serson Erikson, a Canadian dance instructor, and during the early 1930s, they moved to the United States, where he eventually taught at

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Harvard and Yale and worked as a clinician. While in the United States, he took on his wife’s name and became Erik H. Erikson, representing the third name change in his life, a notable event for the person who is associated with the concept of identity crisis. He died in 1994 and, along with Jean Piaget, is considered to be one of the two most prominent figures in developmental psychology. Although Erikson is the primary historical figure in psychosocial theory, others also made significant contributions. Karen Horney also influenced psychoanalytical theory by including more psychosocial elements. In the 1930s through the 1950s, she postulated that social power was a more important factor in neurosis than was biology, the focus of Freud’s theory, and she integrated more social and cultural themes into the framework. Alfred Adler, during this time frame, also highlighted social themes, such as the importance of birth order and one’s position in one’s family, as major elements of psychological development. Several researchers have explored in greater detail Erikson’s ideas on identity development. In the 1960s and later, James Marcia studied the identity development of teenagers and young adults and developed four types of identity statuses based on exploration and commitment levels. These are outlined in the “Major Concepts” section of this entry. Arthur Chickering wrote Education and Identity in 1969 and revised the book later in 1993 with Linda Reisser. They expanded Erikson’s theory by focusing on the stages of identity development while focusing mainly on traditional college students. Psychosocial theory of development has been influential throughout the history of the various mental health professions. The core ideas are taught in undergraduate and graduate courses in psychology and related professions. In addition, Erikson’s theory has substantially directed mental health professions by highlighting the importance of relationships and cultural influences.

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psychoanalytical ideology. However, his focus on relationships and culture demonstrate elements of systems, humanistic, and multicultural perspectives. Because of the fundamental similarities between Erickson’s theory of psychosocial development and Freud’s psychoanalytical theory, it has been named a contemporary psychodynamic or neo-Freudian approach, although the latter term is often debated. The similarities begin with the stage model of psychological development. Both theories believe that age-related developmental tasks or crises related to not fulfilling those tasks guide personality development. Therefore, in both theories, early-life experiences affect development over the life span. Success in one task promotes the likelihood of success in the next task, while problems during one stage can lead to long-term impediments to psychological development. Freud’s tasks related more with physical needs, whereas Erikson focused on social needs. For example, the first stage for Freud’s model is the oral stage, where infants receive physical gratification through feeding and other oral behaviors. The first stage in Erikson’s model is trust versus mistrust, where infants learn to view the world as a safe or unsafe place. Psychosocial theory also has post-Freudian influences connected to attachment theory. John Bowlby and Mary Ainsworth, key figures in attachment theory, highlighted the role of emotional bonds with caretakers as a key component of psychological development. Many researchers now believe that early bonding experiences affect adult relationships and that attachment styles can have lifelong implications.

Major Concepts Although Chickering and Reisser, Marcia, and others have all developed psychosocial theories that have been applied to counseling relationships, Erikson’s approach is considered the most widely used. Therefore, this section briefly describes Erikson’s eight stages of development.

Theoretical Underpinnings Many researchers struggle with classifying psychosocial theory of development from a philosophical and theoretical perspective. Erikson’s theory of psychosocial development, the most widely applied psychosocial model, is deeply rooted in

Trust Versus Mistrust

The first psychosocial stage in Erikson’s model is from birth to approximately18 months of age. This is a time when a child is building the virtues of hope and faith. The individual needs to find a healthy

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balance between stability (trust) and a healthy degree of apprehension with others (mistrust). Autonomy Versus Shame and Doubt

The second stage in Erikson’s theory of development revolves around willfulness and determination. A child 18 months to 3 years of age needs to independently explore his or her world but with some healthy boundaries set by caretakers. Autonomy is developed when caretakers allow children to explore and make choices with fewer restrictions. If caretakers overly restrain children, then the children experience a lack of self-reliance and a sense of doubt that could impede future development. Initiative Versus Guilt

Play is a key factor in this third stage of Erikson’s model for 3- to 6-year-olds. A child is striving to create courage and purpose as part of his or her ego. A healthy proportion needs to occur between learning new things (initiative) as well as taking on responsibility and moral judgment. Children should be encouraged to act on fantasy and imagination. They learn new skills and a sense of purposefulness through these experiences. However, a healthy balance must be achieved. If children focus on their objectives without a sense of guilt toward others, then according to Erikson, they become maladaptive and ruthless.

from the irresponsibility and powerlessness of childhood into the responsibility and power of adulthood. This stage is where the individual begins to learn to live within the rules of society, along with understanding “who” the individual is within that society. When adolescents appropriately explore a variety of roles and activities, they strengthen their sense of self. If they fail to explore these possible identities, then they develop a sense of role confusion, which represents a weak sense of identity. Intimacy Versus Isolation

In this stage of Erikson’s model, people around the approximate ages of 20 to 40 years are focused on close and intimate relationships with others within society while maintaining a healthy balance of not losing themselves within the relationships or isolating themselves from relationships. Generativity Versus Stagnation

This stage in Erikson’s model revolves around raising children and giving back to society. Between the approximate ages of 20 and 60 years, individuals involve themselves not only with other individuals, particularly children, but also with organizations. Many individuals in this stage seek a healthy balance centered on caring for oneself (self-absorption) as well as for others (generativity). Stagnation occurs when individuals become too self-absorbed.

Industry Versus Inferiority

Integrity Versus Despair

Within this stage of Erikson’s model, 6- to 12-year-olds are influenced by more than just caretakers and family, as this is the time when school becomes a key factor, with teachers and peers playing a larger part in children’s lives. In this stage, social skills are a focus for the individual to form competence. As children develop skills and competencies, their sense of industry and confidence increases. A sense of inferiority occurs when these new challenges are not mastered successfully, and children begin to lack confidence. A healthy balance between a sense of competence along with a realization of limitations is needed.

This stage in Erikson’s model begins around the period of retirement, usually around the age of 60 years. This is a time in one’s life when an individual reflects on the past with satisfaction (integrity) or regret (despair), which in turn affects one’s present outlook on life.

Identity Versus Role Confusion

Within this stage, a rite of passage is beneficial for adolescents (12- to 20-year-olds) to progress

Therapeutic Process Psychosocial theory provides a structure for understanding the psychological development of clients and the underlying causes of their psychological problems. Many mental health professionals are aware of this theory and use it as a lens from which to understand client stagnation and as a barometer to monitor client growth. As a distinct model, it does not offer a system for treating clients, although the principles of the model apply well to the therapeutic

Psychosocial Genomics

process. Counselors may use this model to reframe common client issues within a developmental context. For instance, a teenager who is fighting with her parents may not be labeled as dysfunctional but instead may be considered to be exploring identity development. Or a 45-year-old client who is feeling anxious may be wrestling with a lack of being successful in his life (i.e., in the generativity vs. stagnation stage). He may need more time for volunteering or spending time with his family. Although the psychosocial theory of development model does not provide techniques for counseling, it may utilize any treatment objective that promotes the successful completion of Erickson’s eight stages of development. Psychosocial theory, thus, can be extremely valuable for case conceptualization and for developing insight with clients. Trey Fitch and Jennifer Marshall See also Attachment Theory and Attachment Therapies; Ego Psychology; Freudian Psychoanalysis

Further Readings Berk, L. E. (2013). Development through the lifespan (6th ed.). New York, NY: Pearson. Chickering, A. W., & Reisser, L. (1993). Education and identity. San Francisco, CA: Jossey-Bass. Erikson, E. H. (1950). Childhood and society. New York, NY: W. W. Norton. Erikson, E. H. (1958). Young man Luther. New York, NY: W. W. Norton. Erikson, E. H. (1968). Identity: Youth and crisis. New York, NY: W. W. Norton. Marcia, J. E. (1966). Development and validation of ego-identity status. Journal of Personality and Social Psychology, 3, 551–558. doi:10.1037/h0023281 Santrock, J. (2013). Lifespan development (14th ed.). New York, NY: McGraw-Hill.

PSYCHOSOCIAL GENOMICS Psychosocial genomics explores how an individual’s positive encounters with art, beauty, and truth as well as stress and trauma can modulate gene expression, brain plasticity, and the creation of new consciousness. Psychosocial and cultural genomics is the science of how transformational states of mind, body, and spirit can be facilitated during counseling and

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psychotherapy. The holistic arts of mind–body healing from ancient times to the current era of personal genomics are embraced within this new evidencebased theory of counseling and psychotherapy.

Historical Context The psychosocial genomics of mind–body healing was conceived in the 1960s by Ernest Rossi during his 2-year U.S. Public Health Post-Doctoral Fellowship in Clinical Psychology studying psychosomatic medicine with the physician Franz Alexander. Psychosomatic medicine studies the impact of psychosocial and behavioral factors on physical health and life quality standards. At the time, Alexander was a leading Freudian analyst teaching in the psychiatry department at Mount Sinai Hospital in Los Angeles, California. Rossi initially summarized his observations of Alexander’s work with two publications in The Journal of Humanistic Psychology, where he introduced the four-stage creative cycle as the essential dynamic of counseling and psychotherapy. Stage 1 of the four-stage creative cycle is getting interested in working on a problem. Stage 2 is the typically difficult experience of incubation, struggle, emotions, and conflict. This second stage is when many people experience symptoms of stress, anxiety, or depression that lead them to consult a psychotherapist. Stage 3 is the creative moment of getting a flash of insight often described as an “aha!” experience. Stage 4 is the application of this insight for problem resolution in the real world. The four-stage creative cycle of inner experience is an approach for counseling and psychotherapy, whereby the basic problem is to bring together a mass of data (one’s personal experiences) so that new insights (aha! experiences) can generate a better integration of cognition, consciousness, and personality. This new integration of human psychology with biology based on current neuroscience includes gene expression research on social variables, the relaxation response, therapeutic hypnosis, meditation, the therapeutic placebo, and yoga. People frequently feel an immediate sense of relief and purpose about exploring their natural creative cycle when they can understand how their feelings of depression, tension, anxiety, and confusion, in Stage 2, are the natural symptoms of a profound widening of consciousness, or self-awareness, that takes place because of new

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academic and social experiences. Instead of focusing on the typically negative reactions of despair and inadequacy about emotional problems, during Stage 2 of the creative cycle, people are helped to reinterpret and reframe their symptoms as positive life possibilities, which in turn can facilitate the natural growth of their consciousness. In the 1970s, Rossi continued his postdoctoral studies with Milton H. Erickson, who was the founding editor of The American Journal of Clinical Hypnosis and the innovator of a new naturalistic school of therapeutic hypnosis. A distinguishing feature of Erickson’s therapeutic sessions was that they usually lasted 90 to 120 minutes, about double the 50-minute session of conventional counseling and psychotherapy. Rossi hypothesized that Erickson’s long therapeutic sessions shared many features of the human biological cycle known as Basic Rest-Activity Cycle (also called ultradian rhythms). Like cycles of breathing, blood circulation, bowel activity, and appetite, ultradian rhythms were correlated with optimal performance, stress reduction, and healing in normal everyday life. To explore the natural psychobiological sources of Erickson’s mind–body therapy, Rossi coedited two volumes of international research on ultradian rhythms with David Lloyd, a professor in the School of Pure and Applied Biology at the University of Wales. Charles Darwin wrote in his classical volume on The Origin of Species that while we see evidence of how evolution progresses over millions of years, the work of evolution actually proceeds on a daily and hourly basis. Psychosocial genomics facilitates the natural daily and hourly evolutionary work of optimizing adaptive gene expression.

and joyful life experiences, could activate DNA in the new science of epigenetics, which integrates mind, nature, and nurture. Epigenetics is the study of how gene expression changes due to signals from the environment. Important life experiences can turn on epigenomic patterns of activity-dependent gene expression to make the proteins, hormones, neurotransmitters, and growth factors needed to generate the growth of new neural networks in the brain. This became the central insight of psychosocial genomics as a new evidence-based theory, research, and practice of counseling, meditation, and psychotherapy. In 2012, a major breakthrough for the theoretical and experimental underpinning of psychosocial genomics was implied in the simultaneous publication of 30 leading papers by the Encyclopedia of DNA Elements (the ENCODE Project) in major scientific journals such as Nature, Science Genome Research, and Genome Biology. Figure 1 illustrates how the psychosocial genomics of mind–body therapy can be conceptualized as an integration of the four-stage creative cycle with mind–body rhythms on all levels from mind to gene. The top circle of Figure 1 represents classical psychological research with the addition of the more recent emphasis on consciousness studies of art, beauty, truth, and creativity in current neuroscience. Key research at this top level explores how focused attention, positive expectations, and the novelty–numinosum–neurogenesis effect (fascinating, mysterious, and tremendous experiences) tend to evoke the four-stage creative cycle during important life opportunities and crises.

Theoretical Underpinnings

While the psychosocial genomics of counseling and psychotherapy has its theoretical and experimental underpinning firmly rooted in the sciences of math, physics, biology, and genomics, its existential or humanistic aspect is most commonly expressed in the dramas, literature, and psychology of the arts and humanities.

During the 1980s and 1990s, neuroscientists made many startling discoveries documenting how mind– gene communication, cognition (thinking), and consciousness are created on the molecular–genomic (biological–genetic) level in daily life. They learned how novelty, activity, and life experiences could turn on gene expression, stem cell healing, and brain plasticity, which documents how normal daily life experience rewires the circuitry of the human brain. Suddenly, there was a new understanding of how psychological stress and trauma, as well as insightful

Major Concepts

Integrating the Twin Cultures of the Sciences and the Humanities

The educational opportunities as well as social disruptions of the twin but seemingly opposite

Psychosocial Genomics

• • • •

Neuroplasticity • Synaptogenesis • Neurogenesis • Memory • Learning

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Art, Beauty & Truth Attention Expectancy Novelty/Numinosum Enrichment

1 Mind Crisis/Opps

Bioinformatics • Activity • Sensory • Perceptual • Motor

4

2

Brain & Body

Mirror Neurons

Insight/Apps

Intuition

3 • • • •

mRNA Translation Proteins Neurotransmitters Hormones Cytokines

Genomics Adapt/Heal

eRNA Transcription • ~2 Million Micro RNAs • Gene Modulation • Cellular Messengers

Gene Expression DNase Sites ~ 3 Million • • Promoters • Transcription/Translation

Figure 1 The Core Four-Stage Cycle of Psychosocial Genomics Source: E. Rossi, R. Erickson-Klein, & K. Rossi (Eds.), Collected Works of Milton H. Erickson, M.D. on Therapeutic Hypnosis, Psychotherapy and Rehabilitation (16 vols.). Phoenix, AZ: Milton H. Erickson Foundation Press (2008–2014). Note: (1) Experiences of mind are transformed into (2) eRNA molecules in mirror neurons of the brain that turn on (3) genomics—patterns of gene expression that facilitate adaption and healing by (4) optimizing brain plasticity to create new insights for resolving human problems.

perspectives of the sciences and the humanities were well documented by C. P. Snow in his 1959 classic book The Two Cultures and the Scientific Revolution. Psychosocial genomics is the art and science of

facilitating adaptive or healing gene expression and brain plasticity within the daily and hourly work of creating new consciousness and personal identity during important life turning points.

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Important Life Turning Points

Integrating the scientific and the existential or humanistic perspectives in counseling and psychotherapy during important life turning points is a challenge. Many personal problems involving anxiety, fatigue, stress, and feelings of inadequacy can be traced to being stuck in Stage 2 of the creative process. The same can be said of many social issues, such as crime, prejudice, terrorism, and war, as well as business downturns and economic depressions on local, national, or international levels. Psychosocial genomics makes the broad claim that all these personal, cultural, social, and business issues are examples of being stuck in Stage 2 of the four-stage creative cycle.

Techniques Psychosocial genomics’ focus on the four-stage creative process for resolving human problems is evident in its therapeutic techniques. These include a review of the creative aspects of a person’s dreams and early-morning thoughts, the process of self reflection in dreams, and facilitating optimal cycles of circadian and ultradian healing in everyday life.

movie. Individuals are encouraged to self reflect on their dreams relative to their identity and consciousness. Facilitating Optimal Cycles of Circadian and Ultradian Healing in Everyday Life

Learning how to recognize and facilitate optimal cycles of circadian and ultradian creativity and healing in everyday life is a basic therapeutic technique of psychosocial genomics. Ultradian rhythms are the fundamental epigenomic regulators of mind–gene communication that turn on activitydependent gene expression, brain plasticity, and the creation of new consciousness. Most people do not recognize that they have choices in the expression of their natural, four-stage Basic Rest-Activity Cycle, which occurs about 12 times a day. Every 90 to 120 minutes, individuals experience choice points where, with proper training, they can alter this cycle. Every 90- to 120-minute therapy session of psychosocial genomics is a life lesson on how to convert the ultradian stress syndrome into the ultradian healing response.

Therapeutic Process Dreams and Early Morning Thoughts

People are encouraged to linger in bed on awakening for about 20 to 30 minutes, recalling and recording their dreams and early morning thoughts. The first hour or two after awakening are usually the clearest of the day. This is the period when one can learn how to become aware of the new consciousness. This is the ideal time for receiving and realizing the novelty–numinosum–neurogenesis effect, which is when interesting, strange, or unusual cognitions, emotions, and/or images of dreams can become seeds for creating new consciousness and identity. Self Reflection in Dreams

People’s dreams frequently function as a selfreflective apparatus that mirrors their internal world. Typically, dreams are of two types: (1) common experiential dreams, in which the dreamer simply recalls experiencing a vivid here-and-now drama, and (2) observer dreams, wherein dreamers observe themselves in dream dramas as if in a

A psychosocial genomic overview of how mind, brain, and body cocreate each other daily and hourly is illustrated with the Creative Psychosocial Genomic Experience (CPGHE), also known as Mind-Body Healing Experience. The CPGHE is a 20- to 30-minute therapeutic protocol used to activate mind–body healing and problem solving via gene expression and brain plasticity. While the formal administration of the freely available CPGHE can be an impressive introduction to the healing experiences of psychosocial genomics, there are infinite variations that can be developed to fit the needs of most individuals and situations in counseling and psychotherapy. To document the efficacy of the CPGHE and its variations is the most important clinical and research challenge facing psychosocial genomics today. There are many new technologies being developed currently to assess therapeutic mind–body transformations that could be adapted to document the evidence-based psychosocial genomic healing before, during, and after each session. Ernest Lawrence Rossi and Kathryn Lane Rossi

Psychosynthesis See also Complementary and Alternative Approaches: Overview; Creative Arts and Expressive Therapies: Overview; Cyclical Psychodynamics; Erickson, Milton, H.; Maslow, Abraham; May, Rollo; Positive Psychology; Psychosocial Development, Theory of

Further Readings Lloyd, D., & Rossi, E. (Eds.). (1992). Ultradian rhythms in life processes: A fundamental inquiry into chronobiology and psychobiology. New York, NY: Springer-Verlag. Lloyd, D., & Rossi, E. (Eds.). (2008). Ultradian rhythms from molecule to mind: A new vision of life. New York, NY: Springer. Rossi, E. (2000). Dreams, consciousness, spirit (3rd ed.). Phoenix, AZ: Zeig, Tucker & Theisan. Rossi, E. (2002). The psychobiology of gene expression: Neuroscience and neurogenesis in hypnosis and the healing arts. New York, NY: W. W. Norton. Rossi, E. (2007). The breakout heuristic: The new neuroscience of mirror neurons, consciousness and creativity in human relationships (Vol. 1; Selected papers of Ernest Lawrence Rossi). Phoenix, AZ: Milton H. Erickson Foundation Press. Rossi, E. (2012). Creating consciousness: How therapists can facilitate wonder, wisdom, truth and beauty (Vol. 2; Selected papers of Ernest Lawrence Rossi). Phoenix, AZ: Milton H. Erickson Foundation Press. Rossi, E., Erickson-Klein, R., & Rossi, K. (Eds.). (2008–2014). Collected works of Milton H. Erickson, M.D. on therapeutic hypnosis, psychotherapy and rehabilitation (Vols. 1–16). Phoenix, AZ: Milton H. Erickson Foundation Press. Rossi, E., & Rossi, K. (2013). Creating new consciousness in everyday life: The psychosocial genomics of self creation. Seattle, WA: Amazon Digital Services. (A Video eBook available at Amazon.com)

PSYCHOSYNTHESIS Psychosynthesis is a humanistic and transpersonal approach to psychotherapy and counseling. While it has a set of core principles, psychosynthesis is an open approach that continues to be developed by practitioners as new understanding of the human psyche and effective methods of psychotherapeutic intervention are discovered. While the early stages of psychosynthesis psychotherapy have similarities

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to psychoanalysis, psychosynthesis posits that a client is more than reactions to past conditioning and childhood development and has a discrete, realizable core self, contact with which enables him or her to be self-directive, have a sense of purpose, and have an active impulse toward service. Finding this core self within enables a client to reach the heights as well as depths of the psyche; contact a deeper Transpersonal Self, which is universal to all life; and realize all experiences as part of a larger, collective expression of an inner spiritual nature. A psychosynthesis psychotherapist facilitates conditions in which a client may become more centered on this core self, develop the ability to control previously divisive elements of his or her behavior, restructure the personality around this new core self, and realize the essential goodness in all life. The development of will and imagination is an essential component in the practice of psychosynthesis, as is engaging in a nondenominational and personally relevant spiritual practice. While it is primarily used in psychotherapy, psychosynthesis is also applied in education, social work, medicine, business, parenting, and all human interactions and endeavors. Some of its techniques, particularly subpersonality work, have influenced and been incorporated into various other therapeutic models.

Historical Context Roberto Assagioli, an Italian doctor who trained in psychoanalysis, began developing psychosynthesis in the early 20th century, devoting his life to uncovering human potential and exploring the various methods that have been discovered to achieve this. Strongly influenced by concepts and techniques from both Eastern and Western mystery traditions and, later on, the humanistic approaches of Carl Rogers and Abraham Maslow, Assagioli created an approach to psychotherapy that is essentially person centered, with an emphasis on empathy and genuineness but with a directive, educational aspect concerning the actualization of a client’s potential. Since Assagioli’s death in 1974, psychosynthesis continues to be developed and applied in both counseling and psychotherapy. While this development was encouraged by Assagioli, especially with regard to incorporating discoveries from modern research, for instance in

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neurobiology, psychosynthesis has a unique and congruent theoretical center.

Theoretical Underpinnings At the core of psychosynthesis theory is the “egg diagram,” a map of the psyche, which underpins all its major concepts and practices (see Figure 1). Analyzing the psyche through an understanding of its various component parts enables the psychotherapist and the client to work together to put the parts back together into a more effective whole, a synthesis of the previously unintegrated parts. A core self is developed from where a client can more effectively direct his or her life. The aim is not to reach a goal but to engage with the process of life in the spirit of inquiry. The egg diagram includes four distinct but interconnected levels—(1) lower unconscious, (2) middle unconscious, (3) higher unconscious, and (4) collective unconscious—the difference between them being developmental rather than hierarchical. The lower unconscious, corresponding

6 7 3 5 4 2

1 7 Figure 1

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Psychosynthesis Egg Diagram, Formulated by Roberto Assagioli

Source: Psychosynthesis Online/Graeme Wilson/Wikimedia Commons. Note: This diagram depicts various aspects of consciousness as described in psychosynthesis: (1) the lower unconscious; (2) the middle unconscious; (3) the higher unconscious; (4) the field of consciousness; (5) the conscious Self, or “I”; (6) the higher Self, or Transpersponal Self; and (7) the collective unconscious.

to the Freudian subconscious, includes repressed complexes, long-forgotten memories, drives, instincts, and physical functions over which a client (ordinarily) has no conscious control. In therapy, the focus is primarily on the repressed material, often presented by a client as phobias, obsessions, and compulsive urges. The middle unconscious contains material readily accessible to a client, including the thoughts and feelings of everyday life and present or recent experiences; of primary concern in psychotherapy is that which a client, for one reason or another, is choosing not to bring into awareness. The higher unconscious is where a client experiences the deepest sense of an aspiration toward meaning, inspiration, and creativity, and it is the major area of exploration at later stages of psychotherapy concerned with actualizing a client’s potential. The collective unconscious is common to everyone, and there is a constant, active interchange between us and other sentient beings, whether we are aware of it or not. Each client has a personal self, his or her “I,” an unchangeable center that experiences the client’s different states of consciousness, including all thoughts, emotions, and sensations, but in itself is none of these. Generally, the personal self is not experienced in a clearly defined way, and a major part of psychosynthesis psychotherapy is preparing the ground for and helping an individual contact this “I” and make it a living, experienced reality in his or her consciousness. Awareness of the personal self is a primary goal of psychosynthesis as this helps a client effectively direct his or her personality. The personal self is a reflection or spark of the spiritual or Transpersonal Self, which is universal and unaffected by an individual’s conscious experience. Becoming more centered on the personal self may lead a client to clearer contact with and understanding of the Transpersonal Self, not through transcendent experiences but directly through the personality and its interactions with the outer world.

Major Concepts Each human is a fundamentally healthy organism in which there is a temporary complaint or breakdown. Pain, crisis, failure, and all other clientpresenting issues are framed as opportunities for

Psychosynthesis

growth and essential parts of the client’s life purpose. Holding psychotherapy within a transpersonal context reframes and confers meaning to a client’s issues and engenders creativity and inspiration. The Balancing and Synthesis of Opposites

We live in a world of polarities in our inner world no less so than in the outer, so our world experience is based on duality and we are divided within. Psychosynthesis stresses the importance of each part of the psyche, or subpersonality, being made whole in itself before it can be truly synthesized with other parts. Two Dimensions of Growth

Everyone has a personality and a self, so a psychotherapist holds an inclusive bifocal vision, seeing each client as both personality and self, thereby working toward healing (wholeness) both in the everyday world and in relation to the client’s innermost, creative nature. Self-Identification and Disidentification

Through conscious disidentification from the contents of the personality and identification with the self, a client is enabled to direct and harmonize his or her subpersonalities. The Will

Activation of a client’s will increases the client’s capacity to make choices that enrich rather than limit life and that offer the potential for psychospiritual freedom. Spiritual Emergence and Repression of the Sublime

The emergence of previously suppressed or repressed spiritual material is usually accompanied by crisis, offering an opportunity for change and growth.

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Valuing life requires a self-commitment to act in cooperative and responsible ways. Importance of Grounding

Spiritual and transpersonal energies need grounding both for the psychological health of the client and for the treasure such experiences can bring to our world.

Techniques Psychosynthesis is open to development, and each psychotherapist may include techniques from a variety of influences and sources, but there are core techniques that give psychosynthesis its distinctive flavor and direction. Each client has a personal self, reachable through the development of the will, which when contacted helps organize, and ultimately synthesize, all the various parts of the client’s personality. Analytical Inquiry

Through active dialogue and exchange, a psychotherapist evokes an understanding of the workings of the client’s psyche, increasing awareness and discrimination. Tendencies traced back to early development and childhood are explored, always within an understanding that even apparently negative life issues offer the client a creative opportunity for change. Where appropriate, a client might be invited to keep a psychological workbook to facilitate this aspect of the work. Subpersonality Work

Each personality is composed of lots of different parts, called subpersonalities, all having their own needs and desires. Each subpersonality, even those with conflicting thoughts and feelings, has a part to play in a client’s life. Identifying and exploring subpersonalities bring more clarity about their conflicting needs and enable a client, through meeting these needs, to reduce conflict between opposing subpersonalities.

Essential Interconnectedness

Humans are interconnected and interdependent beings, each individual being part of a larger whole with local, social, and global responsibility.

Disidentification and Self-Identification

A basic underlying principle in all psychosynthesis psychotherapy is that we are controlled by

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everything with which our self becomes identified and, conversely, we can gain control and have choice over everything from which we disidentify ourselves. Disidentification involves the client stepping back consciously from limiting identities, attitudes, and outdated roles and beliefs to gain greater perspective and choice. A useful analogy compares subpersonalities to the members of an orchestra; the personal self is the conductor of the orchestra, and the Transpersonal Self is the source of the music.

transmuted or resolved, and build a positive image of a desired state and a sense of a deeper purpose. Meditation and Inner Silence

Meditation, including reflective, receptive, and creative forms, may be introduced, along with techniques for the evocation of serenity and the creation of inner and interpersonal silence. Meditation may enhance mental and emotional development, a clearer sense of identity, and transpersonal exploration.

Purpose and the Creative Will

Although not necessarily directly applied with a client, the therapist is aware of the six stages in the act of will: (1) investigation, (2) deliberation, (3) decision, (4) affirmation, (5) planning, and (6) execution. Various exercises might be introduced for developing a client’s capacity to make healthy, deliberate choices and to connect with a sense of life purpose and motivation. A relationship with the will is encouraged not through struggle or “power over” but in a fluid and easy manner. Imagery and Visualization

Imagery and visualization are used to explore a client’s unconscious, inner processes and to stimulate personal, interpersonal, and transpersonal growth. Imagery, whether guided, spontaneously arising, or from dreams, may help a client draw out and understand aspects of his or her unconscious and express inner wisdom in a stimulating way, connect to inner processes, and work with underdeveloped parts of the psyche. Acceptance and Change

In accepting pleasure, without a craving for it and attachment to it, and in accepting pain, when unavoidable, without fearing it and rebelling against it, a client can learn from both pleasure and pain and can create the space in life for change or not, as appropriate.

Therapeutic Process The aim in psychosynthesis psychotherapy is for a client to become more aware of his or her true self, to become increasingly autonomous while building a sense of interconnectedness with all other living beings, to connect more deeply to a sense of inner purpose and meaning in his or her life, and to be better able to make more effective life choices. While it is rarely linear in practice, psychosynthesis psychotherapy has distinct stages. Analytical inquiry, which helps the client gain knowledge of his or her personality and its behavior patterns, is followed by focusing on ways to control and integrate the various parts of the personality, primarily through disidentification and the creation of a strong center or “I.” Once a strong connection with this “I” is made, the next step is the reconstruction of the personality around this center. These stages can last from a few sessions to many years. For many people, personal psychosynthesis is enough, as it helps them become more harmonious individuals, well adjusted within themselves and within the communities or groups to which they belong. However worthy an achievement this may be, for some clients, it is not enough, and they touch on a need inside to develop spiritually as well. Transpersonal psychosynthesis explores the spiritual regions, areas beyond our ordinary awareness where we find the source of intuition and a sense of value and meaning in life. Will Parfitt

The Ideal Model

The psychotherapist helps the client create a vision or sense of the client’s potential, often with regard to problems that can be envisioned as

See also Existential Therapy; Integrative Body Psychotherapy; Mindfulness Techniques; PersonCentered Counseling; Transpersonal Psychology: Overview

Pulsing

Further Readings Assagioli, R. (1974). The act of will. London, England: Wildwood House. Assagioli, R. (1975). Psychosynthesis: A collection of basic writings. London, England: Turnstone Books. Ferrucci, P. (1982). What we may be: The visions and techniques of psychosynthesis. Wellingborough, England: Turnstone Press. Firman, J., & Gila, A. (2002). Psychosynthesis: A psychology of the spirit. New York: State University of New York Press. Parfitt, W. (2006). Psychosynthesis: The elements and beyond. Glastonbury, England: PS Avalon. Whitmore, D. (1991). Psychosynthesis counseling in action. London, England: Sage.

PULSING Pulsing, also known as Pulsing Rhythmic Bodywork, is a form of somatic therapy that employs rhythmic and rocking manipulation of the body as the primary means of encouraging emotional release and the dissolution of body armor (i.e., chronic muscular tension that reflects repressed emotions). It is a significant development of the Trager approach of somatic education within a conceptual framework that embraces the Reichian theory of body armor. It works indirectly with body armor to avoid the trauma that can often accompany the de-armoring process. Pulsing is presented as a form of somatic self-experiencing and does not take a diagnostic approach that focuses on specific treatments for symptoms; however, some practitioners offer an approach that works more explicitly with the client’s ongoing therapeutic process.

Historical Context Pulsing was developed in the late 1970s by Curtis Turchin, a doctor of chiropractic in California, trained in both the Trager approach (a physical therapy) and Postural Integration (a somatic psychotherapy). He appreciated Trager for its nurturing, respectful, and supportive approach to the client and came to the view that this style of work would be highly suited to assisting the release of body armor. He developed his own Trager-inspired

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style of bodywork that included greater emphasis on the skeletal system and on whole-body experience, set within a framework of somatic psychology, likely derived from Postural Integration. Turchin visited the United Kingdom in 1978 and gave a demonstration of Pulsing at the Open Centre (one of the longest established centers for bodymind development in the United Kingdom). Some of the participants persuaded him to return the following year to train them. Subsequently, the Open Centre became the main center for Pulsing development and training worldwide.

Theoretical Underpinnings Pulsing draws extensively on somatic education systems. These are primarily physical therapies, ones chiefly concerned with the remediation of pain and discomfort in movement caused by maladaptive physical habits developed as a result of injury, poor posture, or emotional stress; they seek to mitigate pain by reeducating the muscles into a more natural and healthy state. However, the theoretical basis of Pulsing extends this view in its acceptance of the Reichian theory of body armor (see next section). It combines hands-on bodywork (in the form of rhythmic manipulation of the musculoskeletal system) with conventional verbal psychotherapeutic techniques to encourage mindfulness, emotional expression and release, and the dissolution of armor.

Major Concepts Three major concepts of pulsing are bodymind, body armor, and mindfulness. Bodymind

Bodymind is a term from humanistic psychology that proposes an alternative to Cartesian mind–body dualism. Bodymind refers to a unified system in which the mind, body, and spirit are dynamically interrelated and changes in one area propagate throughout the whole system. Body Armor

Body armor may be thought of as patterns of chronic muscular tension that not only reflect repressed emotions but also are the mechanism

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through which emotions are repressed. By hardening and desensitizing areas of the body, unwanted feelings may be controlled or excluded from conscious awareness (e.g., deep pelvic tension to both minimize and avoid awareness of sexual excitation). Mindfulness

This traditional Buddhist practice was adopted by Gestalt therapy and by somatic psychologies and is now becoming a mainstream approach. It can be thought of as maintaining a watchful and nonjudgmental awareness of self: the presence and movement in and out of consciousness of thoughts (including imagery and fantasy), emotions, sensations, and states. It may also include comprehension of how these are related or triggered by external or internal stimuli.

Techniques Pulsing promotes safe regression of the bodymind. The primary aim of the practitioner is to help the client reconnect with pleasure to his or her innate movement potential and the freedom and vibrancy of both mind and body that is the inherent state of the bodymind prior to any armoring that has occurred. Some of the more important techniques include rocking, musculoskeletal manipulation, breathwork, and contact. Rocking

The principal feature of Pulsing is that the practitioner maintains a rhythmic rocking of the client’s body throughout the session. The speed and intensity may be varied at times, but there is always a return to a baseline rhythm that is close to a normal fetal heart rate of 120 to 160 beats per minute. It is hypothesized that the rocking recalls the gentle sway experienced by the fetus in the womb or the infant in a cradle. Rocking is also a universal method of self-soothing, while rhythmic movement features in many spiritual practices. The soothing and entrancing rhythm allows for safe regression into a supported and nurturing space. Musculoskeletal Manipulation

While there is some massage of soft tissue, the primary focus is on the skeletal system. The limbs are subjected to various manipulations: pushing–pulling,

lifting–dropping, rotating, and swinging. The application of force in this way opens up a compressed skeletal system, separating the bones and so encouraging the muscles to conform to the changed skeletal pattern. There is also extensive work on the neck, which is viewed as the pathway connecting the mind and the body. Breathwork

Particular attention is given to working the intercostal muscles and freeing the ribcage using a compression–release technique. This aims to encourage fuller and deeper breathing and to promote emotional expression and release. Contact

Pulsing operates at the contact boundary (a term from Gestalt therapy)—the place where the client and the practitioner literally touch—and also bring awareness to the subjective experience of that touch (physical, emotional, and psychological reactions). The practitioner’s use of manipulation of the body combined with verbal interventions encourages the client to shift from simple perception of sensation to a deeper awareness and expression of repressed emotions.

Therapeutic Process A session normally requires one full hour of handson work. It is performed with the client on a massage couch that is wider and more deeply padded than standard couches. The practitioner begins by working on the head and neck, followed by the limbs, and then the torso. The usual practice is to first work the front of the body and then the back. At the end, the client is asked to give a brief feedback on what has been experienced; this may be at greater length with process-oriented work. Pulsing takes a pleasurable and playfully provocative approach to de-armoring. It may be performed in various tones (e.g., nurturing, playful, or cathartic), and indeed, these are often all present within a single session. Within the overall framework of nurturing and supportive rocking, there is likely to be a flow of peaks and troughs, a wave of physical and emotional movement that may range from cathartic expression to profound tranquility. The rocking creates a safe space, while the gentle rhythm has an almost hypnotic effect

Pulsing

that perhaps lulls body armor, thus allowing repressed emotions to surface. The experiencing of pleasure in movement during a session is a key part of the process. Clients tend to report feeling deeply relaxed and energized by a session. This in itself has a positive impact on the client’s sense of well-being; more significantly, it provides an immediate felt benefit to set against the more nebulous (and often unconscious) benefits of defensive armoring. There are perhaps few other therapies where the potential outcome of the process may be so immediately experienced by the client. Richard Lawton

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See also Bioenergetic Analysis; Gestalt Therapy; Postural Integration

Further Readings Gladstone, G. (n.d.). Pulsing—touch with rhythmic movement. Retrieved from http://www.pulsing.org.uk/ articles/gg001.html Lawton, R. (2010). Pulsing—get rhythm! Retrieved from http://www.pulsing.org.uk/articles/rl002.html Turchin, C. (1979). Pulsing. Energy & Character: The Journal of Biosynthesis, 10(2), 67–69. Turchin, C. (1979). Trager body work. Energy & Character: The Journal of Biosynthesis, 10(1), 54–55.

R which leads to the liberation and channeling of the life force. Kelley founded The Radix Institute in the early 1970s to develop and extend Reich’s fundamental teachings. Early in his career, Kelley specialized in vision experiments through his study of the Bates method of vision improvement, which uses simple eye exercises to relax the eyes to achieve better vision rather than correcting vision with glasses or surgery. His research into the relationship between vision and emotion gave him a special appreciation for the importance of working with what Reich called the “ocular segment,” concluding that pulsation of the life force in the eyes is essential for integration of one’s emotional experience. Kelley also introduced the concept of using Reichian principles in group work. Current Radix practitioners continue to develop applications of Kelley’s approach to many therapy and personal-growth issues while continuing his emphasis on well-being, vitality, and the power of the educational model. Many other Radix Institute trainers have influenced the direction and development of Radix theory and practice. For example, Renan Suhl, a Radix Institute trainer, responded in the 1980s to the wider cultural and social recognition of trauma and its effects on people. Suhl concluded that not all human beings develop armor that needs to be “broken down,” as in the classic Reichian model, that many people have insufficient armor to adequately function in the world and, in fact, need different ways to build it. With this perception came a shift in Radix work from the model of energetic catharsis to that of restoring the inward

RADIX Radix is a body-centered holistic therapy that works with the body, mind, and emotions to achieve healing and to develop clients’ capacity to fully engage with life. Radix means “root” or “point of origin.” In the context of Radix therapy, the term refers to the fundamental energy or life force that moves, pulsates, and finds form within each individual. Radix therapists (through talking, movement, breath, touch, vision, and sound) work with a client’s life force to achieve healing and growth and to help clients realize their full potential.

Historical Context Radix is based on principles derived from the work of Wilhelm Reich (1897–1957), a psychoanalyst whose scientific investigation into the human life force was called orgonomy. After studying Reich’s work and attending several of his seminars, Charles Kelley (1922–2005), an experimental psychologist, developed Radix as a form of personal growth work. At the time, Kelley was the director of Applied Vision Research and an assistant professor in psychology at North Carolina State University. He later became editor of the first Reichian-oriented journal, The Creative Process, after Reich’s death. Reich conceived of his work as going “beyond psychology” deep into the realm of the biophysical. Kelley, too, distanced himself from the concept of therapy and conceived of his project as “Education in Feeling and Purpose,” 845

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and outward flow of the energetic pulsation. With contributions from other practitioners, Radix continues to evolve to include biophysical approaches to trauma and biophysical ways of working with attachment issues and other presenting client problems.

Theoretical Underpinnings Radix is rooted in the Reichian perception of muscular tension interrupting the life force flowing in the body. Sometimes this is chronically blocked or trapped in the core and sometimes in the periphery. When trapped in the core, the muscle tension hinders the smooth flow of life force into the eyes, arms, or legs, making it difficult for individuals to see realistically, to reach out with their arms to grasp, to hold or love, or to “stand on their own.” For some individuals, the life force is habitually trapped in the periphery, meaning that the individual is in contact with the world but lacks connection with the self. In both these extreme cases, the goal of Radix is for the individual to find balance, developing a deep self-awareness and an easy movement and engagement in the world. Pulsation, a primary concept in this approach, becomes the heart of the therapeutic or educational enterprise. In this context, pulsation is defined as a rhythmic expansion and contraction of life energy (that which underlies and gives rise to feeling and movement). Radix practitioners observe and actively work with the many subtle ways in which pulsation is interrupted in a client, working to balance the two strokes of that pulsation. When pulsation is in balance, clients can surrender to deep contact with their inner world (i.e., emotions, dreams, vision, and spirit) on the life energy instroke (contraction) and can express their inner world actively on the life energy outstroke (expansion). Practitioners work to bring attention and consciousness to a client’s own experience. A practitioner’s focus on the clients’ experience might involve ocular work (which involves attending to the self and self-perception), helping the clients center or ground themselves, helping them find boundaries they previously lacked, or helping the clients to learn emotional containment. Regardless of the particular direction of the work, the relationship and contact between the client and the practitioner is paramount. Kelley

attached primary importance to practitioners doing their personal work, so that they can tolerate, accept, and respect their clients’ depth and track them in their inner voyage. Practitioners sometimes follow clients to places of considerable intensity and energy, emphasizing the need for practitioners to learn tolerance for these forces in their own lives. Therefore, tolerance, acceptance, and respect for personal experiences are cornerstones of Radix therapy. Other theoretical concepts important to Radix include energetic charge and discharge, a focus on the breath as the most easily used pulsation, the understanding that chronic blocking (whether due to suppression, repression, or directed purposeful activity) leads to muscular armor, and an understanding of the embodiment of character, which is rooted in the energetic flow or blockages to the flow.

Techniques There are several unique techniques used in Radix, including contact, observation, breath, movement and sound, and touch. Contact

The basic Radix premise is that healing takes place in relationship, and contact between the practitioner and the client is the starting point. Contact with a client in the present means meeting the client where the client is emotionally and energetically so that the client feels fully heard, seen, and understood, thereby establishing a base from which the work can deepen. The practitioner observes and registers the quality and nature of the contact—the degree of being present in the eyes, a tension and pulling away in the body, or perhaps an emotional quality to the voice that is incongruent with the spoken words. Observation

The Radix practitioner both observes and feels the client’s energy and observes the client’s skin tone, muscular tension, and posture and the quality and nature of the client’s breathing, sometimes drawing the client’s attention to areas that the practitioner feels are tense and sometimes simply asking the client where he or she is experiencing tension.

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The process of observing together helps establish an atmosphere of learning and self-acceptance. Breath

While there are many types of pulsation in the body, Radix works with the pulsation of the breath because it is both voluntary and involuntary and is integrally involved in blocking or expressing every emotion. In fact, breathing patterns are indicative of one’s basic character or armoring. A full breath involves an active, flexible back, chest, diaphragm, and abdominal muscles. To restore fuller breathing, a practitioner may work with a constricted breath pattern by verbally encouraging a different pattern, having the client move in such a way as to change the breath, or, perhaps, pressing on the client’s chest to facilitate a different breathing pattern. At root, the process results in restoring natural breathing rather than in the client learning how to breathe. Movement and Sound

Once it has been determined what expression may be blocked or, conversely, needs to be contained, movement and sound are essential tools to help redistribute a client’s energy toward full pulsation, contact, better grounding, centering, boundaries, and containment. Changing the breathing pattern, shutting and opening the eyes, running the legs into a mat, standing, curling over, hitting or squeezing a pillow, pushing or leaning against a wall or the practitioner are all movements designed to move energy into various parts of the body and help expression become more full and congruent throughout the whole person. Encouraging sound (humming, yelling, singing, and emotional vocalization) also facilitates full expression and congruence. Touch

In Radix work, touch may be used to bring awareness and energy to a particular part of the body, for physical or emotional support, for containment, to loosen muscles, or to support a sense of contact between the client and the practitioner. Touch is always done with the client’s permission and with a clear intention on the practitioner’s part.

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Therapeutic Process Clients come to Radix work for a variety of reasons, from specific problems to a general desire for personal growth. It is useful for a practitioner to understand a client’s specific goals in doing the work. Each session begins with the practitioner hearing from the client about what is going on for the client in terms of concerns, emotions, and body/ energetic processes. The practitioner listens, observes, and evaluates the client in terms of the client’s process and the need to work toward energetic integration and wholeness. The practitioner may then use any of a wide variety of techniques to redistribute the client’s energy with particular concepts in mind. For example, a practitioner may ask a client who is experiencing anxiety to run in place, shake his or her arms, and make sounds in order to deepen the breath and siphon off excess energy; then the practitioner may ask the client to stand with legs bent and upper body curled forward to help ground and center the client. Once the client’s energy is redistributed, the practitioner facilitates self-awareness in the client and contact between the client and the practitioner to be sure that the client is fully present in the here-and-now. Verbally processing the client’s experience during the session often helps the client integrate his or her experience and accept it as representative of who he or she is. Melissa Lindsay, Narelle McKenzie, and Jim Ross See also Bioenergetic Analysis; Orgonomy; Reich, Wilhelm

Further Readings Glenn, L., & Müller-Schwefe, R. (Eds.). (1999). The Radix reader: A neo-Reichian approach to human growth. Conway, AR: Heron Press. Kelley, C. (2004). Life force: The creative process in man and in nature. Victoria, British Columbia, Canada: Trafford. McKenzie, N., & Showell, J. (1998). Living fully: An introduction to Radix body-centred personal growth work. Adelaide, South Australia, Australia: Centreprint.

Website Radix Institute: www.radix.org

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Rational Emotive Behavior Therapy

RATIONAL EMOTIVE BEHAVIOR THERAPY Rational emotive behavior therapy (REBT) is the vigorous pioneering cognitive approach that heralded in the cognitive revolution that began in the mid-20th century in the fields of psychotherapy, psychology, and counseling. It was created and developed by Albert Ellis (1913–2007), who wrote more than 85 published books and more than 2,000 published articles about REBT, beginning in the early 1950s and throughout his lifetime. REBT is unique in its strong emphasis on the benefits of experiencing and practicing unconditional acceptance and in the precision and vigor it encourages people to employ in their disputation of unhealthy irrational beliefs. It is an activedirective, humanistic approach and is infused with compassion. It is effective as a brief therapy approach as well as for long-term therapy and group therapy and as a tool many members of the general public can learn to apply as a self-help technique through reading books or articles and/ or attending lectures, workshops, and seminars on the approach. Ellis intended REBT to be utilized and learned by both academic and practitioner communities as well as by their clients and by members of the general public, and to that end, many of his publications were written in a style easily understandable and acceptable to individuals in each of those groups. His work continues to influence and help the lives of countless people in empowering and transforming ways.

Historical Context REBT was born from a combination of Ellis’s innovative genius and capacity for problem solving; his desire to help others suffer less emotional misery; the methods he developed for helping himself endure and overcome adversities, which he faced from childhood onward; his research and reading; and his abandonment of the psychoanalytical approach he had been trained in and practiced in his early years as a therapist. He believed that psychoanalysis helped some people feel better but that it did not help them to get sufficiently better and stay better by taking responsibility for their own emotions. His main influences were

philosophers, psychologists, essayists, novelists, poets, and other writers—some of the more influential writers included Socrates, Epicurus, Epictetus, Marcus Aurelius, Seneca, Confucius, Lao Tzu, Gautama Buddha, Ralph Waldo Emerson, John Dewey, George Santayana, Bertrand Russell, Ludwig Wittgenstein, Benedict de Spinoza, Immanuel Kant, David Hume, Henry David Thoreau, Alfred Korzybski, Sigmund Freud, John Watson, Karen Horney, and Alfred Adler. The coping actions and attitudes he came up with to successfully overcome his occasional childhood feelings of depression about parental neglect, anxiety, and extreme shyness in his teen years and his tendencies of impatience and low frustration tolerance are incorporated into the REBT approach. From 1952 to early 1955, he was one of the most active-directive psychoanalytically oriented psychotherapists in the field, and his clients were experiencing better and more lasting results in shorter periods of time than they had done when participating in more traditional modes of psychoanalysis. By 1955, the basic theory and principles of REBT had been formulated, and in 1956, Ellis gave his first major presentation about it to psychologists at the American Psychological Annual Convention held in Chicago. He was booed and jeered and called superficial and simplistic by many of his colleagues and peers at that time who favored the psychoanalytical approach, yet he persisted in continuing to research and write about REBT, utilizing it and teaching it, and by the 1960s, and in the years following, it was embraced and utilized by many practitioners in his field. A number of cognitive approaches and theories, including cognitive therapy, cognitive-behavioral therapy, reality/ choice therapy, dialectical behavior therapy, acceptance and commitment theory, positive psychology, and others, which came after the works by Ellis on REBT were published and presented, include some or many of REBT’s principles. Known in its early years as rational therapy, it deliberately emphasized rational versus irrational components of thinking and showed that rational therapy contrasted greatly with most existing therapies at that time, which Ellis found to include little on cognitive aspects. REBT emphasizes the importance and benefits of working on one’s cognitions and emotions and behaviors. In so doing, it is a most holistic therapeutic modality. In 1961, Ellis changed the name of

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his approach to rational emotive therapy, and in 1993, he added the B—calling it rational emotive behavior therapy (REBT), a title that still remains. Since its early years, REBT has expanded and has been refined, backed by research on it specifically and by much of the abundant cognitive-behavioral therapy research, which also supports its premises. Surveys in the United States in the 1980s named Ellis as the most cited writer in the field since 1957 and found him to be the second most influential psychotherapist of his time. (Carl Rogers was found to be the first, and Sigmund Freud was named as the third most influential one.) A Canadian study at that time found Ellis to be the most influential therapist, followed by Rogers and then Aaron Beck. In his later years, Ellis was writing books and articles and presenting lectures, workshops, seminars, and professional trainings with his wife, partner, and collaborator, Debbie Joffe Ellis, on the various aspects of REBT, and he included seminars and writings on more “spiritual” topics such as REBT and Buddhism. He entrusted Joffe Ellis to continue his work after his passing, which she does throughout the United States and around the globe. In 2004, Ellis was named a “Counseling Legend” at the annual American Counseling Association conference, and Joffe Ellis was given the same recognition at the same conference in 2014.

Theoretical Underpinnings Some basic premises infuse the REBT approach and are the underpinnings of its theory. For instance, REBT acknowledges that each human is fallible, capable of making mistakes, and failing at desired goals; however, the worth of the human being is not defined according to competencies, successes, talents, or any other qualities of character or behavior. REBT asserts that each human has worth simply because he or she is alive. Some general semantic principles are incorporated into REBT. For example, REBT encourages people to constructively evaluate their actions as good or bad, mistaken or advantageous, failures or victories, beneficial or destructive, but it reminds them not to judge their essential worth based on their actions. REBT encourages people to guard against overgeneralizing. REBT acknowledges the influences of both biology and environment in contributing to the thinking patterns and behaviors of

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individuals; however, it asserts that with awareness and motivation to change, people can choose to work at changing any unhealthy thinking/emotion/ behavior tendencies and habits into life-enhancing ones. REBT reminds us that with awareness comes choice. It asserts that the maintenance of therapeutic gains requires ongoing effort, work, and practice. It reminds us that relapse may take place for some people, and that if it does, they can choose to accept it as a common occurrence rather than catastrophize about it, and it then encourages them to return to healthier ways. REBT incorporates relapse prevention techniques. It is a pragmatic, compassionate, realistic, and optimistic approach, encouraging self-awareness and the identification of one’s philosophical beliefs. It encourages people to have the willingness to assess the accuracy of such beliefs and to change any that are not essentially ethical and based on fact and logic. REBT vigorously reminds people that they can choose to use their minds in healthy ways by thinking rationally in order to create healthy emotions and behaviors and, in so doing, enjoy life more. It reminds us that life inevitably contains loss and suffering but by learning to think in healthy ways, one minimizes the suffering and maximizes the joy. REBT also encourages individuals to have social interest and to demonstrate care for others and to be helpful whenever possible, both to other human beings and to the environment around them. REBT encourages its therapists to have empathy and compassion toward their clients and the clients’ predicaments, challenges, and difficulties, with the primary goal being to help a client learn the tools to help himself or herself. It discourages unhealthy dependence of a client on the therapist, which in no way minimizes the therapist’s willingness to embrace his or her role of counselor, educator, and encourager enthusiastically and for as long as is healthily appropriate in the therapeutic relationship. REBT also recommends that therapists do their best to practice its principles so that they too live better lives and, in doing so, serve as healthy models for their clients and others and display solid authenticity in practicing what they preach.

Major Concepts Some of the major concepts of REBT include the idea that we create and control our emotional and

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behavioral destinies, irrational thinking, rational thinking, unhealthy versus healthy negative emotions in response to adverse circumstances, unconditional acceptance, the A B C D E method in response to disturbing emotions, and work and practice. Creating and Controlling Our Emotional and Behavioral Destinies

It is not outer circumstances that create our emotions and lead to our actions but what we tell ourselves about them. We create and control our emotional and behavioral destinies by the way we think. When we think in healthy and rational ways, we create healthy and appropriate emotions; when we think in unhealthy irrational ways, we create unhealthy and often debilitating emotions. REBT clearly defines the features of rational and irrational thinking; it distinguishes between the healthy negative emotions that we may create in response to adverse circumstances by thinking in rational ways and the unhealthy emotions that we create by thinking in irrational ways. Irrational Thinking

REBT describes the main features of irrational thinking as having the tendency to demand (shoulds, musts, oughts) that things be the way we want them to be; it exaggerates, awfulizes, and catastrophizes; it damns the person, others, and life itself when things don’t go the way we think they “should” go; and it has abysmally low frustration tolerance. The three main irrational core beliefs— from which countless others stem—are as follows: 1. I must always be approved of and liked/loved by everyone. 2. You should always treat me well and act the way I think you should. 3. Life should always be fair and just.

Rational Thinking

Rational thinking prefers, as opposed to demands, that things go the way we want them to go; it keeps things in perspective; it is based on empirical facts and reality; it is nondamning of self,

others, and life (unconditionally accepting); and it has high frustration tolerance. Unhealthy Versus Healthy Negative Emotions in Response to Adverse Circumstances

In understanding unhealthy and healthy negative emotions, it is important to first be clear that when it comes to emotions, negative does not mean “bad” but, rather, less pleasant than positive emotions such as joy, happiness, and contentment. The main unhealthy negative emotions that are created from irrational thinking include anxiety, depression, rage, guilt, shame, and jealousy, whereas the main healthy negative emotions include concern, sadness, grief, annoyance, and frustration. The unhealthy emotions can debilitate and lead to destructive behavior; the healthy ones are appropriate responses to disappointments, to not getting what we want, and to getting what we don’t want. A misconception some people hold about REBT is that it is about not feeling painful emotions. This is far from the truth. REBT encourages people to live a full life, which includes the rich tapestry of both pleasing and nonpleasing events and emotions. To minimize inevitable and excessive suffering in response to loss and disappointment, REBT teaches us the difference between creating unnecessary debilitating emotions and creating, allowing, and accepting nondebilitating ones. Unconditional Acceptance

REBT’s principles and practices assert that one can maintain emotional stability and well-being by ongoing effort to acquire and experience unconditional acceptance in three forms: 1. Unconditional self acceptance: One accepts oneself totally—including any mistakes or failures. One attempts to learn from mistakes or failures and to not repeat them, but one does not damn oneself for having made them: separating the actions from the inherent worth of oneself for simply being alive and human. Even if one performs bad actions, unconditional self acceptance reminds the person that he or she is not totally bad, though his or her actions may have been undesirable.

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2. Unconditional other acceptance: One refuses to totally damn the other person even if his or her actions may be damnable—remembering that the other person is a fallible human prone to error as each one of us is; and while still appropriately responding to any bad actions from the other person, REBT reminds us to maintain an attitude of “hating the bad action but not hating the person’s essential being.” REBT recommends striving to feel compassion for wrongdoers. 3. Unconditional life acceptance: One sees circumstances in life that may appear wrong, cruel, unethical, and immoral—and one may do what one can to change them if possible—but at the same time, one accepts that just because some things in life are unfair and unjust, it does not mean that all of life is bad, cruel, and unjust. One refuses to conclude that all of life is hopeless and terrible, even when some things are indeed very bad, and maintains hope and realistic optimism.

The A B C D E Method in Response to Disturbing Emotions

This method clarifies the connection between the activating event and its consequences by identifying the beliefs involved and provides the means for replacing irrational beliefs with rational ones through healthy disputation, which results in the emergence of effective new beliefs, emotions, and behaviors. The boldness, precision, and vigor that REBT encourages individuals to apply when disputing their irrational beliefs is one of the aspects that sets REBT apart from other cognitive approaches. REBT invites individuals to dispute those beliefs realistically, logically, and pragmatically. Work and Practice

REBT reminds us that ongoing work and practice are required for lasting beneficial changes that lead to people not only “feeling” better but also “getting and staying” better!

Techniques The techniques offered in REBT that help clients create and maintain healthy ways of thinking, feeling, and behaving can be broadly divided under

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the headings of cognitive, emotive, and behavioral techniques—though certainly there is overlapping of some. Some of the main techniques within the three categories are discussed in this section. Cognitive Techniques

The A B C D E Method for Emotional and Behavioral Disturbance As noted earlier, this is one of the more important ways of combating emotional and behavioral disturbance and is focused on changing irrational thinking in the following ways: A (Activating Event): Identifying the activating event or adversity that appeared to lead to the response B (Beliefs): Identifying the irrational beliefs following “A” C (Consequence): Recognizing the emotional consequence and any possible behavioral consequences D (Disputing): Disputing each irrational belief as vigorously and thoroughly as possible: realistically, logically, and pragmatically, typically asking questions such as “Where is the evidence for this belief?” “Does it logically follow from my preferences?” “Where is it getting me to hold this belief—is it helping me or hurting me?” E (Effective New Philosophies): Replacing irrational beliefs with healthy and realistic beliefs. As a result, the emotions and behaviors, if any, are likely to become more healthy and life enhancing.

It is helpful for a client to apply this method in writing, and the more often the client does so, the sooner it can be effectively done in the client’s head without the written form. Assessing the Cost–Benefit Ratio of the Beliefs and Behaviors That Are Being Examined For example, a client whose goal it is to end an addiction to smoking would make a list of the advantages and real disadvantages of the harmful addiction and review and strongly think about the disadvantages several times each day. Another example would be of a client who had been avoiding or procrastinating about doing something that would enhance his or her life, writing a list of the advantages and disadvantages of continuing to do

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so, and then reviewing and strongly reminding himself or herself many times daily of the advantages of taking action. Secondary Symptoms This technique seeks to identify any secondary symptoms (e.g., anxiety about anxiety, depression about depression) and then attend to reducing or eliminating them before attending to the primary emotional disturbance. Distraction Methods Palliative and short-term distraction methods are better than inaction. Healthy ones may include doing exercise, yoga, and meditation. They may calm the mind and emotions but do not root out and eliminate the underlying irrational beliefs that created the disturbing emotions in the first place.

client can stand it, does not “need” the approval of others, and chooses to unconditionally accept himself or herself. Coping Statements This technique includes using coping statements strongly and vigorously (e.g., “I can stand what I don’t like—I just don’t like it!”). Use of Humor The use of humor can provide a healthy perspective and prevent the client from taking things too seriously. To this end, Ellis wrote hundreds of “Rational Humorous Songs,” which were often sung by attendees at his workshops and lectures. Behavioral Techniques

In Vivo Desensitization Modeling This includes thinking about people who model and demonstrate the healthy outcomes that the client hopes to achieve. Reading, Watching, and Listening This technique involves reading, watching, and listening to healthy and beneficial material about REBT—healthy philosophies and/or other inspiring and educational works. Emotive Techniques

Rational Emotive Imagery This technique includes visualizing the worst case scenario of the issue the client is working on and evoking the troubling emotion and then practicing reducing or eliminating the emotion through changing the client’s thinking. Shame-Attacking Exercises These exercises involve the client’s performing a nondangerous activity that attracts attention, such as an activity that the client considers shameful or embarrassing (e.g., wearing unusual clothing, calling out subway stops while traveling on the subway), while reminding himself or herself that even if others find the client ridiculous or strange, the

This technique includes exposing oneself gradually to that which one is afraid of: doing uncomfortably what one wants to feel comfortable about (e.g., for people with extreme shyness, saying hello to someone in a coffee shop each day until the fear is reduced and then eliminated over time). Reinforcements: Positive and Negative This technique can be helpful in encouraging the client to stick to his or her goals. Skills Training Learning new skills can support the attainment of the client’s goals (e.g., taking a course in assertiveness training for people suffering from social anxiety). Relapse Prevention This technique includes taking preventive steps that help maintain the client’s forward-moving path toward healthy change.

Therapeutic Process Usually, one of the first steps in the initial REBT session is clarifying the client’s issues and the therapeutic goals. The effective REBT therapist listens well, as much as possible modeling REBT

Rational Living Therapy

principles such as unconditional acceptance, empathy, and compassion. At the same time, the therapist remains alert and communicates in a direct fashion, particularly when identifying selfdefeating beliefs and behaviors that the client presents. The therapist teaches the principles of REBT to the client over time, providing or recommending relevant reading material if appropriate and giving homework chosen from the variety of cognitive, emotive, and behavioral techniques. Humor can be used to provide healthy perspective. The therapist is flexible, creative, willing to add additional and new goals for the client as the sessions progress, and encouraging, and acknowledges positive changes while being patient and tolerant of any client backsliding. The therapist may at times selfdisclose—but only for the benefit of the client’s gaining a clearer understanding and perspective. The REBT approach is greatly life enhancing, and when therapists incorporate it into their ways of life, blocks or challenges experienced during sessions (and in nonwork circumstances) can be more effectively handled. Debbie Joffe Ellis See also Adler, Alfred; Beck, Aaron T.; Classical Psychoanalytic Approaches: Overview; CognitiveBehavioral Therapies: Overview; Cognitive-Behavioral Therapy; Ellis, Albert; Existential-Humanistic Therapies: Overview

Further Readings Ellis, A. (1958). Rational psychotherapy. Journal of General Psychology, 59, 35–49. doi:10.1080/0022130 9.1958.9710170 Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Citadel. Ellis, A. (2003). Similarities and differences between rational emotive behavior therapy and cognitive therapy. Journal of Cognitive Therapy, 17, 225–240. doi:10.1891/jcop.17.3.225.52535 Ellis, A. (2005). Discussion of Christine A. Padesky and Aaron T. Beck, “Science and philosophy: Comparison of cognitive therapy and rational emotive behavior therapy.” Journal of Cognitive Therapy, 19, 181–185. doi:10.1891/jcop.19.2.181.66789 Ellis, A. (2005). The myth of self esteem. Amherst, NY: Prometheus Books. Ellis, A. (with Ellis, D. J.). (2010). All out! An autobiography. Amherst, NY: Prometheus Books.

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Ellis, A., & Ellis, D. J. (2011). Rational emotive behavior therapy. Washington, DC: American Psychological Association. Ellis, D. J. (2014). Rational Emotive Behavior Therapy (DVD—Series 1: Systems of Psychotherapy). Washington, DC: American Psychological Association. Korzybski, A. (1990). Science and sanity. Concord, CA: International Society for General Semantics. (Original work published 1933) Padesky, C. A., & Beck, A. T. (2003). Science and philosophy: Comparison of cognitive therapy and rational emotive behavior therapy. Journal of Cognitive Therapy, 17, 211–229. doi:10.1891/ jcop.17.3.211.52536 Smith, D. (1982). Trends in counseling and psychotherapy. American Psychologist, 37, 802–809. doi:10.1037/0003-066X.37.7.802 Warner, R. E. (1991). A survey of theoretical orientations of Canadian clinical psychologists. Canadian Psychology, 32, 525–528. doi:10.1037/h0079025

RATIONAL LIVING THERAPY Rational Living Therapy (RLT) is a form of cognitive-behavioral therapy (CBT) influenced by neurolinguistic programming and general semantics. This approach is derived from rational emotive behavior therapy (REBT), rational behavior therapy (RBT), and cognitive therapy (CT). In the same tradition as REBT and many other forms of CBT, RLT is considered a comprehensive, shortterm, goal-oriented approach aimed at helping people “get better” through systematic processes that address core issues and lead to long-lasting change. RLT does not support “quick fixes” to simply “feel better” in the present moment. RLT emphasizes the work of the therapist while underscoring the value of the client’s rational self-counseling skills. It is used to treat a variety of issues, including anxiety, depression, relationship problems, substance abuse, and traumatic events.

