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Life Care Planning – Psychological Aspects
A strong foundation in counseling types affords the physician Life Care Planner an opportunity to correlate the individuals’ mental health needs and synthesize a proper set of recommendations. As would follow, the Life Care Planner’s solid foundation in counseling theories is important. This document, produced by Mattson and Canter Life Care Planners, is one tool to learn more.
Sigmund Freud Sigmund Freud (1856-1939) graduated from medical school at the University of Vienna in 1881. Although he has been influential in many aspects of neurology, he is most famous for his work in pioneering the field of psychoanalysis. Freud devoted significant time to developing a model of the human mind, which he split into the conscious, subconscious, and unconscious minds. Freud thought that the unconscious mind was particularly important, with it playing a large role in the client’s behavior. As a result of this, Freud shaped psychoanalysis to heavily focus on bringing aspects of the unconscious mind, ideally those that were causing the psychopathology, to the conscious mind so that the client could examine them and better understand themselves. Freud also developed a structural model of the human psyche with three parts once again: the id, ego, and super ego. In this model, the id was closely related with the unconscious mind, driving instinctual behavior that was not consciously considered. The superego was on the opposite end of the spectrum ensuring that moral norms and standards were followed. The ego was in the middle and as acted a mediator between the goals of the id and the superego, helping the psyche compromise. Freud argued that many maladaptive behaviors and psychopathologies his clients experienced were caused by the defense mechanisms of the ego. These defense mechanisms included repression, denial and projection.
Freud also focused significant attention on his theory of psychosexual development, dividing it into 5 stages, each of which had an object of fixation. These stages are the oral, anal, phallic, latent, and genital stages. Freud argued that in order to become a healthy adult, a person must successfully complete each stage, otherwise they will become “fixated” in the stage and have a disorder that is related to that stage’s object of fixation. For example, should a person never complete the oral fixation stage, they are likely to develop a fixation relating to the mouth and undertake mouth-related maladaptive behaviors such as smoking or verbal aggression.
Psychoanalysis/Historical: The psychoanalytic approach to therapy was developed by Sigmund Freud in the late 19th century and is still used today. It primarily examines how the unconscious mind influences thoughts and behaviors and seeks to bring the unconscious thoughts, fears, and feelings to the conscious mind. Practitioners of psychoanalysis would argue that this allows the client and therapist to gain insight into the root of a problem. It can be used with a wide variety of psychopathologies, most notably depression, anxiety, and specific phobias. Freud’s influences are still the backbone of this approach today, with much of a typical therapy session focused on examining how childhood and past events have shaped the unconscious mind.
Psychoanalysis most often takes the form of talk therapy and often employs the techniques free association and interpretation. In free association, the therapist allows the client to speak freely
Mattson and Canter Life Care Conusltants, LLC | 203-838-6071 | www.mattsoncanter.com without interruption about whatever is on their mind, with the therapist making connections between events, feelings, or thoughts after the client is finished. In interpretation, the client speaks freely, with the therapist interjecting into the client’s narrative with their own thoughts or interpretations.
Although influential, psychoanalysis has generally fallen out of favor, with many critics arguing that its lack of empirical evidence and reliance on vague analysis such as dream interpretation make it inconsistent and non-scientific.
Object Relations Object relations is a theory within psychoanalytic psychology that disagrees with Freud’s idea that sexual drives and aggression drives human behavior. Instead, it argues that human behavior is driven by a need for contact with others and a desire to form relationships. The term object relations refers to the relationship between the self and another person The goal of object relations theory is to help a client identify shortcomings in their relationships with others by examining three key components: the other as perceived by self, the perception of self in relation to the other, and the relationship between self and the other. This requires dipping into the unconscious mind to examine the dynamics of how the relationship forms and functions.
Neo Freudians There are three men who are considered to be the “Neo-Freudians”: Alfred Adler, Erik Erikson, and Carl Jung. As the name suggests, they were heavily influenced by Freudian ideas about the conscious and unconscious minds. Despite this influence however, the Neo-Freudians rejected many of Freud’s ideas, arguing that he focused too heavily on childhood experiences and sex. Instead, they focused more on how culture and social aspects of childhood can shape personality and thinking. Similar to Freud and his psychoanalytic approach, they are often criticized for a lack of empirical evidence on the effectiveness of their treatment and for a heavy focus on philosophy.
