Tuesday, September 6, 2016

Addiction treatment modalities

Outpatient Care

⋄ Techniques vary by clinician but typically include :
o cognitive-behavioral therapy
o problem-solving groups
⋄ Low success rate with heavily addicted individuals.
⋄ Moderate addicts may find that this level of treatment is enough to end their drug abuse problems.

12 Step Programs

⋄ Clients attend meetings.
⋄ Preferable after or in conjunction with some other form of drug treatment
⋄ There is the belief that they will never "recover" from their drug addiction.
⋄ This type of program may leave many feeling powerless (one of 12 steps is to accept powerlessness) over ever ending their battle with drug addiction.
⋄ This type of program may work for some, but has low success rate.

Inpatient Short-Term Rehabilitation

⋄ Substance abuse treatment that lasts typically for 30 days.
⋄ Overseen by medical professionals and trained counselors, often Certified Drug Addiction Specialist.
⋄ Goals are primarily physical stabilization, abstinence from all use, and lifestyle changes.
⋄ Primarily founded in a modified 12-step approach.

Inpatient Long-Term Rehabilitation

⋄ Inpatient long-term residential program is a 24 hour a day 7 days a week treatment.
⋄ Duration can be from several months to a year or more.
⋄ Residential treatment is conducted in non-clinical settings known as therapeutic communities.
⋄ May also include additional treatment strategies such as social education.

Methadone Maintenance Treatment

⋄ For clients with a dependence on heroin or other morphine like drugs.
⋄ Methadone decreases the feeling of pain and reduces emotional responses to withdrawal symptoms.
⋄ A dose typically suppresses an addict's symptoms for 24 hours.
⋄ Downside:
o Clients are physically dependent on
o They may find themselves using it for many years after they start treatment.
o Methadone may be more difficult to withdrawal from than heroin.
o Maintenance involves more time, pain, and expense than heroin withdrawal.

Thursday, September 1, 2016

Sexual abuse treatment for victims, perpetrators, and their families


Sexual assault is a traumatic event from which many victims never fully recover. Victims often develop problems with post traumatic stress disorder (PTSD), depression, poor self-esteem, interpersonal difficulties, and sexual disorders. PTSD is overwhelmingly the most common disorder related to sexual abuse.

Children may have some symptoms that are different from adults such as agitated behavior, repetitive play involving trauma, frightening non-specific dreams, and reenactment of the traumatic event.

Long Term Treatment Goals
Ensure safety from further victimization.
Help client understand and control the feelings and behavior that accompany the assault.
Build self esteem.

Short Term Treatment Goals
Establish therapeutic rapport and open communication with client.
Assess the level of symptomology.
Obtain medical assistance (forensic examination).
Obey child abuse laws (mandatory reporting)
Assess for suicidal tendencies.
Have client tell their story.
Identify and express feelings about the abuse.
Decrease feelings of guilt and shame.
Increase feelings of empowerment.

Therapeutic Interventions
Write out what happened including feelings.
Play Therapy
o Angry tower: build tower, then verbalize while throwing things at the tower, watching it topple, to allow feelings to emerge.
Mutual Story telling
o Client and therapist take turns telling stories (may use puppets dolls or stuffed animals).
Art Therapy
o Associate color with feelings
o Draw different scenes for different feelings
o Have client write letter to perpetrator that describes feelings about the abuse. Process the letter.
Develop personalized Safety Plan
o Self defense classes
o Safety escape routes.
o Who to call in cases of emergency
o Domestic violence safety plans can be searched for online.
Challenging Beliefs
o Discuss myths and realities
o Reduce feelings of shame and guilt
Encourage group work

Family Interventions
Encourage parents to reassure child that they are not angry at family member/victim.
The best things parents can do is believe the client.
Encourage the whole family to find support, as well as being a support for each other.
Establish safety for the whole family.
Have parents request and advocate.
Encourage the family to make sure client knows they are not to blame.
Discuss myths as a family.

Family Therapy for Couples


■ Behavioral couples therapy has been the most researched.
o Attempts to reduce substance abuse directly and through restructuring the dysfunctional couple interactions that frequently help sustain it

■ Integrative Couples therapy addresses some of the limitations of behavioral couples therapy.
o Helps couples to make arguments less harmful by teaching partners accept their differences.
o Therapy based on the importance of how a couple fights, not whether they fight or not.

■ Insight Oriented couples therapy and emotionally focused couples therapy have also been subjected to clinical trail investigations and found to be superior to no treatment.
o Is a combination of behavioral therapy and helping couples understand power struggles, defense mechanisms, and other negative behaviors.

■ Emotionally focused couples therapy maintains that relationship difficulties stem from the disowning of feelings and attachment needs, creating negative Interactional cycles and ineffective communication patterns.
o It has shown greater efficacy than no-treatment await-list controls.
o Enables couples to identify and break free of their destructive emotional cycles such as when one person criticizes and the other withdraws.
o The therapy helps couples build trust in each other.

■ Evidence for the use of Strategic therapy techniques in the context of couples therapy found an integrated systemic therapy model was equally effective as emotionally focused couples therapy and more effective than await-list control in alleviating relationship distress and improving target complaints and conflict resolutions.

Group Counseling Theory

Theoretical approaches to group therapy and dynamics conveniently depend on what the group is and who’s doing the research, perhaps putting the lie to social science as the road to Shangri La. Cartwright and Zander gamely argue that many disparate theories merely validate each and propose (with the confidence of their Victorian forebears) that one day when we know more, a unifying theory will show us to the broad sunlit uplands of useful improvement.

