14 International Journal for Psychotherapy in Africa (1:1)

The Application of Psychotherapy in the Nigerian Armed Forces

Philemon A. Agashua, Jonathan I. Ugese and Funke T. Olofin Department of Psychology Nigerian Defence Academy, Kaduna Email: [email protected] Mobile number: +23408057972305

Abstract The military personnel whose duty is to undertake operational duties are often exposed to trauma and stress; and some develop psychological distress as a result. The burden of mental health distress related to military occupational life is substantial as some military personnel and families flourish while others are not able to cope. Overtime, deployed military personnel and families become psychologically dysfunctional as a result of trauma and acute stress syndrome which result to post traumatic stress disorder (PTSD), depression, anxiety and emotional burn-out. Although, little attempt has been made to assess and meet the mental health needs of the military community holistically. This negligence is costly considering that the psychological health of the military family has been found to be directly related to the readiness, well-being and retention of service members. More so, the impact of negative attachment reactions on the cognitive development of children as a result of separations related to military deployment and postings have been observed. But at the moment, the government and NGO’s have focused mainly on the physical welfare needs of the wounded military personnel only, while the mental wellbeing of their families who are victims of counter-insurgency operations have been overlooked. The study therefore examined the application of psychotherapy in the Nigerian Armed Forces. The researchers also discussed common psychotherapeutic techniques relevant to the treatment of military personnel and families with the need to adopt a preventive approach to mental health promotion.

Key Words: Psychotherapy, Stress, Trauma, Emotional burnout and Resilience.

Introduction There is often less liberty or freedom of The Nigerian Armed Forces which choice in military jobs, where activities are comprised of the Air Force, the Army and highly regimented and must follow strict the Navy is a military profession whose time schedules. The life of a military service duty is to undertake operational duties in the personnel and the family is forever full of air, on the land and in the sea with undue challenges when a service member is pressure of time associated with limitations deployed to a peacekeeping mission or on the control of situations apart from their combat war zone. The multiple life- regimental military duties and assignments. changing stressors and the wartime

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 15 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30 experiences often challenge their ability and Weiss, 2002; Pincus, House, Christensen & that of their families to easily reintegrate Adler, 2001; Pincus, House, Christensen & following deployment. Adler, 2005) characterized by sadness, In carrying out their operational depression, disorientation, anxiety, duties, some service personnel are often loneliness, feeling overwhelmed, numbness, exposed to trauma and stress; and anger and relief (Pincus, et al., 2001; eventually, some develop psychological Wexler & McGrath, 1991). Physical problems as a result. The stress associated reactions such as sleep disturbances are with increased workloads, shifting demands common, and health complaints may and unstable deployment schedules can be emerge (Frankel, Snowden & Nelson, 1992; difficult to manage under any circumstances Woods, Scarville & Gravino, 1995; Wright, (Hosek, Kavanagh & Miller, 2006). While Burrell, Schroeder & Thomas, 2006). the stress of repeated deployments alone can Looking at the psychological contribute to significant relationship and difficulties experienced by deployment of mental health problems, it is clear that the active military personnel as a result of unique stressors associated with military exposure to combat war zone, it is not combat exposure are primary risk factors for surprising that military personnel and their psychological impairment among military families suffer from a wide range of mental personnel. For instance, Hosek, et al, (2006) health problems. With the arrays of these documented the psychological stressors psychological disturbances, it is clear that related to combat exposure and length of many military personnel take a very long deployment. They reported that 11 to time to seek help (Iversen, Liddell, Fear, 18percentof personnel exposed to combat Hotopf, Wessely, 2006); even when they experience symptoms of increased stress do, they tend to be reluctant to fully engage reactions and mental disorders compared to with psychotherapy. Given the above only about 9 percent of those without background, the researchers intend to combat experience. The report also found discuss the concept of psychotherapy, the that as the duration of the deployment tour basic therapeutic techniques used in the increased, so did the rate of adverse stress treatment of military personnel and how reactions (Hosek, et al, 2006). Previous psychotherapy is applied in the various research also confirmed that posttraumatic facets of Armed Forces. stress disorder (PTSD) symptoms are more prevalent among personnel deployed for Aim of the study longer than four months (Adler & Castro, The aim of the paper is to examine the 2001). Reports from veterans in recent applications of psychotherapeutic conflicts indicate that soldiers involved in techniques in the treatment of military non-traditional combat duties, such as personnel suffering from psychological handling dead bodies and disarming difficulties as a result of adjustment to civilians, are also at greater risk for training, deployment and combat. subsequent emotional problems (Adler & Castro, 2001). The Concept of Psychotherapy For the families of the military There are many conceptual approaches to personnel left behind during the deployment psychotherapy, but virtually all these phase, they experience a period of approaches (whether- psychodynamic, emotional destabilization and humanistic, existential or behavioural) have disorganization (MacDermid, Olson & their ultimate goal aimed at improving the

