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PSY 460: Counseling & Interviewing

Scott W. Plunkett, Ph.D. Contact Information
Professor of Psychology Sierra Hall #306e
California State University Northridge [Link]@[Link]
18111 Nordhoff Street [Link]
Northridge, CA 91330-8255

TABLE OF CONTENTS

Becoming a Therapist Overview ................................................................................................................................. 2

Professionalism / Ethics ............................................................................................................................................ 13
Traditional Diagnostic Vs. Transdiagnostic Approaches .......................................................................................... 19
Psychoanalytic & Psychodynamic Approaches ........................................................................................................ 21
Adlerian Therapy ...................................................................................................................................................... 30
Behaviorism Approaches .......................................................................................................................................... 34
Existentialism Therapy Approaches ......................................................................................................................... 40
Humanistic Therapy Approaches.............................................................................................................................. 44
Transactional Analysis (TA) ....................................................................................................................................... 47
Cognitive-Behavioral Therapy (CBT) Approaches..................................................................................................... 54
Genogram Family Mapping ...................................................................................................................................... 68
Family Systems Theory/Therapy .............................................................................................................................. 70
Circumplex Model of Family Dynamics .................................................................................................................... 83
Family Roles in Addicted Families ............................................................................................................................ 87
Brief Psychotherapy Approaches ............................................................................................................................. 88
Interpersonal Assessment ........................................................................................................................................ 93
Brief Overview and Links to Other Therapeutic Approaches ................................................................................... 98

A FEW COMMENTS

❖ Some studies/citations I present in this class might be old. They represent the classic literature on the
topic/theory OR have something unique that merits inclusion.
❖ I cite meta-analyses whenever possible since a meta-analysis determines an overall effect based on results
from multiple scientific studies on the topic (note: meta-analyses means more than one meta-analysis). I also
cite systematic reviews of literature to represent the overall knowledge on a topic.
❖ When I am giving my opinion, I state it is my opinion and denote it in green 9-point, Arial Narrow font.
❖ You don’t have to agree with the research, theories, or my opinions to be successful in this class. One of the
values of a university course is the exchange of ideas (while being respectful of others’ opinions).
❖ Terms I use in my notes.
 AKA = also known as
 e.g., = for example. It is used when listing examples.
• I like many types of foods (e.g., Thai, Persian, Italian).
 i.e., = that is, specifically, or in other words. It is used to clarify, explain, or specify.
• Tonight, I am going to order my favorite dessert (i.e., ice cream).
❖ If you see a typo or click a link that does not work, let me know so I can fix it for future
classes. Thanks!!!
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BECOMING A THERAPIST OVERVIEW

PSYCHOTHERAPY
❖ Comes from Greek word “psyche” (i.e., breath, soul, spirit) and “therapeuein/therapeia” (i.e., to cure or nurse).
❖ Psychotherapy is a deliberate interpersonal relationship by trained professionals to help a client relieve
distress or disability by using approaches and/or techniques based on a particular psychological theory or
paradigm. It is a blend of science (empirical support) and art (subjective/intuitive ability).1
❖ What is the difference between a counselor and a therapist?
 This is tricky. Although some states and many professionals make a distinction between the two, the more
important question is whether the mental health professional is a licensed practitioner.

PROS AND CONS OF BEING A LICENSED THERAPIST

❖ Pros
 Meaningful career and purpose.
 Help individuals, family, and society.
 Engage in a variety of activities (e.g., counseling, psychoeducation, writing, workshops).
 Flexible hours.
 Can be self-employed (e.g., private practice).
 Can work for an agency (e.g., paid vacation and benefits, agency might do the recruiting and billing).
❖ Cons
 Work with people who may not appreciate your help.
 Resistance by clients.
 Can’t help everyone.
 Stressful and emotionally exhausting (e.g., burn-out).
 Paperwork, and more paperwork. Did I mention paperwork?
 Sporadic hours to meet needs of clients.
 If self-employed (e.g., private practice).
• Uncertain salary (e.g., taking vacation may mean no salary).
• No paid benefits.
• The hassle of billing clients and/or insurance companies.
 Salary can be set or variable (depending on client load).

SOME DEGREES/MAJORS LEADING TO BECOMING A MENTAL HEALTH PRACTITIONER

Bachelor degrees and majors Master degrees Doctor degrees
Bachelor of Science (BS) and Arts (BA) Master of Science (MS) and Arts (MA) Doctor of Philosophy (PhD)
Bachelor of Social Work (BSW) Master of Social Work (MSW) Doctor of Social Work (DSW)
Potential Majors MS in Counseling (MSC) Doctor of Psychology (PsyD)
Psychology Master of Marriage & Family Therapy (MFT) Doctor of Marriage & Family Therapy (DMFT)
Child/Human Development Master of Education (MEd) Education Doctorate (EdD)
Sociology Master of Human Relations (MHR) Medical Doctorate (MD)
Social Work Clinical Psychology
Human Services School Counseling
Family Sciences School Psychology
Criminal Justice Criminal Justice
Anthropology Applied Behavioral Analyses
Premed College Counseling

1 Kay, S. R., & Vardy, M. M. (1984). Values and therapy orientations of psychotherapy trainees: A twelve-year update. Psychiatric Quarterly, 56(3), 198–208.
[Link]
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DEGREES LEADING TO LICENSURE

Licensed Clinical
Psychologists Focus Careers Plunk’s Thoughts
Severe Licensed clinical
Clinical Psychology PhD psychopathology, psychologist Advantages – potentially low cost, good practicum placements,
community mental health usually high licensing exam passage rates, smaller cohorts.
Counseling Psychology Community mental health, Professor Disadvantages – highly competitive, must balance
PhD social justice Research scientist research/teaching assistantships with coursework and practicums.
School Psychology PhD Assessment
Advantages – less competitive, more focused on practitioner
model, finish quicker.
Severe psychopathology, Licensed clinical
Clinical Psychology PsyD Disadvantages – expensive, possible limited practicum
community mental health psychologist
placements, oftentimes lower licensing exam passage rates,
much larger cohorts.
Master’s Level Therapists Focus Careers Plunk’s Thoughts
Licensed Marriage and Advantages – practitioner model, finish quicker than doctorate,
Family Therapist (LMFT) more therapy classes than LCSW.
Community mental health Licensed therapist Disadvantages – less training than doctorate, bill insurance at
Licensed Professional lower rates than doctorate, potential clients may think LMFT only
Clinical Counselor (LPCC)
works with couples/families.
Advantages – MSW is very marketable, practitioner model, finish
quicker than doctorate, classes on resources and social services,
potential master’s funding, can bill government insurance.
Licensed therapist
Licensed Clinical Social Community mental health / Disadvantages – less training than doctorate, bill insurance at
Worker (LCSW) advocacy / social justice Social worker lower rates than doctorate, less therapy classes, less known than
other therapy licensures, fieldwork classes during MSW don’t
count towards licensing hours, potential therapy clients may not
want to go to a “social worker.”
Commonalities – graduate degree in the relevant area, pass the licensing exam, 3000-3200 practicum hours.

PROFESSIONALS IN THE HUMAN SERVICES FIELD

❖ Licensed clinical psychologist
 Doctorate (PhD or PsyD) in clinical psychology, counseling psychology, or school psychology.
 In-depth training in psychotherapy and training in psychological assessment.
 In California, 3000 hours of supervised internship accrued over 2 years (minimum).
 Pass the Examination for Professional Practice in Psychology (EPPP) and pass the California Psychology
Supplemental Examination (CPSE).
 Helpful links
• 2017-2022 passage rates of psychology licensing exams by universities in each state:
[Link]
• Rankings of some PsyD programs: [Link]
• American Psychological Association accredited programs: [Link]
• Psychological Clinical Science Accreditation System list: [Link]
❖ Licensed professional clinical counselor (LPCC) / Licensed professional counselor (LPC) / Licensed mental
health counselor (LMHC) (the label varies by state)
 Master’s degree in counseling with specialized training in psychotherapy and psychological assessment.
 3,000 total supervised hours, over 104 weeks (minimum).
 Pass a licensing exam (i.e., written examination and written clinical vignette examination).
 Helpful links
• American Counseling Association: [Link]
• American Mental Health Counselors Association: [Link]
• California Association for Licensed Professional Clinical Counselor: [Link]
• California Mental Health Counselors Association: [Link]
• For more information in California: [Link]
❖ Licensed marriage and family therapist (LMFT)
 Doctorate or master's degree in marriage and family therapy with training in family and relationship issues,
psychotherapy, and psychological assessment.
 3,000 total supervised hours, over 104 weeks (minimum).
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 Pass a licensing exam (i.e., written examination and clinical vignette examination).
 Helpful links
• American Association for Marriage and Family Therapy: [Link]
• California Association for Marriage and Family Therapy: [Link]
• List of accredited MFT programs: [Link]
• For more information in California: [Link]
❖ Social worker
 Seeks to improve the life quality of underprivileged people and those who experience social injustices and
human rights violations by connecting clients to community/institutional resources and advocacy.
 Often requires a master’s degree in social work (MSW), but it varies by state.
 Provides direct services, advocacy, action research, policy changes, teaching, and community mobilization.
 Licensed clinical social worker (LCSW)
• MSW and additional courses in psychotherapy and psychological assessment.
• In California, 3,200 total supervised hours over 104 weeks (minimum).
• Pass a licensing exam (i.e., standard written examination and written clinical vignette examination).
 Helpful links
• ‘Best’ graduate programs in social work: [Link]
• National Association of Social Workers: [Link]
• Social work licensures/labels by state: [Link]
• For more information in California: [Link]
• Information about social work master’s program at CSUN: [Link]
❖ School psychologist
 Facilitates students’ abilities to learn and teachers’ abilities to teach by assessing and diagnosing students,
providing consultation and trainings to educators and parents, and coordinating school services (e.g.,
interventions, treatments).
 Licensed educational psychologist (LEP)
• Usually requires a master’s degree in appropriate area (e.g., school psychology).
• Three years of full-time experience in school psychology (e.g., one year in the credentialed graduate
program and two years working full-time as a school psychologist).
• Pass the LEP licensing exam.
 Helpful links
• National Association of School Psychologists: [Link]
• California Association of School Psychologists: [Link]
• For more information in California: [Link]
❖ School counselor
 Supports K-12 students in academics and life skills, provides career and college guidance, arranges speakers,
and provides referrals.
 Degree and training vary greatly by state (e.g., usually a master’s degree with required courses, teaching
certificate, years of teaching experience, and licensure or certification/credential).
 Helpful links
• American School Counselor Association: [Link]
• California Association of School Counselors: [Link]
• Requirements for California: [Link]
❖ College counselor
 Assist higher education students in academics, personal/social development, and career development.
 Often requires a master’s degree in college counseling and student personnel.
 Helpful links
• American College Counseling Association: [Link]
❖ Certified addiction counselor
 Delivers services to clients with substance use conditions.
 Helpful links
• National certifications can be found here: [Link]
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• California certifying agencies: [Link]

• List of California certifications can be found here: [Link]
❖ Applied behavior analyst (ABA)
 Apply behavior modification to clients based on results of behavioral assessments.
 Helpful links
• Association for Behavior Analysis International: [Link]
• California Association for Behavior Analysis: [Link]
• Certification levels (e.g., BCBA, BCaBA) and requirements: [Link]
• BCBA passage rate by university programs in each state: [Link]
❖ Psychiatrist
 Medical doctorate (e.g., M.D. or D.O.), complete a four-year psychiatric residency, and obtain certification
from the American Board of Psychiatry and Neurology (ABPN).
 Psychiatrists can prescribe and administer medication.
 Training focuses on the biological aspects of mental conditions with some training in psychotherapy.
 Assesses and treats mental illnesses through psychotherapy, hospitalization, and medication.
❖ Psychiatric-mental health nurse practitioner
 Master’s degree in advanced practice registered nursing (APRN) with additional training in psychotherapy
and administering psychiatric medication. APRN’s can prescribe medications in many states.
❖ Occupational therapist (OT)
 Works with patients who have a disabling condition (e.g., mental, physical, developmental, and/or
emotional). The goal is to improve patients’ abilities to perform necessary tasks in their day-to-day lives.
 Graduate degree program accredited by the Accreditation Council for Occupational Therapy Education,
complete supervised fieldwork, and pass the national certifying exam.
 Helpful links
• American Occupational Therapy Association: [Link]
• Occupational Therapy Association of California: [Link]
❖ Other useful links
 California passage rates for each university (LCSW, LEP, LMFT, LPCC): [Link]
 LMFT/LPCC, school psychology, school counseling, and college counseling master’s programs at CSUN: [Link]
education/educational-psychology-counseling
 The Centre for Data & Analysis on Psychology Licensure (for each state, provides types of licenses, licensing requirements, fees, continuing
education requirements, disciplinary actions): [Link]
 More information about licensing guidelines: [Link]
 Occupational Employment Statistics: [Link]

A FEW CERTIFICATIONS/TRAININGS IN PROFESSIONAL HUMAN SERVICES

❖ Child Abuse Mandated Reporter Training: [Link]
❖ Elder and Dependent Adult Mandated Reporter Training: [Link]
❖ Q.P.R. Suicide Prevention Training: Question, Persuade, Refer: [Link]
❖ Adult Mental Health First Aid: [Link]
❖ Mental Health First Aid for different groups (e.g., teens, older adults, first responders, Spanish speakers):
[Link]
❖ Psychological First Aid: [Link]
❖ Systematic Training for Effective Parenting: [Link]
❖ Parenting Effectiveness Training: [Link]
❖ Marital and premarital enrichment and assessment (e.g., Prepare Enrich): [Link]
❖ Sexuality educator, therapist, etc.: [Link]
❖ Mediation and conflict resolution: [Link]
❖ Child Development Teaching Permit: [Link]

© Scott W. Plunkett, Ph.D.

Summer2025 PSY 460: Counseling & Interviewing Page6

IS PSYCHOTHERAPY EFFECTIVE?
❖ Meta-analyses showed that clients in therapy showed more improvement than individuals who did not get
therapy, and these findings were consistent across types of treatment2 and various mental health disorders.3
❖ Consumer Reports study (n = approximately 3,000 people who had been in therapy in the last 3 years).4
 Over 90% of clients reported significant long-term improvement.
 Clients did worse when insurance/managed care limited choice of therapists or resulted in shorter therapy.
 Clients in long-term treatment did considerably better than clients in short-term treatment.
 No significant differences were found between types of psychotherapy on a variety of disorders.
❖ Wampold’s conclusions:5
 Psychotherapy is effective.
 Less important factors to effectiveness of therapy:
• Type of treatment.
• Theoretical basis of the techniques.
• Strictness of adherence to those techniques.
 More influential factors to effectiveness of therapy:
• The therapists’ strength of belief in the efficacy of the technique.
• The therapists’ personal qualities.
• The alliance between client and therapist (e.g., clients’ affectionate and trusting feelings toward the
therapists, clients’ motivation and collaboration, and therapist’s empathetic response).
❖ A meta-analysis compared cognitive behavior therapy, behavior activation therapy, psychodynamic therapy,
interpersonal therapy, supportive therapies, and other treatments.6
 All were all effective in treating depression.
 Cognitive behavior therapy was best when therapy sessions lasted 90 minutes or longer.
 Behavior activation therapy was best when therapy sessions lasted less than 90 minutes.
 Supportive therapies were less effective than other treatments at the end of treatment; however, at follow-
up, there were no significant differences.
❖ Is teletherapy effective?
 A meta-analysis found remote cognitive behavioral therapy (CBT) was better than controls on reducing
anxiety and depressive symptoms in older adults.7
 A meta-analysis found telepsychiatry was effective in decreasing suicide rates and reattempts.8
 Teletherapy versus in-person (i.e., face-to-face) therapy
• A meta-analysis found no significant differences between in-person therapy and teletherapy on (1)
posttreatment outcomes, (2) follow-up treatment outcomes, and (3) client attrition rates.9
o Telephone therapy had less risk of client attrition than videoconferencing therapy.
o Licensed therapists had less client attrition than trainee therapists in teletherapy.

2 Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., Jüni, P., & Cuijpers, P. (2016). Comparative efficacy of seven psychotherapeutic interventions for
patients with depression: A network meta-analysis. FOCUS, 14(2), 229-243. [Link]
3 Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32(9), 752-760. [Link]
066x.32.9.752
Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Johns Hopkins University Press.
4 Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50(12), 965–974.
[Link]
5 Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Lawrence Erlbaum Associates.
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies:
Empirically, "all must have prizes." Psychological Bulletin, 122(3), 203-215. [Link]
6 Braun, S. R., Gregor, B., & Tran, U. S. (2013). Comparing bona fide psychotherapies of depression in adults with two meta-analytical approaches. PLoS ONE, 8(6),
e68135. [Link]
7 Ando, M., Kao, Y.-C., Lee, Y.-C., Tai, S.-A., Mendez, S. R., Sasaki, K., Tang, W., & Papatheodorou, S. (2023). Remote cognitive behavioral therapy for older adults with
anxiety symptoms: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 30(9), 1376–1385. [Link]
8 Shoib, S., Shaheen, N., Anwar, A., Saad, A. M., Mohamed Akr, L., I Saud, A., Kundu, M., Nahidi, M., Chandradasa, M., Swed, S. , & Saeed, F. (2023). The effectiveness
of telehealth interventions in suicide prevention: A systematic review and meta-analysis. International Journal of Social Psychiatry, 70(3), 415–423.
[Link]
9 Lin, T., Heckman, T. G., & Anderson, T. (2022). The efficacy of synchronous teletherapy versus in-person therapy: A meta-analysis of randomized clinical trials.
Clinical Psychology: Science and Practice, 29(2), 167–178. [Link]
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• A meta-analysis found similar results for in-person CBT and technology-assisted CBT (e.g., phone,
videoconferencing) on depression and anxiety in children and young people.10
• A meta-analysis found video-based psychotherapy and in-person psychotherapy had (1) similar efficacy in
reducing depressive symptoms and (2) similar client attrition (i.e., dropout) rates.11
• A systematic review found no significant difference between in-person therapy and telephone therapy on
attentiveness, disclosure, empathy, participation, and therapeutic alliance, but telephone sessions were
significantly shorter than in-person sessions.12
• A meta-analysis found no significant difference between in-person therapy and videoconferencing on
client and therapist ratings of therapeutic alliance.13
• A meta-analysis found no significant difference between in-person therapy and online therapy on
patients’ expectation ratings and treatment outcomes.14
❖ Psychotherapy versus pharmacotherapy (medication)
 A meta-analysis found psychotherapy or combined psychotherapy and pharmacotherapy were more
effective than just pharmacotherapy in treating depression.15
 A meta-analysis found that psychotherapy was more effective than pharmacotherapy for generalized
anxiety disorder.16 Both psychotherapy and pharmacotherapy had medium effect sizes for depression.
 A meta-analysis found cognitive behavioral therapy (CBT) and pharmacotherapies combined were more
effective in treating depression than pharmacotherapies alone at the short- and long-term, but combined
therapies were not more effective than CBT alone at short or long-term.17
 Meta-analyses found that combined therapies (i.e., psychotherapy and pharmacotherapy) were significantly
more effective in treating depression18 and quality of life19 than either treatment by itself.
 75% of adult clients preferred psychotherapy over pharmacotherapy. Females and younger patients were
significantly more likely to choose psychotherapy than males and older adults.20
❖ Recent meta-analyses or systematic reviews on pharmacotherapy and addiction treatment
 Pharmacotherapy and opiate and alcohol dependence: [Link]
 Pharmacotherapy and alcohol dependence: (1) [Link]
(2) [Link]
 Pharmacotherapy and CBT for alcohol use disorders: [Link]
 Pharmacotherapy for amphetamine dependence: [Link]

10 Bevilacqua, L., Fox-Smith, L., Lampard, O., Rojas, N., Zavitsanou, G., Meiser-Stedman, R., & Beazley, P. (2024). Effectiveness of technology-assisted vs face-to-face
cognitive behavioural therapy for anxiety and depression in children and young people: A systematic review and meta-analysis. Clinical Child Psychology and
Psychiatry, 29(4), 1349–1364. [Link]
11
Giovanetti, A. K., Punt, S. E. W., Nelson, E.-L., & Ilardi, S. S. (2022). Teletherapy versus in-person psychotherapy for depression: A meta-analysis of randomized
controlled trials. Telemedicine and E-Health, 28(8), 1077–1089. [Link]
12 Irvine, A., Drew, P., Bower, P., Brooks, H., Gellatly, J., Armitage, C. J., Barkham, M., McMillan, D., & Bee, P. (2020). Are there interactional differences between
telephone and face-to-face psychological therapy? A systematic review of comparative studies. Journal of Affective Disorders, 265, 120–131.
[Link]
13 Seuling, P. D., Fendel, J. C., Spille, L., Göritz, A. S., & Schmidt, S. (2023). Therapeutic alliance in videoconferencing psychotherapy compared to psychotherapy in
person: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 30(10), 1521–1531. [Link]
14 Pontén, M., Jonsjö, M., Vadenmark, V., Moberg, E., Grannas, D., Andersson, G., Boersma, K., Hedman-Lagerlöf, E., Kleinstaeuber, M., Weise, C., Kaldo, V., Ljótsson,
B., Andersson, E., Axelsson, E., & Jensen, K. (2023). Association between expectations and clinical outcomes in online v. face-to-face therapy – an individual
participant data meta-analysis. Psychological Medicine, 54(6), 1207–1214. [Link]
15 Furukawa, T. A., Shinohara, K., Sahker, E., Karyotaki, E., Miguel, C., Ciharova, M., Bockting, C., Breedvelt, J., Tajika, A., Imai, H., Ostinelli, E. G., Sakata, M., Toyomoto,
R., Kishimoto, S., Ito, M., Furukawa, Y., Cipriani, A., Hollon, S. D., & Cuijpers, P. (2021). Initial treatment choices to achieve sustained response in major depression: A
systematic review and network meta-analysis. World Psychiatry, 20(3), 387–396. [Link]
16 Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., Ameringen, M.V., Smits, J. A. J., & Powers, M. B. (2019). Psychological and
pharmacological treatments for generalized anxiety disorder (GAD): A meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49(1), 1–21.
[Link]
17 Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other
psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta‐analysis including 409 trials with 52,702 patients. World
Psychiatry, 22(1), 105–115. [Link]
18 Kamenov, K., Twomey, C., Cabello, M., Prina, A. M., & Ayuso-Mateos, J. L. (2017). The efficacy of psychotherapy, pharmacotherapy and their combination on
functioning and quality of life in depression: A meta-analysis. Psychological Medicine, 47(3), 414-425. [Link]
Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A., & Furukawa, T. A. (2020). A network meta-analysis of the effects of psychotherapies,
pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92–107. [Link]
19 Kamenov et al. (2017)
20 McHugh, R. K., Whitton, S. W., Peckham, A. D., Welge, J. A., & Otto, M. W. (2013). Patient preference for psychological vs ph armacologic treatment of psychiatric
disorders. The Journal of Clinical Psychiatry, 74(06), 595–602. [Link]
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❖ Recent meta-analyses or systematic reviews on pharmacotherapy and psychedelics

 Risk–benefit profile of classical psychedelics: [Link]
 Psychedelic treatments for psychiatric disorders: [Link]
 Adverse effects of psychedelics in clinical treatments: [Link]
 Microdosing psychedelics: [Link]
 Psychedelic therapy for addiction: [Link]
 Cautionary notes on the psychedelic research:
(1) [Link]
(2) [Link]
drugs/F3FDF49E14AAF4D12036BFFC047357B4

PSYCHOTHERAPY COMMONALITIES21
❖ Psychotherapists uses genuinely caring dialogue in a supportive manner with clients.
 Help clients manage issues through empathy, caring, and authenticity.
 Therapist empathy was a moderately strong predictor of clients’ therapeutic outcomes. 22
❖ Psychotherapists emphasizes clients’ self-awareness (“Making the unconscious conscious” – Freud).
 Help clients understand biological, social, and personal motivations.
 Help clients examine conflicts between needs and societal or self-imposed standards.
 Help clients understand defensive mechanisms.
❖ Psychotherapists facilitates client autonomy and self-responsibility.
 Help clients discover and use their own resources.
 Although clients initially rely upon support from the therapist, the goal is to help clients be self-sufficient.
❖ Psychotherapists helps clients discover more conscious and/or higher motivations and self-worth.
 Help clients develop competence and esteem.
 Help clients develop creativity and compassion.
 Help clients feel valuable to oneself and to others.

CLIENT QUALITIES THAT CAN DECREASE EFFECTIVENESS23

❖ Having a lack of motivation.
❖ Being resistant to being controlled by others.
❖ Engaging in resistance to therapy (e.g., unresponsive, not doing homework).
❖ Being hypersensitive.
❖ Having extreme interpersonal dependency and low ego strength.
❖ Having personality disorders (e.g., borderline personality disorder).
❖ Having high levels of antisocial, paranoid, psychotic, or masochistic characteristics.
❖ Aggressive or inappropriate clients
 Most psychologists have felt threatened by clients.24
• Over 80% of psychologists reported being afraid a client would attack them.
• Almost 20% of psychologists reported being physically attacked by at least one client.
• Over 50% of psychologists reported having fantasies a client would attack them.
• Over 25% of psychologists had called security or police for protection from a client.
• About 3% of psychologists reported obtaining a weapon to protect themselves against a client.

21 [Link]
22 Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399-410.
[Link]
23 Castonguay, L. G., Boswell, J. F., Constantino, M. J., Goldfried, M. R., & Hill, C. E. (2010). Training implications of harmful effects of psychological treatments.
American Psychologist, 65(1), 34-49. [Link]
24 Pope, K. S., Vasquez, M. J. T., Chavez-Dueñas, N. Y., & Adames, H. Y. (2021). Ethics in psychotherapy and counseling: A practical guide (6th edition). John Wiley &
Sons.
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 Most psychologists,25 mental health nurses,26 and psychiatrists27 have been victims of stalking behaviors
(e.g., harassment) by at least one client.
 Psychologists’ responses to stalking and harassing behaviors by a client:28
• 33% increased workplace security (66% felt it was effective).
• 18% increased home security (53% felt it was effective).
• 55% confronted the client directly (57% felt it was effective).
• 36% referred clients (43% felt it was effective).
• 5% had the client arrested, and 7% got a restraining order.
• 35% sought advice/assistance from family members or friends (80% felt it was effective).
• 22% sought advice/assistance from police (68% felt it was effective).
• 28% sought advice/assistance from a lawyer (77% felt it was effective).
• 11% sought advice/assistance from a psychotherapist (56% felt it was effective).
• 18% sought advice/assistance from a professional indemnity provider (67% felt it was effective).

CRITIQUES AGAINST THERAPY

❖ No difference was found between psychotherapy and placebo controls.29
❖ People recovered from and found solutions to crises and social problems before psychotherapy came along.
Thus, healing will occur without therapeutic intervention (i.e., just need time and support from others).
 Most “neurotics” would recover without therapy at similar rates as if they had been therapy clients. 30
❖ There is limited/skewed data on which form of psychotherapy is most effective for which issue.
❖ Power differential – There is often a power differential in psychotherapy where the client/patient has little
power in the session, while the psychotherapist has an inordinate amount of power.
❖ Psychotherapists may intentionally or unintentionally force their values and beliefs on clients without taking
into consideration the clients’ values and beliefs. Therapists must be cautious about:
 Forcing values on clients who are in unstable state.
 Undermining alternative ideas or explanations (e.g., spiritual, political, feminist, economic, cultural).
❖ Dropout rate (i.e., premature discontinuation) is high.
 Meta-analyses have found that dropout rates during therapy vary from 17-26%.31
 Children and youth had a 14.6% dropout rate from depression psychotherapy interventions. 32
 In general, meta-analyses have found dropout rates did not seem to vary by therapeutic approach. 33
 Depression diagnosis had the highest dropout rate. E-therapy format had the highest dropout rate.
However, dropout was not significantly associated with the therapist’s licensure status.34

25 Kivisto, A. J., & Kivisto, K. L. (2018). Risk management with clients who stalk, threaten, and harass mental health professio nals. American Journal of Psychotherapy,
71(3), 110–120. [Link]
26 Ashmore, R., Jones, J., Jackson, A., & Smoyak, S. (2006). A survey of mental health nurses’ experiences of stalking. Journal of Psychiatric and Mental Health Nursing,

13(5), 562–569. [Link]

27 Mcivor, R. J., Potter, L., & Davies, L. (2008). Stalking behaviour by patients towards psychiatrists in a large mental health organization. International Journal of Social

Psychiatry, 54(4), 350–357. [Link]

28 Kivisto & Kivisto (2018)
29 Prioleau, L., Murdock, M., & Brody, N. (1983). An analysis of psychotherapy versus placebo studies. Behavioral and Brain Sciences, 6(02), 275.

[Link]
30 Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16(5), 319–324. [Link]
31 Cooper, A. A., & Conklin, L. R. (2015). Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials. Clinical Psychology

Review, 40, 57–65. [Link]

Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators.
Journal of Consulting and Clinical Psychology, 83(6), 1108–1122. [Link]
Gersh, E., Hallford, D. J., Rice, S. M., Kazantzis, N., Gersh, H., Gersh, B., & McCarty, C. A. (2017). Systematic review and meta-analysis of dropout rates in individual
psychotherapy for generalized anxiety disorder. Journal of Anxiety Disorders, 52, 25–33. [Link]
Leichsenring, F., Sarrar, L., & Steinert, C. (2019). Drop‐outs in psychotherapy: A change of perspective. World Psychiatry, 18(1), 32–33.
[Link]
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–
559. [Link]
32 Wright, I., Mughal, F., Bowers, G., & Meiser-Stedman, R. (2021). Dropout from randomised controlled trials of psychological treatments for depression in children

and youth: A systematic review and meta-analyses. Journal of Affective Disorders, 281, 880–890. [Link]
33 Leichsenring et al. (2019)
34 Fernandez et al. (2015)

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Reasons for dropping out:


• Dissatisfaction with the quality of therapy and/or therapy was not working.
• First session was not effective.
• Having a therapist who is perceived as having low multicultural competence/humility.
• Weak therapeutic alliance.
• Financial issues.
• Time.
❖ Some people do not get better from psychotherapy. 35
❖ Some people got worse during psychotherapy.
 5-10% got worse during treatment.36
 10-15% got worse during substance abuse treatment.37
 There are potentially harmful treatments.

WHAT COULD MAKE PSYCHOTHERAPY POTENTIALLY HARMFUL?38

❖ Inadequate assessment.
 Therapist misidentified the client’s most critical issue.
 Therapist failed to assess important characteristics or personality traits of the client.
❖ Lack of match (i.e., poor fit) between the therapist and client.
❖ Weak client-therapist alliance and/or poor collaboration between the client and therapist.
❖ The intervention becomes more about the therapist’s issues than the client’s issues.
❖ Therapists treat outside their expertise area.
 Unskilled or inappropriate use of interventions.
 When a therapist “treats” a client ineffectively or detrimentally, then the opportunity cost is that the client
does not seek out effective treatment.
❖ Negative behaviors by the therapist.
 Having or displaying a lack of empathy toward the clients.
 Providing contradictory messages/information.
 Engaging in confrontational self-disclosures.
 Engaging in hostile control (e.g., belittling, blaming) or insensitive separation (e.g., ignoring, neglecting).
 Therapists tended to be more unfavorable toward their clients when they had worse views of themselves,
possibly due to how they were treated as children.
• When therapists recalled negative memories of parents during their childhood, they had more negative
interpersonal processes during therapy sessions, which related to more negative treatment outcomes.
 Not recognizing or managing countertransference reactions effectively.
• Power struggles can develop when clients engage in resistance (e.g., silence, disagreements) and the
therapist is overly persistent with transference interpretations.
 Engaging in less affiliative autonomy granting (e.g., not affirming or understanding client’s feelings/views).
❖ Using treatment that is not evidence-based and/or that have been shown to be potentially harmful.
❖ Using treatment which incorporates forced confrontation that arouses intense emotional reactions (e.g., boot
camp interventions for conduct disorder, recovered memory techniques, conversion programs).

35 Castonguay, L. G., Boswell, J. F., Constantino, M. J., Goldfried, M. R., & Hill, C. E. (2010). Training implications of harmful effects of psychological treatments.
American Psychologist, 65(1), 34-49. [Link]
36 Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and
behavior change (5th ed., pp. 139–193). Wiley.
37 Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2(1), 53-70. [Link]
6916.2007.00029.x
38 Castonguay et al. (2010).
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Summer2025 PSY 460: Counseling & Interviewing Page11

META-ANALYSIS OF 51 QUALITATIVE STUDIES39

Negative Views of Negative Impacts of
Perceived Therapist Misbehaviors Therapist/Client Relationship Treatment Treatment
Detached or Poor fit with Unpleasant feeling
Devaluated clients 56% 44% 65% 60%
unempathetic intervention during therapy
Engaged in inappropriate verbal reactions Felt a poor fit/match with Dissatisfaction with
40% 25% 50% Fear of therapy process 50%
(e.g., vulgarity, yelling, lecturing) therapist therapy termination
Felt confused/annoyed Lack of change from
Misunderstood clients 37% 23% Unmet expectations 33% 46%
in therapy therapy
Negative views of Worse problems after
Incompetent/inexperienced therapist 37% Did not trust therapist 21% 33% 37%
treatment therapy
Resignation (i.e., loss of
Judged clients 33% 23%
motivation or hope)
Violated boundaries (e.g., physically, dual
relationships, violated confidentiality, 27%
inappropriate self-disclosure)
Did not listen or care 17%
% = the percent of studies where the issue was mentioned by clients

CULTURALLY RESPONSIVE THERAPY

❖ Cultural competence versus cultural humility40
 Cultural/Multicultural competence (AKA awareness, knowledge, sensitivity) in therapy refers to learning
about diverse people’s cultures and beliefs, and then applying the awareness, knowledge, and skills to be
more effective in treating diverse clients.
• Cultural influences vary across time and location. Thus, cultural competence learned in graduate school or
workshops could become outdated, not relevant in a particular area, or not apply to a specific client.
• Cultural competence does not usually involve the therapists’ introspection about their own values, biases,
and filters. Yet, some conceptualizations of cultural competence incorporate therapists’ introspection. 41
 Cultural humility in therapy refers to a lifelong process of introspection and self-critique regarding one’s
beliefs and various cultural identities while learning about other people’s culture to try and redress power
imbalances and to build authentic and trustworthy relationships.
• Cultural humility is not just focused on race/ethnicity; it includes intersections between multiple identities
of both the therapist and client (e.g., national origin, race, ethnicity, faith, age, income, gender, sexual
orientation, abilities, education, immigration status, location, political views, professional socialization).
• Cultural humility acknowledges that the more exposure you have to other cultures, the more you realize
how much you don’t know about others.
 Becoming culturally competent – [Link]
❖ Culturally responsive therapy – Applying cultural humility to embrace the client’s cultural beliefs, values, and
behaviors in the therapeutic process.
 Steps to culturally responsive therapy
• Therapists should engage in cultural humility.
• Therapists should understand their position in the sociocultural hierarchy (i.e., positionality).
• Therapists should reflect on their cultural values, assumptions, biases, and privileges, and how these
shape their beliefs and interactions.
• Therapists should recognize structural oppressions that impact their biases and their clients’ well-being.
• Therapists should learn how clients’ cultures influence their perception of the therapist and therapy.
o Thus, therapists should explore client’s perspectives on pursuing therapy and the therapeutic
relationship.

39 Vybíral, Z., Ogles, B. M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023). Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-
analysis. Psychotherapy Research, 34(3), 279–292. [Link]
40 Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural
education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. [Link]
Yeager, K. A., & Bauer-Wu, S. (2013). Cultural humility: Essential foundation for clinical researchers. Applied Nursing Research, 26(4), 251–256.
[Link]
41 Pedersen, P. B. (2002). The making of a culturally competent counselor. Online Readings in Psychology and Culture, 10(3). [Link]
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• Therapists should explore how clients define/label a presenting problem in their cultural environments.
o Example – A therapist misinterprets Mexican parents’ saying “Mi niño no es bien educado” as meaning
their child is not well educated. The parents are probably trying to say their child is not behaving well-
mannered or appropriately in the family and community. It is important for the therapist and parents to
have the same starting point when defining and exploring the perceived issue(s) of the child.
• Therapists should learn how their clients express emotions and in what circumstances, such as:
o Asking clients how emotions are expressed in their family.
o Asking clients to identify emotions they had in various situations and how they showed their feelings.
• Therapists should identify and integrate clients’ cultural strengths and resources.
• Therapists should be aware of, and open to, other cultural practices in healing and ways of coping (e.g.,
talking to religious leaders, prayer, meditation, spiritual coping, social support, indigenous healing
methods, wholistic healing). Therapists should support clients who use or find meaning in these methods.
• Therapists should check their assumptions.
• Therapists should be able to admit when they do not grasp their clients’ perceptions, values, beliefs, etc.
• Therapists should align or adapt their treatments to their individual clients’ multiple cultural backgrounds.
 Culturally responsive therapy outcomes.
• Having a therapist who is perceived as having low multicultural competence was related to increased risk
of premature termination of therapy (i.e., dropping out). 42
• A meta-analysis found clients’ ratings of therapists’ cultural competence were strongly related to therapy
outcomes; yet, therapists’ self-rated cultural competency were not significantly related to the outcomes.43
• A meta-analysis found therapists’ cultural competence was related to better treatment outcomes and
clinical processes (e.g., better working alliance, higher client satisfaction, better counseling competence,
more session depth).44
• When compared to no treatment and secular psychotherapies, religious/spiritual adapted psychotherapy
demonstrated greater improvement in clients’ psychological and spiritual functioning.45
• Another meta-analysis found that making spiritual/religious adaptations to therapy was beneficial to
clients and seemed to promote well-being and life quality more than secular psychotherapies. 46
❖ Cultural adaptations of mental health treatment – Making treatment adaptations based on a client’s culture,
language, and context to be more compatible with the client’s cultural beliefs and values. 47
 A culturally adapted treatment could incorporate cultural metaphors, language adaptations (e.g., dialects,
culture specific jargon), cultural values (collectivistic versus individualistic), etc.
• Example – The Los Niños Bien Educado (LNBE) parenting program is a cultural adaptation of the Confident
Parenting Program. LNBE is taught in both Spanish and English, uses Hispanic names and proverbs (i.e.,
dichos), and addresses challenges parents may have after immigrating from a Latin American country to
the USA.
 Two meta-analyses found culturally adapted psychotherapy/treatments were more effective in promoting
clients’ psychological functioning than non-adapted psychotherapy/treatments and/or no treatments. 48
 There are treatments/programs that are culturally specific (i.e., developed specifically for a group from the
very beginning) versus cultural adaptations.