Toseland and Rivas list the following five theories important to group practice:

psychoanalytic theory (Freud, et al.)
learning theory (Bandura)
field theory (Lewin)
social exchange or interaction theory (Blau; Homans; Thibaut and Kelly)
systems theory (Anderson; Olsen)

Cartwright and Zander add four others:

sociometric orientation (Jennings; Moreno)
general psychology orientation (looking at individual group members)
empericist-statistical orientation, or group syntality theory (Cattell)
formal models orientation (French & Snyder; Harary, Norman, & Cartwright; Simon)

Shaw includes the FIRO theory of interpersonal relationships (Schutz), along with group congruence theory (Benoit-Smullyan). While emphasizing the interworking of theory and research, Shaw quite sensibly sees each theory as adding its unique part to understanding group behavior.

Eclectic approach -- Corey & Corey suggest therapists take parts from various theoretical models to create a personal approach in tune with their own philosophies of helping and leadership.

Whole Group and Individual

Therapists choose between working with the group as a whole and working with individual members in the group.

Whole group -- This approach attends to group setting, relationship building, task, and process. According to Yalom, process comments serve to keep the group in the moment and help members appreciate how they relate to one another. This should maintain group awareness and goal orientation.

Individual -- As basically individual therapy in a group setting, this approach is sometimes called vertical intervention (as opposed to whole group, horizontal intervention). Kissen suggests that the same therapist may use whole group or the individual approach depending on a group’s internal dynamics.

Outcome and Process

Research into outcome seeks to find out how well groups work, while research into process investigates how they work. What studies there are suggest the heartening result that group therapy is better than no therapy at all, but there’s not enough research out there to definitively compare group to other therapy outcomes. From a research standpoint, it’s uncertain exactly how and why groups work as treatment.


Child Custody


⋅ Therapy Contract
o Foundation based on court order.
o Frequency must be determined prior to counseling process; many will only participate for court minimum requirements.
o Specific confidentiality contract and explanation of confidentiality limitations in essential.

Alliance Building
o Any alliance can be experienced as an alliance against the other in these families
o Extra effort is necessary to establish a multipartial alliance in which the therapist is experienced as caring but also fair.
o Counselor must be honest, provide direct feedback about the behavior occurring but reframe changes sought in the most positive light.
o Problematic behaviors related to the conflict are directly confronted, but the positive intent of each client is always underscored.

o Begin with a form of evaluation that involves:
⋅ Separate meetings with each parent (with or without new spouses, depending on the issues involved) and children
⋅ A review of records of filings in court and other relevant reports available
⋅ Consultations with other therapists involved.
o Identify family strengths and weaknesses.

Treatment Plan
o Should include not only the traditional goals but also:
⋅ Format of future sessions of who will participate
⋅ In what combinations, at what time, and focused on what issues.

⋅ Goal Setting
o Main goal is to reduce the damaging aspects of custody disputes:
• high conflict
• triangulation
• broken family structure
• lack of safety
• Impact on daily functioning


The diagnosis typically assigned for clients and families dealing with divorce is depression. The symptoms are usually the same for children, adolescents, and adults.
Persistent sadness
Inability to enjoy favorite activities
Increased irritability
Physical problems such as headaches and stomach aches
Poor school performance
Poor work performance
Persistent boredom
Low energy
Poor concentration
Changes in eating and or sleeping patterns

Long-term Treatment Goals for Treating Depression due to Divorce
Improved mood and stability
Prevent further episodes of depression
Help the client become well established in a new family living arrangement

Short Term Objectives
Develop therapeutic rapport
Identify feelings and anxieties about divorce
Increase social contacts and create a support system
Develop coping skills to deal with depressive thoughts and feelings
Discuss the feelings about the loss of the family relationship is it was
Help client adapt to new situation

Verbal therapy to discuss feelings
Play/ Art therapy:
o Pairing emotions and colors
o Draw different representations of emotions symbolically
o Use clay or other materials to recreate story
o Puppets to tell a story
o Board games designed to discuss feelings
o List positive and negative emotions or changes
o Journal feelings
o Unsent letters
Parent Education
o Teach parents about typical emotional reactions they will see in their children and how to handle them.
o Encourage parents to make teachers aware of the situation.
o Have parents engage in an activity with the children each week, teach dyadic techniques.

Infertility- inability to conceive during one year of sexual intercourse without the use of contraception, or the inability to carry a pregnancy to live birth.
There are two kinds of infertility diagnoses:
Primary infertility - couples who have never had a child
Secondary infertility - couples who are unable to conceive or to achieve a live birth after having previous children.
Male infertility

Lifestyle habits can markedly affect the quality of the semen.
o Alcohol can damage sperm-producing tissue.
o Tobacco decreases sperm survival and function.
o Diet and vitamins have been researched to affect sperm production.
o Sexual practices can be altered to increase fertility.
• Abstinence periods of three to four days produce larger semen quantities and greater viability.
• Certain common lubricants such as KY jelly, lotions, and oils can kill sperm and decrease fertility.


Female Infertility
Can often lead to profound distress for women and may affect sexual functioning in couple’s relationship and is associated with a wide range of factors:
o Physical- hormonal, anatomical, genetic, immune system
o Psychological- denial, grief, helplessness, anger, anxiety, and guilt
o Environmental- work related stress, family issues, gender role expectations.

Goals of Therapy
Explore their beliefs about creating a family
Identify and explore feelings and reactions to infertility
Create a support system
Provide educational materials related to medical procedures
Assist partners in communication about sexual relationship

Human sexual anatomy, physiology, and development


- Organizing effects during a sensitive period of early development permanently influence genital anatomy and the brain.