Alfred Adler Alfred Adler (1870-1937) is best known for his creation of the field of individual psychology. He was a colleague of Sigmund Freud and worked to help established the field of psychoanalysis, but eventually disagreed with the direction Freud took the field. Instead, Alder focused on how individuals respond to feelings of inadequacy, arguing that Freud’s assertion that sexual conflicts in childhood cause mental illness was incorrect. Adler instead argued that people individually strive for their own unique version of perfection, and that they display positive behavior when they feel adequate and respected. He felt that psychopathology arises when one feels inadequate and inferior when comparing themselves to the ones around them. Thus, individual psychology involves significant examinations of both the individual and the communities in which they live. Adlerian therapy is based on these concepts. It centers around how a client fits in with their community and examines how a client can over-compensate or engage in destructive behavior should they feel inadequate compared to their peers. It uses some aspects of psychoanalysis, notably the use of free association about the client’s family history, early memories, and feelings. In using this technique, a therapist works to allow the client to develop new ways of thinking about how they view their perfect self and their situation. Carl Jung
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Carl Jung was a Swiss psychoanalyst who worked extensively with Sigmund Freud. He is considered by many to be the founder of analytical psychology, which was a response to the criticism that Freud’s psychoanalysis was not empirical science. Analytical psychology focuses on the goal of achieving individualization, a state in which a person is more aware of their collective unconscious (unconscious traits and thoughts shared by all of a species) and personal unconscious. With individualization, a person could better understand their thoughts, feelings, and choices. Similar to Freud, Jung thought that childhood experiences were key in shaping the unconscious and that clients could benefit from bringing such unconscious trauma to the conscious mind. He expanded on this, arguing that people are also influenced by archetypes which were unconscious factors that are not from their own personal life. He thought archetypes made up the collective unconscious, which spanned across the all of humanity to create many of the similarities between people from different parts of the world.
Existential-Humanistic Therapies Existential and humanistic therapies focus less on the symptoms a client is experiencing and more on the client themselves. These two share a belief that people have the ability to be self-aware and make autonomous choices but differ in their underlying theories about why this is the case. The humanistic perspective is based on the idea that human nature is inherently good, and that people can make choices that are in their own best interest. As a result, humanistic therapy encourages growth and self-actualization, with the therapist providing unconditional positive regard and helping the client examine how straying away from their natural self can be the source of problems.
Existential therapy is built around on the idea that all problems that clients face are based one of the four given values of existence: freedom/responsibility, existential isolation, meaninglessness, and death. Although it does consider past events, it does not take the same level of importance as in psychoanalytic therapy. Instead, it only uses past events to help give the client insight into how their future is not determine by their past. Similar to humanist therapy, the therapist will avoid any judgement of the client and encourages the client to take responsibility for successes. This therapy is designed to help clients take ownership of their lives and take responsibility for the choices they make. It has been found to be particularly useful in clients with a terminal illness or with clients who are going through a major life transition.
Carl Rogers Carl Rogers (1902-1987) was a psychologist who added a great deal the humanistic perspective, adding to the work of Abraham Maslow. Rogers rejected psychoanalysis as too deterministic and instead argued that humans are driven to self-actualize, which he defined as fulfilling one’s potential and appreciating life. He argued that self-actualization occurs when someone’s ideal self is the same as their actual self, a match that he called congruency. He described a self-actualized person as open to new experiences, living existentially, trusting in their own feelings, creative, and fulfilled. Another key concept Carl Rogers introduced was the idea of unconditional positive regard (UPR). In UPR, a person is loved by those around them no matter what, even if they make a mistake. Rogers argued that this allowed people to feel comfortable trying out new things and lead directly to self-actualization. This concept contrasts with conditional positive regard, in which praise or
Mattson and Canter Life Care Conusltants, LLC | 203-838-6071 | www.mattsoncanter.com positive regard is only given when someone behaves in a way that is deemed “correct”. Rogers argued that this caused problems, as it forces people to only behave in ways approved by others and to shun trying new activities.
Gestalt therapy The gestalt perspective on therapy is based on the ideas that people are best understood as made up of a mind, body, and soul and that they are heavily influenced by their environment. This results in a therapeutic style that is holistic and takes many different aspects of a client’s lifestyle, history, and thought process into account.
Gestalt therapy puts a heavy focus on helping the client understand the differences between their current reality and what they perceive to be happening. In doing this, practitioners hope to help clients be more aware of their own negative thought and behavioral patterns that create this difference. They argue suppressed anger, anxiety, and other negative emotions keep someone from living in the present moment and create a distorted and unhealthy reality.