42 Anderson, K. N., Bautista, C. L., & Hope, D. A. (2019). Therapeutic alliance, cultural competence and minority status in prem ature termination of psychotherapy.
American Journal of Orthopsychiatry, 89(1), 104–114. [Link]
43 Soto, A., Smith, T. B., Griner, D., Domenech Rodríguez, M., & Bernal, G. (2018). Cultural adaptations and therapist multicultural competence: Two meta-analytic
reviews. Journal of Clinical Psychology, 74(11), 1907–1923. [Link]
44 Tao, K. W., Owen, J., Pace, B. T., & Imel, Z. E. (2015). A meta‐analysis of multicultural competencies and psychotherapy process and outcome. Journal of Counseling
Psychology, 62(3), 337–350. [Link]
45 Captari, L. E., Hook, J. N., Hoyt, W., Davis, D. E., McElroy-Heltzel, S. E., & Worthington, E. L. (2018). Integrating clients’ religion and spirituality within psychotherapy:
A comprehensive meta-analysis. Journal of Clinical Psychology, 74(11), 1938–1951. [Link]
46 Smith, T. B., Bartz, J., & Scott Richards, P. (2007). Outcomes of religious and spiritual adaptations to psychotherapy: A meta‐analytic review. Psychotherapy
Research, 17(6), 643–655. [Link]
47 Soto et al. (2018)
48 Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of
Counseling Psychology, 58(3), 279–289. [Link]
Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy,
47(6), 993–1014. [Link]
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❖ Racial/Ethnic matching between client and therapist – A meta-analysis49 found:

 Cients preferred therapists from the same racial/ethnic background.
 Clients had slightly more positive perceptions of therapists from their own race/ethnicity compared to other
therapists.
 Racial/ethnic matching of clients with therapists resulted in very little benefit to clients’ treatment
outcomes.

PROFESSIONALISM / ETHICS

PROFESSION
❖ A vocation that requires advanced education, training, and skills (intellectual or physical).
❖ A professional is expected to have a set of values, attitudes, skills, and behaviors that coincide with the
standards established by the professional group to which they belong.
 Examples: American Psychological Association ([Link] Association for Psychological Science
([Link] Association for Behavioral and Cognitive Therapies ([Link]
❖ Certification – A program established by a profession to ascertain the competence of its members.
❖ Accreditation – Peer evaluation of institutions to ensure the program meets a minimum standard.
 Accreditation is important to ensure professionals receive quality training in the program.
❖ Characteristics of a profession
 Provides a benefit to society.
 Mastery of knowledge involving intellectual activity and practical judgments related to their work.
 Has a self-regulation process to determine who is admitted and who is expelled.
 Requires continuing education/training.
 Has a code of ethics or guidelines for professional practice.
❖ Professional indoctrination (socialization) – A process of instilling a person with ideas, beliefs, attitudes,
cognitive strategies, and/or skills and methodologies associated with a specific profession.
 Choosing a profession generally means subscribing to its values and agreeing to follow its codes of conduct.
 Professional indoctrination generally begins during the education or training programs.
• Students start learning terminology, history, values, and beliefs of a profession during their education.
• Students usually get more professional socialization in a graduate program than an undergraduate
program. For example, psychology undergraduates learn about many psychology fields. In a clinical
psychology graduate program, they get much more specific indoctrination in the psychotherapy field.
 New employee orientations generally emphasize the values, beliefs, and policies of the organization, which
generally reiterate the values of the profession.

ETHICAL/PROFESSIONAL PRINCIPLES
❖ Ensure clients’ welfare by protecting clients’ interests and contributing to clients’ welfare and growth.
 Not exploiting clients (this would include inappropriate relationships).
 Not harming clients by avoiding or engaging in actions that place them at risk of harm.
❖ Practice with competence by possessing and maintaining appropriate knowledge, skills, and abilities required
by the profession (e.g., appropriate degrees, experiences, continuing education).
 Some therapists provide treatment to clients even though it is outside of their expertise area. This is
problematic. First, they may not be able to help the client. Second, treating the client may have kept the
client from getting more effective treatment. Thus, they are not ensuring the welfare of the client.
❖ Be accountable/responsible for your actions and ensuring services are provided properly.
❖ Maintain integrity by keeping promises, being honest, and maintaining commitments.
49 Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions,
and outcomes. Journal of Counseling Psychology, 58(4), 537–554. [Link]
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❖ Enhance autonomy by respecting autonomy of others and by helping them make their own choices.
 Developing personal autonomy occurs through (1) being task/goal oriented instead of ‘clock’ oriented and
(2) not requiring constant supervision.
❖ Protect confidentiality by keeping to oneself information obtained about others during professional work.
❖ Support fairness/justice by treating people fairly/equally and disregarding irrelevant factors when treating
others.
❖ Maintain professional relationships by acting with regard for the needs, special competencies, and obligations
of colleagues. Being loyal and respectful to colleagues.

ETHICS
❖ Principles of conduct (written or unwritten) that govern an individual, profession, and/or society and that also
guide behavior.
❖ Code of ethics/conduct
 A common set of values adhered to by a body of practicing professionals.
 A code of ethics operationalizes the guidelines for professional behavior for members of the profession.
 Purposes of code of ethics.
• Educative code of ethics provides guidance and increases awareness and ethical inquiry.
• Regulatory or disciplinary code of ethics (i.e., codes of professional conduct) stipulate appropriate
conduct to try and regulate or control professional members’ behaviors. They are often more narrowly
defined and more specific than ethical principles.
❖ Ethical awareness involves continuous questioning and taking personal responsibility for choices.
 Being aware of codes of ethics and legal standards is a vital component of the critical thinking necessary to
make ethical decisions.
 The existence and enforcement of codes of ethics are related to more ethical behavior. 50
❖ Professional organization codes of ethics in helping professions
 American Psychological Association ethics guide: [Link]
 Social work code of ethics: [Link]
 Marriage and family therapist code of ethics: [Link]
 American counseling association code of ethics: [Link]
 School psychologist code of ethics: [Link]
 School counseling code of ethics: [Link]
 ABA code of ethics: [Link]

ETHICAL DILEMMAS
❖ A situation that results in internal conflict in considering what is the “right” thing to do.
❖ When confronted with an ethical dilemma, one should take the following steps:
1. Recognize the dilemma:
 Is there a dilemma? What is the dilemma?
 Have you defined the dilemma accurately? Do others see the dilemma differently? How would you define
the dilemma if you were on the other side of the issue?
2. Consider the alternatives:
 What should you do? Brainstorm and consider other possibilities.
 Can you discuss the problem with affected parties before you make your decision?
3. Consider the likely consequences of each alternative:
 What will happen if you do the following?
 Will the person involved be happy with the consequences?
 How does each alternative compare with the probable results?
 Whom could your decision or action harm?
4. Select a plan of action:

50 Ferrell, O. C., & Skinner, S. J. (1988). Ethical behavior and bureaucratic structure in marketing research organizations. Journal of Marketing Research, 25(1), 103-109.
[Link]
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Follow through and make a decision.

 Remember most decisions can be altered or revised.
5. Evaluate your decision.
 Is it legal?
• Will you be violating policy? code of ethics or standards of conduct? civil, state, or federal law?
 Is it fair/morally acceptable?
• Is it fair to all concerned in the short-term/long-term? Does it promote win-win situations?
• Will the people involved accept the decision? Do all those involved believe this is the “right” decision?
 Is it personally acceptable?
• Would it make you feel good about yourself?
• Would you feel good if the decision were published (e.g., on webpage)?
• Would you be willing to tell others about your decision?
• Would you feel good if your family, friends, colleagues knew about the decision?

CONFIDENTIALITY VS. PRIVILEGED COMMUNICATION

❖ Confidentiality – Not disclosing information about clients learned in a professional relationship without their
appropriate consent (e.g., written), except when required by law or when necessary for the client’s well-being.
❖ Privileged communication refers to a legal standard where the therapist should not disclose certain
information about the client against the client’s will.
 Duty-to-warn principle – It is the responsibility of mental health practitioners (e.g., therapist) and health
professionals (e.g., doctor) to inform third parties or authorities if a client/patient poses a threat to
themselves or another identifiable person.
 “The protective privilege ends where the public peril begins.”51
❖ Mandated reporter is a professional with regular contact with vulnerable populations who is legally required
to report when a client/patient is a danger to self or others, and/or there is reason to believe the client, minor
child, or dependent adult has been a victim of a crime, incest, rape, child abuse, elder abuse.
 Mandated reporters include mental health workers, health care professionals, educators, caregivers,
childcare providers, law enforcement officers, social workers, medical examiners, etc.
 California trainings on mandated reporting are listed on page 5.

BOUNDARIES & BOUNDARY VIOLATIONS

❖ Boundary crossing – When a therapist strays from the strictest professional role. 52
 Can be helpful, neutral, or harmful.
“Nonsexual boundary crossings can enrich therapy, serve the treatment plan, and strengthen the therapist -client working relationship. They can also undermine the
therapy, severe the therapist-patient alliance, and cause immediate or long-term harm to the client. Choices about whether to cross a boundary confront us daily, are
often subtle and complex, and can sometimes influence whether therapy progresses, stalls, or ends.”53
 Potentially helpful or neutral (depending on the context) boundary crossings:
• A therapist is driving in a snowstorm and sees the client walking in the snow. The therapist offers the
client a ride home or to local transportation (e.g., bus station).
o What could be possible negative consequences?
o What other actions might the therapist have done?
o The therapist should (1) act professionally in the car (e.g., deferring therapy issues to the next meeting);
(2) document the situation and context; (3) debrief the client about the situation at the next session;
and (4) document the debriefing. 54
 The challenge is determining when circumstances justify a boundary crossing.

51 Tarasoff v. Regents of the University of California (1976)

52 Knapp, S., & Slattery, J. (2004). Professional boundaries
in nontraditional settings. Professional Psychology: Research & Practice, 35(5), 553-558. [Link]
53 Appelbaum, P., & Gutheil, T. (2007). Clinical handbook of psychiatry & the law, 4th edition. Lippincott Williams & Wilkins.
54 Barnett, J. (2007). Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38(4), 401-410.

[Link]
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❖ Mistaken assumptions related to boundary crossings.55

 Interactions with clients outside of therapy (i.e., boundary crossing) are not related to the therapy.
 Interactions with clients outside therapy have the same meaning as the same interaction with non-clients.
 The client and therapist attribute the same meaning to the boundary crossing.
 A boundary crossing that helps one client will be just as effective with a different client.
 Boundary crossings are trivial isolated events.
 The therapist does not see any negative issues/outcomes from the boundary crossing.
 Self-disclosure is always therapeutic since it shows authenticity and builds trust.
❖ Beneficial boundary crossings
 Beneficial boundary crossings should be consistent with treatment goals, such as:
• Engaging in self-disclosure to help a client (more on this in the ‘self-disclosure’ section).
• Attending important events for clients (e.g., attending graduation when therapy was for bad grades).
• Accompanying an agoraphobic client to an open space or an addict to the first 12-step meeting.
 Many theoretical perspectives support the use of therapeutic boundary crossings, such as:
• Cognitive-behavioral, family systems, existential, humanistic, feminist, multicultural.
 When engaging in a planned therapeutic boundary crossing with client, the therapist should:56
• Ensure the boundary crossing:
o Is consistent with the client’s treatment plan,
o Is in the best interests of the client, and
o Is consistent with the client’s values, culture, diagnosis, etc.
• If possible, discuss the boundary crossing with another therapist ahead of time.
• Document the boundary crossing beforehand (e.g., rationale, context).
• Discuss it with the client beforehand to assess client’s comfort and to prevent misunderstandings.
• Act professionally during the boundary crossing.
• Afterwards, debrief the client (e.g., why it occurred, impact on therapy) and document the debriefing.
❖ Boundary violations occur when therapists cross the line of integrity/decency and/or misuse their power to
exploit the client for their own benefit.57
 Boundary violations occur when therapists:
• Have a lack of understanding regarding boundaries.
• Are not aware of their own boundaries.
• Do not understand their client’s boundaries.
o Example: A therapist hugs a client who is uncomfortable hugging or who perceives hugging as sexual.
• Make inaccurate assumptions about a client’s ability to communicate when a boundary has been crossed.
o Example: The client is too polite or too timid to confront the therapist.
 Boundary violation examples:58
• Inappropriate or exploitive self-disclosure, touch, exchange of gifts, bartering in place of fees,
dual/multiple relationships, length/location of sessions, or contact outside the office.
• Harassing a client not to terminate therapy.
• Hugging clients may be inappropriate because clients may be unable to voice it is uncomfortable, and/or
clients may have problems establishing appropriate boundaries. Example: In a youth shelter, some clients
came from sexually exploitive backgrounds, and hugs were often a gateway to other sexual behaviors.
 Ethical principles related to boundary violations:59
• It is always a therapist’s responsibility to set and maintain appropriate boundaries.
• When boundaries are crossed, both parties are involved, but the client should not be blamed or
stigmatized for crossing boundaries.

55 Pope & Keith-Spiegel (2008)

56 Pope, K., & Keith-Spiegel, P. (2008). A practical approach to boundaries in psychotherapy: Making decisions, bypassing blunders, and mending fences . Journal of
Clinical Psychology, 64(5), 638-652. [Link]
57 Zur, O. (2004). To cross or not to cross: Do boundaries in therapy protect or harm. Psychotherapy Bulletin, 39(3), 27-32.
58 Gutheil, T. G., & Gabbard, G. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155(3),
409-414. [Link]
59 Gutheil, T. G., & Brodsky, A. (2008). Preventing boundary violations in clinical practice. Guilford Press
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• Exploration of boundary violations in a clinically sensitive, but candid, manner can be beneficial to the
client and profession.
 To avoid boundary violations, therapists need to:
• Be aware of the ethical codes and legal standards.
• Be aware of the literature on boundary violations.
• Be aware of their own boundaries.
• Consult with a respected colleague about possible boundary violations.
• Be vigilant in identifying when a client’s boundaries seem to have been violated.
• Educate and empower their clients to know their own boundaries and to express when they feel their
boundaries may have been violated.

DUAL/MULTIPLE RELATIONSHIPS
❖ Situations where a therapist and a client have a therapist/client relationship and other relationship(s).
❖ Dual/multiple relationships between a therapist and client are boundary crossings, but they are not always
boundary violations.
 Client and therapist as sexual partners is a boundary violation.
• About 50% of psychologists in a mail survey indicated they had provided therapeutic services to at least
one client who said they had been sexually intimate with another therapist. 60
• No significant differences in rates were found between psychiatrists, psychologists, and social workers
who acknowledged engaging in sex with their patients. 61
• In an analysis of national studies, no significant differences were found between professions on sex with
clients once other factors were held constant. 62
 Client is a business associate of the therapist. What if the business is viewed bad by the client or therapist?
 Client is an employee of the therapist. What if the therapist needs to fire the client?
 Client loans or borrows money from the therapist. What if the therapist loans money to help the client buy
medication or use public transportation?
 Client and therapist attend social outings together. What if the therapist is invited to a client’s wedding? Is
in the same sports league as the client? Frequents the same bar, club, or religious setting as the client?
 Client is therapist’s family member. What about distant relative?
 Client is therapist’s close friend. What about a casual friend?
 Client is a close friend’s child. What if the close friend’s child says they are being physically or sexually
abused by the parent(s)?
 Client is a student of the therapist. What if the student asks to turn in an assignment late, and then says to
the therapist/teacher, “You know what I am going through at home.”
❖ According to the APA, dual/multiple relationships are not considered unethical when they are not reasonably
expected to cause harm, produce impairment, or risk exploitation.63
❖ Nonsexual and non-exploitive dual relationships are viewed positively in some therapeutic approaches.
❖ Male therapists were more likely to have nonsexual dual relationships with opposite sex clients compared
female therapists.64
“In the many cases in which I have testified as an expert witness regarding abuses in psychotherapy and the standards of care , it is a very common experience for me to
hear the accused therapist pleading the cause of greater humanity, and even love, as the rationale for having had sex with, breast fed, slow-danced with, gone into
business with, move in with, and so on with the complaining client.” – L. S. Brown65

60 Pope, K. S., & Vetter, V. A. (1991). Prior therapist-patient sexual involvement among patients seen by psychologists. Psychotherapy: Theory, Research, Practice,
Training, 28(3), 429-438. [Link]
61 Borys, D. S., & Pope, K. S. (1989). Dual relationships between therapist and client: A national study of psychologists, psych iatrists, and social workers. Professional
Psychology: Research and Practice, 20(5), 283-293. [Link]
62 Pope, K. S. (1994). Sexual involvement with therapists: Patient assessment, subsequent therapy, forensics. American Psychological Association.
[Link]
63 American Psychological Association. (2017, January 1). Ethical principles of psychologists and code of conduct. [Link]
[Link]
64 Petersen, C. (1996). Common problem areas and their causes resulting in disciplinary actions. In L. J. Bass, S. T. DeMers, J. R. P. Ogloff, C. Peterson, J. L. Pettifor, R. P.
Reeves, et al. (Eds.), Professional conduct and discipline in psychology (pp. 71-89). American Psychological Association.
65 Brown, L. S. (1994). Boundaries in feminist therapy: A conceptual formulation. In N. K. Gartrell (Ed.), Bringing ethics alive: Feminist ethics in psychotherapy practice
(pp. 29–38). Haworth Press.
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SELF-DISCLOSURE
❖ Revealing personal information about oneself to clients.
❖ Self-disclosure is viewed as a boundary crossing, but it is not necessarily a boundary violation.
❖ Little training about appropriate self-disclosure is provided in clinical graduate programs.
 Clinical graduate programs may encourage excessive self-disclosure by requiring students to disclose issues
in class under the guise of helping them identify their own triggers and understand themselves better. Thus,
students learn to engage in more self-disclosure with others, which then transfers to their work with clients.
❖ Conflicting views66
 Self-disclosure by a therapist is often viewed as taboo or bad.
• Too much self-disclosure can have detrimental therapeutic effects.
• Traditional psychoanalysts believed in remaining neutral and unknown with little to no self-disclosure.67
“The [therapist] should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him.”
Sigmund Freud
Not self-disclosing could be viewed adversely by clients and promote feelings the therapist does not care.

Humanists, feminists, family systems, and multicultural therapeutic approaches advocate for self-disclosure

as one way to develop rapport, trust, credibility, and empathetic understanding with the client to better
facilitate therapeutic goals.
 Little to moderate self-disclosure by the therapist:
• Was not consistently related to clients’ views of the therapists’ level of trustworthiness, regard, empathy,
congruence, and/or unconditionality.
• Was not consistently related to changes in clients’ problems or issues.
• Was consistently related to clients’ perceiving the therapist as warmer, liking the therapist more, and
more referrals of the therapist to others.
• Was related to more client self-disclosure and more positive effects on clients.
• Had either no effect or a slightly negative effect on perceived expertness of the therapist.
• Had either no effect or a positive effect on perceived attractiveness of the therapist.
❖ Types of self-disclosure68
 Deliberate self-disclosure
• Therapist verbally sharing personal information and past experiences (e.g., lover, friends).
• Therapist nonverbally disclosing (e.g., photos of family, hug, empathetic gesture).
• Therapist’s personal reactions in therapy (e.g., look of shock or judgement when client says something).
 Unavoidable self-disclosure
• Therapists’ age, gender, ethnicity, socioeconomic status, disability, pregnancy, location.
 Accidental self-disclosure (i.e., disclosures outside of the office)
• Living and/or interacting in smaller communities will result in unavoidable disclosures.
• Examples: running into the therapist at a store, sporting event, or wedding.
 Client’s deliberate actions
• A client asks questions about the therapist, searches the internet for personal information about the
therapist, or stalks the therapist (yikes!).
 Clothing and jewelry could be deliberate or unavoidable self-disclosure depending on the intent of a
therapist. For example, a therapist might wear certain clothing to intentionally disclose information, such as
professional status (e.g., suit), religion (e.g., Star of David, crucifixion, hijab), beliefs (e.g., political t-shirt).
However, clothing and jewelry might be unavoidable disclosure since they might unintentionally disclose
information about socioeconomic status (e.g., expensive watch, jewelry, clothing), marital status, etc.

66 Henretty, J. R., & Levitt, H. M. (2010). The role of therapist self-disclosure in psychotherapy: A qualitative review. Clinical Psychology Review, 30(1), 63-77.
[Link]
67 Freud, S. (1958). The dynamics of transference. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 97-108).
Hogarth Press. (Original work published 1912)
68 Zur, O. (2009). Self-disclosure & transparency in psychotherapy and counseling: To disclose or not to disclose, this is the question.
[Link]
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❖ Inappropriate self-disclosure occurs when:69

 The client has poor boundaries.
 The client has personality disorders.
 The client feels burdened or uncomfortable by therapist’s self-disclosure (e.g., sharing sexual fantasies).
 It is done more for the therapist’s benefit than the client’s benefit (e.g., sharing intimate details of abuse).
 It creates a situation where the client needs to care for the therapist.
❖ Self-disclosure might be okay when:70,71
 It is infrequent.
 There is a strong therapeutic alliance.
 It is conducted for the therapeutic benefit of the client (boundary crossings).
 The therapist and client are from the same small community (e.g., LGBTQ, small town, military).
 The values of a therapist and client disagree.
 A therapist makes a mistake in therapy.
 A therapist is establishing credibility such as degrees, licensure, experiences (e.g., children, marital status).
 It is unavoidable or a non-harming self-disclosure in the community.
❖ Interesting studies on self-disclosure:
 Over 90% of therapists self-disclose to clients.72
 Marriage and family therapists were more likely than clinical social workers to self-disclose and to believe
the self-disclosure enhances the therapeutic relationship.73
 Therapists with a feminist theoretical perspective were more likely than other theoretical paradigms to self-
disclose their sexual orientation to clients.74
 Gay men rated male therapists who self-disclosed as gay more favorably than male therapists who self-
disclosed as heterosexual or who did not disclose sexual orientation. 75

TRADITIONAL DIAGNOSTIC VS. TRANSDIAGNOSTIC APPROACHES76

TRADITIONAL DIAGNOSTIC APPROACHES

❖ Traditional diagnostic approaches use formal taxonomic (i.e., classification) systems to categorize mental
health disorders.
 The taxonomies outline hypothetical distinctions between sets of symptoms and indicators of mental health
disorders.
 These taxonomies are chronicled in official compendiums of psychiatric diagnoses, such as:
• Diagnostic and Statistical Manual of Mental Disorders (DSM)
• International Classification of Diseases (ICD).
 These taxonomies guide mental health and medical professionals (e.g., psychologists, therapists,
psychiatrists) in their diagnosis, management, and treatment of mental health disorders.
 These taxonomies are also used by insurance and pharmaceutical companies, governments, and society.
❖ Critiques of traditional diagnostic approaches – There are numerous studies and many clinical justifications
that argue against these strict taxonomies.

69 Appelbaum & Gutheil, 2007; Henretty & Levitt, 2010

70 Henretty & Levitt, 2010
71 Zur, 2009
72 Henretty & Levitt, 2010
73 Jeffrey, A., & Austin, T. (2007). Perspectives and practices of clinician self-disclosure to clients: A pilot comparison study of two disciplines. American Journal of
Family Therapy, 35(2), 95-108. [Link]
74 Berg-Cross, L. (1984). Therapist self-disclosure to clients in psychotherapy. Psychotherapy in Private Practice, 2(4), 57–64. [Link]
75 Atkinson, D. R., Brady, S., & Casas, J. M. (1981). Sexual preference similarity, attitude similarity, and perceived counselor credibility and attractiveness. Journal of
Counseling Psychology, 28(6), 504-509. [Link]
76 Barch, D. M. (2020). What does it mean to be transdiagnostic and how would we know? American Journal of Psychiatry, 177(5), 370–372.
[Link]
Dalgleish, T., Black, M., Johnston, D., & Bevan, A. (2020). Transdiagnostic approaches to mental health problems: Current status and future directions. Journal of
Consulting and Clinical Psychology, 88(3), 179–195. [Link]
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 It is often difficult to discriminate between mental health taxonomies/categories. The boundaries

distinguishing commonly accepted psychiatric disorders are often unclear and do not represent people’s
multifaceted and complicated configurations of mental illness.
 Mental health issues are probably better represented by continuums that range from no symptoms to very
high symptoms instead of using cutoff scores that establish (1) dichotomies (e.g., depressed, not depressed)
or (2) categorical groupings (e.g., no depression, mild depression, moderate depression, severe depression).
 Comorbidity between mental health issues (e.g., anxiety, depression) is more common than absent.
• Comorbid conditions and subsequent treatments are often ignored or given little attention in favor of
treating the individual diagnoses.
 There is considerable variation within each mental health disorder. In other words, individuals diagnosed
with a mental health disorder may have substantially different levels of the diagnostic criteria/symptoms.
• There are 636,120 combinations that meet the diagnostic criteria for PTSD. 77
• There are 1,030 combinations that meet the major depressive disorder diagnostic criteria. 78
 Different diagnostic scales for a disorder capture different symptoms and indicators.
• For example, there were at least 280 instruments to measure depression in 2006.79
• The DSM identifies nine criteria, yet the seven most frequently used depression scales assessed 52 distinct
symptoms.80 Only 12% of the 52 symptoms appeared in all seven scales, while 40% of the symptoms only
appeared in one scale.
 There is a mismatch between recommended treatments for traditional diagnostic disorder and the actual
treatments clinicians use.
• Clinicians recognize that recommended treatments for a specific diagnosis are not always the best
approach for individual clients based on their unique vulnerabilities.
• Conversely, many psychopharmacological (medication) and therapy treatments often work across a range
of mental health disorders due to shared symptomology and vulnerabilities.

TRANSDIAGNOSTIC APPROACHES81
❖ Commonalities of most transdiagnostic approaches
 Mental health issues are reflected along continuums (versus discrete categories) such as identifying the
degree/level of social anxiety or depressive symptoms.
 Components of mental health issues overlap or fit together creating mental health dimensions.
• Broader mental health dimensions are supported by empirical research.
 Mental health dimensions correspond to (1) the underlying biopsychosocial (i.e., biological, psychological,
social) processes and (2) the environmental and genetic vulnerability factors.
 Many psychopharmacological (medication) treatments and therapies cut across multiple symptoms.
 Treatments must be tailored to each clients’ range of symptoms, vulnerabilities, capabilities, etc.
❖ There are a wide range of transdiagnostic approaches, that range from:
 (1) Preserving the diagnostic models (i.e., taxonomies) while trying to better understand the processes
associated with mental issues and developing interventions that cut across various diagnoses.
 (2) Completely eliminating diagnostic models in favor of new ways to depict mental illness.
❖ Three specific approaches
 Transdiagnostic biopsychosocial processes

77 Galatzer-Levy I. R., & Bryant R. A. (2013). 636,120 ways to have posttraumatic stress disorder. Perspectives on Psychological Science, 8, 651–662.
[Link]
78 Fried E. I., & Nesse R. M. (2015). Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study. Journal of Affective
Disorders, 172, 96–102. [Link]
79 Santor D. A., Gregus M., & Welch A. (2006). Eight decades of measurement in depression. Measurement: Interdisciplinary Research and Perspectives, 4, 135–155.
[Link]
80 Fried E. I. (2017). The 52 symptoms of major depression: Lack of content overlap among seven common depression scales. Journal of Affective Disorders, 208, 191–
197. [Link]
81 Dalgleish et al. (2020)
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• Specific biological markers and cognitive processes are not uniquely related to traditional diagnostic
disorders. However, brain research, genetic research, and research on environmental factors demonstrate
that biopsychosocial factors are associated with specific mental health dimensions.
• Thus, process-driven interventions (individual, broader set of processes) can be developed.
 Hierarchical taxonomy of psychopathology (HiToP)82 – This model starts with a higher dimension (i.e.,
psychopathology), comprised by broad mental health dimensions (e.g., internalizing, disinhibited
externalizing), which are comprised of lower-order factors, followed by symptoms.
• See diagram – [Link]
 Transdiagnostic clinical interventions
• Treatment is not tailored to a specific diagnosis; instead, a treatment approach is applied across mental
health issues to better address comorbidity and wide heterogeneity of how symptoms manifest.
o Universal interventions – Applying the same set of evidence-based therapeutic principles with the
broadest applicability across various diagnoses.
o Modular interventions – Applying sets of evidence-based therapy modules tailored to each client.

PSYCHOANALYTIC & PSYCHODYNAMIC APPROACHES

❖ Developed in the late 1800s by Sigmund Freud (1856-1939).

❖ Freud arrived in the United States in 1911, and within a few years, over 95% of American psychiatrists were
being trained in psychoanalysis.
❖ Explores the dynamic workings of the unconscious mind that is greatly influenced by childhood experiences.

ASSUMPTIONS
❖ There is an unconscious part of man that motivates an individual; thus, all behavior is caused.
 Psychic determinism – All behaviors are controlled by unconscious fears and desires.
❖ Development of the individual plays a large role in development of personality.
 Most major patterns of personality are established at age 5 or 6, some at age 3. Therefore, early
experiences can have a long-term effect on personality development.
❖ Life and death instinct – Freud believed people were driven by two conflicting central desires:
 Eros (life drive) is the life instincts that help the child and species survive (e.g., survival, respiration,
sex/propagation, hunger, thirst).
 Thanatos refers to the death instincts in all living things to regain a tensionless or calm state.
❖ Individuals exist in a constant state of conflict.
❖ Everyone is abnormal; it is just a matter of degree.
Note from Plunk: The information on psychosexual stages and personality structures are given for historical purposes. This information is often used to charac terize
psychoanalytic/psychodynamic therapy, yet it is mostly irrelevant to modern conceptions of these approaches (Shedler agrees83).

PSYCHOSEXUAL STAGES OF DEVELOPMENT – NOT A FOCUS IN MODERN ITERATIONS (OR THIS CLASS – ONLY GIVEN FOR REFERENCE)
❖ Based on observation, work with his own clients, and his own developmental experiences, Freud developed a
theory of personality development composed of a series of stages through which every human progressed.
 People are born polymorphous perverse (i.e., many things could be a source of pleasure).
 Psychic (i.e., sexual/libido) energy – Each individual has a fixed amount of psychic energy that is used to
think, learn, and perform other mental functions.

82 Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., Brown, T. A., Carpenter, W. T., Caspi, A., Clark, L. A., Eaton, N. R., Forbes, M. K.,
Forbush, K. T., Goldberg, D., Hasin, D., Hyman, S. E., Ivanova, M. Y., Lynam, D. R., Markon, K., … Zimmerman, M. (2017). The Hierarchical Taxonomy of
Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454–477.
[Link]
83 Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. [Link]
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• As people develop and the sex instinct matures, people can become fixated on specific objects in different
stages of development. The psychic energy (or libido) gradually shifts from one part of the body to
another as the child enters a new stage of psychosexual development.
❖ The stages are named for the principal sources of pleasure (i.e., tension reduction) in each stage.
❖ Oral stage (0-1.5 years)
 The sex instinct seeks pleasure through the mouth (e.g., nursing, spitting, chewing, sucking, biting).
 Major event is weaning (i.e., moving from fluid to solid food).
 Oral dependent – gullibility, optimism/pessimism
• A child who is underfed, weaned too early, or neglected during this stage may become an adult who is
obsessed with stimulating the oral cavity for gratification (e.g., alcoholism, biting nails, smoking, chewing
gum, eating, oral sex).
 Oral aggressiveness – verbal aggressiveness, hostility.
• A child who is overindulged during this stage may later become an adult who regresses to this earlier
dependency by acting helpless, crying, and/or being needy.
❖ Anal stage (1.5-3 years)
 Voluntary defecation becomes the primary method of gratifying the sex instinct
 Major event is potty training
 Anal retentive – perfectionism, orderly, cleanliness, scrooge, meticulous
• Children who are overindulged by parents may find pleasure in holding feces in the body; eventually
becoming an anally retentive adult.
 Anal expulsive – carelessness, disorder, spendthrift
• Children who are harshly ridiculed or punished for “accidents” may respond by refusing to use the toilet
or by excreting spitefully. They may become anxious, inhibited adults who are messy or wasteful.
❖ Phallic stage (3-6 years)
 Called “phallic” stage because the phallus (penis) assumes a critically important role in the psychosexual
development of boys and girls. Children mature enough that their genitals become interesting and sensitive.
They derive pleasure from fondling their genitals. This stage is controversial because Freud argued children
develop an incestuous desire for the other sex parent and resent and/or destroy the same sex parent.
• Oedipus complex – A son desires his mother and has castration anxiety from his father who is a rival. To
decrease anxiety and fear, the boy represses his incestuous desire for his mother and learns to identify
with his father and becomes an ally to his father. The boy learns traditional male roles.
• Electra complex – A daughter has penis envy (desires a phallus), but she realizes having a penis is
unattainable. The daughter desires her father as a sex object to gain some control over the person who
has the phallus she lacks. She blames her mother for the lack of penis and competes with the mother.
Upon resolution, she learns the traditional female roles by allying with her mother.
 Major event is repression of the sexual desire due to its taboo nature.
❖ Latency stage (6-12 years)
 The child has little sexual interest (i.e., “a lull”), and the child’s libido energy is channeled into socially
acceptable activities (e.g., peers, academics, sports).
 The major event is the repression of sexual impulses (until the child hits puberty).
❖ Genital stage (onset of puberty, 12 years and up)
 The child has a reactivation of the genital zone as an area of sensual pleasure. The underlying goal of the sex
instinct is biological reproduction through sexual intercourse. People remain here for the rest of their lives
and satisfy the sex instinct by having children.
❖ As people progress through the stages, they often have problems at a point that must eventually be resolved.
 There is a limited amount of libidinal (sexual life) energy at birth to be invested on problems encountered in
life. If too much libidinal energy is used in earlier stages, then there is only a limited amount to use later.

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STRUCTURES (EXPRESSIONS) OF PERSONALITY – NOT A PRIMARY FOCUS IN MODERN ITERATIONS

❖ Id (Latin for “the it”) refers to the inborn component of the personality driven by basic instincts.
 The id is the only structure present at birth and is an expression of the unconscious that constantly
demands immediate gratification without any consideration of consequences (i.e., pleasure principle).
 The id motivates the individual to move away from pain and toward pleasure. The major function of the id is
to serve the instincts by seeking objects that will satisfy them. The id is impulsive, chaotic, disorganized,
illogical, irrational, no sense of right from wrong, and can’t differentiate reality from fantasy.
 The id is an “unrestrained go system” throughout life. People only learn to control the id to some extent.
❖ Ego (Latin for “self”) is the rational component.
 The ego evolves/develops to deal with the demands of reality (i.e., reality principle)
 The ego was thought of as developing from the id as more and more demands were placed on the infant, as
a source of contact with reality - for adaptation and survival.
 The ego learns to delay gratification until desires can be satisfied in socially acceptable ways.
 The ego serves as moderator between (1) the id and reality and (2) the unrealistic hedonism of the id and
the impractical moralism of the superego.
❖ Superego is the moral component that develops around 3-6 years old.
 The superego develops to help children self-regulate their own behavior and/or internalize the moral
standards and values of their parents (i.e., parent principle). Hence, it becomes the source of guilt and
anxiety that seeks to punish the individual for real or imaginary transgressions.
 The superego consists of one’s internalized moral standards and expression of constraints of society; hence,
it is the conscience that tells a person what is right (good) and what is wrong (evil).
 The superego strives for perfection (i.e., the ego ideal) rather than for pleasure or for reality. Guilt is
produced when an individual ignores rules of the superego or violates the ego ideal.

FREUD’S THEORY HAS BEEN CALLED…

❖ Conflict theory – Inner conflicts (id, ego, superego). The id communicates basic needs, the ego restrains the
impulsive id long enough to find realistic methods of satisfying their needs, and the superego decides whether
the ego’s problem-solving strategies are morally acceptable.
 More recent views of conflict within psychoanalysis focus on competing or contradictory thoughts and
feelings that individuals have regarding uncomfortable experiences, ideas, and thoughts.
❖ Tension reduction theory – All behavior was seen as directly or indirectly attempting to reduce tension. Total
tensionless state = death.
❖ A theory of motivation because of the role of the unconscious in motivating human behavior.

MAJOR CRITICISMS OF FREUD’S PSYCHOANALYTIC THEORY

❖ Very subjective and unstandardized methods.
❖ Little evidence beyond anecdote and self-reflection to support the ideas as developed.
❖ Derived theory from a small number of patients (mostly young, upper-SES females) and himself.
❖ Difficult to generalize to the general population.
❖ Dealt almost entirely with abnormal then tried to generalize to normal.
❖ Too much emphasis on instinct, heredity, biology, and physical maturation on personality development.
❖ Emphasized the erotic aspects of individuals while largely ignoring social and environmental factors.
❖ Requires expressive clients.
❖ Feminists critique his negative view of women (e.g., penis envy).
“All I have to say about femininity is certainly incomplete and fragmentary and does not always sound friendly…If you want to know more about femininity, enquire of
your own experiences of life, or turn to the poets, or wait until science can give you deeper and more coherent information.” (Freud, 1975)
Plunk’s thoughts (supported by Shedler84): Most criticisms of psychoanalysis are for Freud and his psychosexual stages and personality structures; which rarely apply to
current psychoanalytic/psychodynamic therapy approaches.

