Carolyn McGuffog, Ph.D., Ed.D., A.B.S.N.P. Fordham University Therapeutic Techniques Workshop April 15, 2010 also known as insight-oriented therapy evolved from Freudian psychoanalysis psychodynamic therapists believe that bringing the unconscious into conscious awareness promotes insight and resolves conflict Freudian psychology - referred to as the drive or structural model Mental illness is a result of an unsuccessful progression through the psychosexual stages of childhood that results in problems in the balance of your personality structures (the ego, superego, and id) Sexual and aggressive energies originating in the id (or unconscious) are modulated by the ego which moderates between the id and external reality Oral Stage (Birth to 18 months) Focus on oral pleasures (sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality - preoccupation with oral activities. May become overly dependent upon others or may fight these urges and develop pessimism and aggression toward others. Anal Stage (18 months to three years) -focus of pleasure is on eliminating and retaining feces. Through societal pressure, the child learns to control anal stimulation. An anal fixation can result in an obsession with cleanliness, perfection, and control (anal retentive) or messiness and disorganization (anal expulsive). Phallic Stage (ages three to six) - pleasure zone switches to the genitals. A boy develops unconscious sexual desires for his mother and becomes rivals with his father. Fear their father will punish them for these feelings by castrating them (Oedipus Complex). Out of fear of castration, boys identify with their fathers. A fixation at this stage could result in sexual deviancies and weak or confused sexual identity. Electra Complex - girls go through a similar situation, developing unconscious sexual attraction to their father. Latency Stage (age six to puberty) sexual urges remain repressed and children interact and play mostly with same sex peers. Genital Stage (puberty on) - sexual urges are once again awakened. Adolescents direct their sexual urges onto opposite sex peers, genitals are the primary focus of pleasure. Ego Psychology derives from Freudian psychology. Heinz Hartmann therapist focuses on enhancing ego function in accordance with the demands of reality Ego Psychology stresses the individual’s capacity for defense, adaptation, and reality testing Anna Freud (1966) focused her attention on the ego’s unconscious, defensive operations believes the ego supervises, regulates, and opposes the id through defenses Defense mechanisms are constructions of the ego that operate to minimize pain and maintain psychic equilibrium. The superego (conscience) operates to control id drives through guilt. therapist needs to be attuned to the moment-bymoment process of what the patient talks about in order to identify and interpret defenses. Reality Testing: The ego’s capacity to distinguish what is occurring in one’s own mind from what is occurring in the external world. It is the single most important ego function because it is necessary for negotiating with the outside world. Affect Regulation: The ability to modulate feelings without being overwhelmed. Impulse Control: The ability to manage aggressive and/or libidinal wishes without immediate discharge through behavior or symptoms. Judgment: The capacity to act responsibly through identifying possible courses of action, anticipating and evaluating likely consequences, and making appropriate decisions. Object Relations: The capacity for mutually satisfying relationships. The individual can perceive himself and others as whole objects. Thought Processes: The ability to have logical, coherent, and abstract thoughts. In stressful situations, thought processes can become disorganized. Synthesis: The synthetic function is the ego’s capacity to organize and unify other functions within the personality. It enables the individual to think, feel, and act in a coherent manner. It includes the capacity to integrate potentially contradictory experiences, ideas, and feelings; for example, a child loves his or her mother yet also has angry feelings toward her at times. The ability to synthesize these feelings is a pivotal developmental achievement. Defensive Functioning: A defense is an unconscious attempt to protect one from some powerful identity-threatening feeling. Primitive defenses - develop in infancy and involve the boundary between the self and the outer world Mature defenses - deal with internal boundaries such as those between ego and super ego or the id. Primitive Defenses Denial is the refusal to accept reality and to act as if a painful event, thought or feeling did not exist. It is considered one of the most primitive of the defense mechanisms. Projection - attributing your own repressed thoughts and/or undesired impulses to someone else. A variation on the theme of Projection is known as Externalization. In Externalization, you blame others for your problems rather than owning up to any role you may play in causing them. Primitive Defenses Splitting - a person can not integrate both good and bad aspects, so they polarize their view of a person as "all good" or "all bad.” Splitting functions by way of Dissociation, which is the ability to wall off certain experiences and not think about them. Regression -because of partial fixations in any of the psychosexual stages of development, regression can occur when an individual is faced with high levels of stress in their life. Regression is the giving up of mature problem solving methods in favor of child like approaches to fixing problems. Fantasy; - engaging in daydreams about how things should be, rather than doing anything about how things are. Acting out - an inability to be thoughtful about an impulse. The impulse is expressed directly without any reflection or consideration as to whether it is a good idea to do so. Passive-aggression - A thought or feeling is not acceptable enough to a person to be allowed direct expression so person behaves in an indirect manner that expresses the thought or emotion. More mature defenses (between ego and superego) Repression is the blocking of unacceptable impulses from consciousness. Reaction Formation is the converting of wishes or impulses that are perceived to be dangerous into their opposites. A woman who is furious at her child and wishes her harm might become overly concerned and protective of the child's health. Undoing is the attempt to take back behavior or thoughts that are unacceptable. An example of undoing would be excessively praising someone after having insulted them. Rationalization - a post-hoc (after the fact) defense mechanism - offering logical reasons for inexcusable actions. Displacement is the redirecting of thoughts feelings and impulses from an object that gives rise to anxiety to a safer, more acceptable one. Intellectualization is the use of a cognitive approach without the attendant emotions to suppress and attempt to gain mastery over the perceived disorderly and potentially overwhelming impulses. An example might be an individual who when told they had a life threatening disease focuses exclusively on the statistical percentages of recovery and is unable to cope with their fear and sadness. Sublimation is the channeling of unacceptable impulses into more acceptable outlets. first articulated by several British analysts, among them Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and Harry Guntrip human beings are shaped in relation to the significant others surrounding them internal representations of self and others acquired in childhood are later played out in adult relations individuals repeat old object relationships in an effort to master them and become freed from them. Object representation is the mental representation of a person. An external object is an actual person that has been invested with emotional energy. An internal object is a person’s representation of another person. It is a memory, idea or fantasy about that person. Self. Conscious and unconscious mental representations of oneself. Self-representation. A person’s inner representation of himself or herself as experienced in relation to significant others. Self-object. A loss of boundaries, where self and object are blurred and the distinction between self and external object is not clear. (This condition is called “confluence” in Gestalt Therapy). Part Object. This is an object that is part of a person, such as a hand or breast. The other is not recognized as a “whole object”. Whole Object. Another person who is recognized as having rights, feelings, needs, hopes, strengths, weaknesses, and insecurities just like one’s own. Object Constancy. Mahler: object constancy is "the capacity to recognize and tolerate loving and hostile feelings toward the same object; the capacity to keep feelings centered on a specific object; and the capacity to value an object for attributes other than its function of satisfying needs." Stood between classical psychoanalysis and object relations theory proper. Saw the psychic world of infant and child as filled with primitive, murderous and cannibalistic tendencies. Emphasized biological drives and instincts in the infant. Saw drives as inherently aimed toward objects. Task of therapy: To alleviate the early anxieties, and modify the harshness of internalized objects. True self - this is the part of the infant that feels creative, spontaneous, and real. False self - is "built up on the basis of compliance.“ With "good enough" care the true self can emerge, but without it the false self emerges. Holding includes actual physical holding, and caring for the child over time. It is psychological as well as physical. Transitional objects are the infant's first not-me possessions. They are tangible--can be held onto, grasped, hugged. They lessen the stress of separation and soothe the infant. Along with Winnicott, places great emphasis on the importance of holding a child. Psychological holding involves "holding a space" in which the child can be itself and feel protected and secure. Be a container for all that the child brings to you. The Separation-Individuation process has four phases: 1) Hatching. [5 to 9 months]. The infant becomes aware of the differentiation between itself and its mother. It becomes increasingly aware of and interested in its surroundings, mother is point of reference. 2) Practicing. [9 to 16 months]. The infant can now get about on its own, first crawling and then walking freely. The infant begins to explore actively and becomes more independent of its mother. The infant still experiences itself as one with its mother. 3) Rapprochement. [15 – 24 months]. The young child once again becomes close to his mother, but begins to differentiate itself from his mother. The child realizes that his physical mobility demonstrates psychic separateness from his mother. The toddler may become tentative at this point, wanting his mother to be in sight so that, through eye contact and action, he can explore his world. 