What is Journal Therapy?

Introduction

Journal therapy is a writing therapy focusing on the writer’s internal experiences, thoughts and feelings. This kind of therapy uses reflective writing enabling the writer to gain mental and emotional clarity, validate experiences and come to a deeper understanding of themself. Journal therapy can also be used to express difficult material or access previously inaccessible materials.

Like other forms of therapy, journal therapy can be used to heal a writer’s emotional or physical problems or work through a trauma, such as an illness, addiction, or relationship problems, among others. Journal therapy can supplement an on-going therapy, or can take place in group therapy or self-directed therapy.

Brief History

Ira Progoff created the intensive journal writing programme in 1966 in New York. The intensive journal method is a structured way of writing about nature that allows the writer to achieve spiritual and personal growth. This method consists of a three-ring, loose-leaf binder with four colour-coded sections: lifetime dimension, dialogue dimension, depth dimension and meaning dimension. These sections are divided into several subsections. Some of these subsections include topics like career, dreams, body and health, interests, events and meaning in life. Progoff created the intensive journal so that working in one part of the journal would in turn stimulate one to work on another part of the journal, leading to different viewpoints, awareness and connections between subjects. The intensive journal method began with recording the session in a daily log.

The field of journal therapy reached a wider audience in the 1970s with the publication of three books, namely, Progoff’s At a Journal Workshop (1978), Christina Baldwin’s One to One: Self-Understanding Through Journal Writing (1977) and Tristine Rainer’s The New Diary (1978).

In 1985, psychotherapist and journal therapy pioneer, Kathleen Adams, started providing journal workshops, designed as a self-discovery process.

In the 1990s, James W. Pennebaker published multiple studies which affirmed that writing about emotional problems or traumas led to both physical and mental health benefits. These studies drew more attention to the benefits of writing as a therapy.

In the 2000s, journal therapy workshops were conducted at the Progoff’s Dialogue House, Adams’ Centre for Journal Therapy and certificates were given through educational institutions. Generally, journal therapists obtain an advanced degree in psychology, counselling, social work, or another field and then enter a credentialing programme or independent-study programme.

Effects

Journal therapy is a form of expressive therapy used to help writers better understand life’s issues and how they can cope with these issues or fix them. The benefits of expressive writing include long-term health benefits such as better self-reported physical and emotional health, improved immune system, liver and lung functioning, improved memory, reduced blood pressure, fewer days in hospital, fewer stress-related doctor visits, improved mood and greater psychological well-being. Other therapeutic effects of journal therapy include the expression of feelings, which can lead to greater self-awareness and acceptance and can in turn allow the writer to create a relationship with his or herself. The short-term effects of expressive writing include increased distress and psychological arousal.

Practice

Many psychotherapists incorporate journal “homework” in their therapy but few specialise in journal therapy. Journal therapy often begins with the client writing a paragraph or two at the beginning of a session. These paragraphs would reflect how the client is feeling or what is happening in his or her life and would set the direction of the session. Journal therapy then works to guide the client through different writing exercises. Subsequently, the therapist and the client then discuss the information revealed in the journal. In this method, the therapist often assigns journal “homework” that is to be completed by the next session. Journal therapy can also be provided to groups.

Techniques

Journal therapy consists of many techniques or writing exercises. In all journal therapy techniques, the writer is encouraged to date everything, write quickly, keep writings and always tell the complete truth. Some of the journal therapy techniques are as follows:

TechniqueOutline
SprintCatharsis is encouraged by allowing a writer to write about anything for a designated period, such as for five minutes or for ten minutes.
ListsThe writer writes any number of connected items in order to help prioritize and organize.
Captured MomentsWriter attempts to completely describe the essence and emotional experience of a memory.
Unsent LettersThis attempts to silence a writer’s internal censor; it can be used in a grieving process or to get over traumas, such as sexual abuse.
DialogueThe writer creates both sides to a conversation involving anything, including but not limited to, people, the body, events, situations, time etc.
FeedbackImportant to journal therapy as feedback makes the writer be aware of his or her feelings; it also allows the writer to acknowledge, accept and reflect on what they he/she has written before (thoughts, feelings, etc.).

Setting

A quiet and private environment must be created and provided throughout the entire journal writing process. This environment should contain features or elements that can make the writer feel good such as music, candles, a hot drink etc. This environment works to empower the writer and for him/her to associate good feelings with journal writing. To transition into writing, a journal writing session can be started with a drawing or sketch. After journal writing, something active should be done, such as running, walking, stretching, breathing etc. or something that is enjoyable like taking a bubble bath, baking cookies, listening to music, talking to someone, etc.

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What is Writing Therapy?

Introduction

Writing therapy is a form of expressive therapy that uses the act of writing and processing the written word as therapy. Writing therapy posits that writing one’s feelings gradually eases feelings of emotional trauma. Writing therapeutically can take place individually or in a group and it can be administered in person with a therapist or remotely through mailing or the Internet.

The field of writing therapy includes many practitioners in a variety of settings. The therapy is usually administered by a therapist or counsellor. Several interventions exist online. Writing group leaders also work in hospitals with patients dealing with mental and physical illnesses. In university departments they aid student self-awareness and self-development. When administered at a distance, it is useful for those who prefer to remain personally anonymous and are not ready to disclose their most private thoughts and anxieties in a face-to-face situation.

As with most forms of therapy, writing therapy is adapted and used to work with a wide range of psychoneurotic issues, including bereavement, desertion and abuse. Many of these interventions take the form of classes where clients write on specific themes chosen by their therapist or counsellor. Assignments may include writing unsent letters to selected individuals, alive or dead, followed by imagined replies from the recipient, or a dialogue with the recovering alcoholic’s bottle of alcohol.

Research into the Therapeutic Action of Writing

The Expressive Writing Paradigm

Expressive writing is a form of writing therapy developed primarily by James W. Pennebaker in the late 1980s. The seminal expressive writing study instructed participants in the experimental group to write about a ‘past trauma’, expressing their very deepest thoughts and feelings surrounding it. In contrast, control participants were asked to write as objectively and factually as possible about neutral topics (e.g. a particular room or their plans for the day), without revealing their emotions or opinions. For both groups, the timescale was 15 minutes of continuous writing repeated over four consecutive days. It was also instructed that should a participant run out of things to write, they should go back to the beginning and repeat themselves, perhaps writing a little differently.

Typical writing instructions include:

For the next 4 days, I would like you to write your very deepest thoughts and feelings about the most traumatic experience of your entire life or an extremely important emotional issue that has affected you and your life. In your writing, I’d like you to really let go and explore your deepest emotions and thoughts. You might tie your topic to your relationships with others, including parents, lovers, friends, or relatives; to your past, your present or your future; or to who you have been, who you would like to be or who you are now. You may write about the same general issues or experiences on all days of writing or about different topics each day. All of your writing will be completely confidential.