16 International Journal for Psychotherapy in Africa (1:1) patient’s day to day functioning. According between the client and therapist. Another to Weiner (1975), the goal of psychotherapy common feature among different is to relieve a patient’s emotional distress psychotherapies is the instilling in clients of and help him modify personality a sense of hope of improvement. Clients characteristics that are preventing him from generally enter therapy with expectations of realizing his human potential or enjoying receiving help to overcome their problems. rewarding interpersonal relationships. These common features that cut across Similarly, the goal of psychotherapy is to different approaches to psychotherapy, such eliminate or control disabling or troubling as the encouragement of hope and the symptoms so the patient can function better display of empathy and attentiveness on the (American Psychological Association-APA, part of the therapist, are called nonspecific 2009). Furthermore, the APA defined treatment factors. These factors may have psychotherapy as a treatment that involves a therapeutic benefits in themselves, quite relationship between a therapist and patient. apart from the specific benefits associated It can be used to treat a broad variety of with particular forms of therapy. mental disorders and emotional difficulties (APA, 2009).The need for psychologists to Forms of Psychotherapy be flexible and adaptive to the varying There are different forms of psychotherapy needs of the armed forces and the with specific theory-based orientations, requirement for timely intervention are two these include: characteristics that deserve special recognition (Kennedy & Zilmer, 2006). Brief Psychotherapy (BP): The Over the years, the field of development of Brief Psychotherapy was psychotherapy has expanded greatly, not related to those external pressures, as well only in the number of contending as to the advent of a scientific approaches and theories, but also in the understanding of cognitive – behavioural range of people treated, the variety of and multimodal approaches of therapy. professionals involved, and in the more Specific approaches to BP include cognitive recent past, the amount of research devoted –behavioural interventions, problem-focus- to the study of its processes and effects. solution therapy, dialectical behavior Originally conceived as a method of therapy, brief psychodynamic therapy and a treatment of patients with symptom wide range of such specific methods as neurosis, hysteria in the first instance, it has assertiveness training, anger management, come to be used with people who are both weight reduction, smoking cessation, parent more and less disturbed (Agashua, 2007). education, child behavior management, pain By now, forms of psychotherapy have been control, and stress reduction strategies, all used with patients with brain damage or of which are now practiced regularly in psychosomatic problems, with psychotics, military settings. Brief therapy may simply drug addicts, alcoholics, the aged and the be defined as traditional therapy conducted very young, and with patients formerly more quickly (Kennedy & Zilmer, 2006). It believed to have too little ego strength to is so well suited to the work of military collaborate in self-exploration. psychotherapists that traditional long-term Psychotherapy also shares other therapy is virtually nonexistent in the features as well. For one, they are all military. It is divided into three main “talking therapies”. In some cases, there is a phases: Beginning, Middle and End Phases. continuous back-and-forth dialogue As service members are continuously

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 17 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30 moving through different geographic achievement and accomplishment, guilt assignments and are often deployed or provides the opportunity to change oneself engaged in training exercise, both clients for the better, vulnerability motivates a and the therapist are too mobile for long- person to become authentic and life’s term therapy to be realistic. These factors unpredictability provides an individual and limited resources help make brief incentive to take responsible action (Frank, therapy in the military the treatment of 1984). choice. Therapy goals in military mental health clinics tend to be symptom-specific Person-centered therapy: Person-centered and narrow in scope, and therapists tend to therapy (also known as client-centered or be active and directive. Done with proper Rogerian therapy) is a form of talk therapy assessment, planning, and strategy, BP can developed by Carl Rogers in the 1940s and be effective and can occur in short intervals 1950s. Congruence, unconditional positive when needed (Lambart, 2004; Peake, regard, and empathic understanding are the Borduin & Archer, 2000). three core conditions of the person-centered approach to psychotherapy (Sommers- Psychoanalytic (or psychodynamic) therapy Flanagan & Sommers-Flanagan, 2012; -This is a form of clinical practice based on Bozarth, 2002; Witty, 2004). The psychoanalytic theory and principles. These foundation of client-entered practice rests multiple theories focus on increasing self- not on method but rather on the therapist’s understanding and deepening insight into respect for and personal openness to the emotional issues and conflicts that underlie client as a sovereign being of inexhaustible the presenting difficulties (Sommers- depth and meaning(Schmid, 2001). Flanagan & Sommers-Flanagan, 2012).Studies on controlled trials support Gestalt therapy: This is a the efficacy of psychodynamic therapy for phenomenological-existential therapy depression, anxiety, panic, somatoform developed by Frederick Fritz and Laura disorders, eating disorders, substance- Perls in the 1940s. It teaches therapists and related disorders, and personality disorders patients the phenomenological method of (Leichsenring, 2005; Milrod, Leon, Busch, awareness and direct experience, in which Rudden, Schwalberg, Clarkin & Shear, perceiving, feeling, and acting “in the now” 2007). are distinguished from interpreting and reshuffling preexisting attitudes. The goal is Existential therapy – This therapy focuses for clients to become aware of what they are on meaning. The job of the therapist is to doing, how they are doing it, and how they listen for what is important or meaningful to can change themselves, and, at the same the client, supporting the development of time, to learn to accept and value self-awareness and a life lived authentically themselves (Sommers-Flanagan & even in the face of death, illness, or other Sommers-Flanagan, 2012; Rosner, Beutler life concerns(Sommers-Flanagan & & Daldrup, 2000). Sommers-Flanagan, 2012). Existential Psychotherapy perceives client as not living Behavior therapy: Behavior therapy is in psychotherapeutic session alone, but focused on helping an individual understand rather brings with him a whole world how changing their behavior can lead to (Dutta, 2014). The core principles of this changes in how they are feeling. The goal of therapy include: suffering is a human behavior therapy is usually focused on using

18 International Journal for Psychotherapy in Africa (1:1) natural incentives to increase engagement in person. This model allows an opportunity positive or socially reinforcing activities for both men and women, who have (Sommers-Flanagan & Sommers-Flanagan, typically not had their strengths valued by 2012). This therapy focuses on the present their families and by the culture in general, not the past, observable behaviours rather to build on their strengths and inner that unconscious forces and short-term resources toward higher self-esteem and treatment, clear goals, and rapid change personal empowerment. (Seligman, 2006; Weiten, 2007). The treatments do not focus on clients achieving Solution-focused therapy: Solution-focused insights into their behaviour rather the focus approach is founded on the premise that is just on changing the behaviour. clients come to us equipped with solutions to their problems. Insoo Kim Berg is one of Cognitive-behavioral therapy (CBT): the model’s pioneers and the founder of Cognitive Behaviour Therapy (CBT) is one brief solution-focused psychotherapy of the major orientations of psychotherapy (Sommers-Flanagan & Sommers-Flanagan, (Roth & Fonagy, 2005) and represents a 2012; deShazer, Berg, Lipchik, Nunnally, unique category of psychological Molnar, Gingerich & Weiner-Davis, 1986). intervention because it derives from Under this approach, it is the therapist’s role cognitive and behavioural psychological to guide clients towards their own strengths models of human behaviour that include for and resources to solve the problem. instance, theories of normal and abnormal Listening remains one of the approach’s development, and theories of emotion and chief techniques. The therapist responds to psychopathology. Rudd, Joiner and Rajab clients using their words, carefully tracking (2004) identified nine studies with a how they talk about their problems, and cognitive behavioral therapy (CBT) focus or mirroring back the strengths and skills they orientation (Brown et al., 2005; van den already possess. Other techniques, like The Bosch, Koeter, Stijnen, Verheul, & van den Miracle Question, Scaling, and Exceptions, Brink, 2005) that were effective in treating help clients assess their situations and get to suicidality. the solutions behind their problems (De Jong & Berg, 2008; de Shazer, Dolan, Feminist therapy: Feminist therapy grew Korman, Trepper, McCollum & Berg, out of the American women’s movement of 2006). the 1960s, with no single founder but major contributions from Jean Miller, Carolyn Family systems therapy: Family systems Enns, Olivia Espin, and Laura Brown therapy arose during the early and mid-20th (Sommers-Flanagan & Sommers-Flanagan, century, with a “golden age” in the 1970s 2012; Worell & Remer, 2003; Collins, and ’80s based in part on the pioneering 2002; Crawford & Unger, 2000). The model work of Nathan Ackerman, Virginia Satir, stems from a critique of power and and Salvador Minuchin (Chabot, 2011). oppression in Western culture, and focuses Rather than viewing problems as belonging on maintaining a sense of egalitarianism in to the individual, the family systems the relationship between therapist and therapist sees problems as created and client. The therapist doesn’t try to be a maintained by and for the family as a blank screen, but in fact, endeavors to do whole. Family systems therapy, then, is not the opposite by putting its values on the just a set of techniques, but a way of table and allowing the client to relate as a thinking about the world. The significance