4) Object Constancy. (Third year and beyond) Child has an internalized image of the mother. Can hold the image of her inside while she's away. Can use an object like a toy to supply comfort in her absence. The reality principle replaces the pleasure principle. Child is cognitively putting things together, cause and effect. Remember the past and think of the future: Mother will return. Some children at this stage will actively seek the father, fear being re-engulfed by the mother. Beginnings of super-ego development. Learning that there are consequences for acting in certain ways. Developing a conscience. "No, I shouldn't do this." If handled badly by caregivers, this stage involves the development of pathological shame and guilt. In adulthood, "I'm not okay, not good enough, etc." "Object relations does not take into account the social system that creates pathology. It is superficially an interpersonal approach in the dyadic relationship between mother and infant.” VIDEO offshoot of Object Relations Theory posits that each individual's self-esteem and vitality derive from and are maintained by the empathic responsiveness of others to his or her needs self-psychology therapist emphasize the role of empathic listening in treating clients emphasis on narcissism Narcisstic pathology is due to the absence of the parents' empathic response to the child's needs to be mirrored ....The parent may be unable to take pride in the child's accomplishments and may not fulfill the child's need for appropriate admiration. The chronic non-responsiveness of the parent keeps the child from building up the psychic structures to regulate tension and tame affects. An occasional lapse by the parents is no big deal. Therapy. Emphasizes empathic sensitivity to the subjective experience of the patient, especially the patient's experience of the therapist - transference. takes a positive view of human nature and emphasizes the uniqueness of the individual therapists help clients realize potential through change and self-directed growth Humanistic therapy is also an umbrella term for Gestalt, Client-Centered, and Existential therapy. Developed by Carl Rogers in the 1940s, the client-centered method is based on the empowering idea that the client holds the answers to her problems--not the doctor. The client-centered therapist's job is to carefully listen and strive to understand the client, so that she can tap into her natural ability to grow and improve. Client-centered therapy helps the client live in the moment and focus on personality change, rather than on the origins of her personality structure. Rogers believed that the most important factor in successful therapy was not the therapist's skill or training, but rather his or her attitude. Three interrelated attitudes on the part of the therapist are central to the success of personcentered therapy: Congruence Unconditional positive regard Empathy Congruence refers to the therapist's openness and genuineness—the willingness to relate to clients without hiding behind a professional facade. Unconditional positive regard means that the therapist accepts the client totally for who he or she is without evaluating or censoring, and without disapproving of particular feelings, actions, or characteristics. Empathy ("accurate empathetic understanding"). The therapist tries to appreciate the client's situation from the client's point of view, showing an emotional understanding of and sensitivity to the client's feelings throughout the therapy session. Active Listening - therapist shows careful and perceptive attention to what the client is saying. Reflection - paraphrasing and/or summarizing what a client has just said. Self-actualization - personal growth is facilitated by providing a climate in which clients can freely engage in focused, indepth self-exploration. It refers to the tendency of all human beings to move forward, grow, and reach their fullest potential. The concept of self-actualization focuses on human strengths rather than human deficiencies. According to Rogers, self-actualization can be blocked by an unhealthy selfconcept (negative or unrealistic attitudes about oneself). 1. The therapist must develop a warm, friendly relationship with the child in which good rapport is established. 2. The therapist accepts the child exactly as he/she is. 3. The therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his/her feelings completely. 4. The therapist is alert to recognizing the feelings the child is expressing and reflects those feelings back to the child in such a manner that he/she gains insight into his/her behavior. 5. The therapist maintains a deep respect for the child’s ability to solve his own problems if given the opportunity to do so. The responsibility to make choices and to institute change is the child’s. 6. The therapist does not attempt to direct the child’s actions or conversation in any manner. The child leads, the therapist follows. 7. The therapist does not attempt to hurry the therapy along. It is a gradual process and is recognized as such by the therapist. 8. The therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship. Several factors may affect the success of person-centered therapy. 1)If an individual was forced to attend therapy, that person may not work well together with the therapist. 2) The skill of the therapist may be another factor. In general, clients tend to overlook occasional therapist failures if a satisfactory relationship has been established. A therapist who continually fails to demonstrate unconditional positive regard, congruence, or empathy cannot effectively use this type of therapy. 3) A third factor is the client's comfort level with nondirective therapy. Some studies have suggested that certain clients may get bored, frustrated, or annoyed with a Rogerian style of therapeutic interaction. 4) does not lend itself to scientific study. VIDEO based on the philosophical belief that human beings are alone in the world, and that this aloneness can only be overcome by creating one's own meaning, and exercising one's freedom to choose existential therapist encourages clients to face life's anxieties head on and to start making his own decisions. therapist will emphasize that along with having the freedom to carve out meaning comes the need to take full responsibility for the consequences of one's decisions. focus on the client's present and future rather than his past. seeks to integrate the client's behaviors, feelings, and thinking, so that her intentions and actions may be aligned for optimal mental health. therapist will help the client become more self aware, live more in the present, and assume more responsibility for taking care of herself. Techniques include confrontation, dream analysis, and role playing. VIDEO http://www.youtube.com/watch?v=Okkk1XbF6zE&f eature=PlayList&p=4B85FA1730242238&playnext_ from=PL&playnext=1&index=48 founded by Alfred Adler (1870 -1937) an ex-associate of Freud who rejected Freud's notion that sex is the root of all psychological problems. takes a positive view of human nature - we are all goal-oriented creatures who are striving for social connectedness, and we are in control of our destiny. believed many personal difficulties stem from feelings of inferiority - coined the term "inferiority complex.