Don’t worry about spelling, grammar or sentence structure. The only rule is that once you begin writing, you continue until the time is up.

Several measurements were made before and after, but the most striking finding was that relative to the control group, the experimental group made significantly fewer visits to a physician in the following months. Although many report being upset by the writing experience, they also find it valuable and meaningful.

Pennebaker has either written or co-written over 130 articles on expressive writing. One of these suggested that expressive writing has the potential to actually ‘boost’ the immune system, perhaps explaining the reduction in physician visits. This was shown by measuring lymphocyte response to the foreign mitogens phytohaemagglutinin (PHA) and concanavalin A (ConA) just prior to and 6 weeks after writing. The significantly increased lymphocyte response led to speculation that expressive writing enhances immunocompetence. The results of a preliminary study of 40 people diagnosed with Major Depressive Disorder suggests that routinely engaging in expressive writing may be effective in reducing symptoms of depression.

Reception and Criticism of Pennebaker’s Expressive Writing Theories

Pennebaker’s experiments, begun over twenty years ago, have been widely replicated and validated. Following on from Pennebaker’s original work, there has been a renewed interest in the therapeutic value of abreaction. This was first discussed by Josef Breuer and Freud in Studies on Hysteria but not much explored since. At the heart of Pennebaker’s theory is the idea that actively inhibiting thoughts and feelings about traumatic events requires effort, serves as a cumulative stressor on the body, and is associated with increased physiological activity, obsessive thinking or ruminating about the event, and longer-term disease. However, as Baikie and Wilhelm note, the theory has intuitive appeal but mixed empirical support:

Studies have shown that expressive writing results in significant improvements in various biochemical markers of physical and immune functioning (Pennebaker et al, 1988; Esterling et al, 1994; Petrie et al, 1995; Booth et al, 1997). This suggests that written disclosure may reduce the physiological stress on the body caused by inhibition, although it does not necessarily mean that disinhibition is the causal mechanism underlying these biological effects. On the other hand, participants writing about previously undisclosed traumas showed no differences in health outcomes from those writing about previously disclosed traumas (Greenberg & Stone, 1992) and participants writing about imaginary traumas that they had not actually experienced, and therefore could not have inhibited, also demonstrated significant improvements in physical health (Greenberg et al, 1996). Therefore, although inhibition may play a part, the observed benefits of writing are not entirely due to reductions in inhibition.

In a 2013 article by Nazarian and Smyth, writing instructions for the expressive writing task were manipulated – in that 6 conditions were created – i.e. cognitive-processing, exposure, self-regulation, and benefit-finding, standard expressive writing and a control group. While salivary cortisol was measured for each condition, none of the conditions significantly influenced cortisol, but instructions did impact mood differentially depending on the condition. For example, the cognitive-processing as measured post-intervention were influenced not only by the cognitive processing instructions but also by exposure and benefit-finding. These results demonstrate a spill-over effect from instructions to outcomes. In related research Travagin, Margola, Dennis and Revenson cognitive-processing instructions were compared to standard expressive writing for adolescents with peer problems and this research demonstrated better long-term social adjustment compared to standard expressive writing and greater increased positive affect for those adolescents who reported more peer problems than most.

Other Theories Related to Writing Therapy

An additional line of enquiry, which has particular bearing on the difference between talking and writing, derives from Robert Ornstein’s studies into the bicameral structure of the brain. While noting that what follows should be considered “wildly hypothetical”, L’Abate, quoting Ornstein, postulates that:

One could argue … that talk, and writing differ in relative cerebral dominance. … if language is more related to the right hemisphere, then writing may be more related to the left hemisphere. If this is the case, then writing might use or even stimulate parts of the brain that are not stimulated by talking.

Julie Gray, founder of Stories Without Borders notes that “People who have experienced trauma in their lives, whether or not they consider themselves writers, can benefit from creating narratives out of their stories. It is helpful to write it down, in other words, in safety and in non-judgement. Trauma can be quite isolating. Those who have suffered need to understand how they feel and also to try to communicate that to others.”

Clinical Implications of Writing Therapy

Additional research since the 1980s has demonstrated that expressive writing may act as an agent to increase long-term health. Expressive writing can result in physiological, psychological, and biological outcomes, and is part of the emerging medical humanities field. Experiments demonstrate quantitative physiological readout such as changes in immune counts, blood pressure, in addition to qualitative readouts relating to psychiatric symptoms. Past attempts at implementing expressive writing interventions in clinical settings indicate that there are potential benefits for treatment plans. However, the specifics of such expressive writing procedures or protocols, and the populations most likely to benefit are not entirely clear.

Potential Benefits of Expressive Writing

One of the most important aspects of expressive writing used in therapy is the short-term, and long-term effects on the individuals participating. Karen Baikie and Kay Wilhelm go into a brief description of the effects people will have after completing a therapeutic expressive writing session.

The short-term effects after utilising this form of therapy are usually a quick span of feeling distress or being in a negative mood. However, following up with clients after a longer amount of time to measure those effects finds evidence of many mental and physical health benefits.

These benefits include but are not limited to: “Reduced blood pressure, improved mood, reduced depressive symptoms, and fewer post-traumatic intrusion/avoidance symptoms.”

This study also showed that these positive long-term emotional outcomes correlated to positive physical outcomes such as: improved memory, improved performance at work, quicker re-employment and many more. While the short-term effects of this therapeutic practice may seem daunting, in reality they are just the steppingstones for individuals to begin a cycle of growth.

Potential Benefits for Cancer Patients

Illness and disease are experienced on multiple different fronts: biological, psychological, and social. Recent research has explored how narrative medicine and expressive writing, independently, may play a therapeutic role in chronic diseases such as cancer. Comparisons in practice have been made between expressive writing and psychotherapy. Similarly, practices such as: integrative, holistic, humanistic or complementary medicine have already been incorporated into the field. Expressive writing is self-administered with minimal prompting. With further research and refinement, it may be used as a more cost effective alternative to psychotherapy.

Recent experiments, systematic reviews, and meta-analyses examining the effects of expressive writing on ameliorating negative cancer symptoms yielded primarily non-significant initial results. However, analysis of sub-groups and moderating variables suggest that particular symptoms, or situations, may benefit some more than others with the implementation of an expressive writing intervention. For example, a review by Antoni and Dhabhar (2019) examined how psychosocial stress negatively impacts the immune response of patients with cancer. Even if an expressive writing intervention cannot directly impact cancer prognosis, it may play an important role in mediating factors such as chronic stress, trauma, depression, and anxiety.

Potential Benefits for Individuals Recovering from Addiction

The impact of writing therapy for those struggling with addiction plays a significant role in their recovery treatment. Writing exercises – even simple ones such as poetry or stories – have the potential to improve those in addiction recovery the ability to cope with their conditions, and overall health. This activity has not only been linked to alleviate the symptoms related to mental health disorders, but also provides those in recovery the chance to improve their emotional wellbeing by undergoing a therapeutic release of thoughts and feelings such as sadness, anger, guilt, and improving their self-awareness.