Historical Context RLT was developed in the 1990s by Aldo R. Pucci, president of the National Association of Cognitive Behavioral Therapists. Pucci received training in cognitive-behavioral therapy from Maxie C. Maultsby, the founder of RBT. RLT grew from

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Pucci’s modifications to Maultsby’s approach. RLT has continued to evolve since its inception. Recently, RLT has been adapted for work with relationships and couples counseling. RLT incorporates research findings from various areas of psychology, including learning theory, cognitive development, and brain functioning. However, in an age where the implementation of evidence-based practices is emphasized, empirical evidence of the effectiveness of RLT is not available.

Theoretical Underpinnings As a cognitive-behavioral approach, RLT maintains characteristics similar to most cognitive-behavioral therapies. Specifically, RLT closely aligns with the philosophies of REBT, RBT, and CT. RLT incorporates the cognitive model of emotional response and emphasizes aspects of stoicism, suggesting that irrational thinking leads people to emote and behave in irrational ways. This approach suggests that the “shoulds” and “musts” people think are the root of emotional and behavioral problems and ultimately prevent happiness. RLT posits that people engage in self-counseling every day, although they rarely acknowledge these intentional and sometimes unconscious processes. In addition to the traditional theoretical underpinnings of cognitive-behavioral therapy, RLT relies on concepts rooted in neurolinguistic programming, brain development, and general semantics. For example, RLT emphasizes the subconscious mind and the importance of selftalk in ways similar to neuro-linguistic programming. Additionally, RLT focuses attention on the ways in which the left and right hemispheres of the brain communicate. Comparable to general semantics, RLT also values the use of the scientific method to solve daily problems and address dysfunction. This approach suggests that goal setting and the development of rational, behavior-targeted, positive statements are critical aspects to behavior change. Rational living therapists aim to dispute irrational beliefs in a variety of ways and teach clients rational self-counseling skills.

Major Concepts This approach is influenced by a number of cognitive-behavioral therapies. However, RLT has

evolved to include its own unique set of philosophical tenets and concepts. The ABCs of emotions, the four As, irrational labeling, reflexive thoughts, and the rational thinking score are among the major concepts of RLT. ABCs of Emotions

The ABCs of emotions highlight the intermediate role cognition plays in determining emotional responses to events or conditions. The A stands for awareness. The B stands for what we believe or think about that which we are aware of. Such thoughts can be positive, neutral, or negative. The C stands for the emotional consequence experienced as a result of what we believe or think about a given situation. This concept has evolved into a commonly used technique by the same name. Four As

RLT refutes the notion of self-esteem and considers the concept irrational. It suggests that the concept of self-esteem equates to a rating system based on the evaluation of a person as a whole. This approach views the totality of an individual as too complex to be understood by one global term. However, the four As offer a rational alternative to self-esteem and replace this general and problematic concept. The term four As stands for accurate assessment of attributes and abilities. This concept encourages factual assessments of characteristics and qualities as they relate to identified goals. Assessing attributes, rather than the whole person, promotes an objective nonjudgmental perspective that offers a direction for goal attainment. The four As serve to combat common mental mistakes including overgeneralizing, underestimating abilities, discounting coping skills, and overemphasizing failures. Irrational Labeling

Irrational labeling occurs when an individual is described using a single attribute or characteristic (i.e., mean, bad). RLT considers these labels irrational because they fail to completely describe individuals. Rational living therapists believe that people are far too complex for labeling in this manner. Therefore, irrational labeling is discouraged,

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and the subsequent hopelessness that clients often experience from labeling is thwarted. Rational living therapists refrain from using absolute terms such as oppositional, depressed, or dependent to describe clients. As a result, this approach disagrees with the use of diagnostic labeling often used by mental health professionals. Reflexive Thoughts

Reflexive thoughts are automatic, unconscious thoughts that can be either rational or irrational. Problems arise when reflexive thoughts are irrational. RLT emphasizes the importance of developing rational reflexive thoughts in lieu of irrational ones. Rational Thinking Score

The Rational Thinking Questionnaire is a 51-item measure of rational thinking. A Rational Thinking Score is derived from this measure. The score indicates the degree of rationality maintained by an individual.

Techniques A variety of techniques are available in RLT, and the ones most readily used offer structure and serve to empower the client. These techniques include the camera check, positive/negative imagery, the rational action planner, rational questions, and rational hypnotherapy. Camera Check

The camera check, a technique borrowed from RBT, is used in RLT to dispute irrational thoughts. This technique asks the simple question “What would the camera reveal if a photo of the situation were taken?” This technique helps the client view situations in an objective, realistic way. Positive/Negative Imagery

Positive/negative imagery is a visualization technique useful in establishing patterns of rational behavior. Positive imagery promotes rational behavior by emphasizing positive outcomes. Negative imagery highlights the negative results

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stemming from irrational behaviors. Employing negative imagery can bring awareness of such thoughts and can be used to encourage clients to avoid them. Rational Action Planner

The rational action planner is a technique that comprises several commonly used RLT techniques (i.e., ABCs of emotions, camera check, rational questions). This single procedure reinforces the RLT philosophy and assists the client in developing a goal-oriented action plan. Rational Questions

Rational questions is a technique used to help clients challenge their irrational thoughts. An example of a rational question is “Is my thinking based on fact?” This technique disproves the validity of irrational thoughts and encourages rational thinking. Rational Hypnotherapy

RLT posits that hypnosis, whether intentional or unintentional, can be used to influence thoughts processes (i.e., promote rational thoughts). Many rational living therapists are trained in hypnotherapy. Rational hypnotherapy is often utilized when addressing cases of posttraumatic stress disorder.

Therapeutic Process RLT is a structured, goal-oriented, active-directive form of treatment, similar to other cognitivebehavioral therapies. Treatment is short-term, lasting as few as 8 to 10 weeks, with sessions typically 45 to 60 minutes in length. During the initial sessions, an assessment is conducted, offering insight into the client’s negative patterns of irrational thinking and behaving. The assessment provides direction for a targeted treatment in upcoming sessions. Once problematic areas are identified, a variety of strategies and techniques are utilized to challenge and replace irrational thoughts. In some instances, rational hypnotherapy may be employed to facilitate cognitive and behavioral change. With emphasis on the role that rational self-counseling skills play in treatment, homework assignments

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are frequently recommended in RLT. The goal of RLT is to equip clients with the tools and skills needed to be happy, to reach their goals, and to live rationally. Jeffrey M. Warren See also Cognitive-Behavioral Therapies: Overview; Cognitive-Behavioral Therapy; Hypnotherapy; NeuroLinguistic Programming; Rational Emotive Behavior Therapy

Further Readings Pucci, A. R. (2006). The client’s guide to cognitivebehavioral therapy: How to live a healthy, happy life . . . no matter what! Bloomington, IN: iUniverse. Pucci, A. R. (2010). Feel the way you want to feel . . . no matter what! Bloomington, IN: iUniverse. Pucci, A. R. (2011). About rational living therapy. Retrieved from http://www.rational-living-therapy.org/ AboutRLT.htm Pucci, A. R. (2013). Rational living therapy relationship therapy. Retrieved from http://freecbthandouts.com/ cbt-articles/rational-living-therapy-relationshiptherapy/

REALITY THERAPY Reality therapy is an internal control system used by counselors and psychotherapists throughout the world. It is a theory and a method expressed in language understandable to both professionals and laymen and used by individuals in a wide range of settings. Developed by William Glasser in the 1950s and 1960s on the foundational principle that human behavior originates from within the person and is the result of current internal motivations, reality therapy is neither a response to external stimuli nor an attempt to resolve early-childhood conflicts. Glasser and his teacher G. L. Harrington, while working in a mental health hospital, reacted against both their training and current psychiatric practice. They attributed little value to what they believed was the never-ending search for insight and unconscious motivations. Rather, they held their clients responsible for their behavior and taught them that though they did not feel completely in charge of their lives, they nevertheless

had more control over their actions than they at first believed. Subsequently, Glasser added a theory of brain functioning, called control system theory or control theory, as the basis for the delivery system, reality therapy. Because of the central place of human choice in counseling and psychotherapy, Glasser changed the name of the theoretical basis for reality therapy from control theory to choice theory. He further added a five-needs schema (discussed later) as the origin or motivational drive behind human behavior, redefined as a unit composed of actions, cognition, emotions, and physiology. Therefore, strictly speaking, choice theory is separate from reality therapy in that it is the underlying justification for the practice of reality therapy. Glasser has pointed out that choice theory is like a train track and reality therapy is the train. They are interdependent components. However, the phrase reality therapy is most often used to include both the theoretical basis and the process, the train and the track. Because of the emphasis on choosing behavior, especially choosing actions, the reality therapist believes that clients can make effective choices to satisfy their inner motivations, employing skills derived from the WDEP system of reality therapy, which involves helping clients define their wants, examine their behavior (i.e., what they are doing), conduct self-evaluations, and make efficacious plans for improvement. These interventions are built on empathy, positive regard, and genuineness.

Historical Context In 1946, Glasser attained a bachelor’s degree in engineering from Case Western Reserve in Cleveland, Ohio. Preferring to work more directly with people, he entered medical school and became a psychiatrist working in a mental hospital and a correctional institution in Los Angeles, California. During his psychiatric internship, Glasser developed his method to the point of insisting that patients discuss only their current behavior and taught them that, whatever their condition, they have choices. During this evolution, he hesitantly shared this attitude with his supervisor, G. L. Harrington. Rather than rejecting Glasser’s approach, Harrington reached across the desk, extended his hand, and spoke the oft-quoted response, “Join the club.” Together they began a

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reality-based program for the patients in one of the psychiatric wards. After 3 years, approximately 50% of the patients were released from the hospital, with only a 3% rate of return. In 1965, Glasser published his watershed work Reality Therapy. Subsequently, he was asked to lecture on his book throughout North America. For a short time, he labeled his system “reality psychiatry.” But the psychiatric profession characterized by the psychodynamic approach rejected Glasser’s principles. Several counselors, social workers, psychologists, and educators, however, responded favorably and requested further training. As a result, Glasser renamed the system “reality therapy” and founded the Institute for Reality Therapy, now known as William Glasser International, with training programs conducted throughout the world. Because of the widespread acceptance of reality therapy by educators, Glasser and his institute developed systemic applications to schools called Schools Without Failure, later renamed the Glasser Quality School. The core of the application of reality therapy to education consists in creating a school atmosphere in which students can satisfy their five needs and are given as many choices as are reasonably possible. The school personnel learn to communicate with students and parents by using reality therapy interventions. The proven outcome of the program includes enhanced learning and fewer behavioral problems. Robert Wubbolding has extended reality therapy interventions or procedures and formulated a pedagogical tool, the WDEP system, for helping counselors and therapists learn and apply choice theory and reality therapy.

Theoretical Underpinnings Underlying the practice of reality therapy is a theory of human personality: choice theory. This system explains human motivation. Human beings are seen as genetically instructed to satisfy five general motivators or needs. The need for survival causes people to generate behaviors that ensure self-preservation and the survival of the human species. The second need, and often the focus of counseling and therapy, is the need for belonging. Adherents to the principles of reality therapy encourage a discussion of human relationships because they see that at the basis of many disturbances are dysfunctional

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relationships. When human relationships are more satisfying, happiness and a sense of hope result, stress is lessened, and a more fulfilling life is possible. The third human need or motivator is the even more general and often misunderstood need for power. Power, in choice theory, equates not with domination but with achieving a sense of inner control. It includes gaining a sense of achievement, a feeling of self-pride, self-worth or self-esteem, and even a passion for living an industrious life. It can include a sense of victory as in a sporting event. But it is not limited to a zero-sum game in which there are winners and losers. The fourth need, freedom, means making decisions. Human beings are born with a need to choose. In implementing choice theory (i.e., practicing reality therapy), the counselor assists clients to make satisfying choices and to realize that they possess the ability and the possibility of making more choices than previously considered. The fifth need or human motivator is fun. The philosopher Aristotle described a human being as a risible creature. Humans can laugh. Effective users of reality therapy assist clients to see humor in their environment and to choose activities that bring them enjoyment. Clearly, the needs overlap with one another. A person chooses to perform an activity with a friend. They gain a sense of accomplishment from the activity and enhance their relationship. In making such choices, they often feel free of the stressors previously endured. Although the needs lead to specific behaviors, they themselves are general, universal, and multicultural. All people possess the needs and develop specific wants related to each need—a process that lies at the basis of behavioral choices. The collection of wants or desires related to each need is unique for each person. The reality therapist helps clients clarify specific wants so that satisfying them becomes possible. The first goal of the practitioner is to become part of this inner world of client wants and to be seen as someone who demonstrates helpful qualities such as empathy, positive regard, authenticity, and competence. Human behavior results from efforts to satisfy the inner world of wants. The four components of behavior are analogous to the wheels of an automobile, with the driver exerting more direct control over the front wheels, action and cognition, and less direct control over the back wheels, emotions and physiology. Consequently, psychotherapy focuses primarily on the most controllable elements

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of behavior: actions and thinking, especially actions. This principle illustrates that choice theory, and its implementation, reality therapy, is an internal control system in that human behavior generates from within the person and is treated as a choice. An important caveat is that choice is predicated on actions, not on emotions or physiology. Emotions, and to some extent physiology, play the role of lights on the dashboard of the car. When they light up, they suggest to the driver that action is needed. The unity of action, cognition, emotion, and physiology is called total behavior. Human behavior is also purposeful and goal directed. Its purpose is to influence the world or to control it so that the agent of behavior gains the perception of satisfying one or more need and wants related to the need. The chosen behaviors can be effective or ineffective, helpful or unhelpful, productive or counterproductive. Many clients seek the help of therapists because they have made ineffective choices for the purpose of satisfying their needs. Some people desiring pleasure and seeking freedom from stress turn to drugs or alcohol to gain the perception of fulfilling the need for fun, freedom, and even belonging and power. If continually used to an excessive degree, choices become not only ineffective but also harmful. In summary, the theory was originally known as control theory or control system theory, in which the human mind is seen as functioning in a way similar to a control system. For example, a thermostat wants the room temperature at 72 degrees. When it perceives that it is not achieving its purpose, it sends a signal to the heating or cooling unit to generate more effective behaviors to raise or lower the room temperature. The human mind operates in a way analogous to a control system, but in a much more complex manner. As people grow and mature, they are able to insert into their quality world wants that are helpful and altruistic or harmful and even antisocial. They can also choose behaviors that are helpful and humane or dysfunctional and destructive. Additionally, the human mind does not function in isolation. It only develops as a result of interaction with other human beings, a principle scientifically demonstrated in attachment theory and recent studies centering on the neuroplasticity of the brain. Hence, the reality therapist focuses on human relationships in most counseling and therapy sessions.

Major Concepts Because of its emphasis on choice, some textbook authors place reality therapy among the existential systems. Others see reality therapy as a cognitive system because of the emphasis on helping clients evaluate their behavior and because of the principle that feelings or emotions are not the cause of dysfunction but are rather behaviors generated to satisfy the five-needs system. Both of these viewpoints serve as a basis for the major concepts of reality therapy, such as the distinction between choice theory and its delivery system, reality therapy; the central role of wants and needs satisfaction, especially human relationships in choice theory and reality therapy; behavior as purposeful and as a choice; self-evaluation as a necessary prerequisite for change; and the therapeutic alliance or counseling environment, including toxic and tonic behaviors. Distinction Between Reality Therapy and Choice Theory

From a strictly definitional viewpoint, choice theory is distinct from reality therapy. Choice theory, with its needs system of human motivation, its fourfold definition of behavior, and its delineation of behavior as purposeful, constitutes a theory of human personality. Reality therapy, on the other hand, consists in operationalizing and delivering the theory to clients. However, most frequently the term reality therapy includes both choice theory and the practice of reality therapy. Central Role of Wants and Needs Satisfaction

Human behaviors spring from specific wants unique to individuals and related to their fiveneeds system, especially the need for belonging. Regardless of the presenting issue, the practitioner of reality therapy helps clients examine their current human relationships. Even though past experiences have created the clients’ current situation, repeated discussion of personal history is less important than examining current human relationships and improving them. When clients satisfy their need for belonging as currently experienced, their dysfunction and their unhappiness decrease. Their lives improve, and their happiness increases.

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Behavior as Purposeful and as a Choice

The Art of Asking Questions

Similar to Adlerian principles, behavior is goal centered. Its purpose is to affect the world so that the person gains a perception of needs and wants satisfaction. Human beings have little direct control over physiology and emotions and more control over cognition and actions, with actions the most easily controlled and changed. When choices are made to change actions, alterations in thinking, feelings, and even physiology can occur.

Reality therapists ask many questions of clients. The reason is that clients possess strengths and answers that they are often unaware of. The work of the therapist is to elicit information and workable strategies to address clients’ wants and needs.

Self-Evaluation as a Necessary Prerequisite for Change

Helping clients evaluate the effectiveness of their freely chosen actions, the attainability of their wants, and their perceived degree of control (i.e., their locus of control) constitutes the cornerstone in the process of reality therapy. Therefore, a preeminent goal of the reality therapist is to facilitate a skill by which clients learn to self-evaluate. The Therapeutic Alliance

As with many systems of psychotherapy, the effective use of reality therapy is built on a therapeutic alliance. When clients place the therapist in their quality worlds, they see an authentic, ethical, and competent helper. Clients learning from a therapist who models a healthy relationship characterized by empathy, positive regard, and honesty are likely to personalize these qualities and to implement them in their own relationships. A skillful reality therapist assists clients in specific ways to enhance their interpersonal relationships by avoiding the toxic behaviors of arguing, blaming, and criticizing and to realize that they can control only their own behavior.

Techniques Choice theory is an open system in that it allows for the use of many techniques, such as disputing irrational thinking, paradoxical techniques, and the incorporation of the Ericksonian principle stating that often the solution seems to have nothing to do with the presenting issue. And yet there are techniques that are most typical of reality therapy: the art of asking questions, using metaphors, discussing nonproblem areas, and direct teaching of choice theory and reality therapy.

Using Metaphors

Analogies, figures of speech, and a multitude of metaphors help clients externalize their problems, see humor that was previously hidden, and grapple more effectively with effective plans. Discussing Nonproblem Areas

When clients discuss their successes, their healthy relationships, and their wants and needs currently satisfied, they learn that they have a problem. They are not the problem. Direct Teaching of Choice Theory and Reality Therapy

Part of using reality therapy is well-timed instruction about the needs system, the quality world, the behavior as chosen, and the WDEP system of reality therapy. The skilled reality therapist teaches when the appropriate time presents itself.

Therapeutic Process The goal of the reality therapy therapeutic process is to help clients gain more effective control of their lives. Control in the context of reality therapy does not refer to the regulation of other people’s behavior. Another way of describing the goal is that therapy is directed toward helping clients satisfy their five needs effectively and efficiently without infringing on the rights of others. The acronym WDEP summarizes specific therapeutic interventions utilized by the reality therapist. Each letter represents a cluster of skills that practitioners use in a wide variety of settings: clinics, schools, child care, health care, corrections, addictions, parenting, and so on. W represents the exploration of clients’ quality worlds—more specifically, what they want. This process includes identifying their hopes, their dreams, their intense desires, and their whimsical wishes. It often involves helping clients

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clarify unclear pictures of what they want. It can also include a discussion of conflicting wants and what they want from their parents, their spouse, their children, their job, the community, family members, friends, religion or spirituality, social agencies, and any person or group that impinges on their lives. Special focus is given to what they want from themselves or their level of commitment and how much energy they will exert to fulfill their wants. W also refers to asking clients about their perceived locus of control. The therapist assists clients to describe whether they see themselves in control of their lives or victimized by their personal history, society, or current circumstances. D represents interventions focusing on doing or on total behavior, especially clients’ actions. The therapist asks clients specific questions relating to current choices, with emphasis on their relationships with other people. D also stands for an exploration of clients’ self-talk as derived from choice theory. People who feel that they are at the mercy of their external world tell themselves, “I  can’t” or “They won’t let me.” The antisocial person engages in self-talk such as “No one can tell me what to do.” When the most prominent component of behavior is emotion, the reality therapist listens carefully and relates the feeling to the more controllable component of behavior: actions. E stands for self-evaluation, the core of reality therapy. Conducting a searching and fearless selfevaluation is the royal road to behavioral change. Reality therapists ask clients not only to describe the W and the D but also to make a judgment about them. The following interventions are characteristic of E: “Is what you’re doing helping or hurting you?” “Is it really true that you have no control in your life?” “If you make no effort to alter your actions, will anything change for the better?” “Is what you want realistically attainable?” P represents planning. When clients formulate plans, they benefit by addressing not only specific issues but also the side effects that often occur. Deriving a sense of hope and confidence, they realize that they need not remain powerless. They have more control than at first perceived. The plan should be simple, attainable, measurable, immediate, and controlled by the planner, that is, not dependent on others. Robert E. Wubbolding

See also Adlerian Therapy; Cognitive-Behavioral Therapy; Existential-Humanistic Therapies: Overview; Rational Emotive Behavior Therapy; Solution-Focused Therapy

Further Readings Glasser, W. (1965). Reality therapy. New York, NY: Harper & Row. Glasser, W. (1998). Choice theory. New York, NY: HarperCollins. Glasser, W. (2003). Warning: Psychiatry can be hazardous to your mental health. New York, NY: HarperCollins. Glasser, W. (2011). Take charge of your life. Bloomington, IN: iUniverse. Roy, J. (2014). William Glasser: Champion of choice. Phoenix, AZ: Zeig, Tucker & Theisen. Siegel, D. (2012). Pocket guide to interpersonal neurobiology. New York, NY: W. W. Norton. Wubbolding, R. (1988). Using reality therapy. New York, NY: Harper & Row. Wubbolding, R. (1991). Understanding reality therapy. New York, NY: HarperCollins. Wubbolding, R. (2000). Reality therapy for the 21st century. Philadelphia, PA: Brunner Routledge. Wubbolding, R. (2011). Reality therapy: Theories of psychotherapy series. Washington, DC: American Psychological Association. Wubbolding, R., & Brickell, J. (1999). Counselling with reality therapy. Milton Keynes, England: Speechmark. Wubbolding, R., & Brickell, J. (2001). A set of directions for putting and keeping yourself together. Minneapolis, MN: Educational Media Corporation.

REBIRTHING Rebirthing is a controversial approach to working with individuals who have attachment issues, such as those that may be found in children who have been adopted. In this approach, the practitioner works to help the client go through age regression to re-create the experience of being born. It is related to holding approaches and loosely related to attachment-based therapies, although most attachment-based therapies do not have the negative consequences that have been shown in this approach.

Rebirthing

Historical Context Rebirthing emerged in the mid-20th century as an approach to mitigate attachment difficulties. The approach was aimed to help those with attachment challenges bond with their parents (biological, foster, or adoptive). In theory, once a rebirthing was accomplished, a reparenting phase may be warranted to further enhance the attachment process. In the early years of the 21st century, rebirthing came under increased scrutiny, in part due to the death of a 10-year-old girl who underwent the rebirthing process as a result of her reported challenges in attaching to her adoptive mother. The girl was wrapped in a sheet while lying in the fetal position. Four adults subsequently pressed on her with pillows to re-create the birthing process. Despite the girl’s cries for help and her statements that she was unable to breathe, the session continued for more than an hour. She was unconscious and unresponsive when the sheet was removed and was pronounced dead a day later. Rebirthing has faced ethical and legal challenges and has been outlawed in some jurisdictions.

Theoretical Underpinnings Rebirthing is viewed as an outgrowth of regression-based theories, catharsis, holding therapies, and rage reduction models. It has been linked to psychoanalysis, attachment theory, the Z-process, Ericksonian theory, as well as a host of other theories. One of its aims is to interrupt defense mechanisms that block the pathway to healthy parent– child attachment. It is predicated on the notion that the application of compression can re-create the birthing process so that the child is able to bond normally with the parent as the two make eye contact as the child emerges from the simulated womb.

Major Concepts Rebirthing is associated with myriad concepts that vary by practitioner. The major concepts associated with the approach include holding theory, regression theory, attachment, and rage reduction theory. Holding Theory

Holding theory exists in many forms, based on the notion that holding is essential to the establishment of healthy attachment. In the context of

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rebirthing, it may be used as a preliminary intervention. Holding may be applied as a scheduled event, occurring at prescribed intervals throughout the day. An early, and subsequently discredited, version of holding therapy is attributed to Robert Zaslow, who created what he called the Z-process. Regression Theory

Regression theory, as it relates to rebirthing, suggests that it is possible for individuals to experience age regression aimed at ameliorating the lack of achievement of various developmental milestones. Other objectives of regression therapy may include the retrieval of unconscious material or memories that have been repressed. Attachment

A lack of healthy parent–child attachment is a major concept associated with the use of rebirthing techniques. The disruption of the attachment process is thought to give rise to a host of behavioral and relational problems in the child, thus requiring intervention. Rage Reduction Theory

Rage reduction sessions may last for multiple hours and call for the practitioner to come into physical contact with the client through holding techniques. Confrontational, often demeaning statements by the therapist may be repeated throughout the session in an effort to have the child give up manipulative and defensive behaviors. The intent is to help the client reach a state of catharsis so that the rage is released and the child can be re-parented.

Techniques In an effort to re-create the birthing process, practitioners may employ a variety of techniques. Preliminary training in breathwork may precede the formal rebirthing process. The main technique applied in this approach is compression therapy, which is intended to trigger a rebirthing experience to such a degree that the client becomes amenable to bonding with the parent. Confrontation of the client’s statements that are expressed during

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the process is another aspect of the approach. The sessions last for multiple hours, and more than one session may be prescribed by the practitioner. Breathwork

As alluded to in its name, breathwork consists of the use of regulated breathing as a means to address various psychological states. Breathwork may call for the slowing of breath or breathing in prescribed patterns. The general purpose of breathwork may be to achieve enhanced psychological awareness or to help reduce one’s sense of stress. As a corollary to rebirthing, some practitioners have asserted that breathwork can allow one to recapture and deal with repressed traumatic emotions, such as those that have led to obstacles in bonding with parents. Compression Theory

In the quest to re-create the birthing process, early theorists devised compression techniques that called for the swaddling of the client. In addition, this approach often uses pillows or cushions that are placed on the child’s body with pressure applied by the practitioners. Theorists hypothesized that the application of pressure to the child via the swaddling and pillows would trigger psychological regression to the extent that the child could reexperience the birth process. Confrontation

Clients typically cry and call for help during the rebirthing process. Often the child will request a drink or will request to be allowed to use the bathroom. These types of requests are viewed by practitioners as manipulative behaviors and are met with confrontation from the practitioners.

Therapeutic Process Rebirthing calls for the client to be wrapped, sometimes while in the fetal position, in some type of cloth (i.e., a blanket or sheet) in an effort to re-create the womb. The individual’s head may or may not be exposed. Practitioners then use pillows, or similar objects, to press against the client to replicate the birthing process. Cries for help or

requests to go to the bathroom are viewed by practitioners as attempts at manipulation and are thus ignored. The goal is for the child to cry and struggle to push out of the makeshift womb with the ultimate goal of making eye contact with and subsequently attaching to the parent. The role of the practitioner in this process is often to serve as the coach to the client, the parent, and other participants. Sessions are often held in the office of the practitioner, although the sessions could be conducted in the home of the parent. The sessions often last for several hours and as such can be enormously physically taxing to all involved, especially the client. During the rebirthing process, the weight of several adults may be pressing down on the client, who may be completely encapsulated in blankets and pillows, creating a great risk to the client’s physical as well as emotional health. It is important to note that rebirthing has been outlawed in multiple jurisdictions. Its lack of empirical validity has contributed to its discredited status. Peggy L. Mayfield See also Cautious, Dangerous, and/or Illegal Practices: Overview; Classical Psychoanalytic Approaches: Overview

Further Readings Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. Freeman, J. C., Epston, D., & Lobovits, D. (1997). Playful approaches to serious problems: Narrative therapy with children and their families. New York, NY: W. W. Norton. Perry, B. D. (2009). Maltreated children: Experience, brain development and the next generation. New York, NY: W. W. Norton.

REBIRTHING-BREATHWORK Rebirthing-Breathwork, also known as Rebirthing, Connected Breathing, Intuitive Energy Breathing, among other names, is a therapeutic process whose

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practice primarily involves a circular breathing technique and spontaneous form of regression therapy. Founded in the 1970s by Leonard Orr, some of the practices resemble those of ancient yoga methods, though the founder was unaware of this until after he had developed his original theories. It is founded partly on the belief that the act of being born is an inherently traumatic event, leaving a deep psychological imprint that most people are unable to recall but that nonetheless affects their behavior and breathing ability, and that birth trauma has a natural tendency to reach the conscious mind when one is relaxed and feels safe. Rebirthing in this usage is not to be confused with other practices bearing the same name, such as the controversial techniques used to re-create the birth experience for children showing signs of detachment.

Historical Context Rebirthing-Breathwork has been called “an American form of Pranayama Yoga” by Haidakhan Babaji, an Indian saint who identified himself to Orr as the Shiva Mahavatar Babaji, known to many through Paramahansa Yogananda’s Autobiography of a Yogi. Pranayama is a form of yoga concerned with the ancient study of the breath and the methods of breathing practiced by yogis, wherein the effects of such breathing can be felt in the form of healing energy throughout the entire body. Born in 1938 in Walton, New York, Orr was raised in a nonreligious home. He became an evangelical Christian at 18 years of age, but he became disenchanted with the institution of the church and began to study the scripture of many ancient traditions, looking for answers his Christian education stirred within him. As part of his spiritual quest, from 1962 to 1974, he studied the human consciousness and experimented with breathing exercises, deep relaxation, and bathtub meditation and began to spontaneously reexperience memories going as far back as the time of his birth. When others, following Orr’s techniques, similarly described birth memories, the term Rebirthing came into common use to describe this modality. Orr has stated that between 1988 and 1993, he used Rebirthing-Breathwork to heal himself of eight terminal diseases, as well as his senility experience.

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The psychotherapeutic community began taking an interest in Rebirthing-Breathwork after observing its effectiveness in healing patients of the negative effects of their past. The First Rebirthing Method

In 1962, while relaxing in the bath for an extended period of time, Orr had a spontaneous regression that left him weak and unable to move from the tub. He later realized that he had regressed into an infancy memory and an experience of helplessness. This regressed state lasted 3 hours. Orr continued spending extended time in his tub relaxing through feelings of urgency. Each time he relaxed through these urgency barriers, Orr recovered early infancy, birth, and prenatal memories as far back as conception. Orr found many people who were interested in accessing their own early memories, asking him for guidance and support. Orr began by sitting beside the tub supporting them through several urgency barriers. Eventually, he purchased a large house in the Haight-Ashbury district of San Francisco, California, and invited volunteers to move in and help develop his Rebirthing method. This was the beginning of Theta House, which launched the Rebirthing movement into a worldwide phenomenon. The Second Rebirthing Method

Orr decided to move the sessions from the bathtub to a hot tub. With the participant floating and breathing through a snorkel, Orr, in the tub beside the participant, instructed the participant to continue breathing until he or she was overwhelmed with memory and had to come out to integrate the experience. Eventually, Orr noticed that this continuous unbroken rhythm triggered a powerful effect on the participant’s overall breathing pattern. At a certain point, the breathing would become spontaneous, and a powerful circular rhythm would emerge. Ultimately, this realization led to experimenting with the breath alone, without the water. The Third Method: Rebirthing-Breathwork

Orr began to facilitate sessions with participants lying comfortably on the floor or a mattress

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and guiding their breathing into a connected circular rhythm. This method proved to be highly effective in reproducing the same results Orr had noticed in the tub, and Rebirthing-Breathwork was born. With continued refinement, this technique has evolved into the gentle yet powerful RebirthingBreathwork methods employed successfully by thousands of Rebirthing-Breathwork instructors throughout the world today.

Theoretical Underpinnings According to the principles of RebirthingBreathwork, disease and misery are caused by unresolved trauma, misuse of the human mind, poor diet and lifestyle, inadequate rest or solitude, and ignorance of basic cleansing practices. This results in emotional suppression, inhibited breathing, physical contraction, chronic stress, and accumulated waste, causing many common diseases. The therapy seeks to address illness simultaneously from physical, mental, and spiritual perspectives through the study of metaphysical principles and spiritual purification practices, including conscious energy breathing, which accomplishes this automatically. By studying these causes of disease, misery, and death, it becomes possible to bring unconscious thoughts, beliefs, and behaviors into awareness; to resolve unhealed trauma; and to make changes that may ultimately bring healing. Living a conscious life on the path of unlimited personal mastery is the ultimate goal of Rebirthing-Breathwork.

Major Concepts Rebirthing-Breathwork identifies a number of common factors contributing to physical, mental, and spiritual illness, including birth trauma, misuse of the human mind, parental disapproval syndrome, unconscious death urge, school and religious trauma, senility, and emotional energy pollution. Birth Trauma

According to Orr’s principles, birth, at its core, is a natural event. The ability for a successful, healthy birth is innate to all species. By design, the infant passes through the birth canal, moving from the womb to the world; takes its first breath; and is suckled, cared for, and comforted by its mother and

attendants. Under the best of circumstances, this process is challenging. Common medical practices have denaturalized this process and introduced trauma-inducing practices, including spanking a newborn (the traditional explanation has been that this clears the infant’s air passages), cutting the umbilical cord immediately after birth, removing the child from the mother soon after birth, isolation in an incubator, and so on. These practices were probably designed to hasten the child’s acclimation to the world, but they leave behind damage that the person does not remember in later life. Misuse of the Human Mind: Personal Law and Specific Negatives

Personal law refers to the most abstract negative thought that individuals have about themselves. The term law is used because the individual enforces it to the point where deviation from it seems impossible. Individuals will interpret their life experiences in accordance with their personal law and use this as evidence for their false beliefs. Specific negatives are negative thoughts that align with and support one’s most fundamental beliefs. Any given person’s personal law and specific negatives run his or her life until he or she identifies them, disproves them through reason, and replaces them by building a construct of life-enhancing thoughts through recognition of one’s natural innocence, true nature, and unique gifts. Parental Disapproval Syndrome

Much adulthood trauma is related to childhood feelings of betrayal from one’s parents. Among the earliest dynamics between children and their parents is that by which parents withhold affection to discipline the child. This can lead to unhealthy lifelong behavioral patterns in which the child associates love with pain and trauma and thus seeks out unhealthy and dangerous relationships and situations. Without some form of therapy, it is very difficult to overcome parental disapproval syndrome. Unconscious Death Urge

The unconscious death urge is a thought structure consisting of any and all antilife thoughts. At the root of the unconscious death urge is the belief that life is inherently lethal, that existence is unsafe,

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that humans are separated from the source of their being, and that the only way out is death. Ancestral and cultural beliefs and attitudes are the primary source from which we learn these beliefs. RebirthingBreathwork seeks to identify and redirect one’s thinking in a life-enhancing direction. Rebirthing practitioners recommend sitting before an open fire to silence the mind and counteract the urge. School and Religious Trauma

For some, unpleasant experiences in early schooling can stifle creativity and a sense of nurturing, as well as exposing children to “emotional energy pollution.” Such trauma may include negative reinforcement as a means of exercising discipline. Some individuals raised under a harsh religious doctrine may grow up with a sense of shame and false beliefs about themselves and their self-worth. Senility

Practitioners of Rebirthing-Breathwork use the term senility to describe a general surrender to disease. Unhealed trauma, infancy memories, along with accumulated emotional energy pollution will eventually surface as misery, disease, and degeneration. Senility is seen as “the final exam.” When the individual is successful with addressing his or her sources of misery and suffering, the result is longevity. When unsuccessful, the result is increasing stiffness, contraction, and death. Emotional Energy Pollution

Just as Earth has an atmosphere, individual beings, too, have an atmosphere. The individual’s atmosphere is its energy body, which permeates and extends beyond the physical body. The mind and emotions are also contained within the energy body. Thoughts (or mental constructs) and emotions are palpable not only to an individual but also to other individuals, even in the absence of direct communication. The information contained in energy bodies is transferable. In fact, there is a continuous exchange between all life forms within the environment. When individuals are creating thoughts and generating emotions from conditioning, they are creating and generating emotional energy pollution.

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Emotional energy pollution can be removed from the energy body with spiritual purification practices. Basic spiritual purification practices are fasting, good diet, exercise (earth), conscious energy breathing (air), bathing twice per day (water), and sitting by an open flame (fire). These basic spiritual purification practices can clean the mind faster than the mind can clean the mind.

Therapeutic Techniques Two main therapeutic techniques are used in Rebirthing-Breathwork: (1) conscious energy breathing and (2) affirmation and emotional response technique. Conscious Energy Breathing

In practice, Rebirthing sessions center on conscious energy breathing, whose purpose is to liberate the breathing mechanism, develop the ability to breathe energy as well as air, and allow divine energy to move throughout the body. The breathing practiced in the sessions is circular and connected, with relatively full and fast, yet unforced, inhales and relaxed exhales. The goal is to awaken a pattern of breathing that more closely resembles that of an infant; adults tend to breathe disconnected breaths with palpable muscle tension and restrictions. Insufficient breathing is a common problem for most people. Particularly in moments of stress, people frequently hold their breath or restrict their inhale without realizing it. Breathwork is effective in working through this conditioning and the resulting energy blockages that can be caused by subventilation. In a given session, 1 to 2 hours will be devoted to conscious energy breathing; the exact length is determined by the actual duration of an energy cycle. A completed energy cycle can be recognized by feelings of deep relaxation and presence. This type of breathwork is not to be confused with hyperventilation, which is tension based and involuntary. In practice, the individual will become aware of “concentrations of energy” in the form of negative thoughts, suppressed feelings, and sensation in their physical body. “Breathing into” this area and relaxing on the exhale can lead to effective relief for the individual. With practice, this experience can become increasingly more comfortable and enjoyable.

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By breathing in this fashion, clients frequently report feelings of bliss, a release of anger, and a general sense of well-being. Because the Rebirthing sessions re-create infant respiratory patterns, patients can experience long-forgotten memories from early childhood, as well as birth and prenatal memories. Affirmation and Emotional Response Technique

Repetition of high-quality ideas will often cause contrasting ideas and their associated feelings to surface, where they can be experienced and evaluated along with the impact these thoughts have in our lives. Practitioners of Rebirthing-Breathwork utilize written or spoken affirmations for this purpose. Through reason and repetition, one can use this information to negate these negative beliefs and build a high-quality thought structure to replace the outdated information and improve the quality of clients’ lives considerably. Someone who gravitates toward abusive relationships, for example, may be acting from a core belief that he or she is unworthy, so the client’s treatment will include statements affirming his or her worthiness of love and respect and acceptance of relationships embodying these qualities.

Therapeutic Process Rebirthing-Breathwork can usually be taught in 10 to 20 sessions, each session lasting 1½ to 2 hours. The first session involves developing a rapport with the client while gathering background information, including what brings the client to this process and past experience in the area of selfimprovement. This is followed by breathing exercises, preparation for the first breathwork session, and the breathwork session itself. Subsequent sessions involve introducing metaphysical principles, exercises for revealing personal law and specific negatives, unraveling the unconscious death urge, and developing individual affirmation statements. Each of the subsequent sessions concludes with a breathwork session. The primary goal of the breathwork sessions is to teach the client to guide his or her breath into a circular rhythm, merge the inhale with the exhale, breathe energy as well as air, maintain this for at least 1 hour or the completion of an energy cycle,

and obtain a sense of safety through this process, especially through the “breath release: This occurs when the breathing mechanism releases the tension created at birth.” Virginia Peace Arnold See also Body-Mind Centering®; Energy Psychology; Focusing-Oriented Therapy; Mindfulness Techniques; Prayer and Affirmations

Further Readings Churchill, P. (2007). Eternal breath: A biography of Leonard Orr, founder of rebirthing breathwork. Victoria, British Columbia, Canada: Trafford. Orr, L. D. (1995). Breath awareness. Staunton, VA: Inspiration University. Orr, L. D. (1995). The new rebirthing book. Staunton, VA: Inspiration University. Van Laere, F., & Orr, L. D. (2011). Manual for rebirthers. Madrid, Spain: Vision Libros.

RECOVERED MEMORY THERAPY Recovered memory therapy refers to several different techniques based on the premise that memories of brutal, terrifying childhood events can be completely hidden from consciousness but still cause significant emotional problems. The assumption is that the traumatic events were so horrible that the client developed amnesia through a process of repression or dissociation and therefore must be helped to uncover these buried memories in order to heal from the trauma. Recovered memory therapy is highly controversial, and there is strong evidence that recovered memory techniques can produce false memories. The theories and techniques are not scientifically supported and are not generally accepted in the scientific community.

Historical Context Recovered memory therapy began surfacing in the late 1980s in connection with claims of childhood sexual abuse. Therapists specializing in this effort maintain that many incest survivors do not remember their abuse but their abuse results in emotional and physical problems. They claim that clients

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must be helped to retrieve their memories in order to recover from the trauma. Some recovered memories include bizarre ritual satanic abuse. From the beginning, recovered memory therapy was controversial, with critics maintaining that there was no support for the theories the therapy was based on and that clients were in danger of developing false memories of terrible things that never happened. In the 1990s, there were several highly publicized malpractice lawsuits by clients who, when they realized that their memories of incest and ritual abuse were false, successfully sued their therapists. The result of these malpractice lawsuits, along with licensing board revocations, is that recovered memory therapy has virtually disappeared.

Theoretical Underpinnings Recovered memory experts believe that survivors have repressed memories as a protective mechanism that keeps memories out of consciousness. However, the trauma is believed to exert itself unconsciously through emotional and behavioral problems, which are manifested through body memories, flashbacks, nightmares, or dissociation. If the abuse was frequent and prolonged, it is believed that alternate personalities may form to protect the person during the abuse, which can result in the development of multiple personality disorder. Recovered memory therapists believe that large numbers of people have suffered childhood sexual abuse but repressed their memories. They believe that the repressed abuse results in a variety of psychological problems that individuals may deny as the abuse is buried in the unconscious. Typical symptoms include dreams of being pursued, sleep disturbances, eating disorders, substance abuse, compulsive sexuality, sexual dysfunction, chronic anxiety attacks, depression, difficulty with relationships, distrust of others, guilt, impaired selfesteem, self-destructive behaviors, and personality disorders. Retrieval of the repressed memories is believed to be necessary for healing and recovery.

Major Concepts Therapists support the assumption of repressed memories by referring to one or more psychological concepts, including repression, dissociation

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and psychogenic amnesia, posttraumatic stress disorder, multiple personality disorder, body memories, and flashbacks and dreams. Repression

Repression is a mechanism by which the person is unable to remember or be cognitively aware of disturbing feelings, thoughts, or experiences. It is differentiated from ordinary forgetting. Despite the fact that repression is a basic assumption of Freudian personality theory, in this context, it is not empirically supported. Traditional analytically oriented therapists, who may use the concept of repression, are concerned with the client’s perceptions of reality rather than the historical accuracy of the material uncovered in therapy. Also, there is nothing in the repression literature supporting the belief that it is common for repeated episodes of sexual abuse to be completely repressed for years, only to be remembered years later. Dissociation and Psychogenic Amnesia

Dissociation is defined as an alteration in the normally integrative functions of identity, memory, and consciousness. Because the person’s thoughts, feelings, or actions are altered, some information may not be integrated with other information and therefore is not accessible to memory. A dissociated memory is seen as distinctly different from one that is simply forgotten. Dissociation is seen as a protective response to traumatic childhood sexual abuse in which the child dissociates the abuse experiences so that they are not available to memory. Because the child is in an altered state of consciousness, there is limited access to these memories during the ordinary state. Retrieval of the memories is therefore accomplished in adulthood through an altered state of consciousness, such as hypnosis or age regression. Psychogenic amnesia is the dissociation mechanism postulated to explain the lack of memory for childhood abuse. The essential feature of psychogenic amnesia is a sudden inability to recall important personal information. However, there are no empirical data supporting a concept of psychogenic amnesia for a category of events stretching across several years at different times and under different circumstances in differing environments.

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Persons with psychogenic amnesia have undergone severe life stresses, such as violent physical abuse, torture, confinement in concentration camps, or combat. However, most people experiencing trauma do not develop amnesia for the trauma. Case studies on the reactions of people to documented severe trauma indicate that they show many symptoms, but total amnesia for the event is not common. Children below 3 or 4 years of age are unlikely to remember a trauma because of their age, but this is not psychogenic amnesia, dissociation, or repression. Such forgetting is due to the phenomenon of infantile or childhood amnesia. Adults and older children rarely remember events that happen prior to ages 3 to 4 years. This inability to recall events from an early age is a function of the normal process of growth and development. Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is diagnosed when a client develops characteristic symptoms after experiencing a distressing and traumatic event that is outside the range of usual human experience. The event is experienced with intense fear, terror, and helplessness. The symptoms involve reexperiencing the traumatic event, avoidance of stimuli associated with the event, numbing of general responsiveness, and increased arousal. Although the criteria for PTSD mention numbing and efforts to avoid thoughts or feelings, along with psychogenic amnesia for an important aspect of the event, there is no mention of total amnesia for the entire event. Also, to diagnose PTSD, there must be a known stressful event. The diagnosis cannot be given on the basis of the symptoms alone without verification of the event. Multiple Personality Disorder

Multiple personality disorder (now called dissociative identity disorder) may be diagnosed, especially when the alleged abuse is violent and sadistic. Multiple personality disorder is the existence within the person of two or more distinct personalities or personality states. A “protector” personality is said to emerge and take over for the individual, who therefore escapes psychologically from the abuse. However, support for this theory is based only on clinical case reports. In addition,

multiple personality disorder itself is controversial and appears to be heavily dependent on cultural influences for both its emergence and its diagnosis. Skeptics believe that people learn to enact the role of the multiple-personality client and that therapists play an important part in the generation and maintenance of this role enactment. Body Memories

The assumption underlying the body memories concept is that, although there are no conscious memories, the body remembers and the client has physical symptoms that correspond to the childhood abuse. The person is said to retrieve colors, hear sounds, experience odors, and taste sensations, and the person’s body may react in pain or develop stigmata reminiscent of the abuse. The theory is that body memories are emotional, kinesthetic, or chemical recordings stored at the cellular level and can be retrieved. There is no scientific evidence supporting these assumptions. Flashbacks and Dreams

Recovered memory therapists believe that flashbacks confirm the reality of the abuse since the flashback is interpreted as the reliving of an actual traumatic experience. However, flashbacks cannot be assumed to represent a memory of an actual life event. Instead, they are the development from the experience of a “worst fear” scenario. They are likely to reflect the client’s fears of the terrible things assumed to have happened to the client and can be generated out of the focus in therapy. Recovered memory “experts” sometimes view dreams as reflecting actual events. They believe that the boundary between the conscious and the unconscious mind is more permeable while dreaming. However, as with flashbacks, dreams cannot be assumed to reflect actual events. Rather, the content of the dream reflects what the person has been thinking. If clients are reading a survivor’s book or attending a survivors’ group and trying to remember forgotten abuse, it is likely to affect their dreams.

Techniques Recovered memory therapists use a variety of techniques to help clients recover memories, in

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addition to simply asking them about it. The techniques include hypnosis, age regression, Amytal interviews, ideomotor signaling with the unconscious, guided imagery, interpreting flashbacks and dreams, reading books, attending survivors’ groups, bodywork, journaling, and art therapy. There is no empirical support for the assumption that these techniques result in reliable information about real events. Hypnosis, Age Regression, and Amytal Interviews

The use of hypnosis or sodium Amytal (“truth serum”) for memory retrieval raises serious problems about the accuracy of the memories elicited. People are more suggestible under both and are likely to experience the retrieved memories as vivid, detailed, and real even when they are false. When used for age regression, clients who are told that this is a valid technique can come to believe that they can even recall complex past-life identities. Ideomotor Questioning and Guided Imagery

Ideomotor questioning, a variant of hypnotherapy, is intended to be a way of getting information from the unconscious. While in a trance, clients are told to relax while their unconscious does the work, and then, they are asked questions, which are answered by finger signals. In guided imagery, clients are told to relax, take deep breaths, picture a scene, and then relate as many details as possible. The therapist asks questions to guide the images. Interpreting Flashbacks and Dreams

Clients are asked to discuss their flashbacks and dreams as a way of uncovering or clarifying repressed memories. When interpreting dreams, the symbolism of the dream is explored, and clients are helped to actively look for clues about their abuse history in the dream. Reading Books

Clients are often asked to read The Courage to Heal by Ellen Bass and Laura Davis. This book, which has been called the bible of the recovered

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memory movement, asserts that the lack of memories of abuse does not mean that clients have not been abused—if their life shows the symptoms, then they were abused. Other books include Secret Survivors by E. Sue Blume and Repressed Memories: A Journal to Recovery From Sexual Abuse by Renee Fredrickson. These books accept the reality of recovered memories not only of repressed abuse but also of ritual satanic abuse. Survivors’ Groups

Individuals are often referred to survivors’ groups, which are considered to be a powerful stimulus for recovering previously forgotten memories. Because the task of therapy is to recover the hidden memories, group members are encouraged and reinforced as they report new memories. Bodywork

This type of therapy includes massage therapy as well as adaptations designed to unlock memories of repressed abuse. The premise is that as certain places on the body are touched or certain movements are made, memories are released that talk therapy cannot touch. Journaling and Art Therapy

Journal writing is believed to be a way of accessing the unconscious. After getting a flashback or body memory, clients are told to write quickly in their journal without censoring what is written. The client may use free association or just tell a story. In art therapy, clients allow their hand to paint or draw whatever picture it wants to without trying to control the outcome with the conscious mind.

Therapeutic Process With this type of therapy, there is no time limit, and recovered memory therapy can continue for long periods. Often, clients are encouraged to confront their parents or break off ties with their family. They may be hospitalized or referred to survivors’ groups. Therapists use the various techniques, discussed in the previous section, throughout sessions

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for the duration of treatment in an attempt to uncover and heal the trauma of the repressed memory. Hollida Wakefield See also Bibliotherapy; Body-Oriented Therapies: Overview; Hypnotherapy; Other Therapies: Overview

Further Readings Goldstein, E., & Farmer, K. (1992). Confabulations. Boca Raton, FL: Sirs Books. Loftus, E., & Ketcham, K. (1994). The myth of repressed memory: False memories and allegations of sexual abuse. New York, NY: St. Martin’s Press. Lynn, S. J., Lock, T., Loftus, E., Krackow, E., & Lilienfeld, S. O. (2003). The remembrance of things past: Problematic memory recovery techniques in psychotherapy. In S. O. Lilienfeld, S. J. Lynn, & J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology (pp. 205–239). New York, NY: Guilford Press. McNally, R. J. (2005). Debunking myths about trauma and memory. Canadian Journal of Psychiatry, 50, 817–822. McNally, R. J., & Geraerts, E. (2009). A new solution to the recovered memory debate. Perspectives in Psychological Science, 4, 126–134. doi:10.1111/j.1745-6924.2009.01112.x Ofshe, R., & Watters, E. (1994). Making monsters: False memories, psychotherapy, and sexual hysteria. New York, NY: Scribner. Piper, A., Lillevik, L., & Kritzer, R. (2008). What’s wrong with believing in repression? A review for legal professionals. Psychology, Public Policy, and Law, 14, 223–242. doi:10.1037/a0014090 Spanos, N. P. (1996). Multiple identities and false memories: A sociocognitive perspective. Washington, DC: American Psychological Association. Wakefield, H., & Underwager, R. (1994). Return of the furies: An investigation into recovered memory therapy. Chicago, IL: Open Court.

RE-EVALUATION COUNSELING Re-evaluation Counseling (RC) is a growth and awareness process that focuses on repressive forces in clients’ lives that have created unresolved distress. RC is often referred to as co-counseling

because of its emphasis on the egalitarian and bidirectional relationship between the counselor and the client. Simply stated, the roles of the counselor and the client are interchangeable, with each person functioning in both roles; the underlying premise is that people can learn to help one another. Thus, basic counseling skills such as active listening and reflection of feeling are important points of emphasis for the person acting in the counselor role. From an RC perspective, negative behaviors are considered socially generated stressors that can be eliminated through the process of discharge. The idea of discharge is akin to the client-centered concept of conditions of worth as well as the psychoanalytical idea of repression and is the central goal of RC.

Historical Context The origins of RC can be traced to the 1950s. While Harvey Jackins is considered the father of the RC movement, the approach itself is thought to be an offshoot of L. Ron Hubbard’s Dianetics Institute, which later evolved into the Scientology movement. Thus, many of the central tenets of the RC approach (e.g., discharge) are similar to Dianetics principles developed earlier by Hubbard. Jackins developed RC based on his clinical experience watching clients emote (e.g., laugh, cry, shake) and progress from, at times, nonfunctioning to fully functioning states. Based on these experiences, Jackins and colleagues began experimenting with techniques that actively promoted emotional expression among their clients in sessions. In contrast to other counseling approaches, the RC model evolved from hours of clinical observation rather than new or current theories of human behavior. In 1958, Jackins began offering “Personal Re-Evaluation Counseling” classes, in which he and his colleagues taught people to co-counsel. Originally developed in Seattle, the RC movement soon spread nationally, with proponents in California and then the East Coast, and eventually internationally (classes started being offered in England). Today, the co-counseling movement can be found in approximately 93 countries worldwide. In response to the rapid growth and interest, the leaders of the RC movement developed procedures for ensuring competency in the understanding of the theory and practice of the approach. Along these lines, an RC certification process was developed,

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along with a basic structure for organizing RC classes and ensuring minimum levels of competence and adherence. After Jackins’s death in 1999, his son, Tim Jackins, became the leader and International Reference Person for the RC approach. Tim Jackins continues to promote the work of his father and has expanded in other areas as well. Harvey Jackins is responsible for most of the literature written on the approach and was an active contributor to the primary RC journal, Present Time, which reports on new theoretical and clinical developments. While it is not uncommon for proponents of particular theories to espouse, and sometimes exaggerate, the benefits of a given approach, Jackins claimed, “Re-evaluation counseling can be confidently viewed as the very leading edge of the tendency toward order and meaning in the universe” (as cited in Tourish & Wohlforth, 2000, p. 96). Yet there is a lack of empirical evidence concerning the use of RC; the approach has been modified and refined based on the clinical experiences of the RC leaders rather than scientific data. Interestingly, Jackins did not approve the term co-counseling, which became the name of an offshoot of RC developed in the 1960, Co-Counseling International (CCI). While there is an overlap between these two schools of therapy, the primary differences include less emphasis on the “no socializing” guideline in CCI, less consideration on social oppression as a source of distressful patterns in CCI, and differences in leadership structures.

Theoretical Underpinnings RC theory provides a model of what human beings can be like in their interactions with others and their environment. According to Katie Kauffman and Caroline New, who have written extensively on RC, individuals are born with inherent intelligence, zest, and kindness, but these qualities become compromised as a result of accumulated distressing experiences (e.g., fear, hurt, loss, pain, anger, embarrassment) that begin early in life and are continuously reinforced through social oppression. RC posits that people have an inherent desire to rid themselves of negative events or behavior through a natural emotional discharge process of behaviors such as nonrepetitive crying, shaking,

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perspiring, yawning, laughing, or talking. However, in many cases, this emotive process is interrupted (often because of the uncomfortable feeling that may be generated by the discharge behavior itself) and may result in the discharge behavior being equated with the original trauma. More specifically, rather than viewing the release or discharge of emotion related to the trauma as a positive event, it is often perceived as a symptom of the problem behavior, to be interrupted or shut down. In response to this, the RC technique of discharge allows the expression of feeling and helps the individual move beyond the pain. According to proponents of RC, everyone has the capacity to facilitate the discharge process through training in basic counseling techniques. The person in the counselor role listens, engages the other person in the counseling process, and encourages honest emotional discharge and expression. The role of the client is to talk, discharge, and re-evaluate the painful situation. Thus, given the basic structure of the process, the roles of the counselor and the client can be used interchangeably, thereby removing the potential for power imbalances, which can sometimes be problematic in more traditional counseling approaches. Kauffman and New’s 2004 book Co-Counselling lists eight fundamental principles of RC: 1. The basis of human distress is interference with intelligence by hurtful experiences in very specific ways. 2. There is an assumption that humans are inherently wholesome, intelligent, zestful, loving, and good and believe that everyone has the capacity to flourish beyond what has been observed. 3. The only source of dysfunction in a human being is an experience of hurt (physical or emotional). 4. The full range of the discharge process is of central importance. 5. There is a distinct human difference between the person and his or her distress. 6. The peer relationship is critical in RC. 7. The wider social context is an important contributor to distress and hurt.

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8. It is helpful to be part of a group that shares its collective resources of attention and increasing skill.

Chronic Patterns

Chronic patterns are distressful patterns that continuously occur, regardless of setting or environmental cues; they are often considered personality traits.

While the ultimate goal of RC is the discharge of distress, society continuously imposes institutionalized classism, sexism, and racism on a daily basis. Thus, as part of the reemergence process, clients are encouraged to be socially active and apply the techniques and skills learned in RC on a more widespread and global level to help others.

Co-Counselng

Major Concepts

RC Community

A number of major concepts help us understand the process of RC, including discharge, re-evaluation, directions, distress recordings, intermittent patterns, chronic patterns, co-counseling, RC community, fundamentals class, and support groups. Discharge

Discharge is the process of removing distress patterns through outward physical manifestations of the distressing event (e.g., crying, trembling, laughter, and/or talk).

Co-counseling occurs when individuals take turns in the client and counselor roles, each assisting the other in recovering from distressing events.

RC Community refers to the Re-evaluation Counseling community, which began in the 1970s as a network of RC therapists who focused on their own recovery and on assisting others in doing the same. The members agree to adhere to the Guidelines for the Re-evaluation Counseling Communities. Fundamentals Class

The process of re-evaluation occurs after discharge and involves re-evaluation of the material released through discharge, which would not have been otherwise accessible.

Fundamentals class describes the basic RC class that typically meets once a week for instruction in simple communication skills and the co-counseling process. Students or clients view instructor demonstrations of the RC approach and informal cocounseling sessions between class members on a weekly basis. During this introductory level, the emphasis is on respect, active listening, and support.

Directions

Support Groups

Directions refers to a way of contradicting a distressing pattern by maintaining a position or perspective contrary to the distressing recording.

Support groups are ongoing classes available to fundamentals class graduates that focus on a variety of themes (e.g., discrimination, women’s oppression, work-related stress, and inequities).

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Distress Recordings

Distress recordings (i.e., distress patterns) describe the characteristics of a painful event (e.g., sights, smells, sounds) and feelings that are mentally recorded. Intermittent patterns

Intermittent patterns are upsetting patterns that only occur under certain circumstances.

Techniques With proper application of the discharge technique, RC proponents believe that any distressing pattern can be eliminated, although with more serious and complicated issues (e.g., the sudden death of a loved one, sadness, anger, fear), it may require discharge in a more sequential manner, with the most distressing emotions addressed

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prior to dealing with the less distressing feelings. Some of the techniques typically used in this process are creating a warm and supportive environment through the use of touch, facial expressions, active listening, and the choice of appropriate words in communicating with the client; focusing attention on reality; allowing for recognition of feelings rather than suppressing them; trying to build a close and supportive relationship; offering specific acknowledgment and appreciation of the client’s distress; taking a leadership role in empowering clients; maintaining a position that is contrary to the distressing pattern; and telling life stories. In addition, the person acting in the role of the counselor may also want to convey a sense of empathy and reflexively listen to the client to demonstrate his or her understanding of the presenting issues or concerns.

Therapeutic Process The principal activity in RC is one-to-one sessions between members, with each taking turns in the client and counselor roles. The process works best when each participant adheres to the following recommendations: 1. No socializing outside the RC relationship 2. Keeping the process confidential 3. No substance abuse by either participant

Because RC relies on the relationship between peers, the two participants are considered equal regardless of the experience level of either participant. According to Kauffman and New, nearly everything the counselor does is aimed at assisting clients to “cross the bridge” to discharge—to the crying, shaking, perspiring with cold and warm sweat, raging, laughing, and interested nonrepetitive talking and yawning that release tension from recent upsets and stored-up hurts—and give back to the client his or her clear thinking. Thus, in contrast to other counseling approaches, there is no advice giving, interpreting behaviors, or goal setting; the sole objective is removing stored distress. Jackins believed that effective RC counselors displayed approval, delight, and respect for clients

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as well as confidence in a client’s ability to change. From an RC vantage, it is critical that the counselor is able to separate the person from the pattern of behavior; the clearer this distinction, the greater the discharge for the client. That said, in general, clients tend to identify themselves with their distressing patterns, and thus, the counselor must be able to gently challenge clients’ distressing patterns. As with humanistic approaches, in RC, the client is believed to be the expert on his or her own life, and the counselor’s role is to present and create an environment conducive to discharge. There is recognition in RC of the courage required to enroll in RC, which often requires the individual to step out of his or her comfort zone. Along these lines, it can also require a big shift in how individuals typically handle distress, which may be to internalize the hurt rather than speak of it. Thus, in general, the typical RC process involves two people getting together for the purpose of helping each other discharge existing hurts or pain, some of which may be long-standing. Each participant takes turns in the roles of both counselor and client. As noted above, the counselor’s role is to actively listen, acknowledge and clarify, and promote the open and authentic emotion. The client’s job is to openly express existing feelings and emotions. The counselor, in turn, then becomes the client, and the roles are reversed. Keith Klostermann See also Other Therapies: Overview; Person-Centered Counseling

Further Readings Bronstein, P. (1986). Re-evaluation Counseling: A self-help model for recovery from emotional distress. Women & Therapy, 5(1), 41–54. doi:10.1300/J015V05N01_08 Jackins, H. (1997). The list. Seattle, WA: Rational Island Publishing. Kauffman, K., & New, C. (2004). Co-counselling: The theory and practice of Re-evaluation Counseling. New York, NY: Brunner-Routledge. Study Group on Psychotherapy Cults. (1992). A documentary history of the career of Harvey Jackins and Re-evaluation Counselling. Brussels, Belgium: Study Group.

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Tourish, M., & Irving, P. (1996). Group influence and the psychology of cultism within Re-evaluation Counseling: A critique. Cultural Studies Journal, 13(2), 171–192. doi:10.1080/09515079508258695 Tourish, D., & Wohlforth, T. (2000). On the edge: Political cults right and left. Armonk, NY: M. E. Sharpe.

