Systems of Psychotherapy Donald K

Systems of Psychotherapy Donald K. Fromme

Systems of Psychotherapy

Dialectical Tensions and Integration

1 3 Donald K. Fromme Pacific University School of Professional Psychology 222 SE 8th Ave. Hillsboro, OR 97123 USA [email protected]

ISBN 978-1-4419-7307-8 e-ISBN 978-1-4419-7308-5 DOI 10.1007/978-1-4419-7308-5 Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2010935876

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Springer is part of Springer Science+Business Media (www.springer.com) Dedicated to my wife, Marie, for her encouragement, support, constancy, and love. 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 interpre- tation 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. Interper- sonal 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 cha- racteristics 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 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 ef- forts. 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. 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 Her- sen, Dan McKitrick, Russ Miars, Cathy Miller, and Rick Warren.

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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 �� 10 Dialectical Tensions in Psychotherapy Integration �� 12 Integrative Dialectics �� 13 Eclectic Dialectics �� 14 The Dialectics of Common vs. Specific Factors �� 15 The Dialectics of Intervention Levels: Microcontext to Macrocontext �� 16 Level of Intervention �� 16 The Dialectics of Psychotherapy Research �� 18 The Dialectics of Clinical vs. Statistical Significance �� 19 Dialectics of Outcome vs. Process Research �� 23 The Dialectics of Treatment-Focused vs. Patient-Focused Research �� 27 Integrative Implications �� 28 Chapter One: Main Points �� 30 Further Reading �� 31

2 Transtheoretical Approaches: Treatment Planning and the Initial Interview �� 33 The Dialectics of Transtheoretical Treatment Planning �� 33 The Transtheoretical Model (TTM) �� 34 Systematic Treatment Selection �� 37 Integrating the Transtheoretical Model and Systematic Treatment Selection �� 41 Common Factors in Treatment Planning �� 43 Patient-Focused Research �� 44 Planning and Assessment in Clinical Care: The PACC Approach �� 45

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Dialectical Tensions Between Client and Therapist During the Initial Interview ...... 47 Gathering Information While Establishing a Collaborative Relationship ...... 48 Case Illustration: Integrative Transtheoretical Treatment Planning ...... 55 Integrative Implications ...... 56 Case Conceptualization with an Integrative Transtheoretical Approach ...... 57 Stages of Change and Client Variables ...... 57 From Macro to Microcontexts ...... 58 Chapter Two: Main Points ...... 59 Further Reading ...... 60

3 Biomedical Approaches to Treatment ...... 63 Dialectics of the Medical and Psychosocial Models ...... 64 The Diathesis-Stress Dialectic ...... 65 Psychosomatic Illness vs. Medical Illness with Psychological Symptoms ...... 65 Psychopharmacology: A Conceptual Framework ...... 67 Neurons and Synaptic Transmission ...... 67 Pharmacokinetics ...... 69 Pharmacodynamics ...... 70 Neurotransmitters ...... 72 Pharmacotherapy ...... 74 Antidepressants ...... 74 Antipsychotic Drugs ...... 84 Analgesics ...... 85 Anxiolytics ...... 87 Pharmacotherapy with the Elderly and with Children ...... 88 Geriatric Psychopharmacology ...... 89 Pediatric Psychopharmacology ...... 91 Substance Abuse ...... 93 Integrative Implications ...... 96 Integrative Therapy for Schizophrenia ...... 97 Case Illustration ...... 100 Chapter Three: Main Points ...... 101 Further Reading ...... 104

4 Behavioral Interventions ...... 105 Conceptual Framework ...... 106 Exposure-Based Behavior Therapies ...... 107 Systematic Desensitization (Reciprocal Inhibition) ...... 107 Eye Movement Desensitization and Reprocessing (EMDR) ...... 110 Flooding and Implosive Therapies ...... 111 Acceptance or Mindfulness-Based Interventions ...... 112 Case Illustration: Exposure Techniques ...... 112 Contents xiiixiii

Operant-Based Behavior Modification ...... 114 Applied Behavioral Analysis ...... 114 Behavioral Activation ...... 125 Case Illustration: Behavioral Activation (Adapted from Jacobson et al., 2001) ...... 126 Cognitive Behavior Modification Approaches ...... 127 Psychoeducation and Social Skills Training ...... 127 Social Learning Programs (SLPs) ...... 128 Assertiveness Training ...... 128 Thought-Stopping ...... 129 Problem-Solving ...... 129 Self-Instructional Training ...... 130 Stress Inoculation ...... 131 Lazarus’ BASIC-ID Multimodal Therapy ...... 131 Integrative Implications ...... 132 Chapter Four: Main Points ...... 132 Further Reading ...... 134 Videos ...... 135

