Roger’s Client Centered

UNIT 1 ROGER’S CLIENT CENTERED Therapy

THERAPY

Structure
1.0 Introduction
1.1 Objectives
1.2 Views of Human Nature
1.3 Goals of Client Centred Therapy
1.4 The Counselling Process
1.4.1 Empathy
1.4.2 Unconditional Positive Regard
1.4.3 Genuineness or Congruence
1.4.4 Transparency
1.4.5 Concreteness
1.4.6 Self Disclosure
1.4.7 Cultural Awareness in Client Centred Counselling
1.5 Counselling Relationship
1.6 Intervention Strategies
1.6.1 Rogerian View of Psychotherapy
1.6.2 Process of Person Centered Therapy
1.6.3 Therapist’s Role and Functions
1.6.4 Therapy / Intervention Goals
1.6.5 Client’s Experience in Therapy
1.6.6 Relationship between Therapist and Client
1.6.7 Contribution of Person Centered Therapy
1.6.8 Summary and Evaluation
1.6.9 Being Genuine
1.6.10 Active Listening
1.6.11 Reflection of Content and Feelings
1.6.12 Appropriate Self Disclosure
1.6.13 Immediacy
1.7 Clients Who Can Benefit
1.8 Limitations
1.9 Let Us Sum Up
1.10 Unit End Questions
1.11 Suggested Readings

1.0 INTRODUCTION
Carl Rogers is the founder of this approach to counselling. It is also known by
names person centred approach, nondirective counselling and client centred
counselling. This approach can be used in any setting where a helper aims to
promote human psychological growth. As this method of counselling did not
require extensive psychological training, many practising counsellors adopted
this approach and it had a great influence on the preparation of new counsellors.
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Other Therapies for Rogers work is regarded as one of the principal forces in shaping current
Psychological Interventions
counselling and psychotherapy. The present unit deals with Roger’s Client
centered therapy, its characteristic features, its goals and its techniques and
principles.

1.1 OBJECTIVES
After completing this unit, you will be able to:
• Define and describe Roger’s client centred therapy;
• Explain the views of human nature as according to Rogers;
• Elucidate the goals of therapy;
• Describe the counselling process;
• Analyse the importance of counselling relationship; and
• Explain the intervention strategies of client centered therapy

1.2 VIEWS OF HUMAN NATURE

In Rogers client centred therapy, human beings are seen as possessing goodness
and the desire to become fully functioning i.e. to live as effectively as possible.
According to Rogers, if people are permitted to develop freely, they will flourish
and become positive, achieving individuals. Because Rogers’s theory expresses
faith in human nature, it is considered as humanistic approach to counselling.
Rogers client centred therapy is based on a theory of personality referred to as
self-theory. An individual’s view of self within the context of environment
influences his actions and personal satisfactions. If provided with a nurturing
environment, people will grow with confidence toward self-actualisation. If they
do not receive love and support from significant others, they will likely to see
themselves as lacking in worth and see others as untrustworthy. Behaviour will
become defensive and growth toward self actualisation will be hampered.
An important principle of self theory is the belief that a person’s perceptions of
self and environment are reality for that person. For example, if an individual
sees himself as incompetent, he will act on that belief, even if others view him as
brilliant. This personal reality may be changed through counselling but not by a
direct intervention as substituting the judgement of the counsellor for that of the
client.
Thus, the client centered therapist’s perception of people is based on four key
beliefs:
1) People are trustworthy
2) People innately move toward self – actualisation and health
3) People have the inner resources to move themselves in positive directions and
4) People respond to their uniquely perceived world.

1.3 GOALS OF CLIENT CENTERED THERAPY

Person centered therapy, which is also known as client centered, non directive,
or Rogerian therapy, is an approach to counseling and psychotherapy that places
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much of the responsibility for the treatment process on the client, with the therapist Roger’s Client Centered
Therapy
taking a nondirective role.

The goal of client centered therapy is to provide a safe, caring environment where
clients get in closer touch with essential positive elements of themselves that
have been hidden or distorted. Less distortion and more congruence lead to greater
trust that their organism can be relied on for effective reactions to people and
situations.

Two primary goals of person centered therapy are increased self esteem and
greater openness to experience. Some of the related changes that this form of
therapy seeks to foster in clients include:
i) Closer agreement between the client’s idealised and actual selves
ii) Better self-understanding
iii) Lower levels of defensiveness, guilt, and insecurity
iv) More positive and comfortable relationships with others and
v) An increased capacity to experience and express feelings at the moment
they occur.
Rogers believed that people are trustworthy and have vast potential for
understanding themselves and resolving their own problems and that they are
capable of self directed growth if they are involved in a respectful and trusting
therapeutic relationship.

According to Rogers, if the above 3 attitudes are communicated by the helper,

those being helped will become less defensive and more open to themselves and
their world, and they will behave in socially constructive ways. Therapists use
themselves as an instrument of change.

Person centered therapy focuses on the person, not on the person’s presenting
problem. Goal is to assist clients in their growth so they are better able to cope
with both today’s problems and future problems.

The basic drive to fulfillment implies that people move toward health if the way
seems open for them to do so. Thus, the goals of counseling are to set clients free
and to create those conditions that will enable them to engage in meaningful
self-exploration.

Therapists concern themselves mainly with the client’s perception of self and
the world. This approach provides clients with a rare opportunity to be truly
listened to without evaluation or judgment.

Therapist does not choose specific goals for the client. (B-203) Primary
responsibility for the direction of therapy is on the client.
General goals of therapy are:
a) becoming more open to experience,
b) Achieving self-trust,
c) developing an internal source of evaluation,
d) being willing to continually grow
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Other Therapies for This added trust results in reduced feelings of helplessness and powerlessness,
Psychological Interventions
fewer behaviours are driven by stereotypes and more by productive, creative and
flexible decision making.

Self Assessment Questions

1) What are the views of human nature in Roger’s client centered therapy?
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2) Delineate the goals of client centered therapy.
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3) Describe the general and specific goals of client centered therapy.
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1.4 THE COUNSELLING PROCESS

According to Rogers, the counsellor should provide conditions that would permit
self discovery and encourage the client’s natural tendency toward personal growth.
The core conditions of counselling as described by Rogers are empathy,
unconditional positive regard and congruence or genuineness which is considered
necessary and sufficient for therapeutic personality change.

The Person Centred approach remains one of the most popular forms of
psychological counselling. It provides a frame of reference as much as if not
more than a counselling method. In Carl Rogers’ original perspective, clients (as
all people) are seen to engage continually in the attempt to self-actualise. This
optimistic philosophy led to the promotion of a model of counselling in which
clients are regarded as their own best resource for growth and change. Rogers
(1951) early Non Directive approach developed into Client Centered therapy
which emphasised accuracy in empathy. In its current form, the Person Centered
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approach underscores the reciprocal nature of the helping relationship. At the Roger’s Client Centered
Therapy
core is a well known set of constructs about the intrinsic nature of people and the
functioning of the helping relationship rather than the counselling method (the
Core Conditions).

Competent practitioners are thus defined by their level of self awareness and
capacity to engage in a meaningful helping relationship rather than any technical
knowledge of Person Centred counselling. Valuing the unique phenomenological
position of the client, Person Centred counselling still retains the positive and
optimistic value base of early work but now elaborates a more sophisticated
model of humanity.

The concept of core conditions is inextricably linked to the early work of Rogers
(1957). The terminology has since evolved but the fundamental principle of the
concept of core conditions remains essentially unchanged. The original strong
version of the model holds that core conditions are necessary and sufficient for
clients to experience therapeutic change. Later post modern or sophisticated
versions of Person Centred counselling posit that the condition are foundations
for change and adds other broader requirements (Rennie 1998).

The original shortlist of core conditions has been considerably expanded (Carkhuff
1969):
• Unconditional positive regard
• Empathic understanding
• Genuineness and congruence
• Transparency
• Self disclosure
• Concreteness
• Cultural awareness
Creating trust in the helping relationship is a fundamental tenet of all Person
Centred therapy. Not only must the client learn to trust the counsellor, but also
the counsellor must trust that the client is the best person to set their own goals
and access their own resources to achieve them. The problem is, however, that
people often come to counselling because they are thwarted in their capacity to
identify or reach their own goals (Haley 1976).

Rather than being a passive “listening post”, then, the counsellor must strive to
actively listen, actively engaging mind to compare what is being revealed to
previous disclosures. Clients in turn use the process to try to make sense of their
experience.

Egan (1994) distinguishes primary and advanced empathy. Primary empathy is

said to depend on counsellors attending, listening and communicating back their
understanding of the clients position as experienced by the client. Advanced
empathy, however, also incorporates self-disclosure, directiveness and
interpretations. The sophisticated version thus gives a more active role to the
counsellors processing and implicit use of a theoretical framework rather than
relying on purely experiential nature of the counselling encounter as the main
source for the validation of material presented by the client.
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Other Therapies for There is often an opportunity for relearning emotional experiences through
Psychological Interventions
advanced emotional empathy. As the relationship between the client and
counsellor develops so it becomes possible for the client to cautiously re-
experience feelings. This marks the dawning of self-awareness, recognising links
between past and present, preparing the ground for problem resolution (Brems
1999).

The process of therapeutic change in Person centred counselling represents a

movement from purely cerebral to feeling states and gives immediacy. It also
marks a change to an internal locus of control. Mearns (1994) distinguishes
osmotic (slow developing change) and seismic (sudden shift) in experience of
the self. The Person centred approach contains much confrontation. Clients may
be challenged to construct a new response to long held perceptions. Empathy is
itself a confronting activity, challenging clients about the quality and validity of
their feelings. The counsellors own congruence can also challenge clients where
behaviours are offered as challenge to the counselling situation.

Reframing the client’s narrative and confronting discrepancies in their account

can open up possibilities for change. Rogers (1980) posits the counselling process
is a means of rediscovering denied experiences. It aims to put clients in touch
with themselves.

Counsellors confrontation should be born out of respect and a desire to help the
client through the struggle to realise their own potential. It is particularly
important, however, for counsellors to get the power dynamic right so that the
client comes to understand that the counsellor becomes responsible to rather
than for the client (Mearns 1994). The aim, then is to help clients realise their
own power.

Schmid (1998) points out that Person Centred counselling is in fact a radical
approach. The Latin and Greek etymology of “person” is associated with mask
or face. Schmid reminds us that in Greek theatre the mask did not hide the
character but served to reveal the personification of the gods. Contemporary
psychological meaning of the person is defined by two traditions: as an
independent being; as a being in a relationship. Both concepts have powerful
implications for psychotherapeutic counselling. Rogers’s original usage is
consistent with the first definition, representing a celebration of selfhood as
emancipated from the social milieu. The latter definition, however, implies
persons are defined by, and indeed can only exist as, reflections of interactions
with others. Schmid also contends the parallel definition creates a tension which
finds its way into therapy. The client aims to become their own essential self
(independent being). The therapist also tries to manifest self authentically
(congruence). Paradoxically, however, it is the therapeutic relationship (being in
a relationship) which is the sole vehicle for the journey.

Person Centred counselling retains a humanistic philosophy and a

phenomenological focus. Prominence is given to the role of the self in effective
psychological functioning. Post modern trends in counselling extend the concept
of self to include interpersonal, systemic and socio cultural aspects. Psychological
difficulties have to be understood from a variety of subjective meanings and be
context sensitive. It is now seen to be a “relational contextual” self in contrast to
an “autonomous-independent” self of the early Person Centred formulations
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1.4.1 Empathy Roger’s Client Centered
Therapy
It refers to the counsellor’s ability to understand the client at a deep level. Rogers
refers to the internal frame of reference to denote the client’s unique experience
of personal problems. In order to stay within the client’s internal frame of
reference, it is necessary for the counsellor to listen carefully to what is being
conveyed (both verbally and nonverbally) at every stage of counselling. Once
the counsellor understands the feelings and experiences of the client, the same
thing needs to be communicated to the client.

Rogers also uses the term external frame of reference to describe the lack of
understanding and contact. When a counsellor perceives the client from an
external frame of reference, there is little chance that the client’s view will be
clearly heard. This does not help the client to benefit from counselling.

1.4.2 Unconditional Positive Regard

People need love acceptance, respect and warmth from others but unfortunately
these attitudes and feelings are often given conditionally. As many people who
come into counselling have experienced these attitudes, Rogers believed that
counsellors should convey unconditional positive regard or warmth towards
clients if they are to feel understood and accepted. This means that clients are
valued without any conditions attached even when they experience themselves
as negative, bad, frightened or abnormal. When attitudes and of warmth and
acceptance are present in counselling, clients are likely to accept themselves and
become more confident in their own abilities to cope.

1.4.3 Genuineness and Congruence

The Person Centered Therapy relationship must always be an honest one. The
counselor needs to be real and true in the relationship. Individuals who cannot
accept others (i.e. because of personal values and beliefs they hold rigidly and
apply to all), or who will not listen and try to understand cannot do Person
Centered Therapy. The therapist must embody the attitudinal quality of
genuineness and to experience empathic understanding from the client’s internal
frame of reference and to experience unconditional positive regard towards the
client. When the client perceives the therapist’s empathic understanding and
unconditional positive regard, the actualising tendency of the client is promoted.

Congruence means that the counsellor is authentic and genuine. The counsellor
does not present an aloof professional facade, but is present and transparent to
the client. There is no air of authority or hidden knowledge, and the client does
not have to speculate about what the counsellor is ‘really like’.

1.4.4 Transparency
Ttransparency means even negative feelings about a client, if any exist, are
expressed. The therapist shows a non-possessive feeling of love for the client
and is able to, after a time, be empathetic enough to understand the client enough
to metaphorically walk in the individual’s shoes.

1.4.5 Concreteness
The next condition, concreteness, is the counsellor’s skill in focussing the client’s
discussion on specific events, thoughts and feelings that matter while discouraging
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Other Therapies for intellectualised story telling. Concreteness is a precaution against the rambling
Psychological Interventions
that can occur when the other three conditions are employed without sufficient
attention to identifying the client’s themes.

If the counsellor is totally accepting of each client as a person, relates emphatically

to the client’s reality and behaves in a genuine way, the client will be free to
discover and express the positive core of his being. As clients come to perceive
themselves more positively in the nurturing environment, they will function more
effectively. Counsellors not only provide the nurturing environment that is missing
in client’s lives but also serve as role models of how fully functioning persons
relate with others.

1.4.6 Self Disclosure

The issue of degree to which person centered therapists may express and disclose
themselves in the person centered relationships is contentious. However there is
general agreement that self expression and self disclosure and willingness to be
known are different from congruency. The therapist responds to the client from
the therapist’s frame of reference. The therapist should be willing to be known
on the progress and success of therapy.

The issue of the therapist’s self disclosure to the client is constantly revisited and
many take the view that at times and in limited ways this may be a useful thing to
do.

Self disclosure and self expression are most likely to be helpful to the client and
the therapeutic relationship when
• They are relevant to client and the client’s present experiencing.
• They are a response to the client’s experience
• A reaction to the client is persistent and particularly striking.
• In response to the questions and requests from the client, the therapist answers
openly and honestly and helps dispel the mystique.
• When it seems the client wants to ask a question but does not directly voices
it.
• To make an empathic observation – that is to express a perception of an
aspect of the client’s communication or emotional expression
• To correct for loss of acceptance or empathy or incongruence.
• To offer insights and ideas.

1.4.7 Cultural Awareness in Client Centered Counselling

In Culture-Centered Counseling, recognising the centrality of culture can augment
therapy and result in effective treatment of all clients. This approach involves
recognising cultural assumptions and acquiring knowledge and skills to get
beyond them, something that may be done no matter what treatment model a
therapist might use.

Cultural awareness means being cognisant of culture differences that may use
different standards for loudness, speed of delivery, spatial distance, silence, eye
contact, gestures, attentiveness and response rate during communication.
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Some examples of these would be: Roger’s Client Centered
Therapy
• Arab people may avert their eyes when listening or talking to a superior.
• Someone from South America may consider it impolite if you speak with
your hands in your pockets.
• Your Russian patients or clients may want to kiss you on the check to express
their gratitude.
• If your new colleague is from Norway, they may hesitate to use your first
name until they know you better.
• For the Chinese or Japanese, a facial expression that would be recognised
around the world as conveying happiness, may actually express anger or
mask sadness, both of which are unacceptable to show overtly in their culture.
All this may seem like a lot to consider, but the tips for considering cross cultural
communication are really very basic:
1) Use common words
2) Follow basic words of grammar
3) Avoid slang
4) Repeat basic ideas without shouting
5) Paraphrase important points
6) Check for understanding

Self Assessment Questions

1) Describe the counselling process of client centered therapy.
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2) What is empathy? How is useful in therapy?
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3) Describe unconditional positive regard.
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Other Therapies for
Psychological Interventions 4) Elucidate the concepts of congruence, genuineness, transparency and
concreteness.
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5) How does client centered counselling incorporate cultural awareness.
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1.5 COUNSELLING RELATIONSHIP

The underlying philosophy of human nature is more important in the practice of
client-centred therapy than any particular set of techniques or any body of
knowledge. In this therapy, helpers learn how to be counsellors rather than how
to do counselling. Because clients are seen as having the potential to solve their
own problems, counsellors are not perceived as having expert knowledge to
share with clients.

The client centred therapy is based on respect for the client, on the establishment
of an empathic bond and on the willingness of the counsellor to be open and
genuine with the client. In addition to these qualities, there is also an emphasis
on facilitating each client’s growth or self-actualisation which can be achieved
only in the presence of core conditions.

The counselling skills which are essential for the development of a therapeutic
relationship between counsellor and client are:
• Active listening
• Responding to clients through reflection of feeling and content
• Paraphrasing and summarising
• Asking open questions
• Responding appropriately to silence and client non- verbal communication
Silence, acceptance, restatement, empathy and immediacy responses occur most
frequently with the client taking the lead on what is discussed and being
responsible for outcomes. Client centred therapists encourage careful self
exploration but they tend to avoid confrontation and interpretation as tools for
hastening insight.

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The possibility of transference reactions is acknowledged in client centered Roger’s Client Centered
Therapy
therapy but they are not highlighted by the counsellors as they become hindrance
in helping the clients achieve independence and autonomy. Similarly, the concept
of unconscious motivation is also acknowledged in client centred therapy but
counsellors do not focus on it or directly ask the client to work with dreams. But
as the therapy is person centred, if clients wish to look at dreams or unconscious,
they are at liberty to do.

