The therapeutic relation facilitates healing and development; relief from problems, symptoms is by overcoming general difficulties: internal conflicts, faulty assumptive systems, emotional blocks

2.1.2 Directive

The therapist is overtly in charge, prescribing treatment – activities, attitudes, rituals … for solving specific problems, addressing specific target symptoms

Enriched function results from raised self-confidence and inner freedom; that is, general improvement results from

specific improvement

2.1.3 Mixed

Example: evocative related to focal symptoms, directive related to evocative ends

Other eclectic approaches

2.2 The Cognitive – Behavioral – Emotional Dimension

All factors are involved, and any improvement of one creates change in the others – the individual is a whole. The mix of focus varies:

Cognitive therapy provides new information about the self and new ways to conceptualize experience

Since mental illness results in altered behavior and this is observable and objective, changing behavior is a frequent measure of success. Directive therapies tend to focus on troublesome behavior … behavior modification

In evocative therapy the therapist-client alliance tends to result in strong emotions [e.g. transference] which are used in the therapeutic process

2.3 Individual Evocative Therapies

2.3.1 Psychoanalytic

Pain of growth results in [unhealthy] defense mechanisms resulting in maladjustment … and [transference/therapeutic alliance] examines the therapeutic relationship as an integral part of therapy

2.3.2 Existential

Concept: Maladjustment results from confronting the absurd

Tool: Phenomenology

These European therapies are based in “negative” European philosophies

2.3.3 Self-Actualization… Humanistic

Maladjustment is secondary to negative life experience

More weight to recent-current experience

Focus on conscious – time limited – relation with therapist is an equal one [American nature] with covert behavior modification

This therapy, with origins in the United States, has been called the Third Force [after the psychoanalytic and existential therapies]

2.3.4 Summary

Evocative therapies: are client-centered; require a client who is skilled at self-expression, not too fragile – to handle distressful memories; require a skilled therapist

2.4 Individual Directive Therapies

Tendencies [of Directive Therapies]

Address discrete problems/symptoms – in a structured way overcoming specific symptoms leading to a general improvement in function and mental health [this is the philosophy … note, also, that behaviorism questions the existence of the mental]

Naturally time-limited

Uses the therapeutic relation [overtly] as leverage: persuades overtly and powerfully

Keeps patient rooted in present [except Abreactive therapies]

“Are more scientific,” eschewing broad imprecise concepts such as the unconscious or structure of personality [especially behavioristic therapies]

Are efficient in dealing with individuals who have poor tolerance of frustration, poor motivation, and poor ability to express themselves [especially in language], therefore directive therapies are [claimed to be] effective with the following target populations:

Psychotics [especially chronic]

Addicts

The developmentally delayed

In all of the above directive therapies show contrast with evocative therapies

The focus on specific symptoms or specific negative behaviors and the empirical – scientific – observable emphasis [alleged] makes these therapies [and the corresponding theories of social learning, behaviorism] comparatively more attractive in the United States, due to the American pragmatic philosophy, the scientific attitude, the focus on the immediate and the special nature of social medicine in America

Directive therapies considered here are cognitive therapies, behavior therapies and Abreactive therapies:

2.4.1 Cognitive Therapies

Theoretical bases – social learning theory

Assumption: Behavior [behavioral patterns] and emotional states are responses to internalized sentences or automatic thoughts [ = autokinesis = unconscious?]

But cognitivists [cognitive therapists] tend to say: These internalized and automatic thoughts and sentences are not unconscious [which is not sentential in any case], but fleeting and unnoticed [this appears to ignore the body-emotion centered nature of autokinesis]

These considerations are the basis of the cognitive therapy of A. Ellis, known as rational-emotive therapy which assumes that neurotic distress and maladaptive behavior are caused by internalized sentences which represent a pervasive attitude toward life. The rational emotive therapist employs any means, especially [1] interpretation – bringing the internal sentences to the forefront of consciousness and examining their consistency and [2] encourages the patients to engage in behaviors which would demonstrate the falsity of their assumptions. It is assumed that [in contrast to psychoanalysis] there are a finite number of maladaptive internalized sentences

