Therapy with a Map: A Cognitive Analytic Approach to Helping Relationships.
Author(s): Steve Potter.
Edition: First (1st).
Type(s): Paperback and Kindle.
A therapeutic relationship is a web of interactions, tasks and processes in space and time. It is not easy to stay aware of the relationship in the thick of talking and trying to help someone; but doing so boosts flexibility and enables deeper formulation. A therapist who can attend not only to a specific therapeutic model, but also to relational factors underlying all therapy, has a far greater chance of enabling change.
Therapy with a Map sets out a therapeutic process of talking accompanied by visual conversation maps set down in real time on paper. Like all maps, these help us to find our way, notice when we are lost, track our route and survey the wider landscape. The book uses mapping to introduce the tools and concepts of Cognitive Analytic Therapy (CAT), along with other relational, conversational and narrative approaches. By mapping patterns of thinking and relating, therapists can help clients to develop self-understanding, solve problems, and take away a freer, more self-aware relationship with themselves in the world.
The drama triangle is a social model of human interaction – the triangle maps a type of destructive interaction that can occur among people in conflict.
The drama triangle model is a tool used in psychotherapy, specifically transactional analysis.
The triangle of actors in the drama are oppressors, victims and rescuers.
Stephen Karpman used triangles to map conflicted or drama-intense relationship transactions. The Karpman Drama Triangle models the connection between personal responsibility and power in conflicts, and the destructive and shifting roles people play. He defined three roles in the conflict; Persecutor, Rescuer (the one up positions) and Victim (one down position). Karpman placed these three roles on an inverted triangle and referred to them as being the three aspects, or faces of drama.
The Victim in this model is not intended to represent an actual victim, but rather someone feeling or acting like one.
The Victim’s stance is “Poor me!”
The Victim feels victimised, oppressed, helpless, hopeless, powerless, ashamed, and seems unable to make decisions, solve problems, take pleasure in life, or achieve insight.
The Victim, if not being persecuted, will seek out a Persecutor and also a Rescuer who will save the day but also perpetuate the Victim’s negative feelings.
The rescuer’s line is “Let me help you.”
A classic enabler, the Rescuer feels guilty if they do not go to the rescue.
Yet their rescuing has negative effects: It keeps the Victim dependent and does not allow the Victim permission to fail and experience the consequences of their choices.
The rewards derived from this rescue role are that the focus is taken off of the rescuer.
When they focus their energy on someone else, it enables them to ignore their own anxiety and issues.
This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.
The Persecutor insists, “It’s all your fault.”
The Persecutor is controlling, blaming, critical, oppressive, angry, authoritarian, rigid, and superior.
Initially, a drama triangle arises when a person takes on the role of a victim or persecutor. This person then feels the need to enlist other players into the conflict. As often happens, a rescuer is encouraged to enter the situation. These enlisted players take on roles of their own that are not static, and therefore various scenarios can occur. The victim might turn on the rescuer, for example, while the rescuer then switches to persecution.
The reason that the situation persist is that each participant has their (frequently unconscious) psychological wishes/needs met without having to acknowledge the broader dysfunction or harm done in the situation as a whole. Each participant is acting upon their own selfish needs, rather than acting in a genuinely responsible or altruistic manner. Any character might “ordinarily come on like a plaintive victim; it is now clear that the one can switch into the role of Persecutor providing it is ‘accidental’ and the one apologises for it”.
The motivations of the rescuer are the least obvious. In the terms of the triangle, the rescuer has a mixed or covert motive and benefits egoically in some way from being “the one who rescues”. The rescuer has a surface motive of resolving the problem and appears to make great efforts to solve it, but also has a hidden motive to not succeed, or to succeed in a way in which they benefit. They may get a self-esteem boost, for example, or receive respected rescue status, or derive enjoyment by having someone depend on them and trust them and act in a way that ostensibly seems to be trying to help, but at a deeper level plays upon the victim in order to continue getting a payoff.
The relationship between the victim and the rescuer may be one of co-dependency. The rescuer keeps the victim dependent by encouraging their victimhood. The victim gets their needs met by having the rescuer take care of them.
Participants generally tend to have a primary or habitual role (victim, rescuer, persecutor) when they enter into drama triangles. Participants first learn their habitual role in their family of origin. Even though participants each have a role with which they most identify, once on the triangle, participants rotate through all the three positions.
Each triangle has a “payoff” for those playing it. The “antithesis” of a drama triangle lies in discovering how to deprive the actors of their payoff.
Through popular usage and the work of Karpman and others, Karpman’s triangle has been adapted for use in structural analysis and transactional analysis.