84 Shedler, J. (2019). That was then, this is now: An introduction to contemporary psychodynamic therapy. [Link]
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CONTRIBUTIONS OF FREUD’S PSYCHOANALYSIS THEORY

❖ Freud was one of the first theorists in psychology to provide a workable model to understand human behavior.
❖ Popularized the role of early experiences on later development.
❖ Popularized unconscious motivation.
❖ Brought attention to the emotional side of human development.
❖ Freud was one of the first scientists who tried to differentiate between female and male sexual psychologies.
❖ His theory became popular and has served as a reference point for many later theories of personality.
 Theories that are based upon or are similar to Freud’s are often called psychoanalytic.
 Many who started with Freud eventually broke away and developed theories of their own. Most variations
were developed in opposition to one part or another of Freud’s theory.

3 LEVELS OF CONSCIOUSNESS
❖ Conscious is what we are aware of at any given moment. It involves
contact with the real world and is a small part of the person as a Conscious
Contact with real world
whole.
❖ Preconscious is a reservoir (like memory) that holds elements of Preconscious
Just beneath surface of awareness
Ego
experiences that individuals may be unaware of but may bring to (e.g., memories, knowledge) Reality principle

consciousness with little effort.

Superego
 The layer between conscious and unconscious thought. Parent principle
Unconscious
 The preconscious is not a primary focus in modern iterations of Well below surface of
awareness; difficult to
psychoanalyses. retrieve information; all
psychic energy originates Id
in the unconscious
❖ Unconscious – People are unaware of or only vaguely aware of the Pleasure principle

unconscious. It includes forgotten, hidden, or painful memories or

experiences.
 According to Freud, the unconscious is the source of biological
instincts and urges (e.g., hunger, thirst, sexuality, aggression). It
is the primary and most important source of human motivation.
 Dynamic unconscious is a more recent view of the unconscious that involves feelings, thoughts, and
behaviors that individuals actively disavow, reject, or defend against.85 These same feelings, thoughts, and
behaviors actively seek expression through indirect means. Thus, the unconscious is dynamic, not dormant.

ACCESS TO THE UNCONSCIOUS

❖ Dreams provide a window into unconscious inner conflicts.
“Dreams are the royal road to the unconscious.” Freud86
 Manifest content is the surface meaning of dreams (i.e., obvious, conscious content).
 Latent content is the interpreted meaning of dreams (i.e., hidden, unconscious content).
❖ Free association (discussed below)
❖ Hypnosis involves inducing an extremely relaxed state of consciousness in patients so the psychoanalyst can
help patients recover suppressed memories and/or unconscious motivations.
❖ Parapraxis (Freudian slips) refers to errors in speech (e.g., slips of the tongue), thought, or behavior that occur
due to intrusion of an unconscious desire or internal conflict (e.g., Calling a partner by an ex’s name).
❖ Transference (discussed later)

DEFENSE MECHANISMS TO REDUCE ANXIETY

❖ Defense mechanisms refer to strategies (often unconscious) that individuals use to protect themselves from
anxiety and negative emotions. They can help individuals manage painful experiences and emotions, and they

85 Shedler, J. (2019). That was then, this is now: An introduction to contemporary psychodynamic therapy. [Link]
86 Freud, S. (1899). The interpretation of dreams. Franz Deuticke, Leipzig & Vienna.
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can be used to channel their feelings in more positive ways. However, defense mechanisms can be problematic
when used too frequently or too long without ever dealing with the actual issues causing the anxiety.
❖ It can be useful in therapy to help clients identify defense mechanisms they frequently use. Belief in
unconscious defense mechanisms has varied over the years; yet, there seems to be renewed interest and
belief in how various unconscious processes can manifest in conscious behaviors and thoughts. 87
❖ Repression
 The ego pushes id impulses (e.g., fantasies, sexual conflicts) into the unconscious mind.
 Painful or undesirable memories, thoughts, or feelings are stored in the unconscious mind.
 According to Freud, repression is the most powerful and pervasive defense mechanism.
 Traditional examples of repression
• A soldier has no memory of a near-death experience.
• An adult has no recall of being sexually abused when a child.
 Repression is controversial in psychology (e.g., “dissociative amnesia” or “dissociative fugue”).88
• Some studies suggest traumatic events may enhance memory (although distorted) due to heightened
emotional and/or physical sensations. 89
• False memory hypothesis – Psychotherapy may create false memories. 90
 Recent conceptualizations of repression in psychoanalysis downplay the idea that individuals push thoughts
completely into the unconscious. Instead, they discuss how individuals may focus on more general thoughts
related to an event or person instead of the more specific details of uncomfortable memories.
❖ Denial occurs when individuals refuse to acknowledge an uncomfortable or painful truth or emotion; hence
they insist it is not true despite evidence to the contrary.
 Simple denial is when the person pretends the event did not occur. Minimization is when the person
downplays the impact of the event.
 Denial is often the first stage of grieving after a significant loss (e.g., death of a loved one, intense breakup).
 Examples
• A spouse ignores signs of infidelity.
• A student refuses to recognize an obvious lack of preparedness for an exam.
• Parents fail to notice their anorexic daughter is starving.
❖ Regression – An individual experiences too much anxiety or too many conflicts and then behaves in a way that
characterized a previous developmental level. Thus, the individual engages in earlier behaviors associated with
a ‘happier’ time to reduce stress.
 Examples
• A child goes to school for the first day and regresses to the oral comfort of thumb sucking.
• An adult has a temper tantrum when he doesn’t get his way.
• A teenager girl giggles nonstop when introduced to someone she likes.
❖ Displacement occurs unconsciously when emotions, desires, or wishes are redirected from their original
source (i.e., potentially dangerous or inappropriate) to something or someone else that is safer.
 In other words, when individuals feel it is irrational or socially unacceptable to demonstrate certain feelings,
they might displace feelings or behaviors towards a person or animal where it is more acceptable.
 Examples
• A man gets angry with his boss, so he comes home and yells at family members.
• A woman gets mad at her mother, so she breaks something.
• A man sexually desires a famous model that is unattainable, so he seduces more attainable women.
Plunk’s life lesson – We often take out our frustrations on our parents or take our parents for granted because their love is unconditional. Thus, when we get angry at
someone else, we inappropriately displace our anger on our parents. I just “spit in your soup” (see page 34).

87Cramer, P. (2000). Defense mechanisms in psychology today: Further processes for adaptation. American Psychologist, 55(6), 637–646.
[Link]
88 McNally, R. J. (2007). Dispelling confusion about traumatic dissociative amnesia. Mayo Clinic Proceedings, 82(9), 1083-1087. [Link]
89 Otgaar, H., Howe, M. L., Patihis, L., Merckelbach, H., Lynn, S. J., Lilienfeld, S. O., & Loftus, E. F. (2019). The return of the repressed: The persistent and problematic

claims of long-forgotten trauma. Perspectives on Psychological Science, 14(6), 1072-1095. [Link]

90 McNally (2007)

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❖ Projection refers to transferring unacceptable thought, feelings, and/or impulses unto someone or something
else to avoid dealing directly with something threatening and reduce their anxiety.
 Examples
• You feel hatred towards another person, but feeling hatred is unacceptable, so you believe the other
person hates you. This helps you justify your own hatred.
• A wife has thoughts of infidelity, so she projects those feelings onto her spouse and thinks her spouse is
having an affair.
El Salvadoran saying: “The thief thinks everyone else is a thief.”
❖ Rationalization – Individuals create a sensible explanation or excuse for an illogical or unacceptable behavior
making it appear sensible or acceptable.
 Rationalization allows individuals to avoid accepting the real reason that resulted in the present issue.
 Examples
• A mother explains her child being born with fetal alcohol spectrum disorders as God’s divine will.
• A shoplifter blames inflation and high prices to justify the shoplifting when she just enjoys shoplifting.
❖ Intellectualization – Individuals with an emotional attachment to an issue, try to downplay the emotions by
examining the issue intellectually or neutrally.
 Examples
• A man tries to decide whether he is “in love” by creating a pro/con list and doing a cost-benefit analysis.
• A woman is laid off from a long-term job due to downsizing, so she uses logical reasoning to examine it
from the company’s perspective.
❖ Introjection – An individual strongly internalizes values, beliefs, and/or behaviors of another person (usually a
parent or another significant other) or object (e.g., religious symbol) with little contemplation.
 Examples
• Blindly following along with a cult.
• A person automatically adopts a new lover’s political or religious ideology without thought would be
introjecting. Adopting a new lover’s ideas after careful consideration and research is not introjecting.
• A parent’s mannerisms may be observed by a child and then replicated (e.g., “He is just like his father”).
 Introjection can be a protective strategy that individuals use to cope with life.
• For example, a person unconsciously absorbs mannerisms, actions, or values of an unavailable parent so
that some aspect of the parent is present even when the parent is not there.
 When individuals introject too strongly, they have difficulty distinguishing their own identity and values
from another person or object. Thus, they focus on beliefs of others rather than their own personal needs.
• For example, child unconsciously absorbs characteristics of an overly critical parent so that they start
criticizing themselves, leading to low self-esteem and low self-efficacy.
❖ Identification – An individual mirrors the qualities or behaviors of another person to placate the other person
and/or reduce fear and anxiety toward that person.
 Examples: A youth that is bullied then joins the perpetrator in bullying other youth.
❖ Reaction formation – An individual channels unacceptable emotions or impulses into the opposite.
 Examples
• Addict preaching don’t do drugs.
• An anti-pornography activist constantly seeks out pornographic materials to condemn.
• Romantic ideas of chastity and purity may hide crude sexual desires.
• Holiness and devoutness may hide sinful desires.
• Stockholm Syndrome – A hostage victim ‘falls in love’ with the feared person who has power over them.
❖ Sublimation – Negative emotions or instincts are turned into socially useful actions (e.g., creativity, art).
 Sublimation can be a more mature defense mechanism used by healthy individuals except when the
sublimation is used to avoid confronting the negative feelings.
 Examples
• Sexual desires or violent thoughts are turned into art, music, etc.
• Anger towards people is channeled into environmentalism or animal rights.

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• Aggression is channeled into aggressive sports such as American football, rugby, boxing, mixed martial
arts, or rhythmic (ribbon) gymnastics (Plunk: I was kidding on rhythmic gymnastics ☺ ).
❖ Somatization – Transferring painful or uncomfortable emotions into physical symptoms.
 For example, individuals might develop stomach or bowel issues when they become anxious.
❖ There are other defense mechanisms (e.g., isolation, idealization, dissociation, splitting).

TRANSFERENCE AND COUNTERTRANSFERENCE

❖ Transference refers to the unconscious redirection of desires/feelings for a significant other to another person.
 These desires or feelings may be unconsciously retained/repressed from childhood and emerge when a
person does something or acts in a way that triggers the repressed feelings/memories.
 Transference in therapy occurs when clients redirect feelings for a significant other to the therapist.
• A patient starting therapy is entering an unknown situation with an unknown person. 91 Thus, the patient
may apply familiar templates/scripts when dealing with therapist (i.e., a perceived authority figure). It is
important to recognize that the therapist and patient mutually influence their interactions with each
other. Thus, transference is not exclusively created by the patient.
• Examples
o Sexual attraction towards the therapist.
o Anger, hatred, hostility, and/or lack of trust directed towards the therapist.
o Parentification of the therapist and/or extreme dependence on the therapist.
o God-like or guru status of the therapist (hence, power inequalities).
❖ Countertransference is when the therapist redirects desires or feelings towards the client/patient; often
referred to as “emotional entanglement” with a client.
 Examples
• A therapist feels hostility towards a client who resembles or engages in behaviors similar to the therapist’s
abusive parent or cheating spouse.
• Therapist sexually desires a client who resembles a past love/lust object.
• Therapist takes on the distress or psychosis of the client.
 To minimize harms of countertransference, therapists must:
• Be aware of the countertransference to control their emotions, feelings, and desires;
• Identify what role the client is playing in eliciting the countertransference; and
• Discuss the countertransference in their own therapy.
 It is important to reiterate that the therapist and patient mutually influence each other’s interactions.

PSYCHOANALYSIS AND PSYCHODYNAMIC

❖ Traditional psychoanalysis
 Primary contributors are Sigmund Freud and Joseph Breuer.
 Objectives
• To ascertain a patient’s unconscious thoughts, feelings, and inner conflicts that are causing dysfunction.
• To decrease a patient’s tension and suffering by bringing these repressed thoughts into conscious
awareness (i.e., insight, catharsis).
• To help a patient work through a stage that was not resolved or where the patient became fixated.
 Techniques: catharsis, hypnosis, free association, dream analysis, transference, analysis of id, ego, superego.
❖ More contemporary psychoanalytic approaches
 The psychoanalyst is not solely trained to be the ‘detached expert.’
• Instead, the psychoanalyst is allowed to be more empathetic to the patient and to engage in more self-
disclosure to develop more of a therapeutic bond.
• The psychoanalyst gives the patient more autonomy (e.g., disagreeing with the psychoanalyst).
 A psychoanalyst may not focus solely on a patient but may also help clarify to a patient others’ motivations.

91 Shedler, J. (2019). That was then, this is now: An introduction to contemporary psychodynamic therapy. [Link]
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The psychoanalyst may incorporate psychotropic medicines in the treatment to help relieve severe anxiety

or depression. Also, hospitalization may also be used in some cases when the patient is a threat to oneself.
❖ Psychodynamic
 Derives from psychoanalysis. Contributors include Anna Freud, Carl Jung, Karen Horney, Otto Rank, Erik
Erikson, Melanie Klein, Donald Winnicott, John Bowlby, Heinz Kohut, Alfred Adler
 Objectives
• To help clients understand unconscious thoughts, feelings, basic drives, and inner conflicts that are
manifesting as psychic tension, symptoms, and problems.
o More recently, psychodynamic approaches are also examining how the mind and unconscious impact
biological functioning (e.g., somatic component/expression of the mind’s defenses).
• To help the client alter unhealthy defense mechanisms with more adaptive, functional defense
mechanisms to reduce psychic tension.
 Compared to more traditional psychoanalytic therapy, psychodynamic…
• Focuses on Ego more than Id.
• More focused on client’s relationship with their external world (versus the patient-therapist relationship).
• More focused on family of origin.
• More directive.
• Usually shorter and less intensive.
• Considers countertransference.
❖ A summary of various meta-analyses showed that long-term and short-term psychodynamic therapy was
effective in treating various disorders in comparison to no treatment and treatment as usual. 92

TREATMENT IN PSYCHOANALYSIS/PSYCHODYNAMIC APPROACHES

❖ Prerequisites
 Patient must want help.
 Patient must be able to communicate.
 Patient must trust the psychoanalyst.
 The psychoanalyst decides whether the patient is appropriate for psychoanalysis.
 The psychoanalyst decides whether patient is a good fit with the psychoanalyst and the patient’s condition.
❖ Goals
 Help the patient bring what is in the unconscious into the conscious.
 Help the patient adjust to the demands of personal relationships, work, and society.
❖ Roles of the therapist93
 Psychoanalysts help patients explore, identify, and discuss feelings, including contradictory emotions.
• Individuals can have contradictory feelings and motives (i.e., ambivalence, dissonance, inner conflict).
• Often people will try to resolve conflicting emotions by pushing less desirable thoughts out of their
conscious awareness, but these undesirable thoughts can still emerge.
 Psychoanalysts help patients explore ways they, knowingly and unknowingly, avoid distressing thoughts
and emotions.
• Examples: showing up late or avoiding therapy, changing topics, shifting focus from themselves.
 Psychoanalysts help patients explore, identify, and discuss recurring patterns and themes in their
feelings, thoughts, relationships, etc.
• Many psychological difficulties once started as adaptive solutions as patients dealt with challenges. When
circumstances changed, the previous solutions were less effective and/or self-defeating. Yet, the patients
continued to use the same strategies, which then caused new psychological difficulties.
• Patients may be aware of painful recurring patterns in their lives, but they have difficulty escaping them.
• Conversely, patients may be unaware of the recurring patterns until the therapist points them out.
• Example: A person constantly seeks out partners who are very needy but feels smothered by them.

92 Shedler, J. (2010).
93 Shedler, J. (2010, 2019).
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Psychoanalysts help patients explore, identify, and discuss how early experiences (e.g., with attachment

figures) affect the present (e.g., current relationships).
• People view the present through the filter of past experiences.
• People develop templates/scripts/schemas about how the world works from early experiences. These
templates are applied to new situations throughout life until the templates no longer apply and/or they
develop new templates.
o Example: A girl’s father is emotionally unresponsive/unavailable throughout her childhood. Thus, her
early representations of love are associated with emotional deprivation. As an adult, the female is
attracted to men who are emotionally distant/unavailable, while men who are emotionally available are
not interesting or attractive to her.94
• Helping patients explore their templates can help them move forward so they can focus on the present.
 Psychoanalysts have a strong focus on interpersonal relationships.
• Adaptive and maladaptive aspects of self-concept and personality are developed within interpersonal
relationships, especially with attachment figures.
o For example, the female discussed above desires an intimate relationship. Yet, she continually develops
romantic interest/attraction towards unavailable partners. Her romantic interest/attraction may signify
an unconscious compromise between a fear of dependency and a desire for emotional bonding.95
• Mental health issues often result from problematic interpersonal patterns that inhibit individuals’ abilities
to meet their emotional needs.
 Psychoanalysts focus on the relationship between the therapist and the patient (e.g., transference,
countertransference).
• The female patient outlined above may recreate the same pattern in therapy with a male therapist. When
the therapist seems distant (e.g., distracted, bored, inattentive), the patient perceives the therapist as
interesting and important. However, when the therapist seems emotionally responsive (e.g., caring,
empathetic, attentive), the patient perceives the therapist as uninteresting and not important. 96
 Psychoanalysts encourage patients to voice whatever comes to mind (e.g., free association).
• To encourage the development of transference by providing patients a sense of safety and acceptance.
• To help patients freely explore difficult material and experiences from their past, gaining insight and
working through unresolved issues.
• To identify and interpret the patients’ unconscious conflicts that are manifesting in symptoms that
interfere with day-to-day functioning. (Note: The psychoanalyst is the expert).
❖ Traditional psychoanalytic approaches
 Free association – Patients are invited to relate whatever comes into their minds (no matter how trivial)
during the session and not to censor their thoughts. The idea is that this free association of thoughts would
eventually lead to the patient’s unconscious desires, repressed memories, etc.
 Instructing – The psychoanalyst directs patients to verbalize what they are thinking and feeling.
 Exploring – The psychoanalyst asks patients questions to guide the free association and to delve deeper into
their thoughts and feelings.
 Clarifying – The psychoanalyst verbally rephrases and summarizes what the patients have been expressing.
 Confronting – The psychoanalyst confronts patients by identifying the defense mechanisms they are using.
 Interpretation – The psychoanalyst helps patients gain insight into past and present events.
• Interpretation can be dynamic (i.e., focusing on present events) or genetic (i.e., focusing on how past
events are influencing the present).
• Resistance interpretation – Psychoanalyst confronts patients with how they are avoiding their problems.
o Resistance is another defense mechanism by patients who are repressing intrapsychic impulses that
conflict with therapeutic goals (e.g., self-perceptions, societal expectations).

94 Shedler (2019)
95 Shedler (2019)
96 Shedler (2019)
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o Patients may have an inability to deal directly or constructively with their impulses in therapy. Thus,
resistance is an unconscious way for patients to oppose therapy; to bring what is subconscious (fear of
change) into the conscious mind.
o Resistance helps patients maintain their ego (i.e., “self”).
“The resistance accompanies the treatment step by step. Every single association, every act of the person under treatment mus t reckon with the resistance and
represents a compromise between the forces that are striving for recovery and the opposing ones.” Freud (1912)
• Transference interpretation – The psychoanalyst demonstrates to patients how old conflicts manifest in
current relationships. For example, a patient engages in transference (e.g., lust, anger) directed towards
the psychoanalyst that arose from unresolved feelings toward a significant other (e.g., lover, parent).
• Dream interpretation/analyses – The psychoanalyst may explore patients’ thoughts about their dreams
and then show how these are unconscious manifestations related to their current problems.
 Analysis of transference – Patients are encouraged to transfer difficulties with significant authority figures
in their lives to the psychoanalyst. The psychoanalyst then helps patients gain insight through the feelings
and conflicts they expressed.
Overview of psychoanalytic/psychodynamic therapy by Dr. Diane Gehart, MFT Program, CSUN: [Link]
Various forms of psychodynamic have been developed: [Link]

ADLERIAN THERAPY
“You can be healed of depression if every day you begin the first thing in the morning to consider how you will bring a real joy to someone else.” (Alfred Adler)
“Every human being strives for significance; but people always make mistakes if they do not see that their whole significance must consist in their contribution to the
lives of others.” (Alfred Adler)

BACKGROUND
❖ Many of Alfred Adler’s ideas originated from Freud’s psychoanalytical theory.
❖ Adlerian therapy is a positive psychodynamic therapy. Adler’s theory is often referred to as “individual
psychology” because the focus is on each individual. However, individuals do not live in isolation; they develop
within their social relationships (a key concept in Adlerian psychology).
❖ Rudolph Dreikurs (psychiatrist, educator, student and then colleague of Adler) further developed Adler’s
theory into a pragmatic approach: 97
 To understand the purposes behind children’s and adolescents’ unacceptable behaviors.
 To stimulate prosocial behaviors (e.g., cooperative behaviors) without resorting to punishment or reward.
 To extend Adler’s ideas into school-based approaches (e.g., create democratic classrooms, build personal
and social confidence)
❖ Many ideas from Adler and Dreikurs have been fused into family therapy, parent training, and teacher training.
“It would not be easy to find another author from which so much has been borrowed on all sides without acknowledgement than A lfred Adler” (Henri F. Ellenberger,
Psychohistorian, 1970).
Alder is the “…true father of modern psychotherapy” (Albert Ellis, 1970)

BASIC PERSPECTIVE
❖ An individual’s conscious behavior (not the unconscious) is the basis of personality development.
❖ Teleology – People are goal-oriented; their behaviors and emotions move them towards their future goals.
❖ Each person must accept personal responsibility for how they choose to interpret and adapt to life events.
❖ Each individual strives to form a sense of self within their social relationships.
 The family is the first and basic socialization unit.
• Children’s interpretations of life events are influenced by family interactions (before the age of 5).
• Children perceive life events through subjective evaluations of themselves and their environment, which
are learned in the family.

97 Shulman, B. H., & Dreikurs, S. G. (1978). The contributions of Rudolf Dreikurs to the theory and practice of individual psych ology. Journal of Individual Psychology,
34(2), 153-169. [Link]
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• Birth order and/or being an only child influence the family and personality development.
Plunk’s thoughts: I think birth order effects were more pronounced when Adler developed his theory. I also think they are mor e pronounced in some cultures versus
other cultures (e.g., first born son, youngest daughter).
Once children form their sense of self within the family, they continue to form sense of self in the wider

social world; other social contexts for socialization include school, work, society, etc.
❖ Social interest refers to people feeling they are part of a whole. The need to ‘belong’ is a primary social need.
 Individuals are not born with social interest (i.e., it is not innate). Social interest results from social training.
“No human being ever appeared except in a community for human beings …” – A. Adler
“To see with the eyes of another, to hear with the ears of another, to feel with the heart of another. For the time being, thi s seems to me an admissible definition of what
we call social feeling.” – A. Adler
❖ All behavior is purposeful and designed to provide a general sense of ‘belonging.’
 At home, a child’s behavior is seen as an attempt to secure a place in the family.
 In school, the primary social need is trying to fit in or be accepted by their peers.
❖ Healthy social interest/connectedness is an important component of mental health. Maladaptive behaviors
result from choosing behaviors that diminish social interest and/or personal growth.
 Maladaptive behavior occurs when positive attempts at good behavior fail to get desired results.
 Thus, encouraging good behavior can diminish maladaptive behavior.
“It is the individual who is not interested in his fellow men who has the greatest difficulties in life and provides the grea test injury to others. It is from among such
individuals that all human failures spring.” – A. Adler
❖ Striving for perfection – People strive to become successful and overcome areas of inferiority.
 When people feel inferior in one area, they may strive to compensate by becoming superior in other areas.
“To be human means to feel inferior” – A. Adler
“This feeling of inferiority is the driving force, the starting point from which every childish striving originates. … it determines
the very goal of existence and prepares the path along which the goal may be reached.” – A. Adler
 Inferiority complex – Inability to overcome feelings of inferiority.
• It is normal for individuals to try and overcome feelings and thoughts of
inferiorities, especially in their social settings.
 Superiority complex – Overcompensation for feelings of inferiority through
exaggerated and/or extreme views of their own worth.
• Narcissistic personality will have unrealistically high perceptions of their
own importance and abilities.

BELONGING
❖ “Why, do children select uncooperative behavior rather than cooperative behavior?”
 A more useful question is “What does the child get out of the behavior?”
 The primary emotional goal of the child is to belong and be significant in a way that makes sense to the
child.
❖ The child thinks, “I belong if mother is busy with me.” and interrupts his/her mother repeatedly while she is on
the phone. Mom provides plenty of attention, but it’s all negative: “I told you not to bother me when I’m on the
phone! Go to your room.”
 Paradoxically, the belonging sought by the child is lost. The discouragement, rejection, and confusion, which
are obvious to the child, begin to have a cyclic discouraging effect.
❖ If children fail to acquire belonging through socially useful, cooperative, contributing actions, they settle for
belonging at any price such as belonging by being the best at being the worst.
❖ Discouraged children misbehave by attempting to get attention, power, or revenge, or
by giving up because they have lost the courage to find their place by doing the useful
thing.

FOUR GOALS OF CHILDHOOD MISBEHAVIOR98 (AKA mistaken beliefs about how to belong)
❖ Attention – I only belong when you are doing things for me or when you are paying
attention to me.

98 Dreikurs, R. (1957). Psychology in the classrooms. Harper & Brothers.

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❖ Power/Superiority – I only belong when I am the boss or when I am not allowing you to boss me.
 Example: A child cries when he does not get a toy at store. The parent gives in. The child gets power.
❖ Revenge – It is impossible to belong, but I can hurt others like they hurt me. I can get even.
❖ Giving up – It is impossible to belong because I am inadequate, so I will just give up and not try.
❖ Parents should recognize misbehavior by children as an attempt to find security and not respond with anger.
Thus, parents should encourage the child, hold regular family meetings, and let natural consequences occur.
❖ Children must be allowed to make choices so they can learn to take responsibility for their actions and to
accept the consequences of their actions.

BRIEF OVERVIEW OF ADLERIAN THERAPY

❖ Four goals of therapeutic process:
 Establish a therapeutic relationship (i.e., develop rapport).
 Examine/Define the client’s lifestyle and social interest.
 Help the client gain insight.
 Client changes behavior.
“Everything can always be different!” – A. Adler
❖ The therapist-client relationship is based on mutual respect and equality.
 The therapist shares insights, opinions, and feelings with the client to support the therapeutic relationship.
❖ Therapists help clients explore conscious thoughts, beliefs, and logic that prompt behaviors contrary to the
clients’ social interests.
❖ Therapists emphasize unlocking mistaken goals and interactional patterns in the family and the promotion of
effective parenting.
❖ Therapists help clients discover purposes of behavior or symptoms, identify mistakes associated with their
coping strategies, and learn how to correct faulty assumptions and conclusions.
 Correcting just one mistake is progress, and it may be enough to make therapy successful. 99
“Life is just the same as learning to swim. Do not be afraid of making mistakes, for there is no other way of learning how to live!” – A. Adler
❖ Clients are encouraged to take responsibility for their perceptions and behaviors.
❖ The therapist assumes the roles of diagnostician, educator, motivational investigator, model, and collaborator.
❖ Therapy is very cognitive and psychoeducational (i.e., reeducation process in therapy).
❖ Homework is given.
❖ Therapists are eclectic in the techniques they use (i.e., therapists use techniques from multiple theoretical
approaches to address each client's needs).

TECHNIQUES (many are shared between different paradigms such as cognitive behavioral therapy)
❖ Asking “the question”
 Asking clients how they would be different if they were well.
 A variation is asking the parents, “what would be the problem, if this child was not the problem?”
❖ Task setting
 Helping clients set short-term goals that lead toward achieving long-term goals.
❖ Typical day
 Each family member records a day’s activities and brings it to the next session.
 Each day is unique; yet, each day has many similarities.
 The way a family behaves and interacts provides the therapist with important information about family
members’ goals and motivations.
❖ Acting “as if”
 Therapists direct clients to behave as if the problem no longer existed or to behave as they would like to be.
 “Fake it till you make it.”

99 Dreikurs, R. (1967). Psychodynamics, psychotherapy & counseling. Alfred Adler Institute.

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❖ Encouragement
 Therapists encourage and empower clients to recognize they have power to choose and to act differently.
 Encouragement is the most effective way to change people’s beliefs, build confidence, and stimulate
courage. Discouragement prevents people from functioning adequately.
❖ Confrontation
 Therapists challenge clients’ private logic and behavior(s).
❖ Catching oneself
 Therapists help clients learn how to become aware of destructive behaviors so they can control and stop
the behaviors.
❖ Spitting in the client’s soup
 Therapists point out the motivation for clients’ behavior(s). Thus, clients cannot deny knowing the reason
for the behavior if they continue the behavior(s).
 Example: “You say you want to spend more time with friends, but you also say you don’t return their calls.”
❖ Family meetings
 Weekly meeting of all the family members in one household to discuss issues or problems.
 Each member states his or her opinion about the issue and what actions he or she would like to see occur to
bring about a resolution. All viewpoints considered as the family decides which direction is best.
 The goals of the family meeting are to allow all members to have a vote in family decisions and to enhance
the self-concept of the children by giving them respect.
❖ Natural and logical consequences100
 Natural consequences
• Consequences that are natural and require little or no intervention on the part of the parent.
• If a child refuses to eat dinner, the child will be hungry by bedtime. If the parent allows the child to go to
bed hungry, the child will have learned something about appropriate eating behavior.
 Logical consequences
• Arranged consequences for child’s inappropriate behavior when the natural consequences are non-
existent or harmful to the child.
• Examples
o If the child plays in the street, the child must stay in the house for a certain period of time.
o If the child throws food at the table, the meal is over for the child. No food until next meal.
o A child disrupts the family → Time-out away from family.
o A child loses control → Time-out to cool down.
o Not getting dressed in the morning before school → Go to school in pajamas.
o Staying up past bedtime → earlier bedtime tomorrow night.
 General considerations
• Logical consequences are considered discipline as they are arranged by parents to teach and train a child,
• Going without food and being grounded may sound like punishment, but there is a difference. When
children are allowed to suffer consequences of their own actions, they will not like it. However, they
experience the results of their own actions.
• Consequences are directly related to a behavior, and they must make sense.
• A child must understand the reason for consequences and how to avoid the consequences in the future.
• A child is learning about responsibility and will make future choices based on this knowledge.
Good overview of Adlerian therapy by Dr. Diane Gehart, MFT Program, CSUN: [Link]
Another good overview: [Link]

100 Dreikurs, R. (1993). The new approach to discipline: Logical consequences. Pume.
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BEHAVIORISM APPROACHES
“The theoretical goal is the prediction and control of behavior.” – Watson

INTRODUCTION
❖ Behaviorism is a school of psychology and a way of knowing that utilizes science and experimental methods to
ascertain the relationship between the environment and behavior. Classic behaviorism is defined by
observable and measurable muscular movements and glandular secretions.
❖ John B. Watson (1878-1958; father of behaviorism) did not accept psychology’s descriptions and explanation
of conscious states. He felt psychology failed to establish itself as an undisputed natural science. He chose to
look at environmental, non-biological influences of behavior and to discard all references to consciousness.
Thus, he only examined variables that could be operationalized, observed, and measured through uniform
research methods. Watson wrote Psychology as the Behaviorist Views It (1913) (i.e., behaviorist manifesto).
“Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and train him to become
any type of specialist I might select – doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies,
abilities, vocations, and race of his ancestors. I am going beyond my facts and I admit it, but so have the advocates of the contrary and they have been doing it for many
thousands of years.” – Watson
“It seems reasonably clear that some kind of compromise must be effected: either psychology must change its viewpoint so as to take in facts of behavior, whether or
not they have bearings upon the problems of ‘consciousness’; or else behavior must stand alo ne as a wholly separate and independent science.” – Watson
“The behaviorist, in his efforts to get a unitary scheme of animal response, recognizes no dividing line between man and brute . The behavior of man, with all of its
refinement and complexity, forms only a part of the behaviorist’s total scheme of investigation.” – Watson

COMMON BEHAVIORAL THERAPY PREMISES

❖ A behaviorist regards the behavior of an individual to be a product of three factors: (1) genetic endowment
(and limitations), (2) history of behavioral consequences, and (3) the present situation.
❖ All behavior is learned.
❖ Adaptive behaviors can be learned to replace maladaptive behaviors.
❖ Therapeutic goals should be well-defined, measurable, and observable.
❖ Behavioral therapy techniques should be supported with empirical evidence.
❖ Goal – To improve the client’s life.
 Concretely define the problem:
• How does the problem manifest?
• When does the problem exist?
• Where does the problem exist?
• Who does the problem exist with?
 Obtain a developmental history of the problem:
• When did problem begin?
• What solutions have been tried in the past?
 Determine specific incremental steps (minor goals) toward the final goal(s).
 Ascertain the most effective behavioral method to help the client change.

CLASSICAL CONDITIONING
❖ Ivan Pavlov, Russian physiologist (1900-1935), originated classical conditioning.
❖ Symbolic representation accounts for how something with neutral meaning comes to have meaning.101 Thus,
it explains how one thing comes to stand for another, and we come to respond to it like the other.
❖ Concepts
 Stimulus – Any change in physical energy sufficient to cause an organism’s sensory receptors to fire.
 Response – Any observable and measurable muscular movement or glandular secretion.
 Unconditioned stimulus (UCS) – Any stimulus that reliably and automatically elicits the response.
 Conditioned stimulus (CS) – Any initially neutral stimulus that was ineffective in eliciting a given response
but has become capable of doing so.

101 Pavlov, I. P. (1941). Conditioned reflexes and psychiatry. International Publishers.

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 Unconditioned response (UCR) – The response reliably elicited by the UCS (without conditioning).
 Conditioned response (CR) – A learned response that was once elicited only by the UCS.
Process Pavlov’s Experiment with Salivating Dogs Watson’s Experiment with “Little Albert”
CS = no response Metronome = No response from dogs White rat = No response from Albert (11 months old)
UCS = UCR Meat powder = Dogs salivating Loud noise from banging pipes = Albert crying
UCS is paired with the CS in close Metronome and meat powder are presented White rat and loud noise are presented together repeatedly
temporal contiguity (30-50 times) together repeatedly
CS = CR Metronome = Dogs salivating White rat = Albert crying

❖ Extinction – Repeated presentation of CS without pairing it with the UCS until the CS no longer elicits UCR.
 Thus, extinction refers to the gradual disappearance of a previously learned behavior when the behavior is
no longer being paired with the unconditioned stimulus.
❖ Counter conditioning consists of conditioning the stimulus to a different (more desirable) response that is
incompatible with the undesirable/unacceptable behavior.
 The goal is to eliminate a certain learned, undesirable behavior.
 Examples – see aversive counter conditioning / therapy and systematic desensitization below.
❖ Stimulus generalization refers to responding to a similar though different stimulus with same response.
 In the case of Little Albert, he would get anxious and/or cry at white rabbit, white dog, a white fur coat, a
Santa Claus mask with white hair.
❖ Stimulus discrimination is responding to a similar though different stimulus with a different response.
 In the case of Little Albert, he would not get anxious and/or cry at a brown furry animal.

Classical Conditioning Exercise – Armando has no response to squirrels. However, Armando cries whenever his hand is hit with a hammer. Every time
Armando is shown a squirrel, mean Scott hits his hand with a hammer. Now, every time Armando is shown a squirrel he cries.
A. Armando B. Squirrel C. Crying D. Mean Scott E. Hand hit by hammer
_____1. The unconditioned stimulus is which of the following?
_____2. The conditioned stimulus is which of the following?
_____3. The unconditioned response is which of the following?
_____4. The conditioned response is which of the following?
A. Counter conditioning B. Stimulus generalization C. Extinction D. Shaping E. Stimulus discrimination
_____5. If Armando only cries when he sees a squirrel and doesn’t cry when he sees other types of small furry animals or things that look like squirrels,
then we can say _______________ took place?
_____6. Mean Scott does have some compassion and he finally quit hitting Armando’s hand with a hammer every time he was shown a squir rel. Eventually
Armando no longer cries at the sight of a squirrel. What has taken place?
_____7. If Armando cries every time he sees anything that looks like a squirrel (e.g., rat, fox, cat), then we can say ______________ _ has taken place.
Answers: 1E, 2B, 3C, 4C, 5E, 6C, 7B

A Few Classical Conditioning Therapy Techniques

❖ Aversion therapy refers to exposing a client to a stimulus (undesirable behavior) while simultaneously
experiencing something aversive/unpleasant. After repeated presentations, the client will associate the
stimulus with the unpleasant sensations to stop the undesirable behavior.
 A person addicted to drinking has pleasurable experiences when drinking (e.g., feeling ‘buzzed’, having fun).
Aversive counterconditioning pairs drinking with a stimulus (e.g., Antabuse) that elicits an incompatible,
dominant, aversive response (i.e., vomiting). Thus, the person associates drinking to nausea or vomiting,
which becomes more dominant instead of the pleasurable associations.
 Pairing bad-tasting substances on fingernails to discourage nail biting, pairing bad tasting substance on
cigarettes to discourage smoking, or pairing electric shock with drug use.
 Covert sensitization – A behavior is eliminated by pairing its association with an unpleasant thought.
❖ Implosion therapy102
 Clients are inundated with specific experiences until they develop an aversion to an unwanted habit (e.g.,
smoking many cigars until it is no longer pleasurable) or becomes numb to the anxiety-producing stimulus.