REGRESSION THERAPY See Primal Therapy

REICH, WILHELM An early disciple of Sigmund Freud, Wilhelm Reich (1897–1957) was a major, but controversial, figure in the Vienna Psychoanalytic Society. Having advanced character analysis theories and sexual theories, Reich applied these theories to politics and society. Later in his career, Reich developed a therapy for harnessing one’s cosmic energy as a treatment for mental and physical ailments, a therapy that was attacked by the medical and scientific establishment. Reich was born on a farm in Bakovina, now part of the Ukraine. His early life was marred by tragedy. Reich’s mother died of an apparent suicide when Reich was only 13 years of age. His father died only 4 years later of tuberculosis, an illness that Reich later contracted and survived. The family was Jewish but spoke High German and did not actively practice the faith. Nonetheless, the Nazis’ persecution of Jews in the 1930s and 1940s was one of the many psychological and personal struggles Reich endured. Reich served on the front line in the Austrian army during World War I, but the experience of war demoralized him. In particular, Reich grew disenchanted with the military’s patriarchal structure and value system. This dislike for hypermasculine structures provided part of Reich’s strong political arguments in the early 1930s. After the war, Reich enrolled in law at the University of Vienna, but soon, he turned to medicine and, like Freud, graduated as a medical doctor. At the university, Reich became quickly drawn to Freud’s pioneering psychoanalytical work. The two met in

1919, and Reich became part of the Vienna Psychoanalytic Society at the age of 23 years. Like Freud, Reich was a prolific writer. He published numerous important essays in the field following the case study method favored by Freud. Reich’s early therapeutic technique was classical psychoanalysis. Patients would lie on a couch, and Reich would listen to their free associations and dreams and make interpretations that addressed the patients’ childhood experiences, the importance of infantile sexuality, the oedipal complex, the patients’ various defense mechanisms, and the importance of the unconscious and repressed memories that manifest themselves in the patients’ symptoms. At the same time that Reich endorsed Freud’s techniques, he also began to modify them, as early as in 1922 in the article “Two Narcissistic Types.” This article plants the seeds that Reich would later develop into his theory of character analysis. Character-analytic technique, which Reich cultivated throughout the 1920s and published as a book in 1934, moves away from analysis of individual symptoms to an analysis of the entire person’s character. This shift from symptom to person had important implications for therapeutic techniques. First, Reich focused on the patient’s entire presentation during a therapy session. He paid close attention to speech patterns, inflections, posture, gait, seating arrangement, and all manner of nonverbal communication. This shift away from the purely “talking cure” took serious account of the body. Accordingly, Reich’s approach was more holistic than Freud’s was. In fact, for Reich, a patient actually developed what Reich called character armor as the patient’s physical resistance to treatment. A second innovation was the necessary shift toward the present. In focusing on the patient in the here-and-now of the therapy session, Reich stressed the patient’s present behavior rather than past memories. Third, the therapist became more active than the classical psychoanalyst did. Reich faced and often touched his patients in what he considered a therapeutic fashion. He wanted to release the tension or anxiety trapped in knotted muscles. Finally, Reich had a slightly different approach to transference. Rather than focus on the patient’s affection for the therapist, Reich stressed the value of negative transference or hatred of the therapist. Reich strongly felt that this negative

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transference had to be confronted by the therapist for any progress to be made. Reich identified a group of maladaptive character types: neurotic, hysterical, compulsive, phallic-narcissistic, and masochistic. Maladaptive character was contrasted with the very happy and emotionally healthy genital character. Emotionally healthy for Reich meant physically or sexually healthy individuals. Even more than Freud, Reich made the libido theory fundamental to treatment and health. He called his libido theory orgastic potency, a term used to measure a person’s sexual health. Only an orgastically potent individual could live life as a genital character. Reich articulated his evolving sexual theories in The Function of Orgasm published in 1927. For Reich, individuals needed to experience powerful full-body orgasms to maintain a balanced life. Orgasms put a person in open contact with the flow of energy that unresolved anxiety would bind to the body’s armor in unhealthy ways. This position was not necessarily contrary to Freud’s ideas, but Reich’s underlying philosophy of libido radically departed from Freud’s conceptualization. Around 1919, Freud posited the death drive in his book Beyond the Pleasure Principle. Reich never accepted Freud’s theory, and as early as 1923, he made his disagreement with Freud evident. Reich did not believe in man’s inherent aggressiveness but felt that aggression could be successfully overcome through character analysis and fully established orgastic potency. Reich argued for the relationship between sexual repression and aggression in a pioneering book The Mass Psychology of Fascism. In this book, Reich analyzed the psychodynamics of the totalitarian personality, which predated Theodor Adorno’s related social psychoanalytical work in The Authoritarian Personality by more than 15 years. The Mass Psychology of Fascism both brought a phase of Reich’s analytic work to a culmination and simultaneously got him evicted from the Communist Party, of which he had been a member since 1928, and largely ended his political activity. The Mass Psychology of Fascism also brought a psychoanalytical perspective to politics and society. Reich often wondered why poor people did not steal more often than they did. He wondered why so many people living in oppressed conditions of poverty and disenfranchisement did not revolt

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against or reject such conditions to the extent that such a rejection is possible. In his book, he found the answer by linking society to the psyche. This linkage of therapy to social policy represented a pioneering innovation of Reich’s work. Prior to this innovation, traditional psychoanalysis was largely intrapsychic, focusing on the individual mind, but Reich focused on the relationship between the mind and the society. Reich found the family to be a factory for reproducing the social ideology of the dominant class, but he went further by showing how that ideology shaped individual thought and behavior, thus bringing oppression and repression together. While Freud did not approve of Reich’s earlier political activity, he did support Reich’s efforts at bringing mental health services to the working class and the poor. Reich formed a movement that he called The Sex-Pol movement to bring sex education to the urban poor and rural areas, which he treated through mobile van clinics. Ultimately, though Reich later firmly rejected the Communist Party, his affiliation with the party contributed to his ouster from the psychoanalytical community. Ahead of his time, Reich’s progressive views anticipated later social realities such as women’s right to choose, equal rights for women, simple divorce laws, and contraceptives for teenagers. The Mass Psychology of Fascism and Character Analysis represented two important contributions to the history of psychology and counseling, but they also ended Reich’s work in the psychoanalytical tradition. Around 1935, Reich turned toward a concept he called vegetotherapy and, later, orgone therapy. This change in direction moved Reich beyond therapy into a quasi-scientific realm of natural experimentation in harnessing a cosmic energy he called orgone. Reich believed that this orgone energy, a blue-green glow, could be observed, measured, and employed in treatment for both psychological and medical illnesses, including cancer. The psychoanalytical community abandoned Reich, but his charisma and drive attracted a new group of followers in Scandinavia; Forrest Hills, New York (after he fled the Nazis); and eventually in Raingley, Maine. Orogone therapy, a bioenergetic model, used technology, including his infamous orgone accumulator. This box—big enough to accommodate a large male— attempted to layer organic and metallic material to

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attract orgone energy into the box. The patient would absorb this positive orgone energy, which Reich believed restored the patient to a state of well-being. Although orgone therapy appealed to some well-known artists like William Burroughs and J. D. Salinger, as well as the public, the scientific community rejected Reich’s orgone therapy. Ultimately, a Food and Drug Administration investigation of the orgone accumulator led to injunctions against the equipment and, in the end, to Reich’s arrest and imprisonment for 2 years at Lewisburg Federal Penitentiary, where he died of heart failure. Preceding his death, the government sanctioned an unprecedented public book burning of his work. Despite the controversy that surrounds both the science and the politics of Reich’s later work, a number of influential therapists followed and used his postanalytic therapeutic techniques. For example, Elsworth Baker founded the American College of Orgonomy to promote orgone therapy, Alexander Lowen developed bioenergetic analysis (a mind–body treatment modality), and Fritz Perl’s Gestalt therapy owes its foundation to Reich’s work. In fact, the biopsychosocial model that guides much of current counseling is a logical result of Reich’s contribution to the mental health field. His work also has analogies to alternative medical practices and Eastern treatments such as Reiki, frequently used by clinicians today. David Seelow See also Bioenergetic Analysis; Biopsychosocial Model; Characteranalytical Vegetotherapy; Freud, Sigmund; Freudian Psychoanalysis; Gestalt Therapy; Orgonomy; Perls, Fritz; Reiki; Rolfing

Further Readings Corrington, R. S. (2003). Wilhelm Reich: Psychoanalyst and radical naturalist. New York, NY: Farrar, Straus & Giroux. Reich, W. (1970). The mass psychology of Fascism (V. P. Carafagno, Trans.). New York, NY: Farrar, Straus & Giroux. (Original work published 1933) Reich, W. (1972). Character analysis (M. Higgins & C. M. Raphael, Eds.; M. D. Vincent & P. Carfagno, Trans.; 3rd enlarged ed.). New York, NY: Farrar, Straus & Giroux. (Original work published 1934)

Reich, W. (1980). Genitality in the theory and therapy of neurosis: Vol. 2. Early writings (P. Schmitz, Trans.). New York, NY: Farrar, Straus & Giroux. (Original work published 1927) Seelow, D. (2005). Radical modernism and sexuality: Freud/Reich/D. H. Lawrence & beyond. New York, NY: Palgrave Macmillan. Sharaf, M. (1994). Fury on earth: A biography of Wilhelm Reich. New York, NY: Da Capo.

REICHIAN THERAPY See Orgonomy

REIKI Reiki is a symbol-based, channeled-energy technique that finds its roots in traditional Japanese healing. It can be used in conjunction with many other psychological therapy techniques. Reiki techniques are based on the concept that the body is a nonlinear, dynamic, chemical-electrical system where changes in the oscillatory rate in the waves of the extra low-frequency magnetic field allow the release of overcharged energy in areas where imagery and trauma may be stored in muscle memory. There is also research evidence that Reiki produces relaxation effects within the client’s parasympathetic nervous system. Reiki practitioners work with clients in an energy or healing session and may engage in limited dialogue with the client before and after the session to help the client spontaneously speak about presenting issues or areas of psychological “stuckness.” The technique can be hands-off or hands-on, depending on practitioner license and client preference.

Historical Context The development of Reiki is credited to Mikao Usui (1865–1926) in the early 1900s in Japan. Reiki is based on mystic experiences Usui had while on a retreat at the Tendai Buddhist monastery, located on Mount Kurama in Kyoto, Japan. Traditional stories state that Usui had been meditating and fasting for 21 days at the monastery. On

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the final day, he went to the top of the mountain, where, while meditating, he saw a series of symbols in the air in front of him and gained wisdom and insight on how the symbols should be used. He then experienced three miracles. First, he was filled with energy in spite of his fasting, and although he cut his toe while walking back, he put his hands on the injury, and it healed in seconds. Second, he stopped at an inn on his way down the mountain and ate a full meal without difficulty. Third, a young girl with an abscessed tooth was at the inn. He put his hands on her face, and the problem cleared. Following this experience, Usui founded a clinic and began teaching his new techniques. He is said to have taught approximately 2,000 students, with 20 to 21 “master’s”-level students. Several students then founded their own systems: For example, Toshishiro Eguchi formed the Tenohira Ryoji Kenkyo Kai system, and Kaji Tomita established the Tomita Teate Ryoho system. Usui was the founder and first president of the still active Usui Reiki Ryoho Gakkai association. The symbols that Usui saw in his visions, which are used in Reiki, are similar to those displayed in the monastery at Mount Kurama. These symbols have traditional meanings of peace, love, power, and consistency. The symbols are drawn in the air over the student practitioner during Reiki attunement (training) and over the client during Reiki healing sessions, where they support the movement of the Reiki energy wave into the client’s body. Usui taught Chujiro Hayashi, who also founded his own lineage, Hayashi Reiki Ryoho Kenkyu kai. He was not among those students whom Usui made a master teacher. Hayashi taught Hawayo Takata, who brought the Reiki lineage to the West. Takata studied with Hayashi from 1936 to 1938 in Japan, and later Hayashi visited Takata in Hawaii and worked with her for a short time. Takata trained 22 master students in the last 10 years of her life. The attunement process is a ceremony believed to allow the Reiki symbols to be embedded in the practitioner’s body and lived experience. There are different levels of attunement and different symbols used in the process. Masters who are fully attuned are then allowed to attune and train other practitioners. Most of the Usui Reiki lineages practiced in the United States today come from the 22 master practitioners whom Takata trained.

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Currently, there are more than 126 variations of Reiki practiced in the United States. Key differences among these Western versions are the steps taken to achieve attunement and the specific symbols used in the attunement process. Traditional Reiki also displays differences both in the attunement process and in the number of symbols used. The Reiki attunement process usually consists of the Reiki symbols being drawn several times over the top of the head, hands, and forehead. Then, the practitioner doing the attunement thinks about the symbols and blows a puff of air along the midline of the body. Most Reiki is taught in stages. Historically, a student-practitioner is engaged in 10,000 hours of practice between attunements and in hundreds of sessions in clinic settings, under supervision, prior to being allowed to move to the next level. In contrast, today, individuals may be attuned to Levels 1 and 2 in a single weekend and attuned the following weekend to the master teacher level. Today, there are several hundred different energybased techniques practiced in the United States. In addition to Reiki, other types of energy techniques include laying-of-hands healing in a religious or nonreligious setting; qigong, meridian-based or meridian stimulation systems; other symbol-based or channeled-attuned energy systems; totem and shamanic healing; element systems; kinesthetic systems; color systems; and sound systems.

Theoretical Underpinnings As previously discussed, Reiki is based on the theory that channeled energy transferred from an attuned practitioner to a client can effect changes in the client’s energy fields, which in turn can help the client psychologically. Although the mechanisms of action involved in how Reiki works on the body and psyche are not completely understood, there are recent studies that point to the underlying mechanisms. These studies support that Reiki produces oscillations of the amplitude in the body’s extra low-frequency magnetic wave and oscillations in the strength of the body’s radio frequency waves, as well as changes in the microcapillary dilation in practitioners’ hands. Practitioners believe that as they place their hands over or on a client, the channeled energy moves through their hands to the client and causes changes in the

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strength and oscillation of the client’s magnetic and radio waves, which in turn disrupt areas of “stuckness” and allow healing to take place. In addition, there is evidence that a level of brainwave entrainment takes place between the practitioner and the client, supporting a “relaxation effect.”

Major Concepts In addition to the transfer of channeled energy from the practitioner to the client, there are several other concepts important to Reiki: precepts; the use of listening, empathy, and presence; and gratitude. Precepts of Reiki

The precepts of Reiki were developed by Usui and are written on his memorial, which is located at the Saihoji temple in the Suginami district of Tokyo. They are as follows:

one section of the city and represented an acknowledged “profession.” This city section was called the enclave of beggars. Usui founded one clinic within the enclave and practiced Reiki on its members for free. He observed that many would heal and start to move forward with their life but then would fail and return to the beggar community. He determined that the individuals who failed lacked gratitude for the change and improvement in their situation. As a result of this observation, Usui added gratitude as a Reiki precept. Within the practitioner community, it is said, “Gratitude is the most similar energy to enlightenment.” Usui defined an enlightened person as one who is not swayed from his or her state of calm compassion by life’s experiences and who has sufficient clarity in his or her life and physical body so that energy moves through the physical form so freely that the person’s body produces light, meaning tit glows physically.

Do not worry today. Do not get angry today. Be kind to yourself and others today. Work hard today. Be grateful today.

These precepts are to be practiced daily by the practitioner and shared with the client as a method of living with both greater grace and more peace. Listening, Empathy, and Presence

During a Reiki session, the practitioner’s focus is on the client. Listening is a key skill of the practitioner, and it is done with empathy and without judgment both before and after the energy session. Although a typical Reiki session may include the practitioner asking the client questions, it does not involve the kind of therapeutic dialogue found in a psychological or psychiatric therapy session. Practitioners provide compassionate, gentle support throughout treatment. Gratitude

In Japan in the early 1900s, beggars, or homeless members of society, were housed together in

Techniques Reiki consists of three basic techniques. In the first technique, the practitioner uses his or her hands to draw one or more Reiki symbols one or more times over the client’s problem area or a related area. The second technique involves the practitioner placing his or her hands on or just above the client’s body in specific positions, leaving them there for a period of time in a standard or specified pattern to allow the “movement” of the Reiki waves into the client. In some versions of Reiki, the time limit of hand placement is specified; in others, hand placement change is based on practitioner perception. The third technique consists of the practitioner using both of the first two techniques at the same time. Practitioners commonly describe three types of sensations: (1) the sensation of their hands heating or cooling, (2) the energy current wiggling or pulsing, and (3) the current being pulled through the hands. Laboratory studies found that the wiggling and pulsing sensation aligns with changes in the rate of oscillation of the extra low-frequency magnetic field of the practitioner’s hands and the sensation of the energy current being pulled through the hands corresponds to practitioners’ producing direct current from their hands.

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Therapeutic Process Reiki is not a substitute for psychological treatment but is a support process used to facilitate dialogue, trauma release, and client relaxation. It can be used in conjunction with many other therapeutic techniques and interventions, based on practitioner skill and preference or client preference, to support a compassionate and healing client space. When using Reiki in conjunction with a psychological session, the practitioner should describe the technique and obtain consent from the client. When Reiki is added to a standard therapy session, the wiggling of the electrodermal skin current can change the way trauma, which is stored as muscle memory, is released. The effect enables the client to speak about difficult issues with greater ease and comfort. Furthermore, the inclusion of Reiki in traditional therapeutic treatment may produce a change in the regulation of the parasympathetic part of the nervous system, often as a relaxation response. If this change occurs, the therapeutic process may move more quickly, as the client becomes more open to sharing sensitive issues. Melinda H. Connor See also Bioenergetic Analysis; Core Energetics; Emotional Freedom Technique; Energy Psychology; Feldenkrais Method; Healing Touch; Mindfulness Techniques; Therapeutic Touch

Further Readings Ahn, A. C., Park, M., Shaw, J. R., McManus, C. A., Kaptchuk, T. J., & Langevin, H. M. (2010). Electrical impedance of acupuncture meridians: The relevance of subcutaneous collagenous bands. PLoS One, 5(7), e11907. doi:10.1371/journal.pone.0011907 Baginski, B. J., & Sharamon, S. (1988). Reiki: Universal life energy. Mendocino, CA: Life Rhythm. Becker, R. O., & Selden, G. (1985). The body electric: Electromagnetism and the foundation of life. New York, NY: William Morrow. Connor, M., Creath, K., & Schwartz, G. (2004, November). Oscillation of amplitude as measured by an extra low frequency magnetic field meter as a physical measure of intentionality. Paper presented at the Conference Proceedings of the World Qi Gong Congress, San Francisco, CA.

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Connor, M., Jacobs, L., & Schwartz, G. (2005, April). Demographics of energy healing training programs. Paper presented at the Research Symposium Conference Proceedings of the Second QiGong Summit and Whole Person Healing Conference, Washington, DC. Connor, M., Tau, G., & Schwartz, G. (2005, June). Methodological challenges in the evaluation of energy medicine practitioners. Paper presented at the Research Symposium Conference Proceedings of the International Society for the Study of Subtle Energies and Energy Medicine, Boulder, CO. Fung, P. C. (2009). Probing the mystery of Chinese medicine meridian channels with special emphasis on the connective tissue interstitial fluid system, mechanotransduction, cells durotaxis and mast cell degranulation. BioMed Central, 4(10). doi:10.1186/1749-8546-4-10 Miles, P. (2006). Reiki: A comprehensive guide. New York, NY: Penguin. Miles, P., & True, G. (2002). Reiki: Review of a biofield therapy history, theory, practice, and research. Alternative Therapies in Health and Medicine, 8(3), 88–95. National Center for Complementary and Alternative Medicine. (2010, May 4). Reiki: An introduction (NCCAM gackgrounder). Washington, DC: Government Printing Office. Paul, N. L. (2006). Reiki for dummies. Indianapolis, IN: Wiley. Rand, W. L. (n.d.). Usui Memorial. Retrieved from http:// www.reiki.org/reikinews/memorial.html Rand, W. L., & Gaia, L. S. (n.d.). Discovering the roots of Reiki. Retrieved from http://www.reiki.org/reikinews/ rootsreiki.html Vennells, D. F. (1999). Beginner’s guide to Reiki: Mastering the healing touch. New York, NY: Barnes & Noble Books.

RELATIONAL GROUP PSYCHOTHERAPY Relational group psychotherapy refers to a form of therapy in which group members, individually and collectively, advance via a meaning-making process from experience, through expression, to cocreated understanding. Relational group psychotherapy is based on relational theory and assumes that the defining characteristics of group

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life are mutually generated by unconscious as well as conscious participation by all group members, including the therapist.

Historical Context Relational theory builds on multiple psychotherapy constructs—particularly neo-Freudian, Kleinian, Winnicottean, interpersonal, intersubjective, and self theory—as well as on recent empirical literature on early infancy and parent–child attachment. The common denominator is an emphasis on relationships, internal and external, and their dynamic, life-supporting qualities rather than on intrapsychic or “one-person” metapsychological entities like drives, defenses, ego structure, or an archeological unconscious. In an effort to replace the classical model of the “blank screen” analyst and the “regressed” patient or group, relational theorists reconceived therapeutic relationships in terms of co-constructed or mutually inspired interactions. From this perspective, the unconscious as well as interpersonal relationships are considered to be socially constructed and linked to dynamics of power, status, gender, race, age, and cultural norms. Explorations of the past—retrospections—are useful in understanding the present and in releasing the individual and the group from old allegiances, allowing for change and increased growth.

Theoretical Underpinnings Relational psychotherapy does not represent a single theory or a consistent metapsychology but references philosophical, social-constructivist, communication, and systems theories. The important intellectual forbearers include Georg Wilhelm Friedrich Hegel (1770–1831), Friedrich Nietzsche (1844–1900), Martin Heidegger (1889–1976), Sigmund Freud (1856–1939), Sandor Ferenzci (1873–1933), Harry Stack Sullivan (1892–1949), Donald Winnicott (1896–1971), Ronald Fairbairn (1889–1964), Heinz Kohut (1913–1981), Melanie Klein (1882–1960), and Heinrich Racker (1910–1961). The approach described herein is inspired by W. R. Bion’s object relations theory of thinking, modified and extended to relational and group relational therapy. Bion (1897–1979) drew attention to the preverbal mechanisms of introjection, projection,

and projective identification (first described by Klein) that influence how humans hear and think about others’ or a group’s communication, how we convey our experiences, and how this communicative interplay affects the participants and the current state of relationships among the participants. Bion’s conceptualization of thinking—the process of establishing a mental relationship with a personality (including one’s own) and that personality’s emotional experience—defines mentalization, a concept that has become a topic of scholarly interest in the 21st century. Bion propounded how a human need—the need to think and reach emotional truth—conflicts with a desire to avoid the mental pain (e.g., feelings of persecution and depression) that accompanies and is a consequence of emotional thinking.

Major Concepts Among the main concepts associated with relational group psychotherapy are truth, the basic conflict, bonding, perspectivism, enactment, primary emotions and passion, and the centrality of the group therapist. This section discusses each of these concepts in turn. Truth

Truth develops as a process, occurring in relationship to self and others, of seeking and developing emotional awareness. We make truth by grounding and transforming experience through various evolving emotional and intellectual perspectives. Psychotherapeutic treatment focuses on  developing the ability to search for and the capacity to suffer—and enjoy—the creative use of truth in interpersonal relationships. In relational psychotherapy groups, truths—both conscious and nonconscious—are discovered, integrated, and reconfigured in group members’ psyches and interpersonal relationships and in the structure and process of the group itself. Important too are the methods by which truth is reached and the uses to which it is put. The therapist must monitor the process for certain truths, and certain modes of truth seeking may be experienced as destructive to the self or others, and so not beneficial. Even when factual, truth may be challenged as misleading, irrelevant, or inappropriate,

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as a means of buffering against genuine mental interaction. The Basic Conflict

Individuals seek psychotherapeutic treatment because of a need to learn about themselves and others. Emotional truth often hurts, but so too does its absence. Such truth, although necessary for growth and change and often welcomed, can bring to the fore intense ambivalences, impermanence, uncertainty, and the necessity for change. A basic conflict exists within the self and within a group and its members: a conflict between wanting to tolerate, develop, and integrate thoughts and feelings, on the one hand, and wishing to evade an often painful, truth-seeking process, on the other. Emotional thinking and evasion are part of the psychological dimensions of all group members’ consciousness and unconsciousness and of a group’s structure, culture, and process.

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the field of inquiry and is limited by his or her own subjective perceptions. Other members form valid and significant insights regarding the group, including its therapist. A group progresses through the process of understanding and learning as different perspectives are revealed and examined. Enactment

Relational theorists assert that individuals do much of their thinking unconsciously and intersubjectively, responding to various and often subtle aspects of narrative and interaction. Frequently, we learn only retrospectively about what has been going on, when what has been out of awareness emerges into our consciousness. By that time, words and actions have produced enactments, behavioral scenarios with unacknowledged symbolic meaning. A group provides its members with opportunities to experience enactments and make meaning of enactments, with the benefit of insight, hindsight, and mutual feedback.

Bonding

Verbal communication advancing truth seeking depends on establishing preverbal contact and safety, which is based on genuine caring and interest. As a mode of interpersonal behavior, bonding establishes a feeling of empathic connection. The affective experience involves a feeling of mutual communication, in which individuals feel satisfactorily recognized, cared for, and understood. Group cohesion develops from combinations of member-to-member, member-to-subgroup, member-to-entire group, and member-to-therapist bonds. While the dynamics of member–therapist bonding may be subtle and unacknowledged, they influence the bonding of other relationships and the ongoing group process. Perspectivism

Emotional truths are not necessarily logical and consistent, and they emerge on many psychic levels and from different perspectives. A group’s consensus concerning what is said, what is meant, and its significance may be negotiated as well as interpreted, and it is subject to revision. The relational therapist recognizes that, like other members, he or she remains situated within

Primary Emotions and Passion

Our experiences derive significance from how we feel about them. At the most fundamental level, primary emotions, or “instincts”—specifically, to love, to hate, and to know—determine feelings. Loving (as in attachment or bonding), hating (as in expressing frustration or aggression), and coming to know (exercising curiosity) connect us to, as well as disconnect us from, others. However, primary emotions do not operate in pure form. Defense mechanisms often disguise, minimize, exaggerate, or displace feelings, and they are difficult to regulate in situations of anxiety and conflict. Passion has a special meaning as it applies to group process. It refers to the mental activity and mode of connection that can occur in a group when group members remain open to the often discomforting expressions of love, hate, and curiosity. When the group sustains passion, the members progress from merely intellectual to emotional understanding of their relationships, attitudes, and values. Centrality of the Group Therapist

Individually and collectively, group members not only form unconscious transferences but also

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realistically assess the therapist. The therapist’s personality and character, and his or her professional, theoretical, and technical allegiances, influence what occurs and does not occur during group therapy. Indeed, whether speaking or remaining silent, the therapist implicitly “shapes” the working group culture. He or she determines how group relationships and experiences are to be regarded and the emotional depth to which exchanges may be understood. Group members’ view of their therapist—the degree of admiration and respect— may trump the therapeutic impact of the therapist’s ideas.

Techniques Relational psychotherapy treatment aims to facilitate truth seeking and authentic interpersonal interactions. This section describes certain operational strategies and techniques that relational therapists may use to promote change and growth in individuals and in the group itself: combined individual–group psychotherapy, integration–disintegration, use of the therapeutic self, nuclear ideas, and four modes of therapeutic interaction.

individual and group defenses. He or she fosters integration by establishing boundaries and monitoring interpersonal behavior to provide an ongoing sense of safety. But to discover that which members fear to feel, think about, and reveal, the therapist also promotes disintegration, a breaking down of conventional emotional attitudes and group routines. The Therapeutic Self

The relational therapist tends to be more active and interactive than therapists who use traditional analytic approaches. Freer from the classical ideals of neutrality, anonymity, and objectivity, the relational therapist may share thoughts and feelings, offer opinions, and openly attempt to shape the direction of the group process. He or she may not necessarily wait for group tensions or themes to resolve through the members’ activity. To invite the members to relate more openly, the therapist may make it “all about me,” nondefensively provoking discussion regarding his or her interpersonal functioning and leadership qualities. Nuclear Ideas

Combined Individual–Group Psychotherapy

Combined individual–group psychotherapy is in keeping with relational theory, because it supports a multiperson rather than one-person psychology model. In this treatment approach, the group members contribute ideas and insights, much like the therapist does. Honoring the contributions of group members reduces the therapist’s perceived authority and power and fosters a democratic atmosphere of mutual respect and appreciation.

By offering himself or herself as an emotional, thinking, and self-reflecting subject, and treating others similarly, the relational therapist sets up a culture and process in which the group comes to listen for and develop nuclear ideas. These core psychological concepts emerge from the network of communications and interactions. They may develop from anything that captures interest: a premise, a theme, common tension, enactment, or insight. In sustaining focus on a nuclear idea, the therapist encourages exploration of its connections to the group process and the psyches of individual members.

Integration–Disintegration

The relational therapist attempts to assess and respond to the truth needs of the various individuals and the group. The primary task is twofold: pursuing emotions that are meaningful but painful, while at the same time modifying emotional experiences that are present but are felt as too painful to become meaningful. To foster authentic communication and reduce falsity, the therapist works to modify the impact of social anxiety and

Therapeutic Interaction

Leadership involves more than an application of learned theory, tactics, and techniques. It demands self-knowledge and the capacity to use subjective experience to connect to others. Different dimensions of the therapist’s self are called forth to cement bonding to the group and its members, build trust, and allow troubled relationships to evolve and resolve.

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Diplomacy involves the therapist’s strategic use and sharing of leadership power in establishing and maintaining relationships. Integrity emerges from the therapist’s moral and ethical principles and how they are utilized to establish ground rules as well as negotiate conflicting principles and beliefs. Sincerity conveys genuine feeling and conscious intention, which are essential dimensions of bonding. In functioning with authenticity, the therapist communicates with conviction, while acknowledging that his or her interventions are subjective opinions and up for discussion and challenge.

Therapeutic Process Group process may be conceptualized as a series of intrapsychic and interpersonal moves and countermoves to express, redirect, modify, or block the search for truth. The 3 Rs—resistance, rebellion, and refusal—represent three strategies individuals and groups utilize to tolerate, regulate, and negotiate the various iterations of emotional truth. Resistance specifically refers to the creative unconscious, which generates and communicates its own “take” on experience. The group’s discourse and behaviors communicate underlying symbolic meaning, which the therapist may bring to the members’ attention. The therapeutic process focuses on exploration and interpretation, the sharing of thinking, and mutual discovery. Rebellion typically arises from therapist– member conflicts regarding the group’s immediate or long-term focus, values, and methods. What is said to represent truth and when and how empathically it is said may create controversy and opposition. When group members cannot resolve or choose to live with dissent, rebellion can take various action pathways that the therapist attends to and may attempt to resolve: defiance, secession/ exile, anarchy, or revolution. Defiance represents a type of conspicuous pressure exerted against an ongoing process. In secession/exile, group members’ reciprocal allegiances and attachments are threatened or ruptured. Anarchy refers to “antigroup” or high-crisis interludes that threaten to impel destructive behavior. In revolution, rebellious premises and solutions aim to bring the group to a new phase, which may be positive or negative.

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Refusal manifests itself as willful nonparticipation in the interactions and activities of group therapy. Such refusal can vary in persistence, intensity, and legitimacy. To move group relationships (psychic and interpersonal) forward and expand the boundaries of what can be thought and talked about, the therapist encourages thinking about refusal yet also conveys respect for the reasons behind it. Interest in truth remains basic, and members think about ongoing and past group experience when resisting, rebelling against, or even refusing certain emotional links to understanding it. Richard M. Billow See also Group Analysis; Intersubjective Group Psychotherapy; Intersubjective-Systems Theory; Mentalization-Based Treatment; Relational Psychoanalysis

Further Readings Billow, R. M. (2003). Relational group psychotherapy: From basic assumptions to passion. Philadelphia, PA: Jessica Kingsley. Billow, R. M. (2010). Resistance, rebellion and refusal in groups: The 3 Rs. London, England: Karnac Books. Billow, R. M. (2014). Relational group psychotherapy: Developing nuclear ideas. London, England: Karnac Books. Gayle, R. (2009). Co-creating meaningful structures within long-term psychotherapy group culture. International Journal of Group Psychotherapy, 59, 311–333. doi:10.1521/ijgp.2009.59.3.311 Ivey, G. (2008). Enactment controversies: A critical review of current debates. International Journal of Psychoanalysis, 89, 19–38. doi:10.1111/j.1745-8315.2007.00003.x Schermer, V., & Rice, C. (2012). Towards an integrative intersubjective and relational group psychotherapy. In J. L. Kleinberg (Ed.), The Wiley-Blackwell handbook of group psychotherapy (pp. 59–88). Chichester, England: Wiley. Schwartz, H. (2012). Intersubjectivity and dialecticism. International Journal of Psychoanalysis, 93, 401–425. doi:10.1111/j.1745-8315.2011.00543.x Stolorow, R. D. (1997). Principles of dynamic systems, intersubjectivity, and the obsolete distinction between one-person and two-person psychologies. Psychoanalytic Dialogues, 7, 859–868. doi:10.1080/10481889709539224

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RELATIONAL PSYCHOANALYSIS Relational psychoanalysis, a significant approach among contemporary psychoanalytical schools, emerged as a critique of more traditional or classical psychoanalysis. Relational psychoanalysis developed beyond the predominately intrapsychic model of classical analysis into an approach that included both interpersonal and intersubjective dimensions of human experience. Instead of a single theoretical model, relational psychoanalysis became an umbrella covering a diverse range of perspectives based on a common set of core concepts and clinical strategies. The relational tradition emerged in post-Freudian thought and was first recognized as a movement by Jay Greenberg and Stephen Mitchell. It has subsequently been developed by analysts worldwide.

Historical Context Relational psychoanalysis emerged in the United States in the 1970s and 1980s as ego psychology’s prominence declined and the British object relations and Self Psychology theories gained traction in American psychological circles. In 1983, Greenberg and Mitchell coauthored the seminal book Object Relations in Psychoanalytic Theory and coined the term relational. This term synthesized interpersonal psychoanalysis, with its emphasis on the exploration of observable “external” interpersonal relations, and British object relations theory, with its focus on the importance of internalized object relations and the phenomenological map of the internal world. In addition to bridging the object relations and interpersonal traditions, relational theory incorporated elements of Self Psychology, existential psychotherapy, attachment theory, and more contemporary developments in Freudian theory, particularly those of Hans Loewald. Relational theory was strongly influenced by feminism, an emphasis that may reflect the increasingly strong presence of women in the relationalanalytic field, and the realm of psychology in a broader sense. Strongly influenced by the French philosopher Michel Foucault’s critical theory and critique of ideology, the relationalists encouraged a simultaneously interpersonal and sociocultural

self-consciousness in patients seeking psychological treatment. Postmodernism, along with the influences of parent–infant research, neurobiology, cognitive psychology, and trauma research after the Vietnam War, contributed to the psychoanalytical focus of individuality. Individuality began to be seen as a direct result of social context rather than of intrapsychic structures. Later, the influence of queer theory and postcolonialist critique affected the relationalpsychoanalytical understanding of how sex, gender, race, class, transsexuality, alternative family structure, and immigration influence the intersubjective dimensions between the analyst and the patient. The relational movement found an institutional home in 1988 within the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis. In 1990, Mitchell initiated the Relational Perspectives book series, later partnering with Lewis Aron in this effort. Additionally, Mitchell developed the first psychoanalytical journal dedicated to a multiplicity of voices, called Psychoanalytic Dialogues: A Journal of Relational Perspectives. Since Mitchell’s death in 2000, Aron has edited the Relational Perspectives series with Adrienne Harris; as of 2014, 64 books, including 5 volumes of influential articles written by major contributors of the movement, have been released. Relational thought continues to develop at the annual meeting of the Division of Psychoanalysis (i.e., Division 39) of the American Psychological Association and the International Association for Relational Psychoanalysis and Psychotherapy. The Stephen A. Mitchell Center of Relational Studies opened in 2007 in New York City to provide continued education about the theory and clinical practice of relational psychoanalysis.

Theoretical Underpinnings The relational movement emerged across a wide range of theoretical schools and traditions, each of which was distinguishing itself from the Freudian classical tradition, which had taken the individual mind as a basic unit. While Sigmund Freud himself had argued that all individual psychology was group psychology, his fundamental framework was of the individual mind energized by the forces of drive and seeking tension reduction. Relational psychoanalysis developed from a large group of

Relational Psychoanalysis

contributors who continued to build on Greenberg and Mitchell’s ideas as a scaffold to expand the theory and clinical applications. Mitchell developed the framework of the relational matrix to hold the dialectical tension between the self, the other, and the interaction between these two poles. Fairbairnian object relations highlighted the personification of the internal object and the internal experience of the other; Heinz Kohut and Donald Winnicott’s self psychologies emphasized the self and its feeling of realness, aliveness, authenticity, coherence, and continuity. Harry Stack Sullivan’s interpersonalism and John Bowlby’s attachment perspective highlighted the observed interaction between these two poles. Mitchell was also influenced by the work of Merton Gill and his colleague, Irwin Hoffman. Gill was a classical analyst in the United States who challenged the ego psychological understanding of transference as a distortion, misperception, and misattribution. In contrast, Gill emphasized transference as the interaction of the patient and the analyst in a mutually influencing relationship. Gill rejected the idea that the analyst had a superior view of the patient’s intrapsychic reality and instead stressed the exploration of the plausibility of the patient’s construal of the analyst. Robert Stolorow introduced the concept of intersubjectivity to American psychoanalysis, stressing the bidirectional influence of two subjectivities. Rejecting Cartesianism, Stolorow and his colleagues critiqued the myth of the isolated mind. Stolorow’s intersubjective systems theory proposed that minds exist within interpersonal and intersubjective relationships and develop in relational contexts. This framework also grew from the nonlinear dynamic systems theory, which was influential in providing a metaphor for psychoanalysts to conceptualize the process of developmental change within complex systems that did not unfold within a predetermined, linear pattern. Instead, the dynamic-systems framework began to understand that change is nonlinear, spontaneous, and discontinuous. The analyst began to tolerate uncertainty, find meaning in the fragmented communication between the analyst and the patient, and understand how the cocreation of the analyst and the patient would emerge from the ordinary attentions of life and create a new moment of meeting in the different dyadic states.

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Jessica Benjamin contributed another important theory of intersubjectivity distinct from Stolorow’s version. Benjamin, building on her sociological background in the Frankfurt school and feminist studies, proposed an intersubjective recognition theory that views the capacity for mutual recognition and intersubjectiveness between mother and baby as a critical part of development. Benjamin viewed intersubjectivity as a developmental trajectory in which children begin with more primary forms and develop more sophisticated forms of mutual recognition of the other as separate subjects. In contrast, Stolorow defined intersubjectivity in such a way that all relationships between people are intersubjective because there is always bidirectional influence. With the emergence of the relational tradition, there was a shift away from the emphasis on verbal interpretation to a new focus on the verbal and nonverbal, insight and experience, and interpretation and relationship. Peter Fonagy and Mary Target conceptualized mentalization as the ability to make and use mental representations of their own and other people’s emotional states. Conceptualizing mentalization as a disturbance of attachment and a key goal of treatment is consistent with the main thrust of relational psychoanalysis, and the concept has been utilized by many relational authors.

Major Concepts Relational psychoanalysis is fueled by many shared concepts, including multiplicity, dissociation, enactment, and the analytical third. Multiplicity

The relational focus on multiple selves, or multiple self states, is a way of highlighting that people, their selves, or their characters are variable from one context to another. The classical intrapsychic focus, with its delineation of ego integration and ego identity, has tended to privilege psychic structure as the essential factor in the development of personality. By talking about multiple self states, relational analysts like Jody Davies, Donnel Stern, and Philip Bromberg made the point that psychic structure (i.e., the self) varies based on interpersonal context. The theorization of multiple self states derives from both the American interpersonal

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tradition, with its theory of dissociation and personifications, and from British and American object relations theory, with its examination of internal selves and objects, as well as from Kohut’s self-psychological description of vertical splits in the self. Dissociation

Sullivan proposed that self states are derived from the internalization of recurring patterns of interactions in our early significant relationships with others. These relationships shaped distinctive patterns where one is minimizing or avoiding threats of anxiety activated by these relationships. Sullivan understood anxiety in a child as derived through the empathic linkage with the parent. The child discovers that some behaviors are met with parental approval, which enhances the child’s security, whereas other interactions generate anxiety or disapproval from the parent. The child then develops a “good” and a “bad” me, which find their way into the subjective experience of being who the child is. The individual then grows to develop a selective inattention that allows the individual to make a dissociation from certain unaccepted aspects of himself or herself that trigger anxiety. Enactment becomes the “interpersonalization” of the dissociation, where the patient externalizes the part of the self that is hard to realize and attaches it to the analyst. Enactment

Enactment is the process in which an analyst becomes an unconscious participant in the relational matrix of the patient. The analyst is affectively engaged and becomes, with the patient, active in acting out patterns from the patient’s past, often related to past traumas. Enactments allow for the patient and the analyst to dramatize and engage a variety of “old” self and object relations patterns while gradually introducing “new” self and object configurations. Enactment may be valuable in and of itself in that it dramatizes and plays with core relational configurations, especially disruption and repair; in addition, it may be therapeutically useful in that understanding and resolution lead to insight and behavioral and experiential change.

Analytic Third

The analytic “third” is a psychoanalytical concept that refers to an emergent phenomenon or analytic field that steps outside binary oppositions and polarized thinking. There are many conceptions of the “third” among theorists in various schools of psychoanalysis. Benjamin and Aron emphasized a variety of thirds, each of which transcends or deconstructs a binary, such as inner and outer worlds, (e.g., doer/done to or sadist/masochist). For other theorists, such as Thomas Ogden, the third is an extension of the notion of intersubjectivity. It reflects the idea that it takes two people for one person to be able to think or feel. The third requires surrender from the patient and the analyst, allowing each to stay connected to the other’s mind while also accepting the other’s separateness. For some theorists, the third refers to the unconscious psychological field that constitutes the ground of intersubjectivity.

Techniques Relational psychoanalysis and psychotherapy emphasize that therapeutic change takes place within a two-person intersubjective relationship constituted by the mutual influence of two separate subjects. The belief is that analysts inevitably influence the field through their own participation and that the analyst and the patient are always regulating each other in both unconscious and conscious ways. Like all forms of psychoanalysis, the relational approach utilizes an exploration of the relationship patterns between the analyst and the patient, the patient’s current patterns inside and outside the therapy room, and the patient’s history. These repetitive relational patterns reflect the analyst’s and the patient’s distinct personal stories, conflicts, and ways of relating to the world. The use of judicious self-disclosure has been encouraged by some writers within the relational tradition, and some willingness to share subjective experience has become associated with the relational approach, in contrast to the “blank-slate” stance propagated in a one-person psychology model. Many relational analysts value thoughtful and selective disclosure as a way of engaging the patient and stimulating an exploration of the relationship. Relational analysts have been able to

Relational-Cultural Theory

understand their personal associations, feelings, and reactions as a critical part of their empathizing with a patient. Still other relational analysts, such as Joyce Slochower, have emphasized the analyst’s “holding” function, a bracketing of subjectivity that protects the patient’s vulnerable self states.

Therapeutic Process The relational perspective approaches psychotherapy with the belief that analysts inevitably influence the phenomenon they are observing through their own participation in the relational field. The analyst and the patient are continuously influencing each other in conscious and unconscious ways. The ongoing process of therapy allows for mutual influences to develop into relational patterns, or enactments. The repetitive nature of these enactments reflects the individual’s personal history, conflicts, and ways of relating to both the analyst and the patient. Therapeutic relationship allows for the analyst and the patient to identify shared unconscious patterns and create and develop new patterns. Lewis Aron and Melissa Kate McIntosh See also Ego Psychology; Interpersonal Psychoanalysis; Intersubjective-Systems Theory; Object Relations Theory; Self Psychology; Unifying Nonlinear Dynamical Biopsychosocial Systems Approach

Further Readings Aron, L. (1996). A meeting of minds. Hillsdale, NJ: Analytic Press. Aron, L., & Harris, A. (2012). Relational psychoanalysis IV: Expansion of theory. New York, NY: Routledge. Aron, L., & Lechich, M. L. (2012). Relational psychoanalysis. In G. O. Gabbard, B. E. Litowitz, & P. Williams (Eds.), Textbook of psychoanalysis (2nd ed., pp. 211–224). Washington, DC: American Psychiatric. Benjamin, J. (2004). Beyond doer and done to: An intersubjective view of thirdness. Psychoanalytic Quarterly, 73(1), 5–46. doi:10.1002/j.2167-4086 .2004.tb00151.x Greenberg, J., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Maroda, K. (1998). Seduction, surrender, and transformation: Emotional engagement in the analytic process. New York, NY: Psychology Press.

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Mitchell, S. A. (1997). Influence and autonomy in psychoanalysis. Hillsdale, NJ: Analytic Press. Mitchell, S. A., & Aron, L. (1999). Relational psychoanalysis: The emergence of a tradition. Hillsdale, NJ: Analytic Press.

RELATIONAL-CULTURAL THEORY Relational-cultural theory (RCT), and the type of psychotherapy approach that it engenders, differs from other postmodern and feminist approaches in its emphasis on the need for healthy interpersonal connections as a basic requirement for healthy human development. RCT is a type of postmodern feminist therapy that places prominence on both personal relationships and relationships within larger social systems. RCT holds that most problems that bring people into counseling are due to fractured interpersonal relationships and/or pressures from those who have power over the client within social systems. Problems of racism, sexism, classism, and other types of sociopolitical oppression are the common underlying causes of everyday problems for many clients.

Historical Context RCT grew out of the pioneering work of Jean Baker Miller. Miller was a psychiatrist who lived and worked in the northeastern United States during the mid-20th century. The traditional roles of men and women were rapidly changing, as were ideas about race and social class. In 1976, Miller’s landmark book Towards a New Psychology of Women was published. The book outlined her thoughts about the shortcomings of other common approaches to psychotherapy and human development that emphasized independence and separateness as goals healthy adults should strive to achieve. Most of these models saw women’s desire for connection with others as a weakness. Because of their need for relationships, women were often painted as the less intelligent, less capable sex in any setting apart from homemaking. Instead, Miller argued, all people naturally seek affinity and connection with others and are stronger and healthier when they have growth-fostering relationships.

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Miller’s model of psychotherapy also stressed the importance of mutually growth-fostering relationships. In these relationships, both people in the pair are able to grow and receive care and empathy from their partner. At the time, women struggled to achieve mutual growth within their marriages, which were still predicated on a model of the man being dominant in most matters while the woman was subordinate and was expected to serve the needs of the man. Same-sex romantic partnerships were highly stigmatized and generally not accepted in society. The notion that both partners should engage in empathic care and understanding of each other was considered radical in the 1970s. Miller also wrote that men benefit from growth-oriented relationships and, in fact, need nurturing empathic exchanges to be emotionally healthy. This was also a radical departure from the common belief that men are strong and independent and do not need to express emotions. Miller and her theory received a great deal of negative attention from many psychiatrists and psychologists, most of whom practiced from a Freudian perspective. Freudian psychiatrists and psychologists believed that the basis for clients’ problems lay in early experiences that were held in the subconscious. Dream analysis, hypnosis, free association, and similar methods of uncovering and analyzing clients’ repressed memories were the generally accepted techniques in therapy at the time. Miller’s notion that clients’ problems were available to their conscious minds and revolved around their primary relationships seemed foreign in comparison. Miller also faced sexual discrimination on many occasions, and her work was often shunned by male colleagues who refused to accept the idea that a woman could make meaningful contributions to science. However, her ideas became more popular and accepted as women gained more ground during the women’s rights movements in the 1970s and onward. By the mid-1980s, Miller was the center of a group of women psychiatrists, psychologists, and similar professionals who met weekly to discuss their ideas about relational theory. Dubbed the “Monday Night Group,” they met at Miller’s home to discuss ideas about women in society, therapy, theory, and life. Many ideas now found in books and peer-reviewed articles grew out of these Monday night conversations, attended by authors such as Judith Jordan, Irene Stiver, Maureen Walker, Laura Hartling, and Janet Surrey.

In 1981, Miller became the director of the Stone Center at Wellesley College. The Stone Center was the campus counseling center for the college. While working there, Miller continued to refine her theory, encouraged others to write about and add to it, and taught courses on relational psychology at several nearby colleges and universities. Miller died in 2006, but her work continues at the Stone Center, which now also houses the Jean Baker Miller Training Institute. The institute conducts training on RCT for therapists several times a year, curates articles about the approach, and works to spread the practice of RCT.

Theoretical Underpinnings RCT is built on the concept that healthy human social and emotional development leads not only to separateness but also to healthy connections with other people. Radiating out from this central concept are ideas about how people attempt to connect one another, what can go wrong with these connections, and how they might be repaired. Within the past decade, neuroscientists have bolstered the credibility of these ideas with discoveries about the form and function of the human brain and how it is hardwired to connect with others. Absence of connection, especially during the early years of a child’s development, can cause damage to most of the major functions of the brain. Repair to damaged brains is possible, and new research suggests that talk therapy can repair some of the damage done during abusive and neglectful early experiences. Therapists who use RCT harness the self-healing power of the human brain when they work with clients. Scientific validation of earlier ideas about the healing power of connection bolsters RCT claims that healing is done within relationships with others, not in isolation. The primary underpinning of the theory is that all humans need and crave healthy, growth-fostering relationships and will do whatever is required to create and maintain relationships with others. When relationships fail, are painful, or do not meet the needs of the people involved, psychopathology or emotional distress may result. RCT theorists see most depression, anxiety, addictions, traumatic stress, and other types of psychological problems as unsuccessful attempts at connection. Over time, repeated broken relationships may cause clients to retreat into isolation, develop various types of

Relational-Cultural Theory

anxiety, or turn to addictive drugs or behaviors in order to counter the pain they feel. People recover from psychological distress when they are able to examine their past relational problems, learn to have self-empathy and empathy for others, and expand their capacities for future healthy, growth-fostering relationships. It is important to note that relationships refer both to interpersonal relationships and relationships to the broader culture. Clients may suffer from disconnection in their close personal relationships and may also suffer from cultural oppression in the form of sexism, racism, heterosexism, ageism, or other related problems. Therefore, clients are encouraged to examine both close personal relationships and the powerful cultural disconnections that may be present in their lives as part of the healing process.

Major Concepts Mutual Empathy

The therapist’s empathic comments and body language help the client see how his or her experiences and stories can affect others emotionally. Self-Empathy

Clients are encouraged to feel empathy for themselves prior to trying to feel empathy for others. Clients are often unable to discuss their own feelings accurately and are assisted in identifying them and allowing the feelings to be experienced as worthy and important. Five Good Things

The five good things are the elements Miller identified as being present in mutually growthenhancing relationships. They are 1. zest, a feeling of a greater sense of vitality and energy; 2. an ability to take action in mutually growthproducing relationships and in the world; 3. an accurate picture of oneself and the other person(s) (also known as clarity); 4. a greater sense of self worth; and 5. an increased desire for more connections.

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Condemned Isolation

When people give up reaching out to others for meaningful relationships, they are said to experience condemned isolation. They retreat into themselves and do not attempt to connect with others. This is often seen as depression and is a cause of addiction. Relational Templates

People develop a set of expectations for the behavior of others through their lived experiences. These cognitive sets, or schemas, develop into relational templates, which drive a person’s expectations about future relationships. These may vary by the type of relationship (e.g., romantic, professional, etc.) and the type of person (e.g., man, older person, etc.). Central Relational Paradox

People crave and need relationships. This remains true even when a person has experienced painful or negative relationships. Often, the more bad experiences a person has had in relationships, the more he or she feels a need to connect with others.

Techniques RCT does not have a set of specific techniques. However, the ability to communicate mutual empathy with a client is essential to the success of therapy. Beyond the use of mutual empathy, RCT therapists often use expressive arts and cognitive techniques to assist clients in examining their relational templates, relationships, strategies of disconnection, and capacity for self-empathy. RCT may be used with clients across the life span, including groups, couples, families, and individual children, adolescents, and adults.

Therapeutic Process RCT does not have a specific, dogmatic process by which all therapeutic encounters must unfold. It follows the general progression of most current therapies in stages of assessment, working, and termination. All of these typical stages are conducted with a deep, radical respect for the client and his or her coping methods.

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During assessment, the therapist will seek information about the types and qualities of the clients’ past and current relationships. General information about any addictive behaviors, thoughts of self-harm or harm to others, and coping skills is also recorded. In the early phase of therapy, RCT therapists try to learn as much as they can about how the client connects and disconnects with others. The client’s “strategies of disconnection” are crucial to finding the source of distress and the source of healing. Once the therapist has an understanding of the client and his or her context and concerns and the client begins to feel safe within the context of the therapeutic relationship, the therapist begins to help the client explore more deeply fraught areas. Relational templates are explored, along with how these past experiences influence current behavior. The client is encouraged to experience self-empathy as well as empathy for others. The therapist maintains an open, curious, and supportive stance. Advice giving and judgment are not allowed. As the client comes to understand his or her patterns of disconnection and relational templates, and to value his or her own emotional life, the counselor remains supportive and empathic. The therapist may use expressive arts strategies to help the client elicit and process relational memories and emotions. Sometimes, psychoeducation may be used to help the client understand what a healthy relationship is and how healthy relationships differ from toxic ones. The goal of therapy is for the client to increase his or her capacity for healthy, growth-fostering relationships. Mary Catherine Tucker See also Feminist Therapy; Miller, Jean Baker

Further Readings American Psychological Association. (2008). Relational cultural therapy [DVD, APA Systems of Psychotherapy Video Series].Washington, DC: Author. Jordan, J. V. (2009). Relational-cultural therapy. Washington, DC: American Psychological Association. Jordan, J. V., Walker, M., & Hartling, L. (Eds.). (2004). The complexity of connection. New York, NY: Guilford Press. Miller, J. B. (1976). Toward a new psychology of women. Boston, MA: Beacon Press.

Miller, J. B., & Stiver, I. (1997). The healing connection. Boston, MA: Beacon Press. Robb, C. (2006). This changes everything: The relational revolution in psychology. New York, NY: Picador. Walker, M., & Rosen, W. (Eds.). (2004). How connections heal: Stories from relational-cultural therapy. New York, NY: Guilford Press.

RELATIONSHIP ENHANCEMENT THERAPY Relationship Enhancement® is an educationally based skills-training approach to human problems that emphasizes helping people in significant relationships learn and apply skills to help them act as change agents for each other and enhance their relationships. Relationship Enhancement programs are effective with individuals, couples, families, groups, and any important relationship. The key ingredient is helping clients learn skills that enhance the psychological and emotional satisfactions from such close relationships and thereby improve the well-being of the individual and the group (couple or family). The goal is to modify behavior through the learning and generalization of specific interpersonal skills. When people do this in the context of their primary and significant relationships, the changes are more satisfying and long lasting. The problem’s solution is not ignored; rather, the client is taught to solve problems as part of the therapy. The intent is less to help people change than to help them learn to create a secure emotional context in which constructive change is more likely to occur. Once this context is established, clients become more autonomous and differentiated and, ultimately, more intimate with significant people in their lives. Having learned these skills, and trusting that they can solve their own problems, clients are in a better position to deal with life’s crises on their own.

Historical Context When Bernard G. Guerney Jr. created Relationship Enhancement in the 1960s, he was concerned about the efficacy of the prevailing practices used to treat children and their parents. Rather than viewing emotional and behavioral problems as

Relationship Enhancement Therapy

reactions to intrapsychic issues resulting from unconscious and unresolved emotional conflicts, he assumed that the majority of cases were the result of lack of skill in and knowledge about emotional functioning and interpersonal interactions (relationships). He believed that by helping clients learn to improve their emotional and relationship skills in their primary and significant relationships, and through internalizing these skills with practice and attention to their principles, they would be able to resolve intrapersonal and interpersonal conflicts, improve coping, and be responsible for their own problems. Relationship Enhancement was one of the first models to use family members as change agents with one another in a structured, systematic, and time-designated way. Relationship Enhancement began as a program called Filial Therapy, in which parents worked therapeutically as change agents with their own children. Here, parents learned how to conduct child-centered play therapy sessions at home with their own children. Guerney believed that therapeutic change would be more probable and long lasting if parents served as their children’s therapists. It was believed that this process would allow children to experience improved self-concept, emotional regulation, and a more attuned attachment relationship with their parents. Parents would not only learn to improve their parenting skills but also become more empathic and attuned to their children’s development. These skills changed how parents responded to their children, increased children’s self-concept and emotional lives, and ultimately improved family life. The development of Filial Therapy, originally Child Parent Relationship Enhancement Family Therapy, began at a time when there were significant concerns about the ability to provide psychological services to growing populations. As a result, there was growing pressure to develop self-growth and prevention activities by employing paraprofessionals and other nonprofessionals. With a National Institute of Mental Health research grant, Guerney began to explore applying the principles of Filial Therapy to other subsystems and populations and to educational/prevention programs, including Relationship Enhancement programs such as Couple Relationship Enhancement, Parent-Adolescent Relationship Development, Mastering the Mysteries of Love, and Relationship Enhancement Family-of-Origin Consultation.

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Relationship Enhancement therapy skills emphasize the following: empathic understanding and the acknowledgment of this understanding, ownership of oneself (emotional regulation), and emotional attunement, attachment, and intimacy. In Relationship Enhancement Couple Education (Mastering the Mysteries of Love form of Relationship Enhancement), Guerney and colleagues have developed nine Relationship Enhancement skills that are taught: expressive, empathic, problem discussion, problem solution, partner facilitation, self-change, other-change, generalization, and maintenance. Couples and families learn these skills with one another; practice and apply them at home, at work, and in their communities; and generalize and maintain these skills with others who are significant to them. This helps them improve the quality and satisfaction in their lives. In recent years, Barry G. Ginsberg has emphasized the importance of emotion as an organizing principle and emotional engagement/attachment as the underlying principle in all nine skills.

Theoretical Underpinnings Guerney formulated Relationship Enhancement therapy as an integrative, systematic, and timedesignated approach. The key values of Relationship Enhancement therapies emphasize the importance of relationships and that accessing an understanding of our deepest emotions is transformative to ourselves and our relationships. It further suggests that people develop “interpersonal reflexes” that are shaped by early relationships, which in turn shapes the same kind of response in others: Positive responses trigger positive responses and negative responses trigger negative responses. This reciprocal process is out of one’s awareness or consciousness, is derived from family histories, is integrated into the habits of present and new relationships, and explains why people become stuck in habitual patterns. Key to the change process is the ability of individuals in relationships to show deep empathy and other relationship skills that foster understanding and love in relationships. Deep empathy • helps individuals understand the motivations, values, and feelings of others, particularly those significant in their lives;

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• allows for openness and honesty, which are necessary to this understanding of oneself and others; • can occur only in an accepting and nonjudgmental atmosphere; • allows for individuals to understand the underlying feelings and motivations of others; • helps individuals become more congruent in their lives—that is, allows their feelings, behaviors, and thoughts to be in sync; • is best if it occurs in an “empathic relationship,” where people can be open with their deepest emotion with little defensiveness or blame; • promotes security, lessens anxiety, and builds confidence in oneself and the relationship; • promotes a sense of well-being and happiness; • enables partners to become more intimate, collaborative, and problem solvers; • lessens power inequities between partners; • allows individuals to become more flexible and better able to adapt and cope with change; and • helps people emphasize what’s right and not what’s wrong.

When these skills are learned and practiced in one’s significant and important relationships, they can be internalized and integrated in one’s life and relationships, resulting in a more satisfying life experience. In developing Relationship Enhancement therapy, Guerney drew on the pertinent aspects of the major theories to develop this integrative approach, including the following: • The concepts of the unconscious, defense mechanisms, and the value of catharsis were drawn from psychoanalytical theory. • Client-centered (now person centered) therapy emphasizes the importance of empathy, unconditional positive regard including acceptance and nonjudgment, self-understanding, congruence, and self-determination. • Operant conditioning and reinforcement from learning theory are important for this educational approach. • Social learning theory contributed modeling, self-regulation, self-determination and personal behavior, positive reinforcement, shaping, and the importance of practice to effect change.

• Interpersonal theory is central to this integrative approach, stressing the importance of relationships and reciprocal cycles of interaction. • The importance of environment and context in shaping behavior comes from developmental systems theory. • The influence of early emotional and relational development in the formation of personality, the capacity to develop emotional bonds in relationships and develop secure bonds, comes from attachment theory. • All this emerges in the family emotional system, which influences individuals (family systems theory).

Techniques In Filial Therapy, parents are taught child-centered play therapy skills. These skills allow for children to initiate and be self-directed in a nonjudgmental, accepting, and empathic context. Parents learn to be empathic, nonjudgmental, and accepting of their children; learn to set effective limits and consequences; and learn how to conduct play therapy sessions at home with their own children and generalize the principles and skills learned in their play sessions with their children in their everyday lives. This can be done as an individual family therapy or in multifamily groups. In Relationship Enhancement, Couple and Family Therapies, instead of play therapy, couples and families learn relationship skills derived from the same principles and methods as those of Filial Therapy such as the following: Speaking/owning (an expressive skill; taking ownership): Learning to recognize and acknowledge, with acceptance and nonjudgment, one’s underlying feeling motivations for one’s behavior in the present— essentially empathy for oneself Listening/empathic responding (a receptive skill): Learning to suspend judgment and, with acceptance, understand fully the underlying primary emotional motivation for the expressions and actions of others, and acknowledge this understanding to others, particularly in one’s primary and significant relationships—essentially empathy for others Discussion/emotional engagement (an attachment skill; relationship): Learning to give emotional

Relationship Enhancement Therapy

acknowledgment to the meaning and importance of the other person’s feelings in the relationship—an intimacy skill that incorporates speaking and listening skills and increased collaboration in this empathic context.

Then, they practice the skills with one another during the scheduled practice sessions at home and record these practice sessions, which are then used for supervision and reinforcement of the skills in office sessions with the therapist. Clients are taught and reinforced in how to generalize these skills in their everyday lives (generalization skill) and maintain them over time (maintenance skill).

Therapeutic Process Relationship Enhancement programs are education/skill learning based and highly structured, and the training is detailed and systematic and typically time designated. Relationship Enhancement programs proceed in a systematic way. Therapy typically progresses in phases. Tutorial phase: It is a more intensive process and comparable with a traditional therapeutic role. Therapists create a safe, secure, and trusting therapeutic context to model and directly supervise clients in skill practice with one another and help them learn how to conduct skill practice sessions at home. Coaching phase: It is a less intensive process with less frequent meetings with the therapist. This is a generalization phase. Clients conduct structured and taped home practice sessions at designated times each week and bring samples (tapes) of their home practice and generalization activities to the sessions with the therapist. The therapist reinforces the home skill practice and helps maintain the stability and security of the relationship system to help maintain practice over time. Consultant phase: It refers to the trusting relationship between the therapist and clients, which becomes a resource for continued stability and security of the individuals and the relationship. This phase allows for booster sessions and refresher programs and attention to other subsystems and problems of the family.

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Therapy in Relationship Enhancement is defined by this skill-learning process and its practice, helping clients internalize the skills and incorporate them in their everyday lives with one another. Relationship Enhancement emphasizes the importance of emotion as the transformative agent in change, particularly in the development of attachment security in primary relationships. A secure context is necessary to enable individuals and families to improve their functioning. Structuring for success (a positive connotation) is an essential principle to enable families to continue the scheduled weekly half-hour home practice. Clients record and/or self-report these home practices for supervision. Once the clients are engaged in home practice, they are seen less often and office sessions emphasize review of their home practice and their efforts to generalize and maintain the skills in their everyday lives. The emphasis in these sessions is less on problem solving per se and more on applying appropriate principles and methods to each situation. An important principle is for individuals and families to look for the underlying positive (e.g., “You’re important to me.”). Barry G. Ginsberg See also Behavior Therapy; Cognitive-Behavioral Therapies: Overview; Couples, Family, and Relational Models: Overview; Emotion-Focused Therapy; Existential-Humanistic Therapies: Overview; PersonCentered Counseling; Psychoeducational Group; Rogers, Carl; Sullivan, Harry Stack

Further Readings Ginsberg, B. G. (1997). Relationship enhancement family therapy. New York, NY: Wiley. Guerney, B. G., Jr. (1982). Relationship enhancement. In E. K. Marshall & P. D. Kurtz (Eds.), Interpersonal helping skills (pp. 482–518). San Francisco, CA: Jossey-Bass. Guerney, B. G., Jr. (1984). Relationship enhancement therapy and training. In D. Larson (Ed.), Teaching psychological skills: Models for giving psychology away (pp. 171–206). Monterey, CA: Brooks/Cole. Guerney, B. G., Jr. (1977). Relationship enhancement. San Francisco, CA: Jossey-Bass. Guerney, L. (1976). Filial therapy program. In D. H. Olson (Ed.), Treating relationships (pp. 67–92). Lake Mills, IL: Graphic.

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Guerney, L., & Ryan, V. (2013). Group filial therapy. Philadelphia, PA: Jessica Kingsley. VanFleet, R. (2013). Filial therapy (3rd ed.). Sarasota, FL: Professional Resource Press.

REPARATIVE THERAPY

The developers initially used the term interactional and discursive model to highlight the importance of language and social interaction. Then, to emphasize the conceptual distinction between “the language of effects” and “the language of responses,” they coined the terms response-based therapy and, later, response-based practice to denote applications of the approach in different settings.

See Sexual Orientation Change Efforts Theoretical Underpinnings

RESPONSE-BASED PRACTICE Response-based practice (which subsumes response-based therapy) is a specialized model for working with individuals and groups experiencing adversity, including violence and injustice. It is a conceptual framework for research, critical analysis, and policy and consists of methods that are readily adapted across settings (e.g., in child protection, group therapy, victim assistance, refuges and transition houses, policing, family law, trauma treatment, prevention education, community development, and individual and group therapy with victims and offenders and their children). The main tenets of the approach are supported by clinical, social science, and biological science research. Response-based practice grew from direct service with individuals and families in diverse social, cultural, and geographical locations and continues to evolve in collaboration with a wide range of professionals and activists.

Historical Context Allan Wade, Linda Coates, and Nick Todd developed response-based practice in the early 1990s as a model of therapy with victims and perpetrators of violence and their families. The initial group and newer colleagues (Shelly Bonnah, Ann MajeRaider, Cathy Richardson, Gillian-Weaver Dunlop, Cindy Ogden, Robin Routledge, Brenda Adams, Barb McInerney, Vikki Reynolds, and Renee-Claude Carrier) worked with diverse and marginalized groups. Indigenous families and communities, in particular, helped to shape the approach from the outset.