There is little focus on specific action planning except as initiated by the client.
It is assumed that as the client becomes free to actualise his potential through the
exploration process, behaviour change will occur naturally and without prompting
from the counsellor.

1.6 INTERVENTION STRATEGIES

The person centered therapy has certain distinctive components and these are
given below:
• Therapist’s attitude can be necessary and sufficient conditions for change.
• Therapist needs to be immediately present and accessible to clients.
• Intensive, continuous focus on patient’s phenomenological world.
• Process marked by client’s ability to live fully in the moment.
• Focus on personality change, not structure of personality.

1.6.1 Rogerian View of Psychotherapy

• Implied Therapeutic Conditions.
• Client and therapist must be in psychological contact.
• Client must experience distress.
• Client must be willing to receive conditions offered by therapist.

1.6.2 Process of Person Centered Therapy

Therapy begins at first contact.In the first interview, a person centered therapist
will go where the client goes. For Carl Rogers, empathy, unconditional positive
regard, and congruence. (genuineness) were the 3 basic requirements to create a
therapeutic environment.

Respect shown immediately for client. In addition to the basic requirements of

the therapeutic environment for the therapist, Rogers believed the client must
focus on self-concept, locus-of-evaluation and experiencing. Therapy’s length is
determined by client (In person centered therapy termination is decided by the
client).
Quick suggestions and reassurances are avoided.
Empathy involves understanding another individual by “living” in their internal
frame of reference.
Person centered therapists believe that empathy, unconditional positive regard,
and congruence are necessary and sufficient conditions for therapeutic change.

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Other Therapies for Congruence as stated above is a correspondence between the thoughts and the
Psychological Interventions
behaviour of a therapist. This is very essential if intervention has to be effective.
Client centered therapy focuses most heavily on the present. A successful person
centered therapy outcome would be defined by the client’s evaluation that therapy
was beneficial.

1.6.3 Therapist’s Role and Functions

Role: Therapist’s attitude and belief in the inner resources of the client, not in
techniques, facilitate personal change in the client.
i) Use of self as an instrument of change.
ii) Focuses on the quality of the therapeutic relationship.
iii) Serves as a model of a human being struggling toward greater realness.
iv) Is genuine, integrated, and authentic.
v) Can openly express feelings and attitudes that are present in the relationship
with the client.
Functions: to be present and accessible to clients, to focus on immediate
experience, to be real in the relationship with clients.

Through the therapist’s attitude of genuine caring, respect, acceptance, and

understanding, clients become less defensive and more open to their experience
and facilitate the personal growth.

1.6.4 Therapy/ Intervention Goals

The goals are as given below:
i) Helping a person become a fully functioning person.
ii) Clients have the capacity to define their goals.
iii) An openness to experience.
iv) A trust in themselves.
v) An internal source of evaluation.
vi) A willingness to continue growing.

1.6.5 Client’s Experience in Therapy

Incongruence: discrepancy between self-perception and experience in realityà
anxietyà motivation to help.

As clients feel understood and accepted, their defensiveness is less necessary

and they become more open to their experiences.

• Therapeutic relationship activate clients’ self-healing capacities.

• Relationship between Therapist and Client.

• Emphasises the attitudes and personal characteristics of the therapist and

the quality of therapeutic relationship.

• Therapist listening in an accepting way to their clients, they learn how to

listen acceptingly to themselves.
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1.6.6 Relationship between Therapist and Client Roger’s Client Centered
Therapy
A central variable related to progress in person-centered therapy is the relationship
between therapist and client.
• A person-centered therapist is a facilitator.
• It is not technique-oriented.
• A misunderstanding—this approach is simply to restate what the client just
said or the technique of reflection of feelings (It is incorrect).
• The therapeutic relationship is the primary agent of growth in the client.
• Therapist’s presence: being completely engaged in the relationship with
clients.
• The best source of knowledge about the client is the individual client.
• Caring confrontations can be beneficial.

1.6.7 Contribution of Person Centered Therapy

• Active role of responsibility of client.
• Inner and subjective experience.
• Relationship-centered.
• Focus on therapist’s attitudes.
• Focus on empathy, being present, and respecting the clients’ values.
• Value multicultural context.

1.6.8 Summary and Evaluation

Limitation
• Discount the significance of the past.
• Misunderstanding the basic concept: e.g., reflection feelings.
• People in crisis situations often need more directive intervention strategies.
• Client tends to expect a more structured approach.

1.6.9 Being Genuine

Client centred therapists need to be knowledgeable about themselves and
comfortable with this information. They must be more congruent than their clients.
Being genuine does not mean sharing every thought or feeling with the client. It
means being a helpful, attentive, caring person who is truly interested in the
client and able to demonstrate that interest.

1.6.10 Active Listening

The first technique emphasised in client – centered therapy is active listening
and its reflection of content and feelings. Demonstrating empathy for the client
requires highly attentive and interactive listening skills. The physical steps
common to this are facing the clients, leaning toward them and making good eye
contact. This position and the use of facial and body expressions that relate to
the client’s comments will at least initially put the therapists and clients in physical
contact. Then the therapists hear and see what is communicated. Both the words
and the actions of the client are used to develop an understanding of the content
and feelings being presented. 17
Other Therapies for Taking in information is only the first part of active listening. Therapists must
Psychological Interventions
then reflect the content and feelings of clients back to them to have value. For
example, ‘I hear you saying.....,” “so you are feeling......” and “you seem to be
feeling.... because of...” are the ways counsellors and therapists explore with the
client how accurate their empathy is.

The process of active listening helps both counsellor and client clarify the content
and feelings of a situation and is a learning process for each participant. Therapists
who can treat their own mistakes and growth during this learning process in a
genuine manner also help clients accept their uncertainties and weaknesses.

1.6.11 Reflection of Content and Feelings

The first step in the empathy exploration process tends to be the recognition and
reflection of the actual words stated and the feelings that are most obvious. As
client and therapist get to know each other better, an effective therapist would be
better able to see behind these surface interactions and begins to see and convey
feelings clients do not even recognise they are expressing. Describing to the
client what has been recognised is like an extended listening, observing and
reflecting of the person’s world. Reflection can also bring together complex
elements of the client’s world that draw a more accurate picture of the client as a
whole than the individual elements that provide.

1.6.12 Appropriate Self - Disclosure

A genuine relationship enables the client to see relevant parts of the therapist’s
phenomenological world as well as the client’s world. Appropriate self disclosure
allows clients to compare their views of the world with the view of another
individual whom they have come to trust and value as a significant human being.
These comparisons give clients the chance to review and revise their views based
on information they might otherwise not have had available or which has been
too threatening to accept. The supportive relationship allows the client to try out
new thoughts and behaviours at the rate and in a manner most appropriate for
them.

1.6.13 Immediacy
Immediacy provides a here – and - now approach to the relationship in general
and to feelings in particular. The relationship between the therapist and the client
is seen as the most important therapeutic factor in part because it is available for
immediate examination. Therefore, the feelings that both client and therapist are
currently experiencing are often the most therapeutic ones available. Statements
that receive primary emphasis are ones like “How are you feeling now?” and
“your statements make me feel .....”. On the other hand, statements seen as less
therapeutically useful might be “Why did you feel that way?” “What did the
other person think?” or what did you believe then?’

A major reason for client centered therapist’s emphasis on the here and now is
that reactions between client and counsellor or therapist can be verified, checked
and explored immediately by both participants.

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 Roger’s Client Centered
Case Study Therapy

Sunil, a 30 year old young man was graduated in engineering. He is divorced

and no children. He changed three different jobs in 5 years. He approached
for counselling as he feels that he has difficulty in having good interpersonal
relationships. He found that he cannot interact positively with people and
gets easily irritated by others.

The client centered therapist acts as a helper and the main responsibility in
the counselling process has to be taken by the client. The first task of the
counsellor is building relationship with the client in order to develop trust.
At the same time he is encouraged to believe in himself – that he has the
capacity to get along with others and to make friends. Instead of relying on
case histories, analysis in a traditional sense, probing and questioning, the
focus should be on building a relationship that is facilitative.

Self Assessment Questions

1) Discuss the various intervention strategies in client centered therapy.
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2) Describe cognitive view of psychotherapy.
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3) Elucidate the roles and unctions of therapist in client centered therapy.
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4) What important does therapist clinet relationship has?
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Other Therapies for
Psychological Interventions 5) Discuss being genuine, active listening reflecting contents and feelings
as part of therapy.
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1.7 CLIENTS WHO CAN BENEFIT

This therapy has wide application within the helping professions, voluntary sector,
human relations training, group work, education and institutional settings where
the goals are to foster good interpersonal skills and respect for others.

This therapy is also useful in dealing with the clients in the first stage of crisis.

Women clients would benefit from this therapy as they are encouraged to consider
and identify their own feelings and needs, which many women may never been
able to do before.

People with relationship difficulties would also benefit as the client centered
therapist gives them respect, understanding and openness which they may not
have experienced in everyday life.

The principles of the person centered approach have been applied to a variety of
therapeutic situations including marriage counselling and family therapy.

Many self help groups like Alcoholic Anonymous extend core conditions of
respect, understanding and openness for people who want to change.

1.8 LIMITATIONS
Success is dependent on counsellors and therapists maintaining high trust in the
feelings and actions of the client and themselves. Lack of trust often causes
therapists to rely on passive reflection responses. These are necessary but become
inadequate as the need for a more comprehensive therapeutic relationship develops
which includes directness that comes with culturally, situational and personally
relevant feelings and interactions.

1.9 LET US SUM UP

The client centred model is optimistic in its view of humankind. Clients are seen
as basically good and possessing the capabilities for self – understanding, insight,
problem solving, decision making, change and growth.

The counsellor’s role is that of a facilitator and reflector. The counsellor facilitates
a counselee’s self understanding and clarifies back to the client the expressed
feelings and attitudes of the client. In this therapy, giving information for problem
solving is not usually considered a counsellor responsibility. The counsellor would
20
not seek to direct the mediation of the counselee’s inner world but provides a Roger’s Client Centered
Therapy
climate in which the counselee could bring about change in himself.

The core conditions of counselling as described by Rogers are empathy,

unconditional positive regard and congruence or genuineness which are
considered necessary and sufficient for therapeutic personality change.

The counselling skills which are essential for the development of a therapeutic
relationship between counsellor and client are active listening, responding to
clients through reflection of feeling and content, paraphrasing and summarising,
asking open questions and responding appropriately to silence and client non-
verbal communication. Silence, acceptance, restatement, empathy and immediacy
responses occur most frequently with the client taking the lead on what is
discussed and being responsible for outcomes. Client centred therapists encourage
careful self exploration but they tend to avoid confrontation and interpretation
as tools for hastening insight.

1.10 UNIT END QUESTIONS

1) Discuss human nature as a view point from Roger’s therapy angle.
2) Elucidate goals of client centered therapy and delineate the counselling
process.
3) Discuss the various counselling process of client centered therapy.
4) Explain the importance of relationship between client and therapist.
5) Elucidate the intervention strategies.
6) What are the limitations of the client centered therapy?

1.11 SUGGESTED READINGS

Capuzzi, D. &Gross,D.R.(1999). Counselling and Psychotherapy: Theories and
Interventions. Second edition. Merrill, Columbus, Ohio.

Gibson,R.L. & Mitchell,M.H. (1995) Introduction to Counseling and Guidance.

Fifth edition.Merrill, Columbus, Ohio.

Hough, M. (2006). Counselling Skills and Theory. Second edition. Hodder Arnold,
Great Britain.

21
Other Therapies for
Psychological Interventions UNIT 2 FAMILY AND GROUP
PSYCHOTHERAPY

Structure
2.0 Introduction
2.1 Objectives
2.2 Nature and Definition of Family Therapy
2.2.1 History and Theoretical Frameworks of Family Therapy
2.2.2 Techniques of Family Therapy
2.2.3 Values and Ethics in Family Therapy
2.2.4 Models of Family Therapy
2.3 Group Psychotherapy
2.3.1 Group Therapy vs. Individual Therapy
2.3.2 History of Group Psychotherapy
2.3.3 Therapeutic Principles
2.3.4 Settings
2.3.5 Construction of Therapy Groups
2.3.6 Functioning of Therapy Groups
2.3.7 Referral of Patients to Group Therapy
2.3.8 Termination of Therapy Groups
2.3.9 Drop Outs of Group Therapy
2.3.10 Effectiveness
2.4 Advantages of Group Therapy
2.5 Types of Groups
2.5.1 T-Groups
2.5.2 Sensitivity Group
2.5.3 Encounter Groups
2.5.4 Marathon Groups
2.5.5 Task Groups
2.5.6 Psycho Education Group
2.5.7 Mini Groups
2.5.8 In Group and Out Groups
2.6 Let Us Sum Up
2.7 Unit End Questions
2.8 Suggested Readings

2.0 INTRODUCTION
Family therapy, also referred to as couple and family therapy and family systems
therapy, is a branch of psychotherapy that works with families and couples in
intimate relationships to nurture change and development. It tends to view change
in terms of the systems of interaction between family members. It emphasises
family relationships as an important factor in psychological health.

The different schools of family therapy have in common, a belief, that regardless
of the origin of the problem, and regardless of whether the clients consider it an
22
“individual” or “family” issue, involving families in solutions is often beneficial. Family and Group
Psychotherapy
This involvement of families is commonly accomplished by their direct
participation in the therapy session. The skills of the family therapist thus include
the ability to influence conversations in a way that catalyses the strengths, wisdom,
and support of the wider system.

In early years of the development of the field, many clinicians defined the family
in a narrow, traditional manner usually including parents and children. As the
field has evolved, the concept of the family is more commonly defined in terms
of strongly supportive, long-term roles and relationships between people who
may or may not be related by blood or marriage.

Family therapy has been used effectively in the full range of human dilemmas.
There is no category of relationship or psychological problem that has not been
addressed with this approach. The conceptual frameworks developed by family
therapists, especially those of family systems theorists, have been applied to a
wide range of human behaviour, including organisational dynamics. In this unit
we will be dealing with family and group therapy. We will trace the historical
framework of family therapy, present the techniques of family therapy and discuss
the various techniques of family therapy. We then deal with models of family
therapy and delve deeply into group psychotherapy.

2.1 OBJECTIVES
After reading this unit, you will be able to:
• Understand the following aspects related to family and group psychotherapy:
• History and Theoretical Frameworks of Family Therapy;
• Techniques of Family Therapy;
• Models of Family Therapy;
• History of Group Psychotherapy; and
• Therapeutic principles and settings.

2.2 NATURE AND DEFINITION OF FAMILY

THERAPY
Family therapy refers to the joint treatment of two or more members of the same
family in order to change unhealthy patterns of communication and interaction.
Family therapy is generally initiated because of psychological or emotional
problems experienced by a single family member, often a child or adolescent.
These problems are treated as symptomatic of dysfunction within the family
system as a whole. The therapist focuses on the interaction between family
members, analysing the role played by each member in maintaining the system.
Family therapy can be especially helpful for dealing with problems that develop
in response to a particular event or situation, such as divorce or remarriage, or
the birth of a new sibling. It can also be an effective means to draw individuals
who feel threatened by individual therapy into a therapeutic setting.

23
Other Therapies for 2.2.1 History and Theoretical Frameworks of Family Therapy
Psychological Interventions
Formal interventions with families to help individuals and families experiencing
various kinds of problems have been a part of many cultures, probably throughout
history. These interventions have sometimes involved formal procedures or rituals,
and often included the extended family as well as non-kin members of the
community. These interventions were often conducted by particular members of
a community – for example, a chief, priest, physician and so on – usually as an
ancillary function.

Family therapy as a distinct professional practice had its origins in the social
work movements of the 19th century in England and the United States. As a
branch of psychotherapy, its roots can be traced somewhat later to the early 20th
century with the emergence of the child guidance movement and marriage
counseling. The formal development of family therapy dates to the 1940s and
early 1950s with the founding in 1942 of the American Association of Marriage
Counselors and through the work of various independent clinicians and groups
– in England (John Bowlby), the US (John Bell, Nathan Ackerman, Christian
Midelfort, Theodore Lidz, Lyman Wynne, Murray Bowen, Carl Whitaker, Virginia
Satir), and Hungary (D.L.P. Liebermann) – who began seeing family members
together for observation or therapy sessions. There was initially a strong influence
from psychoanalysis (most of the early founders of the field had psychoanalytic
backgrounds) and social psychiatry, and later from learning theory and behaviour
therapy – and significantly, these clinicians began to articulate various theories
about the nature and functioning of the family as an entity that was more than a
mere aggregation of individuals.

The movement received an important boost in the mid-1950s through the work
of anthropologist Gregory Bateson and colleagues – Jay Haley, Donald D. Jackson,
John Weakland, William Fry, and later, Virginia Satir, Paul Watzlawick and others
– at Palo Alto in the US, who introduced ideas from cybernetics and general
systems theory into social psychology and psychotherapy, focusing in particular
on the role of communication.

This group was also influenced significantly by the work of US psychiatrist,

hypnotherapist, and brief therapist, Milton H. Erickson - especially his innovative
use of strategies for change, such as paradoxical directives. The members of the
Bateson Project had a particular interest in the possible psychosocial causes and
treatment of schizophrenia, especially in terms of the putative “meaning” and
“function” of signs and symptoms within the family system.

The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore

Lidz on communication deviance and roles (e.g., pseudo-mutuality, pseudo-
hostility, schism and skew) in families of also became influential with systems-
communications-oriented theorists and therapists. A related theme, applying to
dysfunction and psychopathology more generally, was that of the “identified
patient” or “presenting problem” as a manifestation of or surrogate for the family’s
or even society’s problems.

By the mid-1960s a number of distinct schools of family therapy had emerged.

From those groups that were most strongly influenced by cybernetics and systems
theory, there came MRI Brief Therapy, and slightly later, strategic therapy,
Salvador Minuchin’s Structural Family Therapy and the Milan systems model.
24
Partly in reaction to some aspects of these systemic models, came the experiential Family and Group
Psychotherapy
approaches of Virginia Satir and Carl Whitaker, which downplayed theoretical
constructs, and emphasised subjective experience and unexpressed feelings
(including the subconscious), authentic communication, spontaneity, creativity,
total therapist engagement, and often included the extended family.