102 Astrup, C. (1978). Physicological mechanism of flooding (implosion) therapy. Integrative Psychological and Behavioral Science, 13(4), 195-198.
[Link]
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Flooding (AKA in vivo exposure therapy) is sometimes used to treat a client with a phobia. The client is

flooded with vast amounts of the feared stimulus. The client will initially be very anxious/scared, but the
mind cannot stay anxious/scared indefinitely, and eventually the client will become calm. In theory, the
client will now associate a feeling of calm with the previously feared stimulus.
• A client with ophidiophobia (i.e., fear of snakes) is locked in a room of nonpoisonous snakes. (no thanks!)
• Client who fears riding in a car is locked in a car and driven around until the client is no longer hysterical
and calms down. (a psychiatrist, Joseph Wolpe, did this – yikes!)
❖ Systematic desensitization103
 Systematic desensitization is often successful in treating many anxiety-related disorders and phobias.
 First, a client is taught relaxation strategies to control fear and distress. Then the client imagines a
progression of more and more fearful situations while using the relaxation skills. After the client can control
the anxiety/distress while imagining the fearful situations, then the client will gradually work towards
handling the real life, fearful situations.
 The goal is for the client to become progressively desensitized to the triggers that elicit the distress.
 Example: A client has a fear of flying. After the client learns relaxation skills, the client is instructed to (1)
imagine walking towards a plane while using the relaxation skills; then (2) imagine touching a plane, (3)
imagine getting into a plane, (4) imagine having the plane doors close, (5) imagine hearing the engines start
up, (6) imagine going down the runway, and then (7) imagine taking off. After the client has mastered the
imaginary plane, the process takes place in real life in a step-by-step manner.
CLASSICAL CONDITIONING VERSUS OPERANT CONDITIONING
Classical Conditioning Operant Conditioning
Ivan Pavlov B.F. Skinner
Response elicited Response emitted
Preceding stimulus emphasized Consequences following response emphasized
Temporal contiguity Nature of consequences
Passive organism - Reacts to environment Active organism - Acts upon environment
Reflexive Voluntary

OPERANT CONDITIONING
“A person does not act upon the world, the world acts upon him.” B. F. Skinner
❖ Deals mostly with voluntary behavior that can be observed, described, measured, and recorded.
❖ Changes in behavior stemming from changes in the relation between (A) antecedent event, (B) behavior (i.e., a
response), and (C) consequence (i.e., strengthened or weakened).
❖ A type of learning in which the consequences of a behavior or response determines whether or not that
behavior will be used in the future.
❖ Why does an organism engage in any behavior?
 It is either obtaining reinforcement through the behavior or escaping/avoiding a punishing event.

Reinforcement
❖ Reinforcement – Any stimulus event which when delivered or withdrawn immediately following a response
tends to increase or maintain the probability of that response under the same or similar conditions.
 A reinforcer strengthens, increases, or maintains the probability of the response it follows.
 Unconditioned (i.e., primary) reinforcers function as reinforcers without any prior learning.
• They often meet the basic survival needs of a person (e.g., food, water, warmth, touch).
 Conditioned (i.e., secondary) reinforcers become reinforcers through associations with existing reinforcers.
 It is important to reinforce the behavior, not the person.
❖ Satiation104

103 Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press.

104 Scalzo, R., & Davis, T. N. (2016). Behavioral indicators of satiation: A systematic review. Journal of Developmental and Physical Disabilities, 28(6), 919–930.
[Link]
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 Satiation occurs when a reinforcer loses its value, effectiveness, or power when it is easily accessible, given
too much (i.e., high frequency), or given too long (i.e., high duration).
 Example: When a person begins eating their favorite food, it will be very reinforcing. But, if they continue
eating that food nonstop, the point at which each bite becomes less reinforcing is satiation.
 Secondary reinforcers (e.g., money) are associated with multiple reinforcers, so they are often more
resistant to satiation.
❖ Deprivation
 When a reinforcer gains value, effectiveness, and power due to low access, frequency, or duration.
 If an organism has limited access to a reinforcer or has gone a substantial amount of time without access to
the reinforcer, then the reinforcer is likely to become more effective.
 Example: When a person has not had their favorite food in a long time, then it becomes more reinforcing.
❖ Positive reinforcement (R+): Adding something so it increases the behavior of interest (BOI).
 Example: Giving a child a cookie for taking out the trash. BOI = taking out the trash.
❖ Negative reinforcement (R-): Taking something away so that it increases the behavior of interest (BOI). In
other words, R- is an aversive stimulus removed after the response.
 Example: Taking away buzzing noise by putting on a seat belt increases the BOI (i.e., putting seatbelt on).
 Example: Taking aspirin takes away a backache, so taking an aspirin increases the BOI (i.e., taking aspirin).
❖ Schedules of reinforcement105
 Continuous reinforcement – Instant delivery of a reinforcer each time a specific behavior is performed.
• This method is very difficult to maintain; hence the reinforced behavior is prone to extinction.
• It is often used when teaching new behaviors.
 Fixed interval reinforcement – A reinforcer is provided after specific amount of chronological time occurs.
• Generates high response rates near the end of the interval, but much slower response rates immediately
after the reinforcer.
• Monthly paycheck occurs at the same time each month and is not necessarily based on how much effort
at work was put forth. BOI = showing up to work (where salary is not dependent on sales/effort).
 Variable interval reinforcement – The amount of chronological time between reinforcements differ.
• Generates a slow, steady response rate.
• Assuming that getting a ‘friend request’ on Facebook is a reinforcer, the time between ‘friend requests’
varies and is not dependent upon your logging into Facebook. BOI = logging into Facebook.
 Fixed ratio reinforcement – A set amount of effort must be completed before reinforcement is provided.
• Generates a high, steady response rate with a brief pause after the reinforcer.
• Salespeople who are paid on a “base plus commission” may work hard to reach their sales quota, after
which they might take a break from sales for a few days. BOI = number of sales.
 Variable ratio reinforcement – The amount of effort needed for the reinforcement differs from the last.
• Generates a high, steady response rate.
• Winning is not dependent upon the number of times the lever or tickets are pulled. BOI = pulling a slot
machine lever, lottery.
 Various other schedules (e.g., response-deprivation schedule, Drh schedule, progressive-ratio schedule).

Reinforcement Punishment
(increases the BOI) (decreases the BOI)
Positive (add) R+ P+
Negative (take away) R- P-
BOI = Behavior of interest
Punishment
❖ Punishment refers to any stimulus event when delivered or withdrawn immediately following a response tends
to decrease the probability of that response under the same or similar conditions.
❖ A punisher weakens/decreases the probability of the response it follows.

105 Malott, R. & Trojan-Suarez, E. (2016). Principles of behavior (7th edition). Rutledge.
Miltenberger, R. (2008). Behaviour modification. Wadsworth.
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❖ Positive punishment (P+) refers to adding something so that it decreases the behavior of interest (BOI).
 Washing a child’s mouth with soap to decrease the child’s swearing. BOI = swearing.
❖ Negative punishment (P-) refers to taking something away so that it decreases the behavior of interest (BOI).
 Taking away a child’s iPod to decrease the child’s lying. BOI = lying.
❖ For a punisher to be effective
 Punishment demands continuous surveillance.
• It works opposite of reinforcement because the undesirable behavior must be punished every time.
 A punishment needs to be just strong enough to change the behavior.
• Gradually increasing a punishment’s severity teaches how to deal with punishments; thus, a punishment
is less effective since a person can continue the behavior until the punishment becomes severe enough.
 Punishment needs to be consistent.
 A punishment needs to be immediate.
 A punishment must suit the crime. Use a punishment that stems directly from the undesired behavior.
• Don’t use aggression to punish aggression (e.g., using spanking to punish hitting) because it teaches the
behavior you are trying to decrease.
 Avoid rewards immediately after. The reward might be more valuable than the punishment is aversive.
 It is important to provide a model for alternative behavior.
• If punishment is used to decrease a behavior, then the organism needs to know an alternative behavior to
exhibit in similar or same circumstances.
❖ General effects of punishers
 Punishment suppresses the response/behavior, but it does not eliminate the behavior.
 Punishment leads to escape and avoidance.
• Punishers force a discrimination of the situation in which behaviors can and cannot take place.
 Punishment is often an expression of anger.
 It is easy to get carried away when using punishment.
• When does a parent stop punishing? Usually when the child elicits the appropriate response. If the child
doesn’t cry, then it can turn into a power struggle, and the parent gets carried away.
 Punishment often provides for an aggressive model.
 Punishment generally arouses negative emotions.
 Learned helplessness – resigning to an aversive situation rather than trying to change, escape, or avoid the
negative situation. It is learned through repeated exposure to inescapable or unavoidable aversive events.
• When avoidance of punishment is not possible, some give up (e.g., Seligman study 106).

Other Concepts
❖ Extinction refers to the withholding of response contingent reinforcement until the organism is responding at
the rate it was before conditioning took place.
❖ Generalization – In conditioning, after a conditioned response has been established to a certain stimulus, an
organism’s tendency to respond to other stimuli in the same way.
❖ Discrimination refers to the tendency to respond to a certain stimulus in one way and then to respond to a
similar, but different stimuli, in another way.

Reward & Punishment Exercise

A. Positive reinforcement B. Negative reinforcement C. Positive punishment D. Negative punishment E. Extinction
1. Bertha went to a school dance and met a guy who told her how much he liked her. Then the next time she went to the dance she met another guy who
gave her physical compliments. Now Bertha goes to the dance every chance she gets. The behavior of interest (BOI) is Bertha going to the dance. Which
took place?
2. Pottie W. Skunkett attends class at Oklahoma State University. Every time he attends class, the students quickly leave (because of his terrible smell).
Now Pottie W. Skunkett rarely attends class. The BOI is Pottie attending class. Which took place?

106 [Link]
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3. Every time Bubba goes to the football game with his girlfriend, he becomes embarrassed at how his girlfriend stands up and yells through the loud horn
how good looking the football players are. Now Bubba usually goes to the football games without his girlfriend. The BOI is going to the football game with
his girlfriend. Which took place?
4. Bubba’s girlfriend embarrasses him at football games by yelling in the loud horn how hot men are in uniforms (e.g, band members, referees, football
players, ambulance drivers). Bubba found that if he took his girlfriend’s loud horn away, she could not yell through the loud horn and embarrass him. Now
Bubba goes to all of the football games with his girlfriend. The BOI is going to the football game with his girlfriend. Which took place?

Answers: 1=A (BOI increases due to adding compliments). 2=D (BOI decreases due to taking away students ). 3=C (BOI decreases due to adding yelling
through loud horn / embarrassment). 4=B (BOI increases due to taking away loud horn / embarrassment).

A FEW OPERANT CONDITIONING THERAPY TECHNIQUES

❖ Functional behavioral assessment – Conduct an assessment to identify the behaviors that need to be altered
to help the client learn.
❖ Behavior modification refers to helping the client extinguish or reduce abnormal or maladaptive behaviors
through (1) reinforcing desired behaviors and (2) extinguishing undesired behaviors.
❖ Modeling – The therapist demonstrates a behavior (audible and/or visual) to the client so the client can repeat
the behavior in an appropriate situation.
❖ Antecedent based interventions – An antecedent (A) occurs that triggers a behavior (B) which leads to a
consequence (C).
❖ Shaping refers to reinforcing successive approximations of the desired response that become progressively
closer to the desired behavior. It usually takes the form of first reinforcing behavior that is close to the desired
response and then requiring that the response be more and more exactly like the desired response.
 Superstitious behavior can develop if shaping is not done carefully. When a reinforcer occurs close in time
with a behavior, then the behavior is accidentally reinforced. This also can happen with punishers.
• Examples
o A man wears a new tie to a job interview and gets an offer. He now wears the tie at all interviews.
o A man wears a team jersey to watch his team play, and the team wins. Now, he always wears the jersey.
 Discrete trial training (DTT) / discrete trial instruction (DTI) is a technique to teach behaviors/skills in
simplified and structured steps. 107
• Each skill/behavior is broken down into small teachable components to shape the desired skill/behavior.
• Prompts, modeling, and positive reinforcement are used during each discrete trial to teach each
component (i.e., subunit) one at a time.
o Antecedent (sets up the response)
o Prompts (visual or verbal cues to encourage a behavior)
o Response (target behavior)
o Consequence for a correct response / consequence for an incorrect response
o Inter-trial interval (the interval between discrete trials and indicates the end of that discrete trial)
❖ Behavioral rehearsal – Repeating and refining a specific behavior until clients achieve the desired behavior.
❖ Behavior chaining – Breaking down a complex task into small individual components that are taught
sequentially to make the learning process easier.
 The client is taught and then practices each step one-at-a-time. Once a step is mastered, then the next step
is taught and practiced until each step is mastered.
❖ Generalization – The goal is for clients to transfer the learning from behavioral therapy to other situations.
 Natural environment training – After clients learn behaviors/skills through DTT, they can start learning and
practicing the behaviors/skills in more natural environments (e.g., school, home).
❖ Extinction – Eliminating an undesirable behavior by not reinforcing the target behavior (i.e., BOI).
 Consistency is extremely important because intermittent reinforcement (e.g., ratio, variable) will
perpetuate the targeted behavior.

107 Smith, T. (2001). Discrete trial training in the treatment of autism. Focus on Autism and Other Developmental Disabilities, 16(2), 86–92.
[Link]
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• If parent reinforces a child after doing a behavior many times (e.g., throwing a temper tantrum), then the
child learns to do the behavior many times before it will be reinforced.
The therapist must establish a baseline to determine how often the behavior of interest is occurring before

the withholding of response contingent reinforcers.
 An undesirable behavior will often get worse (i.e., increase in frequency/intensity) before it gets better.
❖ Token economies108
 Tokens (objects with no worth) are rewarded for desired behavior. Tokens can then be exchanged for
something in the future. This is often a technique used with children.
 Seven elements of a token economy
• Desired target behavior
• Tokens to be used (i.e., conditioned reinforcers)
• Backup reinforcers (to be exchanged for tokens)
• Reinforcement schedule
• Rate of token exchange for reinforcers (number of tokens needed to get the backup reinforcer)
• Time and place to exchange tokens for backup reinforcers
• Response cost (penalty where tokens are taken away for inappropriate behaviors)
❖ Behavioral contracts / contingency contracts 109
 The therapist draws up written agreement (i.e., contract) between family members (e.g., parent/child,
spouses) or between therapist and client.
 The problem must be defined and stated in behavioral terms.
 A contract should (1) be clear, explicitly stated, fair, and honest; (2) specify responsibilities and behavioral
expectations of each client; and (3) outline small steps with frequent rewards toward a final behavior.
 Rewards must be agreed upon and given immediately following the completion of the behavior.
• The rewards must be viewed as rewarding by the client.
 Both the client and the therapist engage in systematic monitoring and follow through.
 The focus is on the client’s accomplishments, not the client’s failures.
 The directives in the contract can facilitate communication between the participants because they can help
clarify what is expected of each person and what may be gained in return.
❖ Other techniques: task analysis, structured day, prompting and fading, script fading, redirection, picture
exchange communication system, visual modeling.

EXISTENTIALISM THERAPY APPROACHES

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Viktor E. Frankl

OVERVIEW
❖ Existentialism is a school of philosophy about human nature.
❖ Existentialism emphasizes free will and individual responsibility.
 Individuals define what is important, valuable, or morally right.
 Individuals create purpose/meaning in their lives.
❖ A few notable existentialists: Albert Camus, Simone de Beauvoir, Martin Heidegger, Karl Jaspers, Søren
Kierkegaard, Friedrich Nietzsche, Jean-Paul Sartre.
❖ Most view existentialism as the philosophy underlying humanism and humanistic therapy approaches.
❖ Existential psychology derived from the question “What is the meaning (purpose, essence) of human life?”
 Most philosophers begin with the assumption that there is some structure in which humans can be placed
and defined (e.g., religious, natural law, social, political, economic). Existentialism does not do this.
“Man, first of all exists, encounters himself, surges up in the world – and defines himself afterwards.” Jean-Paul Sartre

108 Miltenberger, R. (2008). Behaviour modification. Wadsworth Publishing.

109 Myrick, R. D. (1987). Developmental guidance and counseling: A practical approach. Educational Media Corp.
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❖ A few existential therapists

 Otto Rank, an Austrian psychoanalyst – sometimes referred to as the first existential therapist. Much credit
is given to him by Carl Rogers, Rollo May, and gestalt psychology.
 Viktor Frank 110 – Austrian psychiatrist and neurologist, created logotherapy
 Ludwig Binswanger – Swiss psychologist
 Rollo May111 – father of American existential psychology (also associated with humanistic psychology)
 Irvin D. Yalom 112
❖ Many important existential therapy concepts (e.g., situational freedom) came from survivors (e.g., Frankl) of
Nazi German’s concentration camps.
❖ Note: Some existentialists (e.g., Yalom) did not view existential psychology as a stand-alone psychological
paradigm; instead, they saw existential psychology as philosophical position that could be integrated into
other therapeutic paradigms (e.g., humanistic therapy, psychoanalysis).

THE FRAGILE SELF113

❖ Existence preceded essence
 Human beings come into the world first and exist.
 Next, they create a sense of self due to their actions.
❖ Human beings are a sum of their individual actions; yet, they re-create themselves every day by their actions.

VALUES EQUAL CHOICES

❖ Most believe that values originate outside the person (e.g., in the culture, society, religion, custom). However,
existentialists argue that external values are ultimately baseless and that we as individuals need to:
 become aware,
 make choices (i.e., no limbo), and
 assume personal responsibility for choices made.
❖ By the act of choosing, individuals create or bring into being their own values because choices are implicitly
based on each person’s own values.
❖ Individuals need to recognize (become aware) that every word and act is a choice, and that responsibility must
be assumed for those choices.
 Life is the choice one makes.
❖ To be authentic is to choose for yourself how you are to be regardless of what others expect, demand, or invite
you to be.
 Conformity negates freedom, responsibility, and authenticity.

HUMAN RELATIONSHIPS
❖ Human beings are not separate from the experiencing of other humans; instead, human experiencing is
interrelated with other humans and the world.
❖ The emphasis is how we relate to ourselves and to others.
❖ One may relate to himself or others as subject or object.
 Subject is an undefined, uncategorized center of consciousness.
 Object is a thing (e.g., table, chair, person) that is defined by its categorical membership.
❖ Existentialism does not have a personality theory that categorizes humanity into types.
❖ People typically relate to others as they relate to themselves.

110 Frankl, V. (1959). Man's search for meaning. Beacon Press. (available at [Link]
111 May, R. (1975). Existential psychotherapy. Roche Laboratories.
112 Yalom, I. D. (1980). Existential psychotherapy. Basic Books.
113 Van Deurzen, E. (1999). Existentialism and existential psychotherapy. In C. Mace (Ed.), Heart and soul: The therapeutic face of philosophy (pp. 230–250). Routledge.

[Link]

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AUTHENTICITY
❖ Inauthentic – A person who relates to oneself (and others) primarily as objects.
❖ Authentic – Relating to people primarily as subjects and taking responsibility for choices.
 Authenticity is the awareness of one’s own freedom and accepting responsibility for one’s own choice.
 Authenticity is a prerequisite for the resolution of one’s identity.

SUFFERING AND ANXIETY

❖ Suffering, anxiety, and the resulting conflict are a basic part of human living.
❖ Human beings will inevitably face challenges and limitations in their lives.
❖ Human beings function most effectively when they face, rather than deny or avoid, challenges and limitations.
❖ Anxiety is not synonymous with fear, and experiencing anxiety (not too little, not too much) is important in
living an introspective, meaningful life.
“Whoever has learnt to be anxious in the right way has learnt the ultimate.” (Kierkegaard, 1844)

FOUR ULTIMATE CONCERNS / GIVENS114

❖ The inevitability of death
 Living in fear of death and/or oblivious to the reality of death can be destructive.
 It is important to find a balance between awareness of death and not being overwhelmed by death.
 Being aware of death and accepting mortality gives life significance.
“Awareness of the nothingness that one came from and the nothingness one is heading for will be a constant reminder of the re lative freedom of the moment.” Emmy
van Deurzen115
❖ Meaninglessness
 Humans struggle for a sense of significance that is distinctly human; they have a need for meaning and
purpose. The meaning of an individual is defined by where the person fits in the system.
“You lose nothing when fighting for a cause ... In my mind the losers are those who don't have a cause they care about.” – Muhammad Ali
❖ Existential isolation
 Even though, human beings are fundamentally interrelated with the experiencing of other human beings
and the world, all humans will realize they are fundamentally alone.
 Human beings desire to be connected to others and want to feel significant in other people’s lives.
• Some will engage in trends and/or do what others want just to feel significant and avoid feeling alone.
• People need to realize they cannot depend on others for validation and significance.
• Thus, humans will be confronted with aloneness, which can cause anxiety.
 People must recognize that validation must come from within.
❖ Freedom and its attendant responsibility (see “values equal choices”)
 As human beings, we can think and make choices because we are capable of self-awareness.
 Human beings function most effectively when they actualize their potential to make choices and take
responsibility for their lives.
 Human beings are self-determining (i.e., essentially free will) in that they assume responsibility for shaping
their lives and destiny.
 Some people want freedom without responsibility for their choices, which leads to:
• Conformity
• Blind allegiance/obedience to organizations and institutions (e.g., political parties, religious institutions,
activist groups).
• Powerlessness – Feeling one is powerless can also lead people to resign their choices and responsibility.
• Living in bad faith – When choosing becomes too much of a burden, people may pretend they do not
have a choice and are not responsible for what happens in their life or around them. 116
“Everything can be taken from a man, but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances.” Viktor E. Frankl

114 Yalom (1980)

115 van Deurzen, E. (2002). Existential counselling & psychotherapy in practice, 2nd edition. Sage.
116 Sartre, J-P. (1943, 1956). Being and nothingness. Routledge.

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EXISTENTIAL THERAPY117
❖ The existential therapist does not typically diagnose or use assessment models (e.g., DSM) that categorize or
label people.
❖ Psychopathology occurs when people neglect to make meaningful choices and fail to strive for their
potential.
❖ Role of existential therapists118
 It is to engage in a personalized collaboration with the clients.
 It is to guide clients in exploring and then confronting their unique challenges (i.e., existential concerns).
 It is not to provide solutions and/or answers to their challenges.
"Discovering possibilities where none seemed previously to exist, is an intrinsically powerful experience for those who have felt powerless and empty."119
❖ The focus is on helping the client explore the value and meaning of life.
 The focus is not on the client’s past. Although the therapist might help clients recognize the outcomes of
prior choices, the focus is on present and future choices.
 Frankl believed each person searches for meaning in life, and that even though this meaning may change
throughout life, the meaning never ceases to be.120
 Meaning can be discovered through (1) accomplishments or achievements, (2) experiencing a value (e.g.,
love, nature, arts, beauty), and/or (3) suffering and reconciling ourselves to fate.
❖ Goals
 Help clients develop self-awareness that promotes freedom, potential, and commitment to better choices.
 Help clients take responsibility for their life and decisions.
• Human beings function best when they actualize their potential and take full responsibility for their
choices and lives.
• Human beings can find personal happiness by recognizing they have the freedom to direct their individual
lives by making the necessary changes.
 To help clients develop an internal frame of reference.
❖ The primary technique is the relationship with the client.
 The therapist should try to interact with the client with an open mind.
• Being receptive instead of dogmatic (i.e., rigid, narrow-minded)
• Relating to clients authentically (i.e., as subjects) and not as objects (i.e., categorizing or labeling).
o Each therapist-client relationship is considered unique.
o To be authentic the therapist enters into a deep personal sharing relationship.
❖ Similarly, the therapist helps the client develop the ability to live authentically (i.e., to be true to oneself).
 This involves lots of introspection, including identifying one’s weaknesses, strengths, and motivators.
 Also, the therapist models how to be authentic.
❖ Confrontation – The therapist challenges the clients to take responsibility of their own lives.
 The therapist helps clients recognize their freedom to make choices (i.e., free will) in the present and future,
and to accept responsibility for their choices. Thus, the clients can become the person they want to be.
 Steps to confronting client121
• Identify client’s incongruities and mixed messages.
• Help client work towards resolution of incongruent and mixed messages.
• Evaluate the change process.
❖ Anxiety can be a paralyzing force that keeps clients from reaching their full potential, but anxiety can also be
a motivational force to help clients live more fully and reach their potential.
 Thus, it is important to raise awareness of anxiety and the resulting responses to anxiety.
 Providing a meaning for anxiety can help alleviate the anxiety.

117 van Deurzen, E. (2002). Existential counselling & psychotherapy in practice, 2nd edition. Sage.
118 Yalom (1980)
119 Bugental, J. F. T., & Bracke, P. E. (1992). The future of existential-humanistic psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 29(1), 28–33.

[Link]
120 Frankl (1959)
121 Ivey, A. E. (1994). Intentional interviewing and counseling: Facilitating client development in a multicultural society. Brooks/Cole Publishing Company

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• A man was severely depressed due to his wife dying. Frankl asks the man, “What would have happened if
you had died first, and your wife would have had to survive without you?” The man states, “Oh, for her this
would have been terrible; how she would have suffered!” Frankl states, “You see, such a suffering has been
spared her, and it is you who have spared her this suffering; but now, you have to pay for it by surviving
and mourning her.” The man said no words, shook Frankl’s hand, and calmly left.
• A female passenger on the plane is afraid of flying. Asking her the purpose of her journey can help her see
that suffering the anxiety is worth it (e.g., closing an vital business deal, seeing children in another state).
❖ Since people face limitations and challenges throughout their lives, therapists can help clients function more
effectively when they face challenges (e.g., “the givens”), rather than avoiding or denying challenges.
 Therapists can help clients face anxieties and embrace aloneness/isolation so as to learn from them.
 Therapists can help clients balance awareness of death with resources that keep clients from being
overwhelmed by death.
❖ There are various existential therapy approaches: 122
 The Daseinsanalysis existential approach (merges psychoanalysis with existential psychology) establishes a
permissive therapeutic relationship where clients can freely express themselves and develop more
openness towards other people, activities, nature, etc.
 A British school of existential therapy embraces a mostly descriptive, phenomenological view where clients
are encouraged to explore their lived experiences.
 The existential-humanistic approach combines humanistic-supportive practices with psychodynamic-
interpretative nature to help clients face the ultimate givens/concerns (e.g., mortality, freedom, isolation,
meaninglessness).
• Supportive-expressive group psychotherapy helps clients with physical problems (e.g., cancer) confront
and adapt to their existential concerns, enhance their social support and relationships, express and cope
with disease-related emotions, and improve their sense of control.
• Experiential-existential approaches combine the existential-humanistic approach with experiential
interventions to assist clients directly face their experiences and existential processes.
 Meaning / Logotherapy approaches help clients establish meaning/purpose through didactic techniques.
• Socratic dialogue
• Structured group exercises
• Paradoxical interventions
o Anticipatory anxiety (i.e., needing sleep) can lead to hyper-intend (i.e., trying too hard to sleep). Logo-
therapist would recommend the person intentionally try to stay awake.123
 Other approaches include eclectic approaches and brief existential therapy approaches.
 A small meta-analysis found (1) the meaning / logotherapy approaches had large effects on self-efficacy and
psychopathology, and (2) supportive-expressive therapy had small effects on psychopathology. 124
Overview of existential therapy by Dr. Diane Gehart, MFT Program, CSUN: [Link]

HUMANISTIC THERAPY APPROACHES

OVERVIEW
❖ Humanistic therapy has roots in existentialism.
 There are approaches that combine existential and humanistic therapy. 125
❖ Emerged in the 1950s in response to psychoanalysis’ focus on pathology and behaviorism’s focus on tabula
rasa approaches and deterministic views.

122 Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical
Psychology, 83(1), 115-128. [Link]
123 Frankl, V. (1959, 2006). Man's search for meaning. Beacon Press.
124 Vos, Craig, & Cooper (2015).
125 Schneider, K. J. & Krug, O. T. (2017). Existential-humanistic therapy (2nd Ed.). American Psychological Association.

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 Maslow referred to humanism as the 3rd force in the evolution of psychology.

Plunk’s comment: Interestingly, some argue that behavioral therapies were developed in response to psychoanalysis and humanis m; thus, they would be the 3rd wave.
 Founders of the humanistic psychology movement were Carl Rogers and Abraham Maslow.
❖ Rejects the idea that people with related characteristics should be categorized as having the same issue.
 Thus, the emphasis is on each client’s individual nature and not diagnosing.
❖ The primary focus is on positive growth and how healthy people strive to achieve.
❖ Humanism is more focused on self-awareness and how the person feels in the present.
 Thus, the focus is not on how the past led to the current feelings/issues.
❖ Holistic focus (Gestalt approach) from the clients’ perceptions of their own behavior, not the therapist’s view.
❖ It is a talk therapy.
 Helps the person use their instinct to find answers, grow, heal, and find fulfillment within themselves.
 Helps the person identify positive qualities and behaviors.
 Therapist provides positive support and empathy.
Maslow’s
❖ Emphases
 Basic goodness of people Self- Hierarchy
 Subjective interpretation of events Actualization of Needs
To reach one’s
 Creativity unique potential
 Authenticity ----------------------------------------
 Self-determinism and free-will Self-Esteem Needs
To achieve, be competent,
 Positive human potential and gain approval/recognition
 Mindfulness -----------------------------------------------------------
 Self-actualization Love & Belonging Needs
“Nobody wants to
• Ideal self matches actual behaviors. To feel accepted and loved, and to belong
kiss when they are
• Accept self and others as being who they are. ------------------------------------------------------------------------------
hungry.” D. Dix
Safety Needs
• Be problem-centered rather than self-centered. To feel secure, safe, and out of danger
• Have a better perception of what’s important. ------------------------------------------------------------------------------------------------
• Highly autonomous (even when it hurts). Physiological Needs
To satisfy basic needs (e.g., hunger, thirst, sex drives)
• Enjoys and seeks out privacy and solitude.
• Not overly self-conscious. Maslow added a higher need than self-actualization called a “Need for Transcendence.”
Transcendence is a spiritual sense of peace, belonging, and oneness with the universe.
• Exhibit sense of humor at foibles,
pretensions, and folly, rather than sadism, obscenity, or rebellion.
• Relate to people as individuals; not by classifications.
• Would rather deal with unpleasant reality than retreat into pleasant fantasy.
• Have a highly developed sense of ethics (might be non-conventional).
• Have a continued freshness of appreciation and avoid grouping experience into categories.
• Have mystical experiences where personal boundaries dissolve (i.e., the experience of oneness).
• Develop close relationships with only a few close friends while remaining concerned with all humanity.

CARL ROGER’S PERSON-CENTERED THERAPY126

“In my early professional years, I was asking the question: How can I treat, or cure, or change this person? Now I would phra se the question in this way: How can I
provide a relationship which this person may use for his own personal growth?” Carl Rogers
❖ General tenets
 Human nature is basically good.
 People (i.e., organisms) subjectively experience and live in constantly changing worlds.
 Interactions in the world change the person (i.e., the self).
 Goal-directed behavior – Behavior is an attempt by individuals to satisfy their need.
 Emotions facilitate goal-directed behavior.
 Values often result from direct experience, but values may also be adapted from others.
 People strive to actualize (i.e., actualizing tendency).

126 Rogers, C. (1951). Client-centered therapy: Its current practice, implications and theory. Constable.
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❖ Person/Client-centered therapy
 Overview
• People have the capacity to understand themselves, to resolve their own problems, and to grow.
• Therapists’ personal qualities are more important than therapists’ theoretical paradigm or techniques.
• Therapy is a non-directive approach.
• The therapist’s role is that of a facilitator and to provide a comfortable environment, rather than to drive
and direct the patient toward recovery.
• This warm and accepting atmosphere can facilitate the conditions necessary for change. In this
environment, clients can:
o Express any feelings or beliefs,
o Explore their self (i.e., discover areas where their self-worth has been distorted and discover
unrecognized strengths and potential),
o Find solutions to their problems, and
o Work towards reaching their potential (i.e., actualize).
 Important attributes of the therapist
• Congruence (genuineness)
o Therapists demonstrate congruence when they: (1) relate authentically to clients (i.e., one human being
to another, not expert therapist talking down to problem-ridden client), (2) are not playing the part of a
therapist, and (3) engage in self-disclosure to show they can relate/understand.
• Unconditional positive regard
o Therapists demonstrate unconditional positive regard when they are accepting of their client’s
characteristics, emotions, and behaviors.
o Acceptance is demonstrated by listening without interrupting (even to give advice) and by not being
judgmental (verbally or nonverbally).
o Example: “Thank you for sharing that story. I can see your experience was infuriating to you.”
o The therapist’s acceptance does not imply approval (or disapproval) of the client’s actions or attitudes.
• Empathy – Therapists use their own experiences, feelings, and behaviors to respond to the client with a
shared understanding of the clients’ experiences, feelings, and behaviors.
o Therapists demonstrate ‘accurate’ empathy by showing they understand the client’s feelings and
comments, and by validating (i.e., accepting) the client’s feelings and comments. Accurate empathy is
confirmed by clients’ verbal and/or nonverbal behaviors.
o Example: “Thank you for sharing that story with me about your brother. I have also faced challenges
with my own sibling, and I know how frustrating that can be.”
o Meta-analysis – Therapists’ empathy was a moderately strong predictor of clients’ therapy outcomes.127
Person/Client-centered therapy session conducted by Carl Rogers – [Link]
Overview of person centered therapy by Dr. Diane Gehart, MFT Program, CSUN: [Link]

OTHER NOTABLE HUMANIST APPROACHES

❖ Nonviolent communication – Marshall Rosenberg
❖ Gestalt therapy – Fritz Perls, Laura Perls and Paul Goodman
 Overview of humanistic therapy (Gestalt therapy) by Dr. Diane Gehart, MFT Program, CSUN: [Link]
 Gestalt therapy session conducted by Fritz Perls: [Link]

SOME CRITICISMS OF HUMANISM

❖ Difficult to study scientifically or empirically.
❖ Self-actualization is not well-defined.
❖ Often viewed as overly optimistic.
❖ Overestimates freedom and rationality of humans.

127 Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399-410.
[Link]
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TRANSACTIONAL ANALYSIS (TA)

KEY CONTRIBUTORS
❖ Precursors to TA
 Sigmund Freud’s intrapsychic conflict and personality structures (e.g., ego).
 Dr. Wilder Penfield, neurosurgeon, who discovered (during open brain surgery) that people’s brains
retained memories of events from childhood as well as the feelings associated with those memories.
 Harlow’s “monkey studies” with cloth and wire mothers.
 Spitz’s research 128 – When orphans were deprived of maternal care and warmth, their physical growth was
underdeveloped, their intellectual and motor development were diminished, and their mortality was high.
❖ Eric Berne
 Medical degree at McGill University (1935) and psychiatric residency at Yale (1941).
 Worked with groups of soldiers during WWII (1943-1946) and with Erik Erickson in San Francisco.
 Denied membership in the psychoanalytic institute (1956) because he was not “doing psychoanalysis.”
 He presented the first paper on transactional analysis (1958)
❖ Thomas Harris129 and Claude Steiner130 were Berne’s students.
❖ Jut Meininger131

TRANSACTIONAL ANALYSIS OVERVIEW132

❖ People are fundamentally okay (i.e., each person has value and worth).
❖ TA focuses on interaction patterns between individuals.
❖ People are responsible for and in control of their own feelings, thoughts, and behaviors.
❖ People are able to change, grow, and engage in healthy interactions.
❖ The desire for recognition is the basic motivating force in people.
❖ Human personality is divided into three ego states (i.e., Parent, Adult, Child) that influence each set of
transactions.
❖ Personal problems arise from within the personality.
 Unproductive and/or counterproductive transactions are indicators of ego state problems.
 The most beneficial method to handling/resolving problems is to recognize the problem exists and take
responsibility for one’s part in the issue.

TRANSACTION
❖ The basic unit of social intercourse (i.e., anything that happens between two people).
 Transactional stimulus refers to verbally or nonverbally communicating with another person.
 Transactional response refers to saying or doing something in response to a stimulus.
❖ Rituals are structured transactions and are the safest form of transactions (e.g., “How are you?” “I am fine.”)
❖ Transactions at work and in planned leisure activities (e.g., playing game with friends) usually involve
somewhat structured transactions that are fairly interesting, yet not too threatening.
❖ Spontaneous transactions can be exciting, but also intimidating or overwhelming.

STROKES
❖ Strokes are responsive social actions that provide recognition and attention to another person.

128 Spitz, R. (1945). Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood. In O. Fenichel et al . (Eds.), The psychoanalytic study of the child
(Vol. 1, pp. 53-74). International Universities Press.
129 Harris, T. A. (1967). I’m OK—you’re OK. Harper & Row.
130 Steiner, C. (1974). Scripts people live: Transactional analysis of life scripts. Grove Press.
131 Meininger, J. (1973). Success through transactional analysis. Grosset & Dunlap.
132 Berne, E. (1961). Transactional analysis in psychotherapy. Grove.