* The genital organs begin to form identically until the second trimester of pregnancy during which the genetic components of the fetus dictate which parts of the anatomy will grow to develop male or female patterns.
- Activating effects are transient and may occur at any time.

* Sexual arousal can be controlled by altering hormone levels.
~ Some sex offenders have been treated this way by being given cyproterone, a drug that blocks the binding of testosterone to receptors in cells.
~ They experience decrease in sexual fantasies and offensive sexual behaviors.
~ Side effects include depression, breast growth, weight gain, and blood clots.
~ They also wear off quickly if offender stops taking daily pill.

o Sex hormones activate specific sexual and parental behaviors.

o Female initiated sexual activities during the monthly cycle are similar, showing biological impact of hormone levels, typically peaking during ovulation.

- The onset of sexual maturity

- Menarche
* A girls first menstruation
- Puberty starts when the hypothalamus begins to release lutenizing hormone releasing hormone at the rate of one burst per hour.

* Hormone stimulates the pituitary to send signal to gonads to release either estrogen or testosterone.

* The sex hormones stimulate growth spurts in secondary sexual characteristics such as breast development and broadening of hips in women and lowering voice and broadening of shoulders in men.

- The time when women permanently stop menstruating.
- Estrogen replacement therapy shows better performance in memory tasks.

Codes of ethics


Ethics the study of what constitutes good and bad human conduct, including related actions and values. Ethical practice by a therapist is when a therapist has good moral sense, follows the code of ethics, is up to date on the existing laws that impact their clients, and have good clinical expertise.

Professional code of ethics functions Define the role of the profession
o Codes express dominant morality of the field
o Define values and goals of the profession.
o Define the standards that both the professionals and users of the professional's services can expect in professional interactions.
Ethical codes guide the conduct of profession and can provide specific guidance about conduct in form of advice or mandates.

Moral Foundations Autonomy- people are allowed the freedom of choice and action.
Nonmaleficence- above all else, the therapist will do no harm.
Justice- humans should be treated fairly with equal distribution of good or bad.
Fidelity- the value of honoring commitments and promoting trust.
Veracity- importance of truth telling
Beneficence- refers to promoting good.

Malpractice claims- legal actions taken against therapist for actions that are believed to fall below the appropriate standard of care and cause injury to client

Common types of malpractice include: Misdiagnosis
Practicing outside area of competence.
Failure to obtain informed consent treatment
Negligent or improper treatment
Physical contact or sexual relationships with patient
Failure to prevent patient from harming themselves or others
Improper release of hospitalized patients
Failure to consult another practitioner or refer a patient
Failure to supervise students/interns
Abandonment of patients




Interpersonal Theory of Psychiatry

Personality is the product of interaction with other individuals. The need to relate is as basic as biological needs.

Individuals go through seven stages of personality development during their lifetime to try to maintain a balanced psychological outlook as their lives change. He believed that the individual was influenced by expectations of others.

The concept of PERSONIFICATIONS is related to the individual’s perception of THEMSELVES and perceptions of OTHERS. When there is a conflict between these two, the individual must strive to resolve the conflict and bring his/her self-concept into balance.

Sullivan’s Concepts of Interpersonal Relationships

PERSONALITY, according to Sullivan, consists of the characteristic ways in which a person deals with other people in his interpersonal relationships.

Personality is basically the result of interaction with significant other individuals. Sullivan believed that the need to relate to others is as important and necessary as our other biological needs.
Sullivan builds his approach to psychiatry on the study of personality characteristics which can be directly observed in the context of interpersonal relationships.
Personality is formed by the interpersonal relationships an individual has, especially with close persons, during his entire lifetime.

Patterns of behavior are modified during aging process, but the basic core remains.
Anxiety is one of the central concepts of interpersonal psychiatry. Sullivan employs this term in a special way. He has a very broad concept of anxiety. By anxiety he means basically all basic types of emotional suffering; thus, anxiety includes anxiousness, guilt, shame, dread, feelings of personal worthlessness, etc. Anxiety can be viewed as a warning signal. All causes of anxiety have one thing in common. They threaten the individual’s feelings of personal worth and competence; they erode his concepts of himself as a capable, esteemed person. Hence, anxiety has a tendency to bind a person in whatever unhealthy interpersonal patterns he has.
Anxiety is always interpersonal in origin. It always arises from long-term or short-term unhealthy relationships between people.

The major task of psychiatric treatment is to decrease the various kinds of emotional discomforts grouped under the term “anxiety,” and thus, to facilitate better interpersonal adjustments.
Eventually, the individual develops a concept of himself called (SELF-DYNAMISM) . This is accomplished by developing and stressing characteristics which meet with approval from significant others and de-stressing aspects which meet with disapproval.

Security is the opposite of anxiety. It is a state of relaxed comfort in which an individual feels no apprhensiveness, self-doubt, guilt, inadequacy, or any other kind of emotional distress. People seek security as a result of the prolonged period of helpless experienced in infancy.

A security operation is a kind of interpersonal action or attitude (which we are often unaware of) a person seeks to abolish anxiety and to become emotionally at ease.
Healthy security operation achieves its goal of diminishing anxiety and increasing security without interfering with the individual’s interpersonal competence.

An unhealthy security operation, on the other hand, reduces anxiety and increases security at a certain cost to the individual. The kinds of costs are extremely varied. They may be limitations in the person’s interpersonal capacities, or they may consist of some kind of emotional discomfort.
It is important to remember that each security operation whether healthy or unhealthy, is interpersonal in nature; it occurs in the context of an individual’s relationship with another person or with a group of persons. It is not an unobservable process going on in something called the “mind.”
One of the most common, and easily defined, healthy security operations is sublimation. In sublimation, a person discharges and gives expression to uncomfortable feelings in interpersonally acceptable ways.