Gestalt therapy can help with problems such as anxiety, depression, and relationship issues, along with physical issues such as migraines and tension. It can occur in both individual and group settings, with a typical session consisting of exercises or experiments. Exercises are designed to bring up a specific emotion or a goal which the therapist can then discuss with the client. An example of an excise is exaggeration, during which a client is asked to repeat and exaggerate a movement or facial expression to help the client be more aware of the emotions attached to the behavior. Experiments are similar in that they allow the client and therapist to examine the client’s though process, are more open ended than exercises because they are more tailored to the client’s concerns. An example of an experiment is asking a socially anxious client to role play starting a conversation with a stranger in order to allow the client to analyze their thought process and behavior during the conversation.
The Gloria Films The Gloria films part of an educational video Three Approaches to Psychotherapy that was released in 1965. The films featured three different famous therapists who demonstrated their techniques in a session with a real client named Gloria. The three therapists involved were Carl Rogers, Albert Ellis, and Fritz Perls, all of whom had made enormous contributions to humanistic, gestalt, and rational emotive behavioral therapy respectively. These films are important because they gave a glimpse into what psychotherapy actually entailed, helping the public understand how somewhat-veiled world of psychotherapy worked. They films are also important because they were translated and sent all over the world to become part of the psychology curriculum at many colleges and universities. Despite their importance, the films raise potential questions of privacy because details of Gloria’s divorce and personal life were exposed to people around the world.
Albert Ellis After receiving his PhD from Columbia University in 1947, Ellis became interested in psychoanalysis and practiced in the field until the early 1950’s. However, he noticed that when he modified the psychoanalytic approach by interjecting the client narrative with his own ideas and interpretations, his clients would improve more quickly. He eventually gave up on
Mattson and Canter Life Care Conusltants, LLC | 203-838-6071 | www.mattsoncanter.com psychoanalysis and began to develop his own school of therapy focused on changing someone’s behavior by confronting them with their irrational thoughts and beliefs. He called this school Rational Emotive Behavioral Therapy and in 1959 he created the Institute for Rational Living to teach others his ideas.
Rational Emotive Behavior Therapy (REBT) Rational Emotive Behavior Therapy (REBT) is a type of cognitive behavioral therapy that was developed by Albert Ellis in the 1950’s. There are three main steps in REBT. First, the therapist helps the client identify irrational thoughts and beliefs. These thoughts take many forms, with a example belief being “I must be perfect in order to be valued and worthwhile”. The goal of this step is to help the client recognize that they have irrational beliefs that control how they respond to situations that should not necessarily cause psychological discomfort. The second step is the therapist directly confronting the client about the beliefs in an effort to point out that the belief is illogical. This aspect is very different from other forms of psychotherapy because the therapist is not simply warm and supportive; rather, the therapist is direct and logical to help the client understand their belief or thought is irrational. The third step is to change behavior after gaining insight into the irrational thoughts or behavior, which can be done in a wide variety of ways that are not specific to REBT.
Aaron Beck Aaron Beck (1921-Present) developed cognitive behavioral therapy in the 1960’s and later founded the Center for Cognitive Therapy. He contributed enormously to the treatment of depression in particular, coining the term Beck’s Cognitive Triad to describe common negative thoughts about the self, the world, and the future. He has also contributed towards the treatment of anxiety and suicidality and developed a number of psychopathological measurement scales such as the Beck Depression Inventory.
Cognitive Behavioral Therapy (CBT): Cognitive Behavioral Therapy (CBT) is a form of talk therapy developed by Aaron Beck in the 1960’s. As its name suggests, it has both cognitive and behavioral aspects, with proponents arguing that psychopathology has roots in both thinking and interactions with the environment. Its core principle is that psychological problems are often caused by unhelpful ways of thinking and negative learned patterns of behavior. The goal is CBT is to change these thought patterns to be more logical and healthy, helping clients better cope with any distress they may encounter. This entails the therapist helping a client learn to recognize distorted thought patterns and better understand how others think and behave. These goals can be achieved through a variety of ways, with exposure therapy, role play, and meditation being particularly popular. The long-term goal of CBT is to help the client better understand themselves so they can act as their own therapist and recognize thought patterns. One aspect of CBT that is different from most other forms of psychotherapy is that it generally focuses on the client’s current life. Although some information about the past can be helpful, therapists are more focused on helping clients more effectively cope with their problems in the present moment and in the future.
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An example of self-defeating thoughts and behaviors for which CBT would be an appropriate treatment.