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 19 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30 of human behavior must always be meaningful pursuit which is essential for understood within a relational context. That achieving existential wellness. Finally, contextual frame includes not only our Socratic Dialogue technique incorporates family relationships, but also the dynamic “interview designed to elicit the patient’s web of overlapping social and cultural own wisdom,” in effect midwifing to systems such as race, class and gender consciousness knowledge that the client (Rhodes, 2012). already possesses (Southwick, Gilmartin, Mcdonough, & Morrissey, 2006). This Logotherapy: This therapy focus on creating technique incorporates the use of Socratic meaning and purpose in human lives questions which aid the client in taking (Frankl, 2006). The creation of meaning and ownership for his or her responsibility to purpose is an attempt to deal with the four lead a life of meaning and purpose (Frankl, existential concerns of death, freedom, 2006; Welter, 1987). isolation, and meaninglessness (Reichenberg & Seligman, 2010). Reality Therapy: Reality therapy, which is Logotherapy attempts to empower clients to developed by William Glasser and Robert find meaning in work, love, suffering, and E. Wubbolding is based on control theory creation. The three fundamental concepts of which explains how the human brain Logotherapy are: freedom of will, will to functions, is a preeminent tool for marriage meaning, and meaning in life (Frankl, and family therapy (Wubbolding, 1988). It 2006). Logotherapy uses three primary can also be integrated into systems theory techniques known as Paradoxical Intention, and adds a practical structure and delivery Dereflection, and Socratic Dialogue (Frankl, system. Reality therapists help clients 2006). Paradoxical Intention, attempts to develop specific, workable plans for get the client to do exactly what he or she is change. Reality therapy is a useful treatment afraid of. The idea here is that when a client method that is effective in motivating wants to achieve a particular end, they students' progress. Reality therapy also develop Anticipatory Anxiety (Frankl, plays a significant role in achievement and 2006). For example, if a client with problem solving abilities. The goals of military-related PTSD cannot fall asleep, his reality therapy were further described by or her stress will manifest in the form of Wubbolding (1988) below: Anticipatory Anxiety as a result of failing to 1. Gain at least a modicum of need fall asleep. Dereflection is based on the idea fulfillment. As in all applications, the that during suffering, we become hyper- therapist helps family members fulfill reflective, constantly focusing inward on their psychological needs without ourselves and our perceptions (Frankl, infringing on the rights of other 2006). Dereflection gets the client to deflect family members. internalization which he suggests manifests 2. Change levels of perception. Family as perpetual self-observation in an attempt members are helped to become less to focus on external meaning-seeking judgmental to each other. behaviors. For example, if a client with 3. Use “quality time.” Time spent military-related PTSD is constantly together in a non-critical way, doing internalizing what he or she experiences and activities that are enjoyable, builds a is in a perpetual state of self-observation, storehouse of positive perceptions that through dereflection, the client will be able serve as a basis for the healthy to replace his or her self-observation with a interactions required for future

20 International Journal for Psychotherapy in Africa (1:1)

problem solving and for negotiating new cadets, therefore, becomes very decisions. significant to prepare such cadets physically 4. Change behavior. The most visible and psychologically for the challenges they goal is to help family members will face while in the NDA. The orientation change how they act toward each and preparatory training of fresh cadets other, both in the therapy session and seeks to allay the fears and anxieties they in the ongoing life of the family. may have about life in the Academy. It seeks to create a very strong impression in Application of Psychotherapy in the the minds of the new cadets using senior Armed Forces Cadets of the Academy to instruct and The following are psychotherapeutic prepare them for life in the Cadets’ techniques used most often in the military Battalion lines. Most importantly, they settings would all have been introduced to the (1) Cognitive Readiness therapy for Academy and their Battalions on the same Preparatory Training and military standard (Agashua, 2015). operations: The goals of basic military To prevent the anticipatory fear, training are to develop loyalty, self- Cognitive readiness therapy is applied in the discipline, physical fitness, self-confidence, preparatory training of the cadets in order to pride in service, and military values in new reduce the fears and anxieties they may trainees (Carbone, 2001). These goals also have about life in the Academy. According point to the fact that the military profession to Morrison and Fletcher (2002), Cognitive thrives on a mission of discipline, order, and readiness is the mental preparation control over its manpower, unlike civilian (including skills, knowledge, abilities, organizations (Gal & Mangelsdorff, 1991). motivations, and personal dispositions) an Thus, it is mandatory that all service individual needs to establish and sustain members including fresh cadets must competent performance in the complex and embrace the art of listening without unpredictable environment of modern question, a major focus during basic military operations. Nothing is certain in training. Critical thinking, challenging military operations as unanticipated tactics, authority, and thinking independently are new technological capabilities, novel not valued characteristics within a military applications of existing technologies, and environment (Katz, 1990). Moreover, the surprise are all notoriously characteristic of military de-emphasizes individuality, combat engagements. Noncombat military discourages introspection and verbalization operations such as peace-making, of emotional states, and encourages strict peacekeeping, humanitarian relief and crisis obedience to highly specified behaviour in a management are also known for their hierarchical fashion, resulting in total potential to bring on unanticipated control of its members (Katz, 1990). challenges. Military units and personnel are In this regard, Agashua (2015) prepared to assume anticipated roles and reported that fresh cadets in Nigerian responsibilities, and much is done to train Defence Academy (NDA) do not resume them for the missions they are expected to training in the Academy on equal footing. perform. These abilities allow individuals Some cadets are raw civilians while others and units to adapt the knowledge and skills are graduates of military schools, who they possess to rapidly evolving operational usually have an advantage militarily to the environments. Training to acquire these rest of their colleagues. De-civilianizing abilities is based on realistic experiences