The Role of the Distance Therapies

With the accessibility provided by the Internet, the reach of the writing therapies has increased considerably, as clients and therapists can work together from anywhere in the world, provided they can write the same language. They simply “enter” into a private “chat room” and engage in an ongoing text dialogue in “real time”. Participants can also receive therapy sessions via e-text and/or voice with video, and complete online questionnaires, handouts, workout sheets and similar exercises.

This requires the services of a counsellor or therapist, albeit sitting at a computer. Given the huge disjunction between the amount of mental illness compared with the paucity of skilled resources, new ways have been sought to provide therapy other than drugs. In the more advanced societies pressure for cost-effective treatments, supported by evidence-based results, has come from both insurance companies and government agencies. Hence the decline in long term intensive psychoanalysis and the rise of much briefer forms, such as cognitive therapy.

Via the Internet

Currently, the most widely used mode of Internet writing therapy is via e-mail (see analytic psychotherapist Nathan Field’s paper “The Therapeutic Action of Writing in Self-Disclosure and Self-Expression”). It is asynchronous; i.e. messages are passed between therapist and client within an agreed time frame (for instance, one week), but at any time within that week. Where both parties remain anonymous the client benefits from the online disinhibition effect; that is to say, feels freer to disclose memories, thoughts and feelings that they might withhold in a face-to-face situation. Both client and therapist have time for reflecting on the past and recapturing forgotten memories, time for privately processing their reactions and giving thought to their own responses. With e-therapy, space is eliminated, and time expanded. Overall, it considerably reduces the amount of therapeutic input, as well as the speed and pressure that therapists habitually have to work under.

The anonymity and invisibility provides a therapeutic environment that comes much closer than classical analysis to Freud’s ideal of the “analytic blank screen”. Sitting behind the patient on the couch still leaves room for a multitude of clues to the analyst’s individuality; e-therapy provides almost none. Whether distance and reciprocal anonymity reduces or increases the level of transference has yet to be investigated.

In a 2016 randomised controlled trial, expressive writing was tested against direction to an online support group for individuals with anxiety and depression. No difference between the groups was found. Both groups showed a moderate improvement over time, but of a magnitude comparable to what one would expect to see over the time period concerned without intervention.

Journaling

The oldest and most widely practiced form of self-help through writing is that of keeping a personal journal or diary – as distinct from a diary or calendar of daily appointments – in which the writer records their most meaningful thoughts and feelings. One individual benefit is that the act of writing puts a powerful brake on the torment of endlessly repeating troubled thoughts to which everyone is prone. Kathleen Adams states that through the act of journal writing, the writer is also able to “literally [read] his or her own mind” and thus “to perceive experiences more clearly and thus feels a relief of tension”.

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What is Neutrality (in Psychoanalysis)?

Introduction

Neutrality is an essential part of the analyst’s attitude during treatment,  developed as part of the non-directive, evenly suspended listening which Freud used to complement the patient’s free association in the talking cure.

Refer to Psychoanalysis.

Early Development

In the Little Hans case study of 1909, Freud criticised the boy’s father (the prime ‘analyst’): “He asks too much and investigates in accord with his own presuppositions instead of letting the little boy express himself”.  In 1912 he laid down the mirror rule, that the analyst should not reciprocate the patient’s confidences, but only reflect back what they themselves contained.  In 1915 he introduced the term neutrality, warning especially against too great eagerness to cure; and in 1919 he wrote against offering guidance or counselling – synthesis as opposed to analysis – as to what form the patient’s cure should take.

Freud’s guidelines, especially with regard to the bracketing of ethical judgements, and personal disclosures, rapidly became accepted in the psychoanalytic mainstream,  as did the need to respect the patient’s speech and not impose preconceptions on it.

Transference

The principle of neutrality took on especial force as regards manifestations of transference, particularly given the strength of the emotions aroused thereby. Neutrality meant resisting the natural impulse to reciprocate affects, so as to remain in a position to analyse the transference, not respond to it.

Deviations and Criticisms

Freud’s analytic practice was noticeably less austere than the principles of neutrality he laid down: he would argue with, praise, and lend money to patients, and even records feeding the Rat Man on one occasion. However the first theoretical challenge to Freud’s concept came from Sándor Ferenczi, who saw the analyst’s attitude of non-disclosure in particular as part of the problem not the solution. Others would subsequently expand on Ferenczi’s points, Nina Coltart for example suspecting the “austere and benevolently neutral manner which we hold as our working ideal” and stressing that “we can do no harm to a patient by showing authentic affect”.

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What are Expressive Therapies?

Introduction

The expressive therapies are the use of the creative arts as a form of therapy, including the distinct disciplines expressive arts therapy and the creative arts therapies (art therapy, dance/movement therapy, drama therapy, music therapy, writing therapy, poetry therapy, and psychodrama).

Unlike traditional arts expression, the process of creation is emphasized rather than the final product. The expressive therapies are based on the assumption that people can heal through the various forms of creative expression. Expressive therapists share the belief that through creative expression and the tapping of the imagination, people can examine their body, feelings, emotions, and thought process.

Brief History

Margaret Namburg, Edith Kramer, Hanna Kwiatkowska and Elinor Ulman have been credited with being the pioneers of the field of sensory art therapy. While all of these scientists made significant contributions, Margaret Namburg has been hailed the “Mother of Art Therapy”. Her work focused on the use of art, mainly as a psychoanalytic diagnostic tool. It followed closely other psychoanalytic practices of the time, and was viewed as the communication of unconscious ideas and emotions that were being expressed by the patient.

Modern Approaches

Today’s art therapy is broken down into three different approaches:

ApproachOutline
PsychodynamicThe psychodynamic approach uses terms such as “transference” and defence mechanism to describe why individuals express the art in the way they do, and why this is an expression of the subconscious.
HumanisticThe humanistic approach is more of a positive psychology approach, and is defined by an optimistic view of humans, and how expression through their art allows them to take control over these emotions.
Learning and DevelopmentThe learning and developmental approach focuses on the art therapy as a method to assist children who have emotional and developmental disabilities.

Definition and Credentialing

Expressive arts therapy is the practice of using imagery, storytelling, dance, music, drama, poetry, movement, horticulture, dreamwork, and visual arts together, in an integrated way, to foster human growth, development, and healing. Expressive arts therapy is its own distinct therapeutic discipline, an inter-modal discipline where the therapist and client move freely between drawing, dancing, music, drama, and poetry.