Another security operation, which often works in a healthy way, is selective inattention. In selective inattention, an individual (in ways of which he is not aware) fails to observe a stressful or emotionally repulsive thing that is occurring in an interpersonal relationship in which he is involved. He simply blots it out from his perception.

Another security operation, which may operate in healthy or unhealthy ways, is called by Sullivan the “as if” process. In an “as if” security operation, an individual behaves “as if” he were someone other than himself in an interpersonal situation. He adopts and acts out a role; the role is false, but it nevertheless makes practical and comfortable an otherwise painful interpersonal situation.
Unhealthy security operations cause a large number of the states which are labeled psychiatric illnesses.

The word self-system is more accurately conveyed by the term self-protecting system. The self-system is composed of all the security operations by which a person defends himself against anxiety and seeks emotional security. Restated in different words, the self-system is composed of all a person’s characteristic, customary interpersonal devices for protecting himself against emotional distress and for seeking more emotional comfort. Sullivan acknowledged this is not observable however the security operations are. (the black hole )

Most people get along fairly well with most other people much of the time. Thus, Sullivan says, there is a basic tendency toward emotional health and sound interpersonal functioning. If other things do not interfere, personalities tend to grow in healthy ways, and interpersonal relationships tend to proceed in a sound manner.

Awareness and unawareness are fundamental concepts in Sullivan’s system of psychiatry, and they differ much from the concepts of “consciousness” and ‘unconsciousness” of Freud, Jung, and others. Sullivan feels that the “un-conscious mind” is a metaphorical concept which Freud invented and that its existence can no more be demonstrated than the existence of other metaphorical concepts. However, a person’ s awareness or unawareness of something can be objectively demonstrated by talking. Moreover, a matter of common observation is that every person is unaware at each moment of many aspects of their behavior. If a person has a high degree of awareness of his personality structure and how it was influenced by the experiences of his early life, he may, in essence, be able to say, “I am aware that the way I was brought up leads me to be very tense and often irritable when things go wrong in ways that undermine my self-confidence and self-esteem.
A person who is unaware of the nature of his interpersonal experiences learns nothing from them; he says that a person who is unaware of something in his interpersonal life simply does not experience it.

The cause of unawareness is anxiety. Abrupt confrontation with the things he excludes from his awareness usually makes a person feel anxiousness, guilt, shame, loathing of himself, or some other form of emotional discomfort.

A psychiatrist’s role is to participate, as an expert in interpersonal relationships and emotional functioning, in observing and helping a person who has problems in these areas; the therapist is not watching from the audience but up on the stage with the client.

A parataxic distortion occurs when an individual treats another person as if he were someone else, usually a significant, close person from the individual’s past life.

The process by which unhealthy interpersonal patterns are corrected. In consensual validation, a person arrives at a healthy consensus with one or more people about some aspect of his feelings, through individual interpersonal relationships, and this consensus is validated by repeated experiences which emphasize its soundness.


Managing Transference and Countertransference


⋄ Feelings client projects onto the counselor.
⋄ Have to do with relationship client has experienced in the past.
⋄ Intensity of feelings has to do with unfinished elements of client’s life.
⋄ Client may identify in the therapist characteristics that are reminiscent of the person they are transferring their emotions from.
⋄ Feelings can be productively explored so client becomes aware of how they are keeping an old pattern functional in other present time relationships.
⋄ Therapy becomes an ideal place to become enlightened to patterns in relationship of psychological vulnerability.
⋄ Clients gain insight into how their unresolved issues lead to dysfunctional behavior.
⋄ Group therapy may provide a microcosm of how people function in general social settings.
⋄ Ask client to tell more about how the therapist has affected them to elicit additional information about how the client developed the transference.
⋄ Do not become defensive.
⋄ “I wonder if I remind you of anyone you have had similar feelings with?”
⋄ There is potential for rich therapeutic progress!
⋄ Carefully take on a symbolic role and allow the client to work through their unresolved conflict.

⋄ Feelings aroused in the counselor by the client.
⋄ Feelings have to do with unresolved conflict from other past or present relationships rather than the therapeutic relationship with this particular client.
⋄ Discuss how you are affected by certain clients in supervision on with a colleague.
⋄ Get other’s perspectives on whether you are maintaining unconditional positive regard.
⋄ Self-knowledge is the basic tool in dealing with Counter-transference.
⋄ Unacknowledged, this can lead to an unproductive group. If leaders are not willing to deal with their own issues, how can they expect clients to do so?
⋄ Counter-transference in groups can be indicated by exaggerated and persistent feelings that tend to recur with various clients of different groups.


Crisis Intervention Models

Crisis intervention with date rape, school violence, substance abuse, adolescent suicide, marital abuse, HIV positive, and hospital intensive care clients.


Step #1: Listen - Establish therapeutic relationship.
- Identify precipitating problems.
- Explore emotions.

Step #2: Assessment- Determine the severity of the crisis.
- Assess potential lethality or physical harm to the person or others.
- Identify past coping skills, strengths and supportive resources.
- Suicide/Homicide assessment
- Determine client’s perception of reality.
- Discuss cultural beliefs about handling trauma.
- Find out if family and social resources are potential resources. Are the resources positive or negative?

Step #3: Treatment Plan 
- Selectively choose and use appropriate approaches to action planning.
- Modify or eliminate past coping skills.
- Create a contract or have client sign treatment plan.
- Identify useful referral resources.
- Use three basic approaches:
        i. Start by being non-directive.
        ii. Be collaborative by working together on a joint plan.
        iii. Be directive if the person does not or will not make a plan.
- During crisis, have only short term objectives.