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 21 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30 that develop what Sternberg (2006) and distinctive elements, including being short Sternberg & Hedlund (2002) describes as term, active, directive, structured, and tacit knowledge (knowledge built up from collaborative, with a core theme being the experience that enables individuals to solve development of individual understanding, real-world, practical problems).Cognitive coping, and mastery of skills essential for readiness therapy is also applied to all day-to-day living (Beck, 1976). military operations, but it is particularly Approximately 60 clinical trials have relevant to situations that arise suddenly and been conducted to target suicidality (Rudd, require immediate attention that are Williams & Trotter, 2008). About 30 of increasingly characteristic of today’s these trials are grounded in a cognitive- “irregular warfare” operating environment behavioral orientation and only 1 has (Hurley, Resnick, & Wahlman, 2007). targeted suicidality in military personnel Post-engagement reviews and (Rudd et al., 1996; Rudd, Joiner & Rajab, analyses such as those provided by 2004). Christianson and Zirkle (1992), Orlansky and Thorpe (1992), and Knarr and (3) Cognitive Processing Therapy (CPT) for Richbourg (2008) point to a general traumatized service personnel (PTSD): description of cognitive readiness in Military personnel are among the most at- military operations as the ability to: risk populations for exposure to traumatic (a) Remove ambiguity and recognize events and the development of patterns in uncertain, confusing, and chaotic posttraumatic stress disorder (Prigerson, situations. Maciejewski, & Rosenheck, 2001; (b) Identify and prioritize problems and Schlenger, Caddell, Ebert, Jordan, Rourke, opportunities presented by these situations. Wilson, 2002). Therefore, CPT is a 12- (c) Devise effective responses to the session therapy that has been found problems or opportunities presented. effective for both PTSD and other corollary (d) Implement these responses. symptoms following traumatic events (Monson, Schnurr, Resick, Friedman, (2) Cognitive therapy to Suicide ideation: Young-Xu, & Stevens, 2006; Resick, Suicide is among the most challenging Nishith, Weaver, Astin & Feuer, 2002; mental health issues faced by the military Resick & Schnicke, 1992). Most veterans today. Suicide has been the second leading may have different needs; they may prefer cause of death in the U.S. military, two sessions a week so that they can get exceeding the number of combat-related therapy finished quickly. They may request losses in both Iraq and Afghanistan (U.S. early morning or evening appointments to Department of Defense, 2012). Since 2008, accommodate their jobs. They may want suicide rates for active-duty personnel their PTSD treatment augmented with exceeded those for comparable-age civilians couples counseling. They may appear a bit (Kang & Bullman, 2008). This trend is more “raw” than the very chronic Vietnam noteworthy when we consider that the veterans that most VA clinicians are military accession process routinely screens accustomed to working with. The more out individuals with serious mental illness, accessible emotions are actually an rendering military service as a protective advantage in processing the traumatic factor for suicide among males in the events and in motivating change, but populations. Studies have shown that therapists who have worked with only very “Cognitive therapy” has a number of chronic (and numbed) veterans may become

22 International Journal for Psychotherapy in Africa (1:1) alarmed when they first work with these interventions may address cognitive, patients. They may think that strong physical, communication, emotional, and emotions or dissociation should be social needs of individuals across the life stabilized or medicated first. (Resick, span. Music therapy provides a safe milieu Monson & Chard, 2006). for military service personnel who are wounded, ill, or injured to (a) nonverbally (4) Army Marriage and Family Therapy: express their inner thoughts and feelings, The Army Marriage and Family Therapy and (b) support verbal processing of was initiated in 2001 as a direct result of the thoughts and reactions. Music therapists Army Family Action Plan aimed at provide services to military personnel, their providing evidence-based relationship families, service members in transition, and therapies for individuals, couples and veterans nationwide. Music therapy Families. The primarily focus of this programs take place during pre- therapy is at those with units that are deploy mobilization, deployment, post-deployment, regularly to combat locations (Cox & and recovery in the case of injury, and Gearhart, 2011). As women become a larger among families of fallen military service percentage of the force, issues that impact personnel (AMTA, 2004). them will become more important. The need of male spouses will also become more (6) Resilience program for Military Combat important; the Army Marriage and Family Operations and Peacekeepers: Military Therapy Program therefore: Operations have undergone a tremendous i. Provide short term clinical metamorphosis and have become counselling to assist sailors with increasingly complex and diffuse; as a problems in daily living that can have result, classic peacekeeper role has become a negative effect upon military the exception rather than the rule. readiness. Peacekeepers now have to be able to ii. Brief solution focused therapy for integrate two seemingly competing roles: individuals, couples, families and the role as peacekeepers with the classic groups. role of warrior (Broesder, Vogelaar, iii. A wide scope of educational, Euwema, & Buijs, 2009). These positive preventive, and therapeutic services to responses are attributed to the resilience of promote an improved quality of life these professionals. Insights into these and increased resilience in resilient responses are thus important as individuals/families. they offer an alternative pathway to iv. Crisis and disaster services. successful adaptation by strengthening resilience factors that enable soldiers to (5) Music Therapy: Music therapy is successfully deal with operational demands defined as “the clinical and evidence-based (Mouthaan, Euwema & Weerts, 2005; use of music interventions to accomplish Newby, McCarroll, Ursano, Fan, Shigemura individualized goals within a therapeutic & Tucker-Harris, 2005; Parmak, Euwema & relationship by a credentialed professional Mylle, 2011; Schok, Kleber, Elands & who has completed an approved music Weerts, 2008). therapy program” (American Music Therapy Association-AMTA, 2004). Music (7) Brief therapy: There is promising therapy services are delivered as part of an evidence that a brief therapy is an effective individualized treatment plan. Specific treatment for substance abuse disorders