Response-based practice integrates and departs from earlier contextual models (e.g., brief, systemic, fifth province, feminist, narrative, solution focused, and discursive) in its focus on the manner in which individuals respond to adversity, resist violence, and work to retain their dignity. Responses to adversity often reveal capacities that can be brought to bear in addressing a wide range of presenting concerns and developing preferred futures. Philosophically, this orientation aligns with a contextual and critical realist perspective. It stems in part from close analysis of human interaction in everyday and extreme circumstances and draws on methods developed in microanalysis, critical discourse analysis, conversation analysis, discursive psychology, culture studies, microsociology, and narrative analysis. Response-based practice acknowledges preexisting competencies evident in everyday living and in the most adverse circumstances. The “problem” resides not in the minds or brains of isolated individuals but in the mistreatment and humiliation of those individuals in the context of violence and injustice and through negative social responses.

Major Concepts Response-based practice integrates several key tenets: 1. Humans are agentive, in and outside of social interaction. 2. Dignity is central to individual and collective well-being. 3. Individuals respond to adversity and resist violence.

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4. Violence is, with rare exceptions, deliberate. 5. Violence is unilateral (i.e., not mutual) and consists of actions by one person (or group) against the will and well-being of another. 6. Language can be used in restrictive or liberating ways, to (a) conceal or reveal violence, (b) obscure or reveal offender responsibility, (c) conceal or elucidate responses and resistance, and (d) blame or contest the blaming of victims. 7. Humans are understood better as responding agents than as affected objects. 8. The social and material context is central to human experience and must be taken into account.

Individuals who face adversity often encounter negative social responses from social networks and authorities. Their experience is sometimes misrepresented in ways that fundamentally change, or distort, the events in question. Positive social responses, based on accurate analysis and descriptions, are “therapeutic” in the sense that they uphold the dignity of the person, clarify responsibility, and provide social redress. The same orientation applies to individuals who perpetrate violence, who generally are more capable and concerned with their responsibility than is generally presumed. Close analysis of the strategies used to commit violence shows that, with rare exceptions, individuals who commit violence already possess the skill and awareness to desist violence prior to therapeutic intervention. Therapy consists in part of elucidating and honoring the capacities evident in victim responses and resistance and, in a complementary way, identifying the preexisting capacity of offenders to choose more respectful courses of action.

Techniques Therapists use a number of techniques to clarify context and interactional details, develop accurate descriptions of violent actions (and other adversities), explore the forms and “situational logic” of responses and resistance to those actions, review the social responses, and discuss individuals’

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responses to those social responses. Response-based practice builds safety, defers to individuals’ concerns and aspirations, contests blaming and attributions of pathology, and formulates individuals instead as agentive and capable responders. This is achieved grammatically with questions and formulations that position individuals (i.e., victims, perpetrators, children) as subjects who respond extemporaneously and deliberately in social interaction. Language is used judiciously to develop accurate descriptions and contest misrepresentations in which violence is portrayed as mutual rather than unilateral, individuals who experience violence are portrayed as passive and affected objects, and individuals who use violence are portrayed as lacking control and deliberation.

Therapeutic Process Therapy is largely a process of providing a positive, socially just response to the person and his or her loved ones. The immediate goal is to uphold dignity (which encompasses safety) and to establish a context in which necessary information can be exchanged in a way that furthers positive change.. The conversation is jargon-free, equitable, and respectful. While the therapist exerts influence through the content of questions and other actions, every effort is made to position the client as competent and as capable of discerning both good process and best outcome. Allan Wade See also Collaborative Therapy; Exposure Therapy; Feminist Family Therapy; Feminist Therapy; Interpersonal Theory; Narrative Therapy; SolutionFocused Brief Therapy; Systemic Family Therapy

Further Readings Coates, L., & Wade, A. (2007). Language and violence: Analysis of four discursive operations. Journal of Family Violence, 22, 511–522. doi:10.1007/s10896007-9082-2 Todd, N., & Wade, A. (2003). Coming to terms with violence and resistance: From a language of effects to a language of responses. In T. Strong & D. Pare (Eds.), Furthering talk: Advances in the discursive therapies (pp. 145–161). New York, NY: Kluwer Academic.

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Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression. Contemporary Family Therapy, 19, 23–39. doi:10.1023/A:1026154215299 Wade, A. (2007). Hope, despair, resistance: Responsebased therapy with victims of violence. In C. Flaskas, I. McCarthy, & J. Sheehan (Eds.), Hope and despair in narrative and family therapy: Adversity, forgiveness and reconciliation (pp. 63–74). Hove, England: Brunner-Routledge.

ROGERS, CARL Carl Rogers (1902–1987) was one of the leading psychologists and psychotherapists of the 20th century. He developed the client-centered or person-centered approach to counseling and psychotherapy and was a pioneer and leader in the humanistic psychology movement of the later part of the century. He also was the first person to record and publish complete cases of psychotherapy and, at the time, did more scientific research on a therapeutic approach than had ever been done. Growing up in a mid-Western American family, Rogers first learned the scientific method as a boy, conducting agricultural experiments on the family farm. He intended to be a modern farmer, but influenced by his religiously conservative family and a 6-month trip during college to Japan, the Philippines, and China, where he attended a World Youth Christian Federation conference, he decided instead to become a minister. When he moved with his new wife, Helen, to New York City in the 1920s to attend Union Theological Seminary, growing religious doubts and a fascination with psychology led him to transfer to Teachers College, Columbia University, where he earned a Ph.D. in clinical psychology. In his dissertation and clinical work, he learned to balance the testing and measurement, and the psychodynamic approaches that were a part of his training, coming to deeply value both the individual’s subjective experience in therapy and the objective investigation of the process of psychotherapy. He put both of these approaches into practice for the next 12 years, working in the child guidance field in Rochester, New York. As a clinical

worker with children and families and as director of his department and then agency, he straddled the fields of social work and psychology, arranging for institutional and foster home placement, recommending changes in school programs, doing family counseling, and providing individual therapy for children and parents. Eclectic in his practice, his main focus was on “what works”—what approaches helped children to successfully adjust to life’s challenges. One therapeutic approach that particularly impressed and influenced him was the relationship therapy developed at the Philadelphia School of Social Work by students of Otto Rank. At the end of his time in Rochester, his first major book, Clinical Treatment of the Problem Child, summarized his learning about environmental and clinical treatment and led to a job offer at Ohio State University. As professor of clinical psychology at Ohio State University, in what might have been the first university clinical practicum for psychologists in the country, rather than just summarize others’ approaches, he began to articulate his own views on effective therapeutic treatment of children and adults. Rogers’s initial “nondirective” counseling and psychotherapy was but one of what he called the “newer therapies” of the time. These approaches were a counterpoint to the widely applied directive methods in college counseling and the medical model of psychiatry with its expert diagnoses and treatment. In contrast, Rogers’s nondirective therapy placed a great deal of faith in the client’s ability to know what hurts and to direct the conversation in therapy. The therapist’s role was not to offer advice, suggestions, interpretations, or probing questions but to rely exclusively on “acceptance” and “reflection of feelings,” which would allow clients to achieve their own insights, leading to their own positive actions. Rogers’s 1941 book Counseling and Psychotherapy: Newer Concepts in Practice described the nondirective approach, provided numerous clinical examples, popularized the word client as the recipient of counseling, and included the first complete psychotherapy case ever published. It became an instant best seller. It appealed widely to psychologists, social workers, counselors, ministers, health care professionals, and others and thus helped spread counseling and psychotherapy to many

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different fields. His being elected president of the  American Academy of Psychotherapists, the American Association of Applied Psychology, and the American Psychology Association evidenced Rogers’s growing influence. The recording and transcribing of actual sessions revolutionized both training and research in counseling and psychotherapy and led Rogers to move to the University of Chicago (1945–1957), where he developed one of the major centers in the world for training and research in the field. There, his nondirective approach gradually evolved into the “client-centered” approach to counseling and psychotherapy. Rogers argued and demonstrated through personal example and extensive research that certain conditions were both “necessary and sufficient” for psychotherapeutic change in clients. Among these were the three “core conditions” of therapist empathy, unconditional positive regard, and congruence. Empathy was the deep and sensitive understanding of the client’s thoughts, feelings, and meanings, which was primarily achieved through the kind of active listening that Rogers came to embody through widely distributed audio and video recordings. Unconditional positive regard was the therapist’s complete acceptance of the client as he or she is, without judgment or imposing “conditions of worth” on the client. Congruence was the therapists’ genuineness and authenticity in the relationship— coming across as a real and caring person rather than playing a professional role. Rogers argued that when these conditions in the therapeutic relationship were present and clients perceived them, then therapeutic progress was inevitable. For the voluminous research that Rogers and his associates did to demonstrate these propositions, he received the first of the American Psychological Association’s Distinguished Scientific Contribution Awards. In the 1960s and 1970s, Rogers was also active, along with Gordon Allport, Abraham Maslow, and others, in developing and popularizing what Maslow called the “third force” in psychology, after psychoanalysis and behaviorism. “Humanistic psychology” emphasized human potential and wellness instead of illness, honored the phenomenological or inner world of the client, and focused holistically on the biological, psychological, social, and spiritual dimensions of human experience. As Sigmund Freud was to psychoanalysis and B. F. Skinner was to behaviorism, Carl

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Rogers became to humanistic psychology. A widely publicized debate and 6-hour dialogue between Rogers and Skinner added to Rogers’s stature as the leading spokesperson for humanistic psychology, as did the dialogues he had with Martin Buber, Paul Tillich, Reinhold Niebuhr, Gregory Bateson, Rollo May, and other leading intellectuals and theologians of the 20th century. Following his tenure in Chicago, Rogers spent another 6 years at the University of Wisconsin before leaving academia in 1963. Rather than rest on his laurels, he spent the next quarter-century applying what he came to call the “person-centered approach” to an ever-widening circle of applications in other fields. In Freedom to Learn, with examples and case studies, he showed how teachers could adapt the three core conditions of (1) empathy (understanding), (2) unconditional positive regard (trust), and (3) congruence (genuineness) to become “facilitators of learning,” unleashing students’ intrinsic motivation, productivity, and creativity. In Becoming Partners: Marriage and Its Alternatives, again through examples and case studies, he explored how realness and open communication could help couples enrich their relationships, whether traditional or unconventional. In Man and the Science of Man, including transcript excerpts from a conference Rogers and colleagues held on the topic, he applied the principles of humanistic psychology to the study of the behavioral sciences. One of the major applications of the personcentered approach that Rogers helped develop and disseminate was the intensive small-group experience known as the “encounter group.” In these groups, facilitated by a leader embodying the core conditions of empathy, positive regard, and congruence, participants learn to lower their facades and defenses and communicate more deeply and authentically with others. Rogers conducted scores of encounter groups with diverse populations, from business executives to educators. He and his colleagues then went on to produce similar results in person-centered communities with much larger numbers of participants. Although the process was more volatile in the larger groups, with more emotion, conflict, and leadership struggles, the benefits of the egalitarian person-centered approach were consistently reaffirmed. The person-centered approach has sometimes been criticized as individualistic; less relevant to

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non-Western, collectivist cultures; and neutral to, or even dismissive of, the client’s social and political context. These critics are usually unfamiliar with the past 20 years of Rogers’s career, in which, not content with personal growth as an outcome of encounter groups or person-centered communities, Rogers worked extensively with non-Western audiences in traditional societies and applied the person-centered approach to cross-cultural communication, intergroup conflict resolution, and even international peacekeeping. He and his team went around the world conducting successful small and large groups, for example, with Catholics and Protestants from strife-torn Northern Ireland, blacks and whites in South Africa under apartheid, and the protagonists in the Central American war between the Contras and Sandinistas. For this work, he was nominated for the Nobel Peace Prize a month before his death. Arguably, no other theory of counseling and psychotherapy has been applied so explicitly in the community and the wider world. Rogers’s theory and practice have also been criticized as naive, superficial, and unworkable with populations with serious mental health diagnoses. Apart from Rogers and colleagues’ own research to the contrary, ironically the latest generation of process and outcome research on a wide variety of therapy approaches appears to be validating much of Rogers’s theory regarding the centrality of the therapeutic relationship to successful counseling and psychotherapy. Howard Kirschenbaum See also Emotion-Focused Therapy; ExistentialHumanistic Therapies: Overview; Focusing-Oriented Therapy; Freud, Sigmund; Maslow, Abraham; PersonCentered Counseling; Skinner, B. F.

Further Readings Kirschenbaum, H. (2009). The life and work of Carl Rogers. Alexandria, VA: American Counseling Association. (UK edition: PCCS Books, 2007) Kirschenbaum, H., & Henderson, V. (Eds.). (1989). The Carl Rogers reader. Boston, MA: Houghton Mifflin. Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications and theory. Boston, MA: Houghton Mifflin. Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin.

Rogers, C. R. (1969). Freedom to learn: A view of what education might become. Columbus, OH: Charles Merrill. (New editions in 1983 and 1994) Rogers, C. R. (1977). Carl Rogers on personal power. New York, NY: Delacorte. Rogers, C. R. (1980). A way of being. Boston, MA: Houghton Mifflin. Rogers, C. R., & Dymond, R. (1954). Psychotherapy and personality change. Chicago, IL: University of Chicago.

ROLFING Rolfing, also known as Rolfing Structural Integration, is a complementary treatment using physical manipulation to treat physical and psychological concerns. Rolfing is a unique, systematic method of bodywork that releases blocked or congested tissue areas in the body. It is designed to bring the client’s body into a nimble and well-balanced relationship within itself and gravity.

Historical Context Rolfing, developed in the 1930s and named after the biochemist Ida Rolf (1896–1979), was originally called Postural Release and then became known as Structural Integration. Based on ideas from biochemistry, Yoga, osteopathy, bodywork, and other related postural training and movement therapies, Rolfing focuses on hands-on manipulation of a client’s fasciae, which are fibrous connective tissues that encapsulate muscles, blood vessels, and nerves. Manipulating the soft tissues, Rolf theorized, improves alignment (symmetry) of the body, resulting in multiple physical and psychological benefits. Although outcome research is limited on Rolfing, this treatment is a popular alternative therapy for an assortment of health concerns. Because Rolf had extensive experience in biochemistry and physics, she researched the myofascial system, and her resulting theory has been considered as the connector therapy between chiropractics and massage. Her theory allows for emotional release to occur with physical release. Although Rolfing is seen as a somewhat painful process, it has evolved to a more gentle manipulation with much less pain. It became somewhat popular during the 1970s and has recently seen a resurgence.

Rolfing

Today, the Rolf Institute of Structural Integration is the only accreditation and credentialing body. There are two paths to credentialing. Individuals can become certified through the institute by completing a 12- to 18-month training program, although those who have experience in bodywork can go through an accelerated program. A Rolfing practitioner, or Rolfer, must receive 18 days of training from 3 to 7 years to qualify to become an Advanced Rolfer. Advanced Rolfers learn how to work outside the usual 10-session format.

Theoretical Underpinnings Rolf researched the impact of earth’s gravity on the human body. She theorized that people hold their bodies in abnormal ways due to injury, emotional stress, and gravity. Furthermore, Rolf believed that a human might face potential injuries, which, although small, can affect the body throughout the life span. For example, if a person falls while riding a bicycle, small injuries may occur. These injuries, such as a strain, sprain, or tear that occurs in a muscle or joint, may not be visible except for minor swelling or inflammation. Although the injury may not be visible, the injured bicyclist may compensate for the pain by limping and may continue to limp as a part of functioning with constant pain. In addition to physical traumas, Rolf theorized that a person might also carry emotional and psychological trauma physically, resulting in psychosomatic or psychogenic problems. Anecdotal evidence suggests that treating fibromyalgia (though not always psychosomatic) patients using Rolfing assists in management of pain and eases physical and psychological symptoms. Referred to as the Rolfing Cycle, the therapy requires 10 one-hour sessions, which are based on three principles: 1. Human beings are physically out of alignment with the earth’s gravity.

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Major Concepts Even though the application of Rolfing begins with the three main principles, it helps clients learn about themselves physically and emotionally. The Rolfer uses these principles to assist clients to increase the efficiency of muscle use. Principle 1: Human Beings Are Physically out of Alignment With the Earth’s Gravity

The human fasciae help make up the human form through the support of muscle groups and are the organ of form. The fasciae are connective tissues that encapsulate muscles, blood vessels, and nerves. Fasciae separate and organize groups of muscles. They help these muscles, if required by body physiology, to touch and to move with minimal friction. Rolfers in training learn to visualize physical blocks that must be aligned as symmetrically as possible. To envision proper alignment, Rolf describes a vertical line that aligns the ear, shoulder, hip, knee, and ankle. The Rolfer manipulates the client’s fasciae to be symmetrical, which may lead to a defined center of balance. Principle 2: Humans Have Improved Function When Aligned With Gravitational Fields

Gravity is the force to be coped with physiologically. Minimal changes in the environment may change how the body interacts with gravity. Over time, the body adjusts to anatomical defects and balance issues. Gravity causes the spine to compress and shrink as a person ages, which is apparent in elderly people. Rolfing is used to realign the body from the ground up, like balancing blocks one on top of the other. The body’s center of gravity is rebuilt, starting with the feet. Successfully coping with gravity may ensure better posture, according to this principle.

2. Humans have improved function when aligned with gravitational fields.

Principle 3: The Human Body Has Plasticity, Through Soft Tissues, Which May Be Aligned With Gravity

3. The human body has a sort of plasticity, through soft tissues, which may be aligned with gravity. The tightening of the soft tissues due to human adaptation to gravity, pain, and stress negatively affects the human musculoskeletal system.

All muscles are wrapped in fasciae, which hold the muscles together and help muscles, muscles systems, and body organs rub against each other without causing trauma. Human fasciae are pliable, similar to the elasticity of plastic, but as with

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plastic, they may stiffen over time. The tightening of the soft tissues due to human adaptation to gravity, pain, and stress negatively affects the human musculoskeletal system. By applying energy and touch, the soft tissues may be released (to become pliable), which promotes anatomical and physiological alignment. The plasticity of the fascia is theorized to be pliable at any age, which makes Rolfing a treatment for clients of most ages. Rolfing can be practiced on most clients to improve posture, increase range of movement, and enhance quality of life.

Techniques The goal of the Rolfing Cycle is to make the client’s physiological structure symmetrical. Rolfing first loosens the superficial fascia before working deeper areas. Improving support in the feet and legs before working the higher structures helps clients benefit from freer movement in daily activities. Rolfing helps a client to feel more efficient and to be more organized and more coordinated, with better posture. Rolfing requires a client to complete 10 one-hour sessions to gain the most benefit. The first 3 sessions are referred to as “sleeve” sessions, the 4th through 7th sessions are called “core” sessions, and the 8th through 10th sessions are “integration.” Sleeve

Session 1: Building Rapport and Efficient Breathing The Rolfer aims to increase the pliability of the soft tissues on the front of the body around the ribs, which may allow for better movement, releasing the diaphragm to work more efficiently. Better breathing allows more oxygen for muscles, which produces better overall movement. The Rolfer manipulates the front of the hips, thighs, and rib cage area, as well as the front and sides of the shoulders. Session 2: Body Support The Rolfer aims to soften the tissues of the lower leg to more efficiently carry the weight of the body. Working from the bottom and moving up helps the client’s feet, ankles, and knees support the body more efficiently, resisting gravity.

Session 3: Hips and Shoulders With more pliability of the soft tissues from the hips to the shoulders, the client experiences smoother muscle movements between the hips and neck. The Rolfer manipulates the front part of the hips, stomach, and chest aligning the thorax. This session incorporates breathing, balance, and the release of stiffened soft tissues. Core

Session 4: Balancing the Hips and Legs These muscle groups associated with the hips and legs are the largest in the body and carry the most body weight. These muscle groups are the core of balance and are dependent on the symmetry and alignment of the feet, ankles, and knees. Manipulation of the hips and legs improves range of motion and balance and gives an overall healthy feeling. Session 5: Abdominal Wall This session aims to balance the soft tissues spanning the front part of the pelvis and lower back by increasing pliability from left to right and from the surface to deeper within. As the deeper pelvic and abdominal restrictions are freed, the shifts in the fascia increase and lead to a supportive and balanced horizontal position. Session 6: Heel to Midback The deep muscles of the back and hips are lengthened, which complements the change that was achieved in the front of the body in Session 5. The Rolfer starts with the legs, and works on the calves, hamstrings, and pelvis, and up both sides of the spine, which establishes more freedom of movement and resilience in the spine. Session 7: Head and Neck As the Rolfer works with the neck, cranium, and face, the rhythms of cranial movement become balanced. Integration

Session 8: Hands, Wrists, Elbows, and Arms Manipulation increases biomechanical flow between the upper extremities and the spine. The Rolfer focuses on the upper body parts, and

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incorporates the body parts with the rib cage, shoulders, arms, and neck and head. Session 9: Lower Extremities Through Hips and Pelvis This session increases biomechanical flow between the lower extremities and the spine. It is often during a lower-body session that the Rolfer integrates the legs with higher structures in the body. This session creates better lower-body integration and support for the upper body. Session 10: Biomechanical Flow Through Extremities, Shoulder, and Pelvic Girdles to Spine In this session, the Rolfer increases the overall uniformity of muscle tone. Session 10 is customized to each client’s body needs and is the final integration of the 10 sessions. The Rolfer involves the whole body in this session.

Therapeutic Process When a Rolfer meets with a client seeking therapy for bodily pain and discomfort, the Rolfer first asks questions about possible injury and then aims at organizing and ordering the body. The Rolfer uses the body’s theoretical, ideal disposition to physically organize a client’s supporting structures. The client commits to participating in a series of 10 hour-long sessions, which are based on the three principles previously mentioned. Clients have reported feeling an emotional release following sessions, leading to a more content psychological state. When the client feels content, he or she may be more amenable to counseling; also, when the client does not feel emotional pain, he or she can work better on problems relating to psychological issues such as depression and anxiety. A counselor could integrate Rolfing into the therapeutic process by partnering with a Rolfer to increase the physical reactions a person may have to a psychological stimulus. Through connecting to the physical manifestations of psychological issues, a client may be better able to identify when his or her mind affects physical health, resulting in better management of overall well-being. Additionally, a counselor could refer a client to a Rolfer when physical pain is blocking the counseling process. Charles Crews and Janet Froeschle

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See also Body-Oriented Therapies: Overview; Core Energetics; Integrative Body Psychotherapy; Postural Integration; Yoga Movement Therapy

Further Readings Anisman, H. (2014). An introduction to stress and health. Thousand Oaks, CA: Sage. Anson, B. (1998). Rolfing: Stories of personal empowerment. Berkeley, CA: North America Books. Brecklinghaus, H. G. (2002). Rolfing structural integration. What it achieves, how it works and whom it helps. Freiburg im Breisgau, Germany: Lebenshaus Verlag. Joshi, V. (2005). Stress: From burnout to balance. Thousand Oaks, CA: Sage. Karrasch, N. (2009). Meet your body: A Rolfer’s guide to release bodymindcore trauma. Philadelphia, PA: Jessica Kingsley. Karrasch, N. (2012). Freeing emotions and energy through myofacial release. Philadelphia, PA: Jessica Kingsley. Rolf, I. P. (1990). Rolfing and physical reality. Rochester, VT: Healing Arts Press.

ROLLNICK, STEVE See Miller, William R.

RUBENFELD SYNERGY Rubenfeld Synergy, or the Rubenfeld Synergy Method (RSM), is an alternative therapy that consists of a combination of talk and touch. The word synergy refers to the increased effectiveness of an intervention when it is combined with an additional intervention. RSM is based on the premise of a holistic mind, body, and spirit connection and the premise that emotions can unconsciously be stored as energies in the physical body. For example, situational or emotional life stressors may show up later as aches and pains, fatigue, or a general apathy or disconnection. The method blends simple movement and body awareness interventions with Gestalt therapy techniques, which include experiential or here-and-now counseling interventions that are used to explore

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feelings and thoughts. RSM supports the idea that an awareness of stress in the body, combined with targeted gentle touch, compassionate listening, and the talking through of emotions, is a healing and restorative process that can reduce both physical and emotional pain. RSM was created by Ilana Rubenfeld in the United States in the late 1970s and has grown to include a full training program that has graduated over 400 Certified Rubenfeld Synergists in the United States, Canada, Great Britain, Australia, and Bermuda. RSM is appropriate for clients of all ages who are able to effectively verbalize emotions and has been used to treat a variety of physical and mental health concerns. In a typical session, the client remains fully clothed and is asked to lie on a padded table or sit in a comfortable chair. The synergist begins by introducing gentle touch to the client’s body. The client is an active participant in the therapy, and the synergist always follows the lead of the client. As the client becomes aware of bodily sensations such as pain or tightness, the client verbally describes these feelings to the synergist. RSM assumes that the body stores memories and messages that may not be realized without touch, and the method is designed to increase awareness between the body, mind, and spirit by sharing messages aloud with the synergist. The synergist will touch pained areas, make careful movements of the body, and verbally offer reflections and support. Sessions generally last between 45 and 50 minutes, but the frequency and duration of treatment vary for each client. Research on RSM is sparse, and there is no direct evidence-based support for the effectiveness of this treatment modality. However, when compared with traditional talk therapy and other types of bodywork alone, a combination of talk and touch therapies (as in RSM) has been shown to have longer lasting impacts on physical pain reduction than any single intervention. Emotional benefits may include the relief of stress, improved self-esteem, and reduced anxiety and depression. In addition, testimonials from clients who have participated in RSM have been quite favorable, especially from those who were disappointed by more traditional counseling, bodywork, or medical interventions. The Rubenfeld Synergy Training Institute provides a rigorous training program (including more than 4 years of educational

requirements and supervised internships) to ensure quality control of the method. There is also an ethical code titled the Standards of Practice and Ethical Principles for Certified Rubenfeld Synergists, which emphasizes the consensual boundaries of talk and touch interventions and the importance of collaboration between the synergist and the client.

Historical Context Ilana Rubenfeld was born in Tel Aviv, Israel, and resided there before immigrating to New York at the age of 5 years. Her parents, Bluma and Leopold, were both of Russian Jewish descent and fled their home country during the Russian Revolution. Rubenfeld’s father was a classically trained pianist who instilled a love for music and art in his daughter, who took up the viola at a young age. Later, Rubenfeld attended both the Manhattan School of Music and Julliard, where she studied to become a conductor. Long hours of both playing and conducting led to significant back problems and muscle spasms, but Rubenfeld found limited relief from medical interventions. She then turned to the F. M. Alexander technique (explained in detail in the following section) to correct her posture and reduce her chronic pain. When touched by the therapist, Rubenfeld experienced a deep emotional reaction. She wanted to talk about the feelings and memories that arose with the physical therapist, but the therapist was unable to assist her in a talk therapy process. Rubenfeld next visited a talk therapist, only to find that she longed for the comforting touch that had evoked her emotions in the first place. In the 1970s, no combination of talk and touch existed, so Rubenfeld created RSM to address the need for a more holistic integration of therapies.

Theoretical Underpinnings RSM was born from a pairing of the F. M. Alexander technique of movement and sensory awareness with Gestalt therapy techniques from Fritz and Laura Perls’s counseling theory, to address Rubenfeld’s desire for a mind–body–spirit connection in healing practices. Later, the Feldenkrais method was added to blend nervous system training and motor skills exercises.

Rubenfeld Synergy

The Alexander technique was created by Frederick Matthias Alexander (1869–1955), a Shakespearean actor who frequently lost his voice with no apparent medical cause. He developed a somatic method to improve body movements and mental functioning, which was found to improve breathing and reduce back pain. The technique corrects muscular and skeletal strain by reteaching individuals to perform physical tasks with a more appropriate posture. Teachers of the Alexander technique often demonstrate it with hands-on coaching, which is what first helped Rubenfeld to identify her own body sensations and to react emotionally. Gestalt therapy techniques, popularized by Fritz and Laura Perls in the 1950s and 1960s, are based in existential and experiential theory. Gestalt therapy focuses heavily on the present, here-and-now experience and the relationship between the counselor and the client to create awareness of psychological roadblocks that may inhibit a desired state of being. Rubenfeld became a student of Fritz and Laura Perls in the early 1970s and found that this method of therapy added a psychotherapeutic structure to the emotional processing component of the theory that later became RSM. Finally, the Feldenkrais Method was developed by Moshé Feldenkrais (1904–1984). Often used by performers and athletes, this method combines Awareness Through Movement exercises, to increase the individual’s range of motion through exploring the relationship between body posture and structure, with Functional Integration, which promotes kinesthetic communication through gentle touching and physical manipulation of the affected areas by a trained therapist. When Rubenfeld met and trained under Feldenkrais, gentle touch and a listening hand became significant tenets of RSM.

Major Concepts RSM has several major concepts relevant to the method, including holistic health, touch therapy, and present-focused change. Holistic Health

The mind, body, spirit, and emotions are connected and inseparable. For example, when the

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body aches, the mind will not rest. One must integrate and treat the whole person to resolve mental and physical issues. Therefore, a combination of treatment modalities, such as talk and touch, is more effective than any one method alone. Touch Therapy

Touch is a nonverbal form of communication that can find emotional messages in the body that are unconscious to the mind. Touch therapy has been utilized for centuries and has been shown to be effective in treating many mental and physical health issues. Trained Rubenfeld synergists can feel the quality of the client’s energy by using “listening hands” and identify physical areas of concern to the client. Each individual’s body tells a unique story that can be brought to awareness through touch. Present-Focused Change

Change can only occur in the present moment, so RSM sessions utilize present-focused talk and experiential therapy. Negative memories of the past can be managed by reliving the experience in the present through both the mind and the body. Simultaneous feeling and processing is essential to the effectiveness of this method. The client holds the responsibility to create change in his or her life through self-healing and self-regulation, and the synergist is there to support and encourage this change.

Techniques A combination of techniques are used in RSM, including forming a collaborative relationship, gentle touch, reflection of feeling and content, here-and-now techniques, and appropriate use of humor. Forming a Collaborative Relationship

RSM requires a respectful, consensual, and collaborative relationship in which the client is both active and directive. The client is responsible for communicating sensations to the synergist and identifying areas of pain, tension, or stress. RSM acknowledges that every individual is unique and

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different clients will prefer different styles of touch, verbal interaction, and movement. The synergist follows the client’s lead and openly provides feedback as needed. Gentle Touch

Touching in RSM begins sparingly and slowly to give the client time to process feelings and memories about prior touch. Using the “Butterfly Touch” theory, very light touching is recommended to initially begin a sensory awakening in the hands or feet. Increased contact, body movement, and massage follow only as the client feels comfortable. Then, the synergist communicates the intention of the touch and perceived sensations. Reflection of Feeling and Content

Repeating the direct words or phrases that a client says, sometimes with a change in inflection or emphasis, or interpreting and restating the meaning or feeling derived from the client’s words is another integral technique of RSM. By using active listening and accurate reflection, the synergist creates an environment in which the client feels respected and appreciated.

Therapeutic Process The therapeutic process of RSM is unique for every client. However, early sessions focus on building a therapeutic alliance and collaborative relationship. Clients are educated about RSM, holistic health, touch therapy, and present-centered change prior to the first therapeutic session with touch. The next sessions focus on processing emotions and sensations that are found in the body through the use of gentle touching, here-and-now techniques, an appropriate use of humor, reexperiencing and restorying of memories, and imagining a future without pain or tension. The goal of each session is to bring about a sense of complete relaxation and a connection of mind, body, spirit, and emotion. Between sessions, the synergist may encourage the client to practice some of the touching and cognitive techniques. As the client’s insight increases regarding his or her emotions and body sensations, the client becomes better prepared to make life changes. Outcomes may include reduced anxiety and depression, increased self-esteem, a sense of empowerment, an uplifted spirit, and increased life satisfaction. Due to the highly individualized nature of RSM, there is no specified length of treatment or recommended number of sessions to achieve progress or satisfaction from the method.

Here-and-Now Techniques

Derived from Gestalt therapy, many different here-and-now techniques are introduced for the client to process emotions and bodily sensations. These may include cognitive, behavioral, or physical interventions to induce relaxation. Humor

While messages and memories of pain and stress can be stored in the body, so can those of happiness and love. The appropriate use of humor—not sarcasm—is a tool to find and identify feelings of pleasure and induce laughter. Balancing difficult emotions with positive ones can interrupt self-destructive habits of storing anger and tension to make way for new coping mechanisms.

Katherine A. Heimsch See also Alexander Technique; Feldenkrais Method; Gestalt Therapy

Further Readings Medina, L. L., & Montgomery, M. J. (2012). Touch therapy combined with talk therapy: The Rubenfeld Synergy Method®. Body, Movement and Dance in Psychotherapy: An International Journal for Theory, Research and Practice, 7, 71–79. doi:10.1080/174329 79.2011.622788 Rubenfeld, I. (2001). The listening hand: Self-healing through The Rubenfeld Synergy Method of talk and touch. New York, NY: Bantam. Rubenfeld Synergy. (2013). Befriend your body: Transform your life. Retrieved from http://www .rubenfeldsynergy.com/

S Mental Research Institute in Palo Alto. Others at the institute at the time included Gregory Bateson, Jay Haley, Robert Spitzer, and Paul Watzlavick, who were working on a communication theory involving schizophrenia. As she worked with Bateson and Jackson, she simplified their communication concepts into two different levels of congruent and incongruent communication. For example, when verbal and nonverbal communications were in harmony, she considered them congruent. If not, she considered the communications incongruent. She identified four universal patterns of incongruent communication: (1) placating, (2) blaming, (3) computing (superreasonable), and (4) distracting (irrelevant). Satir’s identification of congruent and incongruent communication formed the first stage of her theoretical perspective. Many therapists still refer to Satir’s incongruent communication pattern as her main contribution to family therapy. After her work at MRI, Satir moved to Esalen, a human potential center in Big Sur, California, where she became the director of training. While there, she was encouraged and supported by Carl Rogers and Abraham Maslow to include the family as part of the counseling process and to shift full blame away from parents as the cause of their children’s mental illness. She moved away from problem-focused therapy to a more resource-focused practice. Her process at that time became known as the human validation process model. This model was viewed and practiced as a positive belief system of validation, with less focus on resolving the negative impacts of the past and the present.

SATIR, VIRGINIA Virginia Satir (1916–1988), one of the pioneers of family therapy, developed a systemic and positively directional model that has been identified by names such as communication theory of couples and family therapy, the human validation process model, and transformational systemic therapy. Satir has been identified among practitioners in counseling, social work, and psychology as one of the most influential figures in psychotherapy over the past 25 years. Satir was born Virginia Pagenkopf on a farm in Neillsville, Wisconsin, on June 26, 1916. At the age of 20, she began her professional career as a classroom teacher. As a teacher, she was curious and touched by the many difficulties the children were bringing to school beyond their learning focus. She felt that there must be ways to understand and deal with the many problems these children faced. As a result, she decided to go into social work, and in 1941, she started her Master of Social Work degree at the University of Chicago. In 1951, she married Norman Satir and became known as Virginia Satir. Her early professional clinical practice was at the Chicago Home for Girls and at the Institute for Juvenile Research in Chicago. During the late 1950s, she worked with the psychiatrist Harold Visotsky to develop her first family therapy training program at the Illinois State Psychiatric Institute of Chicago. In 1959, she moved to California and joined Don Jackson and Jules Riskin to establish the 905

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Satir then focused her work on emphasizing change and growth. She used the metaphor of an iceberg to demonstrate the different components in an individual that could either hinder change or provide areas for therapeutic growth. According to Satir, change needed to include behavior, feelings, perceptions (often called cognition), expectations, and yearnings. Change therapy thus involved changing many internal and interactive blocks that kept people from becoming more congruent. The next component of Satir’s approach developed out of her own personal appreciation of spirituality, cultivated at an early age as she observed the life force of nature while growing up on a dairy farm in Wisconsin. This element, called transformational change, has, at its base, a deeply spiritual core. Satir believed that all people can access, experience, and live from this spiritual Life Energy and that doing so can be helpful to psychological well-being. The five essential elements for this transformational change consist of therapy that is experiential, systematic, positively directional, change focused, and includes the self of the therapist. Counseling should be experiential in that the client must experience the impact of a past event in the present. It is only when clients are experiencing both the negative energy of the impact and the positive energy of their Life Force in the now that an energetic shift can take place. Therapy must also be systematic in that it must work within the intrapsychic and interactive systems in which the client experiences his or her life. The intrapsychic system includes the emotions, perceptions, expectations, yearnings, and spiritual energy of the individual, all of which interact with one another in a systemic manner. The interactive systems include the relationships, both past and present, that the person has experienced in his or her life and that are internalized. A change in one affects the other. Transformational change is an energetic shift in the intrapsychic system, which then changes the interactive systems. In the Satir model, counseling is positively directional in that the therapist actively engages with the client to help reframe perceptions, generate possibilities, hear the positive message of universal yearnings, and connect the client to his or her positive Life Energy. The focus is on health and possibilities, on appreciating resources and anticipating

growth, rather than on pathologizing or problem solving. Satir’s model is also change focused, with particular attention paid to transformational change. Questions asked throughout the therapy session are change related and give the client an opportunity to explore uncharted waters inside the client’s own intrapsychic system. Finally, as previously mentioned, the congruence of the therapist is essential for clients to access their own spiritual Life Energy. When therapists are congruent, clients experience them as caring, accepting, hopeful, interested, genuine, authentic, and actively engaged. In addition, therapists’ use of their own creative Life Energy in the form of metaphor, humor, self-disclosure, sculpting, and many other creative interventions also comes from the connection they have to their own spiritual Self when in a congruent state. This connection to Life Energy also allows the therapist to access his or her intuitive wisdom, which opens the door to many positive possibilities. In addition to these principles of transformational change, Satir also identified four universal metagoals as the basic underpinnings of her system. The first involves raising self-esteem to influence how a person experiences and judges himself or herself in the present. When a person has a high sense of self-esteem, he or she is experiencing himself or herself positively through his or her spiritual Life Energy, or Self. Second, clients are encouraged to become choice makers. One’s choices are in the direction of health, happiness, peace, and love, and one feels empowered to choose wisely. Many clients feel that they have no choice or are stuck in a dichotomous choice. Satir believed that there is always at least a third choice more in harmony with Life Energy. Third, Satir believed that a goal of counseling is for clients to become responsible. When one is living from the level of Self, one is conscious of one’s internal experiences and is responsible for all feelings, perceptions, expectations, and yearnings as well as one’s behavior. Satir believed that our internal experiences belong to us and that we have choice over them. When we become responsible for our internal world, we experience the vastness of our Being and become responsible for our own growth toward becoming more fully human. Finally, congruence is a deeply embedded concept and goal of the Satir model. Congruence as a

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metagoal implies that people can grow to be in harmony with their own Life Energy and to experience the peace, joy, love, and connection that exist there. When one is more congruent, one is free from negative experiences of the past as one is now living in the present at the level of being. Other ways of describing congruence might include being integrated, real, genuine, or authentic; one is able to accept and honor oneself, to accept and honor the experience of others, and to accept and honor the context in which one is situated. There is an expectation in the Satir model that therapists have attained a fairly high level of congruence in their lives and can be congruent while working with their clients. Although she stressed these core principles, Satir played down the focus on specific techniques. She was focused on activating and encouraging internal growth and harmony to then connect with others at the level of congruence. Her use of sculpting individuals in their incongruent communication stance and its relationship with others became a helpful technique to let surface what was really happening with the clients. She suggested that the personal iceberg could be used to help clients become personally aware and that the counseling relationship could bring hope and genuine acceptance. She thus advocated a therapy consisting of the following recommendations for therapists:

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The Satir approach to counseling continues to develop, even after her untimely death in 1988, led by some of her close students and colleagues. John Banmen See also Human Validation Process Model; Systemic Family Therapy

Further Readings Banmen, J. (2006). Applications of the Satir growth model. Wendell, NC: Virginia Satir Network. Banmen, J. (2008). Satir transformational systemic therapy. Palo Alto, CA: Science and Behavior Books. Satir, V. (1964). Conjoint family therapy (1st ed.). Palo Alto, CA: Science and Behavior Books. Satir, V. (1967). Conjoint family therapy (Rev. ed.). Palo Alto, CA: Science and Behavior Books. Satir, V. (1983). Conjoint family therapy (3rd Rev. expanded ed.). Palo Alto, CA: Science and Behavior Books. Satir, V. (1988). New peoplemaking. Palo Alto, CA: Science and Behavior Books. Satir, V., & Baldwin, M. (1982). Satir step by step. Palo Alto, CA: Science and Behavior Books. Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model: Family therapy and beyond. Palo Alto, CA: Science and Behavior Books. Simon, R. (2007, March/April). Ten most influential therapists: The most influential therapists of the past quarter century. Psychotherapy Networker, 68, 24–37.

1. Prepare yourself: be congruent, be in harmony with your own life energy. 2. Make full, energetic contact with the client. 3. Bring hope, love, caring, curiosity, acceptance, and patience to each session. 4. Explore early on the hopes (positively directional) of the clients in coming to therapy. 5. Explore how the problem was actually not the problem and how to meet yearning better. 6. Set some positively directional goals to work on. 7. Work on changes at the feelings, perceptions, and expectations levels and more directly at the yearning level to help the individual and the family system achieve a sense of harmony and peace within, between, and among the members. 8. Anchor changes in as many ways as possible.

SCHEMA THERAPY Schema therapy is an integration of several different theories that were combined to treat chronic psychological disorders such as depression, anxiety, eating disorders, as well as more severe personality disorders. Healing of maladaptive schema, or pervasive dysfunctional cognitive themes, is the ultimate goal of schema therapy. For the client, the schema includes a set of memories, emotions, bodily sensations, and cognitions; the healing involves techniques that target all of these areas and start with the initial schema assessment inventory. This approach utilizes several theoretical approaches to address dysfunctional patterns of memories, emotions, cognitions (e.g., schemas), and behaviors that developed during childhood.

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Historical Context Developed by Jeffrey Young and colleagues in the 1990s, schema therapy was a response to a deficiency in treating severe mental health disorders formerly categorized under Axis I in the Diagnostic and Statistical Manual, fourth edition, text revision. The concept of schema has been seen throughout history, particularly by the stoic logician Chrysippus (ca 279–206), Kantian philosophy, and cognitive developmental psychology. Within the field of psychology, Jean Piaget’s childhood developmental theory is most closely identified with schema. Also, Aaron Beck utilized the concept of schema in his cognitive therapy; however, the idea was broader. Psychology and psychotherapy thought that schema was an organizing principle by which individuals made sense of their own life experience. It was not until Young and colleagues began thinking deeper, and writing about schema, that it became a formalized modality of treatment.

Theoretical Underpinnings The premise of schema therapy is that all human beings develop schemas (e.g., patterns of thinking) that originate from the person’s developmental life experiences from childhood. Some of these frames of thinking can be healthy, while others can be maladaptive and, hence, damaging. The theoretical underpinning of schema originates from the cognitive-behavioral, attachment, Gestalt, object relations, constructivist, and psychoanalytical schools of thought.

Major Concepts A major concept that drives schema therapy is that these schemas may be maladaptive, and they are categorized into five categories. However, a proper definition of schema should be articulated before discussing the maladaptive categories. Schemas

Schemas are pervasive themes that develop in childhood and are related to one’s perception of self and others. They also comprise memories, emotions, cognitions, and body sensations regarding oneself as developed during childhood and/or adolescence that are dysfunctional to a significant

degree. Young and colleagues have categorized these schemas into different types as well as five domains. Domains of Treatment

According to Young, these schemas can be broken down into 18 different types, divided into five domains. Domain 1: Disconnection and Rejection Clients in this category are unable to create secure and satisfying attachments to others due to unstable, abusive, emotionally cold, and rejecting family relationships. The themes are abandonment/instability, mistrust/abuse, emotional deprivation, defectiveness/shame, and social isolation/ alienation. Domain 2: Impaired Autonomy and Performance Clients in this category typically experience difficulties separating from parental figures. The following are the themes under this category: dependence/ incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, and failure. Domain 3: Impaired Limits Clients in Domain 3 experience difficulties with boundaries. Characteristics are as follows: difficulty with keeping appointments, cooperating with others, and/or setting long-term goals. The themes are entitlement/grandiosity and insufficient selfcontrol/self-discipline. Domain 4: Other-Directedness Clients in Domain 4 will meet the needs of others to the point of harm to self. In addition, the person with this schema often lacks awareness of his or her own anger. The intent behind otherdirectedness behavior is to gain the approval of others, maintain emotional connection, and/or avoid retaliation. The following are the themes: subjugation, self-sacrifice, and approval seeking/ recognition seeking. Domain 5: Overvigilance and Inhibition Clients in this category suppress spontaneous feelings and impulses. They also attempt to meet rigorous rules in their own performance at the

Schema Therapy

expense of happiness. Themes include self-expression, relaxation, close relationships, and/or good health. In addition, clients under this domain are characterized by pessimism and worry. They often feel that their lives could fall apart if they are not vigilant and careful at all times.

Techniques Replacing existing unhealthy schemas with healthy ones is a crucial element of schema therapy. In contrast to other theories, schema therapy has several foundational theoretical underpinnings from therapeutic models such as attachment theory, developmental theory, family systems, neurobiology, and cognitive-behavioral, Gestalt, object relations, constructivist, and psychoanalytical theories. Cognitive strategies, along with experiential ones; behavioral pattern breaking; and the therapeutic relationship itself are considered the foundation of technique within schema therapy. Cognitive Strategies

Cognitive strategies assist the client in articulating a healthy voice to counter the schema, thus strengthening the client’s healthy adult mode. Selfawareness of the schemas is the first step often achieved through the schema inventory. Therapists assist the client in building a logical case against the target schemas. Cognitive strategies assist clients to evaluate externally the veracity of the schemas. The therapist validates the clients’ use of schemas and coping styles as understandable given their life history. Concurrently, the therapist reminds clients that these maladaptive ways of living assisted in their survival then but are no longer healthy. Specific cognitive techniques include the following: 1. Testing the reality of a schema 2. Reframing the evidence supporting a schema 3. Evaluating the advantages and disadvantages of the client’s coping styles 4. Conducting dialogues between the “schema side” and the “healthy side” 5. Constructing schema flash cards, which consist of client acknowledgment of the current feeling, identification of the schema, reality testing, and

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behavioral instructions to assist with countering the maladaptive schema 6. Filing out Schema Diary forms—when a schema is triggered, the client fills out the form to work through the problem to arrive at a healthy solution; clients identify the trigger events, emotions, thoughts, behaviors, schemas, healthy views, realistic concerns, overreactions, and healthy behaviors being implemented

Experiential Strategies

Experiential techniques establish two goals for the client: (1) to trigger the emotions or connection to the early maladaptive schemas and (2) to reparent the client in order to heal these emotions and partially meet the client’s unmet childhood needs. With experiential techniques, clients can transition from knowing the intellectual components of their therapy work to believing in them much deeper in their emotional core. Specific techniques such as imagery and dialogues, relaxation techniques, and bodywork can assist clients in making the cognitive-emotional connections. The rationale for imagery work is threefold: (1) to identify those schemas that are most central for the client, (2) to enable clients to experience schemas on the affective level, and (3) to help clients link emotionally the origins of their schemas in childhood and adolescence with problems in their current lives.

Therapeutic Process Schema therapy is an integrated approach that can last from a few sessions to many years. The therapeutic relationship is the foundational component of schema therapy necessary for client change. Exploring the maladaptive schema inventory and reflecting on the results is the next vital step within the therapeutic process. There are two additional components of the therapeutic process within schema therapy: (1) the therapist stance of empathic confrontation and (2) the use of limited reparenting. The final stage of schema therapy focuses on continuing to explore the causes of the maladaptive schemas and implementation of healthy adult cognitive-behavioral aspects while working with the therapist toward interpersonal success. Jason K. Neill and Candace M. McLain Tait

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See also Beck, Aaron T.; Cognitive-Behavioral Therapy; Constructivist Therapy; Freudian Psychoanalysis; Gestalt Therapy; Object Relations Theory; Schema Therapy

Further Readings Young, J. E. (2002). Schema-focused therapy for personality disorders. In G. Simos (Ed.), Cognitive behaviour therapy (pp. 201–222). New York, NY: Routledge. Young, J. E., Arntz, A., Atkinson, T., Lobbestael, J., Weishaar, M. E., Van Vreeswijk, M., & Klokman, J. (2007). The Schema Mode Inventory. New York, NY: Schema Therapy Institute. Young, J. E., & Brown, G. (1994). Young SchemaQuestionnaire. In J. E. Young (Ed.), Cognitive therapy for personality disorders: A schema-focused approach (Rev. ed., pp. 63–76). Sarasota, FL: Professional Resource Press. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York, NY: Guilford Press.

SCREAM THERAPY See Primal Therapy

SELF PSYCHOLOGY Self Psychology represents a major paradigm shift in psychoanalytical theorizing. Heinz Kohut, an Austrian psychiatrist, came to Chicago in the 1940s and quickly embraced the ego psychological approach dominating analytic thinking at that time. During the 1960s and 1970s, he and a small group of associates at the Chicago Psychoanalytic Institute worked in a study group to expand his research on narcissistic conditions into a fullfledged psychology of the Self. This new approach represented a challenge to the classical drive and defense perspectives offered by Sigmund Freud and the object relations theorists. It represented a substantive shift from conflict psychology to one of deficit psychology. In highlighting how many clients suffer less from intrapsychic conflicts and more from the lack of necessary psychological structures, Kohut opened new doors to understanding both

conflict and Self Pathology. Kohut characterized this as the difference between the “guilty man” (conflict) and the “tragic man” (deficits). In addition, the paradigm informed a gradual shift in psychoanalytical technique from a stance that heretofore had embraced Freudian prescriptions of abstinence and anonymity to a model that endorsed provision and the gratification of substantive developmental needs. This paradigm shift set the stage for the current emergence of relational and intersubjective approaches to psychoanalytic psychotherapy. Kohut introduced the concepts of the Self and the Self Object as foundational constructs for his psychology. The Self is viewed as a reflection of the content of the experiences of the mind but not as an agency or structure of the mind (id, ego, and superego). The Self Object is an object that is experienced as part of the Self and represents a merger state. For Kohut, the Self represents the psyche’s attempt to gain an internal coherence around which relationships with the world and objects can be organized. The Self is the product of the interplay with the Self Objects of childhood.

Historical Context Kohut was a prominent figure in the American Psychoanalytic Association and the Chicago Institute of Psychoanalysis. His training defined him as an ego psychologist, which was the predominant American perspective in the 1940s and 1950s. His early interests included studies of the effect of music on the psychic organization and structures. During the 1950s, Kohut began to feel some dissatisfaction with his psychoanalytical efforts. Many of his clients seemed to be unable to progress or would return for treatment after an initial termination. Coupled with these experiences were personal countertransference experiences during many treatments where he felt unappreciated, taken for granted, and not respected as a separate individual. Unlike other therapists who might blame the client for these feelings, he asked important questions about the efficacy of the current mode of psychoanalytical treatment. He wondered whether it was the treatment that was not working, rather than the resistance of the client leading to unsatisfactory outcomes. These questions led Kohut to begin a series of studies on the topic of empathy, which he eventually defined as

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an affect-neutral data-gathering tool and a form of vicarious introspection. These studies led Kohut to eventually define the boundaries of psychoanalytical treatment as those experiences that were available to empathic resonance. Additionally, Kohut had an increasing interest in narcissism. After reviewing Freud’s classic 1915 article on the topic and investigating the psychological mergers associated with narcissistic disturbance, he began a project to revise our basic understanding of narcissistic states. Eventually, he posited narcissism as not just a pathological condition but a lifelong normal line of development, separate from the object relations line. Kohut believed that people never completely lose Self Object needs for admiration, and idealized object and soothing. For Kohut, a successful lifelong experience with Self Objects left a legacy in several important capacities, including empathy, creativity, the ability to tolerate human impermanence, humor, and wisdom. He referred to these capacities as acquisitions of the ego subsequent to successful narcissistic development. This understanding allowed him to recast narcissistic mergers as necessary psychological experiences for the client’s psychological unfolding. He rescued narcissistic needs from the exclusive domain of psychopathology.

Theoretical Underpinnings The self-psychological perspective is an extension of the evolution of psychoanalytical treatment from an intrapsychic perspective to a field or relational perspective. This approach evolved primarily out of Kohut’s extensive inquiry into the phenomenon of empathy coupled with his research into narcissistic states. Kohut redefined the concept of narcissism and established it as a lifelong line of development, separate from the development of object relations. In conjunction with this research, he introduced the concept of the Self to identify the internal structure in the psychic apparatus, which is separate from the Freudian triad of id, ego, and superego. To understand the self-psychological approach to treatment, it is necessary to explore the theoretical ideas underlying Kohut’s revised developmental theory of narcissism. Kohut did not find that Freud’s discussion of narcissism captured the complexity of his clinical experience.

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While Kohut did not explicate a formal developmental model, it has been extracted from his writings. Kohut postulated that the infant is born in a state of primary narcissism and with a virtual self, which can be defined as a set of psychological tissues that evolve into a Self with the proper environmental responses. The event of birth, however, rapidly destabilizes the sense of narcissistic pleasure and security as postnatal life now places extraordinary burdens on the infant’s nascent psychological organization. The infant has become a predator of its own desires coupled with the ubiquitous infant helplessness. To stabilize in this environment, the infant through omnipotent fantasy creates psychological mergers with its caretakers. Objects are felt to be part of the Self and not separate. It is not that a separate mother is feeding the infant; rather, the infant is feeding itself. Kohut identified this relationship as a Self Object relationship wherein the Self and the object area unite. This process helps stabilize the infant’s anxieties about helplessness. Self Objects fulfill many functions for the growing infant. The two primary functions are mirroring and soothing. Mirroring is the process of admiring and appreciating in a phase-appropriate manner the infant’s growing grandiose and exhibitionistic attempts to master its body and its world. The second primary function is that of soothing. This is where the parental Self Object serves as an idealized object and helps calm the anxieties associated with developmental derailments and experiences of failure and helplessness. Kohut suggested that, in a normal developmental track, the parental environment provides optimal frustrations that do not overwhelm the child’s growing psyche, while at the same time spurring growth. This might be considered analogous to Jean Piaget’s concept of disequilibrium as a necessary condition for progressing through the stages of cognitive development. When the child finds the Self Object failing in its function (and stimulating a premature sense of separateness), this is experienced as an empathic failure. “Good enough” parenting and Self Object functioning will lead the parent to re-attune with the child in its distress. At this point, the child begins to experience the functions associated with mirroring and soothing as qualities that it can internalize through a process Kohut termed transmuting internalization. It is through a series of

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these experiences of failure, re-attunement, and transmuting internalization that the child begins to construct its nuclear self. This self thus contains the abilities formerly only found in the parental Self Object.

Major Concepts Major concepts of Self Psychology include empathy, Self, Self Object, and optimal frustration. Additional concepts include primary and secondary narcissism and transmuting internalization. Empathy

From a Self Psychology perspective, empathy is viewed as an investigative tool. It is affect neutral and represents the process of vicarious identification. Psychoanalytical treatment is limited to those things that are subject to empathy. A therapist’s empathic capacity is the result of the intersection of developmental experiences, training, and continuous self reflection. Self

The Self is defined as a bipolar structure containing the capacities, talents, skills, and ambitions of the individual, accrued and structured through successive experiences of transmuting internalization. This structure then directs the individual’s actions, attitudes, and engagement with the object world. It leads to a feeling of agency and center of action in the world. The cohesive Self reflects the resilient functioning structure, whereas the fragmented Self represents states of disintegration subsequent to narcissistic injury. Self Object

“Self Object” refers to a unique psychological merger that allows the child or client to view objects in his or her environment as actual parts of himself or herself. Narcissistic transferences are generally viewed as Self Object transferences. The mirroring Self Object provides phase-appropriate admiration and encouragement of the exhibitionistic grandiose self. The idealized parental imago self object provides an idealized and soothing function. The alter-ego Self Object reflects the establishment of latency phase relationship, where one needs the sense of being like the therapist.

Optimal Frustration

Optimal frustration refers to the subtraumatic experiences of empathic failure experienced by both the child during development and the client during the course of treatment. It is considered optimal in that the intensity of anxiety experienced does not lead to protracted fragmented states in the nuclear self. Primary Narcissism

Primary narcissism refers to the libidinal body– ego focus of the neonate prior to the establishment of object relations. It is the energy that is given to objects and creates object love in lieu of self-love. Some primary narcissism remains in the psyche. Secondary Narcissism

Secondary narcissism refers to the reinvestment of object love energies into the narcissistically internalized objects (in the ego) that have been lost or have provided massive disappointment to the client. Transmuting Internalization

Transmuting internalization refers to the process of internalization of the psychological functions experienced in the Self Object at the moments of re-attunement subsequent to an optimal and nontraumatic empathic failure. What is internalized is a set of functions (appreciation of strengths and limitations and soothing) rather than the “good mother or good father” seen in object relations theory.

Techniques Techniques of Self Psychology include Self Object transference, bipolar transference, provision, narcissistic rage, and Self Pathology. Self Object Transference

Self object transference refers to the narcissistic transference established with the therapist in which the therapist is needed to fulfill Self Object needs, including mirroring, idealizing, and soothing. These are viewed as developmental transferences, which require the therapist’s active provision, as opposed

Self Psychology

to conflict transference, which deals with projections and distortions from archaic object relations. Bipolar Transference

Bipolar transference refers to the oscillation between Self Object and conflict-based transferences in the therapy hour. When the Self Object transference is interrupted by an empathic failure, the client organizes his or her experience around past conflicts and defenses. The therapist must recognize this and help the client both to engage these states of mind and to reestablish the Self Object transference. Self Object transferences are seen as structure building, whereas conflict transferences lead to structure modification. Provision

In contrast to classical conflict-based theories that prescribe an attitude of deprivation and frustration of infantile needs, the Self Psychology approach endorses a stance based in provision. Acting on the belief that the classical approach of withholding is a variation of retraumatization, Self psychologists endorse a more flexible frame and the provision of narcissistic supplies, including mirroring and soothing, which were absent in the client’s developmental years.

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permanent self fragmentation that is not amenable to analytic treatment due to the client’s inability to establish stable Self Object relations sufficient for structure building. Borderline disorders are also included in the primary category and are viewed as encapsulated psychotic states with the same core of a fragmented self held together by rigid defenses. This would also not be viewed as an analyzable condition. Narcissistic personality disorders are also primary and represent significant yet not permanent damage to the self. Self Object transferences can develop in clients, and structure building can be the reconstruction of a coherent nuclear self. The narcissistic behavioral disorder presents a unique problem in that the addictions and perversions characteristic of these conditions keep the requisite psychic pain at bay and prevent the full efficacy of psychoanalytical intervention. In these situations, the addictions and perversions are interdicted, which in turn cause the client to feel an interiority of pain. In effect, the narcissistic behavioral disorder is converted into a narcissistic personality disorder and is thus amenable to treatment. Other forms of self disorders include the empty self, which is characterized by a lack of vitality and mood disturbance; the overburdened self, which is characterized by a lack of selfsoothing capacity; and the overstimulated self, which is characterized by hypomanic behaviors in response to environmental failure.

Narcissistic Rage

Narcissistic rage refers to the sudden violent rage experienced by clients who have significant narcissistic vulnerability. It denotes a rapid internal decompensation of the individual’s self state, and while seemingly an exaggeration of the identified empathic break, it must be approached with humility and understanding as to the depth of trauma being experienced. The therapist does not try to talk the client out of this fragile state but views it as an opportunity to re-attune in very powerful ways. It can be distinguished from other forms of rage by its appeal to rationality, persistence over time, and matrix in retaliation and righting a wrong. Self Pathology

Self psychologists have identified a variety of self disorders. Primary self disorders include psychosis, which is conceptualized as a protracted and

Therapeutic Process The Self Psychology therapeutic approach can be best captured in the phrase failure and repair. The job of the therapist is to listen empathically to the client’s material, recognizing that multiple levels of communication are possible. These levels determine whether one is dealing with Self Object transferences (e.g., mirroring, idealized parental imago, and alter ego) or the conflict-based transferences identified by Freud, Melanie Klein, and others. The concept of bipolar transference helps point out the ongoing oscillation between these transference constellations. The imperfection of the therapist is sufficient to ensure periodic empathic failures. If these failures are optimal, the therapist is able to reestablish an empathic connection with the client, setting up the conditions for the transmuting internalization of mirroring and soothing functions by the client. It is in the transmuting internalization of

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these functions that the client begins to build up a cohesive nuclear self. If the empathic failures are experienced as “traumatic” by the client, the client may experience a narcissistic rage. The therapist is cautioned to not confront or defend himself or herself at this point but to explore what he or she has done to “injure” the client. This empathic acknowledgment and curiosity help heal the breach and reestablish the self object transference. Allen Bishop See also Ego Psychology; Freud, Sigmund; Klein, Melanie; Object Relations Theory

Further Readings Goldberg, A. (1984). Advances in self psychology. New York, NY: International Universities Press. Kohut, H. (1959). Introspection, empathy and psychoanalysis: An examination of the relationship between mode of observation and theory. Journal of the American Psychoanalytic Association, 7, 459–483. doi:10.1177/000306515900700304 Kohut, H. (1966). Forms and transformations of narcissism. Journal of the American Psychoanalytic Association, 14, 243–272. doi:10.1177/ 000306516601400201 Kohut, H. (1971). The analysis of the self. New York, NY: International Universities Press. Kohut, H. (1972). Thoughts on narcissism and narcissistic rage. Psychoanalytic Study of the Child, 27, 360–400. Kohut, H. (1977). The restoration of the self. New York, NY: International Universities Press. Kohut, H. (1984). How does analysis cure. Chicago, IL: University of Chicago Press. Lessem, P. (2005). Self psychology: An introduction. Lanham, MD: Jason Aronson. St. Clair, M. (2003). Object relations and self psychology: An introduction. Belmont, CA: Cengage Learning. Wolf, E. (1988). Treating the self: Elements of clinical self psychology. New York, NY: Guilford Press.

SELF-HELP GROUPS Self-help groups, sometimes known as mutual-help or support groups, are groups of people who provide mutual support for one another. The members

consist of peers who share similar mental, emotional, or physical challenges or who are interested in a focal issue such as education or parenting. Most self-help groups are voluntary, nonprofit associations open to anyone with similar needs or interests, although sometimes, these groups may be run by a mental health professional. Although the structure tends to be informal, the group undertakes defined tasks. Group participation typically is free of charge or low in cost.

Historical Context Formal support groups may appear to be a modern phenomenon, but they are actually an offshoot of historical fraternal organizations such as Freemasonry, the origins of which date to the end of the 14th century. Historically, people joined together to enhance their chances for survival by sharing their social and economic resources; however, contemporary groups are more likely to organize around a theme or problem. Alcoholics Anonymous, one of the first contemporary selfhelp groups, was founded in 1935 by two alcoholics—a New York broker and an Ohio physician. At the time, the medical profession was perceived as struggling to provide a cure to those battling alcoholism. The importance of self-help groups was not commonly recognized until well after World War II. During the 1960s and 1970s, self-help groups began to spread in the United States. Alcoholics Anonymous groups flourished worldwide, and the self-help movement was growing in North America, empowering men and women to take charge of their lives. The self-help industry was taking shape. Although the mental health professions struggled with the legitimacy of self-help groups well into the latter part of the 20th century, today, self-help groups are acknowledged by mental health professionals, often used as an adjunct to therapy, and sometimes run by counselors and therapists to assist persons who have a focused and ongoing problem with which they struggle. Today, books, DVDs, audio tapes, life coaches, seminars, personal trainers, mentors, and motivational speakers offer self-help services; the self-help industry is worth as much as $10 billion annually. A few of the many examples of self-help groups are groups for addictions, AIDS, Alzheimer’s disease,

Self-Help Groups

anxiety, breastfeeding, brain trauma, cancer, diabetes, domestic violence, eating disorders, families of addicts, fibromyalgia, grief, infertility, miscarriage, depression, Parkinson’s disease, postpartum depression, abuse survivors, stroke, and suicide prevention. Some well-known self-help groups are Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, and Sex Addicts Anonymous.

Theoretical Underpinnings Research on self-help groups suggests that there is no one particular theoretical viewpoint, although many self-help groups have a cognitive, behavioral, or social learning conceptual framework. From a cognitive perspective, it is believed that how we think determines our feelings and behaviors. If people can change their interpretation and understanding, they can explore new thinking. Thus, the experience of being in a self-help group may help people reframe how they think and how they redefine their reality. For instance, a person who has struggled with self-esteem issues due to a mental illness may make self-statements like “I am worthless.” Self-help groups will often encourage individuals to change their self-statements to positive ones (“I am struggling with a mental illness, but I am a good person”). Learning new self-statements from others in a group can change a person’s outlook and behaviors. From a behavioral point of view, behavior is perceived as learning process; therefore, what has been learned can be unlearned. Behavioral theory focuses on observable behaviors and assumes that people behave as they do because of repeated reinforcement contingencies and punishments. In a self-help group, group members can learn new behaviors through discussions and bibliotherapy, try out new behaviors, and be reinforced for their successes within the group. For instance, a person who has struggled with alcoholism can learn new strategies for stopping drinking, such as calling one’s sponsor, seeking help from friends, and/or attending meetings. From a social learning perspective, it is suggested that people can learn new information and behaviors by observing other people (i.e., modeling). Observing how others overcome adversity can be a powerful motivator for individuals and can offer group members new ways of living in the

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world. For instance, observing how someone has overcome his or her sexual addiction by listening to that person’s story and describing the behaviors he or she used can be a model for an individual who has just joined the group. Finally, although some people tend to distinguish support groups and self-help groups, herein they are discussed as the same because they have a common heritage and because their structure is more similar than different. Whereas support groups are more likely facilitated by a professional counselor, self-help groups are more likely run by a peer paraprofessional.

