Adult Intervention — Comprehensive Study Notes | MSc Clinical Psychology

ADULT INTERVENTION
Comprehensive Study Notes

MSc Clinical Psychology | Kristu Jayanti College

Based on: Seligman & Reichenberg (2014), Corey (2015), Lambert (2013)

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UNIT 1: INTRODUCTION TO PSYCHOTHERAPY

1.1 Definitions of Psychotherapy

Psychotherapy is a systematic interaction between a therapist and a client (individual, couple,
family, or group) that applies psychological principles to bring about positive changes in the
client's thoughts, feelings, and behaviours. Several foundational definitions have shaped the
field:
•​ Frank & Frank (1991): Psychotherapy is a healing relationship involving a socially
sanctioned healer, a distressed person, and a series of contacts aimed at relieving distress
through a rationale and prescribed procedures.
•​ Wolberg (1977): A treatment of emotional problems by psychological means in which a
trained person deliberately establishes a professional relationship to remove or modify
existing symptoms, mediate disturbed patterns of behaviour, and promote positive
personality growth.
•​ Strupp (1978): Psychotherapy is an interpersonal process designed to bring about
modifications of feelings, cognitions, attitudes, and behaviour that have proved
troublesome to the person seeking help.

1.2 Therapeutic Commonalities

Therapeutic commonalities (also called nonspecific factors) are elements shared across all
effective psychotherapies, regardless of theoretical orientation. Frank and Frank (1991) identified
four core commonalities:
•​ An emotionally charged, confiding relationship: The therapeutic bond, built on trust,
empathy, and acceptance, is healing in itself.
•​ A healing setting: A professional context that lends legitimacy and hope to the
therapeutic process.
•​ A rationale or conceptual scheme: An explanation of the client's problems that both
therapist and client find plausible.
•​ A ritual or procedure: Specific techniques prescribed by the rationale, which both
participants believe will restore the client's health.

1.3 Common Factors vs. Specific Techniques: Key Research Studies

A major debate in psychotherapy concerns whether outcomes stem from common factors shared
across therapies or from specific techniques unique to each approach.

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Eysenck (1952) — 'The Effects of Psychotherapy: An Evaluation'

Hans Eysenck's landmark and controversial study is the starting point for psychotherapy
outcome research.
•​ Key claim: Approximately two-thirds of neurotic patients improved spontaneously
without treatment (spontaneous remission rate ~66%). He argued psychotherapy offered
no additional benefit over spontaneous improvement.
•​ Methodology: Eysenck compared patients who received psychotherapy with those who
received only custodial care or general practice treatment, finding little difference in
improvement rates.
•​ Criticisms: Methodological flaws: non-equivalent groups, biased measures of
improvement, neglect of severity of initial impairment. His definition of 'improvement'
for untreated patients was more lenient than for treated ones.
•​ Significance: Despite its flaws, the study galvanised the field, prompting rigorous
outcome research and meta-analyses to evaluate therapy effectiveness scientifically.

Glass and Smith (1977) — Meta-Analysis of Psychotherapy Outcome Studies

Mary Lee Smith and Gene Glass conducted the first major meta-analysis to directly address
Eysenck's challenge. Published in 1977 and expanded by Smith, Glass & Miller (1980).
•​ Method: Meta-analysis of 375–475 controlled outcome studies (depending on version)
using effect size as the common metric.
•​ Key finding: The average therapy client was better off than approximately 75–80% of
untreated controls (effect size ≈ 0.85). This was a strong positive endorsement of
psychotherapy's effectiveness.
•​ Conclusion: Psychotherapy works — significantly and substantially — across different
types, client populations, and presenting problems.
•​ Criticisms: Inclusion of studies with methodological weaknesses; allegiance effects
(researchers' orientations affecting results); the 'file drawer problem' (publication bias).

Lambert (1992) — Common Factors Research

Michael Lambert's highly influential work attempted to quantify the relative contributions of
different factors to therapy outcome. His findings are among the most cited in the field.
Lambert estimated that therapeutic change results from four broad factors:
Factor % of Outcome Description
Extra-therapeutic factors 40% Client variables: ego strength, social
support, severity of disorder
Therapeutic relationship (Common 30% Empathy, warmth, therapeutic alliance
factors)
Placebo / Expectancy & Hope 15% Client's hope and expectation of
improvement

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Specific techniques / Model 15% Specific therapeutic techniques (e.g.,

CBT interventions)

Lambert's work suggests that no single school of therapy has a monopoly on effectiveness — the
relationship and extra-therapeutic factors together account for 70% of outcome.

1.4 Therapeutic Relationship

The therapeutic relationship (or therapeutic alliance) is the collaborative bond between therapist
and client. Bordin (1979) described three components:
•​ Bond: The quality of the interpersonal attachment between therapist and client —
warmth, trust, and genuine caring.
•​ Goals: Agreement between therapist and client on the targets of therapeutic work.
•​ Tasks: Agreement on the specific activities carried out during therapy.
Research consistently shows that the quality of the therapeutic alliance is one of the strongest
predictors of positive therapy outcome across all therapeutic modalities.

1.5 Processes of Change (Prochaska's Transtheoretical Model)

Prochaska and DiClemente identified specific change processes that people use as they move
through the stages of change. These processes can be experiential (cognitive/emotional) or
behavioural:

•​ Consciousness Raising: Increasing awareness and information about oneself and the
problem. Techniques include observations, confrontations, interpretations, and
bibliotherapy. (Experiential)
•​ Catharsis / Dramatic Relief: Experiencing and expressing emotions related to the
problem — often through role-playing, grief work, or psychodrama. The emotional
release itself has therapeutic value. (Experiential)
•​ Choosing / Self-liberation: The belief that one can change and the commitment to act on
that belief. Includes willpower, decision-making techniques, and New Year's resolutions.
(Experiential/Behavioural)
•​ Conditional Stimuli / Counter-conditioning: Learning to substitute healthier
behaviours for problem behaviours in the presence of the same stimuli that trigger the
problem. Includes relaxation, assertion, and positive self-statements. (Behavioural)
•​ Contingency Control / Reinforcement Management: Modifying the consequences of
problem behaviours — rewarding oneself for making changes, reducing rewards for
problem behaviours. Includes contracting, covert conditioning. (Behavioural)

1.6 Stages of Change — Prochaska and DiClemente

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The Transtheoretical Model (TTM) proposes that behaviour change occurs in stages. Originally
developed from smoking cessation research, it is now widely applied in clinical practice:

•​ Precontemplation: The individual is not yet considering change and may be unaware of
the problem ('I don't have a problem'). No intention to change in the foreseeable future.
Therapist goal: raise awareness, increase ambivalence.
•​ Contemplation: Awareness that a problem exists; seriously thinking about change but
not yet committed ('I know I should change, but...'). The person weighs pros and cons.
Therapist goal: tip the decisional balance toward change.
•​ Preparation / Determination: Has decided to change and is planning to take action soon
(within the next month). May have made small steps. Therapist goal: help develop a
realistic change plan.
•​ Action: Actively modifying behaviour, experiences, or environment to overcome the
problem. Requires the most commitment and energy. Therapist goal: provide support,
reinforce new behaviours.
•​ Maintenance: Working to consolidate gains and prevent relapse. Change has been
sustained for six months or more. Therapist goal: build coping strategies, develop relapse
prevention plans.
•​ Termination / Relapse: Termination: the person has no temptation to return to old
behaviour and has complete self-efficacy. Relapse: a return to an earlier stage; treated not
as failure but as learning opportunity.

Key concept — Spiral model: Prochaska and DiClemente noted that most people cycle through
the stages multiple times (averaging 3–7 attempts) before achieving lasting change. Relapse is a
normal part of the process, not an endpoint.

1.7 Therapeutic Content

Therapeutic content refers to the subject matter and focus of therapeutic work — what therapist
and client discuss and address. Content varies by approach and client:
•​ Psychodynamic: Unconscious conflicts, early childhood experiences, transference
relationships.
•​ Cognitive: Automatic thoughts, cognitive distortions, core beliefs.
•​ Behavioural: Stimulus-response connections, reinforcement patterns, behavioural
deficits.
•​ Humanistic: Present experience, personal meaning, self-concept, and growth.
•​ Existential: Ultimate concerns such as death, freedom, isolation, and meaninglessness.