Stated simply, the individual in therapy is called upon to recognize, focus on and understand the nature of their maladaptive attitudes [the sentences] and, through a program of rhetoric and action, to unlearn their detrimental attitudes and relearn uplifting attitudes

2.4.2 Behavior Therapies

Underlying philosophy: Mental events do not exist or are epiphenomenal, or are [conceptually] metaphysical, or are practically and therapeutically irrelevant [at best] or counterproductive as therapeutic focus. The same comments apply to the unconscious and the structure of personality

“Scientific basis:” The conditioning theories of Ivan Pavlov and B. F. Skinner [having to do with the effect of controlled – and uncontrolled – stimuli or input on behavior

The objective of behavior therapies: To change behavior

2.4.2.1 Types of stimuli

Reinforcement, after the behavior [reward and punishment]

Counter conditioning, simultaneously with behavior

2.4.2.2 Token economies and behavior

Has research shown that it is not the token economy per se, but the subtler approval/disapproval cues of staff which change behavior? This claim has been made

2.4.2.3 Treatment of phobias

Reciprocal inhibition [relaxation up an anxiety ladder]

Implosive [hyperexposure to fantasies of the object of the phobia]

Flooding [hyperexposure to the object itself]

Reciprocal inhibition is based on positive counter conditioning. A criticism is that implosion or flooding therapies are equally or more effective. The theory behind these, partly based on animal experiments, is that repeated escape from an anxiety-stimulus leads to increased anxiety and that anxiety in animals has been extinguished by forced prolonged contact with the stimulus. In implosive therapy, prolonged overwhelming anxiety is aroused as the patient fantasizes contact with the phobic stimulus at maximum or increasing intensity until exhaustion. Flooding therapy is similar, but exposure is to the actual stimulus

2.4.3 Abreactive therapies and post traumatic stress disorder

“All Abreactive methods or techniques which focus on emotional reexperience are modifications of Freud’s ideas and methods” [decreased stimulus leads to blunting which is a defense which leads to progressive loss of spontaneity, lower activity levels, poor relations – and flashbacks which are surfacing of the unconscious] [repression, avoidance, defensive maneuvers lead to inability to correct initial distortions, self-alienation [the person within vs. social self, etc.]; lack of discovery that the initial stress is no longer a threat]

2.4.3.1 The concept

Purposively evoking the symptoms of post traumatic stress [memories, flashbacks, nightmares, general dissociation … which repeat or even exceed the intensity of the original trauma] in therapy leads [as in implosive therapy] to healing … Also therapeutic control of symptoms [the fact that the therapist can evoke them in a controlled setting] may lead to diminished lack of control over triggers

2.4.3.2 The theory

In heightened states of emotional arousal [with associated/consequential confusion?] the psychic structure is shaken … both emotional arousal and cognitive confusion increase suggestibility … and [consequently?] … the patient is then open to suggestion … to change [and to maintain change?] in the direction suggested by the therapist. … Knowledge of this tendency is based in experiments which also show that changes [from base state/baseline] induced during arousal [by suggestion – ] tend to diminish in time, and therefore maintenance is important

2.4.3.3 The method

The therapist is in charge, supports [and employs some approach to] remembering and recreating the events in fantasy

2.4.4 Abreactive schools and techniques

Primal therapy, reevaluation counseling, Morita [primal/Morita emphasize isolation to heighten the subsequent arousal]

Approaches to inducing altered states: Reichian manipulations and exercises; intense arousal ; narcosynthesis [central nervous system deprivation]; visualization [and LSD]; hypnotic and mystical states; evocation [implosion, using reminders or symbols or autokinetic elements, such as battleground sounds]

“Abreactive methods excel in changing the patient’s self image from one of being at the whim of one’s emotions to one who can withstand and eventually control them”

Post traumatic stress disorder and Abreactive treatment show [by example] the mind-body interconnection

2.5 Antidepressant medication in post traumatic stress disorder

Antidepressant medication [combined with therapy] is useful in treatment of post traumatic stress disorder

2.6 Summary: Individual directive therapies

Cognitive therapies are effective in:

Depression

Anxiety

Behavioral therapies:

Adjunct to milieu therapy

Treatment of phobias

3 Group Therapies

Partial theoretical basis – group dynamics and motivation

Observations: small groups flourish in societies in transition; small groups provide [at least] the illusion of safety