According to the National Organisation for Arts in Health (NOAH), what distinguishes the six creative arts therapies – art, dance/movement, drama, music and poetry therapy as well as psychodrama – from expressive arts therapy is that expressive arts therapy interventions are designed to include more than one of the “expressive” art forms (art, dance, drama, music, poetry), whereas creative arts therapists, such as art, dance/movement, drama, music, poetry and psychodrama therapists, are often intensively trained and educated to use only one modality in their practice. However, NOAH also acknowledged that the terms “are often used interchangeably in the field”, and that in any case all such professionals should collaborate closely. 

The International Expressive Arts Therapy Association (IEATA) is the responsible organisation handling the credentialing of expressive arts therapists.

The National Coalition of Creative Arts Therapies Association (NCCATA) connects all six modalities of the creative arts therapies. However, each modality of the creative arts therapies has its own national association that regulates professional credentials, establishes educational standards and hosts annual conferences for the purpose of exchanging new ideas and research.

Education

Each national association of the different modalities of expressive therapies sets its own educational standards. In the United States, there are a fair number of colleges that offer approved programmes in compliance with the national associations’ credentialing requirements.

There are 37 universities for music therapy, 34 universities for art therapy, seven universities for dance/movement therapy, and five universities for drama therapy, as well as 5 universities for expressive arts therapy, that have approved master’s degree programmes in the United States. In addition, the American Music Therapy Association (AMTA) has 75 undergraduate music therapy programmes approved. Once finished with an academic degree, potential therapists have to apply for credentialing at the responsible national association.

Creative Arts Therapies Modalities

There are six creative arts therapy modalities, recognised by the NCCATA, including art therapy, dance therapy, drama therapy, music therapy, poetry therapy and psychodrama. In some areas, the terms Creative Arts Therapy and Creative Arts Therapist may only be used by those who are properly licensed, as is the case in the State of New York.

Art Therapy

Created in the 1940s, Art therapy consists of the combination of psychotherapy and art. The creative process as well as the created art piece serves as a foundation for self-exploration, understanding, acceptance and eventually healing and personal growth. The creative act in therapy therefore can be seen as a means of re-experiencing inner conflict connected to resolution. The four main types are expression, imagination, active participation, and mind-body connection. Assisting in those with depression, breast cancer, and asthma, art therapy can be done at any age and does not require and skill set. Art Therapy has undergone extensive research which revealed that it decreases anxiety, increases self-concept and quality of life, and reduces negative thoughts. With two main goals in mind, Art Therapy strives to enhance personal and relational goals for those in need. Self-esteem, social skills, and cognitive functions are also said to be an area of importance. A certified art therapist is essential in order for the therapy to ensure improvement, however common art therapy using even a friend to discuss trauma can be enough to help someone.

Dance/Movement Therapy

Like other creative arts therapy modalities, dance/movement therapy is based on the assumption that “mind, body and spirit are inseparable and interconnected” (ADTA). Movement is the primary tool of intervention in a therapy session, but dance/movement therapy also uses the art of play in therapy. Like other creative art therapies it uses primarily nonverbal communication. Dance and movement therapy has shown to be the most beneficial in those who enjoy exercises that involve less talking an expression through movements.

Drama Therapy

Drama therapy refers to the combination of the two disciplines drama/theatre and psychotherapy. Drama Therapy, as a hybrid of both disciplines, uses theatre techniques to treat individuals with mental health, cognitive, and developmental disorders. Through the art of play and pretend, patients gain perspective in therapy to their life experiences, which in the field is referred to as “aesthetic distance”.

Music Therapy

Music Therapy is the use of music, music-making, or other music-related interventions within a therapeutic relationship. Music therapy is a broad field with many areas and populations to specialize in. A holistic practice, music therapy can address emotional/psychological, cognitive, communication, motor, sensory, pain, social, behavioural, end of life, and even spiritual needs. This is due in part to music being processed in many areas of the brain. Music therapy helps patients “communicate, process difficult experiences, and improve motor or cognitive functioning” (Jenni Rook, MT-BC, LCPC, 2016). When used as psychotherapy, at its core, music therapy may use music as a symbolic representation and expression of the psychological world of the individual.

Music Therapy also benefits a variety of disorders, like cardiac and mental disorders. It aids those who suffer from depression, anxiety, autism, substance abuse, and Alzheimer’s. In cases where a person is suffering from mental disorders, music relieves stress, improves self-esteem, etc. Evidence has shown that people who have used Music Therapy in the past have improved in several aspects of life that do not concern just those suffering from mental illness. In music therapy people may improve their singing which may then impact their ability to speak. Therefore, it can change several aspects of life, not just those of helping mental illness.

Poetry Therapy

Poetry therapy (also referred to using the broader term bibliotherapy) stands out from other creative arts therapies, which are all based on the assumption of the existence of a language that functions without words. Poetry therapy, however, is the use of the written word to bring healing and personal growth.

Psychodrama

Psychodrama is a distinct form of psychotherapy developed by Jacob L. Moreno in the early 20th century. Moreno, a trained psychoanalyst himself, had the goal of creating a more effective, action-based form of psychoanalysis as developed by Sigmund Freud and Carl Jung. He developed a clear three phase structure (warm up, action, sharing) to his therapy as well as multiple intervention-methods that are still used by psychodrama therapists today.

Although related, psychodrama and drama therapy describe different modalities within the field of creative arts therapies. Whereas psychodrama uses real-life experience of the patients in therapy to “practice new and more effective roles and behaviors” (ASGPP), drama therapy lets the patients explore more fictional stories, such as improvised scenes, myths or fairy tales.

Benefits

BenefitOutline
Self-DiscoveryThis discovery often leads to a relief of emotional tension caused by past events, and can be used as a coping mechanism.
EmpowermentArt therapy gives individuals the ability to articulate their fears and stresses in a non-conventional way, and often leads to sense of control over these emotions.
Stress ReliefEffective for stress relief by itself, but can provide even better results if paired with other relaxation devices such as guided imagery.
Physical Pain Relief and RehabilitationArt therapy has been shown to help decrease pain in patients who are recovering from illness and injury. It has also been used in patients who are chronically or terminally ill, to provide relief and pain control.

Empirical Evidence

Ball (2002)

Ball conducted long-term research on five children who were considered to be severely emotionally disturbed. These children participated in 50 art therapy sessions, and the results suggested that the art therapy was successful, and the children showed marked progress in their treatment over the course of the 50 sessions.

Pifalo (2006)

In this study, 41 girls or young women who had been sexually abused were given structured group art therapy for eight weeks, and were measured before treatment using the Briere’s Trauma Symptom Checklist for Children (TSCC). They were given the test again after the treatment, and for 9 out of 10 of the girls, a statistically significant reduction in scores on the test were observed.

Bar-Sela, Atid, Danos, Gabay & Epelbaum (2007)

This study worked with 60 adults who had cancer. These adults attended weekly individual art therapy, in addition to watercolour painting classes. After just four sessions, the experimental group saw marked and significant improvement in depression and fatigue, as measured by the Hospital Anxiety and Depression Scale and a brief fatigue inventory. While they showed a decrease in depression, there was no significant difference in the levels of anxiety of the patients.