Major Concepts Seven concepts that tend to be critical for self-help groups are providing support, imparting information, promoting stress reduction, providing an atmosphere of safety, offering a sense of belonging, communicating experiential knowledge, and teaching coping methods. The concepts are explained in the following subsections. Providing Support

The primary purpose of a self-help group is to share support. This is most often mentioned by members who are asked what their group does for them. Support appears to be the essential element that defines a group’s success. Imparting Information

Self-help and support groups provide an opportunity for group members to share information. Such groups depend on peer members exchanging information or on professionals providing information. Information exchanges take place in formal meetings and during informal gatherings before or after meetings. Promoting Stress Reduction

Taking part in a self-help group can promote stress reduction because being a member of a group of people who can relate to similar stressors creates a sense of community and a feeling that one is not alone in this world. This can reduce a person’s feeling of tension and stress.

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Providing an Atmosphere of Safety

Open-Ended Questions

Self-help groups provide a fundamentally safe environment for group members, who describe this sense of safety as unconditional acceptance by group members. Most people rely on families and close friends for this sense of security, but sometimes seeking safety outside one’s primary circle is beneficial.

An open question such as “Can you tell me more about that” can keep the group conversation moving and assist in probing deeper into the topics and feelings raised by group members.

Offering a Sense of Belonging

Joining any group is a demonstration of affiliation. As social beings, people like to feel that they belong to a group. Self-help and support groups offer opportunities for gaining a sense of belonging, which can decrease the feeling of social isolation and create a community. Communicating Experiential Knowledge

Experiential knowledge is a person’s unique lived experience conveyed by personal stories of learning to cope and using the group’s support to help manage one’s struggles. The process of communicating one’s experience in self-help and support groups helps facilitate personal growth. Teaching Coping Methods

How one copes effectively with issues is a process that involves learning new strategies to approach one’s struggles. Group members seek to develop healthier methods for coping with their situations. The group setting provides an opportunity for members to learn and develop their life skills.

Techniques A number of techniques are basic to building rapport and support in a group and to offering an environment of unconditional acceptance. These include listening, open-ended questions, active listening, reflecting, being curious and showing interest, reframing, being open to process, and unconditional acceptance. Although these skills are sometimes taught by a professional who may be running a group, more often, they are learned as a by-product of the group process. Listening

Being able to hear the feelings of others and the content of what they are saying is crucial to the basic skills needed in a self-help group.

Active Listening

Active listening involves engaging and responding to the person who is sharing. This can be demonstrated by expressed words or nonverbal actions that involve a clear sign that one is listening (e.g., nodding the head in agreement, making eye contact, and responding with good listening skills). Reflecting

Reflecting encourages expanding on the topic, adding an acknowledgment, or exploring feelings or unstated thoughts. Being Curious and Showing Interest

Curiosity and interest can help prompt further disclosure and help a group member feel accepted. Reframing

The skill of reframing offers an alternative way of looking at a situation, typically one that is more constructive and positive. An alcoholic who has had a “slip” might be told, “Okay, you started drinking that one time, but that slip has taught you some new triggers that you can avoid in the future.” Being Open to Process

Being open to process involves listening, reframing, and expanding what the person says. Attending behaviors involve eye contact, posture, and verbal and nonverbal cues. Unconditional Acceptance

This involves accepting others with their flaws and problems. Although one may not like everything a person does, one can understand how the person has come to behave the way he or she does due to the problem that brought the person to the self-help group.

Self-Relations Psychotherapy

Therapeutic Process Meeting formats for self-help groups are typically loosely structured with a casual atmosphere. The following activities are common to many group meetings and can be used as a guide for designing a self-help group. Announcements

Any information about community or national activities is shared with the self-help group. Leftover Feelings

Any feelings (appreciation, resentments, fears, etc.) or realizations from the previous meeting are expressed to clear away old feelings and enable everyone to be present. Formal Opening of Meeting

At the agreed-on time, the meeting is called to order by the facilitator. Checking In

Members express how they are feeling (excited, anxious, sad, etc.) and whether they wish to use time in the meeting. It is essential that each member checks in with the other group members.

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Psychotherapy Theories: Overview; Psychoeducational Groups; Yalom, Irvin

Further Readings Gartner, A., & Riessman, F. (1980). Help: A working guide to self-help groups. New York, NY: New Viewpoints/ Vision Books. Kurtz, L. F. (1997). Self-help and support groups. Thousand Oaks, CA: Sage. Nichols, K., & Jenkinson, J. (2006). Leading a support group: A practical guide. New York, NY: Open University Press. Powell, T., & Perron, B. E. (2010). Self-help groups and mental health/substance use agencies: The benefits of organizational exchange. Substance Use and Misuse, 43, 315–329. doi:10.3109/10826080903443594 Remine, D., Rice, R. M., & Ross, J. (1984). Self-help groups and human services agencies: How they work together. Fayetteville, NC: Family Services America. Schopler, J. H., & Galinsky, M. J. (1996). Support groups: Current perspectives on theory and practice. New York, NY: Routledge. Stang, I., & Mittelmark, M. B. (2008). Learning as an empowerment process in breast cancer self-help groups. Journal of Clinical Nursing, 18, 2049–2057. doi:10.1111/j.1365-2702.2008.02320.x Yalom, I. (1995). The theory and practice of group psychotherapy. New York, NY: Basic Books.

Website Alcoholics Anonymous: www.aa.org

Activities or Discussion

At each meeting, the peer counselor has two tasks. The first is to facilitate a self-help group activity or discussion. The second is to keep time to ensure that all members who wish to speak have time to do so. Wrapping Up

The last 5 to 10 minutes are used for closing the meeting. This includes a summary, expressing appreciation, and expressing concerns. Refreshments are typically served at a break or after the meeting, which are optimal times for informal conversations. Agatha Parks-Savage See also Cognitive-Behavioral Group Therapy; Existential Group Psychotherapy; Group Counseling and

SELF-RELATIONS PSYCHOTHERAPY Self-relations psychotherapy has been developed by the American psychologist Stephen Gilligan over the past 30 years. It emphasizes how reality and identity are constructed and how enduring problems represent an unconscious “locking” of a consciousness frame, so that the same negative reality is repeatedly constructed. More important, it describes how these negative frames may be “unlocked” and reorganized to allow new, positive realities to emerge. This entry overviews the self-relations approach, describing its historical influences and theoretical underpinnings as well as some of its core concepts and techniques.

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Historical Context Self-relations psychotherapy was especially influenced by the work of the American psychiatrist/ hypnotherapist Milton Erickson (1901–1980). Erickson emphasized how each person is unique and how each person’s behavioral/experiential pattern could be positively utilized for therapeutic purposes. For example, Erickson counseled a woman who believed that the large gap in her front teeth made her ugly and unlovable by telling her to learn to squirt water through her teeth and then playfully use the squirting to flirt with a young man to whom she was attracted. A second historical influence is humanistic psychology, which emphasized each person’s orientation toward positive growth. A third influence is constructivism, which emphasizes how reality is constructed through various psychological “lens” or “filters.” Taken together, these influences form the base for seeing each person as actively involved in the reality the person experiences and capable of changing those realities in positive directions.

Theoretical Underpinnings In emphasizing how reality is constructed through filters or frames, self-relations psychotherapy identifies three general types of filters: (1) field based— for example, culture, family, social context, and personal history; (2) somatic—for example, a person’s posture, emotional state, body image, and breathing patterns significantly influence the person’s experiential reality; and (3) cognitive—for example, belief systems, goals, thinking patterns, and ways of making meaning are filters that significantly influence experience. Taken together, these patterns create a network or matrix that translates the flow of consciousness into specific concrete realities. In this model, the reality construction moves through two levels: (1) the creative unconscious and (2) the social/conscious world. In the creative unconscious, experience is organized as general (archetypal) patterns around core human experiences, such as “intimacy,” “maintaining boundaries,” and “sexuality.” The archetypal patterns are abstract and general, so that information or energy patterns only become specific as they pass through a person’s filters to become the actual experience in

the social/conscious world. Thus, “intimacy” could be represented and experienced in many different ways, some negative and some positive, depending on the specific filters through which it passes. The filters that translate a general pattern into a specific experience or behavior may be held with either creative flow or neuromuscular lock. When held with creative flow, a person is more fluid, flexible, and mindful, so that the resulting experience tends to be positive. For example, a person holding “intimacy” filters with creative flow will be more attuned and sensitive and more able to adjust understandings and behaviors to find the best fit between the person and the environment. When held with neuromuscular lock, a filter becomes a closed and rigid frame held without positive human presence, thereby creating a negative experience and behavior. In other words, a person in neuromuscular lock is incapable of creative expression in that given area. Thus, a person who suffers a painful intimacy experience may become neuromuscularly locked around that event, such that further intimacy experiences will follow the same general pattern. The goal of self-relations psychotherapy, then, is to identify these locked, negative areas of a person’s life and help that person develop a new relationship of creative flow in such areas, so that new, more positive experiences and behaviors may unfold.

Major Concepts Self-relations therapy emphasizes how a person’s reality is created through his or her filters and that experience may be problematic or positive depending on whether the filters are held rigidly with neuromuscular lock or flexibly with creative flow. The differences between these two relational styles are elaborated further in this section. How Neuromuscular Lock Becomes a Habit

The neuromuscular lock that underlies problematic experience is a form of conditioned stress. Self-relations therapy talks about the “4 Fs” of neuromuscular lock as its most general forms: (1) fight (anger, aggression, resentment), (2) flight (fear, avoidance, anxiety), (3) freeze (high tension, “paralysis by analysis,” dissociation), and (4) fold (depression, apathy, low energy). Each of these general states

Self-Relations Psychotherapy

constitutes a rigid physiological and psychological frame that creates a negative learning state. These negative states may become automatically conditioned, so that they become reactivated each time a person steps into a similar situation. This repetitive negative cycle can culminate in chronic symptoms such as anxiety, depression, and dissociation. A crucial idea is that as long as one attempts to resolve a problem while in one of these negative states, the unintended result is usually re-creating the problem. For example, trying to get rid of anxiety while in an anxious state usually re-creates the anxiety in some way. Thus, self-relations psychotherapy emphasizes first helping clients into a positive (symptom-free) state and then working to change the negative patterns of the symptom while still remaining in the positive state. The Primary Importance of a Creative Flow State

With its core emphasis on how a person’s state strongly influences his or her consequent reality, the self-relations therapist tracks two levels of conversation: (1) the content of the work (e.g., goal, problem, and strategies for change) and (2) the contextual state in which the work is explored (i.e., whether a person is in a state of neuromuscular lock or creative flow). A central part of selfrelations work is thus devoted to how to help a client develop and maintain a positive state so that significant positive changes may be developed.

Techniques To develop a sustainable positive state, self-relations psychotherapy uses a core method called the three positive connections. These connections can be optimized through self-scaling methods and used to transform negative states. The Three Positive Connections

Positive Intention or Goal Setting The first connection is developing a positive intention or goal. This is a simple but often challenging step, as attention in a problem state is usually focused on negative goals (“I just want to get rid of this”) or no goals at all. One simple technique is to have the client slowly and repetitively

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make the statement “What I most want to create in my life is . . . ,” noticing the word or phrase that comes up each time the statement is made. After four or five rounds, the therapist asks the client to select the goal that seems the most resonant. The client is further asked to identify and share a visual image representing the client having achieved the desired goal—for example, enjoying a positive personal relationship or having achieved a professional goal. Mindbody Centering To develop this second positive connection, the client is helped to develop a felt sense of well-being and presence. This might be done by mindbody methods such as breathing, slowing down, attuning to the heart and stomach areas, and remembering positive experiences. The goal is to help a person develop a somatic presence that is relaxed, grounded, open, attuned, and absorbed. Positive Resources To establish this third positive connection, a person is helped to attune to those presences in his or her life that can be called on to support the journey of change. Examples include friends, family members, spiritual beings, historical or ancestral persons, places in nature, and pets. Such connections are used to increase relevant dimensions of the person’s positive state, such as courage, support, guidance, and self-love. Self-Scaling Techniques

Because each positive connection can vary in its intensity level, self-scaling techniques are used to have clients subjectively rate (e.g., on a 1–10 scale) how much connection they feel to a given parameter and also to help them increase the level. The general idea is that a low rating on a scale—for example, “2” on the “connection to positive goal” scale—means a person is not ready to orient toward a challenge (e.g., changing a negative belief, transforming a negative feeling). Such therapeutic efforts are initiated only when self-ratings indicate that the positive connections are sufficiently developed; even then, periodic checking (and close nonverbal observation) is used to ensure that a person remains in the positive state. Again,

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the general idea is that when action is taken while in a positive state, positive outcomes are likely, but when attempted in a negative state, negative outcomes are likely. Transforming Negative Symptoms to Positive Resources

One final technique of note involves transforming negative symptoms to positive resources. To reiterate, each experience (including symptoms) has two levels: (1) a primary general energy or information pattern with many possible forms and values and (2) the psychological relationship to it, which translates it into a specific form and value. Thus, a symptom is a core archetypal experience that is held with the neuromuscular lock of negative human presence. To transform it into a resource, a centered state is developed that allows a person to release negative holding of the experience; then a positive connection is developed, thereby allowing a new, more positive form of the core experience to be created. Consider, for example, a man who has sought the help of a therapist for anxiety. The self-relations therapist helps him center (e.g., by remembering how he felt when fishing), develop a positive intention (e.g., “I want to feel open-hearted and relaxed with my family”), and connect with resources (e.g., his 6-year-old son, a kindly grandfather). When the therapist asks him to sense what would interfere with his positive goal realization, he says, “anxiety.” With guidance, he senses the anxiety as a felt sense in his heart and notes that it feels like himself at 6 years of age. While maintaining his positive connections, the therapist guides him to feel a limbic resonance (“felt sense” or “energetic connection”) with the younger (fearful) presence and to use positive conversation (as if he were talking to his own son) to transform the negative state into a gentle positive energy that he can sense and use as an integral resource. Further work helps him integrate this into daily practice.

Therapeutic Process Self-relations psychotherapy sees therapy as a creative conversation in which both the therapist and the client become centered and open to new possibilities. Both are observers and participants,

working in a creative state of disciplined flow—that is, open to the flow of energy or information (images, felt sense, awareness) but grounded in the creative discipline of a positive state (e.g., the three positive connections of intention, centering, and resources). Thus, it is not a mechanical or rigid process but one in which spontaneous developments often occur. Within the safety and positive nature of a creative flow state, each unfolding moment is positively welcomed and creatively utilized. Stephen Gilligan See also Ego State Therapy; Erickson-Derived or -Influenced Theories: Overview; Focusing-Oriented Therapy; HeartMath; Mindfulness Techniques; Somatic Experiencing

Further Readings Gendlen, E. (1978). Focusing. New York, NY: Bantam Books. Gilligan, S. G. (1983). Effects of emotional intensity on learning (Unpublished doctoral dissertation). Stanford University, Stanford, CA. Gilligan, S. G. (1987). Therapeutic trances: The cooperation principle in Ericksonian hypnotherapy. New York, NY: Brunner/Mazel. Gilligan, S. G. (1997). The courage to love: Principles and practices of self-relations psychotherapy. New York, NY: Norton Professional Books. Gilligan, S. G., & Dilts, R. (2009). The hero’s journey: A voyage of self-discovery. Carmarthen, England: Crown House. Rossi, E. L. (Ed.). (1980). The collected papers of Milton Erickson on hypnosis: Vol. 1. The nature of hypnosis and suggestion. New York, NY: Irvington. Rossi, E. L. (Ed.). (1980). The collected papers of Milton Erickson on hypnosis: Vol. 4. Innovative psychotherapy. New York, NY: Irvington.

SELIGMAN, MARTIN Commonly known as the father of modern positive psychology, Martin Seligman (1942– ) was born in Albany, New York. Events during his adolescent years at times caused him to experience a sense of helplessness, rejection, and loneliness. After graduating from the Albany Academy for Boys, he went

Seligman, Martin

on to earn a B.A. degree from Princeton University in 1964 and a Ph.D. in psychology from the University of Pennsylvania in 1967. Seligman’s work is heavily influenced by the humanistic theorists Carl Rogers and Abraham Maslow. His focus on optimism encourages us to examine strengths and character rather than illness and pathology alone. Ultimately, the focus on positive experiences, traits, and institutions aims to prevent mental illness and improve the quality of life. After spending time at Cornell University as an assistant professor, Seligman returned to the University of Pennsylvania to teach psychology. For several decades, his research was grounded in abnormal psychology. Specifically, he focused on the role of failure and helplessness in animals and humans. These early studies shed light on the role of learning relative to our experiences. He concluded that when people lose control over environmental events, they tend to give up and do not attempt to reclaim that control. This led to the notion of learned helplessness, a staple concept in modern psychology. This is the idea that we may learn to behave helplessly even in the face of opportunities to help ourselves. Learned helplessness is an associated feature of many psychological issues, and Seligman’s efforts had an especially important impact on our understanding and treatment of conditions such as depression. Following decades of research on pessimism by his team, Seligman rather haphazardly experienced an event that shifted his focus. He recounts an interaction with his then 5-year-old daughter. While working in his garden, he yelled at her during a moment of interruption. She responded by reminding him that she had made a decision to stop whining, explained how difficult this was, and concluded that if she could do that then he should be able to stop being a grouch. This exchange had a profound impact on the way he viewed his work as well as the role of psychology. Since World Word II, the focus of psychology had been on treating mental illness. For Seligman, the perspective of his child pointed to the need to nurture strengths rather than correct issues. He surmised that conditions where there is an absence of illness are worth examining. This idea would lead him to focus on the positive qualities of human experience. He wanted to know about identifying and nurturing our strongest qualities. His subsequent work gave

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way to the notion of learned optimism (the counter to his earlier recognition of learned helplessness) and the emergence of positive psychology. Positive psychology is grounded in the present and the future. Seligman urges us to move beyond psychology’s traditional stance of viewing childhood events and circumstances as the chief determinants of life direction. He details important experiences such as a sense of well-being and satisfaction, hope and optimism, and happiness. While debate about these ideas can be traced back to the early philosophers as well as various psychological theorists, it was Seligman who brought research attention on them to the forefront of psychology. His development of positive psychology may be viewed as a response to the illness/medical model of the Diagnostic and Statistical Manual of Mental Disorders. Seligman argues that such a diagnostic perspective is ineffective in terms of prevention. Instead of looking for problems, he set out to explore the factors associated with wellness. Positive psychology seeks to understand and acknowledge those things that make life worth living. His ideas may be viewed as not in opposition to traditional psychology but, rather, as a broadened or balanced perspective of the human condition. This focus on optimism led Seligman and his colleagues to conduct research on cultures spanning the globe. Their work produced a set of common virtues that include wisdom, courage, humanity, justice, temperance, and transcendence. These virtues are significant because they contribute to fulfillment. These qualities tend to be valued and learnable, prompt positive response, and facilitate the betterment of others. Seligman also points out that our character can be strengthened by adverse experiences, such as traumatic events. His recognition of these conditions encourages self-determination. He is careful to acknowledge that there is a difference between the talents we are born with and the strengths we can choose to focus on. This choice provides us with the opportunity for pride and accomplishment, ultimately saying something about who we are. By choosing which strengths to pursue, we are able to attain genuine satisfaction and happiness. Seligman urges that this choice is more important than constantly striving to correct weaknesses. In a nutshell, his goal is to understand the fulfilling aspects of human behavior and what contributes to optimal functioning.

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Over the years, Seligman’s thinking on positive psychology has evolved, and he has continued to develop his approach. He argued in Learned Optimism (1991) that optimism can improve the quality of our lives. This hinges on reinterpreting our behavior and developing a positive internal dialogue. Learned optimism has been shown to have a positive impact on the prevention of depression and anxiety. In Authentic Happiness (2002), he asserted that happiness is something that can be cultivated by naturally utilizing the strengths we already possess. Over time, the consistent use of these strengths develops into positive character traits. He touched on many factors, including money, marriage, relationships, gender, religion, health, and even climate. Seligman concluded that these traditional factors only account for a small portion of our happiness and came to view the cultivation of character as the most important factor. More recently, Seligman has expanded his focus on happiness to include overall well-being. In Flourish (2011), he characterizes the goal of wellbeing as increasing positive emotion, engagement, meaning, relationships, and achievement. It is important to note that positive psychology is not simply the pursuit of what makes us happy. Happiness is only one of the concerns. Nor should it be viewed as positive thinking. He recognized that optimism is not always appropriate. Negative or realistic thinking may be a more suitable response depending on the situation. Thus, his work developed into a systematic and scientific effort to examine those strengths/weaknesses and virtues that allow us to thrive as individuals. His position is that our state of mind is our responsibility and the aforementioned virtues serve as a buffer against mental illness. Seligman’s work has important implications for practicing mental health clinicians. He reminds us of the importance of attending to a client’s strengths. The focus moves away from simply reducing symptoms toward promoting the identification of traits that protect against the development of issues and strengthen resiliency. Seligman outlines several of the strengths built in therapy, such as courage, insight, honesty, perspective, purpose, realism, and optimism. Such an orientation on building positive emotions and meaning helps the client flourish rather than simply survive. The client becomes an

active agent in this process, moving even further away from the orientation of traditional therapy. Seligman cautions that adherence to a disease model hinders our ability to nurture strength. Seligman was appointed president of the American Psychological Association in 1998. During his inauguration address, he announced his agenda for expanding psychology from a singular focus on pathology. Since that speech, positive psychology has enjoyed continuous growth and widespread popularity. This area of psychology now has a broad research base, associated organizations and conferences, and university courses and programs around the world. While some disagreement persists whether positive psychology should stand as its own movement, the work of Seligman has enhanced our understanding of positive emotions and character traits. It encourages the enterprise of psychology to encompass more than victimhood and remediation. His body of work, which includes more than 200 scholarly articles, best selling books, and numerous professional honors, comfortably establishes him as one of the most influential psychologists of the 20th century. Seligman is currently the director of the Positive Psychology Center and the Zellerbach Family Professor of Psychology at the University of Pennsylvania. Recent initiatives include applying positive psychology principles to soldier fitness, therapy, neuroscience, health, and education. His work continues to focus on the development and promotion of wellness principles and the fostering of positive virtues. Everett W. Painter See also Existential-Humanistic Therapies: Overview; Maslow, Abraham; Person-Centered Counseling; Positive Psychology; Rogers, Carl

Further Readings Seligman, M. (1975). Helplessness: On depression, development, and death. San Francisco, CA: W. H. Freeman. Seligman, M. (1991). Learned optimism: How to change your mind and your life. New York, NY: Knopf. Seligman, M. (2002). Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: Free Press.

Sensorimotor Psychotherapy Seligman, M. (2011). Flourish: A visionary new understanding of happiness and well-being. New York, NY: Simon & Schuster. Seligman, M., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55, 5–14. doi:10.1037/0003-066X.55.1.5 Seligman, M., & Pawelski, J. O. (2003). Positive psychology: FAQs. Psychological Inquiry, 14, 159–163. Sheldon, K. M., & King, L. (Eds.). (2001). Positive psychology [Special issue]. American Psychologist, 56(3), 216–263.

SENSORIMOTOR PSYCHOTHERAPY Sensorimotor psychotherapy is an experiential approach to trauma treatment that explicitly brings the client’s embodied awareness into the counseling session. Utilizing the client’s mindful processing of traumatic relational or physical experience, it includes awareness of body sensations, spontaneous movement impulses, and habitual movement patterns as foci of attention. Sensorimotor psychotherapy may be used as the principal method of treatment or in combination with other theoretical approaches. Because trauma deeply affects the body, sensorimotor psychotherapy offers access to unconscious or implicit traumatic material. Bodily awareness serves as a portal through which the unconscious can move into consciousness, offering access via language and new movement patterns; the potential transformation of the client’s understanding of trauma, its attendant affective dysregulation, and imbedded beliefs; and ultimately a more unified body and mind.

Historical Context Pat Ogden developed sensorimotor psychotherapy during the 1980s. Its techniques and interventions were created to work with the effects of trauma, including posttraumatic stress disorder and diagnoses related to complex trauma. Sensorimotor psychotherapy offers treatment for developmental or attachment trauma, trauma resulting from events such as accidents and natural disasters, and complex traumatic stress disorders. For several years, Ogden was an associate of Ron Kurtz, who

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developed the Hakomi body-centered method of psychotherapy, and built sensorimotor psychotherapy in part on this base.

Theoretical Underpinnings Sensorimotor psychotherapy is based on research and clinical practice from diverse disciplines. The practice combines somatic psychotherapy, developmental psychodynamic theory, and cognitivebehavioral approaches. It also incorporates research from attachment theory, studies of dissociation, and neuroscience. As a foundation, sensorimotor psychotherapy employs techniques from the Hakomi method and the writings of the early-20th-century French analyst Pierre Janet. Janet theorized that traumatic experience lives in the body and is residual from the helplessness and terror that occurred at the time. Janet believed that traumatized individuals suffer from movement incompletion, which Janet defined as defensive actions they were unable to take at the time of the trauma. Sensorimotor psychotherapy explicitly focuses on the manifestations of trauma, starting with awareness of body sensation, movement patterns, and impulses. Bringing these from the unconscious to conscious awareness provides a source of healing through the integration of the mind and the body.

Major Concepts Sensorimotor concepts are drawn primarily from somatic psychology, especially Kurtz’s Hakomi body-centered psychotherapy as applied to trauma treatment. These include action tendencies, core organizers, experiments, indicators, mindfulness, the organization of experience, tracking, and the window of tolerance. Action Tendencies

Action tendencies are a readiness for a behavior, latently present until a specific internal or external stimulus activates it. Core Organizers

Core organizers are emotions, beliefs, five-sense perception, movement impulses, gestures, posture,

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habitual movement patterns, and inner body sensations (vertigo, feeling empty, frozen, etc.). Experiments

Experiments are counselor-suggested physical or verbal actions that challenge client beliefs or habits of behavior. Indicators

Indicators are client responses arising from counselor-suggested experiments. Indicators are revealed in client statements such as “I want to hide,” “I don’t feel safe,” or “My throat feels tight.”

Phase-Oriented Treatment

Phase-oriented treatment refers to the steps in sensorimotor trauma treatment and includes (a)  stabilization, (b) memory and emotion work, and (c) integration work. Stabilization includes enhancement of client resources, slowing the pace of the session, guiding the client’s “in the present moment” awareness, and management of nervous system arousal. Memory and emotion work focuses on dual awareness of body and mind responses to traumatic memories and related beliefs, with attention to a sense of mastery over previously overwhelming experience. Integration is the practicing, in and out of session, of emerging new belief, relational, and nervous system arousal patterns. Mindful Awareness of Bodily Experience

Mindfulness

Mindfulness is client awareness of and ability to report on core organizers without judgment as these occur in the present moment.

Mindful awareness of bodily experience is a client practice. The client remains in the present moment during session, observing emerging core organizers.

Organization of Experience

Client Self-Regulation of Bodily Arousal

The organization of experience is habits or unconscious internal organization and beliefs influenced by attachment history, developmentally derived beliefs, and/or traumatic experience.

Client self-regulation of bodily arousal is a treatment goal for the resolution of dysregulated responses to overwhelming physical sensations, emotions, and distorted beliefs. The counselor teaches clients to notice and track the early signs of dysregulation as well as the somatic means for calming the nervous system.

Tracking

Tracking refers to the counselor’s detailed noticing of momentary changes in the client’s nonverbal behavior. Window of Tolerance

The window of tolerance refers to the optimal zone for sensorimotor processing. The nervous system is neither hyperaroused nor hypoaroused.

Techniques Several techniques are associated with sensorimotor psychotherapy: phase-oriented treatment, mindful awareness of bodily experience, mindful awareness of bodily arousal, processing memories, and movement impulses and incomplete actions.

Processing Memories

The sensorimotor approach assumes that memories are encoded explicitly (the story) and implicitly (sensations, images, movement patterns, posture, vague feelings). Clients are encouraged to “drop the story” and to mindfully attend to core organizers. Movement Impulses and Incomplete Actions

Sensorimotor psychotherapy includes a focus on completing actions that were impossible at the time of trauma due to immobilization. Actions that “wanted to happen,” such as striking out, escaping the situation, or defending oneself, continue to live in the body.

Sexual Identity Therapy

Therapeutic Process Sensorimotor psychotherapy is guided by the Hakomi concept of assisted self-study. Establishing a nonjudgmental, present-moment climate is important throughout. Pacing is slow. The client intermittently drops the remembered traumatic story and focuses on present bodily awareness. When indicators of repetitive patterns, sensations, or beliefs emerge, the counselor may suggest an experiment, such as amplifying an observed movement impulse or noticing bodily sensation when the client’s emergent belief is repeated to the counselor. During the session, the counselor monitors and seeks feedback regarding the client’s window of tolerance. Is the client becoming agitated (hyperaroused) or disconnected (hypoaroused)? If so, the counselor asks the client to return to mindful awareness of body sensation. Goals of counseling include nonjudgmental selfobservation, increased client self-regulation, and assisting the client to place traumatic memory in the past. It brings unconscious material, sequestered in the body, into awareness, where it can be integrated into a client’s autobiography and selfunderstanding. Catherine B. Jenni See also Body-Oriented Therapies: Overview; Developmental Counseling and Therapy: Theory and Brain-Based Practice; Hakomi Therapy; Mindfulness Techniques; Rolfing; Somatic Experiencing

Further Readings Fisher, J., & Ogden, P. (2009). Sensorimotor psychotherapy. In C. Courtois & J. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 312–328). New York, NY: Guilford Press. Janet, P. (1925). Principles of psychotherapy. London, England: Allen & Unwin. Kurtz, R. (1990). Body-centered psychotherapy: The Hakomi Method. Mendocino, CA: Life Rhythm. Ogden, P., & Fisher, J. (2014). Sensorimotor psychotherapy: Interventions for trauma and attachment. New York, NY: W. W. Norton. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: W. W. Norton.

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SEXUAL IDENTITY THERAPY Sexual identity therapy (SIT) is a framework designed to assist mental health professionals in their work of helping people resolve dissonance between religious beliefs and sexual orientation. This approach helps therapists assist clients to clarify core beliefs and values about sexuality and their religious beliefs and to develop strategies to pursue congruence between their beliefs and their sexual identity. The framework for SIT is presented in four phases: (1) assessment, (2) advanced informed consent, (3) psychotherapy, and (4) sexual identity synthesis.

Historical Context The framework was first conceptualized in 2005 by Warren Throckmorton and Mark Yarhouse. Throckmorton recommended the framework for therapists who sought to help clients who believe that their religious beliefs contradict their sexual orientation. For some clients, living a life whose behaviors are in line with their religious beliefs despite their sexual orientation might be an objective; for others, acceptance of sexual orientation may be the goal. During the latter part of the 20th century and early part of the 21st century, the American Counseling Association, American Psychiatric Association, American Psychological Association (APA), and National Association of Social Workers developed policy statements that strongly discouraged the use of Sexual Orientation Change Efforts (SOCE) because research suggested that it may be harmful to clients. In 2005, Throckmorton suggested that the creation of neutral guidelines for therapists would best serve those clients struggling with conflicts related to their religious beliefs and sexual orientation. Throckmorton and Yarhouse collaborated to create the SIT framework, which placed clients in charge of setting the direction of therapy while at the same time recognizing that SOCE was rarely successful. In fact, the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation found that change efforts involve risk and that insufficient evidence existed to support the use of SOCE.

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The SIT approach is founded in the personcentered tradition in that clients are encouraged to clarify their values and beliefs related to their religious affiliation and sexual orientation with minimal direction from therapists. For this reason, some clients will affirm their identity as lesbian, gay, bisexual, transgender, intersex, or questioning, while others will affirm a nonaffirming religious tradition despite their sexual orientation and decide to live a life that is behaviorally consistent with those religious beliefs. Therapists are encouraged to leave their ideological loyalties out of the counseling office and assist clients to achieve a resolution that is most satisfactory to them. In 2006, the SIT framework was published on a website dedicated to the approach and then presented at the 2007 APA convention in San Francisco, California. The framework has undergone subsequent revisions to incorporate ongoing research regarding sexual orientation. The approach was considered and then rejected by the National Association for the Research and Therapy of Homosexuality, the only organization that advocates for reparative therapy. The SIT framework has received criticism from sexual orientation change therapists due to the neutral stance of SIT advocates. Criticism has also come from some sexual minority–affirming therapists, as they believe that it does not go far enough in affirming an individual’s sexual orientation. In 2008, Throckmorton and three presenters were slated to present the SIT format before the American Psychiatric Association. However, this presentation was cancelled due to pressure from those who believed that this approach was oppressive to individuals struggling with their sexual orientation. In 2009, the SIT framework was cited favorably by the APA’s Task Force report on therapeutic approaches to sexual orientation. SIT may be used with therapists of many different theoretical persuasions. There is no prescribed number of sessions, and not all clients experience all four phases, which are subsumed under the heading of SIT. SIT is best considered a therapeutic stance of respect for religion and sexual orientation variables along with a dedication to provide clients with the most up-to-date information possible regarding sexual orientation.

Theoretical Underpinnings Sexual identity therapists view sexual orientation as one element of a person’s identity and religious beliefs as another important variable, both of which are important for establishing personal identity. Sexual identity therapists recognize that some clients who hold traditional religious views have a sexual orientation that is in conflict with their religious beliefs. For instance, some who experience same-sex attraction do not identify as gay because they do not engage in same-sex sexuality. Others who have a same-sex attraction along with religious beliefs that conflict with same-sex relationships decide to abandon their religious beliefs. The APA also recognizes a distinction between organismic congruence and telic congruence. Some religious traditions promote telic congruence, which is defined as living consistently with one’s religious beliefs. Sexual minority–affirming approaches to lesbian, gay, bisexual, transgender, intersex, or questioning clients often promote organismic congruence, which can be described as living consistently with one’s experience, in this case, with one’s natural sexual attractions. In SIT, the decision whether to seek telic or organismic congruence, or some combination of the two, is left with the clients.

Major Concepts The framework for SIT is presented in four steps: (1) assessment, (2) advanced informed consent, (3) psychotherapy, and (4) sexual identity synthesis. At any point during the therapy, a previous step may be revisited for further investigation or to explore a new direction in the therapy. Assessment

Clients who present with sexual identity concerns receive a standard mental health assessment. Then, the reasons why the clients requested therapy are explored with attention to what they hope to accomplish. This assessment covers sexual history, current sexuality, religious beliefs and affiliations, and beliefs regarding sexuality. At times, this assessment process leads naturally into a process of belief and values clarification. For other clients,

Sexual Identity Therapy

values clarification comes during the psychotherapy phase. Because therapists using SIT do not prescribe a particular value or behavioral course of action, the assessment process is an individual one. Advanced Informed Consent

Therapists inform clients about current information regarding sexual orientation. Therapists using SIT inform clients that the major mental health associations consider same-sex sexual orientation as normal ways of bonding with individuals. Sexual identity therapists also indicate that change of sexual attractions or orientation is not considered a part of empirical practice due to the durability of sexual orientation. Therapists may inform clients that their religious beliefs will be respected and that some people do live in alignment with their religious views, even if this means living celibately. In addition, clients are informed that their sexual orientation will be respected and that some individuals decide to abandon or change their religious affiliation to be more in line with their sexual orientation. Psychotherapy

SIT provides a framework for existing techniques rather than a specific method of psychotherapy. Many therapeutic models can be used to facilitate congruence and resolution of sexual identity dissonance. The goal of counseling is to help clients live comfortably with their sexual orientation and their religious beliefs. Therapists continually assess for the effects of interventions and are prepared to offer counseling that is effective to treat the mental health disorders or conditions that sometimes accompany sexual identity distress or the distress of being in a religion that denies one’s sexual orientation. At times, referral may be indicated if a therapist does not feel competent to assist a client. Sexual Identity Synthesis

As a consequence of the prior three phases, many clients arrive at a plan to integrate their religious beliefs and sexual orientation. Therapists may assist by helping clients facilitate actions and commitments congruent with their new understanding

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of their sexual orientation, values, and beliefs. Many clients find it helpful to attend support groups and manage their lives in ways that affirm their new identity.

Techniques Because SIT is compatible with many theoretical approaches to counseling, there are not many specific techniques. Therapists must be skilled in basic mental health interviewing and assessment as well as in distinguishing mental and emotional disorders and conditions that can exacerbate sexual identity confusion and dissonance. Because SIT places emphasis on treating any existing mental and emotional conditions simultaneously with or prior to addressing the dissonance of having a sexual identity that is in conflict with one’s religious beliefs, therapists should be skilled in treating such conditions. More specifically, therapists should have expertise in human sexuality and in religion and should be proficient in the use of techniques that help clients clarify their religious beliefs and values and in helping clients understand their sexual orientation. In-depth knowledge of sexual orientation research and of the impact of religious beliefs on one’s sexual orientation is critical to assist clients in providing advanced informed consent. Finally, therapists have to be adept at accepting, honoring, and understanding a person’s sexual orientation and religious beliefs. It is only through being able to hold these conflicting orientations, beliefs, and values simultaneously that a client can make an informed decision about his or her life course and direction.

Therapeutic Process SIT may require only two or three sessions or may last several years. Some clients prefer to attend several sessions with long breaks between episodes. Some clients will change their views on religious and value issues, which may renew dissonance throughout the life span. Sexual identity therapists demonstrate flexibility in adjusting the process of counseling to the needs and pace of clients. Warren Throckmorton

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See also Person-Centered Counseling; Sexual Minority Affirmative Therapy; Sexual Orientation Change Efforts

Further Readings American Psychological Association. (2009). Report of the task force on appropriate therapeutic response to sexual orientation. Washington, DC: Author. Tan, E. S. N., & Yarhouse, M. A. (2010). Facilitating congruence between religious beliefs and sexual identity with mindfulness. Psychotherapy, 47(4), 500–511. doi:10.1037/a0022081 Throckmorton, W. (2012). In praise of round pegs. Edification, 3, 27–28. Throckmorton, W., & Yarhouse, M. A. (2006). Sexual identity therapy: Practice guidelines for managing sexual identity conflicts (Unpublished paper). Retrieved from http://sitframework.com/wp-content/uploads/ 2009/07/sexualidentitytherapyframeworkfinal.pdf Yarhouse, M. A. (2001). Sexual identity development: The influence of valuative frameworks on identity synthesis. Psychotherapy, 38(3), 331–341. doi:10.1037/00333204.38.3.331 Yarhouse, M. A. (2008). Narrative sexual identity therapy. American Journal of Family Therapy, 36, 196–210. doi:10.1080/01926180701236498 Yarhouse, M. A., & Tan, E. S. N. (2004). Sexual identity synthesis: Attributions, meaning-making, and the search for congruence. Lanham, MD: University Press of America. Yarhouse, M. A., Tan, E. S. N., & Pawlowski, L. M. (2005). Sexual identity development and synthesis among LGB-identified and LGB dis-identified persons. Journal of Psychology and Theology, 33(1), 3–16.

SEXUAL MINORITY AFFIRMATIVE THERAPY Sexual minority affirmative therapy provides a frame of reference for working with sexual minority clients, including lesbian, gay, bisexual, and transgender; gender variant; asexual (who experience no sexual attraction); cisgender (who identify as the gender assigned at birth); intersex (whose reproductive anatomy does not fit the typical definitions of male or female); and other emerging categories or self-definitions, such as GSM (i.e., gender and sexual minority). This approach is not

an independent system of psychotherapy but a therapeutic perspective that challenges the notion that same-sex attractions or atypical gender identities are inherently pathological and in need of change or alteration. This therapeutic lens views societal stigma and internalized sexual prejudice as major pathways for the circumstances that bring many sexual minority individuals to therapy. An affirmative perspective is profoundly validating of these clients and their relationships and does not privilege heterosexuality over sexual minority orientations and identities. Affirmative therapy goes beyond the creation of a neutral therapeutic climate, or one that merely “accepts” same-sex attracted individuals. Rather, it creates a safe space for clients to examine and affirm all interconnected identities, including their racial, cultural, gender, ethnic, religious, and sexual identities. This congruence, or coming together, can be life enhancing for individuals who rarely have been allowed to examine the various aspects of themselves free of judgment and censure.

Historical Context The term homosexual was first used in the 1870s in Germany to describe a distinct category of people who were erotically attracted to their own sex. Prior to this, in Western society, these individuals were considered heterosexuals who were behaving immorally, were violating religious law and/or civil law (which often reflected the values of the dominant religion), or were inherently ill and in need of a cure by the medical community. Prior to the 1960s, most psychotherapeutic writing about homosexuality was based on the assumption that homosexuality was a pathological condition to be cured, much like any other disease. Some saw this assumption as more humane than persecuting and prosecuting sexual minorities, as many governments tended to do, or condemning them to eternal damnation, as the tenets of various religions proclaimed. Since that time, in the United States and in other Western nations, mental health professionals have worked to avoid identifying same-sex attraction and atypical gender identity as pathological and to reduce the stigma associated with these identities. Although the concept of an affirmative therapy for sexual minorities may have been used informally, the psychologist Alan Malyon

Sexual Minority Affirmative Therapy

first used the term gay affirmative therapy in the early 1980s. Despite recent societal shifts with regard to the acceptance of sexual minority citizens and ongoing advocacy for their rights in areas such as housing, medical care, military service, employment, and election to public office, heterosexism is prevalent in the United States as a major socializing factor. For example, sexual minority children are pressured to live out traditional gender roles, and most religious groups support only traditional marriages and families. Those who are “different,” such as gender-atypical children, may be targeted or bullied and may feel powerless to fight back. In addition, the family and friends of sexual minority individuals often fail to recognize or understand the extent of the trauma of these socializing factors. Such traumatization can, of course, affect a person’s sense of self and, therefore, can be an important focus of therapy.

Theoretical Underpinnings Because of the stigma and other socializing factors directed toward sexual minorities, an understanding of such bias is critical to providing ethical and effective therapy. To offer competent and bias-free mental health service, clinicians must be aware of the emotional and logistical burdens faced by sexual minorities of all ages, ethnicities, and circumstances. Clinicians with an affirmative perspective appreciate the profound effects of heterosexism on mental health that clients bring to therapy, such as social withdrawal, passivity, anxiety, suspicion, insecurity, depression, substance use, and suicidality, which frequently are the consequences of living in a stigmatizing societal environment. Today, with knowledge gained from a large body of research, professional mental health associations do not view sexual minorities as deficient, ill, or in need of a cure but as healthy human beings who, like all individuals, struggle with problems of living. However, due to continued societal devaluation, some clients bring to counseling the negative mental health effects of societal stigma. A clinician’s mirroring, or reflection of the fundamental goodness and wholeness of these individuals, is vital to counteract the individuals’ sense of shame and failure, which can be perpetuated by others and by institutions.

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For example, many sexual minority individuals have difficulty reconciling their sexual orientation or gender identity with the values of a religion that condemns same-sex behaviors and restricts believers to celibacy or to heterosexual marriage. This struggle can be particularly devastating for individuals who are deeply bonded to their faith and who experience a profound sense of marginalization or exclusion from their families or from their religion. Clinicians utilizing a sexual minority affirmative therapy approach take this experience of rejection seriously, reflect the intensity of clients’ pain, and assist clients in their grief.

Major Concepts As noted previously, sexual minority affirmative therapy provides a frame of reference for clinicians working with sexual minority clients. For this reason, the major concepts of this perspective focus on clinicians’ attitudes toward same-sex-attracted and gender-variant clients and their understanding of the issues that such clients face in their relationships and in society. To direct ethical psychological practice with sexual minority clients, the American Psychological Association (APA), the largest professional psychological association in the United States, has created committees and/or task forces to develop practice guidelines. In 2011, the APA issued Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients, and as of 2013, another task force is working on developing Guidelines for Psychological Practice With Transgender and Gender Non-Conforming Clients. The Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients has incorporated many of the major concepts of sexual minority affirmative therapy into its 21 specific guidelines, arranged into six topic areas: (1) Attitudes Toward Homosexuality and Bisexuality, (2) Relationships and Families, (3) Issues of Diversity, (4) Economic and Workplace Issues, (5) Education and Training, and (6) Research. For example, Guideline 1 addresses the issue of stigmatization, noting that clinicians should strive to understand the effects of stigma, and Guideline 2 affirms that sexual orientations, specifically lesbian, gay, and bisexual orientations, are not mental illnesses. Other principles of the guidelines include the notions that efforts to change sexual orientation are neither effective nor

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safe, that bisexual individuals have unique experiences, that the relationships and families of sexual minorities deserve respect, and that racial and ethnic sexual minorities face multiple challenges. Readers are encouraged to read the complete guidelines, available on the APA’s website, for further understanding and information regarding the application of these guidelines.

Techniques Although sexual minority affirmative psychotherapy is the first therapeutic movement to acknowledge the harm done to sexual minority individuals by heterosexist socialization, there are no techniques that are specific to counseling sexual minority individuals. The clinical work with these clients employs established techniques from an affirming perspective. However, an increasing volume of literature related to the adaption of existing techniques to  the unique issues of these clients exists. Modifications to existing techniques, though, must take into consideration the marginalized world in which some sexual minority clients reside and the unique conditions of their lives. For example, some clients may live in quite stigmatizing and even dangerous situations; others may not be experiencing such dire circumstances, but their past may include considerable stigmatization and distress. Such stigmatization and distress, regardless of the extent, is incorporated into affirmative therapy. The empathy and deep listening used in personcentered therapy is an example of a therapeutic perspective that is considered essential when working with distraught sexual minority clients. Unconditional positive regard, a core concept of person-centered therapy, is valuable in counteracting an individual’s negative or nonexistent views of self. Object relations theorists suggest the techniques of mirroring, or reflecting of the genuine person, and the creating of a safe, or holding, environment for clients. Affirmative therapists can use these object relations techniques to safely contain, or hold, the pain and wounds of sexual minority clients, which can then facilitate the emergence of hope. Some clinicians have proposed using cognitive therapy for addressing the depression and anxiety

sexual minorities may experience from continually facing the biases imposed by society. Reframing and challenging pessimistic cognitions could also be helpful, as well as using a form of narrative therapy to shift the harmful conversations clients have learned to tell themselves about their worth and of their place in society. These negative stories can be transformed into narratives of resilience, competence, and growth. Adlerian theorists focus on early recollections and internalized feelings of inferiority. Bringing these memories and emotions to awareness, subjecting them to examination, and incorporating them into a client’s life can neutralize the self-defeating effects they have had. Finally, expressive techniques such as role-play, movement, art therapy, and psychodrama can help clients develop feelings of power and resourcefulness, which they may have found difficult to mobilize.

Therapeutic Process Sexual minority clients often enter therapy with apprehension. After a lifetime of often feeling unheard and misrepresented, many may be reluctant to confide in a clinician until that individual has earned their trust. In addition, many sexual minority clients fear even exploring the secret that they have kept most hidden—even to themselves. Given this, therapy frequently is a careful and slow process, with the mirroring and affirmation by the clinician being extremely important for client exploration and growth. Clinicians, thus, strive to understand the degree to which heterosexism has affected the context of clients’ lives and to convey to those who are in their care that much of the distress they are experiencing is a result of living in a stigmatizing society and not a result of their own brokenness. Clinicians also carefully examine their own biases regarding same-sex sexual behaviors and atypical gender identities so that their own countertransferences do not impede empathic attunement with clients. While striving toward true impartiality, clinicians additionally may consider their own position regarding heterosexuality in terms of marriage, childbearing, adoption, family structures, religion, and morality—that is, whether they are encouraging clients toward a specific outcome,

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such as opposite-sex attraction, a denial or repression of the clients’ feelings toward their own sex, and being comfortable with the gender of their birth, a particular religion, or therapeutic conversion. With empathy and support, sexual minority clients can navigate their issues and difficulties and can face challenges with increasing courage. An indication of therapeutic success is when sexual minority clients are no longer burdened with feelings of shame and self-deprecation but can live their lives overcoming the same challenges that every human faces. Kathleen Y. Ritter See also Contemporary Psychodynamic-Based Therapies: Overview; Contextual Therapy; Cross-Cultural Counseling Theory; Narrative Therapy; Object Relations Theory; Person-Centered Counseling; Rogers, Carl; Winnicott, Donald

Further Readings American Psychological Association. (2009). Report of the APA task force on appropriate therapeutic responses to sexual orientation. Retrieved from www .apa.org/pi/lgbt/resources/therapeutic-response.pdf American Psychological Association. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67(1), 10–42. doi:10.1037/a0024659 American Psychological Association. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. Retrieved from http://www.apa .org/pi/lgbt/resources/guidelines.aspx Bieschke, K. J., Perez, R. M., & DeBord, K. A. (Eds.). (2007). Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed.).Washington, DC: American Psychological Association. Bigner, J. J., & Wetchler, J. L. (Eds.). (2012). Handbook of LGBT-affirmative couple and family therapy. New York, NY: Routledge. Gonsiorek, J. C. (Ed.). (1982). Homosexuality and psychotherapy: A practitioner’s handbook of affirmative models. New York, NY: Haworth Press. Malyon, A. K. (1982). Psychotherapeutic implications of internalized homophobia in gay men. In J. C. Gonsiorek (Ed.), Homosexuality and psychotherapy: A practitioner’s handbook of affirmative models (pp. 59–69). New York, NY: Haworth Press.

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Ritter, K. Y., & Terndrup, A. I. (2002). Handbook of affirmative psychotherapy with lesbians and gay men. New York, NY: Guilford Press.

Website American Psychological Association: www.apa.org

SEXUAL ORIENTATION CHANGE EFFORTS Sexual orientation change efforts (SOCE) refers to the dangerous and unethical forms of treatment aimed at changing one’s sexual orientation or behavior. SOCE has been called by many names, including, but not limited to, conversion and reparative therapy. The goal of this form of treatment is to assist persons in suppressing their sexual orientation so as to be more socially congruent with the mainstream heterosexual culture; often, this is done for religious purposes. The paradigm in which SOCE has been conceived pathologizes various sexual identities and behaviors while advancing the idea that lesbian, gay, and bisexual (LGB) persons are damaged and in need of repair. As such, no major mental health association has endorsed SOCE, and many have drafted resolutions or position statements cautioning against its use.

Historical Context Prior to the 19th century, same-sex desire and sexual activity were viewed in a religious context, grounded in the Judeo-Christian tradition, as unnatural and as a sin. Legally, same-sex behavior was criminalized, first in 16th-century England and later in other parts of the world. This was challenged and changed in Napoleonic France in the late 18th century, with laws instead focusing on public sexual acts and sexual acts with minors. Men arrested under public sex laws were forced to undergo medical examinations to see if anal sex had occurred, which marked the start of a medical interest in human sexual behavior. In 1857, Auguste Ambroise Tardieu published a study of men arrested under these laws, advancing a theory of sexual development that suggested that these men

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had psychological and behavioral traits that were forms of insanity. Following this report, medical professionals began to view same-sex desire as a pathological, innate illness in need of change. This notion challenged the established norm at the time, which viewed same-sex desire as a choice and as inherently sinful (against the wishes of God) and unlawful. As such, this new medical, yet pathological, view of same-sex behavior was seen as progressive and liberatory because viewing it as an illness shifted the discourse away from viewing same-sex attractions as being an active, sinful choice. Writers at the time argued that since same-sex attractions were innate, such persons should come under psychiatric care rather than legal prosecution. The paradigm that suggested that homosexuality was innate and pathological continued until the early 20th century, when Sigmund Freud, according to Kenneth Lewes, a psychoanalytical scholar, suggested that homosexuality was the natural outcome of a developmental process in some persons. Freud suggested that this developmental process was deeply embedded in the person and thus extremely difficult, if not impossible, to change. In fact, Freud described an unsuccessful attempt he made to change a woman’s same-sex desire after her parents mandated her to go to treatment. Freud concluded his report by stating how unlikely SOCE was to succeed, based on the findings of his case. Other mental health professionals who followed Freud, however, continued to follow the previous paradigm that viewed same-sex desire as innate, pathological, and in need of change. One of those professionals who challenged Freud’s notions in the years that followed was Sandor Rado, who is credited with developing the next model of SOCE. In “A Critical Examination of the Concept of Bisexuality,” Rando (1940) challenged Freud’s suggestions regarding sexual desire, conceptualizing same-sex desire as a phobic flight from heterosexual sexual activity following parents’ prohibitions against childhood sexuality. This theory served as the foundation for later reparative therapy models as well as the rationale for classifying homosexuality as a mental illness. The civil rights movement, political advocacy, and psychological research conducted by scholars such as Alfred Kinsey and Evelyn Hooker during the 1950s and 1960s provided support for the potential declassification of homosexuality from

the Diagnostic and Statistical Manual of Mental Disorders, second edition (DSM-II). However, opposition among some psychiatrists about the removal of homosexuality from the DSM led to a compromise in the DSM-II, published in 1968, with the new diagnosis of Sexual Orientation Disturbance, which was based on a person’s conflict with his or her sexual orientation. This diagnosis was replaced with Ego-Dystonic Homosexuality in the DSM-III, published in 1980. Both diagnoses have been removed from later editions of the DSM. Because empirical research has not supported the effectiveness of SOCE, the American Association of Marriage and Family Therapists (AAMFT), American Psychiatric Association, American Psychological Association, and National Association of Social Workers have all adopted policy statements that caution their professions about treatment efforts centered on changing sexual orientation. In 1999, the American Counseling Association (ACA) Governing Council adopted a statement opposing reparative therapy. The 2014 ACA Code of Ethics has an ethical principle that states the need for professionals to use evidencebased practices in their work; position statements of the AAMFT also follow this principle. ACA (2014) also has a second ethical principle that asks counselors not to utilize techniques, modalities, or theories where substantial evidence demonstrates that such use can cause harm, regardless of whether a client requests this form of treatment.

Techniques Historical medical interventions for changing sexual orientation have included cold sitz baths, castration, sterilization, and lobotomy. Psychiatric treatments have included hypnosis, electroshock therapy, and psychoanalysis. As previously noted, because such forms of treatment are not considered ethically sound or empirically effective, nearly all mental health professional organizations have cautioned practitioners away from SOCE, and many have statements about the need to conduct empirically supported treatment.

Therapeutic Process Because SOCE has not been shown to be effective, and nearly all major mental health organizations have statements condemning or cautioning against

Shapiro, Francine

the use of this form of treatment, a discussion of the therapeutic process is unwarranted. However, because SOCE is potentially harmful for clients, this section briefly addresses the potential side effects of this form of treatment. Side effects for individuals undergoing SOCE may include low self-esteem, self-harm, and suicide. Systemically, the use of this form of treatment reinforces the inappropriate pathologization of LGB persons and furthers the marginalization, discrimination, and mistreatment of these persons. Kristopher M. Goodrich and Sarah Meng See also Sexual Identity Therapy; Sexual Minority Affirmative Therapy

Further Readings American Counseling Association. (2014). ACA code of ethics. Retrieved from http://www.counseling.org/ Resources/aca-code-of-ethics.pdf American Psychological Association. (2009). Report of the APA task force on appropriate therapeutic responses to sexual orientation. Retrieved from http://www.apa.org/ pi/lgbt/resources/therapeutic-response.pdf Drecher, J. (2002). I’m your handyman: A history of reparative therapies. Journal of Gay & Lesbian Psychotherapy, 5(3), 5–24. doi:10.1300/ J236v05n03_02 Group for the Advancement of Psychiatry. (2012). The history of psychiatry and homosexuality. Retrieved from http://www.aglp.org/gap/1_history/ Hooker, E. (1956). A preliminary analysis of group behavior of homosexuals. Journal of Psychology, 42, 217–225. doi:10.1080/00223980.1956.9713035 Hooker, E. (1957). The adjustment of the male overt homosexual. Journal of Projective Techniques, 21, 18–31. doi:10.1080/08853126.1957.10380742 Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Philadelphia, PA: W. B. Sanders. Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the human female. Philadelphia, PA: W. B. Sanders. Lewes, K. (1988). The psychoanalytic theory of male homosexuality. New York, NY: Simon & Schuster. Morgan, K. S., & Nerison, R. M. (1993). Homosexuality and psychopolitics: An historical overview. Psychotherapy: Theory, Research, Practice, Training, 30(1), 133–140. doi:10.1037/0033-3204.30.1.133 Smiley, K. A., & Chaney, M. P. (2010). Reparative therapy. ALGBTIC News, XXXV(2), 6–8.

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SHAPIRO, FRANCINE Francine Shapiro (1948– ), the creator of Eye Movement Desensitization and Reprocessing (EMDR) therapy, was born in Brooklyn, New York. A major motivating factor in Shapiro’s development was the death of her 9-year-old sister when Shapiro was 17 years of age. It caused a ripple effect throughout the rest of her life, especially when Shapiro later conceptualized it as a stress-related condition. This loss became one of the major incentives for her investigations into psychoneuroimmunology, which later evolved into the development of EMDR therapy. Through the advent of EMDR therapy, the field was introduced to a new understanding of psychopathology and rapid healing called the Adaptive Information Processing (AIP) model. Shapiro’s early interest was English literature, and she earned her B.A. and M.A. at Brooklyn College in this field. After teaching high school, she entered a Ph.D. program in Literature at New York University. Concurrently, she became interested in behavior therapy after reading the works of Andrew Salter and Joseph Wolpe. What fascinated her was that a focused, predictable, cause-andeffect approach to human psychology seemed compatible with concepts regarding literary character and plot development. Current research on the correlation of reading literature with a robust theory of mind and concomitant development of empathy also indicates that this was excellent preparation for her later work in psychology. Shapiro was 30 years old and an “ABD” (“all but dissertation”) in English Literature when she was diagnosed with cancer. She confronted the disease with scholarly dedication and acuity. She studied the new field of psychoneuroimmunology to learn about the connection between disease and stress. After her cancer was “cured,” she recognized that while the research appeared to have merit, there was little known about how people could apply this knowledge to their own lives. She took this as a challenge to find what methods were available and which of them worked, and ultimately to make them available to the general public. Over the next decade, she attended cuttingedge trainings and workshops and created interdisciplinary conferences on the subject. She also enrolled in the Clinical Psychology Ph.D. program

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at the Professional School for Psychological Studies in San Diego, California, to find out more formally what was already known. The analytic tools she acquired at New York University to evaluate and understand the deep motives and behavior of characters in literature as they unfolded helped her, as a psychologist, to develop the ability to observe and understand human behavior and character. In 1987, Shapiro took a walk in the park and discovered a relationship between her eye movements and cognitive processes. She noticed that when a distressing thought arose, her eyes spontaneously started moving rapidly back and forth diagonally. When she brought up the thought again, the negative emotion had decreased. She then deliberately moved her eyes while concentrating on disturbing thoughts, finding again that they disappeared and lost their emotional “charge.” This observation became the subject of her doctoral dissertation. During the next 6 months, Shapiro worked with approximately 70 people to create a protocol that could be standardized and used to decrease anxiety, which she called Eye Movement Desensitization. For her doctoral research, she conducted a randomized controlled study that was published in 1989 in the Journal of Traumatic Stress Studies, titled “Efficacy of the Eye Movement Desensitization Procedure in the Treatment of Traumatic Memories.” She taught the procedure to Joseph Wolpe, one of the fathers of behavior therapy, who described the procedure as a “breakthrough” and invited her to write a subsequent article, which was published in the Journal of Behavior Therapy and Experimental Psychiatry. During that time, she was invited to join the faculty of the Mental Research Institute in Palo Alto, California, where she subsequently became a senior research fellow. Shifting away from a behavioral formulation, Shapiro broadened her scope by including the processing of cognition and emotion rather than simply the reduction of arousal, fear, and anxiety. Influenced by Peter J. Lang’s work on memory networks, she had begun thinking in terms of information processing instead of simply desensitization. She developed a new theory of pathology and healing, which eventually became the AIP model. As Shapiro explained in her 1995 text, Eye Movement Desensitization became Eye Movement Desensitization and Reprocessing therapy after she realized—from the evaluation of hundreds of

cases—that when she changed the procedures according to the AIP model, there was a simultaneous desensitization and cognitive restructuring of memories and personal attributions, all of which appeared to be by-products of the adaptive processing of the disturbing memories. This change in name was the result of a paradigm shift that took EMDR therapy beyond its original purpose as a treatment for posttraumatic stress disorder (PTSD) toward becoming an expanded methodology and new approach to psychotherapy. Shapiro believes that EMDR therapy and the AIP model offer the field a redefinition of pathology and healing. According to this model, the primary cause of many clinical complaints is the presence of unprocessed memories of adverse life experiences. Subsequent research has supported this tenet by demonstrating the association of these experiences with both mental and physical dysfunction. By using EMDR therapy procedures to stimulate the intrinsic information-processing system, memories are transformed into useful learning experiences that result in integration, increased resilience, new insight, and a redefinition of the self. For other psychotherapies, the etiology of pathology and the change agents are viewed differently, such as when a belief, emotion, or behavior is seen as the cause of problems and is specifically manipulated to achieve therapeutic effects. In contrast, the AIP model views them as the symptoms of clinical problems and guides the use of EMDR therapy to identify and reprocess the underlying memories causing the dysfunction. For example, EMDR can eliminate phantom limb pain because in many cases it is actually an indicator of a physiologically stored unprocessed memory of a traumatic injury. In sum, a basic AIP conceptualization is that unprocessed memories are the root of the diverse symptoms that make up most diagnoses. Shapiro has been a strong advocate for research, routinely encouraging clinicians to use standardized measures, document outcomes, and share their findings to guide applications and establish best practices. However, many of the early studies of EMDR therapy were component analyses that treated only one memory in multiply traumatized veterans, or used undiagnosed populations or untrained clinicians. Not until 1995, when the first randomized study with appropriate clients who were given the correct amount of treatment was published in the Journal of Consulting and Clinical

Skinner, B. F.

Psychology, was her original study replicated. In 1995, Shapiro published her first edition of Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. She felt that there were a sufficient number of completed studies awaiting publication to demonstrate EMDR therapy as a valid treatment for PTSD. She supported an independent group of clinicians to monitor standards and trainings that became the EMDR International Association. In the same week that Shapiro’s Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures was published, the bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, occurred. She responded to a call for assistance for the local therapeutic community by offering free EMDR training and survivor assistance. This marked the start of the EMDR Humanitarian Assistance Programs (HAP), a nonprofit organization that has since expanded its mandate to treat people in need worldwide. Shapiro believes that through HAP clinicians can forge bonds that transcend their ethnicities, countries, and ideologies. These are the bonds that can assist in healing the trauma and pain that usually would lead to unending cycles of violence and suffering. Humanitarian assistance programs have now become an integral part of the national and regional EMDR therapy organizations throughout the United States, Latin America, Europe, Asia, and Africa. Shapiro is the executive director of the EMDR Institute and the founder and president emeritus of HAP. Among other awards, she is a recipient of the American Psychological Association Division 56 Award for Outstanding Contributions to Practice in Trauma Psychology, the Distinguished Scientific Achievement in Psychology Award presented by the California Psychological Association, and the International Sigmund Freud Award for Psychotherapy presented by the City of Vienna in  conjunction with the World Council of Psychotherapy. EMDR therapy is now recognized worldwide as an empirically validated treatment of trauma. In 2013, the World Health Organization practice guidelines stated that EMDR therapy was one of only two psychotherapy approaches recommended for the treatment of PTSD across the life span. Marilyn Luber

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See also Behavior Therapy; Eye Movement Desensitization and Reprocessing Therapy; Integrative Psychotherapy; Strategic Family Therapy; Strategic Therapy

Further Readings Luber, M., & Shapiro, F. (2009). Interview with Francine Shapiro: Historical overview, present issues, and future directions of EMDR. Journal of EMDR Practice and Research, 3, 217–231. doi:10.1891/1933-3196.3.4.217 Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199–223. doi:10.1002/jts.2490020207 Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York, NY: Guilford Press. Shapiro, F. (2007). EMDR, adaptive information processing, and case conceptualization. Journal of EMDR Practice and Research, 1, 68–87. doi:10.1891/1933-3196.1.2.68 Shapiro, F. (2013). Getting past your past: Take control of your life with self-help techniques from EMDR therapy. New York, NY: Rodale Books. Shapiro, F. (2014). The role of eye movement desensitization and reprocessing therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences. Permanente Journal, 18, 71–77. doi:10.7812/TPP/13-098

Website EMDR Humanitarian Assistance Programs: http://www .emdrhap.org

SKINNER, B. F. The modern psychological theorist Burrhus Frederic Skinner (1904–1990), known to colleagues and the public as B. F. Skinner, was the originator of operant conditioning, a way of shaping the behavior of white rats and pigeons through “schedules of reinforcement.” The organism (rat or pigeon) was contained in the “operant chamber,” known as the “Skinner Box,” and given the opportunity to press a lever, the operation or operant, which delivered a food pellet. The schedule of food delivery that determined the rate of lever pressing was measured by a “cumulative recorder.” This

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device marked the frequency of lever pressing and became the basis for the science of behavioral analysis in the 1930s. Skinner believed that positive reinforcement could also shape human behavior and fashion a better way of living. Skinner spent his boyhood in the small railroad town of Susquehanna, Pennsylvania, about 30 miles south of the New York state line. His father, William, was a lawyer for the Erie Railroad, who had political aspirations that never materialized. His mother, Grace, was a more important parental influence on young Skinner, continually reminding him to be careful of what people would think— hence, making the young man acutely aware of his own behavior and the behavior of others. While growing up in Susquehanna, Skinner had the freedom to roam the countryside and devise toys such as roller skate scooters, seesaws, sleds, and a cannon that shot potatoes over neighbors’ houses. He excelled in the local small high school, where he was introduced to Darwinian evolution and the theory of natural selection, which he enthusiastically endorsed. Skinner enjoyed reading, especially adventure stories in which the characters invented devices or contraptions that altered their environments—Jules Verne’s Mysterious Island and Daniel Defoe’s Robinson Crusoe have been reported to be his favorites. He even fashioned his own boyhood Skinner box, a small enclosed space where he could read and dream. After leaving Susquehanna, Skinner became an undergraduate at Hamilton College in Clinton, New York. Suffering a lonely and miserable freshman year, he was befriended by a chemistry professor whose home was a mecca for intellectuals such as Ezra Pound and Robert Frost. Frost read one of Skinner’s short stories and encouraged him to be a writer. After graduating in 1926, he returned to live with his parents, who had moved to Scranton, Pennsylvania, and tried to write the great American novel. He discovered that he had nothing to say, moved to Greenwich Village for a brief time, gave up writing, and enrolled as a graduate student in psychology at Harvard. Almost immediately, he was drawn to the physiologist and Harvard professor William Crozier, who believed that real science involved controlling experimental variables and avoided all metaphysical assumptions. These concepts became the theoretical basis for Skinner’s behavioral science.