Based on these comments and on subsequent observations, we conclude the importance of small groups in response to human and societal needs, in fashioning transition through innovation, in providing support for individual accomplishment

We may conclude a value to groups that transcends fashions

3.1 Evocative Group Therapy

3.1.1 Benefits

Acceptance, expression, communication in face of antagonism

Unlike families: Can identify and break up distorted communication. This requires [ground rules], openness and continued communication in face of antagonism which leads to trust with profit from feedback

Extra feedback and models, other non-therapists as model, realizing that problems are not unique – even individuals who are outwardly very successful may have the same problems

Support, belonging, even criticism and anger expresses support … Opportunities for altruism engenders support

Can overcome blocks [maladjusted defenses] by transferring [mirror reaction – Disapproving self-traits [without self-knowledge] in others results in discovery] within the group and dealing with the issue … The therapist, too, arouses transference which in turn illuminates fundamental attitudes toward authority, and group setting provides [apparently] a more secure setting for patient to express this – with subsequent exploration and opportunities for resolution

Group coherence: which develops out of sharing and growth, further facilitates the educational communication [as described above]

Assuming therapy groups are composed of emotionally ill persons – why do they [as is known] seldom become cohesive on the basis of unhealthy group standards? “The deepest reason why group patients can reinforce their normal reactions and correct each others’ neurotic reactions is that collectively they constitute the very norm from which, individually, they deviate”

Society in miniature, testing ground for new behavior … for this and the above reasons, groups sometimes succeed where individual treatment fails

3.1.2 Problems

Fear of rejection – therefore not acceptable to all; this is not negative for those who continue – in a mature group no topic is too destructive to handle

Difficulty of establishing cohesiveness and therapeutic standards – the therapist cannot always overcome this – and this is harder to do with evocative groups

Comments

“Though frequently more acceptable, member’s feedback may be less useful than the therapist’s because their own problems and defenses are apt to bias their perceptions”

Transference leads to conflict which results in benefit [1] by working through; that is, the process, and [2] content, working out the issues raised by transference … However [1] the antagonists must feel secure and [2] the transference issues must be detected and appropriately redirected – both require therapeutic skill

“Preparation is an absolutely essential task of the therapist … Explicitly telling patients what to expect from a group and how to participate improves many aspects of group functioning in early meetings”

Comments on encounter groups

A form of evocative group, more popular 1960s – 1980s – without professional leadership

“Encounter groups pioneered techniques that more classical therapy groups have employed” – use of marathon sessions to speed up group formation and facilitate emotional arousal; the “rediscovery” of the human body – and the use of body-therapeutic [touch, massage, … ] to lessen the individual’s alienation from their bodies

3.2 Directive Group Therapy

In directive groups a therapist or an established group code firmly guides the transactions of the members

Examples of professionally led groups: rehabilitation groups for schizophrenic patients, support groups for persons with chronic physical illnesses – multiple sclerosis, rheumatoid arthritis, AIDS [acquired immunodeficiency syndrome], cognitive therapy groups for depression or anxiety. Psychodrama is professional-led, directive in its technique [but evocative in its ends] – for people with mental illnesses and nonspecific distress

Peer self-help groups based on a group code are Alcoholics Anonymous [AA], Recovery Inc. [designed, originally, for patients of state mental hospitals after discharge], self-help and support groups for individuals with chronic mental illnesses [general or specific such as mood disorders], and a proliferation of similar groups [NA, ACOA,…]

3.2.1 Criticisms of Directive Approaches in Group Therapy

That members identify too strongly with the groups’ particular focus

… and that this prevents further growth. [In counter criticism, it could be claimed that the approach provides a percentage success rate of maintenance in cases that would otherwise be in decline . and that a percent of these maintenance cases might be the best that could be hoped for – perhaps without use of much greater resources.]