Gusak (2006)

In this study, the researcher worked with 29 incarcerated men. The men attended eight sessions of group art therapy, and were tested before and after the treatment using the Beck Depression Inventory Short Form. After the eight sessions, all of the men showed significant improvement in the symptoms of depression and their score on the Beck Depression Inventory reflected these improvements.

Bulfone et al. (2009)

In this study Bulfone et al. utilised music therapy as their treatment. 60 women who had been diagnosed with stage 1 or 2 breast cancer were randomly assigned to a control or experimental group. The control group received standard assistance before chemotherapy, while the experimental group had the chance to listen to music before the chemotherapy began. The results showed that the anxiety levels of the experimental group were significantly lower than those of the control group, and also showed a significantly lower level of depression.

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What is Working Through?

Introduction

In psychodynamic psychotherapy, working through is seen as the process of repeating, elaborating, and amplifying interpretations. It is believed that such working through is critical towards the success of therapy.

The concept was introduced by Sigmund Freud in 1914, and assumed ever greater importance in psychoanalysis, in contrast to the immediacy of abreaction.

Interpretation and Resistance

Interpretations are made when the client comes up with some material, be it written, a piece of art, music, or verbal, and are intended to bring the material offered into connection with the unconscious mind. Because of the resistance to accepting the unconscious, interpretations, whether correct or partially incorrect, consciously accepted or rejected, will inevitably require amplifying and extending to other aspects of the client’s life.

In a process Sandor Rado compared to the labour of mourning, the unconscious content must be demonstrated repeatedly in all its various forms and linkages – the process of working through.

Because of the power of resistance, the client’s rational thought and conscious awareness may not be sufficient on their own to overcome the maladjustment, entailing further interpretation and further working through.

Rat Man

Before formulating the concept of working through, in his case study of the Rat Man, Freud wrote of his interpretations:

“It is never the aim of discussions like these to create convictions. They are only intended to bring the repressed complexes into consciousness…and to facilitate the emergence of fresh material from the unconscious. A sense of conviction is only attained after the patient has himself worked over the reclaimed material”.

Transference

The necessity of working through the transference is stressed in almost all forms of psychodynamic therapy, from object relations theory, through the openings offered for working through by transference disruption in self psychology, to the repetitive exploration of the transference in group therapy.

What is a Therapeutic Alliance?

Introduction

A therapeutic alliance, or working alliance, is a partnership between a patient and their therapist that allows them to achieve goals through agreed-upon tasks.

The concept of therapeutic alliance dates back to Sigmund Freud. Over the course of its evolution, the meaning of the therapeutic alliance has shifted both in form and implication. What started as an analytic construct has become, over the years, a transtheoretical formulation, an integrative variable, and a common factor.

Alliance as Analytic

In its analytic permutation, Freud suggested the importance of allowing for the patient to be a “collaborator” in the therapeutic process. In his writings on transference, Freud thought of the patient’s feelings towards the therapist as resembling the non-conflicted, trusting elements of early relationships with the patient’s parents, and that this could serve as the basis for collaboration in this way.

In later years, ego psychologists popularised a construct that they would relate to the reality-oriented adaptation of the ego to the environment. For certain ego psychologists, the construct refocused psychoanalytic thought away from a perceived overemphasis on transference and allowed space for greater technical flexibility across different psychotherapeutic modalities. It also called into question the idea of therapist as a tabula rasa, or blank screen, and turned away from the idealised therapist stance of abstinence and neutrality. Instead, it brought attention to the real, felt dimension of the therapeutic relationship, and made an argument for the therapist as being supportive and the patient as identifying with the therapist.

Alliance as Integrative

Edward Bordin reformulated the therapeutic alliance more broadly, namely beyond the scope of the psychodynamic perspective, as transtheoretical. He operationalised the construct into three interdependent parts:

  • The affective bond between the patient and therapist;
  • Their agreement on goals; and
  • Their agreement on tasks.

This conceptualisation preserved the earlier focus on the affective aspects of the alliance (i.e. bond), while also incorporating more cognitive dimensions as well (i.e. tasks and goals). Bordin’s work led to a desire among researchers to further develop ways to measure the alliance based on his initial operationalisation. Around this time there was a surge of interest in psychotherapy integration and psychotherapy research on the alliance.

Alliance as Intersubjective

Jeremy Safran and J. Christopher Muran, along with their colleagues Catherine F. Eubanks and Lisa Wallner Samstag, advanced a further reformulation of the alliance. They agreed with Bordin that at an explicit level, patient and therapist collaborate on specific tasks. However, on an implicit level, they are also negotiating specific desires derived from underlying needs.

In this regard, the authors invoked the motivational needs for agency (self-definition) and communion (relatedness), and the existential need for mutual recognition (to see another’s subjectivity and to have another see one’s own as the culmination of knowing one exists), to advance an intersubjective consideration.

The authors suggested ruptures invariably occur as result of the inherent tensions in the negotiation of these dialectical needs. They distinguished between withdrawal and confrontation rupture markers, interpersonal communications or behaviour by patient or therapist.

  • The former includes movements away from self or other: that is, movements towards isolation or appeasement, pursuits of communion at the expense of agency.
  • The latter includes movements against the other: that is, movements towards control or aggression, pursuits of agency at the expense of communion. They defined the repair of these ruptures as a critical change process.

Alliance in Psychotherapy Research

Beginning in the 1970s, the alliance construct became a primary focus of psychotherapy research. This can be attributed largely to Bordin’s reformulation, which led to the development of Working Alliance Inventory (WAI) and Lester Luborsky’s Penn Helping Alliance Questionnaire (HAq). The Vanderbilt Psychotherapy Process Scales and the California Psychotherapy Alliance Scales (CALPAS) were other noteworthy measures.

Christoph Flückiger, AC Del Re, Bruce Wampold, and Adam Horvath conducted a meta-analysis on the alliance in psychotherapy. The researchers synthesized 295 independent studies of over 30,000 patients published 1978-2017. Results confirmed a moderate relationship between alliance and psychotherapy outcome.

In addition, Eubanks, Muran, and Safran conducted two meta-analyses on rupture repair in the alliance. The first indicated a moderate relationship between rupture repair and outcome. The second examined the effect of an alliance-focused training on rupture repair. Results suggested some support for the effect of such training.

What is Andy’s Man Club?

Introduction

Andy’s Man Club is described as:

“a talking group, a place for men to come together in a safe environment to talk about issues and problems they have faced or are currently facing”.

Background

It was formed by Luke Ambler and his mother-in-law Elaine after his brother-in-law took his own life.

The club, with its slogan “it’s okay to talk”, started in early 2016 in Halifax with a first meeting of nine men. Since then, the group has expanded across the country and by February 2020 had over 800 men attending every week. Each group meeting is led by a volunteer “group facilitator” who has been trained by the organisation.