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 23 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30 among military personnel for lengthier therapeutic alliance, but also the ways in period of time (Bien, Miller, & Tonigan, which they show empathy as an influence 1993; Gottheil, Weinstein, Sterling, Lundy on outcome (Moore, 2006). & Serota, 1998; McLellan, Arndt, Metzger, Woody & O'Brien, 1993; Miller & Hester, (3) Experience of the therapist: One 1986; Miller & Rollnick, 1991). These may assume due to the old saying “practice studies are positive but are primarily limited makes perfect” that the longer a therapist to program effectiveness studies with has been practicing the more chance to have smaller sample sizes. a successful outcome. Although a few studies have found a small association Factors that Influence the Success of between therapist experience and successful Psychotherapy Outcomes in the Military therapeutic outcome, the majority of the personnel evidence supports the notion that a more For psychotherapy to record any success experienced therapist does not automatically outcome the following factors has to be generate more successful results (Hersoug, present: Hoglend, Monsen, & Havik, 2001). (1) Therapeutic Alliance: Teyber and McClure (2011) define the therapeutic (4) Therapeutic Modality: Langhoff et alliance as a partnership where both al. (2008) suggest that in client-centered therapist and client agree on shared goals, psychotherapy the therapeutic alliance is work together on tasks designed to bring a deemed the primary treatment component, positive outcome, and establish a and in psychoanalysis both transference and relationship built on trust, acceptance, and counter transference are viewed as empathy. With the understanding that the indispensible treatment factors. At times, therapeutic alliance is a main factor in behavior therapy can be seen as more successful treatment outcomes, there also automatic and less personal in which the appears to be other overlapping components therapeutic alliance tends to be seen as less that may affect therapy outcomes. Copper & crucial, yet in order for clients to cooperate Lesser (2011) was one of the first to address and trust in the therapeutic process of the concept that the client is an active behavior therapy, an alliance must first be collaborator in the treatment process. established. Numerous studies have Bordin also agreed with Freud, viewing the concluded that regardless of the therapeutic relationship built, and the collaboration modality, most approaches can produce between therapist and client as, “one of the positive change and that there is no one keys, if not the key, to the change process” superior method for effective therapy (Cooper &Lesser, 2011). (Sullivan, Skovholt & Jennings, 2005).

(2) Empathy: Therapist’s empathy (5) Client toward their client may have a part in Motivation/Personality/Symptomology: Past forming the alliance, its influence on the research that has focused on which client relationship has been shown to be essential. characteristics have an impact on the Moore (2006) suggests empathy is not only therapeutic alliance, such as a client’s communicated verbally, but also with motivation level and their ability to form increased eye contact, body posture, tone of relationships, has shown that these traits and voice, and listening skills. Therapists are characteristics have an impact on both the encouraged to consider not only the alliance and the therapy outcome (Black et

24 International Journal for Psychotherapy in Africa (1:1) al., 2005). It has also been argued that a Saxon, 2008). Other researchers have client’s capacity to form a relationship reported a number of key findings in their could quite possibly provide the foundation study. They found that 10 weeks group BA for the alliance, but it also appears that a sessions helped a substantial number of therapist’s capacity to form relationships is UKAF personnel recover from pre-course just as important (Black et al., 2005). depression; whilst all subjects reported moderate or severe depression symptoms (6) Personality: The overall personality before the course, 90% reported none or or particular personality traits may have an mild depressive symptoms at the 3-month effect on the outcome of the therapist/client follow-up point. Second, this improvement relationship (Coleman, 2006).The client’s in depressive symptoms was associated with participation, quality of their interpersonal a substantial improvement in occupational relationships, attachment, pre-treatment fitness; before treatment around 1 in 20 was expectations, and early therapeutic alliance fit to deploy, whilst 6 months after may have a direct effect on the success of treatment two-thirds were. Lastly, the therapy (Summers & Barber, 2003). improvements in mental health found at the end of the course of treatment were Effectiveness of Psychotherapy in the maintained 3 months later (Wesson, Military Whybrow, Gould & Greenberg, 2013). Research has demonstrated that Increasing Access to Psychological Therapies (IAPT) Relevance of psychotherapy to the initiative has recently published data Nigerian Armed Forces showing an average of 5% of patients’ The Armed Forces of developed countries return-to-work after treatment (Clark, (e.g. United States, United Kingdom) have 2011). The UK Armed Forces (UKAF) recognized the relevance of psychotherapy operates an in-house occupational mental and have made it mandatory for each arm health service and their primary remit is to service to have a psychotherapy unit in maximize the operational effectiveness of order to provide services to their personnel the military units they serve through the with emotional and psychological problems provision of high quality and timely mental during and after operations. However, the health care, which aims to return patients to Nigerian Armed Forces who also undertake full operational fitness wherever same operational duties both internally and possible(Clark, 2011). externally sometimes develop psychological All Behavioural Activation (BA) impairments as a result of exposure to approaches are based on the classic combat stress without access to professional behavioural explanation for depression, psychotherapeutic service. It is therefore, which proposes that the disorder occurs regrettable that the absence of because an individual has experienced a psychotherapy services in the Nigerian reduction in anti-depressant behaviours Armed Forces poses a serious challenge to within their social environment (Martell, service personnel when they develop mental Addis & Jacobson, 2001). Research equally health problems. showed that Behavioural Activation (BA) is Credence to the Nigerian Defence an evidence-based effective psychological Academy (NDA) Nigeria’s premier military treatment for depression such as cognitive university, which now has a Department of therapy (Cuijpers, van Straten, Andersson & Psychology that offer training of Officer van Oppen, 2008; Houghton, Curran & Cadets in courses such as practicum in