1.8 Ethics in Therapy

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APA Ethical Guidelines — Section 10: Therapy

Section 10 of the APA Ethics Code (2017) governs the practice of psychotherapy. Key provisions
include:
•​ 10.01 Informed Consent to Therapy: Clients must be informed about the nature of
therapy, fees, confidentiality, involvement of third parties, and right to refuse or
withdraw. Informed consent must be obtained at the outset and documented.
•​ 10.02 Therapy Involving Couples or Families: The psychologist must clarify roles and
responsibilities from the outset, including who is the identified 'client' and how potential
conflicts of interest will be managed.
•​ 10.03 Group Therapy: The therapist must describe the roles and responsibilities of all
parties and the limits of confidentiality within the group.
•​ 10.04 Providing Therapy to Those Served by Others: Therapists should proceed
cautiously when the client is already receiving services from another professional and
cooperate with other providers when appropriate.
•​ 10.05 Sexual Intimacies with Current Therapy Clients/Patients: Strictly prohibited.
Sexual intimacies with current clients are an absolute ethical violation.
•​ 10.06 Sexual Intimacies with Relatives/Significant Others of Current Clients: Also
prohibited to avoid exploitation of the therapeutic relationship.
•​ 10.07 Therapy with Former Sexual Partners: Psychologists do not accept as therapy
clients persons with whom they have engaged in sexual intimacies.
•​ 10.08 Sexual Intimacies with Former Therapy Clients/Patients: Prohibited for at least
2 years after therapy ends, and even then only in exceptional circumstances with no
exploitation.
•​ 10.09 Interruption of Therapy: Psychologists make reasonable efforts to plan for client
welfare in the event of service interruption.
•​ 10.10 Terminating Therapy: Psychologists terminate when clients have met goals or
when continuation is no longer beneficial. Pre-termination counselling and referrals must
be provided.

Maintaining Confidentiality
Confidentiality is a cornerstone ethical obligation in psychotherapy. It means that information
shared in therapy is kept private and not disclosed to others without client consent. Rationale:
confidentiality enables clients to speak freely, builds trust, and respects autonomy.
Practical aspects of maintaining confidentiality:
•​ Keeping records secure and password-protected.
•​ Not discussing client information in public settings.
•​ Obtaining explicit written consent before releasing records.
•​ Ensuring supervisors and trainees understand confidentiality obligations.

Limits of Confidentiality

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Confidentiality is not absolute. Therapists have both legal and ethical duties to breach
confidentiality in specific circumstances. Clients should be informed of these limits during
informed consent:
•​ Duty to Warn / Tarasoff Decision (1976): When a client poses a serious and credible
threat of harm to an identifiable third party, the therapist must take reasonable steps to
protect the potential victim — which may include warning them or notifying law
enforcement.
•​ Duty to Protect / Suicide Risk: When a client is at imminent risk of serious self-harm or
suicide, the therapist must take protective action, which may include hospitalisation.
•​ Child Abuse / Elder Abuse Reporting: Mandated reporters (including therapists) are
legally required to report suspected abuse or neglect of children, elders, and dependent
adults to appropriate authorities.
•​ Court-Ordered Disclosure: When a judge issues a court order or subpoena, the therapist
may be legally required to disclose records or testimony.
•​ Consultation and Supervision: Information may be shared with clinical supervisors for
the purpose of training and quality care, but supervisees should be informed of this.
•​ Insurance and Managed Care: Disclosure of minimum necessary information may be
required for billing purposes.

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UNIT 2: PSYCHOANALYSIS AND PSYCHODYNAMIC

PSYCHOTHERAPIES

2.1 Classical Psychoanalysis (Freudian)

Goals of Psychoanalysis
•​ Make the unconscious conscious — bring repressed material into awareness.
•​ Restructure the personality: strengthen the ego so it functions on the basis of reality rather
than infantile wishes or rigid defences.
•​ Resolve unconscious conflicts originating from early childhood experiences.
•​ Achieve insight — intellectual and emotional understanding of one's own dynamics.
•​ Improve interpersonal functioning by resolving transference distortions.

Key Treatment Techniques in Classical Psychoanalysis

Therapeutic Alliance
Freud recognised that a working relationship between analyst and analysand was necessary for
treatment to proceed. The alliance provides the safe base from which unconscious material can
be explored. The analyst maintains a posture of technical neutrality — not taking sides in internal
conflicts — while expressing genuine concern for the client's welfare.

Transference
Transference is the client's displacement of feelings, attitudes, and expectations from past
relationships (primarily parental figures) onto the therapist. It is considered the cornerstone of
psychoanalytic treatment.
•​ Positive transference: Warm, loving feelings toward the therapist that initially facilitate
treatment.
•​ Negative transference: Hostile, angry, or suspicious feelings that must be analysed.
•​ Erotic transference: Sexual feelings toward the therapist — must never be acted upon.
Transference neurosis: In classical analysis, the analyst deliberately fosters transference until it
becomes the central focus of treatment — the 'transference neurosis.' Interpreting and working
through transference is the primary vehicle of change.

Countertransference

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Countertransference refers to the therapist's emotional reactions to the client. Originally viewed
by Freud as an obstacle to be controlled (classical view), it is now understood more broadly:
•​ Classical view: Countertransference = therapist's unresolved conflicts distorting the
therapeutic relationship. Must be minimised through personal analysis.
•​ Contemporary view: Countertransference is useful diagnostic information about the
client's internal world and relational patterns (totalistic view).
Therapists are expected to undergo personal psychoanalysis (training analysis) to minimise
countertransference interference.

Free Association
The fundamental rule of psychoanalysis. The client is asked to say whatever comes to mind
without censorship, self-criticism, or logical ordering. The therapist listens for patterns, gaps, and
associations that reveal unconscious material. Resistance to free association (e.g., going blank,
changing subject) is itself clinically meaningful and subject to interpretation.

Abreaction
The reliving and emotional release of repressed memories or traumatic experiences within the
therapeutic setting. Abreaction alone is insufficient — intellectual insight must accompany the
emotional release for lasting change. Early Freud (with Breuer) used hypnosis to facilitate
abreaction; later he relied on free association.

Interpretation and Analysis

Interpretation is the central analytic intervention. The analyst offers hypotheses about the
unconscious meaning of the client's material (dreams, associations, behaviours, transference).
Types of interpretation:
•​ Clarification: Making the client's experience more explicit and precise.
•​ Confrontation: Drawing the client's attention to something they are avoiding.
•​ Interpretation proper: Linking current material to unconscious conflict or past
experience.
•​ Dream interpretation: Dreams are the 'royal road to the unconscious.' Manifest content
(what is remembered) is decoded to reveal latent content (unconscious wish).
•​ Working through: The repeated analysis of the same material across different contexts
and transference configurations, allowing genuine personality change rather than
intellectual insight alone.

Evaluation of Classical Psychoanalysis

•​ Strengths: Pioneered systematic psychotherapy; rich theory of personality development;
emphasis on the unconscious validated by modern neuroscience; transference concept
widely applicable.

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•​ Limitations: Long duration (years) and high cost; limited empirical research base; not
suitable for clients with psychosis, severe character pathology, or low verbal ability;
cultural and gender biases in Freudian theory.

2.2 Adlerian Therapy (Individual Psychology)

Important Theoretical Concepts

View of Human Nature

Alfred Adler saw humans as fundamentally social, teleological (goal-directed), and indivisible
(hence 'individual' psychology — from the Latin individuus, meaning 'undivided'). Behaviour is
purposeful and forward-looking, not merely a product of past determinism. People are creative,
capable of making choices, and responsible for their own lives.

Feelings of Inferiority
Adler believed that all human beings experience feelings of inferiority from childhood — a
universal condition arising from being small and dependent in a world of large, capable adults.
These feelings are the primary motivator of human behaviour:
•​ Normal inferiority feelings → strive for superiority/mastery → healthy compensation.
•​ Inferiority complex: Pervasive, overwhelming sense of inadequacy that paralyses the
person.
•​ Superiority complex: Compensation by exaggerating one's importance; an attempt to
conceal deep inferiority feelings.
The goal of human striving, in Adler's view, is not superiority over others but superiority over
one's own weakness — moving from a perceived 'minus' to a 'plus' position.

Family Constellation and Birth Order

The family — especially the psychological atmosphere and one's position within it — shapes
personality. Birth order creates different psychological situations:
•​ First-born: Initially the centre of attention; dethroned by the second child; may become
conservative, authority-respecting, nurturing, or anxious about losing power.
•​ Second-born / Middle child: Always has a 'pacemaker' ahead; competitive, ambitious,
cooperative, or may feel squeezed.
•​ Last-born / Youngest: Pampered and never dethroned; may be the most ambitious or
feel unable to catch up.
•​ Only child: Raised among adults; may be mature and confident, or spoiled and
dependent.
Note: Adler emphasised the subjective interpretation of one's position more than birth order itself
— what matters is how the individual perceives and responds to their situation.