Family Therapy Movement
After World War II, therapists observed that while many battle-torn veteran patients readjusted well after returning to their families, some patients did not; some even regressed when they returned to their home environment. Researchers felt that they needed an explanation for this and began to explore the dynamics of family life – and thus began the family therapy movement. Prior to this time, psychiatrists and psychoanalysts focused on the patient’s already-developed psyche and downplayed outside detractors. Intrinsic factors were addressed and extrinsic reactions were considered as emanating from forces within the person.
In the 1950s, Eric Berne developed transactional analysis, a method for studying interactions between individuals. This approach was profoundly different than that of Freud. While Freud relied on asking patients about themselves, Berne felt that a therapist could learn by observing what was communicated (words, body language, facial expressions) in a transaction. So instead of directly asking the patient questions, Berne would frequently observe the patient in a group setting, noting all of the transactions that occurred between the patient and other individuals.
The theory of triangulation was originally published in 1966 by Murray Bowen as one of eight parts of Bowen’s family systems theory. Murray Bowen, a pioneer in family systems theory, began his early work with schizophrenics at the Menninger Clinic, from 1946 to 1954. Triangulation is the “process whereby a two-party relationship that is experiencing tension will naturally involve third parties to reduce tension”. Simply put, when people find themselves in conflict with another person, they will reach out to a third person. The resulting triangle is more comfortable as it can hold much more tension because the tension is being shifted around three people instead of two.
Bowen studied the dyad of the mother and her schizophrenic child while he had them both living in a research unit at the Menninger clinic. Bowen then moved to the National Institute of Mental Health (NIMH), where he resided from 1954 to 1959. At the NIMH Bowen extended his hypothesis to include the father-mother-child triad. Bowen considered differentiation and triangles the crux of his theory, Bowen Family Systems Theory. Bowen intentionally used the word triangle rather than triad. In Bowen Family Systems Theory, the triangle is an essential part of the relationship.
Couples left to their own resources oscillate between closeness and distance. Two people having this imbalance often have difficulty resolving it by themselves. To stabilise the relationship, the couple often seek the aid of a third party to help re-establish closeness. A triangle is the smallest possible relationship system that can restore balance in a time of stress. The third person assumes an outside position. In periods of stress, the outside position is the most comfortable and desired position. The inside position is plagued by anxiety, along with its emotional closeness. The outsider serves to preserve the inside couple’s relationship. Bowen noted that not all triangles are constructive – some are destructive.
In 1968, Nathan Ackerman conceptualised a destructive triangle. Ackerman stated “we observe certain constellations of family interactions which we have epitomised as the pattern of family interdependence, roles those of destroyer or persecutor, the victim of the scapegoating attack, and the family healer or the family doctor. Ackerman also recognise the pattern of attack, defence, and counterattack, as shifting roles.
Karpman Triangle and Eric Berne
In 1968, Stephen Karpman, who had an interest in acting and was a member of the Screen Actors Guild, chose “drama triangle” rather than “conflict triangle” as, here, the Victim in his model is not intended to represent an actual victim, but rather someone feeling or acting like one. He first published his theory in an article entitled “Fairy Tales and Script Drama Analysis”. His article, in part, examined the fairy tale “Little Red Riding Hood” to illustrate its points. Karpman was, at the time, a recent graduate of Duke University School of Medicine and was doing post post-graduate studies under Berne. Berne, who founded the field transactional analysis, encouraged Karpman to publish what Berne referred to as “Karpman’s triangle”. Karpman’s article was published in 1968. In 1972, Karpman received the Eric Berne Memorial Scientific Award for the work.
Eric Berne, a Canadian-born psychiatrist, created the theory of transactional analysis, in the middle of the 20th century, as a way of explaining human behaviour. Berne’s theory of transactional analysis was based on the ideas of Freud but was distinctly different. Freudian psychotherapists focused on talk therapy as a way of gaining insight to their patients’ personalities. Berne believed that insight could be better discovered by analysing patients’ social transactions.
Games in transactional analysis refers to a series of transactions that is complementary (reciprocal), ulterior, and proceeds towards a predictable outcome. In this context, the Karpman Drama Triangle is a “game”.
Games are often characterised by a switch in roles of players towards the end. The number of players may vary. Games in this sense are devices used (often unconsciously) by people to create a circumstance where they can justifiably feel certain resulting feelings (such as anger or superiority) or justifiably take or avoid taking certain actions where their own inner wishes differ from societal expectations. They are always a substitute for a more genuine and full adult emotion and response which would be more appropriate. Three quantitative variables are often useful to consider for games:
“The ability of the players to change the currency of the game (that is, the tools they use to play it).
“Some games…can be played properly with only one kind of currency, while others, such as exhibitionistic games, are more flexible”, so that players may shift from words, to money, to parts of the body.
