Description Of Therapeutic Frameworks And Techniques

ATTACHMENT THEORY

According to attachment theory (Bowlby, 1969, 1973, 1980), parental sensitivity and responsiveness to the child’s attachment signals for closeness and safety shape the child’s socioemotional development towards adaptive or maladaptive emotion regulation strategies and the development of a secure or insecure attachment style. The secure child relies on primary attachment behaviours to regulate distress, and learns to tolerate negative affects temporarily to achieve mastery of frustrating situations. In contrast, the insecure child relies on secondary attachment-hyperactivating, and/or avoidant, attachment deactivating strategies to regulate distress (Gross, 2007; Mikulincer & Shaver, 2007). Hyperactivating strategies include excessive reassurance seeking and catastrophising which may lead to depression (Cole-Detke & Kobak, 1996) and partner withdrawal (Mikulincer & Shaver, 2007). Deactivating, avoidant strategies include inhibition or suppression of threat-related thoughts and feelings and diversion of attention from distress cues which may include abuse of substances (e.g., Allen, Hauser & Borman-Spurrel, 1996) and disordered eating behaviour (Cole-Detke & Kobak, 1996).

Bartholomew (1990) has identified a secure attachment style and three insecure styles (preoccupied, fearful, dismissive). A fourth attachment style characterized as disorganized appears to be a response when the source of threat is the attachment figure. Secure attachment is characterized by good self-esteem, positive expectations of others and adaptive coping (Sroufe, 2000b). Insecure-dismissive attachment is characterized by good self-esteem, negative expectations of others and self-reliance (Griffin & Bartholomew, 1994). The other two insecure attachment styles are characterized by low self-esteem, negative expectations of others, poor interpersonal problem solving and avoidant coping including eating psychopathology (Cole-Detke & Kobak, 1996; Burge et al., 1997; Davila, Hammen, Burge, Daley, & Paley, 1996). Insecure attachment (preoccupied and fearful) may operate as a distal predictor of disordered eating which exerts its influence through avoidant coping. Emotional distress triggers insecure attachment styles including avoidant coping, which may partly explain the high prevalence of disordered eating during young adulthood (Simpson & Rholes, 2004).

The Circle of Security parent training aims to increase caregiver sensitivity to the children’s attachment needs and become the Secure Base which encourages adaptive exploration and play. Gottman and Emotion-focused couple therapies encourage the partners to act as the secure base for each other.

COGNITIVE BEHAVIOUR THERAPY (CBT)

CBT is an evidence-based approach demonstrating that cognitions (ie thoughts) influence feelings and behaviours, and that subsequent behaviours and emotions can influence cognitions. Mindfulness meditation enhances your capacity to be more aware of the thoughts and behaviours that need changing. CBT has two aspects: behaviour therapy and cognitive therapy. Behaviour therapy is based on the theory that behaviour is learned and therefore can be changed. Behavioural change techniques include exposure therapy, activity scheduling and skills training (including training in mindfulness meditation, relaxation, stress management, assertiveness, communication, social skills, problem solving, parenting, and anger management). Cognitive therapy is based on research demonstrating that distressing emotions and maladaptive behaviours are the result of unhelpful, automatic patterns of thinking. Our brain has a capacity called neuroplasticity. This means we can reprogram or rewire our brain with helpful patterns of thinking, feeling and behaviours. The process of reprogramming (known as cognitive restructuring) is enhanced by adjunctive use of hypnosis and practice of mindfulness mediation which enables us to observe and unplug our attention from unhelpful thoughts.