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Lifestyle
The lifestyle (Lebensstil) is the characteristic pattern of thinking, feeling, and acting by which
the individual pursues their fictional goal of superiority. It is developed in early childhood (by
age 4–6) and includes:
•​ Self-concept: How one sees oneself.
•​ World-view: How one sees others and the world.
•​ Self-ideal: How one believes one should be.
•​ Ethical convictions: Personal code of right and wrong.

Goals
All human behaviour is goal-directed. Adler distinguished between:
•​ Fictional final goals: The imagined ideal state that the person strives toward ('I will be
worthwhile when I am perfect / loved by all / in control').
•​ These goals are often unconscious and fictional — not based in reality — but they shape
the person's entire lifestyle.

Social Interest (Gemeinschaftsgefuhl)

Social interest is Adler's most original and important concept. It refers to an innate potential —
not an instinct — to relate to and contribute to the community. It includes:
•​ Empathy, cooperation, and contribution to the common good.
•​ The capacity to identify with others and experience their feelings.
Adler considered social interest to be the criterion of mental health: the greater one's social
interest, the healthier one is. Psychopathology represents underdeveloped or misdirected social
interest.

Phenomenological Perspective
Adlerian therapy emphasises the subjective meaning that individuals give to their experience.
Two people in identical situations may perceive them entirely differently; it is the person's
interpretation (not objective reality) that drives their behaviour. The therapist must understand
the client's private logic — the internal logic of their lifestyle.

Treatment Using Individual Psychology

Therapeutic Alliance in Adlerian Therapy

The relationship is collaborative, egalitarian, and respectful. Adler opposed the hierarchical
expert-patient dynamic. The therapist demonstrates:
•​ Empathy and genuine interest in the client's subjective world.

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•​ Encouragement — one of the most important therapeutic tools.

•​ Mutual goal setting and shared responsibility.

Stages of Adlerian Treatment

•​ Stage 1: Establishing the Relationship: Build rapport; establish a collaborative
therapeutic alliance; gather initial information.
•​ Stage 2: Lifestyle Assessment: Conduct a comprehensive lifestyle assessment using the
early recollections technique (earliest memories, which are projective — they reveal
current attitudes), family constellation interview, and birth order information.
•​ Stage 3: Interpretation and Insight: Share interpretations tentatively (often as 'guesses')
about the client's lifestyle, fictional goals, and mistaken beliefs. Promote insight into how
the lifestyle developed and its current consequences.
•​ Stage 4: Reorientation: Help the client develop new behaviours, perspectives, and goals
aligned with social interest. Encouragement is central — the therapist helps the client find
the courage to change.

Interventions
•​ Early Recollections: The client's earliest memories are not historical facts but projective
revelations of current attitudes and lifestyle.
•​ The Question: 'What would be different if you did not have this symptom?' Helps reveal
the secondary gain of the symptom (how it helps avoid responsibility).
•​ Encouragement: Therapist actively supports the client's strengths and potential for
growth.
•​ Acting As If: Client is encouraged to act as if they already are the person they want to
be.
•​ Catching Oneself: Client learns to recognise when they are engaging in self-defeating
lifestyle patterns.
•​ Paradoxical Intention: Prescribing the symptom to reduce its power — the client is
asked to intentionally perform or think about the problematic behaviour.

Evaluation of Adlerian Therapy

•​ Strengths: Ahead of its time — anticipated existential, humanistic, and cognitive
approaches; emphasis on social context; cross-cultural applicability; accessible and
practical.
•​ Limitations: Concepts are difficult to operationalise empirically; birth order effects not
strongly supported by research; less detailed theory of change mechanisms compared to
CBT.

2.3 Brief Psychodynamic Therapy (BPT)

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Important Theoretical Concepts

Underlying Theory
BPT retains the core psychoanalytic insight that current difficulties are rooted in unconscious
conflicts and unresolved developmental issues. It differs from classical analysis in:
•​ Time-limited structure (typically 12–40 sessions).
•​ Active, focused approach: A specific focal conflict is identified at the outset.
•​ More directive therapist stance.
•​ Less emphasis on developing a transference neurosis; more focus on the therapeutic
relationship as a corrective emotional experience.

Selection of Appropriate Clients

Not all clients are suitable for BPT. Criteria for inclusion typically include:
•​ Ability to identify a circumscribed focal problem or conflict.
•​ At least one significant meaningful relationship in their history.
•​ Psychological-mindedness: capacity to think in psychological terms.
•​ Motivation for change and willingness to explore psychological issues.
•​ Ability to tolerate and work with painful affect.
•​ Positive response to trial interpretations during assessment.
Exclusion criteria: Active psychosis, severe personality disorder (e.g., borderline PD), active
substance dependence, suicidality requiring immediate intervention.

The Process of BPT

The therapist actively maintains focus on the agreed-upon focal conflict, redirecting the client
when they drift. The time limit is used therapeutically — the reality of ending stimulates issues
of loss, separation, and attachment.

Phases of BPT
•​ Phase 1: Assessment and Focus Selection: Detailed psychological history;
identification of a central focal conflict (usually an interpersonal pattern related to the
presenting problem).
•​ Phase 2: Treatment: Active interpretation of the focal conflict; linking current
difficulties to past patterns; using the therapeutic relationship as a model for change.
•​ Phase 3: Termination: Begins from the first session (client is reminded of the time limit
throughout); explicitly addresses separation, loss, and the client's capacity for
independent functioning.

Treatment Using BPT

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Goals
•​ Resolve the focal conflict identified at assessment.
•​ Improve the client's interpersonal functioning.
•​ Help the client develop insight into patterns that underlie presenting difficulties.
•​ Promote the client's capacity to continue the change process independently after therapy
ends.

Therapeutic Alliance in BPT

The alliance is central and is developed rapidly in BPT. The therapist is more active than in
classical analysis — they express empathy directly, make early interpretations, and actively
maintain focus. The relationship is used as a corrective emotional experience (Alexander and
French, 1946) — the client experiences a healthy relational response that differs from past
traumatic or frustrating patterns.

Specific Models of BPT: Klerman's Interpersonal Psychotherapy (IPT)

Interpersonal Psychotherapy (IPT) was developed by Gerald Klerman and Myrna Weissman in
the 1970s, originally for the treatment of depression. It is one of the best-researched brief
therapies.

Theoretical Basis of IPT

•​ Rooted in the interpersonal psychiatry of Harry Stack Sullivan and the attachment theory
of John Bowlby.
•​ Depression and other disorders arise in an interpersonal context and are best treated by
addressing interpersonal relationships.
•​ IPT does not require insight into unconscious conflicts; it focuses on current interpersonal
functioning.

The Four Focal Problem Areas of IPT

•​ Grief: Complicated bereavement following the death of a significant person. Goal:
facilitate the mourning process and help the client re-establish interests and relationships.
•​ Interpersonal Role Disputes: Conflicts with a significant other about differing
expectations (e.g., marital disputes). Goal: identify the nature of the dispute and develop
strategies to resolve it.
•​ Role Transitions: Difficulty coping with a change in life situation (e.g., retirement,
divorce, new job, illness). Goal: mourn the loss of the old role and develop skills and
support for the new role.
•​ Interpersonal Deficits: History of social isolation, impoverished relationships, or severe
social skills deficits. Goal: reduce isolation, develop new relationships, improve social
skills.

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Structure of IPT
•​ Initial phase (Sessions 1–3): Assessment, psychoeducation about depression,
explanation of IPT rationale, conduct interpersonal inventory (review of key
relationships), identify the focal problem area.
•​ Middle phase (Sessions 4–9): Address the focal problem area using specific techniques
(communication analysis, exploration, role-playing, clarification, use of therapeutic
relationship).
•​ Termination phase (Sessions 10–12): Review progress, consolidate skills, anticipate
future difficulties, discuss symptoms of relapse.

IPT has strong evidence for major depressive disorder, bulimia nervosa, postpartum depression,
and adolescent depression. It is listed in major clinical guidelines as a first-line treatment.