Concurrently and somewhat independently, there emerged the various

intergenerational therapies of Murray Bowen, Ivan Böszörményi-Nagy, James
Framo, and Norman Paul, which present different theories about the
intergenerational transmission of health and dysfunction, but which all deal
usually with at least three generations of a family either directly in therapy
sessions, or via “homework”, “journeys home”, etc.

Psychodynamic Family Therapy

This, more than any other school of family therapy, deals directly with individual
psychology and the unconscious in the context of current relationships - continued
to develop through a number of groups that were influenced by the ideas and
methods of Nathan Ackerman, and also by the British School of Object Relations
and John Bowlby’s work on attachment.

Multiple-Family Group Therapy

This is a precursor of psychoeducational family intervention, emerged, in part,
as a pragmatic alternative form of intervention – especially as an adjunct to the
treatment of serious mental disorders with a significant biological basis, such as
schizophrenia - and represented something of a conceptual challenge to some of
the “systemic” (and thus potentially “family-blaming”) paradigms of pathogenesis
that were implicit in many of the dominant models of family therapy.

The late-1960s and early-1970s saw the development of network therapy by

Ross Speck and Carolyn Attneave, and the emergence of behavioural marital
therapy (renamed behavioural couples therapy in the 1990s) and behavioural
family therapy as models in their own right.

By the late-1970s the weight of clinical experience – especially in relation to the

treatment of serious mental disorders – had led to some revision of a number of
the original models and a moderation of some of the earlier stridency and
theoretical purism.

There were the beginnings of a general softening of the strict demarcations

between schools, with moves toward rapprochement, integration, and eclecticism
– although there was, nevertheless, some hardening of positions within some
schools. However, there was a growing willingness and tendency on the part of
family therapists to work in multi-modal clinical partnerships with other members
of the helping and medical professions.

From the mid-1980s to the present, the field has been marked by a diversity of
approaches that partly reflect the original schools, but which also draw on other
theories and methods from individual psychotherapy. These approaches and
sources include brief therapy, structural therapy, constructivist approaches (e.g.,
Milan systems, post-Milan/collaborative/conversational, reflective), solution-
focused therapy, narrative therapy, a range of cognitive and behavioural
approaches, psychodynamic and object relations approaches, attachment and
25
Other Therapies for Emotionally Focused Therapy, intergenerational approaches, network therapy,
Psychological Interventions
and multisystemic therapy (MST). Multicultural, intercultural, and integrative
approaches are also being developed.

Many practitioners claim to be “eclectic,” using techniques from several areas,

depending upon their own inclinations and/or the needs of the client(s), and
there is a growing movement toward a single “generic” family therapy that seeks
to incorporate the best of the accumulated knowledge in the field and which can
be adapted to many different contexts. However, there are still a significant number
of therapists who adhere more or less strictly to a particular or limited number of
approaches.

2.2.2 Techniques of Family Therapy

Family therapy uses a range of counseling and other techniques including:
• communication theory
• media and communications psychology
• psychoeducation
• psychotherapy
• relationship education
• systemic coaching
• systems theory
• reality therapy
The number of sessions depends on the situation, but the average is 5-20 sessions.
A family therapist usually meets several members of the family at the same time.
This has the advantage of making differences between the ways family members
perceive mutual relations as well as interaction patterns in the session apparent
both for the therapist and the family.

These patterns frequently mirror habitual interaction patterns at home, even though
the therapist is now incorporated into the family system. Therapy interventions
usually focus on relationship patterns rather than on analysing impulses of the
unconscious mind or early childhood trauma of individuals as a Freudian therapist
would do - although some schools of family therapy, for example psychodynamic
and intergenerational, do consider such individual and historical factors (thus
embracing both linear and circular causation) and they may use instruments
such as the genogram to help to elucidate the patterns of relationship across
generations.

The distinctive feature of family therapy is its perspective and analytical

framework rather than the number of people present at a therapy session.
Specifically, family therapists are relational therapists. They are generally more
interested in what goes on between individuals rather than within one or more
individuals, although some family therapists—in particular those who identify
as psychodynamic, object relations, intergenerational, EFT, or experiential family
therapists—tend to be as interested in individuals as in the systems those
individuals and their relationships constitute. Depending on the conflicts at issue
and the progress of therapy to date, a therapist may focus on analysing specific
previous instances of conflict, as by reviewing a past incident and suggesting
26
alternative ways family members might have responded to one another during it, Family and Group
Psychotherapy
or instead proceed directly to addressing the sources of conflict at a more abstract
level, as by pointing out patterns of interaction that the family might have not
noticed.

Family therapists tend to be more interested in the maintenance and/or solving

of problems rather than in trying to identify a single cause. Some families may
perceive cause-effect analyses as attempts to allocate blame to one or more
individuals, with the effect that for many families a focus on causation is of little
or no clinical utility.

2.2.3 Values and Ethics in Family Therapy

Since issues of interpersonal conflict, power, control, values, and ethics are often
more pronounced in relationship therapy than in individual therapy, there has
been debate within the profession about the different values that are implicit in
the various theoretical models of therapy and the role of the therapist’s own
values in the therapeutic process, and how prospective clients should best go
about finding a therapist whose values and objectives are most consistent with
their own. Specific issues that have emerged have included an increasing
questioning of the longstanding notion of therapeutic neutrality, a concern with
questions of justice and self-determination, connectedness and independence,
“functioning” versus “authenticity”, and questions about the degree of the
therapist’s “pro-marriage/family” versus “pro-individual” commitment.

Self Assessment Questions

1) Explain the concept of family therapy.
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2) Discuss the theoretical frameworks of family therapy.
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27
Other Therapies for 2.2.4 Models of Family Therapy
Psychological Interventions
There are many models of family therapy and these are presented in the table
below.
Models of Family Therapy
Theoretical Theorists Summary Techniques
Model

Adlerian Alfred Adler Also known as “Individual Psychology”. Sees Psychoanalysis,

Family the person as a whole. Ideas include Typical Day,
Therapy compensation for feelings of inferiority Reorienting,
leading to striving for significance toward a Re-educating
fictional final goal with a private logic. Birth
order and mistaken goals are explored to
examine mistaken motivations of children and
adults in the family constellation.

Attachment John Bowlby, Individuals are shaped by their experiences Psychoanalysis, Play
Theory Mary with caregivers in the first three years of life. Therapy
Ainsworth Used as a foundation for Object Relations
Theory. The Strange Situation experiment with
infants involves a systematic process of
leaving a child alone in a room in order to
assess the quality of their parental bond.

Bowenian Murray Also known as “Intergenerational Family Detriangulation,

Family Bowen, Betty Therapy” (although there are also other Nonanxious
Systems Carter, Philip schools of intergenerational family therapy). Presence,
Guerin, Family members are driven to achieve a Genograms,
Michael Kerr, balance of internal and external Coaching
Thomas differentiation, causing anxiety, triangulation,
Fogarty, and emotional cut-off. Families are affected
Monica by nuclear family emotional processes, sibling
McGoldrick, positions and multigenerational transmission
Edwin patterns resulting in an undifferentiated family
Friedman, ego mass.
Daniel Papero

Cognitive John Gottman, Problems are the result of operant conditioning Therapeutic
Behavioural Albert Ellis, that reinforces negative behaviours within the Contracts,
Family Albert family’s interpersonal social exchanges that Modelling,
Therapy Bandura extinguish desired behaviour and promote Systematic
incentives toward unwanted behaviours. This Desensitisation,
can lead to irrational beliefs and a faulty family Shaping, Charting,
schema. Examining Irrational
Beliefs

Collaborative Harry Individuals form meanings about their Dialogical

Language Goolishian, experiences within the context of social Conversation, Not
Systems Harlene relationship on a personal and organisational Knowing, Curiosity,
Anderson, level. Collaborative therapists help families Being Public,
Tom reorganise and dissolve their perceived Reflecting Teams
Andersen, problems through a transparent dialogue about
Lynn inner thoughts with a “not-knowing” stance
Hoffman, intended to illicit new meaning through
28
 Family and Group
Psychotherapy

Peggy Penn conversation. Collaborative therapy is an

approach that avoids a particular theoretical
perspective in favour of a client-centered
philosophical process.

Communica- Virginia Satir, All people are born into a primary survival Equality, Modeling
tions John Banmen, triad between themselves and their parents Communication,
Approaches Jane Gerber, where they adopt survival stances to protect Family Life
Maria Gomori their self-worth from threats communicated by Chronology, Family
words and behaviours of their family Sculpting,
members. Experiential therapists are interested Metaphors, Family
in altering the overt and covert messages Reconstruction
between family members that affect their body,
mind and feelings in order to promote
congruence and to validate each person’s
inherent self-worth.

Contextual Ivan Families are built upon an unconscious Rebalancing, Family

Therapy Boszormenyi network of implicit loyalties between parents Negotiations,
Nagy and children that can be damaged when these Validation, Filial
“relational ethics” of fairness, trust, Debt Repayment
entitlement, mutuality and merit are breached.

Emotion- Sue Johnson, Couples and families can develop rigid Reflecting,
Focused Les Greenberg patterns of interaction based on powerful Validation,
Therapy emotional experiences that hinder emotional Heightening,
engagement and trust. Treatment aims to Reframing,
enhance empathic capabilities of family Restructuring
members by exploring deep-seated habits and
modifying emotional cues.

Experiential Carl Whitaker, Stemming from Gestalt foundations, change Battling,

Family David Kieth, and growth occurs through an existential Constructive Anxiety,
Therapy Laura Roberto, encounter with a therapist who is intentionally Redefining
Walter “real” and authentic with clients without Symptoms, Affective
Kempler, John pretense, often in a playful and sometimes Confrontation, Co-
Warkentin, absurd way as a means to foster flexibility in Therapy, Humor
Thomas the family and promote individuation.
Malone,
August Napier

Feminist Sandra Bern, Complications from social and political Demystifying,

Family disparity between genders are identified as Modeling, Equality,
Therapy underlying causes of conflict within a family Personal
system. Therapists are encouraged to be aware Accountability
of these influences in order to avoid
perpetuating hidden oppression, biases and
cultural stereotypes and to model an egalitarian
perspective of healthy family relationships.

29
Other Therapies for
Psychological Interventions
Milan Luigi Boscolo, A practical attempt by the “Milan Group” to Hypothesising,
Systemic Gianfranco establish therapeutic techniques based on Circular Questioning,
Family Cecchin, Mara Gregory Bateson’s cybernetics that disrupts Neutrality,
Therapy Selvini unseen systemic patterns of control and Counterparadox
Palazzoli, games between family members by
Giuliana Prata challenging erroneous family beliefs and
reworking the family’s linguistic
assumptions.

Medical Goerge Engel, Families facing the challenges of major Grief Work, Family
Family Susan illness experience a unique set of biological, Meetings,
Therapy McDaniel, Jeri psychological and social difficulties that Consultations,
Hepworth & require a specialised skills of a therapist who Collaborative
William understands the complexities of the medical Approaches
Doherty system, as well as the full spectrum of mental
health theories and techniques.

MRI Brief Gregory Established by the Mental Research Institute Reframing,

Therapy Bateson, , (MRI) as a synthesis of ideas from multiple Prescribing the
Heinz von theorists in order to interrupt misguided Symptom,
Foerster attempts by families to create first and second Relabeling,
order change by persisting with “more of the Restraining (Going
same,” mixed signals from unclear Slow), Bellac Ploy
metacommunication and paradoxical double-
bind messages.

Narrative Michael White, People use stories to make sense of their Deconstruction,
Therapy David Epston experience and to establish their identity as a Externalising
social and political constructs based on local Problems, Mapping,
knowledge. Narrative therapists avoid Asking Permission
marginalising their clients by positioning
themselves as a co-editor of their reality with
the idea that “the person is not the problem,
but the problem is the problem.”

Object Hazan & Individuals choose relationships that attempt Detriangulation, Co-
Relations Shaver, David to heal insecure attachments from childhood. Therapy,
Therapy Scharff & Jill Negative patterns established by their parents Psychoanalysis,
Scharff, James (object) are projected onto their partners. Holding Environment
Framo,

Psychoanalytic Nathan By applying the strategies of Freudian Psychoanalysis,

Family Ackerman psychoanalysis to the family system therapists Authenticity, Joining,
Therapy can gain insight into the interlocking Confrontation
psychopathologies of the family members and
seek to improve complementarity

Solution Kim Insoo Berg, The inevitable onset of constant change leads Future Focus,
Focused Steve de to negative interpretations of the past and Beginner’s Mind,
Therapy Shazer, William language that shapes the meaning of an Miracle Question,
O’Hanlon, individual’s situation, diminishing their hope Goal Setting, Scaling
Michelle and causing them to overlook their own
Weiner-Davis, strengths and resources.
Paul
30 Watzlawick
 Family and Group
Psychotherapy
Strategic Jay Haley, Symptoms of dysfunction are purposeful in Directives,
Therapy Cloe Madanes maintaining homeostasis in the family Paradoxical
hierarchy as it transitions through various Injunctions,
stages in the family life cycle. Positioning,
Metaphoric Tasks,
Restraining (Going
Slow)

Structural Salvador Family problems arise from maladaptive Joining, Family

Therapy Minuchin, boundaries and subsystems that are created Mapping,
Harry Aponte, within the overall family system of rules and Hypothesising,
Charles rituals that governs their interactions. Reenactments,
Fishman, Reframing,
Braulio Unbalancing
Montalvo

2.3 GROUP PSYCHOTHERAPY

Group psychotherapy or group therapy is a form of psychotherapy in which one
or more therapists treat a small group of clients together as a group. The term can
refer to any form of psychotherapy when delivered in a group format, including
cognitive behavioural therapy or interpersonal therapy but it is usually applied
to psychodynamic group therapy where the group context and group process is
explicitly utilised as a mechanism of change by developing, exploring and
examining interpersonal relationships within the group.

The broader concept of group therapy refers to any helping process that takes
place in a group, including support groups, skills training groups (such as anger
management, mindfulness, relaxation training or social skills training), and
psycho-education groups. The differences between psychodynamic groups,
activity groups, support groups, problem-solving and psycoeducational groups
are discussed by Montgomery (2002). Other, more specialised forms of group
therapy would include non-verbal expressive therapies such as dance therapy,
music therapy or the TaKeTiNa Rhythm Process.

2.3.1 Group Therapy Vs. Individual Therapy

Group therapy is different from individual therapy in a number of ways, with the
most obvious difference being the number of people in the room with the
psychologist. Originally, group therapy was used as a cost-saving measure, in
institutional settings where many people needed psychological treatment and
there were too few psychologists to provide the treatment. However, in conducting
research on the effectiveness of these therapy groups, psychologists discovered
that the group experience benefited people in many ways that were not always
addressed in individual psychotherapy. Likewise, it was also discovered that
some people did not benefit from group therapy.

The aim of group psychotherapy is to help with solving the emotional difficulties
and to encourage the personal development of the participants in the group. The
therapist (called conductor, leader or facilitator) chooses as candidates for the
group people who can benefit from this kind of therapy and those who may have
a useful influence on other members in the group.
31
Other Therapies for 2.3.2 History of Group Psychotherapy
Psychological Interventions
The founders of group psychotherapy in the USA were Joseph H. Pratt, Trigant
Burrow and Paul Schilder. After World War II group psychotherapy was further
developed by Jacob L. Moreno, Samuel Slavson, Hyman Spotnitz, Irvin Yalom,
and Lou Ormont. Yalom’s approach to group therapy has been very influential
not only in the USA but across the world, through his classic text “The Theory
and Practice of Group Psychotherapy”. Moreno developed a specific and highly
structured form of group therapy known as Psychodrama.

In the United Kingdom group psychotherapy initially developed independently,

with pioneers S. H. Foulkes and Wilfred Bion using group therapy as an approach
to treating combat fatigue in the Second World War. Foulkes and Bion were
psychoanalysts and incorporated psychoanalysis into group therapy by recognising
that transference can arise not only between group members and the therapist
but also among group members. Furthermore the psychoanalytic concept of the
unconscious was extended with recognition of a group unconscious, in which
the unconscious processes of group members could be acted out in the form of
irrational processes in group sessions.

2.3.3 Therapeutic Principles

Yalom’s therapeutic factors (originally termed curative factors) are derived from
extensive self-report research with users of group therapy.

Universality: The recognition of shared experiences and feelings among group

members and that these may be widespread or universal human concerns, serves
to remove a group member’s sense of isolation, validate their experiences, and
raise self-esteem.

Altruism: The group is a place where members can help each other, and the
experience of being able to give something to another person can lift the member’s
self esteem and help develop more adaptive coping styles and interpersonal skills.

Instillation of hope: In a mixed group that has members at various stages of

development or recovery, a member can be inspired and encouraged by another
member who has overcome the problems with which they are still struggling.

Imparting information: While this is not strictly speaking a psychotherapeutic

process, members often report that it has been very helpful to learn factual
information from other members in the group. For example, about their treatment
or about access to services.

Corrective recapitulation of the primary family experience: Members often

unconsciously identify the group therapist and other group members with their
own parents and siblings in a process that is a form of transference specific to
group psychotherapy. The therapist’s interpretations can help group members
gain understanding of the impact of childhood experiences on their personality,
and they may learn to avoid unconsciously repeating unhelpful past interactive
patterns in present-day relationships.

Development of socialising techniques: The group setting provides a safe and

supportive environment for members to take risks by extending their repertoire
of interpersonal behaviour and improving their social skills.
32
Imitative behaviour: One way in which group members can develop social Family and Group
Psychotherapy
skills is through a modeling process, observing and imitating the therapist and
other group members. For example, sharing personal feelings, showing concern,
and supporting others.

Cohesiveness: It has been suggested that this is the primary therapeutic factor
from which all others flow. Humans are herd animals with an instinctive need to
belong to groups, and personal development can only take place in an interpersonal
context. A cohesive group is one in which all members feel a sense of belonging,
acceptance, and validation.

Existential factors: It refers to the learning that one has to take responsibility
for one’s own life and the consequences of one’s decisions.