DIALECTICAL BEHAVIOUR THERAPY (DBT)

DBT is designed to increase the coping skills toolbox, enhance generalisation of skills to the world outside therapy and improve adaptive emotion regulation. The overall goal is the reduction of ineffective action tendencies linked with deregulated emotions. It involves a skills training mode (usually a group) where four basic sets of DBT skills are taught. These are: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. It also involves a one-on-one relationship with a therapist who encourages skill-practice, skill consolidation and skills generalisation in which the focus is on helping the individual to integrate the skills learnt into real-life situations. DBT may also involve team consultation, which is designed to support clinicians. It is effective for anyone experiencing emotion dysregulation and associated relationship challenges

EMOTION FOCUSED THERAPY (EFT)

EFT combines humanistic, experiential and Gestalt therapies directed at in-session intrapsychic and/or interpersonal targets. These targets are thought to play prominent roles in the development and exacerbation of disorders such as depression. Gestalt techniques used in EFT include empty-chair and two chair dialogues between aspects of the self or between the self and another person from the past or present (to enable release of anger and hurt), increased acceptance and compassion for oneself, and development of a new view and understanding of oneself. EFT for couples seeks to identify attachment needs and feelings underlying conflict and improve communication of these needs in a way that encourages a positive response from the partner.

FAMILY THERAPY

Family interventions (including parent-training interventions) are defined as interventions that explicitly focus on altering interactions between or among family members in order to improve the functioning of the family as a unit, its subsystems, and/or the functioning of the individual members of the family. This framework includes systemic couple and family therapy and views the presenting problem(s) as interaction patterns or systems of interacting patterns that need changing and adjusting, rather than viewing problems as residing in a particular person. Family therapy is very useful in building resiliency with step-parenting, family breakdown, chronic medical conditions (such as psychosis or dementia) and in challenging transitions such as managing adolescence or increased dependency in elderly parents and is effective in reducing parental alienation during divorces. It is a relational framework that understands our mammalian need to attach and grieve.

COUPLE THERAPY:

People in relationships seek couple therapy for a number of reasons such as enhancing intimacy, reducing conflict, improving communication and sexual satisfaction, understanding infidelity or reducing disconnection. Couple Therapy is a type of psychotherapy which is provided by an experienced Family Therapist and is aimed at increasing understanding and awareness of interactional patterns that need changing. Alain de Botton in his book The Course Of Love encourages the couple to understand each others “insanity” or sensitivities linked to early attachment experiences and which create interactional misunderstandings. This need to understand how my partner is different to me is also embraced by the book entitled The Five Languages of Love written by Gary Chapman Couple Therapy may increase emotional support, reduce Post Natal Depression (PND) and enhance reconnection after child birth (according to Dr Martien Snellen author of the book Rekindling).

Emotionally Focused Therapy for Couples (EFT-C) created by Leslie Greenberg & Susan Johnson is embedded in Bowlby’s attachment theory of emotional security. It is also embedded in an understanding of insecure attachment patterns developed in childhood and reactivated in significant couple relationships. These may include interactional patterns of pursuit-withdrawal or criticise-defend which increase distress. EFT-C encourages the couple to understand and respond to each other’s attachment needs to repair conflict, increases positivity in interaction and build the experience of the relationship as a secure base.

Gottman Method Couple Therapy is based on extensive research on how to become a Master Couple.. The Sound Relationship House Theory is an integrative approach to couple therapy. It enhances positivity by creating shared meaning and building love maps and reduces factors predicting divorce which are called “The Four Horsemen of the Apocalypse”: Criticism, Defensiveness, Contempt and Stonewalling. It is an affective therapy which integrates EFT-C in its focus on building and repairing the couple’s friendship and love and their secure attachment to each other. It integrates systemic family therapy in its focus on interactional patterns. It integrates narrative therapy in enhancing reflection of how the stories they tell about their lives may restrict them from overcoming their present difficulties, encourages a reframing of those stories and puts a major emphasis on identifying the couple strengths. It is also a psychodynamic couple therapy in enhancing awareness of attachment patterns and stories developed in the family of origin.

INTERPERSONAL PSYCHOTHERAPY (IPT)

IPT is a brief, structured approach that embraces attachment theory and addresses interpersonal issues. The underlying assumption of IPT is that mental health problems and interpersonal problems are interrelated. The goal of IPT is to help clients understand how these problems, operating in their current life situation, lead them to become distressed and put them at risk of mental health problems. Specific interpersonal problems, as conceptualised in IPT, include interpersonal disputes, role transitions, grief, and interpersonal deficits. IPT explores individuals’ perceptions and expectations of relationships, and aims to improve communication and interpersonal skills.