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UNIT 3: COGNITIVE THERAPIES AND GESTALT THERAPY

3.1 Cognitive Behaviour Therapy (CBT) — Aaron T. Beck

Important Theoretical Concepts

Development of Cognitive Distortions

Beck's cognitive model holds that psychological distress arises from distorted thinking, not from
situations themselves. Cognitive distortions develop through:
•​ Early experiences that give rise to core beliefs (unconditional, absolute beliefs about
oneself, the world, and the future — e.g., 'I am unlovable,' 'The world is dangerous').
•​ These core beliefs generate dysfunctional assumptions (conditional rules: 'If I am not
perfect, I am a failure').
•​ When these assumptions are activated by critical incidents, they generate automatic
thoughts — brief, spontaneous, plausible cognitions that produce emotional distress.

Principles of Cognitive Therapy (Beck, 1979 — Eleven Principles)

•​ Cognitive therapy is based on a continually evolving formulation of the client's problems
in cognitive terms.
•​ Requires a sound therapeutic alliance.
•​ Emphasises collaboration and active participation.
•​ Is goal-oriented and problem-focused.
•​ Initially emphasises the present.
•​ Is educative — aims to teach the client to be their own therapist, and emphasises relapse
prevention.
•​ Aims to be time-limited.
•​ Sessions are structured.
•​ Teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and
beliefs.
•​ Uses a variety of techniques to change thinking, mood, and behaviour.
•​ Cognitive therapy is collaborative empiricism — therapist and client work together as
scientists to examine the evidence for and against the client's beliefs.

Levels of Cognitions

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•​ Automatic thoughts: Surface-level, situation-specific, spontaneous cognitions. Easiest to

identify and modify. Example: 'I'm going to fail this exam.'
•​ Intermediate beliefs / Dysfunctional assumptions: Conditional rules and attitudes.
Example: 'If I make a mistake, it means I'm incompetent.'
•​ Core beliefs / Schemas: Deepest level; absolute, global, rigid. Formed in childhood.
Example: 'I am fundamentally flawed.' Core beliefs about self (helpless, unlovable,
worthless), world (dangerous, unfair), and future (hopeless).

Treatment Using Cognitive Therapy

Goals
•​ Reduce symptom severity (especially depression and anxiety).
•​ Identify and modify cognitive distortions.
•​ Address underlying dysfunctional assumptions and core beliefs.
•​ Teach clients cognitive and behavioural skills for self-management.
•​ Prevent relapse through self-therapy skills.

Therapeutic Alliance in CBT

Beck emphasised collaborative empiricism — a genuine partnership in which therapist and client
work together to investigate the client's thoughts as hypotheses rather than facts. The therapist is
warm, genuine, and empathic while also being structured and directive. Socratic questioning
(guided discovery) is central — the therapist asks questions that help the client discover their
own distortions.

Case Formulation
A cognitive case formulation is developed collaboratively and links the client's presenting
problems to their cognitive profile. It typically includes:
•​ Presenting problems and precipitating events.
•​ Relevant childhood data and core beliefs.
•​ Dysfunctional assumptions.
•​ Compensatory strategies.
•​ How the above interconnect to produce current difficulties.

Common Cognitive Distortions (Beck)

•​ All-or-nothing thinking: Thinking in black and white; no middle ground. 'If I'm not
perfect, I'm a total failure.'
•​ Overgeneralisation: Drawing a sweeping conclusion from a single event. 'I failed once,
so I always fail.'

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•​ Mental filter: Focusing exclusively on a negative detail while ignoring the bigger
picture.
•​ Disqualifying the positive: Rejecting positive experiences by insisting they 'don't count.'
•​ Mind reading: Assuming others are thinking negatively without evidence.
•​ Fortune-telling: Predicting negative outcomes as if they are established facts.
•​ Catastrophising: Exaggerating the importance or consequences of events.
•​ Emotional reasoning: 'I feel stupid, therefore I am stupid.'
•​ Should statements: Rigid rules about how oneself and others should behave — creates
guilt and resentment.
•​ Labelling: Attaching a global negative label to oneself or others rather than describing a
behaviour.
•​ Personalisation: Taking excessive personal responsibility for external events.

Eliciting and Rating Cognitions

Techniques to identify automatic thoughts include:
•​ Asking directly: 'What was going through your mind when you felt anxious?'
•​ Imagery: Re-creating the situation in imagination to access thoughts and feelings.
•​ Role-play: Re-enacting a difficult interpersonal situation.
•​ Thought records (Dysfunctional Thought Records — DTRs): Structured worksheet
documenting situation, emotions (rated 0–100%), automatic thoughts (rated 0–100%
belief), evidence for and against, and alternative response.

Determining Validity and Labelling the Distortion

The therapist and client examine evidence for and against the automatic thought using Socratic
questioning. Once examined, the distortion is labelled (e.g., 'That sounds like fortune-telling').
This helps clients recognise patterns across situations.

Assessment of Mood
Standardised measures are used to monitor progress, including the Beck Depression Inventory-II
(BDI-II), Beck Anxiety Inventory (BAI), and session-by-session measures such as the PHQ-9.
Mood ratings are integrated into session structure (beginning and end of session).

Changing Cognitions — Key Techniques

•​ Decatastrophising: 'What is the worst that could happen? What is the probability? Could
you cope?'
•​ Reattribution: Examining responsibility more realistically rather than blaming oneself
excessively.
•​ Cognitive rehearsal: Mentally rehearsing adaptive coping in anticipation of difficult
situations.

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•​ Behavioural experiments: Testing beliefs through real-life action — the most powerful
technique in CBT.
•​ Activity scheduling: Planning pleasurable and mastery activities to combat
depression-related withdrawal.
•​ Graded task assignment: Breaking overwhelming tasks into small, manageable steps.

Termination and Relapse Prevention

CBT explicitly prepares clients for therapy ending:
•​ Therapy is gradually tapered (sessions become less frequent).
•​ Client develops a personal relapse prevention plan.
•​ Client is taught to recognise early warning signs of relapse.
•​ Gains are consolidated and self-therapy skills are reviewed.
•​ Booster sessions may be offered.

Evaluation of CBT
•​ Strengths: Most extensively researched psychotherapy; strong evidence base for
depression, anxiety disorders, OCD, PTSD, eating disorders, psychosis; time-limited and
cost-effective; transparent and teachable.
•​ Limitations: May underemphasise the importance of the therapeutic relationship;
structured format may not suit all clients; less emphasis on early developmental factors;
may not be appropriate for severe personality disorders without modification (e.g., DBT
for BPD).

3.2 Rational Emotive Behaviour Therapy (REBT) — Albert Ellis

Important Theoretical Concepts

Human Development and Emotional Health

Ellis held that humans have both a biological tendency toward irrational thinking and an equally
strong capacity to change their thinking. Emotional disturbance is not caused by events (A —
Activating event) but by beliefs (B — Beliefs) about those events, which produce consequences
(C — emotional and behavioural Consequences). This is the famous ABC model.

Secular Humanism
REBT is grounded in secular humanism — it is non-dogmatic, non-religious, and promotes
rational self-interest alongside concern for others. Ellis emphasised:
•​ Unconditional self-acceptance (USA): Accepting oneself as a fallible human being
regardless of performance.

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•​ Unconditional other-acceptance (UOA): Accepting others as fallible human beings.

•​ Unconditional life-acceptance (ULA): Accepting that life contains adversity and
unfairness.

Thoughts as the Route to Change

Unlike psychoanalysis, REBT does not seek to unearth historical causes of disturbance. Ellis
argued that the way to change emotions and behaviour is to change the beliefs that sustain them
— specifically, to dispute and modify irrational beliefs (iBs) and replace them with rational
beliefs (rBs).

Irrational Beliefs — The Three Core Musts

Ellis identified three major categories of irrational belief, all based on absolutistic 'musts' and
'shoulds':
•​ Must #1 — Demands about self: 'I absolutely must perform well and win approval, or
else I am worthless.' → Leads to depression, anxiety, shame, guilt.
•​ Must #2 — Demands about others: 'Others absolutely must treat me considerately and
fairly, or else they are bad people who deserve to be punished.' → Leads to anger, rage,
resentment.
•​ Must #3 — Demands about the world / life: 'Life absolutely must give me the
conditions I want easily and comfortably, or else it's awful and I can't stand it.' → Leads
to low frustration tolerance, self-pity, procrastination.
The three main derivatives of the musts:
•​ Awfulising / catastrophising: 'It's absolutely terrible that this happened.'
•​ Low Frustration Tolerance (LFT) / I-can't-stand-it-itis: 'I can't bear this discomfort.'
•​ Damnation / global evaluation of self/others: Rating the whole person based on specific
behaviours.

The Format of REBT Sessions

REBT sessions follow a structured but flexible format. The therapist is active-directive and
confrontational. Sessions typically include:
•​ Check-in and session agenda.
•​ Review of homework from last session.
•​ Identification of the activating event and problematic consequences.
•​ Identification and disputation of irrational beliefs.
•​ Setting new homework.