5 Cognitive Approaches ...... 137 Rational Emotive Behavioral Therapy ...... 137 Conceptual Framework ...... 138 Intervention Techniques ...... 139 Cognitive Therapy ...... 140 Conceptual Framework ...... 141 Cognitive-Behavioral Interventions ...... 143 Case Formulation in Cognitive Therapy ...... 147 Case Illustration ...... 147 Schema Therapy ...... 149 Conceptual Framework ...... 150 Intervention in Schema Therapy ...... 153 Case Illustration: Schema Therapy (Summarized from Young et al., 2003, pp. 66–67) ...... 161 Integrative Implications ...... 163 Chapter Five: Main Points ...... 166 Further Reading ...... 169 Websites ...... 169 Videos ...... 169

6 Psychoanalytic Approaches ...... 171 Psychoanalysis ...... 172 Freud’s Instinctual Drive Theory ...... 172 Structural Theory ...... 173 Psychosexual Developmental Stage Theory and Psychopathology ...... 174 Psychoanalytic Treatment ...... 176 xivxiv Contents

Ego Analytic Theory ...... 178 Anna Freud ...... 178 Erik Erikson ...... 181 The Conflict-Free Sphere of Ego Function: Hartmann, Mahler, and White ...... 184 Brief Psychodynamic Psychotherapy ...... 186 Brief Psychodynamic Intervention and Treatment Planning ...... 187 Case Illustration: Core Conflictual Relationship Theme Method ...... 188 Integrative Implications ...... 190 Chapter Six: Main Points ...... 192 Further Reading ...... 193 Videotape ...... 193

7 Psychodynamic Approaches: Object Relations and Self Theory ...... 195 Object Relations Theory ...... 196 Conceptual Framework ...... 196 Self Theory ...... 201 Diagnosis and Treatment Planning in Psychodynamic Psychotherapy ...... 202 Treatment Planning ...... 203 Psychodynamic Intervention Issues ...... 208 Case Illustration: Psychodynamic Therapy (Summarized from McWilliams, 2004, pp. 219–259) ...... 209 Integrating Psychodynamic and Behavioral Therapy ...... 212 Conceptual Framework: Cyclical Psychodynamics ...... 213 Case Illustration (Summarized from Wachtel et al., 2005, pp. 347–354) ...... 215 Integrative Implications ...... 217 Attachment Research ...... 217 Patterns of Attachment ...... 218 Attachment and Problems in Living ...... 219 Chapter Seven: Main Points ...... 220 Further Reading ...... 222 Videos ...... 222

8 Humanism: Experiential Approaches ...... 223 Dialectic Tensions in Gestalt Therapy ...... 224 Perls’ Classical Gestalt Approach: Conceptual Framework ...... 225 Perls’ Theory of Psychopathology ...... 226 Perls’ Approach to Therapeutic Intervention ...... 227 A Contemporary Relational Gestalt Approach (Erving Polster) ...... 229 Conceptual Framework: Community of Selves ...... 230 Intervention in Relational Gestalt Psychotherapy ...... 230 Emotionally Focused Therapy: Bridging the Researcher-Practitioner Gap ...... 233 Conceptual Framework: Emotionally Focused Therapy ...... 234 Contents xvxv

Emotion Theory ...... 235 Intervention in Emotionally Focused Therapy ...... 237 Continuous Case Formulation with Task Markers and EFT Interventions ...... 241 Case Illustration (Continuation with Tracey) ...... 249 Reprocessing Problematic Experiences: Chair Work and Meaning Creation ...... 251 Case Illustration (Conclusion with Tracey) ...... 254 Integrative Implications ...... 258 Chapter Eight: Main Points ...... 259 Further Reading ...... 261 Videos ...... 261

9 Humanism: Phenomenological Approaches ...... 263 Existential Therapy ...... 264 Conceptual Framework ...... 265 Intervention in Existential Approaches ...... 271 Case Illustration ...... 278 Carl Rogers’ Client Centered Therapy ...... 284 Conceptual Framework ...... 284 Pretherapy ...... 287 Motivational Interviewing (MI) ...... 289 Conceptual Framework ...... 289 Client and Therapist Activities ...... 290 Integrative Implications ...... 294 Chapter Nine: Main Points ...... 295 Further Reading ...... 298 Videos ...... 298 Websites ...... 298