Catharsis: Catharsis is the experience of relief from emotional distress through

the free and uninhibited expression of emotion. When members tell their story
to a supportive audience, they can obtain relief from chronic feelings of shame
and guilt.

Interpersonal learning: Group members achieve a greater level of self-awareness

through the process of interacting with others in the group, who give feedback
on the member’s behaviour and impact on others.

Self-understanding: This factor overlaps with interpersonal learning but refers

to the achievement of greater levels of insight into the genesis of one’s problems
and the unconscious motivations that underlie one’s behaviour.

2.3.4 Settings
Group therapy can form part of the therapeutic milieu of a psychiatric in-patient
unit. In addition to classical “talking” therapy, group therapy in an institutional
setting can also include group-based expressive therapies such as drama therapy,
psychodrama, art therapy, and non-verbal types of therapy such as music therapy.
Group psychotherapy is a key component of Milieu Therapy in a Therapeutic
Community. The total environment or milieu is regarded as the medium of therapy,
all interactions and activities regarded as potentially therapeutic and are subject
to exploration and interpretation, and are explored in daily or weekly community
meetings.

In group therapy approximately 6-10 individuals meet face-to-face with a trained

group therapist. During the group meeting time, members decide what they want
to talk about.

Members are encouraged to give feedback to others. Feedback includes expressing

your own feelings about what someone says or does. Interaction between group
members are highly encouraged and provides each person with an opportunity
to try out new ways of behaving; it also provides members with an opportunity
for learning more about the way they interact with others. It is a safe environment
in which members work to establish a level of trust that allows them to talk
personally and honestly. Group members make a commitment to the group and
are instructed that the content of the group sessions are confidential. It is not
appropriate for group members to disclose events of the group to an outside
person.
33
Other Therapies for 2.3.5 Construction of Therapy Groups
Psychological Interventions
Therapy groups may be homogeneous or heterogeneous. Homogeneous groups
have members with similar diagnostic backgrounds (for example, they may all
suffer from depression). Heterogeneous groups contain a mix of individuals with
different emotional problems. The number of group members typically ranges
from five to 12.

2.3.6 Functioning of Therapy Groups

The number of sessions in group therapy depends upon the group’s makeup,
goals, and setting. Some are time limited, with a predetermined number of sessions
known to all members at the beginning. Others are indeterminate, and the group
and/or therapist determine when the group is ready to disband. Membership may
be closed or open to new members. The therapeutic approach used depends on
both the focus of the group and the therapist’s orientation.

In group therapy sessions, members are encouraged to discuss the issues that
brought them into therapy openly and honestly. The therapist works to create an
atmosphere of trust and acceptance that encourages members to support one
another. Ground rules may be set at the beginning, such as maintaining
confidentiality of group discussions, and restricting social contact among members
outside the group.

The therapist facilitates the group process, that is, the effective functioning of
the group, and guides individuals in self-discovery. Depending upon the group’s
goals and the therapist’s orientation, sessions may be either highly structured or
fluid and relatively undirected. Typically, the leader steers a middle course,
providing direction when the group gets off track, yet letting members set their
own agenda. The therapist may guide the group by reinforcing the positive
behaviours they engage in. For example, if one member shows empathy and
supportive listening to another, the therapist might compliment that member and
explain the value of that behaviour to the group. In almost all group therapy
situations, the therapist will emphasise the commonalities among members to
instill a sense of group identity.

Self-help or support groups like Alcoholics Anonymous and Weight Watchers

fall outside of the psychotherapy realm. These groups offer many of the same
benefits, including social support, the opportunity to identify with others, and
the sense of belonging that makes group therapy effective for many. Self-help
groups also meet to share their common concern and help one another cope.
These groups, however, are typically leaderless or run by a member who takes
on the leader role for one or more meetings. Sometimes self-help groups can be
an adjunct to psychotherapy groups.

2.3.7 Referral of Patients to Group Therapy

Individuals are typically referred for group therapy by a psychologist or
psychiatrist. Some may participate in both individual and group therapy. Before
a person begins in a therapy group, the leader interviews the individual to ensure
a good fit between their needs and the group’s. The individual may be given
some preliminary information before sessions begin, such as guidelines and
ground rules, and information about the problem on which the group is focused.
34
2.3.8 Termination of Therapy Groups Family and Group
Psychotherapy
Therapy groups end in a variety of ways. Some, such as those in drug rehabilitation
programs and psychiatric hospitals, may be ongoing, with patients coming and
going as they leave the facility. Others may have an end date set from the outset.
Still others may continue until the group and/or the therapist believe the group
goals have been met.

The termination of a long-term therapy group may cause feelings of grief, loss,
abandonment, anger, or rejection in some members. The therapist attempts to
deal with these feelings and foster a sense of closure by encouraging exploration
of feelings and use of newly acquired coping techniques for handling them.
Working through this termination phase is an important part of the treatment
process.

2.3.9 Drop Outs of Group Therapy

Individuals who are emotionally fragile or unable to tolerate aggressive or hostile
comments from other members are at risk of dropping out, as are those who
have trouble communicating in a group setting. If the therapist does not support
them and help reduce their sense of isolation and aloneness, they may drop out
and feel like failures. The group can be injured by the premature departure of
any of its members, and it is up to the therapist to minimize the likelihood of this
occurrence by careful selection and management of the group process.

2.3.10 Effectiveness
Studies have shown that both group and individual psychotherapy benefit about
85% of the patients who participate in them. Ideally, patients leave with a better
understanding and acceptance of themselves, and stronger interpersonal and
coping skills. Some individuals continue in therapy after the group disbands,
either individually or in another group setting.

Self Assessment Questions

1) Explain any two models of family therapy.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Discuss theoretical principles of group therapy.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
35
Other Therapies for
Psychological Interventions 2.4 ADVANTAGES OF GROUP THERAPY
1) When people come into a group and interact freely with other group
members, they usually recreate those difficulties that brought them to group
therapy in the first place. Under the direction of the group therapist, the
group is able to give support, offer alternatives, and comfort members in
such a way that these difficulties become resolved and alternative behaviours
are learned.

2) The group also allows a person to develop new ways of relating to people.

3) During group therapy, people begin to see that they are not alone and that
there is hope and help. It is comforting to hear that other people have a
similar difficulty, or have already worked through a problem that deeply
disturbs another group member.

4) Another reason for the success of group therapy is that people feel free to
care about each other because of the climate of trust in a group.

2.5 TYPES OF GROUPS

There are many kinds of groups in the group-psychotherapy field. The techniques
used in group therapy can be verbal, expressive, psycho dramatic etc. The
approaches can vary from psychoanalytic to behavioural, Gestalt or encounter
groups. Groups vary from classic psychotherapy groups, where process is
emphasised, to psycho educational, which are closer to a class. Psycho educational
groups usually focus on the most common areas of concern, notably relationships,
anger, stress-management etc. They are frequently more time-limited (10 to 15
sessions) and thus very appealing in a managed care environment.Each approach
has its advantages and drawbacks, and the participant should consult the expert
which technique matches her/his unique personality. Some unique groups are:

2.5.1 T-Groups
These groups are training groups. These are relatively unstructured groups in
which the participants become responsible for what they learn and how they
learn it. A basic assumption appropriate to T- groups is that learning is more
effective when the individual establishes authentic relationships with others.

2.5.2 Sensitivity Groups

It is a form of T-group that focuses on personal and interpersonal issues and on
the personal growth of the individual. There is an emphasis in sensitivity groups
on self – insight, which means that the central focus is not the group and its
progress but, the individual member.

2.5.3 Encounter Groups

These groups are also in the T- group family, although they are more therapy
oriented. This group stresses personal growth through the development and
improvement of interpersonal relationships through an experiential group
processes. Such groups seek to release the potential of the participant.

36
2.5.4 Marathon Groups Family and Group
Psychotherapy
Extended encounter groups are often referred to as marathon groups. The
marathon encounter group uses an extended block of time in which massed
experience and accompanying fatigue are used to break through the participant’s
defenses. Though these groups offer great potential for the group members
increased self – awareness and sensitivity to others, such groups can create high
levels of anxiety and frustration. Therefore, it is essential that if encounter groups
are to have maximum potential and minimal risk, they must be conducted by
highly skilled and experienced counsellor leaders.

2.5.5 Task Groups

These groups are organised to meet organisational needs through task forces or
other organisational groups or to serve individual needs of clients through such
activities as social action groups. These groups are frequently useful to
organisations seeking ways to improve their functioning. Task groups may be
organised to assist clients in dealing with a wide range of needs from spiritual to
educational.

2.5.6 Psycho Education Groups

These emphasise cognitive and behavioural skill development in groups structured
to teach these skills and knowledge. These groups are more guidance in nature
than counselling or therapy oriented.

2.5.7 Mini Groups

A minigroup usually consists of one counsellor and a maximum of four clients.
Because of the smaller number of participants, the potential exists for certain
advantages resulting from the more frequent and direct interaction of its members.
Withdrawal by individuals and the development of factions or cliques are less
likely in minigroups.

2.5.8 In Groups and Out Groups

These groups can be based on almost any criteria such as socioeconomic status,
athletic or artistic accomplishments, a particular ability, etc. In-groups are
characterised by associations largely limited with peers of like characteristics
where as out groups consist of those excluded from in groups.

Social Networks: These result from the choices that individuals make in becoming
members of various groups. As counsellors, we may be concerned with how
these choices are made and their impacts on individuals.

2.6 LET US SUM UP

Family therapy has a variety of origins. It is related to the long-standing emphasis
of psychoanalysis and other psychodynamic approaches on the central role that
early family relationships play in the formation of personality and the
manifestation of psychological disorders.

Family therapy, either alone or in conjunction with other types of treatment, has
been effective in the treatment of children suffering from a variety of problems,
37
Other Therapies for including anxiety, enuresis (bed-wetting), and eating disorders, and also in
Psychological Interventions
working with victims of child abuse. In addition to alleviating the child’s initial
complaint and improving communication within the family unit, family therapy
can also help reduce stress and conflict by helping families improve their coping
skills.

There are a number of approaches to family therapy. Perhaps the best known is
structural family therapy, founded by Salvador Minuchin. It is a short-term method
that focuses on the present rather than the past. This school of therapy views a
family’s behaviour patterns and rituals as central to the problems of its individual
members. Poor communication skills play a key role in perpetuating destructive
interactions within families, such as the formation of alliances among some family
members against others. The goals of structural family therapy include
strengthening parental leadership, clarifying boundaries, enhancing coping skills,
and freeing family members from their entrenched positions within the family
structure. Minuchin divided families’ styles of interacting into two basic types—
enmeshed and disengaged, considering behaviour at either extreme as
pathological, with most families falling somewhere on a continuum between the
two. Minuchin believed that the functioning of family systems prevented
individuals from becoming healthier emotionally, because the family system relied
on its troubled member to play a particular role in order to function in its
accustomed way. This stability is disrupted if an individual changes significantly.

Psychodynamically oriented family therapy emphasises unconscious processes

and unresolved conflicts in the parents’ families of origin. The lasting effects of
such traumatic experiences as parental divorce and child abuse are explored.
This type of therapy focuses more on family history and less on symptoms,
resulting in a lengthier therapeutic process. Therapists who employ an object
relations approach emphasise the importance of having the parents in a family
work out conflicts with their own parents. Some practitioners include grandparents
in their work with families in order to better understand intergenerational
dynamics and deeply rooted behaviour patterns. Ivan Boszormenyi-Nagy, a well-
known proponent of this orientation, would only treat families when members
of three generations could participate in therapy sessions.

Behavioural family therapy views interactions within the family as a set of

behaviours that are either rewarded or punished. The behavioural therapist
educates family members to respond to each others’ behaviour with positive or
negative reinforcement. A child might be discouraged from repeating a negative
behaviour, for example, by losing some privileges or receiving a “time-out.”
Positive behaviour might be rewarded with the use of an incentive chart on which
points or stickers are accrued and eventually exchanged for a reward. Behavioural
approaches sometimes involve the drawing up of behavioural “contracts” by
family members, as well as the establishment of rules and reinforcement
procedures.

Several other family therapy approaches, including that of Virginia Satir, are
primarily concerned with communication. Satir’s system combines the teaching
of family communication skills, the promotion of self-esteem and the removal
of obstacles to the emotional growth so that family members can have full access
to their innate resources.

38
Group therapy is a type of psychotherapy that involves one or more therapists Family and Group
Psychotherapy
working with several people at the same time. Group therapy sessions generally
involve around seven to twelve individuals. The group typically meets once or
twice each week for an hour or two. The minimum number of group therapy
sessions is usually around six, but a full year of sessions is more common.

The specific manner in which the session is conducted depends largely on the
goals of the group and the style of the therapist. Some therapists might encourage
a more free-form style of dialogue, where each member participates as he or she
sees fit. Other therapists might have a specific plan for each session that might
include having clients practice new skills with other members of the group.

There are various types of group therapy; approaches include behaviour therapy,
psychoanalytic therapy, sensitivity training, or Gestalt psychology. The
composition of groups varies as well, with family therapy and marriage counseling
common forms in recent years. Peer group therapy usually consists of a group of
individuals who have similar problems, and can be mediated by a psychoanalyst
or by the members themselves.

2.7 UNIT END QUESTIONS

1) Discuss different models of family therapy.
2) Explain the process of group psychotherapy.
3) What are the advantages of group therapy?

2.8 SUGGESTED READINGS

Ackerman, N.W. (1958). The Psychodynamics of Family Life. Basic Books: New
York.
Ackerman, N.W. (1966). Treating the Troubled Family. Basic Books: New York.
Ackerman, N.W. (1970). Family Process. Basic Books: New York.
Minuchin, Salvador. Family Therapy Techniques. Cambridge: Harvard University
Press, 1981.
Nichols, Michael P., and Richard C. Schwartz. Family Therapy: Concepts and
Methods. Boston: Allyn and Bacon, 1991.
Satir, Virginia. Conjoint Family Therapy. Palo Alto, CA: Science and Behaviour
Books, 1983.
Yalom, I. D., & Lesczc, M. (2005). The theory and practice of group
psychotherapy. New York, NY: Basic Books

39
Other Therapies for
Psychological Interventions UNIT 3 PSYCHODYNAMIC COUPLE
THERAPY

Structure
3.0 Introduction
3.1 Objectives
3.2 Nature and Definition of Couples Therapy
3.3 Approaches to Couples Therapy
3.3.1 Psychodynamic Therapy and Couples Counselling
3.3.2 Systems Approach and Couple Counselling
3.3.3 Client Centered Therapy
3.3.4 Behavioural Approach
3.4 Psychodynamic Couples Therapy: An Object Relations Approach
3.4.1 Clinical Illustration and Analysis: Conflict as a Sale Haven
3.4.2 Projective Identification
3.4.3 Empathy
3.4.4 Transference
3.4.5 Clinical Illustration and Case Analysis
3.5 Use of Transference in Couples Therapy
3.5.1 Clinical Illustration and Case Analysis
3.5.2 The Frame of Object Relations Couples Therapy
3.6 Let Us Sum Up
3.7 Unit End Questions
3.8 Suggested Readings

3.0 INTRODUCTION
The emergence of conflict in a marriage or serious relationship does not
necessarily signal disaster ahead. In fact, it might lead to a great opportunity for
couples to work with a marriage and family therapist to strengthen the love
relationship, restore trust in the relationship, and increase the possibilities for
true intimacy.

Relationship problems are far more likely to develop during times of transition
for couples and their families, such as when starting a new relationship, bringing
a child into the family, dealing with a grandparent’s death, or ending a relationship.
Whether you hope to save a marriage, plan for a divorce, or sort out all the
territory in between, a marriage and family therapist can be an objective source
of support and information about love relationships. In this unit we will be dealing
with nature and definition of couples therapy and follow it up with approaches
to couples therapy. Under this we will discuss the psychodynamic approach,
client centered approach, behavioural approach etc. Then we deal with
psychodynamic couples therapy and discuss the use of transference in couples
therapy.

40
 Psychodynamic Couple
3.1 OBJECTIVES Therapy

After completing this unit, you will be able to:

• Define and describe the nature and definition of couples therapy;
• Approaches to couples therapy;
• Explain psychodynamic theory to couple counselling with case illustration;
• Process of psychodynamic couple therapy;
• Framework of object relations approach; and
• Discuss the use of transference in couple’s therapy.

3.2 NATURE AND DEFINITION OF COUPLES

THERAPY
The terms couples therapy, marriage counseling and marital therapy are all used
interchangeably. These different names have been used to describe the same
process, with the difference often based on which psychotherapy theory is
favoured by the psychologist.
Couples therapy focuses on the problems existing in the relationship between
two people. But, these relationship problems always involve individual symptoms
and problems, as well as the relationship conflicts. For example, if you are
constantly arguing with your spouse, you will probably also be chronically
anxious, angry or depressed (or all three). Or, if you have difficulty controlling
your temper, you will have more arguments with your partner.
In couples therapy, the psychologist will help you and your partner identify the
conflict issues within your relationship, and will help you decide what changes
are needed in the relationship and in the behaviour of each partner, for both of
you to feel satisfied with the relationship.
These changes may be different ways of interacting within the relationship or
they may be individual changes related to personal psychological problems.
Couples therapy involves learning how to communicate more effectively, and
how to listen more closely. Couples must learn how to avoid competing with
each other, and need to identify common life goals and how to share
responsibilities within their relationship. Sometimes the process is very similar
to individual psychotherapy, sometimes it is more like mediation, and sometimes
it is educational. The combination of these three components makes it effective.

3.3 APPROACHES TO COUPLES THERAPY

There are many different approaches to couples therapy, which may be used
alone or combined with other methods by the therapist. Among the oldest is the
psychodynamic approach, which attributes problems within a marriage to the
unresolved conflicts and needs of each spouse. Each client’s personal history
and underlying motivations are central to this mode of therapy. Therapists using
this approach apply the principles of psychoanalysis in their treatment; they may
either treat both marriage partners individually, or treat one spouse in collaboration
with another therapist who treats the other.
41
Other Therapies for 3.3.1 Psychodynamic Therapy and Couples Counseling
Psychological Interventions
As the oldest of the modern therapies, psychodynamic therapy is based in a
highly developed and multifaceted theory of human development and interaction.
Psychodynamic therapy is an insight oriented approach that focuses on
unconscious emotions that manifest in behaviour.