Treatment Using REBT

Goals

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•​ Minimise emotional disturbance and self-defeating behaviour.

•​ Help clients identify, challenge, and change irrational beliefs.
•​ Promote rational thinking, unconditional self-acceptance, and high frustration tolerance.
•​ Equip clients with a durable cognitive philosophy so they can resolve future difficulties
themselves.

Therapeutic Alliance in REBT

The therapeutic relationship in REBT is less central than in person-centred therapy, though Ellis
recognised its importance. The therapist:
•​ Is warm but does not offer unconditional positive regard (UPR) — Ellis warned against
clients becoming emotionally dependent on therapist approval.
•​ Is active, directive, and confrontational — challenging irrational beliefs firmly.
•​ Models rational thinking and rational risk-taking.

Identifying, Assessing, Disputing, and Modifying Irrational Beliefs

The ABCDE model extends the ABC framework:
•​ A: Activating event (actual or inferred).
•​ B: Beliefs (rational or irrational).
•​ C: Consequences (emotional and behavioural).
•​ D: Disputing — challenging the irrational belief.
•​ E: Effective new philosophy — the rational belief that replaces the irrational one.

Approaches to Disputing Irrational Beliefs

•​ Empirical disputing: 'Where is the evidence that you must perform perfectly?' 'What
proof supports the belief that others must treat you fairly?'
•​ Logical disputing: 'Does it logically follow from the fact that you prefer to succeed that
you therefore must succeed?'
•​ Pragmatic / functional disputing: 'Is it helping you to believe this? What are the
consequences of holding this belief?'

Other REBT Intervention Strategies

•​ Shame-attacking exercises: The client deliberately does something mildly embarrassing
in public to learn to tolerate shame without catastrophising.
•​ Rational-emotive imagery: Client imagines a disturbing event, feels the unhealthy
negative emotion, then practises changing it to a healthier emotion by changing their
beliefs.
•​ Bibliotherapy and psychoeducation: Clients read REBT self-help books and complete
worksheets between sessions.
•​ Unconditional self-acceptance exercises: Practising accepting oneself as a fallible
human regardless of performance.

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Evaluation of REBT
•​ Strengths: Highly efficient — addresses core philosophy, not just surface symptoms;
strong emphasis on client autonomy and self-sufficiency; incorporates cognitive, emotive,
and behavioural techniques.
•​ Limitations: Confrontational style may alienate some clients; may undervalue the
therapeutic relationship; limited cultural sensitivity; Ellis's personal style was not
universal; empirical evidence weaker than for Beck's CBT.

3.3 Gestalt Therapy — Fritz Perls

Goals of Gestalt Therapy

•​ Increase awareness of present-moment experience — thoughts, feelings, bodily
sensations, needs, and environment.
•​ Promote integration of fragmented or disowned aspects of self.
•​ Help clients take responsibility for their own experience and choices.
•​ Support authentic self-expression and contact with others.
•​ Resolve 'unfinished business' — unexpressed emotional experiences from the past that
intrude on present functioning.

How People Change in Gestalt Therapy

The paradoxical theory of change (Beisser, 1970): change occurs not by trying to be what one is
not, but by becoming more fully what one already is. The therapist does not push the client to
change; instead, they support the client in deeply experiencing their current state, from which
change naturally emerges. Awareness itself is curative.

Therapeutic Alliance in Gestalt Therapy

The therapeutic relationship is genuine, immediate (I-Thou), and present-focused. The Gestalt
therapist:
•​ Is present as a whole person, not a blank screen.
•​ Engages in authentic dialogue — shares their own experience when relevant.
•​ Uses the relationship as a laboratory for exploring the client's relational patterns.
•​ Challenges the client while remaining warm and supportive.

Key Gestalt Experiments and Techniques

Experiments

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Experiments are structured activities designed to increase awareness, explore behaviour, and try
out new ways of functioning. They are collaborative and exploratory, not prescriptive.

Use of Language
The Gestalt therapist pays close attention to language and encourages clients to:
•​ Use 'I' statements rather than 'it' ('I am anxious' not 'It feels anxious').
•​ Change 'I can't' to 'I won't' — taking ownership of choices.
•​ Change 'I should/must' to 'I want/choose' — reducing shoulds.
•​ Speak in the present tense about past events to bring them into the here-and-now.
•​ Avoid 'but' (which cancels what came before) — use 'and.'

Dreams in Gestalt Therapy

In Gestalt, dreams are not interpreted symbolically (as in psychoanalysis) but are treated as
projections of disowned parts of the self. The client is asked to 'become' each element of the
dream in turn, speaking in the first person and present tense. The goal is to reclaim projected
aspects of self and achieve integration.

Fantasy
Guided fantasy allows clients to explore situations, relationships, or aspects of themselves in
imagination. It can help access avoided material and rehearse new behaviours safely.

Role-Play and Empty Chair Method

The empty chair technique (two-chair dialogue) is one of Gestalt's most distinctive and
researched techniques. An empty chair is placed opposite the client to represent:
•​ A significant other (e.g., parent, partner) with whom the client has unfinished business.
•​ A disowned part of the self (e.g., the 'critical self' vs. the 'experiencing self').
The client alternates between chairs, speaking as each position and responding to the other. This
externalises and enacts internal conflict, facilitating emotional processing, resolution, and
integration. Research by Greenberg and colleagues has demonstrated the effectiveness of the
empty chair technique for resolving 'unfinished business' and internal conflict.

The Body as a Vehicle of Communication

Gestalt therapy places great emphasis on bodily experience. The therapist attends to:
•​ Non-verbal cues: posture, facial expression, gestures, breathing.
•​ Directs the client's attention to bodily experience: 'What are you aware of in your body
right now?'
•​ Recognises body symptoms as communications about avoided experience — e.g., a tight
chest as unexpressed grief.

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Evaluation of Gestalt Therapy

•​ Strengths: Rich repertoire of creative techniques; strong emphasis on present-moment
awareness; integrates emotional and bodily experience; well-researched two-chair
technique; applicable to a wide range of problems.
•​ Limitations: Can be emotionally intense — requires careful pacing; potential for
re-traumatisation if used without care; less structured than CBT — may not suit clients
who need structure; mixed evidence base compared to CBT.

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UNIT 4: PERSON-CENTRED THERAPY AND EXISTENTIAL

THERAPY

4.1 Person-Centred Therapy (PCT) — Carl Rogers

Important Theoretical Concepts

Humanism
Person-centred therapy is grounded in humanistic psychology, which holds that human beings
are fundamentally good, growth-oriented, and capable of self-determination. PCT emphasises
subjective experience, personal meaning, and the inherent dignity of every individual.

Human Potential and Actualisation

Rogers' theory is built on the actualising tendency — an innate, biological motivating force in
every living organism to maintain, enhance, and actualise itself. Applied to humans, this includes
the drive toward growth, fulfilment, creativity, and becoming increasingly complex. Under the
right conditions (when conditions of worth are absent), this tendency naturally propels the person
toward psychological health.

Conditions of Worth
Children learn that they are valued (loved, approved of) only when they think, feel, or behave in
ways that significant others approve of. This conditional positive regard leads the child to
internalise conditions of worth: 'I am only valuable when I am successful / not angry / pleasing to
others.' Consequences:
•​ The child begins to distort or deny experiences that conflict with conditions of worth.
•​ A gap opens between the real self (actual experience) and the ideal self (the self one feels
one must be to be lovable).
•​ This incongruence between real and ideal self produces anxiety and psychological
distress.

Organismic Valuing Process

Before conditions of worth develop, the young child has direct access to their organismic valuing
process — an innate inner compass that evaluates experiences according to whether they
enhance or threaten growth. Experiences that actualise are valued positively; those that do not

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are valued negatively. Conditions of worth disrupt this process by substituting external approval
for internal experience as the criterion of value.

The Fully Functioning Person

The fully functioning person is Rogers' vision of optimal psychological health — the person who
is living fully in accordance with their actualising tendency. Characteristics:
•​ Openness to experience: Neither defensive nor threatened by experience; able to receive
all feelings and perceptions.
•​ Existential living: Living fully in each moment; not rigidly structured by the past or
anxiously anticipating the future.
•​ Organismic trust: Trusting their own inner experience as a guide to behaviour rather
than external rules.
•​ Experiential freedom: Feeling free to choose among options; owning their choices.
•​ Creativity: Being creative and adaptable in response to their environment.