Berne, E. (1964). Games people play: The basic handbook of transactional analysis. Ballantine Books.
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 Strokes can be verbal, nonverbal (e.g., touch, gesture, eye contact), and/or electronic (e.g., email, text).
 Individuals need strokes to survive and thrive (both psychologically and physically).
 Positive strokes (“warm fuzzies”) refer to any recognition that is direct, appropriate, and relevant and
leaves the recipient feeling significant.
• Examples include compliments (e.g., “I like your outfit”) and signs of affection (e.g., “I’m glad we’re
friends”).
 Negative strokes (“cold pricklies”) – Any recognition that is negative.
• Examples include insults, criticism, physical abuse, and laughing at someone.
 Non-stroke – Perceiving no noticeable recognition (i.e., no response) after a transaction stimulus.
• Any stroke is better than no stroke. 133
• Example: Ghosting someone (not acknowledging them) is an example of a non-stroke.
 Example: You run into an ex romantic partner while shopping. You say “Hi!”
• Positive stroke – Your ex smiles and says “Hi” back to you.
• Negative stroke – Your ex says “Whatever,” rolls eyes, and turns the other way.
• Non-stroke – Your ex walks by with no response. You don’t know whether your ex saw you, did not feel
comfortable saying “Hi” back, or intentionally ignored you. Argh!
 When people do not get positive strokes, they seek any kind they can, even if it is negative recognition.
❖ Recognition hunger
 People desire and seek out strokes. 134
 When children are younger, most strokes are physical (e.g., breastfeeding, hugs, cuddling), but as they grow
older, words and gestures become important strokes also.
 During childhood, youth test and learn strategies and behaviors that result in strokes.
❖ Strokes can be internal or external.
 Internal strokes – self-praise, self-soothing behaviors, fantasies
 External strokes – Strokes from others.
❖ Stroke reservoir – Individuals store up strokes (i.e., they remember strokes).
 People need to keep their reservoir filled to feel good about themselves.
 People have different sized reservoirs (i.e., they need different numbers of strokes to feel good).
❖ Stroke value – Each stroke carries value based on the content and the individual who delivers the stroke.
 “I love you” generally has more value than “I like you”.
 “I love you” from a spouse generally has more value than “I love you” from a stranger.
 A diamond ring given as part of a marriage proposal generally has more stroke value than as a birthday gift.
❖ Filtered strokes
 Individuals interpret strokes to maintain their subjective life position (see next section).
 “I noticed you cut your hair” could be filtered (1) into a positive stroke since the other person noticed the
hair was cut or interprets the message as liking the haircut, or (2) into a negative stroke since the person did
not say they liked it or interprets it as disliking the hair.
❖ Strokes can be either unconditional or conditional.
 Unconditional strokes have no strings attached.
• “Your photograph is beautiful.”
 Conditional strokes have strings attached and are designed to change someone’s behavior. 135
• Performance-oriented strokes
o Strokes are only given when a person performs a certain behavior, meets a certain goal, and/or
produces a good result. Thus, strokes are withheld based on someone’s judgment (e.g., parents).
o Conditional stroke rules are known when there are well-developed parent scripts to guide behavior.

133 Stewart, I., & Joines, V. (1987). TA today: A new introduction to transactional analysis. Lifespace Publishing.
134 Berne (1964)
135 Meininger (1973)

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o Children raised in these environments will often become very performance-oriented. However, they
may feel inadequate when they cannot perform well enough to get the strokes. They may also have
trouble understanding how someone can feel good just by trying.
o “For each ‘A’ you get on your report card, I will give you $20.”
o “You make me proud because you were the best hockey player on the ice today.”
• Accommodation-oriented strokes
o Strokes must be earned, but the rules for getting strokes are unknown.
o People receiving mostly accommodation-oriented strokes learn to please others (e.g., agreeing with
them, being funny, being caring, not being controversial) to receive strokes. Yet, people may become
very anxious since they do not know how to give unconditional strokes. Also, they may constantly fear
rejection since they do not know how to receive unconditional strokes.
• Conformity and compromise-oriented strokes
o Strokes are withheld when a person does not conform or follow the rules.
o The parent has given rules on how to keep strokes, but not necessarily on how to get strokes.
o Majority views, family values, and/or family traditions should be followed to get the strokes. Conformity
and compromise are encouraged. Thus, children raised in these settings often lose original thought.
o Example: “Son, I am really proud of you when you dress like that.”

LIFE POSITIONS136
❖ I’m not OK – You’re OK
 Most common life position, especially for small children who hear “No” a lot.
 The person sees others as capable where they are not. A person records all negative strokes and engages in
self-fulfilling prophesy.
 This person may be plagued by constant feelings of inferiority and can result in withdrawal from others. The
person may be constantly overachieving to try and overcome the feelings of inferiority.
❖ I’m not OK – You’re not OK
 The person sees oneself, as well as others, as not worthwhile. This may occur in a neglectful family where
strokes are not given.
 Individuals who attempt suicide were often in this life position.
❖ I’m OK – You’re not OK
 This person sees oneself as worthwhile and capable but sees others as not okay or worthwhile.
 This position often occurs after surviving an extremely traumatic life experience involving significant others.
 Example: If a child is sexually abused across time, s/he may eventually feel that s/he is okay while others are
not. In some cases, this can be an adaptive quality, even if it increases chance of social isolation. But in
other cases, it can lead to criminality or paranoia.
 This life position can result in individuals who exploit or harm others because they believe anything they do
is justified (okay).
❖ I’m OK – You’re OK
 This person sees oneself and others as worthwhile and capable.
 This life position is generally facilitated in a setting where unconditional positive strokes are given out. This
life position is a conscious decision. Some conditional positive strokes can be okay also.
❖ Berne believed people start out as a prince/princess (“I’m OK”), but they could turn into frogs (“I’m not OK”)
through transactions (e.g., parental injunctions). Harris believed people were born into the life position of “I’m
not OK” (frogs), but they could transform into “I’m OK” (prince/princess). This is still an ongoing debate.

136 Harris (1967)

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EGO STATES137,138
❖ Child (language of emotions, felt concept)
 Emotional or feeling-oriented responses to external events. It is the source of spontaneity, creativity,
humor, fun, enjoyment, sadness, anger, etc.
 Natural (free) child (most emotional and spontaneous) represents the natural and spontaneous
impulses/emotions of a very young child (e.g., loving, happy, impulsive, fearful, angry, hateful, sad).
• Examples: (1) “I feel really scared!” (3) “The clown was really funny!” (3) “I love you soooooo much!”
 Little professor (most inquisitive and intuitive) represents a thoughtful, wise, creative, inquisitive, or
imaginative child who knows how to manipulate others to get what s/he wants.
• Examples: (1) “If you will buy me the toy, then you will be the best big brother ever.” (2) “If you take out
the trash for me, you will be the best husband.”
 Adapted child learns to comply with the authority figure (e.g., parents). It represents guilt, shame, and/or
fear when trying to meet the dictates (i.e., oughts/shoulds) of an authority figure. Doing what you ought to
do and when you should do it.
• This child ego state is often the most conforming, but it can turn into a “rebellious child” ego state.
❖ Parent (language of values, taught concept)
 A collection of recordings (i.e., past messages and events) that occurred earlier in life (from parents) that
influence our values, beliefs, and opinions. Although most of these recordings may come from ages 0-5
years, the parent script can be modified throughout life from transactions with other parent-like figures.
• The parent ego state sets limits and is controlling and nurturing.
 Critical parent finds fault, criticizes others, passes judgments, and/or blames others.
• Examples: (1) “Can’t you do anything right?” (2) “You are so disrespectful.” (3) “I can never trust you.” (4)
“Because of you, we’re losing our house.” (5) Child says, “You’re not allowed to smoke here.”
 Nurturing parent provides support, nurturance, comfort, sympathy, and protection.
• Examples: (1) “You are a very special person.” (2) “It will be okay; it could happen to anyone.” (3) “Here, let
me help you with that.” (4) “Don’t worry. I will protect you.”
• Mother smashes finger, and the child nurtures the mother while she is driving to the hospital.
 Prejudicial parent reflects the attitudes/opinions/standards set by authority figures; often without
objective reasoning (i.e., they just follow what they have always heard or seen).
• The person is often just stating cliches they heard without even thinking.
• Tells us what we ought or should do (e.g., how to dress, how to speak, gender roles).
• Examples: (1) “Don’t talk to strangers.” (2) “Kids should be seen and not heard.” (3) “Always chew with
your mouth closed.” (4) “What goes around comes around.” (5) “It is what it is.”
❖ Adult (language of logic/rationality, learned concept) – computer metaphor
 Objectively deals with reality and the outside world, accumulates and organizes information, tests ideas,
estimates probabilities, makes decisions.
• Crossing a busy road or running a chainsaw require processing multiple pieces of data to ensure safety.
 The Adult often validates messages from the Parent.
• Prejudicial Parent: “You should always look both ways before crossing a street.”
Adult: “You are so right. I could get hit by a car if I don’t look both ways.”
❖ Each ego state can be adaptive depending upon the situation. Thus, a well-adapted personality can change
from between ego states depending on the needs of the current situation.
 The child is adaptive when creativity and enjoyment are emphasized (e.g., parties).
 The parent is adaptive when control is needed (e.g., counteract impulses, control children).
 The adult is adaptive when decisions need to be made separate from emotion (e.g., career, finances).
❖ Only one ego state can be functioning at a given time.

137 Berne, E. (1972). What do you say after you say hello. Grove Press.
Berne, E. (1964). Games people play: The basic handbook of transactional analysis. Ballantine Books.
138 Dusay, J. M. (1972). Egograms and the “constancy hypothesis.” Transactional Analysis Bulletin, 2(3), 37-41. [Link]

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TYPES OF TRANSACTIONS
❖ Reciprocal or complementary transactions occur when a transactional response comes from the ego state in
which it was directed. If a Parent addresses a Child, and the Child addresses the Parent
back, a reciprocal transaction has occurred.
 Example 1
• Adult to Adult: “We will start the auction at 2 p.m. so we can finish by 5 p.m.”
• Adult to Adult: “Yes, you are right. I will start setting up the microphone now.”
 Example 2
• Adult to Adult: “Do you know where my car keys are?”
• Adult to Adult: “They might be on the kitchen counter.”

 Example 3
• Critical Parent to Child: “Your room is like a pigsty. You need to clean it now.”
• Natural Child to Parent: “But I want to keep playing. You are sooo mean!”
 Example 4
• Adapted Child to Parent: “I am sorry I could not finish all of my homework on time. I
really feel bad about it.”
• Nurturing Parent to Child: “That is okay. Don’t’ worry about it. It was a lot of
homework, and most of the other students did not finish on time. I won’t penalize
you for it.”

❖ Crossed transactions occur when an ego state different than the ego state that received the stimuli is the one
that responds. In other words, if a Parent addresses a Child, then the Adult responds
back, a crossed transaction has occurred.
 Example 1
• Adult to Adult: “Tonight is the dinner party with the Bakers. The party starts at 7
p.m.”
• Natural Child to Parent: “But, I don’t want to go. I worked hard all day, and now I
just want to get into my sweats, relax, and watch TV. You are always planning these
things so I cannot even relax.”

 Example 2
• Little Professor Child to Parent: “I want to stay out later with my friends. If you let
me stay out with them after curfew, I will love you for the rest of my life.” said as the
pre-teen smiles and looks up at his parent.
• Adult to Adult: “Thank you for letting me know your desire. But, because it is a
school night, you will need to come home at regular time.”

 Example 3
• Adult to Adult: “Do you know where my car keys are?”
• Critical Parent to Child: “You are always losing your keys. You would lose your head
if it weren’t attached.”

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SCRIPTS & GAMES

❖ Scripts – Ways of interacting that are learned from decisions made during childhood.
 Scripts can be healthy (e.g., work hard to advance) or destructive (e.g., addiction, depression, madness).
 Examples of parental strokes that can turn into life scripts for children:
• “You are such a little helper.”
• “You always want to rule to roost.”
• “You are always getting into trouble.”
• “You will be liked by others if you just ______”
 Scripts are maintained by the ‘games’ people play.
❖ Games refer to a classification of repetitive counterproductive transactions (i.e., social interactions) designed
to get strokes, often in devious and sometimes deadly ways.139
 Learned (often predictable) patterns of behavior with a concealed/ulterior motive.
 Games are considered the building blocks of people’s life scripts (i.e., we learn methods to get strokes).
 Most people have a few favorite games they play with different people and in varying intensities.
 Berne identified many games in his book, Games People Play.140
 Wooden leg game
• Don’t expect too much from me because I have a wooden leg (e.g., not smart, addiction, no motivation,
depressed).
• Individuals want to be excused because of some type of malady that was externally imposed upon them.
 Hypochondriac – can only ask for strokes by being sick.
 Unhappy marital partner – exchanges “love” for wealth and/or status.
 Alcoholic
• The real pleasure of an “Alcoholic” is not really the drinking. Instead, the “Alcoholic” gets strokes (both
positive and negative) through the interactions created from the drinking.
o Attention from people.
o Forgiven by people.
o Rescued by people.
o Persecuted by people – although negative, it is still recognition.
 If It Weren’t For You (IWFY)
• A person (player 1) choses to interact with someone (player 2) who will restrict his/her activities (e.g.,
overly controlling husband and submissive wife).
• The payoff is that player 1 can get strokes by blaming player 2 for not allowing him/her to do certain
activities while also not having to take any risks. Player 2 can get strokes by maintaining control.
• When player 1 is with friends, s/he can engage in another game (i.e., “If It Weren’t For Him/Her”).
 Some other examples of games include:
• Why Don't You, Yes But
• Now I've Got You
• I'm Only Trying to Help
• Look what you made me do
• Other examples can be found at [Link]
❖ Ways to stop a game
 Responding from a different ego state than the original interaction intended.
 Identify and respond to the ulterior message instead of the social message.
• If a person says, “I am so ugly. No one wants to date me.” Instead of automatically telling the person how
handsome or pretty they are, you could (from the Adult ego state) say, “It sounds like you are down on
yourself. Let’s explore how to make yourself feel better about yourself.”
 Replace the game strokes with more appropriate positive strokes.

139 Berne (1964)

140 Berne (1964)
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TRANSACTIONAL ANALYSES & THERAPY141

❖ Cognitive (i.e., Adult centered) behavioral-oriented (i.e., transactions) therapy
❖ Help clients change life scripts.
❖ Psychoeducational approach
 Increase clients’ awareness of their transactional behavior (e.g., games and underlying scripts) and how
they give and receive positive and negative strokes.
 Explanation – The therapist teaches the clients about the ego states.
❖ Emphasized group therapy (around 8 people), once-a-week for about 2 hours.
 Group therapy allows a greater number of transactions.
❖ Consciousness raising
 Increase clients’ awareness of their transactional behavior (e.g., games and underlying scripts) and how
they give and receive positive and negative strokes.
 Help the clients understand and recognize ego states.
 Therapist will often ask questions to help in consciousness raising.
• “What ego state are you in?”
• “Which ego state are you talking from?”
• “Which ego state made that gesture/comment?”
 Have the client read books on TA or go to TA classes (i.e., psychoeducational approach).
❖ Therapists must be aware of games the clients’ play.
❖ The therapist generally responds to clients from the Adult ego state.
 Consciousness raising is a very Adult perspective.
 Therapist relates to clients as equals.
 The therapist can respond as a humorous Child or caring Parent, as long as it is genuine.
❖ Therapist will help client access the Adult ego state to analyze actions.
 Specification – Identifying the ego state that is the source of a particular transaction.
 The therapist can help the client identify the impact of complementary and crossed transactions.
 Audio recording can allow for playback of transactions that can be analyzed by the Adults.
 A whiteboard can be used to diagram ego states and complementary/crossed transactions.
❖ Clients complete a script checklist, such as:
 What life position they hold the most and when they decided on this life course.
 The life scripts they have heard/learned.
 Identify favorite fairy tale or childhood story that guides behavior today (script)
 The counter-scripts they developed that help them.
 The games they engage in.
❖ Script rehearsal142 helps clients become more aware of scripts by acting out a scene from a client’s script.
 The therapist is the director, the client is the ‘star’, a group member plays the other primary character in the
scene (i.e., costar), two other group members stand behind the client to represent the Parent ego states,
and the remaining group members represent the Child ego states.
 The scene is played out between the star and costar while the Parent and Child ego states react.
 The scene lasts about 10 minutes, and then a 10-minute debrief of Adult-to-Adult discussion of the scene.
❖ Give clients permission to change their behaviors (e.g., therapeutic interventions/strategies).
 Help clients develop counter-scripts.
 Help clients challenge parental injunctions such as:
• (1) “Don’t trust men.” (2) “Don’t enjoy sex.” (3) “Don't leave food on your plate.” (4) “Don’t show anger.”
❖ Help clients modify unhealthy patterns of stroking.
❖ Contractual therapy (e.g., therapeutic contracts, suicide contracts)

141 Berne, E. (1966). Principles of group treatment. Oxford University Press.

Steiner, C. (1974). Scripts people live: Transactional analysis of life scripts. Grove Press.
142 Dusay, J. (1970). Script rehearsal. Transactional Analysis Bulletin, 9, 117–121.

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❖ Give the client protection (e.g., empathy, support) when confronted with internal pressures (e.g., scripts)
and social pressures to maintain current games.
❖ Illustration – The therapist uses a story or example to make a point.
❖ Role reversals – Family members can play each other’s roles.
 A daughter role plays her father. First, she imitates his angry silence (e.g., glaring), and then she imitates his
harsh reprimands, “Close your mouth when eating, dummy.” Role reversals allow family members to see
themselves more clearly and through someone else’s eyes. They can also result in some humor as they
dramatically play out each other’s behaviors.
❖ Interrogation – Therapists ask a succession of confrontive questions and forces clients to answer from the
Adult ego state.
❖ Crystallization transpires when clients realize that game playing can be given up and they can enjoy the
freedom of choice.
❖ Clients move from student (with therapist as teacher) to self-analyzer (awareness) to teacher.

COGNITIVE-BEHAVIORAL THERAPY (CBT) APPROACHES

ORIGIN
❖ CBT emerged from and integrated ideas from behavioral approaches, the cognitive revolution in the 1960s,
and Adlerian psychology.
❖ CBT has been referred to as the second generation of behavioral therapies.

OVERVIEW Self-defeating Self-defeating Self-defeating

❖ The premise is that thoughts/cognitions cause thoughts emotions actions
feelings and behaviors; not external things (e.g.,
“I am a Depression Not trying
other people, situations, events).
failure!” new things
❖ Thus, the interpretations of situations/events are
more important than the actual situations/events. The interpretations result in automatic thoughts that
influence individuals’ emotions, physiological responses, and behaviors.
❖ Maladaptive cognitions create emotional distress; thus, modifying cognitions will decrease emotional distress
and maladaptive behaviors.
“Men are disturbed not by events, but by the views which they take of them.” Epictetus (Greek Philosopher)
❖ Individuals may not be able to change other people, situations, or events, but individuals can change their own
thoughts, which will change how they feel and behave.
❖ The primary focus is on helping clients understand how their cognitions (way of thinking) influence how they
feel and how they behave.
❖ Hence, the goals are to help the clients: (1) decrease destructive negative emotions, and (2) decrease
problematic/dysfunctional behaviors.
❖ The therapist helps the individual identify and restructure cognitive distortions, appraisals, and deficits (e.g.,
low self-esteem, negative attributions, maladaptive coping, unmanageable life events).
❖ Content-specificity hypothesis – Each emotional disorder is characterized by specific cognitive content.143
Thus, CBT can be tailored to each disorder.
 Meta-analysis of 106 meta-analyses found strong support for the efficacy of CBT treating many disorders. 144

143 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.
144 Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy
and Research, 36(5), 427-440. [Link]
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❖ A meta-analysis found:145
 CBT (compared to control conditions e.g., waitlist, care as usual), had significant moderate to large effects in
treating depression (even at 6- to 12-month follow-up).
 CBT was statistically significantly more effective in treating depression than other types of psychotherapies,
although the difference was small.
 CBT and pharmacotherapies did not significantly differ in the short-term for treating depression, but CBT
was significantly more effective at 6- to 12-month follow-up.
 CBT was effective in treating depression in institutional settings and as unguided self-help interventions.
 CBT was effective in treating depression in children and adolescents.
❖ Various approaches
 Cognitive therapy – Aaron T. Beck (trained in psychoanalysis)
 Rational emotive behavior therapy (REBT) – Albert Ellis (trained in psychoanalysis)
 Rational behavior therapy – Maxie C. Maultsby Jr
 Rational living therapy – Aldo R. Pucci
 Dialectical behavior therapy (DBT) 146
 Brief cognitive behavioral therapy 147
 Metacognitive therapy (MCT)148
 Third wave / next generation of CBT approaches:
• Acceptance and commitment therapy (ACT)149
• Cognitive behavioral analysis system of psychotherapy (CBASP) 150
• Mindfulness-based cognitive therapy (MBCT)151
• Integrative behavioral couple therapy (IBCT) 152
• Functional analytic psychotherapy (FAP) 153

COGNITIVE DISTORTIONS (THOUGHT HOLES)154

❖ Inaccurate thoughts or faulty ways of thinking reinforce negative feelings and thought patterns.
❖ A meta-analysis found a strong effect between cognitive distortions and externalizing behaviors, and that
interventions can reduce cognitive distortions (small effect).155
❖ Mental filtering
 Only focusing on one side or detail of a situation (usually the negative) and filtering out other information.
 Discounting the positives – Filtering out all positive details of a situation while magnifying the negative
details and/or only focusing on what is not working instead of what is working.
• Debbie Downer never thinks of the positives or what goes well; instead, she just focuses on the negatives.

145 Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other
psychotherapies, pharmacotherapies and combined treatment for depression: A comprehensive meta‐analysis including 409 trials with 52,702 patients. World
Psychiatry, 22(1), 105–115. [Link]
146 Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
147 Cully, J. A., Dawson, D. B., Hamer, J., & Tharp, A. L. (2020). A provider’s guide to brief cognitive behavioral therapy. Department of Veterans Affairs South Central

MIRECC, Houston, TX. [Link]

148 Wells, A. (1999). A cognitive model of generalized anxiety disorder. Behavior Modification, 23(4), 526-555. [Link]
149 Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and

Therapy, 44(1), 1-25. [Link]

150 McCullough, J. P., Jr. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy (CBASP). Guilford Press.
151 Crane, R. (2017). Mindfulness-based cognitive therapy: Distinctive features (2nd edition). Routledge.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). The Guilford Press.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Guilford Press.
152 Jacobson, N. S., & Christensen, A. (1996). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. Norton.

Jacobson, N. S., Christensen, A., Prince, S. E., Cordova, J., & Eldridge, K. (2000). Integrative behavioral couple therapy: An acceptance-based, promising new
treatment for couple discord. Journal of Consulting and Clinical Psychology, 68(2), 351-355. [Link]
153 Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. Plenum.

Kohlenberg, R. J., Kanter, J. W., Bolling, M. Y., Parker, C. R., & Tsai, M. (2002). Enhancing cognitive therapy for depression with functional analytic psychotherapy:
Treatment guidelines and empirical findings. Cognitive and Behavioral Practice, 9(3), 213-229. [Link]
154 Burns, D. D. (1980). Feeling good: The new mood therapy. Signet.

Grohol, J. (2019). 15 common cognitive distortions. Psych Central. [Link]

155 Helmond, P., Overbeek, G., Brugman, D., & Gibbs, J. C. (2014). A meta-analysis on cognitive distortions and externalizing problem behavior. Criminal Justice and

Behavior, 42(3), 245–262. [Link]

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 Alternative thought process – Look for the positives in every situation but try not to discount negatives.
 Discounting the negatives – Only seeing the positives without recognizing negative attributes also.
• Stuart Smalley always looks at the world through “rose colored glasses” (i.e., he only sees the positives).
❖ Personalization
 Automatically attributing personal responsibility (e.g., blame, praise) to things where the person has partial,
little, or no control. Also, believing anything others do or say is a direct, personal reaction to them.
• Everyone got food poisoning at the cafe. If only I would’ve suggested where to eat. It’s all my fault.”
• Boss looks upset, and one employee automatically feels it is his fault.
 Alternative thought process – Question what part you played in a situation and how you might not be
(entirely) responsible.
❖ Fallacy of change
 Needing other people to change to suit you and to make you happy.
• A husband thinks that if his partner cleaned more, then he would be happy.
• One spouse tells the other, “If you start buying me flowers each week, then our problems will go away.”
• Peggy Bundy says to her husband, “Just give me money to shop, and I will never ask you for more money.”
 Alternative thought process – Explore other options/compromises and how to be happy without others
having to change.
❖ Polarized thinking / all or nothing thinking / black-or-white thinking / dichotomous reasoning
 Seeing all events and situations as completely perfect or failures; there is no middle ground. People who
engage in polarized thinking will often use absolute words (e.g., always, never, every time, everything,
nothing, all, whole).
• “If I am not perfect, then I must be a failure.”
• “I never do anything right” or “Everyone takes advantage of me” or “I always end up losing.”
• A man miscommunicates with his partner, so he rates the whole relationship as an “absolute failure” since
they have a “complete inability to communicate.” So, he breaks up. He starts dating someone new, and
because they communicate well the first few dates, he rates the relationship as “absolutely perfect.”
 Alternative thought process – Make it a habit to consider other viewpoints and interpretations of events.
❖ Overgeneralization
 Making a general rash conclusion based on inadequate evidence (e.g., single event, action, or occurrence).
 If a bad event happens once, then people expect it to happen again and/or generalize it to similar events.
• A very good goalie slips on the ice, and someone scores a goal on him. The goalie believes he will continue
slipping and losing points for his team in future games.
• A student does poorly on the first quiz, so she thinks she will do bad on the other quizzes.
• Bud Bundy gets turned down on one date, so he automatically thinks no one will want to go out with him.
 Alternative thought process – Question whether the situation could be different and what factors might
have led up to the situation.
❖ Catastrophizing / Magnifying
 Exaggerating the importance of insignificant events and/or blowing mistakes/events out of proportion.
• People will ruminate about something for hours or weeks, even though it was insignificant to others.
• A job candidate has a small stain on his tie and thinks the interviewers will focus on it and not hire him.
• An employee makes a small error and thinks it will result in being fired.
• Parent says, “You’ll never get into college with a ‘B’ in algebra.”
 Alternative thought process – Challenging oneself to see events from other perspectives and other’s views.
❖ Minimization
 Seeing ourselves or events as less than they really are.
• A professor wins the outstanding teaching award, but she minimizes the importance of the award and
continues to believe she is just an average teacher.
• Your dad says, “If YOU got an ‘A’ on the test, college must be super easy.”
• The coach says, “Bobby Hill, if you won the race, the other runners must have stayed home or got sick.”
 Alternative thought process – Challenge yourself to identify why you are capable and worthy.

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❖ Jumping to conclusions – Making assumptions without any concrete evidence.

 Fortune-telling (i.e., predictive thinking) – assuming something will happen in the future without evidence.
• Your grandmother says, “I just know you are going to be kidnapped walking to school.” (Note. This would
also be emotional reasoning).
 Mind reading – Assuming we know what a person is thinking or doing, without checking to see if it is true.
• Your partner says, “I just know you are thinking about cheating on me with someone.”
• Your mom tells you, “I can just tell you don't like it when I say 'hi' to your friends.”
• In bed, Peggy Hill says to her husband, “I know you are thinking about propane and propane accessories.”
• You think, “Everyone is thinking I am a loser because I am eating alone at the restaurant.”
 Alternative thought process – Question whether other explanations or possibilities exist.
❖ Emotional reasoning
 Assuming your emotions are accurate perceptions of reality, even though you may not have evidence.
Emotional reasoning overrules rational thought and reasoning (i.e., “I feel it, therefore it must be true”).
• A spouse “just knows” her partner cheating, even though she has no evidence, and her partner denies it.
• Your dad says, “I just know that new friend of yours is a bad influence.”
• Alternative thought process – Question whether your feelings are keeping you from seeing clearly.
❖ Inappropriate blaming
 Holding other people responsible for your emotional pain or problems by blaming them for your problems.
• Husband says, “You make me have low self-esteem and be depressed when you are nice to other men.”
• Plunk says, “The only reason I am fat is because students keep bringing me sweets.”
 Alternative thought process – Take responsibility for your own feelings and emotional reactions.
❖ Always being right
 Believing that being wrong is unbearable and being right is more important than others’ feelings.
• “I am going to win this argument no matter how bad it makes you feel because I am right.”
• “I don’t care how badly arguing makes you feel.”
 Alternative thought process – Look for common ground and take into consideration other people’s feelings.
❖ Global labeling / Mislabeling
 Assigning negative global labels about self or another person based on one or two qualities or behaviors.
• Your boss says, “You are the best employee because you stayed late last night.”
• “You are a bad son because you forgot to take out the trash.”
• “You are such a filthy pig because you did not wash the sink after doing the dishes.”
 Alternative thought process – Find evidence that disproves the label.
❖ Should/Must statements
 Having a list of rules about how every person should/must behave. Turning personal desires into “right” and
“wrong” issues. These “should statements” can be directed towards self and others. Should statements
induce guilt towards self and frustration towards others.
• A parent wants you to call your grandmother more, so the parent says, “You ought to call your
grandmother today because she may not be alive tomorrow!”
• Parents take their moralistic views on dancing and turn it into something that their child ought to avoid
(e.g., “You should avoid dancing because dancing will increase sinful thoughts!”).
• Client thinks, “I should be able to remember everyone’s names,” Or “I should be able to please everyone.”
 Alternative thought process – Challenge whether things should only be done/viewed a specific way and
whether there are other alternatives to consider.
❖ There are other cognitive distortions such as fallacy of fairness, control fallacies, and heaven’s reward fallacy.

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COMMONALITIES OF CBT APPROACHES156

❖ Time limited – Fewer sessions than most other forms of therapy.
 The average number of sessions is 16 (usually once a week for 4-10 months)
 At the beginning of the formal therapy, the client and therapist determine an end point for the therapy.
❖ Becoming aware of automatic thoughts
❖ Therapeutic relationship is important, but it is not the primary focus.
❖ Therapist/client collaboration – The therapist works collaboratively with the client.
 To identify the client’s goals.
 To identify the client’s thoughts and behaviors that are causing distress.
 To help the client change those thoughts to modify the behaviors.
 To help the client achieve goals.
❖ Therapists administer short, reliable, and valid self-report measures.
 To establish baseline functioning or symptoms and to track therapeutic progress.
 Measures can be completed by clients immediately before and/or during the session.
❖ Homework – Therapists incorporate homework (from the beginning) for more intense and quicker resolution.
 Therapists explain why homework is important to get the clients to ‘buy into’ doing the homework.
 Allows the client to practice the skills acquired during therapy.
 Helps generalize information from therapy sessions to everyday life.
❖ Socratic method/questioning – Therapists ask questions in ways that stimulate clients’ critical thinking and to
help clients find solutions to their problems.
❖ Inductive methods – Therapists make general conclusions based on specific observations.
❖ Psychoeducation – Behaviors and emotional reactions are learned. Thus, they can be unlearned by learning
new ways of thinking and reacting. Therapists engage in psychoeducation to teach clients about cognitive
distortions and alternative ways of thinking, about the issue (e.g., addiction, depression), about coping
strategies, etc. Therapists may make recommendations of readings or videos as part of homework.
 When clients understand how and why they are doing well, they can continue doing well.

A FEW CBT TECHNIQUES

❖ Case/Problem formulations
 Identify the presenting problem(s) (e.g., “What brought you to therapy today?”).
 The therapist, with the client, identifies a problems list.
 Define the symptom(s) clearly:
• Symptom(s) frequency (e.g., “How frequently do the symptoms occur?”)
• Symptom(s) intensity (e.g., “How mild or severe are your symptoms?”
• Functional impact of the symptom(s) (e.g., “Do the symptoms impact your daily functioning and/or create
general distress?”)
Presenting Problem Frequency Severity Functional Impact
3-4 times a week Moderate (5 out of 10) Keeps me from going to social
Feeling anxiety in social situations
Once every 2 weeks Panic attack (10 out of 10) events with friends.
2-3 times daily Mostly mild anxiety (3 out of 10)
Feeling general anxiety of unknown Keeps me from trying new things.
Once every 2 weeks Sometimes severe (8 out of 10)
Identify predisposing factor(s) – Past events that makes the client vulnerable to the problem(s)?

 Identify precipitating factor(s) – What triggers the client’s automatic thoughts/emotions?
 Identify perpetuating factor(s) – What cognitive mechanisms (e.g., cognitive distortions, automatic
thoughts) and/or behaviors maintain the problem(s)?
 Identify protective factors – What resources does the client have to help them with their problem? (e.g.,
social support, hobbies, coping strategies, personal qualities)
❖ Therapy worksheets – Therapists help clients identify the situation(s) where the problem arises, what they

156 National Association of Cognitive-Behavioral Therapists. [Link]

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were thinking and feeling, what evidence supported those thoughts/feelings, what evidence did not support
the thoughts/feelings, and their new interpretation after.
Situation Thoughts Meaning Emotions Evidence Counter-Evidence Perspective
In what situation What automatic Meaning of What What evidence goes
does the problem thoughts came the automatic emotions What evidence supports against thoughts and What is new
occur? to mind? thoughts. occurred? thoughts/feelings? feelings? perspective/view?
Going to A teacher in high school
Professor thinks Anxiety, Other teachers never Maybe that one teacher
professor’s office I am stupid. said I was not very
I’m stupid. frustration said this. was not conscientious.
to ask for help. sharp.
❖ Journaling / Keeping a thoughts/mood diary
 This technique allows the client to document information about feelings, moods, and automatic thoughts
such as times when they occurred, were triggered, the duration and intensity, and the response.
❖ Pleasant activity scheduling
 Clients schedule activities they enjoy or bring pleasure in the future (e.g., once-a-day, once-a-week).
❖ Visualizing the best parts of the day
 The therapist directs the client to visualize the best parts of a day during the session, but then also assigns
this task as homework for each day.
❖ Exposure and response prevention
 Intentionally exposing oneself to the stimulus that generally elicits the maladaptive thoughts and then try to
prevent the automatic response.
 This technique is frequently used in conjunction with journaling.
 Often used for obsessive compulsive disorder.
❖ Cognitive restructuring
 CBT incorporates cognitive restructuring approach of cognitive therapy with behavioral modification
techniques of behavioral therapy.
 The therapist helps clients change how they think about a situation/event by: (1) examining their thoughts,
and then (2) challenging the irrational or self-defeating thoughts (i.e., challenging their inner critic).
❖ Modifying self-talk
 Thought stopping – Stopping automatic negative thinking.
• Example: A client is directed to think obsessively in a self-defeating manner; then suddenly the therapist
yells, “Stop!” The client cannot continue the self-defeating thoughts after the unexpected disruption.
• Clients learn to tell themselves to stop when they realize they are engaging in negative thoughts.
 Writing self-statements to counteract negative thoughts – The therapist helps the client identify self-
defeating thoughts with assertive, positive, or neutral thoughts.
 Positive thought replacement – The therapist helps the client learn that after stopping the self-defeating
thoughts, then the client should replace the thought with positive thoughts from a list.
❖ Visualization/Imagery of the desired behavior – Client visualizes engaging in the desired behavior.
❖ Cognitive and/or behavioral rehearsal
 Client practices the desired thoughts or behaviors with the therapist. Ideally, this will help the client
replicate the thoughts or behaviors outside the therapy session.
❖ Play the script until the end
 The worst case scenario
• The client engages in a thought experiment by imagining the worst possible outcome for a fearful event or
anxiety provoking event. The goal is to help the person realize that even in the worst possible outcome, it
will be okay. Sometimes the client will ruminate to a worst case that has an unrealistic end, so much so,
that even the client sees how ridiculous it is.
• Example: A client gets anxiety thinking about going through a fast-food drive through. The therapist has
the client think through the worst possible outcomes.
 The best case or most likely case scenarios
• The client explores the best possible outcome for the anxiety provoking event to show there are
potentially good outcomes.
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• The client and therapist explore the most likely outcome.

• In both these scenarios, the client and therapist can identify actionable steps towards the best or most
likely outcome so that the client can perceive some control over the anxiety/fear provoking event.
❖ Validity testing
 Therapist instructs clients to articulate objective evidence (i.e., not opinion) that supports their beliefs (e.g.,
cognitive distortions). If clients cannot verbalize objective evidence, then the belief may seem less valid.
❖ Stress inoculation
 Define the nature of stress for the client and how the client copes.
 Teach stress reduction and coping skills (i.e., psychoeducation) to expand skills the client already uses.
 Have the client practice the new skills outside of the therapy room in real life (i.e., homework).
❖ Relaxation or stress-management training
 Progressive muscle relaxation, relaxed breathing, and mindfulness meditation
❖ Mindfulness-based techniques (e.g., mindfulness mediation)
 Teach clients to respond reflectively, instead of reflexively, to stressful events and negative emotions. 157
(“all conflict is bad” example)
 Clients are encouraged to gradually accept their thoughts, feelings, and surroundings with an open,
nonjudgmental, and curious mind. By staying focused on the present, instead of ruminating on past events
or worrying about future events, clients can deal with life stressors more effectively.
 Thus, clients are engaging in behaviors and thought processes that are contrary to avoidance strategies that
maintain and/or exacerbate emotional disorders.
❖ Other techniques: grade exposure, rescripting, treating thoughts as guesses.
Good overview of CBT by Dr. Diane Gehart, MFT Program, CSUN – [Link]
Recommended reading: Dobson, K. S., & Dozois, D. J. A. (editors). (2019). Handbook of cognitive-behavioral therapies (4th edition). The
Guilford Press.