This approach is well suited for working with couples counseling because it
works to identify emotions that manifest in behaviour, it allows the focus of the
sessions to be on the unique situation of each individual client, and it takes into
account how past relationship experiences affect current relationships.

One of the main goals of psychodynamic therapy is client self-awareness and

understanding of how the past can influence present behaviour. It can help settle
past conflicts as well as issues arising from past dysfunctional relationships. It is
derived from the psychoanalytical method that Sigmund Freud researched. Freud
felt that the human mind or psyche was made up of several different levels and
that it is the unconscious mind which contains events from our past. He felt that
forgotten experiences can still affect our present behaviour. In order to treat this,
Freud developed a method by which memories and associations could be brought
to the surface and examined in order to modify our current behaviour.

The therapeutic relationship in psychodynamic counseling is based on acceptance,

empathy and understanding, with an emphasis on developing a good working
alliance that fosters trusts. This relationship creates a safe environment that
promotes healing.

3.3.2 Systems Approach and Couples Counseling

Marriage counseling that follows a systems approach stresses the interaction
between partners as the origin of marital difficulties, rather than their actions or
personality. Behaviour and communication patterns are analysed as well as the
interlocking roles portrayed by the couple or members of the family. Family
members may be conditioned to consistently play “the strong one” or “the weak
one,” or such other roles as “scapegoat,” “caretaker,” or “clown.” Although
initially it may seem that only one member of a family system is troubled, on
closer inspection his or her difficulties are often found to be symptomatic of an
unhealthy pattern in which all the members play an active part.

Systems theory is actually an umbrella term for a range of therapies, and systems-
oriented counseling may take a variety of forms, including both short- and long-
term therapy.

3.3.3 Client Centered Therapy

A popular individual treatment approach also used in marriage counseling is
Rogerian or client-centered therapy, also referred to as humanistic therapy. Here,
the emphasis is on communication and the open sharing of feelings. Through
specially formulated exercises, couples work on improving their speaking and
listening skills and enhancing their capacity for emotional honesty.

3.3.4 Behavioural Approach

Another widely employed mode of marriage counselling is based on a behavioural
42 approach, in which marital problems are treated as dysfunctional behaviours
that can be observed and modified. Couples are made aware of destructive Psychodynamic Couple
Therapy
behaviour patterns, often by systematically recording their behaviour until certain
patterns emerge. The therapist then coaches them in various modifying strategies
with the goal of achieving positive, mutually reinforcing interactions.

Behaviour oriented therapy also focuses on improving a couple’s problem-solving

and conflict-resolution skills. Marriage counsellors may conduct therapy sessions
with both spouses, treating one as the primary client and the other one only
occasionally, while another therapist treats the other spouse. An increasing number
of therapists counsel couples in pairs, with married therapists sometimes working
together as a team. Theoretically, the relationship between the co-therapists is
supposed to serve as a model for their clients. Marriage counselling in groups,
which is becoming increasingly common, offers clients some of the same
advantages that group therapy offers individuals.

Self Assessment Questions

1) Define couple therapy.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Describe the nature of couple’s therapy.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Discuss the different approaches to couples counselling.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) Elucidate psychodynamic approach to couples counselling.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
43
Other Therapies for
Psychological Interventions 5) What is systems approach to couple counselling?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
6) Discuss the application of behavioural approach in couples counselling.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

3.4 PSYCHODYNAMIC COUPLES THERAPY: AN

OBJECT RELATIONS APPROACH
Object relations couples therapy is a psychoanalytically based method of couple
treatment that integrates past with present, conscious with unconscious, and the
intrapsychic with the interpersonal. The object relations approach helps couples
discern how past life experiences as individuals can limit their possibilities in
the present as a couple. It clarifies how unconscious processes can promote
conflict and disappointment. It helps partners take ownership for how their
individual perceptions, fears, and motivations may be shaping their interactions
as a couple.

The most difficult aspect in couple’s therapy is the observation of partners blaming
each other. It is also a common observation that polarisations within the session
in which each partner clings to an unambivalent point of view that is in exact
opposition to that of the other.

In the following example from a marital session, I examine how our

psychoanalytic approach informs a particular understanding of and intervention
in such an argument.

3.4.1 Clinical Illustration and Analysis: Conflict as a Safe

Haven
For Anitha and Vikram, after years of emotional distancing and conflict, a
more friendly relation had gradually evolved during 1½ years of marital
therapy. Physical intimacy, however, remained a remote and improbable
goal. On the surface, Vikram appeared to be the spouse who sought a sexual
connection whereas Anitha disavowed any desire. She blamed her lack of
interest on the many ways she felt that Vikram disappointed her. He attributed
his lack of sexual initiative to her episodes of hostility.

44
 Psychodynamic Couple
In the session, the couple opened with what appeared to be a regressive, Therapy
angry argument, recalling to me the early months of our work. All the old
familiar bones of contention were resurrected. Anitha “ragged” on Vikram
for his failure to take good care of her by seeking out a higher-paying job.
Vikram criticized Anitha for neglecting the needs of the children and letting
the housekeeping go. The therapist discovered that the weekend before this
fight began the couple had had “good family-together time,” and that, more
precisely, the retrograde conflict began shortly after the couple had “cuddled
in bed.” Vikram had drawn close to Anitha and she had responded. This
degree of physical closeness had not occurred in ages. As the discussion
deepened, therapist learned that, Anitha liked this “cuddling . . . but it also
made me mad” because Vikram, she thought, would wrongly conclude she
had forgiven him for all his transgressions. Internalising more and more,
Anitha revealed that she had recently experienced an awakening sexual
desire for Vikram and had asked him to “kiss and hug.” She joked that she
was afraid to have sex because she would have to talk about it in couples
therapy. Anitha said she was reluctant to relinquish her “survival mode”—
that is, her determination to depend only on herself and not to allow herself
to rely on and come close to Vikram.

For Vikram’s part, he admitted that he felt anxious when the couple hugged
and kissed at Anitha ‘s request. She perceived this as a subtle sense of his
distancing after their physical contact. Vikram then associated to his fear of
being dependent on Anitha and to the death of both his parents when he
was quite young.

These seemingly warring adversaries are sharing a common internal ambivalence

over closeness, dependency, and intimacy. Their ordinary, consistent way of
relating involves maintaining a distance, often hostile, which keeps at bay, for
each of them, the anxieties that, would emerge from a more intimate connection.
When they “cuddled in bed,” Vikram was aware of anxiety, whereas Anitha found
herself getting angry at him. With their usual equilibrium destabilised by the
sexual contact, shared anxiety led them to dig up the familiar bones of contention
and to restore, through arguing, their costly but safer distance.

The object relations couples therapist looks beyond the manifest content of an
argument to understand the unconscious factors that may have triggered the
conflict in the couples. Every marriage or intimate couple relationship is likely
to have significant unresolved issues, bones of contention, which may be managed
by compromise or simply tolerated and accepted as a difference, as in “we agreed
to disagree.” When these “bones” suddenly get reactivated in the relationship,
we look for the possible triggers of this current conflict and focus on developing
understanding of the underlying issues. This approach is quite different from
those couples’s therapies that focus entirely on the manifest content of the
conflict—for example, with Anitha and Vikram, the therapist attending to
complaints about poor housekeeping or not seeking more financial security with
a higher-paying job.

3.4.2 Projective Identification

Interpersonal conflict reflects the transposition of intrapsychic conflict within
each partner on to the couple relationship. The mental mechanism that is
45
Other Therapies for responsible for this transformation is projective identification, the core concept
Psychological Interventions
of the object relations approach.
Melanie Klein (1946) defined projective identification as “a combination of
splitting off parts of the self and projecting them onto another person,” later
describing it as “the feeling of identification with other people because one has
attributed qualities or attributes of one’s own to them”. Klein saw this as a
defensive mode evolving from an early infantile developmental stage in which
anxiety is warded off by experiencing intolerable affects, especially aggression,
as if they resided in a space external to the self. This defensive “splitting” thereby
creates the first “me–not me boundary.” As the infant matures, and a self–object
boundary develops, the preobject “not me” realm fuses with the object world,
and what is projected is now directed into the mental image of the other. However,
what is projected, is not only the disavowed aspects of the self but also those
aspects that are cherished.
Much before Klien, Sigmund Freud (1921) provided an example of projective
identification in characterising the “falsification of judgment” that accompanies
the idealisation of loved objects, what we refer to as falling “head over heels” in
love. The tendency that falsifies judgment in this respect is that of idealisation,
but now it is easier for us to find our bearings. We see that the object is being
treated in the same way as our own ego, so that when we are in love a considerable
amount of narcissistic libido overflows onto the object. It is even obvious, in
many forms of love choice, that the object serves as a substitute for some
unattained ego ideal of our own ego, and which we should now like to procure in
this roundabout way as a means of satisfying our narcissism.
In a more modern and comprehensive view (Zinner 2001), we can say that
projective identification is our universal way of perceiving and comprehending
others. When we are interacting with another person, our behaviour toward that
other is determined by our mental image of him or her. Our consequent behaviour
impinges on and affects that other person, but the person we are relating to exists
only within our mind as a construct. This created mental image of the other is
built from sensory stimuli coming from the outside that are then processed by
our own mental apparatus.
We never truly know the other person and what he or she feels. We can only
approximate the actuality and subjectivity of the external object by drawing on
our own experience and attempting to match it with what our senses are receiving
from the outside. We unconsciously regard the actual object as the embodiment
of our mental construct and treat him or her accordingly. This unconscious
recognition of a projected aspect of our self in the object is the identification
process in the mechanism of projective identification. Thus, in this definition,
both projection and identification occur within the mind of one person, the subject.
There appears to be, perhaps, a wired-in propensity to distance oneself from
emotional pain by placing its source outside of the self, a generic process we
refer to as externalisation. When our effort to form a realistic picture of the other
is burdened by a simultaneous need to expel a part of our self, the image of the
other is thus tainted and distorted by our own defensive or empathic functions.

3.4.3 Empathy
It is a form of projective identification that includes an explicit or implicit ongoing
examination in an effort to approximate the actuality of the other. Empathy
46
involves openness and curiosity about the nature and subjectivity of the other as Psychodynamic Couple
Therapy
well as a willingness to alter one’s perceptions depending on fresh impressions
communicated by the other. One hallmark of defensive projective identification
is the sense of certainty that the subject has of the nature of the other and the
inflexibility of the subject’s perceptions regardless of what the other may be
communicating that may differ from these perceptions. Thus, in our understanding
of the interaction of the couple, we ask ourselves not whether projective
identification is occurring but rather to what degree it is serving defensive or
empathic functions.

In intimate relationships, behaviour generated by projective identification may

have a coercive quality that is very likely to evoke in the recipient an experience
of himself or herself that resonates with the way the projecting spouse is behaving
toward him or her. A loving glance can evoke in the partner a feeling of being
lovable. Conversely, a contemptuous sneer from a husband, one of a pattern of
such behaviours, is likely to evoke in the wife a sense of being disgusting and
contemptible. Because both partners are viewing each other through the filter of
projective identification, we can view the entire relationship as a nexus of
interlocking projective identifications generated by both partners, in which the
experience of the self is strongly affected by the way one is perceived and treated.

Participants in close relationships are often in collusion to sustain their mutual

projections—that is, to support each other’s defensive operations and to provide
experiences through which the other can participate vicariously. It is the subject’s
unconscious identification with the recipient of his or her projections that allows
for this vicarious experience of living through the other. For projective
identification to function effectively as a defense, the true nature of the relationship
between the self and its projected part must remain unconscious, although the
individual may feel an ill-defined bond or kinship with the recipient of his or her
projections. The disinheriting of the projected part is not so complete that the
subject loses his or her capacity to experience vicariously a wide range of the
object’s feelings, including those which the subject has himself or herself evoked.
These vicarious experiences contain features associated not only with gratification
but with punishment and deprivation as well.

In the case of Anitha and Vikram, each experienced considerable unconscious

inner conflict over sexual intimacy and its threatening consequence of emotional
dependency. As a way of warding off anxiety, both partners colluded in parceling
out the elements of their own ambivalence into roles each would assume. Thus,
Vikram spoke in behalf of their shared desire for sex, whereas Anitha represented
their fear of physical intimacy. In this manner, the intrapsychic conflict of each
was transformed into interpersonal conflict within their relationship. It does appear
that conflict between partners is often more bearable than conflict within oneself.
When Anitha reversed roles with Vikram and initiated sexual contact, their distant
but stable equilibrium dissolved. Each became anxious and managed to restore
the sexual distance by regenerating conflict in digging up the familiar bones of
contention.

3.4.4 Transference
It is one form of projective identification, as it appears in the psychotherapeutic
setting. The term, however, has been expanded to be almost synonymous with
projective identification by including many situations in which “ a normal 47
Other Therapies for person’s perceptions and affective responses vis-à-vis the self and others are
Psychological Interventions
heavily influenced by the activation of significant relationship representations
from the past” (Gerber and Peterson 2006).

The operation of projective identification within marriage, however, is more

than a matter of externalisation of disavowed or cherished traits. We find that in
the defensive mode, the contents of the projected material contain highly
conflicted elements of the spouse’s object relationships with his or her own family
of origin. Although it is commonplace to think of a husband selecting a mate
who is “just like the girl who married dear old dad,” we are here referring to the
unconscious striving to re enact conflictful parent child relations through such
an object choice. Highly fluid role attributions occur in which a husband, for
example, may parentify his spouse, or, on the other hand, infantilise her by
experiencing the wife as the child he once was.

The externalisation of aspects of old nuclear relationships may serve not only a
defensive need but also a restorative one, to bring back to life, in the form of the
spouse, the individual’s lost infantile objects, both good and bad. The perception
of the partner coloured by the image of a beloved deceased parent may be salutary,
heightening affection for the spouse. On the other hand, it may also be constraining
on the object of the perception insofar as it detracts from her individuality and
may lead to conflict when she does not conform to the parental image. Thus,
recognising the restorative function of these projective identifications may lead
the therapist to fruitful exploration of unresolved grief over the death of the
parent or other important person.

Our understanding of the impact of projective identification on couple

relationships has profound implications for our therapeutic approach. For working
with couples, many therapists utilise some form of a focal problem solving
approach, often cognitive behavioural in style, with a primary focus on the
manifest content of the conflict and perhaps an elaboration of dynamic patterns
across conflicts. According to these methods, a couple enters therapy with its
disputes, and the therapist seeks to resolve the conflict through identifying
strengths, making behavioural contracts, conducting conflict resolution, assigning
paradoxical interventions, or promoting fair fighting techniques, among other
similar interventions. When a couple’s conflict, however, is deeply anchored in
interlocking processes of mutual projective identification, it can be very difficult,
if not impossible, to make progress with most problem-solving strategies. This
follows from our understanding that in these situations, interpersonal conflict is
serving the intrapsychic defense of each partner so that there is a strong
unconscious motivation for sustaining the couple’s disharmony in order to
preserve each partner’s internal equanimity.

The object relations therapeutic approach is indicated for just these kinds of
refractory couple discord. Our theory informs us that the manifest conflict and
anger are not the primary targets of our efforts, but rather we seek to uncover the
sources of pain within both partners that have caused them to use the relationship
as a repository for disavowed aspects of their own selves.

When successful, our exploration of the underpinnings of the manifest conflict

reveals a more poignant subtext in which each partner is able to become aware
of the emotional pain that led to the expulsion of the distress, appearing as anger,
48 into the interpersonal space. Insofar as the therapist’s efforts lead to a shift from
blame to internalisation of conflict within the individual partners, there is a Psychodynamic Couple
Therapy
diminution of anger and an increased capacity for empathy, compassion, and
respect for one another that was not possible when each spouse was the target or
perpetrator of criticism and rage.

The following description of a marital therapy session with Anand and Jaya
illustrates the ebb and flow of externalising and internalising processes in the
relationship, with concomitant shifts between anger and sadness.

3.4.5 Clinical Illustration and Case Analysis

Conflict as a Defense against Fear of Loss
When therapist again reminded Jaya that he could not schedule their sessions to
an earlier time, She quipped, “Don’t any of your patients get better?” This response
reflected her sense of continued bickering with her husband Anand recently,
although not at the level of several weeks ago.

They described a typical fight in which the two of them ended up snapping at
each other in front of Rajani (their 3-year-old daughter) after the child fell and
hurt herself. Each blamed the other for not keeping a watchful eye on the little
girl as she was playing on their bed. This is a typical instance of their taking out
their shared anxiety on one another and polarizing over who would bear all the
worry.

One scene during this altercation involved Jaya panicking when she noticed
some blood in Rajani’s mouth and then shouting at Anand to “get off the fucking
phone” while he was taking his time, casually conversing with his son. She had
actually handed the phone to Anand earlier when he had followed the crying
Rajani into the room. Jaya commented that after this blowup, both felt “heartsick”
at the way they had dealt with Rajani’s injury.

They reported several other bickers during which Jaya was nagging Anand while
he was dragging his feet on a project because he felt again that giving in to Jaya
was being “euchred,” which is his expression for being “led by the nose.” Their
fight seemed to be over the proper height of the wall they were building in the
basement. Jaya wanted a higher wall than Anand, and they couldn’t agree. The
therapist commented that in recent weeks they have been erecting a wall between
them such that they’re not pulling together as a team under stress and, as Jaya
put it earlier, “It’s like we’re having all our old fights all over again.”

Therapist inquired about the deeper layer of concern underlying the wall, and
Jaya teared up, saying, “It’s because when I need him he’s not there. I can’t count
on him being here.” Hearing the reference to Anand’s absence, therapist asked
Jaya if she had been concerned about Anand’s health lately. Anand is considerably
older than her and not scrupulous about his health habits. At this she nodded
affirmatively and began to cry. The conflict seemed to start while he was away
so much recently working so hard on a contract that he, incidentally, just informed
me he had successfully completed. She felt like a “single parent” then and
imagined him dying and how much worse it would be if he did. She worried
about his knees, his hearing, and, above all, about his weight and his drinking.
She revealed she carries a fantasy that at any time he could have a heart attack
and die. Then she would be all alone with Rajani and unable to remain in their
house, because she couldn’t afford it even for 6 months. In this recent concern 49
Other Therapies for she pleaded to Anand to draw up an accounting of how much she would be left
Psychological Interventions
with, and he did. Of course, he was unaware of the poignant aspect of her request
and how frightened she was at the prospect of losing him.