NARRATIVE THERAPY

Narrative therapy has been identified as a mode of working of particular value to Aboriginal and Torres Strait Islander people because it builds on the story telling that is a central part of their culture. Narrative therapy is based on understanding the stories that people use to describe their lives. The clinician listens to how people describe their problems as stories and helps them consider how the stories may restrict them from overcoming their present difficulties. This therapy regards problems as being separate from people and assists individuals to recognise the range of skills, beliefs, and abilities that they already have and have successfully used (but may not recognise) and that they can apply to the problems in their lives. Narrative therapy reframes the stories people tell about their lives and puts a major emphasis on identifying people’s strengths, particularly those that they have used successfully in the past.

BRIEF PSYCHODYNAMIC PSCHOTHERAPY

Short-term psychodynamic psychotherapy is a brief, focal, transference-based therapeutic approach that helps individuals by exploring and working through specific intrapsychic and interpersonal conflicts. It encourages the client’s awareness of the way patterns from the past are projected onto the present and encourages a disentangling of past from present. This includes understanding how the past is projected onto the therapist as transference. It may encourage modification or enhancement of aspects of self which have been internalised through past experience (including representations of parent figures). The therapeutic relationship or alliance is important in its capacity to reduce defensiveness and attain conflict resolution and greater self-awareness.

SCHEMA THERAPY

Schema-focused therapy emphasises identifying and changing maladaptive schemas and associated ineffective coping modes. Schemas are psychological constructs that include beliefs that people have about themselves, the world, and other people, and that are the product of how well their developmental childhood needs were met. Young identified 18 schemas: Disconnection & rejection ( abandonment/instability, mistrust/abuse, emotional deprivation, Impaired autonomy (dependence/incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, failure), Impaired Limits (entitlement/grandiosity, insufficient self-control/self-discipline), Other Directedness (subjugation, self-sacrifice, approval-seeking/recognition-seeking) and Overvigilance and inhibition (negativity/pessimism, overcontrol/emotional inhibition, unrelenting standards/hypercriticalness, Punitiveness). When our schemas are triggered we act in particular modes including Vulnerable Child Mode, Angry Child Mode, Impulsive or Undisciplined Child Mode and Happy Child Mode.Therapy offers healthy reparenting including imaginal correction of past experience.

SOMATIC PSYCHOTHERAPY

Somatic Psychotherapy is grounded in an understanding of the mind-body connection. According to Somatic Psychotherapy the sensations associated with past trauma become trapped within the body. This occurs when the amygdala hijacks the response to trauma such that it is not integrated with information from our prefrontal thinking brain. As such, we cannot express the trauma in language. The trauma is expressed through facial expression, posture, muscular pain or other forms of body language (including chronic fatigue syndrome). The book The Body Keeps The Score written by Bessel Van Der Kolk explains this very well.

SOLUTION-FOCUSED BRIEF THERAPY (SFBT)

SFBT is a brief resource-oriented and goal-focused therapeutic approach that helps individuals change by constructing solutions. It aims to increase optimism and positive expectancies along with the experience of positive emotions to improve outcomes. SFBT includes using specific techniques such as miracle and scaling questions to draw on clients’ strengths and resources to create new meaning for clients that provides a more positive future outlook.

MOTIVATIONAL INTERVIEWING (MI)

MI is a psychotherapy which helps clients to move from a state of indecision or uncertainty and towards finding motivation to make positive decisions and accomplish established goals. It may utilise the concept of the Stages Of Change and seeks to encourage movement from Precontemplation to Contemplation of change and then through the Change gate. The therapist encourages the client to explore and resolve ambivalence, arrive at their own choices and conclusions and hence own the change and be less susceptible to relapse. This may include ambivalence about reducing weight or substance use or leaving an emotionally abusive relationship. The book entitled Should I Stay Or Should I Go by Lundi Bancroft & Jac Patrissi is a useful resource for encouraging exploration of ambivalence about leaving a situation of domestic violence.