Phenomenological Perspective
PCT emphasises the client's subjective, phenomenological world — their perceptions and
experiences as they live them — rather than objective, external reality. The therapist's goal is to
enter and understand the client's internal frame of reference.

Treatment Using Person-Centred Counselling

The Necessary and Sufficient Conditions (Rogers, 1957)

Rogers proposed six conditions that are both necessary and sufficient for therapeutic personality
change:
•​ Condition 1: Two persons are in psychological contact.
•​ Condition 2: The client is in a state of incongruence — anxious and vulnerable.
•​ Condition 3: The therapist is congruent (genuine/authentic) in the relationship.
•​ Condition 4: The therapist experiences unconditional positive regard (UPR) toward the
client.
•​ Condition 5: The therapist experiences empathic understanding of the client's internal
frame of reference and endeavours to communicate this.
•​ Condition 6: The client perceives, at least to a minimal degree, the therapist's UPR and
empathic understanding.
Conditions 3, 4, and 5 are the three core facilitative conditions (the therapist-offered conditions).

Goals in PCT
•​ Greater congruence between real self and ideal self.
•​ Increased openness to experience and reduction of defensiveness.

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•​ Greater self-trust and reliance on the organismic valuing process.

•​ More realistic self-concept.
•​ Increased autonomy, self-direction, and locus of evaluation.

Facilitative Conditions
•​ Congruence (Genuineness/Authenticity): The therapist is transparent, integrated, and
genuine in the relationship. The therapist does not hide behind a professional facade.
Being congruent means the therapist's inner experience and outer expression are
consistent. This is considered the most important of the three conditions.
•​ Unconditional Positive Regard (UPR): The therapist accepts and prises the client as a
person without conditions or reservations. The therapist communicates non-judgmental
warmth and respect — regardless of the client's thoughts, feelings, or behaviours. UPR
counteracts the client's conditioned experiences of conditional love.
•​ Empathic Understanding: The therapist strives to enter and understand the client's
subjective world — to perceive it as if from the inside, without losing the 'as if' quality.
Empathy is communicated through accurate reflections of feeling, tentative exploratory
responses, and checking with the client. Empathy validates experience and facilitates
self-exploration.

Nondirectiveness
PCT is fundamentally nondirective. The therapist does not suggest topics, offer interpretations,
give advice, or set goals. The client determines the direction of therapy. The therapist's role is to
provide the facilitative conditions within which the client's own actualising tendency can work.
Contemporary PCT allows for more active expression by the therapist (as in the dialogic
approach), but the principle of respecting client self-determination remains central.

Evaluation of PCT
•​ Strengths: Substantial research base — Rogers pioneered the use of audio-recorded
therapy sessions for research; the therapeutic alliance research confirms that Rogers' core
conditions predict outcome across all therapies; humanistic values; widely applicable.
•​ Limitations: May be insufficient for clients with severe disorders requiring structured
interventions; nondirectiveness may be culturally inappropriate (some clients expect
direction); may underestimate the importance of specific techniques; Rogers' conditions
have been critiqued as necessary but perhaps not sufficient for all clients.

4.2 Existential Therapy

Important Theoretical Concepts

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Ultimate Concerns of the Human Condition

Existential therapy is grounded in existential philosophy (Kierkegaard, Sartre, Heidegger,
Merleau-Ponty) and is not a single unified approach but a philosophical orientation. Irvin Yalom
identified four ultimate concerns (or 'givens of existence') that inevitably confront every human
being:
•​ Death: The awareness of one's own mortality — the most fundamental source of
existential anxiety. How we relate to our finitude determines much of how we live.
•​ Freedom / Responsibility: The existential view holds that humans are radically free —
there is no predetermined essence or script. This freedom entails full responsibility for
one's choices and life.
•​ Existential Isolation: The fundamental aloneness of each human being — one cannot
fully share one's subjective experience with another. Even the most loving relationships
cannot eliminate this fundamental separateness.
•​ Meaninglessness: Since there is no inherent meaning in the universe (existential
vacuum), each person must create their own meaning. The awareness of this can produce
existential despair.

Existential Anxiety vs. Neurotic Anxiety

•​ Existential (ontological) anxiety: Normal, universal anxiety arising from confronting
the ultimate concerns of existence — death, freedom, isolation, meaninglessness. It is not
pathological and cannot be eliminated; it is to be faced and integrated.
•​ Neurotic anxiety: Anxiety that arises from the avoidance of existential anxiety. When a
person cannot face the givens of existence, they construct defences and restrictions that
limit their freedom and produce neurotic symptoms. Existential therapy aims to help
clients face, rather than avoid, existential anxiety.

Human Development and Development of Emotional Difficulties

From an existential perspective, psychological difficulties arise from:
•​ Refusing to confront the ultimate concerns — denial of death, avoidance of freedom and
responsibility, inability to tolerate isolation, flight from meaninglessness.
•​ Making choices and commitments that are inauthentic — conforming to others'
expectations, living in 'bad faith' (Sartre).
•​ Failure to create genuine meaning and purpose.

Dasein
Heidegger's concept of Dasein ('being-there') refers to the particular mode of existence of human
beings — always situated in a world, always in relationship, always temporal (past, present,
future). Binswanger and Boss developed Daseinsanalysis, applying Heidegger's ontology to
psychotherapy. Key aspects of Dasein:
•​ Thrownness: We are 'thrown' into a situation (body, family, culture, historical period) we
did not choose.

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•​ Fallenness: The tendency to fall into inauthenticity — to be absorbed in the 'das Man' (the
'they' — conforming to anonymous social norms).
•​ Projection: Moving forward into possibilities — choosing and creating a future.

Concept of Mental Health

Mental health from an existential perspective involves:
•​ Authenticity: Living in accordance with one's own values and taking responsibility for
one's choices.
•​ Awareness and acceptance of the ultimate concerns.
•​ The capacity for genuine relationship with others despite existential isolation.
•​ The creation of personal meaning and commitment to values.

Potentials of the Human Condition

Rather than focusing exclusively on pathology, existential therapy emphasises human potentials:
•​ Capacity for self-awareness and self-transcendence.
•​ Freedom to choose one's attitude toward any given set of circumstances (Frankl —
logotherapy).
•​ Capacity for love, creativity, and meaningful engagement with life.
•​ Ability to find meaning even in suffering (Frankl's logotherapy).

Treatment Using Existential Therapy

Goals
•​ Help clients become aware of their freedom and responsibility.
•​ Facilitate authentic confrontation with the ultimate concerns.
•​ Help clients clarify their values and commit to meaningful projects.
•​ Reduce neurotic anxiety by increasing the capacity to face existential anxiety.
•​ Promote authentic, responsible living.

Therapeutic Alliance in Existential Therapy

The therapeutic relationship is the primary vehicle of change. The therapist offers:
•​ Presence: Full engagement with the client's experience.
•​ Authentic encounter: The therapist is not a blank screen but a genuine human being.
•​ Non-judgmental acceptance.
•​ Willingness to enter the client's phenomenological world.
The relationship is an I-Thou encounter (Buber) — two persons meeting in their full humanity.

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The Process of Treatment

Existential therapy does not follow a structured protocol. The process is phenomenological —
exploring the client's lived experience without imposing a theoretical framework. Therapy tends
to move through:
•​ Exploration of the client's current life situation and its meaning.
•​ Identification of avoided existential concerns.
•​ Confrontation with the ultimate concerns (gently and appropriately timed).
•​ Exploration of the client's values, commitments, and sources of meaning.
•​ Encouraging authentic choice-making and responsibility.

Specific Intervention Strategies

•​ Phenomenological exploration: Careful, unhurried exploration of the client's experience
as they live it.
•​ Confronting freedom and responsibility: Helping the client see that they are the author
of their own life.
•​ Exploring death awareness: Using awareness of mortality as a catalyst for more
authentic and purposeful living.
•​ Meaning-making: Helping the client identify, create, or recommit to sources of meaning.
•​ Paradoxical intention (Frankl): Used in logotherapy — the client is asked to intend or
wish for the very thing they fear, reducing the anticipatory anxiety around the symptom.
•​ Dereflection (Frankl): Redirecting the client's attention away from themselves and
toward meaningful engagement with the world.

Evaluation of Existential Therapy

•​ Strengths: Addresses the deepest human concerns; applicable across cultures (the
ultimate concerns are universal); emphasises human dignity, freedom, and responsibility;
provides a meaningful framework for working with issues of death, loss, and meaning.
•​ Limitations: Limited empirical research base due to difficulty operationalising
existential concepts; abstract philosophical concepts may be inaccessible to some clients;
lacks specific techniques; may not be suitable for acute presentations requiring structured
intervention.

