Systems of Psychotherapy

Transcription

1 Systems of Psychotherapy

2 Donald K. Fromme Systems of Psychotherapy Dialectical Tensions and Integration 1 3

3 Donald K. Fromme Pacific University School of Professional Psychology 222 SE 8th Ave. Hillsboro, OR USA ISBN e-isbn DOI / Springer New York Dordrecht Heidelberg London Library of Congress Control Number: Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they arenot identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (

4 Dedicated to my wife, Marie, for her encouragement, support, constancy, and love.

5 Preface The author s principal thesis is that each of the existing therapeutic systems is based on a partial, incomplete picture of human functioning, problems, and change. Some focus narrowly on microcontextual factors affecting human problems; e.g., biomedical interventions typically focus on neurohormonal imbalances, while behavioral therapies focus on relatively small units of behavior and reinforcement contingencies. At the other extreme, macrocontextual approaches minimize the role of the person and focus on environmental factors: e.g., family therapies examine how problematic patterns of interaction evolve among family members over time, while ecosystemic therapies address the socioeconomic and cultural factors such as poverty and oppression that are at the heart of many problems that people have. Other approaches cover still other factors located between these extremes that impact human problems. Although there is often significant overlap in the factors considered by different approaches, most are defined by an emphasis on just a few of the possible factors. Cognitive therapies note the importance of other factors, but nevertheless focus primarily on beliefs and reasoning. Similarly, experiential therapies focus on the emotions and psychodynamic therapies on early attachment experiences. Their inclusion of the individual s subjective experience and interpretation of events gives them a broader focus than the microcontextual approaches, but still that focus is partial. Humanistic therapies are considered holistic and endeavor to understand clients in their own terms; but giving priority to internal, subjective experience means that a client s objective situation and behavior are given less consideration. Interpersonal therapies take note of the fact that human problems invariably involve other people and thus are more toward the macrocontextual pole in their focus on clients relationships with significant others; once again, other important areas are given less importance. As Chapter 1 discusses, therapy outcome research consistently shows therapy to be more effective than non-treatment. However, few differences are found in efficacy of different approaches, once experimenter allegiance and demand characteristics are controlled. The few differences that are found suggest that some approaches work better with some problems than others do; e.g., family therapy seems to work best for family-related problems. Perhaps in recognition that no one vii

6 viii Preface approach is equally helpful for all clients, most practicing clinicians now use more than one set of ideas or techniques in their work and identify themselves as eclectic or integrative. The field of psychotherapy is currently experiencing an exciting explosion of new ideas and approaches. Traditional ideas about the nature of science and reality are being challenged by therapists espousing the ideas of postmodern philosophy. Postmodernists suggest that ideas about reality are constructions and could always be otherwise. They also emphasize the importance of language and culture in how people construct their views of the world. New, integrative therapies that provide broader, more inclusive conceptions of human problems are being proposed, with some already gaining strong empirical support for their use. This text introduces readers to some of the debates fueling current developments in psychotherapy. It reviews the philosophical differences that separate different approaches and the ways each major therapeutic system has inspired integrative efforts. Rather than viewing the various systems as competitors, the focus is on what is uniquely valuable in each approach with an eye toward how those unique factors might eventually be combined into a comprehensive view of human functioning. Chapter 1 discusses the philosophical and empirical debates that are spurring current developments in the field. Chapter 2 examines transtheoretical and common factors that are relevant to every therapeutic approach, including basic interviewing and assessment skills. Chapter 3 provides an introduction to psychopharmacology in the belief that every helping professional needs to understand how this essential tool can help clients with the most serious, debilitating problems. The approaches in Chapters 4 13 are organized according to their focus of intervention, moving from microcontextual to macrocontextual levels. Chapter 14 reviews important postmodern and integrative approaches that were not discussed earlier, while Chapter 15 is a first approximation of what a fully comprehensive, multilevel therapeutic approach might look like. Because the author believes the therapeutic relationship to be the most important factor in outcomes, the term client is used throughout the book to emphasize that therapy is a process co-created by therapist and client. The one exception is Chapter 3 in which the medical model s use of the term patient seemed more appropriate. Third-person plural pronouns are used whenever possible.