The night before, Jaya arrived home late from work to find Anand devouring a
12-ounce steak. This upset her considerably although she did not mention it to
Anand. To her this was an example of his self-neglect. Ordinarily, when she is
home and cooking dinner, she prepares meals that are suitable for a man with
heart disease, such as beans and rice. She was angry at him in the session for his
“not letting yourself use me as a resource,” because she is able to prepare for him
foods that are tasty and healthful. “Instead, you act like I’m your enemy,” she
says when she admonishes him for eating foods that are unhealthful for him.

Reflecting on this session, we see that this couple has recently been bickering
again as Jaya said, “It’s like we’re having all our old fights all over again.” She is
referring to the bones of contention—”our old fights”—unique to this couple.
Her guilty perception of their backsliding into conflict is transformed into a
wisecracked projective identification in which she blames therapist, in the
transference, for not getting “any of patients . . . better.” Rather than eliciting the
manifest content of their recent bickering, there is need to search for the precipitant
of this current round of conflict.

Hearing her critical reference to Anand —”I can’t count on him being here”—
therapist associates to the possibility of her losing him and ask if she is concerned
about his health. This question reveals the source of their recent tensions, as
Jaya begins to cry and tell how, in the face of Anand’s recent prolonged absence,
she worries that he might die and leave her and their daughter, Rajani. In their
relationship, the fear of death and loss is parceled out by projective identification.
Anand is cavalier in his dismissal of the dangers to his health from his very
casual attitudes about his eating, drinking, and lack of exercise. Jaya, on the
other hand, carries all the worry for the couple about the consequences of his
health habits. Because he does not internalise his own concern about dying
prematurely, Anand runs the risk of fulfilling that grim prophecy by, for example,
gorging on a 12-ounce steak the night before the session. Interestingly, this
behaviour may be his way of expressing his own feeling of abandonment by
Jaya, who came home too late to cook a healthful dinner for him.

These interactions illustrate a fundamental consequence when a couple uses their

relationship as a repository of disavowed and devalued projections. They are
unable to work as a team because their polarisation causes them to pull in opposite
directions. In distinction, when each partner in a couple is able to internalise
intrapsychic conflict and tolerate anxiety, ambiguity, or sadness, the pair can
function as a team and benefit from its joint and collaborative efforts. In this
connection, Jaya lamented to Anand that “You are not letting me use you as a
resource.”

Their failure to share anxiety and guilt following Rajani’s fall is another example
of how defensive projective identification leads to couple conflict and dysfunction.
The role of the worrier switched during the interaction so that at first, Aanand
was moaning “Oh my gosh! Oh my gosh!” while Jaya handed him the phone so
that he could speak with his son, a nonurgent matter. He was bearing the anxiety
for both of them. Spotting a small amount of blood in Rajani’s mouth, Jaya
50
panicked, as the defense against her anxiety crumbled. At that point she became Psychodynamic Couple
Therapy
the worrier and raged at Anand for being on the very phone she had handed him
moments before. Because of the work that they had previously done in therapy
about their flawed handling of anxiety connected with Rajani, both recognised
their return to an old pattern of blaming and felt “heartsick” about what they had
allowed to happen.

During their conflict over Rajani’s fall, however, what remained constant was
the polarisation of attitudes.

Another important feature of object relations couples therapy is to listen for the
symbolic and metaphoric quality of the content of marital conflict. In the session
with Anand and Jaya, a significant and emotionally charged argument persists
over how high to build a wall within their basement. When such an intensity of
feeling arises over what would appear to be a manageable difference of opinion,
therapists should look for the metaphoric meaning of what is contested. In this
case, in recent weeks a “wall” was being erected as the couple distanced itself
through “having all of our old fights” after Anand’s return from his travels.

A primary goal of object relations couples therapy is to help each partner

reinternalise what he or she has projected into the interpersonal sphere in a way
that has burdened the relationship. The conflicted internal relationships can only
be resolved intrapsychically. When such reinternalisation occurs, there is a striking
shift from anger and polarisation within the couple toward sadness, tenderness,
and poignancy in each partner. This transition is evident in the session with
Anand and Jaya as they finally share the “heartsick” feeling at how they divided
and fought over Rajani’s fall. Similarly, their arguments over the wall and their
old fights are ameliorated when they become aware of their concerns about
abandonment and death.

Following the successful reinternalisation of projected elements, there can be

considerable individual intrapsychic work done in the course of the couple
sessions. What often does occur, however, is that the partners seek out individual
psychotherapy with a different therapist as a complement to the couple treatment?
Both Anand and Jaya had been in individual therapy before the couples work
began and continued with that synergistic combination.

Self Assessment Questions

1) Discuss psychodynamic couple’s therapy as an object relations approach.
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Other Therapies for
Psychological Interventions 2) What is projective identification?
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3) Discuss empathy and transference in psychodynamic couple’s therapy.
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3.5 USE OF TRANSFERENCE IN COUPLES

THERAPY
According to the object relations approach, the world of internalised object
relationships is transposed onto the world of actual interpersonal relations through
the mechanism of projective identification. This transposition occurs in a variety
of spheres, not just within the couple relationship. Interactions with children,
friends, employers, colleagues, and others are governed by the same psychological
mechanism. Transference is the form of projective identification that occurs in
the therapeutic relationship.

In couple’s therapy, transference feelings and marital issues are often inextricably
interwoven threads of the same interpersonal fabric. Because the couple’s therapy
is a three-person relationship, there is an increase in the permutations; the forms
of this transference may take in contrast with individual psychotherapy.

First, as in individual work, there is the focused transference that each partner
feels toward the therapist based on that partner’s internal object world.

Second, there is a very common triangular transference configuration in which

each partner is seeking to be the one preferred by the therapist at the expense of
the other.

This three some interaction often re enacts sibling experiences in competition

for the favour of their parent.

More often than not, each partner enters couple treatment with the fantasy hope
that the therapist will validate his or her point of view and work to change his or
her partner’s wrongful attitudes and behaviour.

Many of the early efforts by the therapist are devoted to helping the couple
understand that each partner is contributing to the problematic interactions in
52
their relationship. This requires that the therapist actually be able to rise above, Psychodynamic Couple
Therapy
in attitude and behaviour, the drumbeat of blaming and fault finding that so
frequently take place in an adversarial couple situation. Even handedness and
neutrality in the therapist are greatly aided by his or her understanding of the
complex and complementary interplay of the internal object world of the partners
as it is transposed onto their current relationship.

Third, there is a complex transference that encompasses the experience of the

entire three-person group in interaction. One such instance is the shared fantasy
within the couple that the couple treatment is in itself a danger to the integrity of
the relationship and the safety of individual members, rather than a resource for
help, healing, and growth.

Especially where words have been used as instruments of aggression rather than
of understanding and support, there may be a great fear of becoming open and
vulnerable in the session, with a consequent constriction of communication and
a perception of the therapist as an agent of harm. It is therefore an early priority
that the therapist recognise and explore this shared fantasy that talking is dangerous
because language, the very vehicle for healing in therapy, is seen paradoxically
as the greatest threat to the safety and security of the couple.

Because of the emotional power inherent in a group, strong counter transference

experiences are to be expected in couples therapy, and it is often a challenge to
convert these feelings into stimuli for constructive therapeutic reflection and
intervention, in contrast to internalising them so that they colour the therapist’s
self experience in a way that helps no one in the threesome.

This attitude that the treatment situation is one of harm rather than of help is
often discovered through the therapist’s own counter transference experiences
in a variety of ways. For example, the therapist may find himself or herself, in
the face of the couple’s silence and constricted communication, feeling the need
to energise the interaction with frequent superficial interventions.

In the absence of the therapist’s forced efforts the group feels lifeless and defeated,
and the therapist’s sense of himself or herself as helpful and competent may
suffer. It is useful for the therapist to be aware of such personal reactions because
they serve as a signal that there is some problematic fantasy operating within the
threesome that requires explicit exploration. In this instance, the therapist can
use his or her sense of ineffectiveness to ask directly about the couple’s experience
of the therapy and the therapist, and what their fears are of saying what is on
their mind in the session.

The elucidation of transference by the therapist offers the valuable opportunity

to examine the marital relationship in the here and now of the session. This in-
the-moment examination is often more highly affectively charged than the
couple’s rehearsing of the more remote then-and there events of the previous
week. Working in the here and now is especially helpful to the therapist, as he or
she has the opportunity to experience and learn from his or her counter transference
reactions as the drama unfolds in the session. It is also necessary to address
problematic negative transference issues that might lead to acting out or an
interruption of treatment if ignored.

53
Other Therapies for 3.5.1 Clinical Illustration and Case Analysis
Psychological Interventions
Work in the transference is illustrated in the couple treatment of Thrivedi and
Tulasi. The session occurs soon after a difficult interruption, involving a lengthy
unanticipated absence by the female therapist and the death of Thrivedi’s mother.
The hour opens with an extended silence and downcast expressions:
Tulasi: I feel so bad. Everything’s falling apart. I’m too angry, hurting.
Therapist: Your relationship is falling apart?
Tulasi: Yeah, and between me and myself.
Thrivedi: It’s also a hard time for me. I’m feeling very alone. I’m not through
feeling the loss of my mother. I’m feeling alone with Tulasi, too, feeling
there’s not much room for me. I’m not sure what to do about that.
Therapist: You look quite sad.
Thrivedi: I’ve had pretty sad days. I wrote all the thank-you notes for people
who helped a lot. I’m feeling pretty bad, pretty sad. Yesterday, I spent time
going back through things . . . greeting cards . . . business stuff. I felt pretty
sad, pretty alone.
Therapist: You feel alone in your grieving or without your mother?
Thrivedi: Both . . . [Thrivedi recounts how he called his uncle and aunt,
who were close to his mother] . . . it’s a sad thing.
Therapist: Right now you seem very closed in, inside your grief.
Thrivedi: Yeah.
Therapist: Is your grief complicated? I had the impression your relationship
with your mother was not satisfying for you, which would complicate your
grief.
Thrivedi: The last few years she tried to reach out and we worked through a
lot of stuff. She was a critical person, not easy to talk to. I was always
feeling I’d be criticized.

Thrivedi and the therapist engage in a discussion in which the therapist especially
questions him about his relationship with his mother. Throughout, Tulasi remains
utterly silent, often staring out into space. Thrivedi is responsive to the therapist’s
interventions. He begins to cry, concluding, “No matter how bad things were,
she loved me and now she’s gone.”
Thrivedi: All these feelings are overwhelming. I don’t know how to be with
Tulasi when she’s having all these feelings, too. Somehow it feels like it has
to be either her or me. I don’t know how to work it so that we can both be
depressed or sad or both be mourning.
Therapist: You have the idea that Tulasi is feeling cut out because I’m talking
to you and drawing you out?
Thrivedi: Yeah, I do. And feeling she’s resenting it a lot . . . [silence] . . . I
know part of the problem is I want somebody to take care of me . . . to be
kind . . . and I know that’s not fair . . . to expect . . . of her. It took me a lot
to get to the point where I could recognise that. I just don’t know how
things are supposed to be anymore.
54
During the course of the session thus far, the therapist has been acutely aware of Psychodynamic Couple
Therapy
Tulasi’s conspicuous silence and lack of involvement. The therapist found herself
irritated at Tulasi and was determined to keep the channel of communication
open with Thrivedi by ignoring Tulasi’s efforts to undermine it. This counter
transference experience was familiar to her in working with this couple. She had
frequently felt as if she were compelled to make a choice between devoting
attention to one spouse or the other. The partner not receiving the therapist’s
attention at the moment would remain silent and sullen. Thus, the interaction
had a quality of taking turns rather than of give and take. Aware that she was
acting out her own counter transference irritation, the therapist decided to shift
to interpretation.
Thrivedi: I’ve been feeling I have to have something to help me get through
this. I don’t have Tulasi. I just don’t know how to get to her . . . without her
feeling resentful. It’s like I have to totally be on my own or I have to rely on
Tulasi —those two things—the dependency I want isn’t good, isn’t healthy,
but I still want it . . . and I feel like there must be some appropriate halfway
point, but I don’t know how to get there.
Therapist: You do both look as though if either of you were to want anything
from the other you’d be very disappointed. Is that what breaks down so fast,
Tulasi? Fall apart very quickly, you said. [Silence.]
Tulasi: Sitting here while you’ve been talking to Thrivedi has been very
difficult. I find myself resenting a couple of things you said. I resent the
time you’re spending with him—I feel very small.
Therapist: When I’m talking to Thrivedi it doesn’t feel like you’re both
getting something because if he’s getting something, then you’re not.
Tulasi: Yeah.
Therapist: That makes you feel very small.
Tulasi: Well, he’s got this enormous grief to deal with and he needs a lot. I
shouldn’t get mad when you’re helping him.
Therapist: It’s such a deep loss and both of you have a need for an abiding
presence that’s just for you. That need is very strong. You’re both talking
about how you’re struggling with the fact that it’s not there—a very reliable,
immediate, understanding presence—how much you each need it and how
much it’s not there either from each other or from anyone, really.
Tulasi: That’s a lot of what happens to me. It’s not there. I don’t think I ever
really had it. Sometimes I feel I have it, but then I lose it, which I do, then I
can’t . . . I can get through a session with my individual therapist, and then
I can do what I need to do with Thrivedi, except then when something comes
up between us, then I can’t hold on to it. If I don’t have it, then I don’t want to
deal with all his stuff. But I can’t adjust. If I can’t have it, then I’m through. .
. . Sometimes it feels really good, but there’s an awful lot of pain with it, all
that pain around therapy this summer, I can’t get away from it.
Therapist: You mean my absence and the effect it had on everything?
Tulasi: Yeah. I was afraid, really afraid. I felt badly. I was a little weird. I
didn’t notice it was a pattern. When I was supposed to see you and I didn’t,
I’d get weird, but I didn’t connect it.
Therapist: Maybe now with things settling down, seeing me for a couple of
weeks, maybe now it will be possible to understand these feelings, not just
to have to endure them.
Tulasi: Yeah. 55
Other Therapies for This excerpt reveals a highly interwoven blend of transference, countertransference,
Psychological Interventions
and marital issues. A triangular configuration is evident, but it is, however, a pre-
oedipal, or oral, triangle in which there is a competition not for a sexual
relationship with the parent of the opposite sex but rather for the basic supplies
of emotional survival. The raw data for the therapist’s grasp of the marital
unconscious assumption come from several sources. She reflects on the manifest
behaviour in the session, which is characterised by the lack of give and take, and
the sullen silence of each spouse when the therapist is attending to the other.

She contemplates the manifest verbal content—for example, Thrivedi’s regret

that “It has to be her or me” but not both who can be sad or mourning. The
therapist includes in her consideration Thrivedi’s story of a mother who was not
warm, but a “critical person, not easy to talk to.” A crucial part of the mix is the
tension within the therapist over the competition for her attention and her own
irritated determination to defy Tulasi’s envy to the point of ignoring her. Out of
her experience in the here and now, the therapist is able to formulate for herself
an unconscious assumption governing the marital relationship. That is, those
resources for a basic sense of worth and for psychological survival are limited
and only sufficient for one partner. Whatever sustenance is received from the
good object, couple, or individual therapist is ephemeral. There is a tenuous
capacity for one spouse to give to the other without experiencing envy for what
the other is getting and rage at what one is giving up. The couple shares this
fantasy and, in the session, the transference vision of the therapist as the central
source of sustenance.

The specific transference feeling of each spouse toward the therapist at any given
moment is different, determined by whether the therapist is seen as attending to
or ignoring Thrivedi or Tulasi. In this excerpt, the therapist’s capacity to grasp
the here-and-now situation inclusive of both transference and marital dynamics
allows her to focus her intervention on the issue that carries the highest affective
charge of the moment. Therapeutic interventions are most effective when directed
toward issues linked to strong affects. In the absence of an affectively toned
area, interpretations are received with intellectualisation and little emotional
impact. In couples therapy, we see this latter phenomenon in the all-too-frequent
retrospective bland analyses of the marital fight of the previous week.

3.5.2 The Frame of Object Relations Couples Therapy

The frame of the couples treatment and the nature of the therapist’s activity
follow from the object relations theory. Sessions are held once or more times
weekly at a set time. The length of treatment is open-ended, and termination
evolves naturally out of completion of the task. Meetings take place only when
both partners are able to be present and begin when both have arrived.

Concurrent individual psychotherapy can act in synergy with the couples work,
in which the partners each have their own individual therapist who is not also
the couples therapist. It is advisable that the couple’s therapist not do both forms
of treatment. When one partner meets with the couples therapist in the absence
of the other partner, there is the risk that the therapist will learn something that
would disturb the absent mate should he or she become aware of this information.
Thus, the therapist is left with the dilemma of having to protect the confidentiality
of the spouse with whom he or she met alone and therefore having to hold a
56
secret that cannot be shared with the absent partner. This is an untenable position Psychodynamic Couple
Therapy
for the therapist, whose responsibility is to the couple as a whole and not to only
one spouse. In addition, when the therapist wears both hats in doing the individual
and couples work, jealousy and destructive competition can arise, and this only
serves to compound the adversarial relationship that existed in the first place.

With separate individual and couples therapists, either the patient can transmit
understanding gained across the boundary of the two therapies, or both therapists
can confer as needed with permission. The couples therapist’s responsibility is
to the couple as a unit, and his or her stance should be one of evenhandedness in
the presence of conflict. Primarily, the therapist serves as an observer, listener,
active formulator, and interpreter of the forces that shape the couple’s interaction.

Active behavioural interventions mainly involve encouraging the partners to use

direct and attentive communication with each other in the session rather than to
speak to each other through the therapist by referring to the spouse as “he” or
“she.” Homework, such as experimentation with physical intimacy, is a creative
product of the couple’s imagination rather than a generic exercise determined by
the therapist.

Object relations couples therapy attends to both the interpersonal and the
intrapsychic simultaneously. It is a flexible approach tailored to the nature of the
relational difficulty and to the developmental level of each partner. Thus, the
treatment is an approach to formulating and intervening rather than a prescription
of specific interventions and tasks that could apply to all couples. What is constant,
however, in the object relations approach is the attention to the way in which the
world of early internalised relationships has unconsciously come to life again in
the current life of the couple.