Other similar organisations have come to exist, some with a local focus and others with a national.

In 2021 they earned the Queens’s award for voluntary service.

Similar Charities

  • It’s tricky to talk.
  • Talk Club.
  • MenSpeak.
  • Men Walk Talk.
  • Proper Blokes Club.
  • It’s Worth Talking About.
  • Man-Down.

Locations

There are a variety of locations (as of November 2021):

  • Altrincham.
  • Batley.
  • Bradford.
  • Brighouse.
  • Dewsbury.
  • Doncaster.
  • Dundee.
  • Dunfermline.
  • Edinburgh.
  • Exeter.
  • Glenrothes.
  • Gosport.
  • Halifax Central.
  • Halifax North.
  • Hartlepool.
  • Hebden Bridge.
  • Huddersfield Ainley Top.
  • Huddersfield Central.
  • Hull Central.
  • Hull North.
  • Leeds East.
  • Leeds West.
  • Manchester.
  • Newton Abbot.
  • Oldham.
  • Perth.
  • Peterborough.
  • Plymouth.
  • Porthcawl.
  • Preston.
  • Rhondda.
  • Rochdale.
  • Rotherham.
  • Scarborough.
  • Sheffield.
  • Stafford.
  • St. Andrews.
  • Sunderland.
  • Torbay.
  • Wakefield.

What is Systems-Centred Therapy?

Introduction

Systems-centred therapy (SCT) is a particular form of group therapy based on the Theory of Living Human Systems developed by Yvonne Agazarian.

The theory postulates that living human systems survive, develop, and transform from simple to complex through discriminating and integrating information. Corresponding to the small and rigorously defined set of concepts, SCT defines a set of methods, techniques and instruments. SCT practitioners use these with individuals, couples and groups to explore the experience of their differences and work with these to integrate them. Using the method of functional subgrouping, these living human systems increase their ability to see both sides of their issues and resolve them productively. The theory was first developed in Agazarian’s 1997 book, Systems-Centred Therapy for Groups, and grew out of her earlier work in group psychotherapy under the influence of such figures as W.R. Bion and John Bowlby through the further input of the general systems theory of Ludwig von Bertalanffy.

SCT explains how living human systems contain their energy within functional boundaries and direct it towards their goals: the primary goals of survival and development and the secondary goals of environmental mastery. In SCT training groups, all members work in functional subgroups rather than work alone. Subgroups work both sides of every issue in the group-as-a-whole.  This practice strengthens both the therapeutic capacity of the training group and allows individual members to choose which side of the conflict has therapeutic salience for their own personal work.

Theory of Living Human Systems: An Introduction

SCT and consultation developed by Yvonne Agazarian is based on the Theory of Living Human Systems, a theory that can be applied to any living human system as small as one individual or a large group and couples, families, classrooms, committees, businesses or even nations. Thus the theory offers a set of ideas for thinking about how living human systems work that can be applied at any level.

The theory defines “a hierarchy of isomorphic systems that are energy-organizing, self-correcting and goal directed” – working on the assumption that psychic patterns will be repeated in the same form (isomorphy)at every nested level of interaction. Each of these constructs is then operationally defined with methods developed that test the hypothesis of the theory. In this way, it offers a comprehensive systems theory and methodology of practice that can be applied in clinical, organisational and educational settings. Most importantly, Agazarian’s theory of living human systems introduces the hypothesis that the single essential process by which living human systems survive, develop and transform is by discriminating and integrating differences.

Working with Differences

Differences are challenging for people, whether they are differences in opinions, beliefs, ideas, wishes, or feelings. Differences are challenging even when we find them inside of ourselves. Groups often respond to differences that are “too different” by ignoring the differences, avoiding the differences, trying to change or convert the differences or blaming, judging or scapegoating the differences. Groups that respond in these ways to differences can survive unchanged for a long time since anything that challenges the status quo does not become incorporated into the group or is rejected by the group.

Because of this tendency, Systems-centred therapists or consultants pay a lot of attention to communication within the system. They are particularly looking to reduce the defensive “noise” within the communication.  Noise is defined as contradictions, (Simon and Agazarian), ambiguities and redundancies (Shannon and Weaver). This concept of noise was developed from work by Shannon and Weaver who formulated observations about the inverse relationship between noise and information transfer. By highlighting and reducing contradiction, ambiguities, and redundancies, i.e. “noise”, communication is more effective in transferring information and the system has a better chance of discriminating and integrating its differences.

According to the theory of living human systems, groups that are able to take in and use differences are able to not only survive but also develop and transform. This kind of development enables groups to use their differences as resources to find solutions to problems that are more comprehensive and responsive to the complexity of the problem. They are able to move with less difficulty toward their goals.

Functional Subgrouping

In systems-centred therapy, members are taught to manage differences and resolve conflicts by a technique called functional subgrouping. Rather than individual members working alone, functional subgrouping requires that all members of a system that are similar work together to deeply explore their similarity. When that subgroup finishes its exploration, the subgroup holding a difference begins its work, exploring their similarities with one another. Inevitably, as the members of a subgroup talk with each other, they discover differences (i.e. differences within the apparently similar) within their subgroup and also, find similarities with the other subgroup (similarities in the apparently different). By using functional subgrouping, the whole group has a better chance of integrating its differences rather than rejecting differences. When a group can make use of its differences it becomes more complex and interesting akin to the way music is enriched by harmonies or interwoven themes. The group moves from the survival of the status quo to development and transformation.

SCT clients learn through experience. By exploring one’s experience rather than explaining it, members learn to tell the difference between comprehensive understanding (words first, experience second) and apprehensive understanding (experience first, words second). Clients learn to restore the connection between their comprehensive, thinking self and their emotional, intuitive self. Learning this skill leads to “containing” the energy and gaining the knowledge that frustrations and conflicts arouse, rather than discharging, binding or constricting it in defensive symptoms.  Energy in SCT is understood as the ability of the group or individual to work towards its goals.

Working with Perspectives

Another important part of the theory of living human systems is that groups function more effectively when there is the capacity to shift perspective from the perspective of the individual to the perspective of the whole group.  Being able to shift perspective from seeing things from the perspective of a person in a group (or couple or family or business, etc.) to the perspective of a member of the group creates a climate of mutual work toward a common goal. Individuals who are able to make the shift from the perspective of an individual to the perspective of a member or systems-centred perspective are less likely to take personally the inevitable challenges that arise as a human system moves toward its goal.  When we take things less personally, we are less likely to get bogged down in frustration, hurt feelings and unproductive arguments. When we understand ourselves in the context of the systems that we belong to and co-create – our families, schools, businesses, labour unions, political parties, churches, sports clubs – we not only participate in their tasks, we are also involved in their development: establishing the distribution of authority and the degree of trust that help these systems survive and grow. Doing this, we contribute to the system balance between innovation and continuity, and at the same time strike a balance between our own desire to learn and our want for security.