“ will use information about a client's family history, birth order, and behavior patterns to help the client set new, socially satisfying, and attainable goals VIDEO http://www.youtube.com/watch?v=TiFDTS6aF0 Ego identity is the conscious sense of self that develops through social interaction. Each stage in Erikson’s theory is concerned with becoming competent in an area of life. If the stage is handled well, the person feels a sense of mastery, or ego strength. If the stage is managed poorly, the person will emerge with a sense of inadequacy. Stage 1 - Trust vs. Mistrust (Birth – one year) Because an infant is utterly dependent, the development of trust is based on the dependability and quality of the child’s caregivers. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. Psychosocial Stage 2 - Autonomy vs. Shame and Doubt (early childhood) Focused on children developing a greater sense of personal control. Erikson believed that learning to control one’s body functions, food choice, toy preferences, etc. leads to a feeling of control and a sense of independence. Children who successfully complete this stage feel secure and confident, while those who do not are left with a sense of inadequacy and self-doubt. Psychosocial Stage 3 - Initiative vs. Guilt (preschool years) Children begin to assert their power and control over the world through directing play and social interaction. Children who are successful feel capable and able to lead others. Those who fail to acquire these skills are left with a sense of guilt, self-doubt and lack of initiative. Psychosocial Stage 4 - Industry vs. Inferiority (5-11) Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement will doubt their ability to be successful. Psychosocial Stage 5 - Identity vs. Confusion (Adolescence) During adolescence, children are exploring their independence and developing a sense of self. Those who receive proper encouragement and reinforcement through personal exploration will emerge from this stage with a strong sense of self and a feeling of independence and control. Those who remain unsure of their beliefs and desires will feel insecure and confused about themselves and the future. Cognitive therapy focuses primarily on the thoughts and emotions that lead to certain behaviors, while behavioral therapy deals with changing and eliminating those unwanted behaviors. Cognitive Behavioral Therapy focuses on both thoughts and behavior. focuses on changing undesirable behaviors. involves identifying objectionable, maladaptive behaviors and replacing them with healthier types of behavior. Therapist analyzes the behaviors of the patient that have a negative impact on the life of the patient. Once analysis is complete, the therapist chooses appropriate treatment techniques. Treatments can include such techniques as: Environment Modification – assess antecedents to the undesirable behavior and modify those antecedents – determine what triggers the behavior – determine what purpose the behavior serves – find alternative means of achieving that goal. Positive Reinforcement – specify target behavior, determine a reinforcer (reward), make the reinforcement contingent on the occurrences of the targeted behavior - social reinforcer – praise - material reinforcer – stickers. Modeling (Social Learning) – demonstrates for the child a more appropriate response - can be used to teach skills or to model coping behavior - Symbolic modeling – model is in a story or a puppet - Participant modeling - models guide the child. Shaping – a way of helping a child get progressively closer to a targeted goal – successive approximations – teach skills gradually towards a desired goal. - child is given positive reinforcement for closer and closer approximations to the desired response. Social Skills Training is a form of behavior therapy that can help people who have difficulties relating to other people and regulating their behavior. Teach interpretation of social cues and appropriate behavioral responses. Role playing. Social Stories – teach social skills by providing detailed information about confusing situations focusing on: the important social cues, the events and reactions the individual might expect, the actions and reactions that might be expected of him, and why. The goal of the story is to increase the child’s understanding of and make him more comfortable in social situations. Assertiveness Training is a form of behavior therapy designed to help people stand up for themselves—to empower themselves. - Assertiveness is a response that seeks to maintain an appropriate balance between passivity and aggression. Self-Control Strategies – teach a child to use new behaviors and ways of thinking that enhance the child’s sense of control. Cognitive selfcontrol programs teach children to monitor, evaluate and reinforce themselves for using more adaptive behaviors and coping skills. Exposure – gradual and systematic confrontation of anxiety provoking stimuli so that habituation occurs – anxiety subsides or decreases as a result of repeated exposure – in vivo exposure is superior to imagined exposure, can use both. Response Prevention - exposure to a feared stimulus while not engaging in any safety behaviors. - subject experiences habituation to the feared stimulus, while practicing a