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 25 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30 psychotherapy, military psychology and factors influencing treatment engagement clinical psychology. In her primary goal, the and retention prediction of differential Department of psychology provides training treatment responses.The full integration of to cadets in the basic principles and practice psychotherapeutic services in the conduct of of psychotherapy which had greatly helped the Nigerian Armed Forces will greatly in the adjustment of cadets to the military assist in the areas of personal adjustment to and academic training in the Academy. It military life and training, deployment, has been established that some of the combat operations and the provision of graduates of psychology who are rehabilitation services for personnel and commissioned as officers today would their families. eventually form the bed-rock or nucleus for providing professional psychological References services to the Armed Forces at various Adler, A., & Castro, C. (2001). U.S. levels of command. The researchers wish to soldiers and peacekeeping therefore recommend that: deployments. Pentagon Technical i. The Nigerian Armed Forces should Report A584293. U.S. Army Medical embrace the science of psychotherapy Research and Material Command. in the management of and conduct of Frederick, MD. modern warfare. Agashua, P.A. (2007). Psychotherapy and ii. Psychotherapy units should be its place in Nigeria. Keynote address established in each service of the at the 2007 Annual National Armed Forces and manned by trained Conference of Nigerian Society for professionals to provide Psychotherapy, held at Benue Hotels, psychotherapeutic services to both Makurdi, Benue State, 23rd to 27th military personnel and their families October, 2007. with emotional and psychological Agashua, P.A. (2015). Factors Influencing problems. Cadets Adjustment to Training in the iii. Psychological Resilience training Nigerian Defence Academy. The programmes should be introduced to International Journal of Humanities both the military and civil populace to & Social Studies. Vol 3 Issue 5, pp promote combat readiness and coping 308-314. strategies during war and peace-time. American Music Therapy Association. (2004). About music therapy. Conclusion Retrieved from http:// Psychotherapy is an effective and efficient www.musictherapy.org/about/musicth treatment for psychological disorders of all erapy/. kinds affecting military personnel. American Psychiatric Association (APA, Psychotherapy had proven to be useful and 2009). Let’s talk about it is still useful in helping military personnel Psychotherapy. Arlington, VA: to have best chance of recovering for high Wilson Blvd. Suite. standard of occupational fitness. An Beck, A. T. (1976). Cognitive therapy and increasing number of novel therapeutic the emotional disorders. New York, approaches have shown to be effective to NY: International Universities Press. varying degrees, but progress in the field is Bien, T.H., Miller, W.R., & Tonigan, J.S. unlikely without better understanding of (1993). Brief interventions for alcohol treatment mechanisms, patient preferences,

26 International Journal for Psychotherapy in Africa (1:1)

problems: A review. Addiction 88: treatment of depression and anxiety 315-336. disorders: the IAPT experience. Black, S., Hardy, G., Turpin, G., & Parry, International Review of Psychiatry, G. (2005). Self-reported attachment 23, 375–384. styles and therapeutic orientation of Coleman, D. (2006). Therapist-clint five- therapists and their relationship with factor personality similarity: A brief reported general alliance quality and report. Bulletin of the Menninger problems in therapy. Psychology & Clinic, 70(3), 232-241. Psychotherapy: Theory, Research & Collins, K. A. (2002). An examination of Practice, 78, 363-377. feminist psychotherapy in North Bozarth, J. D. (2000). Non-directiveness in America during the 1980s. Guidance client-centered therapy: A vexed and Counselling, 17(4), 105–112. concept. Paper presented at the Cooper, M.G., & Leeser, J.G. (2011). Annual Meeting of the Eastern Clinical social work practice an Psychological Association, Baltimore. integrated approach (4th ed.). Broesder, W., Vogelaar, A., Euwema, M., Boston, MA: Allyn & Bacon. & op den Buijs, T., (2009). The Cox, A.L., & Gearhart, B. (2011). Military peacekeeping warrior. Manuscript Marital and Family Therapy: Policies submitted for publication. and practices. Army Medicine, Brown, G. K., Ten Have, T., Henriques, G. Bringing value inspiring trust R., Xie, S. X., Hollander, J. E., & (Unclassified Document). Beck, A.T. (2005). Cognitive therapy Crawford, M., & Unger, R. R. (2000). for the prevention of suicide attempts: Women and gender: A feminist A randomized controlled trial. psychology (3rd ed.). Boston: Journal of the American Medical McGraw-Hill. Association, 294, 563–570. Cuijpers, P., van Straten, A., Andersson, G., Carbone, E.G. (2001). Job Satisfaction, & van Oppen, P. (2008). Occupational Stress, and Personality Psychotherapy for depression in Characteristics of Air Force Military adults: a meta-analysis of comparative Training Instructors. Military outcome studies. Journal of Medicine, 166 (9), 800-803. Consulting and Clinical Psychology, Chabot, D.R. (2011) Family systems 76, 909–922. theories of psychotherapy. In De Jong, P., & Berg, I. K. (2008). Norcross, J.C., Vandenbos, G.R. & Interviewing for solutions (3rd ed.). Freedheim, D.K. (Eds.), History of Belmont, CA: Thomson Brooks/Cole. Psychotherapy (pp.173-202). de Shazer, S., Berg, I. K., Lipchik, E., Washington, DC: American Nunnally, E., Molnar, A., Gingerich, Psychological Association. W., Weiner-Davis, M. (1986). Brief Christianson, W. M., & Zirkle, R. A. therapy: Focused solution (1992). 73 Easting battle development. Family Process, 25 (2), replication—A Janus combat 207- 221. simulation (IDA Paper P-2770). de Shazer, S., Dolan, Y.M., Korman, H., Alexandria, VA: Institute for Defense Trepper, T.S., McCollum, E.E., & Analyses. Berg, I.K. (2006), More than Clark, D. (2011). Implementing NICE miracles: The state of the art of guidelines for the psychological