Step #4: Termination - Review progress on treatment plan.
- Plan for expanding resources and support system.
- Schedule a follow up session.

Person Centered Therapy

Person Centered Therapy

The Therapy Process

■ Six conditions necessary and sufficient for personality changes to occur:
o Two persons are in physiological contact
o The first, the client is experiencing incongruence
o The second, the therapist, is congruent or integrated in the relationship
o The therapist experiences unconditional positive regard or real caring for the client
o The therapist experiences empathy for the client’s internal frame of reference and endeavors to communicate this to the client
o The communication to the client is, to a minimal degree, achieved.

■ Three Requirements for Therapy

o Genuineness
■ Accurate empathic understanding
■ Genuineness or realness in relations between therapist and client
■ Being oneself in the therapeutic relationship with the client

o Unconditional positive regard
■ Acceptance and caring
■ NOT approval of all behavior

o Congruence
■ Understanding of client’s frame of references
■ Ability to deeply grasp the client’s subjective world and communicate this to the client

Role of the Therapist
o Focuses on the quality of the therapeutic relationship
o Serves as a model of a human being struggling towards greater realness
o Is genuine, integrated, and authentic, without a false front
o Can openly express feelings and attitudes that are present in the relationship with the client

Risk factors and relational patterns of endangerment


Risk factors for Victimization
o Being female
o Young age
o Being a minority
o Drug and alcohol use
o High-risk sexual behavior
o Exposure to victimization as a child
o Low education level
o Unemployment
o Low SES
o Little or no support system
o Low self esteem
o Adolescence or developmental transition period
o Having a verbally abusive, jealous, or possessive partner
o Couples with income, educational, or job status disparities
o Dominance and control of the relationship by the male
o Weak community sanctions against victimization (e.g., police unwilling to intervene)
o Traditional gender norms (e.g., women should stay at home and not enter workforce, should be submissive)

Risk Factors for Perpetration
o Low self-esteem
o Low income
o Low academic achievement
o History of delinquency in youth
o Drug and alcohol use and abuse
o Depression or other psychological diagnosis
o Anger management issues
o Axis II disorders
o Past history of abuse
o Social isolation
o Unemployment
o Emotional dependence or codependence
o Belief in strict gender roles
o Abuse of power and control
o Past history of victimization
o Marital conflict, fights, tension, and other struggles
o Marital instability divorces and separations
o Unhealthy family enmeshment or blurred boundaries


Mahler (Object Relations Theory)

MAHLER (Object Relations Theory)

Based on psychoanalytic concepts with four stages of development:
        Fusion with mother
        Symbiosis Period
        Separation-Individuation Period
        Constancy of self and object
The psychosocial perspective is comparable with the psychosexual view of development.
In object-relations theory, there is an emphasis on early development as a decisive factor influencing later development.

Children who do not experience the opportunity to differentiate self from others may later develop a narcissistic character disorder.

Heinz Kohut is a leading contemporary psychoanalytic theorist.

Analytic therapy is oriented toward achieving insight.
Object-relations theorists focus on matters such as symbiosis, separation, differentiation, and integration.


Non-standardized Assessment Tests

* First developed and popularized in clinical settings by Monica McGoldrick and Randy Gerson.
* Developed principally within the context of Murray Bowen’s intergenerational family systems theory, genograms offer an efficient and effective process for explaining repetitive behaviors and patterns.
* Essentially, genograms are graphic representations of an individual’s extended family that typically cross at least three generations.
* Use of genograms implies a respect for intergenerational family experiences as historical antecedents to contemporary areas of strength and difficulty.
* Most genograms include basic information about number of families, number of children in each family, birth order, and deaths. Some genograms include information on disorders running in the family such as alcoholism, depression, diseases, alliances, and living situations.
* Genograms reflect an individual’s point of view. Although most members of a family agree on the basics of a family tree, there may be major differences when describing the relationships among family members.
* Interpretation is influenced by the creator of the Genogram. There is no absolute “right” Genogram for one family. Different family members may have differing perspectives on the relationships in the family and may therefore construct genograms of the same family very differently.

Scaling Questions
* Used primarily in Solution Focused Brief Therapy.
* Used to track differences and progress in the client.
* Helpful in prioritizing goals.
* Ranges of a scale can be defined in each time a question is made.
* Typically range from worst (zero) to the best (ten).
* Client may rate same question repeatedly as therapy progresses.
* Client may be asked to identify times when the client felt lower on the scale.
* Establishing goals or generating solutions comes from having the client identify what a higher score will look like for them and what they need to get there.
* Strength focused questions include “What have to done to get to this (higher) score?” “What has stopped you from slipping one point lower down the scale?"
* Exception questions include “Have you ever been higher on the scale?” “What is different on the days when you are one point higher on the scale?” “How would tell you that it was a 'one point higher' day?"
* Future focus questions include “Where on the scale would be good enough for you?” “What would a day at that point on the scale look like?"