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UNIT 5: RECENT TRENDS IN THERAPY

5.1 Acceptance and Commitment Therapy (ACT)

Developed by Steven Hayes (1980s–1990s), ACT is a third-wave cognitive-behavioural therapy
grounded in Relational Frame Theory (RFT) — a functional-contextual account of language and
cognition.

Core Philosophy: Psychological Flexibility

The central goal of ACT is to increase psychological flexibility — the ability to contact the
present moment as a conscious human being, and to change or persist in behaviour when doing
so serves valued ends. Psychological rigidity (the opposite) is the root of much psychological
suffering.

The Six Core Processes (ACT Hexaflex)

•​ 1. Acceptance: Actively and non-judgmentally embracing private experiences (thoughts,
feelings, sensations) rather than avoiding or suppressing them. Acceptance is not
resignation — it is allowing experience without unnecessary struggle. 'Open up.'
•​ 2. Defusion (Cognitive Defusion): Changing the way the client relates to their thoughts,
rather than changing the thoughts themselves. Techniques create distance between the
client and their thoughts: observing thoughts as thoughts, not facts ('I notice I'm having
the thought that I am worthless'). 'Unhook.'
•​ 3. Contact with the Present Moment (Mindfulness): Flexible attention to the present
moment without judgment — observing experience as it unfolds. Based on mindfulness
practices drawn from Buddhist traditions. 'Be present.'
•​ 4. Self-as-Context (The Observing Self): Distinguishing between the conceptualised
self (the story one tells about oneself) and the observing self — the stable, consistent 'I'
that notices all experiences. The observing self cannot be damaged or threatened. 'Pure
awareness.'
•​ 5. Values Clarification: Identifying what truly matters to the client — chosen life
directions that cannot be achieved like goals but are lived continuously. Values are the
engine of committed action. 'What matters?'
•​ 6. Committed Action: Setting goals guided by values and persisting in valued action
even in the presence of difficult thoughts and feelings. ACT incorporates behavioural
techniques (goal-setting, exposure, skill-building) in the service of values. 'Do what it
takes.'

The ACT Model of Psychopathology

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ACT uses the term 'psychological inflexibility' or 'experiential avoidance' to describe the root of
psychopathology. When a person fuses with unhelpful thoughts, avoids painful experiences,
loses contact with the present, and acts inconsistently with their values, suffering results.

Evidence Base
ACT has substantial empirical support across a wide range of problems: depression, anxiety,
OCD, chronic pain, workplace stress, substance use, and psychosis. It is included in NICE
guidelines and APA Division 12 empirically supported treatment lists.

5.2 Dialectical Behaviour Therapy (DBT)

Developed by Marsha Linehan in the late 1980s, originally for chronically suicidal women with
borderline personality disorder (BPD). DBT integrates standard cognitive-behavioural
techniques with acceptance-based strategies drawn from Zen Buddhism and mindfulness.

The Core Dialectic

The fundamental dialectic in DBT is between acceptance and change: the client must be accepted
as they are (validation) while simultaneously being encouraged and helped to change. The
synthesis of these two positions is the therapeutic goal.

Theoretical Basis: Biosocial Theory

Linehan's biosocial theory of BPD holds that BPD develops from the interaction between:
•​ Biological vulnerability to emotional sensitivity (high emotional reactivity, slow return to
baseline).
•​ An invalidating environment in childhood — one that dismisses, punishes, or ignores the
child's emotional experience.
This combination produces pervasive emotional dysregulation — the core deficit in BPD that
DBT targets.

The Four Modes of DBT Treatment

•​ Individual therapy: Weekly 50-60 minute session. The therapist and client work
collaboratively to address problems in a hierarchy: life-threatening behaviour first,
therapy-interfering behaviour second, quality-of-life-interfering behaviour third, then
skills acquisition.
•​ DBT Skills Training Group: Weekly group (2–2.5 hours) in which clients learn and
practise DBT skills. The group is structured psychoeducationally.
•​ Phone coaching: Clients can call their individual therapist between sessions for brief
coaching on applying skills in the moment of crisis.

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•​ Therapist consultation team: The 'therapy for the therapist' — regular team meetings to
support therapist motivation, adherence to the treatment model, and prevent burnout.

The Four DBT Skill Modules

•​ Mindfulness: The foundational skill — observing, describing, and participating in
experience without judgment. 'What' skills (observe, describe, participate) and 'How'
skills (non-judgmentally, one-mindfully, effectively).
•​ Distress Tolerance: Skills for surviving crises without making things worse. TIPP
(Temperature, Intense exercise, Paced breathing, Paired muscle relaxation), ACCEPTS,
self-soothe, IMPROVE, radical acceptance.
•​ Emotion Regulation: Understanding and managing emotional responses. Identifying and
labelling emotions, reducing vulnerability (PLEASE skills: treat PhysicaL illness,
balance Eating, avoid Altering substances, balance Sleep, get Exercise), building mastery,
opposite action, checking the facts.
•​ Interpersonal Effectiveness: Skills for getting what one needs in relationships while
maintaining the relationship and self-respect. DEAR MAN (Describe, Express, Assert,
Reinforce, Mindful, Appear confident, Negotiate), GIVE, FAST.

Evidence Base
DBT has the most extensive empirical support of any treatment for BPD. It has also been
adapted for adolescents, eating disorders, PTSD, and substance use disorders.

5.3 Cognitive Analytical Therapy (CAT)

Developed by Anthony Ryle in the UK in the 1980s, CAT is a time-limited (16–24 sessions),
integrative therapy that combines cognitive and psychoanalytic concepts, particularly object
relations theory.

Core Concepts
•​ Reciprocal Roles (RRs): CAT understands psychological difficulties through reciprocal
role patterns — internalised relationship templates formed in early life (e.g.,
'abusing-to-abused,' 'neglecting-to-neglected'). These RRs are enacted both in
relationships with others and in internal self-management.
•​ Procedural Sequence Object Relations Model (PSORM): Describes how people enact
problematic patterns through sequences of mental and behavioural procedures. Three
main problem procedures: traps (self-reinforcing cycles), dilemmas (false either/or
choices), and snags (goals and change are sabotaged as if dangerous).
•​ Sequential Diagrammatic Reformulation (SDR): A visual map (diagram) created
collaboratively by therapist and client, showing the client's core reciprocal roles and how
they lead to problematic procedures. The SDR is a key therapeutic tool for recognition
and change.

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Tools of CAT
•​ Reformulation letter: A written letter from therapist to client (typically delivered at
session 4) summarising the client's history and the development of their problematic
patterns in an empathic and non-pathologising way.
•​ Sequential Diagrammatic Reformulation (SDR): Visual map of reciprocal roles and
problem procedures.
•​ Goodbye letter: Written by both therapist and client at the end of therapy, reflecting on
progress and what has been learned.

Evidence Base
CAT has a growing evidence base, particularly for personality disorders, BPD, eating disorders,
and complex presentations. It is widely practised in NHS settings in the UK.

5.4 Interpersonal and Social Rhythm Therapy (IPSRT)

Developed by Ellen Frank and colleagues at the University of Pittsburgh, IPSRT combines
Klerman's Interpersonal Psychotherapy (IPT) with Social Rhythm Therapy to treat bipolar
disorder.

Theoretical Basis
IPSRT is based on two key hypotheses:
•​ Social rhythm hypothesis: Regular daily routines (social rhythms — sleep, meals, social
stimulation) stabilise biological circadian rhythms. Disruption to social rhythms can
destabilise circadian rhythms, triggering mood episodes in bipolar disorder.
•​ Interpersonal hypothesis (from IPT): Interpersonal life events and relationships are
important triggers and consequences of mood episodes. Addressing interpersonal
difficulties reduces bipolar episode frequency.

Components of IPSRT
•​ Psychoeducation: Providing information about bipolar disorder, its course, treatment,
and the importance of mood stability.
•​ Social Rhythm Metric (SRM): A self-monitoring tool on which clients track the timing
and regularity of daily routines (wake time, meal times, social contact, activity levels,
bedtime). Irregularity in these rhythms is linked to mood destabilisation.
•​ Interpersonal work (IPT component): Addressing the same four focal areas as IPT
(grief, role disputes, role transitions, interpersonal deficits) as they relate to bipolar
disorder.

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Evidence Base
IPSRT has demonstrated effectiveness as an adjunct to pharmacotherapy for bipolar I disorder —
reducing episode frequency and improving social functioning. It is typically delivered in
conjunction with mood stabilisers.