Member’s problems are oversimplified to confirm with ideology … in practice, however, success depends on balance between rationale and individual experience

3.2.2 Evocative vs. Directive Group Therapy

It is clear, from the discussion, that evocative and directive groups are indicated for different populations, towards different ends, and deploy different levels of resources

3.3 Mixed Evocative-Directive Group Therapies

An example is psychodrama – which is directive toward evocative ends

3.4 Family Therapy

3.4.1 Applications

Treatment of family problems [example: relationship counseling]

Treatment of individual problems by involving the family:

Meetings with significant others

Focusing on relationships with others

3.4.2 Theoretical Orientations

Uses group dynamics: the sociobiology and psychology of small groups are drawn from the mainstream dynamic, behavioral, cognitive, existential traditions

Existential family therapy uses metaphors to communicate the common pain of the human condition: to recognize and support one another in facing common suffering and so disrupt entrenched dysfunctional patterns of interaction

Clearly, cognitive and psychodynamic approaches may be employed to the same ends

3.4.3 Family systems theory

Therapies that, drawing from the above, treat the symptoms of the individual as manifestations of current and historical problems in the individual’s most intimate social relationships [this assumption is the basic tenet of family systems theory]

3.4.3.1 Principles

The healthy family is adjusting, with complementary roles; adults share decisions – with clear lines of authority. Parents are parents and children are not overburdened with responsibility or confidences

3.4.3.2 Objective

Achieve the ideal of the healthy family

3.4.3.3 Specific Methods

Reframing of illness as an opportunity in an attempt to help the family [using this assumption when it is not true – or in a way is not true – can be destructive]

Support for this approach is from the observations: A high level of expressed emotion in families of chronic schizophrenics leads to increased frequency and heightened intensity of relapses … an example for illustrating family systems concepts: Although schizophrenia appears to be associated with low economic status [families], a better indicator seems to be that schizophrenics tend more to come from families whose behavioral style [without psychosis] is similar to the characteristic behavioral style of the psychotic. Schizophrenic patients and that family aspects of treatment may well incorporate encouraging [with appropriate reason and persuasion] healthier family interaction

Comment: Severer cases are harder to treat

3.4.3.4 Uses of Family Therapy

Family therapy is good for problems which family relations precipitated and or maintained

Addictions

Adolescent delinquency

Eating disorders

Psychosomatic illnesses [very hard-to-treat with indiviudal therapy]

Adjunct treatment of schizophrenics in in- and outpatient therapy

3.5 Inpatient Therapy

3.5.1 Where

State hospital

Private psychiatric hospitals

Psychiatric ward in a general hospital

Inpatient ward – community mental health hospital

Jails and prisons

Group homes

Halfway houses

Sheltered workshops

Partial hospitals

Shelters – for runaways – for battered women

3.5.2 Approaches

Psychosocial view

Organic view

Physical and chemical treatment

Psychotherapeutic hospitalcommunity

3.6 The Intrapsychic Psychosocial Milieu

3.6.1 The Traditional Mental Hospital – The Hierarchy

Physician – psychiatrist

Clinical psychologists

Nurses – social workers – specialists

Assistants

Patients

3.6.2 Milieu Therapy

Democratization, open information, patients part of decision process – an ideal – apparently productive [at least in circumstances] – depends on charismatic leadership – warmth, trust, belief

Social model as example

Behavior regulation: all phases – stabilization

Testimony of improved patients

Healthy behavior precedes healthy change

3.6.3 Therapies Within the Milieu

3.6.3.1 Therapies in inpatient settings

Milieu therapy

Psychopharmacology

Group therapy

Individual psychotherapy

3.6.3.2 Special problems of group therapy in inpatient settings

Fluctuating membership – time spent on orienting new members, farewell [debriefing] to leaving patients:

Response: Directive, present focus [tendency]

Patients have [in some inpatient settings] no choice over being there, a wide variety of problems and levels of function

Response: Directive, time-limited, select patients

3.6.3.3 Appropriate forms of group therapy for inpatient settings

Given the problems – psychodrama may be particularly appropriate [mime in the case of patients with limitedskill in linguistic expression]

Other appropriate forms: art, music, poetry, dance… [some of these forms are especially useful for individuals with limited powers of linguistic expression … or for those whose linguistic expression is a block or avoidance strategy]

Psychoeducation [presentations, videos, discussion, … ]

Family therapy [reintegration … ]

Sharing, problem solving

Visualization, relaxation … hypnotherapy

Activities of daily living [ADL] groups, social[ization] groups [community groups]

One to one therapy

3.7 Guide Lines for Group Therapy

State rules