fearincompatible behavioral response to the stimulus - causes some short-term anxiety but facilitates long-term reduction in obsessive and compulsive symptoms. Systematic Desensitization – process of reducing anxiety or fear by replacing a maladaptive response with an adaptive one – accomplished by breaking the association between a stimulus and the anxiety or fear response – prevent the fear response from occurring by replacing it with an opposing response such as relaxation and positive self-statements – imagine a hierarchy of anxiety provoking scenes in combination with incompatible responses. VIDEO OCD http://www.youtube.com/watch?v=G5dlLL3FFzg Relaxation, Guided Imagery, and Visualization Techniques Deep Breathing - take a breath, hold it and then release it slowly. Progressive muscles relaxation - focus on different muscles of the body and relax them in a progressive way. Visualization - imagine beautiful, peaceful scenes. Tape Positive Self Statements Affirmations are positive thoughts or statements about some outcome you wish to achieve. Affirmations redirect your values, help formulate goals or prepare you for challenging situations. Bibliotherapy – therapeutic books for children provide a child model who copes with a similar situation. Psychoeducation - providing accurate information on a topic which is usually done by teaching children about the relationship between events, thoughts, feelings and behaviors. Journal Writing: jot down negative comments when you think them, write a general summary of your thoughts at the end of the day, or just start writing about your feelings on a certain topic and later go back to analyze it for content, journaling can be an effective tool for examining your inner process. Replace Negative Statements - Once you’re aware of your internal dialogue, here are some ways to change negative statements: Milder Wording: turning more powerful negative words to more neutral ones can actually help neutralize your experience. Change Negative to Neutral or Positive: As you find yourself mentally complaining about something, rethink your assumptions. Are you assuming something is a negative event when it isn’t, necessarily? [For example, having your plans cancelled at the last minute (negative), but what can you do with your newly-freed schedule (positive)]. Thought-Stopping: As you notice yourself saying something negative in your mind, you can stop your thought mid-stream my saying to yourself “Stop”. Saying this aloud will be more powerful, and having to say it aloud will make you more aware of how many times you are stopping negative thoughts, and where. Change Self-Limiting Statements to Questions: Self-limiting statements like “I can’t handle this!” or “This is impossible!” are particularly damaging because they increase your stress in a given situation and they stop you from searching for solutions. Turn it into a question “How can I handle this?” or “How is this possible?” Rubber-Band Snap - walk around with a rubber band around your wrist; as you notice negative self-talk, pull the band away from your skin and let it snap back. It’ll serve as a slightly negative consequence that will make you more aware of your thoughts and help to stop them. therapist will then encourage her to change her actions to align with her new, rational beliefs to relieve her emotional problems active approach often includes homework assignments developed by Albert Ellis and was one of the first cognitive-behavioral therapy approaches. posits that our emotions result from our beliefs, many of which are irrational, and thus cause us to suffer unnecessarily. therapist will question the client's beliefs to help use her natural ability to think clearly EMDR is an information processing therapy that helps clients cope with trauma, addictions, and phobias. patient focuses on a specific thought, image, emotion, or sensation while simultaneously watching the therapist's finger or baton move in front of his or her eyes. Then the client is asked to think of new thoughts, while again simultaneously focusing on the external stimulus. believe that the treatment loosens one's traumatic memories and allows them to be reprocessed with positive ones a therapeutic methodology developed by Marsha M. Linehan to treat persons with borderline personality disorder (BPD). Individuals with BPD react abnormally to emotional stimulation due to invalidating environments during upbringing and biological factors as yet unknown. their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to return to baseline. Borderlines have ineffective methods for coping with these sudden, intense surges of emotion. Hence, emotional lability and crises (drama) prevail in their lives. DBT teaches patients skills to manage emotional trauma rather than focusing on the crises. DBT combines standard cognitivebehavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. Individual Component The therapist and patient therapist and patient work towards improving skill use and discuss issues that come up during the week, recorded on diary cards. Follow a treatment target hierarchy. Selfinjurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Group Component ordinarily meets once weekly for two to two-and-a-half hours, clients learn to use specific skills that are broken down into four modules: core mindfulness skills interpersonal effectiveness skills emotion regulation skills distress tolerance skills views problems within the family as the result not of particular members' behaviors, but of the family's group dynamic. family is seen as a complex system having its own language, roles, rules, beliefs, needs and patterns. therapist helps each individual member understand how her childhood family operated, her role in that system, and how that experience has shaped her role in her current family. therapists with the MFT credential are usually trained in Family Systems therapy.