7 Acknowledgments The author owes a debt of gratitude to the following friends and colleagues who graciously read sections of this text and provided invaluable suggestions. Thanks to Genevieve Arnaut, Lorna Smith Benjamin, Steve Berman, Larry Beutler, Paul Feldman, Erik Fromme, Jason Fromme, Eva Dreikurs Ferguson, Miller (Rocky) Garrison, Eva Gold, Rhonda Goldman, Sandy Jenkins, Robert Julien, Michel Hersen, Dan McKitrick, Russ Miars, Cathy Miller, and Rick Warren. ix

8 Contents 1 The Dialectics of Psychotherapy: Philosophical and Empirical Debates... 1 Dialectical Tensions in Psychotherapy: Philosophical Assumptions... 3 Scientific Modernism... 5 Phenomenology... 7 General Systems Theory... 8 Postmodern Criticism and Philosophy Dialectical Tensions in Psychotherapy Integration Integrative Dialectics Eclectic Dialectics The Dialectics of Common vs. Specific Factors The Dialectics of Intervention Levels: Microcontext to Macrocontext Level of Intervention The Dialectics of Psychotherapy Research The Dialectics of Clinical vs. Statistical Significance Dialectics of Outcome vs. Process Research The Dialectics of Treatment-Focused vs. Patient-Focused Research Integrative Implications Chapter One: Main Points Further Reading Transtheoretical Approaches: Treatment Planning and the Initial Interview The Dialectics of Transtheoretical Treatment Planning The Transtheoretical Model (TTM) Systematic Treatment Selection Integrating the Transtheoretical Model and Systematic Treatment Selection Common Factors in Treatment Planning Patient-Focused Research Planning and Assessment in Clinical Care: The PACC Approach xi

9 xii Contents Dialectical Tensions Between Client and Therapist During the Initial Interview Gathering Information While Establishing a Collaborative Relationship Case Illustration: Integrative Transtheoretical Treatment Planning Integrative Implications Case Conceptualization with an Integrative Transtheoretical Approach Stages of Change and Client Variables From Macro to Microcontexts Chapter Two: Main Points Further Reading Biomedical Approaches to Treatment Dialectics of the Medical and Psychosocial Models The Diathesis-Stress Dialectic Psychosomatic Illness vs. Medical Illness with Psychological Symptoms Psychopharmacology: A Conceptual Framework Neurons and Synaptic Transmission Pharmacokinetics Pharmacodynamics Neurotransmitters Pharmacotherapy Antidepressants Antipsychotic Drugs Analgesics Anxiolytics Pharmacotherapy with the Elderly and with Children Geriatric Psychopharmacology Pediatric Psychopharmacology Substance Abuse Integrative Implications Integrative Therapy for Schizophrenia Case Illustration Chapter Three: Main Points Further Reading Behavioral Interventions Conceptual Framework Exposure-Based Behavior Therapies Systematic Desensitization (Reciprocal Inhibition) Eye Movement Desensitization and Reprocessing (EMDR) Flooding and Implosive Therapies Acceptance or Mindfulness-Based Interventions Case Illustration: Exposure Techniques

10 Contents xiii Operant-Based Behavior Modification Applied Behavioral Analysis Behavioral Activation Case Illustration: Behavioral Activation (Adapted from Jacobson et al., 2001) Cognitive Behavior Modification Approaches Psychoeducation and Social Skills Training Social Learning Programs (SLPs) Assertiveness Training Thought-Stopping Problem-Solving Self-Instructional Training Stress Inoculation Lazarus BASIC-ID Multimodal Therapy Integrative Implications Chapter Four: Main Points Further Reading Videos Cognitive Approaches Rational Emotive Behavioral Therapy Conceptual Framework Intervention Techniques Cognitive Therapy Conceptual Framework Cognitive-Behavioral Interventions Case Formulation in Cognitive Therapy Case Illustration Schema Therapy Conceptual Framework Intervention in Schema Therapy Case Illustration: Schema Therapy (Summarized from Young et al., 2003, pp ) Integrative Implications Chapter Five: Main Points Further Reading Websites Videos Psychoanalytic Approaches Psychoanalysis Freud s Instinctual Drive Theory Structural Theory Psychosexual Developmental Stage Theory and Psychopathology Psychoanalytic Treatment

11 xiv Contents Ego Analytic Theory Anna Freud Erik Erikson The Conflict-Free Sphere of Ego Function: Hartmann, Mahler, and White Brief Psychodynamic Psychotherapy Brief Psychodynamic Intervention and Treatment Planning Case Illustration: Core Conflictual Relationship Theme Method Integrative Implications Chapter Six: Main Points Further Reading Videotape Psychodynamic Approaches: Object Relations and Self Theory Object Relations Theory Conceptual Framework Self Theory Diagnosis and Treatment Planning in Psychodynamic Psychotherapy Treatment Planning Psychodynamic Intervention Issues Case Illustration: Psychodynamic Therapy (Summarized from McWilliams, 2004, pp ) Integrating Psychodynamic and Behavioral Therapy Conceptual Framework: Cyclical Psychodynamics Case Illustration (Summarized from Wachtel et al., 2005, pp ) Integrative Implications Attachment Research Patterns of Attachment Attachment and Problems in Living Chapter Seven: Main Points Further Reading Videos Humanism: Experiential Approaches Dialectic Tensions in Gestalt Therapy Perls Classical Gestalt Approach: Conceptual Framework Perls Theory of Psychopathology Perls Approach to Therapeutic Intervention A Contemporary Relational Gestalt Approach (Erving Polster) Conceptual Framework: Community of Selves Intervention in Relational Gestalt Psychotherapy Emotionally Focused Therapy: Bridging the Researcher-Practitioner Gap Conceptual Framework: Emotionally Focused Therapy