REFRAMING
❖ Framing refers to the way a conflict/event is described or how a proposal is worded.
❖ Reframing expands perceptions of an event by giving a different frame through which to view a situation. 158 By
restating the underlying interests, needs, and wants in different terms, it changes how a thought is presented
to support more positive views. 159
 “Every experience in the world and every behavior is appropriate, given some context, some frame.”160
 Reframing can help acknowledge feelings, establish common ground, and deescalate conflict.
 The challenge with reframing is not to trivialize the situation; hence, it is necessary to be conscious about
the verbal and nonverbal delivery of the reframe.
❖ Content reframing refers to changing the meaning of a situation/behavior.
 Identify alternate meanings and/or a positive benefit for the same situation/behavior/action.
 “Retreat, hell! We're not retreating, we're just advancing in a different direction.” (General Oliver Well).
 Student: “I just watched TV and napped all week before school started. I was so lazy and unproductive.”
Plunk: “You must have needed a break. Good for you for relaxing and engaging in self-care.”
 Daughter: “My mother constantly interferes in my life and won’t let me stay out with my friends.”
Content reframe: “It sounds like your mother would like to protect you because she loves you.” in this case,
the therapist reframed the meaning from intrusiveness to love.

157 Hofmann, S. G., Sawyer, A. T., & Fang, A. (2010). The empirical status of the “new wave” of cognitive behavioral therapy. Psychiatric Clinics of North America, 33(3),
701–710. [Link]
158 Sandidge, R. L., & Ward, A. C. (1999). Reframing. In J. F. Gardner & S. Nudler (Eds.), Quality performance in human services: Leadership values, and vision (pp. 201-

221). Paul H. Brookes.

159 Mayer, B. (2000). The dynamics of conflict resolution. Jossey-Bass Publishers.
160 Bandler, R., & Grinder J. (1982). Reframing. Real People Press.

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Client: “I hate having to drive 30 miles to work.”


Therapist: “What a great opportunity to decompress and listen to books or music with
no interruptions.”
 Friend complaining: “My 85-year-old grandpa is never home when I visit him.”
Plunk: “What a blessing that he is so healthy and active."
❖ Context reframing refers to taking a situation/behavior that appears to be useless,
harmful, or distressing and demonstrate how the same situation/behavior can be useful in
a different context.161
 Most behaviors/actions are useful or appropriate in some context.162
 Thus, changing the context/setting of a situation/event can change its meaning.
 One way to change the context is to change the time and/or space of the event.
 Examples
• Rudolph’s red nose was viewed as weird and funny. However, change the context to a
“foggy Christmas eve,” and the red nose becomes an asset.
• Parent: “It is exhausting having such a dramatic child.”
Therapist: “Yep, but she’ll be amazing in speech and theater in high school."
• Mother: “My son talks back. He always questions our authority and opinions.”
Therapist reframes the context to peer relations: “You are lucky to have a son who won’t blindly follow his
peers but will make his own choices and have his own opinions.”
• Client: “My partner is so detail-oriented in everything he reads. It drives me nuts.”
Therapist: “That is a great skill when he is looking over credit card statement or bank statements.”
• Parent: “My 4-year-old son always wakes up too early in the morning and wakes me up.”
Parent educator: “That will be great when he starts school since he will get up in time for school."
• Client: “My spouse is too competitive when we play games.”
Therapist: “Your spouse’s competitiveness is why she has been promoted so frequently at work.”
• A college student was upset because her parents spent their life savings building an extension on their
house for her to live in after she got married. Dr. Milton Erikson reframed the situation. He praised the
parents for their willingness to share in the rearing of their future grandchildren (e.g., babies crying all
night, toddlers crawling through the house, babysitting, toys everywhere). This reframe (i.e., setting the
view of the situation in the future) created a positive but very descriptive representation of being a
grandparent. The parents decided to rent the rooms in the new addition to ‘mature’ adults and use the
rent money to support their future grandchildren’s education.
❖ Virginia Satir incorporated both context and content reframes after a dad complained his daughter was too
stubborn. Satir said stubbornness can be good when she needs to protect herself or achieve something. This
reframe switched the context, which made stubbornness a strength. Second, Satir said the daughter learned to
be stubborn from her dad. This reframe forced the dad to associate his stubbornness with hers. Thus, the dad
had to recognize the worth of her stubbornness or deny the worth of his own stubbornness.

RATIONAL EMOTIVE BEHAVIOR THERAPY – ALBERT ELLIS

“As I see it, psychoanalysis gives clients a cop-out. They don’t have to change their ways … they get to talk about themselves for 10 years, blaming their parents and
waiting for magic-bullet insights.” Albert Ellis

Origin163
❖ Albert Ellis introduced “rational therapy” in 1957. It was renamed “rational emotive therapy” to emphasize
emotional outcomes. Then, it was renamed “rational emotive behavior therapy” to highlight the importance of
behavioral factors. Most recently, it was called “rational-emotive and cognitive-behavior therapy.”
❖ A meta-analysis found REBT generated medium and strong effect sizes for various mental health outcomes.

161 Sandidge & Ward (1999)

162 Bandler, R., & Grinder J. (1982). Reframing. Real People Press.
163 David, D., Cotet, C., Matu, S., Mogoase, C., & Stefan, S. (2018). 50 years of rational-emotive and cognitive-behavioral therapy: A systematic review and meta-

analysis. Journal of Clinical Psychology, 74(3), 304–318. [Link]

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Basic Premises164
❖ Thinking, emotions, and actions are interdependent (i.e., influence each other).
❖ People want to be happy and have a good quality of life.
❖ People are born with strong tendencies to be rational and self-helping as well as irrational and self-defeating.
❖ People are born naïve (i.e., gullible) and suggestible (i.e., teachable). Thus, they learn beliefs, feelings, and
ways to act from significant others (e.g., parents and other caretakers).
 A child can learn dysfunctional or functional ways to perceive and react to the world from parents.
 It is important for significant others (e.g., parents, teachers) to help children gain unconditional self-
acceptance and to believe they are okay.
❖ When people accept dysfunctional (or functional) beliefs from others, they often carry them on later in life.
 People are constantly evolving (‘becoming’).
❖ For better or worse, people create complex ways (e.g., imagining, language, dream symbols) to process their
feelings and actions and the resulting consequences.
❖ It is peoples’ beliefs about events that influence their behaviors and mental health.
 It is not the events themselves, but how people perceive them.
 People become habituated to their dysfunctional and self-defeating thoughts and behaviors.
 A person thinks, “I am a bad person.” A healthier thought is “I did a bad thing.”
❖ People must accept and tolerate themselves as well as others to achieve life goals.
❖ People mostly have control over their thoughts, emotions, and behaviors.
❖ To change, people must first recognize how they think and react (i.e., develop insight). Then, they can choose
how they think and act.
❖ When people keep challenging their dysfunctional philosophies, new more rational beliefs can emerge.
 Challenging a dysfunctional thought (e.g., “I am worthless”) through self-talk (e.g., “I am capable”).
❖ Therapy that is active and directive is more helpful than therapy that is passive and less active.
❖ REBT is more behavioral than most other forms of CBT.
❖ REBT recognizes that there can be a biological aspect to mental health problems.

The Three Musts / Irrational Beliefs165

❖ I must do things well and win others’ approval, otherwise I am incompetent and worthless.
 This irrational belief often results in anxiety, panic attacks, hopelessness, worthlessness, and depression.
“I must be thoroughly competent, adequate, achieving, and lovable at all times, or else I am an incompetent worthless person” – A. Ellis
❖ Others must treat me nice and fairly or else they are bad people.
 This irrational belief often results in anger and vindictiveness.
“Other significant people in my life, must treat me kindly and fairly at all times, or else I can’t stand it, and they are ba d, rotten, and evil persons who should be severely
blamed, damned, and vindictively punished for their horrible treatment of me” – A. Ellis
❖ Life must be easy and comfortable otherwise I will be miserable. Stated another way, “I must get what I want,
when I want it; and I must not get what I don't want. It's terrible if I don't get what I want, and I can't stand it.”
 This irrational belief can result in (1) feeling anger, self-pity, and despair, as well as (2) inaction, avoidance,
and procrastination.
“Things and conditions absolutely must be the way I want them to be and must never be too difficult or frustrating. Otherwise , life is awful, terrible, horrible,
catastrophic, and unbearable” – A. Ellis

164 Ellis, A. (1962). Reason and emotion in psychotherapy. Citadel.

Ellis, A. (2003). Early theories and practices of rational emotive behavior theory and how they have been augmented and revised during the last three decades.
Journal of Rational-Emotive & Cognitive-Behavior Therapy, 21(3/4), 219-243. [Link]
DiGiuseppe, R.A., & Doyle, K. A. (2019). Rational emotive behavior therapy. In K. S., Dobson & D. J. A. Dozois (Eds.), Handbook of cognitive-behavioral therapies (4th
edition) (pp. 191-217). The Guilford Press.
165 Ellis, A. (2003)

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A Adversity / B C
Beliefs Consequences
Activating Event

The A-B-C Model of Psychological Disturbance and Change

❖ Adversity or activating event – Something happens that potentially causes stress or anxiety.
 Could be an external or internal event.
 Could be a past, present, or future event.
❖ Beliefs – Events are evaluated through one’s perceptions of the event (i.e., meaning attached to the event).
❖ Consequences – Beliefs are what influence the emotional and behavioral outcomes of the activating event.
 If the activating event (A) is evaluated (B) in a rigid and/or dysfunctional manner, then the consequences (C)
are likely to be maladaptive (e.g., destructive, self-defeating).
 If the activating event (A) is evaluated (B) in a flexible and/or constructive manner, then the consequences
(C) are likely to be adaptive (e.g., constructive, self-helping).

Therapy166
❖ Goal – To help people live rational and productive lives.
❖ Therapists are empathetic, persistent, rational, logical, and empirical.
 Therapists must apply the theory to their own personal lives.
❖ The first few sessions are devoted to teaching the A-B-C model.
❖ Therapists teach clients how to think rationally, logically, and empirically.
❖ Acceptance – The therapist helps the client accept reality.
 Unconditional self-acceptance
• No one is perfect. There is no reason why I am not perfect.
• We all have good qualities and bad qualities. I am not better or worse than other people.
 Unconditional other-acceptance
• No one is treated fairly all the time. There is no reason why people must treat me fairly.
• People who treat me unfairly are no better or worse than other people.
 Unconditional life-acceptance
• Life does not always work out like we want it to, and it is not always pleasant.
• There is no reason why life is not perfect.
• Life is not always awful, and it is bearable most of the time.
❖ Therapists teach clients not to condemn themselves or others for poor choices/behaviors. In other words, a
person is not globally ‘bad’ because they engaged in poor choices.
❖ Insight – Therapists show clients how they are hurting themselves and/or irrationally condemning themselves.
 Therapists explain that everyone thinks irrationally at times.
 Therapists help clients realize they can reduce frequency, duration, and intensity of their irrational beliefs.
 Three insights:
• We don’t just get upset; we distress ourselves through our inflexible beliefs.
• We maintain our suffering by adhering to our irrational beliefs.
• The only way to get better is by a concentrated effort to change our beliefs.
❖ Therapists teach clients how to directly contradict and undermine self-defeating irrationalities, self-
deprecating talk, and/or negative communications with others.
 Examples: positive self-talk and positive imagery
❖ Confrontation – Therapists directly challenge clients’ illogical or irrational beliefs.
❖ Disputing – The therapist helps the client dispute irrational beliefs.
 Cognitive disputation – Therapists ask clients questions that challenge the logic of their responses.

166 Ellis, 2003; [Link]

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• “What proof is there that this belief is false?”

• “What is the worst possible outcome that could occur if you fail?”
Imaginal disputation – Therapists direct clients to visualize a situation where they responded differently

than they normally would, and then the clients’ self-talk is examined.
• First, therapists direct clients to imagine a situation where they became upset. Second, the clients’ self-
talk is examined. Third, the clients are directed to change their self-talk in the situation.
 Behavioral disputation – Therapists direct clients to behave in ways that are opposite to the way they
would like to respond to the situation.
❖ Cool and hot beliefs
 Cool beliefs are objective thoughts (e.g., “There is an otter.”)
 Warm beliefs are evaluative thoughts (e.g., “I hate otters, and they should be killed.”)
❖ The emotional control card
 The card has a list of self-destructive feelings along with the corresponding non-defeating feelings.
 The client is directed to carry the card. When the client is confronted with a difficult situation, the client can
refer to the card to counter the negative self-talk.
REBT session conducted by Albert Ellis: [Link]

ACCEPTANCE AND COMMITMENT THERAPY (ACT)

❖ Overview of ACT167
 ACT is less focused on reduction of symptoms of a specific disorder. Instead, ACT focuses on transdiagnostic
approach (e.g., psychological flexibility, intolerance to uncertainty) of psychopathology.
 Painful or distressing thoughts and experiences can dominate a person’s attention (i.e., being fused with
thoughts). Outside of ACT this might be referred to as brooding rumination or negative rumination.
 Trying to control, deny, avoid, or suppress painful experiences/emotions is counterproductive and can lead
to more pain and distress.
 Acceptance
• Clients are encouraged to acknowledge and accept thoughts and feelings, even negative
thoughts/feelings.
• Clients learn to accept that having these feelings are appropriate in some situations.
• Thus, clients learn strategies to stop struggling with, avoiding, and/or denying their thoughts and feelings.
 Cognitive defusion
• Clients learn how to detach from distressing thoughts/emotions by focusing on the process of thinking.
Techniques include:
o Seeing a thought as a passing event.
o Observing thoughts without judgment.
o Labeling automatic responses.
o Singing or saying thoughts out loud in a silly voice.
o Zooming out – The client is instructed to imagine floating high in the air where everything below looks
small and insignificant.
 Being present
• Clients are encouraged to focus on how they feel in the moment by being mindful in the present moment.
• Part of being present includes observing feelings and thoughts without judgement and without trying to
change the thoughts.
• Clients are encouraged to focus less on future “what ifs.”
 Self as context

167 Hayes, S. C., & Lillis, J. (2012). Acceptance and commitment therapy. American Psychological Association. [Link]
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research
and Therapy, 44(1), 1–25. [Link]
Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). The Guilford Press.,
[Link]
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• People often think they are bad or unworthy because they have bad thoughts or feelings. Thus, clients are
encouraged to accept that they are not defined by their experiences, thoughts, and feelings.
Values

• Clients are encouraged to choose personal values or standards in various domains they want to live up to.
 Committed action
• Clients are encouraged to set goals and then identify and take tangible steps to make changes that align
with their values/standards.
 Clients develop psychological flexibility where their behaviors align with their values instead of letting
emotions drive their behavior.
❖ ACT effectiveness
 A meta-analysis found ACT was more effective in treating depression even at 3-months follow-up versus the
control groups.168
 A review of meta-analyses found ACT was effective in treating individuals with substance use, pain, anxiety,
depression, and transdiagnostic groups.169 In addition, ACT was generally more effective than treatment as
usual and untreated control groups (e.g., placebo, waitlist). ACT was generally more effective than other
active treatments, except for CBT.
 A meta-analysis found ACT was more effective than treatment as usual and waitlist control groups in
treating children with anxiety and depression.170 No significant difference was found between ACT and
traditional cognitive behavioral therapy (CBT) on treating anxiety, depression, and other mental and
behavioral disorders. No significant differences were found between traditional CBT or treatment as usual
on secondary outcomes (e.g., quality of life, well-being). However, ACT was significantly more effective than
untreated control groups on secondary outcomes.

DIALECTICAL BEHAVIOR THERAPY171

The Three Minds
❖ Marsha Linehan, Ph.D., developed DBT as an intervention for borderline
personality disorder.
❖ Dialectical philosophy
Logical Wise Emotional
 Two contradictory ideas can exist simultaneously; both can be true.
mind mind mind
 People need to move beyond black-and-white thinking and find balance in
opposing forces (e.g., “the three minds”)
❖ Biosocial theory
 Biological vulnerability
• Lack an “emotional skin.”
• Experience things more intensely. Chronic
Biological Invalidating
• More reactive to events and stressors. emotional
vulnerability environment
• Higher sensitivity to emotions: dysregulation
o activated more easily,
o heightened in response, and
o slower return to baseline (i.e., slower to come back down once activated).
 Invalidating environment
• Significant others fail to treat emotional expression with attention, respect, and understanding.
• Inappropriate or inconsistent responses.
❖ Treatment goals
 To create a life worth living.

168 Bai, Z., Luo, S., Zhang, L., Wu, S., & Chi, I. (2020). Acceptance and Commitment Therapy (ACT) to reduce depression: A systematic review and meta-analysis. Journal
of Affective Disorders, 260, 728–737. [Link]
169 Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses.

Journal of Contextual Behavioral Science, 18, 181–192. [Link]

170 Fang, S., & Ding, D. (2020). A meta-analysis of the efficacy of acceptance and commitment therapy for children. Journal of Contextual Behavioral Science, 15, 225–

234. [Link]
171 Linehan, M. M. (2015). DBT skills training manual (2nd edition). Guilford Press.

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 To increase clients’ desire for change.

 To build clients’ emotions skills and capabilities.
 To help clients generalize gains outside therapy.
 To restructure clients’ environments.
❖ Strategies for balancing acceptance and change
 Mindfulness – Awareness and acceptance of the present moment by focusing on just one thing, in the
moment, without judgment.
• Meditation strategies
• WHAT skills
o Observe – Just notice or experience an event without labeling or describing the event. In other words,
just experience the event/interaction without reacting to the experience.
o Describe – Put words to experiences. When a feeling, thought, or reaction occurs, put words to describe
the observable facts of the experience (e.g., “My body is tensing up, and my hands are in a fist”).
o Participate – Allow yourself to be involved and present in the experience without ruminating and/or
being self-conscious (i.e., become one with the experience).
 Distress tolerance – Develop techniques and strategies to accept, find meaning for, and tolerate distress.
• Wise mind ACCEPTS:
o Distract with Activities (e.g., hobbies, gardening, going for a walk).
o Distract with Contributing (e.g., do something for someone such as babysit).
o Distract with Comparisons (e.g., compare yourself to your earlier self, or someone who is doing about
the same or worse than you).
o Distract with opposite Emotions (e.g., listen to fun music or watch a comedy when sad).
o Distract by Pushing away (e.g., imagine a wall between yourself and the aversive situation; then push
the wall away).
o Distract with other Thoughts (e.g., counting ceiling tiles or clouds).
o Distract with other Sensations (e.g., take a hot bath or cold shower, put your face into the sun or
breeze).
 Emotion regulation – Understanding emotions and emotional development.
• People have a vulnerability to negative emotions.
• Develop techniques for building positive emotions.
• PLEASE regulate.
o PL: Treat physical illness.
o E: Balance eating.
o A: Avoid mood-altering drugs.
o S: Get enough balanced sleep.
o E: Exercise consistently and often.
 Interpersonal effectiveness
• Assertiveness.
• Interpersonal problem solving.
• Think FAST to keep self-respect.
o Be Fair.
o No Apologizing when you are not to blame (i.e., no ritual/automatic apologizing).
o Stick to your values.
o Be Truthful.
 DEAR MAN Skill to promote effective interpersonal communication and healthy relationships while also
getting needs met.
• Describe the present situation.
o Being objective and sticking to the facts helps another person understand your perspective of the
situation.
• Express your feelings.

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o Communicating your feelings about the present situation avoids the assumption that another person
knows how you are feeling.
• Assert your desire.
o Clearly stating what you want (including saying ‘no’) avoids the assumption that another person knows
your desire.
• Reinforce.
o Letting another person know the positive (and/or negative) outcomes related to meeting your
needs/desire allows the other person the opportunity to make an informed decision.
• Mindfulness.
o Being mindful can help you stay focused on the goals and on-topic regarding the present situation. Also,
being mindful can help you avoid distractions (e.g., responding to attacks, bringing up past situations)
while you repeatedly ask for what you want.
• Appear confident.
o Maintaining a confident demeanor (e.g., making eye contact) and voice (e.g., no stammering,
appropriate volume) can make you look more competent and effective.
• Negotiate.
o Being open to alternative ideas and willing to compromise can result in a mutually acceptable outcome.
❖ Multimodal treatment (psychotherapy is not based in a specific protocol)
 Individual psychotherapy
• Skills use is encouraged and consolidated in individual therapy sessions.
• Problems are addressed hierarchically.
• Diary cards (do an image search for DBT diary cards on the internet).
• Chain analysis – excellent description of chain analysis: [Link]
 Phone coaching
• Problem solving focus.
• Brief, as needed, and not for in-depth therapy.
 Consultation team meetings
• 1-2 hours per week.
• Address client difficulties and therapist difficulties.
 Skills groups
• Skills are acquired in group therapy (2+ hours per week).
• Skills training:
o Acquisition
o Strengthening
o Generalization

Good overview of DBT by Dr. Diane Gehart, MFT Program, CSUN – [Link]

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GENOGRAM FAMILY MAPPING

A genogram is used to provide a graphic representation of the family’s basic structure, demographics, history, and
interaction patterns.172 The practitioner and clients construct the genogram together (usually early in therapy). It
is revised as new information becomes available. It provides a lot of data and insight for the therapist and clients.
It can be used as an informational, assessment, diagnostic, preventive, and intervention tool. As a clinical
assessment tool, it helps the therapist and individual/family think systematically about how events, relationships,
problems, issues, events, and symptoms are related to patterns in the family (i.e., how events and relationships
are interdependent). The therapist can use the genogram to identify potential prevention and intervention points.

REASONS TO DO A GENOGRAM
❖ Enhances rapport building and ‘joining’ with the family.
❖ Facilitates systematic history taking.
❖ Helps simplify a complex system by providing a graphical representation of the family.
❖ Helps the therapist visualize the family “at a glance” and aids in analyzing family processes.
❖ Helps family members gain a holistic view of their family.
❖ Provides a method for developing an efficient clinical summary and facilitates case management.
❖ Connects symptom/problem to context.
❖ Assists with treatment planning and identifies points of prevention, stressors, risk factors, and intervention.
❖ Assists with research.

GENERAL GUIDELINES FOR CONSTRUCTING A GENOGRAM

❖ There is no “right” or “one” way to construct a genogram.
❖ Begin with the immediate household and then move to the extended family system.
❖ Go from the present to the past.
❖ Solicit the easy information first and then move to the potential anxiety-producing information.
❖ List facts before judgments.
❖ Solicit as many perspectives as possible from the different family members.

→ See PDF in Canvas files called “[Link]”

172McColdrick,
M., & Gerson, R. (1985). Genograms in family assessment. Norton.
McGoldrick, M., Gerson, R., Shellenberger, S. (1999). Genograms. assessment and intervention. 2nd edition. Norton.

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GENOGRAM SYMBOLS
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Male Female M ‘92 LT ‘92 LT ‘95

M ‘92
Married couple; husband on left, Living together, affair, Gay couple Lesbian couple
wife on right (m = marriage date) or dating
Transgender (LT = cohabiting date)
Sexual orientation can be shown by
M2F F2M putting letters underneath a person’s
symbol or name. H = heterosexual,
Male to Female
G = gay, L = lesbian, B = bisexual,
female to male M ‘92 S ’97 M ‘92 D ‘97
Q = questioning, P = omnisexual /
s = separation date d = divorce date polisexual

Index person or ’92- -‘04

identified client ‘04
21
Birth date is Death date is m ‘88 d ‘92 m ‘95 d ’01 LT ‘03
above left, above right
Deceased age is inside Man with two ex-wives and current live-in partner

Children are drawn in birth order with the oldest child on the left; squares = male, circles = female

Stillbirth Abortion
Miscarriage
Biological Adopted Foster Fraternal Identical Pregnancy
child child child twins twins

Other Other Substance Suspected Serious mental or Substance abuse In recovery from
marriages marriages abuse sub. abuse physical problem and physical or substance abuse
and children mental problem

Very close Enmeshed Conflictual Close and Enmeshed and Estranged or

or fused conflictual conflictual cut-off

Distant Focused on
Sexual abuse

Other information which may be on the genogram

Ethnic background Religion or religious change m ‘92 d ‘97 m ‘99
Education Occupation or unemployment
Military service Current location of family members
Trouble with law Physical abuse or incest
Obesity Psychological problems
Smoking Medical problems
Retirement Dates when members left home (i.e., LH ‘85) Dotted line around people infers they live together

Other Genogram Symbols

[Link]
[Link]
[Link]

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FAMILY SYSTEMS THEORY/THERAPY

Many therapists feel frustrated when the client goes home and relapses. The relapse may be blamed on the client
(e.g., “He didn’t want to change” or “She is a bad person”), parents (e.g., “Poor parenting equals bad children”),
family (“They’re a dysfunctional family”), or society (e.g., “Social media is causing dysfunctional behaviors,” or “His
choice of friends keeps him in trouble”). Each explanation gives one primary cause to behaviors, and interactions
between individuals, family, and society are often not considered. Family systems theory (FST) views the family as
a unit of interconnected people that reciprocally influence each other over time. FST believes prevention efforts
and interventions should target the family when possible. Thus, practitioners are trained to work with the whole
family; yet, managing an entire family system can be overwhelming and complex. Interviewing, assessing, and
intervening in the family require different methods than working with individuals.

OVERVIEW173
❖ Family systems is a collection of loosely related perspectives that have significant application to the family.
❖ Systems exist in the environment. All systems are open to influence from the environment, although some are
more open than others. When new information comes into the system, the system may resist change (i.e.,
morphostasis) or it may change, grow, or develop (i.e., morphogenesis).
❖ The primary focus is on process rather than on structure of the system.
“There is no such thing as an individual, there are only fragments of families.” – Carl Whitaker

WHOLENESS AND NONSUMMATIVITY

❖ Wholeness
 The family system is made up of a group of individuals who form a complex and
unitary whole.174
 The family system cannot be wholly understood by simply looking at the parts since
the system consists of more than the individual family members.
• The whole is distinctly different from the sum of the contributions of individual members because each
family is characterized by structural rules of relating that determine how members interact with each
other. Thus, the family system comprises the individual members, subsystems, and the whole system.
 Two people relating together are not independent because they mutually interact with one another.
 A change in one part of the system will impact the total system.175
 When part of the group is together and one or two are not there, their absences are felt. The group does
not feel whole until all are present; hence the absent members influence the present family members.
❖ Nonsummativity
 A system is greater than the sum of its parts; 176 the whole is different than the sum of its parts. 177
 The family as a system composed of interconnected parts where the family system is greater than the sum
of the individual family members.
 Thus, the effects of system membership on individual or system behaviors are greater than a simple
summation of the behavioral tendencies or characteristics of the individuals comprising the system.
 Nonsummativity suggests looking at how the parts are organized.
❖ Note: Wholeness and nonsummativity are often considered “two sides of the same coin.”
❖ Dualism refers to taking the crucial elements of a whole system and treating them as separate parts and not as
parts of the whole. Dualism basically implies that the parts are independent and not connected.178

173 Whitchurch, G. C., & Constantine, L. L. (1993). Systems theory. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R. Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family
theories and methods: A contextual approach (pp. 325-352). Plenum.
174 Whitechurch & Constantine (1993)
175 Becvar, D. S., & Becvar, R. J. (1999). Systems theory and family therapy. A primer (2nd ed.). University Press of America.
176 von Bertalanffy, L. (1952). Problems of life: An evolution of modern biological thought. Wiley.
177 Lewin, K. (1939). Field theory and experiment in social psychology: Concepts and methods. The American Journal of Sociology, 44(6), 868-896.

[Link]
178 Dell, P. F. (1982). Beyond homeostasis: Toward a concept of coherence. Family Process, 21, 21-44. [Link]

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 Examples of dualism from other theories include mind/body, mind/brain, mental/somatic aspects of illness.
 Example: A counselor only sees the wife in a marriage characterized by spousal abuse. The counselor often
sees the wife as separate from the husband in the dynamic, yet in actuality, they are tied together.
 Systems theory rejects dualism.

CAUSALITY
❖ Too often, people/therapists want to attribute one cause to an event (e.g., boy drinks because dad drinks).
❖ Linear causality (i.e., cause-effect) refers to one-way causal links (i.e., A causes B).
 People often want to attribute one cause to an event. Linear causality suggests problems are within an
individual or somebody/something caused the problem. Thus, removing the cause would cure the problem.
• Example: Husband nags so wife drinks. Husband stops nagging. Does wife stop drinking?
 Linear causality takes a process and slices it at a given time to look at it (i.e., punctuation). In a process
there is no starting point. (Note: Any cause/effect relationship is an observation of an individual).
❖ Punctuation refers to the simplistic segmenting of a complex interaction sequence in such a way that a
beginning of the sequence is posited, and “cause” and “effect” elements are arbitrarily assigned. 179 In other
words, arbitrary starting and ending points are assigned to an event by an observer.
 Two ways to punctuate the same event:
• “He drinks because she nags” vs. “She nags because he drinks.”
• Parents say, “We are strict because you disobey.” The child says, "I disobey because you are so strict.”
❖ Families are not linear; hence, systems theorists reject linear causality and punctuation.180
 Thus, family systems theorists try to expand A causes B by looking at mutual causes (i.e., circular causality)
or multiple causes (e.g., equifinality) because the cause of any event or outcome may never truly be known.
❖ Circular causality (reciprocal/mutual causality) refers to mutual interactions of causes and consequences.181 A
affects B, which then affects A, and so on, in a circle of events which modify each other. The effect of an event
returns indirectly to influence the original event through one or more intermediate events.182
 Examples
• The father’s drinking influences his son to drink. The son gets in trouble; this influences the father to get
stressed out, so he drinks, which then increases the likelihood of his son drinking.
• A child cries, parent yells at the child, and the child cries more.
• A mother yells at her daughter for being late, the daughter decides to stay out late to get back at her
mom. The mom then gets upsets and yells at her daughter more, and then grounds her, and so on.
❖ Equifinality refers to how the same results can be obtained by different means and by starting from different
beginning points.183 In other words, there are many different means to the same endpoint/outcome, and no
matter where one begins, the end will be the same.184
 Even though family systems may start from different beginning points, they can achieve the same goals
through different means or developmental routes.
 A simplistic example: We may take different roads to campus, but we all arrive at the same place.
 Very different family backgrounds, living conditions, and family interaction patterns may still produce
adolescents with very similar outcomes (e.g., delinquency, drug abuse, or valedictorian).
 Example: A youth drinks for many reasons (e.g., parent drinks, easy access to alcohol, family acceptance of
drinking, peer pressure, feels good, tastes good). However, drinking does not have one specific cause. This
decreases the focus on the “why”. What becomes important is the focus on the present-centered “what.” In
other words, what is going on, and how is the system maintaining the behavior?

179 Montgomery, J., & Fewer, W. (1988). Family systems and beyond. Human Sciences Press.
180 Becvar, R. J., & Becvar, D. S. (1982). Systems theory and family therapy. University Press of America.
Dell (1982), Montgomery & Fewer (1988)
181 Keeney, B. (1979). Ecosystemic epistemology: An alternative paradigm for diagnosis. Family Process, 18, 117-127. [Link]
182 Montgomery & Fewer (1988).
183 von Bertalanffy (1952)
184 Becvar & Becvar (1982); von Bertalanffy (1952)

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 A therapist who is open and flexible might use an equifinality perspective when treating individuals,
couples, and/or families by recognizing that different treatments from various theoretical paradigms could
result in similar outcomes.185
❖ When looking at equifinality and circular causality together it demonstrates how any arbitrarily designated
behavior may have many “whys” and may be influencing many other behaviors.
❖ Multifinality (equipotentiality) refers to how similar initial conditions may lead to dissimilar end-states.
 Individuals with very similar family backgrounds and living conditions in early childhood may have very
different outcomes in adolescence.
 Examples
• Identical twins may have different end states.
• A father who drinks may end up with a son who drinks or a son who swears never to drink.
❖ Fit means behaviors in a family system have a complementary nature (i.e., they fit together). 186
 The concept of ‘fit’ was developed to replace the notion of causality.
 Fit is more appropriate than cause-effect in being applied to what happens in living systems. 187
 If the behaviors of A and B are dissimilar, but mutually fit together (e.g., spectatorship fits exhibitionism),
the behaviors are linked so that the more of A's behavior stimulates more of B's fitting behavior. Thus, the
relationship between the behaviors is complementary.188
 Fit is tentative and evolving.
❖ Reification – Labeling a behavioral pattern and then using the label as an explanation of the pattern. 189
 Reification is common in social sciences and the medical field.
• Reification: I purge (e.g., laxatives, diuretics, enemas), fast, and exercise all the time because I am bulimic.
Not reification: Because I purge, fast, and exercise all the time, I am considered bulimic.
• Reification: The reason I display my displeasure, resentment, and aggression through unassertive passive
ways is because I am passive-aggressive.
Not reification: I have been called passive-aggressive because I display my displeasure, resentment, and
aggression through unassertive passive ways.
• Reification: I have an overdependence on other people (e.g., for approval, making decisions, mood)
because I have dependent personality disorder.
Not reification: Because I have an overdependence on other people (e.g., for approval, making decisions,
mood), I have been diagnosed as dependent personality disorder.
• Other common examples include mid-life crisis, codependency, anorexia, etc.
 Reification is an example of a linear causal explanation since the label is supposedly predicting the
behaviors. According to systems theory, we need to avoid reification.

ORGANIZATIONAL COMPLEXITY / HIERARCHICAL ORGANIZATION

❖ Hierarchical organization (i.e., “layering” of systems of increasing complexity) is an important concept in
systems theory. Family systems are comprised of smaller subsystems and larger suprasystems. 190
 Suprasystem refers to any system larger than the family.
• Examples: family of origin, ethnicity, community, geographic region, religion, laws.
 Subsystems are comprised of members who join together to perform various functions. 191
• Subsystems function the same as the larger system except they may be less complex, and they may get
part of their organization, structure, function, and self-regulatory characteristics from the larger system.
• Each subsystem has its own rules, boundaries, and unique characteristics.

185 Samman, S. K., & Moreno, J. (2018). Equifinality in family systems theory. Encyclopedia of Couple and Family Therapy, 1–3. [Link]
15877-8_265-1
186 Dell (1982)
187 Montgomery, & Fewer (1988)
188 Bateson, G. (1972). Steps to an ecology of mind: Collected essays in anthropology, psychiatry, evolution, and epistemology. University of Chicago Press.
189 Montgomery & Fewer (1988)
190 Whitechurch & Constantine (1993)
191 von Bertalanffy, L. (1968). General system theory: Foundations, development, applications. George Braziller.

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• Every individual is a subsystem.

• Dyads are subsystems comprised of two people (e.g., marital dyad, parental dyad).
• Subsystems can be composed by generation (e.g., parent subsystems versus children subsystem), gender
(e.g., father/son subsystem), or shared qualities/interests (e.g., sibling subsystem).
• A spouse/marital subsystem is formed when two adults join with the purpose of forming a family. The
spouse subsystem has specific tasks vital to the family’s functioning.
• The parental subsystem is formed with the birth of a child.
o The spouse subsystem must differentiate to perform the tasks of socializing a child. A boundary is
established which allows a child access to each parent while excluding the child from spouse functions.
• The sibling subsystem is the first social laboratory where youth can experiment with peer relationships.
o Siblings can support, isolate, scapegoat, and learn from each other. They learn to negotiate, cooperate,
compete, make friends and allies, and how to achieve recognition of their skills.
• Within each subsystem, the family members will have different levels of power and functions. 192
o Example: A daughter may have little power in the overall family system. Yet, in the mom-daughter dyad
the daughter may be more of an equal since they share interests, and she functions as a confidant to
the mom. The daughter may have little power in the sibling subsystem since she is the only girl with 5
older brothers who view her as the baby. So, if a therapist sees the daughter by herself or with her
mother, she will likely react differently than if she were with her brothers.
 Generally, larger systems have more control over smaller systems, yet influence can go either way.
• The family system generally has more control than the smaller sibling subsystem.
• The community suprasystem generally has more control over the family system (e.g., setting curfew
times, or making schooling mandatory through age 16, setting speed limit laws).
• Smaller systems may have an influence on larger systems but usually do not have control over them.
 Family systems therapists should examine all levels and transactions between the different systems.
❖ Interdependence – Individuals and subsystems that comprise the whole system are mutually dependent and
mutually influenced by one another.
 Each person’s family-related behavior is associated with and fits with family behaviors of each family
member.193 Even factors that seem to only influence one family member still influence the whole family.

MAP
❖ A person’s subjective view of the world; a frame of reference that helps individuals or
families make sense of their behaviors and the world. Thus, a map is a subjective outline or
shorthand version of the world that is constantly evolving due to the constant flow of
information.
❖ Maps are tentative because they are always in process. The map evolves to accommodate new and varied
informational input. This is necessary for the survival of the system or individual.
❖ Clients may have difficulty seeing the world in any other way than their map.
❖ The more therapists find out about a client’s map, the more they can relate to and empathize with them.
❖ The challenge for a therapist is trying (1) to understand a client’s map, and (2) to acknowledge that their map
is correct for them, and (3) to provide information that will challenge the map (e.g., reframing) and change
behavior to affect the map.
 E.g., Court-ordered clients begin anger management class thinking it’s useless and won’t help (i.e., their
map). The instructor needs to challenge their map in a way that can facilitate a 2nd order change in their
map and interactions.
❖ Family mapping – Diagramming a family’s organizational structure, boundaries, and patterns of interaction.
 It is useful in hypothesizing family functioning and forming goals for structural change.
 It can also help show how family interaction patterns “fit” with each other across generations.

192 Minuchin, S. (1974). Families and family therapy. Harvard University.

193 Montgomery & Fewer (1988)
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 Family mapping is useful in hypothesizing family functioning and forming goals for structural change.
 Examples:
• Genogram194
• Circumplex model (Olson, 2000) / Couple and family map195
• Kvebaek board196
• Family system test197

STRATEGIES AND RULES198

❖ Strategies (also called rules of relating) refer to the patterns of interaction within the family. In other words,
families develop strategies to manage its demands and/or accomplish basic tasks.
❖ Rules refer to recurring patterns of interaction (i.e., well-established strategies) that define
acceptable/appropriate and unacceptable/inappropriate behavior in the family.
 Rules reflect family values, define roles of individual family members, and help maintain the family system.
 Overt rules refer to explicitly/openly stated rules.
• Examples: Parents explicitly state, “boys do not cry” or “marriage comes before children.”
 Covert rules refer to implicit versus openly stated rules. However, all family members know the rules.
• Examples: Family members know that anger cannot be expressed in the family or that they can go to each
other to talk about their problems even though neither are explicitly stated out loud.
 Meta rules – Rules about rules (e.g., which rules are more important and limits or exceptions to rules).
• Example: Women do inside chores and men do outside chores. (Exception) Women plant the flowers.
• Example: (Rule) Parents tell their children they can come and talk to them about anything. (Exception)
They do not want to hear their children tell them about their sex lives.