Phases of Development

The systems-centred methods which developed from the theory of living human systems offers a map of predictable phases for the development of human systems. In the first phase of development, a system comes to terms with the issues of giving and taking authority and with the authority that resides in the members. Successful management of this phase leads to cooperation between members and between members and leaders. Unsuccessful management of this phase results in members behaving defiantly or compliantly which inevitably undermines the group’s development.

In the second phase, called the intimacy phase, the group wrestles with the challenges of closeness and distance from fellow members. This is the phase of team building for workgroups and the phase in which the issues related to separation and individuation are explored in therapy groups. As the group works in this phase it explores the pull to becoming enchanted with itself or becoming disenchanted and falling into despair with no energy to do its work. Successful management of this phase allows members to gain greater access and intimacy with themselves and also to work together with others in a climate of tested and mutual trust.

In the third phase of development, the group has the opportunity to develop a greater access to its emotional and rational intelligence and develops the capacity to use that information effectively in the service of the group’s goals. The group works more efficiently as it is more able to accept the reality of the role each member plays in the group, and stays more connected to the goal of the group and the reality of the environment in which the group is working.

Successfully managing the challenges of these phases of development means that the system is capable of developing an effective distribution of authority, establishing a climate of trust, and developing the capacity for system adaptation and learning. Wheelan (2005) has shown that work groups that are more developed in their phases have increased productivity.

As Psychotherapy

The theory of living human systems has been applied to psychotherapy as well as to business, organisational and educational consultation. In its application to psychotherapy, a unique aspect of this theory is that it is equally applicable to both individual and couples psychotherapy and to group psychotherapy. SCT posits that much of a person’s suffering is related to viewing oneself only from the perspective of the individual self, a person-centred view. By developing a capacity to see oneself from the perspective of the system one is a part of, a systems-centred perspective, the psychotherapy client is able to more consciously influence their own development and the development of the systems they are a part of.

A SCT therapist uses the phases of development described in the theory of living human systems to systemically train a client to recognise states of mind that interfere with reaching the client’s goal. These interfering states of mind are referred to as defences. Two of the most common defences that bring people to psychotherapy are anxiety and depression;  these are addressed in the first phase of treatment. Clients are taught how to recognise and reduce these defences so that they are freed to traverse life less painfully and more smoothly. SCT work is a partnership in which the therapist governs the structure of the therapy and clients make a series of manageable choices at different “forks in the road”. Each fork is a choice a person makes between familiar defences and experiencing the emotion, conflict or impulses that triggered the defence. The systems-centred therapist teaches the client to systematically weaken the defence, such as anxiety or tension, in a structured sequence that matches the client’s ability to choose. As each defence is undone, the client can choose to take the fork in the road away from the symptoms generated by their defensive responses, and towards discovering the conflicts, between their emotions or impulses and the fears of their emotions or impulses, that were being defended against. As SCT psychotherapy proceeds, the client acquires skills that increase their ability to undo their own defences. Through this process, clients regain their ability to use their common sense,  (and existential humour!) to manage the every day conflicts between themselves and reality. Clear outcome criteria for each step are in the sequence of defence modification locates the client in the SCT treatment plan. Because each defence modification addresses a specific symptom, therapy can be delivered either continuously or chunked into modules. SCT can therefore be applied to the goals of both short-term and long-term therapy.

Criticism

Irvin D. Yalom has seen the formation of subgroups as a negative indicator in the context of group therapy.

What is Dialectical Behaviour Therapy?

Introduction

Dialectical behaviour therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders, ADHD, and interpersonal conflicts.

There is evidence that DBT can be useful in treating mood disorders, suicidal ideation, and for change in behavioural patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them, in a manner comparable to the philosophical dialectical process of hypothesis and antithesis, followed by synthesis.

This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.

Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.

DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from contemplative meditative practice. DBT is based upon the biosocial theory of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomised clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalisations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Overview

DBT is considered part of the “third wave” of cognitive-behavioural therapy, and DBT adapts CBT to assist patients to deal with stress.

This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.

Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.

DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client’s feelings at any given time, while, nonetheless, informing the client that some feelings and behaviours are maladaptive, and showing them better alternatives. DBT focuses on the client acquiring new skills and changing their behaviours, with the ultimate goal of achieving a “life worth living”, as defined by the patient.

In DBT’s biosocial theory of BPD, clients have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behaviour.

DBT skills training alone is being used to address treatment goals in some clinical settings, and the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new settings, for example, supporting parenting.

Four Modules

Mindfulness

Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations.

The concept of mindfulness and the meditative exercises used to teach it are derived from traditional contemplative religious practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one’s emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their five senses: touch, smell, sight, taste, and sound. Mindfulness relies heavily on the principle of acceptance, sometimes referred to as “radical acceptance”. Acceptance skills rely on the patient’s ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology.

Acceptance and Change

The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea that one should face situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies.

Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient:

  • Precontemplation is the first stage, in which the patient is completely unaware of their problem.
  • In the second stage, contemplation, the patient realises the reality of their illness: this is not an action, but a realisation.
  • It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists.
  • Finally, in stage 4, the patient takes action and receives treatment.
  • In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse.

After grasping acceptance and change, a patient can fully advance to mindfulness techniques.

There are six mindfulness skills used in DBT to bring the client closer to achieving a “wise mind”, the synthesis of the rational mind and emotion mind: three “what” skills (observe, describe, participate) and three “how” skills (nonjudgementally, one-mindfully, effectively).

Distress Tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by person-centred, psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behaviour therapy emphasizes learning to bear pain skilfully. This module outlines healthy coping behaviours intended to replace harmful ones, such as distractions, improving the moment, self-soothing, and practicing acceptance of what is.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and non-judgemental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Emotion Regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. DBT skills for emotion regulation include:

  • Identify and label emotions.
  • Identify obstacles to changing emotions.
  • Reduce vulnerability to emotion mind.
  • Increase positive emotional events.
  • Increase mindfulness to current emotions.
  • Take opposite action.
  • Apply distress tolerance techniques.

Emotional regulation skills are based on the theory that intense emotions are a conditioned response to troublesome experiences, the conditioned stimulus, and therefore, are required to alter the patient’s conditioned response. These skills can be categorised into four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions:

  • Learning how to understand and name emotions:
    • The patient focuses on recognising their feelings.
    • This segment relates directly to mindfulness, which also exposes a patient to their emotions.
  • Changing unwanted emotions:
    • The therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions.
    • While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion.
  • Reducing vulnerability:
    • The patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future.
  • Managing extreme conditions:
    • The patient focuses on incorporating their use of mindfulness skills to their current emotions, to remain stable and alert in a crisis.