Self Assessment Questions

1) In couples therapy how are transference feelings and marital issues inter
related?
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2) What is three person group interactions in couples therapy?
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Other Therapies for
Psychological Interventions 3) Discuss counter transference experience in couple’s therapy.
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4) Discuss active behavioural interventions in couple therapy.
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5) Discuss object relations couples therapy.
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3.6 LET US SUM UP

Relationship problems are far more likely to develop during times of transition
for couples and their families, such as when starting a new relationship, bringing
a child into the family, dealing with a grandparent’s death, or ending a relationship.
There are different approaches to couples therapy like systems approach,
behavioural approach, client – centred therapy and psychodynamic approach.
The central concept of object relations couples therapy is the transposition of the
internalised object world of each partner into the interpersonal sphere of the
relationship. The mental mechanism that transforms the intrapsychic into the
interpersonal is projective identification. Unconscious forces are paramount in
choosing intimate partners as well as in guiding the interaction of the couple.
The relationship of the couple, in its most refined form, can make possible
empathic and collaborative efforts in which the whole is greater than the sum of
its parts. In contrast, for defensive purposes, the couple relationship may become
the repository of devalued aspects of each partner, leading to conflict, polarisation,
and dysfunction. Interpersonal conflict may be more tolerable than intrapsychic
distress, leading partners to resist efforts to reduce the level of interpersonal
conflict.
The primary goal of object relations couples therapy is to foster reinternalisation
of projected devalued aspects of each partner, leading to a reduction in couple
58
conflict, enhanced empathy, but an increase in individual emotional pain. Those Psychodynamic Couple
Therapy
devalued aspects of the self that have become reinternalised are now available
for intrapsychic resolution, which may take place as part of the couples therapy
as well as in concurrent individual therapy with another therapist.

The couple’s therapist seeks the underlying issues that precipitate conflict rather
than focusing on resolving the manifest content of the conflict. Anger is seen as
reactive to hurt and emotional pain within the individual partners. Use of
transference–counter transference phenomena in the here and now of the couple
session may provide access to affectively charged and workable dynamics that
are central to the couple relationship itself.

3.7 UNIT END QUESTIONS

1) Discuss the nature and definition of couples therapy.
2) Discuss the different approaches to couple therapy.
3) Explain the psychodynamic approach to couples counselling.
4) What is systems approach to couple counselling?
5) Discuss the psychodynamic couples therapy as an object relations approach.
6) How is transference used in couple counselling?

3.8 SUGGESTED READINGS

Framo, J.L. (1970). Symptoms from a Family Transactional Viewpoint. In Family
Therapy in Transition. Edited by Ackerman. NW. Boston, MA, Little, Brown,
1970, pp 125–171.

Gabbard, G.O. Beck, J.S. Holmes. (2005). Psychodynamic Couple Therapy.

Oxford University Press, New York.

Sholevar, G. P. & Schwoeri,L.D. (2003). Textbook of Family and Couples

Therapy: Clinical Applications. American Psychiatric Association. Washington,
D.C

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Other Therapies for
Psychological Interventions UNIT 4 PSYCHOTHERAPY INTEGRATION

Structure
4.0 Introduction
4.1 Objectives
4.2 Definition of Integrative Psychotherapy
4.3 Historical Overview of the Integrative Movement
4.4 Variables Responsible for Growth of Psychotherapy Integration
4.5 Different Ways to Psychotherapy Integration
4.5.1 Eclecticism
4.5.2 Differences between Eclecticism and Psychotherapy Integration
4.5.3 Theoretical Integration
4.5.4 Assimilative Integration
4.5.5 The Common Factor Approach
4.5.6 Multi Theoretical Approaches
4.5.7 The Trans Theoretical Model
4.5.8 Brooks-Harris’ Multi Theoretical Model
4.5.9 Helping Skills Approach to Integration
4.6 Evidence Based Therapy and Integrative Practice
4.7 Future of Psychotherapy Schools and Therapy Integration
4.8 Let Us Sum Up
4.9 Unit End Questions
4.10 Glossary
4.11 Suggested Readings

4.0 INTRODUCTION
A major emphasis of this unit is on helping you construct your own integrated
approach to psychotherapy. Research has indicated that psychotherapy is moving
toward an integrated approach to therapy. Throughout the world, when you ask a
psychologist or counsellor what his or her theoretical orientation is, the most
frequently given response is integrative or eclectic. It is highly likely that upon
graduation, you will integrate one or more of the theories presented in this block.
This unit explores in detail the integrative approach to therapy. This unit traces
the historical development, variables responsible for, the different models and
future of integrative approach.

4.1 OBJECTIVES
After completing this unit, you will be able to:
• Define and describe the concept of integrative psychotherapy;
• Describe the historical perspective of the integrative movement;
• Explain the variables responsible for growth of psychotherapy integration;
• Analyse the different ways to psychotherapy integration;
60
• Explain evidence based therapy and integrative practice; and Psychotherapy Integration

• Analyse the future of psychotherapy schools and therapy integration.

4.2 DEFINITION OF INTEGRATIVE

PSYCHOTHERAPY
Integrative psychotherapy is an attempt to combine concepts and counselling
interventions from more than one theoretical psychotherapy approach. It is not a
particular combination of counselling theories, but rather it consists of a
framework for developing an integration of theories that you find most appealing
and useful for working with clients. According to Norcross (2005):

Psychotherapy integration is characterised by dissatisfaction with single school

approaches and a concomitant desire to look across school boundaries to see
what can be learned from other ways of conducting psychotherapy. The ultimate
outcome of doing so is to enhance the efficacy, efficiency, and applicability of
psychotherapy.
Within this integrative therapy we have Meaning Therapy which is an integrative
approach. Meaning therapy (MT), also known as meaning centered counseling
and therapy (MCCT), is an integrative, positive existential approach to counseling
and psychotherapy. Originated from logo therapy, MT employs personal meaning
as its central organising construct and assimilates various schools of
psychotherapy to achieve its therapeutic goal. MT focuses on the positive
psychology of making life worth living in spite of sufferings and limitations. It
advocates a psycho educational approach to equip clients with the tools to navigate
the inevitable negatives in human existence and create a preferred future. The
paper first introduces the defining characteristics and assumptions of MT. It then
briefly describes the conceptual frameworks and the major intervention strategies.
In view of MT’s open, flexible and integrative approach, it can be adopted either
as a comprehensive method in its own right or as an adjunct to any system of
psychotherapy.
Integrative psychotherapy offers a safe environment for the exploration of body,
mind, emotion and spirit, and their impact on health, personal fulfilment and
relationships.
Because everyone is unique, my therapeutic approach is shaped according to
your particular needs and wishes. Together we bring your authentic, true self
into focus, calling forth your inner strengths and resiliency while you explore
your vulnerabilities and concerns. We may use insight, mindfulness, an interactive
style of guided imagery, the Work of Byron Katie, solution focused therapy,
EMDR, EFT, and cognitive behavioural therapy, to name a few. EMDR refers to
EMDR stands for Eye Movement Desensitisation Reprocessing, a highly effective
and well-researched therapeutic method developed in 1987 by Dr. Francine
Shapiro, for healing many types of psychological distress including past or recent
trauma, self esteem issues, creativity blocks, complex unresolved grief, being
the victim of a violent crime, combat experiences, and performance anxiety. It is
also used to enhance performance, build self-confidence and inner resiliency.
Our brains can process and integrate most of our experiences without leaving a
lasting negative effect. But research in the area of trauma tells us that when an
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Other Therapies for experience is very intense or threatening, the ability to process the experience
Psychological Interventions
can get stuck along with negative interpretations or beliefs. EMDR works to
unlock the lodged memories and reengage the brain’s natural ability to integrate
the experience.
EFT refers to Emotional Freedom Technique or EFT for short. It is one of the
most remarkable health innovations in the last 100 years. It is based on impressive
discoveries regarding the bodies’ energy system. It works on just about every
emotional and physical issue you can name. In fact it often works where all else
has failed and can work where conventional medicine has no answers. EFT has
its basis in Chinese acupuncture and psychology but instead of using needles
you simply tap on well established meridian points on the upper body. EFT is a
painless and relaxing method of healing.
EFT is a powerful technique and a potent technique that helps you take control
of your body and your thoughts. This technique was developed by Gary Craig in
1990 and has originated from acupuncture, kinesiology, and psychology. This
wonderful technique has shown amazing results in developing attitude and
behaviour, resolving personal problems, decreasing stress, and restoring life
balance.
Emotional Freedom Technique is an efficient technique offering solutions to
stress related problems and helps in balancing the body’s energy system. This
painless technique effectively deals with any psychological or physiological
problem and shows concrete results within a short time.
EFT aims at returning the mind, body, and emotions of an individual to a balanced
and harmonious state so that he or she is free from negative emotions.
EFT is a gentle method that works by balancing the body’s energy system.
Many a times we are affected by bad relationships, traumas, or losses. Work
related stress, depression, interpersonal problems, and anxieties also affect our
mental health. These negative emotions block the flow of energy in our system
and have a detrimental effect on our health. EFT helps in releasing these negative
emotions and resolving the problem.
EFT involves treating physiological or psychological problems by tapping specific
acupressure points with fingers. It is you who taps yourself. I have no need to
touch you at all. My role is to tell you where to tap and also what to say as you
tap. The procedure can be done over the telephone or the Internet. It is easy to do
and I have never had a client who found it difficult.
EFT helps in Pain Management, Addictions, Allergies, Weight Loss, Headaches,
Asthma, Trauma, Abuse, Depression, Eating Disorders, Blood Pressure, Anorexia,
and many more diseases and maladies.
EFT often works where every other treatment fails. In fact EFT helps with virtually
every physical and emotional problem that one can think of.
Self Assessment Questions
1) What is integrative psychotherapy?
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62
 Psychotherapy Integration
2) Describe the characteristics of integrative psychotherapy.
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3) What is EMDR? Explain
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4) Elucidate the EFT technique.
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4.3 HISTORICAL OVERVIEW OF THE

INTEGRATIVE MOVEMENT
Integrative therapy draws on some of the oldest techniques of psychotherapy. It
was developed during the 1970s by Richard G Erskine PHD and at The Institute
for Integrative Psychotherapy.
The Integrative psychotherapy model recognises the use of other therapeutic
approaches such as humanistic, cognitive, gestalt and psychodynamic and attempts
to fuse them into a approach that is of benefit to the individual. The facilitation
of a person’s ‘wholeness’ to improve their quality of life.
The movement toward integration of the various schools of psychotherapy has
been in the making for decades. On the whole, however, psychotherapy integration
has been traditionally hampered by rivalry and competition among the various
schools. Such rivalry can be traced to as far back as Freud and the differences
that arose between him and his disciples over what was the appropriate framework
for conceptualising clients problems. From Freud’s Wednesday evening meetings
on psychoanalysis, a number of theories were created, including Adler’s individual
psychology. As each therapist claimed that he had found the one best treatment
approach, heated battles arose between various therapy systems. When
behaviourism was introduced to the field, clashes took place between
psychoanalysts and behaviourists.
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Other Therapies for During the 1940s, 1950s, and 1960s, therapists tended to operate within primarily
Psychological Interventions
one theoretical school. Dollard and Miller’s (1950) book, Personality and
Therapy, was one of the first attempts to combine learning theory with
psychoanalysis. In 1977, Paul Wachtel published Psychoanalysis and Behaviour
Therapy: Toward an Integration. In 1979, James Prochaska offered a trans
theoretical approach to psychotherapy, which was the first attempt to create a
broad theoretical framework.

In 1979, Marvin Goldfried, Paul Wachtel, and Hans Strupp organised an

association, the Society for the Exploration of Psychotherapy Integration (SEPI),
for clinicians and academicians interested in integration in psychotherapy
(Goldfried, Pachankis, & Bell, 2005). Shortly thereafter in 1982, The International
Journal of Eclectic Psychotherapy was published, and it later changed its name
to the Journal of Integrative and Eclectic Psychotherapy. By 1991, it began
publishing the Journal of Psychotherapy Integration. As the field of
psychotherapy has developed over the past several decades, there has been a
decline in the ideological cold war among the various schools of psychotherapy
(Goldfried, Pachankis, & Bell, 2005).

Integrative therapy is different from eclectic therapy. Integration is like choosing

raw ingredients to make a balanced and nutritious meal, from a recipe to be used
again, whilst eclecticism is like visiting the salad bar to select prepared food for
just that meal, equally nutritious, and a different selection can be made next
time.

It is this considered, methodical attempt to bring theories and practices together

that sets the integrationists apart from the eclectics.

Paul Wachtel, a central figure in the integrative movement since the seventies,
says that eclecticism tends to focus on “what works,” and relies heavily on
empiricism and statistical analysis to discover what seems to work. For Wachtel,
it is this lack of theory that distinguishes the eclectics from the more theoretically
grounded integrationists, who should be able to say not only what works, but
why it works.

Tullio Carere, a committed integrationist, sketches the history of psychotherapy

integration in several phases (www.cyberpsych.org/sepidocs.htm). The first, the
“latency” phase, began in the early 1930’s but was not a well defined area of
interest, he says. The 1970’s saw the more clear delineation of integration as a
concern, with more concerted efforts being made at rapprochement across the
boundaries. An interim phase, he says, was marked by the launch of the Society
for the Exploration of Psychotherapy Integration (Sepi) in 1983 and the growing
concern with a range of themes in integration and common theoretical and clinical
languages.

The third phase, he suggests, is beginning with the new century, and, if successful,
will see integrative psychotherapy moving from an area of interest to a scientific
discipline.

Psychotherapy integration is not a new school, but there are new schools which,
while integrative, are discrete new schools which draw on and systematically
integrate the most useful ideas they can find from other schools.
64
A typical integrative brand of therapy is Eye Movement Desensitisation and Psychotherapy Integration
Reprocessing, (EMDR). But the history of EMDR is illustrative of the emergence
of discrete new schools.

The history of EMDR has been dogged by controversy which makes other, more
traditional modality wars look tame by comparison. Those opposed to the method
have slated the lack of evidence and theoretical grounds for its claimed efficacy
(see page 16 of this edition). In response, its proponents have scrambled for
more research-based evidence of its value and recruited thousands of practitioners
as trainees and advocates of the method.

To be truly integrative then, means to largely abandon one’s religious favour

about any particular method, including any discrete approaches or philosophies
which are themselves integrative of other approaches. Sound like a difficult
balancing act? Well, why do you think it has taken integrationism 70 years to get
integrated into our psychotherapeutic repertoires?

4.4 VARIABLES RESPONSIBLE FOR GROWTH OF

PSYCHOTHERAPY INTEGRATION
Norcross and Newman (1992) have summarized the integrative movement in
psychology by identifying eight different variables that promoted the growth of
the psychotherapy integration trend in counselling and psychotherapy.

First, they pointed out that there was simply a proliferation of separate counselling
theories and approaches. The integrative psychotherapy movement represented
a shift away from what was the prevailing atmosphere of factionalism and
competition amongst the psychotherapies and a step toward dialogue and
cooperation.
Second, they noted that practitioners increasingly recognised the inadequacy of
a single theory that is responsive to all clients and their varying problems. No
single therapy or group of therapies had demonstrated remarkable superior efficacy
in comparison to any other theory.
Third, there was the correlated lack of success of any one theory to explain
adequately and predict pathology, personality, or behavioural change.
Fourth, the growth in number and importance of shorter-term, focused
psychotherapies was another factor spearheading the integrative psychotherapy
movement.
Fifth, both clinicians and academicians began to engage in greater communication
with each other that had the net effect of increasing their willingness to conduct
collaborative experiments.
Sixth, clinicians had to come to terms with the intrusion into therapy with the
realities of limited socioeconomic support by third parties for traditional, long-
term psychotherapies. Increasingly, there was a demand for therapist
accountability and documentation of the effectiveness of all medical and
psychological therapies. Hence, the integration trend in psychotherapy has also
been fuelled by external realities, such as insurance reimbursement and the
popularity of short-term, prescriptive, and problem-focused therapists.
65
Other Therapies for Seventh, researchers identification of common factors related to successful therapy
Psychological Interventions
outcome influenced clinician’s tendency toward psychotherapy integration.
Increasingly, therapists began to recognise there were common factors that cut
across the various therapeutic schools.

Eighth, the development of professional organisations such as SEPI, professional

network developments, conferences, and journals dedicated to the discussion
and study of psychotherapy integration also contributed to the growth of the
movement. The helping profession has definitely moved in the direction of
theoretical integration rather than allegiance to a single therapeutic approach.
There has been a concerted movement toward integration of the various theories.
Self Assessment Questions
1) Present the historical overview of integrative psychotherapy movement.
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2) Elucidate the variable responsible for the growth of integrated
psychotherapy.
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4.5 DIFFERENT WAYS TO PSYCHOTHERAPY

INTEGRATION
This section provides an overview of how theorists and practitioners have tried
to integrate the various theoretical approaches to therapy. Perhaps in examining
how others have integrated their therapy with different concepts and techniques,
we might feel more comfortable in thinking about how we might pursue this
same avenue. Clinicians have used a number of ways to integrate the various
counselling theories or psychotherapy, including technical eclecticism, theoretical
integration, assimilative integration, common factors, multitheoretical
psychotherapy, and helping skills integration.

4.5.1 Eclecticism
Eclecticism may be defined as an approach to thought that does not hold rigidly
to any single paradigm or any single set of assumptions, but rather draws upon
multiple theories to gain insight into phenomena. Eclectics are sometimes
criticized for lack of consistency in their thinking. For instance, many
66
psychologists accept some features of behaviourism, yet they do not attempt to Psychotherapy Integration
use the theory to explain all aspects of client behaviour. Eclecticism in psychology
has been caused by the belief that many factors influence human behaviour;
therefore, it is important to examine a client from a number of theoretical
perspectives.

4.5.2 Differences between Eclecticism and Psychotherapy

Integration
Typically, eclectic therapists do not need or have a theoretical basis for either
understanding or using a specific technique. They chose a counselling technique
because of its efficacy, because it works. For instance, an eclectic therapist might
experience a positive change in a client after using a specified counselling
technique, yet not investigate any further why the positive change occurred. In
contrast, an integrative therapist would investigate the how and why of client
change. Did the client change because she was trying to please the therapist or
was she instead becoming more self-directed and empowered?