BOUNDARIES199
❖ Boundaries are hypothetical constructs that define membership in a system and represent the point of contact
between the system and other systems (i.e., subsystems and suprasystems).
❖ Simply by identifying a system, we identify a boundary as to who and what are included in the system. Thus,
boundaries help to distinguish between the various subsystems and suprasystems.
❖ Boundaries determine the rules of the family, and they act as a buffer for information coming in and going out
of a system. Boundaries serve to regulate the flow of information and feedback to the systems.
 The boundary of a family system may keep members from telling others about the sexual abuse in the
family. There may be unspoken (i.e., covert) rules that say information does not leave the house.
 A family system might only accept information that supports their family values while not allowing
information into the family that is not compatible with their values.
❖ Consistent boundaries generally contribute to more functional systems. Also, clear subsystem boundaries will
generally contribute to more optimal family functioning.

194 McColdrick, M., & Gerson, R. (1985). Genograms in family assessment. Norton.
195 Olson, D. H., Sprenkle, D. H., & Russell, C. S. (1979). Circumplex model of marital family systems: I--Cohesion and adaptability dimensions, family types, and clinical
applications. Family Process, 18, 3-27. [Link]
196 Botelho, R. J., Shields, C. G., & Novak, S. J. (1992). Using the Kvebaek board for brief systems consultation: A teaching tec hnique for preceptor-resident encounters.

Family Systems Medicine, 10(1), 91-97. [Link]

Kvebaek, D. J. (1973). Skulpturtest: Et diagnostisk hjelpemiddel i familieterapi. [The Sculpture Test: A diagnostic tool in family therapy]. Oslo, Norway: Sandoz
Informasjon, No. 1.
197 Gehring, T. M., & Wyler, I. L. (1986). Family-system-test (FAST): A three dimensional approach to investigate family relationships. Child Psychiatry and Human

Development, 16, 235–248. [Link]

Kahn, J. S., & Meier, S. T. (2001). Children’s definitions of family power and cohesion affect scores on the family system test. The American Journal of Family
Therapy, 29, 141-154. [Link]
198 Anderson, S. A., & Sabatelli, R. M. (1995). Family interaction: A multigenerational developmental perspective. Allyn & Bacon.

Barnes, H. L., & Olson, D. H. (1985). Parent-adolescent communication and the Circumplex Model. Child Development, 56, 438-447.
[Link]
199 Becvar & Becvar (1982), Minuchin (1974), Montgomery & Fewer (1988)

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❖ Types of boundaries
 External boundaries – Invisible barriers that defines a family’s relationship to other external systems. In
other words, families establish strategies and rules for interacting with outsiders.
 Internal boundaries – boundaries within the family, such as between the subsystems.
• Personal boundaries – Invisible barriers that surround individuals and subsystems that regulate the
amount of contact with others. (See the Circumplex Model for more on internal boundaries).
o Enmeshed internal boundaries – Family systems with a low tolerance for individuality and more focus
on family obligations and identity.
o Disengaged internal boundaries – Family systems with a high tolerance for individuality but less focus
on family obligations and identity.
• Generational boundaries – Invisible lines of separation between generations. Healthy generational
boundaries allow (1) parents to maintain parental roles and (2) children to maintain child roles.
o Parentification refers to a role reversal where the parents rely on a child for nurturance or when the
child has the power/control. A parentified child is often an overly responsible child who has power and
authority that more appropriately belongs to the parents. The child is allowed to violate boundaries and
intrude in decisions that should be made by the parents. Parentification of a child often occurs in
families with some type of substance abuse or mental health issue where the parent’s caregiving ability
is diminished. The parentified child may have later relationship issues or anxiety as an adult.
❖ Permeability – The degree of difficulty or ease that information and system members have in crossing the
boundaries between systems.
❖ Open and closed systems – A very closely related concept to boundaries is that of openness and closedness of
the system. These two terms refer to the boundaries a family system establishes among family members and
with other systems. Family systems fall along a continuum from openness to closedness.
 Open systems – All family systems are open to some extent to survive. The more input from family
members or other systems the more it is open. Those family systems that are extremely open lack clear
boundaries and have very little family identity.
• Example: A single mom and her children allow others to move in and out of the home. Every time she
remarries, they adopt the man’s last name and values. Her children have been removed and placed back
in the home many times. This system would be very open and would lack clear boundaries, functions,
roles, and rules. There would not be a congruent family identity among the members. It would take an
intense crisis to pull the family system together for a short time.
 Closed systems – If the boundaries of the family do not allow much input from other family members or
from other systems, then the family system would be more closed. Systems with closed boundaries would
allow limited information to come in and would restrict the outward flow of information. 200
 When a system is more closed, there is less opportunity for adaptation. In an extremely closed system, the
boundaries may be very rigid, and the information flow between systems would be hindered. In this type of
family system, what affects one member would affect the others.
• Example: An incestuous family is often very closed. They might restrict others from the house. The rules
and roles may be very rigid. If one family member had a nervous breakdown, it would affect all the other
members. They might be afraid the family secret would get out, or they may lose a sexual partner.
 A family system cannot survive if it is completely closed to other family members and to other systems.
Thus, no system is completely closed, and all family systems are open to some extent. 201

CHANGE
❖ Equilibrium/Homeostasis – A state of balance between opposing forces.
 Systems are characterized by a relatively steady state, or homeostasis, that is maintained through
regulation and family norms.202

200 von Bertalanffy (1968)

201 Montgomery, & Fewer (1988)
202 von Bertalanffy (1968)

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❖ Feedback loop – Path of communication in a system. Feedback is considered either positive or negative based
on the effect it has on the system, not on its content.203 204
 Negative feedback (AKA morphostatic feedback, constancy loops, deviation-attenuating loops).
• Forces that maintain the current system’s structures and members’ behaviors. Thus, it is the forces that
try to maintain the system’s current rules, interaction patterns, and/or power structures in the family.
Negative feedback attempts to maintain the status quo (i.e., system morphostasis).
o Example: A wife learns new ways to communicate from her therapist. She tries them with her husband
who makes fun of her. So, she quits using the new communication techniques. Thus, the interaction
patterns in the marital dyad are maintained. The husband making fun of her is negative feedback
designed to maintain current interaction patterns in the marital dyad.
• Important note – Negative feedback is not necessarily good or bad. It is simply a process that negates
changes or disturbances in the system.
o Example: A husband is always surprising his wife with romantic gestures (e.g., cards, poems, and
flowers). Each time he does this, his wife responds very positively. The wife responding positively is
negative feedback because it helps maintain the current interaction patterns.
 Positive feedback (AKA morphogenic feedback, deviation-amplifying loops, variety loops).
• Forces that try to alter the family system’s rules, interaction patterns, and/or power structures. In other
words, the net effect increases the probability of the family member increasing a given behavior, which
alters the system. Positive feedback helps the system “grow”, create, and innovate, and/or evolve.205
o Example: A therapist teaches a couple new communication techniques. The therapist is providing
positive feedback since the new techniques are designed to change family interaction patterns.
“The family structure must be able to adapt when circumstances change.” (Minuchin, 1974)
All feedback produces some change, even negative feedback. Thus, all systems are constantly evolving

even in response to negative feedback.
❖ First order change refers to a minor change in the system, yet the system itself is not altered (i.e., the system
develops or makes an adaptation). In other words, 1st order changes in the family system are minor structural
changes among the system’s components that might occur because of one member changing his or her
behavior, yet the system itself does not change and is vulnerable to relapses.
 1st order change often leads to a vicious circle because the system itself does not change.
 In 1st order change, the most logical cause of the behavior is the focus of the therapeutic change. 206 So, the
system, as a whole, maintains stability and organizational integrity.
❖ Second order change is a major, higher level of change where the system itself is altered. The system makes a
transformation (e.g., rules, roles, and underlying beliefs that direct the family members’ behaviors are altered).
 2nd order change will be the family system’s adaptation to the individual’s changes, resulting in the
transformation of status and meaning within the system and the evolution of new elements of structure.
This type of change is much more dramatic and enduring, such as when the entire system is reorganized
into new transactional patterns.
 2nd order change breaks the vicious cycle of the problem situation and allows other solutions to emerge.
 A system’s organizational change that is of such magnitude the former system ceases to exist and a new
system (or systems) with a different membership and different patterns replaces it. 207
 It is enormously important in counseling couples/families where problems are characterized by rigid,
maladaptive patterns. If the patterns themselves are not altered, there is little hope that the individual
behavior will change in a significant way without the client’s leaving the system.208

203 Olson, D. H., Sprenkle, D. H., & Russell, C. S. (1979). Circumplex model of marital family systems: I--Cohesion and adaptability dimensions, family types, and clinical
applications. Family Process, 18(1), 3-27. [Link]
204 Becvar & Becvar (1982); Dell (1982)
205 Olson et al. (1979)
206 von Bertalanffy (1968)
207 Montgomery & Fewer (1988)
208 von Bertalanffy (1968)

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FAMILY TRIANGLES
“Unburdening yourself to a friend will make you feel better. It will also lessen the likelihood that you’ll engage the probl em at its source.” – Nichols & Schwartz209
❖ A two-person system (i.e., dyad) is inherently unstable.210 A two-person system can’t tolerate much anxiety or
tension before involving a third person. When anxiety or tension becomes too high within the dyad, a third
person (or activity or thing) is brought in to serve as a stabilizing force and to reduce anxiety in the dyad.
 The smallest stable system is a three-person relationship (i.e., triangle). Three people can contain and/or
handle more anxiety by spreading the anxiety between all three relationships.
❖ Family triangles (triangulation) refer to a process of establishing a triadic interaction so two persons are allied
against a third, which diffuses tension by focusing on someone else. Thus, a conflict-ridden, dyadic relationship
is expanded to include a third person (e.g., child, therapist) to cover up or defuse the conflict. 211
 People pulled into triangles often have limited awareness of the process and are often vulnerable in some
way. Triangles can involve non-family members (e.g., doctor, friend), an activity (e.g., hobby), or thing (e.g.,
pet) that is focused on reducing/masking anxiety in the dyad.
 Although a triangle can allow a participant to decrease anxiety, it can also freeze the conflict in place. In
other words, nothing gets resolved since the original issue/conflict is not addressed.
❖ Rigid triangle – An inflexible triangle that maintains across time, which prevents the system from changing. In
rigid triangles, the same (often vulnerable) outsider is generally targeted.
 One child in the family is consistently used as a “third leg” of the triangle to make it more stable. This child
might be selected because of his or her position in the family, looks, behavior, or other characteristics. 212
❖ Split loyalties triangle213 – When a parent demands that a child sides with him/her against the other parent.
 The child is in a no-win situation.214
• Expressing love or concern for one parent can be viewed as betraying the other parent.
• Siding with one parent may be viewed as attacking by the other parent, which places the child in an
intense loyalty conflict.
 A child may become frozen when trying to navigate a split loyalty triangle.
 Adolescents may see the family as disintegrating, and they may start “acting out” to distract attention from
the parental conflict.215 The parents may form a temporary coalition to deal with the problem, but then the
split loyalties triangle reemerges.
❖ Detouring occurs when spouses ignore issues in their own relationship and focus on the child's issues.
 Detouring-supportive triads – Parents ignore their own conflict by uniting to protect a child who is sick,
weak, or vulnerable. Thus, parents are able to conceal their conflicts in their common concern for the child.
• Example: Minuchin observed diabetes mellitus/ketoacidosis symptoms would often subside when a
diabetic child was admitted to the hospital, but the symptoms would often reemerge when the child went
back home.216 Over 200 cases were examined, and the conclusion was that the ketoacidosis episodes
were related to family conflict. Specifically, parents would detour their conflict by focusing their worry,
their anxiety, and even their arguments about the child. The child would become stressed and
emotionally overwhelmed by the extreme focus, ultimately resulting in the episodes of ketoacidosis. This
could occur because the emotional arousal would result in higher concentrations of free fatty acids, which
would then be metabolized by the liver into ketone bodies, which led to more severe symptoms.
 Detouring-attacking (scapegoating) – Spouses attempt to avoid the conflict between themselves by seeking
and/or exaggerating problems in another family member.

209 Nichols, M. P., & Schwartz, R. C. (2001). Bowen family systems therapy. In M. P. Nichols & R. C. Schwartz (Eds.), Family therapy: Concepts and methods (5th ed., pp.
137-171). Allyn and Bacon.
210 Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson.
211 Bowen (1978); Minuchin (1974); Montgomery & Fewer (1988)
212 Minuchin (1974)
213 Minuchin, S., Rosman, B., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Harvard University Press.
214 Berg-Cross, L. (2000). Basic concepts in family therapy: An introductory text. Haworth Press.
215 Berg-Cross (2000)
216 Minuchin, Rosman, & Baker, (1978)

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• The person recruited to be the scapegoat is usually the child. Thus, stress/conflict between spouses gets
redirected through a child so that the spouse subsystem gives the impression of harmony. 217
 Detouring can inadvertently exacerbate or reinforce a child’s problem behavior(s).
• Example: Focusing on a child’s slight lisp with constant correction, focusing on child’s misbehavior, or
focusing on a child’s achievements. 218
❖ Coalition – A subsystem that has an alliance between two or more family members against another member.
 Short-term alliances between family members are normative.
• Examples: (1) mother and daughter plan a surprise birthday day for the father, (2) the father and son
secretly eat fast food behind the mother’s back.
• But, when the alliances become stable across time, they can become problematic.
 An alliance between the family members against the other family member is usually covert.
 Coalitions can either promote family effectiveness (e.g., an ‘intervention’) or they can be detrimental to
family effectiveness.219
 Cross-generational coalition220 – When two family members from different generations develop an alliance
against a third member.
• Parent-child coalition – When a child and a parent form a close, rigid alliance against another parent.
Rigid, stable parent-child coalitions can be problematic when the attachment between the parent and the
child exceeds that between the parents.
❖ Triangles are not always problematic.
 For example, the marital dyad is having an argument, but their child comes home to share good news about
school. The marital dyad suspends the argument (temporarily) to share in the good news.
 Different cultural groups may encourage family triangles, such as Chinese father/son, African
brother/brother, or Hindu mother/son.221
 Triangulation can be used as a therapeutic technique. The therapist becomes the third point in the triangle
to stabilize the system.222 For example, the therapist might relieve the child by entering the triangle and
then act as a “go-between” to challenge and change the structure of the system. In this situation, the
therapist must remain calm and not get caught up in the family’s dynamics.

SOME FAMILY THERAPY TECHNIQUES

❖ Family photos223
 The therapist directs the client or family to bring and discuss a family photo album or family pictures.
 The therapist observes the verbal and nonverbal responses to the photos.
• Which pictures are shown first/last, quickly/slowly, etc.
• Who in the family was left out and who had more photos.
• What feelings are elicited when showing and discussing the photos.
 This technique provides insight into the family system, such as family relationships and interaction patterns;
family roles; family customs, traditions, and special times; alignments and splits.
 Variations include having the client/family bring and discuss (1) ‘significant/meaningful’ family photos, or (2)
pictures of past generations.
❖ Speaker’s chair224
 This technique can be used when family members constantly interrupt each other.
 A speaker’s chair is designated, and only the family member sitting in the chair may speak.
 The therapist may designate a speaker’s object (e.g., talking stick, rubber ball) that plays the same function.

217 Olson, Sprenkle, & Russell (1979)

218 Berg-Cross (2000)
219 Montgomery & Fewer (1988)
220 Berg-Cross (2000)
221 Berg-Cross (2000)
222 Nelson, T. S. (2003). Transgenerational family therapies. In L. L. Hecker & J. L. Wetchler, (Eds.), An introduction to marriage and family therapy (pp. 255-293).

Haworth Press.
223 Sherman, R., & Fredman, N. (1986). Handbook of structural techniques in marriage and family therapy. Brunner/Mazel.
224 Haley, J. (1976). Problem-solving therapy: New strategies for effective family therapy. Jossey-Bass

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❖ Crediting225
 The therapist selects each family member one-at-a-time.
 Each family member is directed to inform the family how they contribute to the family’s well-being.
 The therapist will generally begin with a family member who has been triangulated between two members
who are in conflict or who has been a scapegoat.
❖ Anatomy of a relationship226
 Therapists observe and describe their perception of the relationship between the clients/family members.
 The clients listen to how the therapists perceive their relationship.
 Next, the clients share their own perceptions of their relationship.
 These different perceptions provide insight for both the therapists’ view of the clients’ relationships and for
the clients about how others perceive their relationship.
❖ Challenging the structure227
 A therapist identifies and explains a family interaction pattern that the therapist observed.
 Next, the therapist discusses the interaction pattern with the family.
 The old interaction must be undermined to make way for a new pattern.
 Then, the family chooses one of the following options: (1) to obey the existing pattern, (2) to disobey the
pattern in an indirect way, (3) to disobey the pattern in a direct way, or (4) to eliminate the pattern entirely.
 If the family decides to disobey or eliminate the pattern, the therapist helps them chose a strategy.
❖ Family sculpting228
 The therapist instructs a family member to physically arrange other family members to represent how s/he
perceives the family.
 This technique allows the family to see how one of its members thinks and feels about the other members –
based on how each person was positioned.
 The therapist could have each family member act as the sculptor.
❖ Family choreography229
 The therapist directs family members to arrange themselves in two ways:
• How they currently see the family.
• How they would like to see the family.
 Next, the therapist directs family members to reenact a family scenario in two ways:
• How they see it in the present.
• How they would like to see it in the future.
 Both these family choreography techniques provide important insight into how the family members would
like to see the family in the future, which can help with establishing therapy goals and rationale for change
in family interaction patterns.
❖ Enactment230
 The therapist constructs a scenario where a typical interaction between family members is played out.
 The therapist can instruct the family members to talk or interact to observe the problematic interactions.
 Next, the therapist can modify the interactions in the enactment (e.g., increase intensity, prolong duration).
 The goal is that the therapist-directed modifications of the enactment can help the family learn alternative
ways of dealing with problems.
❖ Circular questioning231
 The family members are asked (one at a time) to express their views on the relationships, interaction
pattern, and/or differences between other family members.

225 Boszormenyi-Nagy, I., & Framo, J. L. (1965). Intensive family therapy. Harper and Row.
226 Satir, V., & Baldwin, M. (1983). Satir step by step: A guide to creating change in families. Science and Behavior Books.
227 Minuchin, S., Montalvo, B., Guerney, B. G., Rosman, B. L., & Schumer, F. (1967). Families of the slums. Basic Books.
228 Duhl, F. S., Kantor, D., & Duhl, B. S. (1973). Learning space and action in family therapy: A primer of sculpting. In D. Bloch (Ed.), Techniques of family psychotherapy:

A primer (pp. 167–183). Grune & Stratton.

229 Papp, P. (1976). Family choreography. In P. Guerin (Ed.), Family therapy: Theory and practice (pp. 465-479). Gardner Press.
230 Minuchin, S., & Fishman, H. (1981). Family therapy techniques. Harvard University Press.
231 Selvini Palazzoli, M., Boscolo, L., Cecchin, C., & Prata, G. (1980). Hypothesizing-circularity-neutrality. Family Process, 19(1), 73-85. [Link]

5300.1980.00003.x
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• Each family member is asked the question in a logical order until a circle of all the members is completed.
This procedure helps define the role the symptom is playing within the family.
The questions are used to gain insight from each member about family structure and interaction patterns.

 The circular interview gives each family member an opportunity to share their own perspectives and to
incorporate others’ views of the issue/problem.
 This strategy allows the family to begin viewing themselves systemically, and helps the therapist generate
hypotheses and corresponding interventions.
❖ Family ritual232
 Therapist directs the family to engage in an action or series of actions designed to alter the family’s roles.
 E.g., A family lives with an intrusive grandmother. The parents are directed to read the following message
each night to the grandmother: “Thank you for your numerous suggestions on how to discipline our child.
We would surely fail if it weren’t for your loving help.” The grandmother is directed to read the following
response: “I love you and am willing to completely sacrifice my own life and happiness to make sure you
don't fail to discipline your child the right way.” Any deviation from the positively connoted messages should
move the family members toward more functional interactions.
❖ Paradoxical interventions
 Paradoxical interventions may be directed toward the whole family or to certain family members as a way
to facilitate change. They are usually only tried after more straightforward interventions do not work.
 Prescribing the symptom233 (also called ‘putting the client in control of the symptom’)
• The therapist encourages or recommends the continuation of the client’s maladaptive behavior or
symptom (e.g., worrying, cursing, indecisiveness).
• Explicit directions are given to clients about maintaining the behavior (i.e., when, where, with whom, and
what amount of time they should do these things).
• Clients now have the disagreeable task of continuing the negative behavior. As clients follow the directive
by the therapist, they learn the behavior can be voluntarily controlled. Clients now have a different
perception about the behavior AND how the behavior is maintained.
• Sometimes this technique can even result in the behavior being viewed in a humorous way.
 Prescribing indecision
• The same as ‘prescribing the symptom,’ but it focuses specifically on indecisiveness in the family/couple.
• Families/Partners are often immobilized by the inability to make decision, even on minor things (e.g.,
where to eat). This can result in exacerbated stress and anxiety.
• First, the therapist reframes the indecisiveness.
o Family members / partners avoid making decisions because they care about each other’s desires.
o Indecisiveness is the outcome of taking time to make a decision on important issue(s).
• Hence, the therapist gives a directive not to make hasty decisions. All decisions must be verbally
deliberated for a specified amount of time (including minor decisions such as where to eat). When the
family spends so much time deliberating, they learn how this takes time away from other activities.
 Black radio
• This technique is similar to ‘prescribing the symptom.’
• The therapist directs the client to amplify/exaggerate the message/behavior until the clients can’t bear it,
finds it silly, and/or doesn’t know how to deny it.
• Example: Parents do not want their child to curse, but the child insists they do not realize they are cursing.
The therapist has the child say four curse words before every sentence. The family is instructed to
monitor the child’s compliance. The result is that (1) the child learns to control the cursing, (2) the family
becomes somewhat desensitized to the curse words, and (3) the curse words may actually take on a new
meaning as the family all laughs at how silly it is to start every sentence with four curse words.
 Restraining – The therapist discourages or denies the possibility of change.234

232 Selvini Palazzoli, M., Cecchin, C., Boscolo, L., & Prata, G. (1978). Paradox and counterparadox. Jason Aronson.
233 Rabkin, R. (1977). Strategic psychotherapy. Basic Books.
234 Stanton, M. D. (1981). Strategic approaches to family therapy. In A. S. Gurman, & D. Kniskern (Eds.), Handbook of family therapy. BrunnedMazel.

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• When a family is resistant or ambivalent to change, the therapist aligns with the resistance/ambivalence.
So, the therapist warns the family about the dangers of change, restrains the family from trying to change,
and/or asks the family to change slowly. The therapist might even encourage the family to go back to
relapse to the previous way of interacting. When the therapist tries to restrain the family, the family will
align against the therapist and try to change. Also, the family learns they can control the behavior.
• The therapist says, “I do not think you will ever be able to resolve the problem because it seems like you
are okay with how things are.” The idea is that the family will be oppositional to the therapist since they
argue against everything else the therapist suggested. In this case, they argue for why they can improve.
• The therapist says, “If your child gets better, you and your spouse may not have anything to talk about” or
“may not have anyone to blame for the family problems.” In this case, the spouses start proving that they
have other things to talk about, which can promote the parent dyad.
 Positioning – Therapist exaggerates the family’s position which turns their resistance back on themselves.235
• E.g., becoming more pessimistic than the client/family
• E.g., Parents are constantly complaining about their daughter’s defiance, so the therapist says, “Maybe
you should put her up for adoption.” In which case, the parents defend why they would not do that.

STRENGTHS
❖ Broad in scope, yet not just generalities.
❖ Translates well into therapy and intervention.
❖ Mid-range theories have developed from family systems theory (e.g., Circumplex Model – see next section).

WEAKNESSES
❖ Fairly complex theory.
❖ Traditional statistics measure linear relationships, but family systems theory is concerned with curvilinear and
other non-linear relationships.
❖ Tends to undervalue the importance of individual attributes such as the biological components.
❖ Criticized for poor explanatory power because it is difficult to clearly identify and measure constructs. Hence,
many of the concepts remain unclear (i.e., difficult to operationalize) and/or unverified by research.
❖ Feminist critique
 Limited recognition of power in family systems obscures the privilege of dominant groups.
 Systemic constructs often reflect sex bias. For example, enmeshment is pathologized, while differentiation
is promoted. This devalues a way of relating that is common to many women.
 Clinically, systems theory generally emphasizes therapist neutrality.
 Ironically, feminists view it as not systemic enough.
 Interdisciplinary scholarship has demonstrated that all cultures utilize gender and generation as
fundamental categories of organization, but systems theory ignores gender concerns.

APPLICATION OF FAMILY SYSTEMS THEORY TO FAMILY VIOLENCE

❖ Domestic violence is seen as a symptom of the overall family system.
❖ Domestic violence affects the entire system. By focusing on the family system and working/orchestrating
change within the system, then change occurs in the individual members of the system. 236
❖ Systemic thinkers do not focus on who’s to blame in domestic violence for this would be linear causality.
Instead, the focus is on how the system maintains the domestic violence (i.e., negative feedback). However,
each person in the system is responsible for his/her own behaviors in a contextual explanation.
❖ Violence between family members has many causes and roots (i.e., equifinality). Some of the many
predecessors of violence include normative structures, personality traits, frustrations, and conflicts.
 Family violence imagery is often learned in early childhood from parents, sibling, and other children.

235 Stanton (1981)

236 Minuchin (1974)
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 Family violence stereotypes are continually reaffirmed for adults and children through ordinary social
interactions and the mass media (i.e., negative feedback).
❖ More family violence occurs than is reported. Most family violence is either denied or ignored.
❖ Violent acts by violent persons may generate positive feedback (i.e., a violent person may get someone to
change his/her behavior to what the violent person wants).
❖ Most of the time when violence occurs it is not the first time. Systems perspective tries to contextualize the
event (i.e., place the interaction within a broader context).
 A systems therapist would try to identify patterns in the family that maintain the domestic violence.
 The next step would be to try and identify a medium for change to take place.
❖ The communication system is often indirect; family members frequently have difficulty expressing feelings.
 They often make statements about what they don’t want instead of what they do.
 Lots of blaming of self for violent behavior rather than mutual responsibility for the behavior.
❖ These families often lack common friends and activities.
❖ There are often affairs, public quarrels, and attempts at triangulation.
❖ Persons who are labeled violent may be encouraged to play out a violent role, either to live up to the
expectations of others, or to fulfill their own self-concepts of being violent or dangerous.

A FEW FAMILY THERAPY APPROACHES

❖ Bowen Model of Family Therapy
 [Link]
 Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson.
 Nichols, M. P., & Schwartz, R. C. (2001). Bowen family systems therapy. In M. P. Nichols & R. C. Schwartz (Eds.), Family therapy:
Concepts and methods (5th ed., pp. 137-171). Allyn and Bacon.
❖ Structural Family Therapy – Salvador Minuchin
 Colapinto, J. (2000). Structural family therapy. In A. M. Horne (Ed.), Family counseling and therapy (3rd ed., pp. 140-169). F. E.
Peacock.
 Minuchin, S. (1974). Families and family therapy. Harvard University Press.
 Minuchin, S., & Fishman, C. H. (1981). Family therapy techniques. Harvard Press.
 Minuchin, S., & Nichols, M. P. (1993). Family healing. The Free Press.
❖ Transformational Systemic Therapy – Virginia Satir
 Satir, V. (1983). Conjoint family therapy (3rd ed.). Science and Behavior Books.
 Satir, V. (1988). The new peoplemaking. Science and Behavior Books.
 Satir, V. M., & Bitter, J. M. (2000). The therapist and family therapy: Satir’s human validation process model. In A. M. Horne (Ed.),
Family counseling and therapy (3rd ed., pp. 62-101). F. E. Peacock.
❖ Functional Family Therapy
 Alexander, J. F., & Parsons, B. V. (1982). Functional family therapy: Principles and procedures. Brooks⁄Cole.
❖ Strategic Family Therapy – Jay Haley
 Haley, J., & Richeport-Haley, M. (2003). The art of strategic therapy. Brunner-Routledge.
 Madanes, C. (1981). Strategic family therapy. Jossey-Bass.
 Stanton, M. D. (1981). Strategic approaches to family therapy. In A. Gurman & D. Kniskern (eds.), Handbook of family therapy (pp.
361-402). Brunner/Mazel.
❖ Multisystemic Therapy
 Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (1998). Multisystemic treatment of
antisocial behavior in children and adolescents. Guilford.
❖ Multidimensional Family Therapy
 Liddle, H. A., & Hogue, A. (2001). Multidimensional family therapy for adolescent substance abuse. In E. F. Wagner & H. B. Waldron
(Eds.), Innovations in adolescent substance abuse interventions (pp. 229–261). Elsevier.
❖ Psychodynamic Family Therapy
 Rasheed, J. M., Rasheed, M. N., & Marlet, J. A. (2011). Family therapy: Models and techniques. Sage.

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CIRCUMPLEX MODEL OF FAMILY DYNAMICS

The Circumplex Model is considered a midrange theory that developed out of family systems theory. The model
uses flexibility and cohesion to describe types of marital and family systems. Communication is the process that
facilitates and/or restricts the flexibility and cohesion in the family. The model is used in research as well as in
family therapy (i.e., for diagnosing and treatment planning for families).

FAMILY FLEXIBILITY (ADAPTABILITY)237

❖ Family flexibility refers to the family system’s ability to change its power structure, role relationships, and
relationship rules in response to stress and life events.
❖ Family flexibility is on a continuum ranging from significant flexibility (which leads to chaotic families) and very
little flexibility (which leads to rigid families).
❖ Rigid (low)
 Authoritarian leadership, strict discipline, limited
discussion
 Very stable and unchanging roles
 Unchanging rules
❖ Structured (low to moderate)
 Leadership sometimes shared, somewhat democratic,
organized discussion
 Stable roles, but can change when needed
 Few rule changes
❖ Flexible (moderate to high)
 Leadership often shared, democratic, open discussion
 Role sharing but somewhat consistent
 Moderate rule changes when needed
❖ Chaotic (very high)
 Lack of leadership, lenient discipline, endless
discussion
 Dramatic role shifts
 Frequent rule changes (little consistency)

FAMILY COHESION (BONDING)238

❖ Family cohesion is defined by the level of emotional bonding/proximity members have with one another and
the degree of individual autonomy a person experiences in the family system.
❖ Family cohesion is viewed as being on a continuum with disengagement and enmeshment (i.e., emotional
entanglement) as the two ends.
❖ The focus is on how the system balances separateness versus togetherness.
❖ Disengaged family (very low cohesion) – low bonding and high autonomy
 Separate time, space and interests predominate. Hence, there is little involvement among family members.
Disengaged family members “do their own thing.” Family members are often oblivious to the effects of their
actions on each other.
 Members have limited attachment or commitment to their family, lack loyalty and belonging, lack the
capacity for interdependence, and are unable to turn to one another for support and problem-solving.
 Primarily “I” instead of “We”
❖ Separate family (low to moderate cohesion)

237 Olson (2000); Olson, Sprenkle, & Russell (1979)

238 Olson, D. H. (2000). Circumplex model of marital and family systems. Journal of Family Therapy, 22(2), 144-167. [Link]
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More emotional separateness than togetherness (but not as extreme as the disengaged system).

 More independence than dependence
 More “I” than “we”
 While time apart is more important, there is some time together. Activities and interests are generally
separate, but a few are shared.
 Some joint decision-making and some loyalty.
❖ Connected family (moderate to high cohesion)
 Moderate to high closeness and considerable loyalty to the relationship.
 More togetherness than separateness.
 There are separate friends and friends shared by the couple. Shared interests are common with some
separate activities.
 More “we” than “I”, more dependence than independence
❖ Enmeshed family (very high cohesion / relational entanglement) – high bonding and low autonomy
 Enmeshment is an extreme pattern of family organization where there is an over identification with the
family that results in extreme bonding and limited individual autonomy. 239
• High levels of enmeshment characterize families with infants and very young children (especially between
mother and the children). Very young children need much more care, so this interaction style is useful.
• However, it can become less functional when the children get older. Older children may not be able to
develop independence and autonomy when the families stay enmeshed.240
 The lack of subsystem differentiation discourages autonomous exploration and mastery of problems.
 In the pathological range, a family’s lack of differentiation makes any separation from the family an act of
betrayal.241
 Extreme amount of emotional closeness and loyalty is demanded. Individuals are very dependent on each
other and reactive to one another.
 There is a lack of personal separateness and little private space is permitted. The energy of the individuals is
mainly focused inside the family, and there are few outside friends or interests.
 Primarily “we”

GENERAL CONSIDERATIONS ABOUT THE CIRCUMPLEX MODEL

❖ The communication dimension (3rd dimension) is not shown in the 2-dimensional model, but it is important.242
 Communication includes active listening, self-disclosure, empathic responding, respect, and clarity and
continuity of discussions. 243
 The better the communication the more possibility of adaptation or movement in the model. Greater
communication increases the resources of the family to adapt and move around in the models.
 The lower the communication, the fewer resources the family has to adapt.
❖ The Circumplex Model should not be used to describe dysfunction because there is a lot of diversity in families.
More specifically, different cultures have different views.
 In general, couples/families with balanced (two central levels) cohesion and adaptability will generally
function more adequately across the family life cycle than those at the extreme of these dimensions.
However, an unbalanced/extreme family is not dysfunctional when it is normative for the system and all
members are in agreement. Yet, one member can throw the system off balance.
 If the normal expectations of a couple/family support extreme behaviors (on one or both dimensions), they
will function well as long as all family members are satisfied with these expectations.
❖ To deal with situational stress and developmental changes across the family life cycle, families will change their
cohesion and adaptability, to adapt to the stress.

239 Montgomery & Fewer (1988)

240 Mullis, F., & Edwards, D., (2005). Consulting with parents: Applying family systems concepts and techniques. Professional School Counseling, 5(2), 116-123.
241 Minuchin, S. (1974). Families and family therapy. Harvard University.
242 Barnes, H. L., & Olson, D. H. (1985). Parent-adolescent communication and the Circumplex Model. Child Development, 56(2), 438-447.
[Link]
243 Olson, D. H., & Gorall, D. M. (2003). Circumplex model of marital and family systems. In F. Walh (Ed.), Normal family processes (pp. 514–547). Guilford.

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In times of stress, balanced systems often change to another system type to adapt.

 In time of stress, unbalanced systems often stay in the extreme pattern, which can often create more stress.
❖ It is difficult to assess rigid, chaotic, and enmeshed from an insider’s view. People are usually better at typing
other families. Observational approaches tend to be better.
❖ Chaotic flipper – When families are in one of the extremes such as chaotically disengaged or rigidly enmeshed,
they will often flip flop to another extreme instead moving toward the center of the model.

ASSUMPTIONS
❖ Systems will change in response to developmental needs and situational stress.
❖ Unbalanced systems are not necessarily dysfunctional. Extreme behaviors on cohesion and flexibility…
 Can be appropriate for certain stages of the life cycle, or when a family is under stress.
 Families often gravitate toward either enmeshment or disengagement when boundaries are unclear. 244
 Can be problematic when families are stuck at the extremes.
❖ Balanced systems, in comparison to unbalanced systems, will generally…
 Function more adequately
 Have more positive communication.

CHANGE, STRESS, AND THE CIRCUMPLEX MODEL245

❖ First Order Change
 Too little change (i.e., rigid system) and too much change (i.e., chaotic system) are related to less functional
patterns in families.
 Structured and flexible family types generally have more balanced levels of change.
 First order change is curvilinear.
❖ Second Order Change
 Second order change refers to movement from one
system type to another system type.
 Second order change is linear.
❖ Change and equilibrium
 There is higher change in balanced systems.
 Lower change in unbalanced systems.

FAMILY DEALING WITH FATHER’S HEART ATTACK246

53 51

M.‘93

17 15 13

244 Minuchin (1974)

245 Olson (2000).
246 The image is from: Olson, D. H. (2000). Circumplex model of marital and family systems. Journal of Family Therapy, 22(2), 144-167.
[Link]
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RESEARCH WITH THE CIRCUMPLEX MODEL

❖ In general, research studies in the U.S. have shown that balanced families will function more adequately than
midrange or extreme/unbalanced families.
 In over 250 studies using FACES (described below) as a linear measure, balanced couple and family systems
tended to be more functional compared to unbalanced systems. In several studies using the Clinical Rating
Scale (i.e., a curvilinear measure) the hypothesis is also supported. These two assessment tools are designed
for research, for clinical assessment and treatment planning with couples and families.
 Balanced family types have a larger behavioral range and are more able to change compared with extreme
family types. They tend to have more positive communication skills than extreme families.
 Positive communication skills will enable
balanced couples/families to change their
level of cohesion and adaptability more
easily than those at the extremes.
❖ First chart notes247
 The first groupings are typologies of a
family with a member who is diagnosed as
neurotic (pre-therapy).
 The first groupings are typologies of a
family with a member who is diagnosed as
schizophrenic (pre-therapy).
 The 3rd grouping are the family typologies
after the families completed therapy.
 The 4th groupings are for families without a
member who is neurotic or schizophrenic.
❖ Second chart notes248
 Current family = typologies of the current family
with a sexual offender.
 Family-of-origin = typologies of the family that the
sexual offender was raised in.
 Non-offender refers to typologies of families
without a known sexual offender.