Dimensions of Sexual Experience
* Trance State
o Akin to sensate-focus activities.
o Introspective attention to one’s kinesthetic cues of arousal.
o Individual becomes absorbed in sex.
* Role Enactment
o Playing out roles of sexual fantasies and/or scripts
o Successful role enactment is indicated by in-depth integration with role during sex.
o Minimal involvement is indicated by avoidance, disinterest, or “faking it”
* Partner Engagement
o Profound personal meaning is found in the sexual involvement with the partner
o Ranges from appreciation to sense of mystical union.
o Characterized by a unique, loving bond.
Power Hierarchies- on being Needed and Wanted
* Wanting to be wanted- the individual searches for a reflected sense of self
* Not wanting to want- attempt to maintaining boundaries to protect the ego.
* Wanting to be wanted and gratified by not wanting to reciprocate- the individual is insecure about being exploited or abandoned and develops a narcissistic demand to be unilaterally gratified.
* Not wanting to be wanted- the individual avoids any reciprocity.
These power hierarchies develop in response to differentiation and object relations issues from childhood in family-of-origin. Marriage devises the opportunity to resolve family-of-origin issues and individual long term development/existential conflicts.



Impact on Birth Parents

o Grieving the Loss of the Child. - Sense of loss.
- Loss of immediate life plans.
- Most struggle with the decision to place the child for adoption; those who decide to do so begin to plan for a great loss in their own lives with the hope that placing the child for adoption will result in a better life for their baby and for themselves.
- Trauma can be impacted by the process, lack of support, the behavior of the adoption agency, or level of communication with adopting family.
- Clients often express feelings of numbness, shock, and denial, as well as grief.

o Normalize these as typical reactions to loss. - An added struggle with this type of loss is the greater sense of privacy around it which may limit help from support systems who may not be informed.
- Due to the secrecy, this loss often lacks typical cultural rituals or ceremonies to gain closure.

o Grieving Other Losses. - Loss of parenting role.
- Feelings of loss may reoccur during holidays, anniversaries or birthday.
- Stress of pregnancy and adoption may take a toll on the partner/marital relationship.
- If client is young, this may also cause a significant issue in parental relationships.
- If young, the client my have to drop out of school.

o Guilt and Shame. - Societal values often show a lack of understanding over the circumstances leading up to adoption.
- Culturally, there is an association of shame with unplanned pregnancy.
- Client may express feelings of unworthiness.
- Clients who discuss their feelings with supportive friends, family, or counselors may more easily come to terms with their decision over time and be able to integrate the experience into their lives in a healthy way.

o Identity Issues. - Clients often ask themselves if they are “parents”.
- Some mothers may experience a sense of incompleteness after giving birth.
- Parent status is not acknowledged by society, family, or friends for those who give up children for adoption.
- The issue of being involved in the child’s life and how to integrate with the adoptive family is an important one.

o Long-Term Issues. - Feelings about the adoption may be life long, but varying in intensity.
- Some of the factors that have been found to be associated with long-standing grief include:
⋄ A birth parent's feeling that she was pressured into placing her child for adoption against her will
⋄ Feelings of guilt and shame regarding the placement
⋄ Lack of opportunity to express feelings about the placement
- For some birth parents, the ability to establish a successful marriage or long-term relationship may depend on the openness with which they can discuss their past experiences of birth and adoption placement.
- Some birth parents never tell their spouses or subsequent children of their earlier child.

Ethical Practices with Culturally Diverse Clients


■ Current ethical codes are based on individualism which is a Western characteristic.

■ There is significantly less focus on the role of family, group identity, lifestyle and religious beliefs which have equal importance to individuality in other cultures.

■ The AAMFT code of ethics states “therapists do not discriminate against or refuse professional service to anyone on the basis of race, sex, religion, or national origin.”

■ It is ethical for counselors to know their own biases and how they may impact service delivery.

Cultural Competence
o Recognize cultural diversity
o Understand the role that culture and ethnicity play in the sociopsychological and economic development of diverse populations
o Understand that socioeconomic and political factors significantly impact the psychosocial, political, and economic development of ethnic and culturally diverse groups
o Help clients to understand, maintain, or resolve their own cultural identification
o Understand the interaction of culture, gender, and sexual orientation on behavior and needs

Implications for Clinicians
o Many ethical codes have not yet adequately dealt with some cultural issues related to technology and assessment or the counseling relationship with culturally diverse clients.
o Ethnic minorities will continue to underutilize services, prematurely terminate, or fail to show positive treatment outcomes if remedies are not applied and enforced.
o Goal is to learn how to identify, understand, and accommodate the needs of differing clients.


Experiential Therapy

Experiential Therapy

Aim of Existential Therapy
■ Rejects deterministic outlook on mankind
■ People are free and responsible for their choices and actions
■ People are the authors of their lives
■ Existential therapy encourages clients to:
o Reflect on life
o Recognize range of alternatives
o Decide among them
o Help clients recognize ways they passively accepted circumstances and surrendered control
o Help clients to start to consciously shape their own lives by exploring options for creating a meaningful existence.

Tasks of the Therapist
■ Invite clients to recognize how they have allowed others to decide for them
■ Encourage clients to take steps toward autonomy

■ The Question
o “Although you have lived in a certain pattern, now that you recognize the price of some of your ways, are you willing to consider creating a new pattern?”
■ Relationship between therapist and client
o Therapy is a journey taken by BOTH therapist and client
● The person to person relationship is key
● The relationship demands that therapists be in contact with their own phenomenological world
o The core of the therapeutic relationship
● Respect and faith in the client’s potential to cope.
● Sharing reactions with genuine concern and empathy

General Systems Theory


Developed by Ludwig von Bertalanffy in 1968.

Explains how organisms thrive or die in accordance with their openness or closedness to their environments.

Focus changed from linear causality to circular causality- idea that events are related through a series of interacting loops or repeating cycles.

Set of elements standing in interaction.
Each element is affected by whatever happens to any other element.
System is only as strong as its weakest part.
System is greater than sum of its parts.
Boundaries are more or less permeable depending on the amount and type of feedback received.