Integrative and eclectic therapists also differ in the extent to which they adhere
to a set of guiding, theoretical principles and view therapy change. Practitioners
who call themselves eclectic appear to have little in common, and they do not
seem to subscribe to any common set of principles. In contrast, integrationists
are concerned not only with what works but why it works. Moreover, clinicians
who say they are eclectic tend to be older and more experienced than those who
describe themselves as integrationists. This difference is fast disappearing because
some graduate schools are beginning to train psychologists to be integrationists.

4.5.3 Theoretical Integration

Theoretical integration is perhaps the most difficult and sophisticated of the three
types of psychotherapy integration because it involves bringing together
theoretical concepts from disparate theoretical approaches, some of which may
present contrasting worldviews. The goal is to integrate not just therapy techniques
but also the psychotherapeutic theories involved as Dollard and Miller (1950)
did with psychoanalysis and behaviour therapy. Proponents of theoretical
integration maintain that it offers new perspectives at the levels of theory and
practice because it entails a synthesis of different models of personality
functioning, psychopathology, and psychological change.

4.5.4 Assimilative Integration

The assimilative integration approach to psychotherapy involves grounding
oneself in one system of psychotherapy but with a view toward selectively
incorporating (assimilating) practices and views from other systems. Assimilative
integrationists use a single, coherent theoretical system as its core, but they borrow
from a broad range of technical interventions from multiple systems. Practitioners
who have labelled themselves as assimilative integrationists are: (1) Gold (1996),
who proposed assimilative psychodynamic therapy; (2) Castonguay et al. (2004),
who have advocated cognitive-behavioural assimilative therapy; and (3) Safran,
who has proposed interpersonal and cognitive assimilative therapy (Safran &
Segal, 1990).
Assimilative integrationists believe integration should take place at the practice
level rather than at the theory level. Most therapists have been trained in a single
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Other Therapies for theoretical approach, and over time many gradually incorporate techniques and
Psychological Interventions
methods of other approaches. Typically, therapists do not totally eliminate the
theoretical framework in which they were trained. Instead, they tend to add
techniques and different ways of viewing individuals.

4.5.5 The Common Factor Approach

The common factors approach has been influenced by the research and
scholarships of such renowned leaders in psychotherapy as Jerome Frank (1973,
1974) and Carl Rogers (1951, 1957). Clearly, Rogers’s contributions to common
factors research has become so accepted by clinicians throughout the world that
his core conditions (or necessary and sufficient conditions to effect change in
clients) have become part of the early training of most helping professionals.
Researchers and theorists have transformed Rogers’s necessary and sufficient
conditions into a broader concept that has become known as “therapeutic alliance”
(Hubble, Duncan, & Miller, 1999). The therapeutic alliance is important across
the various counselling theory schools; it is the glue that keeps the person coming
to therapy week after week. Currently, more than 1,000 studies have been reported
on the therapeutic alliance (Hubble, Duncan, & Miller, 1999).

The common factors approach seeks to determine the core ingredients that
different therapies share in common, with the eventual goal of creating more
parsimonious and efficacious treatments based on their commonalities. This
search is predicated on the belief that commonalities are more important in
accounting for therapy outcome than the unique factors that differentiate among
them.

There is no standard list of common factors, but if a list were to be constructed,

it surely would include:
• A therapeutic alliance established between the patient and the therapist.
• Exposure of the patient to prior difficulties, either in imagination or in reality.
• A new corrective emotional experience that allows the patient to experience
past problems in new and more benign ways.
• Expectations by both the therapist and the patient that positive change will
result from the treatment.
• Therapist qualities, such as attention, empathy, and positive regard, that are
facilitative of change in treatment.
• The provision by the therapist to the patient of a reason for the problems
that are being experienced.
Irrespective of the type of therapy that is practiced, each of these common factors
is present. It is difficult to imagine a treatment that does not begin with the
establishment of a constructive and positive therapeutic alliance. The therapist
and the patient agree to work together and they both feel committed to a process
of change occurring in the patient. Within every approach to treatment, the second
of the common factors, the exposure of the patient to prior difficulties, is present.
In some instances the exposure is in vivo (occurs in real life), and the patient will
be asked directly to confront the source of the difficulties. In many cases, the
exposure is verbal and in imagination. However, in every case, the patient must
express those difficulties in some manner and, by doing so, re-experiences those
68 difficulties through this exposure.
In successful treatment, the exposure usually is followed by a new corrective Psychotherapy Integration
emotional experience. The corrective emotional experience refers to a situation
in which an old difficulty is re-experienced in a new and more positive way. As
the patient re-experiences the problem in a new way, that problem can be mastered
and the patient can move on to a more successful adjustment.
Having established a therapeutic alliance and being exposed to the problem in a
new and more positive context, both the therapist and the patient always expect
positive change to occur. This faith and hope is a common factor that is an
integral part of successful therapy. Without this hope and expectation of change,
it is unlikely that the therapist can do anything that will be useful, and if the
patient does not expect to change, it is unlikely that he or she will experience any
positive benefit from the treatment.
The therapist must possess some essential qualities, such as paying attention to
the patient, being empathic with the patient, and making his positive regard for
the patient clear in the relationship. Finally, the patient must be provided with a
credible reason for the problems that he or she is undergoing. This reason is
based in the therapist’s theory of personality and change. The same patient going
to different therapists may be given different reasons for the same problem. It is
interesting to speculate as to whether the reason must be an accurate one or
whether it is sufficient that it be credible to the patient and not remarkably at
variance with reality. As long as the reason is credible and the patient has a way
of understanding what previously had been incomprehensible, that may be
sufficient for change to occur.

4.5.6 Multi Theoretical Approaches

Recently, therapists have developed multi theoretical approaches to therapy.
Multitheoretical frameworks do not attempt to synthesise two or more theories
at the theoretical level. Instead, there is an effort to “bring some order to the
chaotic diversity in the field of psychotherapy and “preserve the valuable insights
of major systems of psychotherapy” (Prochaska & DiClemente, 2005, p. 148).
The goal of multi theoretical approaches is to provide a framework that one can
use for using two or more theories. Two examples of multi theoretical frameworks
are (1) the trans theoretical approach by Prochaska and DiClemente, and (2)
multi theoretical therapy by Brooks-Harris.

4.5.7 The Trans Theoretical Model

The most widely recognised model using a multi theoretical framework has been
the trans theoretical model developed by Prochaska and DiClemente (1984, 2005).
The trans theoretical model is a model of behavioural change, which has been
the basis for developing effective interventions to promote healthy behaviour
change. Key constructs are integrated from other counselling theories. The model
describes how clients modify problem behaviour or how they develop a positive
behaviour. The central organising construct of the model is the stages of change.
The theorists maintain that change takes place through five basic stages: (1) pre
contemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance.
In the pre contemplation stage, people are not intending to take action in the
foreseeable future, usually measured as the next 6 months. During the
contemplation stage, people are intending to change within the next 6 months.
In the preparation stage, clients are intending to take action in the immediate
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Other Therapies for future, usually measured as the next month. Clients in the action stage have
Psychological Interventions
made specific overt modifications in their life styles within the past 6 months.
During the maintenance stage, clients work to prevent relapse, a stage which is
estimated to last from 6 months to about 5 years. The termination stage of change
contains clients who have zero temptation and 100% self-efficacy. They are
confident they will not return to their old unhealthy habit as a way of coping.
The trans theoretical model also proposes 10 processes of change, which are the
covert and overt activities that people use to progress through the stages. The
first 5 processes involve experiential processes of change, while the last 5 are
labelled behavioural processes, and these are used primarily for later-stage
transitions. For instance, during the experiential processes of change, people
experience consciousness rising and social liberation. The 5 behavioural processes
of change range from stimulus control to counter-conditioning to self-liberation.
The trans theoretical model does not make assumptions about how ready clients
are for change in their lives. The model proposes that different individuals will
be in different stages and that appropriate interventions must be developed for
clients based on their stages of development.
The trans theoretical model assumes that the different systems of psychotherapy
are complementary and that different theories emphasise different stages and
levels of change.

4.5.8 Brooks-Harris’ Multi Theoretical Model

The most recent multi theoretical model for psychotherapy comes from Brooks-
Harris, who provides a framework that describes how different psychotherapy
systems come together. Brooks-Harris (2008) begins with the premise that
thoughts, actions, and feelings interact with one another and that they are
influenced by biological, interpersonal, systemic, and cultural contexts.
Given this overarching premise, he integrates the following theoretical
approaches: (1) cognitive, (2) behavioural, (3) experiential, (4) bio psychosocial,
(5) psychodynamic, (6) systemic, and (7) multicultural. A brief explanation of
each of these areas is provided below (table 6.5.2). His framework emphasises
at what point a therapist might consider using elements of psychodynamic theory
or multicultural theory. A major umbrella in multicultural psychotherapy consists
of the focal dimensions for therapy and key strategies.
MULTI THEORETICAL PSYCHOTHERAPY
Cognitive strategies deal with the focal dimension of clients’ functional
and dysfunctional thoughts.
Behavioural skills–focal dimension of actions encourage effective client
actions to deal with challenges.
Experiential interventions result in adaptive feelings.
Bio psychosocial strategies emphasise biology and adaptive health practices.
Psychodynamic – interpersonal skills are used to explore clients’
interpersonal patterns and promote undistorted perceptions.
Systemic – constructivist interventions examine the impact of social
systems and support adaptive personal narratives.
Multicultural – feminist strategies explore the cultural contexts of clients’
issues.
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Brooks-Harris presents five principles for psychotherapy integration, which Psychotherapy Integration
include
1) Intentional integration,
2) Multidimensional integration,
3) Multi theoretical integration,
4) Strategy-based integration, and
5) Relational integration.
The first principle says that psychotherapy integration should be based on
intentional choices. The therapist’s intentionality guides his or her focus,
conceptualisation, and intervention strategies.

Principle two (multidimensional) proposes that therapists should recognise the

rich interaction between multiple dimensions.

The third principle asserts that therapists take into consideration diverse theories
to understand their clients and guide their interventions.

The fourth strategy based principle states that therapists combine specific
strategies from different theories. Strategy-based integration uses a pragmatic
philosophy. Underlying theories do not have to be reconciled.

The fifth or relational principle proposes that the first four principles must be
enacted within an effective therapeutic relationship.

Brooks-Harris’ (2008) model offers a good plan for therapists seeking to

implement an integrative multitheoretical approach. He outlines strategies for
each of the seven core areas. For instance, cognitive strategies should encourage
functional thoughts that are rational and that promote healthy adaptation to the
environment. In addition, he enumerates a catalogue of 15 key cognitive strategies,
which include identifying thoughts, clarifying the impact of thoughts, challenging
irrational thoughts, providing psychoeducation, and supporting bibliotherapy.

To integrate behavioural therapy into one’s practice, he suggests some of the

following catalogue of key strategies: assigning homework, constructing a
hierarchy, providing training and rehearsal, determining baselines, and schedules
of reinforcement.

4.5.9 Helping Skills Approach to Integration

Clara Hill (2004) has provided a helping skills model to therapy integration. Her
model describes three stages of the helping process that are based on different
therapy schools.

The first stage of helping is labelled exploration. Using Rogers’ client-centered

therapy as the therapy school of choice, Hill (2004) emphasises the counselling
skills of attending, listening, and reflection of feelings.

The second stage is termed insight, and this stage is based on psychoanalytic
theory; therefore, such skills as interpreting and dealing with transference are
stressed.

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Other Therapies for The third stage is termed the action stage, and this stage is based largely on
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cognitive-behavioural techniques. Using the helping skills model, training would
focus on teaching graduate students techniques associated with each of these
three therapeutic schools.

Self Assessment Questions

1) What are the ways to integrate psychotherapy?
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2) Differentiate between eclectic therapy and integrative therapy.
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3) What is meant by assimilating integrations?
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4) Explain common factor approach in Integrated Psychotherapy.
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5) Discuss multi theoretical approach.
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 Psychotherapy Integration
6) Explain Brooke Harris Multi theoretical approach to integrative
psychotherapy.
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4.6 EVIDENCE BASED THERAPY AND

INTEGRATIVE PRACTICE
Regardless of whether a therapist uses an integrative approach or one based on a
single therapy school, he or she will have to take into consideration whether or
not empirical support exists for a chosen treatment approach. Evidence based
practice (EBP) is a combination of learning what treatments work based on the
best available research and taking into account clients culture and treatment issues.

The American Psychological Association (2006, p. 273) conceptualises evidence

based practice as “the integration of the best available research with clinical
expertise in the context of patient characteristics, culture and preferences.”
Evidence based practice emphasises the results of experimental comparisons to
document the efficacy of treatments against untreated control groups, against
other treatments, or both.
The arguments in favour of EBP are reasonable.
First, clients have a right to treatments that have been proven to be effective.
Second, managed care requires counsellor accountability in choosing a method
of treatment.
Increasingly, counsellors may have to consult with research studies to determine
which approach is the most efficacious with what mental health disorder. Helping
professionals may be required to answer for using a therapeutic approach with a
specific disorder.

How does a therapist implement EBP in practice? The therapist must gather
research that informs him or her about what works in psychotherapy. Such
information should be obtained before treatment is begun.

There are several major resources for evidence-based practice. For instance, the
Cochrane Collaboration (http://www.cochrane.org) sets standards for reviews
of medical, health, and mental health treatments and provides “systematic
reviews” of related research by disorder. Cochrane Reviews are designed to help
providers, practitioners, and patients make informed decisions about health care
and are the most comprehensive, reliable, and relevant source of evidence on
which to base these decisions. Moreover, the United States government also
offers treatment guidelines based on EBP principles at the National Guideline
Clearinghouse (http://www.guideline.gov/). This site contains very good
information on medication.
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Other Therapies for Other online resources for EBP and treatment guidelines include the American
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Psychiatric Association (APA), which offers practice guidelines for mental health
(http://www.psych.org/psych_pract/treatg/pg.prac_guide.cfm).

4.7 FUTURE OF PSYCHOTHERAPY SCHOOLS

AND THERAPY INTEGRATION
What does the future look like for psychotherapy schools? Norcross, Hedges,
and Prochaska (2002) used a Delphi poll to predict the future of psychotherapy
over the next decade. The experts who served as participants in the poll predicted
that the following theoretical schools would increase the most: cognitive-
behaviour therapy, culture-sensitive multicultural counselling, Beck’s cognitive
therapy, interpersonal therapy, family systems therapy, behaviour therapy,
technical eclecticism, solution-focused therapy, and exposure therapies.

Therapy orientations that were predicted to decrease the most included classical
psychoanalysis, implosive therapy, Jungian therapy, transactional analysis,
humanistic therapies, and Adlerian therapy.

The poll also showed how psychotherapy is changing. The consensus is that
psychotherapy will become more directive, psychoeducational, technological,
problem-focused, and briefer in the next decade. Concomitantly, relatively
unstructured, historically oriented, and long-term approaches are predicted to
decrease i.e. Short term is in, and long term on its way out.

4.8 LET US SUM UP

Psychotherapy integration is defined as an approach to psychotherapy that includes
a variety of attempts to look beyond the confines of single-school approaches in
order to see what can be learned from other perspectives. It is characterised by
openness to various ways of integrating diverse theories and techniques.
The movement toward integration of the various schools of psychotherapy has
been in the making for decades. On the whole, however, psychotherapy integration
has been traditionally hampered by rivalry and competition among the various
schools. Such rivalry can be traced to as far back as Freud and the differences
that arose between him and his disciples over what was the appropriate framework
for conceptualising clients’ problems.
Norcross and Newman (1992) have summarized the integrative movement in
psychology by identifying eight different variables that promoted the growth of
the psychotherapy integration trend in counselling and psychotherapy.
Clinicians have used a number of ways to integrate the various counselling theories
or psychotherapy, including technical eclecticism, theoretical integration,
assimilative integration, common factors, multitheoretical psychotherapy, and
helping skills integration.
Regardless of whether a therapist uses an integrative approach or one based on a
single therapy school, he or she will have to take into consideration whether or
not empirical support exists for a chosen treatment approach. Evidence-based
practice (EBP) is a combination of learning what treatments work based on the
best available research and taking into account clients’ culture and treatment issues.
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 Psychotherapy Integration
4.9 UNIT END QUESTIONS
1) Define the term integrative psychotherapy. Trace the historical overview of
integrative psychotherapy movement.
2) Explain the common factors approach to psychotherapy integration.
3. Discuss the difference between technical eclecticism and assimilative
integration.
4) What are the possible ways of integrating psychotherapy?
5) What are the arguments in favour of evidence based psychotherapy in
practice?
6) What does future hold for psychotherapy schools?

4.10 GLOSSARY
Common Factors : This term is used when the techniques are
common to all approaches to psychotherapy.
Assimilative Integration : It is an approach in which the therapist has a
commitment to one theoretical approach but
also is willing to use techniques from other
therapeutic approaches.
Technical Eclecticism : In this approach, diversity of techniques is
displayed but there is no unifying theoretical
understanding that underlies the approach.
Theoretical Integration : This model requires integrating theoretical
concepts from different approaches, and
these approaches may differ in their
fundamental philosophy about human
behaviour.
Multitheoretical Approaches : These approaches provide a framework that
one can use for using two or more theories.
Evidence-based Practice(EBP): It is a combination of learning what
treatments work based on the best available
research and taking into account clients’
culture and treatment issues.

4.11 SUGGESTED READINGS

Corsini, Raymond J., Wedding, Danny. (2008). Current Psychotherapies. USA:
Brooks/Cole.
Messer, S. B. “A critical examination of belief structures in interpretive and
eclectic psychotherapy.” In Handbook of Psychotherapy Integration,edited by J.
C. Norcross and M. R. Goldfried. New York: Basic Books, 1992: 130-165.
Sommers-Flanagan, John., Sommers-Flanagan, Rita. (2004). Counseling and
psychotherapy theories in context and practice: Skills, strategies, and techniques.
Hoboken, New Jersey: John Wiley & Sons, Inc.
Stricker, G., and J. Gold. (Eds.) Comprehensive handbook of psychotherapy
integration. New York: Plenum, 1993. 75