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 27 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30

solution focused therapy. New York: Hurley, W. J., Resnick, J. B., & Wahlman, Haworth Press. A. (2007). Improving capabilities for Dutta, T. (2014). Efficacy of Existential irregular warfare, Volume I: Psychotherapy Among Substance Framework and applications. Abusers. The International Journal of Alexandria, VA: Institute for Defense Social Sciences and Humanities Analyses. Invention. Vol 1( 5), pp 2349-2031. Iversen, A., Liddell, K., Fear, N., Hotopf, Frankel, H., Snowden, L.R., & Nelson, L.S. M., & Wessely, S. (2006). Consent, (1992). Wives adjustment to military confidentiality, and the Data deployment: An empirical evaluation Protection Act. British Medical of a family stress model. International Journal; 332:165–169. Journal of Sociology of the Family, Kang, H. K., & Bullman, T. A. (2008). Risk 22, 93-117. of suicide among US veterans after Frankl, V. (1984). Man’s search for returning from the Iraq or meaning. New York , Washington Afghanistan war zones. Journal of the Square Press. American Medical Association Frankl, V. (2006). Man's search for (JAMA), 300(6), 652–653. meaning. Boston, MA: Beacon Press. Katz, P. (1990) Emotional metaphors, Gal, R., & Mangelsdorff, A.D. (1991), Socialization and roles of drill Handbook of Military Psychology. sergeants. Ethos, 18(4), 457-480. (eds.). New York: Wiley Kennedy, C.H., & Zillmer, E.A. (2006). Gottheil, E., Weinstein, S.P., Sterling, R.C., Military Psychology: Clinical and Lundy, A., & Serota, R.D. (1998). A Operational Applications. New York: randomized controlled study of the The Guildford Press. effectiveness of intensive outpatient Knarr, W., & Richbourg, R. (2008). treatment for cocaine dependence. Learning from the fi rst victory of the Psychiatric Services, 49(6):782-787. 21st century: Mazare Sharif. Hersoug, A., Hogland, P., Monsen, J., & Alexandria, VA: Institute for Defense Havik, O. (2001). Quality of working Analyses. alliance in psychotherapy therapist Lambart, M. (2004). Bergin and Garfield’s variables and patient/therapist handbook of Psychotherapy and similarity as predictors. The Journal behavioural change. Ney York: of Psychotherapy Practice and Wiley. Research, 10, 205-216. Langhoff, C., Baer, T., Zubraegel, D., & Hosek, J., Kavanagh, J., & Miller, L. Linden, M. (2008). Therapist-patient (2006). How Deployments Affect alliance, patient-therapist alliance, Service Members. The Rand mutual therapeutic alliance, therapist- Corporation. Santa Monica, Ca: The patient concordance, and outcome of Rand Corporation. CBT in GAD. Journal of Cognitive Houghton, S., Curran, J., & Saxon, D. Psychotherapy: An International (2008). An uncontrolled evaluation of Quarterly, 22. group behavioural activation for Leichsenring, F. (2005). Are depression. Behavioural and psychodynamic and psychoanalytic Cognitive Psychotherapy, 36, 235– therapies effective? International 239. Journal of Psychoanalysis, 86, 841– 868.

28 International Journal for Psychotherapy in Africa (1:1)

MacDermid, S.M., Olson, T.M., & Weiss, Morrison, J. E., & Fletcher, J. D. (2002). H. (2002). Supporting military Cognitive readiness (IDA Paper P- families throughout deployment. 3735). Alexandria, VA: Institute for Military Family Research Institute. Defense Analyses. Retrieved January 22, 2007, from Mouthaan, J., Euwema, M.C & Weerts, J. http://www.cfs.purdue.edu/mfri/pages (2005). Band of Brothers in United /research/MFRI_Brief_Deployment_S Nations Peacekeeping: Social upport.pdf bonding among Dutch peacekeeping Martell, C. R., Addis, M. E., & Jacobson, N. veterans. Military Psychology, 17, S. (2001). Depression in Context: 101-114. strategies for guided action. New Newby, J.H., McCarroll, J.E., Ursano, R.J., York: Norton. Fan, Z., Shigemura, J., & Tucker- McLellan A.T., Arndt, I.O., Metzger, D.S., Harris, Y. (2005). Positive and Woody, G.E., & O'Brien, C.P. negative consequences of (1993). The effects of psychosocial deployment. Military Medicine, 170, services in substance abuse treatment. 815-819. Journal of the American Medical Parmak, M., Euwema, M. C, &Mylle, J. J. Association (JAMA), 269(15):1953- C. (2011). Situational adaptation: 1959. Soldiers’ behavioural tendencies Miller, W.R., & Hester, R.K. (1986). modify during a combat deployment. Inpatient alcoholism treatment: Who Manuscript submitted for publication benefits? American Psychologist Peake, T.H., Borduin, C.M., & Archer, R.P. 41(7): 794-805. (2000). Brief Psychotherapies: Miller, W.R., & Rollnick, S. (1991). Changing frames of mind (3rded.). Motivational Interviewing: Preparing Northvale, NJ: Jason Aronson. People To Change Addictive Pincus, S.H., House, R., Christensen, J., & Behavior. New York: Guilford Press. Adler, L.E. (2001). The emotional Milrod, B., Leon, A. C., Busch, F., Rudden, cycle of deployment: A military M., Schwalberg, M., Clarkin, J., family perspective. Journal of the Shear, M. K. (2007). A randomized Army Medical Department, 615-23. control trial of psychoanalytic Pincus, S.H., House, R., Christensen, J., & psychotherapy for panic disorder. Adler, L.E. (2005). The emotional American Journal of Psychiatry, 164, cycle of deployment: a military family 265–272. perspective. Retrieved January 22, Monson, C.M., Schnurr, P.P., Resick, P.A., 2007, from Friedman, M.J., Young-Xu, Y., & http://www.hooah4health.com/deploy Stevens, S.P. (2006). Cognitive ment/familymatters/emotionalcycle.ht processing therapy for veterans with m military-related posttraumatic stress Prigerson, H. G., Maciejewski, P. K., & disorder. Journal of Consulting & Rosenheck, R. A. (2001). Combat Clinical Psychology, 74, 898-907. trauma: Trauma with highest risk of Moore, L.A. (2006). Empathy a clinician’s delayed onset and unresolved perspective. The ASHA Leader. posttraumatic stress disorder Retrieved September 16, 2011 from symptoms, unemployment, and abuse http://www.asha.org/Publications/lead among men. Journal of Nervous and er/2006/060815 /f060815e.htm. Mental Disease, 189, 99–108.