10 Psychotherapy and Social Context ...... 299 Individual Psychology ...... 300 Intentionality ...... 300 Individual Psychology’s Conceptual Framework ...... 301 Intervention Approach ...... 306 Case Illustration ...... 311 Interpersonal Theory: Harry Stack Sullivan ...... 313 Conceptual Framework ...... 314 Communication Analysis: Social Reinforcement of Unconscious Processes ...... 315 Conceptual Framework ...... 316 Intervention Approach ...... 319 Case Illustration ...... 321 Integrative Implications ...... 323 Self-Regulation and General Systems Theory ...... 323 Intentionality and Interpersonal Relations as Integrative Concepts ...... 325 xvi Contents

Chapter Ten: Main Points �� 326 Further Reading �� 328 Website �� 328 Videos �� 328

11 Contemporary Interpersonal Approaches �� 329 Communication Theory: Process vs. Content �� 330 Interpersonal Process in Therapy �� 332 Conceptual Framework �� 332 Interpersonal Process Intervention Principles �� 336 Interpersonal Reconstructive Therapy �� 344 Case Formulation in Interpersonal Reconstructive Therapy �� 345 Structural Analysis of Social Behavior �� 346 Therapeutic Intervention �� 349 Case Illustration (Summarized from Benjamin, 2006, pp. 2, 17–20) �� 356 Interpersonal Therapy �� 358 Conceptual Framework �� 358 Intervention Techniques �� 359 Case Illustration (Summarized from Crowe and Luty, 2005) �� 360 Integrative Implications �� 362 Chapter Eleven: Main Points �� 363 Further Reading �� 364 Video �� 365

12 Family Systems and Couples Approaches �� 367 Systems Approaches to Family Therapy �� 368 Cybernetics and Family Systems Theory �� 368 Strategic Family Therapy �� 370 Multigenerational Approaches �� 374 Structural Therapy �� 377 Experiential Therapy with Couples and Families �� 384 Attachment-Based Family Therapy �� 389 Postmodern Family Approaches �� 390 Narrative Therapy �� 391 Solution-Focused Therapy �� 392 Other Approaches �� 393 Object Relations Family Therapy �� 394 Cognitive-Behavioral Couples and Family Therapy �� 394 Integrative Implications �� 397 Chapter Twelve: Main Points �� 398 Further Reading �� 399 Videos �� 399 Websites �� 400 Contents xvii

13 Ecosystemic Issues and Approaches �� 401 Privileged and Oppressive Ecosystems �� 402 Feminism and Multiculturalism �� 404 Minorities and Oppression in the United States �� 405 Ecosystemic Interventions �� 413 Family Networking �� 414 Multisystemic Therapy �� 417 Community Mental Health �� 421 Power, Symptoms, and Ethics �� 423 Integrative Implications �� 424 Chapter Thirteen: Main Points �� 425 Further Reading �� 427 Videos �� 427 Websites �� 427

14 Postmodernism and Integrative Therapies �� 429 Constructivism in Therapy �� 430 Intersubjective Approaches �� 430 Cognitive-Experiential-Interpersonal Negotiation of Alliance Ruptures �� 433 Integrative Postmodernism: Functional Contextualism �� 442 Dialectical Behavior Therapy �� 443 Acceptance and Commitment Therapy �� 450 Integrative Implications �� 465 Chapter Fourteen: Main Points �� 465 Further Reading �� 468 Video �� 468 Websites �� 468

15 Epigenetic Systems: A Meta-Integrative Model of Human Functioning and Therapy �� 469 An Epigenetic Systems Model of Human Development and Functioning �� 472 Motivation: Interpersonal Needs and Self-Determination Theory �� 474 Cognitive-Experiential Self-Theory (CEST) and Personal-Agentic Processes �� 476 Developmental Stages and Tasks �� 477 Problems in Living �� 482 Case Illustration: Epigenetic Case Conceptualization �� 486 Epigenetic Systems and Treatment Planning �� 489 Intervention Principles �� 491 Epigenetic Treatment Planning and Intervention �� 492 Case Illustration: Epigenetic Treatment Planning �� 494 xviii Contents

Integrative Conclusions �� 496 Chapter Fifteen: Main Points �� 497 Further Reading �� 500

Appendices �� 501 Appendix A: Initial Interview & Treatment Planning Tools �� 501 Appendix B: Therapeutic Intervention Tools �� 504

Bibliography �� 505

Author Index �� 537

Subject Index �� 543 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 1985–1986 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.

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