12 Contents xv Emotion Theory Intervention in Emotionally Focused Therapy Continuous Case Formulation with Task Markers and EFT Interventions Case Illustration (Continuation with Tracey) Reprocessing Problematic Experiences: Chair Work and Meaning Creation Case Illustration (Conclusion with Tracey) Integrative Implications Chapter Eight: Main Points Further Reading Videos Humanism: Phenomenological Approaches Existential Therapy Conceptual Framework Intervention in Existential Approaches Case Illustration Carl Rogers Client Centered Therapy Conceptual Framework Pretherapy Motivational Interviewing (MI) Conceptual Framework Client and Therapist Activities Integrative Implications Chapter Nine: Main Points Further Reading Videos Websites Psychotherapy and Social Context Individual Psychology Intentionality Individual Psychology s Conceptual Framework Intervention Approach Case Illustration Interpersonal Theory: Harry Stack Sullivan Conceptual Framework Communication Analysis: Social Reinforcement of Unconscious Processes Conceptual Framework Intervention Approach Case Illustration Integrative Implications Self-Regulation and General Systems Theory Intentionality and Interpersonal Relations as Integrative Concepts

13 xvi Contents Chapter Ten: Main Points Further Reading Website Videos Contemporary Interpersonal Approaches Communication Theory: Process vs. Content Interpersonal Process in Therapy Conceptual Framework Interpersonal Process Intervention Principles Interpersonal Reconstructive Therapy Case Formulation in Interpersonal Reconstructive Therapy Structural Analysis of Social Behavior Therapeutic Intervention Case Illustration (Summarized from Benjamin, 2006, pp. 2, 17 20) Interpersonal Therapy Conceptual Framework Intervention Techniques Case Illustration (Summarized from Crowe and Luty, 2005) Integrative Implications Chapter Eleven: Main Points Further Reading Video Family Systems and Couples Approaches Systems Approaches to Family Therapy Cybernetics and Family Systems Theory Strategic Family Therapy Multigenerational Approaches Structural Therapy Experiential Therapy with Couples and Families Attachment-Based Family Therapy Postmodern Family Approaches Narrative Therapy Solution-Focused Therapy Other Approaches Object Relations Family Therapy Cognitive-Behavioral Couples and Family Therapy Integrative Implications Chapter Twelve: Main Points Further Reading Videos Websites

14 Contents xvii 13 Ecosystemic Issues and Approaches Privileged and Oppressive Ecosystems Feminism and Multiculturalism Minorities and Oppression in the United States Ecosystemic Interventions Family Networking Multisystemic Therapy Community Mental Health Power, Symptoms, and Ethics Integrative Implications Chapter Thirteen: Main Points Further Reading Videos Websites Postmodernism and Integrative Therapies Constructivism in Therapy Intersubjective Approaches Cognitive-Experiential-Interpersonal Negotiation of Alliance Ruptures Integrative Postmodernism: Functional Contextualism Dialectical Behavior Therapy Acceptance and Commitment Therapy Integrative Implications Chapter Fourteen: Main Points Further Reading Video Websites Epigenetic Systems: A Meta-Integrative Model of Human Functioning and Therapy An Epigenetic Systems Model of Human Development and Functioning Motivation: Interpersonal Needs and Self-Determination Theory Cognitive-Experiential Self-Theory (CEST) and Personal-Agentic Processes Developmental Stages and Tasks Problems in Living Case Illustration: Epigenetic Case Conceptualization Epigenetic Systems and Treatment Planning Intervention Principles Epigenetic Treatment Planning and Intervention Case Illustration: Epigenetic Treatment Planning

15 xviii Contents Integrative Conclusions Chapter Fifteen: Main Points Further Reading Appendices Appendix A: Initial Interview & Treatment Planning Tools Appendix B: Therapeutic Intervention Tools Bibliography Author Index Subject Index

16 About the Author Donald K. Fromme is Professor Emeritus in the Department of Psychology at Oklahoma State University and also in the School of Professional Psychology at Pacific University, where he continues teaching part-time. He served as Director of the Psychological Service Center at both universities as well as Director of Intern Training at Pacific. He has also taught overseas with the University of Maryland University College on several occasions. During sabbaticals, he has taught at the University of Carabobo in Venezuela and the University of Exeter in England. In he was a Senior Fulbright Research Fellow at the University of Rome. He has published research focusing on emotional communication, empathy, and the qualitative experience of being part of a step-family. He has also chaired 60 graduate theses and dissertations. Now retired, he previously maintained a part-time private practice together with his wife. xix