Interpersonal Effectiveness

The three interpersonal skills focused on in DBT include self-respect, treating others “with care, interest, validation, and respect”, and assertiveness. The dialectic involved in healthy relationships involves balancing the needs of others with the needs of the self, while maintaining one’s self-respect

Tools

Specially formatted diary cards can be used to track relevant emotions and behaviours. Diary cards are most useful when they are filled out daily. The diary card is used to find the treatment priorities that guide the agenda of each therapy session. Both the client and therapist can use the diary card to see what has improved, gotten worse, or stayed the same.

Chain Analysis

Chain analysis is a form of functional analysis of behaviour but with increased focus on sequential events that form the behaviour chain. It has strong roots in behavioural psychology in particular applied behaviour analysis concept of chaining. A growing body of research supports the use of behaviour chain analysis with multiple populations.

Efficacy

Borderline Personality Disorder

DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. A 2009 Canadian study compared the treatment of borderline personality disorder with dialectical behaviour therapy against general psychiatric management. A total of 180 adults, 90 in each group, were admitted to the study and treated for an average of 41 weeks. Statistically significant decreases in suicidal events and non-suicidal self-injurious events were seen overall (48% reduction, p=0.03; and 77% reduction, p=0.01; respectively). No statistically-significant difference between groups were seen for these episodes (p=.64). Emergency department visits decreased by 67% (p<0.0001) and emergency department visits for suicidal behaviour by 65% (p<0.0001), but there was also no statistically significant difference between groups.

Depression

A Duke University pilot study compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behaviour therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behaviour therapy in remission.

Complex Post-Traumatic Stress Disorder (CPTSD)

Exposure to complex trauma, or the experience of traumatic events, can lead to the development of complex post-traumatic stress disorder (CPTSD) in an individual. CPTSD is a concept which divides the psychological community. The American Psychological Association (APA) does not recognise it in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though some practitioners argue that CPTSD is separate from post-traumatic stress disorder (PTSD).

CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others. CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress, and that the most common precedents are sexual traumas. Currently, the prevalence rate for CPTSD is an estimated 0.5%, while PTSD’s is 1.5%. Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organisation (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers.

Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognise CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterised by low self-esteem, interpersonal deficits, and deficits in affect regulation. These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with borderline personality disorder (BPD).

Similarities between CPTSD and Borderline Personality Disorder

In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit splitting, mood swings, and fears of abandonment. Like patients with borderline personality disorder, patients with CPTSD were traumatised frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviours to cope. Thus, treatment for CPTSD involves stabilising and teaching successful coping behaviours, affect regulation, and creating and maintaining interpersonal connections. In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality). Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom. Because of the two disorders’ shared symptomatology and physiological correlates, psychologists began hypothesising that a treatment which was effective for one disorder may be effective for the other as well.

DBT as a Treatment for CPTSD

DBT’s use of acceptance and goal orientation as an approach to behaviour change can help to instil empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming overwhelmed by their history of trauma. This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client’s suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation, DBT can be an option to stabilize suicidality and aid in other treatment modalities.

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviours (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame. The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories. The recommended multiphase model consists of establishing safety, distress tolerance, and social relations.

Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective. Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.

A study co-authored by Linehan found that among women receiving outpatient care for BPD and who had attempted suicide in the previous year, 56% additionally met criteria for PTSD. Because of the correlation between borderline personality disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms. Some providers opt to combine DBT with other PTSD interventions, such as prolonged exposure therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or cognitive processing therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories).

For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma’s occurrence and how it may continue to affect them throughout their lives. Participants in clinical trials such as these exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviours were reported.

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low. Biosocial theory posits that emotion dysregulation is caused by an individual’s heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed).

An individual who has these features is likely to use maladaptive coping behaviours. DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency. The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.

Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (i.e. shortening treatment). Populations with comorbid BPD may need to spend longer in the “Establishing Safety” phase. In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately. In populations with comorbid substance use, adaptations may be made on a case-by-case basis.

For example, a provider may wish to incorporate elements of motivational interviewing (psychotherapy which uses empowerment to inspire behaviour change). The degree of substance use should also be considered. For some individuals, substance use is the only coping behaviour they know, and as such the provider may seek to implement skills training before target substance reduction. Inversely, a client’s substance use may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.

What is Clinical Behaviour Analysis?

Introduction

Clinical behaviour analysis (CBA; a third-generation behaviour therapy) is the clinical application of behaviour analysis (ABA). CBA represents a movement in behaviour therapy away from methodological behaviourism and back toward radical behaviourism and the use of functional analytic models of verbal behaviour – particularly, relational frame theory (RFT).

Current Models

CBA therapies include acceptance and commitment therapy (ACT), behavioural medicine (such as behavioural gerontology and paediatric feeding therapy), community reinforcement approach and family training (CRAFT), exposure therapies/desensitisation (such as systematic desensitisation), functional analytic psychotherapy (FAP, such as behavioural activation (BA) and integrative behavioural couples therapy), and voucher-based contingency management.

Acceptance and Commitment Therapy

Acceptance and commitment therapy is probably the most well-researched of all the third-generation behaviour therapy models. Its development co-occurred with that of relational frame theory, with several researchers such as Steven C Hayes being involved with both. ACT has been argued to be based on relational frame theory, although this is a matter of some debate within the community. Originally this approach was referred to as comprehensive distancing. Every practitioner mixes acceptance with a commitment to one’s values. These ingredients become enmeshed into the treatment in different ways which leads to ACT being either more on the mindfulness side or more on the behaviour-changing side. ACT has, as of May 2021, been evaluated in over 600 randomised clinical trials for a variety of client problems. Overall, when compared to other active treatments designed or known to be helpful, the effect size for ACT is a Cohen’s d of around 0.6, which is considered a medium effect size.

Behavioural Activation

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching law model of reinforcement. A recent review of the research supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Community Reinforcement Approach and Family Training

Community reinforcement approach and family training (CRAFT) is a model developed by Robert Meyer and based on the community reinforcement approach (CRA) first developed by Nathan Azrin and Hunt. The model focuses on the use of functional behavioural assessment to reduce drinking behaviour. CRAFT combines CRA with family therapy.

Functional Analytic Psychotherapy

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. The basic FAP analysis utilises what is called the clinically relevant behaviour (CRB1), which is the client’s presenting problem as presented in-session. Client in-session actions that improve their CRB1s are referred to as CRB2s. Client statements, or verbal behaviour, about CRBs are referred to as CRB3s. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Integrative Behavioural Couples Therapy

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couples relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Clinical Formulation

As with all behaviour therapy, clinical behaviour analysis relies on a functional analysis of problem behaviour. Depending on the clinical model this analysis draws on B.F Skinner’s model of Verbal Behaviour or relational frame theory.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group in clinical behaviour analysis ABA:I. ABA:I serves as the core intellectual home for behaviour analysts.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis.

The Association for Contextual Behavioural Science is devoted to third-generation therapies and basic research on derived relational responding and relational frame theory.