MEASUREMENT249
❖ The Family Adaptability and Cohesion Evaluation
Scales (FACES) is a self-report assessment instrument
developed to use in diagnosis and treatment planning
with the Circumplex Model. It is based on extensive
testing with families and counselors. FACES is a 111-
item instrument designed to measure a family member’s perception of family cohesion and adaptability.
❖ PREPARE-ENRICH was developed for use in premarital and relationship enrichment counseling/ classes
following this model.

APPLICATION OF THE CIRCUMPLEX MODEL TO DOMESTIC VIOLENCE

❖ Families with domestic violence are often characterized by being closed systems. There is a firm commitment
to maintaining a tight boundary between the family and the outside world. The family generally has strong,
inflexible family rules that range from overt rules governing the movement of the abused spouse to unstated

247 Clarke, J. (1984). The family types of neurotics, schizophrenics and normals. Unpublished doctoral dissertation. Family Social Science, University of Minnesota.
248 Carnes, P. (1989). Contrary to love: Helping the sexual addict. CompCare Publications.
249 Olson, D. H., Sprenkle, D. H., & Russell, C. S. (1979). Circumplex model of marital family systems: I--Cohesion and adaptability dimensions, family types, and clinical

applications. Family Process, 18(1), 3-27. [Link]

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rules that every family member observes. A common rule is secrecy. Family members may be aware of the
violent behavior, but they may not speak about “it.” The battered spouse might not confront the abusive
spouse, and in actuality may even make excuses for the other’s behavior or deny the severity of the beating. In
battering families there are rigid rules and roles as well as a limited capacity to cope with change as needed.
❖ Boundaries and roles are often unclear, diffuse, and may be inappropriately reversed at times. There is often
difficulty in setting limits and following through with limits. For example, an abused wife may never say “no” to
battering and passively accepts it. If she does set limits (e.g., pressing charges) she may not follow through.

FAMILY ROLES IN ADDICTED FAMILIES

GENERAL CONSIDERATIONS
❖ When a parent has an addiction, the family system often revolves around the addict and their addiction.
❖ Each family member maintains certain roles (see below) to keep the system balanced.
❖ The roles are interchangeable, however there is less flexibility in a family with more problems.
❖ Family members may play more than one role.
❖ Even if the addict ceases to use substances, the family has a difficult time making a second order change.250

FAMILY ROLES
❖ Addicted parent – This is the parent who has the addiction.
❖ Chief enabler – This family member allows the addiction to continue by “saving” the abuser from the
consequences of his or her actions and helping the addiction to occur (e.g., buying alcohol/drugs for the
person who is addicted).
 For example, if a substance-dependent parent does not go to work/school, the chief enabler might make
excuses for that absence.
 The chief enabler’s life often revolves around the addict’s life; hence, this person may sacrifice his/her own
needs, desires, and goals to take care of the addicted person.
 The chief enabler may also feel responsible for the other person’s addiction.
 The chief enabler is often the other parent, but it is possible for one of the children to take this role (e.g.,
contributing to family finances by getting a job).
❖ Surrogate parent/little parent – This family member (usually an older child) will take on the role of parenting
the younger siblings, especially when the parents are immersed in the addiction. Sometimes, the surrogate
parent may even parent the parents.
❖ Family hero/hero child – This youth fulfills the family values to create the illusion of a successful family.
 For example, if a family values sports, then the child excels in sports. If the family values education, then the
child excels in academics. If the family values criminal activities, then the child excels in criminal activities.
 The parents often publicly brag about the family hero’s accomplishments.
 The family hero may sacrifice their own needs and goals to achieve due to pressure to be successful.
 The family hero is often vulnerable to addiction due to feelings of pressure to achieve, sacrificing needs, and
feelings of guilt and inadequacy.
❖ Scapegoat – This family member, often an adolescent, is thought of as the “problem child” because they
display many unacceptable behaviors (e.g., substance abuse, criminal behavior, aggressive acts, school
problems) to (1) draw attention away from the parent’s addiction, and/or (2) act out the family anger.
 When a scapegoat was younger, they might have been blamed for things they had little control over. So, as
the scapegoat got older, they always felt like they were in trouble or blamed for anything that went wrong.
 The scapegoat often feels hopeless and like a failure.
 Family members may believe if the scapegoat would stay out of trouble, their problems would go away.

250 Ziter, 1988

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❖ Mascot – This family member does not like conflict, hence this member often uses humor or antics to bring
happiness and divert attention away from family conflict and problems.
 The mascot is often popular with other children, but they may have trouble forming intimate relationships
because of fear of conflict.
 The mascot might be a baby or toddler who brings happiness to the family just by being there.
❖ Lost/forgotten child – This family member rarely causes any problems and is relatively invisible.
 The lost child has friends and engages in activities unknown to the other family members.
 The lost child may live in a world of books, fantasy, video games, computer, and/or television.
 Often, this family member feels sad and alone. As an adult, the lost child may disconnect from the family.

Takes care of Gary when he’s “sick”.

Cooks lunch for Gay every day.
Often prepares supper for Gary’s family

BRIEF PSYCHOTHERAPY APPROACHES

“If therapy is to end properly, it must begin properly.” Jay Haley, Problem-Solving Therapy, 1987

THE PROBLEM251
❖ On average, clients participate in three to six sessions, and many clients only attend one session. Hence, the
first session is very important.
❖ Yet, the first session is often unproductive from the standpoint of the client (see next section).
 Traditional therapy first session
• Intake paperwork is completed; sometimes by an assistant.
• First meeting between the therapist and client.

251 Amini, R. L., & Woolley, S. R. (2011). First-session competency: The brief strategic therapy scale-1. Journal of Marital and Family Therapy, 37(2), 209–222.
[Link]
Talmon, M. (1990). Single-session: Maximizing the effect of the first (and often only) therapeutic encounter. Jossey-Bass.
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o Build rapport (also referred to as ‘joining’)

o Discuss rules of counseling: (1) fee for services; (2) rules regarding canceling sessions; (3) boundaries; (4)
client and therapist rights; (5) right of confidentiality, mandated reporting, reasons for breaking, and
confidentiality forms for talking to other people (e.g., school counselor, previous therapist, doctor); and
(6) right to refuse services and right to leave.
• Begin assessment.
• Wrap up first session with initial, temporary treatment goals and set an appointment for the next session.
❖ Unfortunately, clients often feel little concrete relief from the problem(s) that brought them to therapy.
Traditional Psychotherapy Brief Psychotherapy
Focuses on causes of problems Focuses on solutions
Past orientation Present and future orientation
Diagnoses what is wrong with that client. Identifies client’s strengths and resources
Focuses on what is not working for the client. Identifies what is working for the client (i.e., what is going well).
Focuses on resolving issues over time. Focuses on solutions that work in the shortest time possible.

SOME EARLY CONTRIBUTORS

❖ Milton Erickson, hypnotherapy and strategic family therapy
❖ Jay Haley, strategic family therapy
❖ Richard Bandler, neurolinguistic programming

OVERVIEW OF BRIEF PSYCHOTHERAPY

“It's easier to cure a phobia in ten minutes than in five years.” Richard Bandler, Time for a Change, 1993
❖ The first session is critical in the treatment/intervention.
❖ Early symptomatic improvement in therapy is related to better depression and anxiety treatment outcomes. 252
❖ It is a very direct and solution-based approach to a presenting problem.
❖ The primary emphases are the factors that sustain/maintain the problem and prevent change. Hence, less
attention is given to the causes of a problem and/or reasons that resulted in the client coming into therapy.
❖ The focus is on establishing and meeting therapeutic goals.
 Thus, more attention is put on the present and future than on the past.
 Treatment sessions are goal-directed and goal-driven.
❖ There is an underlying belief that change is continuous; hence clients always have the capacity to change.
❖ Brief psychotherapy encompasses a variety of approaches, such as:253
 Brief psychodynamic therapy 254
 Eye movement desensitization and reprocessing 255
 Solution focused brief therapy (described below)
 Brief strategic family therapy (described below)
 Brief cognitive behavioral therapy (described below)
 Single-session interventions (i.e., therapy content is delivered in one session).
• A single-session acceptance and commitment therapy (ACT) intervention resulted in significant decreases
in fear of childbirth and lower anxiety in pregnant (14-37 weeks gestation) women.256

252 Beard, J., & Delgadillo, J. (2019). Early response to psychological therapy as a predictor of depression and anxiety treatmen t outcomes: A systematic review and
meta-analysis. Depression and Anxiety, 36(9), 866–878. [Link]
253 Center for Substance Abuse Treatment. (1999). Brief interventions and brief therapies for substance abuse. Treatment Improvement Protocol (TIP) Series, No. 34.

[Link]
254 Ho, C., & Adcock, L. (2017). Short-term psychodynamic psychotherapy for the treatment of mental illness: A review of clinical effectiveness and guidelines. Canadian

Agency for Drugs and Technologies in Health. [Link]

255 [Link]
256 Howard, S., Houghton, C. M. G., White, R., Fallon, V., & Slade, P. (2022). The feasibility and acceptability of a single -session Acceptance and Commitment Therapy

(ACT) intervention to support women self-reporting fear of childbirth in a first pregnancy. Psychology & Health, 38(11), 1460–1481.
[Link]
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• A meta-analysis found youth receiving single-session interventions did better than youth in the control-
group (most of which did not receive any intervention).257
o Effects were largest for anxiety and conduct problems.
o Effects were weakest for substance abuse.
o Effects were larger for children than adolescents.
o Effects were largest for youth-focused cognitive-behavioral approaches than other treatments.
o Effects were smaller at follow-ups exceeding 13 weeks.
o Effects did not differ between self-administered versus therapist-administered interventions.

SOLUTION FOCUSED BRIEF THERAPY258

❖ Based on social constructionist philosophy.
❖ The goal is solution building (i.e., solution talk) instead of focusing on problem (i.e., problem talk).
 It is not necessary to know the cause or function of a problem to resolve it.
 Offers resources to enhance clients’ life quality when clients lack solutions for their own problems.
❖ Transform the client’s focus away from what is wrong (i.e., problem) and onto what is going right (i.e.,
exceptions to problems)
 Therapists help clients identify what is going right and/or what works, and then encourages the client to
keep doing it (and do it more).
 The parts of the client’s life that are going well are used as a foundation to build an improved lifestyle.
 If something is not working, then therapists tell clients to do something different.
❖ Therapists help clients stay focused on what’s possible and changeable, instead of what’s impossible and
intractable. Small change is all that is necessary.
❖ Therapists help clients visualize and construct their ideal future.
❖ Therapists help clients identify available skills, strengths, and resources.
❖ Techniques and types of questions to facilitate sessions and change:
 The systematic problem-solving model259 guides the types of questions outlined below.
• What is the problem or situation?
• What have you tried?
• What has worked or not worked?
• What else could you do?
• What is your next step?
 Opening questions
• “What would you like to accomplish in therapy?”
• “How will you know if therapy is a success?”
 Miracle question
• “Suppose that tomorrow there was a miracle and your problem was solved. What would be different
tomorrow now that the miracle has taken place? How would you know the miracle has taken place?”
 Relationship question
• Therapist asks the client to identify who would notice if s/he accomplished the goal on the scale and/or
how significant others would know when s/he reached the goal.
 Exception-finding questions
• Therapists ask clients to explain about a time that was an exception to their general demeanor.
• Example: A client is sad and unhappy, so the therapist has the client identify a time when the client could
remember being happy. Then the therapist and client try to figure out why the client was happy then.
 Previous solution questions / coping questions

257 Schleider, J. L., & Weisz, J. R. (2017). Little treatments, promising effects? Meta-analysis of single-session interventions for youth psychiatric problems. Journal of the
American Academy of Child & Adolescent Psychiatry, 56(2), 107–115. [Link]
258 De Jong, P., & Berg, I. K. (2007). Interviewing for solutions (3rd Ed.). Thompson Brooks/Cole.

De Shazer, S., Dolan, Y, Korman, H., Trepper, T., McCollum, E., & Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy.
Routledge.
259 Myrick, R. D. (1987). Developmental guidance and counseling: A practical approach. Educational Media Corp

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• Therapists explain to clients how people solve problems every day and then asks questions.
• Therapists remind clients they engage in useful coping strategies even when they are overwhelmed or
dealing with difficult situations.
• (1) “What have others done to resolve your type of situation?” (2) “Are there things you have done that
helped?” (3) “How have you kept things from becoming worse?”
Scaling questions

• Therapists have the client rate on a scale of 1 to 10 the current situation, willingness to change, and/or
confidence in ability to attain goals or change.
 Validating and complimenting
• The therapist validates how difficult the client’s problems are. Then, the therapist compliments what the
client is already doing well.
• Validating and complimenting help the client know the therapist was listening.
• Compliments can help focus the client on what is working.
• The therapist can also help the client engage in self-compliments through appreciatively toned questions.
o “How have you managed to carry on so well?”
 Inviting clients to do what is working
• Therapists encourage client to do more of what seems to work.
 Present/Future-oriented questions
• “What can you do tomorrow to make progress?”
• “What will you do next week that shows you that you are still making progress?”
 Therapist feedback to clients towards the end of the session
• Compliment the clients on what they are doing well that is leading to change.
• Use a bridge statement (i.e., reasoning) that links the compliment to a task that will be assigned.
• Assign a task to keep the client focused on progress (e.g., homework).
 Homework is assigned.
• Homework can be a representation to the clients that they are actively doing something to change.
• Thus, homework can help clients focus on change and stay optimistic about the future.
❖ Research of effectiveness
 A meta-analysis on treating depression found:260
• Short-term psychodynamic psychotherapy (STPP) was significantly more effective at reducing symptoms
than control conditions. STPP was not significantly different from other psychotherapies at post-
treatment and follow-up. STPP was more effective at reducing anxiety symptoms than other treatments.
 An experimental study showed that clients at a prison who participated in solution focused brief therapy
generally did better than those who used traditional prison services.261
 A meta-analysis indicated solution focused brief therapy was effective in treating psychosocial outcomes in
medical settings and had potential of improving patients’ health-related behaviors. 262
Good overview of solution focused therapy by Dr. Diane Gehart, MFT Program, CSUN – [Link]

BRIEF COGNITIVE BEHAVIORAL THERAPY263

❖ 4-8 sessions instead of 12-20 sessions.
❖ Issues appropriate for brief CBT include anxiety, depressive disorders, social isolation, grief, lifestyle
changes/transitions (e.g., exercise, diet, changing jobs/residences), mental health problems related to medical
issues, etc. However, brief CBT may not be appropriate for Axis II disorders (e.g., antisocial personality
disorder, borderline personality disorder).
260 Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J. M., Van, H. L., … Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy
for depression: A meta-analysis update. Clinical Psychology Review, 42, 1–15. [Link]
261 Lindforss, L. & Magnusson, D. (1997). Solution-focused therapy in prison. Contemporary Family Therapy, 19(1), 89-103. [Link]
262 Zhang, A., Franklin, C., Currin-McCulloch, J., Park, S., & Kim, J. (2018). The effectiveness of strength-based, solution-focused brief therapy in medical settings: a

systematic review and meta-analysis of randomized controlled trials. Journal of Behavioral Medicine, 41(2), 139–151. [Link]
[Link]/10.1007/s10865-017-9888-1
263 Cully, J. A., Dawson, D. B., Hamer, J., & Tharp, A.L. (2020). A provider’s guide to brief cognitive behavioral therapy. Department of Veterans Affairs South Central

MIRECC, Houston, TX. [Link]

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❖ Patient criteria: motivated to change, willing to commit time and energy, not overwhelmed with life stressors,
able to work independently, and willingness to do homework.
❖ Develop a strong therapeutic relationship (e.g., showing empathy, being genuine/authentic, expressing
positive regard/respect, engaging in active listening).

BRIEF STRATEGIC FAMILY THERAPY / BRIEF FAMILY THERAPY

❖ The focus is on identifying and then changing repetitive family interaction patterns (i.e., structures) that
maintain the problem.
❖ The first session is extremely important to help the client(s) begin identifying solutions to problems. 264
❖ Assumptions265
 Symptoms in a family member reflect problems in the family system.
• The symptoms are maintained by the interaction patterns in the family system.
• When symptoms (i.e., problems) in a family member emerge, the family often repeats the same
ineffective behaviors to resolve the problem.
 If symptom-maintaining patterns are changed or eliminated, then the symptom will disappear.
❖ Planned and practical interventions
 Therapist identifies the maladaptive interaction patterns that maintain the problem.
• Families often don’t recognize that their interaction patterns are the problem.
 Interventions are planned to help the family develop more effective interaction patterns.
 Interventions must be adapted to the unique characteristics of each family.
 Treatment goals should be achievable.
❖ Focusing on why the family interaction patterns occur can distract the therapist (and family) from observing
the family’s maladaptive and ineffective attempts to solve the problem.

SINGLE-SESSION INTERVENTIONS
❖ Single-session interventions are structured therapeutic interventions that purposefully involve a single
encounter with a provider (e.g., therapist) or program (e.g., online, self-guided activity).266
 Many clients only engage in one therapeutic experience, but a single experience can still be helpful.
 Single-session interventions can:
• Provide immediate support to clients when they need it.
• Increase accessibility due to cost effectiveness (e.g., time, money) and lack of therapists.
• Increase responsiveness by mental health services.
❖ Aims267
 Help clients recognize and identify their strengths, abilities, and tools (e.g., coping skills) that facilitate
meaningful change, and
 Help clients believe that taking a step (no matter how small) at any moment can help them move towards a
better future.
❖ Common uses
 Mental health / suicide hotlines.
 Intervening in a mental health crisis.
 In conjunction with more traditional therapy (e.g., during crisis, follow-up “booster”).
❖ In addition to common uses, single-session interventions can also be used in many other situations, such as:
 Learning strategies to manage insomnia, anxiety, or depressive symptoms.
 Setting life goals.
 Preventing sexually transmitted diseases.

264 Nardone, G., & Salvini, A. (2007). The strategic dialogue: Rendering the diagnostic interview a real therapeutic intervention. Karnac Books.
265 Peake, T. H., Borduin, C. M., & Archer, R. P. (1988). Brief psychotherapies: Changing frames of mind. Sage.
266 Hoyt, M. F., Bobele, M., Slive, A., Young, J., & Talmon, M. (Eds). (2018). Single-session therapy by walk-in or appointment: Administrative, clinical, and supervisory

aspects of one-at-a-time services. Routledge.

267 Schleider, J. L. (2024). Little treatments, big effects: How to build meaningful moments that can transform your mental health. Robinson.

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❖ A meta-analysis found youth receiving single-session interventions did better than youth in the control-group
(most of whom did not receive any intervention). 268
 Effects were largest for anxiety and conduct problems.
 Effects were weakest for substance abuse.
 Effects were larger for children than adolescents.
 Effects were largest for youth-focused cognitive-behavioral approaches than other treatments.
 Effects were smaller at follow-ups exceeding 13 weeks.
 Effects did not differ between self-administered versus therapist-administered interventions.

ADDITIONAL RESOURCES
De Jong, P., & Berg, I.K. (2007). Interviewing for solutions (3rd Edition). Brooks/Cole: Pacific Grove.
De Shazer, S. & Dolan, Y. (2007). More than miracles: The state of the art of solution-focused brief therapy. Haworth Press.
Gingerich, W., & Eisengrat, S. (2000). Solution-focused brief therapy: A review of the outcome research. Family Process, 3(4)9, 477-498.
[Link]
McGee, D., Del Vinto, A., & Bavelas, J. (2005). An interactional model of questions as therapeutic interventions. Journal of Marital and
Family Therapy, 31(4), 371-384. [Link]

INTERPERSONAL ASSESSMENT

ISSUES TO CONSIDER BEFORE WORKING IN THE HELPING PROFESSION

❖ Helping professionals have implicit biases and privileges that could unintentionally impact their ability to
effectively work with others. The challenge for helping professionals is to identify their biases and privileges.
 Hopefully, before providing services, helping professionals learn how to undermine their own biases and
recognize how their own privileges impact their service delivery.
• Note: Applicants to MSW programs are often asked this in their personal statement.
❖ How do therapists’ values impact their delivery of services?
 Religious beliefs (e.g., divorce, masturbation, premarital sex, birth control, extra-marital affairs).
 Beliefs regarding unwanted pregnancy (e.g., abortion, adoption, keeping baby).
 Beliefs regarding spanking / corporal punishment.
 Beliefs regarding drinking alcohol and/or recreational drugs.
❖ If a therapist shares the client’s values, beliefs, and background, does that make therapy more effective?
 Would an Armenian client benefit from an Armenian therapist? Could this cause issues?
 Should a religious client only see a therapist from the same religion? Is it more beneficial or problematic?
❖ What assumptions do people make regarding their clients? How do these assumptions impact service delivery?
❖ Do therapists need to experience the client’s issue to be effective?
 If a therapist has a similar experience, does that mean the therapist can work with and understand the
client better?
 Does it take a recovering alcoholic/addict to provide effective therapy? Is this true for helping someone who
is depressed? anxious? schizophrenic? etc.
❖ What issues can decrease helping professionals’ effectiveness and what issues should they avoid?
 What are the therapist’s perceptual filters, biases, and triggers?
 Can the therapist effectively work with murderers, rapists, abusers, sex offenders?
 Are there age groups the therapist prefers not to work with?
 Can the therapist continue to work with a client who threatened him/her?

268 Schleider, J. L., & Weisz, J. R. (2017). Little treatments, promising effects? Meta-analysis of single-session interventions for youth psychiatric problems. Journal of the
American Academy of Child & Adolescent Psychiatry, 56(2), 107–115. [Link]
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TEMPERAMENT AND INTERPERSONAL RELATIONSHIPS

❖ There are numerous theories and classification systems of personality/temperament style in existence such as:
 Jung’s Temperament Styles
 DISC Basic Personality Types Model
 Big Five Personality
 Meyers-Briggs Personality Type
 Keirsey Temperament Styles
 Beaver’s Animal Classifications
 True Colors / Spectrum Temperament Development’s Full Color Spectrum
❖ Each classification system has advantages and disadvantages.
❖ Similarities across classification systems
 For most classification systems, there is no best, better, worse, or worst type.
• The one exception is that the Big Five pathologizes one side of each continuum (see below).
 The classification systems identify preference for a type but not the strength of ability in the type.
• People might have a preference for extroversion (e.g., being outgoing), but it does not mean they are
great at being extroverted. People might have a preference for intuition (e.g., thinking before speaking),
but they are not necessarily good at being intuitive.
 People are better than another person at identifying their own type.
 People using the classification systems should avoid stereotyping or pigeonholing a person.
• Just because a person is first color Blue does not mean the person has all the characteristics of being Blue.
 Types are useful for understanding a person’s preferred ways to think, make decisions, and interact.
Understanding the types help us communicate and relate to others based on how people think and interact.
 They all include introvert and extrovert interaction styles.
• Introvert
o Derives primary energy from the inner world (e.g., thoughts, ideas, self-reflection, information).
o Ponders and rehearses thoughts before saying them out-loud.
o May appear quiet, reflective, and reserved. Needs emotional, physical, and mental space.
o Prefers solitude or one-on-one activities to group activities.
o Can be sociable, but usually selective in revealing too much personal information.
o Prefers fewer close relationships to many casual ones.
o If too much energy is expended in the outside world (e.g., interacting with people), then retreating to a
more private setting can help reenergize.
• Extrovert
o Derives primary energy from interactions with the outside world (e.g., things, people, places, activities);
the more interaction, the better.
o Thinks out-loud and talk things through while thinking.
o Sociable, outgoing, and likes to be with people; very approachable and generally feels at ease starting a
conversation with someone.
o If too much attention is devoted to inner world (i.e., by oneself), then the outside world must be
engaged to rejuvenate.

THE BIG FIVE PERSONALITY TRAITS269

❖ Individuals are born with (heredity) and then develop (environment) aspects of the five traits.
❖ It is based on work from different research institutes that arrived at similar findings.
❖ It is a descriptive model of personality that has been widely used and validated in numerous cultures.
❖ The Big 5 has strong predictive ability with a wide range of behaviors.

269 [Link]
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BIG FIVE PERSONALITY TRAITS

Factors Dichotomies / Traits Description
Openness to Creative or inventive vs.
Open-minded, emotional, adventurous, values new ideas, curious, interested in art
experience Conforming or cautious
Efficient or organized vs.
Conscientiousness Disciplined, results-oriented, structured, traditional, dutiful
Unstructured or careless
Outgoing or energetic vs. High energy level, people person, extroverted (i.e., gets stimulated by being around
Extraversion
Solitary or withdrawn others)
Friendly or compassionate vs.
Agreeableness Compassionate, cooperative, forgiving, pragmatic
tough-minded or callous
Sensitive or nervous vs. Confident
Neuroticism Sensible, vulnerable, in extreme can be emotionally unstable and neurotic
or resilient

❖ A meta-analysis indicated the Big 5 personality traits were related to mental health treatment outcomes:270
 Lower levels of neuroticism were related to better treatment outcomes.
 Higher levels of extraversion, agreeableness, conscientiousness, and openness were related to better
treatment outcomes. For example…
• Agreeableness was positively related to therapeutic alliance.
• Conscientiousness was positively related to abstinence from substances.
 Assessing personality traits when starting therapy can infer possible strengths and barriers to treatment.

MYERS-BRIGGS PERSONALITY TYPE (MBTI)

❖ It is based on Carl Jung’s psychological types. 271
❖ Individuals are born with and develop preferred ways of thinking, interacting, and perceiving the world.
❖ It is the most researched personality classification system, but it is not as easy to apply as some systems.
❖ MBTI was shown to be a reliable and valid instrument to assess individuals’ personality types/preferences. 272
MYERS-BRIGGS TYPES
Dichotomies Preferences Description
Introversion Derives primary energy from inner world (e.g., thoughts, ideas, self-reflection, information). If too much energy is
Energy
(I) expended in the "outside" world, then retreating to a more private setting can help reenergize.
Orientation
Extraversion Derives primary energy from outside world (e.g., things, people, places, activities). If too much attention is devoted to
(I vs. E)
(E) inner world, then the outside world must be engaged to rejuvenate.
Perceiving Sensing
Prefers basic information and data that are clear and concrete and fits well with current experience.
Mental (S)
Process Intuition
Prefers information and data that are more abstract, conceptual, big-picture, and represents future possibilities.
(S vs. N) (N)
Judging Thinking Prefers making decisions in an objective, logical, and rational manner with a focus on accomplishing tasks and getting
Mental (T) results.
Process Feeling Prefers making decisions in a visceral, harmonious, and value-oriented way with a focus on how decisions and actions
(T vs. F) (F) impact other people.
Outer Judging
Relies upon thinking or feeling preference to manage outer life; likes closure, organization, and planning.
World (J)
Orientation Perceiving Relies upon sensing or intuition preference to manage outer life; which generally results in an open, adaptable, flexible
(J vs. P) (P) style of relating to things and people. Lack of closure is often tolerated.
Good overview of application of MBTI by Dr. Diane Gehart, MFT Program, CSUN – [Link]

❖ The Keirsey Temperament Styles, Beaver’s Animal Classifications, and True Colors are based on the MBTI. The
goal of these classification systems was to give names to each MBTI personality type to make it easier for
people to remember and apply the types.

270 Bucher, M. A., Suzuki, T., & Samuel, D. B. (2019). A meta-analytic review of personality traits and their associations with mental health treatment outcomes. Clinical
Psychology Review, 70, 51–63. [Link]
271 Jung, C. G. (1923). Psychological types. Harcourt Brace.
272 Myers, I. B., McCaulley M. H., Quenk, N. L., & Hammer, A. L. (1998). MBTI manual (A guide to the development and use of the Myers Briggs Type Indicator (3rd

edition). Consulting Psychologists Press.

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COLORS TEMPERAMENT DEVELOPMENT MODEL273

❖ Classifications of Gold, Blue, Green, and Orange are used for simplicity.
❖ Everyone is born with a “natural” temperament/color that provides each person with a unique array of gifts,
talents, and skills. The natural temperament directly influences attitudes, behaviors, and perceptions.
❖ People are born with the capacity to develop skills and strengths of the other temperaments. People develop
traits of a secondary temperament through life experiences and relationships. When a secondary
temperament is developed effectively, it blends with the natural temperament. The two can be used in unison,
with the natural temperament leading the way.
❖ People possess traits and skills from their third and fourth colors, but these colors are usually less developed
than their natural and secondary colors.
❖ People can enhance relationships with others, personal growth, and success by understanding, appreciating,
and developing skills from all the temperaments and both interaction styles (i.e., introversion, extroversion).
Plunk’s thought – I think classification systems give us a shared vocabulary that makes it easier to communicate. For example, it is easier to tell someone you more
introverted than extroverted instead of listing all the introverted qualities. Similarly, if you tell someone that you are INTJ (for someone who knows the MBTI) or that you
are orange, green, blue, gold (for someone who knows Colors), then it quickly communicates a lot of information about you. Of course, the challenge is not stereotyping
or pigeonholing people. Also, I was trained in MBTI and Colors (i.e., Spectrum Temperament), and I have conducted research with Big Five, Colors, and Keirsey. I think the
Colors model is easier for most people to remember and use in their daily lives, which is why I give more attention to it in the notes and lecture.

273 [Link]
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SPECTRUM TEMPERAMENT STYLES (Animal classifications1; Keirsey Temperament Sorter2; Myers-Briggs3)

Gold Blue Green Orange
Beaver1/Guardian2/ Golden Retriever1/Idealist2/ Lion1/Rationale2/ Otter1/Artisan2/
Sensing-Judging3 Intuitive-Feeling3 Intuitive-Thinking3 Sensing-Perceiving3
Relationships; Meaning and
Knowledge and information;
Needs

To be responsible to home and significance in life; To feel unique Freedom, fun, excitement,
Explanations and answers; To
family; To be useful and belong. and authentic; To contribute, variety, stimulation.
gain intellectual competence.
encourage, and care.
Values

Integrity, unity in relationships, Intelligence, insight, fairness, Independence, resourcefulness, Integrity, unity in relationships,
unity in family. justice. courage, skill. unity in family.
Wants to follow school rules; Has a more difficult time fitting
Understood and respected Extremely imaginative; Finds it Acts older than age; Focuses on
into school routine than others;
authority; Comfortable with difficult to fit into structure of subjects that are mentally
Learns by doing and
academic routine; Generally school; Reacts with sensitivity to stimulating; Impatient with drill
experiencing rather than by
Child

completes homework; Easiest of hostility, unfriendliness, or and routine; Questions authority;

listening and reading; Needs
all types to adapt to the rejection; Responds to Finds it necessary to respect
physical involvement in the
educational system. encouragement rather than teachers before being able to
learning process; Motivated by
competition; Seeks recognition. learn from them.
competition and sense of fun.
More serious; traditional and Heart rules the brain; Romantic; Head rules heart; Once feelings Seeks a relationship with shared
conservative views of love and Wants harmonious relationships; are stated, they’re obvious to a activities and interests; Likes to
Relationships

marriage; Desires to build a Believes in perfect love that lasts partner, so feelings don’t need to explore new ways to energize the
secure, predictable life with forever; Brings drama, warmth, be restated; Uneasy when relationship; Enjoys giving
partner; Demonstrates love and and empathy to relationships; emotions take control; Once a extravagant gifts that bring
affection through the practical Enjoys symbols of romance; relationship is established, leaves obvious pleasure to loved one;
things done for loved ones; Role Cherishes small gestures of love; it to maintain itself, and turns Thrives on physical contact; A
in family – parental. A nurturer. energies back to career. bold lover.
Doesn’t get bogged down in
Very intuitive; Understands details; Lives life by own
Follows rules and respect Doesn’t take things too seriously;
people; Strong desire to influence
Life

authority; Strong sense of what is standards; Natural non- Spontaneous; Considers life as a
others so they may lead more conformist.
right and wrong in life. game; Focuses on here and now
significant lives.
Provides stability; Maintains Independent thinker; Drawn to Bored and restless with routine
organization; Handles details and challenge in careers; Likes to and structured jobs; Satisfied in
Often works in the arts,
work hard; Backbone of many develop models, explore ideas, or careers that allow independence
communications, education, and
organizations; Work comes build systems to satisfy needs; and freedom; Likes to use
Work

the helping professions; Good at

before play, even if having to Work is play; Likes innovation; physical coordination and tools;
motivating and interacting with
work overtime to complete the Once an idea is perfected, leave Views tools as an extension of
others.
job; Likes lists; A helper; Strong the project to be maintained and self; Natural trouble-shooter,
work ethic. supported by others. performer, and competitor.
Caring, concerned, concrete, Authentic, affectionate, Active, adventurous, bold,
conservative, conventional, communicative, compassionate, Abstract, analytical, big picture, charming, competitive, daring,
cooperative, industrious, devoted, dramatic, emotional, calm, collected, conceptual, cool, courageous, eager, exciting,
Attributes

dependable, detail-oriented, empathetic, enthusiastic, feeling- dominant, global, hypothetical, fraternal, fun-loving, generous,
efficient, faithful, loyal, oriented, flexible, harmonious, idea-oriented, inventive, humorous, immediate, impactful,
meticulous, orderly, organized, idealistic, imaginative, peaceful investigative, leader, logical, impetuous, impulsive, open-
practical, prepared, procedural, inspirational, personal, poetic, motivator, perfectionist, problem minded, opportunistic, optimistic,
punctual, responsible, sensible, sincere, spiritual, sympathetic, solver, visionary. physical, realistic, risk-taker,
stable, thorough, traditional tender, unique, vivacious, warm. skillful, trouble-shooter, witty.

© Scott W. Plunkett, Ph.D.

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COMMUNICATING/INTERACTING WITH CLIENTS WHO EXHIBIT DIFFERENT COLOR TEMPERAMENTS

Gold Clients Blue Clients Green Clients Orange Clients
• Emphasize home, family, duty, • Emphasize relationships, family, • Emphasize fairness, logic, • Emphasize independence, excitement,
tradition, and responsibility. and feelings. knowledge, and intelligence. activities, and the present situation,
• Be specific and concrete. • They will likely respond to • They do not need constant not past situations.
• They may have more therapists who nurture the nurturing and respond to facts • Connect through common interests
traditional and conservative therapist-client relationship. and logic more than emotion. and activities.
views. • They respond to sincerity and • They need to understand the • They want therapy to be fun or
• They will generally follow the warmness. reason behind rules/homework. engaging and to have a variety of
rules and respect authority. • They desire to have their • They like to be viewed as experiences.
• They will generally follow- feelings and emotions validated. leaders and problems solvers • They may not follow-through with
through with homework. • They may appreciate self- and respond more to the big homework, and they may not take
disclosure from the therapist. picture than details. therapy too seriously.

BRIEF OVERVIEW AND LINKS TO OTHER THERAPEUTIC APPROACHES

BIBLIOTHERAPY
❖ Therapists recommend readings to clients, and then discuss these readings during individual or group therapy
to help clients understand other perspectives and to understand themselves.
[Link]

EXPRESSIVE ART THERAPY

❖ Therapists utilize creative processes (e.g., drawing, painting, sculpting, journaling, storytelling, reading poetry,
making videos, dancing) as a way to help clients express themselves and to promote healing and recovery.
[Link]
 Northern California Art Therapy Association (NorCATA) – [Link]
 Southern California Chapter of American Dance Therapy Association (SCCADTA) – [Link]

EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY (EMDR)

❖ Therapists encourage clients to focus on a distressing experience (e.g., trauma memory) or adverse body
sensation while simultaneously experiencing a stimulus that is presented to both sides of the body (i.e.,
bilateral stimulation) which results in decreased emotional arousal associated with the adverse events. The
bilateral stimulation could be eye movements, sounds, etc.
[Link]

FEMINIST THERAPY
❖ Therapists develop authentic connections with female clients to help them overcome societal challenges (e.g.,
bias, oppression, discrimination, stereotyping) negatively impacting their mental health.
[Link]

HYPNOTHERAPY
❖ Therapists help clients reach a relaxed, focused state of concentration through mental imagery and/or
soothing verbal repetition to diminish peripheral awareness, increase suggestibility, and identify resources
within themselves to achieve desired changes (e.g., behavioral, pain management).
[Link]

MOTIVATIONAL INTERVIEWING
❖ Therapists use a focused, intentional, and goal-directed approach to help clients explore and resolve
ambivalence and increase motivation to make positive changes.
[Link]

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MUSIC THERAPY
❖ Therapists have clients listen to, reflecting on, and/or create music to relax, to enhance mental/physical
health, to manage pain, and/or to express themselves.
[Link]

NEUROFEEDBACK / BIOFEEDBACK
❖ Therapists utilize a computer-based program to assess clients’ physiological functions (e.g., brainwave
activities, blood pressure) and then use auditory or visual signals to help clients recognize and modify thought
patterns to learn better emotion regulation and to improve brain functions.
[Link]

PLAY THERAPY
❖ Therapists use play with children (1) to develop trust; (2) to better understand the child’s thoughts (e.g.,
style/types of play, choice of play objects); and (3) to give children another way to express their thoughts and
communicate.
[Link]

PSYCHODRAMA
❖ Therapists have clients act out past experiences (e.g., role-playing, soliloquy, role reversal) to help clients
explore issues and gain better insight.
[Link]

REMINISCENCE THERAPY (LIFE REVIEW THERAPY)

❖ Therapists help clients with a memory or cognitive disorders (e.g., Alzheimer’s disease, dementia) recall past
life events to enhance their psychological well-being. Therapists may use props (e.g., photos, letters,
memorabilia) or sensory stimulation (e.g., smells, listening to a song) to relive memories.
[Link]
❖ This is a technique a person could use with a family member or loved one who has a memory disorder.
[Link]

© Scott W. Plunkett, Ph.D.