Cognitive therapy Cognitive therapy is a subtype of cognitive behavioral therapy. It is most commonly used to treat anxiety and depression but can be used for other psychopathologies. Just like CBT, it is based on the cognitive model, which examines how the way we perceive situations subsequently influences our thoughts and emotions. Thus, a cognitive therapy treatment would focus on identifying a client’s dysfunctional “automatic thoughts” after perceiving a situation and then working down to the core beliefs behind the thought. Cognitive therapy is one of the more active forms of psychotherapy, with the client and therapist working together to identify and correct the distorted thoughts and beliefs. Cognitive therapy is different from CBT because it considers only cognition to be the root of psychopathology while CBT considers both behavior and cognition to be involved.
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Reality Therapy Also known as Glasser therapy, reality therapy was developed by Dr. William Glasser (1925-2013) in the 1960’s and is based on choice theory. Choice theory argues that people have five basic needs that they attempt to fulfill through their behavior: love/belonging, power, fun, freedom, and survival, with love/belonging being the most important. The two key tenets of choice theory are that that nearly all behavior is a choice and that an individual can only control his or her own behavior. As a result, in under the lens of choice theory and reality therapy, all problems arise from unsatisfying present relationships. Because of the strong focus on present relationships, the therapist and client will rarely discuss the past, instead focusing primarily on the present. The goal of reality therapy is to have the client develop a strong internal locus of control1 and the skills to develop strong relationships. Therapists practicing reality therapy often use the acronym WDEP: Wants, Doing, Evaluation, and Planning. These four aspects encompass discuss1)what the client wants from therapy 2) what the client is doing try and bring about happiness 3)critically evaluating if the client’s actions are working 4)planning to improve behavior in the future.
Solution Focused Brief Therapy (SFBT) Solution Focus Brief Therapy (SFBT) is a short-term therapy developed in the 1970’s. Unlike many other types of therapy that focus on the past or the present, SFBT focuses predominantly on the future and is designed to help the client find solutions instead of dwelling on problems. It operates on the principle that each person is their own personal “expert” and knows how an improved future would look and feel. Using the client’s knowledge of their own behavior patterns and experiences, the therapist will help the client create a plan to help them achieve to a positive future scenario. SFBT has been found to be useful in children with behavioral or academic concerns, family therapy, and couples’ therapy. It is generally not recommended for people with mental health problems such as anxiety or depression as it is too forward focused to alleviate the negative symptoms experienced in the present.
Family Systems Therapy Family systems therapy is a form of psychotherapy that is designed to help individuals with their problems within the context of the family unit. This is achieved by having the entire family work together to gain a better understanding of the group dynamic and how each individual person and their actions contribute to the group. It heavily relies on the principle that the actions of one individual affects everyone in the family. In family systems therapy, each family member is given an opportunity to express how they are effected by a problem. The goal of this to not only help the person for whom the therapy is designed understand their actions, but also to help the family better understand how they can support and help each other to build a better support system. Family systems therapy can be used for many different issues such as anxiety, depression, bipolar disorder, eating disorders, conflicts, and discipline problems.
Internal Family Systems Therapy Internal Family Systems therapy (IFST) is a form of psychotherapy that examines the numerous subpersonalities (families) within a client’s personality. In everyone, these subpersonalities each
1 An internal locus of control is when someone believes they control the outcomes of their actions and lives.
Mattson and Canter Life Care Conusltants, LLC | 203-838-6071 | www.mattsoncanter.com have their own unique viewpoint and interact with each other and the self (the core essence of a person that coordinates the families) to dictate behavior. The subpersonalities can engage in extreme behavior, causing conflict between one another and the self which contributes to psychopathology of behavioral problems. The goal of IFST is to use family systems therapy (described above) to help realign misguided subpersonalities to restore balance and harmony under the direction of the self. An important tenet of IFST is that each subpersonality, even if it is causing problems, it not inherently bad. Rather, it can be too “extreme” or “loud” and subsequently cause conflict with other sub-personalities.
IFST can be used to treat individuals, couples, and families. It has been shown to be effective for trauma, abuse, compulsive behaviors, depression, bipolar disorder, eating disorders, anxiety, phobias, and substance dependency. A typical session will revolve around helping the client become more familiar with one or more of their sub-personalities so that this part can better communicate with the self and the other sub-personalities.
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Mattson and Canter Life Care Conusltants, LLC | 203-838-6071 | www.mattsoncanter.com
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