“Some people give up their games easily, others are more persistent”, referring to the way people stick to their games and their resistance to breaking with them.
“Some people play their games in a relaxed way, others are more tense and aggressive.
Games so played are known as easy and hard games, respectively”, the latter being played in a tense and aggressive way.
The consequences of games may vary from small paybacks to paybacks built up over a long period to a major level. Based on the degree of acceptability and potential harm, games are classified into three categories, representing first degree games, second degree games, and third degree games:
Undesirable but not irreversibly damaging.
May result in drastic harm.
The Karpman triangle was an adaptation of a model that was originally conceived to analyse the play-action pass and the draw play in American football and later adapted as a way to analyse movie scripts. Karpman is reported to have doodled thirty or more diagram types before settling on the triangle. Karpman credits the movie Valley of the Dolls as being a testbed for refining the model into what Berne coined as the Karpman Drama Triangle.
Karpman now has many variables of the Karpman triangle in his fully developed theory, besides role switches. These include space switches (private-public, open-closed, near-far) which precede, cause, or follow role switches, and script velocity (number of role switches in a given unit of time). These include the Question Mark triangle, False Perception triangle, Double Bind triangle, The Indecision triangle, the Vicious Cycle triangle, Trapping triangle, Escape triangle, Triangles of Oppression, and Triangles of Liberation, Switching in the triangle, and the Alcoholic Family triangle.
While transactional analysis is the method for studying interactions between individuals, one researcher postulates that drama-based leaders can instil an organisational culture of drama. Persecutors are more likely to be in leadership positions and a persecutor culture goes hand in hand with cutthroat competition, fear, blaming, manipulation, high turnover and an increased risk of lawsuits. There are also victim cultures which can lead to low morale and low engagement as well as an avoidance of conflict, and rescuer cultures which can be characterised as having a high dependence on the leader, low initiative and low innovation.
The Winner’s Triangle was published by Acey Choy in 1990 as a therapeutic model for showing patients how to alter social transactions when entering a triangle at any of the three entry points. Choy recommends that anyone feeling like a victim think more in terms of being vulnerable and caring, that anyone cast as a persecutor adopt an assertive posture, and anyone recruited to be a rescuer should react by being “caring”.
Vulnerable: A victim should be encouraged to accept their vulnerability, problem solve, and be more self-aware.
Assertive: A persecutor should be encouraged to ask for what they want, be assertive, but not be punishing.
Caring: A rescuer should be encouraged to show concern and be caring, but not over-reach and problem solve for others.
The Power of TED, first published in 2009, recommends that the “victim” adopt the alternative role of creator, view the persecutor as a challenger, and enlist a coach instead of a rescuer.
Victims are encouraged to be outcome-oriented as opposed to problem-oriented and take responsibility for choosing their response to life challenges.
They should focus on resolving “dynamic tension” (the difference between current reality and the envisioned goal or outcome) by taking incremental steps toward the outcomes he or she is trying to achieve.
A victim is encouraged to see a persecutor as a person (or situation) that forces the creator to clarify his or her needs, and focus on their learning and growth.
A rescuer should be encouraged to ask questions that are intended to help the individual to make informed choices.
The key difference between a rescuer and a coach is that the coach sees the creator as capable of making choices and of solving his or her own problems.
A coach asks questions that enable the creator to see the possibilities for positive action, and to focus on what he or she does want instead of what he or she does not want.
Do you know the difference between anxiety and stress? What can you do when you have a panic attack? How do you know when it is time to get help?
Anxiety is a mental health crisis that has gripped over three crore Indians. In Anxiety: Overcome It and Live without Fear, clinical psychologist Sonali Gupta delves into the condition, using case studies to identify how anxiety can be triggered at work, in relationships, and by social media. Gupta shares a unique glimpse into this mental health condition in India, especially among Gen Z and millennials.
Recommending strategies and techniques for anxiety-prone readers, this book will help you confront your fears and take control of your life.
Author(s): Freddy Jackson Brown and Duncan Gillard.
Edition: First (1st).
Do you want to change your relationship with painful thoughts and feelings that are holding you back from making changes to improve your life?
In this book, you will discover how to identify negative and unhealthy modes of thinking and apply Acceptance and Commitment Therapy (ACT) principles throughout your day-to-day life, creating a healthier, richer and more meaningful existence with yourself and others.
Psychological interventions for antisocial personality disorder.
Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).
Therefore the purpose of this review was to evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.
The researchers searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. They also searched reference lists and contacted study authors to identify studies.
Selection criteria concisted of randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.
Data collection and analysis consisted of standard methodological procedures expected by Cochrane.
This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called ‘standard Maintenance'(SM) in some studies).
Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants.
Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks).
Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention.
One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence).