Agashua, P.A.; Ugese, J.I.; & Olofin, F.T. (2016). The Application of Psychotherapy in the 29 Nigerian Armed Forces, International Journal for Psychotherapy in Africa 1(1):14-30

Reichenberg, L., & Seligman, L. (2010). outpatient intervention targeting Theories of counseling and suicidal young adults: Preliminary psychotherapy: Systems, strategies, results. Journal of Consulting and and skills (3rd ed.). Upper Saddle Clinical Psychology, 64, 179–190. River, NJ: Pearson Education. Rudd, M. D., Williams, B., & Trotter, D. Resick, P. A., & Schnicke, M. K. (1992). (2008). The psychological and Cognitive processing therapy for behavioral treatment of suicidal sexual assault victims. Journal of behavior: What are the common Consulting and Clinical Psychology, elements of treatments that work? In 60(5), 748 – 756. D. Wasserman (Ed.), The Oxford Resick, P.A., Nishith, P., Weaver, T.L., textbook of suicidology. Oxford, UK: Astin, M.C., & Feuer, C.A. (2002). A Oxford University Press. comparison of cognitive processing Schlenger, W. E., Caddell, J. M., Ebert, L., therapy, prolonged exposure and a Jordan, B. K., Rourke, K. M., Wilson, waiting condition for the treatment of D. (2002). Psychological reactions to posttraumatic stress disorder in terrorist attacks: Findings from the female rape victims. Journal of National Study of Americans’ Consulting and Clinical Psychology, Reactions to September 11. Journal of 70, 867 – 879. the American Medical Association, Rhodes, P. (2012). Nothing to fear? 288, 581–588. Thoughts on the history of family Schmid, P. (2001). Comprehension: The art therapy and the potential contribution of not knowing. In G.Wyatt (Series of research. Australian & New Ed.) & S. Haugh & T. Merry (Vol. Zealand Journal of Family Therapy, Eds.), Rogers’ therapeutic conditions: 33(2), 171-182. Evolution, theory, and practice (Vol. Rosner, R., Beutler, L.E., & Daldrup, R.J. 2, pp. 53–71). Llangarron, United (2000). Vicarious emotional Kingdom: PCCS Books. experience and emotional expression Seligman, L. (2006). Theories of in group psychotherapy. Journal of Counselling and psychotherapy: Clinical Psychology. Vol 56, 1-10. Systems, strategies, and skills. (2nd Roth, A., & Fonagy, P. (2005) What Works ed.). Upper Saddle River, New Jersey: for Whom: A critical review of Pearson Education, Ltd. psychotherapy research. Second Smith, M. L., & Glass, G. V. (1977). Meta- Edition. The Guildford Press, analysis of psychotherapy outcome London. studies. American Psychologist, 32, Rudd, M. D., Joiner, T., & Rajab, M. H. 752–760. (2004). Treating suicidal behavior: Sommers-Flanagan, J., & Sommers- An effective, time-limited approach. Flanagan, R.(2012). Counseling and New York, NY: Guilford. Psychotherapy: In Context and Rudd, M. D., Joiner, T., & Rajab, M. H. Practice. (2nd ed.). Hoboken, NJ: (2004). Treating suicidal behavior: John Wiley & Sons. An effective, time-limited approach. Southwick, S., Gilmartin, R., Mcdonough, New York, NY: Guilford. P., & Morrissey, P. (2006). Rudd, M. D., Rajab, M. H., Orman, D. T., Logotherapy as an adjunctive Stulman, D. A., Joiner, T. E., & treatment for chronic combat-related Dixon, W. (1996). Effectiveness of an PTSD: A meaning-based intervention.

30 International Journal for Psychotherapy in Africa (1:1)

American Journal of Psychotherapy, Weiner, I.B. (1975). Principles of 60(2), pp 161-174. Retrieved from Psychotherapy. New York: John http://web.ebscohost.com/ehost/detail Wiley and Sons. ?sid=f43253-2688-457. Weiten, W. (2007). Psychology: Themes & Sternberg, R. J. (2006a). Creating a vision Variations. (7th ed.). Pacific Grove, of creativity: The first 25 years. CA: Thomson Publishing Inc. Psychology of Aesthetics, Creativity, Welter, A. (1987). Counseling and the and the Arts, 5 (1), 2–12. search for meaning. Retrieved from Sternberg, R., & Hedlund, J. (2002). http://books.google.com/books/feeds/ Practical intelligence, g, and work volumes?q=9780849905841. psychology. Human Performance, 15, Wesson, M., Whybrow, D., Gould, M., & 143–160. Greenberg, N. (2013). An Initial Sullivan, M., Skovholt, T., & Jennings, L. Evaluation of the Clinical and Fitness (2005). Master therapists’ for Work Outcomes of a Military construction of the therapy Group Behavioural Activation relationship. Journal of Mental Programme. British Association for Health Counseling, 27, 48-70. Behavioural and Cognitive Summers, R. F., & Barber, J.P. (2003). Psychotherapies. Therapeutic alliance as a measurable Wexler, H.K., & McGrath, E. (1991). psychotherapy skill. Academic Family member stress reactions to Psychiatry, 27(3). military involvement separation. Teyber, E., & McClure, F.H. (2011). Psychotherapy, 28(3), 515-519. Interpersonal process in therapy an Witty, M. (2004). The difference integrative model (6th ed.). Belmont, directiveness makes: The ethics and CA: Brooks/Cole Cengage Learning. consequences of guidance in United States Department of Defense. psychotherapy. The Person-Centered (2012). Army 2020: Generating Journal, 11, 22–32. health & discipline in the force. Wood, S., Scarville, J. & Gravino, K. Washington, DC: Department of (1995). Waiting wives: Separation Defense. and reunion among Army wives. van den Bosch, L. M., Koeter, M.W., Armed Forces & Society, 21, 217-36. Stijnen, T., Verheul, R., & van den Wright, K.M., Burrell, L.M., Schroeder, Brink, B.W. (2005). Sustained E.D., & Thomas, J.L. (2005). Military efficacy of dialectical behaviour souses: Coping with the fear and therapy for borderline personality reality of service member injury and disorder. Behaviour Research and death. In Castro, C.A., Adler, A.B., & Therapy, 43, 1231–1241. Britt, C. A. (Eds.), Military Life: The van den Bosch, L. M., Koeter, M.W., psychology of serving in peace and Stijnen, T., Verheul, R.,&van den combat (Four Volumes). Bridgeport, Brink, B.W. (2005). Sustained CT: Praeger Security International. efficacy of dialectical behaviour Wubbolding, R. (1988). Using reality therapy for borderline personality therapy. New York, NY: disorder. Behaviour Research and HarperCollins. Therapy, 43, 1231–1241.