ACCEPTANCE & COMMITMENT THERAPY (ACT)

ACT is based on a contextual theory of language and cognition known as relational frame theory. It makes use of a number of therapeutic strategies, many of which are borrowed from other approaches, including CBT and DBT (mindfulness). ACT focuses on the context and function of psychological experiences (e.g., thoughts, feelings, and sensations) as the target of interventions, rather than on the actual form or frequency of particular symptoms. In ACT, individuals increase their acceptance of the full range of subjective experiences, including distressing thoughts, beliefs, sensations, and feelings in an effort to promote desired behaviour change that will lead to improved quality of life. A key principle is that attempts to control (rather than observe) unwanted subjective experiences (e.g., anxiety) are often ineffective. Consequently, individuals are encouraged to connect with their experiences fully and without defence while moving toward valued goals. ACT also helps individuals to identify their values and translate them into specific behavioural goals.

CLINICAL HYPNOSIS

Hypnotherapy involves the induction of the state of trance or hypnosis. Hypnotisability is a stand-alone trait ranging from 0 to 5. It is not linked to gullibility. Clients who are highly hypnotisable are very responsive to their own negative self-talk. Hypnotherapy involves education about hypnosis and discussion of common misconceptions and induction procedure. Induction techniques include various methods for reducing sensory stimulation such eye fixation and flattened sound (such as the therapist’s voice or Pachelbel’s Canon). The initial experience of hypnosis enhances susceptibility to deepening techniques (with suggestions of elevator travel down or steps down). Hypnotherapy is a powerful adjunct to CBT and is useful for imaginal reparenting experiences in Schema Therapy. The client is responsive to guided imagery, anchoring techniques, ego-strengthening experiences and suggestions, verbal reprogramming, creating positive expectancies through positive imaginal experiences and creating affect bridges between past positive experiences and the present. The client emerges from the hypnotic experience in response to alerting suggestions to re-connect to sensory experiences in their surroundings.

EYE MOVEMENT DESENSITISATION AND REPROCESSING (EMDR)

EMDR is a therapy developed by Francine Shapiro to rapidly reduce distress linked to traumatic events. It involves the narrowing of attention to the memory which enhances trance and encourages exposure rather than avoidance. The client is asked to rate the subjective unit of distress (SUDs) associated with the memory, identify the associated negative belief and the believability of the preferred positive belief. The technique uses bilateral stimulation which may include right/left eye movement, or bilateral sound or tactile stimulation (such as tapping) in brief, sequential doses while the client is focusing on the memory. These enable reprocessing and release of distressing sensations, feelings, images and thoughts associated with traumatic memories. The goal is to reduce the SUDs, desensitise reactivity to triggers and increase the believability of the positive cognition. EMDR aims to reprocess past memories to reduce associated distress and forge positive associative links. EMDR then targets current circumstances that elicit distress such that internal and external triggers are desensitised. EMDR further seeks then to embed positive imaginal templates of future events to enhance feelings of self-efficacy. Although EMDR is used primarily in trauma therapy, it may also be effective with escape behaviours associated with distress such as binge eating or substance abuse.

RADICAL EXPOSURE THERAPY (RET)

RET is a form of exposure therapy that effectively resolves memories of disturbing events that perpetuate PTSD, anxiety, fears and emotional reactivity. It draws on the protocol of EMDR and combines it with the tapping sequence of the Emotional Freedom Technique (EFT). It is radical because the reduction in distress is rapid. It is a form of exposure therapy because the focus is on imaginal exposure to specific, disturbing memories. Once the memory network is activated, the tapping is used to prevent reconsolidation of the original memory. The tapping is not bilateral. When clients have to concentrate on two things at once being an activated memory and copying a complicated tapping sequence and repeating verbal cues to the trauma modelled by the therapist they overload their brain’s working memory. This prevents reconsolidation of the traumatic memory in its same form. There is more therapist engagement than in EMDR. The therapist repeats the client words used to describe sensations, imagery, feelings and thoughts linked to the disturbing memory whilst maintaining eye contact. This contributes to a strong interpersonal connections between the client and therapist. The goal is to reduce the Subjective Units of Distress (SUDS) associated with the memory and interlinked memories.

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