5.5 Solution-Focused Brief Therapy (SFBT)

Developed by Steve de Shazer and Insoo Kim Berg at the Brief Family Therapy Centre,
Milwaukee, in the 1980s. SFBT is radically future-focused and non-pathologising.

Core Philosophy
•​ Build on strengths and solutions rather than exploring problems and deficits.
•​ The client is the expert on their own life.
•​ Small changes can produce large ripple effects.
•​ If it works, do more of it. If it doesn't work, do something different.
•​ The client does not need insight into the cause of the problem to solve it.

Key Assumptions of SFBT

•​ Every client has strengths and resources.
•​ Exceptions to the problem always exist — times when the problem is absent or less
severe. These exceptions contain the seeds of the solution.
•​ The therapeutic relationship is collaborative and egalitarian.
•​ Goals are small, concrete, positive, and meaningful to the client.

Core SFBT Techniques

•​ The Miracle Question: 'Suppose tonight while you sleep, a miracle happens and the
problem that brought you here is solved. When you wake up tomorrow, what would be
the first small sign that tells you something is different?' This helps the client articulate a
concrete, positive vision of their desired future.
•​ Scaling Questions: 'On a scale of 0–10, where 10 is the miracle and 0 is the worst the
problem has ever been, where are you today? What would a step up the scale look like?'
Scaling externalises progress, identifies resources, and sets small achievable goals.
•​ Exception Questions: 'Tell me about a time when the problem didn't happen / was less
bad. What was different? What were you doing?' Identifies client strengths and existing
solutions.
•​ Coping Questions: 'How have you managed to cope as well as you have, given how
difficult things have been?' Elicits resilience and strengths in the face of adversity.
•​ Compliments: The therapist genuinely identifies and verbalises client strengths and
resources, building self-efficacy.

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•​ Formula First Session Task: The client is asked to observe between sessions what they
want to continue to have happen in their life — directing attention toward existing
positives.

Evidence Base
SFBT has a growing evidence base, particularly in educational, child welfare, and community
settings. It has been found effective for depression, anxiety, and relationship problems. Its brevity
(typically 3–8 sessions) makes it highly cost-effective.

5.6 Eye Movement Desensitisation and Reprocessing (EMDR)

Developed by Francine Shapiro in 1987, originally for treating PTSD. EMDR is an eight-phase,
structured trauma-processing therapy that uses bilateral stimulation (typically lateral eye
movements) to facilitate the processing of traumatic memories.

Theoretical Basis: Adaptive Information Processing (AIP) Model

Shapiro's AIP model holds that:
•​ The brain has a natural information-processing system that digests disturbing experiences
and integrates them into adaptive memory networks.
•​ When a traumatic event is sufficiently overwhelming, it is stored dysfunctionally — in its
original, unprocessed form, with the original images, emotions, bodily sensations, and
maladaptive beliefs frozen in memory.
•​ Bilateral stimulation during EMDR activates and accelerates the information-processing
system, allowing the traumatic memory to be fully processed and integrated, losing its
disturbing quality.

The Eight Phases of EMDR

•​ Phase 1: History-Taking and Treatment Planning: Comprehensive client history;
identification of target memories; safety assessment.
•​ Phase 2: Preparation: Psychoeducation about EMDR; establishing safety (calm place
exercise); introducing bilateral stimulation; building therapeutic alliance.
•​ Phase 3: Assessment: Identifying the target memory and its components: image (worst
part of the memory), negative cognition (NC — belief about self, e.g., 'I am helpless'),
positive cognition (PC — desired belief, e.g., 'I have control now'), Validity of Cognition
(VOC — rating PC belief 1–7), emotion, SUDS (Subjective Units of Disturbance 0–10),
body sensation location.
•​ Phase 4: Desensitisation: Client holds the target image, NC, and body sensation in mind
while following bilateral stimulation (eye movements, taps, or auditory tones). Sets of
bilateral stimulation are interspersed with brief check-ins ('What are you noticing?'). The
client is instructed to 'just notice' whatever arises without judgment. Processing continues
until SUDS reaches 0 or 1.

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•​ Phase 5: Installation: The positive cognition is linked to the target memory and
strengthened using bilateral stimulation until VOC reaches 7.
•​ Phase 6: Body Scan: Client holds the target memory and PC together and scans the body
for any residual tension or disturbance.
•​ Phase 7: Closure: Returns the client to equilibrium at the end of each session, regardless
of whether processing is complete. Client uses the safe place or other containment
techniques.
•​ Phase 8: Re-evaluation: At the start of the next session, the therapist reviews the client's
experience since the last session and the current state of processed targets.

Evidence Base
EMDR is one of the most extensively researched and validated treatments for PTSD. It is listed
as a first-line treatment in NICE guidelines (UK), WHO guidelines, the International Society for
Traumatic Stress Studies (ISTSS), and the APA. Evidence also supports its use for phobias, panic
disorder, and other anxiety conditions.

Why Bilateral Stimulation Works — Current Understanding

The mechanism of action of bilateral stimulation remains debated:
•​ Working memory hypothesis: Bilateral stimulation taxes working memory, reducing the
vividness and emotional impact of traumatic images.
•​ REM sleep hypothesis: Bilateral stimulation mimics the eye movements of REM sleep,
during which memory consolidation occurs.
•​ Orienting response hypothesis: Bilateral stimulation activates an investigative orienting
response, facilitating information processing.
Some meta-analyses suggest that the bilateral stimulation component may not be the active
ingredient, and that EMDR's effectiveness may be largely attributable to the exposure component
(Phase 4). This remains a topic of active research.

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EXAM QUICK-REFERENCE SUMMARY

Key Theorists and Their Primary Contributions

Therapist Therapy Key Concept
Freud Psychoanalysis Unconscious, transference, free association,
Oedipus complex
Adler Individual Inferiority, social interest, lifestyle, birth order
Psychology
Klerman & Weissman IPT Interpersonal focus, four problem areas,
time-limited
Beck CBT Cognitive distortions, automatic thoughts,
collaborative empiricism
Ellis REBT ABC model, irrational beliefs, three core
musts, disputing
Perls Gestalt Here-and-now, empty chair, awareness,
unfinished business
Rogers PCT Actualising tendency, UPR, empathy,
congruence, UPR
Yalom Existential Ultimate concerns: death, freedom, isolation,
meaninglessness
Hayes ACT Psychological flexibility, hexaflex, defusion,
values
Linehan DBT Dialectic, biosocial theory, four skill modules,
BPD
Ryle CAT Reciprocal roles, SDR, reformulation letter
Frank IPSRT Social rhythm, circadian rhythms, bipolar
disorder
de Shazer/Berg SFBT Miracle question, scaling, exceptions,
strengths
Shapiro EMDR AIP model, bilateral stimulation, 8 phases,
PTSD
Prochaska & DiClemente TTM Stages of change, processes of change

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Lambert (1992) — The 40-30-15-15 Rule (Must Know!)

Extra-therapeutic factors 40% | Therapeutic relationship 30% | Expectancy/Placebo 15% |
Specific techniques 15%

Stages of Change — Quick Mnemonic: P-C-P-A-M

Precontemplation → Contemplation → Preparation → Action → Maintenance (→
Termination/Relapse)

Rogers' 6 Necessary and Sufficient Conditions

(1) Contact | (2) Client incongruence | (3) Therapist congruence | (4) UPR | (5) Empathic
understanding | (6) Client perceives UPR and empathy

EMDR 8 Phases — Mnemonic: H-P-A-D-I-B-C-R

History | Preparation | Assessment | Desensitisation | Installation | Body scan | Closure |
Re-evaluation

DBT 4 Skill Modules — Mnemonic: MDIE

Mindfulness | Distress Tolerance | Interpersonal Effectiveness | Emotion Regulation

ACT Hexaflex — 6 Processes

Acceptance | Defusion | Present Moment | Self-as-Context | Values | Committed Action

IPT 4 Problem Areas

Grief | Role disputes | Role transitions | Interpersonal deficits

APA Ethics — Limits of Confidentiality

Tarasoff / Duty to warn | Suicidal risk | Child/elder abuse | Court order | Supervision | Insurance
billing

Eysenck vs. Smith & Glass — Key Numbers

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Eysenck (1952): ~66% spontaneous remission (therapy no better than no treatment). Smith &
Glass (1977): effect size ≈ 0.85 (therapy client better off than ~75–80% of untreated controls).

Good luck tomorrow, Nam! You've got this.

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