Skinner defended his doctoral dissertation, “The Concept of the Reflex,” in 1931, arguing that the mental reflex was always simply behavior and referring to the synapse as a philosophical concept. The prestigious Harvard Junior Fellowship allowed him to expand his work on behavioral science into his first book, The Behavior of Organisms, which was published in 1938. By then, he had married Yvonne Blue and had become the father of the first of two girls, Julie and Deborah. In 1936, he accepted his first academic position at the University of Minnesota. While at the University of Minnesota, Skinner became involved in “Project Pigeon,” a project that involved positively reinforcing pigeons to guide missiles or bombs in an effort to help the United States win World War II. After achieving tremendous accuracy, he unsuccessfully tried to convince the National Defense Research Committee that pigeon guidance was more accurate than the gyroscope system that had been developed during World War I. Nonetheless, Project Pigeon augmented Skinner’s conviction that a science of behavior could be of value in human affairs—even if indirectly. The transfer of reinforcement conditioning into the human social world marked a momentous shift in Skinner’s focus. It eventually brought him into contention with writers (e.g., Robert Wood Krutch and Ayn Rand) and psychologists, who believed that Skinnerian behavioral engineering of humans threatened traditional American beliefs about freedom and individual choice. Yet Skinner shared broad humanist values with these individuals. Whatever their essential disagreements, they all wanted to help people live better lives. They were all altruistic. In 1944, Skinner began work on another invention—the “Baby Tender” or “Aircrib”—the first that directly involved humans rather than pigeons. Indeed, the Baby Tender became the infant home for his second daughter, Deborah, for the first 2 years of her life. Skinner had noted that pigeons could be handheld and restrained but still be free to peck keys. He recalled that his first daughter, Julie, had been restrained by diapers and nightgowns and that she slept on a thick mattress zipped into a flannel blanket—a virtual prisoner in her own garb. But the Baby Tender allowed Deborah, clad in only a diaper, to have her own enclosed space with a large window and a stretch

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canvas bottom that could be removed and cleaned in seconds. The crib was equipped with thermostatically filtered air that prevented her skin from becoming contaminated with urine and sweat. Her mother could remove her from the Baby Tender for play or feeding at any time. Otherwise, she was comfortable and safe in her special crib. He sent an article, “Baby Care Can Be Modernized,” to Ladies Home Journal, which published it as “Baby in a Box” in October 1945. It brought Skinner national attention with two diverging reactions. Some criticized the device for restricting mother and child contact; others saw the crib as a progressive invention freeing both the baby and the mother. At the end of World War II, Skinner left the University of Minnesota for Indiana University, where he chaired the psychology department from 1946 to 1947. He returned to his alma mater, Harvard, as full professor in 1948, where he remained until his death in 1990. He remained fully involved in intellectual endeavors, publishing seven books and 30 articles. In 1971, his controversial book Beyond Freedom in Dignity appeared and created a firestorm of criticism. Skinner argued that only societies shaped by behavioral engineering could allow humanity to survive in a world increasingly fixated on individual freedom while looming catastrophes such as overpopulation, nuclear war, and ecological destruction grew ever nearer. As in his 1948 novel Walden Two, which created a fictional behaviorally engineered community, this best seller maintained that concepts such as freedom, consciousness, and God were simply entrenched myths that blinded humankind from understanding that only a behavioral science could save the human species. But some psychologists, such as Carl Rogers, who had debated Skinner earlier in 1956, asked if scientists were to control the future of humankind, who would control the scientists? The linguist Noam Chomsky, who reviewed Beyond Freedom and Dignity for the New York Review of Books, insisted that a genuine scientist would not dismiss the experimental study of self-consciousness and mental states. In September 1971, Skinner appeared on the cover of Time with the clearly negative caption “We Can’t Afford Freedom.” He also appeared on a number of television talk shows, such as William Buckley’s Firing Line, where he tried, mostly

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unsuccessfully, to defend his position. He remained unmoved by critics. In 1954, he visited a private school in Cambridge that his daughter Deborah attended. Observing that the teacher gave an assignment and then checked on the students to see how they were proceeding, Skinner noticed that some students finished quickly and were bored, whereas others were struggling to even get started. In an effort to devise a better way of teaching, Skinner developed a simple teaching machine in which a plastic slider covered the correct answer until the student wrote the correct answer and then moved to the next questions. The questions were sequenced with small gradations of difficulty so that most students had little problem with moving ahead in little steps. Getting the correct answer was the reinforcement that elicited movement of the slider to the next question. Although International Business Machines and several other large companies contracted Skinner to build a teaching machine, all rejected this slider model. In 1968, Skinner wrote The Technology of Teaching; however, it was not widely read among the general public. Later, Skinner agreed that the computer could do a far better job with programmed instruction than his simple slider machine. At the end of his life, suffering from leukemia, Skinner believed that human beings had passed the point of no return. Humanity had failed to implement a science that could ensure they had a future. He often noted that many psychologists understood that the brain originated mental life. But he argued that the brain was part of the body, and once you focus on the body, you should be focused on behavior and seek to change it. Daniel Bjork See also Behavior Therapies: Overview; Behavior Therapy; Cognitive-Behavioral Therapies: Overview; Cognitive-Behavioral Therapy; Ellis, Albert; Rational Emotive Behavior Therapy; Rogers, Carl

Further Readings Skinner, B. F. (1938). The behavior of organisms. New York, NY: Appleton-Century-Crofts. Skinner, B. F. (1948). Walden two. New York, NY: Macmillan. Skinner, B. F. (1953). Science and human behavior. New York, NY: Macmillan.

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Skinner, B. F. (1958). Verbal behavior. New York, NY: Appleton-Century-Crofts. Skinner, B. F. (1968). The technology of teaching. New York, NY: Appleton-Century-Crofts. Skinner, B. F. (1971). Beyond freedom and dignity. New York, NY: Knopf.

SOCIAL COGNITIVE THEORY Social cognitive theory is a comprehensive theory of human agency that examines the interlinkages between persons, behaviors, and environments. From this perspective, human behavior is viewed as the result of the interplay between intrapsychic factors within individuals and the broad range of social environments that impinge on them: (a) those environments that are imposed on them, (b) those they select, and (c) those they create. This theory was systematically articulated by Albert Bandura in his 1986 book Social Foundations of Thought and Action: A Social Cognitive Theory. Social cognitive theory has been applied in a variety of areas, including clinical, counseling, and educational settings; family processes; aggressive behavior; gender development; and morality—in fact, in almost every area of human conduct. In its application in therapeutic and counseling contexts, in keeping with the conceptualization of human functioning within the triadic model of reciprocal determinism, interventions are directed at personal, environmental, and behavioral factors. From this perspective, an intervention focusing on altering aggressive behavior in schools, for example, would involve teachers and counselors to modify emotional states and correct faulty beliefs about aggressive behavior (personal factors), improve interpersonal skills and ways of handling interpersonal conflict (behavioral factors), and modify classroom and school structures that contribute to aggressive behavior (environmental factors).

Historical Context Although social cognitive theory only dates to 1986, with the publication of Bandura’s book Social Foundations of Thought and Action: A Social Cognitive Theory, it had been in the making for many decades. Prior to this publication, Bandura’s writings and research had been captured

under the title of social learning theory. Social learning theory represented a wide range of viewpoints, and it became increasingly apparent to Bandura that his approach, which for some time had included psychosocial phenomena and selfregulatory processes that extended beyond learning principles, was not adequately covered by the descriptive label of social learning theory. He replaced the ill-fitting social learning theory label that had previously designated his work with the more general label of social cognitive theory. In the preface to his 1986 book, Bandura acknowledges the importance of both the social and cognitive aspects of human behavior, affect, and motivation. One of his first collaborations was at Stanford University with Richard Walters, which led to two major books—Adolescent Aggression (1959) and Social Learning and Personality Development (1963). In the latter book, Bandura and Walters presented a comprehensive account of social learning theory that addressed the development and modification of human behavior—moving from a behavioristic approach to a more cognitively based theory that took account of the social context in which behavior was performed. Even in the 1960s, the cognitive emphasis in Bandura’s approach was evident in his classic Bobo doll studies on children’s emulation of aggressive models and in his 1963 book with Walters, Social Learning and Personality Development. In his view of observational learning, for example, more attention was given to cognitive processes than was typical in most social learning theory approaches. He continued to develop the role of cognitive processes in human development and change; these processes were not disembodied from the experience of the individual but were embedded within the ongoing experiences of the individual. This approach paved the way for his placing human agency at the cornerstone of social cognitive theory. People were not only influenced by their environments, but they also selected and created them as they did their own destiny. Bandura introduced the term self-efficacy into the literature in 1977 in his publication “Self-Efficacy: Toward a Unifying Theory of Behavioral Change” and further expounded self-directedness in human functioning and the self-regulatory processes governing human behavior in his 1997 book SelfEfficacy: The Exercise of Control. Bandura’s early work bore the seeds for the later development of social cognitive theory, in which

Social Cognitive Theory

human functioning is conceived within the triadic model of reciprocal determinism, involving the interplay of personal, behavioral, and environmental factors. This, more cognitive approach to understanding human behavior also gave rise to the role of the self in guiding the course of human development, adaptation, and change. The importance of self reflection, self-regulatory processes, and self-organizing individuals who were not only reactive to their environmental circumstances but also proactively shaped their life course within sociocultural constraints was emphasized. In a departure from traditional behavioristic approaches to human functioning, Bandura acknowledged, along with his predecessor William James, the role of introspection and human thought in understanding human behavior. Social cognitive theory also differs from biological theories that emphasize the role of evolutionary forces. Instead, biological factors are viewed as interacting determinants of human behavior within the model of reciprocal determinism, not its sole determinants. And, as Bandura and Bussey noted in their 1999 article “Social Cognitive Theory of Gender Development and Differentiation,” environmental innovations and technological change create selection pressures for evolutionary change as much as evolved biological attributes dictate social behavior; both factors influence each other bidirectionally.

Theoretical Underpinnings In the social cognitive theory approach, greater attention is directed toward cognition than in the earlier, more behavioristic approaches of social learning theory. While behavior change is at the cornerstone of any therapeutic intervention from this perspective, achieving behavioral modification requires not only behavior change but also cognitive change, along with a consideration of the social context in which the behavior occurs. As already stated, this approach views the development, maintenance, and modification of human functioning within the triadic model of reciprocal causation. It is postulated that personal factors, environmental factors, and behavior influence one another bidirectionally. The personal factors comprise cognitive, affective, and biological events; the environmental factors refer to a range of social influences that people encounter in their daily lives; and behavior encompasses the broad range of activity patterns.

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There is no fixed manner in which these three sources of influence are expected to interact with one another. Although the interaction among the three sources of influence is bidirectional, the influence is not necessarily equal among sources, nor is it fixed. The way these variables interact with one another may vary in different contexts and at different phases in development. For example, in family contexts where rigid rules are enforced, there is little leeway for personal factors to exert a strong influence on individual behavior. Similarly, at the societal level, where there are authoritarian rules in place and many sociocultural constraints, there is little room for developing personalized life trajectories. In contrast, in more egalitarian families and societies, where less rigid lifestyles are prescribed, individuals are better able to personalize and direct their own life course. Therefore, the manner in which these three sources influence the course of development depends on the activities involved, the situation, and sociostructural constraints and opportunities. It is apparent that this model extends the conception of human development and functioning beyond any simplistic shaping by the environment. People are active contributors to their own development. Even in the most oppressive of circumstances, individuals are able to exert some influence over their life course. The environment is not a monolithic structure imposed on people that demands conformity. Rather, people are able to select alternate environments and even create their own environments. People who are shunned by some sections of society do not wait until similar others appear in their immediate environment. Instead, they seek out others who share similarities with themselves, and some may even embark on changing societal views. Although this approach recognizes individual and sociostructrual constraints in human adaptation and change, it also recognizes the agentic capabilities of individuals to direct and shape their life trajectories. From the perspective of this integrated theory, environmental influences operate through the self-system mechanisms to influence behavior. The manner in which environmental influences are synthesized determines future action, rather than environments acting in some unspecified omnipotent manner. Agentic control is largely exercised through the self-system mechanisms. Observational learning plays a central part in human development and change. Individuals can acquire new skills and change old habits through

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observing others, without having to undergo trialand-error learning or receive response consequences for their performances. By observing others and observing the outcomes associated with different performances, people learn those activities that are valued by others and that lead to rewarding outcomes and those that do not. In this way, individuals select suitable models consistent with their goals and the outcomes they hope to achieve. The self system is further evident in people’s self-regulatory capabilities. Internal standards are developed from a wide source of environmental influences and serve as a gauge against which to self-evaluate the anticipated behavioral enactment. People act in ways that bring anticipated selfsatisfaction and shy away from those activities that bring self-disapproval. In this way, people are motivated to behave in ways that are congruent with their internal standards. This self-directness is central to social cognitive theory. In keeping with this approach is the self-conception of self-efficacy beliefs, in which an individual’s behavior is motivated not only by societal and personal acceptance but also by whether one believes in one’s own capabilities to behave in a certain way independent of the actual skill levels attained. Perceived self-efficacy refers to a person’s belief in his or her ability to effectively perform a specified activity or to think in a particular way.

of influence to affect behavioral outcomes. These modes of influence and the major psychological processes of social cognitive theory are described in the following subsections. Modes of Influence

Modeling Modeling is a major mode for the acquisition of information and for behavior change. Bandura’s research on modeling has been crucial in delineating the psychological processes associated with learning from observing models. Consistent with the cognitive emphasis of this theory, Bandura specified attentional, retentional, production, and motivational processes that are involved in determining what is learned from observing models and what aspects of those performances are reproduced. His early research shunned the idea that modeling is mere mimicry. People are selective in what they learn from models and in what they decide to emulate. In a therapeutic context particularly, similarity between the model and the observer is one factor that leads to heightened observational learning and also reproduction of the modeled behavior. Modeling can be used to teach new skills, such as social skills, or to reduce anxiety-related disorders, such as phobias. Enactive Experience

Major Concepts The focus on human agency in this theory means that self-regulatory processes are pivotal in underpinning human behavior. These self-regulatory processes, while individually derived, are informed by the social environment. Different individuals who experience the same environment may develop different judgmental aspects of the self-regulatory processes depending on their experiences and how these experiences are synthesized. People are not simply conduits of their environmental experiences; they are active participants in shaping and selecting their experiences, which contribute to the range of variability in human functioning. The actual processes, however, remain invariant across individuals. The modes of influence that lead to acquiring new skills and behavior can also be used to modify behavior. From this theoretical viewpoint, it is possible to identify modes of influence as well as the psychological processes that enable those modes

Enactive experience involves abstracting the evaluative outcomes resulting from one’s actions. Evaluative outcomes for performing different behaviors provide a rich source of information about the social sanctioning of different types of conduct. Not only do different behaviors lead to different outcomes, but different people respond to the same behavior differently, with these outcomes often varying in different contexts. People extract, weigh, and integrate this diverse information to form their own expectations regarding the outcomes of different types of conduct. Direct Tuition Direct tuition is an instructional method for providing information about ways to behave in different situations. It is a method for informing people about the diverse forms of behavior and their suitability in different contexts. Tutoring can also be used to generalize the informativeness of specific

Social Cognitive Theory

modeled behavior and behavior outcomes for enactment in other contexts. It is most effective when it is based on shared values and weakened when what is being taught is contradicted by what is modeled. Regulators of Conduct

Social Outcome Expectations From the three modes of influence described above, individuals develop their social outcome beliefs. These beliefs are not simply transmitted in a wholesale manner but are constructed from these three modes of influence. According to social cognitive theory, these social outcome expectations influence behavior through their informational and motivational functions. People are motivated to perform those behaviors for which they anticipate receiving social approval and to shun those behaviors for which they anticipate receiving social disapproval. Self-Outcome Expectations Over the course of development, once personal standards for conduct are developed, self-sanctions are increasingly used to regulate conduct. The standards provide the guidance, and self-sanctions provide the motivation to behave in accord with the standards. Anticipation of self-censure for violating the standards aligns conduct with standards, whereas behaving in ways consistent with the standards brings self-satisfaction and a sense of self-worth. Self-Efficacy Beliefs Perceived self-efficacy refers to personal beliefs about performing specific actions in particular contexts as well as exercising control over thought processes, motivation, affect, and physiological states. These self-beliefs are linked to specific domains of functioning and are not global, traitlike assessments of capabilities.

Techniques The techniques that are used in treatment derive directly from the theoretical constructs of social cognitive theory. The major aim of therapeutic intervention from the social cognitive theory perspective is not simply to remedy a particular problem but to enable people to surmount future challenges by enhancing their knowledge,

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competencies, and resilient self-beliefs that will enable them to effectively exert control over their life course. The different classes of determinants and mediating mechanisms, which have already been discussed, come into play in varying ways in the therapeutic context, depending on the problem being addressed. Knowledge structures are scripts and self-schemata for behavioral enactment and rules of action that enable the development of complex behavioral competencies. These structures and competencies are acquired, adapted, and changed through observational learning, direct tuition, and enactive experience, as discussed previously. Apart from addressing the acquisition and modification of knowledge structures and competencies in the therapeutic context, it is necessary to address the role of regulators and motivators of human functioning, which are an integral part of social cognitive theory. These multilevel factors operate mainly through forethought. The ability to anticipate potential outcomes for pursuing a particular course of action is another way in which behavior is regulated and modified. The anticipated outcome expectancies include external outcome expectancies, vicarious outcomes, and self-evaluative reactions. It is the interplay of these different types of outcome expectancies that influences human functioning. Apart from therapeutic remediation to build skills and competencies, weak self-efficacy beliefs contribute to poor performances. There are four major sources that inform self-efficacy beliefs, and these can be used to strengthen them: (1) enactive mastery, (2) vicarious experience, (3) verbal persuasion, and (4) physiological and affective states. The first mode of influence, involving enactive mastery, provides the most authentic evidence of a person’s capabilities as this requires successful performance of the behavior to be mastered. The more individuals are successful in their performances, the greater the boost in confidence about their capabilities. However, in situations where skills need to be acquired or anxieties overcome, guided mastery is required for individuals to develop the required skills or to overcome self-debilitating thoughts, as in the case of phobic behavior. Enabling conditions that utilize mastery aids, joint performance of intimidating activities with a therapist, and breaking down intimidating tasks into manageable units of easily mastered steps help teach skills and boost confidence. Modeling can also be used to increase

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Social Cognitive Theory

competencies and people’s beliefs in their competencies to carry out the modeled activities. Vicarious experience, which involves seeing people who are similar to oneself master new skills or overcome fears, gives observers the belief that they too can perform successfully, thereby raising their self-efficacy beliefs. Verbal persuasion, although not as influential as enactive mastery in strengthening self-efficacy beliefs, can also be used to boost selfefficacy beliefs. When others convey confidence in a person’s abilities rather than doubt, self-efficacy beliefs can be strengthened, particularly when the persuasory information is realistic. By helping to allay self-doubts, people are able to strive more to develop new skills. Persuasory efficacy information can be provided in the form of evaluative feedback when a skill is being acquired. The manner in which the information is framed is crucial for its influence on self-efficacy beliefs and self-directed change, particularly when advocating healthpromoting behavior. The final source for creating and altering self-efficacy beliefs is physiological arousal and affective states. Somatic indicators and mood are often used to inform self-efficacy beliefs in various domains, including behavioral accomplishments, health functioning, and coping with stress. When people focus on their physiological stress reactions, less attention is directed to their performance. In addition, interpretation of these somatic indicators can influence self-efficacy beliefs. For example, the more that anxiety during a mathematical task is ascribed to lack of ability rather than to task difficulty, the more debilitating the effect on performance through weakening selfefficacy beliefs and creating self-doubts.

Therapeutic Process There is no set time or number of sessions required for the therapeutic process using social cognitive theory principles. There can be as few as two or three sessions and as many as a number of sessions lasting over several months. The aim of therapeutic intervention based on social cognitive theory is to develop competence and self-belief in one’s competence to perform the newly acquired behavior. Acquisition of new behavioral repertoires and thought patterns is not sufficient for termination of the therapeutic process. In addition, the development of the ability for self-regulative change, where individuals are able to exercise control over their

own thoughts and behavior and over the events in their lives, is necessary. Self-efficacy is the process that underpins the effectiveness of any form of treatment. From the social cognitive theory perspective, a range of treatments can be used. Intervention is not confined to individual or group interventions but can occur at the societal level. Modeling diverse behaviors through television drama series with varying levels of acceptance can change group behavior and thought patterns on a large scale. At the individual level, therapeutic programs can be tailored to individual needs, with the major goal being that of equipping the person with sociocognitive skills to deal effectively with future events that may arise. Kay Bussey See also Bandura, Albert; Cognitive-Behavioral Group Therapy; Cognitive-Behavioral Therapies: Overview; Mindfulness-Based Cognitive Therapy; Motivational Interviewing

Further Readings Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215. doi:10.1037/0033-295X.84.2.191 Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Freeman. Bandura, A., Ross, D., & Ross, S. A. (1961). Transmission of aggression through imitation of aggressive models. Journal of Abnormal & Social Psychology, 63, 575–582. doi:10.1037/h0045925 Bandura, A., Ross, D., & Ross, S. A. (1963). Imitation of film-mediated aggressive models. Journal of Abnormal & Social Psychology, 66, 3–11. doi:10.1037/h0048687 Bandura, A., & Walters. R. H. (1959). Adolescent aggression. New York, NY: Ronald Press. Bandura, A., & Walters, R. H. (1963). Social learning and personality development. New York, NY: Holt, Rinehart, & Winston. Bussey, K. (2011). The influence of gender on students’ selfregulated learning and performance. In B. J. Zimmerman & D. H. Schunk (Eds.), Handbook of self-regulation of learning and performance (pp. 426–441). New York, NY: Routledge. Bussey, K., & Bandura, A. (1999). Social cognitive theory of gender development and differentiation. Psychology Review, 106, 676–713. doi:10.1037/0033-295X.106 .4.676

Solution-Focused Brief Family Therapy

SOLUTION-FOCUSED BRIEF FAMILY THERAPY Solution-focused brief family therapy (SFBFT) is a brief, future-oriented, goal-directed, and pragmatic approach to family therapy and family systems work. This therapy is focused on identifying and punctuating families’ strengths to develop solutions to client-identified concerns. Treatment is typically short-term, and SFBFT has a growing evidence base demonstrating its efficacy with a wide array of demographics and symptomatology.

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innate strengths and previous successes. Accordingly, it is not necessary to understand the origins of the problem, how the problem developed, the nuances of what it looks like, or even how the problem is maintained in order to fix it. In fact, SFBFT believes that focusing on the problem will tend to maintain the problem and intentionally maintains a future-oriented approach that seeks to avoid problem-focused talk. These foundational beliefs keep the therapy present and future oriented with the goal of cocreating solutions to the “problem” as the family identifies it. These solutions, no matter how small, build momentum toward a realistic future that the family has defined as a better life.

Historical Context SFBFT was developed by Steve de Shazer, Insoo Kim Berg, and their colleagues at the Brief Family Therapy Center in Milwaukee, Wisconsin, during the 1980s through watching hundreds of tapes, identifying what was working, and doing more of it. Both de Shazer and Berg had been trained at the Mental Research Institute (MRI) in Palo Alto, California, and were greatly influenced by the MRI’s pragmatic and brief way of conducting therapy. What emerged was a therapy that focuses not on problems but on solutions and that has a strengths-based orientation, a present and a future focus, and a collaborative discovering of what is currently working and what can work in the future. From its inception, SFBFT was applied to families at an inner-city outpatient mental health center. Today, SFBFT is widely used in couples and family work.

Theoretical Underpinnings SFBFT falls under the social-constructivist metatheory as it believes that language used by the client and within the client’s social milieu is responsible for the construction of the client’s reality. SFBFT does not operate from a traditional theoretical conceptualization that endeavors to explain how systems and subsystems interact within families to maintain problem behaviors; instead, SFBFT is rooted in the belief that families are healthy and competent, know what is best for them, and have within them the resources to make the changes they need to make. As a result, SFBFT believes that the goal of therapy is not to solve or eradicate problem behaviors but to capitalize on the family’s

Major Concepts A number of core solution-focused tenets are the foundation of the SFBFT approach. The major concepts include the following: if it isn’t broke, don’t fix it; if something is working, do more of it; if it’s not working, do something different; small steps can lead to large changes; the solution is not directly related to the problem; the language to describe a solution is different from the language to describe a problem; no problem happens all the time, there are always exceptions; and the future is both created and negotiable. If It Isn’t Broke, Don’t Fix It

This refers to the fact that SFBFT focuses only on addressing what the family identifies as the problem. In this way, sessions are kept brief and don’t detour into a morass of past or problemoriented talk. If Something Is Working, Do More of It

The counselor’s job is to focus on and punctuate the family’s strengths. This tenet reminds counselors to believe in the inherent capabilities of a family and to allow the family to define and decide what is working and what will work in the future. If It’s Not Working, Do Something Different

This tenet reinforces that SFBFT does not blame the family when things do not go well. When interventions do not work or when family patterns

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persist that do not lead to change, the counselor does not explore why. Rather than engaging the family around the problem or dysfunction, the counselor maintains the focus on what did work and continues to cocreate solutions that may work in the future. Small Steps Can Lead to Large Changes

The focus in SFBFT is always on making small changes that move the family in the right direction. This tenet reflects the belief that the counselors are not the authority on what needs to happen and, as a result, do not push for larger scale change; rather, they help the family harness its strengths to make small changes that the family identifies as useful. SFBFT believes that small changes will lead to additional changes that naturally build momentum toward larger changes. The Solution Is Not Directly Related to the Problem

This tenet exemplifies SFBFT’s true departure from most therapies’ logic models. Typically, therapies start with an examination of the problem to understand how it was created or maintained. Once that is understood, the counselor can work to do something differently that will stop the mechanisms that maintain it. SFBFT counselors don’t believe that understanding the problem or its history is helpful in solving it. Furthermore, they don’t believe that the path to change has to have anything to do with the problem. The path to change is rooted solely in helping the family move forward by enacting solutions that capitalize on its inherent strengths. In this way, the family begins to change, and its ability to be healthy in any direction is enhanced. The Language to Describe a Solution Is Different From the Language to Describe a Problem

The language of problem-focused talk tends to be deficit oriented, rooted in the past, and immutable. The language of solutions tends to be the opposite; it tends to be positive, to be future oriented, and to imply that change is possible. The very core of this approach involves reframing the family’s problem by continually changing the language

used: Instead of deficits, the family talks about strengths; instead of a problem, there are solutions; instead of remaining mired in conflict, there are memories of successes. No Problem Happens All the Time, There Are Always Exceptions

According to SFBFT, problems can change and never happen all the time. This tenet focuses the counselor on finding exceptions to problems no matter how immutable they seem, leading to counselors actively listening for, punctuating, and encouraging the finding of exceptions to problems. The Future Is Both Created and Negotiable

This tenet reflects the underlying philosophy that people are not locked in a set of behaviors but are participants in constructing their reality. In this way, the world is a hopeful place where clients are capable of actively changing their lives. This tenet focuses treatment on working toward a realistic future that the family defines as a better life.

Techniques In SFBFT, several core techniques are utilized to facilitate client movement toward strength-focused and solution-oriented interactions. The major techniques are miracle questions, scaling, and listening for, finding, and punctuating solutions and exceptions. Miracle Questions

The miracle question is a technique that gets families to begin to think in terms of solutions. The counselor asks the members of the family to imagine that a miracle has happened and the problem that led them to the counselor’s office has disappeared overnight. The counselor then asks them to identify one thing that they notice that is different now that this miracle has occurred. By having family members describe one small thing that is different after the miracle has occurred, the counselor is getting them to begin to talk in the language of solutions and set manageable, solution-focused goals. This technique can be applied to the entire family, and the counselor then elicits collaboration

Solution-Focused Brief Family Therapy

or consensus on goals the family would like to work toward. If the miracle question is addressed to a family member individually, it can be used to help all members of the family begin to notice and support the individual in attaining these manageable goals. Scaling

Scaling is utilized as both an assessment of progress in the session and an intervention itself. In practice, it involves asking the family members to scale from 1 to 10 (where 10 indicates that everything is perfect and 1 is the worst it can possibly be) where they are at the moment and where they would like to be. That number then serves as the assessment of how the family is doing. As an intervention, the counselor helps the family members develop their answer and then asks them what would be different if they were one number higher. In this way, the counselor facilitates solutionoriented talk and gently pushes the family toward thinking about goals. The counselor can also use the technique over multiple sessions and compare the family’s change across sessions. If the family’s numbers increase, the counselor will ask, “How did you do that?” and build on the success. If the family’s numbers do not change, the counselor will ask, “How did you manage to keep your score the same?” And if the numbers decrease, the counselor can ask, “How did you manage to not have the number fall even further?” In each instance, the counselor is attempting to have the family members discuss in detail what they are doing right and where their strengths lie. Listening For, Finding, and Punctuating Solutions and Exceptions

This is a consistent part of the counselor’s work in SFBFT. The counselor is actively shaping and directing the session by listening for signs of previous solutions, finding exceptions to problems, and emphasizing them with enthusiasm and support. In this way, treatment is always moving away from problem-oriented talk and working toward developing strengths, focusing on how they can be applied to the present and future, and building practical solutions to collaboratively identified problems.

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Therapeutic Process As the name implies, SFBFT is brief and typically works with whoever attends the session. Counselors begin with a positive, solution-oriented stance that seeks to collaboratively determine both the pace and the content of the session. From the beginning, SFBFT counselors seek to shift the focus of the conversation from problem-focused talk to solution-focused talk by asking for and intentionally listening for statements about previous or current solutions or exceptions to the problem. As strengths and previous solutions are developed, the session moves to the current problem as the family defines it, occasionally using scaling techniques to identify the family’s view of the severity of the problem. From there, the counselor seeks to develop a measurable goal of what needs to happen for the family to feel that it is making progress. After the goal is established, the session is focused on cocreating with the family solutions that are practical and reasonable for the members to implement. Throughout this process, the counselor resists engaging the family system in accounts of what is not working and is actively engaged in finding solutions and exceptions to the problem behaviors. This parallels other family systems’ focus on not becoming enmeshed in dysfunctional family patterns and continually focuses treatment on working toward small successes that allow clients to improve their lives. John Dewell See also Brief Therapy; de Shazer, Steve, and Insoo Kim Berg; Solution-Focused Brief Therapy; Strategic Family Therapy; Structural Family Therapy; Systemic Family Therapy

Further Readings de Castro, S., & Guterman, J. T. (2008). Solution-focused therapy for families coping with suicide. Journal of Marital & Family Therapy, 34(1), 93–106. doi:10 .1111/j.1752-0606.2008.00055.x Conoley, C. W., Graham, J. M., Neu, T., Craig, M. C., O’Pry, A., Cardin, S. A., . . . Parker, R. I. (2003). Solution-focused family therapy with three aggressive and oppositional acting children: An N = 1 empirical study. Family Process, 42, 361–374. doi:10.1111/ j.1545-5300.2003.00361.x

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Solution-Focused Brief Therapy

Lee, M. Y. (1997). A study of solution-focused brief family therapy: Outcomes and issues. American Journal of Family Therapy, 25, 3–17. doi:10.1080/ 01926189708251050 Lipchik, E., Derks, J., Lacourt, M., & Nunnaly, E. (2012). The evolution of solution-focused brief therapy. In C. Franklin, T. Trepper, W. J. Gingerich, & E. E. McCollum (Eds.), Solution-focused brief therapy: A handbook of evidenced-based practice (pp. 3–19). New York, NY: Oxford University Press. Paylo, M. J. (2005). Helping families search for solutions: Working with adolescents. Family Journal, 13(4), 456–458. doi:10.1177/1066480705278687 Trepper, T. S. (2012). Solution-focused brief therapy with families. Asia Pacific Journal of Counseling and Psychotherapy, 3(2), 137–148. doi:10.1080/21507686. 2012.718285

SOLUTION-FOCUSED BRIEF THERAPY Solution-focused brief therapy (SFBT) is a postmodern constructivist approach to psychotherapy closely associated in its origins with the early development of family therapy. Steve de Shazer and Insoo Kim Berg, the two most significant figures in the approach, met in the mid-1970s at the Mental Research Institute in Palo Alto, California, where their mentor John Weakland and his colleagues, the Palo Alto Group, were founding their problem resolution brief therapy. Leaving Palo Alto in 1978, de Shazer and Berg set up the Brief Family Therapy Center (BFTC) in Milwaukee, Wisconsin, where, with a group of talented collaborators, they developed an approach that was to prove both challenging and increasingly influential. Currently, the influence of the solution-focused approach is found beyond psychotherapy in the fields of education, mental health, social work, coaching, leadership, and organizational development, utilized by many practitioners who would not describe themselves as psychotherapists. Central to the development of the approach were de Shazer’s commitment to minimalism, the paring away of all that appears to be unnecessary in the change process, and Berg’s emphasis on the centralizing of the client, an emphasis often expressed in terms of the aspiration to leave no footprints in the client’s life. Initially regarded by many as an

unwelcome challenge to mainstream thinking and practice, SFBT since its development has been incorporated into a new psychotherapeutic mainstream that has become more collaborative and more interested in brief interventions.

Historical Context At the point when de Shazer and colleagues set up the BFTC, their interest, following that of the Palo Alto Group, lay in problem patterns and how to interrupt them. The Palo Alto Group had developed the idea that problems are maintained by the repeated application of the wrong solution, and central to their approach was the idea that therapy needs to be directed toward creating the conditions under which clients do something different; anything different they proposed would disrupt the established problem pattern and create the possibility of a new pattern being established. However, as the BFTC team were focusing on problem patterns, they became aware of something that fundamentally shifted their approach and that can be seen as foundational in the development of what came to be termed solution-focused brief therapy—namely, that there are exceptions within every problem pattern. They noticed that clients spontaneously and almost invariably refer to times when the problem could have happened and did not, times when the problem happened but with less intensity or with shorter duration—in other words, times when things were better. Rather than writing these episodes off as chance events and thus essentially insignificant, the BFTC team came to see them as significant, as moments when the client already has a small part of a solution pattern. This transformed the way BFTC framed the interaction between the client and the therapist. Therapy was no longer focused on having the client do something different; rather, it began to focus on encouraging clients to do more of what they were already doing that was working. The influence of Milton Erickson is evident in the early version of SFBT, for example, in the therapist’s lack of interest in an explanation of why the problem is occurring or in the client’s psychological history. Neither the Ericksonian nor the SFBT approach has a framework for developing diagnoses or for hypothesizing about client problems. Additionally, both approaches share an interest in projecting the

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client into an imagined future using what Erickson described as the crystal ball technique and SFBT came to refer to as the miracle question. Both approaches are also interested in the construction of therapeutic tasks. Along with other innovations, the founders of SFBT brought a new way of thinking about the nature of therapy. The metaphor of therapy as conversation increasingly took center stage in the solution-focused literature. de Shazer reminded his readers that there are no wet beds in therapy, just descriptions of wet beds, and the therapist’s task is thus reframed, namely, to construct with the client a different sort of narrative, one that can be described as progressive rather than regressive. The central therapeutic preoccupation is to invite the client to describe life differently, a description based in solution talk rather than problem talk. The key themes of solution talk involve focusing on the client’s preferred future rather than the failed past, focusing on the client’s resources rather than the client’s deficits, focusing on progress rather than “stuckness,” and focusing on whatever the client is doing that is useful rather than the opposite. The task of the therapist is defined as inviting clients into a different conversation, helping clients shift from talking themselves into problems to talking themselves out of them. With this new way of thinking about therapy, a different conceptual framework was introduced by de Shazer as the underpinning of his approach. Erickson became less influential in the later development of SFBT; his place was taken by social constructionism, with de Shazer referring increasingly to Jacques Derrida, Michel Foucault, and, in particular, Ludwig Wittgenstein. Wittgenstein’s later philosophical writings, in particular his writings about language games, served de Shazer well as a way of conceptualizing the change process. Within this new perspective, solutions are viewed as interactionally constructed realities, emerging as the client and the therapist coconstruct new meanings in their talking together.

Theoretical Underpinnings de Shazer stated that there is no theory in the SFBT approach. Instead, he asserted that SFBT is merely a description of a way of talking with clients that is associated with clients making changes. The

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approach espouses no particular theory of the person, of human development, or of relationships. SFBT is not normative and does not claim to have any idea of how people should live their lives. It has no theory of problem beyond the most minimal idea, inherited from the Palo Alto Group, that people get stuck in their lives doing things that do not work for them and fail to notice what it is that they are doing that works, and indeed might work better if they were to do more of it. The approach has no formally delineated theory of change beyond the idea that as people describe their lives differently, this is associated with lived changes. While social constructionism and Wittgenstinian thinking are referred to in the key SFBT texts, both theories largely represent a post hoc attempt to explain why the approach works rather than an integral part of the model that has shaped the development of the practice.

Major Concepts Solution-focused brief therapy, as its name implies, is an outcome-focused approach. The therapist chooses to assume that every client is motivated and that clients are experts on their own lives, knowing both what they want from therapy and, in response to the therapist’s questions, the best way to achieve what they want. An Outcome-Focused Therapy

Most therapeutic approaches require some knowledge of the nature of the problem presented to proceed, but in this respect, SFBT differs. To determine the direction of the therapy, what is required is that clients specify what they want, their best hopes from the therapy. Merely telling the therapist the nature of the difficulty cannot serve to determine what it is that the client wants instead, because knowing what will not be happening tells one little about what will. The task for the therapist and the client is to construct together the preferred future, the life that will flow from the client’s best hopes being realized. SFBT is focused on the construction with the client of the desired outcome rather than deconstruction of the problematic present: It is an outcome-focused approach. Every question that the therapist asks must be connected to the client’s best hopes; if the question

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fails this test of legitimacy, it will be regarded as intrusive and impositional. Some clients require the therapist to hear something of their distress prior to moving with the therapist into solution talk; when so required, a solution-focused brief therapist will hear, acknowledge, and validate the client’s distress without asking questions about it, which might serve to detain the client in problem elaboration. Questions as Invitations

At the heart of SFBT lies a structured set of questions that the therapist deploys flexibly, in a way that fits sufficiently with the client’s responses such that they make sense to the client and also serve to move the conversation in the direction of solution talk. In asking these questions, the therapist is not trying to make sense of the client’s situation or, indeed, to make sense of the client. The therapist attends to the client’s responses to build the platform for the next question, each question building on the client’s previous answer. Questions are conceived as invitations to clients to describe their lives in a particular way, rather than as tools to seek deeper information about their lives. Theoretically, a client who remains silent while answering the questions privately might derive as much benefit from the process as a client who answers out loud (although silent responses make it impossible for the therapist to craft the next question in a way that is delicately attuned to the client’s last answer).

cooperate leaves the therapist with the onus of finding a way of working with and fitting with the client’s response. Clients Are the Experts on Their Own Lives

SFBT proposes that only clients can know what they want from therapy and only clients can describe the lives that they want. Furthermore, the approach assumes that clients will have their own best ways of building their preferred futures, even if at the outset of therapy that is not clear to them. The approach seeks in this way to centralize the client, restricting the role of the therapist to the asking of useful questions and to the creation of the conditions within which it will be possible for the client to work. The therapist’s expertise in SFBT is largely conversational, centered on a capacity to engage clients in this specific conversational process. When therapists feel that they have been unable to help a client find a way forward, they may be tempted to make suggestions; however, this usually involves their stepping away from truly solution-focused work.

Techniques SFBT is a highly disciplined conversational process using a range of specific questions that serve to shift clients’ attention and to engage the client in solution talk. The shift of attention is enhanced and amplified by the therapist’s use of selective summarization, by end-of-session suggestions, as well as by the therapist’s focused listening.

Every Client Is Motivated

Solution-focused brief therapists assume that every client wants something as a consequence of meeting with a therapist. The question facing therapists is to discover what it is that their clients want and to put this at the center of the work. The more therapists stay connected to what clients want, the more clients will appear motivated. In a similar way, de Shazer announced early in his work the death of resistance, and consequently, SFBT has no concept of client-based resistance. Every client, de Shazer argued, shows a unique way of attempting to cooperate, and the therapist’s job is to cooperate with that way. Framing the client’s response, whatever it might be, as an attempt to

Listening With a Constructive Ear

Eve Lipchik, one of the original members of the BFTC team, coined the phrase listening with a constructive ear. She proposed that there is a difference between hearing and listening. In SFBT, the therapist hears whatever the client requires to be heard but focuses his or her attention and listening specifically on those things that fit in with the likelihood of progress on the client’s part, namely, strengths, competences, resources, and capacities. This process is continuous and foundational and serves to construct an appreciative context for the conversation, which in turn is associated with enhanced flexibility on the client’s part.

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Questions

The core of solution-focused practice resides in questions and the capacity of the therapist to invite the client into detailed descriptions that will typically take the client beyond the previously thought and previously articulated material. This process requires a capacity on the therapist’s part to slow down clients’ responses with simple requests for more detail: for example, “What else and how else might you know and who else might notice . . . ?” Solution-focused questions can be subdivided into three major groupings: (1) future-oriented questions, (2) present- and past-oriented questions, and (3) progress-oriented questions. Future-oriented questions enable the therapist to establish a contract for the work, to find out what the client wants, and then to support the client in describing how life will be different when the contract is achieved. Asking about clients’ best hopes from the work together represents the starting point for most solution-focused conversations, and once established, enquiring of clients how they will know that their best hopes are happening allows for the detailing of that picture. The miracle question is just one such future-focused question, typically framed as follows: Imagine you go home from here, do what you have to do for the rest of the day, and at some point you go to bed and go to sleep. And while you are asleep a miracle happens, and as a result of the miracle, your best hopes from coming here all happen, just that since you are asleep you can’t know that the miracle has happened. When you wake up tomorrow how will you know? What will be different that will tell you that a miracle has happened?

The question is intended to support the development of a detailed picture of the client’s preferred future. Asking questions from the perspectives of those most closely associated with clients and how those people will respond differently when progress is occurring facilitates the development of detail and creates an interactional richness in the description, embedding the preferred future into the network of relationships at the heart of the client’s life. With present- and past-oriented questions, the solution-focused therapist is interested in instances and exceptions, times when even small elements of

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the preferred future are happening and times when the problem is less dominating of clients’ lives. Having established such moments, the solutionfocused therapist invites clients to consider what they have done to bring such moments about (strategy questions) and what they might have drawn on to do so (identity questions). Clients are invited to discover themselves in their successes. In addition, solution-focused therapists ask progress-oriented questions that invite clients to notice any possible progress made. Pretreatment change questions serve to draw clients’ attention to differences already occurring prior to arriving for their first meeting. Other progress questions, such as scale questions, are used to make clients’ progress toward their preferred futures more visible, and each follow-up meeting will start with the question “What has been better since we last spoke?” This question shapes the direction of clients’ attention and will often have been preceded by an invitation to the clients between sessions to pay attention to anything that is moving in their preferred direction. Solution-Focused Summary and Suggestion

Typically, solution-focused sessions end with the therapist summarizing what the client has said that fits with the idea that change is expectable. This summary might include strengths and capacities that the client has noticed and named during the meeting, whatever the client is doing that is useful, signs of hope, instances, and exceptions. The therapist may then offer the client a minimally interventive noticing suggestion, inviting the client to pay careful attention to signs of progress and what it is that the client is doing that is associated with this progress.

Therapeutic Process SFBT is not a time-limited process. de Shazer defined the word brief in the approach’s title as meaning “as long as it takes and not one session more.” Clients are involved in determining the gaps between sessions, which typically tend to be longer than is characteristic of other therapies, such that a four-session therapy might take place over a period of 8 weeks or more. Presently, there is no evidence of problem presentations for which

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SFBT is significantly less effective, and there are therefore no exclusion criteria and no need for a therapeutic assessment prior to commencement. As clients determine the contract—that is, what they want from the work—so clients also determine when they are ready to finish, with a typical attendance of between three and four sessions. Solution-focused client descriptions are tentative and provisional—today’s picturing of how tomorrow might look when clients’ lives are moving in the direction of the preferred future. There is no attempt by the therapist to get people to change, no action planning, just a supportive and persistent process of inquiry that seeks to engage clients’ attention on where they might want to go and what they are already doing that is useful. The client’s pathway toward change is unpredictable, and neither the client nor the therapist can know what steps the client will take until they are taken. Evan George, Chris Iveson, and Harvey Ratner See also Constructivist Therapies: Overview; de Shazer, Steve, and Insoo Kim Berg; Narrative Therapy; Palo Alto Group; Solution-Focused Brief Family Therapy; Strategic Family Therapy

Further Readings Franklin, C., Trepper, T. S., Gingerich, W. J., & McCollum, E. E. (Eds.). (2012). Solution-focused brief therapy: A handbook of evidence-based practice. New York, NY: Oxford University Press. Iveson, C., George, E., & Ratner, H. (2012). Brief coaching: A solution focused approach. London, England: Routledge. Ratner, H., George, E., & Iveson, C. (2012). Solution focused brief therapy: 100 key points and techniques. London, England: Routledge. de Shazer, S. (1984). The death of resistance. Family Process, 23, 11–17. doi:10.1111/j.1545-5300.1984 de Shazer, S. (1985). Keys to solution in brief therapy. New York, NY: W. W. Norton. de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York, NY: W. W. Norton. de Shazer, S. (1994). Words were originally magic. New York, NY: W. W. Norton. de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W., & Weiner-Davis, M. (1986). Brief therapy: focused solution development. Family Process, 25, 207–221. doi:10.1111/j.1545-5300.1986 .00207.x

de Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum. E., & Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy. New York, NY: Haworth Press.

SOMATIC EXPERIENCING Somatic Experiencing® theory is premised on the idea that trauma affects the brain, mind, and body. However, the body is often neglected in the psychotherapy of trauma. Somatic Experiencing teaches that trauma is not caused by the event itself but, rather, develops by the failure of the body, mind, spirit, and nervous system to process extreme adverse events. Many approaches to treating trauma aim to correct faulty cognitions and/or access and express emotional content. In contrast, the approach presented here engages the “Living Body,” through contacting primal sensations that support core autonomic self-regulation and coherence. Work at this level allows the body to speak its mind. In doing this, the processing moves upward from these core sensations toward feelings or emotions and cognitions. This way, both the mind and the body are given an equal place in an integrative and holistic treatment of trauma.

Historical Context In the early 1970s, Somatic Experiencing was developed by Peter A. Levine, a biophysicist and stress researcher, who received his doctorate in medical biophysics from the University of California, Berkeley, in 1977 and then in psychology from the International University in 1979. Levine’s clinical work began in the late 1960s with a private practice focusing on mind–body awareness and stress reduction. He refined his techniques to specifically engage humans’ innate capacity to rebound from exposure to life threats and in response to overwhelming events. As an ardent student of naturalistic animal behavior (ethology), he recognized that animals in the wild exhibited an apparent immunity to becoming traumatized. Combining this understanding with his studies of comparative neurophysiology, Levine realized that, as part of the animal kingdom, humans utilize the same parts of the brain to mediate survival instincts

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and behaviors. He reasoned that the human animal should exhibit the same capacity to rebound from threatening encounters. Through mind–body awareness, Somatic Experiencing evolved to help people tap into the same innate resilience. Somatic Experiencing is taught worldwide and has been shown to be effective in mental health, medicine, physical and occupational therapies, bodywork, addiction treatment, education, as well as community leadership.

Theoretical Underpinnings Somatic Experiencing offers a framework to assess where a person is “stuck” in the fight, flight, freeze, or collapse responses to threats and provides clinical tools to resolve these fixated psychophysiological triggers. When acutely threatened, we mobilize vast energies to protect and defend ourselves. Our muscles contract to fight or flee. However, if our actions are ineffective, we freeze or collapse. This “last-ditch” innate defense of shutdown, when observed in animals, is called tonic immobility and is meant to be a temporary state of paralysis. A wild animal exhibiting this acute physiological shock reaction will either be eaten or, if spared, resume life as before its brush with death. Humans, in contrast to other animals, frequently remain stuck and do not fully reengage in life after experiencing overwhelming threat. Through rationalizations, judgments, shame, enculturation, and fear of our body sensations, we are able to disrupt our innate capacity to self-regulate, essentially “recycling” disabling terror and helplessness. Traumatized individuals exhibit a propensity for freezing in situations where a nontraumatized individual might only sense danger or even feel some excitement. Instead of being a last-ditch reaction to inescapable threat, paralysis becomes a “default” response to a wide variety of situations in which one’s feelings are highly aroused. For example, the arousal of sex may turn unexpectedly from excitement to frigidity, revulsion, or avoidance. If the nervous system does not reset after an overwhelming experience, then cardiovascular, digestive, respiration, immune, and sleep system functions become disturbed. Unresolved physiological distress can also lead to an array of cognitive, emotional, and behavioral symptoms.

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Major Concepts Somatic Experiencing facilitates the completion of self-protective motor responses and the release of thwarted survival energy bound in the body, thus addressing the root cause of trauma symptoms. This is done by gently guiding clients to develop increasing tolerance for difficult bodily sensations and suppressed emotions. It is critical to resolve the biological shock reactions and then, secondarily, process related emotions, perceptions, and cognitions. This entails bringing the client out of immobility and into the active, empowered defensive responses that were lacking at the time of the traumatic experience. Another key concept in Somatic Experiencing is to not retraumatize the client by exposing the client’s experience too rapidly or too intensely. To do this, the therapist must accurately track the client’s inner experience. Levine developed SIBAM to chart this “bottom-up” process, working from the body to emotions and cognitions. SIBAM is an acronym for sensation (internal-interoceptive), image, behavior (both voluntary and involuntary), affect (feelings and emotions), and meaning (including old or traumatic beliefs and new perceptions). These five elements are the channels of experience that occur during a session. Therapists first work with sensation and image, then move into behavior and affect, which then provides new meaning for the client. Being able to track the client’s channel allows the therapist to use the appropriate language. For example, to respond to the traumatic belief “I am a bad person,” an appropriate response might be “Oh, so you have the thought that you are a bad person,” that is, normalizing that this is an (potentially neutral) observation and then reflecting, “Where in your body do you notice that?” Somatic Experiencing catalyzes corrective bodily experiences that contradict those of fear and helplessness while resetting the nervous system, restoring inner balance, enhancing resilience to stress, and increasing people’s vitality, equanimity, and capacity to actively engage in life.

Techniques When working with traumatic reactions, such as states of intense fear, Somatic Experiencing provides therapists with nine essential building blocks.

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In therapy sessions, these steps are intertwined and dependent on one another and may be accessed repeatedly and in any order, although Steps 1 through 3 must always be present.

immobility response is the key both to avoiding the prolonged debilitating effects of trauma and to healing even entrenched symptoms. Step 7: Resolve Hyperarousal States

Step 1: Establish an Environment of Relative Safety

The therapist must help create an atmosphere that conveys refuge, hope, and possibility. For traumatized individuals, this can be a delicate task. Step 2: Support Initial Exploration and Acceptance of Sensation

Traumatized individuals try to escape their internal sensations. However, without these primal sensations, instincts, and feelings, they are unable to orient to the here-and-now. Therapists must be able to help their clients self-soothe and befriend their bodily sensations. Step 3: Establish “Pendulation” and Containment: The Innate Power of Rhythm

While trauma is about being frozen or stuck, pendulation is the constant shift between pleasant and unpleasant felt experience. No matter how horrible one is feeling, those feelings can and will change. This helps the client to “contain” strong feelings and sensations so that they can be experienced without causing further dissociation. Step 4: Implement Titration

Titration is about carefully touching into the smallest “drop” of survival-based arousal, and it helps prevent retraumatization. Step 5: Replace Passive With Active Responses

This technique provides a corrective experience by supplanting the passive responses of collapse and helplessness with active, empowered, and defensive responses. Step 6: Uncouple Fear From Immobility

This technique separates the conditioned association of fear and helplessness from the (normally time limited but now maladaptive) biological immobility response. The “physiological” ability to go into, and then come out of, the innate (hardwired)

This step aims to resolve hyperarousal states by gently guiding the “discharge” and redistribution of the vast survival energy mobilized for lifepreserving action. This is often experienced as waves of gentle involuntary shaking and trembling, followed by changes from tight, shallow breathing to deep, spontaneous, and relaxed breathing. Step 8: Engage Self-Regulation

In this step, self-regulation is engaged to restore “dynamic equilibrium” and relaxed alertness. Step 9: Orient to the Here-and-Now

In this final step, the therapist helps the client orient to the here-and-now, contact the environment, and reestablish the capacity for social engagement.

Therapeutic Process The following vignette illustrates how Somatic Experiencing can be applied in practice, in this case to help treat a survivor of the terrorist attacks on the World Trade Center on September 11, 2001: Sharon was working on the 80th floor of the north tower of the World Trade Center the morning of 9/11. After witnessing the walls in her office moving 20 feet in her direction, Sharon mobilized immediately, springing to her feet and readying to flee for her life. However, she was slowly and methodically led down 80 floors via stairwells filled with the suffocating, acrid smell of burning jet fuel and debris. After she finally reached the mezzanine 80 minutes later, the south tower suddenly collapsed. The shock waves lifted Sharon into the air, throwing her violently on top of a crushed bloody body. An off-duty police detective discovered her and helped her find her way out of the wreckage and away from the site, through absolutely thick, pitch blackness. In the weeks following her survival, a dense yellow fog enveloped her in a deadening numbness. Sharon felt indifferent by day; merely going through the motions of living, with little passion.

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Her great passion for classical music, no longer diverted her; she could no longer stand listening to it. While she was numb most of the time, at night she was awakened by her own screaming and sobbing. For the first time in her life, this once highly motivated executive could not imagine a future for herself; terror had become the organizing principle of her life. Seeking the help of a therapist, Sharon tells the therapist about the horrors of the event, blandly, as though it had happened to someone else. The therapist notices a slight, expansive gesture made by Sharon’s arms and hands. To the therapist, Sharon’s body is telling another story, a story that is hidden from her mind. Perplexed at first, Sharon describes the gesture as though she is “holding something.” Unexpectedly, a fleeting image of the Hudson River appears in her mind’s eye. Sharon becomes agitated as she tells her therapist how she is haunted by the smoldering smoke plumes. They evoke the horribly acrid smells from that day; she feels a burning in her nostrils. Rather than letting her go on “reliving” the traumatic intrusion, the therapist firmly contains and coaxes her to also continue focusing on the sensations of her arm movements. A spontaneous image emerges in Sharon’s mind, one of boats moving on the river. They convey to her a comforting sense of timelessness, movement, and flow. “You can destroy the buildings but you can’t drain the Hudson,” she pronounces softly. Then, rather than going on with the horrifying details of the event, she describes (and feels) how beautiful it had been when she had set out for work on that “perfect autumn morning.” She becomes aware of a sense of relief. As she looks quizzically at her hands, first one then the other, both she and her therapist breathe a sigh of relief. Sharon can now begin to stand back and “simply” observe these difficult, uncomfortable, physical sensations and images without becoming overwhelmed by them. When the first plane hit the building, only 10 stories above her office, the explosion sent a shock wave of terror through her body. Sharon needed to inhibit the primal urge to run and walked in an orderly line down the stairs along with dozens of other terrified individuals; this was the case, even though her body was “adrenaline charged” to run at full throttle. In following her “body story,” islands of safety begin to form in Sharon’s stormy trauma sea. As she attends to this

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“felt sense,” she becomes aware of an overall feeling of agitation in her legs and arms and tight “lumps” in her gut and throat. In suspending the compulsion for understanding, she experiences a sudden burst of energy, which she describes as “coming from deep inside my belly; it’s red, bright red, like a fire.” Her experience then shifts into (what she recognizes as) a strong urge to run, concentrated in her legs and arms. She feels this as a release of energy and exhilaration. When she eventually reached the mezzanine, the south tower collapsed, and she was thrown violently into the air. Finally, there was the stark horror of finding herself lying semiconscious on a dead body. With the new resources she has gained, Sharon is now able to process the emotional reality of this horror. Sharon no longer feels trapped in the anguish of the event; it has begun to recede into the past, where it belongs. It is now possible for Sharon to travel on the subway to hear her favorite music at Lincoln Center. Life is beginning again.

Peter A. Levine See also Mindfulness-Based Stress Reduction

Further Readings Levine, P. A. (1996). Waking the tiger, healing trauma. Berkeley, CA: North Atlantic Books. Levine, P. A. (2010). In an unspoken voice: How the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books. Van der Kolk, B. (2014). The body keeps the score: Brain, mind, body in the healing of trauma. New York, NY: Viking Adult.

Website Somatic Experiencing Trauma Institute: www .traumahealing.com/

STATUS DYNAMIC PSYCHOTHERAPY Psychotherapists’ primary time-honored paths to change have been through modifying their clients’ behaviors, cognitions, insights into unconscious factors, and patterns of interaction with significant others. Status dynamic psychotherapy (SDP) presents a further—and complementary—therapeutic

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option: that of bringing about changes in clients’ statuses, which, as employed in SDP, means relational position or place.

Historical Context Status dynamics is the creation of Peter Ossorio (1926–2007), professor of psychology at the University of Colorado. It represents the clinical applications of his much larger system, descriptive psychology, which was originally formulated in the late 1960s and developed continually since that time. An extremely broad range framework, descriptive psychology has been applied to psychotherapeutic practice and to a wide array of clinical problems, including posttraumatic stress disorder, depression, and eating disorders. Nonclinically, it has been applied to diverse enterprises such as organizational functioning, human spirituality, and artificial intelligence programs for NASA.

Theoretical Underpinnings SDP is concerned with clients’ statuses as crucial determinants of the range of behaviors in which they are able to participate. All individuals occupy a variety of positions in relation to everything in their world, and these are their statuses. In psychotherapy, statuses that frequently come into play include clients’ actual and perceived positions in relation to (a) themselves (e.g., imposer of degrading labels on themselves such as “worthless”), (b)  significant others (e.g., victimized by some other), (c) their presenting concern (e.g., helpless victim of a mental disorder), or (d) society (e.g., stigmatized as “mentally ill”). From a clinical perspective, the crucial point of focusing on clients’ statuses is that the occupation of certain relational positions restricts clients’ ability to act—their behavior potential—while the occupation of others expands this potential. From one position, they are unable to exercise power or control over their problems and/or deem themselves ineligible to act in needed ways. From another position, these barriers do not exist, and they are able to exercise such power. In SDP, therapists use this fact about statuses, and the behavior potential inherent in them, to benefit their clients. The primary goal is to bring about positive change through empowering status assignments—essentially, assisting clients in

recognizing and occupying positions of enhanced power and eligibility from which they can act to bring about desired changes. Such “repositioning” of clients is different from (while being complementary to) historically preferred strategies such as modifying clients’ cognitions and behavioral competencies.

Major Concepts Key major concepts of SDP include status, behavior potential, status assignment, and world, all of which are articulated elsewhere in this entry.

Techniques Repositioning Victims as Perpetrators

Psychotherapy clients often hold victim formulations of their problems. That is, they conceive their position in relation to their problems in such a way that the problem’s source, and thus resolution, is seen as lying outside their personal control. This problem source may be seen as something personal (e.g., a mental disorder) or something environmental (e.g., the unchangeable character of a significant other). In either case, it is seen as something that is not subject to the client’s personal control, and the client’s perceived status is thus that of a helpless victim. SDP presents a general strategy for repositioning clients in the grip of such victim formulations. This strategy includes, first of all, assessing to determine if in fact these clients occupy heretofore unrecognized positions of power and control vis-à-vis their problems. If such positions are discovered, the strategy then involves reframing their problems into perpetrator formulations—redescriptions that articulate their positions of power—and presenting these to clients. Finally, the strategy entails assisting clients in approaching their problems from this new and different position of enhanced power and control. For example, a young bulimic woman, Laura, initially experienced herself as the helpless victim of inexplicable compulsions to binge. On assessment, it became clear that she occupied a different, far more powerful position, that of a harsh, restrictive, pleasure-denying regulator of herself, whose self-imposed regimen was resulting in the selfrebellious behavior of binge eating. Therapeutic

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efforts in Laura’s case subsequently focused primarily not on her eating behavior but on getting her to attack her problem from this high power position of harsh self-regulator and from this position working to modify her modes of selfmanagement. Successful achievement of this objective resulted not only in her adoption of more benign and effective ways of regulating herself but also in the cessation of her bingeing and purging. Other Features of SDP

SDP embodies many further features that, due to space limitations, cannot be covered here. These include (a) a different approach to the therapeutic relationship wherein nine different statuses are assigned to clients on an a priori basis; (b) a new formulation of the self-concept, as well as interventions designed to circumvent its notorious resistance to change in the face of disconfirming facts; (c) a unique approach to therapeutic storytelling; and (d) a large set of therapeutic policies—that is, general guidelines or choice principles for the effective conduct of psychotherapy.

Therapeutic Process In SDP, the therapeutic process is threefold. It consists, first of all, in assessing the client’s world, conceived here as coming to an understanding, both empathic and objective, of this world and of the client’s perceived status/position within it. Second, it involves figuring out why and in what respects the client’s current status has rendered this world problematic for him or her. Third, it involves helping the client reconstruct his or her world in such a way, focusing heavily on status change, that it can be rendered no longer problematic. Raymond Bergner See also Brief Therapy; Cognitive-Behavioral Therapy; Solution-Focused Brief Family Therapy; SolutionFocused Brief Therapy

Further Readings Bergner, R. (2007). Status dynamics: Creating new paths to therapeutic change. Ann Arbor, MI: Burns-Park. Ossorio, P. (1997). Essays on clinical topics: The collected works of Peter G. Ossorio (Vol. 2). Ann Arbor, MI: Descriptive Psychology Press.

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Website Index of SDP Papers: www.sdp.org/sdp/papers/

STORYPLAY THERAPY StoryPlay® therapy is an Ericksonian, resiliencybased, indirective model of play therapy that interweaves cultural diversity, metaphor, natural healing abilities, and creativity to effect transformational change, healing, and problem solving for children, adolescents, families, and communities who have experienced trauma, grief, disaster, adversity, or loss. Because play is the language of children and creativity is the language of play, the StoryPlay model unites these pivotal elements to form a tapestry of unique methods for moving past the limitations of diagnostic labeling to access and reawaken the resilient child within.