One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. ‘Driving whilst intoxicated’ programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months.
Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19).
The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU.
Psychosocial risk management (PSRM; ‘Resettle’) versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).
There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour.
Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.
Gibbon, S., Khalifa, N.R., Cheung, N.H-Y., Vollm, B.A. & McCarthy, L. (2020) Psychological interventions for antisocial personality disorder. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007668.pub3.
Ferment – A Memoir of Mental Illness, Redemption, and Winemaking in the Mosel.
Author(s): Patrick Dobson.
Edition: First (1st).
Publisher: Skyhorse Publishing.
Type(s): Hardcover and Kindle.
A deeply moving account of one man’s return to the German town where he first pursued a career in winemaking, and his attempt to reckon with the mental illness, alcoholism, and enduring relationships that defined the most formative chapter of his life.
After an attempted suicide by hanging – with his son in the next room – author Patrick Dobson checks into a mental hospital, clueless, reeling from bone-crushing depression and tortuous, racing thoughts. A long overdue diagnosis of manic depression offers relief but brings his confused and eventful past into question.
To make sense of his suicide attempt and deal with his past, he returns to Germany where, three decades earlier, he arrived as twenty-two-year-old – lost, drunk, and in the throes of untreated mental illness – in search of a new life and with dreams of becoming a winemaker. The sublime Mosel vineyards and the ancient city of Trier changed his life forever.
Ferment charts his days in Trier’s vineyards and cellars, and the enduring friendships that would define his life. A winemaker and his wife become like parents to him. In their son, he finds a brother, whose death years later sends Dobson into a suicidal tailspin. His friends, once apprentices like himself, become leaders in their fields: an art historian and church-restoration expert, an art- and architectural-glass craftsman, a painter and photographer, and a theologian/journalist. The relationships he builds with them become hallmarks of a life well-lived.
In Ferment, Dobson reconnects with the people who stood by him through his dissolution and eventual recovery. In these relationships, he seeks who he was and how his time in Germany changed him. He peers into his memory to understand how manic depression and alcoholism affected who he was then and how his time in Germany made him who he’s become.
The ACOA Trauma Syndrome: The The Impact of Childhood Pain on Adult Relationships.
Author(s): Tian Dayton.
Edition: First (1st).
Publisher: Health Communications.
Type(s): Paperback and Audiobook.
The ACoA syndrome is a post-traumatic stress reaction in which pain from the stress of growing up with parental addiction emerges years even decades later in adult relationships.
Adult Children of Alcoholics suffer from a post-traumatic stress created by their dysfunctional family situations.
Through insightful analysis and thoughtful examination, bestselling author and renowned psychologist Tian Dayton shows ACoAs how and why this family trauma has such a profound effect on adult relationships and provides the tools for marshalling resilience and restoring health and happiness.
Dr. Dayton explores how our brains and bodies process childhood trauma and how those traumas can become the catalyst for unhealthy, self-medicating behaviours including drug and alcohol abuse, food issues, and sex, gambling, and shopping addictions.
Readers who have experienced previous trauma will learn how they developed PTSD and how they can heal both personally and interpersonally.
When Someone You Know Has Depression – Words to Say and Things to Do.
Author(s): Susan J Noonan M.D. MPH.
Edition: First (1ed).
Publisher: John Hopkins University Press (JHUP).
Type(s): Paperback, Audiobook, and Kindle.
Mood disorders such as depression and bipolar disorder can be devastating to the person who has the disorder and to his or her family. Depression and bipolar disorder affect every aspect of how a person functions, including their thoughts, feelings, actions, and relationships with other people. Family members and close friends are often the first to recognise the subtle changes and symptoms of depression. They are also the ones who provide daily support to their relative or friend, often at great personal cost. They need to know what to say or do to cope with the person’s impaired thinking and fluctuating moods.
In When Someone You Know Has Depression, Dr. Susan J. Noonan draws on first-hand experience of the illness and evidence-based medical information. As a physician she has treated, supported, and educated those living with – and those caring for – a person who has a mood disorder. She also has lived through the depths of her own mood disorder. Here, she has written a concise and practical guide to caring fevor someone who has depression or bipolar disorder. This compassionate book offers specific suggestions for what to say, how to encourage, and how to act around a loved one – as well as when to back off.
Dr Noonan describes effective communication strategies to use during episodes of depression and offers essential advice for finding appropriate professional help. She also explains how to reinforce progress made in therapy, how to model resilience skills, and how caregivers can and must care for themselves. Featuring tables and worksheets that convey information in an accessible way, as well as references, resources, and a glossary, this companion volume to Dr. Noonan’s patient-oriented Managing Your Depression is an invaluable handbook for readers navigating and working to improve the depression of someone close to them.