Person Centered Therapy


Person Centered Therapy

Theoretical Foundations
■ Focus is on the person and not the presenting problem
o Philosophical movement that emphasizes worth of the individual and the centrality of human values
o Attends to matters of ethics and personal worth
o Gives credit to the human spirit
o Emphasis on creative, spontaneous, and active nature of humans
o Optimistic
o Human capacity to overcome hardship and despair
■ Non-Deterministic o Beliefs that it is oversimplification to view people as controlled by fixed physical laws.
o Encouragement of therapy that considers individual initiative, creativity, and self fulfillment
■ Self Actualization o Innate process by which a person tends to grow spiritually and realize potential
■ The Experiencing Person o Important issues must be defined by the client
o Special concerns are discrepancies between what a person thinks of himself and the total range of things he experiences

■ Listening
■ Accepting
■ Respecting
■ Understanding
■ Empathic Responding

Gestalt Therapy

Gestalt Therapy

■ Existential and Phenomenological
o Grounded in the client’s “here and now”
■ Initial goal is for clients to gain awareness of what they are experiencing and doing now
■ Promotes direct experiencing rather than the abstractness of talking about situations
■ Rather than talk about childhood trauma, the client is encouraged to become the hurt child
■ Holistic approach to personality vs. mechanistic approach of Freud.
■ Value of examining present situations vs. repressed intra-psychic conflicts from early
■ Focus on process versus content
■ On presently experienced vs what is revealed by client from memory
■ Self understanding comes from individual’s behavior in the present versus why they behave as they do
■ Therapist goal: create experiments for client to assist their self awareness of what they are doing and how they are doing it.

Therapy Process
■ Promote awareness in client through
o Insight
o Self acceptance
o Knowledge of the environment
o Responsibility for choices
o Paradoxical theory of change
o Ability to make contact with others
o Clients expected to do their own seeing, feeling, sensing and interpreting vs passively allowing therapist to give insight and answers
■ Concepts of human nature
o Clients are manipulative
o Avoid self reliance
o Avoid taking on personal responsibility
o Clients have to stand on own two feet to deal with life problems themselves
o Move clients from environmental supports to self-support
o Help clients reintegrate disowned parts of personality

Adlerian Therapy

Adlerian Therapy 

Social Interest
■ Adler’s most significant and distinctive concept.
■ Refers to an individual’s attitude toward and awareness of being part of the human community.
■ Mental health is measured by the degree to which we successfully share with others and are concerned with their welfare.
■ Happiness and success are largely related to social connectedness.

Role of Birth Order Psychological Positions
■ Motivates later behavior.
■ First born/ Oldest o Favored pseudo-parents, high achievers
o Receives more attention, spoiled
■ Second born o Rivalry and competition
o Behaves a in a race, often opposite first child
■ Middle Child o Often feels squeezed out
■ Last born o More pampered, “baby,” creative, rebellious, revolutionary, avant-garde
■ Only Child o Does not learn to share or cooperate with other children
o Learns to deal with adults

■ Encouragement is the most powerful method available for changing a person’s beliefs
■ Helps build self-confidence and stimulates courage
■ Discouragement is the basic condition that prevents people from functioning
■ Clients are encouraged to recognize that they have he power to choose and act differently

5 Basic Tasks
■ Acceptance
■ Achieving Intimacy
■ Work
■ Spiritual Dimension
■ Community/Friendship

Experiential Therapy

Experiential Therapy
Theory Foundation

■ Modern person has means to live but often has no meaning to live for- this is the malady of our times, meaninglessness or existential vacuum
■ Purpose of therapy is to challenge people to find meaning and purpose through suffering,
work and love

■ It takes courage to BE 
o Our choices determine the kind of person we are
o We are in constant struggle with
● Our want to grow toward maturity and independence
● Realizing expansion and growth is often a painful process
● Struggling between security and dependence and delights and pain of growth

■ Phenomenological approach
o People’s perceptions or subjective realities are considered to be valid data for investigation
o Phenomenological discrepancies
● Two people perceiving the same situation differently

■ Non-Deterministic approach
o Existentialist argue that it is an oversimplification to view people as controlled by fixed physical laws
o Encouragement of theories that consider individual initiative, creativity, and self fulfillment
o Focus on active, positive aspects of human growth

I-Though dialogue vs. I-It Dialogue

o I-though
● human confirms the other person as being of unique valued
● Direct mutual relationship

o I-it
● Person uses others but does not value them for themselves
● Utilitarian
o Self disclosing of therapist emotional response to client’s demonstration of valuing of client’s feelings and perspective.

Gestalt Therapy

Gestalt Therapy

Five Major Channels of Resistance

o Tendency to uncritically accept other’s beliefs and standards without assimilating them to make them congruent with who one is
o Passively incorporate what the environment provides, spending little time on becoming clear about what we need or want.

o Disown aspects of self by assigning them o the environment
o Trouble distinguishing between inside and outside world
o Disown attributes of self that are inconsistent with self image and put onto other people
o Avoid taking responsibly of feelings and person one really is
o Keeps self powerless to initiate change

o Process of distraction
o Keeps difficult to sustain sense of contact with reality
o Overuse of humor, abstract generalization, and questions rather than statements, resulting in emotional depletion
o Diminished emotional experience by seeking through and for others

o Do things to self rather than others

o Blurring differentiation between self and environment
o Fitting in, absence of conflict, belief all people feel and think the same way
o High need for acceptance and approval
o Stay safe, never express own feelings
o Therapist uses W’s questions to get client to open up