Historical Context In response to Hurricane Iniki, a catastrophic natural disaster that devastated the island of Kaua’i, Hawaii, on September 11, 1992, Joyce Mills developed a community-based program to meet the needs of the children, youth, and families on the west side of the island. Along with local elders and community residents, natural healing activities were implemented on a weekly basis. The foundation of these activities was stories. These stories provided cultural appreciation and, at the same time, activated a process of healing for those who participated. For example, children were told a resiliency-focused cultural story and then were given art materials to use to create a symbolic representation of the story. They were never told to talk about the hurricane, yet, while they were together, they talked and supported one another in ways that were not directed. The premise was to reconnect them with their inner strengths so that they could discover new possibilities for healing from the trauma. This was the basis of what eventually became known as StoryPlay. Today, aspects of StoryPlay have been used in a variety of settings and modalities, including individual, group, hospital, classroom, sand tray, music, and art therapies. Centered on activating the resiliency pathway within each client, the approaches

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implemented in StoryPlay are designed to transform posttraumatic stress disorder into posttraumatic stress healing. These approaches are indirect and differ greatly from the dominant debriefing models often used after a trauma or disaster. No one is asked to relive a traumatic event in any way. Instead, clients are provided with natural healing activities that use creativity, metaphor, and cultural wisdom to facilitate reconnection to inner strengths and resources.

artistic metaphors, breathing and relaxation exercises, sensory synchronicity, wellness and balance, and therapeutic rituals and ceremonies. Therapeutic Metaphors

Real-life, made-up, and myth stories are created and utilized to open new pathways for healing and problem solving. Story Crafts

Theoretical Underpinnings The difference between StoryPlay and other models of play therapy is the recognition, development, and utilization of indirect suggestions to facilitate positive unconscious associative patterns for transformational change. This is a direct application of Milton Erickson’s use of indirect suggestions that spoke to the client’s unconscious mind rather than seeking conscious awareness. Interspersing indirect suggestions when a child is playing allows the child to continue to be absorbed in the play activity while, at the same time, receiving the suggestions developed in accordance with what the child needs to heal or reach his or her full potential. The following provides an example: A child is playing in the sand tray with miniature horses he has taken from the box of horses. In a directive model, the therapist might say, “We can also build a coral for the horses in which they can sleep.” In a nondirective model, the therapist might say, “You are playing with the horses.” In the indirective StoryPlay model, the therapist might say, “I wonder how many things those horses will discover as they are playing in the sand.” Rather than telling the child what to do with the horses or repeating back to the child what the therapist observes, the StoryPlay therapist intersperses the indirect suggestion “how many things those horses will discover” while the child is playing. The suggestion is meant to activate the possibilities of new discoveries within the child and implies that there will be new discoveries.

Techniques The interventions include the development and utilization of therapeutic metaphors, story crafts,

These are a series of natural healing activities that expand therapeutic stories and metaphors into artistic expression. Artistic Metaphors

These specific drawing strategies are used to assist in pain and fear management, to facilitate transformational healing from trauma, and to improve problem-solving skills. Breathing and Relaxation Exercises

The Magic Happy Breath, Mini-mind Vacation, and Heartsong Mediation are some of the exercises designed to reduce stress, help with selfdisregulation issues, and assist with issues related to attention-deficit/hyperactivity disorder. Sensory Synchronicity

With sensory synchronicity, particular approaches are utilized to help the therapist identify a child’s sensory system that is a strength and a sensory system that may be blocked because the child experienced traumatic events, learning challenges, or a physical illness. Wellness and Balance

Wellness and balance refers to an exercise that facilitates the need for recognition of self-care in four areas of functioning: mental, emotional, physical, and spiritual. Therapeutic Rituals and Ceremonies

Based on respect for a client’s multicultural values and principles, rituals and ceremonies are

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cocreated with clients to meet their individual needs.

Therapeutic Process Rather than focusing on reliving the problem or trauma, StoryPlay utilizes the inner resources, gifts, and strengths of each child, adolescent, family, and community to help them heal from and overcome adversity. Each session is designed to meet the individual needs of the client. The recognition and utilization of inner resources and strengths is the centering focus of each session. The sessions are from 60 to 90 minutes in accordance with the client’s need. The length of treatment varies as well. There is a closure session, which includes the cocreation and use of therapeutic ritual and ceremony in accord with cultural and spiritual beliefs. Joyce C. Mills See also Erickson-Derived or -Influenced Theories: Overview; Ericksonian Therapy; Hypnotherapy; Nature-Guided Therapy; Neuro-Linguistic Programming; Play Therapy; Positive Psychology; Possibility Therapy; Self-Relations Psychotherapy

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STRATEGIC FAMILY THERAPY Developed by Jay Haley and later by Cloe Madanes, strategic family therapy is an outgrowth of the work of the psychiatrist Milton Erickson. A primary feature of this therapy is that the responsibility is on the therapist to plan a strategy for solving the client’s presenting problems or symptomatic behavior. In this process, the therapist sets clear goals, which always include solving the presenting problem. The emphasis is not on a method to be applied to all cases but on designing a strategy for each specific problem. Because the therapy focuses on the social context of human dilemmas, the therapist’s task is to design an intervention in the client’s social situation. Therapy is planned in steps to achieve the goals, and every problem is defined as involving at least two or three people. Interventions usually take the form of directives about something that family members are to do, inside and outside the therapy session, with the focus being on how people communicate with one another, the use of metaphors and analogies, and the hierarchical organization of the family.

Further Readings Hines, P., Mills, J. C., Bonner, R., Sutton, C. E., & Castellano, C. (2007). Healing and recovery after trauma: A disaster response program in first responders. In A. J. Sargent (Ed.), Systemic responses to disasters: Stories of the aftermath of hurricane Katrina (AFTA Monograph Series) (pp. 61–66). Washington, DC: American Family Therapy Academy. Malchiodi, C., & Crenshaw, D. A. (Eds.). (2014). Creative arts and play therapy for attachment problems. New York, NY: Guilford Press. Mills, J. C. (1999). Reconnecting to the magic of life. Phoenix, AZ: Imaginal Press. Mills, J. C., & Crowley, R. J. (2014). Therapeutic metaphors for children and the child within. New York, NY: Routledge. Oaklander, V. (2007). Hidden treasure. London, England: Karnac Books. Short, D., Erickson, B. A., & Erickson-Klein, R. (2005). Hope and resiliency: Understanding the psychotherapeutic strategies of Milton H. Erickson. Norwalk, CT: Crown House. Siegel, D. J. (1999). The developing mind. New York, NY: Guilford Press.

Historical Context During the 1950s, Gregory Bateson, Jay Haley, Don Jackson, and John Weakland attempted to describe the problems or symptomatic behavior that people exhibited in terms of their relationships with others. During this project, Bateson proposed that communication between human beings can be described in terms of levels (e.g., message content and nonverbal message) and that these levels can conflict in paradoxical ways. For instance, a person can say, “I love you” and look askance at the person to whom he or she is directing the message. Or as Epimendies, the Greek philosopher, suggested, an ancient Greek could say, “I am lying” and yet be telling the truth if, indeed, he was lying (meaning, he is not lying). Here, we see the complexity of human communication. The investigation of how messages “frame” other messages in conflicting ways was a focus of the project undertaken by Bateson and his colleagues. The term double bind was coined to describe dual messages that conflict paradoxically.

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By 1962, when the project ended, they had made the shift from describing symptoms as individual phenomena to describing them as communicative behavior between people. For instance, a mother might say to her child, “I want you to spontaneously do as I say” (one cannot be spontaneous and do what another says). Placed in this double bind, the child may then respond with disturbing behavior to this contradictory communication. Up to this point, the mother’s conflicting communication would have been explained by references to her nature or to her need to respond to a child who was communicating in disturbing ways. What was lacking was a way to conceptualize the larger social context to which family members were adapting. Through the 1960s and the 1970s, for the first time, family structures—such as cross-generation coalitions when a spouse joins a child against the other spouse—began to be delineated. In the 1970s, Haley described pathological systems in terms of malfunctioning hierarchies, for example, one where a mother and a child are in an overly intense relationship and the father is peripheral. As strategic family therapy developed in the 1970s, interventions usually took the form of directives designed to change the ways in which people relate to one another. Paradoxical directives, which send multiple messages to the clients and subtly challenge the clients to change, were developed. For example, after telling the family that he or she wants to help them change, a therapist might suggest that there might be negative consequences to changing, challenging the family to prove the therapist wrong by changing. In the 1980s, Madanes suggested that the social organizations of people who present to therapy with problems or with symptomatic behavior have a dual hierarchy that requires conflicting levels of communication. She developed strategies to change such organizational structures so that symptomatic behavior is no longer appropriate and adaptive. Just as Bateson proposed that there is a human dilemma when dual levels of messages are incongruent, Madanes proposed that in a social organization such as a family, dual hierarchies can be incongruent. In fact, she suggested that dual levels of messages will be incongruent if the organization has incongruent hierarchies.

With this organizational view, it is possible to see the conflicting levels of messages in context— the conflicting hierarchies in the organizations where people communicate. A mother who asks her child to obey her spontaneously can be in an organization where (a) she is in charge of the child by the fact of being a parent, but (b) the child is also in charge of her because of the power of disturbing behavior or because of the power given by coalitions with family members of high status. Therefore, the mother must give directives because of the nature of her position, but she can only express helplessly the wish that the child might do as she says. Today, strategic family therapy is commonly used by many family therapists and taught in most family therapy training programs. However, obtaining the skills necessary to be able to understand the complexity of human communication, perceive dysfunctional hierarchies, give appropriate directives, and work effectively with families is not easily come by and may take years of training to refine.

Theoretical Underpinnings Strategic family therapy views the individual within the broader context of the family system and examines how symptoms are a function of communication among people, the structure of the family, and the organizational hierarchy in the family structure.

Major Concepts Some of the major concepts of strategic family therapy that drive the theory are analogies and metaphors, the concept of self-determination, an interactional view, directives, the family as a selfhelp group, and the stages of emotional and spiritual development. Analogies and Metaphors

A behavior is analogical to another behavior when there is a resemblance between them in some particular way, even though they may be otherwise unlike. A behavior is metaphorical for another behavior when it symbolizes or is used in place of another behavior. Symptomatic behavior has been

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considered analogical and metaphorical in certain specific ways: 1. A symptom may be a report on an internal state and also a metaphor for another internal state. For example, a person’s headache may be expressing more than one kind of pain. 2. A symptom may be a report on an internal state and also an analogy and a metaphor for another person’s symptoms or internal states. For example, a boy who refuses to go to school may be expressing his own fears and also his mother’s fears. The boy’s fear is analogical to the mother’s fear (in that fears are similar) and also metaphorical (in that the boy’s fear symbolizes or represents the mother’s fear).

Self-Determination

Central to the strategic family approach is the belief that a person is capable of making a plan for his or her own future and that each person is responsible for who she or he is. No matter what the circumstances, there is always a choice to be made. The individual is not predetermined by chemistry, the family, or the social context. An Interactional View

The most efficient way of changing a person is to change the social context of the person—the ongoing relationships with significant others. These significant others are usually the family, but sometimes, the most important interactions are with friends, at school, or at the workplace, so the therapist also intervenes in those relationships. Directives

The most frequent intervention is the directive. People are asked to do certain things in therapy and, between sessions, outside of the therapy room. Directives can be straightforward or indirect, metaphorical or paradoxical. Most directives involve introducing a minor change in a small segment of behavior, with the expectation that a small change can have larger consequences.

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The Family as a Self-Help Group

In its origins, family therapy was thought to be a “cure” for the whole family that was considered to be “sick” or “pathological.” Rather than viewing the family as sick or healthy, strategic family therapy views the family as the ultimate self-help group. No one can help or interfere as much with the well-being of a person as those who have ongoing relationships—who have a history, a present, and a future together. Emotional and Spiritual Development

There are four stages of emotional and spiritual development: 1. The need for certainty and security by having power and control over one’s own life and over significant others 2. The wish to be loved, appreciated, and cared for 3. The desire to give love to others, to protect and care for the people one loves 4. The need to repent for mistakes, wrongdoings, and harm caused to others and to forgive others for harm caused to oneself

These needs are hierarchical in that the first need we develop as children is the need for certainty and security. Then, we develop the wish to be loved, followed later by the desire to love and protect others, and finally by the need to repent and to forgive. The therapist moves the individual client and his or her family through these stages, which are essential for a meaningful, satisfying life.

Techniques There are many ramifications to the idea that conflicting levels of communication reflect conflicting hierarchies within an organization. A major issue for the therapist is the opportunity that arises for new forms of therapeutic intervention. Although nearly 100 techniques exist, what follows is a description of some of the most successful of these strategies.

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Correcting the Hierarchy

Haley developed a variety of strategies for reorganizing a malfunctioning hierarchy. One way is to shift from the presenting system to a different problematic one before reorganizing the family into a more functional hierarchy. For example, if a mother and a child are in an overly intense relationship and the father is peripheral, the first stage can be one where the father takes total control of the child and the mother is excluded. This is a problematic system, and from it, one can move to a healthier one. Another way of doing this might be to ask the father to do a minor thing with the child that the mother would not approve of. In this case, it will be difficult for the mother to take charge of what the father and the child do because it is something she does not want. Another way of correcting the hierarchy is to encourage the parents to agree on rules and on consequences for the child if the rules are disobeyed.

who try to overcome their own problems in order to help the child. In the strategy of pretending, developed by Madanes, the therapist encourages the child to pretend to have the presenting problem and encourages the parents to pretend to help the child. In this way, the child no longer needs to actually have the problem to protect the parents; pretending to have it is enough to become the focus of concern for the parents. But the parents’ concern will also be a pretense, and the situation will have changed to a game—to make-believe and play. The strategy of pretending can also be used with adults. For example, a depressed man can be asked to pretend to be depressed (at a time when he is actually not depressed) and to do it in such a way that his wife will not be able to tell whether he’s really depressed or not. This will change the way the wife typically responds to her husband’s depression, and he, in turn, will have to change.

Life Stages

Interactional Metaphors

Haley described the life cycle of the family in stages: courtship, early marriage, dealing with young children, children leaving home, retirement, and old age. Serious problems or symptoms can arise in any of these life stages. For instance, during the leaving home stage, serious symptoms may develop that hinder the young person from leaving home. Consciously or unconsciously, the young person may worry about what will happen to the parents if he or she leaves (e.g., the possibility of divorce). Haley developed strategies to hold the parents together so that the young person can leave without fear (i.e., without fear that the parents’ relationship will deteriorate and result in divorce).

Building on the concepts of analogies and metaphors, Madanes proposed that not only can an individual’s messages be assigned meaning in the context of other messages but also the interaction between people is analogical and can be assigned meaning in a context of other interactions. That is, a sequence of interactions usually has a second referent different from the sequence explicitly expressed. The interaction between two people in a family can be an analogy and a metaphor, replacing the interaction of another dyad in the family. For example, a mother may be upset and worried, and her husband may try to reassure and comfort her. If a child develops a recurrent pain, the mother may become preoccupied with reassuring and comforting the child in the same way that the father was previously reassuring and comforting her. The mother’s involvement with the child in a helpful way will preclude her involvement with the husband in a helpless way, at least during the time in which the mother is involved with the child. The interaction between the mother and the child replaces the interaction between the wife and the husband. If the child’s recurring pain disappears, the mother will go back to being helpless. Thus, if the child abandons the recurring pain, the therapist will intervene so that the mother can be

Pretending

Presenting problems or symptomatic behavior in an individual can be the result of an incongruity in the hierarchical organization of the family. For example, when a child has problems or symptomatic behavior, he or she becomes the focus of attention for the parents, and so the child takes on a superior position, distracting the parents from other concerns. Often, the child, wittingly or unwittingly, protects the parents,

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helpful and competent most of the time, instead of being helpless. Madanes developed a series of strategies to increase mothers’ self-confidence and competence. Prescribing the Pretending of the Function of the Symptom

This is a strategy where family members perform, in a playful way, actions that represent what the therapist believes to be the function of the presenting problem. These actions are a condensed, abbreviated, somewhat symbolic, and somewhat humorous version of the family drama. The roles of family members are reversed. For example, if a daughter is depressed, the mother is asked to pretend to be depressed, and the daughter is asked to help the mother; if a son has fears, the father may be asked to pretend to be afraid, and the son may be asked to protect his father. In this case, the therapist might conceptualize the function of the presenting problem as a child covertly helping the  parent through the problem. In the playful prescription, the parent overtly asks for help, and the child overtly helps the parent. The result is that the child no longer resorts to helping the parent in covert, problematic ways. The parent’s request for help and the child’s helpfulness are now overt in a playful, humorous way. Prescribing a Reversal in the Family Hierarchy

This strategy, developed by Madanes, consists of putting the children in charge of one aspect of their parents’ lives—their happiness. The children are asked to give suggestions to the parents as to how they could be happier and to organize special events for the parents, such as a dinner or a party. As the children give love to their parents (by actually giving them directives or by taking care of them), the parents not only become more responsible and caring toward the children, but they also often resolve many of their own problems. Children are often surprisingly wise in their advice, and with the therapist’s encouragement, they can be very helpful. The strategy is especially useful when parents are rejecting or incompetent, because little or nothing is expected from them and all demonstrations of love and concern are solicited from the children.

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Steps for Repentance

Madanes developed a successful method for the rehabilitation of the sexual criminal and the victim of incest. The method varies depending on whether or not the victim is part of the family. The following is a summary of the steps when the victim is a younger relative of the offender and is present in the sessions. First, the therapist gathers the family and asks each family member what he or she knows about the sexual crime, pointing out that the offender’s actions were solely his responsibility and that neither the victim nor anyone else is to blame. Then the therapist asks the parents and the offender why what the offender did was wrong. After everyone has spoken, the therapist explains that the sexual crime caused a spiritual pain in the victim (because sexuality and spirituality are related in human beings, a sexual attack can be considered an attack on the spirit of the person). Then, the therapist acknowledges the spiritual pain of the offender for having inflicted this pain on another human being and the pain of every family member because of the hurt inflicted on the child. The offender is asked to get on the floor on his knees in front of the victim and express his sorrow and repentance for what he did. The family and the therapist judge whether the offender is sincere. If anyone says that the offender is hypocritical, then the offender must repeat the repentance until everyone agrees that the offender is sincere. The next step involves the therapist asking the whole family to kneel in front of the victim and for each to express his or her sorrow for not having protected the victim and prevented the abuse. In subsequent sessions, the adults discuss future consequences should the offender commit another sexual crime, and agree on a punishment. They also agree on what acts of reparation toward the victim will be required from the offender. The therapist enlists from the extended family a protector who will be tasked with making sure that the victim is not hurt again. The therapist discusses sexuality with the offender, encouraging repression and establishing certain steps for the offender to follow should an inappropriate sexual impulse arise. With the victim, the therapist encourages the perspective that the victimization, although

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traumatic, will not be the major event in the child’s life. This establishes that the offender, not the victim, should carry the shame. In a sense, these steps are a set of operational instructions for transforming bad relationships into good ones. They have been used successfully with many different kinds of family violence. Also, in a sense, these steps are a ritual by which a family or a group can self-critique and change its own routine behavioral sequences as its members cooperate to heal an afflicted individual member.

Therapeutic Process Because strategic family therapy encompasses many different strategies, there is no one specific therapeutic process. However, the general guidelines are to begin by interviewing everyone involved with the presenting problem or symptomatic behavior. Once the therapist has gathered information, he or she formulates a strategy and plans one or more directives that are given to the family to be followed in and out of the therapy sessions. If this strategy does not solve the problem, the therapist expands the unit, inviting extended family and/or other significant others to participate. A new strategy and new directives are formulated based on the new information and new resources that these others bring to the therapy. Because strategic family therapy is not an orthodoxy that proposes one method to be used always in the same way, it borrows from other schools of therapy any techniques that are helpful in solving the presenting problem and improving people’s lives. Cloe Madanes See also Erickson, Milton H.; Erickson-Derived or -Influenced Theories: Overview; Haley, Jay; Madanes, Cloe; Strategic Therapy

Further Readings Haley, J. (1976). Problem-solving therapy: New strategies for effective family therapy. San Francisco, CA: Jossey-Bass. Madanes, C. (1981). Strategic family therapy. San Francisco, CA: Jossey-Bass. Madanes, C. (1984). Behind the one-way mirror: Advances in the practice of strategic therapy. San Francisco, CA: Jossey-Bass.

Madanes, C. (1990). Sex, love and violence: Strategies for transformation. New York, NY: W. W. Norton. Madanes, C. (1994). The secret meaning of money. San Francisco, CA: Jossey-Bass. Madanes, C. (1995). The violence of men. San Francisco, CA: Jossey-Bass. Madanes, C. (2006). The therapist as humanist, social activist and systemic thinker . . . and other selected papers. Phoenix, AZ: Zeig, Tucker & Theisen.

STRATEGIC THERAPY Strategic therapy is an approach that stems from Milton Erickson’s family therapy and includes diverse approaches, all of which have certain characteristics in common. Strategic therapy differs from strategic family therapy in that the focus is on the individual instead of a couple or family, while still being aware of the social system the individual is a part of.

Historical Context During the first half of the 20th century, under the influence of psychoanalysis, Rogerian therapy, and psychodynamic therapies, the focus of therapy was on intrapsychic issues, and the client mostly determined the course of therapy. Within this context, therapists either interpreted client concerns within a preset therapeutic model or used empathy and acceptance to try and understand the client’s situation, believing that clients could find their own solutions to their concerns. These insight-oriented models used the same approach with every client, regardless of the client’s presenting problem. Strategic therapy was developed as a reaction to the passivity of these approaches, as it emphasized that the therapist needed to take a more active, directive, and influential role with clients and suggested that the role could change dramatically as a function of the presenting problem. The major proponent of this new approach was Jay Haley, who based many of his ideas on the innovative work of Milton Erickson. Clarifying and explaining Erickson’s approach, integrating communication theory and system ideas from Gregory Bateson and the Palo Alto Group, and introducing many new therapeutic strategies, Haley came up with a

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new, dynamic approach to conducting therapy, which he called strategic therapy. Others who were influential in the approach include John Weakland, Richard Fisch, and Paul Watzlawick from the Mental Research Institute in Palo Alto, California; the “Milan Group”; and Giorgio Nardone. Since its early beginnings, strategic therapy has grown and is an approach taught in many graduate programs in counseling, social work, and psychology as well as in training centers. Today, the literature describes well over 100 strategies that are associated with strategic therapy.

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there are coalitions across generations (i.e., when a parent sides with a child against the other parent) or where those lower in the hierarchy (e.g., children) have undue power over those higher in the hierarchy (e.g., parents).

Major Concepts Two main concepts associated with strategic therapy are (1) defining the problem and (2) analogies and metaphors. Defining the Problem

Theoretical Underpinnings Some guiding concepts of strategic therapy are derived from cybernetics, which is the study of how information-processing systems (families, schools, corporations, etc.) are self-correcting, controlled by feedback loops. Systems are seen as maintaining a homeostasis, which reflects their usual state of functioning. This state can be dysfunctional or healthy. For instance, one family may have a verbally abusive spouse, and each time that individual becomes outraged, the other spouse withdraws and the children leave the home to play with their friends (to “escape”). If the spouse who withdraws attempts to become more assertive, the verbally abusive spouse becomes more abusive, thus ensuring that the system maintains its homeostasis, or the usual way of functioning. Within this context, problems are viewed as interactions between people where any deviation from the norm (the norm may be dysfunctional or healthy) may result in a negative feedback loop that will return the system to its previous state. Positive feedback loops, on the other hand, occur when the system develops new ways of interaction among its members, and change is thus brought about. In the example above, a new way of interacting might be for the abused spouse to call his or her mother-in-law (as soon as the verbal abuse starts) to tell her how much he or she loves her. Change in one part of the system effects change in other parts of the system and may lead to changes in other areas of life. Within systems, it is important to consider the hierarchy, as an individual is more disturbed in direct proportion to the number of malfunctioning hierarchies in which the individual is embedded. A malfunctioning hierarchy is one where

A problem is defined as a type of behavior that is part of a sequence of acts between several people. Symptoms such as depression or phobias are thought of as contracts between people and therefore as adaptive to relationships. The therapist is included in such relationships, because he or she defines the problem. The strategic therapy approach emphasizes a distinction between (a) identifying a problem presented in therapy and (b) creating a problem by applying a diagnosis or by characterizing a person in a certain way. Psychiatric and psychological diagnostic criteria are seldom used in strategic therapy, and the first task of the therapist is to define a presenting problem in such a way that it can be solved. To label a client as “bipolar” or “clinically depressed” is to participate in the creation of the problem that the therapy must solve. Sometimes the label creates a problem, so that the solution is made more difficult. For example, “depression” is more difficult to resolve than “laziness”; “clinical depression” is not easy to cure, but “difficulty in holding a job” is more amenable to change. Analogies and Metaphors

The strategic approach emphasizes the analogical in the way it conceptualizes a problem. It is assumed that a problem or a symptom is the way in which one person communicates with another. For example, in the case of a depressed man who does not work, it would be assumed that this is the way the man and his wife (and/or his mother, father, children, etc.) communicate about some specific issues, such as whether the husband should do what his wife or his mother wishes. That is,

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when the man says, “I’m depressed,” he is analogically, or metaphorically, expressing a problem. He is also solving it because, for example, it is not his fault that he won’t work—it is his “depression.” This solution, however, is usually unsatisfactory for everyone involved. Often, the focus of therapy is on changing analogies and metaphors, for example, by telling stories that resemble the client’s problem and also contain a solution to the problem. A client can be asked to say he has a particular problem or symptom—a stomach ache, for example—when in fact he has not, so that the verbal statement serves the same metaphorical purpose as the original problem he presented with, but without the pain. Some people are able to say, “You give me a pain” and not have the pain, while others must develop a pain as a way of making a statement about their situation.

Techniques Common interventions employed in strategic therapy include directives, rituals, ordeals, and the stages of emotional and spiritual development. Directives

Interventions usually take the form of directives about something that the client will do during the session and/or outside the session. These directives are designed to change the ways in which the client relates to others and to the therapist. Directives are also used to gather information by observing the way the client responds to instructions. The strategic therapy approach assumes that all therapy is directive and that a therapist cannot avoid being directive, because even the issues he or she chooses to comment on and his or her tone of voice are directive. In this therapy, directives are deliberately planned, and they are the main therapeutic technique. Directives may be straightforward or paradoxical, direct or indirect, and simple or complex. An example of a straightforward directive is to say to a man, “I would like you to be especially nice to your wife this week.” An indirect way of saying this is “I don’t want you to be so nice to your wife this week that she might have a heart attack.” An example of a paradoxical directive, let’s say to

someone with panic attacks, is to say, “I would like you to deliberately have a panic attack right now here in my office” or “I would like you to have a panic attack every morning as soon as you get up.” The paradox lies in the fact that the client wants the therapist to help him or her get rid of the panic attacks and, in that context, the therapist is requesting the panic attack. A symptom is, by definition, involuntary, so if the client can have the symptom deliberately, then it is not a symptom. This approach is based on the idea that some people who present for therapy are resistant to the help offered; the therapist expects the client to be defiant and thus not be willing to deliberately produce the symptom, thus proving to the client that he or she has control over the symptom. Paradox first entered therapy as a therapeutic strategy when Viktor Frankl (in the early 1950s) developed it to show clients that they had control over their symptoms. However, it was Gregory Bateson and colleagues (in the late 1950s) who systematically formulated paradox for use in solving presenting problems in therapy. They showed that paradox is a basic constituent of mental problems and can be used effectively in their resolution. Most directives are planned to improve relationships, involve people who have been previously disengaged, promote agreement and good feeling, increase positive interchanges, provide information, and help people organize in more functional ways. Based on the notion that a small change can have larger consequences, most directives are aimed at relatively few or relatively small changes in behavior. Rituals

A special kind of directive is the ritual. Here, the therapist recommends a ceremony consisting of a series of actions performed according to a prescribed order. Rituals are useful in marking the transition from one stage of life to another or to indicate a transition in a relationship. The intensity of the ritual should be commensurate with the severity of the problem presented to therapy. For minor problems, a birthday party or a trip to visit relatives may be appropriate. A serious transition may require a more complex ritual, for example, a ceremony of renewal of marital vows.

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Ordeals

The ordeal is a strategy devised by Erickson to make it more difficult for a person to have a symptom than not to have it. A man with insomnia, for example, may be told that if he does not fall asleep by a certain time, he has to get up and scrub the floors. The ordeal should be more unpleasant than the symptom but beneficial to the person with the symptom. Ordeals are particularly appropriate for problems of self-inflicted violence (e.g., bulimia), for obsessions, and for compulsions because these often occur with people who are methodical, motivated, and hardworking. They compulsively perform an action that they do not like or want to do. So at the request of the therapist, they can perform another action that they also do not like and do not want to do. The secret of using this strategy successfully is to motivate the person to apply the ordeal. Stages of Emotional and Spiritual Development

Cloe Madanes described four stages of emotional and spiritual development. At the lower level is the first stage, where the person is concerned with controlling and dominating his or her environment, including the relationships the individual is in. A somewhat higher level is the second stage, where the person is concerned with being loved. Yet higher is the third stage, where the person wants to give his or her love to others. At the fourth stage, the person needs to repent for whatever harm he or she has caused others and to forgive whatever harm was done to him or her. When a therapist determines that a client is at Level 1—wanting to dominate and control—he or she moves the person to the next level—wanting to be loved. If the client is stuck in wanting to be loved (Level 2), the therapist moves him or her to wanting to give love (Level 3). If the client is overly focused on loving, the therapist moves the client to the stage of admitting and repenting for the harm the client has caused and forgiving the harm caused to the client (Level 4). If the client is stuck in repentance and forgiveness, the client has to be moved once again to the first stage of focusing on controlling his or her environment, and so on. That

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is, the stages take the form of a spiral as the person moves from one stage to the other to have a balanced life.

Therapeutic Process From the first meeting, the therapist focuses on the following: • What is the client’s relationship with himself or herself • What is happening with the client’s relationships with others • What is happening with the client’s relationship with the social environment—the values and norms of the social context within which the client lives • How the problem presented manifests within those relationship patterns • How the patient has tried so far to solve the problem • How the problem situation can be changed as quickly as possible

Before designing a strategy, the therapist needs to be able to answer the following questions: • How does the client define the problem? • How does the problem manifest itself? • In whose company does the problem appear, worsen, or not appear? • Where does the problem usually appear or not appear? In what situations? • How often does the problem appear, and how serious is it? • What has been done and is currently being done (by the client alone or by others) to resolve the problem? • Whom or what does the problem benefit? • Who could be hurt by the disappearance of the problem?

Once this information is obtained, the therapist designs a strategy that usually consists of suggestions or directives about what the client will do. In subsequent sessions, the client reports on the results of the strategy, and then the strategy is continued, or a new strategy is designed. Regular follow-ups after termination are recommended.

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Because in strategic therapy a specific therapeutic plan is designed for each problem, there are no contraindications in terms of client selection and suitability. The approach has been used with clients of all ages and all socioeconomic classes and with all kinds of presenting problems. This is a pragmatic approach that allows the therapist to borrow from other models of therapy any techniques that may be useful in solving a presenting problem. Cloe Madanes See also Erickson, Milton H.; Erickson-Derived or -Influenced Theories: Overview; Haley, Jay; Madanes, Cloe; Palo Alto Group; Strategic Family Therapy

Further Readings Bateson, G. (1972). Steps to an ecology of mind. New York, NY: Ballantine Books. Haley, J. (1973). Uncommon therapy. New York, NY: W. W. Norton. Haley, J. (1976). Problem-solving therapy. San Francisco, CA: Jossey-Bass. Haley, J. (1984). Ordeal therapy. San Francisco, CA: Jossey-Bass. Madanes, C. (1990). Sex, love and violence. New York, NY: W. W. Norton.

STRUCTURAL FAMILY THERAPY Structural family therapy is a systemic model of therapy developed by Salvador Minuchin in the 1960s and 1970s. One of the most influential in the field of family therapy, its distinctive features are the decisive role attributed to the family both in accounting for the behavioral problems of its members and in working toward their resolution, and the responsibility placed on the therapist as a catalyst of change.

Historical Context In the early 1960s, Minuchin was the intake psychiatrist at the Wiltwyck School for Boys, a residential facility in Upstate New York for juvenile delinquents from the inner city. Looking for an alternative to traditional psychotherapeutic

approaches that did not seem to help that population, Minuchin turned his attention to the youngsters’ families. He noted that parenting and other interpersonal contacts were erratic and inconsistent and that the families tended to be isolated from their community, while other families living in the same poor neighborhoods but not having delinquent children were better organized and connected with others. Minuchin and his collaborators then set out to coach the youngsters’ families into more structured ways of interacting. Acknowledging the concrete, action-oriented style of the families, Minuchin introduced nontraditional, “more doing than talking” techniques. Families of the Slums, published in 1967, provides a thorough account of the experience. In 1965, Minuchin left Wiltwyck to lead the Philadelphia Child Guidance Clinic, bringing with him two of his collaborators, the clinician Braulio Montalvo and the researcher Bernice Rosman. They were joined by Jay Haley, whose thinking influenced and was influenced by Minuchin’s. Serving a heterogeneous urban population, the clinic made Minuchin’s approach available to a wider spectrum of families and problems and helped expand and precise it. By the early 1970s, it began to be known as “structural family therapy”; its tenets were formulated and illustrated with abundant clinical material in the classic Families and Family Therapy, published in 1974. The clinic’s association with a children’s hospital opened up an opportunity to apply the model to the treatment of psychosomatic conditions like asthma, diabetes, and anorexia. Unlike the disorganized families of Wiltwyck, families with psychosomatic children tended to be too rigidly organized and in need of more flexibility. The action techniques developed at Wiltwyck to facilitate communication with “nonverbal” clients were now helpful in dealing with clients who talked too much. Minuchin and his collaborators Rosman and Lester Baker also demonstrated experimentally the impact of family interactions on individual physiology and presented their clinical and research findings in Psychosomatic Families, published in 1978. In the mid-1970s, as interest in the structural approach was growing, Minuchin stepped down as director and created the clinic’s Family Therapy Training Center. The concepts and techniques

Structural Family Therapy

taught at the center to hundreds of practitioners became the subject matter of Family Therapy Techniques, written by Minuchin in collaboration with his student and eventual colleague Charles Fishman and published in 1981. Two years later, Minuchin moved to New York and founded the Family Studies Institute, dedicated to the training of family therapists and the application of structural principles in programs that affect the lives of low-income families. A product of that effort was Working With Families of the Poor, which Minuchin coauthored with his wife, Patricia, and Jorge Colapinto. Following Minuchin’s retirement in 1993, the Family Studies Institute was renamed the Minuchin Center for the Family.

Theoretical Underpinnings Structural family therapy conceptualizes individual behavior as a function of the individual’s family context. A boy’s violent outbursts, for instance, are seen as his participation in a larger picture that may include a protective mother and an authoritarian father. “I try to set limits,” says the mother, “but then my son throws a temper tantrum, and if I don’t give in, his father will get involved and things will get worse.” The mother’s giving in preempts her husband’s roughness, which in turn may be a response to what he sees as the mother’s spoiling of their son. Completing the picture, the disagreement between the parents provides a fertile ground for the son’s tantrums. Complementarity designates this correspondence or “fit” between the behaviors of family members. An assertive mother and an obedient child fit each other. So do the parents who work as a team, and the parent and the teenager who negotiate issues of responsibility or autonomy. These are all examples of functional complementarity. Complementarity can also be dysfunctional: a disobedient child and her ineffective mother, a couple where one pursues and the other withdraws, and a rebellious teenager and a rigidly authoritarian parent. To account for the formation of complementary patterns, structural therapists resort to the physiological concept of homeostasis, the tendency of an organism to maintain a quasi equilibrium. Giving in before “things get worse” keeps internal tension within acceptable levels. Homeostatic patterns develop over time as family members constantly

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accommodate to one other. Once the complementary roles of mother, father, and child are set, deviations from the “script” tend to be countered by corrective movements. But homeostasis does not fully describe the family’s process. Counterdeviation moves notwithstanding, the family constantly evolves toward increasing complexity, adapting to changing internal and external demands: Children are born and grow; parents age; there may be illnesses, financial hardship, and changes of homes, jobs, or schools. A wellfunctioning family is not defined by the absence of stress or conflict but by how effectively it handles them. An “ineffective” mother may bring into play the assertiveness that she demonstrates in other relationships; a “rough” father may allow his tender side to show through the apparent gruffness. By contrast, a family becomes dysfunctional when it maintains a relational structure that no longer works. Giving in to a child’s tantrums may not be a problem when the child is 2 years of age and the family functions as a more or less self-contained unit, but it may become one if it continues when the child reaches school age. The process of mutual accommodation that generates the family’s transactional structure also underlies the development of individual identity. As the child interacts with parents, siblings, and others, some traits (e.g., shyness) are selected, while others (e.g., assertiveness) are discouraged. Because the child participates in different transactions, the resulting identity is multifaceted: A girl may be domineering in her interactions with her younger brother and submissive in relationship to her father. The concept of an evolving, multifaceted identity has significant implications for assessment and treatment. The structural family therapist assumes that clients are functioning with just a fraction of their potential and that traits that may not be apparent at first sight, such as the capacity to nurture or to exercise responsible leadership, may be or have been active in other contexts. Thus, the same family that displays dysfunctional interactions holds—in the form of hidden or underutilized strengths—the keys to better functioning. In therapy, it is not necessary for a mother to work through the historical origins of her low selfesteem before she can become a competent parent. For example, if the father does not interfere in her

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relationship with her son, she can actualize her latent competency. At a deeper philosophical level, the structural therapist’s interventions are rooted in the belief that individual differentiation is not achieved through retrenchment into oneself but through participation in multiple relationships. The goal is not the self-sufficiency of the rugged individual but the mutual reliance on the network.

Subsystems

Subsystems are groups of family members defined by gender, generation, common interests, or functions. For instance, a husband and wife form the spouse subsystem, whose function is to provide mutual support. They are also part of the parental subsystem, organized around issues of nurturance, guidance, and discipline. Within the sibling subsystem, children learn to make friends, handle conflict, and provide and receive support.

Major Concepts A number of major concepts that originated with structural family therapy are now used by most family therapists. Here, we take a look at just a few of them: family structure, subsystems, boundaries, and hierarchies. Family Structure

Family structure is the set of rules, often unspoken but observable, that dictate the “who, how, and when” of interactions—for instance, that a mother will give in to her son who is throwing a tantrum before the father takes punitive action. The structure can be pictured as a map where women are represented by circles and men by squares, each positioned higher or lower in the diagram depending on their relative power within the family and interconnected by single, double, broken, or wavy lines to denote the quality of their relationships. The family map in Figure 1 depicts a very close relationship between mother and son, a more distant one between father and son, a conflictive relationship between father and mother, and a hierarchical arrangement where the mother holds more power.

MOTHER FATHER

Boundaries

Boundaries define subsystems. A boundary can be depicted as an encircling line around two or more family members that shields them from the rest, allowing for self-regulation. Boundaries protect the spouses from the intrusion of in-laws, children, and others, and the sibling subsystem from excessive parental interference. Like the membrane of a cell, good boundaries are defined well enough to let the members of a subsystem negotiate their relationship autonomously, but they are also flexible enough to allow for participation in other subsystems. When boundaries are too weak between two or more family members, the latter are said to be overinvolved; the behavior of one member immediately affects the others. There is a heightened sense of belonging and mutual worrying, protection, and loyalty demands; one member’s attempts to change elicit resistance from the others. On the other hand, when boundaries are too rigid, there is excessive distance among the members, a lack of mutual support and protection, scarce communication, and excessive tolerance of deviant behavior—a situation described as disengagement. Overinvolvement and disengagement may describe the whole family structure or different relationships within the family; for instance, there may be overinvolvement between mother and son and disengagement between the father and both of them. This triangular pattern, common in families with a symptomatic child, may allow for detouring: The parents avoid dealing with their own conflicts by focusing their shared concern on the child. Hierarchy

SON

Figure 1

A Structural Map

Hierarchy refers to the different degrees of decision-making power held by the various members. In general, parents should be in charge of

Structural Family Therapy

their children—not as dictators but as providers of guidance and protection. However, while some form of hierarchical arrangement is necessary, families can function with a variety of arrangements. For instance, a grandmother or an older child may function in a parental capacity, provided there is a clear delineation of responsibilities. Hierarchical patterns that are clear and flexible tend to work well; too rigid or too erratic patterns are problematic—in one case, the children’s autonomy is impaired; in the other, they experience a lack of guidance and protection. In a flattened hierarchy, parents and children hold the same amount of power, as when a mother and her teenage daughter argue like sisters. In a reversed hierarchy, the children hold more power, as when the teenager controls the parent by acting out. In a cross-generational coalition, two members on different levels of the hierarchy join forces against a third one; for instance, a father supports his son in disobeying the mother, or a grandmother and her grandchild “gang up” against the child’s parent.

Techniques Some of the main techniques utilized by structural family therapists, such as tracking and reframing, are applied in one way or another by therapists of all persuasions. However, structural therapists are specific in what they track (i.e., the family’s structure) and how they reframe (i.e., by locating the problem in the family interactions rather than the individual). A third primary technique, enactment, is a trademark of structural family therapy. Tracking

Tracking is used to get a picture of the family structure. For instance, to assess affiliations, complementary patterns, power distribution, and styles of conflict resolution, the therapist first observes the interactions between the family members, paying attention to the process rather than the verbal content: who takes the initiative, who interrupts, who completes phrases, supports, or criticizes. Additional information is gathered by asking family members to interact in specific ways (“Can you move closer to your daughter and discuss this issue with her?”), inquiring about events at home (“How was it decided that your son would not go to school last Wednesday?”), and exploring how

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patterns developed over time (“How did it come to happen that the father is the disciplinarian and the mother the softy?”). Reframing

Reframing is the process of zooming in or out on a problem situation to obtain a different perspective on the problem. While the quest for an alternative perspective is common to most therapists, structural therapists emphasize particularly the reframing of “individual” problems as relational ones. If a girl who has been labeled as hyperactive is displaying her symptoms by running around the room while her mother begs her to sit down, the therapist may ask the mother, “Is that how the two of you spend your time together?”— thus locating the problem in the interaction instead of in the girl. If the father then succeeds in quieting the girl, the therapist may note that she is more or less hyperactive depending on whom she is interacting with. Other reframings typically utilized by structural therapists aim at shifting the meaning of behaviors from negative to positive (“You wouldn’t be so angry at each other if you did not care so much for each other”) or, conversely, from positive to negative (“Your father is helpful, but if he does everything for you, you will always remain incompetent”). Enactment

Reframing sets the stage for the most powerful restructuring technique, enactment. Having identified the problem as a relational one, the structural therapist directs the family members to interact differently than what they usually do: “Discuss this with your wife, and don’t let your daughter distract you” or “Don’t check with your mother when you are talking to your father.” The purpose of an enactment is to have the family members experience one another in novel ways; in the examples given, the therapist pursues that goal by drawing a boundary around two family members, shielding them from the intrusion of a third one, so that they can address their differences. Because of the natural tendency of the family to regress to its established ways, enactments need to be sustained by the therapist. Consistent with the premise that change comes from actualizing skills that have been deselected in the course of the

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family’s development but are available to the family in latent form, structural therapists prefer to take a decentralized position, resisting the pull to “cure” individuals, teach communicational skills, or arbitrate differences; instead, therapists encourage the family members to interact with one another, and they intervene selectively as needed to keep the interaction going and direct it toward a new desired outcome. For instance, the therapist may intervene to enforce the boundaries of an enactment when they are infringed. If a father moves to overimpose his authority when the mother is trying to assert her own (“Do what your mother says”), the therapist may block him (“Let your wife do it”). Structural therapists also interject their comments on the enactment, not by making long interpretations but by briefly punctuating stumbling blocks (“She gave you that look again, and you dropped the issue”) and successes (“Great, now that you got the children to play on their own, we can resume our conversation”). To push the family beyond their “comfort zone,” the therapist may need to elevate the temperature of the session. This can take a mild form, like extending the duration of an enactment (“You need to keep talking until you reach an agreement”), or, if the family’s patterns are particularly rigid, a more intense one, like the technique of unbalancing, where the therapist supports one family member—typically the less powerful—more than the others. An enactment, no matter how intense, does not beget durable change by itself. It does shake the family out of their homeostatic arrangement and shows that change is possible and what it might look like; but consolidating the change—thickening the boundary around the parental subsystem, making more room for an adolescent’s autonomy, shifting to a different way of negotiating power and control—requires more work. New ways of relating must be experienced repeatedly, with each successful enactment expanding the family’s relational repertoire, until a qualitatively different and healthier transactional structure emerges and holds.

Therapeutic Process The purpose of structural family therapy is to free the family from the constraining patterns that it has constructed over time, so that it can resume its

development. Structural therapists are proactive and encouraging, and they challenge families to take a different look at their problems and to change how they interact. This requires a strong connection with the family members, the ability to understand their problems in context, and a willingness to direct them toward better ways to relate to one another. Through joining, the therapist gains the acceptance of the family, as a temporary member with permission to influence the system from within. Joining calls for respecting the family’s existing structure (e.g., by addressing the parents before the children); validating all members’ perspectives and expressions of concern, sadness, anger, fear, and even rejection of therapy; and suspending judgment, interpretations, or diagnoses. But it must also communicate that therapy can make a difference, by introducing some measure of challenge to the family’s presentation (“You say that you have had it with your son, but your face says you are very concerned for him”). Joining begets an initial assessment of the family—as the therapist experiences how the family does and does not work; who is close to whom; which members are in conflict; what are the subsystems, the affiliations, and the triangles; and how their transactions relate to the problems at hand. The therapist is also alert to indications of strengths that the family may not be aware of, or value enough, and organizes all the information into a preliminary map of the family structure and the possible roads to change, which will continue to be redrawn through the process of treatment. Consistent with structural theory, therapy aims at restructuring the family system, which, depending on the case, may mean decreasing or increasing the levels of involvement among individuals and subsystems, and/or realigning hierarchies. The goal is not just to extricate individuals from unhealthy family binds but also to make those binds healthier, allowing for both belonging and differentiation. When the structural therapist encourages more distance between a mother and a child, it is not to isolate either one but to make room for them to participate in other subsystems—child–father, wife–husband, and child–siblings—where they can actualize alternative aspects of their selves. Jorge Colapinto

Sullivan, Harry Stack See also Haley, Jay; Madanes, Cloe; Minuchin, Salvador; Strategic Family Therapy; Strategic Therapy; Systemic Family Therapy

Further Readings Colapinto, J. (1988). Teaching the structural way. In H. Liddle, D. Breunlin, & R. Schwartz (Eds.), Handbook of family therapy training and supervision (pp. 17–37). New York, NY: Guilford Press. Colapinto, J. (1991). Structural family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy (Vol. 2, pp. 417–443). New York, NY: Brunner/Mazel. Lappin, J. (1988). Family therapy: A structural approach. In R. Dorfman (Ed.), Paradigms of clinical social work (pp. 220–252). New York, NY: Brunner/Mazel. Minuchin, P., Colapinto, J., & Minuchin, S. (2007). Working with families of the poor. New York, NY: Guilford Press. Minuchin, S. (1972). Structural family therapy. In G. Caplan (Ed.), American handbook of psychiatry (Vol. 2, pp. 178–192). New York, NY: Basic Books. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S., Montalvo, B., Guerney, B. G., Rosman, B. L., & Schumer, F. (1967). Families of the slums. New York, NY: Basic Books. Minuchin, S., Reiter, M., & Borda, C. (2013). The craft of family therapy: Challenging certainties. New York, NY: Routledge. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press.

SULLIVAN, HARRY STACK Harry Stack Sullivan (1892–1949), the founder of the interpersonal theory of mental illness, was born in Norwich, Upstate New York, the son of the only Catholic, Irish American family in the village. Although the modest farm that his family owned in this rural, economically struggling community may not have been the best environment for an introverted, alert, and bookish boy, Sullivan had several supportive figures in his youthful years, including a teenage boy with whom he established an unusually close emotional bond.

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This may have contributed to the significance that Sullivan would place on same-sex friends, or “chums” in his term, in his theory of interpersonal relationship, which he developed later in his life. On a scholarship to attend Cornell University, Sullivan as a college freshman in 1909 seemed to be an intellectually promising, if socially awkward, young man. Soon, however, Sullivan found himself involved in difficulties that contributed to his mental instability, which resulted in his suspension from the school. The nature of the trouble is unclear, but it was serious enough for him to decide not to go back to Cornell. Two years later, he began pursuing a degree in a medical school in Chicago, associated with Valparaiso University, Indiana. After stints as an industrial physician and a surgeon in the U.S. Army, Sullivan went as a liaison officer to St. Elizabeth Hospital in Washington, D.C., in 1921, and then, the following year, to Sheppard and Enoch Pratt Hospital (also referred to as Sheppard-Pratt) in Towson, Maryland, where he became familiar with mentally ill patients for the first time in his medical career. It was at Sheppard-Pratt that Sullivan’s talent as a psychiatrist blossomed. In particular, his ability to talk with young, male, schizophrenic patients in sharply insightful, often therapeutically effective, ways quickly made him a renowned figure in the psychiatry of the time, which struggled to understand the debilitating illness. The hospital physicians used a psychoanalytically oriented talk therapy, but it was not clear at first if the method would be useful for the treatment of severely disturbed schizophrenic patients. Sullivan showed that it could be, as the success rate in his ward appeared extremely high. This was a striking accomplishment, especially given the general understanding of the time that psychoanalysis was effective for neurosis but not necessarily for psychosis. An often overlooked aspect of his clinical work at Sheppard-Pratt was that many of his patients were homosexual men. A closeted homosexual man himself, and by 1928 living with his lover James Inscoe, who would become his lifelong partner, Sullivan was committed to eradicating homophobia, which he believed could cause mental disturbances including schizophrenia. Lacking a critical mass of like-minded people to push forward this progressive view publically or politically, Sullivan concentrated his efforts on reducing the

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internalized homophobia and self-hatred among his patients in a protected, clinical environment. He was critical of traditional or religious teaching about sexuality as well. The prohibition of masturbation, premarital sex, and interracial sexual relations became the target of his critique of “outdated” morality, which he considered responsible for considerable damage to a person’s self-esteem. Although he followed in Sigmund Freud’s steps in many ways as one of America’s neo-Freudians, Sullivan’s evolving theory marked a clear departure from classical psychoanalysis. He understood illnesses in social, interpersonal interactions rather than in purely psychological dynamisms. So it was that Sullivan in the 1930s became increasingly convinced that not only mental disorders but also the sociocultural and interpersonal conflicts that cause them needed to be addressed by psychiatrists. Thus, he embarked on several intellectual and institutional initiatives that were to change psychiatric education and research in a way that promoted prevention and a better social acceptance of the mentally ill. He worked with luminous intellectuals of the era such as Edward Sapir, Harold Lasswell, Ruth F. Benedict, and Margaret Mead, expanding the horizon of interdisciplinary collaborations between psychiatry and the social sciences. Sullivan wanted psychiatry to be a science, and his way of accomplishing this goal was to expand the discipline outward. During the 1930s, Sullivan also undertook private practice in New York City, with the hope that treating neurosis would help prevent more serious conditions such as schizophrenia. He continued to pursue his goal of debunking internalized homophobia among his patients and students, although some of his practices involving sexual intimacy with patients and students crossed ethical boundaries and shocked many colleagues. Sullivan was not a prolific or eloquent writer, but his interpersonal theory reached maturity and fame in the late 1930s and early 1940s. Although most of his monographs were published posthumously, his insights into mental illness as a result of conflicted interpersonal relationships became well-known through his articles, lectures, and seminars. His interdisciplinary journal Psychiatry, along with the institutions that he either established (The Washington School of Psychiatry) or was affiliated with (Chestnut Lodge Hospital),

served as his intellectual outlets. Pushing his understanding of mental illness in social milieus further, Sullivan asserted that an individual personality is “illusory” because it cannot be isolated from interactions with others. This view was closely related to his clinical experience, as he believed that as an observer, a doctor always participated in what happened in an interpersonal encounter with a patient. Thus, what a doctor observed was not a fixed personality of a patient but a patient in the process of relating to the doctor. To comprehend a patient, then, a doctor must become a “participantobserver,” who collects the data not only of the dynamisms of the ongoing doctor–patient interactions but also of the “life history” of both the patient and the doctor that shapes the current therapeutic relationship. In the life history of a patient, Sullivan sought to find elements of healthy development, such as a positive relationship with a chum in preadolescence. Equally important, he tried to find as possible causes of illness a range of interpersonal failures and embarrassments at all stages of personality development. The last decade of Sullivan’s work, from 1939 to his death in 1949, was devoted to the making of the psychiatric screening system for the U.S. Army and to establishing international mental health programs for the World Health Organization, the World Federation for Mental Hygiene, and UNESCO. However, these efforts were plagued with serious limitations. Originally modeled on his participant observation and life history methods, the mass screening of prospective soldiers became a hasty, often dysfunctional, and ultimately unreliable diagnostic procedure. There is little doubt that Sullivan’s intention was to protect psychologically fragile military recruits from possible mental breakdowns in the army environment. But the screening system fell harshly on the rejected individuals, including homosexual persons who were denied the right to serve the nation because of their “homosexual proclivity” or “psychopathic personality.” And yet, his work for national mobilization in World War II elevated Sullivan’s reputation, leading him to serve as one of the major architects of postwar liberal mental health policies, such as the International Congress on Mental Health and the UNESCO Tensions Project. Both of these programs aimed to study and prevent the interpersonal and international tensions that cause wars.

Supportive Psychotherapy

By the end of the 1940s, Sullivan was an enigmatic figure whom many of his students and colleagues found mysterious and not easily approachable. Nonetheless, Sullivan’s interpersonal theory became one of the major components of psychoanalytical treatment and theory of mental illness after World War II, when psychoanalysis reached its golden age in the United States. To be sure, the influence of psychoanalysis on psychiatry declined after biological and neuroscientific approaches to mental disorders became mainstream. But Sullivan’s interpersonal approach to mental illness continues to be a vital component of the clinical practice of many psychologists, psychotherapists, and counselors today. He was an important pioneer in midcentury interdisciplinary collaboration. Also, he is remembered as a practitioner of extraordinary talent and a theorist who passionately and fearlessly pursued disciplinary border crossing in the history of American psychiatry and social sciences. Naoko Wake See also Classical Psychoanalytic Approaches: Overview; Contemporary Psychodynamic-Based Therapies: Overview; Freud, Sigmund; Freudian Psychoanalysis; Horney, Karen; Interpersonal Theory; Neo-Freudian Psychoanalysis

Further Readings Bérubé, A. (1990). Coming out under fire: The history of gay men and women in World War Two. New York, NY: Free Press. Evans, F. B., III. (1996). Harry Stack Sullivan: Interpersonal theory and psychotherapy. New York, NY: Routledge. Hale, N., Jr. (1995). The rise and crisis of psychoanalysis in the United States: Freud and the Americans, 1917–1985. New York, NY: Oxford University Press. Perry, H. S. (1982). Psychiatrist of America: The life of Harry Stack Sullivan. Cambridge, MA: Belknap Press. Sullivan, H. S. (1953). Conceptions of modern psychiatry. New York, NY: W. W. Norton. Sullivan, H. S. (1954). The psychiatric interview. New York, NY: W. W. Norton. Sullivan, H. S. (1964). The fusion of psychiatry and social sciences. New York, NY: W. W. Norton. Wake, N. (2011). Private practices: Harry Stack Sullivan, the science of homosexuality, and American liberalism. New Brunswick, NJ: Rutgers University Press.

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SUPPORT GROUPS See Self-Help Groups

SUPPORTIVE PSYCHOTHERAPY Supportive psychotherapy is a dyadic approach aimed at improving symptoms, self-esteem, psychological function, and adaptive skills. With its roots in the psychodynamic approach, the purpose of supportive psychotherapy is to help clients cope with psychological symptoms rather than make personality adjustments. Supportive psychotherapy is traditionally used for clients who do not have the cognitive or psychological abilities to endure intensive psychodynamic approaches to psychotherapy. However, supportive psychotherapy is not restricted to use with impaired individuals and can be utilized to address a range of client concerns. Relatively healthy individuals can also benefit from supportive psychotherapy in dealing with short-term problems, such as relationship concerns.

Historical Context In the early 20th century, psychoanalysis was the primary approach in psychological treatment. By the 1950s, some psychoanalysts, such as Kurt Eissler, saw a need for an approach to therapy with more limited objectives than those of psychoanalysis—to treat clients with cognitive or psychological impairments (e.g., addiction, eating disorder) that made traditional psychoanalysis more difficult. Supportive psychotherapy was developed by individuals such as Eissler, Jerome Frank, and Herbert Schlesinger to address this need. Since its establishment in the 1960s, supportive psychotherapy has evolved and also taken on elements of cognitivebehavioral therapy, interpersonal therapy, and other influences. Despite supportive psychotherapy’s long tenure in the helping professions, teaching and training in supportive psychotherapy have been limited. The Accreditation Council on Graduate Medical Education’s Residency Review Committee for Psychiatry is now mandating competency for graduates in supportive psychotherapy.

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Theoretical Underpinnings Supportive psychotherapy was initially derived from the psychodynamic approach, but has grown to include aspects of cognitive-behavioral and interpersonal therapy approaches as well. Originally intended as a less intensive form of psychoanalysis, supportive psychotherapy focuses on the individual’s issues at hand, such as issues of self-esteem, interpersonal functioning, and coping strategies. While past issues and past behavior are discussed in supportive psychotherapy, more attention is paid to present conflicts and the present behavior of the client.

past and present conflicts. The supportive psychotherapist works to prevent anxiety from increasing during the sessions. Conversational Style

Supportive psychotherapy seeks to have an informal interaction between the client and the therapist rather than the therapist teaching a lesson or interrogating the client. Unlike traditional psychoanalysis, exploration of mental content is not a focus in supportive psychotherapy, and therapy unfolds more like a conversation than in a structured therapeutic format.

Major Concepts

Techniques

Supportive psychotherapy uses concepts related to psychodynamic theory, in addition to those from cognitive-behavioral and interpersonal therapy approaches including conscious and unconscious, therapeutic alliance, self-esteem, anxiety, and conversational style.

Techniques for supportive psychotherapy are aimed at lifting the client up in an effort to improve his or her self-esteem, psychological function, and adaptive ability. Techniques include praise, reframing, normalizing, advice and teaching, rehearsal, paraphrasing, and confrontation.

Conscious and Unconscious

Praise

Conscious issues for the client are often discussed, but therapists utilizing supportive psychotherapy do not seek to uncover unconscious conflicts within the client. Defense mechanisms, like rationalization or denial, are not explored unless they have become maladaptive to the client and his or her relationships.

A therapist genuinely praising the client for successes, achievements, or positive changes can have a profound effect on the client’s self-esteem and encourage healthy psychological function and adaptation.

Therapeutic Alliance

Supportive psychotherapy seeks to create a safe environment for the client by creating an alliance between the client and the therapist that is positive and caring, and promotes change in sessions.

Reframing

Reframing occurs when the therapist shares a different and more positive perception of a client’s statements or beliefs. A constructive reframing of a client’s narrative can be effective in helping the client see his or her situation from another perspective. Normalizing

Self-Esteem

Therapists utilizing supportive psychotherapy seek to improve clients’ self-esteem by conveying acceptance, approval, interest, respect, and admiration toward the clients during sessions. Anxiety

Supportive psychotherapy works to alleviate conscious anxieties in clients by not focusing on

By using normalizing, therapists show clients that their feelings, thoughts, and behaviors are not uncommon and are often experienced by others. Advice and Teaching

Therapists using supportive psychotherapy will often take opportunities to share their advice with clients in dealing with certain issues. Additionally, teaching a client a new skill or coping technique is

Symbolic Experiential Family Therapy

used often in supportive psychotherapy. Advice and teaching can be used together to reinforce desired behavioral changes.

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has reached his or her goals or when the client decides to discontinue therapy. Therapy may resume in the future at the client’s discretion. Brett K. Gleason

Rehearsal

Rehearsal entails the therapist considering in advance what difficulties the client may encounter in the obtainment of a goal and then structuring strategies to overcome them with the client in session. Paraphrasing

Paraphrasing involves the therapist reporting back to the client what the client said in an effort to convey understanding of what the client just explained. Confrontation

Confrontation involves the therapist bringing the client’s attention to a feeling, thought, or behavior that was expressed, perhaps without realization, and challenging the client to address it or pointing out discrepancies or inconsistencies in the feeling, thought, or behavior.

Therapeutic Process Supportive psychotherapy is limited to meeting the goals and needs of the client. A client with many needs may be involved in supportive psychotherapy for several months or even years. Supportive psychotherapy should not go beyond the completion of client goals to address personality changes or explore the past deeply. Brief forms of supportive psychotherapy exist for crisis intervention. Brief supportive psychotherapy typically lasts five to eight sessions and is used for clients with limitations of time or money. The beginning sessions of supportive psychotherapy focus on the formation of the therapeutic alliance. The therapist seeks to understand the presenting issues of the client and to form clinical goals. Middle sessions have the therapist focusing on the continuation of the therapeutic alliance, as well as using psychoeducational and skill-building interventions to help the client with the accomplishment of his or her goals. Termination in supportive psychotherapy does not have an official process. Termination takes place once the client

See also Behavior Therapy; Classical Psychoanalytic Approaches: Overview; Cognitive-Behavioral Therapy; Freudian Psychoanalysis; Interpersonal Psychoanalysis

Further Readings Dewald, P. A. (1994). Principles of supportive psychotherapy. American Journal of Psychotherapy, 48(4), 505–518. Werman, D. S. (1984). Principles of supportive psychotherapy. New York, NY: Brunner/Mazel. Winston, A., Rosenthal, R. N., & Pinsker, H. (2004). Introduction to supportive psychotherapy. Arlington, VA: American Psychiatric.

SYMBOLIC EXPERIENTIAL FAMILY THERAPY Symbolic experiential family therapy (SEFT) emerged from the clinical experience of Carl Whitaker and continues to develop in the clinical experience of experiential practitioners. A magical therapeutic spirit—constituted by a blend of imagination, wisdom, attention, and empathy—residing in an individuated practitioner is the energetic core of experiential family therapy. In therapeutic interviews, the practitioner creates a climate invigorated by the systemic dialectics of individuation and belonging, creativity and adaptation. Even though veiled by endless discord and suppression, the energetic core of the human spirit yearns for an ideal, is creative, and is thus implicitly noncompliant. The SEFT practitioner looks for fragments of health in the family’s living patterns and helps families discover the possibility of becoming a healing community with the assertive competence to deal with their problems. Additionally, therapy encourages individual family members to gain access to more of themselves through experience and to increase adequacy, as individuals and as a group. The best access to experience comes with therapeutic play and expansion of symbolic awareness. The therapy

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process is suspended in the medium of language used both to describe experience and to create experience.

Historical Context SEFT evolved from Whitaker’s seminal work with his Atlanta colleagues in experiential psychotherapy, as his attention moved from working with individuals to therapy with families as multigenerational systems. Whitaker had no training in psychoanalytical dynamics. His ideas about psychotherapy came from play therapy with young children and doing co-therapy with patients with schizophrenia before the introduction of antipsychotic medicines. He paid specific attention to the psychotherapeutic process. Working with those with schizophrenia and with children can have an impact on how language is used in therapeutic practice; as a result, Whitaker in his therapy sessions used language that was artful, poetic, and not inhibited by theory. In 1965, he left his private practice in Atlanta to become professor of psychiatry at the University of Wisconsin Medical Center. There he worked exclusively with couples and families. He routinely included grandparents and other members of his patients’ social networks. He worked with the range of emotional and psychological disorders, including what are thought of as major mental disorders. His interviewing style has been described as engaging, mysterious, perplexing, interesting, and sometimes upsetting. His therapeutic interviewing pattern implicitly criticized and raised questions about conventional cultural patterns, in the way an artist’s work implicitly interrogates a culture. During his years in Wisconsin, August Napier, Ph.D., and David Keith, M.D., beginning as learners, became coauthors, copractitioners, and colleagues, cultivating the growth of experiential family therapy in their careers.

practitioners. He read widely but valued original thinking, resisted adaptation, and was constantly developing novel ideas. His thinking was influenced by Otto Rank, an unconventional analyst with an experiential bent; Susanne K. Langer, who paid careful attention to the symbolic understructure of experience; and Gregory Bateson, a critical thinker with an interest in primary process and the interpersonal components of schizophrenia. Overall, the conceptual formulations of SEFT are an open-ended theoretical collection including fragments from systems theory, existential philosophy, Bateson, dialectical ideas, psychoanalytical theory, Donald Winnicott, theology, literary theory, Zen, hypnotherapy, play therapy, and more. Experiential therapy attends to an energetic healing, symbolic process. It pays attention to the pain and emotional hunger at the root of patients’ emotional troubles and encourages patients to be noncompliant and creative in the interest of expanding health. In SEFT, patients’ psychopathology is seen as a symptom of patients’ frustrated yearning for intimacy and for enlivening family relationships. That is, mental and behavioral disorders are assumed to arise out of a failed effort to make things better.

Major Concepts A number of concepts drive the process of SEFT and include having an understanding of the change process, knowing the role of the practitioner, depathologizing identified patients (family members), identifying culturally invisible pathology, keeping an eye toward family morale, maintaining the personhood of the practitioner, acknowledging the importance of families playing, using everyday language, considering three generations of patterns, giving the emotional process priority, expanding the relation system, using co-therapy and consultation, and learning from experience. The Change Process

Theoretical Underpinnings Whitaker consistently characterized experiential therapy as “atheoretical.” He insisted that his methods were grounded in clinical experience. In his view, theory interferes with clinical responsiveness and erodes the crucial creative spirit of

The family practitioner, regardless of his or her discipline, is viewed as a change agent, both nurturing and challenging, one who catalyzes metamorphosis in thinking and behavior patterns in families. The artful work of the practitioner is to locate the yearning, the concealed energy for

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growth in the family story. To do this, the practitioner takes action and uses language in novel, playfully destabilizing ways. The process of therapy is to recycle the family’s experiential debris— such as defiance, depression, or bipolarity—and process it into yearning, desire, and a deepening sense of individuation and belonging. Language is used in ways that challenge the possibility of fixed meanings. In this clinical framework, everything considered psychopathological is related to impasses in interpersonal relationships past and present, until proven otherwise. Genetics and neurophysiologic explanations may be part of the problem but never the whole story. Nurturing, experience, and symbolic reality are fundamental components in the evolution of these complex problems. Role of the Practitioner

The metaphorical model for the experiential practitioner is the foster mother who provides a blend of structure and nurturing in a time-limited relationship. And, of course, the foster mother is a role played by practitioners, who in their heads are a generation older than the oldest family member in the session. Depathologizing

In SEFT, the person identified as troubled by the family is considered the healthiest member of the family, defeated in his or her attempt to restore vigor to relationships. Symptoms are suppressed or failed efforts at repair. Individual psychopathology represents a thwarted attempt to fix the family. For instance, a child’s depression may be seen as a result of failing to relieve the mother’s chronic distress about the father’s distance. Defiance begins as a collapse of fealty (trust in leadership). The child or adolescent loses faith in the parents’ capacity to be nurturing leaders. Initially, the defiant behavior insists that the parents be more alive. Culturally Invisible Pathology

Culturally invisible pathology is behavior practitioners overlook because it matches conventional cultural values. Culturally invisible pathology is toxic to the core of family morale. The identified

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patient provides a counterbalance to culturally invisible pathology in the family and is dedicated to undermining the family’s apathy about invisible pathology. Some culturally invisible symptoms are the following: (a) loss of or dead imagination, (b) inability to laugh, (c) irony deficiency, and (d) fundamentalism, political or religious. Another formulation involves “abnormally normal” families, who can talk at length about the identified patient, while everything else is normal. Their sense of normality is unrealistic, symptomatic of their inability to metacommunicate about relational experience (i.e., to make remarks about interpersonal communication, such as “You sound like you are afraid of her”). They give only brief descriptions to the practitioner’s queries; thus, the first interview typically last only 20 minutes. They resist putting experience into words; thus, there is no capacity for talking about emotional pain. Family Morale

Health is rooted in the group spirit of the family. When the family morale improves, the security of all members is likely to increase. The increased security enables family members to reflect on what they may be contributing to the problem. That is, each family member is able to use the relationship with the practitioner to become a patient. This way, they can question themselves and expand their consciousness of what goes on in their family and in their lives. The patient, then, becomes someone who is learning or has learned to use a relationship with another to question himself or herself and bring about change in his or her living. Personhood of the Practitioner

The dynamics of therapy are in the personhood of the practitioner in relation to the process dynamics of the family. This is a critical therapeutic, experientially open precept, requiring reflection. As incongruous as it sounds, the practitioner may be the most important patient. The practitioner develops a therapeutic consciousness founded in impeccable constancy to a structured pattern of practice, which guides decision making and enables him or her to make use of fantasy, free association, and body responses to a family in the clinic. The

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structure provides a safe ground for creative therapeutic action. As with improvisational music, where the quality of a music performance resides in the tension between structure and improvisation (the musician begins in a musical structure, which he or she leaves when improvising, but knows how to return to the structure), the effectiveness of SEFT is found in the interplay between structure and creativity Play Therapy as a Paradigm

Priority to Emotional Process

The practitioner gives priority to emotional process over cognitive processes. This therapy process attends to and is energized by the chaos and crisis at the core of modern living, where conventional linear logic may create unintentional distortions. Clinically based learning and conceptual development are implicit in family therapy. Expanding the Relational System

All experiential psychotherapy is play. If a family do not know how to play, it is the practitioner’s job to teach them. Play is purposeless and always carries the risk of meaning nothing. The primary reality of therapy is metaphorical and ironic. The capacity for play with language is a part of health; when it is possible to play with language, it is possible to play with life and its meanings.

When therapy is not working, it is common for the practitioner to add people to either side of the therapeutic relationship. Colleagues, grandparents, ex-spouses, probation officers, pastors, teachers, and former practitioners may be added as consultants. They come in for one interview to help the practitioner help the family who is stuck. In this process, it is critical to understand that consultants are treated differently than patients.

Use of Everyday Language

Cultural Influences of Modern Psychiatry

The practitioner uses the language of personal experience, everyday language, which abounds with ambiguity and inference, as opposed to the more specific language of a particular profession or an applied theory. This style creates an atmosphere of informality, invites participation, and makes personhood more accessible on both sides of the therapeutic relationship. In this process of acting at an apparently less sophisticated level, distinctions are usefully clouded—mind/body, smart/dumb, doctor/patient, innocent/guilty, sick/ healthy, personal/impersonal—and standard perceptions are obscured in ways that confuse but stimulate, and open up the possibility of change or adjustment. Metaphorical and ironic use of language is an invitation to interaction and reflection.

Modern biological psychiatry, with its emphasis on individual diagnosis and the use of medication, is based on hypotheses about behavior and psychopathology that almost insist that practitioners not be “distracted” by the whole family. Conventional modern psychiatry uses a syntax that has affected the way practitioners use language to talk about human pain and has shaped the ways clinical practitioners of all disciplines think about emotional distress. Additionally, psychiatry’s focus on pathology as opposed to an implicit yearning to grow de-emphasizes the possibility of change and interferes with enhancing family vitality and strengths. In contrast, experiential therapeutic principles are founded in a clinical syntax for including the family in a way that destabilizes living and thinking patterns and opens up the possibility for relational and intrapsychic change.

Three-Generational Patterning

Family living is organized by out-of-consciousness multigenerational patterns. The practitioner’s initial history interview of the family includes questions about the families in which the adults grew up. Unconsciously, families prepare for the future by looking backward to where they came from, expecting the past to be replayed in the future. It is common practice to have the grandparents come in for a consultation interview.

Co-Therapy and Consultation

The use of co-therapy, especially with more difficult families, is part of this therapeutic method. Usually, two practitioners join together in a professional partnership to provide ongoing treatment. Co-therapy is therapeutically effective and cost-effective; more happens in fewer sessions. Consultation is a variant of co-therapy.

Symbolic Experiential Family Therapy

The practitioner may first see the family alone and then invite a colleague in for a consultation interview with the family. The consultant may also periodically attend continuing treatment sessions. The processes of co-therapy teaming and consultation can be helpful and therapeutically enriching. Another co-therapy variant is the consultation group, a therapy group for the professional self of the practitioner. A group of colleagues meet regularly to talk about impasses in treatment cases. Groups of this sort can vitalize practitioners and make their work more enjoyable and growth producing. Learning From Experience

This is vital to the development of good practitioners. Adequate experiential family therapy depends on the ability of the practitioner to learn from one’s own experience and the capacity to dialogue with colleagues about those experiences.

Techniques There are few specific techniques. Instead, the practitioner keeps in mind the overall process of therapy that he or she brings to the session. Thus, the practitioner keeps in mind his or her personhood during the session, depathologizes the patient, uses everyday language, considers three generations of patterns, has an eye toward culturally invisible pathology, remembers that the emotional process is a priority and that all families need to know how to play, and expands the relational system to significant others when needed. There is a countercultural spirit in experiential family therapy. The practitioner learns to be a practitioner by doing therapy and by talking with colleagues about their work. Practitioners are encouraged to value their experience and develop their own ideas. Being a professional psychotherapist is a disciplined art enhanced by practice. The practitioner practices not in the service of self-gain but in service of some obscure but vital spirit.

Therapeutic Process During therapy, there are a number of processes that one would expect to occur. For instance, the practitioner includes the whole family, conducts a family history, pushes for open conversation,

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interviews the children about the parents, remembers that the problems are in the family and tries not to get caught up in the family anxiety, transforms history from being factual to being symbolic, and considers termination as a process, not the end. Including the Whole Family

The first interview can happen only once, and the more family members present for that session, the more productive the interview will be. An interpersonal mind-set is induced by asking questions about relationships. Father is asked, “Can you tell me what your family is like? How does the family work?” To the 13-year-old son, the practitioner might say, “How do Mom and Dad relate with each other?” Three generations are considered in the assessment. The parents are pressured to describe the families from which they came and what the parents were like when they were their children’s age. Conducting a Family History

A history of the family is taken during the first interview with the entire family present. The history is focused on the family as a whole and its patterns, not just the person with symptoms. The process is implicitly therapeutic for the family. They often see themselves as they have never seen themselves before. In the process of taking the history, the practitioner is not passive but comments, paraphrases, and infers. Language is used to induce experience in the interest of producing change in how the family thinks and behaves. For families, the history can induce a shift from linear content to a narrative-transcending process. The practitioner develops a mind-set including historical events along with associations and images that are stored in his or her mind. Pushing for Open Conversation

It is important that the identified patient hears other family members talk explicitly about their concerns. The practitioner asks that each family member speak directly to him or her so that the other family members overhear but are not required to respond or allowed to comment. Children’s fantasies and nightmares are typically far worse than any reality they hear or see in a therapy hour.

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Interviewing Children About the Parents

The practitioner talks to the children about the parents in the third person, mirroring the talk with the parents about the children: “What does Dad do when Mom is crying?” “What do you do when Mom and Dad are having a fight?” “How do you kids know when Dad or Mom is angry?” “When you worry about your family, what do you worry about the most?” Remembering That the Problems Belong to the Family

SEFT practitioners remember that the problems belong to the family, not to the practitioners. When practitioners become overinvolved with the family’s real world, they lose their capacity to function effectively in their therapeutically vital symbolic role. It is the practitioner’s job to raise family anxiety so that they have to mobilize dormant or deactivated resources to deal with the struggles they confront. Transforming the Family Interview

The practitioner keeps a “poet’s mind” attuned in listening to family stories. All major, intractable “psychiatric” problems have components rooted in the symbolic experience of the family. The etymology of symbolic means “thrown together.” In the symbolic history, things, people, events, and concepts are “thrown together”: What happened plus what else happened and when plus what it meant characterize the layers of significance. Considering Termination As a Process, Not the End

At the end of each interview, the practitioner asks the family if they want to come back. Continuation of therapy depends on the family initiative, not on the practitioner’s perception of their needs. The family are pushed to decide about coming back, based on whether they are getting anything out of the therapy. Experiential family therapy is often unintentionally brief, from 8 to 12 sessions. Anxiety decreases, and although the problems may remain, they are less intense, and the family are prepared to go on with their lives as a healing community.

There is almost never a termination “process”; rather, the practitioner and the family members figure out a way to go on living while enduring the mystery of not knowing (just because there are questions does not mean that there are answers). In general, therapeutic possibilities are much greater in family therapy than in other therapies; change happens more quickly and is more enduring. David V. Keith See also Existential Therapy; Experiential Psychotherapy; Phenomenological Therapy; Whitaker, Carl

Further Readings Connell, G., Mitten, T., & Bumberry, W. (1999). Reshaping family relationships: The symbolic therapy of Carl Whitaker. Philadelphia, PA: Brunner/Mazel. Keith, D. (2014). Process, practice, and magic: Continuing the experiential approach of Carl Whitaker. Phoenix, AZ: Zeig, Tucker & Thiessen. Keith, D., Connell, G., & Connell, L. (2001). Defiance in the family: Finding hope in therapy. Philadelphia, PA: Brunner-Routledge. Keith, D., & Whitaker, C. (1981). Play therapy: A paradigm for work with families. Journal of Marital and Family Therapy, 7, 243–254. doi:10.1111/j.1752–0606.1981.tb01376.x Napier, A., & Whitaker, C. (1978). The family crucible. New York, NY: Harper & Row. Neil, J., & Kniskern, D. (1982). From psyche to system: The evolving therapy of Carl Whitaker. New York, NY: Guilford Press. Whitaker, C. (1989). Midnight musings of a family therapist (M. Ryan, Ed.). New York, NY: W. W. Norton. Whitaker, C., & Bumberry, W. (1988). Dancing with the family: A symbolic-experiential approach. New York, NY: Brunner Mazel.

SYSTEMATIC DESENSITIZATION Systematic desensitization is a behavioral technique that effectively reduces symptoms in specific phobias and other anxiety disorders. It was developed by Joseph Wolpe and is based on two animal models of treatment, Pavlovian counterconditioning and reciprocal inhibition, to overcome dysfunctional fearful behavior. Systematic desensitization

Systematic Desensitization

proceeds in three basics steps: First, the therapist teaches the client a relaxation technique; then, the client and the therapist elaborate a fear hierarchy (ranking events that are anxiety eliciting for the client); and finally, the client is confronted by the situations of the hierarchy in ascending order of anxiety while he or she engages in relaxation techniques. Exposure to the anxiety-eliciting situations is traditionally implemented by imagining these situations, although in vivo exposure is also used. Systematic desensitization is widely known as a successful and empirically supported therapy that has been traditionally used to treat major anxiety disorders as well as test anxiety, sexual dysfunctions, and other behavioral problems.

Historical Context In the 1950s, Wolpe defined a psychotherapeutic method to treat anxiety based on the animal learning literature, which he named systematic desensitization. As a psychiatrist formed in psychodynamic theories, Wolpe was unsatisfied with the outcome of psychoanalytical treatment. His contact with James G. Taylor and Leo Reyna, who were followers of Clark L. Hull and Kenneth Spence, respectively, exposed him to the experimental foundations of learning principles. His interest consequently changed to the area of classical conditioning and psychopathology. During this period, Wolpe came to know about Ivan Pavlov’s neurotic dogs, J. H. Masserman’s neurotic cats, and Mary C. Jones’s and John B. Watson’s treatment for fear in kids based on the pairings of a fearful stimulus or event with food (i.e., an appetitive stimulus). During 1947 and 1948, in his office at the Witswatersrand University Medical School in Johannesburg, South Africa, Wolpe built experimental chambers to study neurotic behavior and its treatment in cats. His subjects received mild electric shocks in an experimental chamber immediately after an auditory cue was presented. The animals responded to the shocks with responses indicative of fear, such as crouching, trembling, and howling, and these responses were soon evoked by the auditory cue as well as by exposure to the chamber. Wolpe then tried to extinguish this Pavlovian association by confronting his subjects with the auditory cue and the experimental

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chamber in the absence of shocks. Unfortunately, this approach did not have much of a therapeutic effect on the cats. However, Wolpe observed that after the cats were fed in the presence of the fearevoking stimuli, these stimuli no longer evoked fear responses. Specifically, Wolpe began feeding the animals in situations that resembled the original context in which the fear was acquired. As the fear responses were reduced, he moved to situations that were increasingly more similar to the situations in which the traumatic situation originated (initially, it was impossible to feed the cats in this context given that the anxiety was too strong). After this procedure, the cats were no longer afraid of the context, but they still exhibited fear to the auditory cue; thus, Wolpe fed the animals at a certain distance from the auditory cue and continued feeding the cats closer and closer to the sound source, like he had done with the experimental chamber. Eventually, the cats stopped being anxious in the presence of the auditory cue. Wolpe concluded that the anxiety response was incompatible with the eating response; he called this relearning produced by incompatible responses reciprocal inhibition. Wolpe suggested that the reciprocal inhibition principle could be applied to the treatment of anxious clients. He evaluated diverse responses that could interfere with anxiety (e.g., sexual responses, assertive responses, pleasant emotional excitement, and nonaversive shocks) and found that deep muscular relaxation was the most efficient response to accomplish the task. Before Wolpe, Edmund Jacobson had treated neurotic clients by extensive training in muscle relaxation. Jacobson’s relaxation was prescribed to be performed at all times, however; in Wolpe’s systematic desensitization procedure, relaxation was contingent with the anxious response, so relaxation and anxiety would inhibit reciprocally. Furthermore, the systematic component ensured that the relaxation response is always stronger than the anxious responses and, consequently, it is the relaxation response that overcomes the anxiety and not the other way around. This occurs because in this technique the anxiety response is induced by presenting anxietyeliciting situations ranked in ascending order. Despite the researched efficacy of systematic desensitization, it has been controversial whether reciprocal inhibition is the mechanism behind the

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behavioral change. In 1968, Gerald Davison proposed that the learning principle underlying systematic desensitization was counterconditioning, a process first described by Pavlov. Presumably, both counterconditioning and reciprocal inhibition (and maybe even other principles) partially contribute to the reduction of anxious responses to fearful stimuli. Even when the original operational description of systematic desensitization provided by Wolpe was modified and improved, several studies continued to prove the effectiveness of the technique in treating anxious clients. However, in recent decades, the use of systematic desensitization has decreased, and psychotherapists favor the use of modern exposure techniques (e.g., exposure therapy, flooding). Although studies regarding the effectiveness of systematic desensitization report more evidence than other empirically validated treatments for anxiety, scientific research on the topic has declined since the 1970s.

Theoretical Underpinnings Systematic desensitization assumes that the etiology and treatment of clients with anxiety is based on learning principles. Clients with anxiety disorders have developed a fearful emotional reaction to nonharmful stimuli and situations (i.e., an irrational fear). This is explained by the establishment of a Pavlovian association between an initially nonharmful stimulus and a threatening and anxiety-eliciting situation. Wolpe proposed the principle of reciprocal inhibition as the theoretical mechanism underlying systematic desensitization. Reciprocal inhibition occurs when two incompatible responses are prompted simultaneously. In other words, two incompatible psychological states, such as anxiety and relaxation, cannot occur at the same time in an organism. At a physiological level, reciprocal inhibition is based on the notion that the sympathetic activation of the nervous system, which operates in reaction to stress to facilitate fight or flight responses, is diminished by the parasympathetic activation induced by relaxation techniques. In reciprocal inhibition, it is important to evoke the incompatible response (relaxation) in the presence of the undesirable response (anxiety). Due to the interference created by the relaxation response, anxious clients no longer experience fearful reactions to previously anxiety-eliciting stimuli.

Several revisions of Wolpe’s traditional systematic desensitization technique opened the possibility that other theoretical mechanisms, different from reciprocal inhibition, may play a role in the behavioral change produced by this technique. Davison postulated that systematic desensitization might operate through counterconditioning, a phenomenon first described by Pavlov. In counterconditioning, a cue that predicts an aversive consequence is paired with an appetitive outcome. As a result of this procedure, organisms form a new association between the cue and the appetitive outcome that will interfere with the old aversive association when the stimulus is presented in the future. In the case of systematic desensitization, the anxiety-eliciting event plays the role of the cue, and the anxiety response plays the role of the aversive consequence. When the technique is applied, a new learning is formed. The event is the same, but it is now followed by an appetitive instead of an aversive consequence, so the event now has a new meaning. Although reciprocal inhibition and counterconditioning are quite similar processes, they differ in that reciprocal inhibition assumes that the habit of the anxious response is reduced due to competition of outputs (relaxation interferes with anxiety) whereas counterconditioning assumes that the association between the cue and the appetitive outcome (learned through systematic desensitization) interferes with the expression of the association between the event and anxiety. Presumably, the two processes partially contribute to the behavioral change expressed in the reduction of anxiety due to what was once an anxiety-eliciting stimulus. Furthermore, some researchers state that reciprocal inhibition may be responsible for the short-term effects of systematic desensitization whereas counterconditioning may explain the long-term efficacy of this therapeutic technique.

Major Concepts As mentioned, systemic desensitization as a treatment for dysfunctional fearful behavior is grounded in two animal models of treatment: reciprocal inhibition and counterconditioning. Reciprocal Inhibition

Reciprocal inhibition is a process in which a habit is not performed in the presence of its eliciting stimulus given that an incompatible response,

Systematic Desensitization

also associated with the stimulus, interferes with its expression. For example, in the case of a specific phobia to dogs, a dog is the anxiety-eliciting stimulus, and getting anxious in the presence of a dog is the habit. According to the reciprocal inhibition principle, if anxiety is interfered in the presence of the dog, then the probabilities of getting anxious the next time the client is confronted with a dog will decrease. Counterconditioning

Counterconditioning refers to basic phenomena based on classical conditioning. A conditioned response is reduced when the conditioned stimulus that elicits it is repeatedly paired with a second unconditioned stimulus that evokes a response opposite to the one elicited by the unconditioned stimulus with which the conditioned stimulus was initially associated. As a result, a new, classically conditioned association is formed. In the case of conditioned fear, which is assumed to be involved in the etiology of phobias and other anxiety disorders, a fear-inducing conditioned stimulus stops eliciting fear after being repeatedly paired with an appetitive unconditioned stimulus (i.e., a pleasant outcome).

Techniques With systematic desensitization, techniques are closely related to the three steps of the therapy. In the first step, the therapist teaches the client a relaxation method or an alternative incompatible response. The second step consists of the elaboration of a fear hierarchy. The third step consists of systematic exposure to the situations considered in the fear hierarchy while the client is relaxed. Training in Relaxation or Alternative Incompatible Response

Traditional systematic desensitization uses the technique of deep muscle relaxation. The therapist guides the client to tense and relax specific muscles, starting from the muscles of the hands, followed by those of the arms, head, shoulders, then the muscles of the middle body, and finally the muscles of the lower body. The idea is for the client to tense a small group of muscles for a few seconds and then relax them, allowing the client to

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discriminate between the two states. Alternative responses incompatible with anxiety are also used. For example, emotional excitement, sexual arousal, meditation, imagining positive outcomes, breathing exercises, and nonaversive (distracting or interfering) electric shocks are often used to elicit alternative anxiety-incompatible responses. Elaboration of a Fear Hierarchy

The therapist and the client identify situations that make the client anxious. These situations are related to the phobic object in specific phobias (e.g., viewing a spider for those with arachnophobia). The standard is to create lists of approximately 10 events or items to work on in the following sessions. The list begins with the event inducing the least anxiety and ends with the event that induces the most anxiety. Systematic Exposure to Fear-Inducing Events While the Client Is Relaxed

This is the actual desensitization procedure. It begins by helping the client to completely relax, and then the lowest anxiety-inducing event in the hierarchy is presented. In the original systematic desensitization, the events are presented to the imagination. However, in vivo presentation of the events can be used for clients who are not disturbed by imagining the situations of the hierarchy. Presentation of the items to the imagination lasts a few seconds and is repeated until the client is no longer disturbed by the event. Then, the procedure is repeated with the next anxiety-inducing event in the hierarchy.

Therapeutic Process Between three and six initial sessions are used to collect information about the client and to train the client in the deep muscle relaxation technique, which occupies the beginning of the sessions and extends for approximately 15 minutes. The remaining time in the sessions is used to construct delimited anxiety-eliciting situations, which then are listed in order depending on the level of anxiety they induce in the client. After the initial sessions, the actual desensitization begins. Anxiety responses elicited by the events of the hierarchy are systematically confronted with relaxation until

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Systemic Constellations

these situations no longer induce anxiety. The gains achieved during systematic desensitization are typically maintained in the long-term. Mario A. Laborda and Gonzalo Miguez See also Behavior Therapy; Classical Conditioning; Exposure and Response Prevention; Exposure Therapy; Operant Conditioning; Pavlov, Ivan; Prolonged Exposure Therapy; Skinner, B. F.

Further Readings Head, L. S., & Gross, A. M. (2008). Systematic desensitization. In W. T. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 542–549). Hoboken, NJ: Wiley. Rachman, S. (1967). Systematic desensitization. Psychological Bulletin, 67, 93–103. doi:10.1037/h0024212 Wolpe, J. (1952). Experimental neuroses as learned behavior. British Journal of Psychology, 43, 243–268. doi:10.1111/j.2044–8295.1952.tb00347.x Wolpe, J. (1954). Reciprocal inhibition as the main basis of psychotherapeutic effects. Archives of Neurology and Psychiatry, 72, 205–226. doi:10.1001/archneurpsyc .1954.02330020073007 Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Wolpe J. (1968). Psychotherapy by reciprocal inhibition. Conditional Reflex, 3, 234–240. doi:10.1007/BF03000093 Wolpe, J., & Plaud, J. J. (1997). Pavlov’s contribution to behavior therapy: The obvious and the not so obvious. American Psychologist, 52, 966–972. doi:10.1037 /0003

SYSTEMIC CONSTELLATIONS Systemic constellations is an intervention that aims to identify or release prereflective, transgenerational patterns that are rooted in family, community, and organizational systems. The intervention integrates existential phenomenology, family systems therapy, and the ancestor respect of South African Zulu culture. This process addresses the unhealthy, destructive, or ineffective dynamics within systems. Anecdotal and case study data suggest that participants experience a heightened awareness of embedded patterns of behavior that plays itself out within the system.

Historical Context Bert Hellinger (1925– ) developed systemic constellation therapy. Hellinger was a German Catholic who was recruited by the Hitler Youth during Nazi-era Germany. When he declined to join, he was considered an enemy and faced persecution. To escape this persecution, he joined the German regular army. While serving in combat during World War II, he was captured and imprisoned in an Allied prisoner-of-war camp in Belgium. After escaping from imprisonment, he returned to Germany, where he entered a Catholic religious order. He became a priest and practiced for 20 years. Part of that time was spent in South Africa, where he was a missionary to the Zulu. In the late 1960s, he left the priesthood, married, and started studying psychoanalysis. By the time Hellinger was 60 years old, he had spent 15 years studying psychoanalytical theory, primal therapy, transactional analysis, psychodrama, Gestalt therapy child psychology, and hypnotherapy. Hellinger combined his work as a private practice clinician utilizing eclectic existential therapy, his extensive therapeutic training, and his experiences as a missionary with the Zulu to form the theoretical basis of systemic constellations therapy.

Theoretical Underpinnings Systemic constellations therapy, done within a group format, has three primary theoretical origins: (1) phenomenology, (2) Zulu ancestor reverence, and (3) family systems therapy. Developing a representational constellation that highlights the systemic problems, is an essential component of the approach. Phenomenology

Hellinger’s perception of phenomenology consisted of individuals resisting their need for scientific inquiry to grasp the unknown and allow their attention to focus on self and the understanding of consciousness from the individual’s first-person perspective. Zulu Ancestor Reverence

In their traditional culture, the Zulu live and act in a religious world in which their ancestors are the central focal point. Ancestors are regarded as

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positive, beneficial, and creative presences within the Zulu culture. Failure to show ancestors proper respect invites adversity, whereas proper respect ensures benefit. Systemic constellations supports a similar position toward intergenerational system dynamics and looks at the organization or family as a whole. Family Systems Therapy

Hellinger’s approach recognizes the transgenerational connectedness concept from the family therapy approach of Böszörményi-Nagy and Virginia Satir. Böszörményi-Nagy and Satir both believed that generational issues get played out unconsciously in current family members.

Major Concepts Some of the major concepts of systemic constellations are (a) the three principles, (b) constellations, (c) soul, (d) conscience, and (e) belonging, balance, and hierarchy. Three Principles

Hellinger’s major concepts are best explored through several principles and themes. He identified the therapeutic intervention and the fundamental structures as three principles, which he named the orders of love: (1) parents give and children receive, (2) every member of the system has an equal and unequivocal right to belong, and (3) each system has an unconscious group conscience that regulates guilt and innocence as a means to protect the survival of the group. They include soul; conscience; belonging, balance, and hierarchy; and existence. These themes have no religious connotations or scientific references as used in Hellinger’s approach. Constellation

A constellation is a spatial arrangement of individuals from a family, community, or organization that reflects both the current conscious experience of the persons in the constellation as well as the unconscious patterns that have been passed down from previous generations. Systemic constellations create new understanding about generational heritage, and through the process of systemic constellations therapy, often what is realized is that a

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member of the system is repeating or compensating for prior sufferings. The approach works to suggest new healing resolutions within the created and symbolic constellations in a session. Soul

The soul is the source of drives and impulses that are deeply rooted. Individuals cannot recall their origins, and their purpose cannot be reached by the conscious mind. Conscience

Conscience is that which serves to join individuals to a specific person or group, or separate them. Its purpose is to join individuals to their family or other system. Belonging, Balance, and Hierarchy

Belonging controls membership in the system. Balance maintains equilibrium between giving and taking in relationships. A tiered order (hierarchy) positions the members of the system in relation to one another. Violations and disruptions to these themes can cause illnesses, accidents, estrangements, dysfunction, and deviant behavior.

Techniques In a session, individuals present a closely focused and pressing personal, professional, or organizational issue and select members from the group to stand in as the representatives of members of the problem system. With help from the facilitator, the individuals then place these members in a symbolic model of the system. Once placed, the representatives do not speak, act, or move. This placement becomes the constellation. The silence and stillness of a session allows the individuals and the representatives to tune into the unconscious collective will of the system. The individuals are able to perceive a prereflective, systemic connection between past family ancestral patterns and the current problem. The process is brought to a close when the individuals gain insight and the facilitator removes himself or herself from the scenario. The individuals then visualize an image of healing. In the last step, the facilitator suggests one or two healing sentences to be said in the session.

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Therapeutic Process The process normally occurs once with 10 to 30 participants who serve as representatives, but it may occur over two or more sessions when used in business or other organizational settings. There are active participants and observing participants. Individuals are not diagnosed, and facilitators may or may not have a medical or counseling background. This process can be seen as intense and is best for people who wish to experience individual growth or are looking to resolve a temporary disturbance in their life or group. Individuals barely speak during a session. For many individual clients, systemic constellations therapy is used in addition to conventional therapy. Tracy L. Jackson See also Böszörményi-Nagy, Ivan; Existential Therapy; Family Constellation Therapy; Human Validation Process Model; Multigenerational Family Therapy; Psychodrama; Satir, Virginia

Further Readings Cohen, D. (2006). Family constellations: An innovative systemic phenomenological group process from Germany. Family Journal, 14(3), 226–233. doi:10.1177/ 1066480706287279 Crawford, J. (2013). Sister of the heart and mind: Healing and teaching with family system constellations. Women & Therapy, (1–2), 100–109. doi:10.1080/02703149 .2012.720554 Talarczyk, M. (2011). Family constellation method of Bert Hellinger in the context of the code of ethics for psychotherapists. Archives of Psychiatry and Psychotherapy, 13(3), 65–74. Weinhold, J., Hunger, C., Bornhäuser, A., Link, L., Rochon, J., Wild, B., & Schweitzer, J. (2013). Family constellation seminars improve psychological functioning in a general population sample: Results of a randomized controlled trial. Journal of Counseling Psychology, 60(4), 601–609. doi:10.1037/a0033539

SYSTEMIC FAMILY THERAPY Systemic family therapy, practiced and developed by the Milan School of family therapy, is also known as the Milan Approach. Like most family

systems theories, this theory sees the family, not the individual, as the symptomatic client and ultimately allows the family to understand the complex interactions and relationships of its members. Systemic family therapists seek to understand how the family has come to organize itself by using unspoken and subtle family dynamics and processes, with the goal of helping the family find new ways to organize itself relationally and emotionally so that the family members no longer produce symptoms.

Historical Context As a group of psychoanalytical psychiatrists in the late 1960s, Luigi Boscolo, Gianfranco Cecchin, Mara Selvini Palazzoli, and Giuliana Prata began working with couples and families in therapy sessions. In contrast to the individual focus of most psychoanalysts of the time, the group started to discuss their ideas and thoughts regarding their experiences working with these couples and families. In 1971, the group opened the Milan Center for the Study of the Family, where they treated couples and families and deepened their understanding of family communication and relational patterns. Gregory Bateson’s research on communication theory, circular systems, and cybernetics was critical to the group and became foundational in their work with families. The group also incorporated ideas from Murray Bowen’s multigenerational family systems, Jay Haley’s strategic model, and Salvador Minuchin’s structural theory. The term Milan Approach was coined by Lynn Hoffmann, another family therapist, to identify the original contributions of Boscolo and Cecchin after they parted from Palazzoli and Prata at the end of the 1970s. The years between the late 1970s and early 2000s are considered the “roaring years” of the Milan Approach. During this time, Boscolo and Cecchin founded their school, the Milan School of family therapy, which facilitated the expansion of the Milan Approach and solidified its significance. The school’s founders and theorists were continually seeking and processing new information to expand their theoretical foundations and understanding of the family and family therapy. In particular, they were influenced by a number of their students who were working in

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various settings, as well as by their own travels throughout the world, which enriched their perspective and theoretical work.

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implement a collaborative therapeutic process in which the therapist is not the expert.

Major Concepts Theoretical Underpinnings The theoretical roots of the Milan Approach can be traced to the development of communication theory by Bateson and his colleagues in Palo Alto, California (sometimes called “the Bateson Project”). This approach looked at the complex ways people communicate in systems and was one of the first approaches that viewed the development of psychological and psychiatric symptoms from a communication and systematic perspective. This project developed and expanded on concepts regarding general systems theory and cybernetics. Circular causality and triadic interactions became foundational to the Milan School’s understanding of family interactions. These concepts assert that individuals within a family are interconnected (A causes changes in B, which in turn causes changes in C, which eventually causes changes in A). In its initial theoretical development, the Bateson Project focused on how people communicate in relationships and create “relational patterns.” These relational patterns can be observed and understood within family systems. Bateson hypothesized that these patterns could be modified with appropriate methods of communication. These methods include techniques by which a therapist interviews and converses with each member of the family while in the presence of the family system. During the session, the therapist could consult with colleagues, observing the session through a one-way mirror. Sessions would typically end with a final intervention, such as a poignant comment, a reframing, or a prescription. This original treatment modality was strongly strategic, which means that therapy was focused on helping solve the presenting problem in the system. This approach was not particularly concerned about the past or mentalistic concepts like the unconscious or insight. However, over the years, the theory has become increasingly postmodern and has moved toward inviting couples and families to discuss their life circumstances, especially relative to their relational patterns. Since the very beginning, the Milan Approach has strived to

Some of the major concepts important to the Milan Approach are using a systemic approach with clients, understanding the importance of observer cybernetics, mapping families, using storytelling and narratives, taking a social-constructivist perspective, and honoring different theoretical approaches. Systemic Approach

The Milan Approach views individuals, couples, and families systemically. Human systems—such as families, groups, and organizations—respond to established recurring patterns. Change is believed to occur from within the system, and the priority is to identify problems in the system and implement therapeutic strategies that cause disruptions to the established patterns and interactions. Change then occurs as the system develops new paths toward growth and transformation. Observer Cybernetics

Observer cybernetics, also called second-order cybernetics, supposes that the family affects the therapist just as the family is affected by the therapist. Thus, it is believed that there can never be true therapeutic objectivity because the therapist is affected by the family system. Given this, however, the therapist can still affect the system, and in fact, just his or her presence within the system should change the system in some manner. Therefore, therapists must be flexible and attempt to understand how their ideas, emotions, and reactions play a dramatic role in the unfolding nature of the family dynamics. Maps

The family comes into therapy with an established “map,” which is reflective of the unique manner in which the family interacts. This map reflects the family homeostasis, which describes the manner in which family members are likely to respond in different situations. Families with dysfunction are treated by modifying their map.

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Storytelling and Narrative Therapy

Bateson, whose thoughts deeply influenced the Milan Approach, stated that our minds work by stories. Therefore, it is not surprising that aspects of narrative therapy, a therapy that examines individuals and family stories, have come to play a major role in the development of the Milan Approach. The founders of systemic family therapy had talents that contributed to this narrative aspect. For instance, Boscolo was a talented storyteller who used stories as a key therapeutic resource for establishing rapport with clients. Cecchin reinterpreted the stories told by individuals and families using principles that are similar to those of the Italian theatre tradition commedia dell’arte. This type of theatre originated in Italy in the 16th century and comprises improvised stories that are sometimes surprising or even bizarre; however, these stories can trigger processes of change. These talents have proved to be integral in the theoretical development of the Milan Approach: Understanding a family’s stories from the multiple perspectives of the family members has become a critical tool in mapping the family and understanding the family system. Social Constructionism

The current Milan Approach is strongly influenced by social constructionism, or the belief that society and the individual construct truth and meaning. This foundation is especially important with regard to therapeutic conversations in that the therapist values the client’s stories, views the client as the expert about his or her life, and respects the client’s values and beliefs. In addition, because truth is viewed as subjective, pathology and diagnosis are downplayed, as they are seen as the product of an external reality often based on oppressive social mores. The therapist seeks to make the therapeutic process nonpathological by depicting the problem and the recovery as part of a wider process of change and transformation, involving not only relationships and family issues but also cultural issues and transformations in the client’s life environment.

working with clients. Thus, the Milan School tries to foster professional and scientific relations with colleagues from all over the world and acknowledges that different fields and perspectives can be a source of learning for all professionals and scholars in this field. At the same time, this cooperation helps to better appreciate the common grounds underlying the different schools and approaches.

Techniques As a social-constructionist methodology that seeks to understand client narratives, the Milan Approach to working with families takes a respectful, inquisitive, curiously questioning, nonpathological approach with families as it uses circular questioning, specific techniques to conclude the interview, positive connotations, and creativity. Circular Questioning

The core of the Milan techniques resides in circular questioning, which consists of asking family members different kinds of questions to best understand the family’s and its members’ narratives and unique perspectives on their lives. There are several types of circular questioning: hypothetical, triadic, future oriented, and rank oriented. Hypothetical Questions Hypothetical (what if . . .) questions allow family members to develop new ideas about how they can live in the world: for instance, What if your family were able to be loving to one another— what do you think that would look like? This type of question allows the members of the family to both look at the current ways it communicates and begin to imagine new ways of communicating. The responses to these questions are representations, often highly metaphorical, of the relationships taking place within the family. They help the therapist to remain active and in touch with the family, give the family hope for the future, and help the family members see that they can abandon and replace old maps with new ones that are more in line with healthy functioning.

Honoring Different Theoretical Approaches

Although the Milan Approach takes a relaxed critical stance against strict adherence to a theory, it does recognize the important role that theory can play in the development of novel ways of

Triadic Questions Triadic questions provide insight into family interactions and allow each member of the family to understand the role the other members plays

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during significant interactions. For instance, the question “When Mom criticizes your brother, what does Dad do?” helps the therapist and the family see the intricate dynamic that occurs between Mom, Dad, child, and brother at a significant communication point. Future-Oriented Questions Future-oriented questions allow the family to discuss expectations and concerns about the future. They can be helpful in understanding how family members react to potential changes in the family, and the responses can be useful in assessing if progress has been made and in identifying goals. For instance, the question “How do you figure Mom and Dad will get by when you leave home?” can give the therapist and the family an inkling into to how Mom and Dad are getting along now (statements about how people will do in the future are often reflections of how they are doing in the present) and can be helpful in identifying what issues to work on in therapy. Rank-Oriented Questions Rank-oriented questions (Who in this family is the unhappiest when Jack plays hooky?) allow the family to identify how the problems that one member is experiencing can affect other members of the system. In addition, they tend to help the family understand who is in a position of power, the major personality traits of individual family members, and the gender and cultural placement of family members. For instance, the question “Who is in charge of this family?” tells the therapist who holds power in the family and if the power is held by gender roles. Follow-up questions like “How does that person keep his or her power?” can reveal interesting dynamics in the family. Concluding Intervention

Each session is concluded with an important intervention, such as a prescription, which is a suggestion of what the family should do; a ritual, which is something unique to the family that the family can do on an ongoing basis (e.g., saying a prayer, having a family discussion, etc.); or a reframing, which refers to describing a trait of the family in a new, more positive way (e.g., a family that argues a lot can be described as a family that

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really wants to discuss its feelings). These interventions are determined by the therapist and help establish the family’s last impression before leaving the session. Positive Connotations

The Milan Approach seeks to depathologize clients, so the therapist will try to reframe negative concepts into positive concepts. For example, if a client describes herself using these words, “I am cranky, this is who I am!” then through a series of questions formulated according to a circular epistemology, the therapist will offer an alternative view in which the presumed personality traits will take on a more positive meaning. As a result, as the therapist asks this series of questions, the client realizes that her crankiness is really worry about ensuring the positive health of her family. Thus, the original description, which was perceived to be the only possible and unchangeable way of perceiving the individual, is complemented with other possible, plausible descriptions for the client, thus generating an experience of more freedom for the client. This is likely to facilitate a positive change not only for the individual but also for the whole family system. Creativity and Respect

Cecchin, one of the theory’s founders, encouraged the use of creativity with families and in the therapeutic relationship. He also advocated the sacred role often played by the therapist and that the therapist approach the family with the utmost respect and reverence.

Therapeutic Process All Milan therapy starts with one (or two) initial consultation sessions, in which therapists assess whether they can be helpful, develop treatments plans, and negotiate the goals of the therapy with the family. The ideal setting for family therapy is a room with seats arranged in a circle and the therapist sitting together with the family. In another room, there are other therapists observing the session via a one-way mirror or video. Before closing the session, the therapist leaves the room to talk with the group of observing therapists, at which point the therapist receives input regarding the family and

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possible therapeutic interventions or techniques, especially for the closing intervention. The therapist then rejoins the family to close the session, often utilizing input from the group. Throughout the treatment, the group of therapists behind the mirror gradually becomes an important protagonist of the therapeutic process. This group is likely to influence the clients’ perceptions also. The Milan Approach advocates for time to lapse (about 1 month) between sessions, enough time for the effects or results of the previous session to have occurred. This perspective is unique in family systems theories. According to Bateson’s approach, on which systemic family therapy is based, the therapeutic process is focused on communication in context and on the concept that pathology can make sense when considered as part of broader processes. All therapeutic techniques or interventions take place in a positive environment because people do not easily change when they are blamed or criticized. Each participant in the session has the same dignity and rights regardless of his or her label, pathology, or rank within the system. Dignity is also important when issues related to diversity of cultures arise in the therapeutic process. Throughout treatment, the family’s narratives are discussed, because the past, present, and future narratives can provide powerful connections and implications. The Milan Approach focuses on emotions and considers them to be a pathway to participation and a trigger to change. In the Milan Approach, the best way to conclude therapy is based on a shared perception, both by the therapist and by the family, that a positive process of change has been set in motion. When these conditions occur and interfere as little as possible with the family members’ autonomous ways of changing, the therapist proposes to terminate the therapeutic relationship. Enrico Cazzaniga and Massimo Schinco See also Ackerman Relational Approach; Böszörményi-Nagy, Ivan; Bowen, Murray; Couples, Family, and Relational Models: Overview; Haley, Jay; Minuchin, Salvador; Multigenerational Family Therapy; Palo Alto Group; Satir, Virginia; Solution-Focused Brief Family Therapy; Strategic Therapy; White, Michael

Further Readings Boscolo, L., Cecchin G. F., Hoffmann, L., & Penn, P. (1987). Milan systemic family therapy. New York, NY: Basic Books. Boscolo, L., & Bertrando, P. (1993). I tempi del tempo: Una nuova prospettiva per la consulenza e la terapia sistemica [The times of time: A new perspective in systemic therapy and consultation]. Torino, Italy: Boringhieri. (English translation published by W. W. Norton, New York) Boscolo, L., & Bertrando, P. (1996). Systemic therapy with individuals. London, England: Karnac Books. Cecchin, G. F. (1987). Hypothesizing, circularity and neutrality revisited: An invitation to curiosity. Family Process, 26, 405–413. Cecchin, G. F., & Apolloni, T. (2003). Idee perfette: Hybris delle prigioni della mente [Perfect ideas: Hybrid prisons of the mind]. Milan, Italy: Franco Angeli. Cecchin, G. F., Lane, G., & Ray, W. A. (1992). Irreverence. A strategy for therapist’s survival. London, England: Karnac Books. Cecchin, G. F., Lane, G., & Ray, W. A. (1997). The cybernetics of prejudices in the practice of psychotherapy. London, England: Karnac Books.

SYSTEMS-CENTERED GROUP THERAPY Developed by Yvonne Agazarian in the 1990s, systems-centered therapy and training (SCT) for groups is a comprehensive systems approach where each of the methods and techniques was developed by first operationally defining the specific theoretical constructs and then applying each construct in practice. The core method in SCT for groups is functional subgrouping, notable for lowering acting out of scapegoating and enabling groups to explore and integrate differences or conflicts in the here-and-now. SCT also emphasizes influencing group norms quickly, because once norms are set, they influence what is and is not possible. SCT leaders work actively in the early phases of a group to influence norms that support group development (e.g., functional subgrouping, eye contact, centering, starting and stopping on time). Furthermore, SCT leaders discourage

Systems-Centered Group Therapy

importing social norms such as explaining and vagueness or ambiguity.

Historical Context In the 1980s, Agazarian worked as part of the American Group Psychotherapy Association’s General Systems Committee to apply general systems theory to group therapy. When this committee disbanded, Agazarian continued this work, ultimately developing her theory of living human systems, which has been applied to systems of all sizes: person, couple, family, therapy group, work team, and even a whole organization. In contrast to models that are person centered or leader centered, Agazarian developed a systems-centered approach that lowers the human tendency toward self-centeredness and personalizing. A number of theorists’ work influenced Agazarian: Ludwig von Bertalanffy’s definition of isomorphy, James Miller’s equation of energy with information, Claude Shannon’s theory of communication, Kurt Lewin’s force field model of driving and restraining forces on the path to a goal, Warren Bennis and Herbert Shepard’s phases of group development, and Habib Davanloo’s work in actively weakening defenses. Also, Agazarian and Anita Simon’s sequential analysis of verbal interaction (SAVI) significantly contributed to SCT. In developing SAVI, they applied Shannon’s theory of communication to verbal communication, creating a system for coding communication behaviors as approaching or avoiding the goal of communication. Using SAVI to code both individual and group communication patterns revealed that the group pattern governs individual patterns. In one study, Agazarian coded an entire session of an ongoing therapy group; it showed a group pattern of flight. Looking at the sequence of patterns in the group, every time an individual’s communication shifted out of flight to a work pattern, the next speaker reintroduced flight so that the group pattern remained in flight. Most dramatically, at one point the group had three communications in sequence in a work pattern and the therapist then responded in a way that took the communication pattern back to flight. This recognition contributed to SCT’s emphasis on establishing norms for valid communication as quickly as possible, because once

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norms are established, they govern the people in the group, including the therapist. Agazarian’s work assumes that human beings have difficulty with differences. Because SCT introduced a different approach for group therapists, especially in its active leadership to influence group norms, it is not surprising that Agazarian’s SCT methods have taken time to gain acceptance. Today, more than 20 years after SCT was introduced as a coherent approach, SCT’s functional subgrouping has become well-known and widely used in the group therapy field. The entirety of the theory and method is as yet less widely understood.

Theoretical Underpinnings Agazarian has defined a theory of living human systems as a hierarchy of isomorphic systems that are energy organizing, goal directed, and system correcting. In brief, hierarchy is defined as a set of three systems, where one system always exists in the context of the system above it and is the context for the system below it (picture concentric circles). Thus, living humans systems are always nested in a context and cannot be fully understood when seen in isolation. Applying this to a therapy group, the hierarchy of systems is the group-as-awhole (the largest circle of the three concentric circles), the member (the middle circle), and the person (the smallest circle). The person system supplies the energy for the whole hierarchy. Members organize their energy toward the goal of the group. Whenever there is a conflict, members cluster together to explore similarities using functional subgrouping. The norms of the group-as-a-whole develop and transform as differences are integrated, thus supporting development and transformation at all levels of the system hierarchy. Isomorphy is defined as similarity in structure and function for the systems in a hierarchy. Structure is defined as boundaries, which open to energy or information. Boundaries close to noise in communication (defined as ambiguity, contradiction, or redundancy) and to differences that are experienced as too different. SCT leaders monitor and influence boundary permeability at all system levels (e.g., teaching group members to interact with less noise when they contribute). Groups function to survive, develop, and transform from simpler to more complex systems through the process of

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discriminating and integrating differences. SCT’s method of functional subgrouping puts this construct into practice, where members learn to join first on similarities, with differences being explored in a different subgroup with others who have a similar difference.

Major Concepts Although SCT has a developing body of research, it is foremost a theory-driven approach, and its guiding concepts have come from operationally defining each theoretical construct, which then links to methods and techniques. From defining hierarchy, SCT assumes that one’s context has as much if not more to do with how one functions than one’s personal dynamics. For example, when we are in our family context, we behave and relate in one way and when we are in our work context, in another way. Thus, SCT shapes the norms of the group context by influencing the variables of structure, function, energy, goal orientation, and system hierarchy. SCT also asserts that learning to see one’s system context supports change. Just as a group always exists in a context (e.g., a group exists within a counseling center and its norms), group members always exist in the context of the therapy group, its norms, and the phase of group development. For example, in the flight phase, members commonly feel anxious. Sarah was very anxious in her first group, worried that something was wrong with her and thinking she did not belong in the group. As soon as she heard the leader say it was normal to be anxious in a new group and others talked of being anxious too, she saw that how she felt was a product of the context. Putting this idea into practice enables groups to weaken the human pull to personalizing, or taking one’s self as the only context. Seeing the larger context of one’s experience lowers the distress and anguish, which increase when we take things just personally, and helps us shift from self-centered to systems-centered thinking. By defining boundaries, SCT works with the awareness that how a group communicates is more important than what is said. SCT leaders actively influence the communication norms (the “how”) by lowering noise in communication. This leaves the group free to choose “what” to explore. For example, members are asked to be specific when

they are ambiguous or to get to the bottom line when they are redundant. By defining function, SCT posits that the central mechanism of change is the process of discriminating and integrating differences. This is put into practice with functional subgrouping, a core SCT method. In defining a goal-directed strategy, SCT presupposes that weakening the restraining forces opposing the goal is an easier and more sustainable change strategy than trying to increase the driving forces. For example, in the flight phase, SCT introduces a skill that weakens the restraining force of negative predictions and future speculations (e.g., “This group will not work out for me”). This then frees the group to reality-test (a driving force) in the present (How is the group working for you right now?”).

Techniques Each of the techniques below was developed by applying SCT theory and its constructs, and they link to the concepts discussed in the previous section. For example, Agazarian’s definition of function guided her work in developing both the method of functional subgrouping and the techniques that implement subgrouping to enable groups to integrate differences rather than scapegoating them. Functional Subgrouping

Right from the start of the group, SCT leaders introduce functional subgrouping by asking participants to say whatever they want and then end by saying “Anyone else?” The next speaker’s job is to build on the first with his or her own version and then say “Anyone else?” This pattern continues until someone brings in a difference and the group signals readiness for a different subgroup to explore. Functional subgrouping builds a group climate for integrating differences rather than the common human responses of trying to convert, reject, attack, or otherwise scapegoat differences. Responses to differences may be subtle, like a redirection, as when Dick describes excitement and Jane responds, “I’m a little excited, but I am more anxious.” Or they can be more overt, as when Dick says, “Jane, I don’t know why you are anxious. This group is perfectly harmless. You shouldn’t feel

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that way. Just relax, and you’ll feel more excited.” Introducing functional subgrouping whenever there is a difference or conflict interrupts incipient or overt scapegoating communications and instead asks those who are feeling similarly to explore together.

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For example, in a new group, those who are anxious explore with others who are also anxious; and in turn, those who are excited explore excitement together. An illustration of this depicts both the theory and the practice of functional subgrouping (see Figure 1).

1B.

1A.

Anxious

Excited

Time 1: Group comes together

Time 2: A difference emerges–represented here by round and square

1D.

1C.

Time 3: In turn, each subgroup explores and discovers differences within its similarity

Time 4: Discovering similarities across difference

1E.

Time 5: Integration in the group-as-a-whole and greater complexity

Figure 1

Illustration of Functional Subgrouping in a New Group

Sources: S. P. Gantt, Functional Subgrouping and the Systems-Centered Approach to Group Therapy, in J. Kleinberg (Ed.), The Wiley-Blackwell Handbook of Group Psychotherapy, pp. 116–117. Oxford, England: Wiley (2011). Copyright 2010 by Susan P. Gantt. Reprinted with permission of the author; “Developing the Systems-Centered Functional Subgrouping Questionnaire-2,” by R. M. O’Neill, S. P. Gantt, G. M. Burlingame, J. Mogle, J. Johnson, & R. Silver, 2013. Group Dynamics: Theory, Research, and Practice, 17(4), pp. 252–269. doi:10.1037/a0034925

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Members were asked what it was like to begin as a new group (Figure 1A). Some voiced anxiety and others excitement. The group then formed two subgroups (Figure 1B), the “anxious” subgroup depicted here by circles and the “excited” subgroup by squares. Each subgroup in turn explored its experience. Exploring in the context of one’s similar subgroup creates the security needed for neurobiological change as participants find others who are like them in that moment. Then, while relating to similarities, boundaries open, and they discover small differences (Figure 1C). Some anxious subgroup members reported feeling calmer (Figure 1C, the solid figures) and others curious (the dots), and still others noticed both apprehension and excitement (the stripes). The excited subgroup then explored together (squares in Figure 1B and C), joining on similarities and discovering small differences within these similarities (Figure 1C), including calmness, curiosity, and apprehension. Integration occurred as both subgroups discovered their similarities across what were initially two different subgroups (Figures 1D and E), finding curiosity, excitement, and apprehension in common. The group had developed greater complexity (Figure 1E) and more resources. Group members learned to explore together: legitimizing anxiety, excitement, apprehension, and curiosity and lowering the group’s anxiety, an important step in a new group’s flight subphase. SCT groups use functional subgrouping whenever there is a conflict or difference that cannot easily be integrated or resolved. Sometimes this is a conflict within the group itself and requires the group to integrate the differences by exploring each viewpoint, rather than one subgroup trying to convince the other. In a group further along in its development, conflict may first surface inside one member. In one group, Dawn talked about hating her partner but being afraid of feeling so angry. A “but” always signals two subgroups. SCT leaders monitor for “but,” which signals a difference or conflict, and then ask the group to divide into the two sides of the conflict to explore each side, one at a time, using subgrouping. The group then discovers who resonates with which side of Dawn’s conflict, resulting in one subgroup exploring the experience of hating their partner and another subgroup exploring their fears about their feelings.

Fork in the Road of Choice

The fork-in-the-road technique is first introduced early in a group as the fork between “explaining” (redundantly going over what one already knows, which introduces noise and closes boundaries) versus “exploring” and opening to the unknown. Group members are asked to choose whether to explore the wish to explain their experience or to explore their experience. For example, Dick reports, “I am angry because Tom was late.” Dick is asked to choose whether to explore his experience of anger or explore the part of him that wants to explain why he is angry. Similarly, the “yes, but” social communication pattern is reframed as a fork in the road and then modified by introducing functional subgrouping and asking members to choose which subgroup to explore, the “yes” or the “but.” This allows the group to weaken contradictions, which are another source of noise in group communication. Lowering Personalizing and Learning Contextualizing

SCT groups learn to discriminate between personalizing, when members perceive something as being just about themselves, versus contextualizing, or learning to see the bigger picture. For example, if Tom takes it “just personally” that others do not like it when he is late for group, he will have one feeling (irritation at the group or turning his irritation back on himself and feeling badly). If, instead, he sees it from the point of view of his member role, where he recognizes the impact on the group when anyone is late, then he will have another perspective and different feelings (curiosity about the impact and empathy for himself and the group). Or if he sees himself as part of a subgroup of late members, he is likely to be less defensive and more curious about what the late subgroup is expressing for the whole group. When he can see the “late” subgroup as containing one side of a group conflict or issue and the “on time” subgroup comprising the other side, then he is free to support the group’s exploring the two sides of its conflict. Weakening personalizing also supports personal development. Personal development is at the heart of every group member’s goal. SCT sees the pathway to development as taking membership both in

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the group, to support the group’s goals, and in oneself as a person, to support one’s personal goals. Learning to shift from a self-centered to a systems-centered focus lowers personalizing and enables membership development, which then develops the person’s capacity to take a member role in other life contexts. Weakening Defenses (or Restraining Forces) in the Context of the Phase of the Group’s Development

There is extensive group literature on phases of development. Uniquely, Agazarian has conceptualized each phase of development as a system defined according to its system properties: its goal orientation, driving and restraining forces, boundary permeability, and discriminations or integrations. SCT identifies three phases of group development: (1) the authority phase and its subphases (flight, transition between flight and fight, fight and interpersonal role-locks between members [e.g., one up paired with one down, and vice versa], and the crisis of hatred with the leader), (2) the intimacy phase, and (3) the work phase. SCT leaders then work with the group to weaken the restraining forces to development according to the group’s phase. Clinically, restraining forces are called defenses. Members are introduced to specific skills that enable them to weaken their own defenses relevant to the phase of development. Weakening the defenses linked to the group’s phase enables SCT leaders to work in attunement with the group and makes it less likely that the leader will ask the group to do work it cannot yet do. The authority phase work is to weaken externalizing and blaming others, especially those in authority, in order to be freer to take one’s own authority. Toward this goal in the flight subphase, SCT weakens social communication by working with a here-and-now task, rather than social introductions, which lead to stereotyped hierarchies based on outside roles. Once functional subgrouping is established, each group starts with a brief period of centering, connecting to the ground, one’s breathing and one’s own center. This supports shifting out of habitual roles and into here-and-now membership with access to one’s centered knowing. SCT also modifies the communication defenses to build a valid communication system. Defenses

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related to symptoms of anxiety, tension, or low energy are also weakened in this subphase. In the transition subphase between flight and fight, SCT weakens the defenses against the retaliatory impulse (boomeranging back on the self in depression or hostile outrage against others), which is aroused whenever a difference is too different or one feels hurt. When the retaliatory impulse is explored rather than enacted, it deepens the connection to one’s life force. The group then moves to the role subphase, exploring and weakening habitual roles and rolelocks enacted in the group (e.g., one up/one down, dominant/submissive). As these roles are weakened, group cohesion increases, and the group explores its hatred of the leader (equivalent to the negative transference), a key step in learning to take one’s own authority. The group then shifts into the intimacy phase, where the goal is exploring the issues in separation and individuation. Exploring the origin of the roles that imprison members in their relationships, both in the group and in their lives, modifies the early roles that maintain insecure attachment patterns. Having undone the split inherent in the authority phase of blaming others and one’s past, the work in this phase orients to revisiting the past in a way that enables reworking of early attachment patterns and developing a new coherent narrative. In the work phase, the goal is to use what one knows in context, weakening the tendency to personalize one’s experience or to legislate rules at the expense of common sense. Here, the group focuses on the ongoing work of learning to use comprehensive and apprehensive knowledge in here-and-now work together. Also, the group revisits earlier phase dynamics whenever they reoccur, thus enabling the group to work through its phase dynamics at increasingly deeper levels of experience.

Therapeutic Process The heart of the therapeutic process in an SCT group is discriminating and integrating differences in the service of surviving, developing from simpler to more complex, and transforming at all system levels. This is accomplished through developing group norms that support functional subgrouping, learning to shift from person to member, and

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learning skills that weaken the defenses in sequence in each phase of group development. These processes simultaneously modify the symptoms that bring people to therapy and lead to increased common sense and emotional intelligence. Susan P. Gantt See also Attachment Group Therapy; Group Analysis; Group Counseling and Psychotherapy Theories: Overview; Psychodynamic Group Psychotherapy; Tavistock Group Training Approach

Further Readings Agazarian, Y. M. (1997). Systems-centered therapy for groups. New York, NY: Guilford Press. Agazarian, Y. M. (2001). A systems-centered approach to inpatient group psychotherapy. Philadelphia, PA: Jessica Kingsley. Agazarian, Y. M. (2012). Systems-centered group psychotherapy: A theory of living human systems and its systems-centered practice. GROUP: The Journal of the Eastern Group Psychotherapy Society, 36(1), 19–36. Agazarian, Y. M. (2012). Systems-centered group psychotherapy: Putting theory into practice. International Journal of Group Psychotherapy, 62(2), 171–195. doi:10.1521/ijgp.2012.62.2.171

Agazarian, Y. M., & Gantt, S. P. (2000). Autobiography of a theory: Developing a theory of living human systems and its systems-centered practice. London, England: Jessica Kingsley. Agazarian, Y. M., & Gantt, S. P. (2005). The systems perspective. In S. Wheelan (Ed.), Handbook of group research and practice (pp. 187–200). Thousand Oaks, CA: Sage. Gantt, S. P. (2011). Functional subgrouping and the systems-centered approach to group therapy. In J. Kleinberg (Ed.), The Wiley-Blackwell handbook of group psychotherapy (pp. 113–138). Oxford, England: Wiley. Gantt, S. P., & Agazarian, Y. M. (2010). Developing the group mind through functional subgrouping: Linking systems-centered training (SCT) and interpersonal neurobiology. International Journal of Group Psychotherapy, 60(4), 515–544. doi:10.1521/ijgp.2010 .60.4.515 O’Neill, R. M., Gantt, S. P., Burlingame, G. M., Mogle, J., Johnson, J., & Silver, R. (2013). Developing the systemscentered functional subgrouping questionnaire-2. Group Dynamics: Theory, Research, and Practice, 17(4), 252–269. doi:10.1037/a0034925 Simon, A., & Agazarian, Y. M. (2000). The system for analyzing verbal interaction. In A. Beck & C. Lewis (Eds.), The process of group psychotherapy: Systems for analyzing change (pp. 357–380). Washington, DC: American Psychological Association.

T England. This approach grew from his work with returning military personnel who suffered from psychiatric disorders (termed shell shock then and posttraumatic stress disorder currently). Bion introduced the concept of container–contained, for how members project onto the group as an entity, not just as a collection of individuals, and for the group to study its own process as the container of those projections. This method also incorporated his ideas about community, self-determination, and the importance of providing structure for therapeutic services. Bion was influenced by the psychoanalytical work of Melanie Klein, who had introduced the notion of projective identification (the unconscious process of sending feelings and others unconsciously catching them) as part of a larger body of work in child and developmental analytic theory. Bion continued in this vein through the 1950s; in 1957, the Tavistock Institute and the University of Leicester sponsored the first group relations conference. A. K. Rice, a member of the Tavistock Centre for Applied Social Research, helped move the focus from the roles assumed at work to group leadership dynamics and issues of authority relationships in groups. He was also instrumental in introducing the concept that much could be learned from studying the conference and/or group itself. Rice sponsored the first group relations conference in the United States in 1965, and his A. K. Rice Institute continues to provide conferences and training in the Tavistock approach. The Tavistock approach uses a different language than is usually found in group therapy. For

TAVISTOCK GROUP TRAINING APPROACH Central to the Tavistock Group Training Approach is the concept of the group behaving as a collective system whose major task is to survive. Groups come into being when individuals become aware of their common relationship and work toward a common task, either in response to external or internal needs or as a group-based conscious choice. The Tavistock approach assumes that the group becomes the focus, rather than the individuals, and places attention on the collective identity created by the group members. The Tavistock Group Training Approach makes use of psychoanalytical concepts, especially projection, resistance, the unconscious being reflected in behavior, and an analysis of relationships in the here-and-now. The interventions generally move between conscious work mode and unconscious resistance that is observed in the group process, and these differences are highlighted by the consultant, or group leader. This consultant intervention is intended to make the unconscious conscious so that it can be examined and understood.

Historical Context The Tavistock approach was developed in the late 1940s, after World War II, by Wilfred Bion at the Centre for Applied Social Research, located in the Tavistock Institute of Human Relations in London, 997

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example, Tavistock group work settings are referred to as conferences, workshops, or educational events instead of therapy, and the group leader is called a consultant.

Theoretical Underpinnings Many of the concepts used in the Tavistock approach are derived from traditional psychoanalytical theories and include things such as the importance of the leader remaining aloof so that group members can project onto him or her and understanding how resistances play a role in protecting group members from accessing unconscious interpersonal and intrapersonal issues. The Tavistock approach proscribes that the group leader remain aloof and remote from the group, provide interpretations of the group’s behavior, and act as a screen for group members’ projections. Making the unconscious conscious is a psychoanalytical concept that is seen in the projections of the unconscious needs, wishes, fantasies, and desires onto the group leader, who is purposefully emotionally unavailable to the group members. The group leader observes these processes in the group as a whole and summarizes these as comments to the group. This allows for unconscious material to become visible to the group members and for members to move toward conscious exploration. Also, in Tavistock groups, resistance is expected but is not always recognized by the group members. The leader observes the group, attends to what the group as a whole is resisting, comments, and thus allows the resistance to be more visible for group members’ exploration. One of the methods