Other Forms of Resistance

■ Control of environment o Resistance to contact
o Boundary disturbance

■ Blocks to energy manifested by
o Tension in part of body
o By posture
o Keeping body tight and closed
o Not breathing deeply
o Looking away from people when speaking
o Numbing feelings
o Speaking with restricted voice

Analytic Therapy- Carl Jung

Analytic Therapy- Carl Jung

Therapeutic Goals
o Merging past and present
o Explore the Conscious/unconscious
o Develop self knowledge
o Individuation- reclaiming undeveloped parts of self through reflection on life/past

Key Ideas
View of Man
o Man’s behavior is conditioned not only by his individual/racial history (causality) but also by aims and aspirations (teleology- explanation of behavior based on future goals)

Collective Unconscious
o Shared by all but modified by personal experience

Personal Conscious
o Unique life experiences and perceptions

■ Theory of Personality
o Psyche
■ Conscious/unconscious

o Personal Conscious
■ Only understood through dreams and analysis and makes itself known through complexes and emotions

o Personal Shadow
■ Archetypal representing thoughts, feelings, and actions that disown by projecting them outward (contains everything that could or should be part of the ego that the ego denies or refuses to develop, either positive or negative)
■ Reclaiming is an essential task for mature personality.

o Archetype
■ Pathway of communication between unconscious and conscious
■ Understanding archetypes (images of unconscious) helps one to understand the self

o Principles of Opposites
■ Animus vs. Over Characteristics
■ Conscious vs. Unconscious
■ Personal vs. Shadow
■ Mind vs. Body

Psychoanalysis- Freud/Erikson/Mahler

Psychoanalysis- Freud/Erikson/Mahler
Role of Therapist
■ Invisible- Blank Screen (detachment)
■ Fosters transference
■ Focus on Resistance

Therapeutic Goals
■ Bringing the unconscious to the conscious
■ Strengthen the ego

Key Ideas
Deterministic- problems are rooted in the first six years of life and trapped in unconscious motivations
Reality Principle- maximize gratification minimize punishment
Biological Drives- sex and instincts
Parts of Personality- Id/Ego/Superego
Id- Pleasure principle, “Demanding Child,” deterministic, unconscious, satisfy basic survival
Ego- Reality principle, “Traffic Cop,” mediator between Id and Superego
Superego- Moral Principle, “The Judge,” strive for perfection

Psychosexual Stages of Development
Oral Phase- 0-1 years, greedy, mistrust, unable to form intimate relationships
Anal Phase- 1-3 years, anal retentive, aggressive
Phallic Phase- 3-6 years, identity disturbance (Oedipal/ Electra complex)
Latency- 6-12 years, Socialization stage
Genital- 12+, Interpersonal relations freedom to love/work

■ Brief psychodynamic therapy (BPT)- treating selective disorders within an established time.
■ Hypnosis
■ Dream Interpretation
■ Free Association
■ Projective Techniques
■ Freudian Slips


Diagnostic interviewing techniques


o Client asked direct questions in areas determined by interviewer
o Questioning may be open or closed.
Open= unlimited answer options
Closed= Yes, No, or one word questions

o Restate the clients cognitive or emotional material
o Demonstrate empathic understanding
o Rogerian Client-Centered Therapists rely heavily on reflection
o Overuse is counterproductive - important areas are left unaddressed

Restatement (Paraphrasing): 
o Rephrase what client says.
o Demonstrates active listening.
o Reflection is type of intervention, clarifies and joins themes.

o Accompanied by utilizing other techniques such as questioning, paraphrasing, restating
o Shows understanding of client in the interview
o If done from a not knowing stance, should not invoke defensive response.

o May be used to call client out on discrepancies
o Is often used with substance abusers in order to break denial and/or rigid defenses
o This may increase anxiety and avoidance but is necessary and can be constructive.

o The sharing of personal experiences by the therapist to the client relative to the session with the purpose of helping.
o Intended to facilitate client disclosure.
o Should be used minimally
o Must be careful not to cross boundaries.

o While this may occur unintentionally there are many benefits if used correctly.
o Provides both client and therapist time to process what is being understood.
o Timing is essential
o Promotes introspection

o Therapist test the limits of what client is willing to process.
o May be used to determine clients level of insight.

Reframing (Cognitive reframing): 
o This allows for a different perspective
o Used to challenge negative self concepts and harmful thinking patterns.
o The purpose is to lead to behavioral change.


Gestalt Therapy

Gestalt Therapy

Major Principles

o Interested in the whole person
o Emphasis on integration of thoughts feelings, behaviors, body and dreams

■ Field Theory
o Organism must be seen in its environment or its context as part of a constantly changing field
● Relational
● In flux
● Interrelated
● In progress

■ Figure Formation Process
o How client organizes environment from moment to moment
o Background
● The undifferentiated field or ground
o Figure
● The emerging focus of attention

■ Organismic Self Regulation
o Restore equilibrium or contribute to growth and change

Therapy Process
■ The Now o Power in the present
o Nothing exists except the now
o The past is gone and the future has not yet arrived
o For many people the power of the present is lost
● They may focus on their past mistakes or engage in endless resolutions and plans for the future.

■ Unfinished Business o Feelings about the past are unexpressed
o These feelings are associated with distinct memories and fantasies
o Feelings not fully experienced in the background and interfere with effective contact
o Preoccupation, compulsive behavior, wariness oppressive energy and self defeating behavior.

■ Layers of Neurosis o Perls likens the unfolding of adult personality to the peeling of an onion.
o Phony layer- stereotypical and inauthentic
o Phobic layer- fears keep clients from seeing themselves
o Impasse layer- giving up power
o Implosive layer- fully experiencing deadness
o Explosive layer- letting go of phony roles